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FOCUSED LEARNING for the
psychiatry clerkship
Tips on what to know to IMPRESS

ATTENDINGS and EARN HONORS
on the shelf exam
Completely UPDATED
FOR THE DSM-5
FIRST AID FOR
THE®
PSYCHIATRY
CLERKSHIP
FOURTH EDITION
LATHA GANTI, MD, MS, MBA, FACEP Sean M. Blitzstein, MD

Director, VACO Southeast Specialty Care Director, Psychiatry Clerkship
Center of Innovation Clinical Associate Professor of Psychiatry
Orlando VA Medical Center University of Illinois at Chicago
Professor of Emergency Medicine Chicago, Illinois
University of Central Florida
Orlando, Florida
MATTHEW S. KAUFMAN, MD
Associate Director
Department of Emergency Medicine
Richmond University Medical Center
New York, New York
New York / Chicago / San Francisco / Athens / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / Singapore / Sydney / Toronto
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CONTENTS
Contributing Authors v
Introduction vii
Chapter 1: How to Succeed in the Psychiatry Clerkship 1
Chapter 2: Examination and Diagnosis 11
Chapter 3: Psychotic Disorders 21
Chapter 4: Mood Disorders 33
Chapter 5: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders 47
Chapter 6: Personality Disorders 63
Chapter 7: Substance-Related and Addictive Disorders 79
Chapter 8: Neurocognitive Disorders 97
Chapter 9: Geriatric Psychiatry 113
Chapter 10: Psychiatric Disorders in Children 121
Chapter 11: Dissociative Disorders 133
Chapter 12: Somatic Symptom and Factitious Disorders 139
Chapter 13: Impulse Control Disorders 145
Chapter 14: Eating Disorders 151
Chapter 15: Sleep-Wake Disorders 159
Chapter 16: Sexual Dysfunctions and Paraphilic Disorders 171
Chapter 17: Psychotherapies 179
Chapter 18: Psychopharmacology 189
Chapter 19: Forensic Psychiatry 209
Index 217
iii
CONTRIBUTING AUTHORS
Sean M. Blitzstein, MD Kelley A. Volpe, MD
Director, Psychiatry Clerkship Chief Resident, Department of Psychiatry
Clinical Associate Professor of Psychiatry University of Illinois at Chicago College of Medicine
University of Illinois at Chicago Chicago, Illinois
Chicago, Illinois Eating Disorders
Examination and Diagnosis Sleep-Wake Disorders
Personality Disorders Psychotherapies
Substance-Related and Addictive Disorders Forensic Psychiatry
Geriatric Psychiatry
Somatic Symptom and Factitious Disorders
Sexual Dysfunctions and Paraphilic Disorders Alexander Yuen, MD
Resident, Department of Psychiatry
University of Illinois at Chicago
Amber C. May, MD Chicago, Illinois
Resident, Department of Psychiatry Psychotic Disorders
University of Illinois at Chicago Mood Disorders
Chicago, Illinois Impulse Control Disorders
Anxiety, Obsessive-Compulsive, Trauma and Stressor-Related Disorders Psychopharmacology
Neurocognitive Disorders
Psychiatric Disorders in Children
Dissociative Disorders
v
INTRODUCTION
This clinical study aid was designed in the tradition of the First Aid series of
books. It is formatted in the same way as the other books in this series; how-
ever, a stronger clinical emphasis was placed on its content in relation to psy-
chiatry. You will find that rather than simply preparing you for success on the
clerkship exam, this resource will help guide you in the clinical diagnosis and
treatment of many problems seen by psychiatrists.
Each of the chapters in this book contains the major topics central to the
practice of psychiatry and has been specifically designed for the medical stu-
dent learning level. It contains information that psychiatry clerks are expected
to learn and will ultimately be responsible for on their shelf exams.
The content of the text is organized in the format similar to other texts in the
First Aid series. Topics are listed by bold headings, and the “meat” of the top-
ics provides essential information. The outside margins contain mnemonics,
diagrams, exam and ward tips, summary or warning statements, and other
memory aids. Exam tips are marked by the icon, tips for the wards by the
icon, and clinical scenarios by the icon.
vii
Chapter 1
How to Succeed in the

Psychiatry Clerkship
Why Spend Time on Psychiatry? 2 Keep Patient Information Handy 3
How to Behave on the Wards 2 Present Patient Information in an Organized Manner 3
Respect the Patients 2 How to Prepare for the Clerkship (Shelf ) Exam 4
Respect the Field of Psychiatry 2 Study with Friends 4
Take Responsibility for Your Patients 3 Study in a Bright Room 4
Respect Patients’ Rights 3 Eat Light, Balanced Meals 4
Volunteer 3 Take Practice Exams 4
Be a Team Player 3 Pocket Cards 5
1
2 Chapter 1 HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP
The psychiatry clerkship will most likely be very interesting and exciting.
A key to doing well in this clerkship is finding the balance between drawing
a firm boundary of professionalism with your patients and creating a relation-
ship of trust and comfort.
Why Spend Time on Psychiatry?

For most, your medical school psychiatry clerkship will encompass the
entirety of your formal training in psychiatry during your career in medicine.
Being aware of and understanding the features of mental dysfunction in psy-

chiatric patients will serve you well in recognizing psychiatric symptoms in
your patients, regardless of your specialty choice.
While anxiety and depression can worsen the prognosis of patients’ other
medical conditions, medical illnesses can cause significant psychological
stress, often uncovering a previously subclinical psychiatric condition. The
stress of extended hospitalizations can strain normal mental and emotional
functioning beyond their adaptive reserve, resulting in transient psychiatric
symptoms.
Psychotropic medications are frequently prescribed in the general popula-

tion. Many of these drugs have significant medical side effects and drug
interactions. You will become familiar with these during your clerkship
and will encounter them in clinical practice regardless of your field of
medicine.
Because of the unique opportunity to spend a great deal of time interacting

with your patients, the psychiatry clerkship is an excellent time to practice
your interview skills and “bedside manner.”
How to Behave on the Wards
R E S P E C T T H E PAT I E N T S
Always maintain professionalism and show the patients respect. Be respectful

when discussing cases with your residents and attendings.
R E S P E C T T H E F I E L D O F P S Y C H I AT R Y
■■ Regardless of your interest in psychiatry, take the rotation seriously.

■■ You may not agree with all the decisions that your residents and attendings
make, but it is important for everyone to be on the same page. Be aware of
patients who try to split you from your team.
■■ Dress in a professional, conservative manner.
■■ Working with psychiatric patients can often be emotionally taxing. Keep
yourself healthy.
■■ Psychiatry is a multidisciplinary field. It would behoove you to continu-
ously communicate with nurses, social workers, and psychologists.
■■ Address patients formally unless otherwise told.
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 3
TA K E R E S P O N S I B I L I T Y F O R Y O U R PAT I E N T S
Know as much as possible about your patients: their history, psychiatric and
medical problems, test results, treatment plan, and prognosis. Keep your
intern or resident informed of new developments that they might not be
aware of, and ask them for any updates you might not be aware of. Assist the
team in developing a plan; speak to consultants and family members. Never
deliver bad news to patients or family members without the assistance of your
supervising resident or attending.
R E S P E C T PAT I E N T S ’ R I G H T S
1. All patients have the right to have their personal medical information kept
private. This means do not discuss the patient’s information with family
members without that patient’s consent, and do not discuss any patient in
public areas (e.g., hallways, elevators, cafeterias).
2. All patients have the right to refuse treatment. This means they can refuse
treatment by a specific individual (the medical student) or of a specific
type (no electroconvulsive therapy). Patients can even refuse lifesaving
treatment. The only exceptions to this rule are if the patient is deemed
to not have the capacity to make decisions or if the patient is suicidal or
homicidal.
3. All patients should be informed of the right to seek advance directives on
admission. Often, this is done by the admissions staff or by a social worker.
If your patient is chronically ill or has a life-threatening illness, address
the subject of advance directives with the assistance of your resident or
attending.
VOLUNTEER
Be enthusiastic and self-motivated. Volunteer to help with a procedure or a

difficult task. Volunteer to give a 20-minute talk on a topic of your choice, to
take additional patients, and to stay late.
BE A TEAM PLAYER
Help other medical students with their tasks; teach them information you
have learned. Support your supervising intern or resident whenever possible.
Never steal the spotlight or make a fellow medical student look bad.
K E E P PAT I E N T I N F O R M AT I O N H A N D Y
Use a clipboard, notebook, or index cards to keep patient information, includ-

ing a history and physical, lab, and test results, at hand.
P R E S E N T PAT I E N T I N F O R M AT I O N I N A N O R G A N I Z E D M A N N E R
Here is a template for the “bullet” presentation:
“This is a [age]-year-old [gender] with a history of [major history such

as bipolar disorder] who presented on [date] with [major symptoms,
such as auditory hallucinations] and was found to have [working diag-
nosis]. [Tests done] showed [results]. Yesterday, the patient [state impor-
tant changes, new plan, new tests, new medications]. This morning the
patient feels [state the patient’s words], and the mental status and physi-
cal exams are significant for [state major findings]. Plan is [state plan].”
The newly admitted patient generally deserves a longer presentation following

the complete history and physical format.
Many patients have extensive histories. The complete history should be pres-
ent in the admission note, but during ward presentations, the entire history
is often too much to absorb. In these cases, it will be very important that you
generate a good summary that is concise but maintains an accurate picture of
the patient.
How to Prepare for the Clerkship (Shelf ) Exam

