Chapter 15: The Mental Status, Psychiatric, and Social Evaluations

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. Students of medicine at all levels should consult specialized texts dealing 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 provide appropriate diagnosis and therapy for all coexistent psychiatric and nonpsychiatric illnesses simultaneously, not sequentially. Delayed diagnosis of organic disease in patients with psychiatric illness is all too common; the clinician must take extra care evaluating these complicated patients.

The distinction between neurologic and 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.

Behavior disorders and violence are also common problems in our society. To properly evaluate and care for patients, clinicians must be knowledgeable about the patient’s social situation. Social factors cause patients to present with a wide variety of physical and psychiatric complaints. A complete social and psychiatric history with attention to a history of abuse (such as physical, sexual, emotional, and financial, etc.), current safety, and the patient’s resources is essential for all patients.

This chapter does not provide a complete diagnostic approach to psychiatric illness. Rather, our purpose is to introduce common psychiatric syndromes encountered in clinical practice and provide guidance for recognizing them. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), published by the American Psychiatric Association, is a particularly valuable resource [American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013]. 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 interview and exclusion of medical illnesses. The psychiatric interview requires time, patience, and experience. Many screening questionnaires are available to assist the evaluation of psychological symptoms. Useful screening tools include the Mini-Cog, SLUMS test, the Folstein Mini-Mental State Examination (MMSE), clock drawing test, Beck Depression Inventory, Hamilton Depression Scale, and the Prime MD instruments. None of these instruments is perfect, but they can assist in evaluation and identification 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 has been used most often, but the authors are now charging for its use. A validated alternative is the SLUMS tool (Fig. 15-1), developed at Saint Louis University, which is open source [Tariq SH, Tumosa N, Chibnall JT, Perry MH III, Morley JE. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder—a pilot study. Am J Geriatr Psychiatry. 2006;14:900–910]. The Mini-Cog is another 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]. Errors in either task indicate the need for detailed evaluation of cognitive function.

The psychiatric evaluation addresses the following dimensions of mental processes.

Level of Consciousness

Patients are described as alert, lethargic, stuporous, or in coma. These are arbitrary categories and the mental status may fluctuate. Although patients may be lethargic from medications or intoxications, all patients who are less than fully alert must be assumed to have an organic neurologic disorder until proven otherwise.

Orientation

This has four dimensions: person, place, time, and situation. Does the patient know who he and others in the room are? Does he know their names and roles? Does he know where he is—the place, city, state, country? Does he know the year, season, day, and date?

Attention

This is the ability to stay on task and follow a conversation and interview while avoiding distractions. Attention deficits are the hallmark of confusional states and delirium and should alert the clinician to the possibility of a metabolic disorder. Decreased attention is too frequently attributed to a lack of cooperativeness when, in fact, the patient is unable to cooperate. Digit span recall is a good test of attention. Have the patient repeat random sequences of digits starting with two and working up. Seven is normal whereas four or less is definitely abnormal. Tests of serial 7s, serial 3s (subtract 3 sequentially, starting at 20), and attempting to spell “world” backward are other tests of attention. A nonverbal task is the tap-no-tap test. Have the patient tap his or her hand twice when you tap once; if you tap twice, they are not to tap. Always consider the patient’s level of education in interpreting these tasks.

Memory

This is the ability to register and retain material from previous experience. Memory is a complex phenomenon. It is usefully classified as immediate recall (registration), short- and long-term memories. Immediate recall is the ability to register items presented. Short-term memory is the ability to recall the registered items within 5 to 10 minutes. Long-term memory is the ability to recall events from the more distant past from days to years. Specific tests of immediate recall and short-term memory are included in the SLUMS and MMSE. Short- and long-term memories are evaluated while taking the history. Find out what the patient is really interested in (such as politics, sports, cooking, etc.) and ask them detailed questions about their interest, questions that demand specific quantitative, rather than vague qualitative answers.

Thought

This is how the brain communicates consciously with itself. Thought has several dimensions. The content of thought is what the patient is thinking about. Is it appropriate to his or her situation and a reasonable perception of the world? The sequence of thoughts is also important. How are they linked one to the next? Can the patient digress and get back to the original point? The logic a person uses to connect events and explanations should be evaluated. What is the nature of cause and effect in his or her life? What are the reasons he gives for seeking care? Insight is the ability to look at one’s self and situation with comprehension and understanding. Lack of insight into the nature or consequences of behaviors or thoughts is an important clue to mental illness. Judgment is the ability to make reasonable assessments of the external world and choices between alternative actions. How are decisions made? How does the patient evaluate alternatives? How are potential benefits and risks considered?

Perception

This is a global term for the way in which a person experiences the world through the senses. Distortions of perception can be symptoms of either neurologic or psychiatric disease. Hallucinations are sensory experiences perceived only by the patient, not by an observer. They may be auditory, visual, tactile, gustatory, or olfactory. Auditory hallucinations are particularly common in psychosis, whereas visual hallucinations are more common in delirium. Gustatory and olfactory hallucinations are common in partial seizure disorders (temporal lobe epilepsy). Illusions are the incorrect perception of objects seen by both the patient and the observer. These are particularly common with sensory impairment such as visual loss. Structural perception is the ability to place objects and shapes in relation to one another. It can be tested by having the patient copy interlocked pentagons or perform clock drawing.

