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Alex Kolevzon, MD
Fellow in Child and Adolescent Psychiatry
Mount Sinai School of Medicine
New York, New York
Craig L. Katz, MD
Clinical Assistant Professor of Psychiatry
Director, Psychiatric Emergency Department
Mount Sinai School of Medicine
New York, New York
Current Clinical Strategies Publishing
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Evaluation of the Psychiatric Patient
I. Establishing rapport A. The first step in interviewing a psychiatric patient is to establish rapport and create an environment where the patient feels comfort able disclosing personal information. The examiner should begin by introducing him self and stating the purpose of the interview. B. The examiner should be caring, competent, and concerned about helping. Good listen ing will often provide the patient with confi dence in the examiner and facilitate trust and openness. II. Interview structure A. The structure of the clinical interview does not usually follow a rigid format. It is best to guide the patient through their psychiatric history by listening to specific cues the pa tient provides and responding with appropri ate questions and comments. B. History taking typically begins with open-
ended questions, which allow the patient to tell the story in his own words. Directed, or more close-ended questions, are used later to elicit specific details when the examiner requires further elaboration. III. Observation A. How the patient speaks and behaves is equally important as what they say. Assess ment begins with simple observation of the patient. Personality characteristics and the way in which patients view themselves and interact with their environment are also considered with the presenting complaint. B. The emphasis of the clinical interview is to establish a working diagnosis based on Diagnostic Criteria (DSM-IV-TR) and to develop an appropriate treatment plan. Much of the interview is focused on asking specific questions designed to reveal the presence of symptoms consistent with mood, psychotic, and anxiety disorders. IV. Mental status exam A. The mental status exam is an assessment that provides a common language to de scribe patient characteristics. The interview provides data that help to elucidate elements of the patient’s presenting complaints and history. The mental status of the patient may change with each exam, and results are relevant only to the time of the interview. B. When discussing an impression of a patient, it is useful to begin by summarizing the mental status exam. V. Written format A. The psychiatric report presents the history in a specific written format. The report includes a proposed multiaxial diagnosis and summa rizes the clinical impression and manage ment recommendations. B. Suggestions for further work-up are also included, such as laboratory testing, neuro logical examinations, diagnostic testing, and gathering information from family, friends, and other health-care providers. Interviewing Techniques
Technique Reflection Facilita tion Silence Confron tation Clarifica tion Transition Reinforce ment Interpreta tion Summa tion Explana tion Description Empathic repetition of patient’s words to show understanding Nodding, saying yes, or uh-huh, to help con tinue the interview Allowing the patient time to think or cry Challenging the patient by pointing out something overlooked or denied Eliciting details and addressing contradic tions Switching topics Giving positive feedback to encourage dis closure Offering insight to facilitate awareness Summarizing information to confirm under standing Explaining the treatment plan and answering questions
Adapted from Psychiatry Essentials: A Systematic Review, Hanley & Belfus Inc, 2001
The Psychiatric History
Identifying data: Patient’s name, age, gender, marital status, occupation, current living situation, language, and ethnic background. Chief complaint: Provide the reason that the patient is seeking care using the patient’s own words in quotation marks. History of present illness: Document current symptoms as described by the patient; date of onset, duration and course of symptoms. Obtain a chronological description of recent events leading up to the presentation, precipitating events, and any other psychosocial stressors. This section should include a psychiatric review of symptoms that assesses the presence of affec tive, psychotic, and anxiety disorders. Past psychiatric history: Past and current diagnoses; a detailed description of past illness, hospitalizations, and treatments. Include past problems with suicidal thinking and attempts. Substance abuse history: Alcohol, cocaine, heroin, marijuana, amphetamines, barbiturates, hallucinogens, and prescription medications, such as opioids or benzodiazepines. If alcohol use is present, screen for abuse or dependence with questions about attempts to cut down, anger, guilt, eye-openers, history of blackouts, shakes, sei zures, or delirium. Ask about the amount of sub stance used, money spent daily, weekly, or monthly. Ask about method of use, such as in haled, intranasal, or intravenous. Social history: Developmental history if rele vant, level of education, social history with atten tion to important relationships and family conflict; marital history, religion, occupational history, and history of violence or criminal activity. Details of past traumatic events; physical abuse or sexual abuse. This section should cover the major do mains of the patient’s life, including work, love, and recreation. Family history: Presence of psychiatric illness in family members, dementia, psychiatric treatment, use of psychiatric medication, presence or history of substance abuse, and history of suicide or suicide attempts. Past medical history: Past and current medical problems, treatments, and allergies. Medications: Psychiatric, medical, over-the counter, and alternative medications.
Mental status exam: General description of the patient’s appearance, speech, mood, affect, thought process, thought content, perceptual disturbance, suicidal ideation, homicidal ideation, sensorium and cognition, impulse control, judg ment, insight, and reliability (see Mental Status Exam in the following section). The mental status exam should contain enough information to allow other physicians to recognize the patient from the description alone. Diagnosis: Psychiatry adheres to a biopsychosocial model where problems are understood as consisting of biological, psychologi cal, and social dimensions. Diagnosis is made across five separate axes to delineate primary psychiatric disorders and substance abuse, personality disorders and mental retardation, general medical illness, psychosocial stressors, and global functioning. This multiaxial system supports an approach to understanding the pat ient, which includes medical, psychiatric, and
social problems. Axis I General psychiatric conditions and substance-related disorders Axis II Personality disorders and mental retar dation Axis III General medical conditions Axis IV Psychosocial stressors Axis V Global assessment of functioning (GAF) on a scale from one to 100 (see Table 5)
Differential diagnosis: Include all psychiatric, medical, and neurological possibilities. Assessment/plan: Include the patient’s age, gender, working diagnosis, and reason for admis sion or discharge. Write orders to admit the pa tient if necessary, specify admission status (eg, voluntary or involuntary), specify observation status (eg, one-to-one, every 20 minutes), con sider medical and neurological evaluations, pro pose treatment, and recommend gathering addi tional information from family and other health care personnel. A/P: Mr. Smith is a 45-year-old man with schizo phrenia, paranoid type, who presents with com mand auditory hallucinations telling him to jump off the Golden Gate Bridge in the context of medication non-adherence for the past two months.
C Admit to psych 6, voluntary status, q20 observation C Check vital signs q shift, regular diet, NKDA C Restart risperidone at 1 mg bid and titrate as necessary C Contact outpatient psychiatrist to gather additional information (Dr. Jones, x1234)
Table 5. Global Assessment of Functioning
Score 91-100 Description of functioning Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. Absent of minimal symptoms (eg, mild anxiety), good functioning in all areas, interested and in volved in a wide range of activities, socially effec tive, generally satisfied with life, no more than everyday problems or concerns (eg, an occa sional argument with family members). If symptoms are present, they are transient and normal reactions to psychosocial stressors (eg, difficulty concentrating after family argument); no more than slight impairment is social, occupa tional, or school functioning (eg, temporarily fall ing behind in schoolwork). Some mild symptoms (eg, depressed mood or mild insomnia) OR some difficulty in social, occu pational, or school functioning (eg, occasional truancy, or theft within the household), but gener ally functioning pretty well, has some meaningful personal relationships. Moderate symptoms (eg, flat affect and circum stantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (eg, few friends, conflicts with peers or coworkers). Serious symptoms (eg, suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (eg, no friends, unable to keep a job). Some impairment in reality testing or communica tion (eg, speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas such as work or school, family relations, judg ment, thinking, or mood (eg, depressed person avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Behavior is considerably influenced by delusions or hallucinations OR serious impairment in com munication or judgment (eg, sometimes incoher ent, grossly inappropriate behavior, suicidal, pre occupation) OR inability to function in almost all areas (eg, stays in bed all day; no job, home, or friends). Some danger of hurting self or others (eg, suicide attempts without clear expectation of death; fre quently violent; manic excitement) OR occasion ally fails to maintain minimal personal hygiene (eg, smear feces) OR gross impairment in com munication (largely incoherent or mute). Persistent danger of severely hurting self or other (eg, recurring violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death. Inadequate information
Adapted from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiat ric Association, 2000
The Mental Status Exam
General description: Appearance (clothing, hygiene, posture, body type), behavior (psychomotor agitation, psychomotor retardation, restlessness), and attitude towards the interviewer (cooperative, well-related, guarded, hostile, apa thetic). Speech: Quantity of speech (eg, talkative, sparse), rate (eg, rapid, slow), volume (eg, whis pered, loud), spontaneous, impediments (eg, stuttering, lisp), and rhythm. Mood: Emotional state recorded in the patient’s own words (eg, “depressed,” “anxious,” “scared,” “happy,” “angry”). Affect: The interviewer’s observation of the pa tient’s emotional state, which includes the general quality (eg, dysphoric, euthymic) and depth of the affect (eg, normal, blunted, or flat). Affect may be labile (alternating rapidly between two extremes) or inappropriate (incongruence between subject matter and emotional expression).
. ideas are related. General themes that characterize the patient’s thinking should be described (eg. but speech may be difficult to follow Flow of thought with ideas that are co herent but unrelated Flow of thought is interrupted by si lence. Examples of thought con tent include suicidal ideation. followed. tangentiality. Table 1. and the patient does not return to the same topic when speech re sumes Individual ideas and speech are inco herent Word association by rhyming Flight of ideas Loosening of associations Thought block ing Word Salad Clang associa tions Neologisms Creating new words Adapted from Psychiatry Essentials: A Systematic Review. flight of ideas. Hanley & Belfus Inc. poverty of content. repetitious. Verbal expression can follow a linear and logical train of thought called goal-directed (normal). or gustatory. Sensorium and cognition: Administer the mini mental state exam (Table 3). or lapse into increasing levels of disorganization. Table 2. and phobias (see Table 2). or neologisms (see Table 1). assess abstract vs. 2001 Thought content disturbance: Refers to what the patient is thinking. or obscure An unfounded fear that triggers panic Ideas of reference Ideas of influence Paranoid ideation Obsession Compulsion Poverty of content Phobia Adapted from Psychiatry Essentials: A Systematic Review. obsessions. and a point is never made Rapid thinking with fast changes in top ics. or persecuted A recurrent thought experienced as intrusive A repetitious act designed to allevi ate anxiety Thought that is vague. anger at their parents). paranoid content. delusions. tactile. word salad. false beliefs without a cultural basis Belief that the television or radio speaks directly to patient Belief that other forces control the patient’s behavior Thoughts of being harmed. ideas of reference. such as circumstantial thought processes. 2001 Perceptual disturbance: Hallucinations may be auditory. olfactory. thought blocking. compulsions.Thought process disturbance: Refers to the logical and semantic connections between pa tient’s thoughts (form). visual. Distinguish between hallucinations and illusions. Hanley & Belfus Inc. Thought Process Disturbance Thought Disturbance Circumstantialit y Tangentiality Description Speech includes irrelevant details but eventually makes a point Speech is not goal-directed. Thought Content Disturbance Thought Content Delusions Description Fixed. homicidal ideation. loosening of associations.
general knowledge. month (1) “Where are you?” state (1). vocabulary. The Mini-Mental State Exam Category Instructions to Patient Maximum Score 5 Orientation “Can you tell me the date?” year (1). Table 3. hospital (1). truthfulness. 1975 Impulse control: Assess the patient’s ability to think before acting and their ability to talk about their emotions rather than acting on them. 66 (1) “Recall the names of the above 3 objects” table (1). point to a pencil (1) “Say no ifs ands or buts” “Take this paper in your right hand (1). flower (1). floor (1) “Repeat the names of these 3 objects” table (1). car (1) Registration 5 3 Attention and Calculation “Subtract by 7s starting from 100” 93 (1). car (1) “Name the object the examiner is holding” point to a watch (1). date (1). season (1). day (1). 79 (1). and overall intelligence. 86 (1).concrete thinking. fold it in half (1). 72 (1). and extent of disclosure. Insight: Refers to the patient’s awareness and understanding of illness. and put it on the floor (1)” “Read this aloud and do what it says” show the patient a sign that says CLOSE YOUR EYES “Write a sentence of your own” 5 Recall 3 Language 2 1 3 1 1 Construction “Copy this design” show the patient a pair of intersecting pentagons 1 Adapted from Folstein. . town (1). country (1). especially with regard to making medical deci sions. Does the patient see himself as others do? Reliability: Accurate and consistent reporting of symptoms. Judgment: Determine the patient’s ability to understand behavior and its consequences. flower (1).
Substance abuse history: Assess temporal relationship between any substance use and depressive symptoms.” or “irritable. Speech: Decreased volume. Ask about irritable or depressed mood. distractibility. date of onset. but often impoverished.” “sad. too much or too little sleep. content disturbance may reach delusional proportions in depression with psychotic features. and Cushing’s disease may present with symptoms of depression. corticosteroids. and suicidal ideation. and chemotherapy may cause depressive symptoms. Mood: Often described as “depressed.” Affect: Constricted in dysphoric range. Suicidality: Suicidal ideation is present in more than half of depressed patients. or sometimes restlessness. stimulants. but con gruent with the patient’s reported mood. and normal rhythm. antibiotics. previous depressive or manic epi sodes. A plan needs to . History of suicide attempts and specific methods employed. analgesics. or work life. including dates and locations. past medications. and substance abuse are the most common comorbid conditions with major depressive disorder. For example. psychomotor retarda tion. Panic disorder. slow rate. outpatient therapy. weight loss or weight gain. and psychosocial stressors. side effects. Rule out bipolar disorder with questions about periods of persistently elated mood. diurnal variation in severity of symptoms. Medications: Antihypertensives. difficulty staying asleep. Assess severity of depressive symptoms by noting impact on their home. racing thoughts. Thought content: Ruminations of guilt about the past. seasonal variation. Perceptual: Auditory. hypnotics. guilt or regret about the past. persistent alcohol use or cocaine withdrawal may present with depressive symptoms. school. or hypersomnia). problems with concentra tion. Past medical history: Hypothyroidism. anticonvulsants. assess potential lethality of previous attempts. poverty of con tent. sedatives. Parkinson’s dis ease. HIV. oral contracep tives. If the patient is suicidal.Depression . duration. or paranoid ideation. systemic lupus erythematosus. history of psychiatric hospitalizations. early morning wakening. increased goal-directed activity. seizure disorders. hopeless about the future. poor eye contact.History Taking History of present illness: Current symptoms. changes in appetite. increased self-esteem. Assess type of insomnia (sleep onset. antipsychotics. Rule out psychotic features or schizoaffective disorder by asking about hallucina tions and delusions. decreased libido. history of panic attacks or other anxiety symptoms. Thought process: Linear and goal-directed in the majority of patients. psychomotor agitation or retardation. migraine headaches. pressured speech. and hedonism. Mental Status Exam General description: Stooped or downcast posture. anemia. and adherence to treatment. loss of interest in previously pleasurable activities. anxiolytics. decreased energy. diabetes. command or visual halluci nations may occur with psychotic features. hopelessness. Past psychiatric history: Previous psychiatric diagnoses. posttraumatic stress disorder. speech may not be spontaneous. ask about the presence of a plan.
dementia. bereavement. and head trauma. bipolar II disorder. vitamin B12 and folate levels. and HIV in high-risk patients.be specified if present. Huntington’s disease. temporal lobe epilepsy. The patient may have a good fund of knowledge and vocabulary. and vitamin defi ciency. but not de layed recall. chronic disease. Judgment: Often impaired by the intensity of depressive symptoms. Sensorium/cognition: Oriented. Assess how the patient manages or resists suicidal impulses. Reliability: Patients may overemphasize symp toms in the midst of a depressive episode. medications. chemis try. substance-induced mood disorder. urinalysis with toxicology screen. cyclothymia. Impulse control: Generally intact except when patients have psychomotor agitation or severe anxiety. liver function tests. Diagnostic testing: The Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory. Insight: Distorted with exaggerated emphasis on depressive symptoms. bipolar I disorder. schizoaffective disorder. multiple sclerosis. Homicidality: May occur with psychotic features. infection. without disturbance in abstract thinking. Neurological: Parkinson’s disease. and adjust ment disorder with depressed mood. Differential Diagnosis Psychiatric: Dysthymia. cancer. or minimize symptoms for fear of appearing “crazy. cerebral tumors. blood alcohol level. . schizoaffective disorder. The mini-mental state exam score should be greater than 27 unless depressive pseudodementia is present. concentration is often poor. depressed type.” Laboratory data: Complete blood count. and language deficits are rare. some problems with immediate recall (registration). Diagnosis: Axis I: Major depression. urine pregnancy test. thyroid function tests. Medical: Hypothyroidism.
