Question

1. Select a famous person living or dead to assess for mental illness and give a brief description of the illness pathophysiology

2. Describe the demographics and behaviors of that person to support the diagnosis of illness.  

3. Using the mental status exam or brief psychiatric scale evaluate that persons mental status with available pertinent information from the literature

4. Determine a DSM-IV diagnosis for that person

Answer 1

1) Description for pathopphysiology

Pathophysiology it is a convergence of pathology with physiology – is the study of the disordered physiological processes that cause, result from, or are otherwise associated with a disease or injury. Pathology is the medical discipline that describes conditions typically observed during a disease state, whereas physiology is the biological discipline that describes processes or mechanisms operating within an organism. Pathology describes the abnormal or undesired condition, whereas pathophysiology seeks to explain the functional changes that are occurring within an individual due to a disease or pathologic state.

EtymologyEdit

The term pathophysiology comes from the Ancient Greek πάθος (pathos) and φυσιολογία (phusiologia).

Nineteenth centuryEdit

ReductionismEdit

In Germany in the 1830s, Johannes Müller led the establishment of physiology research autonomous from medical research. In 1843, the Berlin Physical Society was founded in part to purge biology and medicine of vitalism, and in 1847 Hermann von Helmholtz, who joined the Society in 1845, published the paper "On the conservation of energy", highly influential to reduce physiology's research foundation to physical sciences. In the late 1850s, German anatomical pathologist Rudolf Virchow, a former student of Müller, directed focus to the cell, establishing cytology as the focus of physiological research, while Julius Cohnheim pioneered experimental pathology in medical schools' scientific laboratories.

Germ theoryEdit

By 1863, motivated by Louis Pasteur's report on fermentation to butyric acid, fellow Frenchman Casimir Davaine identified a microorganism as the crucial causal agent of the cattle disease anthrax, but its routinely vanishing from blood left other scientists inferring it a mere byproduct of putrefaction.^[2] In 1876, upon Ferdinand Cohn's report of a tiny spore stage of a bacterial species, the fellow German Robert Koch isolated Davaine's bacterides in pure culture—a pivotal step that would establish bacteriology as a distinct discipline—identified a spore stage, applied Jakob Henle's postulates, and confirmed Davaine's conclusion, a major feat for experimental pathology. Pasteur and colleagues followed up with ecological investigations confirming its role in the natural environment via spores in soil.

Also, as to sepsis, Davaine had injected rabbits with a highly diluted, tiny amount of putrid blood, duplicated disease, and used the term ferment of putrefaction, but it was unclear whether this referred as did Pasteur's term ferment to a microorganism or, as it did for many others, to a chemical.^[3] In 1878, Koch published Aetiology of Traumatic Infective Diseases, unlike any previous work, where in 80 pages Koch, as noted by an historian, "was able to show, in a manner practically conclusive, that a number of diseases, differing clinically, anatomically, and in aetiology, can be produced experimentally by the injection of putrid materials into animals."^[3] Koch used bacteriology and the new staining methods with aniline dyes to identify particular microorganisms for each.^[3] Germ theory of disease crystallized the concept of cause—presumably identifiable by scientific investigation.^[4]

Scientific medicineEdit

The American physician William Welch trained in German pathology from 1876 to 1878, including under Cohnheim, and opened America's first scientific laboratory—a pathology laboratory—at Bellevue Hospital in New York City in 1878.^[5] Welch's course drew enrollment from students at other medical schools, which responded by opening their own pathology laboratories.^[5] Once appointed by Daniel Coit Gilman, upon advice by John Shaw Billings, as founding dean of the medical school of the newly forming Johns Hopkins University that Gilman, as its first president, was planning, Welch traveled again to Germany for training in Koch's bacteriology in 1883.^[5] Welch returned to America but moved to Baltimore, eager to overhaul American medicine, while blending Vichow's anatomical pathology, Cohnheim's experimental pathology, and Koch's bacteriology.^[6] Hopkins medical school, led by the "Four Horsemen"—Welch, William Osler, Howard Kelly, and William Halsted—opened at last in 1893 as America's first medical school devoted to teaching German scientific medicine, so called.^[5]

Twentieth centuryEdit

BiomedicineEdit

The first biomedical institutes, Pasteur Institute and Berlin Institute for Infectious Diseases, whose first directors were Pasteur and Koch, were founded in 1888 and 1891, respectively. America's first biomedical institute, The Rockefeller Institute for Medical Research, was founded in 1901 with Welch, nicknamed "dean of American medicine", as its scientific director, who appointed his former Hopkins student Simon Flexner as director of pathology and bacteriology laboratories. By way of World War I and World War II, Rockefeller Institute became the globe's leader in biomedical research.

