PSYCHIATRY Medical School Crash Course™
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Table of Contents Preface ..............................................................................................................................................6 Introduction ......................................................................................................................................1 History of Psychiatry ..........................................................................................................................2 Key Takeaways ........................................................................................................................................ 4 Quiz Questions ........................................................................................................................................ 4 Quiz Answers: ......................................................................................................................................... 7 Mental Status Evaluation ...................................................................................................................8 Key Takeaways ...................................................................................................................................... 12 Quiz ....................................................................................................................................................... 12 Quiz Answers ........................................................................................................................................ 14 Depressive Disorders ....................................................................................................................... 15 Dysthymia ............................................................................................................................................. 15 Major Depressive Disorder ................................................................................................................... 16 Bipolar Disorder .................................................................................................................................... 18 Postpartum Depression ........................................................................................................................ 21 Seasonal Affective Disorder .................................................................................................................. 22 Premenstrual Dysphoric Disorder ......................................................................................................... 23 Key Takeaways ...................................................................................................................................... 26 Quiz ....................................................................................................................................................... 26 Quiz Answers ........................................................................................................................................ 27 Anxiety Disorders............................................................................................................................. 28 Panic Disorder ....................................................................................................................................... 29 Generalized Anxiety Disorder ............................................................................................................... 30 Obsessive-compulsive Disorder ............................................................................................................ 32 Social Phobia ......................................................................................................................................... 34 Post-traumatic Stress Disorder ............................................................................................................. 35 Key Takeaways ...................................................................................................................................... 38 Quiz ....................................................................................................................................................... 39 Quiz Answers ........................................................................................................................................ 40 Psychoses ........................................................................................................................................ 41 Schizophrenia........................................................................................................................................ 41
Acute Psychosis..................................................................................................................................... 43 Postpartum Psychosis ........................................................................................................................... 44 Acute Delirium ...................................................................................................................................... 46 Key Takeaways ...................................................................................................................................... 48 Quiz ....................................................................................................................................................... 49 Quiz Answers ........................................................................................................................................ 50 Substance Use Disorders .................................................................................................................. 51 Alcohol Abuse ....................................................................................................................................... 51 Tobacco Abuse ...................................................................................................................................... 54 Opiate Abuse ........................................................................................................................................ 56 Hallucinogen Abuse .............................................................................................................................. 57 Inhalant Abuse ...................................................................................................................................... 59 Amphetamine Use Disorder .................................................................................................................. 60 Key Takeaways ...................................................................................................................................... 61 Quiz ....................................................................................................................................................... 62 Quiz Answers: ....................................................................................................................................... 63 Eating Disorders ............................................................................................................................... 64 Bulimia .................................................................................................................................................. 65 Anorexia Nervosa .................................................................................................................................. 65 Binge Eating Disorder............................................................................................................................ 66 Key Takeaways ...................................................................................................................................... 67 Quiz Questions ...................................................................................................................................... 68 Quiz Answers ........................................................................................................................................ 69 Personality Disorders ....................................................................................................................... 70 Key Takeaways ...................................................................................................................................... 72 Quiz ....................................................................................................................................................... 72 Quiz Answers ........................................................................................................................................ 73 Electroconvulsive Therapy................................................................................................................ 74 Medical Therapy for Psychiatric Disorders ............................................................................................ 75 Antidepressants .................................................................................................................................... 75 Antipsychotics ....................................................................................................................................... 77 Mood Stabilizers ................................................................................................................................... 78 Benzodiazepines ................................................................................................................................... 79
