THIRD EDITION CASE FILES® Psychiatry Eugene C. Toy, MD

THIRD EDITION CASE FILES® Psychiatry Eugene C. Toy, MD The John S. Dunn, Senior Academic Chair and Program Director The Methodist Hospital Ob/Gyn Residency Program Houston, Texas Vice Chair of Academic Affairs Department of Obstetrics and Gynecology The Methodist Hospital Houston, Texas Associate Clinical Professor and Clerkship Director Department of Obstetrics and Gynecology University of Texas Medical School at Houston Houston, Texas Associate Clinical Professor Weill Cornell College of Medicine Debra Klamen, MD, MHPE Associate Dean of Education and Curriculum Professor and Chair, Department of Medical Education Professor, Department of Psychiatry Southern Illinois University School of Medicine Springfield, Illinois New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved. 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Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. Mc- Graw-Hill has no responsibility for the content of any information accessed through the work. Under no circum- stances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise. DEDICATION In loving memory of my grandparents, Lew Yook Toy and Manway Toy, who courageously pioneered our family’s legacy in this great country. – ECT To my wonderful husband, Phil, who loves me and supports me in all things. To my mother, Bonnie Klamen, and to my late father, Sam Klamen, who were and are, always there. – DLK This page intentionally left blank CONTENTS Contributors / vii Preface / xi Acknowledgments / xiii Introduction / xv Section I How to Approach Clinical Problems 1 Part 1. Approach to the Patient 2 Part 2. Approach to Clinical Problem Solving 12 Part 3. Approach to the Diagnostic and Statistical Manual of Mental Disorders 14 Part 4. Approach to Reading 15 Section II Psychiatric Therapeutics 21 Part 1. Psychotherapy 22 Part 2. Psychopharmacotherapy 23 Section III Clinical Cases 43 Sixty Case Scenarios 45 Section IV Listing of Cases 469 Listing by Case Number 471 Listing by Disorder (Alphabetical) 472 Listing by DSM-IV Categories 474 Index / 477 This page intentionally left blank Staci Becker, RN, MS Nurse Educator Adjunct Instructor Department of Medical Education Southern Illinois University School of Medicine Springfield, Illinois Acute Stress Disorder Bipolar Disorder, Manic (Adult) Borderline Personality Disorder Dependent Personality Disorder Dysthymic Disorder Factitious Disorder Major Depression, Recurrent Narcissistic Personality Disorder Pain Disorder Paranoid Personality Disorder Schizotypal Personality Disorder Somatization Disorder Sean Blitzstein, MD Director, Third Year Clerkship Associate Professor of Psychiatry University of Illinois at Chicago Staff Psychiatrist Veterans Administration Chicago Healthcare System Chicago, Illinois Alcohol Dependence Cocaine Intoxication Conversion Disorder Dementia Major Depression in Elderly Patients Mood Disorder Not Otherwise Specified Neurosis Opioid Withdrawal Panic Disorder versus Thyroid Medication Overuse Posttraumatic Stress Disorder Psychosis Caused by a General Medical Condition vii Renu Gupta, MD Resident Department of Psychiatry University of Illinois at Chicago Chicago, Illinois Philip Pan, MD Director, Outpatient Services Assistant Professor Department of Psychiatry Southern Illinois University School of Medicine Springfield, Illinois Adjustment Disorder Alcohol Withdrawal Amphetamine Intoxication Antisocial Personality Disorder Avoidant Personality Disorder Benzodiazepine Withdrawal Delirium Malingering Phencyclidine Intoxication Schizoid Personality Disorder Schizophrenia, Paranoid Substance-Induced Mood Disorder Steve Soltys, MD Professor and Chair Department of Psychiatry Southern Illinois University School of Medicine Springfield, Illinois Anxiety Disorder Secondary to a General Medical Condition Attention-Deficit/Hyperactivity Disorder Bipolar Disorder (Child) Bulimia Nervosa Gender Identity Disorder Generalized Anxiety Disorder Hypochondriasis Major Depression with Psychotic Features Mild Mental Retardation Primary Insomnia Separation Anxiety Disorder Tourette Disorder Tom Wright, MD Medical Director and Interim Executive Director Community Partnerships, Inc. Madison, Wisconsin Anorexia Nervosa Autistic Disorder Conduct Disorder Fetishism Histrionic Personality Disorder Obsessive-Compulsive Disorder (Child) Obsessive-Compulsive Personality Disorder Schizoaffective Disorder Sleep Terror Disorder Social Phobia This page intentionally left blank PREFACE We appreciate all the kind remarks and suggestions from the many medical students over the past 3 years. Your positive reception has been an incredible encouragement, especially in light of the short life of the Case Files® series. In this third edition of Case Files®: Psychiatry, the basic format of the book has been retained. Improvements were made in streamlining many of the chapters. Also, numerous clinical cases were rewritten to be representative of more typical patient presentations rather than the “flamboyant” presentation. We debated about whether to group the cases together so that students could compare related disorders such as cases 1–10 would be “personality disorders” to allow for side-by-side comparison. We decided not to use this systematic grouping approach, since patients do not present to their doctors in the real world in this manner. Rather, patients present with symptoms and signs, and it is the “job” of the student and clinician to sort out whether there is a psy- chiatric issue, and which diagnosis is likely. Nevertheless, the case listing in the back of the book and the index will allow a student to quickly reference similar cases for the sake of comparison. The multiple choice questions have been carefully reviewed and rewritten to ensure that they comply with the National Board and USMLE Step 2 CK format. Some new psychiatric medications have been introduced as well. By using this third edition, we hope that the reader will continue to enjoy learning psychiatry through the simulated clinical cases. It