Molecular paradigmEdit

The 1918 pandemic triggered frenzied search for its cause, although most deaths were via lobar pneumonia, already attributed to pneumococcal invasion. In London, pathologist with the Ministry of Health, Fred Griffith in 1928 reported pneumococcal transformation from virulent to avirulent and between antigenic types—nearly a switch in species—challenging pneumonia's specific causation.^[7][8] The laboratory of Rockefeller Institute's Oswald Avery, America's leading pneumococcal expert, was so troubled by the report that they refused to attempt repetition.

When Avery was away on summer vacation, Martin Dawson, British-Canadian, convinced that anything from England must be correct, repeated Griffith's results, then achieved transformation in vitro, too, opening it to precise investigation.Having returned, Avery kept a photo of Griffith on his desk while his researchers followed the trail. In 1944, Avery, Colin MacLeod, and Maclyn McCarty reported the transformation factor as DNA, widely doubted amid estimations that something must act with it.At the time of Griffith's report, it was unrecognized that bacteria even had genes.

The first genetics, Mendelian genetics, began at 1900, yet inheritance of Mendelian traits was localized to chromosomes by 1903, thus chromosomal genetics. Biochemistry emerged in the same decade.^[12] In the 1940s, most scientists viewed the cell as a "sack of chemicals"—a membrane containing only loose molecules in chaotic motion—and the only especial cell structures as chromosomes, which bacteria lack as such.Chromosomal DNA was presumed too simple, so genes were sought in chromosomal proteins. Yet in 1953, American biologist James Watson, British physicist Francis Crick, and British chemist Rosalind Franklin inferred DNA's molecular structure—a double helix—and conjectured it to spell a code. In the early 1960s, Crick helped crack a genetic code in DNA, thus establishing molecular genetics.

In the late 1930s, Rockefeller Foundation had spearheaded and funded the molecular biology research program—seeking fundamental explanation of organisms and life—led largely by physicist Max Delbrück at Caltech and Vanderbilt University. Yet the reality of organelles in cells was controversial amid unclear visualization with conventional light microscopy.Around 1940, largely via cancer research at Rockefeller Institute, cell biology emerged as a new discipline filling the vast gap between cytology and biochemistry by applying new technology—ultracentrifuge and electron microscope—to identify and deconstruct cell structures, functions, and mechanisms. The two new sciences interlaced, cell and molecular biology.

Mindful of Griffith and Avery, Joshua Lederberg confirmed bacterial conjugation—reported decades earlier but controversial—and was awarded the 1958 Nobel Prize in Physiology or Medicine.At Cold Spring Harbor Laboratory in Long Island, New York, Delbrück and Salvador Luria led the Phage Group—hosting Watson—discovering details of cell physiology by tracking changes to bacteria upon infection with their viruses, the process transduction. Lederberg led the opening of a genetics department at Stanford University's medical school, and facilitated greater communication between biologists and medical departments.^[

Disease mechanismsEdit

In the 1950s, researches on rheumatic fever, a complication of streptococcal infections, revealed it was mediated by the host's own immune response, stirring investigation by pathologist Lewis Thomas that led to identification of enzymes released by the innate immune cells macrophages and that degrade host tissue.^[15] In the late 1970s, as president of Memorial Sloan–Kettering Cancer Center, Thomas collaborated with Lederberg, soon to become president of Rockefeller University, to redirect the funding focus of the US National Institutes of Health toward basic research into the mechanisms operating during disease processes, which at the time medical scientists were all but wholly ignorant of, as biologists had scarcely taken interest in disease mechanisms.Thomas became for American basic researchers a patron saint

2) Demographics

Demography  is the statistical study of populations, especially human beings.