Intellect

Intellect is generally held to be an innate brain faculty, though it is difficult to separate deficits of intellect from deficits of education. The clinician must know the patient’s educational and literacy level in order to properly evaluate his or her intellect. Culture greatly influences tests of intellect and it is hazardous to make assessments across cultures. There are several dimensions of intellect. What is his or her information level? Does he know about important local, national, or international events? What are his or her sources of information? Calculations, the ability to manipulate numbers, are tested by simple and gradually more complex arithmetic tasks. Abstraction is the ability to see general principles in concrete statements. Abstractions are tested by asking the patient to interpret proverbs, for example, “people in glass houses shouldn’t throw stones” = “don’t criticize others for things you have probably done yourself.” Interpretation at the simplest level, for example, “they would break the windows,” is indicative of a concrete thinking and a deficit in abstract thinking. Remember that proverbs are culturally bound and may not be recognizable to people from different cultural backgrounds. Reasoning is the ability to solve problems involving simple logical sequences. Language is what one brain uses to communicate with another brain. It is tested in the interview and by having the patient follow both written, verbal instructions and write a sentence. Assess the patient’s vocabulary and the complexity of the patient’s spoken language. Other dimensions of language are fluency of speech, body language, facial expression, and other nonverbal forms of communication; all should be thought of as language.

Mood

Mood is the sustained affective state of the patient: how they feel. It is more like the tidal flow of emotion than the waves of affect. Mood is classified as normal, depressed, or elevated. Mood should be assessed, by asking the patient, how his or her mood has been over the last 2 weeks. Other questions used to evaluate mood include questions regarding how the patient feels about his or her life, the patient’s thoughts of the future, the patient’s confidence in his or her abilities, and the patient’s hopes, and the intensity of these feelings. If depression is suspected, it is mandatory to inquire about suicidal thoughts or plans. Depressed patients may show blunted affect with little range.

Affect

This is the more transient state of emotion, which varies from minute to minute and day to day, depending upon the setting and types of social and personal interactions in which a person is engaged. Affect is the clinician’s assessment of emotion and is assessed by facial expression, tone, and modulation of voice and specific questions about how the patient feels. Affect is also measured by considering intensity and range of expression. Affective states include happy, sad, angry, fearful, worried, and wary.

Appearance and Behavior

Close observation of the patient during the interview will provide important information. How is he dressed and groomed? How is his personal hygiene? Does he make and sustain eye contact? Does he answer questions promptly and fully? Are there areas of questioning that he avoids or tries to deflect? What is his body language? Is he fidgeting or unusually still? What is his tone of voice, volume, and speech rhythm?

Psychiatric Symptoms and Signs

This chapter discusses symptoms and signs together because in psychiatric illness the symptoms and signs manifest together as the patient’s behaviors and the patient’s perception and description of those behaviors.

Abnormal Perception

We perceive the world through our senses, which we take as reliable and valid measures of the external environment. Sensory perceptions are distorted as a result of injury to the sensory organs or pathways, from abnormal processing of the sensory perceptions or from false perceptions arising within the brain. Abnormal perceptions arising from primary injury to the sensory organs and their pathways are often negative (loss of perception) or represent an exaggeration or distortion of the normal sensory signal (e.g., tinnitus, paresthesia, hyperalgesia, allodynia). Altered perception from the processing centers and cortex are more often complex.

Hallucinations

Hallucinations are abnormal sensory perceptions (auditory, visual, olfactory, tactile/somatic, or gustatory) that the patient may or may not recognize as unreal. There are no external cues. Auditory hallucinations are common in schizophrenia; visual hallucinations are more typical of delirium. Olfactory and gustatory hallucinations suggest partial seizures.

Illusions

Illusions are a misinterpretation of real sensory events. Illusions are commonly associated with delirium during which poor attentiveness leads to false attribution of sensory phenomena such as misidentification of people and behaviors.

Confusion—Delirium

See Chapter 14.

Abnormal Sleep Perceptions—Parasomnias

These are disorders of perception or behavior associated with sleep. The most common parasomnias are nightmares and sleep terrors. Auditory hallucinations occurring upon falling asleep (hypnogogic) and awakening (hypnopompic) are common, and do not indicate pathology without other hypnagogic symptoms.

Sleepwalking

This is classified as a parasomnia. The patient may perform complex activities while asleep and awaken with no recollection. Hypnotic drugs increase the risk of sleepwalking because of induction of antegrade amnesia.

Periodic Leg Movements of Sleep

Frequent leg movements during sleep are associated with arousals in obstructive and central sleep apneas. They can be quite disturbing to the bed partner, but the patient is unaware of the activity, other than finding the partner absent or the bedding disrupted. When the patient complains of an inability to hold the legs still on going to bed, consider restless legs syndrome.

Abnormal Affect and Mood

Feelings are the way we react emotionally to the perceptions and events of our lives. Normally, we have a range of feelings throughout the day and the intensity of our feelings varies over time. Abnormal extremes of feelings, in degree or duration, may indicate a psychiatric disorder.

Change in Behavior or Mood

Any significant behavior change should raise concern for a medical or psychiatric illness. Changes in school or job performance and withdrawal from social activities are frequent in disorders of mood, thought, and substance abuse.

Elevated Affect and Mood

Elevation of mood is a normal transient response to positive events. The diagnosis of mania requires an abnormally elevated, expansive, or irritable mood lasting at least 1 week plus three or more of the following: inflated self-esteem or grandiosity, decreased need for sleep, more talkative, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in pleasurable activities with a high potential for painful consequences (physical, sexual, or financial). Hypomania is similar, although the symptoms are milder and of shorter duration.

