• Part 1 Approach to the Patient

• Part 2 Approach to Clinical Problem Solving

• Part 3 Approach to the Diagnostic and Statistical Manual of Mental Disorders

• Part 4 Approach to Reading

Part 1. Approach to the Patient

It is a difficult transition from reading about patients with psychiatric disorders, as well as reading the diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), to actually developing a psychiatric diagnosis for a patient. It requires the clinician to understand the criteria and be able to sensitively elicit symptoms and signs from patients, some of whom have difficulty providing a clear history. The clinician must then put together the pieces of a puzzle in order to find the single best diagnosis for the patient. This process can require further information from the patient’s family, additions to the medical and psychiatric history, careful observation of the patient, a physical examination, selected laboratory tests, and other diagnostic studies. Establishing rapport and a good therapeutic alliance with patients is critical to both their diagnosis and their treatment.

HISTORY

1. Basic information:

   1. Data such as name, age, marital status, gender, occupation, and language(s) spoken other than English, if applicable, is included with identifying information. Ethnic background and religion may also be included if they are pertinent to the diagnosis.

   2. It is helpful to include the circumstances of the interview because they provide information about potentially important patient characteristics that can be relevant to the diagnosis, the prognosis, or adherence. Circumstances include where the interview was conducted (emergency setting, outpatient office, in restraints) and whether the episode reported was the first occurrence for the patient.

   3. Sources of the information obtained and their reliability should be mentioned at the beginning of the psychiatric history.

2. Chief complaint: The chief complaint should be written exactly as the patient states it, no matter how bizarre. For example, “The space aliens are attacking outside my garage so I came in for help.” Putting the statement in quotes lets readers know it is a verbatim transcription of what the patient actually said, rather than the writer’s words. Other individuals accompanying the patient can then add their versions of why the patient is presenting currently, but the chief complaint stated in the patient’s words helps with the initial formulation of a differential diagnosis. For example, if a patient comes in with a chief complaint about aliens, as just noted, one would immediately begin to consider diagnoses that have psychosis as a component and conduct the interview accordingly.

   CLINICAL PEARL

   • When recording a chief complaint in the patient’s own words, put quotation marks around the patient’s statements to indicate that they are indeed the patient’s words, not the writer’s. For example: A 45-year-old woman comes to the emergency department with the chief complaint, “I know everyone is going to try to hurt me.”

3. History of present illness (HPI): This information is probably the most useful part of the history in terms of making a psychiatric diagnosis. It should contain a comprehensive, chronological picture of the circumstances leading up to the encounter with the clinician. It is important to include details such as when symptoms first appeared, in what order, and at what level of severity, as this information is critical in making the correct diagnosis. Relationships between psychological stressors and the appearance of psychiatric and/or physical symptoms should be carefully outlined. Both pertinent positives (the patient complained of auditory hallucinations) and pertinent negatives (the patient reports no history of trauma) should be included in the HPI. In addition, details of the history such as the use of drugs or alcohol, which are normally listed in the social history, should be put in the HPI if they are thought to make a significant contribution to the presenting symptoms.

4. Psychiatric history: The patient’s previous encounters with psychiatrists and other mental health therapists should be listed in reverse chronological order, with the most recent encounters listed first. Past psychiatric hospitalizations, the treatment received, and the length of stay should be recorded. Other details, like whether or not the patient has received psychotherapy, of what kind, and for how long, are also important. Any pharmacotherapy received by the patient should be recorded, and details such as dosage, response, length of time on the drug, and adherence to the medication should be included. Any treatments with electroconvulsive therapy (ECT) should be noted as well, including the number of sessions and the associated effects.

5. Medical history: Any medical illnesses should be listed in this category along with the date of diagnosis. Hospitalizations and surgeries should also be included with their dates. Episodes of head trauma, seizures, neurologic illnesses or tumors, and positive assays for human immunodeficiency virus (HIV) are all pertinent to the psychiatric history. If it is felt that some aspect of the medical history may be directly pertinent to the current chief complaint, it should be mentioned in the HPI.

6. Medications: A list of medications, including their doses and their duration of use, should be obtained. All medications, including over-the-counter, herbal, and prescribed, are relevant and should be delineated.

7. Allergies: A list of agents causing allergic reactions, including medications and environmental agents (dust, henna, etc), should be obtained. For each, it is important to describe what reaction actually occurred, such as a skin rash or difficulty breathing. (Many patients who have a dystonic reaction to a medication consider it an allergy, although it is actually a side effect of the medication.)