Demography encompasses the study of the size, structure, and distribution of these populations, and spatial or temporal changes in them in response to birth, migration, aging, and death. As a very general science, it can analyze any kind of dynamic living population, i.e., one that changes over time or space (see population dynamics). Demographics are quantifiable characteristics of a given population.

Demographic analysis can cover whole societies or groups defined by criteria such as education, nationality, religion, and ethnicity. Educational institutions usually treat demography as a field of sociology, though there are a number of independent demography departments.Based on the demographic research of the earth, earth's population up to the year 2050 and 2100 can be estimated by demographers.

Formal demography limits its object of study to the measurement of population processes, while the broader field of social demography or population studies also analyses the relationships between economic, social, cultural, and biological processes influencing a population.

There are two types of data collection—direct and indirect—with several different methods of each type.

Direct methodsEdit

Direct data comes from vital statistics registries that track all births and deaths as well as certain changes in legal status such as marriage, divorce, and migration (registration of place of residence). In developed countries with good registration systems (such as the United States and much of Europe), registry statistics are the best method for estimating the number of births and deaths.

A census is the other common direct method of collecting demographic data. A census is usually conducted by a national government and attempts to enumerate every person in a country. In contrast to vital statistics data, which are typically collected continuously and summarized on an annual basis, censuses typically occur only every 10 years or so, and thus are not usually the best source of data on births and deaths. Analyses are conducted after a census to estimate how much over or undercounting took place. These compare the sex ratios from the census data to those estimated from natural values and mortality data.

Censuses do more than just count people. They typically collect information about families or households in addition to individual characteristics such as age, sex, marital status, literacy/education, employment status, and occupation, and geographical location. They may also collect data on migration (or place of birth or of previous residence), language, religion, nationality (or ethnicity or race), and citizenship. In countries in which the vital registration system may be incomplete, the censuses are also used as a direct source of information about fertility and mortality; for example the censuses of the People's Republic of China gather information on births and deaths that occurred in the 18 months immediately preceding the census.

Map of countries by population

Rate of human population growth showing projections for later this century

Indirect methodsEdit

Indirect methods of collecting data are required in countries and periods where full data are not available, such as is the case in much of the developing world, and most of historical demography. One of these techniques in contemporary demography is the sister method, where survey researchers ask women how many of their sisters have died or had children and at what age. With these surveys, researchers can then indirectly estimate birth or death rates for the entire population. Other indirect methods in contemporary demography include asking people about siblings, parents, and children. Other indirect methods are necessary in historical demography.

There are a variety of demographic methods for modelling population processes. They include models of mortality (including the life table, Gompertz models, hazards models, Cox proportional hazards models, multiple decrement life tables, Brass relational logits), fertility (Hernes model, Coale-Trussell models, parity progression ratios), marriage (Singulate Mean at Marriage, Page model), disability (Sullivan's method, multistate life tables), population projections (Lee-Carter model, the Leslie Matrix), and population momentum (Keyfitz).

The United Kingdom has a series of four national birth cohort studies, the first three spaced apart by 12 years: the 1946 National Survey of Health and Development, the 1958 National Child Development Study,^[14] the 1970 British Cohort Study,^[15] and the Millennium Cohort Study, begun much more recently in 2000. These have followed the lives of samples of people (typically beginning with around 17,000 in each study) for many years, and are still continuing. As the samples have been drawn in a nationally representative way, inferences can be drawn from these studies about the differences between four distinct generations of British people in terms of their health, education, attitudes, childbearing and employment patterns

Behaviors of that person to support the Diagnosis of illness:

Illness behavior refers to any actions or reactions of an individual who feels unwell for the purpose of defining their state of health and obtaining physical or emotional relief from perceived or actual illness. These behaviors include how individuals monitor and interpret bodily sensations, utilize healthcare resources, discuss illness or symptoms with providers, and adhere to prescribed medical regimens.

