Human Behavior Online Tutorial

Mark Vakkur, M.D. => mvakkur@hotmail.com

Welcome! This is an online human behavior and psychiatry tutorial designed for the Emory School of Medicine Human Behavior Course, but available to all. I hope you find it useful. Please let me know how it can be improved.

  Human Behavior 2000-2001 Schedule

The Basics:   
The Mental Status Exam
Psychiatric Assessment: DSM-IV,  Five Axis Formulation
Psychodynamic Theory
History and Background
The Ego, Id, Superego;
Oedipus Complex
Psychodynamic Defense Mechanisms
Personality Disorders
Psychotherapy: 
    Introduction to Psychotherapies
    Psychoanalysis and Psychodynamic Psychotherapy
    Cognitive-Behavioral Therapy
Child and Adolescent Psychiatry

Substance Abuse and Dependence
 
Mood Disorders

   Raw Note File (unedited text file with little psychiatry factoids)

  Fall Schedule:

Block 1:  Fundamentals of Human Behavior August 3, 2000 - August 23, 2000

Block 2: Child Development

Block 3: Mood Disorders

Block 4: Substance Abuse

 Spring Schedule:

Writing Assignment: 20 points credit.

    Home

     The mental status exam is the heart of the psychiatric evaluation.   Technically part of the neurological exam, the mental status exam has both objective and subjective components.  A properly performed mental status exam allows you to describe the important aspects of observed and reported cognitive and emotional functioning and helps guide further examination and study.

     The setting of the mental status exam is critical.  Insure that you and the patient are comfortable.  Asking a frightened, paranoid patient if they would like a blanket or something to eat can do wonders in terms of building rapport.  Make sure that the patient has as much privacy as the situation allows, minimize distractions, such as television or hallway conversations, and prepare yourself to focus entirely on what the patient is telling you.  This may be very difficult when on call with many other responsibilities and limited time, but a rushed mental status exam will ironically cost you more time and effort as you attempt to get the information you need.

     Remember also that a mental status exam is more than simply a means of gathering information.  It is also therapeutic.  Your first contact with the patient, the mental status exam sets the stage for your future relationship.  Being empathic, warm, yet neutral can often be very soothing even to a patient who is very agitated, depressed, frightened, or angry.  You may be rushed and distracted by other things, but your patient will often remember your first encounter even years later.

 As with any other portion of the physical exam, having a systematic approach insures that you will be comprehensive and efficient, by forcing you to focus on several different areas in turn.

 Appearance:  How is the patient dressed?  What about the patient's grooming, hygiene, and body language?  Often the first things you notice about a patient are significant.
 Orientation:  There are four general elements to orientation:  person; place; time; and situation.  Orientation to person is simply the ability to identify one's name and is the last element of orientation to be lost, usually only in very severe dementia or in psychotic states.  It's a good idea to preface your inquiry with a general comment about the fact you ask every patient these questions (otherwise patients will often take offense at your asking them their name or where they are).  Orientation to place is the ability to name where they are, or at least what building, city, or state they are in.   Time includes the date (allow a day or two error for inpatients who are frequently somewhat disoriented), day of week, year, and season.   Situation is the ability to describe their global circumstances, for example:  "I came to the emergency room with chest pain and the doctors are evaluating me to see if I had a heart attack.  You must be some clown they called in from psychiatry."
 Registration/Recall:   Registration is the ability to repeat back a piece of information immediately after hearing it.  It is a good idea to memorize three objects yourself before examining a patient and to use those three objects consistently.   I use dog, ball, and truck.  A more rigorous exam might use a combination of adjectives and nouns, for example, brown dog, red ball, and green truck, or a combination of tangible and intangible items, for example, loud noise or high ideals.  Recall is the ability to repeat back the information after a space of 3-5 minutes.  It is important to inform the patient that you will ask the information again in a few minutes (then remember yourself to ask!).  Give them a few seconds to commit the information to memory.
 Behavior and Motor Activity :  do they make eye contact as you enter the room, do they cross their arms and stare sullenly at the floor, or are they flirtatious or intrusive?  Psychiatrists often speak of psychomotor agitation (e.g., pacing, hand-wringing, excessive fidgeting) or retardation (paucity of spontaneous movements, general bradykinesia).  The latter is classic for melancholic depression, but medical conditions such as hypothyroidism or parkinsonism must be considered.  Other things to look for are bizarre, repetitive motions known as stereotypies seen in some forms of schizophrenia.  Also, look for perioral, periorbital, or tongue twitching which may indicate past exposure to neuroleptics (antipsychotic medications).
 Speech :  The most important elements of speech are rate, fluency, and content.   The rate of speech can be increased in conditions such as mania or stimulant intoxication or decreased in conditions such as depression or sedative intoxication.  The fluency is of more interest to the neurologist in sorting out aphasias, but can also be helpful to the psychiatrist in determining if a patient is responding to internal stimuli.  Thought blocking, in which the patient stops in mid-sentence and fails to pick up the thread of conversation without prompting, is a sign of severe psychosis.  The content of speech is perhaps the most important and the most subjective part of the exam.  The underlying assumption of the mental status exam, an assumption not always valid, is that speech is a reflection of thought.  A patient whose every word exudes hopelessness, despair, and the pointlessness of everything must be distinguished from a patient who ruminates over bowel functioning, somatic concerns, or sexuality.  Step back every now and then and pay attention to the overall theme of what the patient is saying.  See thought process, below, for more aspects of speech to pay attention to.
 Thought Content:  thought content includes assessment for the presence of a number of important psychiatric signs or symptoms, including:

  Hallucinations:  these come in several flavors.  Auditory hallucinations can be voices (very common in  schizophrenia) or recurrent sounds (such as of helicopters, artillery common in combat veterans suffering posttraumatic stress disorder).  Visual hallucinations often imply an organic etiology (such as delirium, withdrawal, or some central nervous system lesion), but can be seen in schizophrenia and other psychiatric states.  Visual hallucinations of deceased love ones are common in grieving.  Other types of hallucinations include tactile, olfactory, or gustatory.
  Delusions:  fixed, false, idiosyncratic beliefs.  Common delusions are grandiose and persecutory.  They may take a religious or historical theme.  You cannot talk a patient out of a true delusion (by definition).  The best way to assess a delusion is to take an objective, logical stance.   Without sounding judgmental or confrontational, try to get the patient to elaborate on his belief system, citing evidence for and against the delusional conclusion.  For example, if someone believes hit men are trying to kill him and he states that he owes $10,000 in gambling debts to a man named Rocko who promised to break his legs, then this may be based in reality (you aren't paranoid if everyone IS out to get you).  However, if he says he knows someone is trying to kill him because the television commentator mentioned it would rain tomorrow.  (This is also an example of looseness of association and a possible idea of reference).
  Ideas of reference:  special messages from the television, radio, or other objects all qualify as ideas of reference.  For example, a patient who believes he is really the president of the United States may tell you she gets messages from the local newscasters telling her to be on the alert for the coming coup that will restore her to office.  Patients who experience ideas of reference may place extreme significance on benign or random events (e.g., a helicopter passing overhead, a certain commercial, or even a song on the radio).
  Suicidal ideation:  no mental status exam is complete without an assessment for dangerousness, specifically suicidal or homicidal ideation.  Both have three parts:  ideation; intent; and plan.  Ideation covers a range from occasional fleeting thoughts, such as, "I'd be better off dead," to a recurrent, intrusive obsession with suicide or murder.  This is a judgment call, but always take any suicidal statements, however vague, very seriously.  Remember that patients can and do commit suicide in the hospital, so never assume that being in an institutional setting is a guarantee of safety.  Explore how strong the thoughts are.  Patients who are chronically suicidal can sometimes rate the strength of their suicidal ideation on a scale from 1 to 10.
  Intent refers to whether the patient is simply thinking about or even wishing her own death or has an intent to actively do something to bring it about.  This is also a judgment call; you aren't responsible for reading the patient's mind, but you are responsible for asking and documenting the patient's response.
  Having a suicidal or homicidal plan is an indication of seriousness and should make you consider hospitalization for safety.  A patient with suicidal ideation, intent, and plan should be hospitalized and put on suicide precautions.  Assess the lethality and reality of the plan.   A patient who threatens to overdose on Prozac and ends up taking 10 pills in a gesture is less worrisome than a patient who is found with a loaded gun to her head, although both should be taken very seriously.
  The only element unique to homicidal ideation is target:  you have a medicolegal obligation to report and protect any intended victim of assault or homicide.  If a patient tells you he is thinking of killing his wife, he cannot leave the emergency room until he either reassures you that he has no intent or plan or until you have called her and made every reasonable step (including commitment or incarceration) to prevent him from harming her.
 