If you have studied the core psychiatric symptoms and illnesses, you will know
a great deal about psychiatry. To specifically study for the clerkship or shelf
exam, we recommend:
2–3 weeks before exam: Read this entire review book, taking notes.
10 days before exam: Read the notes you took during the rotation and the
corresponding review book sections.
5 days before exam: Read this entire review book, concentrating on lists and
mnemonics.
2 days before exam: Exercise, eat well, skim the book, and go to bed early.
1 day before exam: Exercise, eat well, review your notes and the mnemonics,
and go to bed on time. Do not have any caffeine after 2 pm.
Other helpful studying strategies include:
STUDY WITH FRIENDS
Group studying can be very helpful. Other people may point out areas that
you have not studied enough and may help you focus more effectively. If you
tend to get distracted by other people in the room, limit this amount to less
than half of your study time.
STUDY IN A BRIGHT ROOM
Find the room in your home or library that has the brightest light. This will
help prevent you from falling asleep. If you don’t have a bright light, obtain a
halogen desk lamp or a light that simulates sunlight.
E AT L I G H T, B A L A N C E D M E A L S
Make sure your meals are balanced, with lean protein, fruits and vegetables,
and fiber. A high-sugar, high-carbohydrate meal will give you an initial burst
of energy for 1–2 hours, but then your blood sugar will quickly drop.
TA K E P R A C T I C E E X A M S
The purpose of practice exams is not just for the content that is contained in
the questions, but the process of sitting for several hours and attempting to
choose the best answer for each and every question.
POCKET CARDS
The “cards” on the following page contain information that is often helpful in
psychiatry practice. We advise that you make a photocopy of these cards, cut
them out, and carry them in your coat pocket.
Mental Status Exam
Appearance/Behavior: apparent age, attitude and cooperativeness, eye

contact, posture, dress and hygiene, psychomotor status
Speech: rate, rhythm, volume, tone, articulation
Mood: patient’s subjective emotional state—depressed, anxious, sad,

angry, etc.
Affect: objective emotional expression—euthymic, dysphoric, euphoric,

appropriate (to stated mood), labile, full, constricted, flat, etc.
Thought process: logical/linear, circumstantial, tangential, flight of

ideas, looseness of association, thought blocking
Thought content: suicidal/homicidal ideation, delusions, preoccupa-

tions, hyperreligiosity
Perceptual disturbances: hallucinations, illusions, derealization, deper-

sonalization
Cognition:
Level of consciousness: alert, sleepy, lethargic
Orientation: person, place, date
Attention/concentration: serial 7s, spell “world” backwards
Memory:
Registration: immediate recall of three objects
Short term: recall of objects after 5 minutes
Long term: ask about verifiable personal information
Fund of knowledge: current events
Abstract thought: interpretation of proverbs, analogies
Insight: patient’s awareness of his/her illness and need for treatment
Judgment: patient’s ability to approach his/her problems in an appropri-

ate manner
Delirium
Characteristics: acute onset, waxing/waning sensorium (worse at night),

disorientation, inattention, impaired cognition, disorganized thinking,
altered sleep-wake cycle, perceptual disorders (hallucinations, illusions)
(continued)
Etiology: drugs (narcotics, benzodiazepines, anticholinergics, TCAs, ste-

roids, diphenhydramine, etc.), EtOH withdrawal, metabolic (cardiac,
respiratory, renal, hepatic, endocrine), infection, neurological causes
(increased ICP, encephalitis, postictal, stroke)
Investigations:
Routine: CBC, electrolytes, glucose, renal panel, LFTs, TFTs, UA,
urine toxicology, CXR, O2 sat, HIV
Medium-yield: ABG, ECG (silent MI), ionized Ca2+
If above inconclusive: Head CT/MRI, EEG, LP
Management: identify/correct underlying cause, simplify Rx regi-

men, d/c potentially offensive medications if possible, avoid benzo-
diazepines (except in EtOH withdrawal), create safe environment,
provide reassurance/education, judiciously use antipsychotics for acute
agitation
Mini-Mental State Examination (MMSE)
Orientation (10):
What is the [year] [season] [date] [day] [month]? (1 pt. each)

Where are we [state] [county] [town] [hospital] [floor]?
Registration (3): Ask the patient to repeat three unrelated objects (1 pt.
each on first attempt). If incomplete on first attempt, repeat up to six
times (record # of trials).
Attention (5): Either serial 7s or “world” backwards (1 pt. for each

correct letter or number).
Delayed recall (3): Ask patient to recall the three objects previously
named (1 pt. each).
Language (9):
■■ Name two common objects, e.g., watch, pen (1 pt. each).
■■ Repeat the following sentence: “No ifs, ands, or buts” (1 pt.).
■■ Give patient blank paper. “Take it in your right hand, use both hands
to fold it in half, and then put it on the floor” (1 pt. for each part
correctly executed).
■■ Have patient read and follow: “Close your eyes” (1 pt.).
■■ Ask patient to write a sentence. The sentence must contain a
subject and a verb; correct grammar and punctuation are not
necessary (1 pt.)
■■ Ask the patient to copy the design. Each figure must have five sides,
and two of the angles must intersect (1 pt.).
Mania (“DIG FAST”)
Distractibility
Irritable mood/insomnia
Grandiosity
Flight of ideas
Agitation/increase in goal-directed activity
Speedy thoughts/speech
Thoughtlessness: seek pleasure without regard to consequences
Suicide Risk (“SAD PERSONS”)

Sex—male
Age >60 years
Depression
Previous attempt
Ethanol/drug abuse
Rational thinking loss
Suicide in family
Organized plan/access
No support
Sickness
Depression (“SIG E. CAPS”)

Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor Ds
Suicidal ideation
Hopelessness
Helplessness
Worthlessness
Drugs of Abuse
Drug Intoxication Withdrawal

Alcohol Disinhibition, mood lability, Tremulousness,
Benzodiazepines incoordination, slurred hypertension, tachycardia,
speech, ataxia, blackouts anxiety, psychomotor
(EtOH), respiratory depression agitation, nausea, seizures,
hallucinations, DTs (EtOH)
Barbiturates Respiratory depression Anxiety, seizures,

delirium, life-threatening
cardiovascular collapse
(continued)
Opioids CNS depression, nausea, Increased sympathetic

vomiting, sedation, decreased activity, N/V, diarrhea,
pain perception, decreased diaphoresis, rhinorrhea,
GI motility, pupil constriction, piloerection, yawning,
respiratory depression stomach cramps, myalgias,
arthralgias, restlessness,
anxiety, anorexia
Amphetamines Euphoria, increased attention Post-use “crash”:

Cocaine span, aggressiveness, restlessness, headache,
psychomotor agitation, pupil hunger, severe depression,
dilatation, hypertension, irritability, insomnia/
tachycardia, cardiac hypersomnia, strong
arrhythmias, psychosis psychological craving
(paranoia with amphetamines,
formication with cocaine)
PCP Belligerence, impulsiveness, May have recurrence

psychomotor agitation, of symptoms due to
vertical/horizontal nystagmus, reabsorption in GI tract
hyperthermia, tachycardia,
ataxia, psychosis, homicidality
LSD Altered perceptual states

(hallucinations, distortions
of time and space), elevation
of mood, “bad trips” (panic
reaction), flashbacks
(reexperience of the
sensations in absence of
drug use)
Cannabis Euphoria, anxiety, paranoia,

slowed time, social
withdrawal, increased
appetite, dry mouth,
tachycardia, amotivational
syndrome
Nicotine/ Restlessness, insomnia, Irritability, lethargy,

Caffeine anxiety, anorexia headache, increased
appetite, weight gain
First Aid for the Psychiatry Clerkship, 4e; copyright © 2015 McGraw-Hill. All rights reserved.
Psychiatric Emergencies
Delirium Tremens (DTs):