Barbiturates .......................................................................................................................................... 82 Stimulants ............................................................................................................................................. 83 Key Takeaways ...................................................................................................................................... 87 Quiz Questions ...................................................................................................................................... 88 Quiz Answers ........................................................................................................................................ 89 Dynamics of Suicide ......................................................................................................................... 90 Key Takeaways ...................................................................................................................................... 93 Quiz Questions ...................................................................................................................................... 94 Quiz Answers ........................................................................................................................................ 95 Grief and Loss .................................................................................................................................. 96 Key Takeaways ...................................................................................................................................... 99 Quiz ....................................................................................................................................................... 99 Quiz Answers ...................................................................................................................................... 101 Conclusion ..................................................................................................................................... 102 Take Away Points ................................................................................................................................ 102 Test Questions ............................................................................................................................... 104 Answers to the Test ............................................................................................................................ 120
Preface Welcome to the Introduction to Psychiatry. This course will teach you the basics of what you need to know about the world of psychiatry. There are several sections in this course that are dedicated to the subject of psychiatry. After each section, there will be “Key Takeaways,” which help you remember the most important features of the section. There will be a short quiz after each section and a final exam at the end of the course, which will test you on the subjects you learn in the course. Psychiatry is the study of mental disorders and their treatment. In this course, you will learn about the various kinds of psychiatric disorder. You will learn about how psychiatrists diagnose mental disorders and cognitive disorders by doing a mental status examination or a mini mental status examination. You will also learn about the various kinds of mental disorders. You will hear information about depressive disorders, such as Dysthymia, major depressive disorder, bipolar disorder, seasonal affective disorder, and premenstrual dysphoric disorder. These are mood disorders that influence individual’s thoughts, behaviors, and affect. Psychotic disorders will also be discussed. These are disorders in which the patient has a break with reality. The various psychotic disorders include delirium, which is a short period of psychosis caused by a physical illness, acute psychosis, schizophrenia, and postpartum psychosis. Anxiety disorders are covered in this course. The various anxiety disorders include generalized anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive-compulsive disorder, and social phobia. These cause patients to suffer from extreme fear that interferes with their activities of daily living. Many people with anxiety disorders require psychotherapy and medications to control their symptoms. This course also covers substance abuse disorders. This includes tobacco abuse, alcohol abuse, amphetamine abuse, hallucinogen abuse, benzodiazepine abuse, and inhalant abuse. Most drugs of abuse are highly addictive and have physical dependence and tolerance to the drug. Some drugs of abuse are not addictive physically but have psychological dependence. By definition, substance abuse disorders have a negative impact on the individual’s life and activities of daily living. Eating disorders are also discussed in this course. There are three main eating disorders, such as binge eating disorder, anorexia nervosa, and bulimia. All involve problems with eating but manifest themselves in very different ways. Personality disorders are an aspect of this course. They involve pervasive ways of thinking and behaving that originate in childhood experiences and possibly have genetic origins. There are many different types of personality disorders that interfere with activities of daily living. Because they are ingrained in the individual’s personality, they are notoriously difficult to treat. Psychotherapy can temper some of the symptoms but cannot cure the disorder. You will also learn about the various drugs used to treat psychiatric disorders. There are antidepressant drugs, antipsychotic drugs, stimulant drugs, and drugs for the treatment of anxiety and sleep, such as benzodiazepines and barbiturates.
Suicide is also discussed in this course. Suicide is the intentional ending of one’s own life. There are many risk factors for suicide, including having a previous history of attempted suicide, mental illnesses, poverty, and substance abuse. There are different types of suicide, including rational suicide, altruistic suicide, mass suicide, and murder-suicide. The course also covers issues of grief. Grief stems from having a real or perceived loss, such as the death of a loved one, the loss of a job, or the death of a pet. People grieve differently but often go through various stages of loss, such as denial, anger, bargaining, depression, and acceptance. At the end of this course, you will understand the basics of psychiatric disorders and their treatment. They all have different symptoms and treatments but share issues related to having an impact on the patient’s life and those around them. Hopefully, you will come to a greater understanding of psychiatric disorders and will be able to recognize them in a clinical setting.
Introduction Psychiatry is a type of medical specialty that focuses on the diagnosis of mental disorders, the prevention of these disorders, and the treatment of mental and emotional disorders. These include several types of emotional abnormalities related to a person’s perceptions, behavior, mood, and cognition. Psychiatrists act to assess an individual’s medical and emotional history, such as their mental status and past medical history. They do a mental status examination to see if the individual has a cognitive deficit. They also do psychological testing to find out if the person has an emotional disorder. The psychiatrist may also do neuroimaging techniques or other neurophysiological tests. Mental disorders are described in the Diagnostic and Statistical Manual of Mental Disorders, which is published by the American Psychiatric Association as well as the International Classification of Diseases. This manual is made by the World Health Association. The main treatments used in psychiatry are psychotherapy and psychiatric medicine. There are other treatments used in modern psychiatry. These include community treatment, supported employment, and community reinforcement. Treatment can be done while the patient is an inpatient or when they are an outpatient. It all depends on how severe the disorder is. Research and psychiatric treatment are usually done by an interdisciplinary team. These include mental health counselors, epidemiologists, public health specialists, social workers, nurses, and radiologists. They work together to manage patients with psychological diseases.
