Psychiatric and social disorders are common in medical settings. They are associated with an increased risk for nonpsychiatric illness and frequently confound the evaluation of patients presenting with nonspecific complaints. The student of medicine at all levels should read more specialized texts that deal with psychiatric illness and seek formal psychiatric consultation whenever doubt exists concerning psychiatric diagnosis. It is imperative to recognize that the presence of a psychiatric diagnosis in no way decreases the probability of serious organic disease in a patient with appropriate signs or symptoms. The challenge is to render appropriate diagnosis and therapy for all coexistent psychiatric and nonpsychiatric illnesses simultaneously, not sequentially. Delay in the diagnosis of organic disease in patients with psychiatric illness is all too common and should caution the clinician to take extra care in the evaluation of patients with psychiatric symptoms.
The distinction between what we classify as neurologic or psychiatric illness is a function of our understanding of brain physiology and pathophysiology. The distinction often rests on the presence of identifiable structural, genetic, physiological, or biochemical disorders in the neurologic category and their absence in psychiatric disease. Many psychiatric syndromes show genetic predispositions and respond to medications that alter brain function. Functional imaging studies are increasingly identifying localized abnormalities of brain function in some psychiatric disorders. For the practitioner, it is sufficient to recognize that the disorders we classify as psychiatric, although representing disorders of brain function, will be recognized by their clinical signs with abnormalities of thought, mood, affect, and behavior rather than specific tests of brain structure and clinical laboratory testing.
Social behavioral disorders and violence are also common problems in our society. To properly evaluate and care for patients, clinicians must be knowledgeable about the social situation of their patient. Social factors lead to patients presenting with a wide variety of complaints both physical and psychiatric. A complete social and psychiatric history with attention to current safety, a history of abuse (such as physical, sexual, emotional, financial, etc.), and the resources available to the patients for their care is essential in the evaluation of all patients.
This chapter does not provide a complete diagnostic approach to psychiatric illness. Rather, our purpose is to alert the clinician to the common psychiatric syndromes likely to be encountered in clinical practice and to provide some guidance to their recognition. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), published by the American Psychiatric Association, is a particularly valuable resource with which all practitioners should become familiar [American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994]. In addition to diagnostic criteria, the manual provides an overview of the epidemiology and presentation of mental disorders.
The Mental Status Evaluation
Psychiatric diagnosis is based upon the patient interview and the exclusion of medical illness by appropriate history, physical examination, ...