IV. and adjustment disorder. Patients with clinical depression may require hospitalization for suicidal ideation. see page 92. would be used for patients who experience anxiety and insomnia in their symptom profile. psychomotor agitation or retarda tion. such as paroxetine. Constant visual observation (1:1) should be considered in suicidal patients. loss of energy. These ele ments interact with psychosocial stressors and increase the patient’s vulnerability to affective disturbance. and dopamine is the proposed etiological mechanism. and in including sea sonal pattern or postpartum specifiers. In treating the patient with major depression. group. and a dysregulation of serotonin. C. feelings of guilt or worthlessness. Epidemiology. Genetic factors influence the devel opment of depression. and substance-induced mood disor ders should be excluded. C. and suicidal ideation. References. B. decreased interest in activities. Etiology. D. . such as dysthymia. bereavement. a more sedating antidepressant. sleep changes. The diagnosis of major depression re quires at least five of the following nine symptoms for a duration of at least two weeks: depressed mood. or if they are unable to care for themselves in their daily lives. III. most evidence supports the integration of antidepressant medication and psychother apy. The time course is important in excluding differential diagno ses. B. epinephrine. Clinical evaluation A. The majority of patients with depression will have suicidal thinking and 10-15 percent will eventually commit suicide.Treatment A. In evaluating the patient with depression. Comorbid substance abuse is also a common finding in depres sion. interpersonal. Major depression affects up to 10 percent of men and 20 percent of women at some point in their lifetime.Major Depressive Disorder Discussion I. II. the history of present illness should describe the full extent of symptoms. poor concentration. The specific choice of antidepressant typically depends on symptom patterns and differing side effect profiles. behavioral. and psychodynamic psychotherapy. appetite changes. Anxiety symptoms and disorders frequently occur with major depression and also in crease suicide risk. Psychotherapy options include cognitive. Fluoxetine is considered a more activating antidepressant and can be used in patients with poor energy and hypersomnia. For example. Previous suicide attempts and feelings of hopelessness are associated with an increased risk of suicide. family. The examiner should ask about suicidal ideation and the presence of a plan.
Assess psychotic features. disulfiram. Ask about religious preoccupa tion and political preoccupation. distractibility. euphoria. hyperactive. depending on the patient’s ability to focus or cooperate. cocaine. restless. and difficult to interrupt. diagnoses. with poor atten tion and concentration. and CNS stimulants (eg. and grandiosity. inflated self-esteem. increased volume. labile at times with rapid shifts to irritability. Social history: Living situation. Substance abuse history: Alcohol. Note extent of recent stressors. visual. but may be bizarre and incoherent at . mind reading. marijuana. Thought content: Grandiose delusions of great wealth and intelligence. and level of education. Medications: Antidepressants. Increased goal-di rected activity. employment. and analgesics.History Taking History of present illness: Current symptoms. bipolar disorder. euphoric. Thought process: Pressured. and date of onset. Mental Status Exam General appearance: The patient appears ex cited. comorbid alcohol and other substance abuse. includ ing impact of manic symptoms on relationships and occupational functioning. psychotic disorders. The patient may be easily distracted. Family history: History of depression. but may also be hostile and uncooperative. methylphenidate) can cause manic symptoms. paranoid delusions. with variable immediate and delayed recall. or ideas of refer ence. Mood: “Great. such as grandiose delusions. feelings of having special powers. barbiturates. Homicidality: Typically denies. ask about energy during the day. thought broadcasting. Suicidality: May be present. and psychomotor agitation. They may be engaging and entertaining. elevated mood.” Affect: Expansive. with flight of ideas. excessive involvement in pleasur able activities. benzodiazepines. Assess for concurrent or alternating depressive symptoms. suicide attempts. isoniazid. and sub stance abuse in family members. talkativeness. bromocriptine. such as clairvoyance. especially in mixed manic states with depressive symptoms. Past psychiatric history: Past hospitalizations. manic episodes. Ask the patient how much he or she has been sleeping. Racing thoughts. Speech: Rapid rate. increased quantity.Mania . Past depressive symptoms. Sensorium/cognition: Alert and oriented. suicide. heroin. Irritability. hallucinogens. risk-taking behavior. psychotic symp toms. procarbazine. duration. and patho logical gambling. depression during adolescence. Thinking is not concrete or abstract. or command halluci nations may occur with psychotic features. disrobing in public. Past medical history: Ask about all medical and neurological problems because many diseases can cause symptoms consistent with mania (see differential diagnosis). ideas of reference. levodopa. amantadine. sometimes alternating with intense dysphoria. and dressed in color ful or dramatic clothing. treatments. marital status. hypersexuality. and outpatient follow-up. ideas of influence. corticosteroids. levothyroxine. psychosocial support. money spending. Perceptual: Auditory. or other special powers.
liver function tests. neoplastic disease.times. thyroid function tests. . cerebrovascular accidents. Judgment: Impaired. ceruloplasmin. The patient may be hypersexual and repeatedly attempt to touch the examiner. temporal lobe epilepsy. carcinoid syndrome. renal failure. magnetic resonance imaging. corticosteroids. antidepressants. vitamin B12. and Pick’s disease. chemis try. multiple sclerosis. substance-in duced manic symptoms (eg. Diagnosis: Axis I: Bipolar I disorder. Insight: Impaired. Wilson’s disease. head trauma. schizoaffective disorder. PCP). schizoaffective disorder. levothyroxine. procarbazine. and toxicology screen. Impulse control: Impaired. amylase. computed tomography. Laboratory data: Complete blood count. lipase. vitamin B12 deficiency. personal. isoniazid. borderline personality disorder. amphetamines. bromo criptine. or substance-abuse histories. cyclothymia. bipolar type. vitamin B3 deficiency (pellagra). Diagnostic testing: Electroencephalography. Manic patients often do not understand how their symptoms affect behavior or other people. and medication-induced mania (eg. vitamin B3. Medical: Hyperthyroidism. Patients experiencing manic episodes may not be able to give accurate infor mation about past medical. CNS infection. and delirium. amantadine. Patients may like the symptoms of mania and do not recognize the need for treat ment. RPR. Differential Diagnosis Psychiatric: Bipolar II Disorder. manic episode. disulfiram. CNS stimulants). psychiatric. Neurological: Huntington’s disease. Reliability: Limited. levodopa.
IV. Mania is characterized by elevated mood and at least three of the following seven symptoms for a period of one week: inflated self-esteem. and family psychotherapy also play important roles in helping patients and families develop insight and cope with chronic illness.Acute mania is treated with antipsychotic medication and benzodiazepines because these agents have sedative effects. and carbamazepine. Psychosis . and degree of functional impairment. especially on inpatient units. mixed state). decreased need for sleep. Clinical evaluation A. and the diagnosis of mania is often made based on information from friends and family in combination with the patient’s mental status exam.Throughout the course of bipolar disorder. rapid cycling). supportive therapy.The presence or history of one manic epi sode is sufficient to make the diagnosis of bipolar disorder. There is often a delay in the diagnosis of bipolar disorder because the disorder may initially present with depressive symptoms. C. B. and symptoms typically begin late in adolescence. racing thoughts.Treatment A. such as lithium. experience these episodes concurrently (ie. D. date of onset. III. Etiology. Patients who present with manic symptoms may require inpatient hospitalization be cause they are a danger to themselves or others due to impulsive behavior and im paired judgment. B. Mood stabilizers. recent stressors. particularly serotonin and norepinephrine. II. Four symp toms are required for diagnosis if the mood is only irritable. E. or in some instances. a patient may cycle frequently between dis crete episodes of mania and major depres sion (ie. pressured speech. even in the absence of past depressive symptoms.Bipolar I Disorder Discussion I. One proposed etiology is impaired regulation of the biogenic amines.Acutely manic patients may be unreliable historians. Hypomania is a less severe form of mania that does not occur with psychotic features and is consistent with a separate diagnostic entity called bipolar II disorder. Symptoms of psychosis are often elicited by first asking. increased goal-di rected activity. There is no such entity as unipolar mania. It is equally prevalent in men and women. Bipolar I disorder affects approxi mately one percent of the population.Psychoeducation. Bipolar disorder is associated with genetic factors. C. Epidemiology. in creased distractibility. are started for long-term prophylaxis of mood cycling. Psychotic features may occur in the context of a manic episode. duration. and this is an important distinction between mania and hypomania. Mania occurs in the context of bipolar I disorder and schizoaffective disorder.History Taking History of present illness: Current symptoms. bipolar type. and manic symptoms may not develop for many years. see page 92. sodium divalproex. References. Hypomania may eventually progress into mania. “Have you felt like your mind has been playing tricks on you?” Ask about unusual or odd experiences. Manic patients can be violent. . but the pattern of inheritance remains unclear. and hedonism.
and neuroleptic malignant syndrome. level of education. Corticosteroids. job history. Withdrawal from sub stances. plans. symptoms of previous psychotic episodes. thought broadcasting. derailment. and who administers the medication. loosening of associations. anticholinergics. head trauma. Previous treatments. and Wilson’s disease. akathisia. herpes encephalitis. inside or outside their head). childhood trauma or illness. such as barbiturates and alcohol. recre ational activities. and levodopa can all cause psychotic symptoms. can also cause psychotic symptoms. Ask about a history of violence or responding to command hallucinations. neurosyphilis. Assess disorganized behavior by asking about eating habits. dementias. thought insertion. CNS lesions. Assess number of hospitalizations. Ask about the presence of visual. duration of hospitalization. delusions of guilt or sin. and management by an intensive case manager or outpatient therapist. Substance abuse history: Rule out substance induced psychotic symptoms with questions about alcohol. Assess the impact of psychotic symptoms on daily functioning. and a history of suicide attempts should also be assessed. adherence. Assess delusional con tent. Past medical history: Psychotic symptoms can be caused by delirium. or bipolar I disorder. seizures. and social withdrawal. medication history with duration and dosages. Wernicke-Korsakoff syndrome. paranoid thinking. Ask about current psychiatric care. dosages. such as circumstantiality. ideas of reference. and reasons for first hospitalization. hallucinations. date of first psychiatric contact. grandiose delusions. Parkinson’s disease. tangentiality. Social history: Prenatal insults.auditory. number of voices the patient hears. amphetamines. tardive dyskinesia. cerebrovascular disease. and whether hospitalizations tend to occur during a specific time of year. major depression with psychotic features. Medications: Ask about medical and psychiatric medications. fear. num ber per year. or neolo gisms. Family history: Presence of psychotic disorders or odd and eccentric personality traits in family members. Past psychiatric history: Previous psychiatric diagnoses. social functioning. and olfactory hallucinations. and side effects from past medications: dystonia. tactile. and source of income. suspiciousness. and magical thinking. social and sexual activity. somatic delusions. housing. AIDS. cocaine. apathy. (including command hallucinations. treatment adherence. Suicidal ideation. Ask about symptoms of clinical depression and mania to exclude schizoaffective disorder. cannabis. . parkinsonism. and agitated behavior. Ask the patient about negative symptoms such as anhedonia. day treatment programs. and voices commenting or conversing). hallucinogens. word salad. special powers. distant relatives. or other household members. relationship history. ideas of influence. and PCP use. Allow the patient to speak freely to assess the presence of thought disorders. systemic lupus erythematosus. Ask the patient to describe where the voices are coming from (eg.
neighbors. herpes encephalitis. Thinking is usually concrete. and normal pressure hydrocephalus. although auditory hallucinations are most common. Ideas of reference. carbon monoxide or heavy metal poisoning. and somatic. olfactory.Mental Status Exam General description: Disheveled. The patient does not understand why he has been brought to the hospital. tangential. Insight: Limited. guarded. friends. possible psychomotor agitation or retardation (including catatonia). factitious disorder. coworkers. borderline. or magnetic resonance imaging for new onset psychosis. B12 deficiency. or grandiose delusions. the patient may appear to be responding to hallucinations. no apparent language deficits. computed tomography. and serum ceruloplasmin. brief psychotic. thought insertion or withdrawal. delirium. Impulse control: Possibly poor impulse control (eg. Perceptual: Hallucinations may be auditory. neurosyphilis. or gustatory. thyroid function tests. Judgment: Impaired. menac ing. tactile. and paranoid personality disorders. Sensorium/cognition: Alert and oriented. fair fund of knowledge and vocabulary. autistic disorder. schizoaffective. Creutzfeldt-Jakob disease. Poor concentration. Thought process: Illogical. Reliability: May be significantly impaired. cerebral neoplasm. and 10 percent of people with schizophrenia will eventually commit suicide. systemic lupus erythematosus. RPR. schizoid.” or “scared. blood alcohol level. Laboratory data: Complete blood count. Neurological: Epilepsy. Diagnosis: Axis I: Schizophrenia. and malin gering. doctors. bipolar I disorder. Medical: AIDS. schizotypal. urinalysis with toxi cology screen. obsessive-compulsive disorder (OCD).” “bad. poverty of speech (alogia). liver function tests. shared psy chotic. and Wilson’s disease. cerebrovascular disease. lunges at security guard about whom patient has become paranoid). visual.” Affect: Often blunted or flat. substance-induced psychotic disorder. Diagnostic testing: Electroencephalography. Scale for the Assessment of Negative Symptoms (SANS). poorly related. . Mood: “Fine. and the Scale for the Assessment of Positive Symp toms (SAPS). Differential Diagnosis for Psychosis: Psychiatric: Major depression with psychotic features. Speech: Normal rate. HIV testing. government agencies or strangers. possi ble impairment in the ability to immediately repeat or recall words depending on the presence of distracting hallucinations or formal thought disor der. head trauma. rhythm. dementia. Suicidality: Suicide attempts occur more fre quently in patients with psychotic disorders. Thought content: Paranoid delusions about family. schizophreniform. and volume. Homicidality: Homicidal ideation directed towards objects of paranoia. and delusional disorders. erotic. The mini-mental state exam is not reliable in acutely psychotic patients. Corrob orative data is usually helpful. vitamin B12 and folate levels. with loosening of associations. The patient has a markedly altered sense of reality. suspicious. uncooperative at times. WernickeKorsakoff syndrome. chemis try.
