Required

Textbooks
1. The American Psychiatric Publishing Textbook
of Psychiatry (6th ed.)
2. Diagnostic and Statistical Manual of Mental
Disorders (5th ed.)
DSM-5
Pg. 4 of the Syllabus
Psychiatric Assessment
&
DSM-5
Richard B. Seely, M.D.
Psychiatrist
 Biopsychosocial Model
Biological
Behavior is the result of chemical and neural
processes
Psychosocial
Behavior is the result of psychological processes
such as learning and the interaction of the
individual with life experiences
 Psychiatric Diagnosis
Reduces complexity of clinical phenomena
Creates a structure to understand mental
disorders
Facilitate communication between clinicians
Often related to prognosis
Schizophrenia
Bipolar Disorder
Developmental disorders
 Psychiatric Diagnosis
Depression
Multiple processes
Genetic risk
Life experiences (resilience)
Unipolar vs. bipolar
Neurotransmitter systems involved
HPA axis
Neuroplasticity
Default mode network
Antidepressant analog to fever: aspirin?
 Summary
Psychiatric nosology is primarily descriptive
and not directly related to etiology
Does not directly lead to a treatment
True in other areas of medicine as well
HTN is not defined by etiology, but by blood
pressure
DM is not defined by etiology, but my blood
glucose
Diagnoses can change with better knowledge
Pre hypertension
Pre diabetes
 DSM
Diagnostic and Statistical Manual of the
American Psychiatric Association
 DSM History 1

DSM-I (1952) Common language (86 pages)

DSM-II (1962) Descriptions (92 pages)
Feighner/Research Diagnostic Criteria
(1972/74)
Attempt to establish reliability using specific
symptoms
 DSM History2
DSM-III (1980) (482 pages)
Criteria : Objective and observable to improve
reliability
DSM-III-R (1987)
DSM-IV (1994)
DSM-IV-TR (2000)
DSM-5 (2013)
 Chinese Menu Approach
Advantages Disadvantages
Improved reliability False sense of certainty
May sacrifice validity
 Major Depression
1. depressed mood
2. markedly diminished interest or pleasure
3. weight loss or weight gain
4. insomnia or hypersomnia
5. psychomotor agitation or retardation
6. fatigue or loss of energy
7. feelings of worthlessness or guilt
8. diminished ability to concentrate
9. recurrent thoughts of death
 Salient Changes
DSM-IV to DSM-5
Integrated dimensional approach to diagnosis
and classification
Incorporated via select diagnoses
more latitude to assess the severity of a condition
does not imply a concrete threshold between
normality and a disorder
Replaced multiaxial system
Diagnostic criteria for many disorders
 Salient Changes
DSM-IV to DSM-5
Several disorders combine different
categorical disorders conceptualized as
occurring along a single spectrum
a dimensional component adding a severity measure to
diagnostic categories (to document the severity of a
specific disorder: some clinician-related/some patient-
related)
Removed Global Assessment of Functioning
listing of psychosocial stress(ors) or contributing
medical conditions
 DSM-5
Definition of a Mental Disorder
A health condition characterized by a
significant dysfunction in an individuals
cognitions, emotions, or behaviors that
reflects a disturbance in the psychological,
biological, or developmental processes
underlying mental functioning
Some disorders may not be diagnosable until
they have caused significant distress or
impairment of performance
 DSM-5: Overview
Manual: composed of three (3) sections:
Section 1: introduction to DSM-5, with information on
how to use the updated manual; definition of mental
disorder
Section 2: outline the categorical diagnoses according
to a revise chapter organization (20)
Section 3: include the conditions that require further
research before their consideration as formal
disorders, as well as measurement instruments
Appendix: highlights of changes from DSM-IV to DSM-
5 diagnoses and codes, numerical listing of DSM-5
diagnoses and codes (ICD 9 and ICD 10)
 DSM-5: Overview
DSM-5 is a diagnostic and statistical manual; it is
NOT a treatment manual
DSM-5 is based on a mix of research , economic
concerns, social preferences, and professional
consensus
DSM-5 is used for a basic mental health practice,
to facilitate an objective assessment of
symptom presentations in a variety of clinical
settings and for insurance reimbursement
 Use of DSM-5:
Structure of Disorder Chapters
Section 2:
Criteria
Subtypes and/or specifiers
Severity
Explanatory text (new or expanded)
 Use of DSM-5:
Chapter Structure
Neurodevelopmental Disorders
Schizophrenia Spectrum and other Psychotic
Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
 Use of DSM-5:
Chapter Structure
Somatic Symptom and Related Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunction
Gender Dysphoria
Disruptive, Impulse-Control, and Conduct
Disorders
Substance-Related and Addictive Disorders
 Use of DSM-5:
Chapter Structure
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Mental Disorders
Medication-Induced Movement Disorders and
Other Adverse Effects of Medication
Other Conditions That May Be a Focus of
Clinical Attention
Psychiatric Assessment
 Interviewing Techniques
Establish Safety
Setting
Introduce self / greet patient
Be mindful of escalating agitation
Do not allow inappropriate behavior
Exit
 Interviewing Techniques
Establish rapport
Begin interview asking demographic data
Convey warmth and friendliness,
Arrange seating eye level
Matching behavior
 Interviewing Techniques
To Rule In/Out
use more focused, direct, detailed questions
How is your sleep?
Do you have difficulty falling asleep?
Do you find yourself waking up in the middle
of the night?
How many times?
Do you feel rested?
Assess Unspoken Behaviors
Process of interview: How patient says it

