Contents

I.      Clinical Reasoning. 2

II.     A Mental Status Examination  – The AMSITTE. 2

The AMSITTE Mental Status Examination. 3

III.        The Mental Status Examination and Psychiatric Syndromes. 4

Table 1              Psychiatric Syndromes based on mental status findings. 4

IV.        The Differential Diagnosis. 5

Table 2.        Formulating a Differential Diagnosis. 5

A.     Comments on Diagnostics. 6

V.     How to Present a Case  (see Nussbaum 2013) 7

A.     General 7

B.     New Case  ( 2 to 10 minutes) 7

C.        Follow up Case ( 30 seconds to 2 minutes) 7

D.        Task. 8

 

I.                Clinical Reasoning  

The process of generating the differential diagnosis entails the skills of clinical examination of the person’s to identify the clinical syndrome and then to use clinical reasoning with our fund of information to best identify the etiological causes of the syndrome.  This is best done with the idea of hypothesis generation to stimulate a treatment plan to verify and test the hypothesis rather than a final diagnosis to which the treatment plan is rigidly adhered.   As shown in Table 1 we find it useful to conceptualize syndromes that are identified as the predominant symptoms from the clinical examination.  Although the DSM-V does not use a hierarchical diagnostic system it is heuristically useful to use the formerly accepted hierarchical system of dementia, psychosis, affective, other syndromes in our formulation.  Next we analyze the syndromes according to the four domains of diagnosis as taught by my colleague Dr. Robert Averbuch (personal communication).  These domains are to be considered in every diagnostic case the domains and consist of general medical condition, substance related including medications, psychiatric syndromes and stress related or trauma related syndromes. For the purposes of this chapter we will subsequently go in detail only for the first domain of general medical conditions.

II.             A Mental Status Examination  – The AMSITTE

The examination occurs at a point in time and  reported in the present tense.   The exam is reported as findings or conclusions supported by findings.  Use headers and subsection headers in writing the exam to facilitate reading.  Stay on task,   be concise.  Use the affirmative voice.  Omit explanatory comments.  Use the phrase “as evidenced by……”.    Use quantitative terms, ie  mild, moderate, or severe. Use active voice.  Use declarative statement, eg   “is”  as opposed to “seems”.   Use adverbial adjectives sparingly.   Avoid (do not use):  slightly, very, somewhat, appears as if, apparently, practically etc  Comment on current  suicidal ideation (ideas, wish, intent, plan or compulsion) and homicidal ideation (ideas, wish, intent, plan or compulsion)

The AMSITE (pronounced “am sight”)  mental status exam is anchored in 3 ways

1. The mnemonic AMSITTE aids in organizing the elements of the mental status exam during the interview and presentation (c.f. AMSIT by Dr. David Fuller).
2. The order of the exam is organized along a simplistic neurocognitive developmental model of brain and behavior
   1. the first developmental stage of a organism is its [appearance and behavior],
   1.  secondly it is expressive of internal physiological states, [mood and affect]
   1.  thirdly the organism distinguishes itself from the environment and others, [sensorium = orientation to person, place, situation and time plus attention]
   1. fourthly it acquires information,[intellectual functioning]
   1. maturationally the vertebrates are able to reason and formulate associations,  interpreted perceptual input [thought processes]
   1. formulate content [thought content] according to cognitive schema
   1. and at the highest level of maturity and cortical development the organism can formulate a hypothesis , [plan and anticipate consequences [executive control functions]
3. The AMSITTE content uses terms that have validity in clinical practice, reliable in assessment and are widely used.  For advanced practitioners the content terms are also anchored in terms of severity according to widely used, validated, rating scales such as the BPRS for additional heuristic value.

 A structured, anchored, mental status exam improves reliability among clinicians.   For purposes of teaching we use a dogmatic structure so that it is easier for the student to master. With experience, the clinician will adapt the examination to the situation.