is certainly a privilege to be a teacher for so many students, and it is with humility that we present this edition. The Authors xi This page intentionally left blank ACKNOWLEDGMENTS The curriculum from which the ideas for this series evolved was inspired by two talented, forthright students, Philbert Yau and Chuck Rosipal, who have since graduated from medical school. It has been a great joy to work with Debra Klamen, a brilliant psychiatrist, educator, and lover of horses, and with all the excellent contributors. I appreciate McGraw-Hill’s belief in the con- cept of teaching through clinical cases. I am greatly indebted to my editor, Catherine Johnson, whose exuberance, experience, and vision helped to shape this series. I am also grateful to Catherine Saggese for her excellent pro- duction expertise, and Christie Naglieri for her wonderful editing. I cherish the ever-organized and precise Gita Raman, senior project manager, whose friendship and talent I greatly value; she keeps me focused, and nurtures each of my books from manuscript to print. At Southern Illinois University, I thank Dr. Kevin Dorsey for his help and support in completing this project. At the Methodist Hospital, I applaud the finest administrators I have encountered: Drs. Marc Boom, Judy Paukert, H. Dirk Sostman, and Karin Larsen-Pollock, and Mr. Reggie Abraham for their commitment to medical education, and Marla Buffington for her sage advice and support. Without my esteemed col- leagues, Drs. Saul Soffar, Earl Lord, and Sterling Weaver, this book could not have been written. Most of all, I appreciate my loving wife, Terri, and my four wonderful children, Andy, Michael, Allison, and Christina, for their patience and understanding. Eugene C. Toy xiii This page intentionally left blank Mastering the cognitive knowledge within a field such as psychiatry is a for- midable task. It is even more difficult to draw on that knowledge, procure and filter through the clinical data, develop a differential diagnosis, and finally form a rational treatment plan. To gain these skills, the student often learns best by directly interviewing patients, guided and instructed by experienced teachers and inspired toward self-directed, diligent reading. Clearly, there is no replacement for education at the patient’s side. Unfortunately, clinical sit- uations usually do not encompass the breadth of the specialty. Perhaps the best alternative is to prepare carefully crafted cases designed to simulate the clinical approach and decision making. In an attempt to achieve this goal, we have constructed a collection of clinical vignettes to teach diagnostic or ther- apeutic approaches relevant to psychiatry. Most importantly, the explanations for the cases emphasize mechanisms and underlying principles rather than merely rote questions and answers. This book is organized for versatility: to allow the student “in a rush” to read the scenarios quickly and check the corresponding answers, as well as to provide more detailed information for the student who wants thought- provoking explanations. The answers are arranged from simple to complex: a summary of the pertinent points, the bare answers, an analysis of the case, an approach to the topic, a comprehension test at the end for reinforcement and emphasis, and a list of resources for further reading. The clinical vignettes are purposely presented in random order to simulate the way that real patients present to a practitioner. A listing of cases is included in Section IV to aid stu- dents who desire to test their knowledge of a certain area or to review a topic, including the basic definitions. Finally, we intentionally did not primarily use a multiple-choice question (MCQ) format because clues (or distractors) are not available in the real world. Nevertheless, several MCQs are included at the end of each scenario to reinforce concepts or introduce related topics. HOW TO GET THE MOST OUT OF THIS BOOK Each case is designed to simulate a patient encounter by using open-ended questions. At times, the patient’s complaint differs from the issue of greatest concern, and sometimes extraneous information is given. The answers are organized into four different parts. xv xvi INTRODUCTION PART I 1. A Summary: The salient aspects of the case are identified, filtering out extraneous information. The student should formulate a summary of the case before looking at the answers. A comparison with the summation appearing in the answer will help improve the student’s ability to focus on the important data while appropriately discarding irrelevant information, a fundamental skill required in clinical problem solving. 2. A Straightforward Answer to each open-ended question. 3. An Analysis of the Case consisting of two parts: a. Objectives: A listing of the two or three main principles that are crucial for a practitioner in treating the patient. Again, the student is challenged to make “educated guesses” about the objectives of the case on initial review of the case scenario, which helps to sharpen his or her clinical and analytical skills. b. Considerations: A discussion of the relevant points and a brief approach to the specific patient. PART II An Approach to the Disease Process consisting of two distinct parts: a. Definitions: Terminology pertinent to the disease process. b. Clinical Approach: A discussion of the approach to the clinical problem in general, including tables and figures. PART III Comprehension Questions: Each case contains several MCQs that reinforce the material presented or introduce new and related concepts. Questions about material not found in the text are explained in the answers. PART IV Clinical Pearls: A listing of several clinically important points that are reit- erated as a summation of the text and allow for easy review, such as before an examination. SECTION I How to Approach Clinical Problems 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 disor- ders, and reading the diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), to actually developing a psychiatric diagnosis for a patient. It requires the physician 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 diag- nosis 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: a. Identifying information includes name, age, marital status, gender, occupation, and language(s) spoken other than English if applicable. Ethnic background and religion can also be included if they are pertinent. b. 