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History of Psychiatry The first topic is that of the history of psychiatry. Psychiatry is the study of mental illnesses. People have studied psychiatry for many millennia, and there are records of mental illnesses being written about since the ancient times. Ancient Greek doctors and medicine men from prehistoric times dealt with mental illnesses although there were no treatments for mental diseases. This first section talks about the history of psychiatry and what people did to understand and treat mental disorders from the ancient times to modern times. In this section, we will discuss the history of psychiatry. Mental illness dates to prehistory; however, it wasn’t until the year 1808 that the term “psychiatry” was first developed. The word was first developed by a professor by the name of Johann Christian Reil. He wrote a paper that used the word “psychiatry” in it. It comes from two Greek words, which are psyche, which means soul or mind and iatros, which means physician. Throughout human history, mental disorders were believed to be of supernatural origin. This means that the mentally ill were believed to be under the possession of evil spirits. Many treatments during this era were based on sorcery and magic. A common cure for mental disorders was exorcism. The first hospitals for the treatment of mental disorders were developed in the eighth century in Islamic countries. In modern times, psychiatry was practiced in the seventeenth and eighteenth centuries. Mental health hospitals started to use humane treatments for mentally ill patients in the nineteenth century. This is when psychiatry was first seen as a field of medicine. It wasn’t until the twentieth century that drugs were developed to treat psychiatric disorders. The earliest textbooks on mental disorders came from ancient India. One textbook came from the Ayurvedic textbook, called the Charaka Samhita. The first hospital for treating mental disorders was built in India in the third century BCE. The Greeks also wrote about mental disorders. In the fourth century BCE, Hippocrates believed that physiological problems in the body were the cause of mental disorders. Hippocrates visited Democritus, who was cutting up animals in his garden. Democritus told Hippocrates that he was cutting animals to find the cause of melancholy and mental illness. Democritus wrote a book on melancholy and mental illness and Hippocrates came to believe that there were physiological changes that caused mental illness. During the fifth century BCE, emotional disorders, particularly psychoses, were believed to be of supernatural origin. This was the belief that continued through the time of the Ancient Greeks and Ancient Rome. Egyptians also believed that mental illness was supernatural. Teachers of religion used exorcism and other barbaric methods to treat mental disorders. In ancient Islamic countries, research was done in the areas of psychology and psychiatry. There were many papers written about mental diseases. A man by the name of Abu Zayd al-Balkhi wrote a textbook on neurotic disorders in the ninth century. He believed that there were four kinds of emotional disorders. They included fear, anger, sadness, and obsession. Abu Zayd al-Balkhi divided depression into three categories. These included normal depression, endogenous depression that came from inside the body, and reactive depression, that came from outside the body. 2
There were hospitals for mental diseases created in Baghdad in 705 AD. Hospitals were built in the early eighth century in the city of Fes and in the city of Cairo. Specialist hospitals included the Bethlem Royal Hospital in London. They were built starting in the thirteenth century to treat mental conditions but only housed mental patients and did not treat them. Eventually, the attitudes toward mentally ill patients began to change. Treatments became more compassionate. In the year 1758, an English doctor named William Battie wrote a paper called the Treatise on Madness that discussed the management of mental disorders. It reviewed the treatment methods used at the Bethlem Hospital, where patients were treated for mental disorders using barbaric methods. Battie was not happy about these types of treatments and believed that treatment should include maintaining patient friendliness, giving them good food, providing fresh air, and keeping family and friends away from the patients. Battie believed that mental disorders came from dysfunctions in the brain and body instead of in the mind. Another breakthrough came in the year 1795, when a man by the name of Tony Robert-Fleury ordered that chains be removed from female mental patients at the Paris Asylum. Two other physicians, Phillipe Pinel and William Tuke, advocated for humane treatment of mental patients. One of the treatment methods was to allow patients to move around outside. Instead of dungeons, patients were placed in sunny rooms that were well ventilated. A student of Phillipe Pinel known as Jean Esquirol, developed ten new mental hospitals that were based on the same principles of humane treatment for the mentally ill. While many doctors tried to stop the use of physical restraint of patients, it was used widely throughout the nineteenth century. At the Lincoln Asylum, located in England, a