■■ Typically within 2–4 days after cessation of EtOH but may occur
later.
■■ Delirium, agitation, fever, autonomic hyperactivity, auditory and
visual hallucinations.
■■ Treat aggressively with benzodiazepines and hydration.
Neuroleptic Malignant Syndrome (NMS):
■■ Fever, rigidity, autonomic instability, clouding of consciousness,
elevated WBC/CPK
■■ Withhold neuroleptics, hydrate, consider dantrolene and/or
bromocriptine
■■ Idiosyncratic, time-limited reaction
Serotonin Syndrome:
■■ Precipitated by use of two drugs with serotonin-enhancing properties
(e.g., MAOI + SSRI).
■■ Altered mental status, fever, agitation, tremor, myoclonus, hyperre-
flexia, ataxia, incoordination, diaphoresis, shivering, diarrhea.
■■ Discontinue offending agents, benzodiazepines, consider cyprohep-
tadine.
Tyramine Reaction/Hypertensive Crisis:
■■ Precipitated by ingestion of tyramine containing foods while on
MAOIs.
■■ Hypertension, headache, neck stiffness, sweating, nausea, vomiting,
visual problems. Most serious consequences are stroke and possibly
death.
■■ Treat with nitroprusside or phentolamine.
Acute Dystonia:
■■ Early, sudden onset of muscle spasm: eyes, tongue, jaw, neck; may
lead to laryngospasm requiring intubation.
■■ Treat with benztropine (Cogentin) or diphenhydramine (Benadryl).
Lithium Toxicity:
■■ May occur at any Li level (usually >1.5).
■■ Nausea, vomiting, slurred speech, ataxia, incoordination, myoclonus,
hyperreflexia, seizures, nephrogenic diabetes insipidus, delirium,
coma
■■ Discontinue Li, hydrate aggressively, consider hemodialysis
Tricyclic Antidepressant (TCA) Toxicity:
■■ Primarily anticholinergic effects; cardiac conduction disturbances,
hypotension, respiratory depression, agitation, hallucinations.
■■ CNS stimulation, depression, seizures.
■■ Monitor ECG, activated charcoal, cathartics, supportive treatment.
notes
Chapter 2
EXAMINATION AND DIAGNOSIS
History and Mental Status Examination 12 Diagnosis and Classification 18

Interviewing 12 Diagnosis as per DSM-5 18
Taking the History 13 Diagnostic Testing 18
Mental Status Examination 14 Intelligence Tests 18
Mini-Mental State Examination (MMSE) 17 Objective Personality Assessment Tests 19
Interviewing Skills 17 Projective (Personality) Assessment Tests 19
General Approaches to Types of Patients 17
11
12 Chapter 2 EXAMINATION AND DIAGNOSIS
History and Mental Status Examination
INTERVIEWING
Making the Patient Comfortable

The initial interview is of utmost importance to the psychiatrist. With prac-
WARDS TIP tice, you will develop your own style and learn how to adapt the interview to the
individual patient. In general, start the interview by asking open-ended ques-
The HPI should include information tions and carefully note how the patient responds, as this is critical infor-
about the current episode, including mation for the mental status exam. Consider preparing for the interview by
symptoms, duration, context, stressors, writing down the subheadings of the exam (see Figure 2-1). Find a safe and
and impairment in function. private area to conduct the interview. Use closed-ended questions to obtain the
remaining pertinent information. During the first interview, the psychiatrist
Date and Location:
Identifying Patient Data:
Chief Complaint: Past Medical History:
History of Present Illness:
Allergies:
Past Psychiatric History: Current Meds:
First contact:
Developmental History:
Diagnosis:
Prior hospitalizations:
Relationships (children/marital status):
Suicide attempts:
Outpatient treatment:
Education:
Med trials:
Work History:
Substance History: Military History:
Housing:
Smoking: Income:
Family Psychiatric History: Religion:
Legal History:
FIGURE 2-1. Psychiatric history outline.

EXAMINATION AND DIAGNOSIS Chapter 2 13
must establish a meaningful rapport with the patient in order to get accu-
rate and pertinent information. This requires that questions be asked in a WARDS TIP
quiet, comfortable setting so that the patient is at ease. The patient should
feel that the psychiatrist is interested, nonjudgmental, and compassionate. If you are seeing the patient in the ER,
In psychiatry, the history is the most important factor in formulating a diag- make sure to ask how they got to the
nosis and treatment plan. ER (police, bus, walk-in, family member)
and look to see what time they were
triaged. For all initial evaluations, ask
why the patient is seeking treatment
today as opposed to any other day.
TA K I N G T H E H I S T O R Y
The psychiatric history follows a similar format as the history for other types of
patients. It should include the following: WARDS TIP
■■ Identifying data: The patient’s name, gender, age, race, marital status,
place and type of residence, occupation. When taking a substance history,
■■ Chief complaint (use the patient’s own words). If called as a consultant, remember to ask about caffeine and
list reason for the consult. nicotine use. If a heavy smoker is
■■ Sources of information. hospitalized and does not have access
■■ History of present illness (HPI): to nicotine replacement therapy,
■■ The 4 Ps: The patient’s psychosocial and environmental conditions pre- nicotine withdrawal may cause anxiety
disposing to, precipitating, perpetuating, and protecting against the cur- and agitation.
rent episode.
■■ The patient’s support system (whom the patient lives with, distance and
level of contact with friends and relatives).

■■ Neurovegetative symptoms (quality of sleep, appetite, energy, psycho- KEY FACT
motor retardation/activation, concentration).
■■ Suicidal ideation/homicidal ideation. Importance of asking about OTC use:
■■ How work and relationship have been affected (for most diagnoses in Nonsteroidal anti-inflammatory drugs
the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (NSAIDs) can ↓ lithium excretion → ↑
[DSM-5] there is a criterion that specifies that symptoms must cause lithium concentrations (exceptions may
clinically significant distress or impairment in social, occupational, or be sulindac and aspirin).
other important areas of functioning).
■■ Psychotic symptoms (e.g., auditory and visual hallucinations).
■■ Establish a baseline of mental health:
■■ Patient’s level of functioning when “well” WARDS TIP

■■ Goals (outpatient setting)
■■ Past psychiatric history (include as applicable: history of suicide attempts, Psychomotor retardation, which
history of self-harm [e.g., cutting, burning oneself], information about pre- refers to the slowness of voluntary
vious episodes, other psychiatric disorders in remission, medication trials, and involuntary movements, may
past psychiatric hospitalizations, current psychiatrist). also be referred to as hypokinesia or
■■ Substance history (history of intravenous drug use, participation in outpa- bradykinesia. The term akinesia is used
tient or inpatient drug rehab programs). in extreme cases where absence of
■■ Medical history (ask specifically about head trauma, seizures, pregnancy status). movement is observed.
■■ Family psychiatric and medical history (include suicides and treatment
response as patient may respond similarly).
■■ Medications (ask about supplements and over-the-counter medications).
■■ Allergies: Clarify if it was a true allergy or an adverse drug event (e.g., KEY FACT
abdominal pain).
■■ Developmental history: Achieved developmental milestones on time, Automatisms are spontaneous,
friends in school, performance academically. involuntary movements that occur
■■ Social history: Include income source, employment, education, place of during an altered state of consciousness
residence, who they live with, number of children, support system, reli- and can range from purposeful to
gious affiliation and beliefs, legal history, amount of exercise, history of disorganized.
trauma or abuse.
M E N TA L S TAT U S E X A M I N AT I O N
WARDS TIP
This is analogous to performing a physical exam in other areas of medicine. It
A hallmark of pressured speech is
is the nuts and bolts of the psychiatric exam. It should describe the patient in
that it is usually uninterruptible and
as much detail as possible. The mental status exam assesses the following:
the patient is compelled to continue
speaking. ■■ Appearance
■■ Behavior
■■ Speech
■■ Mood/Affect
KEY FACT ■■ Thought Process
■■ Thought Content
An example of inappropriate affect is a ■■ Perceptual Disturbances
patient’s laughing when being told he ■■ Cognition
has a serious illness. ■■ Insight
■■ Judgment/Impulse Control
The mental status exam tells only about the mental status at that moment; it
can change every hour or every day, etc.
KEY FACT
You can roughly assess a patient’s

Appearance/Behavior
intellectual functioning by utilizing the ■■ Physical appearance: Gender, age (looks older/younger than stated age),
proverb interpretation and vocabulary type of clothing, hygiene (including smelling of alcohol, urine, feces),
strategies. Proverb interpretation is posture, grooming, physical abnormalities, tattoos, body piercings. Take
helpful in assessing whether a patient specific notice of the following, which may be clues for possible diagnoses:
has difficulty with abstraction. Being ■■ Pupil size: Drug intoxication/withdrawal.
able to define a particular vocabulary ■■ Bruises in hidden areas: ↑ suspicion for abuse.
word correctly and appropriately use ■■ Needle marks/tracks: Drug use.
it in a sentence reflects a person’s ■■ Eroding of tooth enamel: Eating disorders (from vomiting).
intellectual capacity. ■■ Superficial cuts on arms: Self-harm.
■■ Behavior and psychomotor activity: Attitude (cooperative, seductive, flat-

tering, charming, eager to please, entitled, controlling, uncooperative,
hostile, guarded, critical, antagonistic, childish), mannerisms, tics, eye
WARDS TIP contact, activity level, psychomotor retardation/activation, akathisia,
automatisms, catatonia, choreoathetoid movements, compulsions, dysto-
nias, tremor.
To assess mood, just ask, “How are you
feeling today?” It can also be helpful to
have patients rate their stated mood on Speech
a scale of 1–10. Rate (pressured, slowed, regular), rhythm (i.e., prosody), articulation (dysarthria,
stuttering), accent/dialect, volume/modulation (loudness or softness), tone,
long or short latency of speech.
WARDS TIP Mood

