PSCHIATRY

Objectives

By the end of the psychiatry rotation, a medical student is expected to have a good understanding of the following:

 Practical skills

o Conducting a systematic psychiatric interview

o Performing and documenting a comprehensive MSE

o Providing psychiatric patient counseling (including motivational interviewing)

o Displaying professional conduct and empathic attitude towards all psychiatric patients and their families

o Establishing a therapeutic alliance with less compliant psychiatric patients (e.g., psychotic, aggressive, or
suicidal patients)

o Accessing and interpreting psychiatric evidence-based data and scientific literature

o Performing a differential diagnosis between primary and secondary causes of psychiatric disorders

o Being able to collaborate with each member of the multidisciplinary team involved in psychiatric
patients care

 Clinical knowledge

o DSM-5 criteria for the most common mental disorders

o Pathophysiology, clinical findings, diagnosis, and treatment of the most common primary and secondary
mental disorders

o Mechanisms of action, major side effects, indications, and contraindications of the most commonly
used psychotropic drugs

o Common drug interactions

o Most common drugs of abuse and their side effects

 When seeing a patient with a history of violent/aggressive behavior, remember to leave the door of the
examination room open, position yourself near the door, and make sure the patient does not block the exit.
Also, never wear items that the patient could easily pull or grab.
History taking
General information

 History taking is a very important part of the psychiatric patient encounter and it usually takes longer compared
to other rotations.

 The etiology of every patient's psychiatric condition is unique and thus requires a unique approach to  history
taking.

o Familiarizing yourself with the specifics of your patient's disease and its contributing factors (e.g., certain
stressors, family history) will help you to understand your patient better and allow you to construct a
more well-rounded management plan.

o Make first observations regarding the patient's behavior, as this will be important for the MSE later.

 An important goal of history taking is building rapport with the patient.

o Make the patient comfortable:

 Choose an appropriate location: quiet room, comfortable seating options

 Minimize disturbances: If possible, mute your telephone and put up a “do not disturb” sign.

 Limit the number of people present: If possible, it should only be you and the patient.

o Be compassionate and respectful.

o Start with open-ended questions (e.g., “How are you feeling today?”), as this will encourage the patient
to speak freely.

o If you want to learn more about a specific detail of the patient's history or guide the patient during the
interview, use close-ended questions (e.g., “Do you feel guilty about what happened?”).

o Make use of reflective listening to ensure that you have understood everything correctly and to show
the patient that you are listening.

o Avoid using overly complicated language/medical terminology.

1. An important goal of psychiatric history taking is building rapport with the patient.

2. Interviewing psychiatric patients usually takes longer than interviewing patients during other clinical rotations.

History of the present illness

Keep in mind that the order given below is not fixed. If the patient does not feel comfortable talking about their
psychiatric symptoms, you can start the interview with less intimate topics that would help establish a connection with
the patient (e.g., social history, family history).

 General information: age, gender, ethnic and cultural background

 Source of information: patient or a family member/friend

 Chief symptoms: should include the patient's own words

 History of the present illness

o Symptoms

 Presentation
  Duration

 Severity

 Longitudinal development: episodic, chronic

 Modifying factors (e.g., stress)

o Reason for patient's visit

o Effect on social and occupational functioning

o Neurovegetative symptoms: changes in appetite, weight, sleep, energy, sexual functioning

o Features of specific psychiatric illnesses (e.g., pertinent positives and negatives)

o Current substance use

o Suicidal ideation or homicidal ideation

 Psychiatric history

o History of psychiatric conditions

o Previous psychiatric hospitalization: when, where, and why

o Use of psychotropic medications: drugs, dosages, effectiveness, and side effects

o Suicide attempts or self-harm: why, when, how

o Past medical records available to consult

 History of substance use

o For each used substance:

 Age of first use

 Recent and lifetime usage

 Frequency and quantity: minimum, maximum, average

 Route of administration: oral, IN, IV, IM

 Consequences of use: health issues, family problems, job demotion, civil disobedience

o Association between substance use and psychiatric symptoms

o History of withdrawal symptoms

o Attempted sobriety/participation in rehabilitation programs

 Medical history

o Current medical problems

o Neurological history (e.g., head trauma, seizures)

o Medications: both prescribed and over-the-counter

o Allergies

 Developmental history
 o Pregnancy and birth: complications, exposure to embryotoxic substances

o Achievement of developmental milestones

o History of childhood diseases

 Social history

o Education and employment

o Place of residence and who they live with

o Relationships: marital status, friendships

o Number of children

o Support system: family, friends

o Religious or spiritual beliefs

o Sexual history and sexual orientation

o History of trauma or abuse: verbal, physical, sexual

o Legal history

 Family history

o Background: ethnic, socioeconomic, religious

o Psychiatric disorders

o Familial diseases

 Emergency contact information

 Adjust the interview on a case-by-case basis, as each psychiatric patient is unique and thus requires a unique
approach.

