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Required Textbooks

1. The American Psychiatric Publishing Textbook
of Psychiatry (6th ed.)
2. Diagnostic and Statistical Manual of Mental
Disorders (5th ed.)
DSM-5

Pg. 4 of the Syllabus

Psychiatric Assessment
&
DSM-5
Richard B. Seely, M.D.
Psychiatrist

Biopsychosocial Model • Biological – Behavior is the result of chemical and neural processes • Psychosocial – Behavior is the result of psychological processes such as learning and the interaction of the individual with life experiences .

Psychiatric Diagnosis • Reduces complexity of clinical phenomena • Creates a structure to understand mental disorders • Facilitate communication between clinicians • Often related to prognosis – Schizophrenia – Bipolar Disorder – Developmental disorders .

Psychiatric Diagnosis • Depression • Multiple processes – Genetic risk – Life experiences (resilience) – Unipolar vs. bipolar – Neurotransmitter systems involved – HPA axis – Neuroplasticity – Default mode network • Antidepressant analog to fever: aspirin? .

but my blood glucose • Diagnoses can change with better knowledge – “Pre hypertension” – “Pre diabetes” . Summary • Psychiatric nosology is primarily descriptive and not directly related to etiology • Does not directly lead to a treatment • True in other areas of medicine as well – – HTN is not defined by etiology. but by blood pressure – DM is not defined by etiology.

DSM • Diagnostic and Statistical Manual of the American Psychiatric Association .

DSM History 1 • DSM-I (1952) Common language (86 pages) • DSM-II (1962) Descriptions (92 pages) • Feighner/Research Diagnostic Criteria (1972/74) – Attempt to establish reliability using specific symptoms .

DSM History2 • DSM-III (1980) (482 pages) – Criteria : Objective and observable to improve reliability • DSM-III-R (1987) • DSM-IV (1994) • DSM-IV-TR (2000) • DSM-5 (2013) .

“Chinese Menu” Approach Advantages Disadvantages • Improved reliability • False sense of certainty • May sacrifice validity .

Major Depression 1. feelings of worthlessness or guilt 8. insomnia or hypersomnia 5. markedly diminished interest or pleasure 3. recurrent thoughts of death . depressed mood 2. weight loss or weight gain 4. fatigue or loss of energy 7. psychomotor agitation or retardation 6. diminished ability to concentrate 9.

Salient Changes DSM-IV to DSM-5 • Integrated dimensional approach to diagnosis and classification – Incorporated via select diagnoses • more latitude to assess the severity of a condition • does not imply a concrete threshold between “normality” and a disorder – Replaced multiaxial system • Diagnostic criteria for many disorders .

Salient Changes DSM-IV to DSM-5 • Several disorders combine different categorical disorders conceptualized as occurring along a single spectrum • a dimensional component adding a severity measure to diagnostic categories (to document the severity of a specific disorder: some clinician-related/some patient- related) • Removed Global Assessment of Functioning – listing of psychosocial stress(ors) or contributing medical conditions .

DSM-5 Definition of a Mental Disorder • A health condition characterized by a significant dysfunction in an individual’s cognitions. or behaviors that reflects a disturbance in the psychological. biological. or developmental processes underlying mental functioning • Some disorders may not be diagnosable until they have caused significant distress or impairment of performance . emotions.

numerical listing of DSM-5 diagnoses and codes (ICD 9 and ICD 10) . as well as measurement instruments – Appendix: highlights of changes from DSM-IV to DSM- 5 diagnoses and codes. with information on how to use the updated manual. DSM-5: Overview • Manual: composed of three (3) sections: – Section 1: introduction to DSM-5. definition of mental disorder – Section 2: outline the categorical diagnoses according to a revise chapter organization (20) – Section 3: include the conditions that require further research before their consideration as formal disorders.

it is NOT a treatment manual • DSM-5 is based on a mix of research . economic concerns. DSM-5: Overview • DSM-5 is a diagnostic and statistical manual. social preferences. to facilitate an objective assessment of symptom presentations in a variety of clinical settings and for insurance reimbursement . and professional consensus • DSM-5 is used for a basic mental health practice.