Mood is the emotion that the patient tells you he feels, often in quotations.
A patient who is laughing one second
and crying the next has a labile affect. Affect
Affect is an assessment of how the patient’s mood appears to the examiner,
including the amount and range of emotional expression. It is described with
the following dimensions:
WARDS TIP
■■ Type of affect: Euthymic, euphoric, neutral, dysphoric.
A patient who giggles while telling ■■ Quality/Range describes the depth and range of the feelings shown.
you that he set his house on fire and Parameters: flat (none)—blunted (shallow)—constricted (limited)—full
is facing criminal charges has an (average)—intense (more than normal).
inappropriate affect. ■■ Motility describes how quickly a person appears to shift emotional states.
Parameters: sluggish—supple—labile.
■■ Appropriateness to content describes whether the affect is congru-

ent with the subject of conversation or stated mood. Parameters: WARDS TIP
appropriate—not appropriate.
A patient who remains expressionless
and monotone even when discussing
Thought Process extremely sad or happy moments in his
The patient’s form of thinking—how he or she uses language and puts ideas life has a flat affect.
together. It describes whether the patient’s thoughts are logical, meaningful,
and goal directed. It does not comment on what the patient thinks, only how
the patient expresses his or her thoughts. Circumstantiality is when the point
of the conversation is eventually reached but with overinclusion of trivial or
irrelevant details. Examples of thought disorders include: KEY FACT
■■ Tangentiality: Point of conversation never reached; responses usually in
the ballpark. Examples of delusions:
■■ Loosening of associations: No logical connection from one thought to ■■ Grandeur—belief that one has
another. special powers or is someone
■■ Flight of ideas: Thoughts change abruptly from one idea to another, usu- important (Jesus, President)
ally accompanied by rapid/pressured speech. ■■ Paranoid—belief that one is being
■■ Neologisms: Made-up words. persecuted

■■ Word salad: Incoherent collection of words. ■■ Reference—belief that some event
■■ Clang associations: Word connections due to phonetics rather than actual is uniquely related to patient (e.g.,
meaning. “My car is red. I’ve been in bed. It hurts my head.” a TV show character is sending
■■ Thought blocking: Abrupt cessation of communication before the idea is patient messages)
finished. ■■ Thought broadcasting—belief that
one’s thoughts can be heard by

others
Thought Content ■■ Religious—conventional beliefs
Describes the types of ideas expressed by the patient. Examples of exaggerated (e.g., Jesus talks to me)
■■ Somatic—false belief concerning
disorders:
body image (e.g., I have cancer)
■■ Poverty of thought versus overabundance: Too few versus too many ideas
expressed.
■■ Delusions: Fixed, false beliefs that are not shared by the person’s culture
and cannot be changed by reasoning. Delusions are classified as bizarre
(impossible to be true) or nonbizarre (at least possible).
■■ Suicidal and homicidal ideation: Ask if the patient feels like harming WARDS TIP
him/herself or others. Identify if the plan is well formulated. Ask if the
patient has an intent (i.e., if released right now, would he go and kill him- The following question can help screen
self or harm others?). Ask if the patient has means to kill himself (firearms for compulsions: Do you clean, check,
in the house/multiple prescription bottles). or count things on a repetitive basis?
■■ Phobias: Persistent, irrational fears.
■■ Obsessions: Repetitive, intrusive thoughts.
■■ Compulsions: Repetitive behaviors (usually linked with obsessive thoughts).
Perceptual Disturbances WARDS TIP

■■ Hallucinations: Sensory perceptions that occur in the absence of an actual
stimulus. An auditory hallucination that instructs
■■ Describe the sensory modality: Auditory (most common), visual, taste, a patient to harm himself or others is
olfactory, or tactile. an important risk factor for suicide or
■■ Describe the details (e.g., auditory hallucinations may be ringing, homicide.
humming, whispers, or voices speaking clear words). Command
auditory hallucinations are voices that instruct the patient to do
something.
■■ Ask if the hallucination is experienced only before falling asleep
(hypnagogic hallucination) or upon awakening (hypnopompic hal

lucination).
■■ Illusions: Inaccurate perception of existing sensory stimuli (e.g., wall

appears as if it’s moving).
■■ Derealization/Depersonalization: The experience of feeling detached from
one’s surroundings/mental processes.
Sensorium and Cognition

Sensorium and cognition are assessed in the following ways:
■■ Consciousness: Patient’s level of awareness; possible range includes:
WARDS TIP Alert—drowsy—lethargic—stuporous—coma.
■■ Orientation: To person, place, and time.
Alcoholic hallucinosis refers to ■■ Calculation: Ability to add/subtract.
hallucinations (usually auditory, ■■ Memory:
■■ Immediate (registration)—dependent on attention/concentration and
although visual and tactile may occur)
that occur either during or after a can be tested by asking a patient to repeat several digits or words.
■■ Recent (short-term memory)—events within the past few minutes,
period of heavy alcohol consumption.
Patients usually are aware that these hours or days.
■■ Remote memory (long-term memory).
hallucinations are not real. In contrast
to delirium tremens (DTs), there is no ■■ Fund of knowledge: Level of knowledge in the context of the patient’s
clouding of sensorium and vital signs culture and education (e.g., Who is the president? Who was Picasso?).
are normal. ■■ Attention/Concentration: Ability to subtract serial 7s from 100 or to spell
“world” backwards.
■■ Reading/Writing: Simple sentences (must make sure the patient is literate
first).
■■ Abstract concepts: Ability to explain similarities between objects and
understand the meaning of simple proverbs.
Insight
Insight is the patient’s level of awareness and understanding of his or her
problem. Problems with insight include complete denial of illness or blaming
it on something else. Insight can be described as full, partial/limited, or none.
Judgment
Judgment is the patient’s ability to understand the outcome of his or her
actions and use this awareness in decision making. Best determined from
information from the HPI and recent behavior (e.g., how a patient was
brought to treatment or medication compliance). Judgment can be described
as excellent, good, fair, or poor.
Mrs. Gong is a 52-year-old Asian-American woman who arrives at

the emergency room reporting that her deceased husband of 25
years told her that he would be waiting for her there. In order to meet
him, she drove nonstop for 22 hours from a nearby state. She claims that
her husband is a famous preacher and that she, too, has a mission from
God. Although she does not specify the details of her mission, she says
that she was given the ability to stop time until her mission is completed.
She reports experiencing high levels of energy despite not sleeping for
22 hours. She also reports that she has a history of psychiatric hospital-
izations but refuses to provide further information.
While obtaining her history you perform a mental status exam. Her
appearance is that of a woman who looks older than her stated age.
She is obese and unkempt. There is no evidence of tattoos or piercings.
She has tousled hair and is dressed in a mismatched flowered skirt and
a red T-shirt. Upon her arrival at the emergency room, her behavior is
demanding, as she insists that you let her husband know that she has
arrived. She then becomes irate and proceeds to yell, banging her head
against the wall. She screams, “Stop hiding him from me!” She is unco-
operative with redirection and is guarded during the remainder of the
interview. Her eye contact is poor as she is looking around the room.
Her psychomotor activity is agitated. Her speech is loud and pressured,
with a foreign accent.
She reports that her mood is “angry,” and her affect as observed during
the interview is labile and irritable.
Her thought process includes flight of ideas. Her thought content is

significant for delusions of grandeur and thought broadcasting, as evi-
denced by her refusing to answer most questions claiming that you are
able to know what she is thinking. She denies suicidal or homicidal ide-
ation. She expresses disturbances in perception as she admits to fre-
quent auditory hallucinations of command.
She is uncooperative with formal cognitive testing, but you notice that
she is oriented to place and person. However, she erroneously states that
it is 2005. Her attention and concentration are notably impaired, as she
appears distracted and frequently needs questions repeated. Her insight,
judgment, and impulse control are determined to be poor.
You decide to admit Mrs. Gong to the inpatient psychiatric unit in order
to allow for comprehensive diagnostic evaluation, the opportunity to
obtain collateral information from her prior hospitalizations, safety mon-
itoring, medical workup for possible reversible causes of her symptoms,
and psychopharmacological treatment.
M I N I - M E N TA L S TAT E E X A M I N AT I O N ( M M S E )
The MMSE is a simple, brief test used to assess gross cognitive functioning.
See the Cognitive Disorders chapter for detailed description. The areas tested
include:
■■ Orientation (to person, place, and time).
■■ Memory (immediate—registering three words; and recent—recalling
three words 5 minutes later).
■■ Concentration and attention (serial 7s, spell “world” backwards).
■■ Language (naming, repetition, comprehension).
■■ Complex command.
■■ Visuospatial ability (copy of design).
Interviewing Skills
G E N E R A L A P P R O A C H E S T O T Y P E S O F PAT I E N T S
Violent Patient
One should avoid being alone with a potentially violent patient. Inform
staff of your whereabouts. Know if there are accessible panic buttons. To
assess violence or homicidality, one can simply ask, “Do you feel like you
want to hurt someone or that you might hurt someone?” If the patient
WARDS TIP expresses imminent threats against friends, family, or others, the doctor
should notify potential victims and/or protection agencies when appropri-
To test ability to abstract, ask: ate (Tarasoff rule).
1. Similarities: How are an apple and
orange alike? (Normal answer: “They
are fruits.” Concrete answer: “They are Delusional Patient
round.”) Although the psychiatrist should not directly challenge a delusion or insist
2. Proverb testing: What is meant by that it is untrue, he should not imply he believes it either. He should simply
the phrase, “You can’t judge a book acknowledge that he understands the patient believes the delusion is true.
by its cover?” (Normal answer: “You
can’t judge people just by how they
look.” Concrete answer: “Books have Depressed Patient
different covers.”) A depressed patient may be skeptical that he or she can be helped. It is impor-
tant to offer reassurance that he or she can improve with appropriate therapy.
Inquiring about suicidal thoughts is crucial; a feeling of hopelessness, sub-
stance use, and/or a history of prior suicide attempts reveal an ↑ risk for sui-
cide. If the patient is actively planning or contemplating suicide, he or she
should be hospitalized or otherwise protected.
KEY FACT
A prior history of violence is the most Diagnosis and Classification

