Psychiatric and social disorders frequently confound patient evaluation in medical settings. A psychiatric diagnosis in no way decreases the probability of organic disease in a patient with appropriate signs and symptoms. We must strive to simultaneously, not sequentially, diagnose and appropriately treat coexisting psychiatric and medical illnesses. Delayed diagnosis of organic disease in patients with psychiatric illness is all too common; clinicians must take extra care evaluating these complicated patients. Consult with a psychiatric colleague whenever there is concern for a confounding psychiatric disorder.
The distinction between neurologic and psychiatric illness is likely an artifact of our limited understanding of brain physiology and pathophysiology. Disorders with identifiable structural, genetic, physiological, or biochemical disorders are considered neurologic and those without psychiatric. 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 psychiatric syndromes are recognized by abnormalities of thought, mood, affect, and behavior rather than specific tests of brain structure or clinical laboratory testing.
Behavior disorders, including violence, are also common problems in American society. To properly evaluate and care for patients, clinicians must know each patient’s social situation, which can influence their physical and psychiatric complaints. All patients deserve a complete social and psychiatric history with attention to current living arrangement, past or current abuse (e.g., physical, sexual, emotional, and/or financial), current safety, education and literacy, and social resources.
This chapter introduces common psychiatric syndromes encountered in clinical practice and provides 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 DSM reviews the epidemiology and presentations of mental disorders.
THE MENTAL STATUS AND PSYCHIATRIC EVALUATION
The Mental Status Evaluation
Psychiatric diagnosis relies on the interview and exclusion of medical illness. Psychiatric interviews require time, patience, and experience. Standardized screening questionnaires assist when evaluating 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 is perfect, but each helps categorize patients by standardized criteria.
The clinician assesses the mental status throughout the history and physical exam. When problems are suspected, formal testing is indicated. The MMSE has been used most often, but the authors charge for its use. A validated open source alternative is the SLUMS tool (Fig. 15-1), developed at Saint Louis University. The Mini-Cog, another validated screening tool, combines the MMSE registration and recall questions with clock drawing. The latter ...