The examination occurs at a point in time and  reported in the present tense.   The exam is reported as findings or conclusions supported by findings.  Use headers and subsection headers in writing the exam to facilitate reading.  Stay on task,   be concise.  Use the affirmative voice.  Omit explanatory comments.  Use the phrase “as evidenced by……”.    Use quantitative terms, ie  mild, moderate, or severe. Use active voice.  Use declarative statement, eg   “is”  as opposed to “seems”.   Use adverbial adjectives sparingly.   Avoid (do not use):  slightly, very, somewhat, appears as if, apparently, practically etc  Comment on current  suicidal ideation (ideas, wish, intent, plan or compulsion) and homicidal ideation (ideas, wish, intent, plan or compulsion)

III.             The Mental Status Examination and Psychiatric Syndromes

Let us briefly describe the clinical syndromes and how we identify them.  In the DSM-V delirium is defined as an alteration in cognitive function with decrease in attention fluctuations and levels of alertness that occur over a relatively short period of   time. Any psychiatric or somatic symptom can be present in delirium but the hallmark clinical feature is a relatively brief onset in the context of medical versus substance conditions and a predominant impairment of attention. Dementia which is now called major or minor neurocognitive disorder, is characterized by impairment in memory and other cognitive functions which may be insidious as an Alzheimer’s disease or acute as in physical trauma or multi-infarct dementia. The difference in major and minor categorizations is the level of functional impairment. Psychosis is generally defined as a syndrome with impaired reality testing manifested by hallucinations, delusions or disorganization of the speech and behavior. There may be some cognitive and affective dysfunction present but the predominant impairment is in reality testing. The category of affective syndromes is defined as a disturbance and mood this can be either elevated as in mania or depressed is in depression or mixed. Psychotic symptoms may be present but the predominant focus of attention is the disturbance in mood. Anxiety syndrome is characterized by excessive worry but absent significant impairment from cognition, psychosis or affective disturbances.

Table 1              Psychiatric Syndromes based on mental status findings

Psychiatric Syndrome by symptom cluster on mental status examination	Mood and Affect	Sensorium (levels of consciousness, attention, orientation)	Intellectual functioning (language, fund of information, memory, etc)	Thought processes and content	Executive control functions
Delirium	+	+++	++	+	+
Major Neuro-cognitive	+	++	+++	+	+
Psychosis	+/-	+/-	+/-	+++	+/-
Affective	+++	+/-	+/-	+/-	+/-
Other

IV.          The Differential Diagnosis

In consideration of general medical conditions which can cause a syndromes it is heuristically useful to think of the variety of syndromes associated with just a few conditions. For example autoimmune disease, HIV disease, syphilis and thyroid dysfunction are associated with each of the major syndromes of delirium, neurocognitive disorder, psychosis, affective disorder or anxiety disorder in any mix of predominance. By definition delirium must be in the context of a physiological disturbance. Other conditions classically have a more specific association, for example psychosis associated with anti-NMDA receptor encephalitis, depression associated with pancreatic cancer or anxiety associated with pheochromocytoma.   See Table 2 for listing of additional medical disorders.

Substances and medications may also be associated either to all the syndromes or more classically associated with a specific syndrome. For example alcohol misuse has 16 different DSM 5 diagnoses ranging from delirium from intoxication or withdrawal alcoholic dementia alcohol-related sleep disorder alcohol colic hallucinosis or the anxiety associated with alcohol craving whereas amphetamines are classically associated with paranoid psychotic syndromes and may be associated with anxiety or disturbances in mood. More specific effects of medications is the example of beta-blockers associated with depression. Additional medication and substance related specifics are in Table 2.