important predictor of future violence.
DIAGNOSIS AS PER DSM-5
The American Psychiatric Association uses a criterion-based system for diag-

noses. Criteria and codes for each diagnosis are outlined in the DSM-5.
WARDS TIP
In assessing suicidality, do not simply

ask, “Do you want to hurt yourself?” Diagnostic Testing
because this does not directly address
suicidality (he may plan on dying in
a painless way). Ask directly about INTELLIGENCE TESTS
killing self or suicide. If contemplating
suicide, ask the patient if he has a plan Aspects of intelligence include memory, logical reasoning, ability to assimilate
of how to do it and if he has intent; a factual knowledge, understanding of abstract concepts, etc.
detailed plan, intent, and the means to
accomplish it suggest a serious threat. Intelligence Quotient (IQ)
IQ is a test of intelligence with a mean of 100 and a standard deviation of
15. These scores are adjusted for age. An IQ of 100 signifies that mental age
equals chronological age and corresponds to the 50th percentile in intellec-
tual ability for the general population.
KEY FACT
Intelligence tests assess cognitive function by evaluating comprehension, fund
of knowledge, math skills, vocabulary, picture assembly, and other verbal and
The Minnesota Multiphasic Personality
performance skills. Two common tests are:
Inventory (MMPI) is an objective
psychological test that is used to assess
Wechsler Adult Intelligence Scale (WAIS):
a person’s personality and identify
psychopathologies. The mean score ■■ Most common test for ages 16–90.
for each scale is 50 and the standard ■■ Assesses overall intellectual functioning.
deviation is 10. ■■ Four index scores: Verbal comprehension, perceptual reasoning, working
memory, processing speed.
Wechsler Intelligence Scale for Children (WISC): Tests intellectual ability in

patients ages 6–16. WARDS TIP
IQ Chart
OBJECTIVE PERSONALIT Y ASSESSMENT TESTS Very superior: >130
Superior: 120–129
These tests are questions with standardized-answer format that can be objec- High average: 110–119
tively scored. The following is an example: Average: 90–109
Low average: 80–89
Minnesota Multiphasic Personality Inventory (MMPI-2) Borderline: 70–79
■■ Tests personality for different pathologies and behavioral patterns. Extremely low (intellectual
■■ Most commonly used. disability): <70
PROJECTIVE (PERSONALIT Y) ASSESSMENT TESTS
Projective tests have no structured-response format. The tests often ask for
interpretation of ambiguous stimuli. Examples are:
Thematic Apperception Test (TAT)

■■ Test taker creates stories based on pictures of people in various situations.
■■ Used to evaluate motivations behind behaviors.
Rorschach Test
■■ Interpretation of inkblots.
■■ Used to identify thought disorders and defense mechanisms.
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Chapter 3
PSYCHOTIC DISORDERS
Psychosis 22 Pathophysiology of Schizophrenia: The Dopamine Hypothesis 26

Delusions 22 Other Neurotransmitter Abnormalities Implicated in Schizophrenia 27
Perceptual Disturbances 22 Prognostic Factors 27
Differential Diagnosis of Psychosis 22 Treatment 27
Psychotic Disorder Due to Another Medical Condition 23 Schizophreniform Disorder 29
Substance/Medication-Induced Psychotic Disorder 23
Schizoaffective Disorder 29
Schizophrenia 23
Brief Psychotic Disorder 30
Positive, Negative, and Cognitive Symptoms 24
Three Phases 24 Delusional Disorder 30
Diagnosis of Schizophrenia 24 Culture-Specific Psychoses 31
Psychiatric Exam of Patients with Schizophrenia 25
Comparing Time Courses and Prognoses of
Epidemiology 26
Psychotic Disorders 31
Downward Drift 26
Quick and Easy Distinguishing Features 31
21
22 Chapter 3 PSYCHOTIC DISORDERS
Psychosis
Psychosis is a general term used to describe a distorted perception of real-
WARDS TIP ity. Poor reality testing may be accompanied by delusions, perceptual distur-
bances (illusions or hallucinations), and/or disorganized thinking/ behavior.
Psychosis is exemplified by either Psychosis can be a symptom of schizophrenia, mania, depression, delirium,
delusions, hallucinations, or severe and dementia, and it can be substance or medication-induced.
disorganization of thought/behavior.
DELUSIONS
Delusions are fixed, false beliefs that remain despite evidence to the contrary
and cannot be accounted for by the cultural background of the individual.
They can be categorized as either bizarre or nonbizarre. A nonbizarre delu-

sion is a false belief that is plausible but is not true. Example: “The neighbors
are spying on me by reading my mail.” A bizarre delusion is a false belief that
is impossible. Example: “A Martian fathered my baby and inserted a micro-
chip in my brain.”
Delusions can also be categorized by theme:

■■ Delusions of persecution/paranoid delusions: Irrational belief that one is
being persecuted. Example: “The CIA is after me and tapped my phone.”
■■ Ideas of reference: Belief that cues in the external environment are
uniquely related to the individual. Example: “The TV characters are
speaking directly to me.”
■■ Delusions of control: Includes thought broadcasting (belief that one’s
thoughts can be heard by others) and thought insertion (belief that others’
thoughts are being placed in one’s head).
■■ Delusions of grandeur: Belief that one has special powers beyond those of
a normal person. Example: “I am the all-powerful son of God and I shall
bring down my wrath on you if I don’t get my way.”
■■ Delusions of guilt: Belief that one is guilty or responsible for something.
Example: “I am responsible for all the world’s wars.”
■■ Somatic delusions: Belief that one is infected with a disease or has a cer-
tain illness.
P e r c ep t u a l D is t u r b a n c es
■■ Illusion: Misinterpretation of an existing sensory stimulus (such as mistak-

ing a shadow for a cat).
■■ Hallucination: Sensory perception without an actual external stimulus.
WARDS TIP ■■ Auditory: Most commonly exhibited by schizophrenic patients.
■■ Visual: Occurs but less common in schizophrenia. May accompany

Auditory hallucinations that directly tell drug intoxication, drug and alcohol withdrawal, or delirium.
the patient to perform certain acts are ■■ Olfactory: Usually an aura associated with epilepsy.
called command hallucinations. ■■ Tactile: Usually secondary to drug use or alcohol withdrawal.
D i f f e r en t i a l D i a g nosis o f P s y c h osis
■■ Psychotic disorder due to another medical condition

■■ Substance/Medication-induced psychotic disorder
■■ Delirium/Dementia
■■ Bipolar disorder, manic/mixed episode
■■ Major depression with psychotic features
PSYCHOTIC DISORDERS Chapter 3 23
■■ Brief psychotic disorder

