Lecture 1


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Lecture 1

  1. 1. Psychiatry Presented by Jimmy Santana, P.A. - C
  2. 2. Session Objectives <ul><li>Understand the complete psychiatric examination including the mental status exam </li></ul><ul><li>Understand what belongs in each axis of the DSM- IV system </li></ul>
  3. 3. What Is the Mental Status Exam? <ul><li>A comprehensive survey of the current state of the patient’s mental functioning </li></ul>It assesses:. <ul><li>General presentation </li></ul><ul><li>State of Consciousness </li></ul><ul><li>Attentiveness </li></ul><ul><li>Speech pattern </li></ul><ul><li>Orientation </li></ul><ul><li>Mood and affect </li></ul><ul><li>Form of Thought </li></ul><ul><li>Though Content </li></ul><ul><li>Perceptual Ability </li></ul><ul><li>Judgment </li></ul><ul><li>Memory </li></ul><ul><li>Intellectual Functioning </li></ul>
  4. 4. General Presentation <ul><li>What do you look for when evaluating the patient’s appearance? </li></ul><ul><ul><ul><li>Posture </li></ul></ul></ul><ul><ul><ul><li>Grooming </li></ul></ul></ul><ul><ul><ul><li>Appearance for age </li></ul></ul></ul><ul><ul><ul><li>Clothing </li></ul></ul></ul>
  5. 5. General Presentation <ul><li>How do you evaluate the patient’s behavior? </li></ul><ul><ul><ul><li>Mannerisms </li></ul></ul></ul><ul><ul><ul><li>Psychomotor agitation or retardation </li></ul></ul></ul><ul><ul><ul><li>Tics </li></ul></ul></ul>
  6. 6. General Presentation <ul><li>How do you evaluate the patient’s attitude towards the examiner? </li></ul><ul><ul><ul><li>Cooperative </li></ul></ul></ul><ul><ul><ul><li>Seductive </li></ul></ul></ul><ul><ul><ul><li>Hostile </li></ul></ul></ul><ul><ul><ul><li>Defensive </li></ul></ul></ul>
  7. 7. Sensorium and Cognition <ul><li>What do you look for when evaluating the patient’s state of consciousness? </li></ul><ul><ul><ul><li>Level of alertness </li></ul></ul></ul><ul><ul><ul><ul><li>Glasgow Coma scale [ 3(coma) to 14(completely alert)] </li></ul></ul></ul></ul><ul><ul><ul><li>Lethargy or sleepiness </li></ul></ul></ul>
  8. 8. Sensorium and Cognition <ul><li>How do you determine if the patient is oriented to person, place, and time? </li></ul><ul><li>Person </li></ul><ul><ul><ul><li>What is your name? </li></ul></ul></ul><ul><ul><ul><li>Whom do you live with? </li></ul></ul></ul><ul><li>Place </li></ul><ul><ul><ul><li>Where are you now? </li></ul></ul></ul><ul><li>Time </li></ul><ul><ul><ul><li>What is the year, season, time of day? </li></ul></ul></ul>
  9. 9. Sensorium and Cognition <ul><li>How do you evaluate the patient’s memory? </li></ul><ul><li>Immediate memory </li></ul><ul><ul><ul><li>Ask to remember three words and question after 5 minutes </li></ul></ul></ul><ul><li>Recent memory </li></ul><ul><ul><ul><li>Ask about activities in the last 24 hours </li></ul></ul></ul><ul><li>Remote memory </li></ul><ul><ul><ul><li>Ask about place of birth, schools attended, or historical information that most people would know </li></ul></ul></ul>
  10. 10. Sensorium and Cognition <ul><li>How do you determine if the patient can concentrate and pay attention? </li></ul><ul><li>Make sure that the patient pays attention to you without distractions </li></ul><ul><li>Ask to repeat a string of three to six numbers forward and backwards </li></ul><ul><li>Ask to spell the word WORLD backward </li></ul>
  11. 11. Sensorium and Cognition <ul><li>Evaluation of the patient’s cognitive abilities </li></ul><ul><ul><ul><li>See if the patient can read and write (simple) </li></ul></ul></ul><ul><ul><ul><li>Copy a simple drawing </li></ul></ul></ul><ul><ul><ul><li>Concrete thinking (describe how a pear and an apple are alike) </li></ul></ul></ul><ul><ul><ul><li>Abstract thinking (a rolling stone gathers no moss) </li></ul></ul></ul><ul><ul><ul><li>Intelligence </li></ul></ul></ul><ul><ul><ul><ul><li>Factual knowledge(how many years are in the term of a U.S. president) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Calculational ability (how much is 9 times 7) </li></ul></ul></ul></ul>
  12. 12. Sensorium and Cognition <ul><li>Evaluation of patient’s speech </li></ul><ul><ul><ul><li>Speech too loud or too soft </li></ul></ul></ul><ul><ul><ul><li>Speech pressured (seems to push to speak quickly) </li></ul></ul></ul><ul><ul><ul><li>Articulate clearly </li></ul></ul></ul><ul><ul><ul><li>Deficiencies in language (show poor use of words or poor vocabulary) </li></ul></ul></ul>
  13. 13. Sensorium and Cognition <ul><li>Mood and Affect </li></ul><ul><ul><ul><li>Feeling low, hopeless, helpless, suicidal (depression) </li></ul></ul></ul><ul><ul><ul><li>Feeling high, euphoric, irritable (mania) </li></ul></ul></ul><ul><ul><ul><li>Affect blunted, restricted, or flat (mood abnormalities) </li></ul></ul></ul><ul><ul><ul><li>Congruent (mood and affect similar) </li></ul></ul></ul><ul><ul><ul><li>Are the patient’s mood and affect appropriate to current situation </li></ul></ul></ul>