8. Family history: A brief statement about the patient’s family history of psychiatric as well as medical disorders should be included. Listing each family member, his or her age, and medical or psychiatric disorders is generally the easiest, clearest way to do this.

9. Social history:

   1. The prenatal and perinatal history of the patient is relevant for all young children brought to a psychiatrist. It can also be relevant in older children and/or adults if it involves birth defects or injuries.

   2. A childhood history is important when evaluating a child and can be important in evaluating an adult if it involves episodes of trauma, long-standing personal patterns, or problems with education. For a child, issues such as age of and/or difficulty in toilet training, behavioral problems, social relationships, cognitive and motor development, and emotional and physical problems should all be included.

   3. Occupational history, including military history.

   4. Marital and relationship history.

   5. Education history.

   6. Religion.

   7. Social history, including the nature of friendships and interests.

   8. Drug and alcohol history. Both the quantity of substance(s) used and the duration of their use should be documented.

   9. Current living situation.

10. Review of systems: A systematic review should be performed with emphasis on common side effects of medications and common symptoms that might be associated with the chief complaint. For example, patients taking typical antipsychotic agents (such as haloperidol) might be asked about dry mouth, dry eyes, constipation, and urinary hesitancy. Patients with presumed panic disorder might be questioned about cardiac symptoms such as palpitations and chest pain or neurologic symptoms such as numbness and tingling.

MENTAL STATUS EXAMINATION

The mental status examination comprises the sum total of the clinician’s observations of the patient at the time of the interview. Of note is that this examination can change from hour to hour, whereas the patient’s history remains stable. The mental status examination includes impressions of the patient’s general appearance, mood, speech, actions, and thoughts. Even a mute or uncooperative patient reveals a large amount of clinical information during the mental status examination.

1. General description:

   1. Appearance: A description of the patient’s overall appearance should be recorded, including posture, poise, grooming, hygiene, and clothing. Signs of anxiety and other mood states should also be noted, such as wringing of hands, tense posture, clenched fists, or a wrinkled forehead.

   2. Behavior and psychomotor activity: Any bizarre posturing, abnormal movements, agitation, rigidity, or other physical characteristics should be described.

   3. Attitude toward examiner: The patient’s attitude should be noted using terms such as “friendly,” “hostile,” “evasive,” “guarded,” or any of a host of descriptive adjectives.

2. Mood and affect:

   1. Mood: Mood is the emotion (anger, depression, emptiness, guilt, etc) that underlies a person’s perception of the world. Although mood can often be inferred throughout the course of an interview, it is best to ask the patient directly, “How has your mood been?” Mood should be quantified wherever possible—a scale from 1 to 10 is often used. For example, a person rates his or her depressed mood as 3 on a scale of 1 to 10 where 10 is the happiest he or she has ever felt.

   2. Affect: This is the person’s emotional responsiveness during the examination as inferred from his or her expressions and behavior. In addition to the affect noted, the range (variation) of the affect during the interview, as well as its congruency with (consistency with) the stated mood, should be noted. A labile affect denotes a patient whose emotional responsiveness varies greatly (and often quickly) within the interview period. A blunted or constricted affect means that there is little variation in facial expression or use of hands; a flat affect is even further reduced in range. For example, “Ms. Jones reports that her mood is depressed (2 out of 10 where 10 is the best she has ever felt). Her affect is constricted and congruent with her mood.”

3. Speech: The physical characteristics of the patient’s speech should be described. Notations as to the rate, tone, volume, and rhythm should be made. Impairments of speech, such as stuttering, should also be noted.

4. Perception: Hallucinations and illusions reported by the patient should be listed. The sensory system involved (tactile, gustatory, auditory, visual, or olfactory) as well as the content of the hallucination (eg, “It smells like burning rubber” or “I hear two voices calling me bad names.”) should be indicated. Whereas some clinicians use perception as a separate category, others combine this section with the thought content portion of the write-up/presentation.

5. Thought process: Thought process refers to the form of thinking or how a patient thinks. It does not refer specifically to what a person thinks, which is more appropriate to the thought content. In order of most logical to least logical, thought process can be described as logical/coherent, circumstantial, tangential, flight of ideas, loose associations, and word salad/incoherence. Neologisms, punning, or thought blocking also should be mentioned here.