Table 2.        Formulating a Differential Diagnosis

Syndrome	General Medical	Substance	Pattern	Stress
Cognitive/ Dementia /Delirium	DELIRIUM DUE TO ____ e.g. hyponatremia,   MAJOR OR MINORNEUROCOGNITIVE DISORDER Due to … Alzheimer’s, Vascular FTD Huntington’s  MAJOR OR MINOR NEUROCOGNITIVE DISORDER Due to … Traumatic Brain injury	DELIRIUM due to ____ e.g. substance intoxication   Substance withdrawal Medication induced	n/a	Dissociative Amnesia; Dissociative Identity Disorder;    Other Specified Dissociative Disorder Unspecified Dissociative Disorder
Psychosis	PSCHOTIC DISORDER DUE TO Another Medical Condition —(general medical condition) Alzheimer’s Huntington’s,	Substance Induced Psychotic disorder (with delusions; with hallucinations)	Schizophreniform, Schizotypal PD, Delusion disorder, Schizophrenia, Bipolar disorder with psychotic features, Schizoaffective disorder, Shared psychotic disorder Cluster A PD	Brief psychotic disorder
Affective	MOOD DISORDER DUE TO  (general medical condition) Anemia, hypothyroidism, HIV, cancer of pancreas	e.g. Substance or Medication  induced induced Mood disorder	Bipolar disorder, Major depression, Dysthymia, Cyclothymia,	Adjustment disorder with depressed mood, Adjustment disorder with anxiety and depressed mood
Anxiety	ANXIETY DISORDER DUE TO –(general medical condition) pheochrmocytoma	e.g. Substance of Medication induced Anxiety Disorder	GAD, Phobia Panic Disorder Panic Attack Social Anxiety Cluster C PD	Acute Stress Disorder;
Trauma and Stressor Related Disorders				Adjustment Disorders Acute Stress Disorder; PTSD,
Obessive-Compulsive Related Disorders	OCD   DISORDER DUE TO  (general medical condition)	e.g. Substance of Medication induced OCDr	OCD Hoarding Trichotillomania Excoriation Body dysmorphic	Other Specified OCD Disorder Unspecified OCD Disorder
Somatic, Sleep or  Sexual	CHANGE DUE TO —	Other Substance or Medication  induced disorder	Somatic Symptom disorder Illness Anxiety Disorder Sleep Disorders, Sexual and Gender Identity Disorders;, Eating Disorders, Paraphilias; Factitious Disorders
Disruptive, Impulse Control Conduct Disorder		Other Substance or Medication  induced disorder	Impulse Control Disorders; Cluster B Personality Disorders	Adjustment disorder with disturbance of conduct; Malingering

A.                 Comments on Diagnostics

1. Be careful of mutually exclusionary diagnoses  for example:
   1. Conduct disorder and Antisocial PD  (age cut off at 18 yo)
   2. Major Depression   versus  Bipolar Disorder    (once bipolar, always bipolar)
   3. Schizophrenia   versus     Delusional Disorder
2. Do   not   overlook  diagnoses that MAY   CO_OCCUR
   1. Malingering with any other dx
   2. Delirium superimposed on other dx
   3. Substance Abuse
3. Some Dx  have specific exclusionary criteria and frequently co-occur with other DX
   1. PTSD  excludes acute stress disorder but co-occurs with most other disorders
4. Some DX   are not reliably diagnoses in certain contexts
   1. Eg  Personality disorders dx are not reliable in the context of symptomatic severe axis I disorders
   2. Affective disorders are not reliable in context of acute drug intoxication syndromes.
5.  ” r/o”  and “e/f”   are plans, not diagnoses  
6. List MEDICAL diagnoses for medical conditions that are potentially relevant to understanding the persons mental disorder and its treatment ()

V.              How to Present a Case  (see Nussbaum 2013)

A.                 General

The purpose of the case presentation is to present clinical information to the listener for the purpose of discussion and decision making.  The case presenter must organize collected clinical information and present it in a logical structured format.

Always follow a structure (eg the H&P template)

The amount of material may be expanded or condensed based on context of presentation but the logical structure remains the same (this is called “accordion” compression or expansion of the case persentation).

See the article by Wies et al  to understand the preference of a stair case presentation versus a skyline presentation.

The common practice of including the diagnoses with the chief complaint is a corruption of logical integrity.   Also note that the case presentation is a high level cognitive skill and is distinctly different from a news story or news update of the events of the a given time period.

 

B.                 New Case  ( 2 to 10 minutes)

This type of presentation will mirror the H&P write up with the amount of detail guided by the listener (usually the attending).  The presenter has the responsibility for knowing the entire expanded content for presentation.

C.                 Follow up Case ( 30 seconds to 2 minutes)

This type of presentation will assume the listener has some knowledge of the case and is reminded on details by the presenter.  The important portions are the new information that is logical follow up to the original plan.  Thus the presenter must know the original plan, the interventions and the key measures that are being monitored both for clinical outcome and for safety.   New findings and events are presented as pertinent.

D.                  Task

The student or resident must know why the patient is being seen, the proposed plan and the key monitor measures and results plus any new pertinent information.

•  30 –  

The Staircase Model vs Skyline for case presentations,   cf Wei et al 2011