 Thought Process:  This is an assessment of how a patient's thoughts flow and is heavily dependent upon and related to an assessment of their speech.   First, assess the connectedness of each of the patient's ideas.  Do they flow logically one from the other?  If so, the patient's thought processes would be described as cogent.  Do they flow logically, but stray from the flow of conversation to the point that the patient takes you on a "wild goose chase."  If so, is the patient experiencing flight of ideas, a hallmark of mania?  Or is the patient circumstantial and overinclusive, a sign of organicity or obsessive-compulsiveness?  Does the patient never return to the original flow of conversation, in which case you would describe the thought process as tangential?   If the ideas are not logically connected, or jump several times, invite the patient to help you understand his logical system.  For example, you might say,  "I don't quite follow what you just said.  Could you help me see the connection between your income tax return and the proliferation of nuclear weapons?"   These concepts are difficult to understand, so examples follow:
 Flight of ideas:  "My name?  Why it's Bob, as in Bob Dole.  Did you know Dole is from Kansas?  Kansas - what a state!  Did you know Kansas produces more wheat than most countries in the world?  Wheat is important.  In fact, without wheat, there would be no Wheaties.   Wheaties makes me regular.  I hate being constipated, don't you?  I think constipaton is the root of most of the evils in the world.  I'll bet you Hitler was constipated.  That's because he was a vegetarian.  What other questions do you have?"
 Circumstantial:  "My name?  I thought you'd never ask.  You doctors are always asking so many useless questions, you forget the most important ones.  I had a doctor once back in 1982 - or was in 1983? - I think he was a family practitioner, or maybe he was an internist.  No, definitely an internist.   Anyway, he treated me for thirteen years without ever once addressing me by name.  I think he didn't know my name.  Maybe I was just Patient Number 7155 or something.  But now that you asked, my name is Bob."
 Overinclusive:  "You want me to describe my pain?  Well, it's sort of a dull pain on the left side of my chest, except when it's sharp, in which case it drifts over the right side of my chest and I've noticed I tend to be more flatulent with the sharp pain.   I sometimes get sharp pain and sometimes dull.   Sometimes it's neither sharp nor dull, but a little of each, sort of at the same time."
 Loose associations:  "My name?  Well, I'd tell you my name except for the weather, which is humid.  Hot weather really bothers me, makes me want to paint my car blue.   I got fired last week.  Chocolate is my favorite flavor of pudding.  Centrally planned economies will always fail because no one can regulate the temperature in that room you're going to admit me too."
 Mood and Affect:  Mood is what the patient reports to you.  Affect is what you observe.   Mood should be described as dysphoric (sad), euphoric, or euthymic (normal range).  You can also use qualifiers such as labile, angry, irritable, or anxious.  Affect, on the other hand, includes facial expression, tone of voice, body language and other objective manifestations of mood.   Affect is typically described as constricted (sad), bright, or normal range.  You should also note whether the affect is congruent with the underlying reported mood (for example, a patient who laughs while talking about how much they miss their dead mother could be said to have an inappropriate or mood incongruent affect).
 Cognition:  Several objective tests exist to test cognition, from pencil and paper IQ tests to the mini-mental status exam, but the latter is probably the best for bed-side testing purposes.  If you are rushed and wish to perform a quick and dirty test, ask the patient to manipulate coins ("If I have four quarters, two dimes, and a nickel, how much money do I have?  If I take away a dime and a nickel, how much is left?"), perform serial 7s ("Take 99, subtract 7, then subtract 7 from that, etc."), spell the word "WORLD" forward and backward, or to interpret proverbs ("What do people mean when they say a bird in the hand is worth two in the bush?  Don't count your chickens before they hatch?").  For proverb interpretation, note whether the explanation is concrete - merely a restatement of the proverb in different words - or whether the patient is capable of abstraction, moving from the specific to the general.  Vocabulary, diction, and word usage are also very good indicators of global cognitive functioning, although you must adjust somewhat for educational background.
 Insight and Judgment:  Insight is a patient's awareness of themselves and their condition.  Judgment as used on the mental status exam refers most commonly to an assessment of the patient's ability to avoid behavior that might be harmful to themselves or others.
 
