1. Ten Leading Causes of Disability in the World Note: DALYs=disability-adjusted life-years. Ten Leading Causes of Disability in the World Note: DALYs=disability-adjusted life-years. Type of DisabilityCost (in DALYs) Cumulative % of Cost Unipolar major depression42,97210.3 Tuberculosis19,67314.9 Road traffic accidents19,62519.6 Alcohol use14,84823.2 Self-inflicted injuries14,64526.7 Manic-depressive (bipolar) illness13,18929.8 War13,13432.9 Violence12,95536.0 Schizophrenia12,54239.0 Iron deficiency anemia12,51142.0

2. Two Major Traditions in Psychiatry u Biomedical u Psychodynamic

3. Purposes of Diagnosis in Psychiatry u Simplify our thinking u Facilitate communication u Predict outcome u Decide on treatment u Aid search for etiology

4. Overview DSM u Childhood Disorders u Delirium, Dementia u Substance Induced Disorders u Schizophrenia and Other Psychotic Disorders u Mood Disorders u Anxiety Disorders u Somatoform Disorders u Personality Disorders

5. Overview DSM u Factitious Disorders u Dissociative Disorders u Sexual and Gender Identity Disorders u Eating Disorders u Sleep Disorders u Impulse-Control Disorders u Adjustment Disorders

6. MENTAL STATUS EXAM u APPEARANCE provides many clues to patient’s mental state. Observe carefully. Look at type and condition of clothing, hygiene, apparent health, any mannerisms, unusual actions, signs of intoxication or withdrawal, signs of hallucinating. u PSYCHOMOTOR ACTIVITY: may be agitated, normal, slowed and provides clues to overall mental state.

7. MENTAL STATUS EXAM u ATTITUDE: How the patient relates to the examiner provides important clues. Attitude may be summarized in one or several words such as guarded, suspicious, hostile, friendly, ingratiating, manipulative, seductive, cooperative, threatening, flattering…reflecting much about the patient’s ability to function and relate.

8. MENTAL STATUS EXAM: SPEECH u Evaluate tone, rate and volume of speech. u Look for the rapid, pressured speech of mania, the slowed speech of the profoundly depressed person. Other important variations from normal are seen in anxiety and in intoxicated states.

9. MENTAL STATUS EXAM: MOOD AND AFFECT u Mood is the prevailing subjective emotional state, primarily how the patient says he/she feels. u Affect is how the mood is expressed and refers primarily to the observable facial expression.

10. MENTAL STATUS EXAM: DESCRIPTION OF MOOD u EUTHYMIC u HAPPY u SAD u EUPHORIC u IRRITABLE u ELATED u ANXIOUS u ANGRY u Often, the most clear and colorful means of describing mood is to use the patient’s own words

11. MENTAL STATUS EXAM: ASSESSING AFFECT u Look for how appropriate the affect is and whether it corresponds to the topic under discussion. A full range of emotional expression is normal. Note any incongruent between affect and topic at hand. Look for lability of affect. u Blunted or flat affect is static regardless of topic at hand. u In mood disorders the affect is confined to either mania or depression and does not have full range.

12. ASSESSMENT OF SUICIDE u The interviewer must develop an estimate of suicide risk with each patient by determining: u Extent of current suicidality u Presence of risk factors for suicide u Presence of psychiatric diagnosis associated with risk for suicide

13. SUICIDALITY AT TIME OF INTERVIEW u Passive wish to die versus wanting to kill self u Extent of specific plan u Does the person have the means? u How lethal is the plan? u Suicide note u Arrangements made?

14. ASSESS FOR SUICIDE RISK FACTORS u History of violence u Family history of suicide u History of prior attempts u Male u Single, divorced or separated u History of certain types of trauma

15. IS PSYCHIATRIC DISORDER PRESENT THAT IS ASSOCIATED WITH SUICIDE? u MOOD DISORDER u SCHIZOPHRENIA u PANIC DISORDER u SUBSTANCE ABUSE OR DEPENDENCE u SOME TYPES OF PERSONALITY DISORDERS

16. MENTAL STATUS EXAM: THOUGHT PRODUCTION u A patient’s thinking is mostly assessed by observing their verbal communication and judging their level of interest in the world around them. u Poverty of thought is seen in schizophrenia and depression. u Racing thoughts or “flights of ideas” are seen in mania. u Thought blocking is an abrupt cessation of conversation, after which the person is unable to recall the topic.