There are no pathognomonic signs of schizo phrenia. Two out of five symptoms for a duration of at least 6 months are required for diagnosis. Schizophrenia is the most common psychotic disorder.Discussion I. Delusional disorder occurs in older patients and is char acterized by non-bizarre delusions. D. Assessment of premorbid personality characteristics may reveal shy. Etiology. shortness of breath. III. schizophreniform disorder. disorganized behavior. nausea. or if they are unable to care for themselves. affecting one percent of the population. Screen specifi cally for obsessive-compulsive disorder (OCD) with questions about obsessions. such as risperidone or olanzapine. animals. such as palpitations. duration. References. or social isolation during childhood.The difference between schizophrenia. and compulsions. frequency. heights. agitated behavior that is potentially dangerous. Ask about panic symptoms. such as fears of . trembling. are currently the first line of treatment. time of onset. needles. II. somatic complaints. withdrawn behavior. deficits in personal and social function). and the symptom presentations vary widely. but men are initially affected earlier than women.The five main symptoms of schizophrenia are delusions. hallucinations. sweating. A genetic basis for schizophrenia is widely accepted. and premorbid functioning. Clinical evaluation A. obsessions. elevators). fears. Treatment A.Schizophrenia requires lifelong treatment with antipsychotic medication. Socio occupational functioning in Delusional Disor der may not be impaired beyond the direct effect of the delusion itself. feeling of choking. see page 92. disorganized speech. Atypical antipsychotics.Psychotic symptoms may also occur in clini cal depression and mania. derealization or depersonalization phenomena. and brief psy chotic disorder is mainly in symptom dura tion.Patients with schizophrenia may require admission for suicidality. Ask about agoraphobia and other avoidant behav ior. Men and women are equally affected.Clozapine is reserved for treatment-resistant schizophrenia. performance.The history of present illness should focus on specific symptoms. including psychosocial therapies. Shared psychotic disorder is rare and occurs in the context of a close relationship with another person who suffers from a known psychotic illness. paraesthesias. phobias (eg. B. dizziness. illness duration. C. irritability. worries. chest pain. IV. and it posits that schizo phrenia results from an interaction between biologic vulnerability and environmental stress. play a supportive role in the treatment of psychotic disorders. Anxiety .Day treatment programs. D. The stress diathesis theory is the prevailing model. Epidemiology. Schizoaffective disorder is diagnosed in the presence of psychotic symptoms and a prominent mood disturbance. symptom triggers.Schizophrenia . C. and negative symptoms (ie. severe distress from their psychosis. B.History Taking History of present illness: Current symptoms. and fear of losing control or dying. prodromal signs. The typical age of onset for schizophrenia is in young adulthood.
irritable. Understands the nature and consequences of his illness. or separation anxi ety as a child. cannabis. Huntington’s disease and a history of head trauma increase the risk of OCD. Mental Status Exam General description: Restless. such as clean ing. opioid. Ask questions about accompanying compulsions. Screen for comorbid alcohol. and compulsive slowness.contamination. may be more talkative than usual. fearful of recurrent panic. disasters. and cerebrovascular disease can all mimic or directly cause symptoms of anxiety. sexual abuse. myocardial infarction. Abruptly stopping antidepressant and anxiolytic medication may also cause anxiety. Withdrawal from alcohol. intact memory. but with normal rhythm and volume. and theophylline may cause anxiety. counting. which appears similar to anxiety. sympathomimetics. Homicidality: Rare. ask about exposure to a life-threatening event. Sensorium/cognition: Alert and oriented. hypertension. opioids and benzodiazepines can also cause anxiety. command auditory. physical abuse. nightmares. phobia or obsessions. decreased interest in activities. Medications: Aspirin. For posttraumatic and acute stress disorder. hand washing. Past psychiatric history: Previous psychiatric diagnoses. Thought process: Pressured. and prescription medication abuse and dependence. untreated anxiety is a risk factor for suicide. exposure to violence. fidgeting. especially with comorbid clinical depression. nicotine.” “out of control. Suicidality: May be present. and need for symmetry. psychotherapy. Insight: Good. Speech: Rate may be increased. Social history: Details of trauma history. or visual hallucinations. checking. Judgment: Fair. Past medical history: Mitral valve prolapse. No evidence that the patient is a danger to himself or others. but linear and goal-directed. ruminative. panic attacks or phobias in the past. patient is afraid of what bad events may happen in the future. Thought content: Preoccupied about somatic complaints. pathological doubt. Substance abuse history: Amphetamines. Assess history of psychiatric hospi talizations. Mood: “Scared. asthma.” “nervous. pharmacologic treat ments. intru sive recollections of the event. carcinoid syndrome. Impulse control: Fair. penicillin. and adherence. hypervigilance. and startling easily.” Affect: Anxious. The mini-mental state exam score is greater than 24. antihyperten sives. although the patient may place exaggerated emphasis on anxiety symptoms. and hyperarousal with insomnia. hyperthyroidism. poor concentration. COPD. psychomotor agitation. and hallucinogens may pro duce symptoms of anxiety. Antipsychotic medications may induce a state of restlessness known as akathisia. antichol inergics. intrusive thoughts. Assess comorbid depressive symptoms. but congruent with stated mood. or war. side effects. caffeine. Perceptual: No auditory. epilepsy. ordering. . no apparent lan guage deficits or disturbance in abstract thinking. good fund of knowledge and vocabulary. history of Tourette’s disorder. hypoglycemia. avoidant behavior.
mitral valve prolapse. Neurological: Epilepsy. II. chronic obstructive pulmonary disease. feelings of chok ing. obsessive-compul sive disorder. Symptoms are described consistently. chemis try. Medical: Myocardial infarction. and pathological doubt and checking. Anxiety Disorders . Anxiety disorders are among the most common psychiatric diagno ses and typically begin in adolescence or young adulthood. angina. the patient must experience panic attacks. social phobia. Diagnostic testing: Electrocardiography. chills or hot flushes. Differential Diagnosis Psychiatric: Adjustment disorder with anxiety. . and classical condition ing (ie. urinalysis with toxicology screen and blood alcohol level. such as obsessive fears of contamination and compulsive cleaning. dizziness.Discussion I. chest pain. separation anxiety disorder. and specific triggers for anxiety can often be clearly identified by the patient. de pendent. specific stimuli become paired with anxiety responses) account for most symptom presentations. fear of dying. somatization disorder. and hypoglycemia. avoidant. trembling. and subsequent avoidant behavior. B. irritability. impaired regulation of serotonin. Symptoms of OCD follow several patterns. paraesthesias. C. Generalized anxiety disorder is character ized by at least six months of pervasive worry or concern in addition to symptoms of muscle tension. and borderline personality disorders. echocardiography. Generalized Anxiety Disorder. Diagnosis: Axis I: Panic disorder. major depression. liver function tests. obsessive-compulsive. The etiology varies according to the specific disorder. Anxiety may be an appropriate and adaptive response to stress but is consid ered pathological when symptoms begin to impair functioning. anticipatory anxiety about having attacks. specific phobia. urine pregnancy test. and derealization or depersonaliza tion.Reliability: Good. hyperthyroidism. agoraphobia. restlessness. Clinical evaluation A. need for symmetry and slowness. and chest x-ray. vitamin B12 and folate levels. insomnia. shortness of breath. III. Etiology. calcium. carcinoid syndrome. Panic attacks last between five and 20 minutes and are characterized by at least four of the following 13 symptoms: palpita tions. dysthymia. sweating. but a combination of in creased sympathetic discharge. factitious disorder. posttraumatic and acute stress disorder. asthma. Laboratory data: Complete blood count. vertigo. Panic disorder may occur with or without agora phobia. tumors. In order to diagnose panic disorder. hyperten sion. Obsessive-compulsive disorder is character ized by recurrent and intrusive thoughts that cause anxiety (obsessions) and repetitive behaviors designed to relieve the anxiety (compulsions). hypochondriasis. fear of losing control. substance intoxication or withdrawal. nausea. and difficulty concentrating. and head trauma. hyperparathyroidism. Epidemiology. thyroid function tests. cardiac arrhythmias. cerebrovascular disease.
panic attacks. and self-injurious behavior. Assess symptoms of re-experiencing the event through nightmares. Substance abuse history: Alcohol and drug abuse are very common comorbid conditions in posttraumatic stress disorder. obsessive-compul sive disorder. decreased libido. substance abuse. flashbacks. Benzodiazepines are a very effective short term treatment. such as animals or needles. burglary. see page 92. Ask about associated symptoms such as survivor guilt. Acute Stress and Posttraumatic Stress . social phobia. date of event. decreased interest in activities. irritability.Treatment A. anxiety. . guilt about not preventing the traumatic experience. agoraphobia).History Taking History of present illness: Ask about a traumatic event witnessed or experienced directly. such as borderline personality traits. disasters. venlafaxine. Avoidant behavior of stimuli associated with the trauma. References. Symptoms of substance intoxication or withdrawal may mimic posttraumatic stress symptoms. Clomipramine. C. Psychosocial therapies play a significant role in the treatment of anxiety disorders. and GAD. history of childhood trauma. Specific phobias are focused on stimuli. and buspirone are also effective. anger. such as. hostility. impulsivity. and exaggerated startle response. E. Assess symptoms of increased arousal. Cognitive-behavioral therapy is effective in panic disorder. Social phobia involves fears of humiliation and embarrass ment in public. and sexual abuse. Social history: History of exposure to trauma. and agoraphobia. hyperactivity. agoraphobia. suicidal ideation. and hypnosis is used in OCD. decreased concentration. recurrent recollections. stress disor ders. and personality disorders occur with increased frequency in patients who experience posttraumatic stress disorders. physical abuse. or unless there are other potentially dangerous comorbid psychiatric problems. Acute stress and posttraumatic stress disor ders are also categorized as anxiety disor ders and are reviewed in the following chap ter. Evaluate current social support and recent stressful life changes. systematic desensitiza tion. mirtazapine. Behavioral therapy with techniques such as graded exposure. and dependence over time. IV. Past psychiatric history: Major depression. war. specific phobia. but may lead to symptom exacerbation. Pharmacotherapy consists of selective serotonin reuptake inhibitors. panic disorder. and feeling of a foreshortened future. B. and rigid coping mechanisms. feeling that external events (rather than internal) control life changes. emotional numbing. and illusions. nefazodone.D. depression. relaxation techniques. Assess premorbid risk factors. sleep abnormalities. detachment from other people. rape. such as clinical depression. hallucinations. terrorism. shame. tolerance. Hospitalization is rarely required unless anxiety precludes patients from taking care of themselves (eg. somatic symptoms. and duration of current symptoms.
rejection. The patient may storm out of the interview when an unpleas ant question is posed. Clinical evaluation A. and flashbacks. history of head trauma. but memory. Laboratory data: Complete blood count. “on edge. Etiology. or alternative treatments. rape. Homicidality: Denies. II. and. The patient understands the nature of symptoms and underlying illness. adjustment disorder. illusions. and malingering. Mood: “Scared. Speech: Rate and volume may be increased or decreased. Posttraumatic stress disorder (PTSD) occurs following a traumatic event involving the risk of death or physical injury that is either witnessed or experienced directly. or withdrawn with poor eye-contact secondary to feelings of humiliation. and attention could be impaired. rapist). seizure disorder. panic disorder. Differential diagnosis: Head trauma. Patients with borderline personality traits or a past history of childhood trauma are more likely to experience symptoms following a traumatic event. the mini-mental state exam score re mains greater than 24. Sensorium/cognition: Alert and oriented. concentration. less commonly. acute stress disorder. Judgment: Fair.” “depressed. chemis try. seizure disorder. and recurrent thoughts about traumatic event. generalized anxiety disorder. Past medical history: Childhood illness. PTSD may occur in up to 30 percent of people who experience trauma and is common in combat veterans and victims of assault. Impulse control: Possibly impaired. phobias. or dysphoric. dissociative disor ders. anxious. urine toxicology screen. an active plan. PTSD is caused by the traumatic stressor. Epidemiology. medical. major depression. Suicidality: Passive ideation to end suffering. substance-related disorders. dysthymia. The patient is able to stop him self from hurting other people. borderline personality disorder. post-con cussion syndrome. The patient may overemphasize the extent of the symptoms. Insight: Good. or terrorism. over-the counter.” “nervous.Family history: Psychiatric illness or history of trauma in first-degree family members. Diagnosis: Axis I: Posttraumatic stress disorder and acute stress disorder.” Affect: Irritable. Clinical features of PTSD follow three . Thought process: Linear and goal-directed. and chronic medical illness. rhythm is typically normal. factitious disorder. urine pregnancy test. Reliability: Fair.” hypervigilant. and blood alcohol level. Mental Status Exam General appearance: Restless. However. Medications: All psychiatric. But patient may have non specific homicidal ideation towards those per ceived to be responsible for the trauma (eg. Thought content: Ruminations of guilt. III. Perceptual: Olfactory or other hallucinations reminiscent of event. biological and psychosocial factors also contribute because only a minority of people who experience trauma develop PTSD. Posttraumatic Stress DisorderDiscussion I.
and concentrating. and cyproheptadine may specifically reduce nightmares. The onset of PTSD symptoms may occur at any time following the traumatic event. Clonidine may be an effective adjunctive treatment to reduce sympathetic arousal. amnesia. and impaired concentra tion. continuous alcohol abuse can cause dementia. recent memory. Clonidine. Treatment A. see page 92. but imipramine and amitriptyline have also been used. Rule out delirium by assessing causative precipitants. Ask questions about memory loss. Cognitive Impairment . level of conscious ness. and perceptual disturbance. irritability. Acute stress disorder is diagnosed when symptoms begin within four weeks of the event and last less than four weeks. Patients with PTSD may require inpatient hospitalization for stabilization in cases of suicidal risk or if functioning has become severely impaired. and cognitive therapy. assess gradual or stepwise decline. symptom acuity. Ask about word finding difficulties. naming objects. avoiding stimuli associ ated wi th the traumatic event. Language distur bance (aphasia). anger. Dissociative symptoms may also occur. Substance abuse history: Alcohol intoxication and withdrawal may cause cognitive impairment. avoidant behavior.major symptom patterns: re-experiencing the event. exaggerated startle response. motor activity (apraxia).History Taking History of present illness: Begin with questions about current symptoms and duration. and attention. Ask about diurnal variation of symptoms (sundowning). and increased arousal. delusional thinking. planning. Long-term management is usually achieved with selective-serotonin reuptake inhibitors. Determine acute or gradual onset of symptoms. C. memory for time. and executive functioning should be assessed in addition to memory loss (amne sia). domestic chores). recognizing faces. Pharmacotherapy includes the use of sedatives and hypnotics for the acute symp toms of anxiety and sleep disturbance. Patients may experience amnesia or feel as though they have stepped outside of their bodies and exist in a state of unreality. person. tricyclic antidepressants. and a history of transient cognitive impairments associ ated with medical illness or surgery. activities of daily living (eg. Nightmares and flashbacks are common symptoms that are typically accom panied by anxiety. . recogni tion (agnosia). Past psychiatric history: Clarify a history of depressive symptoms to consider pseudodementia. References. tying shoes. psychotic symptoms in the past. impulsivity. place. agitation. and psychotic symptoms. Psychosocial treatment involves encour aging the patient to discuss the details revolving around the event. Long-term. and remote memory. apathy. B. hypervigilance. wandering. If cognitive impairment is worsening. Ask about previous amnestic episodes. depressed mood. dressing. B. organizing. III. A focus on facilitating improved coping mechanisms and behavior therapy with relaxation training may also be helpful. insomnia. supportive therapy. C.