6. Thought content: The actual thought content section should include delusions (fixed, false beliefs), paranoia (a form of delusion), preoccupations, obsessions and compulsions, phobias, ideas of reference, poverty of content, and suicidal and homicidal ideation. Patients with suicidal or homicidal ideation should be asked whether, in addition to the presence of the ideation, they have a plan for carrying out the suicidal or homicidal act as well as their intent to do so.

7. Sensorium and cognition: This portion of the mental status examination assesses organic brain function, intelligence, capacity for abstract thought, and levels of insight and judgment. The basic tests of sensorium and cognition are performed on every patient. Those whom the clinician suspects are suffering from an organic brain disorder can be tested with further cognitive tests beyond the scope of the basic mental status examination.

   1. Consciousness: Common descriptors of levels of consciousness include “alert,” “somnolent,” “stuporous,” and “clouded consciousness.”

   2. Orientation and memory: The classic test of orientation is to discern the patient’s ability to locate himself or herself in relation to person, place, and/or time. Any impairment usually occurs in this order as well (ie, a sense of time is usually impaired before a sense of place or person). Memory is divided into four areas: immediate, recent, recent past, and remote. Immediate memory is tested by asking a patient to repeat numbers after the examiner, in both forward and backward orders. Recent memory is tested by asking a patient what he or she ate for dinner the previous night and asking if he or she remembers the examiner’s name from the beginning of the interview. Recent past memory is tested by asking about news items publicized in the past several months, and remote memory is assessed by asking patients about their childhood. Note that information must be verified to be sure of its accuracy because confabulation (making up false answers when memory is impaired) can occur.

   3. Concentration and attention: Subtracting serial 7s from 100 is a common way of testing concentration. Patients who are unable to do this because of educational deficiencies can be asked to subtract serial 3s from 100. Attention is tested by asking a patient to spell the word “world” forward and backward. The patient can also be asked to name five words that begin with a given letter.

   4. Reading and writing: The patient should be instructed to read a given sentence and then do what the sentence asks, for example, “Turn this paper over when you have finished reading.” The patient should also be asked to write a sentence. Examiners should be aware that illiteracy might impact a patient’s ability to follow instructions during this part of the examination.

   5. Visuospatial ability: The patient is typically asked to copy the face of a clock and fill in the numbers and hands so that the clock shows the correct time. Images with interlocking shapes or angles can also be used—the patient is asked to copy them.

   6. Abstract thought: Abstract thinking is the ability to deal with concepts. Can patients distinguish the similarities and differences between two given objects? Can patients understand and articulate the meaning of simple proverbs? (Be aware that patients who are immigrants and/or have learned English as a second language can have difficulty with proverbs for this reason rather than because of a mental status disturbance.)

   7. Information and intelligence: Answers to questions related to a general fund of knowledge (presidents of the United States, mayors of the city in which the mental status examination is conducted), vocabulary, and the ability to solve problems are all factored in together to come up with an estimate of intelligence. A patient’s educational status should be taken into account as well.

   8. Judgment: During the course of the interview, the examiner should be able to get a good idea of the patient’s ability to understand the likely outcomes of his or her behavior and whether or not this behavior can be influenced by knowledge of these outcomes. Having the patient predict what he or she would do in an imaginary scenario can sometimes help with this assessment. For example, what would the patient do if he or she found a stamped envelope lying on the ground?

   9. Insight: Insight is the degree to which a patient understands the nature and extent of his or her own illness. Patients can express a complete denial of their illnesses or progressive levels of insight into knowing that there is something wrong within them that needs to be addressed.

PHYSICAL EXAMINATION

The physical examination can be an important component of the assessment of a patient with a presumed psychiatric illness. Many physical illnesses masquerade as psychiatric disorders and vice versa. For example, a patient with hypothyroidism can first present to a psychiatrist with symptoms of major depression. Thus, an examiner should be alert to all of a patient’s signs and symptoms, physical and mental, and be prepared to perform a physical examination, especially in an emergency department setting. Some patients can be too agitated or paranoid to undergo parts of the physical examination, but when possible, all elements should be completed.

1. General appearance: Cachectic versus well nourished, anxious versus calm, alert versus obtunded.

2. Vital signs: Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, height, and weight.

3. Head and neck examination: Evidence of trauma, tumors, facial edema, goiter (indicating hyper- or hypothyroidism), and carotid bruits should be sought. Cervical and supraclavicular nodes should be palpated.

4. Breast examination: Inspection for symmetry, skin or nipple retraction with the patient’s hands on hips (to accentuate the pectoral muscles) and with arms raised. With the patient supine, the breasts should then be palpated systematically to assess for masses. The nipple should be examined for discharge, and the axillary and supraclavicular regions for adenopathy.

