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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.
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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.
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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.
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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.
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The Mental Status and Psychiatric Evaluation
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The Mental Status Evaluation
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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, ...