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 compliance. Circumstances include where the interview was conducted (emer- gency setting, outpatient office, in leather restraints) and whether the episode reported was the first occurrence for the patient. c. 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. 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 circum- stances leading up to the encounter with the physician. 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 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 con- tribution 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 hospi- talizations, the treatment received, and the length of stay should be recorded. Whether or not the patient has received psychotherapy, 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 compliance with 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 medica- tions 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 gen- erally the easiest, clearest way to do this. 9. Social history: a. The prenatal and perinatal history of the patient is probably 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. b. 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, behav- ioral problems, social relationships, cognitive and motor develop- ment, and emotional and physical problems should all be included. c. Occupational history, including military history. d. Marital and relationship history. e. Education history. f. Religion. g. Social history, including the nature of friendships and interests. h. Drug and alcohol history. Both the quantity of substance(s) used and the duration of their use should be documented. i. 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 physician’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: a. 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. b. Behavior and psychomotor activity: Any bizarre posturing, abnormal movements, agitation, rigidity, or other physical characteristics should be described. c. 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: a. Mood: 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 quanti- fied wherever possible—a scale from 1 to 10 is often used. For example, a person rates his depression as 3 on a scale of 1 to 10 where 10 is the happiest he has ever felt. b. Affect: The person’s emotional responsiveness during the examination as inferred from his/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 blunted or constricted affect means that there is little variation in facial expression or use of hands; a flat affect is even fur- ther reduced in range. 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) should be indicated, as well as the content of the hallucination (eg, “It smells like burning rubber,” “I hear two voices calling me bad names.”). Of note is that whereas some clinicians use perception as a sepa- rate category, others combine this section with the thought content por- tion 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, 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 about 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. a. Consciousness: Common descriptors of levels of consciousness include “alert,” “somnolent,” “stuporous,” and “clouded consciousness.” b. 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 order. Recent memory is tested by asking a patient what she ate for dinner the previous night and asking if 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 confabu- lation (making up false answers when memory is impaired) can occur. c. Concentration and attention: Subtracting serial 7s from 100 is a com- mon 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. d. 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. e. 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. f. 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 problems with proverbs for this reason rather than because of a mental status disturbance.) g. 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 of course be taken into account as well. h. 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 some- times help with this assessment. For example, what would the patient do if he or she found a stamped envelope lying on the ground? i. 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 pancreatic cancer 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, 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 pal- pated 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 ascer- tained, 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 systemati- cally 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 discol- oration. 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, ten- derness, 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 physicians 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, gaits, 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 labora- tory 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 sub- stances such as lysergic acid diethylamide (LSD) or cocaine in a patient’s system. Laboratory tests are also useful in long-term monitoring of medica- tions such as lithium and valproic acid. I. Screening tests A. A complete blood count (CBC) to assess for anemia and thrombocy- topenia B. Renal function tests C. Liver function tests D. Thyroid function tests E. Laboratory studies including determinations of chloride, sodium, potas- sium, bicarbonate, serum urea nitrogen, creatinine, and blood sugar levels F. Urine toxicology or serum toxicology tests when drug use is suspected II. Tests related to psychotropic drugs A. Lithium: A white blood cell (WBC), serum electrolyte determina- tion, thyroid and renal function tests (specific gravity, blood urea nitrogen [BUN], and creatinine), fasting blood glucose determina- tion, pregnancy test, and an electrocardiogram (ECG) are recom- mended before treatment and yearly thereafter (every 6 months for a thyroid stimulating hormone [TSH] and creatinine). Lithium levels should also be monitored at least every 3 months once the patient has been stabilized on the medication. B. 