Use of DSM-5: Structure of Disorder Chapters • Section 2: – Criteria – Subtypes and/or specifiers – Severity – Explanatory text (new or expanded) .

Use of DSM-5: Chapter Structure • Neurodevelopmental Disorders • Schizophrenia Spectrum and other Psychotic Disorders • Bipolar and Related Disorders • Depressive Disorders • Anxiety Disorders • Obsessive-Compulsive and related Disorders • Trauma.and Stressor-Related Disorders • Dissociative Disorders .

and Conduct Disorders • Substance-Related and Addictive Disorders . Use of DSM-5: Chapter Structure • Somatic Symptom and Related Disorders • Feeding and Eating Disorders • Elimination Disorders • Sleep-Wake Disorders • Sexual Dysfunction • Gender Dysphoria • Disruptive. Impulse-Control.

Use of DSM-5: Chapter Structure • Neurocognitive Disorders • Personality Disorders • Paraphilic Disorders • Other Mental Disorders • Medication-Induced Movement Disorders and Other Adverse Effects of Medication • Other Conditions That May Be a Focus of Clinical Attention .

Psychiatric Assessment

Interviewing Techniques
• Establish Safety
– Setting
• Introduce self / greet patient
• Be mindful of escalating agitation
• Do not allow inappropriate behavior
• Exit

Interviewing Techniques
• Establish rapport
• Begin interview asking demographic data
• Convey warmth and friendliness,
• Arrange seating eye level
– Matching behavior

detailed questions • “How is your sleep?” • “Do you have difficulty falling asleep? • “Do you find yourself waking up in the middle of the night?” • “How many times?” • “Do you feel rested?” . direct. Interviewing Techniques • To Rule In/Out – use more focused.

Assess Unspoken Behaviors Process of interview: How patient says it • Are they congruent? • Psychomotor behavior • Inconsistencies • Eye contact • Memory. concentration • Evaluate affect .

Mental Status Examination • PE Equivalent • Determined by observation (Process) – appearance. affect • Asking Questions – mood – speech – thoughts – memory – perceptions . body language.

smells • Stated age • Facial expression . disheveled • Hygiene – clean. casual. unusual • Grooming – neat. Appearance / Attitude • How does patient come to interview – clothes.

manipulative. bizarre • Behavior – psychomotor agitation – aggression – psychomotor retardation . guarded. suspicious. aloof – seductive. defiant. oppositional. Attitude / Behavior • Attitude – cooperative.

Attitude / Behavior • Abnormal movements – tremor . TD – tics – vocal. facial. motoric • Stereotypic – persistent repetitive movement • Ritualistic .

Affect / Mood • Mood – Ask the patient: “How’s your mood?” • Or identify – “So how long have you been depressed?” • Mood is what patient describes • Climate .

incongruent – appropriate. expansive • What the patient conveys in verbal behaviors – congruent. – irritable. Affect • Observation of moment to moment emotional tone • Facial expressions – sad. tearful. labile . smiling.

pressured. Speech • Rate – slow. hyper-verbal • Rhythm (prosody) • Coherence – logical line of thought • Spontaneous • Clanging – speech pattern where thinking is driven by word sounds .

Speech • Echolalic – immediate and involuntary repetition of words or phrases just spoken by others • Word Salad – words joined incoherently • Increased latency of response .

Thoughts • Thought Process – how it’s said • Thought Content (Form of Thought) – what is said .

Thought Processes • Inferred by speech patterns • Goal directed • Circumstantial • Disorganized – looseness of associations (rapid. disjointed) • Tangential (topic to topic) • Derailment .

Concrete – proverbs. Thought Processes • Latency • Poverty of thought (Alogia) • Perseverative – repetitive responses to multiple questions – inability to change sets • Abstract vs. similarities .

Thought Content • Suicidal ideation – intention. impaired reality testing) – abnormality of thought content – fixed or loosely held false beliefs not explained by cultural background . plan • Homicidal ideation – intention. plan – need to report • Delusions (psychotic.

