Diagnosis of Mental Illness; DSM IV-TR-Mental Status Exam-McGinnis
Behavioral Science Lecture 13
Classification of mental disorders published by the American Psychiatric Association. Based on scientific data, data reanalysis by task force and field trials to verify the data. Classification system based on description not cause. Manual not a textbook. No description of treatment.
Multiaxial System of Evaluation-5 Axes
Axis I: clinical disorders and other conditions that may be a focus of clinical attention. Axis II: personality disorder and mental retardation. Axis III: any physical disorder or general medical condition that is present in addition to the mental disorder. Axis IV: psychosocial and environmental factors that significantly contribute to the development or exacerbation of the current disorders. Axis V: global assessment of function (GAF) scale-100 point scale in which the clinician judges the patient's overall level of functioning.
Mental Disorder According to DSM IV
Clinically significant behavioral or psychological syndrome that occurs in an individual and is associated with present distress or disability or with a significantly increased risk of suffering death, prior disability or an important loss of freedom. The syndrome must not be merely an expectable and culturally sanctioned response to a particular event. Must be a dysfunction in the individual. Neither deviant behavior (political, religious or sexual) nor conflicts between the individual and society are mental disorders unless it is a symptom of dysfunction in the individual as described.
Diagrammatic tracks that organize the clinician's thinking to arrive at a presumptive diagnosis.
ICD -10 (International Classification of Disease and Related Health Problems)
Developed by World Health Organization. Not official in US. Required by Medicare. Less restrictive than DSM. 3 axes: clinical diagnosis, disablements, and contextual factors.
A group of possible diagnoses which have similar features, overlapping pathology and presentation. An all inclusive list from which a final diagnosis is made.
Mental Status Examination
A formal evaluation of the examiner's observations and impressions of the patient at the time of the interview. It is a description of the patient's appearance, speech, actions and thoughts during the interview. The examination of the patient is used to assess mental functioning and its relationship to underlying pathology.
Outline of Mental Status Exam
Appearance, speech, mood and affect, thought, perceptual disturbances, sensorium and recognition, impulse control, judgment and insight, and reliability.
Grooming, hygiene, dress and posture. Hair (color, styling, texture, grooming), height, weight, body shape, clothing, jewelry, scar formation, skin, tattoos. Eye contact, eye movements, facial expression. How old compared to chronological age.
Physical characteristics of speech; quantity, rate of production, quality (pressured speech, manic rambling).
Mood and Affect
Mood: patient's predominant emotional state (sad, angry, happy, depressed). Affect: the expression and expressivity of the patient's emotions (flat, blunted, restricted, heightened, labile).
Thought (Process and Content)
Process: "form" of thinking. "How" they think-thinking which may reflect impaired reality testing and evidence of perceptual disturbances. (organized vs disorganized thought process). Content: "what" they think. Ideas, beliefs, preoccupations, obsessions.
Hallucinations: false sensory perception not associated with real external stimuli. Visual, auditory, olfactory, gustatory, tactile. Hallmark of psychosis. Completely made up/nothing there. Illusion: misperception or misinterpretation of real external sensory stimuli. Not an indicator of psychosis. Distort what is there. Disturbed perceptions of self or environment: depersonalization, derealization.
Sensorium and Cognition
Alertness and level of consciousness (alert to coma). Orientation: time, place, person. Memory: immediate attention and recall (seconds to 1 min), recent memory (minutes to a few days), recent past memory (past few months), remote memory (distant past). Concentration and Attention: Attention is the ability to focus perception on an outside or inside stimulus and Concentration is sustained attention to an internal thought process. Capacity to read or write. Visuospatial ability. Abstract thinking. Fund of information and intelligence.
Ability to control impulses related to internal or external stimuli.
Judgment and Insight
Judgment: ability to assess a situation correctly and to act appropriately within that situation. Insight: ability of the person to understand the true cause or meaning of a situation.
Levels of Insight
Awareness; slight awareness; awareness but faulty causality; intellectual insight; true emotional insight-know cause of problem and what should be done to deal with it.
Tests For Assessing Mental Status
Direct Observation: Appearance, behavior, speech, mood affect, thought content and process, alertness and level of consciousness. Direct Questioning: perceptual disturbances, orientation. Memory: immediate retention and recall-digit span; recent memory-word recall, day's events; recent past memory-current events of last few months; remote memory-verifiable information about personal and general past events. Concentration: serial subtractions, reverse spelling, changing sets (no-go test). Reading and Writing: write a sentence; read sentence and follow instructions. Visuospatial Ability: copy figure (clock, geometric figure-Alzheimer's). Abstract Thinking: similarities; interpret proverbs. Fund of Knowledge and Intelligence: computations; vocabulary; facts