Illness behaviors can be organized into two broad categories:

• Self-care behavior – Any action taken to manage or improve a health condition in the absence of direct medical attention, which includes managing symptoms and caring for minor injuries. Research indicates that a majority of health problems are managed via self-care behaviors and that most individuals will attempt self-treatment prior to seeking medical attention.

• Healthcare utilization behavior– Any action that involves direct use of healthcare services

3) Evaluation of the persons mental status examination:

Definition

The mental status examination is a structured assessment of the patient's behavioral and cognitive functioning. It includes descriptions of the patient's appearance and general behavior, level of consciousness and attentiveness, motor and speech activity, mood and affect, thought and perception, attitude and insight, the reaction evoked in the examiner, and, finally, higher cognitive abilities. The specific cognitive functions of alertness, language, memory, constructional ability, and abstract reasoning are the most clinically relevant.

Technique

In his Treatise on Insanity, published in 1801, Pinel, one of the fathers of modern psychiatry, gave some advice to his contemporary colleagues.

To seize the true character of mental derangement in a given case, and to pronounce an infallible prognosis of the event, is often a task of particular delicacy, and requires the united exertion of great discernment, of extensive knowledge and of incorruptible integrity.

One could scarcely improve on this advice in the present-day approach to mental status evaluation. The knowledge that the modern physician can bring to bear on this task is certainly much more extensive than in 1801. Nevertheless, the observational skills and subtle discriminations that constitute "great discernment," and the traits of professional and scientific integrity that are likewise required, must be cultivated afresh in each generation of physicians.

The mental status examination, in many respects, lends itself less well to a systematic and structured approach than other portions of the examination of the patient. On the one hand, because mental status testing can be threatening to the patient and requires much cooperation on the part of the patient, it is desirable to leave the mental status testing to the end of the overall evaluation when the patient can be placed most at ease and when some degree of rapport has been established between the examiner and the patient. On the other hand, the mental state of the patient colors the accuracy and sensitivity of the entire medical history, and from this standpoint, the physician wishes he or she could perform a mental status examination as a prelude to the rest of the medical history in order to have the assessment as a template against which to measure the accuracy of the rest of the history. The successful clinician must develop a style in which much of the mental status examination is performed through relatively unstructured observations made during the routine history and physical. The way in which the patient relates the history of the present illness will reveal much about general appearance and behavior, alertness, speech, activity, affect, and attitude. A primary technique, then, in mental status testing is the imposition of some structure on these observations and raising them from the level of subliminal impressions to clinically useful descriptions of behavior.

When there is history or evidence of clinically significant psychiatric illness, such as aberrant behavior or thinking, abnormalities on neurologic examination, or difficulties in day-to-day performance on the job or in social situations, then a formal dissecting of specific cognitive abilities should be performed near the close of the physician–patient encounter. When this is done, the examination needs to be introduced carefully to the patient, with some explanation as to why it is being done, in order to enlist patient cooperation rather than resistance. The structured mental status examination should focus on the observations listed in Table 207.1.

Table 207.1

The Mental Status Examination.

Level of Consciousness

The level of consciousness refers to the state of wakefulness of the patient and depends both on brainstem and cortical components. Levels are operationally defined by the strength of stimuli needed to elicit responses, and the scheme of Plum and Posner (1980) is widely accepted.

A normal level of consciousness is one in which the patient is able to respond to stimuli at the same lower level of strength as most people who are functioning without neurologic abnormality. Clouded consciousness is a state of reduced awareness whose main deficit is one of inattention. Stimuli may be perceived at a conscious level but are easily ignored or misinterpreted. Delirium is an acute or subacute (hours to days) onset of a grossly abnormal mental state often exhibiting fluctuating consciousness, disorientation, heightened irritability, and hallucinations. It is often associated with toxic, infectious, or metabolic disorders of the central nervous system. Obtundation refers to moderate reduction in the patient's level of awareness such that stimuli of mild to moderate intensity fail to arouse; when arousal does occur, the patient is slow to respond. Stupor may be defined as unresponsiveness to all but the most vigorous of stimuli. The patient quickly drifts back into a deep sleep-like state on cessation of the stimulation. Coma is unarousable unresponsiveness. The most vigorous of noxious stimuli may or may not elicit reflex motor responses.

