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PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: CLINICAL
ASSESSMENT-HALLUCINATIONS AND DELUSIONS AND INSTRUCTIONS FOR ADMINISTRATION OF MINI-MENTAL STATE EXAMINATION
Medical and surgical patients who develop hallucinations or delusions are almost always delirious. A hallucination is a perception without a stimulus (e.g., the patient sees people in the room when no one is there). Hallucinations are distinguished from illusions, in which stimuli are present, but misidentified (e.g., the patient sees an intravenous line as a snake). A delusion is a fixed, false, idiosyncratic belief (e.g., the patient is convinced, despite reassurance from family members and staff, that her physicians are trying to kill her).
Orientation:
(1) Ask for the date. Then ask specifically for parts omitted, for example, “Can you also tell me what season it is?” One point for each correct.
(2) Ask in turn “Can you tell me the name of this hospital?” (town, county, etc.). One point for each correct.
Registration-Ask the patient if you may test his memory. Then say the names of 3 unrelated objects, clearly and slowly, about one second for each. After you have said all 3, ask him to repeat them. This first repetition determines his score (0-3), but keep saying them until he can repeat all 3, up to 6 trials. If he does not eventually learn all 3, recall cannot be meaningfully tested.
Attention and calculation-Ask the patient to begin with 100 and count backwards by 7. Stop after 5 subtractions (93, 86, 79, 72, 65). Score the total number of correct answers.
If the patient cannot or will not perform this task, ask him to spell the word “world” backwards. The score is the number of letters in correct order. E.g. dlrow = 5, dlorw = 3.
RECALL-Ask the patient if he can recall the 3 words you previously asked him to remember. Score 0-3.
Language-Naming: Show the patient a wrist watch and ask him what it is. Repeat for a pencil. Score 0-2.
Repetition: Ask the patient to repeat the sentence after you. Allow only one trial. Score 0 or 1.
3-Stage command: Give the patient a piece of plain blank paper and repeat the command. Score 1 point for each part correctly executed.
Reading: On a blank piece of paper, print the sentence “Close your eyes”, in letters large enough for the patient to see clearly. Ask him to read it and do what it says. Score 1 point only if he actually closes his eyes.
Mental Disorders
Epilepsy Copying: On a clean piece of paper, draw intersecting pentagons, each side about 1 in and ask him to copy it exactly as it is. All 10 angles must be present and 2 must intersect to score 1 point. Tremor and rotation are ignored.
Estimate the patient’s level of sensorium along a continuum, from alert on the left to coma on the right.
*7/172/2*

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DELIRIUM: OTHER CLINICAL CHARACTERISTICS OF DELIRIUM-DISTURBANCE IN EMOTIONAL STATE
Mental Disorders Intense emotions are usually reflected in the patient’s facial expression and behavior. Thus, delirious individuals who are frightened may run from the ward or barricade themselves in their rooms, those who are despondent may try to commit suicide, and those who are irritable may shout or strike at others. Fear and anger are often accompanied by tachycardia and hypertension.
Abnormal moods are more readily identified in hyperactive-hyper-alert delirium because that form of the syndrome is productive of speech and behavior. Patients with hypoactive-hypoalert delirium often appear apathetic and do not respond to events that ordinarily lead to emotional reactions (e.g., visits from loved ones). Apathetic states tend to be more sustained than dysphoric and euphoric ones.
*13/172/2*

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MENTAL HEALTH: A REVOLUTION IN PSYCHIATRY
In the 1950s, 600,000 Americans languished in state mental hospitals. Today, many seriously afflicted mental patients live outside institutions. State hospitals hold only 130,000 patients.
The revolution in treatment of the mentally ill began in 1954 with a drug called Thorazine, which relieved the psychosis associated with schizophrenia and manic-depressive syndrome. Other drugs followed. Lithium and Elavil modify the extreme mood swings of manic-depressives; tranquilizers such as Librium and Valium relieve anxiety.
Psychiatrists today prescribe any number of mood-altering drugs. And thanks to sophisticated new blood tests that measure how much of the drug has entered the patient’s body, doctors can administer safe doses.
In addition, psychiatrists are treating psychotic, depressed patients prone to suicide. When suicide seems imminent, the physician may recommend electro-shock-or, the term they prefer, electroconvulsive – therapy (•Ўў). Doctors have modified “shock treatments.” They send electricity into a patient’s brain. Unprotected, the person’s body arched in epileptic-like tremors. In some cases, •Ўў ended with a broken spine. Physicians now have markedly reduced the amount of electricity. They also use general anesthesia plus a muscle relaxant to prevent muscle spasms. The body, asleep, remains still.
Scientists believe that the electricity alters the brain’s chemistry, clearing depression. Proponents say •Ўў has cut the suicide rate dramatically, with few side effects except a temporary loss of memory. Surprisingly, •Ўў is safer than drugs.
*6/266/5*