Are they congruent?

Psychomotor behavior
Inconsistencies
Eye contact
Memory, concentration
Evaluate affect
Mental Status Examination
PE Equivalent
Determined by observation (Process)
appearance, body language, affect
Asking Questions
mood
speech
thoughts
memory
perceptions
 Appearance / Attitude
How does patient come to interview
clothes, unusual
Grooming
neat, casual, disheveled
Hygiene
clean, smells
Stated age
Facial expression
 Attitude / Behavior

Attitude
cooperative, oppositional, guarded, defiant, aloof
seductive, manipulative, suspicious, bizarre
Behavior
psychomotor agitation
aggression
psychomotor retardation
 Attitude / Behavior
Abnormal movements
tremor , TD
tics
vocal, facial, motoric
Stereotypic
persistent repetitive movement
Ritualistic
 Affect / Mood
Mood
Ask the patient: Hows your mood?
Or identify
So how long have you been depressed?
Mood is what patient describes
Climate
 Affect
Observation of moment to moment
emotional tone
Facial expressions
sad, tearful, smiling,
irritable, expansive
What the patient conveys in verbal behaviors
congruent, incongruent
appropriate, labile
 Speech
Rate
slow, pressured, hyper-verbal
Rhythm (prosody)
Coherence
logical line of thought
Spontaneous
Clanging
speech pattern where thinking is driven by word
sounds
 Speech
Echolalic
immediate and involuntary repetition of words or
phrases just spoken by others
Word Salad
words joined incoherently
Increased latency of response
 Thoughts

Thought Process
how its said
Thought Content (Form of Thought)
what is said
 Thought Processes
Inferred by speech patterns
Goal directed
Circumstantial
Disorganized
looseness of associations (rapid, disjointed)
Tangential (topic to topic)
Derailment
 Thought Processes
Latency
Poverty of thought (Alogia)
Perseverative
repetitive responses to multiple questions
inability to change sets
Abstract vs. Concrete
proverbs, similarities
 Thought Content
Suicidal ideation
intention, plan
Homicidal ideation
intention, plan
need to report
Delusions (psychotic; impaired reality testing)
abnormality of thought content
fixed or loosely held false beliefs not explained by
cultural background
 Delusions
Persecutory/Paranoid
Jealousy
Sin / guilt
Grandiose
Religious
Somatic
Ideas / Delusions of Reference
 Ideas / Delusions of Reference
Idea of reference
patient is suspicious yet senses its erroneous
Delusion
patient believes it
Delusions of being controlled
belief that actions and feelings controlled by
outside source
Mind Reading
 Thought Broadcasting
others can hear your thoughts
Thought Insertion
thoughts are being inserted into ones mind
Thought Withdrawal
someone has removed your thoughts
 Perceptual Disturbances
Psychotic