  14. 14. Thought <ul><li>Evaluation the patient’s form or process of thought: </li></ul><ul><ul><ul><li>Do thought patterns make sense </li></ul></ul></ul><ul><ul><ul><li>Do thought patterns follow each other logically </li></ul></ul></ul><ul><ul><ul><li>Do thought patterns move rapidly from one to another (flight of ideas) </li></ul></ul></ul><ul><ul><ul><li>Do thought patterns repeat over and over </li></ul></ul></ul><ul><ul><ul><li>Do patient response to the rhyming sounds rather than the meanings of words </li></ul></ul></ul>
  15. 15. Thought <ul><li>Evaluation of patient’s thought content </li></ul><ul><ul><ul><li>Patient can’t get thoughts out of head (compulsive or obsessive) </li></ul></ul></ul><ul><ul><ul><li>Patient has fear of eating in public (phobias) </li></ul></ul></ul><ul><ul><ul><li>Patient believes that he/she has cancer without physical evidence (hypochondriacal) </li></ul></ul></ul><ul><ul><ul><li>Patient believes that someone is after him/her (delusional) </li></ul></ul></ul><ul><ul><ul><li>Patient believes that someone on TV is talking about him/her (ideas of reference) </li></ul></ul></ul><ul><ul><ul><li>Thoughts of suicide or homicide </li></ul></ul></ul>
  16. 16. Thought <ul><li>Patient’s perception </li></ul><ul><ul><ul><li>Misinterpretation of reality (thinks a coat on a chair in a dark room is really a man) [illusions] </li></ul></ul></ul><ul><ul><ul><li>False sensory perception (hearing voices or seeing insects) [hallucinations] </li></ul></ul></ul>
  17. 17. Thought <ul><li>Patient’s judgment </li></ul><ul><ul><ul><li>Assess the appropriateness of patient’s behavior </li></ul></ul></ul><ul><ul><ul><li>[what would you do if you found a stamped, addressed letter on the sidewalk?] </li></ul></ul></ul>
  18. 18. Thought <ul><li>Assessment of patient’s insights </li></ul><ul><ul><ul><li>Determine whether the patient understands that he/she has a illness </li></ul></ul></ul><ul><ul><ul><li>Determine whether the patient understands own contributions to the illness </li></ul></ul></ul>
  19. 19. Thought <ul><li>Patient’s reliability </li></ul><ul><ul><ul><li>Using the patient’s responses, collateral information from friends or family to judge whether the patient is telling the truth or providing accurate information </li></ul></ul></ul><ul><li>Patient’s level of impulse control </li></ul><ul><ul><ul><li>Using the patient’s history and current behavior to assess whether the patient is able to control his/her aggressive and sexual impulses </li></ul></ul></ul>
  20. 20. Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition <ul><li>DSM IV is published by the American Psychiatric Association. </li></ul><ul><li>Allows the diagnostic coding of specific psychiatric illness(es). </li></ul><ul><li>The patient is coded along five axes. </li></ul><ul><li>A definitive diagnosis can be made using only the first three axes. </li></ul>
  21. 21. Diagnostic and Statistical Manual of Mental Disorders, 4 th edition <ul><li>Axis I </li></ul><ul><ul><ul><li>Clinical disorders </li></ul></ul></ul><ul><ul><ul><ul><li>Schizophrenia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Panic disorder </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Major depression </li></ul></ul></ul></ul><ul><ul><ul><li>Other disorders </li></ul></ul></ul><ul><ul><ul><ul><li>Medication induced disorders </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Malingering </li></ul></ul></ul></ul>
  22. 22. Diagnostic and Statistical Manual of Mental Disorders, 4 th edition <ul><li>Axis II </li></ul><ul><ul><ul><li>Personality disorders </li></ul></ul></ul><ul><ul><ul><ul><li>Personal characteristics that may be overshadowed by the diagnosis in axis I, but that are longstanding and enduring and often have profound effect on patient functioning </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Mental retardation (IQ below 70) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dependent </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Avoidance </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Histrionic </li></ul></ul></ul></ul></ul>
  23. 23. Diagnostic and Statistical Manual of Mental Disorders, 4 th edition <ul><li>Axis III </li></ul><ul><ul><ul><li>General medical conditions </li></ul></ul></ul><ul><ul><ul><li>Physical illnesses that may be related to or affect the psychiatric problem </li></ul></ul></ul><ul><li>Axis IV </li></ul><ul><ul><ul><li>Psychosocial and environmental stressors </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Death of spouse or family member </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Job loss </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Divorce </li></ul></ul></ul></ul></ul>
  24. 24. Diagnostic and Statistical Manual of Mental Disorders, 4 th edition <ul><li>Axis V </li></ul><ul><ul><ul><li>Global assessment of functioning (GAF) </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Quantification of how well the patient is functioning in everyday life </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>GAF score of 91 – 100 indicate the patient is functioning in a superior fashion </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>GAF score 1 – 10 indicate the patient is in serious danger of suicide or of hurting others </li></ul></ul></ul></ul></ul>
  25. 25. “ Next session’s topic is Drug and Alcohol abuse”