Depressed Affect and Mood

Depressed affect is a normal brief response to negative events and feelings. Depression of mood is more persistent. It may be accompanied by loss of interest in activities or pleasure, anorexia, weight loss, insomnia or somnolence, psychomotor agitation or retardation, fatigue, inappropriate guilt and/or a sense of worthlessness, loss of the ability to concentrate, thoughts of death, and suicidal ideation. When persistent for more than 2 weeks and accompanied by changes in sleep, eating, and behavior, it may indicate an episode of major depression. Dysthymia is a persistent, usually lifelong form of mildly depressed affect, not meeting criteria for a major depression.

Anxiety

This is a state of apprehension or fear accompanied by increased sympathetic nervous system activity. It is a normal response to threats, either physical or psychological, which resolves with resolution of the threat. It is abnormal when the feeling occurs or persists in the absence of real danger.

Phobias

These are irrational fears of situations, events, or objects that produce uncontrollable fear and anxiety. Pathological phobias lead to alterations in social or psychological function.

Anhedonia

This is the absence of pleasure from activities that are normally emotionally rewarding, including eating, sexual stimulation, social activities, and personal or business success. It is a characteristic of depression.

Depersonalization

This is a feeling of being outside the body, an observer of yourself and surroundings. It is accompanied by a loss of affective connection with the people and events in one’s environment. It is normal during highly stressful, traumatic events, but abnormal in other situations, if persistent, or recurrent. Depersonalization may occur with anxiety disorders.

Abnormal Thinking

Thinking is the process by which we connect and explain events to ourselves and others. It is a relational activity of great complexity. Thought disorders may be manifested by verbal symptoms or by unusual behaviors resulting from the disordered thoughts.

Paranoia

This is a feeling of being systematically threatened or persecuted by a person, persons, or organizations. It is pathological when the paranoia results from a fixed delusion and leads to alterations in activities. Paranoia may be a relatively mild personality trait or a manifestation of psychosis.

Disordered Thinking

Thinking is usually logical and linked to an explicit rational system of cause and effect. The train of thought connecting each sequential idea is either apparent to an observer or readily explained by the patient and comprehensible to the observer. Disordered thinking is unconnected from thought to thought or connected by irrational or incomprehensible explanations. It is a sign of schizophrenia.

Delusions

Delusions are unreal perceptions of the causal relations between perceptions, events, and people. They have their basis in real sensory perceptions and events, but the linkages are illusory. Delusions are often described as fixed, false beliefs and are pathological when they continue to be believed despite strong, otherwise persuasive, evidence to the contrary. Delusions are characteristic of schizophrenia, manic psychosis, and delirium.

Obsessions

Obsessions are recurrent intrusive thoughts or fears that cannot be suppressed or controlled despite knowing they are unreasonable. When function is impaired it becomes obsessive–compulsive disorder.

Compulsions

Compulsive activities are repetitive stereotypic behaviors that the person feels compelled to perform in order to reduce distress or fear of an unavoidable outcome if they stop. When function is impaired it becomes obsessive–compulsive disorder.

Abnormal Memory

The hippocampus and temporal lobes are essential to memory formation and storage. Abnormal memory results from failure to register, retain, or recall information. Memory for names is frequently impaired with normal aging and is not a cause for concern. Short-term memory loss or the inability to make new memories leads to disorientation, behavioral changes, and severe functional impairment. Memory loss is the most common characteristic of the dementias and may be the only finding in mild cognitive dysfunction.

Amnesia

Amnesia is a loss of memory. It can be retrograde for events of the past, or antegrade, the inability to form new memories. It can be either global or selective for particular events or domains of memory. It is indicative of brain injury or psychological disorder.

Confabulation

Confabulation occurs in the setting of severe memory loss. The patient constructs fabulous explanations for events and behaviors for which the memory of the correct explanation is lost. This is typical of Korsakoff syndrome.

Abnormal Behaviors

How we behave, our actions in private and public, is the result of how we feel, how we think, and how we perceive the constraints and rewards of the social environment. Behavior is culturally bound such that behaviors appropriate in one culture or setting may be quite inappropriate in another. Normative evaluations of private thoughts, feelings, and behaviors are problematic at best; however, public behaviors are reasonably and readily subject to normative evaluation. Behaviors which are consistently abnormal or unacceptable are indicative of personality or psychiatric disorders.

Suicidal Behavior

See Suicide.

Stereotypic Behaviors

Activities, movements, or vocalizations that are stereotypically repeated without appropriate precipitants or explanation suggest either tics or compulsions or possibly complex partial seizures.

Catatonia

Catatonic patients often exhibit a profound retardation in motor activity, retaining postures, expressing negativism, and repeating the phrases or motions of other persons (echolalia, echopraxia). However, patients can have excessive motor activity, which is apparently purposeless and not influenced by external stimuli. Catatonia is most common in affective disorders but is also seen in psychosis.

Abnormal Sexual Feelings and Behaviors—Paraphilias

Paraphilias are abnormal and/or unusually intense feelings of sexual arousal toward inappropriate sexual objects such as children, animals, or nonhuman objects, or the need for inappropriate behaviors such as sadism or masochism during sexual activity. Paraphilic thoughts are not necessarily abnormal, but when acted upon with nonconsenting partners or children, they are indicative of psychiatric illness.

Bulimia

Bulimia is alternating binge eating and purging with either induced vomiting or other cathartic activity. When the pattern is sustained and secretive, it is a major eating disorder.

Anorexia Nervosa

See Anorexia Nervosa and Bulimia Nervosa.