Patients have aggres sive outbursts with difficulty controlling anger. and amnesia. inattentive. tangential. Huntington’s disease. alternative treat ments. and volume in general. Ask about risk factors associated with m u l t i -i nfa r c t d e m e n t i a : h yp e r t e n s i o n . Social history: Ask about housing. and renal disease (uremia). Toxic levels of medications can cause delirium (eg. withdrawal symptoms. poorly related. antipsychotics. but possibly dysarthric if associated with cerebrovascular disease. seizures. Speech: Normal rate. atrial fibrillation. irritable. . anticonvulsants. hypnotics). Registration and recall may be impaired. and labile with inter mittent hostility. limited eye contact. demyelinating disorders. Family members and care givers should be interviewed for information. and HIV testing. Homicidality: May occur in association with paranoia. and the assistance of a home-health aide. chemis try. On the clock-drawing task. patients may bunch numbers together. disinhibition. angry and uncooperative. and hypercoagulable states. income. systemic lupus erythematosus. Sensorium/cognition: Non-delirious. hyperlipidemia. Suicidality: Varies with level of self-awareness and presence of psychosis or affective symptoms. and blackouts (anterograde amnesia). such as people stealing from the patient or impersonating family members. and safety in the home. and anticonvulsants. Perceptual: Auditory. diabetes. steroids. liver disease (hepatic encephalopathy). nursing home care. Medications: Obtain details of medications with dosages and duration of treatment. sedatives. Family history: Alzheimer’s disease. Medications that can cause symptoms of dementia include anticholinergics. toxicology screen. children.Ask about extent of use. concentration is impaired. urinalysis. Ask about over-the-counter medications. cardiovascular disease. and confabulation. shakes. Mood: “Fine. rhythm. marital status. difficulty following train of thought. Patients are socially inap propriate and potentially disinhibited. and command hallucinations are possible. and confused. vitamin B12 and folate levels. smoking. thyroid function tests. thiamine level. Assess extent of family sup port. and apraxia affects ability to follow commands. Thought process: Illogical. antihypertensives. delirium tremens. visual.” “depressed. obesity. supervised living. Reliability: Impaired. and patients tend to minimize symptoms. Mental Status Exam General appearance: Disheveled. The mini mental state score will be less than 24 in de mented patients. head trauma. antihypertensives. and dietary supplements. or indicate the time incorrectly. word finding difficulties are common. and Parkinson’s disease have a pattern of familial inheritance and may be associated with symptoms of dementia. skip num bers. demented patients should be alert. Insight: Insight is characteristically absent. perseverative at times. Laboratory data: Complete blood count. homocysteine level. anticholinergics. Impulse control: Limited.” Affect: Dysphoric. CNS infection. RPR. Thought content: Paranoid delusions. but may not be oriented to place or time. Past medical history: Assess history of cerebrovascular disease. Benzodiazepines can mimic or exacerbate symptoms of dementia by causing confusion. Judgment: Impaired.
They may fail to recognize objects or family members (agnosia). Hunting ton’s disease. B. amnesia. Pick’s disease. Weschler memory scale.Discussion I. Wisconsin Card Sorting Test (executive function). Alzheimer’s disease is respon sible for approximately half of all cases of cognitive impairment in the elderly. vascular demen tia. and normal aging. magnetic resonance imaging. Dementia . Trail Making A and B (cogni tive processing speed). II. Patients with un derlying dementia and the elderly are at the greatest risk of developing delirium. or apathetic behavior. sarcas tic. and Huntington’s disease. schizo phrenia. Patients with Alzheimer’s dementia typically demonstrate a gradual. such as Lewy Body disease. Pick’s disease. C. Diagnosis: Axis I: Delirium. vitamin B12 and folate deficiency. Alzheimer’s disease is a result of neuropathological changes that include amyloid protein deposition. and have difficulties with everyday tasks. uremia. C. depression. Vascular dementia is caused by multiple infarctions due to atherosclerotic plaques and thromboemboli occluding cerebral vessels. CNS infection. traumatic brain injuries. HIV-related dementia. and planning and organizational abilities are often impaired (executive functioning). hydrocephalus. digit span test (attention and recall). hyperthyroidism. hepatic encephalopathy. Halstead Battery Category Test (abstraction). However. computed tomography. hypercalcemia. Demen tia affects up to 50 percent of the population over age 85. Lewy Body dis ease. Alzheimer’s disease is more likely than with other causes of dementia to cause personal ity changes and aggressive. Etiology A. Weschler Adult Intelligence Scale. the primary task is to rule out delirium and reversible causes of dementia. D. Wilson’s disease. Epidemiology. Parkinson’s disease. should be considered in the differential diagnosis.Diagnostic testing: Chest x-ray. Language disturbance can cause word-finding difficulties (aphasia). III. Medical: Alzheimer’s disease. Differential Diagnosis: Psychiatric: Amnesia. depres sion (pseudodementia). dementias. Patients may wander in their neighborhood. mania. Hachinski ischemia score. irritable. B. Vascular dementia shows a more stepwise decline in functioning where each infarct causes abrupt impairment. Parkinson’s disease. Boston Naming Test (language).Clinical evaluation A. In evaluating a patient with cognitive impair ment. such as dressing or tying shoelaces (apraxia). dementia. Delirium is associated with medical illness and surgical procedures. progressive decline in cognitive functioning. and Delirium Rating Scale. demyelinating disorders. The onset and progression of cognitive decline provide important clues to the diagnosis. Approximately 40 percent of all patients have a family history of the disease. pace around their house. cerebral neoplasm. heavy metal poisoning. Vascular dementia causes 15 to 20 percent cases of cognitive impairment in the elderly. The hallmark of dementia is memory loss (amnesia). Delirium causes . Alzheimer’s and vascular dementia together account for the vast majority of dementia cases.
psychotic symptoms in the past. anger). and language distur bance. see page 92. and behav ior (eg. B. catatonia. nightmares. extent of family support.a sudden onset of mental status changes with altered level of consciousness and a rapidly fluctuating course. causative precipitants. agitation). Ask about abnormalities of mood (eg. . and agitated be havior associated with dementia. and hyperthermia. flushing. although the symptom presentation is similar to dementia. Delirium . and reduced clarity of awareness of the environment. Substance abuse history: Alcohol intoxication and withdrawal may cause cognitive impairment. and depression. vomiting. diabetes. Delirium requires treatment of the underlying etiology. Alzheimer’s disease is treated with cholinesterase inhibitors for symptomatic improvement and to possibly slow cognitive decline. insomnia. and a history of transient cognitive impair ments associated with medical illness or surgery. amnesia. Family history: Ask about family history of psy chiatric illness and dementia. Atypical antipsychotics are used to treat delusions. Ask about sleep disturbance. fluctuating levels of conscious ness. hallucinations. reversal of the sleep-wake cycle. delirium. Ask about current symptoms. daytime drowsiness. visual hallucinations). such as hyperactivity with increased startle response. sundowning). tachycardia. nau sea. declining health. hypnopompic and hypnagogic halluci nations. E. Assess psychomotor distur bance. ability to sustain attention. arousability. or incoherent speech. D. Delirium does not occur more frequently among family members unless the underlying etiology is heritable. disorientation. nature of onset. and dura tion. and exacerbation of symptoms at night (ie.History Taking History of present illness: Assess impaired consciousness. Vascular dementia is treated by reducing risk factors. delirium develops over a short period of time and symptoms fluctuate over the course of the day. Past psychiatric history: Ask about previous delirious episodes. hyperlipidemia. Social history: Ask about housing. marital status. Ask about all substances used. C. such as. ability to focus. smoking. and chil dren. changes in the flow of speech. References. such as hypertension. Alcohol depend ence increases the risk of developing delirium. sweating. and obesity. Treatment A. Language disturbance may include rambling. and psychotic symptoms. employment. Hypoactivity may manifest with slowed reaction time. IV. perception (eg. memory impairment. and history of withdrawal symptoms. Supportive psychotherapy may help pa tients and their families to cope with the stress associated with loss of autonomy. extent of use. Assess cognitive changes. Agitated behavior is the most common reason for admission for patients with de mentia or delirium. and impaired cognitive functioning.
Perceptual: Auditory and visual hallucinations are most common in delirium. Reliability: Limited. heavy metal poison i n g . Mental Status Exam General appearance: Inattentive. and dissociative disor ders. Table 6. chest x-ray. serum medication levels.Past medical history: Assess history of seizure disorder. limited eye contact. confused. neoplasm. Thought process: Tangential. folate). or trauma. substance intoxication or withdrawal. disoriented. mania. and delirium not otherwise specified Differential Diagnosis Psychiatric: Dementia. vita min B12. RPR. antipsychotics. and labile. antihypertensives. and sedatives can cause delir ium. Impaired memory and concentration. Ask about over-the-counter medication and alternative treatments. antihypertensives. and folate levels. toxicology screen. liver disease (hepatic encephalopathy). thiamine. Judgment: Impaired. vascular disease. B12. and electrolyte imbalance. computed tomography. and renal disease (uremia). substance intoxication delirium. poor attention and limited problem-solving abilities. Medical: Epilepsy. Laboratory data: Complete blood count. with dosages and duration of treatment. Patients may be inappropri ate and disinhibited. rhythm. depression. Sensorium/cognition: Not alert. lithium. or irrelevant speech. Suicidality: Varies according to the presence of psychosis and affective symptoms. anticonvulsants. Delirium vs. Homicidality: May occur in association with paranoia. thiamine. vitamin deficiencies (eg. delirium due to multiple etiologies. Toxic levels of anticholinergics. antipsychotics. Thought content: Paranoid delusions without systematized content. h e p a t i c encephalopathy. schizophrenia. Speech: Normal rate. Attention and thinking are typically too impaired to give a reliable history. Medications: Obtain details of medications. irritable. and Delirium Rating Scale. Impulse control: Limited. with fluctuating level of consciousness. hypoxia. Ask about cardiovascular disease. anticholinergics. carbon dioxide toxicity. and volume.” “afraid. anticonvulsants. head trauma. Insight: Fair. lithium. sedatives. HIV testing. chemis try. uremic encephalopathy. and lumbar puncture with CSF examination if indicated. medi cation toxicity (eg. Patients realize the nature of their symptoms. urinalysis. steroids). incoherent. infection.” Affect: Dysphoric. Patients may be ag gressive with difficulty controlling anger. e n d o c r i n e d ys f u n c t i o n . cardiac failure. Diagnosis: Axis I: Delirium due to a general medical condition. Dementia Delirium Clouding of conscious ness Dementia No changes in conscious ness . steroids. infection. brief psychotic disorder. blood and urine cultures if indicated. substance withdrawal delirium. Diagnostic testing: Electroencephalography. thyroid function tests. Mood: “Angry.
C. haloperidol) are used for psychotic symptoms. Up to one-third of patients on surgical wards. systemic disease (eg. B. and blood loss. In anticholinergic toxicity. D. High-potency antipsychotics with low anticholinergic side effects (eg. asterixis. The hallmark of delirium is clouding of consciousness accompanied by a reduced ability to sustain attention. and the reticular formation may be the primary neuroanatomical area. agitated behavior. tachycardia. alcohol dependence. Causes of postoperative delirium include pain. The most common causes of delirium are central nervous system disease. Maintaining an environment that minimizes stimulation may reduce agitation. Other risk factors include preexist ing brain damage. Delirium requires treatment of the underlying etiology. Acetylcholine has been hypothesized to be the major neurotransmitter involved in delir ium. pallor. Symptom severity may fluctuate over the course of the day. cardiac failure). fever. and malnutrition. Delirium should always be suspected in patients on medical or surgical wards with psychiatric symptoms that are new or abrupt in onset. nau sea.Clinical evaluation A. The presence of delirium increases mortal ity. Patients typically have impaired cognitive function with mem ory deficit and disorientation. Treatment A.Discussion I. References. Etiology A. tremor. Agitated behavior is the most common reason for admission or consultation in patients with delirium. electrolyte imbalance. II. ranging from severe impairment and disorganization to periods of lucidity. infection. B. Medi cating symptoms should usually be avoided. ataxia. and incontinence.Significant deficit attention Less attention deficit Gradual onset (weeks to years) Chronic duration Gradual worsening symptoms of Abrupt onset (hours to days) Transient duration Fluctuating severity symptom Delirium . C. or intensive care units expe rience delirium over the course of their hospital admission. B. or other accidents. Symptoms tend to develop abruptly over several hours and may last days to weeks. Perceptual and psychomotor disturbances also occur. IV. Suicidal Ideation . and vomiting. Neurological signs of delirium may include dysphasia. sweating. and substance or medication intoxication or withdrawal. B. see page 92. physostigmine may be used in repeated doses. recent surgery. Physical signs of delirium may include flushing. C. medical wards. III. Patients must be carefully monitored to avoid potential harm from falls. Epidemiology A. C. Patients with underlying dementia and the elderly are at the greatest risk of developing delirium. a history of delirium.History Taking .
mood lability. Ask about avail ability of lethal amounts of the substance abused and method of use. and assess evidence of plans for the future. Alcohol abuse and dependence is most commonly associated with suicide. Consider features of personality disorders in the assessment of suicidal ideation. treatments. substance abuse disorders. Distinguish between passive and active suicidal ideation in assessing intent by asking about specific plans. Epilepsy. cognitive disorders. Family history: A history of suicide in the family increases the risk for suicide. Always ask about the availability of weapons or medication to assess means. spouse. Social history: Ask about marital status. Huntington’s disease. marital conflict. anxiety. children. duration. and accidental overdose is a frequent cause of death in substance abusers. poor social support. feel ings of hopelessness. or reunion with a deceased loved one. Ask about anything the patient may feel they have to live for. dementia and AIDS are all associated with depression and increase the risk of suicide. such as a trip to see children. espe cially in the presence of comorbid psychiatric disorders.History of present illness: The interview should begin with questions about current symptoms. Past psychiatric history: Ask about all past psychiatric symptoms. social support. legal trouble. and other cluster B personality traits. and perceived consequences. Assess the lethality of the plan. substance abuse. Heroin dependence is also associated with increased rates of suicide. Suicide is more likely to occur in patients just recovering from suicidal depression or in the few weeks to months follow ing discharge from the hospital. and adjustment disorders. family conflict. borderline personality disorder. and psychosis. or work. organic mental disorders. living situation. or concern that hospitalization may interfere with an important event. such as. . and date of onset. Also ask about family history of psychiatric illness and treatment. and feelings of social isolation. diagnoses. means. the ability to resist suicidal impulses. cardiovascular disease. and loss of a loved one are significant risk factors for suicide. multiple sclerosis. Assess suicide potential by addressing intent. Suicide is most commonly associated with major depression. Divorce. Patients with a history of suicide attempts are at greater risk. plans. living alone. such as writing a will or giving away personal belongings. Ask about command auditory hallucinations. and what factors influence the degree of determination. financial trouble. such as financial benefit to the family. Evaluate concurrent depressive symptoms. or legal problems. and previous suicide attempts. illness in the family. Negative consequences of suicide such as emo tional pain to the family should be discussed. unstable relationships. such as poor impulse control. recent loss of a loved one. employ ment. schizophrenia. anxiety disorders. unsta ble self-esteem. antisocial personality disorder. interpersonal stress. Ask about recent life changes. Substance abuse history: Ask about all sub stances used. illness in the family. but also occurs with significantly increased rates in bipolar disorder. Past medical history: Comorbid medical illness increases the risk of suicide. Ask about the perceived consequences of suicide and evaluate the patient’s beliefs about a desirable outcome. Substance abuse can some times be perceived as a form of suicidal behavior. unemployment. and ask about any preparations made.