Diagnostic and Statistical Manual, Fourth Edition (DSM-IV)

Lecture Outline and Learning Objectives

     The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) is the latest attempt to classify complex phenomena such as various presentations of mental illness into a set of specific disorders that share common characteristics.  The objective of the Diagnostic and Statistical Manual system is to improve reliability and validity among diagnosticians and observers, improve diagnosis, treatment, and research.
     Reliability, remember, is the extent to which different observers agree on a particular diagnosis.   (If they are all wrong, but consistently wrong, they would still have high reliability, just low validity.)  Reliability can be thought of as how closely a series of shots taken with a rifle fall on a target;  even if they are far from the bullseye, if they are close together then reliability will be high.  Reliability can also be viewed as reproducability.
     Validity, on the other hand, is how close the diagnosis of a given instrument falls to some gold standard, or how "correct" it is.  Using the rifle range analogy, validity is how close the shot lands to the bullseye.  Scattered shots centered around the bullseye might have high validity, but low reliability.  Obviously, with subjective phenomena such as mental illnesses, a gold standard is generally lacking.  Agreement between professionals using a clinical interview and some predefined criteria is as close to a gold standard as we can come using today's technology.  Platelet studies, MRI, and PET scans offer some "hard" evidence for some psychiatric disorders, but none is practical as a screening tool.
     Psychiatric researchers must focus on common characteristics, lontitudinal course, reported subjective symptom and observed signs of various illness and empirical evidence to various interventions to determine the validity of an illness or a classification system.
     Before the Diagnostic and Statistical Manual, clinicians used idiosyncratic terms defined in either theoretical or abstract ways.  For example, one's clinician's depressive neurosis might be another clinician's dysthymia.  This made standaradized research of psychiatric disorders almost impossible.  In addition, recently third party payers have become very interested in linking reimbursement to diagnosis; for example, therapy for personality disorders might not be fully reimbursed, whereas treatment of an Axis I disorder (see below) such as major depression would be.  This obviously puts pressure on clinicians to give some diagnoses more than others, thereby diluting the validity of the diagnostic system.
     The Diagnostic and Statistical Manual attempts to be atheoretical and descriptive.  It attempts to rely as much as possible on observed behavior and reported symptoms and does not attempt to explain etiology.  A tremendous effort has been made to incorporate the most recent research findings into the Diagnostic and Statistical Manual, now in its fourth edition (and frequently referred to as DSM-IV).  The DSM-IV is the most widely used diagnostic manual in the United States and one of the most widely used in the world.
     Note that the Diagnostic and Statistical Manual does not address treatment or outcome.

     The Diagnostic and Statistical Manual uses a Five Axis system to help guide the evaluation of the psychiatric patient.
     Axis I includes major psychiatric diagnoses, such as major depression, bipolar disorder (manic depression), schizophrenia, alcohol dependence, or posttraumatic stress disorder.  Traditionally, Axis I disorders are considered by insurance companies and third party payers, to be the most serious psychiatric disorders, even though a severe Axis II disorder can be just as disabling.
     Axis II is where developmental disorders are coded; these include personality disorders and mental retardation.  The Axis I- Axis II dichotomy is somewhat controversial, particularly since an emerging body of evidence indicates a strong biological underpinning to temperament and personality.
     Axis III is where any medical disorders such as hypertension or diabetes are coded.
     Axis IV provides a six point rating scale for psychosocial stressors that contribute to the presentation of the current disorder.  The coding ranges from none to catastrophic:
 

     Note that some judgment must be used here, but there is a tendency to overrate psychosocial stressors.  Most psychiatric patients probably fall in the moderate to severe range of psychosocial stressors.
     Axis V:  Global Assessment of Functioning (GAF):  this is a scale ranging from 0 to 90, 90 being the highest functioning:
 

     Note also that every diagnosis in the DSM-IV has a numerical code associated with it and may have several modifiers.  For example, alcohol intoxication is 303.00; alcohol dependence is 303.90; and alcohol abuse 305.00.  (There is no need to memorize these numbers; they are simply given as examples.)
     V Codes:  These codes represent issues or problems that do not represent major psychiatric disorders, but may contribute to the presentation.  For example, academic problems could be coded as v62.30, malingering v65.20,  marital problems v61.10, uncomplicated bereavement v62.82.

[source:  p. 175, Kaplan; DSMIV]