When examining patients with reduced levels of consciousness, noting the type of stimulus needed to arouse the patient and the degree to which the patient can respond when aroused is a useful way of recording this information.

Appearance and General Behavior

These variables give the examiner an overall impression of the patient. The patient's physical appearance (apparent vs. stated age), grooming (immaculate/unkempt), dress (subdued/riotous), posture (erect/kyphotic), and eye contact (direct/furtive) are all pertinent observations. Certain specific syndromes such as unilateral spatial neglect and the disinhibited behavior of the frontal lobe syndrome are readily appreciated through observation of behavior.

Speech and Motor Activity

Listening to spontaneous speech as the patient relates answers to open-ended questions yields much useful information. One might discern problems in output or articulation such as the hypophonia of Parkinson's disease, the halting speech of the patient with word-finding difficulties, or the rapid and pressured speech of the manic or amphetamine-intoxicated patient. Overall motor activity should also be noted, including any tics or unusual mannerisms. Slowness and loss of spontaneity in movement may characterize a subcortical dementia or depression, while akathisia (motor restlessness) may be the harbinger of an extrapyramidal syndrome secondary to phenothiazine use.

Affect and Mood

Affect is the patient's immediate expression of emotion; mood refers to the more sustained emotional makeup of the patient's personality. Patients display a range of affect that may be described as broad, restricted, labile, or flat. Affect is inappropriate when there is no consonance between what the patient is experiencing or describing and the emotion he is showing at the same time (e.g., laughing when relating the recent death of a loved one). Both affect and mood can be described as dysphoric (depression, anxiety, guilt), euthymic (normal), or euphoric (implying a pathologically elevated sense of well-being).

Affect must be judged in the context of the setting and those observations that have gone before. For example, the startled-looking patient with eyes wide open and perspiration beading out on the forehead is soon recognized as someone suffering from Parkinson's disease, when the paucity of motion and diminished eye blink are noted and the beads of perspiration turn out to be seborrhea.

Thought and Perception

The inability to process information correctly is part of the definition of psychotic thinking. How the patient perceives and responds to stimuli is therefore a critical psychiatric assessment. Does the patient harbor realistic concerns, or are these concerns elevated to the level of irrational fear? Is the patient responding in exaggerated fashion to actual events, or is there no discernible basis in reality for the patient's beliefs or behavior?

Patients may exhibit marked tendencies toward somatization or may be troubled with intrusive thoughts and obsessive ideas. The more seriously ill patient may exhibit overtly delusional thinking (a fixed, false belief not held by his cultural peers and persisting in the face of objective contradictory evidence), hallucinations (false sensory perceptions without real stimuli), or illusions (misperceptions of real stimuli). Because patients often conceal these experiences, it is well to ask leading questions, such as, "Have you ever seen or heard things that other people could not see or hear? Have you ever seen or heard things that later turned out not to be there?" Likewise, it is necessary to interpret affirmative responses conservatively, as mistakenly hearing one's name being called, or experiencing hypnagogic hallucinations in the peri-sleep period, is within the realm of normal experience.

Of all portions of the mental status examination, the evaluation of a potential thought disorder is one of the most difficult and requires considerable experience. The primary-care physician will frequently desire formal psychiatric consultation in patients exhibiting such disorders.

Attitude and Insight

The patient's attitude is the emotional tone displayed toward the examiner, other individuals, or his illness. It may convey a sense of hostility, anger, helplessness, pessimism, overdramatization, self-centeredness, or passivity. Likewise, the patient's attitude toward the illness is an important variable. Is the patient a help-rejecting complainer? Does the patient view the illness as psychiatric or nonpsychiatric? Does the patient look for improvement or is he or she resigned to suffer in silence?

Patient attitude often changes through the course of the interview, and it is important to note any such changes.

Examiner's Reaction to the Patient

The feelings aroused in the examiner by the patient are often a source of very useful information. These data are sometimes subtle and easily overlooked as the examiner, in an attempt to remain objective, fails to note how he or she is responding to the patient.