5. Cardiac examination: The point of maximal impulse should be ascertained, and the heart auscultated at the apex of the heart as well as at the base. Heart sounds, murmurs, and clicks should be characterized.

6. Pulmonary examination: The lung fields should be examined systematically and thoroughly. Wheezes, rales, rhonchi, and bronchial breath sounds should be recorded.

7. Abdominal examination: The abdomen should be inspected for scars, distension, masses or organomegaly (ie, spleen or liver), and discoloration. Auscultation of bowel sounds should be accomplished to identify normal versus high-pitched and hyperactive versus hypoactive sounds. The abdomen should be percussed for the presence of shifting dullness (indicating ascites), and palpated to assess liver span and the presence or absence of masses.

8. Back and spine examination: The back should be assessed for symmetry, tenderness, or masses. Costovertebral angle tenderness should be documented.

9. Pelvic and/or rectal examination: Although these examinations are not often done in the emergent setting of psychiatric illness, it is important to realize that many patients with a psychiatric illness do not see their health care providers regularly and that these important preventive maintenance procedures are often neglected. Patients should be reminded of the need for these examinations.

10. Extremities and skin: The presence of tenderness, bruising, edema, and cyanosis should be recorded.

11. Neurologic examination: Patients require a thorough assessment, including evaluation of the cranial nerves, strength, sensation, gait, and reflexes.

LABORATORY TESTS

Compared to other medical practitioners, psychiatrists depend more on the patient’s signs and symptoms and the clinician’s examination than on laboratory tests. There are no definitive assays for bipolar disorder, schizophrenia, or major depression. However, assays can be used to identify potential medical problems appearing as psychiatric disturbances, as well as to look for substances such as lysergic acid diethylamide (LSD) or cocaine in a patient’s system. Laboratory tests are also useful in long-term monitoring of medications, such as lithium and valproic acid.

1. Screening tests

   1. A complete blood count (CBC) to assess for anemia and thrombocytopenia

   2. Renal function tests

   3. Liver function tests

   4. Thyroid function tests

   5. Laboratory studies to determine levels of chloride, sodium, potassium, bicarbonate, blood urea nitrogen, creatinine, and serum glucose

   6. Urine toxicology or serum toxicology tests when drug use is suspected

2. Tests related to psychotropic drugs

   1. Lithium: A white blood cell (WBC) count, serum electrolyte determination, thyroid and renal function tests (specific gravity, blood urea nitrogen [BUN], and creatinine), fasting blood glucose determination, pregnancy test, and an electrocardiogram (ECG) are recommended before treatment and yearly thereafter (every 6 months for thyroid-stimulating hormone [TSH] and creatinine levels). Lithium levels should also be monitored at least every 3 months once the patient has been stabilized on the medication.

   2. Clozapine: Because of the risk of developing agranulocytosis, patients taking this medication should have their WBC and differential count measured at the onset of treatment, weekly during treatment for the first 6 months, every other week during chronic treatment, and for 4 weeks after discontinuation of treatment.

   3. Tricyclic and tetracyclic antidepressants: An ECG should be obtained before a patient begins treatment with these medications.

   4. Carbamazepine: A pretreatment CBC should be obtained to assess for agranulocytosis. A CBC should be drawn every 2 weeks for the first 2 months of treatment, and thereafter, once every 3 months. Platelet, reticulocyte, and serum iron levels should also be determined, and all these tests performed yearly thereafter. Liver function tests should be performed initially, every month for the first 2 months of treatment, and every 3 months thereafter. Carbamazepine levels should be monitored this often as well. Serum electrolytes and an ECG should be done before treatment and yearly thereafter as well.

   5. Valproate: Valproate levels should be monitored every 6 to 12 months, along with liver function tests. Because this drug is teratogenic, pregnancy tests should be drawn before initiating this drug.

3. Psychometric testing

   1. Structured clinical diagnostic assessments

      1. Tests based on structured or semi-structured interviews designed to produce numerical scores.

      2. Scales useful in determining the severity of an illness and in monitoring the patient’s recovery.

      3. Examples: Beck Rating Scale for Depression, Hamilton Anxiety Rating Scale, Brief Psychiatric Rating Scale, and Structured Clinical Interview for DSM-5 Dissociative Disorders (SCID-5).