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MENTAL HEALTH: BEHAVIOR THERAPY
Several years ago, I put a pigeon named Harold into a cage equipped with an electrically controlled feeding trap. By tapping a button, I could open the trap door and let the bird take a corn kernel.
Whenever Harold moved to the right, I’d open the trap door. He would snap up the released corn kernel. Then I’d wait until he turned more to his right. Another bit of corn. Again and again, I fed Harold until he turned completely in a circle.
Without a word, I had changed Harold’s behavior using a technique developed in the 1940s by Dr. B. F. Skinner at Harvard University.
Psychologists have since modified Dr. Skinner’s behavior modification method for use in the counseling room, where they call it behavior therapy.
Today’s behavior therapists “positively reinforce,” or reward, the behavior they want to encourage. With my own grandson, Ethan, I came closest to treating a human being with the technique used on Harold’, the pigeon. I toilet-trained Ethan in 1 day with a method invented by Dr. Nathan Azrin of Nova University in Fort Lauderdale, Florida. I fed Ethan little salted crackers and fruit juice every time he came close to using the toilet. I added lots of love. In a few hours he was toilet trained. (My experience taught me that it is easy to change the mood of 2-year-old children simply by toilet-training them at 18 months, thereby avoiding the conflict between parent and child. The behavior of children in the “terrible twos” can drive parents to distraction.) Many parents scold or spank their children to train them. Such punishment, or negative reinforcement, also brings about the desired behavior. But negative reinforcement breeds hostility; therefore, professional behavior therapists don’t use it.
A troubled family can transform itself with a kind of behavior therapy called family contracting. Each person promises to stop disruptive behavior or to help the others do so. Each parent and child selects a reward, approved by the others. Everyone keeps score. Those who change their behavior get the rewards.
Unlike a psychotherapist, a behavior therapist who treats phobias does not care what originally scared you. Instead, the therapist relaxes you, then has you imagine the feared situation (e.g., riding in an elevator, holding a cat, or swimming).
Dr. Aaron T. Beck, of the University of Pennsylvania, builds up the confidence of depressed patients with a form of behavior therapy called cognitive therapy. It deals with what people think they know.
For example, suppose you think, “I am worthless and no use to anybody.
Who will ever want to marry me?” That’s what you think you know. When you are depressed, everything looks bad. The cognitive therapist would have you write down all of your qualities, good and bad. (“I am not beautiful. I am not tall. But I am friendly. I am smart.”) This therapy confronts you with a balanced, more realistic look at yourself. After several sessions of such exercises, moderate depression lifts. Dr. Albert Ellis, a New York psychologist, discovered this method in parallel to Dr. Beck.
*5/266/5*

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DEALING WITH THE CAUSE OF INSOMNIA: DEPRESSION AND SADNESS
Although it’s possible to be both anxious and depressed, usually the last thing a depressed person wants to do is rush around: one of the most common symptoms of depression is lack of energy. Depression comes in many forms and degrees of severity There are two main types: reactive depression, triggered by unhappy or difficult events, and endogenous depression that can strike some people regularly for no good reason at all. At its worst it becomes clinical depression, which may need medical or psychiatric treatment.
As long as you are not clinically depressed, you can start helping yourself Ђ” and the sooner the better, before the habit of depression becomes too ingrained. You will need to make an effort to go against the lethargy that keeps you down. But it really is possible to change your self-denigrating thoughts and feelings about yourself, though you may need some help in doing so.
Anti-Depressant
Mental DisordersLong-term depression often harks back to childhood. Unloving or over-critical parents have perhaps instilled the message that you are no good, unlovable, or always in the wrong, and the computer obediently repeats these messages. You don’t have to believe them.
The vast majority of people can learn to feel better about themselves, just as one learns a new skill. But you will have to take the first steps, by deciding to make the change.
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Other names: Eskalith, Lithotabs

PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE:
CLINICAL ASSESSMENT-COGNITION
Cognitive impairment is a central feature of delirium, dementia, and mental subnormality, all of which can complicate medical and surgical disorders. A patient who cannot focus her attention, remember to take her medication, or understand an operative consent form cannot participate fully in her care. Such cognitive deficits are commonЂ”and often unrecognizedЂ”in the general hospital setting .
The most widely used screening test for cognitive impairment is the Mini-Mental State Examination (MMSE), a reliable and valid instrument that takes between five and ten minutes to administer. The MMSE was not designed to determine the cause of cognitive
Mental Disorders A perfect score on the MMSE is 30. Although scores of 23 and below generally indicate cognitive impairment, performance on the test is affected by age and educational level.
An appropriate time to assess the patient’s cognition is just before the physical examination: “I’m going to do your physical exam in a few minutes, but first I want to check your memory, concentration, and a few other things. Can you tell me, for example, what the date is today?” When the MMSE is introduced in a matter-of-fact way, most patients see it for what it isЂ”part of a thorough evaluation. If abnormal results are obtained, repeated testing is indicated. How often such testing should be done depends on the clinical situation: with an inpatient who has delirium, an MMSE should be obtained at least every day; with an outpatient who has a slowly progressive dementia, it should be obtained every few months.
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SCHIZOPHRENIA: THE TWO FACES OF ILLNESS
All this has led psychiatrists to identify two kinds of schizophrenia patients: those who respond to the drugs, with control of the dopamine system, and those who don’t. Responsive patients show the outward signs of the disease – hallucinations, delusions, and strange behavior; the
non-responders are withdrawn, unemotional, seemingly devoid of feelings of pleasure.
For decades psychiatrists have held that many types of schizophrenia exist and that it may be the result of many different, separate diseases.
Dr. Richard J. Wyatt, chief of the Neuropsychiatry Branch of the National Institute of Mental Health, at St. Elizabeth’s Hospital in Washington, D.C., draws this parallel with mental retardation: “A hundred years ago, we said that low IQ meant mental retardation. Since then, we’ve found a whole series of diseases that cause brain damage leading to a low IQ and retardation. Identifying the symptoms of schizophrenia is like having the results of an IQ test. I suspect that we’ll find a number of diseases that make up the schizophrenia syndrome.”
Scientists have discovered certain kinds of brain damage in some schizophrenics but not others and have found a low blood flow in the thinking part of the brain in some schizophrenics. A doctor in England found evidence of a virus-like particle. A U.S. physician found strange antibodies in the spinal fluid.
During the 1940s and 1950s, many psychiatrists believed angry relations between members of families caused schizophrenia in their children. As a result, many parents were tortured by guilty feelings of taking the blame for their child’s illness. Most experts now reject that theory as unproved. Once again, however, evidence reveals that, even though families’ behavior does not cause schizophrenia, the way families act toward their sick family members can prevent or trigger a relapse. In London, Dr. Julian Leff and his colleagues have identified family characteristics that affect schizophrenic patients. If a family’s responses are warm and loving, for example, a relapse is prevented; but if they are hostile, critical, or over-involved, the patient suffers more frequent episodes.
These findings set off a series of studies to learn whether doctors and social workers can train families to change behavior and ease sick family members. Nina Schooler, assistant chief of the Schizophrenia Research Branch at the National Institute of Mental Health, heads its multicity project. “People with schizophrenia are sensitive to stress, particularly interpersonal stress,” she says. “We are working to educate the family to protect the patient against it.”
Researchers also are trying to learn whether a patient can manage on less medication. The daily dose is reduced, or drugs are given to a patient only when the family detects the signs of odd behavior that warn of an oncoming episode.
Sarah Edwards estimates that, for the first 6 years of Ben’s illness, the family spent $250,000 on his medical treatment. Ben now lives alone; his disease is stabilized. At his sister’s wedding, says his mother, “It was hard to believe he was not OK. He is not so frightened as he once was and can control his own life.”
Out of the need for family support has grown the National Alliance for the Mentally 111, a group of parents and other relatives who teach themselves the facts of schizophrenia and where to find help. They learn that:
Ђў schizophrenia is probably a brain disorder,
Ђў drugs don’t always quiet symptoms,
Ђў most victims have their first episode in their late teens or early 20s,
Ђў it attacks boys more than girls, and
Ђў there is no cure – yet.
The family sessions help. “I get understanding from people who know what I am talking about,” Mrs. Edwards says. “I ache so. I share my problems with people who are worse off.”
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MENTAL HEALTH: CONSIDER YOUR OPTIONS
Sometimes a close friend or relative has to tell you that “you’re not quite yourself” and need help. More often, only you are aware that something is wrong, but you don’t do anything about it because you believe it is shameful to have an emotional problem, or you think that you should be able to heal yourself. If you are a man, you’re even more likely than a woman to shy away from professional treatment.
Besides making an emotional commitment, getting professional help for mental distress requires a financial commitment as well. Psychotherapy is expensive. Depending on where you live and what kind of therapist you pick, you’ll spend between 20 and 100 dollars an hour, one to five times a week, for a year or more. (In an emergency, some psychotherapists can get results in 6 weeks.) If you want to cut the cost, try group therapy. For some people, it is even more effective than private one-on-one therapy because they learn from the others in the group. Behavior therapy, which is a short-term treatment, will probably not cost as much as psychotherapy, though the hourly rates may be the same.
You can find less costly help in community mental health centers and social service agencies. A local hospital or university may have a clinic. Or contact your church or synagogue.
And, of course, there are countless self-help groups. Alcoholics Anonymous is the most famous. But other groups help gamblers, overeaters, drug abusers, bereaved parents, and people with all sorts of personality and emotional problems.
Many counties have mental health agencies that can put you in touch with local self-help groups. Or they will give you the number of a hotline you can phone if a crisis arises.
People in emotional turmoil often find it difficult to make the phone call that will get them the help they need. That’s why having a friend you trust is so important. A friend can do for you what you cannot do for yourself.
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PSYCHIATRIC DIMENSIONS OF MEDICAL PRACTICE: CLINICAL
ASSESSMENT-MOOD
Mental Disorders Questions about the patient’s emotional state often follow naturally from questions about her present illness: “It sounds like you’ve been having a tough time. How are your spirits holding up?” Physicians should assess the mood of hospitalized patients on a daily basis, not only to understand the nature of their experience, but also to acknowledge that they are human beings, rather than machines. Physicians should take the same approach with outpatients who suffer from chronic, recurrent, or painful conditions: ask about mood at every visit.
When a patient’s distress is persistent, it is important to inquire about hopelessness and suicidal thoughts.
*5/172/2*