doctor by the name of Robert Gardiner Hill developed a treatment method for many types of mental patients that eliminated the use of physical restraints. In 1838, France created a law that regulated admissions to asylums in England. In the nineteenth century, there was a big effort in England that modified the laws to make the treatment of the mentally ill more humane. Asylums needed to have written rules about the treatment of mental patients and they were required to have a qualified physician on staff. In the United States, the first mental asylum was built in New York in 1850. Following that, many other states built mental hospitals in the 1850s and 1860s that were designed to cure and not just house mental patients. Around 1800, France and England had only a few hundred patients in mental asylums. By the early 1900s, this number rose to many hundreds of thousands of patients. This was because doctors felt that mental illness needed to be treated in institutions. There was an increase in the numbers of patients treated so that asylums became nothing more than institutions that housed the mentally insane with few treatments given. By the early part of the 1800s, psychiatry was advanced to the point where mental illnesses included mood disorders, delusions, and irrationality. By the twentieth century, there were different ideas regarding the origin of mental disorders. Ideas began to evolve that involved the idea that mental illnesses were all biologically caused. Psychiatry became a combination of neurology and neuropsychiatry. Sigmund Freud made forward advances in psychiatry by developing psychoanalytic theories used to treat mental patients. Freud’s psychoanalytic theory began to be used by other psychiatrists who treated patients in their offices instead of in asylums. Fewer patients were treated in
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asylums, and more patients were allowed to live in their homes while being treated for mental disorders. Freud’s psychoanalytic theory faded away by the 1970s, when doctors began to believe that mental disorders were strictly biological in nature. This was when psychopharmacology was developed and patients were treated with drugs instead of psychotherapy. Neurotransmitters were identified, and drugs were developed that acted on the neurotransmitters to decrease the symptoms of mental disorders. In the 1980s, neuroimaging was used to help identify areas of the brain responsible for the development of mental diseases. In 1952, chlorpromazine was developed for the treatment of schizophrenia which made large advances in the treatment of the disease. Lithium was developed in 1948 for the treatment of mood disorders such as bipolar disorder. Psychotherapy was offered only for patients who had psychosocial problems. In 1963, President John F. Kennedy introduced laws that developed the National Institute of Mental Health that provided for Community Mental Health Centers for patients who were discharged from state mental hospitals. These community mental health centers provided psychotherapy for patients with minor mental health issues. There were no means at that time to follow and treat seriously mentally ill patients who were discharged from the hospital. This resulted in an increase in homeless mentally ill patients who could not get jobs to support themselves.
Key Takeaways • • • • • • •
Psychiatry was present since prehistoric times. The term psychiatry was first coined in 1808. Patients began to be housed in mental asylums around 1850. There were thousands of inpatients with psychiatric disorders around 1900. Freud developed his psychoanalytic theory in the early 1900s. Biologic theories on psychiatric illnesses began around the 1970s. Neuroimaging began around the 1980s.
Quiz Questions 1. Which president introduced laws to provide for the National Institute of Mental Health? a. Franklin D. Roosevelt b. Dwight Eisenhower c. John F. Kennedy d. Richard M. Nixon 2. What was the first drug introduced for the treatment of schizophrenia? a. Prochlorperazine b. Chlorpromazine c. Ziprasidone d. Quetiapine 4
3. Which individual promoted the psychoanalytic theory? a. Sigmund Freud b. Erick Erickson c. Karl Jung d. Elisabeth Kubler-Ross 4. When were there thousands of patients in mental asylums? a. The middle of the 1700s b. The beginning of the 1800s c. The beginning of the 1900s d. The beginning of the twenty-first century 5. When was the first asylum built in the United States? a. 1750 b. 1850 c. 1900 d. 1950 6. When were the first psychiatrists beginning to believe that psychiatric disorders had a biological basis? a. 1900 b. 1950 c. 1960 d. 1970 7. What is the language of origins for psychiatry? a. The French language b. The Greek language c. The Latin language d. The German language 8. When was neuroimaging for the diagnosis of mental disorders first discovered? a. 1950 b. 1960 c. 1970 d. 1980 9. What was the first drug used for the treatment of bipolar disorder? a. Chlordiazepoxide b. Carbamazepine c. Lithium d. Depakote 10. When were the first hospitals created for the treatment of mental disorders? 5
a. b. c. d.
Around 700 AD Around 1200 AD Around 1800 AD Around 1900 AD
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Quiz Answers: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
c. b. a. c. b. d. b. c. c. a.