” “angry. with paucity of speech. porphyria. and cirrhosis. history of attempts via overdose. Women are more likely to attempt suicide. Impulse control: Variable.” “worthless” Affect: Constricted. adjustment disorder. The patient wishes to die but may not understand the significance of the underlying illness. cerebrovascular disease. chemis try. and tricyclic antide pressants. Medications: Ask about all medications.000 commit suicide. Mental Status Exam General appearance: Withdrawn.” “sad. and urine pregnancy test. slow. A history of poor impulse control increases the risk of suicide. Speech: Not spontaneous. Huntington’s disease. Judgment: Impaired. anorexia nervosa. panic and other anxiety disorders. One-third of people with schizophre nia will attempt suicide and an estimated 10 . Insight: Fair. Perform the mini-mental state exam in patients with suspected dementia or cognitive impairment related to depression. Axis II: Borderline and antisocial personality disorders. Approximately 12 peo ple per 100. Suicidal Ideation . congruent Thought process: Linear. B. and men are more likely to complete suicide. and approximately 15 percent of patients will eventually commit suicide. espe cially ones potentially lethal in overdose. schizophrenia and other psychotic disorders. anticonvulsants. reliability is crucial in assessing commitment to safety.” “hopeless. cirrhosis. such as barbiturates. and anorexia nervosa. dysphoric. soft. dementia. multiple sclerosis. alcohol and other substance abuse disorders. uncooperative. commit to safety). urinalysis with toxicology screen and blood alcohol level. Perceptual: Possible auditory hallucinations with commands to “just do it” or “end it. Reliability: Fair. Differential diagnosis: Axis I: Major depression. Suicide is most frequently associated with major depression. Suicide is the eighth-leading cause of death in the United States. Mood: “Depressed. the patient may be unable to commit to contacting someone if feeling suicidal. but may have in creased response latency.Other medical problems that occur with mood disorders also increase suicidal risk and include: Cushing’s disease. and porphyria. Axis III: Neoplastic disease. and rates among adolescents have increased signifi cantly in recent decades. bipolar I disorder. with poor eye-contact. The patient may not under stand how their behavior will affect family and friends. Thought content: Possible ruminations of guilt or obsessive thoughts about suicide methods.Discussion I. Laboratory data: Complete blood count. Homicidality: Denies Sensorium/cognition: Memory and concentration may be impaired. Cushing’s disease. Diagnostic testing: Testing should be done according to the differential diagnosis and de pending on symptom presentation. epilepsy. or he may be unable to agree not to hurt himself (ie. AIDS.” Suicidality: Positive ideation with plans to jump in front of traffic. Epidemiology A.
mental retardation. see page 92. such as localized. alcohol dependence. Consider timing of onset and whether amnesia has a self serving component. B. Suicidal ideation must be thoroughly as sessed in the mental status exam.percent will complete the act. References. Risk factors for suicide include depression. social responsibility. prior suicidal behavior. and degree of actual impairment (if any). or reunion with the dead. assess adherence to a known clinical picture. III. Other theories include ideas of self-punishment. Identify external incentives. Clinical evaluation A. Reduced central seroto nin is associated with suicidal behavior. A specific plan. Malingering . lack of social support. and previous suicide attempts should lower the threshold for inpatient admission. Suicide is associated with a combina tion of psychological and biological factors. In malingered cognitive disorders. recent divorce or loss of a loved one. Virtually all symptoms may be feigned. or generalized. Also consider issues of secondary gain. Underlying medical and psychiatric illness must be appropriately addressed. but amnesia. such as head injury. C. work. detail the nature of symp toms and onset. hopelessness. hospital admission for free room and board. medications (eg. methadone). with . and dissociative disorders. Malingerers are rarely able to feign thought process disturbance. B. In malingered mental retardation. unemployment. first exclude other possible causes of amnesia. assess for discrepancies between level of educational or work achievement and reported intellectual func tioning. or refuge from the police. such as financial gain. Patients attempting to malinger psychosis often claim abrupt onset. Feel ings of hopelessness are often a reliable predictor of suicide. duration. medical or psychiatric illness. Ask about the nature of amnesia. benzodiazepines. Patients should be questioned about their specific plans and availability of means. Assess degree of intentionality. Treatment A. such as avoidance of military duty. selective.History Taking History of present illness: Current symptoms. psychosis. Patients with malingering amnesia often have selective amnesia with oppor tune timing. or jail. effect on behavior. increased age (>45). In malingered amnesia. true psychosis. date of onset. degree of symptom exaggeration. IV. Suicidal ideation typically requires inpatient hospitalization unless patients can reliably commit to safety. assess for impaired social functioning. The majority of patients will reveal thoughts of suicide prior to at tempts. and distinguish between patterns of prior and current test performance. cognitive disorders. and thought process disturbance.Etiology. In malingered psychosis. alcohol abuse. and family history of suicide II. escape from suffering. such as perseveration. A previous history of attempts and a family history of suicide greatly increase risk. and posttraumatic stress symptoms are the most common. and typically are unaware of the social impairment that accompanies most cogni tive disorders. seizure disorders. depression. Freud believed that suicide represented aggres sion turned inward.
and consider the possibility that patients are drug-seeking. Trunk and extremities may show marked restlessness as compared to facial expression. unlike in true psychosis. Suicidality: Suicidal thoughts and plans are frequently reported in attempts to gain hospital admission. Social history: Ask about employment and source of income to assess possible issues of secondary gain. Malinger ing is more common in military and prison popula tions. People with substance depend ence may seek hospital admission by feigning psychiatric symptoms. and narcissistic personality traits. Medications: Ask about prescription. rather than intermittent. Past psychiatric history: Ask about past psychi atric diagnoses. malingerers may be eager to call attention to their symptoms. but may be uncoop erative or overly dramatic. and alternative medications. irritability. There is no evidence of familial patterns in malin gering. Behavior is not likely to be consistent with delusions. Speech: Slow to fast rate. but is rarely self-deprecating. Thought disorder is very difficult to imitate. Ask about a history of legal problems. Unlike true psychosis. Mental Status Exam General appearance: Calm. malingered hallucinations are often continuous. Substance abuse history: Ask about substances abused. histrionic. Family history: Ask about family history of psy chiatric illness. and malingerers often think that the more bizarre the delusion. are not associated with delusions. Homicidality: Homicidal ideation is also a fre quent presenting complaint. Malingerers may repeat questions to give themselves time to think of an answer and often say. substance abuse. . and malingerers may threaten homicide. ask about diurnal variation. and their behavior is not consistent with delusional content. and are vague in their content. Malingerers are more likely to have antisocial. Delusional content is more likely to be paranoid or grandiose. decreased libido. Mood: “Depressed. Thought process: Linear. the more likely they are to be believed. treatment. Patients also tend to think that the more bizarre their behavior. Malingerers are less likely to be aware of the more subtle symptoms of depression or that depressive withdrawal extends to social and recreational activities as well as work. In malingered depression. the more convincing they are. and suicidality. borderline. over-the counter. and anhedonia.” Thought content: Delusions may be claimed to have sudden onset. Patients report an inability to ignore the voices and do not have strategies to diminish them. or current warrants.symptoms that do not adhere to any known disor der. Volume also varies. Malingered mania may be accompanied by rapid speech that tires easily as the interview progresses. Past medical history: Ask about medical prob lems and rule-out the possibility that complaints may be related to an underlying medical illness. Perceptual: Unlike in true psychotic disorders. arrests. “I don’t know. and hospitalizations.” Affect: Congruent to reported mood. Malingerers may not know the subtle characteris tics of hallucinations beyond reporting “hearing voices” (see Table 7).
Epidemiology A. and neuropsychological testing as needed. Judgment: Fair. Reliability: Limited.Discussion I. Malingerers are likely to contradict themselves in their symptom reporting. magnetic resonance imaging. Etiology A. Laboratory data: Complete blood count. 2 + 2 =5). and Ganser’s syndrome. factitious disorder. concentration. The patient understands that symptoms are being intentionally produced. II. malingerers may give approximate answers to simple questions (eg. other somatoform disorders. Malingering is the intentional production of false or grossly exaggerated symptoms that is motivated by external incentives. The degree of impairment in judgment will vary on an individual basis. Malingered vs. Insight: Intact. Impulse control: Potentially impaired. attempts to challenge or confront the patient may be met with anger or threats. Table 7. and intellectual impairment are often feigned. B. and be tween ten and 20 percent among criminal defendants. urine toxicology screen. Adults with antisocial personality disorder and children with conduct disorder are more likely to lie about symptoms for external incentives. The other cluster B personality disorders are also more frequently associ ated with malingering. Diagnostic testing: Skull x-ray to rule out head trauma. Other tests may include a polygraph to assess physiological stress and the Minnesota Multiphasic Personality Inventory (MMPI) to detect inconsistent answers. . True Hallucinations Malingered Hallucinations Continuous Originating from inside the head Vague or inaudible content Not associated with delusional content Stilted language is common Unable to use strategies to diminish voices Voices persist throughout sleep Commands are always obeyed Visual hallucinations are common Visual hallucinations may be seen in black and white Visual hallucinations may change if eyes are open or closed True Hallucinations Intermittent Originating from outside the head Relatively clear and spe cific content Associated with delusional content Stilted language is rare Able to use strategies to diminish voices Sleep provides a respite from the voices Commands are rarely obeyed Visual hallucinations are rare Visual hallucinations are seen in color Visual ha llucinations rarely change if eyes are open or closed Malingering . chemis try. five percent in the military. Malingering is estimated to occur in approxi mately one percent of mental health pa tients.Sensorium/cognition: Memory. Diagnosis: Axis I: Malingering Differential diagnosis: Conversion disorder.
Because of its association with antisocial personality disorder. E. G. Comorbid psychiatric illness should be assessed and treated. Malingering is suspected when the clinical presentation is characterized by symptoms that are vague and overly dramatized and not consistent with known clinical conditions. IV. fidgeting. Clinical features A. Malingerers should not be admitted to the hospital unless true illness cannot be ruled out. and obtaining drugs. They should be approached with clinical neutrality and confronted only after careful assessment. Malingering should always be suspected whenever specific external incentives. Extending the duration of an interview may facilitate the diagnosis by exhausting the patient’s ability to malinger. are present. and lack of cooper ation during an interview may indicate malin gering. If malingering is confirmed. Management F. external incen tives should be addressed and alternate means of achievement explored. References. B. Restlessness. There may be a significant discrepancy between the rehearsed and calm facial expression of a malingerer as compared to their body movement and behavior. III. avoiding work.B. evading criminal prosecution. obtaining financial compensation. such as avoiding work or the military. Malingering has an understandable motive that can be identified only after true medical or psychiatric illness has been ruled out. . and the history may reveal past episodes of injury. D. Malingerers may experience difficulty suppressing correct answers to questions. Findings may appear consistent with self-inflicted injury. C. These patients often display a marked dis crepancy between claimed disability and objective findings. The most frequent reasons for malingering are avoiding military duty. some theories propose hypoarousability as a predisposing factor. see page 92.
Family history: Substance abuse and major depressive disorder occur with increased fre quency among first-degree relatives of patients with borderline personality disorder. dependency. Suspected antiso cial personality disorder should be assessed by asking about a history of conduct disorder symp toms beginning before age 15 and a history of attention-deficit/hyperactivity disorder. and dissociative symptoms. Evaluate for comorbid depressive symptoms and substance abuse or dependence. marijuana. anxiety disor ders. sedatives. and functional impairment. impulsivity. Substance abuse is frequently seen in patients with borderline and antisocial personality disor ders. incarceration. Antisocial traits may also be more likely to occur in family members of patients with antisocial personality disorder. . childhood history of illness. Antisocial personality disorder should be assessed by asking about impulsivity. and current medical problems. duration. and outpatient follow-up. hallucinogens. and substance abuse occur with increased frequency in patients with cluster B personality disorders. irritability. self-entitlement.Dramatic or Emotional Personality Disorders . If antisocial personality disorder is suspected. Substance abuse history: Alcohol.image. poor self. Past medical history: Perinatal complications. hostility. somatization disorder. deceitfulness. associated distress. impaired sense of identity. Current living situa tion. ask the patient if they feel calm or relieved following self-injurious behavior. hypnotics. Narcissistic personality disorder is suggested by a sense of self-impor tance. Histrionic personality disorder should be assessed by asking about need for attention and flirtatious and seductive behavior. arrogance. Borderline personality disorder should be as sessed by asking about interpersonal relation ships. sexual history. history of head trauma. treatments. self-esteem. date of onset. arrests. grandiosity. and exposure to substance abusing parents. disregard for the safety and rights of other people. heroin. diagnoses. such as derealization and depersonalization. a history of legal problems. psychosocial stressors. Past psychiatric history: Past hospitalizations. infection. and lack of remorse. anxi ety. mood swings. neglect. Medications: All prescription and over-the coun ter medications. self-mutila tion. brain damage. and current warrants should be assessed. employment. cocaine. amphetamines. Depression. rape. relationships. physical or sexual abuse. anger. and empathy. irritability. aggressive ness. depressed mood. Alcohol abuse in particular is associated with antisocial personality disorder. fear of being alone. and analgesics. and assessment of promiscuity. feelings of emptiness or abandonment. Social history: History of abandonment.History Taking History of present illness: Current symptoms. anxiolytics. History of suicide attempts or self-mutilation. suicidal ideation.
narcis sistic. alternates between slow and rapid rates. Diagnostic testing: Projective psychological testing. somatoform disorders. The most frequently encoun tered personality disorders on inpatient psychi atric units fall into the dramatic and emotional cluster. Insight: Limited.Mental Status Exam General appearance: Well-dressed. Perceptual: Patients may endorse auditory. histrionic. or vague suicidal ideation that is difficult to characterize. generalized anxiety disorder. seductive. irritable. good concentration. Suicidality: Passive (no plan). Thought process: Linear. Dramatic or Emotional Personality Disorders . Patients may also report the feeling of being outside their body (depersonalization). such as the Rorschach and the Thematic Apperception Test. Personality disorders are likely caused by an interaction between biological predisposition and environmental influence. Hamilton Rating Scale for Depression. Judgment: Limited. antisocial. visual. or command auditory hallucinations. histrionic. The mini mental state exam is usually normal. such as pain and dehydration. Sensorium/cognition: Alert and oriented. and narcissistic personality disorder. but thoughts may be much more explicit in antisocial personality disorder. well groomed. well-related. II. The cluster B personality disorders are borderline. Etiology. also called cluster B. but vague. urine toxicology screen. active (with a specific plan). RPR. Diagnosis: Axis II: Borderline. expansive.” “depressed. The patient does not recognize the nature of the illness and may relate symptoms to environmental stressors alone. Cluster B personality disorders are more com mon in women with the exception of antisocial personality disorder. Antisocial and borderline personality disorders . thyroid function tests. blood alcohol level. Goal-directed. Homicidality: Vague homicidal thoughts may occur in borderline personality disorder. Speech: Variable volume. adjustment disorder. the details of which are difficult to elicit. Epidemiology.” Affect: Labile. thinking is concrete. Reliability: Poor. major depressive disorder. intact memory. in colorful clothing. and antisocial personality disorders. exces sively ingratiating. Thought content: Patients may be preoccupied with somatic complaints and perceived medical problems. Mood: “Very bad. and posttraumatic stress disorder. and without signs of psychomotor retardation or agitation. dramatic. Laboratory data: Complete blood count. Differential diagnosis: Bipolar I and II disorders. and inappropri ate at times. but with appropriate fund of knowledge. Impulse control: Limited. particularly if they perceive that their symptoms are not being taken seriously.Discussion I. History is vague. Patients may attempt to hurt themselves during the course of the interview. and pregnancy test. chemis try. substance-in duced mood disorder. and the CAGE questionnaire are often positive. The patient does not under stand how behavior affects other people. and symptom reporting is inconsistent.