Dyssomnias

These include difficulty getting to or maintaining sleep (insomnia), abnormal daytime sleepiness or sudden sleep onset (narcolepsy), sleep-disorder breathing (obstructive or central sleep apnea, and other disorders of the circadian sleep cycle (e.g., jet lag). Always ask about sleep quality and disruption. Abnormal sleep patterns may result from or lead to psychiatric disorders. Terminal insomnia is associated with major depression, whereas initial insomnia characterizes atypical depressive disorder [Schenek CH, Mahowald MW, Sack RL. Assessment and management of insomnia. JAMA. 2003;289:2475–2479].

Psychiatric Syndromes

The disorders in this section are presented to help the clinician recognize them for the purposes of treatment or referral to a psychiatrist. Indications for psychiatric consultation or referral include suicidal or homicidal ideation, psychotic symptoms, severe anxiety or depression, mania, dissociative symptoms, and failure to respond to therapy.

To facilitate research, the American Psychiatric Association developed criteria for the diagnosis and classification of mental disorders. These have proved reliable and have improved the diagnosis and therapy of these problems. Practitioners should consult the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013].

Multiaxial Assessment

The DSM-V uses a multiaxial assessment method that provides a systematic approach to describing these disorders. Every clinician needs to be familiar with this system.

Axis I: Clinical Disorders; Other Conditions That May be a Focus of Clinical Attention

These are the major psychiatric and behavior syndromes addressed in the DSM-V. If more than one disorder is present, the principle disorder or reason for the current visit is listed first.

Axis II: Personality Disorders; Mental Retardation

These are listed separately from Axis I disorders because they may coexist and complicate the diagnosis and management of Axis I problems.

Axis III: General Medical Conditions

Here are listed medical conditions, by system, which may be important for understanding and management of the Axis I and II disorders.

Axis IV: Psychosocial and Environmental Problems

Problems in the patient’s psychosocial and physical environment which influence the diagnosis, management, or prognosis of the Axis I, II, and III problems are enumerated here.

Axis V: Global Assessment of Functioning

The practitioner’s assessment of the patient’s global level of function is recorded using the Global Assessment of Functioning Scale, a 0 to 100 scale descriptive of the degree of functional impairment from the psychiatric (Axis I and II) disorders. The full scale is in the DSM-V.

There are few, if any specific signs or laboratory findings of psychiatric disease, so diagnosis depends upon an experienced observer obtaining a complete history from the patient and a collateral informant.

Acute and Subacute Confusion

Delirium

Metabolic abnormalities (including prescription and nonprescription drugs), pain, restraints, or sleep deprivation impair cognitive function, particularly attention, judgment, and perception. This is usually a metabolic encephalopathy. Failure to recognize and treat delirium is associated with a high incidence of long-term morbidity and increased mortality. Delirium is frequently confused with a primary psychiatric disorder, especially by examiners who have not known the patient in the premorbid state. Delirium is characterized by loss of attentiveness, fluctuations of mental status, progressive loss of orientation, and confusion. Persons at highest risk are the older adults, especially those on multiple medications. The chief features are decreased attentiveness (distractibility, loss of train of thought), alteration of consciousness (from hypervigilance and agitation to lethargy or coma), disorientation (for time and place), illusions (misinterpreted sensory impressions), hallucinations (mostly visual), wandering, fragmented thoughts, delusions, recent memory loss, and affective changes. The patient may be restless, or picking at the bedclothes. Hypoactive delirium may occur as well. Myoclonus may be present [Wong CL, Holroyd-Leduc J, Simel DL, Straus SE. Does the patient have deliuium? Value of bedside instruments. JAMA. 2010;304:779–786]. Some forms of delirium, for example, alcohol withdrawal, produce prominent autonomic dysfunction with fever, tachycardia, and hypertension (delirium tremens). CLINICAL OCCURRENCE: Common causes of delirium include drug intoxication or withdrawal (e.g., narcotics, sedatives, tranquilizers, alcohol, steroids, salicylates, digitalis, alkaloids), liver disease, uremia, hypoxia, hypoventilation, congestive heart failure, electrolyte abnormalities, urinary retention, fever, and infection. In hospitalized patients, sensory deficits, restraints, Foley catheters, and invasive procedures are associated with an increased incidence of delirium.

Anxiety Disorders

Generalized anxiety disorder

Anxiety is an experienced emotional state caused by activity in the deep cortical structures of the limbic system. In addition to the subjective feelings, anxiety triggers stress responses via the autonomic nervous system that are felt by the patient and may heighten the anxiety. Most persons experience some anxiety in response to stress, but excessive or continuous unfocused anxiety may be so debilitating as to require therapy. The causes of anxiety may be real, potential, or imagined. Symptoms and signs mediated by the autonomic system include palpitations, tachycardia, tremor, chest pain, hyperventilation with paresthesia and dizziness, faintness, fatigue, diaphoresis, nausea, vomiting, diarrhea, and abdominal distress. The Hamilton Anxiety Rating Scale can be used to assess severity. Significant impairment of social, occupational, or other functioning is required for diagnosis.

Panic attack

Sudden intense fear or discomfort occurs without an evident external cue. Symptoms include palpitations, sweating, tremor, shortness of breath, choking, chest pain, nausea, faintness or dizziness, paresthesias, and/or flushing accompanied by overwhelming cognitive turmoil, as in fear of dying, losing control, or going crazy. Symptoms peak within 10 minutes and rarely last more than 30 minutes, leaving the patient feeling exhausted.

Panic disorder

This is the condition of recurrent panic attacks accompanied by an ongoing apprehension of recurrent attacks, worry about the prognostic implications of the attacks (their physical and psychological meaning), or significant changes in behaviors as a result of the attacks.