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Mental Status Evaluation The next topic of discussion is the mental status examination. Psychiatrists and general practitioners use the mental status examination to determine if the patient has a cognitive deficit. There are two types of mental status examinations that will be discussed in the next section. These include the mental status examination and the shorter version, known as the mini mental status examination. Both of these tests measure a person’s cognitive functioning. In this section, we will discuss the ways doctors use mental status evaluations to evaluate the patient with a psychiatric disorder. It is not generally used by general practitioners or internists but is used by neurologists and psychiatrists who use the test to assess the cognitive abilities of the mental patient. The mental status examination can detect impairments in cognition, memory, and can detect disorders of thought processes in patients suspected of having a mental or cognitive disorder. The goal is to detect subtle changes in the mental status examination that cannot be picked up by simply interviewing the patient. There are several parts to the mental status examination. Together they are used to help detect mental disorders and cognitive deficits. The first aspect of the mental status examination is to look at the patient’s appearance. Take note of how the patient looks. Are they neatly dressed and have they paid attention to their grooming and clothing? Are they disheveled and have they failed to pay attention to their clothing and grooming? A mentally disturbed or cognitively impaired patient generally does not have good grooming habits and will not be well dressed and clean. The second aspect of the mental status examination is the level of alertness. Find out if the patient is conscious or not. If they aren’t conscious, can the patient be aroused using verbal stimuli or by eliciting a pain response from the patient. Find out if the patient can remain focused on the conversation and can answer questions appropriately. Determine if they have a normal attention span. The third aspect of the mental status examination is an evaluation of the patient’s speech pattern. Do they have a normal speech pattern and is the volume, quantity, and tone of their speech within normal limits? Do they pronounce words correctly or is their speech slurred and incomprehensible? The fourth aspect of the mental status examination is the patient’s behavior. Does the patient have a pleasant demeanor and cooperative with the examination? Are they agitated and unable to focus on the conversation? What is the attention span of the patient? Is the patient’s behavior appropriate for the situation they are in? The fifth aspect of the mental status examination is an assessment of the patient’s orientation. Are they aware of their environment and do they know their location and what they are doing at the doctor’s office? Do they know the name of their examiner? Can they tell the examiner details of the day of the week, the date, and the current year?
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The sixth aspect of the mental status examination is an evaluation of the individual’s mood? Ask them how they are feeling using direct questions, such as are they sad, depressed, angry or happy? Is their mood appropriate for the situation they are currently in? The seventh aspect of the mental status examination is an assessment of the patient’s affect. Pay attention to the appearance of the patient. Observe the patient during the interview. Decide if they are making eye contact with you during the evaluation. Determine if they are especially excitable. Take note of the tone of their voice. You may observe that their affect is flat, which means that it doesn’t change throughout the evaluation. Other types of affect include being excitable, depressed or appropriate for the current conversation. The eighth aspect of the mental status examination is the patient’s thought process. This is an evaluation of the way the patient is thinking. Do they seem to have a logical train of thought and do they present themselves in an organized fashion? If they do not seem to be organized, determine how far off base they are with respect to organization. Decide if they tend to stray away from the topic at hand. Find out if their thoughts are linked together or if they are having a flight of ideas as is seen in bipolar disorder. The ninth aspect of the mental status examination is the content of their thoughts. Describe what the patient is thinking about. Do they seem to have paranoid ideation or are they having delusions, which are beliefs that are untrue? What are their delusions related to? Do they have phobic thoughts? Are they hallucinating? Ask them if they hear or see things that other people do not hear or see. Are they fixated on a single idea and unable to get off the topic? Is the content of their thoughts consistent with their observed affect? Do they have suicidal ideation or homicidal ideation? Ask them specifically about their suicidality and determine if they have a specific date, time, or plan related to suicide. Asking about suicide has not been shown to plant a seed of suicidal thinking in the patient so it is okay to ask them about it. The tenth aspect of the mental status examination is an assessment of memory. Assess their short-term memory by giving them three objects to remember. Ask them to list back the objects so that you know that they have heard them correctly. Talk to them again for about five minutes and then ask them to recall the objects after waiting five minutes. Evaluate their long-term memory by asking about their past. Aske them where they were born and raised. Ask them about their family history. Ask them to list the jobs they have had in the past. The eleventh aspect of the mental status examination is finding out if the patient can perform mathematical calculations. Can they add and multiply numbers together? Are their answers appropriate to their level of education? Ask them if they have difficulty balancing their checkbooks or giving the correct amount of money when buying things at the store. This part of the evaluation also assesses the patient’s attention span and their ability to remain focused on a task. The twelfth aspect of the mental status examination is an evaluation of the patient’s judgment. Give them a scenario and ask the patient what they would do in that scenario. You can ask them what they would do if they found a stamped letter on the ground in front of a mailbox. If they say they would put the stamped letter in the mailbox, this is an example of correct judgment. If they say anything else, perhaps their judgment is impaired.
