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