   2. Psychological testing of intelligence and personality

      1. Tests designed to measure aspects of the patient’s intelligence, ability to process information, and personality.

      2. Tests generally administered by psychologists trained to administer and interpret them.

      3. These tests play a relatively small role in the diagnosis of psychiatric illness; the psychiatric interview and other observable signs and symptoms play a much larger role. These tests are therefore reserved for special situations.

      4. Objective tests generally consisting of pencil-and-paper examinations based on specific questions. They yield numerical scores and are statistically analyzed.

         1. Minnesota Multiphasic Personality Inventory: This self-report inventory is widely used and has been thoroughly researched. It assesses personality using an objective approach.

         2. Projective tests: These tests present stimuli that are not immediately obvious. The ambiguity of the situation forces patients to project their own needs into the test situation. Therefore, there are no right or wrong answers.

            1. Rorschach test: This projective test is used to assess personality. A series of 10 inkblots are presented to the patient, and the psychologist keeps a verbatim record of the patient’s responses to each one. The test brings the patient’s thinking and association patterns into focus. In skilled hands, it is helpful in bringing out defense mechanisms, subtle thought disorders, and pertinent patient psychodynamics.

            2. Thematic Apperception Test (TAT): This test also assesses personality but does so by presenting patients with selections from 30 pictures and 1 blank card. The patient is required to create a story about each picture presented. Generally, the TAT is more useful for investigating personal motivation (eg, why a patient does what he or she does) than it is for making a diagnosis.

            3. Sentence completion test: A projective test in which the patient is given part of a sentence and asked to complete it. It taps the unconscious associations of the patient to locate areas of functioning in which the interviewer is interested. For example, “My greatest fear is.…”

         3. Intelligence tests: These tests are used to establish the degree of intellectual disability in situations where this is the question. The Wechsler Adult Intelligence Scale is the test most widely used in clinical practice today.

         4. Neuropsychologic tests: The aim of these tests is to compare the patient being tested with the general populaton of similar background and age. They are used to identify cognitive deficits, assess the toxic effects of substances, evaluate the effects of treatment, and identify learning disorders.

            1. Wisconsin Card Sorting Test: This test assesses abstract reasoning and flexibility in problem solving by asking the patient to sort a variety of cards according to principles established by the rater but not known to the sorter. Abnormal responses are seen in patients with damaged frontal lobes and in some patients with schizophrenia.

            2. Wechsler Memory Scale: This is among the most widely used battery of tests for adults. It tests rote memory, visual memory, orientation, and counting backward, among other dimensions. It is sensitive to amnestic conditions such as Korsakoff syndrome.

            3. Bender Visual-Motor Gestalt Test: A test of visuomotor coordination. Patients are asked to copy nine separate designs onto unlined paper. They are then asked to reproduce the designs from memory. This test is used as a screening device for signs of organic dysfunction.

4. Further diagnostic tests

   1. Additional psychiatric diagnostic interviews (eg, the Diagnostic Interview Schedule for Children)

   2. Interviews conducted by a social worker with family members, friends, or neighbors

   3. Electroencephalogram to rule in or rule out a seizure disorder

   4. Computed tomography scan to assess intracranial masses

   5. Magnetic resonance imaging to assess intracranial masses or any other neurologic abnormality

   6. Tests to confirm other medical conditions

Part 2. Approach to Clinical Problem Solving

A clinician typically undertakes four distinct steps to solve most clinical problems in a systematic fashion:

1. Making a diagnosis

2. Assessing the severity of the disease

3. Selecting treatment based on the disease

4. Following the patient’s response to the treatment

MAKING A DIAGNOSIS

A diagnosis is made by careful evaluation of the database, analysis of the information, assessment of the risk factors, and development of a list of possibilities (the differential diagnosis). The process involves knowing which pieces of information are meaningful and which can be discarded. Experience and knowledge help the clinician “key in” on the most important possibilities. A good clinician also knows how to ask the same question in several different ways by using different terminology. For example, patients at times can deny having been treated for bipolar disorder but answer affirmatively when asked if they have been hospitalized for mania. A diagnosis can be reached by systematically reading about each possible disease. The patient’s presentation is then matched up against each of the possibilities, and each disorder is moved higher up or lower down on the list as a potential etiology based on the prevalence of the disease, the patient’s presentation, and other clues. The patient’s risk factors can also influence the probability of a diagnosis.

Usually, a long list of possible diagnoses can be pared down to the two or three most likely ones based on a careful delineation of the signs and symptoms displayed by the patient, as well as on the time course of the illness. For example, a patient with a history of depressive symptoms, including problems with concentration, sleep, and appetite, and symptoms of psychosis that started after the mood disturbances may have major depression with psychotic features, whereas a patient with a psychosis that started before the mood symptoms may have schizoaffective disorder.