Narcissistic personality disorder patients appear extremely self-entitled with a grandi ose sense of importance. Psychopharmacologic treat ment of personality disorders is limited. Patients with personality disorders may require inpatient hospitalization for suicidality or severe impairment in function ing. but actually suffer from low self-esteem and are extremely sensitive to criticism. Personality disorders are diagnosed on Axis II. deviates from cultural standards. They are difficult to assess in the context of acute Axis I pathology. and volatile interpersonal relationships. and impulsivity. These patients had conduct disorder as a child. B.may demonstrate familial inheritance. Personality disorders are defined by a per vasive pattern of behavior that is persistent over time. Histrionic and borderline personality disorders are asso ciated with a history of physical or sexual abuse. D. C. Antisocial personality disorder patients are often manipulative. and have a lack of remorse about their behavior. see page 92. Treatment usually consists of long-term psychotherapy. deceitful. although antidepressants such as selective serotonin reuptake inhibitors may be used to treat comorbid depression. Patients may report that the pain of self mutilation serves to bring them back to reality during a state of identity diffusion or dissociation. They constantly require attention and may misinterpret superficial relationships as being more intimate than they are in reality. References. . B. but these disorders are usually very difficult to treat. poor impulse control. but express themselves in a dramatic fashion. IV. Histrionic personality disorder patients have shallow emotional responses. Borderline personality disorder patients exhibit a clinical tetrad of labile affect. C. III. anxiety. E. Dissociative phenomena of depersonaliza tion and derealization may occur and con tribute to feelings of identity confusion. and frequently have a history of vio lence and other criminal activity. unsta ble self-image. Mood stabilizers and antipsychotics are used for mood lability and behavioral control. Prognosis varies individually according to level of functioning and the presence of social support.Treatment A. Clinical evaluation A. and causes significant distress or functional impairment to the patient. F. and clinicians tend to defer their diagnosis until acute issues have resolved. Narcissistic patients are preoccupied with selfish pursuits and may be unrealistically ambitious.
with poor eye contact. outpatient treatment and medications. or home. Family history: Psychiatric. developmental milestones. duration. seizures. . school. attention deficit. compulsive behavior. such as hand wringing. pervasive developmental disorders. hyperactivity. Past psychiatric history: Previous hospitaliza tions. neonatal anemia. rocking in place. and impaired social interaction may occur more frequently in family members. fragile X syndrome. poor impulse control. social interaction. Assess language development. tuberous sclerosis. babbling. Recent stressors. but screening questions should be asked. Mental Status Exam General appearance: Inattentive.Developmental Delay . Mental retardation. uncooperative. such as rocking and spinning. affective lability. current living situation. and apraxic gait in females may suggest Rett’s disorder. Social history: Family relationships. specific trauma or stressors. Homicidality: Denies. and neurological lesions all occur with greater fre quency in children with developmental disorders. peculiar rhythms. temper tantrums. depressed or irritable mood. Mood: Apathetic. and developmental disorders in relatives. and grimacing. Thought content: No delusions present. Affect: Constricted. Speech: Possibly incomprehensible. motor and vocal tics). low frustration toler ance. stereotypic behaviors. moving.History Taking History of present illness: Ask about current symptoms. Developmental history: Perinatal history. and rigid adherence to specific routines. with echolalia and perseveration. and non-spontane ous. and self-injurious behavior (eg. easily irritable. shallow. hand wringing. past diagnoses. delayed language develop ment. Perceptual: The presence of hallucinations should raise suspicion of childhood onset schizo phrenia. congenital rubella. and recent stressors or changes in the patient’s life. Thought process: Possibly incoherent. and Tourette’s disorder (eg. Substance abuse history: Substance abuse is rare in young children. changing school. and social relationships at day care. school achievement. disengaged. Associated symptoms may include agitated behavior. age of onset. neurological. Motor incoordination. respiratory distress syndrome. recipro cal play. screeching. Ask specifically about comorbid obsessive-compulsive symptoms. Always consider accidental ingestion. phenylketonuria. and unpredictably labile. and special education. eye contact. exposure to marital conflict. learning disorders. not pervasive developmental disorders. scratching. Past medical history: Perinatal complications. and birth of a sibling. although self-injurious behavior may appear when the patient feels frustrated during the course of the examination. preoccupation with inanimate objects. Suicidality: The patient usually denies suicidal thoughts. hyperactivity. stereotypic movements. head banging). such as divorce of parents. biting. Medications: Prescribed medications and over the-counter.
commu nication disorders (eg. neuropsychological testing audiometry. with temper tantrums and self injurious behavior. and congenital deafness. learning disorders. and short attention span. Diagnosis: Axis I: Autistic disorder. chemis try. selective mutism. egocentricity. Interviewers must rely on family. Differential diagnosis: Mental retardation with behavioral symptoms. Judgment: Limited. and electroenceph alography. and Rett’s Disorder. Asperger’s disorder. Laboratory data: Complete blood count. and lead testing. screening for phenylketonuria and other inborn errors of metabolism. teachers. The patient becomes easily angered. Reliability: Limited. thyroid function tests. The patient lacks understand ing of behavior’s consequences and how it affects others. Cognitive abilities may be impaired by mental retardation. mixed receptive-expressive language disorder). Insight: Limited. . increased distractibility. childhood onset schizo phrenia. Autism Behavior Checklist. Vineland Adaptive Behavior Scale. urinalysis. concrete thinking. Impulse control: Limited. psychosocial deprivation. The patient does not understand the nature of his illness. such as head banging. childhood disintegrative disorder. Diagnostic testing: Autism Diagnostic Interview (ADI).Sensorium/cognition: Alert. Child hood Autism Rating Scale. chromosomal analysis. and other caregivers for informa tion. magnetic resonance imaging.
ataxia. reducing odd behavior. Audiometry should be per formed to rule out deafness. and they may become easily frustrated or anxious if ritualistic behaviors are interrupted. The etiology of autism is genetic in origin. irritability. perinatal complications. Autistic disorder is the most common and affects approximately 1. and compulsive. Inpatient hospitalization may be re quired for agitated or self-injurious behav ior. Rett’s disorder occurs only in girls. impaired social interaction. People with pervasive developmental disorders may require residential care with full-time supervision. It is typically diagnosed by the age of three. Epidemiology. and developing language. aggression. and affected children tend to suffer a chronic. such as metal. followed by a loss of acquired language. The most com mon initial feature is delayed language development. see page 92. B.7 out of 1000 children. . and stereotypic movement. Asperger’s Disorder is a less severe form of autism where language development remains intact. Antipsychotics may effec tively reduce agitation. Patients with Rett’s disorder eventually become wheelchair bound and lose all language ability. and one-third may develop a seizure disor der. IV. Selective serotonin reuptake inhibitors are used for impulsivity. such as apraxia. References. Childhood disintegrative disorder is characterized by normal development for two years. and self-injurious behavior. and mental retarda tion. Behavioral therapy and educational methods are focused on increasing social interaction. There is significant evidence linking autism to heritable neurological disorders. Improvement may occur over time.Pervasive Developmental Disorders . III. C. The four pervasive develop mental disorders are autistic disorder. D.Discussion I. and limited behavioral repertoire. lifelong course. Comorbid obsessive-compulsive symp toms are common in autistic disorder. B. C. Autistic disorder is characterized by the clinical triad of impaired language develop ment. II. E. Rett’s disorder. Approximately two-thirds of patients with autistic disorder have mental retardation. and Asperger’s disorder. ritualistic behavior. occurring more frequently in boys. impaired social interaction. Rett’s disorder is characterized by symptoms of autism in addition to progressive neurologi cal signs. and lim ited behavioral repertoire. Treatment A. Pa tients tend to become preoccupied with inanimate objects. Etiology. but with an unclear mode of transmis sion. Pharmacotherapy is useful for symptom atic management. Clinical evaluation A. childhood disintegrative disorder. Clonidine is used for hyperactivity.
adoption. divorce. school performance. dysphoric. and shouting.” Affect: Irritable. Mood: “Fine” or “depressed. such as persistent worry. phenobarbital. vocal tics. hyper activity. domestic violence. such as nausea and vomiting. Grade in school. Social history: Family relationships. poor eye-contact. . compul sions. Tic disorders occur with increased frequency in family members of children with ADHD. identifiable stressors. blinking. cocaine. forgetfulness. constant need for attention. but with some difficulty following a coherent train of thought due to problems concentrating and distractibility. Motor tics. date of onset. learning disorders. reluctance to attend school. heroin. Mental Status Exam General appearance: Restless. fear or dislike for school or social situations. difficulty sleeping away from home. and conduct disorder are all common comorbid conditions. antisocial personality disorder.History Taking History of present illness: Current symptoms. learning disorders. social relationships with peers. Ask about the presence of somatic symptoms. medication. irritability. such as substance abuse. cigarette smoke. fidgeting. home). obsessions. Medications: CNS stimulants. and sexual behavior. Thought content: No active delusional content. and impulsivity. speed. easily distracted. Family history: Psychiatric illness in family members. nightmares. antidepressants. raising eyebrows. Substance abuse history: Alcohol. Past medical history: Prenatal exposure to toxins. hyperthyroidism. but appropriate. irritability. and caffeine can cause symptoms of attention deficit and hyperac tivity. depressive symptoms. Low birth weight. seizure disorder. cocaine. pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). depres sion. alcohol. special education. duration. mumbling rhythm. unco operative. Speech: Decreased volume. anxiety. and emotional neglect. irritability. crank). theophylline. Ask about inattention. Obsessive-compulsive symptoms. physi cal abuse. marital conflict. Ask about anxiety symptoms. talking excessively. conduct disorder. history of mood lability. hypoxia. ecstasy. childhood lead expo sure. Ask about past hospitaliza tions. suicidal ideation. and cigarettes. distractibility. crystal meth. Assess symptoms of difficulty listening and following instructions. Determine in which environments symptoms occur (eg. and interrupting. ADHD. neck twisting. carbamazepine. sexual abuse. grunting. excessive fear of being alone. Perceptual: Denies hallucinations or illusions. Thought process: Linear and goal-directed. school. hallucinogens. amphetamines (eg. and violence. bipolar disorder. Tourette’s disorder. may express frustration. lead. marijuana. Assess the presence of depression.Attention-Deficit and Hyperactivity . Past psychiatric history: Previous psychiatric diagnoses. and panic. and head trauma. benzodiazepines. fidgeting. divalproex. and outpatient psychiatric treatment. increased rate. phobias. belching.
and Wilson’s disease. sub stance abuse. ADHD is usu ally diagnosed by five years of age. such as at school and at home. chemis try. Medical: Hyperthyroidism. Etiology. thyroid function test. and because the psychostimulants used to treat ADHD may . zinc protoporphyrin (ZPP) to detect lead exposure. carbamazepine. Symptoms must also occur in at least two settings. amphetamines. and Achenbach Child Behavior Checklist. Impulse control: Patients may get up frequently during the interview and even walk away. Reliability: Limited. learning disorders. cocaine. oppositional defiant disorder. substance-induced (eg.Discussion I. Other psychiatric disorders that are easily mistaken for ADHD include conduct disor der. Tourette’s disorder. Homicidality: Denies homicidal ideation. and prevalence estimates range from 3 to 10 percent of school-age children. malnutrition. and bipolar disorder. Conners Hyperactivity Scale. Recent attention has been focused on the specific roles of dopa mine. These disorders must first be excluded because treatment varies dramatically. lead poisoning. barbitu rates. Sensorium/cognition: Alert and oriented. Tourette’s disorder. Neurological: Seizure disorder. serotonin. but both genetic and environmental influences have contributing roles.Suicidality: No active suicidal ideation. impaired concentration. learning disorders. no apparent language deficits. streptococcal infection. due to young age. physical or sexual abuse. brain damage. motor compul sions associated with obsessive-compulsive disorder. theophylline. Clinical evaluation A. B. Attention-Deficit/Hyperactivity Disorder . bipolar disorder. posttraumatic stress disorder. Diagnostic testing: Neuropsychological testing. Differential Diagnosis Psychiatric: Conduct Disorder. glutamate. Insight: Limited. and symptoms must occur before the age of seven. Thinking may be concrete. Patient inconsistently reports symptoms. caffeine). The diagnosis of ADHD requires at least six symptoms of inattention and/or hyperac tivity for at least six months. intact memory. and cigarettes. Age appropriate. GABA. lead. Laboratory data: Complete blood count. Epidemiology. benzodiazepines. Diagnosis: Axis I: Attention Deficit/Hyperactivity Disorder. and norepinephrine. Judgment: Fair. III. and normal oppositional behavior. Attention-deficit/hyperactivity disorder (ADHD) is a common illness that accounts for up to half of child psychiatry outpatient visits and inpatient hospitalizations. and central nervous system infection. major depression. II. and urine toxicology screen. This disorder occurs more frequently in boys than girls. mental retarda tion. teratogenic effects of alcohol. normal hyper activity. separation anxiety disorder. oppositional defiant disorder. pseudoephedrine. major depression. The etiology of ADHD is unclear. anxiety disorders. pregnancy test.
performance. destruction of property. depression. and schizophrenia all occur with greater frequency in family members of children with conduct disorder. psychosocial stressors. hostility. and allergies. substance abuse. and fire setting. ADHD. heroin. communication disorders. learning disorders. Inpatient admission may be required for agitated or aggressive behavior. bipolar disorder. Social history: Family relationships. C. and school truancy. developmental disorders. and blaming others for misbehavior. rule violations. conduct disorder. weapon use. barbiturates. Ask about comorbid psychotic symptoms. School level. stealing. Ask about alcohol use. Ask about alcohol and other substance abuse in family members. marijuana. Medications: Include all psychiatric. adoption. Aggression towards people. learning disorders. panic attacks. Assess symptoms of depres sion and mania to rule out a comorbid mood disorder. and neglect. ignoring parental curfews. and outpatient psychiatric treatment. Past medical history: Perinatal complications. B. general. and non-prescription medications. Theft. foster care. References. lying. and antipsychotics to target aggressive symp toms. cocaine. income. depressive or manic episodes. domestic violence. such as auditory hallucinations or paranoid delusions. Treatment of ADHD consists of psychostimulants for inattention. Family history: Antisocial personality disorder. fighting. Neuropsychological testing is often required to rule out an underlying learning disorder. head trauma. running away from home.History Taking History of present illness: Current symptoms. frequent arguing. . sexual assault. past hospitalizations. and mental retardation may all occur with increased frequency in patients with conduct disorder or oppositional defiant disorder. see page 92. clonidine for hyperactivity. and juvenile detention. Past psychiatric history: Previous psychiatric diagnoses. selective-serotonin reuptake inhibitors for impulsivity. hyperactivity. duration. divorce. Attention deficit. caretakers. and pain medication. Substance abuse history: Substance abuse is frequently seen with Conduct Disorder. Psychosocial therapies include individual psychotherapy and behavior modification techniques that help the child to reduce anxiety and improve self-esteem.Treatment A. attendance. medications. General defiance of authority figures. cheating. past illness. impulse control problems. amphet amines. legal history. Disruptive Behavior .significantly exacerbate symptoms of other disorders. temper tantrums. seizures. physical or sexual abuse. Family members. date of onset. arrests. IV. incarceration. school person nel and pediatricians should be interviewed. phobias. bullying. and special education. Gang involvement.
