What Every Medical Student Should Know About Psychiatry

  1. How to do a good mental status exam
  2. Some appreciation of the bread and butter psychiatric diagnoses and how they are organized in the DSM-IV; no one expects you to make the correct diagnosis, but it helps to be in the right ballpark:
  3. Primary Affective, e.g., major depression, bipolar disorder

    Primary Psychotic, e.g., schizophrenia

    Organic (including substance abuse), e.g., delirium, alcohol dependence

    Hybrid: e.g., schizoaffective disorder, cocaine dependence and chronic paranoid schizophrenia; borderline personality disorder and dysthymia.

  4. Some appreciation of the tremendous overlap between psychiatric and medical illness.


The Mental Status Exam


Elements of the mental status exam:

 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.


 Orientation:  to person; place; time; and situation. 

 Behavior and Motor Activity


 Thought Content:  pertinent positive and negative signs and symptoms:


Delusions:  fixed, false, idiosyncratic beliefs. 

Ideas of reference:  special messages from the television, radio, or other objects  Suicidal ideation:  no mental status exam complete without. Intent? Plan?

Homicidal ideation:  Intent? Plan? Target?

Thought Process:  assessment of flow of thoughts; pertinent positives/negatives:

 Flight of ideas



 Loose associations
 Mood and Affect:  Mood is what the patient describes; affect is what you observe.  


Serial 7s or coin manipulation

Proverb Interpretation

Vocabulary and diction (adjusted for culture and education)

 Insight and Judgment

Insight = patient's awareness of themselves and their condition. 

Judgment = global term most narrowly used to assess a patient's ability to avoid harmful behavior





Diagnostic and Statistical Manual, Fourth Edition (DSM-IV)

The Five Axis Classification System

     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

     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:

 None: no identifiable stressors.
 Mild:  starting graduate school, having a child leave home.
 Moderate:  marriage, marital separation, loss of job.
 Severe:  divorce, birth of first child, extreme poverty.
 Extreme:  death of  a spouse, serious physical illness, or victim of rape, serious illness in self or child, ongoing sexual or physical abuse.
 Catastrophic:  suicide of spouse, concentration camp victim, natural disaster.

     Axis V:  Global Assessment of Functioning (GAF):  this is a scale ranging from 0 to 90, 90 being the highest functioning:

 90:  no symptoms or dysfunction.
 80: transient symptoms.
 70: mild, e.g., depressive mood or insomnia, mild difficulty in social or occupational functioning.
 60: moderate symptoms, e.g., flat affect, circumstantial speech, panic attacks, moderate difficulty in social or occupational functioning.
 50:  serious symptoms, e.g., suicidal ideation, frequent shoplifting, obsessive rituals.
 40:  some impairment in reality testing or serious difficulty in multiple areas.
 30:  behavior influenced by severe psychiatric symptoms, e.g., delusions, suicidal ideation, or auditory or visual hallucinations.
 20:  some danger of hurting self or others.
 10:  persistent danger to self or others, or complete inability to attend to personal hygiene.

     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.