Mental status examination (MSE)

 The MSE is an important diagnostic tool in neurological and psychiatric practice, that is used to assess a patient's
mental state and behaviors both quantitatively and qualitatively based on the following criteria:

o Appearance and behavior

o Speech

o Mood and affect

o Thought process and content

o Perceptual disturbances

o Sensorium and cognition

o Insight and judgment at a specific point in time

 See the mental status examination article for more information.

 Do not confuse the Mental Status Examination (MSE) with the Mini-Mental Status Examination (MMSE). The MSE is
used to thoroughly assess the behavioral and cognitive functioning of psychiatric patients, whereas the MMSE is
used as a screening tool for dementia.

Physical examination

 Although history taking is the primary focus of psychiatric clinical examination, a thorough physical

examination of every new patient is essential. It is not always possible to easily differentiate between primary
mental disorders and insidious life-threatening secondary causes of psychiatric symptoms (e.g.,
infectious encephalitis, brain tumor).

 A very important part of the physical exam is the neurological examination.

 For more details on specific examinations, see:

o Neurological examination

o Head and neck examination

o Cardiovascular examination

o Pulmonary examination

o Abdominal examination
Appropriate professional conduct

 Be compassionate and respectful: Under no circumstances is it acceptable to make fun of the patients.

 Do not worry if a patient asks you to leave the room: Some patients might feel ashamed about their condition or
specific details and do not want students involved in their care.

 Patients may lie to you

o Try to remain objective.

o Report back what the patient told you and explain to your team why you think the patient may have
lied.

o Do not confront the patient, but try to understand why the patient may have concealed the truth.

 Under no circumstances confront patients about their delusions: It is more advisable to express confusion and
ask for clarification in the politest way possible (e.g., “I am confused, I thought ….; could you help me clarify
that?”).

 Try not to be easily offended: Psychiatric patients may speak to you in a disrespectful manner. Remind yourself
that it has nothing to do with you, and is most likely because the patient is in a bad place at the moment.

 Try to de-escalate tense situations: Remain calm and try your best to calm down agitated patients.
  Be aware of your language and affect: If you look anxious, patients might feel similar and respond to that with
aggression.

 Do not hesitate to ask for help if you are unsure about something.

 Listen to the nurses: They spend more time with patients than you do and therefore may have a lot of valuable
information. It is possible that patients have told the nurses something they did not tell you.

 Never forget to do a risk assessment: While it may be uncomfortable, it is absolutely essential to ask patients
about thoughts of suicide, self-harm, and thoughts of harming others.

 Remember that safety comes first: Be cautious with patients who have a history of violent/aggressive behavior.
Ask the staff for guidance when you are about to interview a patient with such a history.

 Humor, when appropriately applied in the clinical setting, can help build patient rapport and trust. Remember,
though, that this approach might not be applicable to every psychiatric patient and therefore should be used
with caution.

Tips for the psychiatry shelf exam

 Familiarize yourself with the diagnostic criteria and timelines for anxiety disorders, mood
disorders, psychotic disorders, and personality disorders. 
 Remember the differences between schizophrenia, schizophreniform disorder, schizotypal personality
disorder, and schizoid personality disorder.
 Since the question stems are long, timing could be your greatest challenge:
o Be wary of the multitude of details in the question stem and learn how to filter them by
practicing questions beforehand.
o Skip questions you are unsure about, and focus on winning points from the ones you know
the answer to.
 As there will be a lot of questions on psychotropic drugs, make sure to learn their most common side
effects, and skip the general, less common details.
 If possible, try scheduling your psychiatry and neurology shelf exams consecutively, as there tends to be
an overlap in the covered topics.

Remember the differences between schizophrenia, schizophreniform disorder, schizotypal personality

disorder, and schizoid personality disorder.
 MENTAL STATUS EXAMINATION
Summary

The mental status examination (MSE) is an important diagnostic tool in both neurological and psychiatric practice. MSE
is used to describe a patient's mental state and behaviors, both quantitatively and qualitatively, at a specific point in
time. The main components of an MSE are appearance and behavior, mood and affect, speech, thought process and
content, perceptual disturbances, sensorium and cognition, and insight and judgment. The clinician conducting an MSE
collects data by observing the interviewed individual's behavior and asking specific questions. The findings of the MSE
summarize the results of a psychiatric examination on a comprehensive, cross-sectional level. When integrated with the
interviewee's biographical information and psychiatric history, MSE findings form the basis for diagnostic and
therapeutic decisions. A thorough MSE also provides essential information for establishing a diagnosis according to DSM-
5 criteria.

