Kaplan + Sadock's Synopsis of Psychiatry, 11e

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21.1 Introduction and Overview

Amnestic Disorder Amnestic disorders are classified inDSM-5 as major neurocognitive disorders caused by other medical conditions . They are marked pri- marily by memory impairment in addition to other cognitive symp- toms. They may be caused by (1) medical conditions (hypoxia), (2) toxins or medications (e.g., marijuana, diazepam), and (3) unknown causes. These disorders are discussed in Section 21.4. Clinical Evaluation During the history taking, the clinician seeks to elicit the devel- opment of the illness. Subtle cognitive disorders, fluctuating symptoms, and progressing disease processes may be tracked effectively. The clinician should obtain a detailed rendition of changes in the patient’s daily routine involving such factors as self-care, job responsibilities, and work habits; meal prepara- tion; shopping and personal support; interactions with friends; hobbies and sports; reading interests; religious, social, and rec- reational activities; and ability to maintain personal finances. Understanding the past life of each patient provides an invalu- able source of baseline data regarding changes in function, such as attention and concentration, intellectual abilities, personal- ity, motor skills, and mood and perception. The examiner seeks to find the particular pursuits that the patient considers most important, or central, to his or her lifestyle and attempts to dis- cern how those pursuits have been affected by the emerging clinical condition. Such a method provides the opportunity to A. General Description 1. General appearance, dress, sensory aids (glasses, hearing aid) 2. Level of consciousness and arousal 3. Attention to environment 4. Posture (standing and seated) 5. Gait 6. Movements of limbs, trunk, and face (spontaneous, resting, and after instruction) 7. General demeanor (including evidence of responses to internal stimuli) 8. Response to examiner (eye contact, cooperation, ability to focus on interview process) 9. Native or primary language B. Language and Speech 1. Comprehension (words, sentences, simple and complex commands, and concepts) 2. Output (spontaneity, rate, fluency, melody or prosody, volume, coherence, vocabulary, paraphasic errors, complexity of usage) 3. Repetition 4. Other aspects Table 21.1-1 Neuropsychiatric Mental Status Examination

appraise both the impact of the illness and the patient-specific baseline for monitoring the effects of future therapies. Mental Status Examination After taking a thorough history, the clinician’s primary tool is the assessment of the patient’s mental status. As with the physi- cal examination, the mental status examination is a means of surveying functions and abilities to allow a definition of per- sonal strengths and weakness. It is a repeatable, structured assessment of symptoms and signs that promotes effective com- munication among clinicians. It also establishes the basis for future comparison, essential for documenting therapeutic effec- tiveness, and it allows comparisons between different patients, with a generalization of findings from one patient to another. Table 21.1-1 lists the components of a comprehensive neuropsy- chiatric mental status examination. Cognition When testing cognitive functions, the clinician should evaluate memory; visuospatial and constructional abilities; and reading, writing, and mathematical abilities. Assessment of abstraction abil- ity is also valuable, although a patient’s performance on tasks such as proverb interpretation may be a useful bedside projective test in some patients, the specific interpretation may result from a variety of factors, such as poor education, low intelligence, and failure to understand the concept of proverbs, as well as from a broad array of primary and secondary psychopathological disturbances. D. Mood and Affect 1. Internal mood state (spontaneous and elicited; sense of humor) 2. Future outlook 3. Suicidal ideas and plans 4. Demonstrated emotional status (congruence with mood) E. Insight and Judgment 1. Insight a. Self-appraisal and self-esteem b. Understanding of current circumstances c. Ability to describe personal psychological and physical status 2. Judgment a. Appraisal of major social relationships b. Understanding of personal roles and responsibilities F. Cognition  1. Memory a. Spontaneous (as evidenced during interview) b. Tested (incidental, immediate repetition, delayed recall, cued recall, recognition; verbal, nonverbal; explicit, implicit)  2. Visuospatial skills  3. Constructional ability  4. Mathematics

a. Object naming b. Color naming c. Body part identification d. Ideomotor praxis to command

 5. Reading  6. Writing  7. Fine sensory function (stereognosis, graphesthesia, two-point discrimination)  8. Finger gnosis

C. Thought 1. Form (coherence and connectedness) 2. Content

a. Ideational (preoccupations, overvalued ideas, delusions) b. Perceptual (hallucinations)

 9. Right-left orientation 10. “Executive functions” 11. Abstraction

(Courtesy of Eric D. Caine, M.D., and Jeffrey M. Lyness, M.D.)