A developing sense of dysphoria in the examiner may be the first clue that the physician is dealing with a depressed patient. Frustration may be the response to the help-rejecting complainer while a feeling of being off-balance and slightly out of touch with the conversation may be an early indication that one is dealing with a schizophrenic patient.

Structured Examination of Cognitive Abilities

The preceding sections of the mental status examination provide a Gestalt view of the patient and his illness. A structured examination of specific cognitive abilities is a more reductionistic approach to the patient and pays careful attention to neuroanatomic correlates. Such testing logically follows a hierarchic ordering of cortical function with attention and memory being the most basic functions on which higher-ordered abilities of language, constructional ability, and abstract thinking are layered.

Attention

The testing of attention is a more refined consideration of the state of wakefulness than level of consciousness. An ideal test of attentiveness should assay concentration on a simple task, placing minimal demand on language function, motor response, or spatial conception. Reaction times are frequently slowed in patients who have diminished attentiveness. This may become evident early in the course of examination and provide an important clue that the examiner is dealing with decreased attentiveness. One test often recommended is the ability to listen to digit spans of increasing length and repeal them back to the examiner. Another is to have the patient listen to a digit span and then repeat it backward. Perhaps a better test is to have the patient listen to a string of letters in which one letter is repeated frequently but randomly and to tap each time that letter is heard, for example, "Please tap each time you hear the letter K."

T L K B K M N Z K K T K G B H W K L T K …

The number of errors the patient makes is noted. Another test might be to have the patient count the number of times a given letter appears on a page full of randomly ordered letters.

Language

The left perisylvian cortex mediates most aspects of language function in 99% of right-handed individuals and over half of left-handed individuals. Thus, an aphasia implies damage to the left hemisphere about 95% of the time. Basic examination of language function should include an assessment of spontaneous speech, comprehension of spoken commands, reading ability, reading comprehension, writing, and repetition.

The assessment of spontaneous speech is performed as the patient supplies answers to open-ended questions. In this evaluation one looks for disorders of articulation, abnormalities of content, disorders of output, and paraphasic errors. Phonemic errors are mistakes in pronunciation; semantic errors are errors in the meaning of words; neologisms are meaningless nonwords that have a specific meaning for the patient.

Repetition is tested by having the patient repeat sentences with several nouns and pronouns, for example, "That's what she said to them yesterday," and "No ifs, ands, or buts."

Comprehension is tested with several levels of responses. First the patient is asked complex yes and no questions such as, "Do you take off your clothes before taking a shower?" thereby minimizing the need for motoric and speech acts. Second, questions where gesture alone can be an adequate response are asked, for example, "Point to where people may sit down in this room." finally, the patient is asked to follow a command with a motor response: "Squeeze my fingers."

Word-finding disability may be suspected when spontaneous speech is halting in nature as the patient searches for the proper word. To test this ability, the patient is asked to name a number of objects of several categories ranging from the everyday to the more unusual. To stress this ability further the naming of parts of objects, for example, the crystal of a watch, the lead of a pencil, is also tested. Word fluency is more specifically tested by having the patient generate as many words in a given category as he or she is able in a fixed time period. Standard tests ask for such things as "items found in a supermarket" or "words beginning with the letters F, then A, then S."

Reading is tested by having the patient read out loud, listening for errors and testing reading comprehension by having the patient follow a written command, for example, "Close your eyes." Standardized short stories are available that patients can be asked to read and then later recall. These are scored on the remembrance of key items.

Writing is tested by having the patient sign his name, generate spontaneous sentences, or describe an object in writing.

Memory

Memory disturbance is a common complaint and is often a presenting symptom in the elderly. Memory can be grouped simplistically into three subunits: immediate recall, short-term memory, and long-term storage.

Short-term memory is the most clinically pertinent, and the most important to be tested. Short-term retention requires that the patient process and store information so that he or she can move on to a second intellectual task and then call up the remembrance after completion of the second task. Short-term memory may be tested by having the patient learn four unrelated objects or concepts, a short sentence, or a five-component name and address, and then asking the patient to recall the information in 3 to 5 minutes after performing a second, unrelated mental task.

Orientation largely reflects recent memory function. Questions such as, "Where are we right now? What city are we in? What is today's date? What time is it right now (to the nearest hour)?" are pertinent questions.