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. C. Tricyclic and tetracyclic antidepressants: An ECG should be obtained before a patient begins treatment with these medications. D. 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. E. Valproate: Valproate levels should be monitored every 6 to 12 months, along with liver function tests. Because this drug is teratogenic, preg- nancy tests should be drawn before initiating this drug. III. Psychometric testing A. Structured clinical diagnostic assessments 1. Tests based on structured or semistructured 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-IV Dissociative Disorders (SCID-IV) B. 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. Such tests play a relatively small role in the diagnosis of psychi- atric 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 examina- tions based on specific questions. They yield numerical scores and are statistically analyzed. a. Minnesota Multiphasic Personality Inventory: This self-report inventory is widely used and has been thoroughly researched. It assesses personality using an objective approach. b. Projective tests: These tests present stimuli that are not imme- diately 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. i. Rorschach test: This projective test is used to assess per- sonality. 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. ii. 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 most useful for investigating personal motivation (eg, why a patient does what he or she does) than it is in making a diagnosis. iii. 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. ” c. Intelligence tests: These tests are used to establish the degree of mental retardation in situations where this is the question. The Wechsler Adult Intelligence Scale is the test most widely used in clinical practice today. d. Neuropsychologic tests: The aim of these tests is to compare the patient being tested with “normal” people of similar back- ground and age. They are used to identify cognitive deficits, assess the toxic effects of substances, evaluate the effects of treatment, and identify learning disorders. i. Wisconsin Card Sorting Test: This test assesses abstract rea- soning and flexibility in problem solving by asking the patient to sort a variety of cards according to principles estab- lished 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. ii. Wechsler memory scale: This is the most widely used battery of tests for adults. It tests rote memory, visual memory, orien- tation, and counting backward, among other dimensions. It is sensitive to amnestic conditions such as Korsakoff syndrome. iii. 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 repro- duce the designs from memory. This test is used as a screening device for signs of organic dysfunction. IV. Further diagnostic tests A. Additional psychiatric diagnostic interviews (eg, the Diagnostic Interview Schedule for Children) B. Interviews conducted by a social worker with family members, friends, or neighbors C. Electroencephalogram to rule in or rule out a seizure disorder D. Computed tomography scan to assess intracranial masses E. Magnetic resonance imaging to assess intracranial masses or any other neurologic abnormality F. 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. Rendering 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 possi- bilities (the differential diagnosis). The process involves knowing which pieces of information are meaningful and which can be discarded. Experience and knowledge help the physician to “key in” on the most important possi- bilities. A good clinician also knows how to ask the same question in several different ways and to use 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 dis- order 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 symp- toms 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, 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 malig- nancy, 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 DISEASE Many illnesses are stratified according to severity because prognosis and treatment often vary based on these factors. 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. 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. FOLLOWING THE RESPONSE TO TREATMENT The final step in the approach to disease 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, stan- dardized 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 measured marker does not respond according to what is 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 fourth edition, text revision (DSM-IV-TR), is published by the American Psychiatric Association. It is the official psychiatric coding system used in the United States. The DSM-IV-TR describes mental disorders and only rarely attempts to account for how these disturbances come about. Specified diag- nostic criteria are presented for each disorder and include a list of features that must be present for the diagnosis to be made. The DSM-IV-TR also systemati- cally 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-IV-TR uses a five-axis system that evaluates patients along several dimensions. Axes I and II make up the entire classification of mental disorders. Each patient should receive a five-axis diagnosis, which usually appears at the end of a write-up in the assessment section. Axis I: Clinical disorders and other disorders that can be the focus of clinical attention such as schizophrenia, major depression. Axis II: Personality disorders and mental retardation only. Axis III: Physical disorders and other general medical conditions. The physical condition can 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).