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Ten Leading Causes of
Disability in the World
Type of Disability
Cost (in
DALYs)
Cumulative %
of Cost
Unipolar major depression
42,972
10.3
Tuberculosis
19,673
14.9
Road traffic accidents
19,625
19.6
Alcohol use
14,848
23.2
Self-inflicted injuries
14,645
26.7
Manic-depressive (bipolar) illness
13,189
29.8
War
13,134
32.9
Violence
12,955
36.0
Schizophrenia
12,542
39.0
Iron deficiency anemia
12,511
42.0
Note: DALYs=disability-adjusted life-years.
Two Major Traditions
in Psychiatry
Biomedical
Psychodynamic
Purposes of Diagnosis
in Psychiatry
Simplify
our thinking
Facilitate communication
Predict outcome
Decide on treatment
Aid search for etiology
Overview DSM
 Childhood
 Mood
Disorders
Disorders
 Anxiety Disorders
 Delirium,
 Somatoform
Dementia
Disorders
 Substance Induced
 Personality
Disorders
Disorders
 Schizophrenia and
Other Psychotic
Disorders
Overview DSM
 Factitious
 Eating
Disorders
Disorders
 Sleep Disorders
 Dissociative
 Impulse-Control
Disorders
Disorders
 Sexual and Gender  Adjustment
Identity Disorders
Disorders
MENTAL STATUS EXAM
 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.
 PSYCHOMOTOR ACTIVITY: may be
agitated, normal, slowed and provides clues
to overall mental state.
MENTAL STATUS EXAM
 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.
MENTAL STATUS EXAM:
SPEECH
Evaluate
tone, rate and volume of
speech.
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.
MENTAL STATUS EXAM:
MOOD AND AFFECT
Mood
is the prevailing subjective
emotional state, primarily how the
patient says he/she feels.
Affect is how the mood is
expressed and refers primarily to
the observable facial expression.
MENTAL STATUS EXAM:
DESCRIPTION OF MOOD
 EUTHYMIC
 HAPPY
 SAD
 EUPHORIC
 IRRITABLE
 ELATED
 ANXIOUS
 ANGRY
 Often,
the most
clear and colorful
means of
describing mood
is to use the
patient’s own
words
MENTAL STATUS EXAM:
ASSESSING AFFECT
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.
 Blunted or flat affect is static regardless of topic at
hand.
 In mood disorders the affect is confined to either
mania or depression and does not have full
range.

ASSESSMENT OF
SUICIDE
The
interviewer must develop an
estimate of suicide risk with each
patient by determining:
Extent of current suicidality
Presence of risk factors for suicide
Presence of psychiatric diagnosis
associated with risk for suicide
SUICIDALITY AT TIME
OF INTERVIEW
Passive
wish to die versus wanting
to kill self
Extent of specific plan
Does the person have the means?
How lethal is the plan?
Suicide note
Arrangements made?
ASSESS FOR SUICIDE
RISK FACTORS
History
of violence
Family history of suicide
History of prior attempts
Male
Single, divorced or separated
History of certain types of trauma
IS PSYCHIATRIC DISORDER
PRESENT THAT IS ASSOCIATED
WITH SUICIDE?
 MOOD
DISORDER
 SCHIZOPHRENIA
 PANIC DISORDER
 SUBSTANCE ABUSE OR
DEPENDENCE
 SOME TYPES OF PERSONALITY
DISORDERS
MENTAL STATUS EXAM:
THOUGHT PRODUCTION
A patient’s thinking is mostly assessed by observing
their verbal communication and judging their level
of interest in the world around them.
 Poverty of thought is seen in schizophrenia and
depression.
 Racing thoughts or “flights of ideas” are seen in
mania.
 Thought blocking is an abrupt cessation of
conversation, after which the person is unable to
recall the topic.

MENTAL STATUS EXAM:
THOUGHT PROCESS
THE
MANNER IN WHICH
THOUGHTS ARE ASSOCIATED,
THE TRAIN OF THOUGHT
Normal is goal-directed with
coherence
Abnormal may manifest in
different ways
DISORDERS OF
THOUGHT PROCESS
 CIRCUMSTANTIALITY
 TANGENTIALITY
 LOOSE
ASSOCIATIONS
 VERBIGERATION
 WORD SALAD
 NEOLOGISMS
 CLANG ASSOCIATIONS
 ECHOLALIA
DISORDERS OF THOUGHT
CONTENT: PREOCCUPATION
 PHOBIA:
irrational fear or dread,
results in avoidance behaviors and
anxiety
 OBSESSION: disturbing, intrusive
thought
 COMPULSION: irresistible urge to
perform usually meaningless activity,
often is ritualistic
DISORDER OF THOUGHT
CONTENT: DELUSIONS
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.
DELUSIONS
 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
 Contrast these with MOOD
INCONGRUENT DELUSIONS….
DELUSIONS THAT ARE
NOT MOOD CONGRUENT
 Delusions
of reference: outside events
refer to the self
 Delusions of control: outside forces are
controlling oneself in some way
 Schneider’s first-rank symptoms of
schizophrenia -- may also occur in
psychotic mood disorders and delirium
SCHNEIDERIAN FIRST
RANK SYMPTOMS
Thought
insertion
Thought withdrawal
Thought broadcasting
Passivity feelings
Delusional perception
Auditory hallucinations
PERCEPTUAL DISTURBANCE
Illusions
are misperceptions of
existing stimuli
Hallucinations occur in the absence
of sensory stimuli
Can involve any of the five senses
but the type can provide clues as to
diagnosis -- hallucinations are a
symptom only
HALLUCINATIONS
 AUDITORY:
seen in psychotic disorders
such as schizophrenia, mania, psychotic
depression
 VISUAL: seen in medical, toxic disorders
 TACTILE: substance-withdrawal
delirium
 OLEFACTORY AND GUSTATORY: seen
as prodrome of complex partial seizure
COGNITIVE
FUNCTIONING
Level
of consciousness varies from
lethargy to various levels of
alertness
Orientation -- check for this to
person, place, time, situation
Concentration/attention -- test by
serial 7’s or serial 3’s
MENTAL STATUS EXAM:
MEMORY ASSESSMENT
SIMPLE MEMORY TESTS CAN ASSESS
RETROGRADE AND ANTEROGRADE MEMORY
FUNCTION
 Remote memory is for events in the distant past,
often the last memory system affected in dementia
 Recent memory is for the last few months
 Immediate recall requires attention more than
memory
 Short-term memory is tested with remembering
three objects immediately and after 5 minutes

MENTAL STATUS EXAM
 Make
a estimate of the patient’s level of
intelligence
 Insight -- how aware is the person of
their situation
 Judgment -- how able is the person to
stay out of harm, provide for self,
handle finances
 History and interview should provide
ample opportunity to assess
CONDUCT OF THE MENTAL
STATUS EXAMINATION
 In
open-ended, unstructured interviewing,
assess appearance, orientation, level of
consciousness, behavior, attitude, speech,
thought form and content, affect.
 Direct, focused questioning and exploration
will be required to assess mood, suicidal and
homicidal ideation, perceptual disturbance,
cognitive functioning.