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The thirteenth aspect of the mental status examination is a measurement of the patients higher cortical functioning and abilities to reason. Have them give you an interpretation of complex ideas. This might involve giving them a common phrase such as “People in glass houses shouldn’t throw stones”. Ask them what this phrase means. If they give you a literal interpretation of the phrase, their higher cortical functioning may be abnormal. If they give you the correct abstract interpretation of the phrase, you can consider their higher cortical functioning to be intact. When using the mental status examination, you can detect a couple of mental disorders. The first is delirium. This is also called an acute confusional state, a toxic metabolic state, or an altered mental status. It is a common diagnosis among hospitalized patients with physical illnesses, such as liver failure, kidney failure, hypoxia, sepsis, or the ingestion of toxic substances. In delirium, there can be a wide variation in the patient’s presentation. The patient may be unarousable or very agitated. They may have abnormalities in their vital signs that can help diagnose the cause of the delirium. The patient may have delirium because of hypotension or infection that can be detected by evaluating their vital signs and doing medical testing. The patient may be hallucinating or paranoid as part of their delirium. They may be suffering from delusions. In delirium, the onset of the confusion is sudden and will give them an abnormal mental status examination. The best way to deal with this type of delirium is to treat the underlying medical disorder that is the cause. Patients at high risk for an abnormal mental status examination secondary to delirium are generally elderly patients who have many medical problems. They can become confused and will have an abnormal mental status examination with even a small precipitating illness. In some cases, an early psychotic disorder or dementia can appear to be delirium. The difference is that psychotic disorders and dementia are not reversible with treating physical conditions and there doesn’t seem to be a recognizable physical illness causing the abnormal mental status examination. It sometimes takes time to sort out the difference between delirium and either acute psychosis or dementia. Dementia can also be detected by an abnormal mental status examination. The onset of dementia is slow and develops over several years or months. It is an uncommon diagnosis in patients under the age of fifty (50), but its incidence rises dramatically with age. Patients with dementia are often disheveled and do not keep up appropriate appearances. Mildly impaired patients can answer basic questions and will only have difficulty with things like addition, multiplication, or memory. More severely affected patients with dementia can be unable to answer even simple questions and will have wide variations in their affect and mood. Very severely affected patients will be completely unable to care for themselves and will have marked abnormalities in their mental status examination with impairments in judgment, memory, and higher cortical function that tend to get worse over time. Next, we will discuss the mini-mental status examination or Folstein test. This is a questionnaire that has a total of 30 points. It is used in clinical settings and in research settings as a measurement of cognitive disabilities. It is a good screening tool for early dementia and can follow the course of the dementia when given to the patient several times over the course of a month or year. It takes only 5-10 minutes
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to give and can measure the patient’s attention span, calculating abilities, memory recall, orientation, memory recall, and the ability to follow simple commands. Because it is simple to do, it can be used by clinicians in all medical disciplines and can be used at the bedside or in an office setting. It has the disadvantage of not being able to detect minor cognitive impairments and may not be able to detect early Alzheimer’s dementia. It is a verbal test so that it doesn’t detect problems with visuospatial function or constructional function. The mini mental status examination includes asking the patient simple questions and giving them problems to solve. It asks the patient to state the time and place of the test, to repeat a list of words given to them, to perform simple mathematical tasks, such as the serial seven test in which they are asked to count backward from one hundred seven numbers at a time. Their basic motor skills are assessed as are their use of language and the comprehension of language. The basic aspects of the mini mental status evaluation include an assessment of these things: The first is orientation to time. This is when the examiner asks the patient to tell them the time from the broadest representation of time to the narrowest representation of time. A lack of orientation to time has been linked to a future decline in cognitive functioning. The second is orientation to place. This is also done from the broadest representation of time to the narrowest representation of time. The examiner can narrow down the place to the person’s street location or to the floor they are on in a facility. The third is the evaluation of registration. The patient is asked to repeat named prompts to see if they can follow directions and speak clearly. The fourth is an evaluation of attention and calculation. This involves asking the patient to spell “world” backward