17. MENTAL STATUS EXAM: THOUGHT PROCESS u THE MANNER IN WHICH THOUGHTS ARE ASSOCIATED, THE TRAIN OF THOUGHT u Normal is goal-directed with coherence u Abnormal may manifest in different ways

18. DISORDERS OF THOUGHT PROCESS u CIRCUMSTANTIALITY u TANGENTIALITY u LOOSE ASSOCIATIONS u VERBIGERATION u WORD SALAD u NEOLOGISMS u CLANG ASSOCIATIONS u ECHOLALIA

19. DISORDERS OF THOUGHT CONTENT: PREOCCUPATION u PHOBIA: irrational fear or dread, results in avoidance behaviors and anxiety u OBSESSION: disturbing, intrusive thought u COMPULSION: irresistible urge to perform usually meaningless activity, often is ritualistic

20. DISORDER OF THOUGHT CONTENT: DELUSIONS u DELUSION = a fixed, false belief that does not have basis in reality, not a part of religion or culture. The patient holding a delusion cannot be talked out of it, even with evidence to the contrary.

21. DELUSIONS u Mood congruent delusions: themes are consistent with depression, such as centered around sin, nihilism, poverty, decay or consistent with mania, such as delusions about holding special powers u Contrast these with MOOD INCONGRUENT DELUSIONS….

22. DELUSIONS THAT ARE NOT MOOD CONGRUENT u Delusions of reference: outside events refer to the self u Delusions of control: outside forces are controlling oneself in some way u Schneider’s first-rank symptoms of schizophrenia -- may also occur in psychotic mood disorders and delirium

23. SCHNEIDERIAN FIRST RANK SYMPTOMS u Thought insertion u Thought withdrawal u Thought broadcasting u Passivity feelings u Delusional perception u Auditory hallucinations

24. PERCEPTUAL DISTURBANCE u Illusions are misperceptions of existing stimuli u Hallucinations occur in the absence of sensory stimuli u Can involve any of the five senses but the type can provide clues as to diagnosis -- hallucinations are a symptom only

25. HALLUCINATIONS u AUDITORY: seen in psychotic disorders such as schizophrenia, mania, psychotic depression u VISUAL: seen in medical, toxic disorders u TACTILE: substance-withdrawal delirium u OLEFACTORY AND GUSTATORY: seen as prodrome of complex partial seizure

26. COGNITIVE FUNCTIONING u Level of consciousness varies from lethargy to various levels of alertness u Orientation -- check for this to person, place, time, situation u Concentration/attention -- test by serial 7’s or serial 3’s

27. MENTAL STATUS EXAM: MEMORY ASSESSMENT u SIMPLE MEMORY TESTS CAN ASSESS RETROGRADE AND ANTEROGRADE MEMORY FUNCTION u Remote memory is for events in the distant past, often the last memory system affected in dementia u Recent memory is for the last few months u Immediate recall requires attention more than memory u Short-term memory is tested with remembering three objects immediately and after 5 minutes

28. MENTAL STATUS EXAM u Make a estimate of the patient’s level of intelligence u Insight -- how aware is the person of their situation u Judgment -- how able is the person to stay out of harm, provide for self, handle finances u History and interview should provide ample opportunity to assess

29. CONDUCT OF THE MENTAL STATUS EXAMINATION u In open-ended, unstructured interviewing, assess appearance, orientation, level of consciousness, behavior, attitude, speech, thought form and content, affect. u Direct, focused questioning and exploration will be required to assess mood, suicidal and homicidal ideation, perceptual disturbance, cognitive functioning.