electroencephalography. The patient minimizes symp toms and lies about past behavior. Perceptual: Hallucinations are unlikely. may occur in severe cases. Differential diagnosis: Bipolar disorder. Thought process: Linear and goal-directed. and urine toxicology screen. learning disorders. B. The patient may demonstrate destructive or threatening behavior. II. these . Mood: “Fine. and poorly related.Discussion I. but may also occur as a pathological entity and possible precursor to conduct disorder. Laboratory data: Complete blood count. It is estimated to be present in more than half of all juvenile delinquents and incarcerated youth. and normal oppositional behavior. such as paranoid ideation. Sensorium/cognition: Alert and oriented. Biopsychosocial factors play a signifi cant causative role in conduct disorder. or attention defi cit/hyperactivity disorder. hostile. but congruent and full range. rhythm.” Affect: Dysphoric. and the Achenbach Child Behavior Checklist. Diagnostic testing: Neuropsychological testing. ADHD. The hallmark characteristic of conduct disorder is disruptive behavior that violates the rights of others and persists for at least 12 months.Mental Status Exam General appearance: Suspicious.” or “angry. major depression. mental retardation. uncooperative. Conduct disorder is the most common reason for an inpatient hospitalization or outpatient visits in children and adolescents. Reliability: Limited.” “good. dysthymia. Thinking is concrete. The patient may be demeaning or challenging toward interviewer. Conduct disorder is more prevalent in boys. Insight: Limited. Clinical evaluation A. Epidemiology. irritable. learning disorders. and is not associated with legal problems. oppositional defiant disorder. but cognitive abilities may be impaired by mental retardation. The patient lacks understand ing of how his behavior affects others. Conduct disorder greatly increases the risk of developing antiso cial personality disorder. Aggres sive and violent behavior in general may be associated with decreased serotonin metabolite (5-HIAA) in cerebrospinal fluid. Conduct Disorder . Suicidality: No active suicidal ideation elicited. Impulse control: Impaired. Judgment: Limited. The patient may deny all symp toms and not recognize the presence of a prob lem. Oppositional defiant disorder is a less severe form of conduct disorder defined as a recurrent pattern of defiant and hostile behavior towards authority figures. substance-induced behavioral symptoms. and volume. Diagnosis: Axis I: Conduct disorder. Homicidality: Denies homicidal ideation and may be flippant or dismissive when questioned about violence history. chemis try. Thought content: Delusional thinking. thyroid function tests. While there is clear genetic transmission of aggressive and violent tendencies. In oppositional defiant disorder. Etiology. and it is usually diagnosed before 13 years old. III. Oppositional behavior may be normal and adaptive. Speech: Normal rate. impulse control disorders. pregnancy test. behavior does not violate the rights of others.
and outpatient treatment. such as fear of contamination. and obsessive-compulsive disorder are more . and marijuana. food rituals. and sexual maturity. and need for control. Amenorrhea. duration. B.Treatment for disruptive behavior re volves around firm limit-setting and estab lishing predictable consequences for breaking rules. the possibility of psychotic symp toms must also be assessed. anxiolytics. school achievement. Treatment A. ipecac. enemas. diuretics. clinical depres sion. anxiety symptoms. heroin. dental caries. domestic conflict. Social history: Family relationships. Ask the patient about their perception of body weight and self image. divorce. Previous episodes of binge-eating or purging behavior. bulimia. stealing. C. see page 92. medications. and laxatives. Ask about medications. history of depres sion. References. hypnotics. previous weight loss episodes. Substance abuse history: Amphetamines. C. obsessive-compulsive behavior. including family members and peers. suicide attempts. sexual promiscuity. Impulse control problems. Formal psychiatric evaluation and clearance may also be required before the child is allowed to return to school. stealing. analgesics. past suicide attempts. checking. or substance abuse among family members. mood lability. precipitants. and recent dieting. suicidality. cocaine. Assess comorbid obsessive-compulsive symp toms. abuse. preoccupation with food. enemas. abuse of laxatives. and perceived societal pressure to be thin. appetite suppressants. or clonidine are used for aggression. separation from parents.Psychotherapy with behavioral training is effective at reducing impulsive and ag gressive behavior. date of onset. IV. and impulse control problems.History Taking History of present illness: Ask questions about current symptoms. parenting styles. diuretics. school truancy. peer relationships. and actual weight loss. and parents should be taught techniques to facilitate appropriate behav ior. The family must be in volved. Attempt to gauge degree of independence. binge-eating behavior. Early symptoms of bipolar disorder may be initially misdiagnosed as conduct disor der. and excessive exercise.behaviors usually occur in the context of strict or punitive parenting styles. somatic complaints. Past psychiatric history: Past hospitalizations. Eating Disorders . dieting. poverty. Antipsychotics. gastrointestinal distress. and sleep disturbance. vomiting or purging. mood stabilizers. self-mutilation. Ask about depressive symptoms. and substance abuse. perfectionism.Inpatient hospitalization becomes neces sary if patients pose a danger to them selves or other people. alcohol. Selective serotonin reuptake inhibitors may be effective for impulsivity and irritability. In severely violent cases of conduct disorder. such as sedatives. fear of weight gain. Family history: Anorexia.
and electrocardiography. Speech: Normal rate. Epidemiology. dexamethasone-suppression test. Patients are often extremely secretive and do not fully disclose extent of symp toms. amylase. Past medical history: Ask about a history of malignancy. somatization disorder. and suicidal ideation must be thoroughly assessed. cardiomyopathy secondary to ipecac toxicity. and dental caries. thyroid function tests. cholesterol. fearful of gaining weight. evasive. with intact memory and concentration. Diagnosis: Axis I: Anorexia nervosa and bulimia nervosa. carotene level. Assess medical complications related to weight loss and purging activity. Diagnostic testing: Height and weight measure ment. and dismissive or minimizing of serious symptoms. unconcerned. Thought process: Linear and goal-directed. Sensorium/cognition: Cognition may be affected by weight loss. potentially hostile. anorexia and weight loss associated with medical illness or malignancy. although most patients are alert and oriented. obsessive-compulsive disorder. Binge-eating and purging behavior persists despite consequences. amenorrhea. Patients may deny all symptoms or the presence of a problem. Mental Status Exam General appearance: Cachectic. Klüver-Bucy syndrome. Medications: Ask about psychiatric. Laboratory data: Complete blood count. Anorexia Nervosa and Bulimia Nervosa . and child-like. over-the-counter. Kleine-Levin syndrome. liver function tests. edema. chemis try. Eating disorders typically first present during adolescence. Reliability: Limited. Language deficits or disturbance in abstract thinking are usually not present. Weight loss continues de spite medical complications. gastric and esophageal erosion.Discussion I.likely to occur in family members of patients with eating disorders. and volume. borderline personality disorder with binge eating. cardiac arrhythmias. orange colored skin. Differential diagnosis: Clinical depression. cold intolerance. pregnancy test. seizures. rhythm. osteoporosis. inappropriate at times. dysphoric. obsessional or bizarre thinking revolving around food. patients may be convinced that they are overweight despite significant weight loss. body dysmorphic disorder. with lanugo hair. salivary gland enlargement. Impulse control: Limited. Mood: “Fine. and alternative medications.” Affect: Irritable. Judgment: Limited. Thought content: Preoccupied about body weight and image. medical. Perceptual: No auditory or visual hallucinations. Insight: Limited. Homicidality: Denies. difficulty concentrating and fatigue. and urine toxicology screen. They occur more frequently in women and are associated with significant morbidity and mortality secondary to . psychotic disor ders with delusional thinking revolving around food. Suicidality: Suicide occurs more frequently in patients with eating disorders. uncooperative.
circumstances of use. hallucinations. Etiology. C. D. References. see page 92. work. route of administration. substance-related legal problems.History Taking History of present illness: The date of first and last use of the substance should be defined. vomiting. Patients with eating disorders have dis turbed eating behavior. and insomnia. hypnotic.After medical stabilization and restora tion of nutritional status.Cognitive behavioral therapy is effective in the treatment of eating disorders. and insomnia. muscle aches. irritabil ity. Sedative. bulimia nervosa may respond to antidepressant treatment even in the absence of depressive symp toms. and lack of menstruation for at least three consecutive cycles. amount of substance used. insomnia. II. dehy dration. agitation. yawning. Anorexia nervosa is characterized by refusal to maintain body weight above 85 percent of ideal. and seizures. becoming Annoyed by people who criticize the alcohol use . weekly. dysphoria. ask about dysphoria. nausea. B. Guilt about drinking. For cocaine withdrawal. In anorexia. Barbiturate abuse . ask about shakes. lacrimation. nausea. rhinorrhea. triggers. If substance dependence is suspected. and anxiolytic withdrawal may include tremors. ask about the need for increasing amounts of the substance to produce intoxication (tolerance) and withdrawal symptoms. For opioid withdrawal. Clinical evaluation A. In bulimia. cardiac arrhythmias. and a distorted body image. C. Longest period of sobriety. Determine the frequency and patterns of use.medical complications from weight loss and purging activity. Substance Use . IV. monthly. Failure to fulfill obligations at home. anxiety. ask about anxiety. Patients with bulimia nervosa binge eat and experience a loss of control over eating behavior. vomiting. Al though anorexia nervosa is typically resis tant to pharmacotherapy. patients have a dis torted body image and are frequently respond ing to societal pressures to be thin.Hospitalization may be required in pa tients with eating disorders for medical stabilization of electrolyte imbalance. driving). seizures. excessive concern about body weight. Treatment A. B. The history should assess the full extent of symptoms despite the tendency for these patients to remain extremely secretive about their eating behavior. The onset of anorexia or bulimia may be the result of difficulty adjusting to develop mental changes of puberty and adolescence. and orientation. and Eye openers to steady nerves in the morning (CAGE questionnaire). starvation may be an effort by patients to control their bodies in response to overly controlling parents or the lack of a sense of autonomy. III. patients are typi cally treated with a combination of psycho therapy and pharmacotherapy. or school. For alcohol withdrawal. but maintain normal body weight. Screening for alcohol abuse should be accomplished by asking about feeling the need to Cut down. and psychosocial stressors. psychotic symptoms. daily. a preoccupation with food. or gastroin testinal complications. and substance use in situations that are danger ous (eg. diarrhea.
amphetamines. history of violence or criminal activ ity. hallucinogens.” Affect: Constricted to the dysphoric range. Past psychiatric history: Past history of sub stance abuse. dementia. Social history: Living situation. Speech: Slurred rhythm. medications. cardiomyopathy. peptic ulcer disease. and words are sometimes incomprehensible. restless with mild shaking of the hands. poor concentration. Assess physical signs of alcoholism. such as mood lability. cellulitis. hypertension. Mood: “Depressed. Substance abuse may also induce delirium. sexual dysfunction. gastritis. Sensorium/cognition: Inconstant alertness with variable degrees of orientation to place and time. nutritional deficien cies. employment. Patients may be dismissive of concerns about their drug use. anxiety. Complica tions from cocaine use. such as HIV. level of education. hepatitis. may appear older than stated age. Substance abuse history: Ask about all sub stances used: alcohol. and spider nevi. increased volume. Perceptual: Depending on the level of intoxication or extent of withdrawal. such as varices. but appropriate. hepatosplenomegaly. and breath may smell of alcohol. amnesia. ascites. so ideation and plans need to be assessed. and seizures. irritability. poorly groomed. . family history of suicide and psychiatric illness. Homicidality: Possible homicidal ideation with plans that vary in specificity. gives irrelevant answers to questions. impulsivity. Mental Status Exam of the Intoxicated Patient General appearance: Disheveled. anxiety disorders. Suicidality: Substance abuse increases suicidal risk. ag gressiveness. substance abuse treatment pro grams. cardiac arrhythmias. anxiety disorders. such as liver disease. cocaine. or osteomyelitis. Medication toxicity may mimic the symptoms of substance intoxication. antisocial personality disorder. and borderline personality disorder occur with increased frequency in people with substance abuse disorders. Family history: Alcohol and substance-related disorders in first-degree relatives. malodorous. such as ulceration of the nasal septum.should be carefully assessed because withdrawal is potentially fatal. anx ious. Thought process: Circumstantial. Complications from intravenous drug use. hospitalizations. and sleep disorders. Past medical history: Ask about medical compli cations from alcohol abuse. physical or sexual abuse history. normal rate. marijuana. and analgesics. psychosis. Medications: All medications including prescrip tion and over-the-counter. Question the patient and family members about behavioral changes. gait is ataxic. poor registration and recall. mood disorders. Suicide is more frequent in people with substance abuse disorders. Thought content: Paranoid ideation and ideas of reference occur. gynecomastia. Mood disorders. and neuropathy. A history of attention-defi cit/hyperactivity disorder and conduct disorder increases the risk of developing an alcohol-related disorder. patients may have audi tory. past psychi atric diagnoses and treatment. or tactile/olfactory hallucinations. heroin. benzo diazepines. Sub stance abuse increases the risk of violence to wards others. and impaired judgment. visual. pancreatitis.
or anxiolytic-related disorders. triglycerides. intoxication. and underlying comorbid psychiatric illness. Alcohol Abuse and Dependence . III. coagulability panel. and electrocardiogram. phencyclidine related disorders. hallucinogen-related disorders.related disorders. Substance abuse is defined as substance dependence when tolerance and withdrawal symptoms develop. Diagnosis: Axis I: Substance-related depend ence. Withdrawal is characterized by physiological symptoms that develop upon cessation of use. abuse. amy lase. they continue to use the substance in situations where it is physically dangerous. nicotine-related disor ders. and anxiety disorder. delirium. lipase. The initial signs of alcohol withdrawal are sweating and tachycardia. sexual dysfunction. withdrawal. sedative-. II. and polysubstance dependence. Differential Diagnosis: Alcohol-related disorders. liver function tests. Alcohol-related disorders are thought to result from a multiplicity of factors. inhalant-related disorders. Alcohol is the most commonly abused substance in the United States. Insight: Limited. Epidemiology. and urinalysis with toxicology screen. blood alcohol level. The patient does not recognize the substance abuse as a problem and relates difficulties to environmental stressors or “depres sion. There are frequent inconsisten cies in the patient’s story and symptom reporting. Tremors or “shakes. parent or peer influ ences. cocaine related disorders. Impulse control: When intoxicated. and cases of alcoholic demen tia may show scores less than 24. and dependence may develop in up to half of these cases. hypnotic-. chemis try. cholesterol. including biological predisposition. they have substance-related legal problems. Alcohol withdrawal delirium (delirium tremens) may present two to three days . psychotic disorder. Judgment: Impaired. Substance abusers are unable to fulfill work or personal obliga tions. Tolerance occurs when the user requires increasing amounts of the substance in order to become intoxicated. dementia. opioid-related disorders. C. amphetamine.” seizures. D. The clinical features of substance abuse are a maladaptive pattern of use that leads to significant impairment. Etiology. behavior may be aggressive and unpredictable. Diagnostic testing: CAGE Screening Question naire. Clinical evaluation A. caffeine-related disorders. Michigan Alcoholism Screening Test (MAST). B12 and folate level.Discussion I. and sleep disorder. There is often a lack of regard for how substance abuse affects family members and friends. Ap proximately 20 percent of men and 10 percent of women have abused alcohol at some point in their lifetime. Alcohol Use Disorders Identification Test (AUDIT). cannabis-related disorders. Laboratory data: Complete blood count. mood disorder.” Reliability: Poor. B. and auditory and tactile hallucinations (formication) may also occur within the first 48 hours of alcohol cessation. and continue to use despite resultant inter personal problems. chest x-ray.The patient may refuse to cooperate with a mini mental state exam. amnestic disorder.