■■ Schizophrenia WARDS TIP
■■ Schizophreniform disorder
■■ Schizoaffective disorder It’s important to be able to distinguish
■■ Delusional disorder between a delusion, illusion, and
hallucination. A delusion is a false belief,
an illusion is a misinterpretation of an
P S YCH O T I C diso r de r due t o a no t h e r M edi c a l Condi t ion external stimulus, and a hallucination
is perception in the absence of an
Medical causes of psychosis include: external stimulus.
1. Central nervous system (CNS) disease (cerebrovascular disease, multiple
sclerosis, neoplasm, Alzheimer’s disease, Parkinson’s disease, Huntington’s
disease, tertiary syphilis, epilepsy [often temporal lobe], encephalitis, prion
disease, neurosarcoidosis, AIDS).
2. Endocrinopathies (Addison/Cushing disease, hyper/hypothyroidism, hyper/
hypocalcemia, hypopituitarism).
3. Nutritional/Vitamin deficiency states (B12, folate, niacin).
4. Other (connective tissue disease [systemic lupus erythematosus, temporal
arteritis], porphyria).
DSM-5 criteria for psychotic disorder due to another medical condition include:
■■ Prominent hallucinations or delusions. WARDS TIP
■■ Symptoms do not occur only during an episode of delirium.
■■ Evidence from history, physical, or lab data to support another medical Elderly, medically ill patients who
cause (i.e., not psychiatric). present with psychotic symptoms such
as hallucinations, confusion, or paranoia
should be carefully evaluated for
S u b s ta n c e / M edi c at ion - indu c ed ps y c h o t i c diso r de r
delirium, which is a far more common
finding in this population.
Prescription medications that may cause psychosis in some patients include
anesthetics, antimicrobials, corticosteroids, antiparkinsonian agents, anti-
convulsants, antihistamines, anticholingerics, antihypertensives, NSAIDs,
digitalis, methylphenidate, and chemotherapeutic agents. Substances such as
alcohol, cocaine, hallucinogens (LSD, Ecstasy), cannabis, benzodiazepines,
barbiturates, inhalants, and phencyclidine (PCP) can cause psychosis, either
in intoxication or withdrawal.
DSM-5 Criteria
WARDS TIP
■■ Hallucinations and/or delusions.
■■ Symptoms do not occur only during episode of delirium. To make the diagnosis of schizophrenia,
■■ Evidence from history, physical, or lab data to support a medication or a patient must have symptoms of the
substance-induced cause. disease for at least 6 months.
■■ Disturbance is not better accounted for by a psychotic disorder that is not
substance/medication-induced.
Schizophrenia
A 24-year-old male graduate student without prior medical or psy-

chiatric history is reported by his mother to have been very anxious
over the past 9 months, with increasing concern that people are watch-
ing him. He now claims to “hear voices” telling him what must be done
to “fix the country.” Important workup? Thyroid-stimulating hormone
(TSH), rapid plasma reagin (RPR), brain imaging. Likely diagnosis?
Schizophrenia. Next step? Antipsychotics.
Another random document with
no related content on Scribd:
and numbers of people we should like to meet here. You
remember he had come back invalided from the Soudan, and
though he was quite young, about thirty, he had gained great
distinction. He was Major Caruth, I think, and his name must
have been Alexander, for his mother called him 'Alec.'
Everyone liked them both, but we used to think him just a
little reserved."
"I thought him extremely polite—quite a model of courtesy, in

fact."
"Well, yes, he was, and especially to the elder ladies; but he

never showed any marked attention to any of the younger
ones. He was the most devoted son possible, and it was quite
beautiful to see the manner in which he looked up in his
mother's face when she came to his side with that inquiring
glance on hers."
"He had nearly died, and he was all she had," replied Mrs.
Evans. "Heir to a fine property, I believe. I scarcely think that
Mrs. Caruth could be the one Joyce mentioned. Was it likely
there would be any intimacy between the daughter of a poor
country clergyman and people of position like those Caruths?"
"I do not know. You see, clergymen go everywhere."
"But not always their wives and daughters," said Mrs. Evans.
"Did you notice the name of the place Joyce's friend lived at? I
have the address of those we met at Mentone; it was Ferns—
something—crag, probably."
"Was it Fernsclough?" said Augusta, eagerly.
"I really believe it was."
"Then the lady is the same. Her place is Fernsclough, Salop."

"Well, what of that? Her giving Joyce a character to go out as
children's maid puts away the suggestion of intimacy at once.
She might do that, and never speak to or communicate again
with one who was disgracing herself by taking a sort of
servant's place."
"Joyce said that Mrs. Caruth wanted her to go to Fernsclough

for an indefinite time."
"Perhaps that was an invention, in order to raise herself in our

eyes, my dear child. I have seen more of life and character
than you have, Augusta."
"I can hardly think that," replied the girl; "I could not imagine
Joyce saying an untrue word. She is not that sort of girl. And,
mamma, she is my cousin and a lady, though she is not rich. I
cannot help feeling sorry for her. If these friends of hers
should turn out to be the Caruths we met, and at some future
time we should see them again, what will they think of us for
letting Joyce go?"
"Think, you foolish girl! What can they think? Just that as she
was too proud to go to Fernsclough, she was too headstrong
to be guided by us, and went her own wilful way. You need not
trouble your head about that."
But Augusta was not quite happy, in spite of her mother's

assurances; and Adelaide was still less so.
CHAPTER IV.
THOUGH Joyce Mirlees' twenty-first birthday brought some
clouds and storms, it was not wholly without peace and
brightness. More than a dozen letters reached her from
various quarters. Her uncle did not forget Joyce, but wrote
warmly and lovingly, and promised to be at The Chase before
she left it.
Other letters were from old friends at Welton, who did not fail
to send birthday greetings and simple gifts to their former
pastor's daughter. One packet, containing some beautiful
fancy articles, came to her from her Sunday scholars, who had
worked them for the dear teacher whose absence they
regretted more and more, they said. Yet it was plain that one
and all pictured Joyce amongst loving kinsfolk, and amid
luxuries of every kind, for they seemed half afraid that their
simple tokens of love would look very poor and mean amongst
her birthday gifts in her new and splendid home.
If those who had bestowed such patient labour on the dainty

articles could have seen how Joyce looked at them through
gathering tears, but with a glad face, and heard her soft
whisper, "Not alone in the world. Not forgotten, though
absent, thank God!" they would have been more than repaid.
The very answering of these gave Joyce happy employment

during the afternoon. Besides, she had not been without
personal greetings. The very servants at The Chase had
learned to love their master's orphan niece, who spoke gently,
and thought of and for them, as they went about their daily
duties. They ventured to offer good wishes, and one little
country girl begged her to accept a pin-cushion which she had
risen earlier to make for Miss Joyce.
There were loving words, too, from Sarah Keene, who

alternately rejoiced and wept over her nursling, bewailing her
coming departure with one breath, and expressing her firm
conviction in the next, that it would be overruled for good,
and that her darling would be above all of them yet.
There was one more letter not named hitherto, which, though
full of kindness, brought some disappointment. The writer,
Mrs. Caruth, said all that could be expected from an old and
true friend. But there was no other message, though she
mentioned casually that her son, being quite well, had
rejoined his regiment instead of availing himself of the longer
leave at his disposal.
It was still early evening, and Joyce was in her own room,
when she heard a light tap at the door, and the words, "May I
come in, Cousin Joyce?"
The voice was Adelaide's, but the tone of it was so different

from her ordinary one that Joyce could hardly believe her
ears. She, however, opened the door and convinced herself
that her visitor was indeed Adelaide, the elder and much more
beautiful of her two handsome cousins. She also somewhat
resembled Mr. Evans in disposition; but, like him, had rarely
courage to express her sentiments when they differed from
those of her mother and sister.
"May I come in?" she repeated, as she hesitated on the

threshold of Joyce's room.
"Certainly. I am glad, very glad, to have you."
"That is kind, Cousin Joyce; kinder than I deserve. I am come

to make a confession, Joyce; I have been very unkind to you.
Will you forgive me?"
"I do not understand. You have done nothing," said Joyce,

amazed at the visit, words, and look of her cousin, who had
taken her hand, and was holding it between both her own.
"Perhaps I have not done much, after all," she said; "but one
has often as much cause to grieve for the not doing what is
right and kind as for active unkindness. Cousin Joyce, I have
had a revelation to-day. I have had a peep at my own heart
and life, and I am dissatisfied with both, especially in
connection with yourself. When you spoke to my mother this
morning and told her what you were going to do, how you had
made up your mind to leave the only relatives you have in the
world, because under their roof you had a shelter, not a home,
I felt so sorry for you, so ashamed for ourselves. It was your
birthday morning. You are twenty-one to-day. I was the same
four months ago, and then my mother did not know how to
lavish enough of costly things upon me. I had cards—works of
art that had cost pounds; flowers in profusion, letters,
messages, callers, jewellery, finery of all kinds, and a grand
evening party given in my honour. And you, Cousin Joyce, had
nothing but the coldest greeting, and an offer of our
secondhand and third-best clothes. Please let me finish—" for
Joyce would have stopped the confession half-way. "I do not
know how it was brought about, but I seemed to see
everything you had endured under this roof from the day of
your coming. No welcome, no sympathy, no home, no
friends."
"Yes, my uncle has always been kind, and I have had Sarah
Keene. Besides, I was but a stranger who had to win the
affection of strangers, though they might be relatives; and I
really believe you care for me after all!" cried Joyce, looking
up into Adelaide's face, and smiling through the tears which
her cousin's words had brought to her eyes. "Forgive me,
Adelaide. I want forgiveness, too, for I have judged you rather
hardly, I am afraid."
"No, you have not; I have never been kind, but I want to be
now." And two pairs of arms went out, and two girls' lips met
for the first time in mutual affection and forgiveness. Then
they sat down side by side, each encircling the other with one
embracing arm.
"We shall be friends as well as cousins for the future. Until