Agoraphobia

This is a persistent fear of situations which might cause embarrassment or discomfort without escape, or which might precipitate a panic attack. These are often social situations involving groups of people, particularly within confined surroundings such as classrooms, churches, and stores. Agoraphobia commonly accompanies panic disorder.

Social phobia

These patients have a compelling desire to avoid social contact, fearing embarrassment or humiliation.

Specific phobias

Phobia may develop for almost any type of event or interaction. To qualify as a phobia the anxiety must be consistently produced by the exposure, the fear must be excessive and unreasonable, and recognized as such by the patient, who then alters her usual patterns of behavior to avoid the situation, leading to social disruption or extreme distress.

Acute and post-traumatic stress disorders

Persons experiencing an event involving threatened or actual injury or death to themselves or others may develop significant anxiety either soon afterward as an acute stress disorder or later with recurrences in posttraumatic stress disorder. Flashbacks, depersonalization, denial, avoidance of stimuli that induce the memories, and enhanced arousal are manifestations of post-traumatic stress disorder (PTSD) [Yehuda R. Post-traumatic stress disorder. N Engl J Med. 2002;346:108–114].

Obsessive–compulsive disorder

Obsessive thoughts and compulsive behaviors occur in any combination. The patient recognizes that the connection between the behavior and the feared event or outcome is unreasonable. The obsessive and compulsive behaviors, such as hand washing, door locking or checking, cleaning or arranging of possessions, consume more than one hour a day and interfere with social functioning.

Disorders of Mood

Mood is the person’s sustained affective state. Mood can be depressed or elevated, or can cycle between depression and elevation. It is important to ascertain both the amplitude of the swings (the severity of the depression or elevation) and the rate of cycling between the states. Depressed and elevated moods are part of normal life. Grieving for a lost spouse or loved one may last for several months but does not globally impair function.

Dysthymia

This is a persistent, often lifelong, state of mildly depressed mood that is not sufficiently severe to meet criteria for major depression. Unlike depression, which is episodic, dysthymia is more chronic, a trait rather than a state.

Depression

Depression is a sustained daily lowering of mood or loss of interest or pleasure for at least 2 weeks accompanied by change in weight, sleep, psychomotor activity, fatigue, feelings of worthlessness, difficulties with concentration and recurrent thoughts of death. Depression accompanies many serious medical illnesses or the medications prescribed for their treatment; this must be considered before making a diagnosis of major depression. Depression occurs at all ages, but first episodes are most common in the fourth and fifth decades. Depression has psychological, behavioral, and somatic manifestations: loss of appetite and change in weight (up or down); sleep disturbances, most frequently terminal insomnia, although increased sleep can be seen; decreased energy for activities; decreased interest in usual activities and decreased pleasure from usually pleasurable activities; restlessness or listlessness; feelings of guilt and worthlessness; inability to concentrate, initiate activities or make decisions; and thoughts of death or suicide, either passive or active. If depressed mood is sustained more than 2 weeks and accompanied by four or more of these symptoms, depression is present [William JW Jr, Noël PH, Cordes JA, Ramirez G, Pignone M. The rational clinical examination. Is this patient clinically depressed? JAMA. 2002;287:1160–1170].

Hypomania, mania, bipolar disorder, and mixed episodes

Mania is characterized by episodes of abnormally elevated mood lasting for at least 1 week. Hypomania is less extreme and functionally successful, as opposed to the destructive consequences of mania. Mania or depression may occur alone (unipolar), or the patient may cycle between mania and depression sequentially over weeks, months, or years (bipolar), or within a single day (mixed episode).

Suicide

Suicide attempts are a common and frequently fatal manifestation of psychiatric illness. Expressed suicidal ideation, threats, gestures, and attempts are progressively more serious signs of a potentially life-threatening situation. Persons at highest risk include older men and adolescents, those with a specific plan, those intending to use firearms already in their possession, those who use substances, especially alcohol, and those with previous aborted attempts. All threats of suicide and expressions of suicidal ideation or intent must be taken seriously and immediate psychiatric consultation should be obtained. The practitioner’s first obligation is to ensure the patient’s safety pending psychiatric evaluation.

Personality Disorders and Abnormal Behaviors

Personality is a global description of how we think, feel, and interact with the world around us. Acceptable feelings and behaviors are culturally determined. Personality disorders are defined as persistent (rather than episodic) lifelong patterns of maladaptive feelings, thoughts, and behaviors. Patients have two or more of the following: abnormal cognition, that is, how they perceive other people, actions, and themselves; abnormal feelings about themselves, people, and events, either in type, intensity, or duration; difficulty functioning with other people socially, educationally, or occupationally; and difficulty with impulse control, leading to inappropriate behaviors. Personality traits are consistent over time, regardless of changes in the social surroundings, and produce significant stress and disruption of their lives. These disorders are pervasive and inflexible; they do not change over time with or without therapy. Treatment is aimed at helping people function within the bounds of their disorder. Underlying medical disorders and substance abuse must be excluded before the diagnosis can be made. Examples include narcissism, borderline, antisocial, histrionic, dependent, avoidant, and obsessive–compulsive personality disorders.

Personality Disorder Clusters

Personality disorders are divided into three clusters. Understanding these clusters and the specific personality types within each is helpful for learning to effectively manage these individuals and their medical problems. Remember that everyone has some of these traits; it is the disruption of global function that separates a disorder from a trait.

Many clinicians would rather avoid dealing with people who have personality disorders. The normal emotional responses to these interactions are used assist us in both recognizing the specific disorders and deal effectively with them. Remember that the patients have not chosen these personalities and the personality disorder stands between you and effective management of the medical problems.