Past psychiatric history: Past psychiatric diag noses. and perceived bodily changes like enlarged extremities. Inpatient admission is also considered when outpatient detoxification has failed. Benzodiazepines are used for withdrawal prophylaxis and acute management of seizures. bipolar disorder. Ask about comorbid symptoms of depression and anxiety. marijuana. E. and histrionic personality disorder. .after cessation. Patients with acute alcohol intoxication may require inpatient admission to prevent the development of seizures and delirium tremens. borderline personality disorder. memory loss for specific intervals of time. IV. or for personal infor mation. benzodiazepines. ask specifically about alcohol. Consider whether amnestic events are of a stressful or traumatic nature. accumulating posses sions without remembering how they were ac quired. Dissociative Amnesia is assessed by asking about episodic memory loss.Treatment A. or to treat psychotic symptoms. Dissociative symptoms can appear in schizophre nia. B. panic disorder. monitor suicidality. persistent failed ef forts to cut down. Depersonalization Disorder is assessed by asking about feeling unreal. ask about memory loss for childhood events. obsessive-compulsive disorder. but patients are at risk for up to one week. potential triggers. duration. flash backs. gradual onset of symptoms. Substance abuse history: Substance intoxica tion can cause dissociative symptoms. headaches. and associated distress. If Dissociative Identity Disorder is suspected. Long term inpatient rehabilitation and ongoing outpatient substance-abuse counseling are required to prevent relapse. date of onset. Delirium typically occurs only in people who have abused alcohol heavily for many years. blank spells. Somatoform Disorders. References. hallucinogens.History Taking History of present illness: Current symptoms. voices coming from inside. being recognized by people the patient does not know. Dissociative Fugue is assessed by asking about recent travel and identity confusion. Ask about losing time. looking at oneself from overhead or at a distance. Ask the patient if he has ever been told about out-of-character behavior. see page 92. hospitalizations. or if he has ever found himself in places without knowing how he arrived. Dissociation . to treat dehydration. ask about another person existing inside the patient. major depression. and spending an enor mous amount of time trying to obtain the substance. Patients are hydrated if necessary and thiamine is given to prevent the develop ment of Wernicke’s Encephalopathy. acute or post-traumatic stress disorder. being outside one’s body. or being called by a different name. Also in dissociative identity disorder. and barbiturates. forgetfulness. Other symptoms of substance dependence include taking larger amounts of a sub stance than intended. and treatments. and other people taking control of the patient. blackouts. memory gaps. C. sudden vs. therefore. A history of anxiety and depressive symptoms is a predisposing factor to developing a dissociative disorder. dizziness. perceptual clouding.
Perform a full mini-mental state exam in patients with amnesia to rule out demen tia. relatives seeing a psychiatrist. Medications: Medications. rhythm. Homicidality: Denies. and depersonalization disorder. Differential Diagnosis Psychiatric: Delirium. and volume. dissociative identity disorder.” Affect: Anxious. Laboratory data: Complete blood count. sexual abuse or other traumatic events.Social history: Family relationships. Thought process: Linear and goal-directed. Ask about legal history and possible motivations for secondary gain. Hypothyroidism and hypoglycemia can also cause depersonalization symptoms. Mental Status Exam General appearance: Patients may appear in distress. marital discord. Thought content: No delusional content elicited. somatization disorder. obsessive compulsive disorder. toxicology screen and blood alcohol level. such as derealization or depersonalization. Reality testing is characteristically intact. Insight: Limited. and the Dissociative Experience Scale. or they may be unaware of symptoms. including over-the counter and alternative treatments. Diagnosis: Axis I: Dissociative amnesia. Patients typically understand how behavior affects others and voluntarily seek treatment. clearly disturbed by the amnesia or dissociative experience. Impulse control: Impaired during times of ex treme stress. posttraumatic stress disor der. exposure to domestic violence. cogni tion is intact. Suicidality: Suicidal ideation is possible during times of extreme stress. but may experience dissociative symptoms. and migraine headaches can all cause dissociative symptoms. thyroid function tests. Doubling may also occur in which patients feel as though they are observing themselves from a distance. Sensorium/cognition: Alert and oriented. history of physical abuse. head trauma. chemis try. dementia. Family history: Psychiatric disorders in family members. dysphoric. Mood: “Scared. computed tomography. including beta-blockers and anticholinergics. disso ciative fugue. Patients are unaware of the relation of the symptoms to past experiences or their significance as a psychological defense mechanism. seizures. acute stress disorder. Perceptual: The patient typically denies auditory or visual hallucinations. Conversion Disorder. schizophrenia. substance intoxication or . Judgment: Fair. brain tumors. or taking psychiatric medication. Speech: Normal rate. The patient is able to describe symptoms in detail unless amnesia prevents awareness. General appearance can vary according to personality in dissociative identity disorder. Past medical history: Neurological disorders. Dissociative identity disorder may occur more frequently among first degree relatives. and pregnancy test. bipolar disorder. major depression. Reliability: Good. Depersonal ization may be a side effect of several medica tions. divorce. Diagnostic testing: Electroencephalography.
brain tumor. which protect against experiencing the pain of trauma. Psychotherapy may help patients to recog nize the impact of past traumatic events and . or witnessing a death. Dissociative fugue is extremely rare. and may describe feeling unreal. hypothyroidism. C. emotional neglect. Unlike dissociative amnesia. IV. such as divorce or financial hardship. although a non-pathological variant that is not distressful to the patient also exists. Clinical evaluation A. The history of present illness should focus on the nature of the symptoms and try to differentiate from among the dissociative disorders. The patient may refer to himself as “we. Patients may also describe observing themselves from a distance. barbiturates. Dissociative amnesia typically has an abrupt onset. Etiology. III. fatigue. which mandates hospitalization. and cerebrovascular disease. encephalitis. B. such as physical abuse.Discussion I. botulism. fever. barbiturates. selective for certain events. It is characterized by two or more distinct identities that alternate in controlling the patient’s behavior. D. In dissociative fugue. head trauma. patients wander away from home for hours to days and may assume another identity. loss of a loved one. E. hallucinogens. Inpatient hospitalization is rarely neces sary unless symptoms of comorbid psychiat ric disorders are present and require admis sion. carbon monoxide poisoning. C. patients have a sense of detachment from them selves. Benzodiazepines. and medication toxicity or side effect.withdrawal (alcohol. Risk factors include a history of trauma. Dissociative phenomena are consid ered immature psychological defense mecha nisms. migraine. patients in a fugue state do not recognize their memory loss or identity confusion. and the patient is aware of the memory loss. borderline personality disorder. Neurological: Epilepsy. benzodiazepines. Amnesia is the most common dissociative disorder. Patients with dissociative identity disorder may not recognize the existence of different identities within themselves. sexual abuse. II. but are more common in young women. Dissociative Disorders . In depersonalization disorder. marijuana). and relaxation techniques may all be useful to facilitate recall in amnesia. or in a dream-like state.” and typically the patient does not recall time spent in alternate self states. but may occur in the context of psychosocial stressors. Depersonalization symptoms are experienced as abnormal and distressful. hyperventilation. hypnosis.Treatment A. Dissociative disorders may occur in people of any age. sensory deprivation. or generalized across a lifetime. It is possible that alternate identities in dissociative identity disorder may exhibit impulsivity and suicidal or homicidal behav ior. Memory loss may be localized for a specific period of time. Dissociative identity disorder was previ ously called multiple personality disorder. Medical: Hypoglycemia. Epidemiology. and histrionic personality disorder. B.
sedatives. a history of abuse. Dementia. seizures. Ask about pain. treatments. and menorrhagia. duration. nose. surgeries. Mood: “Scared. level of education. and analgesics. cocaine. and neuro logical symptoms. multiple sclerosis. history of physi cal or sexual abuse.” Affect: Dysphoric or anxious. HIV.History Taking History of present illness: Current symptoms. Previous conversion symptoms. Substance abuse occurs more frequently in patients with somatization disorder and increases the risk of suicide. A fear of having a medical illness suggests hypochondriasis. Conversion disorder symptoms appear neurologi cal in origin and may consist of deficits in any sensory or motor system. Past medical history: Ask about past medical illness. nausea.address the associated pain with improved coping strategies. and neurologi cal problems. and divorce. anxiolytics. anxiety. and somatization disorder occur more frequently in family members of patients with somatization disorder. such as loss of a loved one. acute intermittent porphyria. bloating.” “upset” or “depressed. such as hair. paralysis. Somatization disorder is as sessed by asking about pain. heroin. and in the context of psychosocial stressors. income. Conversion symptoms are more likely to occur in patients with a low level of education. References. marijuana. schizophrenia. diarrhea. brain tumors. eyes. psychosocial stressors. hallucinogens. and mouth. cluster B personality disorders. Weakness. and suicide attempts. and constipation. and seizures. skin. sexual dysfunction. marital conflict. Substance abuse history: Alcohol. difficulty swal lowing. systemic lupus erythematosus. low socioeconomic status. and psychosocial stressors. Body dysmorphic disorder is assessed by asking about preoccupation with an imagined bodily defect and perceived misshapen body parts. Social history: Living situation. Family history: Substance abuse. Thought process: Linear and goal-directed. gastroin testinal distress. Medications: Medical. depres sion. polymyositis. Decreased libido. see page 92. irregular menses. hypnotics. and Guillain-Barre syndrome can all cause symptoms that mimic somatization disorder and conversion disorder. sensory deficits. double vision. erectile or ejaculatory dysfunction. blindness. Mental Status Exam General appearance: Calm and cooperative. myasthenia gravis. date of onset. the patient may not exhibit an appropriate level of concern about symptoms. hospitalizations. and volume. and associated distress. Past psychiatric history: Ask about past hospi talizations. alternative. family relation ships. Speech: Normal rate. loss of balance. diagnoses. . Somatization . and histrionic per sonality disorder are seen more frequently as comorbid illness in somatoform disorders. and all over the-counter medications. vomiting. but often ruminative about symptoms. The patient may show inappropriate (incongruent) affect when describing potentially serious symptoms. rhythm.
Diagnosis: Axis I: Somatization disorder. The etiology of somatoform disorders includes Freudian theories of repressed intrapsychic conflict. but have no medical cause. The patient describes symptoms in detail. B. Laboratory data: Complete blood count. urinalysis. Paralysis. but may have a history of suicide attempts. Concern about symp toms and fear of illness do not reach delusional proportions in somatoform disorders. The prevalence of somatoform disorders varies according to the specific disorder. AIDS. pain disorder. Creutzfeldt-Jakob disease.Discussion I. phobias. two gas trointestinal symptoms. and schizophrenia may all present with somatic complaints consistent with somatoform disorders. myasthenia gravis. Epidemiology. II. There is no evidence of poor impulse control. panic disorder. polymyositis. Conversion disorder is characterized by motor and sensory symptoms that appear neurological in origin. Homicidality: Denies. There are also recent neuro imaging studies and other data to support biological and genetic roles in the development of somatoform disorders. Specific complaints must include four pain symptoms. but pain is the most common present ing complaint. Ideas of reference of people noticing the perceived defect may occur in body dysmorphic disorder. one sexual symptom other than pain. hypochondriasis. and electrocardiogram should be done as needed on a symptom-oriented basis. Suicidality: Denies active suicidal ideation. conver sion disorder. Medical/neurological: Brain tumors. systemic lupus erythematosus. but may exaggerate the severity. optic neuritis. and secondary gain where patients derive specific benefit from entering the sick role. III. electroen cephalography. Etiology. intact memory and concentration. The patient is aware of effect behavior may have on others. multiple sclerosis. Reliability: Fair. blindness. and periodic paralysis. misinterpreted somato sensory input. Somatization disorder is diagnosed by a history of multiple physical complaints be ginning before age 30. and good fund of knowledge. Judgment: Fair. Sensorium/cognition: Alert and oriented.Thought content: Illogical. Diagnostic testing: Physical and neurological exams. Differential Diagnosis Psychiatric: Major depression. magnetic resonance imaging. generalized anxiety disorder. histrionic personality disorder. and one neurological symp tom. and mutism are the most common conver- . Somatoform disorders are characterized by physical symptoms that are not intention ally produced. Somatoform Disorders . Perceptual: Denies hallucinations or illusions. C. liver function tests. The patient does not understand the psychological nature of symptoms. body dysmorphic disorder. chemis try. Insight: Limited. Clinical evaluation A. Impulse control: Fair. Guillain-Barre syndrome. Laboratory examinations should be symptom-oriented to rule out specific differential diagnoses. borderline personality disor der.
Patients with body dysmorphic disorder may have a long history of plastic surgery. and different body parts can be affected throughout the course of the disorder. In pain disorder.sion symptoms. D. Hypochondriasis patients are convinced they have a particular disease despite all evidence to the contrary. E. Body dysmorphic disorder is character ized by a preoccupation with an imagined or exaggerated bodily defect. and rituals to hide the defect may also develop. compul sive checking of the defect.” where patients do not appear appropriately con cerned about seemingly serious symptoms. Treatment A. The classic sign associated with conversion disorder is “la belle indifference. . but psychological factors must also play a significant role. IV. Routine physical and neurological exams are helpful for reassurance and to rule out the development of an underlying medical etiology. Biofeedback training and relaxation techniques may also be helpful to reduce symptoms. Inpatient hospitalization for patients with somatoform disorders may be required for stabilization if functioning is severely im paired or suicidal ideation is present. G. B. Pseudoseizures may also occur in conversion disorder. such as a de formed nose. F. D. Hypochondriasis can be distinguished from other somatoform disorders because patients are preoccupied with the fear of having an illness. symptoms can affect any part of the body and must be severe enough to cause impairment in social and occupa tional functioning. Body dysmor phic disorder may respond to serotonin reuptake inhibitors. and they are most common in patients who already suffer from a seizure disorder. There may be an underly ing medical condition contributing to the pain. Pharmacotherapy is useful in treating comorbid anxiety and depressive disorders. Treat ment usually consists of cognitive-behav ioral or insight-oriented psychotherapy. Ideas of reference. C. rather than concern about the symptoms themselves. Pain disorder is sometimes treated with amitriptyline or gabapentin.
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