ASSESSING THE SEVERITY OF THE DISEASE

After ascertaining the diagnosis, the next step is to characterize the severity of the disease process; in other words, describe “how bad” it is. With a malignancy, this is done formally by staging the cancer. With some infections, such as syphilis, staging depends on the duration and extent of the infection and follows its natural history (ie, primary syphilis, secondary syphilis, latent period, and tertiary/neurosyphilis). Some major mental illnesses, such as schizophrenia, can be characterized as acute, chronic, or residual, whereas the same clinical picture, occurring with less than 6-month duration, is termed schizophreniform disorder. Other notations frequently used in describing psychiatric illnesses include “mild,” “moderate,” “severe,” “in partial remission,” and “in full remission.”

SELECTING TREATMENT BASED ON THE DISEASE

Many illnesses are stratified according to severity because prognosis and treatment often vary based on these factors. For example, some patients with suicidal ideation but no intent or plan can be treated as outpatients, but other patients who report intent and a specific plan must be immediately hospitalized and even committed involuntarily if necessary. If neither the prognosis nor the treatment is influenced by the stage of the disease process, there is no reason to subcategorize a disease as mild or severe.

FOLLOWING THE PATIENT’S RESPONSE TO TREATMENT

The final step in the approach is to follow the patient’s response to the therapy. The measure of response should be recorded and monitored. Some responses are clinical, such as improvement (or lack of improvement) in the level of depression, anxiety, or paranoia. Obviously, the student must work on becoming skilled in eliciting the relevant data in an unbiased, standardized manner. Other responses can be followed by laboratory tests, such as a urine toxicology screening for a cocaine abuser or a determination of lithium level for a bipolar patient. The student must be prepared to know what to do if the test does not return the result expected. Is the next step to reconsider the diagnosis, to repeat the test, or to confront the patient about the findings?

Part 3. Approach to the Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, currently in its 5th edition, (DSM-5), is published by the American Psychiatric Association. It is the official psychiatric coding system used in the United States. The DSM-5 describes mental disorders and rarely attempts to account for how these disturbances come about. Specified diagnostic criteria are presented for each disorder and include a list of features that must be present for the diagnosis to be made. The DSM-5 also systematically discusses each disorder in terms of its associated descriptors such as age, gender, prevalence, incidence, and risk; course; complications; predisposing factors; familial pattern; and differential diagnosis.

The DSM-5 no longer uses a five-axis system that evaluates patients along several dimensions, as was done in the previous DSM-IV-TR. In order to help readers make the change to DSM-5, a brief discussion of the DSM-IV-TR axes will be given, immediately followed by a comparison to the new DSM-5 methodology.

In DSM-IV-TR, Axes I and II made up the entire classification of mental disorders. The five-axis diagnosis usually appeared at the end of a write-up in the assessment section.

• Axis I: Clinical disorders and other disorders that were the focus of clinical attention such as schizophrenia and major depression.

• Axis II: Personality disorders and intellectual disability only.

• Axis III: Physical disorders and other general medical conditions. The physical condition could be causing the psychiatric one (eg, delirium, coded on Axis I, caused by renal failure, coded on axis III), be the result of a mental disorder (eg, alcoholic cirrhosis, coded on Axis III, secondary to alcohol dependence, coded on Axis I), or be unrelated to the mental disorder (eg, chronic diabetes mellitus).

• DSM-5 changes: DSM-5 has gone to a nonaxial documentation of diagnosis (formerly Axes I, II, and III). This is in keeping with the idea that mental disorders are related to physical or biological factors or processes, and that general medical conditions are related to behavioral and/or psychosocial factors or processes. In the documentation of mental disorders, providers should now document other pertinent medical disorders as part of the diagnosis too. In DSM-5, the new notations of diagnosis (medical and psychiatric), with separate notations for psychosocial and contextual factors, and for disability (functioning), should all be included at the end of a write-up in the assessment section.

• Axis IV: This axis was used to code the psychosocial problems contributing to the patient’s psychiatric problem. Information about these stressors can be helpful when it is time to develop treatment plans for the patient. Problems could include those involving the primary support group, educational problems, job problems, housing problems, economic problems, problems with access to health care, or problems related to the legal system/crime.