Cluster A: the odd and eccentric

Generally, people with these disorders avoid the medical profession. When they do present, they frequently have somatic complaints such as chronic fatigue and pain.

There is a pervasive suspiciousness of others. They are always questioning the motivations of those around them and suspect that they are not being dealt with honestly.

These individuals are detached and do not form personal or social relationships. They only come to physicians for specific indications or services and otherwise prefer to be socially and personally isolated. The range of their emotional responses is restricted.

These people are recognized by their eccentric behaviors and often eccentric dress. They have social deficits and unusual cognitive and perceptual experiences. Think of the people who have been abducted by aliens, but otherwise function appropriately.

Cluster B: the dramatic, emotional, and erratic

This is the group we often think about when we discuss personality disorders. These patients consume an inordinate amount of physician time and emotion without ever getting better, the folks you fear to see on your clinic schedule. Learning to deal with them effectively will help both you and your staff. These patients usually bring more pain and suffering to others than to themselves. Cluster B patients present with somatic complaints and may be seeking disability or drugs. They often have a history of reactions to many medications or feel that their metabolism is different than others.

There is a disregard for the rights of others and a lifelong pattern of difficulty with social and legal limits on behavior. They do not seem to have a conscience nor display regret or guilt for violating the rights of others.

Borderline patients are emotionally labile and never happy or satisfied. Life is a constantly dysphoric experience. Their relationships are unstable and they are given to impulsive actions, not infrequently with self-harm. The emotional lability and intensity of their experiences often makes their caregivers uncomfortable [Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet. 2004;364:453–461; Gunderson JG. Clinical practice. Borderline personality disorder. N Engl J Med. 2011;364:2037–2042].

These patients have excessive emotionality, often acting out their feelings. They can be sexually provocative and attention seeking. They may be inappropriately dressed (e.g., revealing clothing, excessive make up and jewelry, overly formal or casual, etc.) and have provocative attention-seeking behaviors when alone with the clinician.

The need to be admired and recognized as exceptional in some, if not all their activities, distinguishes these individuals. They are often grandiose and disclose their close relationships with the rich and famous. They are self-centered and lack empathy or insight into the feelings of others.

Cluster C: the anxious and fearful

These people are never satisfied. They have constant fears that produce avoidant, dependent, or obsessive behaviors that disrupt their lives; they bring more suffering on themselves than those around them. These patients present to clinicians with anxiety manifest as seeking second opinions or needing reassurance. They often have somatic complaints and/or many sensitivities to medications or environmental exposures.

The patient feels inadequate in personal and social interactions, so tends to avoid social situations. They are overly sensitive to negative evaluations of every type; such evaluations are taken a statement of personal weakness not as an opportunity for improvement. No amount of reassurance is adequate to overcome this pervasive feeling.

These patients need to be cared for. They are submissive and clinging and are fearful of separation from others. They can become very dependent upon their providers if given the opportunity. They do not take responsibility for their care but shift that to others.

These are the perfectionists who must have control at all times of their environment and their relationships. They are orderly in the extreme.

Other Personality Disorders

Somatoform and related disorders—hysteria, hypochondriasis, Briquet syndrome

Patients with these disorders have many physical complaints without medical explanations. They have usually visited several physicians, “who can’t seem to find out what’s wrong” with them. The diagnosis should not be made until organic causes for the complaints are excluded by thorough examination. Patients have often had repeated extensive evaluations so, absent serious abnormalities on the screening physical and laboratory examinations, the clinician should always obtain complete records of all previous workups before initiating expensive or invasive evaluations [McCahill ME. Somatoform and related disorders: delivery of diagnosis as the first step. Am Fam Physician. 1995;52:193–203].

This is more common in women, begins before age 30, and leads to frequent medical visits for evaluation and treatment. Symptoms are of a degree that social, school, and job performances are impaired. Diagnostic criteria include pain in at least four different sites, two or more nonpainful gastrointestinal symptoms, at least one sexual or reproductive symptom without pain, and one pseudo-neurologic symptom. The symptoms cannot be explained by a known medical condition or result from medication, alcohol, or illicit drug abuse. Unlike factitious disorder, the patient is not fabricating the symptoms or causing self-injury [Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med. 1999;130(11):910–921].

Hypochondriac patients persist in expressing the fear of a serious illness despite the reassurance of concerned physicians who have searched thoroughly for clinical evidence of organic disease and found none [Barsky AJ. Clinical practice. The patient with hypochondriasis. N Engl J Med. 2001;345:1395–1399].

In these disorders, patients consciously and intentionally produce symptoms and/or signs of disease to gratify psychological needs.

Munchausen syndrome is dramatic or dangerous behavior resulting in frequent hospitalizations for presumed severe illness. The most common symptoms and signs simulated are urinary or gastrointestinal bleeding, diarrhea, fever, seizures, and hypoglycemia.

This is intentionally deceptive behavior in which persons claim to have symptoms or signs of disease in order to benefit them in some way, for example by obtaining narcotics or financial support for disability.

Eating Disorders

Marked changes in food selection and abnormal eating behaviors can indicate either organic disease or psychiatric disease.

Anorexia nervosa

Anorexia nervosa is most common in adolescent and young women with an overwhelming concern about body image and weight. It is accompanied by distortion of the perceived body image—the patient seeing an overweight person where observers see normal body form or even emaciation. The patients may be obsessed with food, preparing meals for others but not eating themselves. Excessive exercise may accompany the anorexia as a means of achieving the desired body image. Appetite is severely suppressed or absent. Patients become severely malnourished with retardation of secondary sexual maturation, absent menses, and osteoporosis. Patients are at high risk for death from complications of malnutrition. Early recognition and intensive treatment is essential.