When conducting the MSE or interpreting MSE findings, it is important to consider the cultural background of both the
clinician conducting the MSE and the interviewee because behavioral patterns vary significantly across cultures (e.g.,
nodding your head as a sign of approval in some countries might signify disagreement in others). Other factors that
should be taken into account when conducting an MSE include the religious, educational, and social backgrounds of the
interviewed individuals. Similarly, the clinician should be aware of any potential language barriers. The MSE is not to be
confused with the Mini-Mental State Examination (MMSE), which is a screening tool for dementia but can also be used
as part of the MSE to assess sensorium and cognition.

General structure
The MSE is composed of the following components: [1]

 Appearance and behavior  Thought process

 Sensorium and cognition  Thought content

 Mood and affect  Perceptual disturbances

 Speech  Insight and judgment

Appearance

 Abnormalities in appearance can provide insight into an individual's lifestyle and ability to care for themselves.

 Such abnormalities can be the first indicator of a number of psychiatric conditions.

o Individuals with severe depression may present with significant weight loss or appear disheveled.

o A patient with histrionic personality disorder might wear what is considered an inappropriately

seductive outfit or excessive makeup, either in the context of the patient's cultural norms or in contrast
to how they dressed previously.

o An individual that is currently experiencing a manic or hypomanic episode may present with extremely

colorful hair or dress in brightly colored or flamboyant clothing.

o Needle marks or jaundice could indicate substance abuse.

 When assessing a patient's physical appearance, a physician should pay attention to the following features:
 o Estimated age by physical appearance: should be compared with the patient's stated age

o Body habitus

 Bodyweight (e.g., the patient is obese or underweight)

 Physical abnormalities (e.g., marfanoid habitus )

o Posture (e.g., open or closed, tense or relaxed)

o Hygiene

 Level of grooming (e.g., meticulously shaved or excessively scruffy)

 Presence of body odor and/or halitosis

o Dress: the amount and type of clothing used by the patient, taking into consideration the patient's
cultural norms

o Distinguishing features

 Wounds (e.g., burns, scratches, needle marks) and/or scars 

 Tattoos and/or body piercings

 Dental braces, jewelry, glasses

Behavior

 Similar to appearance, the assessment of an individual's behavior can also provide important clues for
establishing a diagnosis.

o Psychomotor agitation is commonly observed in individuals experiencing mania, whereas psychomotor

retardation is usually seen in individuals with depression.

o Glancing repeatedly at different parts of the room is commonly seen in individuals experiencing auditory
or visual hallucinations (e.g., in schizophrenia).

o Abnormal motor activity (movements, gait) can be a sign of an underlying neurological disorder or a side
effect of psychotropic medication.

 A physician should pay attention to the following aspects of an individual's behavior:

o Eye contact

 Level of eye contact (e.g., none, decreased, normal, increased)

 Type of eye contact (e.g., fleeting, intrusive)

o Attitude toward the interviewer (e.g., friendly, cooperative, indifferent, evasive, defensive, seductive)

o Level of distress (e.g., mild, moderate, severe)

 Disorders of diminished motivation: characterized by impairment in goal-directed behavior, thought, and

emotion [2]

o Because they are not classified as disorders within DSM-5, it is uncertain if they are distinct disorders or
symptoms that overlap with other conditions.

o There are three types that vary in severity:

  Apathy: the least severe form of DDM characterized by reduced motivation and/or goal-directed
behavior

 Abulia: a more severe form of DDM characterized by diminished in purposeful movements, will,

and/or initiative 

 Akinetic mutism: the most severe form of DDM characterized by the absence of movements and
paucity of speech determined by lack of motivation 

Abnormal motor activity

 Abnormal movements: See “Examination of the motor system” and “Muscle appearance” in neurological
examination.

 Gait: See gait assessment in neurological examination for more information.

 Apraxia: difficulty performing targeted, voluntary movements despite an intact motor function and the
willingness to perform the movement

o Ideomotor apraxia: difficulty imitating actions; mismatch between intention and expression (e.g.,
instead of waving, a patient will scratch his ear) 

o Ideational apraxia: difficulty planning and completing multistep actions when interacting with objects 

o Constructional apraxia: difficulty drawing or creating objects out of different parts

o Apraxia of lid opening: difficulty voluntarily opening the eyes in the absence of levator palpebrae muscle
palsy

Sensorium

 The evaluation of sensorium assesses a patient's level of consciousness and their orientation to person, place,

and time.

 Because sensorium impairments can have vital implications, the evaluation of sensorium should be performed at
the beginning of the MSE.