• DSM-5 changes: DSM-5 now recommends that a selected set of the ICD-9-CM V codes and the new Z codes contained in ICD-10-CM be used to document psychosocial and environmental problems that may affect the patient’s diagnosis, treatment, and prognosis. (Axis IV will no longer be used per se, though the important information that it used to convey will be kept as above.)

• Axis V: This axis was used to provide a global assessment of functioning (GAF). The scale was based on a continuum of health and illness, using a 100-point scale on which 100 was the highest level of functioning. People who had high GAF values before an episode of illness often had a better prognosis than those whose functioning was at a lower level premorbidly.

• DSM-5 changes: DSM-5 recommends that the GAF be dropped because of questionable psychometrics and a general lack of clarity. Instead, it is suggested that clinicians use the WHO Disability Assessment Schedule (WHODAS) to provide a global measure of disability.

Part 4. Approach to Reading

The clinical problem-oriented approach to reading is different from the classic “systematic” researching of a disease. Patients rarely present with symptoms that permit a clear diagnosis; hence, the student must become skilled in applying textbook information in the clinical setting. Furthermore, a reader retains more information when reading with a purpose. In other words, the student should read with the goal of answering specific questions. There are several fundamental questions that facilitate clinical thinking:

1. What is the most likely diagnosis?

2. What should the next step be?

3. What is the most likely mechanism for this process?

4. What are the risk factors for this condition?

5. What complications are associated with this disease process?

6. What is the best therapy?

7. How can you confirm the diagnosis?

Note that Questions 3 and 4 are used less in the field of psychiatry than in other specialties, such as medicine, where the pathophysiology and risk factors of a particular disease process may be known. Likewise, confirmation of a diagnosis (Question 7) is less often made by further laboratory tests or other diagnostic studies but can be achieved by carefully obtaining additional history from family, colleagues, and so on. The preceding questions should, however, be kept in mind for all patients.

WHAT IS THE MOST LIKELY DIAGNOSIS?

The method of establishing a diagnosis was covered in the previous section. One way to attack this problem is to develop standard “approaches” to common clinical situations. It is helpful to understand the most common presentation of a variety of illnesses, for example, a common presentation of major depression.

The clinical scenario might be the following:

A 36-year-old woman presents to her physician with the chief complaint of a depressed mood and difficulty sleeping. What is the most likely diagnosis?

With no other information to go on, the student notes the depressed mood and the vegetative symptom of insomnia. Using the “common presentation” information, the student might make an educated guess that the patient has a major depressive disorder.

However, what if the scenario also includes the following?

She states that she has been depressed and has had trouble sleeping since she was raped 2 weeks ago.

Then the student would use the clinical pearl: A diagnosis of acute stress disorder should be considered in a patient with a depressed mood, insomnia, and a history of recent trauma.

WHAT SHOULD THE NEXT STEP BE?

This question is difficult because the next step has many possibilities: obtain more diagnostic information, rate the severity of the illness, or introduce therapy. It is often a more challenging question than what is the most likely diagnosis because there can be insufficient information to make a diagnosis and the next step can be to pursue more diagnostic information. Another possibility is that there is enough information for a probable diagnosis and that the next step is to assess the severity of the disease. Finally, the most appropriate answer can be to start treatment. Hence, based on clinical data, a judgment needs to be rendered regarding how far along one is in the following process:

Frequently, students are taught to “regurgitate” information that someone has written about a particular disease but are not skilled in describing the next step. This ability is learned optimally at the bedside, in a supportive environment, with freedom to make educated guesses, and with constructive feedback. A sample scenario describes a student’s thought process as follows:

1. Make a diagnosis: “Based on the information I have, I believe that Ms. Smith has major depression because she has a depressed mood, problems with concentration, anhedonia, insomnia, loss of appetite, anergia, and an unintentional weight loss of 10 lb in 3 weeks.”

2. Stage the severity of the disease: “I don’t believe that this is severe disease because the patient does not have suicidal ideation or any psychotic symptoms. I don’t think the patient needs to be hospitalized at this time either.”

3. Treat based on the severity of the disease: “Therefore, my next step is to treat her with a selective serotonin reuptake inhibitor (SSRI) such as paroxetine.”

4. Follow the response: “I want to follow the treatment by assessing her depressed mood (I will ask her to rate her mood on a scale of 1 to 10 weekly), her insomnia (I will ask her to keep a sleep log), and her appetite (I will weigh her weekly).”

In a similar case, when the clinical presentation is unclear, perhaps the best next step should be diagnostic in nature, such as a thyroid function test to rule out hypothyroidism.