Bulimia nervosa

Bulimia is recurrent, secretive, binge eating. Patients feel unable to control the compulsive eating and resort to induced vomiting, purging with laxatives, and/or abuse of diuretics to avoid weight gain. Clues include erosion of tooth enamel from acid emesis, abrasions on the roof of the mouth and callus on the backs of the fingers from induced vomiting, and electrolyte disorders from use of laxatives and diuretics. Nutritional deficiencies and malnutrition are uncommon [Mehler PS. Clinical practice. Bulimia nervosa. N Eng J Med. 2003;349:875–881].

Binge eating syndrome

Large meals are eaten rapidly and accompanied by guilt and discomfort. In addition to eating rapidly, patients eat alone and/or secretively despite feeling full and not being hungry. They often express self-disgust at their eating habits; depression may be increased. They do not vomit or increase exercise to compensate for their increased intake. If the above symptoms are present for more than 2 days per week for >6 months, the diagnosis of binge eating syndrome can be made.

Night eating syndrome

Patients with this disorder consume >50% of their total daily energy intake after the evening meal. They may snack continuously after the meal as well as awaken frequently to eat. They feel tension and anxiety that is relieved by eating. They are not hungry on awakening and tend to eat refined sugars and high carbohydrate snacks at other times.

Alcohol-Related Illness

Alcoholic beverages are ubiquitous and commonly used social lubricants. Alcohol intake should not exceed two drinks per day for males and one for females. There is great variability in individual tolerance to the effects of alcohol; increased tolerance develops with increased use. Problems related to alcohol use have biological, social, and psychological roots. Each person lies somewhere on the continuum from abstinence to alcoholism; the clinician’s task is to identify each person’s use of alcohol, now and in the past, and the risk for addiction and social disruption. All patients should be asked about the frequency, amount, and type of beverages consumed; whether their use is in a social context or if they drink alone; whether they drink to become intoxicated; and whether they have memory losses, or driving or other infractions of the law related to alcohol. CAGE is an acronym which helps recall questions that focus on cutting down, annoyance by criticism, guilty feelings, and eye openers (early morning drinks). Positive responses to the CAGE questions should raise the index of suspicion for chronic alcohol abuse. Alcohol abuse is commonly associated with other forms of substance abuse, including tobacco [Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352:596–607; Kitchens JM. The rational clinical examination. Does this patient have an alcohol problem? JAMA. 1994;272:1782–1787].

Problem Drinking

There is alcohol consumption in excess of the recommended amounts but without dependence or serious social, legal, or occupational issues. Binge drinking in young adults is a common form of problem drinking.

Alcohol Abuse

Regular use of alcohol in excess of the recommended limits, without dependence, but associated with impairments in social functioning, interpersonal and relationship conflicts, legal issues, occupational difficulty, or repeated risky behaviors, such as driving while intoxicated indicates alcohol abuse.

Alcohol Dependence

This is a compulsive behavioral disorder of drinking ethyl alcohol in biologically damaging quantities and repeatedly creating circumstances that are physically and socially damaging. Two key elements are increasing tolerance so that escalating amounts are consumed and withdrawal symptoms when attempts are made to discontinue or moderate drinking. The diagnosis is certain when behaviors that damage the drinker’s health and reputation occur repeatedly. Such behavior is socially stigmatized so the patient often is reluctant to admit to it and may use subterfuges and untruths to conceal the truth. To uncover the facts, the clinician must be persistent and gain the patient’s confidence. Often, the questioning must be oblique instead of blunt. Details are sought that are diagnostically pertinent but not recognized as being associated with alcoholism. A history of previous treatment for alcoholism, injury without explanation, unexplained seizures, job loss, and arrests for driving under the influence are important. Physical signs consistent with chronic alcoholism include cutaneous vascular spiders, hepatomegaly, wrist drop, peripheral sensorimotor neuropathy, cerebellar ataxia, and alcohol or aldehyde on the breath.

Impulse Control Disorders

This group of disorders includes repetitive behaviors that range from the relatively minor (hair twisting and pulling: trichotillomania) to the socially disruptive (compulsive gambling, explosive disorder) and to the criminal (kleptomania, pyromania). Repetitive impulsive socially disruptive behaviors may be the result of psychiatric disorders, epilepsy, or tics (Tourette syndrome).

Adjustment Disorders

Sudden, especially unwanted, disruptions of the social environment can produce profound changes in mood and behavior. Failure to adjust in a reasonable period of time with restoration of normal mood, or persistent maladaptive or self-destructive behaviors, is indicative of an adjustment disorder with or without accompanying anxiety or depression. Common events requiring adjustment are termination of an intimate relationship, divorce, changing schools or communities, loss of employment, getting married, and becoming a parent.

Prolonged Grieving

Grieving the loss of a loved one is a normal event, an adjustment to a new type of life. The form and pattern of appropriate grieving is both individually and culturally determined [Maciejewski PK, Zhang B, Block SD, Prigerson HG. An empirical examination of the stage theory of grief. JAMA. 2007;297:716–723]. Normal grieving is a gradual process resolving the acute loss with a developing new appreciation for the lost person. With this resolution comes a restoration of a sense of purpose and the ability to find joy in life. Grieving associated with social withdrawal and depression disrupting normal activities and relationships and persisting for more than 2 months may indicate transition from the normal grief process to a psychiatric disorder.