Orientation to person, place, and time 

 Can be assessed by asking the patient their full name, the current date, and the current location

 Disorientation is a state characterized by the loss of the notion of time, place, and/or space.

o Awareness to time is lost first, followed by orientation to place, and lastly to self.

o Common causes include:

 Hypoxia  Head trauma

 Vitamin deficiencies  Dehydration

 Infections  Substance abuse

 Hypoglycemia

Level of consciousness

 Level of consciousness is a person's level of arousability and response to external stimuli (e.g., verbal, painful
stimuli).
 It is typically assessed by evaluating the patient's response to external stimuli and can be described using the
following:

o Alertness

 A state of awareness of oneself and the surrounding environment

 Considered a normal finding

o Somnolence

 A state of drowsiness from which a patient can be easily aroused

 The patient responds normally except for a slight delay when addressed. 

o Lethargy

 A state of impaired consciousness and drowsiness from which the patient can be awoken if
exposed to moderate stimuli [3]

 The patient has decreased interest in the surrounding environment and tends to fall back asleep
after being aroused.

o Obtundation

 A state of impaired consciousness characterized by increased sleepiness and a slow response to

external stimuli

 Similar to lethargy, the patient has a decreased interest in the surrounding environment and
experiences drowsiness between the sleeping episodes.

o Stupor

 A state of insensitivity bordering on unconsciousness from which the patient is not easily

awoken, except if exposed to strong external stimuli, (e.g., sternal rub) and into which the
patient returns in the absence of further stimulation

 Communication is not possible and a painful stimulus provokes a withdrawal response.

o Coma

 A state of complete unarousable unresponsiveness regardless of the stimulus, typically lasting

for 2–4 weeks [4]

 A comatose state is characterized by closed eyes and decreased/absent reflex responses and

motor activity, but preserved circulatory function and breathing drive. 

o Delirium

 A transient loss of consciousness, cognitive function, and psychomotor behavior that is usually
the result of an underlying medical condition (e.g., acute kidney injury)

 See delirium for more information.

 A quantitative assessment of consciousness is more likely to be used in clinical settings because it provides a
more objective assessment of the patient's level of consciousness.

 Glasgow Coma Scale (GCS): A common neurological scoring scale used for the evaluation of consciousness in
acute settings (especially after head injury) and sometimes for monitoring patients in the ICU.
 o Patient's verbal, motor, and eye-opening responses are scored on a scale of 1–6 points; 1 point denotes
a complete lack of response and 6 points denotes normal findings.

o See “Diagnostics” in traumatic brain injury for more information.

Cognition

Cognition is the mental process of gaining knowledge and understanding via thinking, experiencing, and sensing, and
includes many aspects listed below. The assessment of cognitive function during an MSE is usually performed using
screening tools such as the MMSE and/or the Saint Louis University Mental Status Examination (SLUMS). (See “Cognitive
assessment” in major neurocognitive disorder for more information.)

 Attention and concentration

o The ability of an individual to focus and sustain their thoughts on a specific task/topic

o Can be assessed by asking the patient to spell a word backward or count in twos 

 Memory

o The process of recalling information

o Classified according to the length of time a particular piece of information can be recalled.

 Sensory (immediate) memory

 The shortest type of information storage 

 Can be assessed by asking the patient to repeat a set of numbers or words in the original
order

 Short-term memory

 Information is stored for a few minutes in order to be processed and used while
performing a task 

 Can be assessed by asking the patients to look at a set of numbers/words/images for a

couple of seconds, and then asking them to recall the items 5 minutes later

 Long-term memory

 Information is stored for days to years

 Can be assessed by asking the patient about an objectively verifiable personal or

historical fact (e.g., date of marriage, a former president's name)

o Amnesia: loss of memory

 Retrograde amnesia: inability to recall memories and/or information acquired prior to the

incident

 Anterograde amnesia: inability to recall memories and/or information acquired after the

incident

 Global amnesia: inability to recall memories and/or information acquired prior to and after the
incident
 o Confabulation: filling in lapses of memory with fabricated events, without the intention of deceiving the
interviewer

 Calculation

o The ability to perform simple calculations, according to the patient's level of education

o Can be assessed by asking the patient to continuously subtract 7 starting from 100

o Acalculia: inability to perform simple calculations (usually a sign of parietal lobe lesions)

 Language: see “Language” section below.