now, we have been neither," said Adelaide. "I wish you were
not going away, Joyce. If you will stay, I will try to make The
Chase more of a home to you than it has been. But how can
you, after what mamma said this morning? I think that
proposal about the dresses and your helping to alter ours was
too dreadful."
And the girl blushed with shame at the recollection.
"I should not have minded about working early and late if you
had wanted help and we had worked together," said Joyce. "If
any one here had been ill, I should have thought nothing too
much to do for them, night or day. Supposing that my uncle
had been poor, and had given me a home with his children, I
would have slaved for him and them most cheerfully, and
taken care that his kindness should have cost him nothing in
the end. But you are all rich, and every wish can be gratified;
and the thought of being sent to sew under the orders of
Russell was—"
"Hush, dear Joyce! I cannot bear it," interposed Adelaide, as

she laid her white hand on her cousin's lips. "That alone would
have driven you from us, and after what mamma said, you
cannot stay. Now you must show you have forgiven me by
taking this little birthday gift," and drawing a ring-case from
her pocket, Adelaide tried to place a beautiful ring on Joyce's
finger.
"Do not ask me, dear; I cannot take it," said Joyce.
"I bought it myself, and I have so large an allowance that it

cost me nothing; I wish it had. The having too much money
takes from us the joy of self-sacrifice."
"I cannot take it," repeated Joyce. "How would that diamond
look on the hand of a maid to little children? Besides, I have
rings that belonged to my mother, if I wished to wear any."
"You have not forgiven me," sighed Adelaide.
"Yes, and I will take a gift, too, and prize it. Spend ten
shillings on a little brooch in cut steel, and I will wear it, and
never part with it while I live. And give me your likeness; I
should like to have it, though I shall always picture your face
as it looks to-night."
"You shall have these trifles, Joyce, and I will keep this, no
matter how long, until you are willing to wear it." And
restoring the ring to its case she put it into her pocket. "Now
what else can I do for you?" she asked.
"My uncle breakfasts earlier than you and the rest do. I have
been used to pour out his coffee and join him at table. I think
he will miss me at first. Will you sometimes breakfast with
him?"
"How selfish I have been not to notice this, or care for his
loneliness! Rely on me, I will breakfast with him always,
unless by some special chance I have been up very late the
night before."
"I shall neither be missed nor wanted," said Joyce. "Indeed, I

begin to fear I shall soon be forgotten."
But she smiled as she said it, for she was glad to think that
the father and daughter would be brought together by her
own departure.
Then these two girls became more confidential, and Joyce

gave her cousin every particular respecting the work she had
undertaken, the manner in which she had obtained the
situation, and of the fact that Mrs. Caruth was sending her
own maid to accompany her on her journey to Springfield
Park.
"It seems quite amusing to think that one who is travelling

with such an object should be so attended, does it not?" asked
Joyce.
Adelaide looked thoughtful, then replied, "Mrs. Caruth must

think a great deal about you. Does she understand what you
are going to do?"
"I am not sure, but I do know she is my friend. She was

almost like a mother to me until I was about seventeen, and
when I had none of my own. Then—"
"Then what?"
"Her son came home for a time, and she had him, and I
became more of a companion to my father."
"I believe I have seen both Mrs. Caruth and her son. Does she
call him Alec?"
"Always. He is about thirty-two now. You see I was only nine

when he was twenty, and as the child of his old tutor, he made
a pet and playfellow of me. It seems strange that we should
both be grown-up people after a few years."
"He is very fond of his mother, and she of him," said Adelaide.
"Indeed, he seems a good, noble-minded man altogether.
Augusta thought there was no one like him during the eight
weeks we spent at Mentone."
A statement which did not appear to give unqualified

satisfaction to Joyce, for she paused a moment, then, in a
constrained voice, though with an attempt at archness, she
asked—
"Did Major Caruth think there was no one like Augusta?"
"He neither troubled himself about her nor any other girl. I
mean so far as paying special attention went. He was
everything that was kind and courteous, but the elder ladies
and the children absorbed the larger share of his time—
somewhat, I think, to the disgust of the grown-up girls. If
hazarded a guess, it would be that he had no heart left to
give, and that he was far too noble and true a man to pay
unmeaning attentions, which could lead to nothing but regrets
and pain for another. I suppose he has no sister, or he would
be a model 'brother of girls.'"
"No, but he is a brother of girls for all that. He would be to all

such, if circumstances called for his help, what the son of a
pure-minded, virtuous, Christian mother should be. I know
him so well."
Joyce's face was lighted up by a bright, glad look, born of

precious memories, but it faded as she said, "I am not likely
to meet Major Caruth again. I was Miss Mirlees, and a power
at Welton, as the parson's daughter in a country parish always
is, you know. Three days hence I shall be 'only a servant.'"
"Joyce, you must give up this plan of yours; I cannot bear to

think of it. My father cares for you; I want you at The Chase.
Augusta will come over to my side, for she is not nearly so
hard as she seems. We have both been carefully educated in
selfishness, and even a first step in the right direction costs a
great effort. But I can stir her to it, and we will make a
combined attack on my mother, who must give in. Say you
will stay."
"Not now, dear. But if ever the time should come when I can
be sure you all wish for me, or if I am needed by any, I will
return."
Adelaide was obliged to be satisfied with this. The girls parted
with expressions of affection and pledges of future friendship;
and Joyce laid her head on her pillow with a lighter heart than
she had done for months past.
Mr. Evans was expected home the evening before his niece
was to leave The Chase, but in place of him came a telegram
—
"Accident on line. Train delayed, but none injured. Expect me

at noon to-morrow."
Joyce was to leave the station at nine, so her uncle would not
arrive till after she was gone. Mrs. Evans declined to see her,
but sent word that when Joyce came to her senses, and was
prepared to submit and acknowledge she had done wrong,
she might write and say so.
Augusta, doubtless urged thereto by her sister, rose early

enough to say farewell to her cousin. Sarah Keene watched
her out of sight as well as she could through falling tears, and
prayed for a blessing on her head, and Adelaide, bravely
mounted beside Joyce in the shabby conveyance which took
her and her luggage to the station, whispered cheery words to
the very last moment, when, in company with Dobson, Mrs.
Caruth's staid waiting-woman, she started on her journey.
Moved still further by the new and better feelings just born in
her heart, Adelaide declined to drive with Mrs. Evans and
Augusta, and went instead to meet her father on his return at
noon.
It was a great surprise to Mr. Evans when he saw Adelaide's

beautiful face glowing with eager expectation, in search of
some traveller whose arrival she anticipated. He did not for a
moment associate her presence with his own home-coming,
until her eyes met his as the train stopped, and stepping
forward, she exclaimed—
"Papa, I am so glad you are here safe and sound!" And lifting
her face to his she kissed him lovingly again and again, then
slipping her arm through his, went with him to the carriage
which awaited them.
"That first kiss was poor Cousin Joyce's," she said. "She left it
for you, and I promised to deliver it."
"Joyce's! She is surely not gone? I thought you would all have
joined to keep her until my return. My only sister's only child
to leave The Chase in such haste!"
"She could not stay. I tried hard to persuade her, for, papa, I
am sorry I have not been kinder to Joyce. We are friends now,
dear friends, and I hope we shall always be so. I cannot blame
Joyce for going. How could she stay? But you do not know all
yet. I trust things will turn out better than they seem to
promise. I think I ought to tell you all about Joyce's birthday
and what was said, only you must promise to say nothing to
mamma. I cannot help thinking she is a little sorry now, and
she is more likely to feel regret about Joyce's going if no one
speaks of it."
Then Adelaide told her father all that had passed, and Mr.
Evans listened, not altogether sadly, for his daughter made
the most of all that had been bright for Joyce on her birthday
—the loving letters and souvenirs from Welton, Mrs. Caruth's
consideration for her cousin's safe convoy, the opening of
hearts between themselves, and the new-born friendship,
which was to bind them more closely than the ties of
relationship had done.
"And," continued Adelaide, "Joyce will never disgrace the

name she bears. I only wish I were more like her."
There was much to cheer Mr. Evans in what he heard from his
daughter, and acting upon her suggestion, he made no
allusion to Joyce's departure. His silence was both a relief and
a reproach to his wife, who expected a scene, and was
conscious that, in spite of her desire to free herself from a
sense of responsibility, she could not even excuse herself for
her treatment of Joyce.
On the following morning, when Mr. Evans went down,

expecting to take his breakfast in solitude, and feeling how
much he should miss Joyce's gentle ministry, he found
Adelaide already seated at the table. She rose as he entered
and lifted her face for a kiss.
"Now another, papa," she said. "That is for Joyce. You must
give me one every morning for her, as I am her deputy."
It was such a new thing for Mr. Evans to be greeted thus by

his own children, that he could hardly realize that he was
awake, but he showered many kisses on the fair, bright face
that waited for them.
"I did not expect to see you, my dear," he said.
"No, dear papa, but I must try to be a better daughter. I told