Thought Disorders

Psychosis: Schizophrenia

Schizophrenia is now considered to comprise a group of diseases that are probably etiologically distinct. Primary psychotic disorders occur in adolescence or young adult life. Onset of psychotic symptoms at older ages should raise concern for organic brain disease, drug intoxication or withdrawal, or psychosis complicating major depressive or bipolar disease. Schizophrenia involves problems in thinking, affect, socializing, action, language, and perception. Positive symptoms represent an exaggeration or distortion of normal functions, including delusions and hallucinations, especially auditory. Negative symptoms are losses of normal functions such as affective flattening, alogia, anhedonia, and avolition. Disorganizational symptoms include disorganized speech or behavior and short or absent attention span. Several subtypes are recognized. Catatonic patients exhibit a profound change in motor activity, retaining postures, expressing negativism, and repeating the phrases or motions of other persons (echolalia, echopraxia). Paranoid patients are preoccupied with at least one systematized delusion or auditory hallucination related to a single subject. Disorganized schizophrenic patients are disorganized in their speech and behavior and display a superficial or inappropriate affect.

Other Disorders

Other major categories of psychiatric syndromes which we do not have space to present inclusively include substance-related disorders; disorders usually first diagnosed in infancy, childhood, or adolescence (including mental retardation, learning disorders, autism, attention-deficit and disruptive behavioral disorders, and tic disorders); dissociative disorders; sexual and gender identity disorders; sleep disorders; impulse-control disorders; adjustment disorders; relational problems (e.g., parent to child, siblings); and problems related to abuse or neglect. The reader should consult the DSM-IV-TR for detailed discussion of these diagnoses.

Evaluation of Social Function and Risk

Health status is strongly correlated with socioeconomic standing. Among the factors known to correlate with health status are family income, community of residence, education, social connectedness (the number and strength of interpersonal relationships), marital status, and employment status. In addition to any role the social environment plays in the incidence of ill health, it often places significant limitations on the ability of an individual and family to cope with the financial and social demands of illness. The result is a vicious spiral of unmet needs.

Evaluation of the patient’s social environment should be part of a global patient assessment. The clinician should inquire about marital status, living arrangements, financial limitations and concerns, health insurance, education, literacy (do not assume that several years of elementary and secondary education equates to being able to read or write), interpersonal relationships and personal support system, use of community social support systems, and sense of personal safety and security. For the older adults and chronically ill, it is important to inquire about the availability of heat in the winter and air conditioning in the summer.

When questions arise; or problems are identified, consultation with your local social service agencies is strongly advised. They are often able to assist patients with medications, transportation, and a wide variety of other services. Identification of abuse or neglect is especially important and the caregiver is required to report to the appropriate social agency children (younger than age 18 years), elders (older than age 64 years), or dependent adults of any age who may be victims of abuse or neglect. The first priority in this situation is securing the safety of the patient, which may require hospitalization.

A description of a complete social evaluation is beyond the scope of this text. Axis IV of the DSM-V lists the following specific areas of psychosocial and environmental problems. This list is an excellent organizational scheme for identification and classification of these problems:

1. Problems with primary support group.

2. Problems related to the social environment.

3. Educational problems.

4. Occupational problems.

5. Housing problems.

6. Economic problems.

7. Problems with access to health care services.

8. Problems related to interaction with the legal system/crime.

9. Other psychosocial and environmental problems.

Common Social Syndromes and Problems

• Abuse and Neglect

Abuse is common and can affect persons of any age and either sex. Child and elder abuse affects both males and females, whereas women are much more commonly affected in midlife. Abuse can be physical, sexual, emotional, or financial. The examiner should first inquire whether the patient has ever felt unsafe in a relationship, then whether there are concerns about current safety, and last whether they wish help in dealing with the current problems. The patient’s safety, not the identification of a perpetrator, is the first and most important goal of the interview. Remember that reporting of child, elder, and dependent adult abuse and neglect are mandatory.

Domestic violence

Violence in the home or between intimate sexual partners is common and often difficult to assess. In surveys of ambulatory practice, more than 20% of women have been abused at one time and 5% of women have been abused within the last year [McCauley J, Kern DE, Kolodner K. et al. The “battering syndrome”: prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med. 1995;123:737–746]. Sensitive questioning and a willingness to provide assistance are essential for diagnosing these problems [Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med. 1999;341:886–892].

Elder abuse

This is an increasingly recognized problem. It can take many forms, and because many elders are dependent upon others for their personal needs, they may be unwilling to volunteer a complaint. This is further complicated when family members are the offending individuals. Abuse may take place in the home or in institutional settings. An empathetic nonjudgmental approach to the evaluation including questions designed to elicit the patient’s feelings (“Do you feel safe?”) may help identify problematic situations [Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;363:1263–1272].

Illiteracy

Inability to read and/or write is not uncommon. The patient is often embarrassed by the problem and will not volunteer this information. Learn to inquire tactfully and nonjudgmentally about the patient’s educational and literacy skills. Illiteracy should be suspected when there is poor adherence to therapy plans and follow-up [Bass PF III, Wilson JF, Griffith CH. A shortened instrument for literacy screening. J Gen Intern Med. 2003;18:1036–1038].

Homelessness

Homeless persons are at high risk for medical illness and abuse and have high rates of serious psychiatric illness.

Isolation

Social isolation is common, especially in the older adults, in those with impaired motor or communication skills, and in those with financial limitations. Isolation makes dealing with chronic illness more difficult and may increase the rate of cognitive decline in the older adults.

Institutionalization

A significant proportion of our society spends time living in various institutional settings from the relatively benign, such as boarding schools, to the punitive, such as prisons. Other institutional settings that may impact on health status are nursing homes and homes for the developmentally disabled. It is important to know the stresses and limitations each of these environments places on our patients.