Delusions • Persecutory/Paranoid • Jealousy • Sin / guilt • Grandiose • Religious • Somatic • Ideas / Delusions of Reference .

Ideas / Delusions of Reference • Idea of reference – patient is suspicious yet senses its erroneous • Delusion – patient believes it • Delusions of being controlled – belief that actions and feelings controlled by outside source • Mind Reading .

• Thought Broadcasting – others can hear your thoughts • Thought Insertion – thoughts are being inserted into one’s mind • Thought Withdrawal – someone has removed your thoughts .

familiar. conversing with each other – location. music • Assess – gender. critical. sounds. noise. frequency • Must Discern: if command in nature . Perceptual Disturbances Psychotic • Hallucinations – false perception in absence of identifiable external stimulus • Auditory – voices.

parasomias • Illusions – misperception of external stimulus • Sleep – Hypngogic – Hypnopompic . shapes. Perceptual Disturbances Psychotic • Visual – people. devil. God • Tactile – burning / crawling • Olfactory – unusual smells vs.

Memory • Immediate / Registration – repeat 3 words • Recent – recall 3 words after 5 minutes • Remote – historical facts. birthday .

Intelligence / Insight • Similarities. vocabulary • Insight : – Does the patient have an understanding of what’s wrong with him or her? .

Orientation • Person • Place • Time .

Judgment • Reasonable • Immature • Effected by emotional state • Impulsive .

Mini Mental State Exam Folstein • Orientation • Registration • Attention and Calculation • Recall • Language .

Identifying Data • Informant • Age – Patient • Handedness – Family • Race – Other • Gender • Source of Referral • Marital status • Occupational status • Highest grade attained .

Chief Complaint • “What seems to be the problem?” – patient’s own words .

HPI • Patient speaks freely • Exceptions 3 –5 minutes – paranoid – relaxes patient – uncooperative • Patient speaks main – psychotic concerns – drunk / intoxicated • Observe – hyper-verbal – thought process – speech – coherence .

gradual. – Acute. relationships. drugs. work. children. Provisional Dx Content of interview: What patient says • Become more direct – Onset of symptoms – Precipitants • stressors. NONE. chronic .

Provisional Dx • Symptom severity • Establish symptom – effect on functioning pattern – in different settings – MNA Panic Attack • Psychic pain – Mood worse in AM – “How distracting are – Postpartum the voices?” – Seasonal – “What do you feel when you have flashbacks?” .

Provisional Dx • Prior treatment hx – incorporate into HPI • Medication – Doses – Length of Rx – Effectiveness • Psychotherapy – How long – For what .

negatives • Sexual activity • Must cover – Suicidal and homicidal ideation. plan – Alcohol and substance use and abuse – Psychotic processes . Review of Systems Psychiatric Syndromes • Covers other Dx – As in medicine – Helps to establish differential – Pertinent positives. intent.

when. how. why • ECT • Rehab / Detox • Suicide Hx – When. intervention • Medication Hx : – What . intention. Past Psychiatric Hx • Chronological order • Outpatient / Inpatient – where. how long. effectiveness . how much.

Substance Hx incorporate in HPI if CC • Drug of Choice • Onset: first drink • Severity: blackouts. DUI’s • Tolerance: how much. escalating • How often • Money spent • Consequences • IV Drug Abuse .

Family Psychiatric Hx • Relatives – Psych Hx • Drugs / ETOH • Suicide Hx • Adopted .

Medical Hx • Brief ROS • Current medical problems • Surgical Hx • Head trauma – Loss of consciousness (LOC) – Seizures • Pregnancy Hx .

Social / Developmental Hx • Work Hx – Past / Present • Military Hx • Legal Hx • Abuse Hx – Physical – Emotional – Sexual .

Social / Developmental Hx children: very thorough • Born / Raised • Childhood problems • Education • Relationship with parents • Marital Hx • Religious / Cultural attitudes .

Plan • Work-Up: Psychiatric Patients require the same careful. • Labs • Psychological Testing • Treatment . high quality work up as any other patient • Mandatory – To rule out medical causes of psychiatric illnesses or • Specific Treatments – ECT. etc. lithium.