 Fund of knowledge

o The amount of general information an individual stores in their long-term memory

o Can increase with education; decreases in a number of conditions (e.g., dementia)

o Can be assessed by asking the patient to name the last five presidents or the state capital

 Abstract reasoning

o The ability to analyze information, detect patterns and connections between different pieces of data,
and apply that knowledge to practice

o Can be assessed by asking the patient to find the similarities between objects (e.g., the similarities
between a triangle and a square)

 Executive function

o A set of cognitive functions that allows an individual to plan, evaluate, and execute new and complex
tasks

o Can be assessed by using neuropsychological tests, such as the Wisconsin Card Sorting Test or the clock
drawing test 
Clock-drawing test

If an individual is unable to correctly draw

the numbers and hands on the clock, a
deficit in spatial or abstract thinking may be
present. The clock-drawing test is often used
in combination with the MMSE (mini-mental
state examination), which increases the
sensitivity of the testing.

Evaluation of the clock-drawing test

Six grades of severity to evaluate the clock-

drawing test:

(1) No impairment

(2) Minor deficit in visual and spatial

thinking, e.g., help lines and numbers on the
border

(3) Faulty drawing of the clock, e.g., missing

or inverted hands

(4) Medium deficit in visual and spatial

thinking, e.g., faulty, irregular distances
between the numbers or numbers > 12

(5) Major deficit in visual and spatial

thinking, e.g., extreme variant of grade 4

(6) No clock discernable

Language

General considerations

 In contrast to speech, language stands for the structured use of words and syntax according to a set of  pre-
established rules (e.g., grammar, semantics).

 Can be assessed based on the patient's ability to name objects, read, and write

 The most common types of impairment of language include:

o Aphasia:

 Inability to produce or understand verbal or written language

 Caused by pathology in the dominant hemisphere (usually the left)

 In contrast with dysarthria, there is no motor dysfunction of the vocal apparatus

 See “Types of aphasia” in neurological examination for more details.

o Agraphia: inability to write

o Alexia: a form of visual agnosia with severe reading problems as a result of interrupted connections
between the visual cortex and language-related areas

 Subtypes include pure alexia without agraphia, alexia with agraphia, and aphasic alexia.

Mood and affect

Mood

 Refers to the patient's subjective assessment of their emotions when asked how they feel

 Mood should be described using the patient's own words (e.g., happy, ecstatic, sad, guilty, angry, exhausted,
frustrated, frightened) and placed within quotation marks.

 Most psychiatric conditions are associated with some degree of mood alteration.

o Patients with depression may feel “sad” or even state that they feel “nothing at all.”

o Patients with mania are more likely to feel “marvelous” or “ecstatic.”

o Individuals with social anxiety disorder may state that they feel “frightened” or “embarrassed” when
exposed to a large group of people.

Affect (psychiatry)

 Refers to the physician's objective assessment of a patient's emotions conveyed both verbally and nonverbally
during an interview

 A comprehensive description of a patient's affect should cover all of the following characteristics:

o Quality: dysphoric, neutral, euthymic, detached, anxious, irritable, hostile, sad, angry, or euphoric

o Congruency: congruent or incongruent with stated mood

o Range: flat, blunted , full, or exaggerated

 o Mobility: fixed, constricted, labile, or mobile

o Appropriateness to situation: appropriate vs. inappropriate emotions

 It is important to assess a patient's affect during the MSE because changes in affect are characteristic of a large
number of psychiatric conditions.

o Individuals with schizophrenia often have a blunted, inappropriate affect.

o Individuals affected by mania may have an exaggerated and euphoric affect.

o Individuals with severe depression may have a fixed and/or constricted affect.
SPEECH

Speech is the spontaneous production of the spoken language (i.e., the act of speaking ) and is characterized by
the following:
o Rate: rapid, normal, slow, or pressured
o Volume: loud, normal, soft, or whispered
o Quantity: logorrheic, talkative, responsive, or reserved
o Articulation and fluency: incomprehensible, accented, stuttered, lisping, mumbled, slurred, clear,
or articulated
o Speech latency: increased, decreased, or no latency
Because speech impairment is characteristic of a large number of conditions, it is an important diagnostic tool.
o Individuals with depression may have soft, almost incomprehensible speech with increased
latency.
o Individuals in a manic state are often logorrheic and speak loudly and extremely fast.
o Individuals with schizophrenia usually have disorganized, incomprehensible speech.
Some of the speech abnormalities that can be observed during an MSE include:
o Mutism: an inability to speak that is caused by a structural or motor dysfunction of the vocal
apparatus or that is the result of an individual's unwillingness to speak despite having an
intact vocal apparatus (e.g., akinetic mutism)
o Dysarthria: the impaired articulation of words resulting from motor dysfunction of the vocal
apparatus
o Echolalia: the involuntary repetition of another person's speech
o Palilalia: the involuntary repetition of words or phrases with increasing rapidity
o Alogia/poverty of speech: impaired thinking that manifests with reduced speech output (e.g.,
always replying to questions with one-word answers)
o Pressured speech: accelerated thoughts that are expressed as rapid, loud, and
voluminous speech often in the absence of social stimulation
o Neologisms: the creation and use of new words that are only understood by the
speaker (e.g., Pepsidiction = Pepsi + addiction, Spritependency = Sprite + dependency)
o Word salad: incoherent thinking expressed as a sequence of words without a logical connection
 Characteristic of schizophrenia and dementia
  Example: “They’re destroying too many cattle and oil just to make soap. If we need soap
when you can jump into a pool of water, and then when you go to buy your gasoline, my
folks always thought they should get pop but the best thing to get is motor oil and
money.” 