WHAT IS THE LIKELY MECHANISM FOR THIS PROCESS?

This question goes further than making the diagnosis and also requires the student to understand the underlying mechanism of the process. For example, a clinical scenario can describe a 26-year-old man who develops a sudden onset of blindness 3 days after being told of his mother’s death. The student must first diagnose a conversion disorder, which can occur after an emotionally traumatic event, once physical explanations for blindness have been ruled out. Then the student must understand that there is a psychodynamic explanation for the particular nature of the symptoms as they have arisen. The mechanism for the conversion disorder, blindness in this scenario, is the patient’s fear (and guilt) about never “seeing” his mother again. Although many mechanisms of disease are not well understood in psychiatry at the present time, it is anticipated that they will be further elucidated as the fields of neuropsychiatry and neuroimaging continue to grow.

WHAT ARE THE RISK FACTORS FOR THIS PROCESS?

Understanding the risk factors helps a practitioner establish a diagnosis and determine how to interpret tests. For example, understanding the risk factor analysis can help in treating a 56-year-old man who presents to a clinician with a chief complaint of loss of memory. If the man does not have a family history of (and thus a risk for) Huntington chorea, an autosomally transmitted disease, the workup for memory loss would not likely include an examination of his genotype. Thus, the presence of risk factors helps categorize the likelihood of a disease process.

WHAT ARE THE COMPLICATIONS OF THIS PROCESS?

Clinicians must be cognizant of the complications of a disease so that they understand how to follow and monitor the patient. Sometimes the student has to make a diagnosis from clinical clues and then apply the knowledge of the consequences of the pathologic process. For example, a woman who presents with a depressed mood, anhedonia, anergia, loss of concentration, insomnia, and weight loss is first diagnosed as having major depression. A complication of this process includes psychosis or suicidal ideation. Therefore, understanding the types of consequences helps the clinician to become aware of the dangers to the patient. Not recognizing these possibilities might lead the clinician to miss asking about psychotic symptoms (and treating them) or to overlook a potentially fatal suicidal ideation.

WHAT IS THE BEST THERAPY?

To answer this question, the clinician needs to make the correct diagnosis, assess the severity of the condition, and weigh the situation to determine the appropriate intervention. For the student, knowing exact doses is not as important as understanding the best medication, route of delivery, mechanism of action, and possible complications. It is important for the student to be able to verbalize the diagnosis and the rationale for the therapy. A common error is for a student to jump to a treatment by making a random guess; as a result, he or she receives correct or incorrect feedback. In fact, the student’s guess can be correct, but for the wrong reason; conversely, the answer can be a reasonable one with only one small error in thinking but can simply be labeled “wrong.” Instead, the student should verbalize the steps so that feedback can be given at every reasoning point.

For example, if the question is what is the best therapy for a 24-year-old woman with an elated mood, lack of a need for sleep, excessive buying behavior, hypersexuality, and psychomotor agitation, the incorrect manner of responding is for the student to blurt out “a mood stabilizer.” Rather, the student’s reasoning should resemble the following: “The most common cause of these kinds of symptoms is mania, which would make the diagnosis bipolar disorder. There was no mention of a general medical condition (such as hyperthyroidism) or a substance abuse problem (such as cocaine use) that would account for these symptoms. Therefore, the best treatment for this patient with probable bipolar disorder would be lithium or valproic acid (after the final diagnosis is made).”

HOW CAN YOU CONFIRM THE DIAGNOSIS?

In the previous scenario, the 24-year-old woman is likely to have bipolar disorder, manic phase. Confirmation can be achieved by obtaining an additional history of manic or depressive episodes from the patient and/or from family members and friends who have observed her behavior over a period of time. Further information about the presence of other symptoms common in mania can also be helpful, as is ruling out any general medical conditions or substance abuse problems. The student should strive to know the limitations of various diagnostic tests and the manifestations of disease.

SUMMARY

1. There is no replacement for a meticulously constructed history and physical examination.

2. There are four steps in the clinical approach to a patient: making a diagnosis, assessing the severity of the disease, treating based on the severity of the disease, and following the response to treatment.

3. There are seven questions that help bridge the gap between the textbook and the clinical arena.

4. The DSM-5 has moved to a nonaxial system to delineate patient presentations/disorders. These include the diagnosis (formerly Axes I, II, and III), an assessment of psychosocial and environmental/contextual stressors (formerly Axis IV), and a global assessment of disability (formerly Axis V) using the WHODAS.

References