Lecture 1

04/11/2304/11/23 IntroductionIntroduction 11

PsychiatryPsychiatry

Presented byPresented by

Jimmy Santana, P.A. - CJimmy Santana, P.A. - C


Session ObjectivesSession Objectives

Understand the complete psychiatric Understand the complete psychiatric examination including the mental examination including the mental status examstatus exam

Understand what belongs in each Understand what belongs in each axis of the DSM- IV systemaxis of the DSM- IV system


What Is the Mental Status What Is the Mental Status Exam?Exam?

A comprehensive survey of the A comprehensive survey of the currentcurrent state of the patient’s state of the patient’s mental functioning mental functioning

It assesses:.

1. General presentation

2. State of Consciousness

3. Attentiveness

4. Speech pattern

5. Orientation

6. Mood and affect

Form of Thought Though Content Perceptual Ability Judgment Memory Intellectual Functioning


General PresentationGeneral Presentation

What do you look for when evaluating What do you look for when evaluating the patient’s appearance?the patient’s appearance?

PosturePosture GroomingGrooming Appearance for ageAppearance for age ClothingClothing



How do you evaluate the patient’s How do you evaluate the patient’s behavior?behavior?

MannerismsMannerismsPsychomotor agitation or retardationPsychomotor agitation or retardationTicsTics



How do you evaluate the patient’s How do you evaluate the patient’s attitude towards the examiner?attitude towards the examiner?

CooperativeCooperativeSeductiveSeductiveHostileHostileDefensiveDefensive


Sensorium and CognitionSensorium and Cognition

What do you look for when evaluating the What do you look for when evaluating the patient’s state of consciousness?patient’s state of consciousness?

Level of alertnessLevel of alertness– Glasgow Coma scale [ 3(coma) to 14(completely alert)]Glasgow Coma scale [ 3(coma) to 14(completely alert)]

Lethargy or sleepinessLethargy or sleepiness



How do you determine if the patient is How do you determine if the patient is oriented to person, place, and time?oriented to person, place, and time?PersonPerson

What is your name?What is your name? Whom do you live with?Whom do you live with?

PlacePlace Where are you now?Where are you now?

TimeTime What is the year, season, time of day?What is the year, season, time of day?



How do you evaluate the patient’s How do you evaluate the patient’s memory?memory?Immediate memoryImmediate memory

Ask to remember three words and question after Ask to remember three words and question after 5 minutes5 minutes

Recent memoryRecent memory Ask about activities in the last 24 hoursAsk about activities in the last 24 hours

Remote memoryRemote memory Ask about place of birth, schools attended, or Ask about place of birth, schools attended, or

historical information that most people would historical information that most people would knowknow



How do you determine if the patient can How do you determine if the patient can concentrate and pay attention?concentrate and pay attention?

Make sure that the patient pays attention to Make sure that the patient pays attention to you without distractionsyou without distractions

Ask to repeat a string of three to six numbers Ask to repeat a string of three to six numbers forward and backwardsforward and backwards

Ask to spell the word WORLD backwardAsk to spell the word WORLD backward



Evaluation of the patient’s cognitive abilitiesEvaluation of the patient’s cognitive abilities

See if the patient can read and write (simple)See if the patient can read and write (simple) Copy a simple drawingCopy a simple drawing Concrete thinking (describe how a pear and an apple are Concrete thinking (describe how a pear and an apple are

alike)alike) Abstract thinking (a rolling stone gathers no moss)Abstract thinking (a rolling stone gathers no moss) IntelligenceIntelligence

– Factual knowledge(how many years are in the term of a U.S. Factual knowledge(how many years are in the term of a U.S. president)president)

– Calculational ability (how much is 9 times 7)Calculational ability (how much is 9 times 7)


Sensorium and CognitionSensorium and CognitionEvaluation of patient’s speechEvaluation of patient’s speech

Speech too loud or too softSpeech too loud or too softSpeech pressured (seems to push to speak Speech pressured (seems to push to speak

quickly)quickly)Articulate clearlyArticulate clearlyDeficiencies in language (show poor use of Deficiencies in language (show poor use of

words or poor vocabulary)words or poor vocabulary)


Sensorium and CognitionSensorium and CognitionMood and AffectMood and Affect

Feeling low, hopeless, helpless, suicidal Feeling low, hopeless, helpless, suicidal (depression)(depression)

Feeling high, euphoric, irritable (mania)Feeling high, euphoric, irritable (mania)Affect blunted, restricted, or flat (mood Affect blunted, restricted, or flat (mood

abnormalities)abnormalities)Congruent (mood and affect similar)Congruent (mood and affect similar)Are the patient’s mood and affect appropriate to Are the patient’s mood and affect appropriate to

current situationcurrent situation


ThoughtThought

Evaluation the patient’s form or process of Evaluation the patient’s form or process of thought:thought:

Do thought patterns make senseDo thought patterns make sense Do thought patterns follow each other logicallyDo thought patterns follow each other logically Do thought patterns move rapidly from one to Do thought patterns move rapidly from one to

another (flight of ideas)another (flight of ideas) Do thought patterns repeat over and overDo thought patterns repeat over and over Do patient response to the rhyming sounds rather Do patient response to the rhyming sounds rather

than the meanings of wordsthan the meanings of words


ThoughtThoughtEvaluation of patient’s thought contentEvaluation of patient’s thought content

Patient can’t get thoughts out of head (compulsive or Patient can’t get thoughts out of head (compulsive or obsessive)obsessive)

Patient has fear of eating in public (phobias)Patient has fear of eating in public (phobias) Patient believes that he/she has cancer without Patient believes that he/she has cancer without

physical evidence (hypochondriacal)physical evidence (hypochondriacal) Patient believes that someone is after him/her Patient believes that someone is after him/her

(delusional)(delusional) Patient believes that someone on TV is talking about Patient believes that someone on TV is talking about

him/her (ideas of reference)him/her (ideas of reference) Thoughts of suicide or homicideThoughts of suicide or homicide


ThoughtThought

Patient’s perceptionPatient’s perception

Misinterpretation of reality (thinks a coat on Misinterpretation of reality (thinks a coat on a chair in a dark room is really a man) a chair in a dark room is really a man) [illusions][illusions]

False sensory perception (hearing voices or False sensory perception (hearing voices or seeing insects) [hallucinations]seeing insects) [hallucinations]


ThoughtThought

Patient’s judgmentPatient’s judgment

Assess the appropriateness of patient’s Assess the appropriateness of patient’s behaviorbehavior

[what would you do if you found a stamped, [what would you do if you found a stamped, addressed letter on the sidewalk?] addressed letter on the sidewalk?]


ThoughtThought

Assessment of patient’s insightsAssessment of patient’s insights

Determine whether the patient understands Determine whether the patient understands that he/she has a illness that he/she has a illness

Determine whether the patient understands Determine whether the patient understands own contributions to the illnessown contributions to the illness


ThoughtThought

Patient’s reliabilityPatient’s reliability Using the patient’s responses, collateral information Using the patient’s responses, collateral information

from friends or family to judge whether the patient from friends or family to judge whether the patient is telling the truth or providing accurate informationis telling the truth or providing accurate information

Patient’s level of impulse controlPatient’s level of impulse control Using the patient’s history and current behavior to Using the patient’s history and current behavior to

assess whether the patient is able to control his/her assess whether the patient is able to control his/her aggressive and sexual impulsesaggressive and sexual impulses


Diagnostic and Statistical Diagnostic and Statistical Manual of Mental Disorders, 4Manual of Mental Disorders, 4 thth

EditionEdition DSM IV is published by the American DSM IV is published by the American

Psychiatric Association.Psychiatric Association. Allows the diagnostic coding of specific Allows the diagnostic coding of specific

psychiatric illness(es).psychiatric illness(es). The patient is coded along five axes.The patient is coded along five axes. A definitive diagnosis can be made using A definitive diagnosis can be made using

only the first three axes.only the first three axes.



editionedition Axis IAxis I

Clinical disordersClinical disorders– SchizophreniaSchizophrenia– Panic disorderPanic disorder– Major depressionMajor depression

Other disordersOther disorders– Medication induced disordersMedication induced disorders– MalingeringMalingering



editionedition Axis IIAxis II

Personality disordersPersonality disorders– Personal characteristics that may be Personal characteristics that may be

overshadowed by the diagnosis in axis I, but that overshadowed by the diagnosis in axis I, but that are longstanding and enduring and often have are longstanding and enduring and often have profound effect on patient functioningprofound effect on patient functioning

Mental retardation (IQ below 70)Mental retardation (IQ below 70) DependentDependent AvoidanceAvoidance HistrionicHistrionic



editionedition Axis IIIAxis IIIGeneral medical conditionsGeneral medical conditionsPhysical illnesses that may be related to or Physical illnesses that may be related to or

affect the psychiatric problemaffect the psychiatric problem

Axis IVAxis IVPsychosocial and environmental stressorsPsychosocial and environmental stressors

Death of spouse or family memberDeath of spouse or family member Job lossJob loss DivorceDivorce



editionedition Axis VAxis VGlobal assessment of functioning (GAF)Global assessment of functioning (GAF)

Quantification of how well the patient is Quantification of how well the patient is functioning in everyday lifefunctioning in everyday life

GAF score of 91 – 100 indicate the patient is GAF score of 91 – 100 indicate the patient is functioning in a superior fashionfunctioning in a superior fashion

GAF score 1 – 10 indicate the patient is in GAF score 1 – 10 indicate the patient is in serious danger of suicide or of hurting othersserious danger of suicide or of hurting others


“Next session’s topic is Drug and Alcohol abuse”

Lecture 1

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