Thought process

 Thought process is the act of thinking and is characterized by the number of thoughts as well as their flow and
coherence.

 A physician evaluates a patient's thought process by analyzing the patient's responses to different types of
questions when taking their medical history or during their physical examination.

 When describing an individual's thought process, the following terms can be used:

Thought processes

Description Characteristic of Example

 Schizophrenia

 Bipolar disorder
 Nonlinear thought expressed  When a patient is asked
as long-winded explanations  Epilepsy where they are from, they
Circumstantial thought
and with multiple deviations describe their favorite
process  Intellectual
from the central topic before a hometown diners before
disability
central idea is finally expressed answering your question.
 Developmental
delay [7]

 Nonlinear thought expressed as

a gradual deviation from a  When asked about
focused idea or question.  Schizophrenia their medical history, the
Tangential thought patient describes the
 The patient provides multiple,  Anxiety
process hospitals they have stayed in
unnecessary details related to  Delirium [8] without mentioning their
the question without actually medical conditions.
answering the question.

 When asked about their job,

 Incoherent thinking expressed  Schizophrenia the patient remembers some
Loose
as illogical, sudden, and  Other psychotic funny stories from their
associations/derailments
frequent changes of topic disorders [9] childhood and then starts
talking about the weather.

 The quick succession of  Bipolar  When asked how they are

Flight of ideas thoughts usually expressed as a disorder (manic feeling, the patient delivers
continuous flow of phase) a 10-minute monologue on
Thought content

 Thought content refers explicitly to what an individual is thinking about (i.e., main themes and beliefs) and is
usually evaluated based on the presence of delusions, obsessions, compulsions, phobias,
and homicidal or suicidal ideation.

 Important because a large number of psychiatric conditions are associated with various disturbances of  thought
content, some of which are pathognomonic (e.g., suicidal ideation for patients with severe depression)

 Consider the individual's social, cultural, and educational background, since the understanding of normality
varies among these things.

Delusions

 Delusions are fixed, false beliefs (unrelated to one's religious beliefs or culture) that are maintained despite
being contradicted by reality or rational arguments.

 All delusions can be classified as either:

o Bizarre delusions: delusions that cannot be true or are inconsistent with the patient's social and cultural
norms (e.g., a patient insisting that they can fly)

o Nonbizarre delusions: delusions that could be true or are consistent with the patient's social and
cultural norms (e.g., a patient insisting that they have won the lottery when this is not the case)

 Based on their mood congruence, delusions can be classified as either:

o Mood congruent delusions: the content of delusions is consistent with the patient's current mood (e.g.,
a manic patient insisting they have special powers)

o Mood incongruent delusions: the content of delusions is not consistent with the patient's
current mood (e.g., a patient having a manic episode insisting that they are being chased by a murderer)
Delusions according to their content

Type Description Assess by asking patient if they:

Persecutory  The patient insists that they are being cheated on, conspired  Feel wronged or threatened by a person or
delusions against, or harassed. group of individuals

 The patient has an exaggerated distrust of others and is  Sometimes have the feeling that a person or
Paranoia
suspicious of their motives. group of individuals wants to harm them

 The patient insists that they have special powers or  Feel like they are destined for something
Grandiosity
importance (e.g., a patient saying they can read minds). special or have special abilities

 The patient believes that other individuals are in love with

 Have a special someone who is in love with
Erotomania them (e.g., a patient claiming a famous actress is sending
them and sending secret messages
them love letters).

 The patient believes their partner is unfaithful without  Have the feeling that their partner is
Jealousy
justification. unfaithful to them

 The patient believes that normal events are of special  Have the feeling that people on the street, on
Delusion of
importance to them (e.g., an individual might feel that a the radio, or on TV are talking about them
reference
television reporter is talking about them). and trying to send them messages

 The patient believes there is something abnormal about

Somatic  Think that there is something wrong with a
their body function or appearance (e.g., an individual might
delusions part of their body
feel like they are missing a hand).