or to count backward from one hundred in increments of seven. This serial seven evaluation is appropriate when the patient does not speak English as their primary language. The fourth is an evaluation of recall. The patient is asked to recall words that are given to them by the examiner. They are given words and asked to recall them five minutes later. The fifth is an evaluation of the patient’s language abilities. They are asked to name a pencil and a watch shown to them by the evaluator. The sixth is an evaluation of the patient’s ability to speak back a phrase. This is known as repetition. The seventh is an evaluation of the patient’s ability to repeat complex commands. The patient can draw a figure to see if they can accurately draw it. Sometimes the patient is asked to draw the face of a clock to see if they put the numbers in the correct places. Points are given for correct responses. There are a total of thirty points possible in the test. Any score of 24 points or higher represents normal cognition. Point scores below this can reflect a mild, moderate, or severe cognitive deficit. Very low scores are often seen in dementia, although low scores can be seen in other mental disorders. In some cases, physical impairments, such as hearing or vision impairments can cause an artificially low mini mental status examination because the patient physically cannot answer the questions properly. They may have a motor deficit that impairs their ability to write and draw. The mini mental status examination can tell the difference between different types of dementias. For example, patients with Alzheimer’s dementia have low scores in time and place orientation and low scores in recall when compared to patients with Lewy body dementia, Parkinson’s dementia, or vascular 11
dementia. It cannot adequately evaluate patients who are at a high risk for dementia but do not yet have the disease.
Key Takeaways • • •
• •
The mini mental status examination and the mental status examination measure a person’s cognitive dysfunction. Dementia and delirium can be measured by these examinations. There are several parts to the mental status examination that measure appearance, level of alertness, speech pattern, behavior, orientation, mood, affect, thought process, thought content, memory, judgment, mathematical calculations, and higher cortical functioning. The mini mental status examination is a shorter test with 30 points allocated if the person has completely normal cognitive functioning. The mini mental status examination measures orientation to time, orientation to place, registration, recall, language abilities, repetition, and the ability follow complex commands.
Quiz 1. What is the purpose of the mini mental status examination? a. To detect dementia b. To detect delirium c. To identify depressive symptoms d. To identify psychotic thoughts 2. How many points are given in a perfect score for the mini mental examination? a. There are no points given b. There are 30 points in a mini mental status examination c. There are 15 points in a mini mental status examination d. There are 10 points in a mini mental status examination 3. In a mental status exam, the function of registration is demonstrated by the patient doing what? a. Drawing a figure b. Doing serial sevens c. Repeat named prompts d. Remember three objects 4. What is the importance of appearance in a mental status examination? a. There is no importance of the patient’s experience b. Patients who are disheveled are likely to have cognitive delays c. Patients who are neatly dressed may have early Alzheimer’s dementia d. Patients who are wearing mismatched clothing often have financial difficulties paying for clothing
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5. How is recall established in the mental status examination? a. Patients are asked to do serial sevens b. Patients are asked to draw an object c. Patients are asked to remember three objects d. Patients are asked to draw a clock face 6. When a patient has a lack or orientation to time, what is the likely prognosis? a. They are likely to have future psychosis b. They are at an increased risk of Parkinson’s disease c. They are likely to have an increased risk of cognitive delay d. They are likely to have an increased risk of depression 7. Besides dementia, what psychiatric disorder can be diagnosed with a mental status examination? a. Depression b. Delirium c. Parkinson’s disease d. Bipolar disorder 8. Why is suicidality a part of the mental status examination? a. Patients with delirium are at a high risk of suicide b. Understanding the content of the patient’s thoughts are not generally done c. It is important to understand the content of the individual’s thought processes d. It may cause the patient to have suicidal thoughts 9. How is orientation to time evaluated in the mental status examination? a. The patient is asked what time they had breakfast b. The patient is asked what time their appointment was c. The patient is asked what time it is from the broadest to narrowest time frame d. The patient is asked what time they go to bed 10. How is mathematical calculation determined in the mental status examination? a. The patient is asked to perform serial sevens b. The patient is asked to do simple mathematic calculations c. The patient is asked to draw a clock face with numbers d. The patient is asked to count to one hundred
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Quiz Answers 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
a. b. c. b. c. c. b. c. c. b.
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