Psychiatric and social disorders are common in medical settings. They are associated with an increased risk for nonpsychiatric illness and frequently confound the evaluation of patients presenting with nonspecific complaints. The student of medicine at all levels should read more specialized texts that deal with psychiatric illness and seek formal psychiatric consultation whenever doubt exists concerning psychiatric diagnosis. It is imperative to recognize that the presence of a psychiatric diagnosis in no way decreases the probability of serious organic disease in a patient with appropriate signs or symptoms. The challenge is to render appropriate diagnosis and therapy for all coexistent psychiatric and nonpsychiatric illnesses simultaneously, not sequentially. Delay in the diagnosis of organic disease in patients with psychiatric illness is all too common and should caution the clinician to take extra care in the evaluation of patients with psychiatric symptoms.
The distinction between what we classify as neurologic or psychiatric illness is a function of our understanding of brain physiology and pathophysiology. The distinction often rests on the presence of identifiable structural, genetic, physiological, or biochemical disorders in the neurologic category and their absence in psychiatric disease. Many psychiatric syndromes show genetic predispositions and respond to medications that alter brain function. Functional imaging studies are increasingly identifying localized abnormalities of brain function in some psychiatric disorders. For the practitioner, it is sufficient to recognize that the disorders we classify as psychiatric, although representing disorders of brain function, will be recognized by their clinical signs with abnormalities of thought, mood, affect, and behavior rather than specific tests of brain structure and clinical laboratory testing.
Social behavioral disorders and violence are also common problems in our society. To properly evaluate and care for patients, clinicians must be knowledgeable about the social situation of their patient. Social factors lead to patients presenting with a wide variety of complaints both physical and psychiatric. A complete social and psychiatric history with attention to current safety, a history of abuse (such as physical, sexual, emotional, financial, etc.), and the resources available to the patients for their care is essential in the evaluation of all patients.
This chapter does not provide a complete diagnostic approach to psychiatric illness. Rather, our purpose is to alert the clinician to the common psychiatric syndromes likely to be encountered in clinical practice and to provide some guidance to their recognition. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), published by the American Psychiatric Association, is a particularly valuable resource with which all practitioners should become familiar [American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994]. In addition to diagnostic criteria, the manual provides an overview of the epidemiology and presentation of mental disorders.
The Mental Status Evaluation
Psychiatric diagnosis is based upon the patient interview and the exclusion of medical illness by appropriate history, physical examination, and, if needed, a selection of laboratory tests. The psychiatric interview requires time, patience, and experience. A wide variety of screening questionnaires are available to assist the clinician in the evaluation of psychological symptoms. Useful screening tools include the Mini-Cog, the Mini-Mental State Examination, clock drawing test, Beck Depression Inventory, Hamilton Depression Scale, and the Prime MD instruments [Spitzer RL, Williams JBW, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: The Prime-MD 1000 study. JAMA. 1994;272:1749–1756 [PubMed: 7966923]. Overreliance upon these tools is not encouraged, but they can assist in the evaluation and selection of patients for referral.
The clinician is assessing the mental status during the history and physical examination. When problems are suspected, formal testing is indicated. The MMSE (Table 15–1), an efficient inventory of cognitive function.
Table 15–1 Mini-Mental State Examination
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Table 15–1 Mini-Mental State Examination
_____What is the time (date/day/month/year)?
_____Where are we (state/county/city/hospital/ward)?
_____Name three objects and ask the patient to repeat them until all three are learned. Record the number of trials.
Attention and Calculation
_____Ask the patient to subtract serial 7s for five times.
_____Ask the patient to recall the three objects named above.
_____Naming: Pencil and watch.
_____Repetition: “No ifs, ands, or buts.”
_____Three-stage command: “Take paper in your right hand, fold it in half, and put it on the floor.”
_____Reading: Obey instruction given in writing: “Close your eyes.”
_____Writing: “Write a sentence.”
_____“Copying: Construct a pair of intersecting pentagons and ask the patient to copy them.
The Mini-Cog is a validated screening test that uses the registration and recall questions from the MMSE and the clock drawing exercise. The latter is performed by drawing a circle and placing the numeral “12” in its proper clock position. Then ask the patient to fill in the remaining numerals followed by indicating a particular time such as “4:35” [Scanlan J, Borson S. The Mini-Cog: Receiver operating characteristics with expert and naive raters. Int J Geriatr Psychiatry. 2001;16:216–222 [PubMed: 11241728]. Errors in either task indicate the need for detailed evaluation of cognitive function.
The psychiatric evaluation addresses several dimensions of mental processes that are briefly discussed below.
- Level of Consciousness. See Impaired Consciousness. Patients are described as alert, lethargic, stuporous, or in coma. These are arbitrary categories and the patient's mental status may fluctuate. Although patients with mental illness may be lethargic from medications or intoxications, all patients who are less than fully alert should be assumed to have an organic neurologic disorder until such has been excluded.
- Orientation. This has four dimensions: person, place, ...
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