Religious  The patient believes they have divine powers, receive  Have been in contact with a religious figure or
delusions messages from God, or that they actually are God. have a spiritual mission of some sort

Delusion of  The patient believes they are financially incapacitated or that  The feeling that they are in some financial
poverty poverty is inevitable. trouble

 To of
Delusion remember
guilt the different
The patient believes that they have wronged someone and/or  The feeling that they harmed someone or
types of delusions (Grandiosity, Erotomanic, Ideas of reference, Paranoid, Persecutory,
are responsible for something bad. have done something bad
Somatic, Jealousy), think: “Grand, Erotic Ideas can cause Paranoia, Persecution and So much (so-ma-tic) Jealousy.”
 The simultaneous occurrence of two or more delusions;
Mixed delusions  See above
neither delusion is predominant

Unspecified  A type of delusion that does not fit the criteria of other types
 N/A
delusion or that cannot be clearly defined

SUICIDAL AND HOMICIDAL IDEATION

 Suicidal ideation: any type of thoughts that an individual has regarding ending their own life (see suicide for
more details)

 Homicidal ideation: thoughts regarding ending someone else's life

 Assessment
 o Ask the patient if they sometimes feel that life is not worth living and if they have ever felt the desire to
harm other people.

o Can range from a brief consideration of the act to concrete planning of the time, place, and/or method
of suicide/homicide.

 Assess the threat (organized plan, access to weapons).

 Admit the patient involuntarily if they refuse medical care.

 In homicidal threats, inform the authorities and the threatened individual.

Obsessions and compulsions

 Obsession: A repetitive, persistent, intrusive, and unpleasant thought or urge that causes severe distress
and anxiety.

 Compulsion: Ritualistic, repetitive behaviors (e.g., touching, washing) or mental act (e.g., counting, repeating a
word silently) carried out in an effort to relieve urges and decrease obsession-related distress.

 Assessment

o Ask the patient if there is something they constantly think about and whether they engage in any
specific behavior to get rid of the persistent thoughts

o See obsessive-compulsive disorder for more information.

Phobias

 A specific phobia is a persistent (≥ 6 months) and intense fear of one or more specific situations or objects
(phobic stimuli).

 Some common examples of phobias include agoraphobia (fear of unknown places and

situations), claustrophobia (fear of enclosed places), arachnophobia (fear of spiders), and hematophobia (fear of
blood).

 Can be assessed by asking the patient whether they are scared of anything and how long this fear has affected
them

 See anxiety disorders for more information.

Perceptual disturbances

 Perceptual disturbances are characterized by disruption in perception, which may be caused by physical and/or
mental disorders.

 Hallucinations

Hallucinations are a type of perceptual abnormality in which sensory experiences occur in the absence of external
stimuli.

Can be assessed by asking the patient if they ever hear, see, feel, smell, or taste things that other individuals do not.

Some of the most common causes of hallucinations include:

Substance abuse Fever (especially in children and the elderly)

Delirium or dementia Narcolepsy

Epilepsy Schizophrenia
 Sensory impairment (e.g., deafness, blindness)

TYPES OF HALLUCINATIONS
Type Description Epidemiology/etiology
1. Auditory A false perception of sound The most common type of hallucination
hallucination (e.g., hearing voices) Usually seen in psychiatric disorders (e.g., schizophrenia,
depression with psychotic features)
2. Visual A false perception of sight (e.g., The most common type of hallucination in patients
hallucination seeing faces) with delirium or dementia
3. Olfactory A false perception of smell, usually The most common type of hallucination seen in patients
hallucination unpleasant (e.g., the smell of burnt with focal-onset temporal lobe seizures (including
or rotten food) symptomatic epileptic seizures caused by brain tumors)
4. Gustatory A false perception of taste, usually Rare; also associated with aura in focal-onset temporal lobe
hallucination unpleasant (e.g., a metallic taste) epilepsy
5. Somatic A false perception of touch (e.g., the A common finding in alcohol withdrawal and intoxication
(tactile) sensation of a snake wrapping around with
hallucination one's leg) stimulants (e.g., cocaine, amphetamine, methamphetamine)
A symptom of delusional parasitosis (e.g., “cocaine crawlies”
in cocaine intoxication)
6. Sleep Vivid, often frightening visual See narcolepsy for more information.
hallucination or auditory hallucinations that can
s be hypnagogic (while going to sleep)
or hypnopompic (while waking up)
See narcolepsy for more information.
7. Synesthesia Not a type of hallucination, but N/A
a perceptual disturbance in which
stimulation of one sense produces a
sensation related to another sense
(e.g., an olfactory stimulus that
produces a visual sensation)

Illusions

 Perceptual disturbances characterized by inaccurate perception (distortion) of real sensory input (e.g.,

perceiving a stationary object as being in motion) 

 Note: Illusion has no sensory input compare to hallucinations.