Hallucinations
false perception in absence of identifiable external
stimulus
Auditory
voices, noise, sounds, music
Assess
gender, familiar, critical, conversing with each
other
location, frequency
Must Discern: if command in nature
 Perceptual Disturbances
Psychotic
Visual
people, shapes, devil, God
Tactile
burning / crawling
Olfactory
unusual smells vs. parasomias
Illusions
misperception of external stimulus
Sleep
Hypngogic
Hypnopompic
 Memory
Immediate / Registration
repeat 3 words
Recent
recall 3 words after 5 minutes
Remote
historical facts, birthday
 Intelligence / Insight
Similarities, vocabulary
Insight :
Does the patient have an understanding of whats
wrong with him or her?
Orientation

Person
Place
Time
 Judgment
Reasonable
Immature
Effected by emotional state
Impulsive
 Mini Mental State Exam
Folstein
Orientation
Registration
Attention and Calculation
Recall
Language
 Identifying Data
Informant Age
Patient Handedness
Family Race
Other
Gender
Source of Referral
Marital status
Occupational status
Highest grade
attained
 Chief Complaint
What seems to be the problem?
patients own words
 HPI
Patient speaks freely Exceptions
3 5 minutes paranoid
relaxes patient uncooperative
Patient speaks main psychotic
concerns drunk / intoxicated
Observe hyper-verbal
thought process
speech
coherence
 Provisional Dx
Content of interview: What patient says

Become more direct

Onset of symptoms
Precipitants
stressors, relationships, work, children, drugs, NONE.
Acute, gradual, chronic
 Provisional Dx
Symptom severity Establish symptom
effect on functioning pattern
in different settings MNA Panic Attack
Psychic pain Mood worse in AM
How distracting are Postpartum
the voices? Seasonal
What do you feel
when you have
flashbacks?
 Provisional Dx
Prior treatment hx
incorporate into HPI
Medication
Doses
Length of Rx
Effectiveness
Psychotherapy
How long
For what
 Review of Systems
Psychiatric Syndromes

Covers other Dx
As in medicine
Helps to establish differential
Pertinent positives, negatives
Sexual activity
Must cover
Suicidal and homicidal ideation, intent, plan
Alcohol and substance use and abuse
Psychotic processes
 Past Psychiatric Hx
Chronological order
Outpatient / Inpatient
where, when, how long, why
ECT
Rehab / Detox
Suicide Hx
When, how, intention, intervention
Medication Hx :
What , how much, effectiveness
 Substance Hx
incorporate in HPI if CC

Drug of Choice
Onset: first drink
Severity: blackouts, DUIs
Tolerance: how much, escalating
How often
Money spent
Consequences
IV Drug Abuse
 Family Psychiatric Hx
Relatives
Psych Hx
Drugs / ETOH
Suicide Hx
Adopted
 Medical Hx
Brief ROS
Current medical problems
Surgical Hx
Head trauma
Loss of consciousness (LOC)
Seizures
Pregnancy Hx
 Social / Developmental Hx
Work Hx
Past / Present
Military Hx
Legal Hx
Abuse Hx
Physical
Emotional
Sexual
 Social / Developmental Hx
children: very thorough

Born / Raised
Childhood problems
Education
Relationship with parents
Marital Hx
Religious / Cultural attitudes
 Plan
Work-Up: Psychiatric Patients require the same
careful, high quality work up as any other patient
Mandatory
To rule out medical causes of psychiatric illnesses or
Specific Treatments
ECT, lithium, etc.
Labs
Psychological Testing
Treatment