Immediate recall can be tested once again by having the patient repeal digit spans, both forward and backward. Long-term memory can be tested by the patient's ability to recall remote personal or historic events (e.g., the naming of previous presidents, major wars, date of the bombing of Pearl Harbor) or answer select questions from the WAIS information subtest. Obviously, in asking remote personal events, the physician must be privy to accurate information to judge the accuracy of the patient's response.

Constructional Ability and Praxis

Apraxia is the inability, not due to weakness, to perform previously learned motor acts. The more common of these are ideomotor apraxias wherein the patient can initiate movements and manipulation of objects but is unable to pretend a given action. This modality is tested by asking the patient to "sew on an imaginary button," "use an imaginary scissors," or "light an imaginary cigarette."

Ideatory apraxia is the breakdown of higher-ordered sequencing of steps in the manipulation of real objects. It is tested by serial step commands, for example, "Take this piece of paper in your left hand, then fold it up, place it in the envelope, and seal the envelope."

Constructional inability is loss of the capacity to generate line drawings or manipulate block designs from verbal command or visual reproduction. Geschwind (1965) has pointed out that the older term "constructional apraxia" is insufficient to describe this ability as it involves integration of occipital, parietal, and frontal lobe functions and is therefore more complex than the word "praxis" would indicate. The patient is tested by being shown line drawings of increasing complexity and being asked to reproduce them. Next, the patient is asked to generate pictures from memory, for example, "Draw a clock face; put in the numbers; draw hands on the clock to say 8:20." Finally, the patient may be asked to manipulate blocks (multicolored cubes from WAIS-R) to reproduce stimulus designs.

4) DSM-IV diagnosis for that person:

Appendix D—DSM-IV-TR Mood Disorders

Publication Details

In substance abuse treatment settings, you are likely to encounter clients with a variety of diagnoses of depressive illnesses. Most of these diagnoses fall in the category of Mood Disorders, as specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR; APA, 2000). You can, however, also work with people who have a diagnosis of Adjustment Disorder with Depressed Mood. Additionally, people with a variety of other psychiatric illnesses are susceptible to depression, and some of those illnesses are described in this appendix.

The descriptions of depressive disorders and their primary symptoms are taken from DSM-IV-TR. Please refer to the source document for a more complete description of these disorders.

1. Major Depressive Episode and Major Depressive Disorder

Major Depressive Disorder requires two or more major depressive episodes.

Diagnostic criteria:

Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day

1.

Depressed mood most of the day.

2.

Diminished interest or pleasure in all or most activities.

3.

Significant unintentional weight loss or gain.

4.

Insomnia or sleeping too much.

5.

Agitation or psychomotor retardation noticed by others.

6.

Fatigue or loss of energy.

7.

Feelings of worthlessness or excessive guilt.

8.

Diminished ability to think or concentrate, or indecisiveness.

9.

Recurrent thoughts of death (APA, 2000, p. 356).

2. Dysthymic Disorder

Diagnostic criteria:

Depressed mood most of the day for more days than not, for at least 2 years, and the presence of two or more of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning:

1.

Poor appetite or overeating.

2.

Insomnia or sleeping too much.

3.

Low energy or fatigue.

4.

Low self-esteem.

5.

Poor concentration or difficulty making decisions.

6.

Feelings of hopelessness (APA, 2000, p. 380).

3. Bipolar Episode and Bipolar Disorder

Bipolar disorder is characterized by more than one bipolar episode. There are three types of bipolar disorder:

1.

Bipolar 1 Disorder, in which the primary symptom presentation is manic, or rapid (daily) cycling episodes of mania and depression.

2.

Bipolar 2 Disorder, in which the primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalization, but are sufficient to be observable by others).

3.

Cyclothymic Disorder, a chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder (APA, 2000, pp. 388–392).

Manic episodes are characterized by:

A.

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)

B.

During the period of mood disturbance, three (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:

(1)

increased self-esteem or grandiosity

(2)

decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

(3)

more talkative than usual or pressure to keep talking

(4)

flight of ideas or subjective experience that thoughts are racing

(5)

distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

(6)

increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

(7)

excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)" (APA, 2000, p. 362).

