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

Ten Leading Causes Ten Leading Causes of of Disability in the Disability in the WorldWorld

Note: DALYs=disability-adjusted life-years.Note: DALYs=disability-adjusted life-years.

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

Two Major Two Major TraditionsTraditions

in Psychiatryin Psychiatry

Biomedical

Psychodynamic

Purposes of Purposes of DiagnosisDiagnosis

in Psychiatryin PsychiatrySimplify our thinkingFacilitate communicationPredict outcomeDecide on treatmentAid search for etiology

Overview Overview DSMDSM

Childhood Disorders

Delirium, Dementia

Substance Induced Disorders

Schizophrenia and Other Psychotic Disorders

Mood Disorders

Anxiety Disorders

Somatoform Disorders

Personality Disorders

Overview Overview DSMDSM

Factitious Disorders

Dissociative Disorders

Sexual and Gender Identity Disorders

Eating Disorders Sleep Disorders Impulse-Control

Disorders Adjustment

Disorders

MENTAL STATUS MENTAL STATUS EXAMEXAM

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.


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 MENTAL STATUS EXAM:EXAM:

SPEECH 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 MENTAL STATUS EXAM:EXAM:MOOD AND AFFECTMOOD 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 MENTAL STATUS EXAM:EXAM:DESCRIPTION OF DESCRIPTION OF MOODMOOD

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 MENTAL STATUS EXAM:EXAM:ASSESSING AFFECTASSESSING 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 ASSESSMENT OF SUICIDE 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 SUICIDALITY AT TIME OF INTERVIEWTIME 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 ASSESS FOR SUICIDE RISK SUICIDE RISK

FACTORSFACTORS

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 IS PSYCHIATRIC DISORDER PRESENT THAT IS PRESENT THAT IS

ASSOCIATED WITH SUICIDE?ASSOCIATED WITH SUICIDE?

MOOD DISORDER SCHIZOPHRENIA PANIC DISORDER SUBSTANCE ABUSE OR

DEPENDENCE SOME TYPES OF PERSONALITY

DISORDERS


THOUGHT THOUGHT PRODUCTIONPRODUCTION

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.


THOUGHT PROCESSTHOUGHT 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 DISORDERS OF THOUGHT PROCESSTHOUGHT PROCESS

CIRCUMSTANTIALITY TANGENTIALITY LOOSE ASSOCIATIONS VERBIGERATION WORD SALAD NEOLOGISMS CLANG ASSOCIATIONS ECHOLALIA

DISORDERS OF THOUGHT DISORDERS OF THOUGHT CONTENT: CONTENT:

PREOCCUPATIONPREOCCUPATION

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 DISORDER OF THOUGHT CONTENT: THOUGHT CONTENT:

DELUSIONSDELUSIONS

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.

DELUSIONSDELUSIONS

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 DELUSIONS THAT ARE NOT MOOD NOT MOOD

CONGRUENTCONGRUENT

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 SCHNEIDERIAN FIRST RANK FIRST RANK SYMPTOMSSYMPTOMS

Thought insertion Thought withdrawal Thought broadcasting Passivity feelings Delusional perception Auditory hallucinations

PERCEPTUAL PERCEPTUAL DISTURBANCEDISTURBANCE

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

HALLUCINATIONSHALLUCINATIONS

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 COGNITIVE FUNCTIONINGFUNCTIONING

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


MEMORY ASSESSMENTMEMORY 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


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 CONDUCT OF THE MENTAL STATUS MENTAL STATUS

EXAMINATIONEXAMINATION

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.

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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