 Assess by asking the patient whether they sometimes misinterpret real things around them, such as shadows or
faint noises

 Similar to hallucinations, illusions can be categorized according to the misinterpreted sensory input as visual,

auditory, tactile, olfactory, and gustatory.

 Although illusions are characteristic of some mental disorders (e.g., schizophrenia), most illusions are

physiological in nature and generated by each individual's perceptive assumptions based on their psychological
profile (e.g., influenced by darkness, fatigue, or under the influence of drugs or alcohol).

Dissociation (psychiatry)

 A psychological defense mechanism that is a natural protective response to a traumatic or stressful experience.

 Characterized by disruption and/or discontinuity of normal consciousness, memory, identity, and perception of

oneself (e.g., derealization, depersonalization)
  Can be assessed by asking the patient whether they sometimes feel detached from themselves or others or if
the world around them sometimes feels unnatural

 See dissociative disorders for more information.

Agnosia

 Characterized by impaired recognition of sensory stimulus (most commonly visual) [14]

 Can be tested by presenting different objects or exposing a patient to different stimuli (depending on
recognition of which modality is tested)

 Can still recognize the objects using different sensory modalities (unless multiple senses affected)

 Types include:

o Visual agnosia: inability to recognize visually presented objects despite otherwise normal vision

 Caused by a lesion in the visual association cortex in the occipital lobe (Brodmann area 19)

or ventral visual stream in the temporal lobe

o Auditory agnosia: inability to recognize sounds despite intact hearing

 Caused by lesions of the auditory ventral stream (anterior superior temporal gyrus).

o Tactile agnosia (astereognosis): inability to recognize objects by touch using texture, shape, and
temperature as cues without visual input

 Caused by a lesion in the contralateral parietal lobe (areas 5 and 7).

o Visuospatial dysgnosia: inability to localize and orient oneself and/or identify relationships between
objects in the environment

 Often associated with damage to the right posterior parietal area of the brain.

o Prosopagnosia: inability to recognize familiar faces, while the ability to name parts of the face (e.g.,
nose, mouth) or identify individuals by other cues (e.g., clothing, voices) is left intact.

 Caused by bilateral lesions or large unilateral lesions of the ventral occipitotemporal cortex

(fusiform gyrus)

o Autotopagnosia: inability to localize different parts of the body upon request

 Caused by damage to left posterior parietal area of the cortex

Hemineglect (also known as unilateral neglect or spatial neglect)

 Hemineglect is the impaired ability to perceive and respond to different types of stimuli coming from one side of
the body usually due to a brain unilateral injury (most commonly strokes). Note: This inability is not due to a lack
of sensation.

 Typically associated with right hemisphere damage resulting in neglect (esp. visual) of the left side [15]

 The lesion is usually contralateral to the side where the perception is absent. Example: A patient with a lesion
located in the right parietal lobe will be unable to respond to visual stimuli from the left field.
  Can be tested by asking to copy a figure, draw the face of a clock, cancel symbols on a paper, etc. An individual
with hemineglect is only able to copy the part of the image or cancel symbols on the perceived side.

 Common types:

o Motor neglect (The patient does not move the limbs on the contralesionally side of the body despite the
neuromuscular ability to move it.)

o Sensory or perceptual neglect (Patients become unaware of objects on the contralateral side of the
lesion.)

Insight and judgment

Insight 

 Insight is an individual's awareness and understanding of their current medical problem, and it can be assessed
based on the following:

o Recognition that one has a current medical condition

o Compliance with treatment

o Ability to relabel unusual mental events as pathological

 Anosognosia is the inability of a person to recognize their neurologic impairment. (Commonly referred to as lack
of insight) E.g., a stroke patient with hemiparesis who denies having any kind of problem.

o Usually associated with acute brain injuries, such as stroke or trauma

o Also characteristic of the following psychiatric conditions:

 Psychosis

 Depression

 Personality disorders

 Bipolar disorder

 Obsessive-compulsive disorder

 Substance abuse

Judgment

 The ability of an individual to make considerate decisions when performing a task based on their understanding
of the current circumstances and their problem-solving abilities; a higher cortical function

 Primarily elicited when taking the patient's history by discussing recent behaviors.  Judgment can also be
assessed by asking the patient to elaborate on a hypothetical situation. (E.g., “If you woke up in the middle of
the night and smelled smoke, what would you do?”) or interpret a well-known idiom.

 Impaired judgment is not specific and can occur in a number of psychiatric and neurological conditions
(e.g., delirium, substance-related disorders, dementia). 

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