Depressive episodes are characterized by symptoms described above for Major Depressive Episode.

4. Substance-Induced Mood Disorder

Substance-Induced Mood Disorder is a common depressive illness of clients in substance abuse treatment. It is defined in DSM-IV-TR as “a prominent and persistent disturbance of mood . . . that is judged to be due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or somatic treatment for depression, or toxin exposure)” (APA, 2000, p. 405). The mood can manifest as manic (expansive, grandiose, irritable), depressed, or a mixture of mania and depression.

Generally, substance-induced mood disorders will only present either during intoxication from the substance or on withdrawal from the substance and therefore do not have as lengthy a course as other depressive illnesses.

5. Mood Disorder Due to a General Medical Condition

It is not as common to find depression due to a general medical condition in substance-abuse treatment settings, but it is important to note that depression can be a result of a medical condition, such as hypothyroidism or Parkinson's disease. The criteria for diagnosis are similar to Major Depressive Episode or a manic episode; however, the full criteria for these diagnoses need not be met. It is important in diagnosis to establish that the depressive symptoms are a direct physiological result of the medical condition, not just a psychological response to a medical problem.

6. Adjustment Disorder With Depressed Mood

Adjustment disorder is a psychological reaction to overwhelming emotional or psychological stress, resulting in depression or other symptoms. Some situations in which an adjustment disorder can occur include divorce, imprisonment of self or a significant other, business or employment failures, or a significant family disturbance. The stressor may be a one-time event or a recurring situation. Because of the turmoil that often occurs around a crisis in substance use patterns, clients in substance abuse treatment may be particularly susceptible to Adjustment Disorders. Some of the common depressive symptoms of an adjustment disorder include tearfulness, depressed mood, and feelings of hopelessness. The symptoms of an adjustment disorder normally do not reach the proportions of a Major Depressive Disorder, nor do they last as long as a Dysthymic Disorder. An acute adjustment disorder normally lasts only a few months, while a chronic adjustment disorder may be ongoing after the termination of the stressor.

7. Other Psychiatric Conditions in Which Depression Can Be a Primary Symptom

Sometimes depression is symptomatic of another mental disorder. This is particularly true when the nature of the mental disorder causes excessive distress to the individual. While, in this context, the depression is a symptom, it is still important to recognize its impact on the person and his or her ability to respond to substance abuse treatment.

Some of the psychiatric disorders in which depression can play a major role include:

A. Posttraumatic Stress Disorder (PTSD)

Symptoms include episodes of reexperiencing the traumatic event or reexperiencing the emotions attached to the event; nightmares, exaggerated startle responses; and social, interpersonal, and psychological withdrawal. Chronic symptoms may include anxiety and depression. PTSD is categorized as an anxiety disorder.

B. Anxiety Disorders, including Panic Disorder, Agoraphobia (fear of public places), Social Phobias, and Generalized Anxiety Disorder

Symptoms of anxiety disorders are most often on the anxiety spectrum, but the chronic stress faced by individuals with anxiety disorders can produce depressive symptoms including irritability, hopelessness, despair, emptiness, and chronic fatigue.

C. Schizoaffective Disorder and Schizophrenia

Individuals with schizoaffective disorder have, in addition to many of the symptoms of schizophrenia, a chronic depression with most of the features of Major Depressive Disorder. Because of the difficulty individuals with schizophrenia have in coping with the daily demands of living, depression is often a symptom. With both schizoaffective disorder and schizophrenia, the depression adds an additional dimension to treatment, specifically in helping the person mobilize in the face of their depression to cope with their illness.

D. Personality Disorders

People with personality disorders are particularly susceptible to depression. These individuals are at high risk for substance use disorders. As a result, it is not uncommon to find clients in substance abuse treatment with all three diagnoses. Because personality disorders are categorized in DSM-IV-TR as Axis 2 disorders (see DSM-IV-TR for a description of multiaxial assessment), it is common to find their depression diagnosed separately (from the personality disorder) as an adjustment disorder, dysthymia, or major depressive disorder.