you yesterday that I was beginning to learn new lessons. If I
become what I wish to be, remember, Joyce was my first
teacher. When I asked what I could do for her, she told me
what I might do in a little way for you. But for her, I should
not be here; however, I will not leave you to a lonely meal
again."
And Adelaide kept her promise.
CHAPTER V.
JOYCE reached the station nearest to Springfield Park at three
o'clock, having had a change of trains, and a stoppage of an
hour and a half on the road. Mrs. Caruth's maid, returning
direct to Fernsclough, would rejoin her mistress before six.
Her train would not, however, start for twenty minutes, so she
was able to tell her mistress that she had seen Miss Mirlees in
charge of a grey-haired coachman, who, with two little girls,
awaited her arrival.
"Are you the young person for Springfield Park?" asked the
man.
Joyce replied in the affirmative.
"I am the coachman. The groom would have brought only a

trap, but the little ladies were wild to see their new maid, and
Mrs. Ross would only trust the children with me."
The man intended Joyce to understand that to drive any but

members of the family and their friends would be beneath the
dignity of so old a servant, and that the presence of the little
girls explained his own.
"No doubt Mrs. Ross feels that the children are safest with
you," said Joyce.
"Just so. She has had time to know what I am, for I drove her
when she was no bigger than the least of them, and I was in
her father's service. Now you step in next the eldest one—
Miss Mary. She should have been a boy by rights, but nobody
would like to change her for one now. Your things will be
brought by that lad, who has a trap close at hand. They are all
together, I suppose?"
Joyce pointed to her belongings on the platform, said farewell

to her escort, and sent messages of thanks and love to Mrs.
Caruth. Then she followed the coachman to a little carriage, in
which were seated two lovely children in the present charge of
the station-master's daughter.
"Come in," cried the elder child. "We wanted to see you, so
mamma let Price bring us. I am Mary, 'papa's Molly,' they call
me, and that is Alice. She turns her face away because she is
shy, but she will be friends soon. Mamma said we must be
very good and not make you sorry, because you have no
father and mother."
Tears sprang into Joyce's eyes, which the child noted instantly,
and her own face grew sorrowful.
"Why do you cry?" she said. "Let me kiss the tears away, as
mamma does mine, if I am only sorry, not naughty."
The winsome creature pulled Joyce's head down to her own

and smiled, until her new attendant was fain to smile in
response.
"There, that is right. Now look how pretty the park is, and see
the deer under the trees. They feed out of our hands, and
they will know you very soon, because you will be with us."
Joyce saw that her new surroundings would be even more

beautiful than her uncle's home, and she drank in with delight
the loveliness which met her eyes on every side, whilst Mary
prattled unceasingly till they reached the house. There she
was met by a pleasant, motherly person, who introduced
herself as Mrs. Powell, the housekeeper, and led her upstairs
to a good-sized cheerful room, very comfortably furnished,
and opening into a still larger one, in which were two little
beds. Both rooms again opened into the day nursery, a
delightful apartment, in which everything suggested the
personal superintendence of a thoughtful, loving mother.
The little girls had been taken charge of by Mrs. Ross's maid,
Paterson, and the housekeeper told Joyce that when she was
ready she was to come to her own room for refreshment.
"Here are your boxes in good time," said Mrs. Powell; and
thus Joyce was able to make the needed change in her dress.
She was about to go down, when, recollecting her new
position, she turned back for one of the aprons, ironed so
carefully by Sarah Keene's hands, and over which, as badges
of coming servitude for her darling, she had shed many a tear.
"Never mind," thought Joyce; "they are honourable badges, so

long as they accompany faithful performance of duty, work
done as in God's sight, and depending for its success on His
blessing."
So, with a bright face, the reflection of a brave heart, she

went down, after having occupied a few moments in thanking
God for a safe journey and a kind reception.
"I always have an early cup of tea," said Mrs. Powell, "and I
thought it would be the best for you, along with something
more substantial, after a journey. Your future meals will be
taken upstairs with the children. Mrs. Ross will see you in the
morning; but she and the master are away—only for the day;
they will be back to-night. My mistress trusted you to me, and
I promised to make you comfortable," said Mrs. Powell, with a
look of great kindness in her motherly face.
"It was very good of her to leave me in such hands," said

Joyce, with an answering smile. Then Mrs. Powell dropped her
voice to a whisper—
"Let me say a word about yourself, my dear. My mistress

trusts me, and she said—only to me, mind—that the friend
who wrote in answer to her inquiries had told her a little of
your history. How that you were a lady, used to be served
instead of serving others, and that if you chose to accept a
home with her, there was one open to you; but that you
preferred service to a life of dependence."
"What did Mrs. Ross say? I hope she did not think I wished to
deceive her in any way," said Joyce.
"No, indeed. She honours you for preferring work to

dependence, and says that if she finds you what she has been
led to expect, you, in turn, shall find a real home and true
friends at Springfield Park. There, my dear, I hope you will
sleep the sounder for knowing this; and if it will comfort you
to hear it, my heart warms to you, and you have one friend
already."
To Joyce this was like having her old friend Sarah Keene by
her side, and she thanked the kindly housekeeper most
heartily and gratefully for her encouraging words.
But the tea was being neglected, and Mrs. Powell turned
Joyce's attention in that direction; so, impelled by a healthy
girlish appetite, she made a hearty meal, much to her new
friend's satisfaction.
One hour after she spent with the children, of whom, however,
she was not to take formal charge until the morning. Then the
housekeeper, being at leisure, showed her through the house
and a portion of the gardens, and finally left her to indulge in
happier thoughts than she could have imagined would be
possible to her under her new circumstances.
Joyce rose early and dressed the children, the little one having
overcome her shyness, and being now willing to make friends.
She was sitting, telling them a baby-story, when Mrs. Ross
entered the nursery after breakfast, and greeted her with the
utmost kindness.
At the sight of their mother, the children rushed to her side,

and, clasped in her arms, forgot for the time their anxiety to
know the end of Joyce's fairy story.
How the girl sped at Springfield Park may be gathered from a
letter, written after three months' experience, to Sarah Keene.
Many shorter letters had been exchanged between Mr. Evans,
Adelaide, the old nurse, and Joyce; but she purposely
refrained from saying much about her position, until a
sufficient time had elapsed to allow her to form a fair
judgment as to the wisdom of the step she had taken.
MRS. ROSS SENT A NOTE A LITTLE LATER.
"
Springfield Park, Sept. 6th."
"After three months, dear old nurse and friend,
I can say that I am glad I came here. Every one
is good to me; the children are so sweet that it is
delightful to work for them; and I do work,
Sarah."
"I try to earn every penny, and I have proof

that Mrs. Ross is satisfied. Yesterday she told me
how glad she was that the children had learned to
love me, and that she was much pleased with my
mode of managing them. Then she gave me my
quarter's wages, and I found considerable
sweetness in receiving my first earnings. I was to
have seventeen pounds a year and all found; but
Mrs. Ross placed a five-pound note in my hand,
and would not receive any change."
"You must know I cannot occupy my time in

only dressing and attending to the children and
their clothes; the former are so docile, the latter
so handsome and abundant that they receive
little damage, and when at all shabby they are
given away; so I began to teach, and turned
everything I knew to account in order to benefit
my darling charges."
"Mrs. Ross found out what we were doing, and

said, 'You are teaching my children to love
information by leading them gently, and making it
attractive. How have you acquired such an
excellent method?'"
"'I taught in our Welton Sunday Schools,' I

said. 'My little scholars were the children of the
very poor; but I took more pains with them
because their learning time is short and their
opportunities are few. If my method has any
merit, it is owing to my dear father's example,
which I tried to copy.' My eyes filled. I could not
keep back my tears when I thought of him, and
of all I owed to his loving training."
"Mrs. Ross laid a gentle hand on my shoulder,

and said, 'Do not cry, Joyce. I feel deeply for you.
It must be hard to look back and think how things
were whilst he lived. I have heard so much of
your father's excellences, and how you were both
loved by rich and poor.'"
"'I am not unhappy,' I replied. 'Service here is

not servitude, and I am much better satisfied to
earn my bread than to owe it to the charity of
another.'"
"'You are right; but I should be wrong to accept

the faithful labours of a governess in return for a
nursemaid's salary. Henceforth you will receive
forty pounds a year, and, Miss Mirlees, I shall look
for you, with the children, in the drawing-room
daily, when we have no formal company and are
alone, or have only a few friends.'"
"I began to wonder if my old Welton frocks

would be good enough, but that evening a parcel
came to me, containing a dress-length of good
mourning silk, with all requisites for making it up.
Mrs. Ross sent a note a little later, to say that it
was a mark of the satisfaction felt by her husband
and herself at the improvement in their children."
"I can now wear my dear mother's watch and

ornaments without their seeming unsuitable, and
I shall once again find myself amongst people of

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First Aid for the Psychiatry Clerkship,

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Tips on what to know to IMPRESS

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Chapter 1: How to Succeed in the Psychiatry Clerkship 1

Chapter 2: Examination and Diagnosis 11

Chapter 3: Psychotic Disorders 21

Chapter 4: Mood Disorders 33

Chapter 5: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders 47

Chapter 6: Personality Disorders 63

Chapter 7: Substance-Related and Addictive Disorders 79

Chapter 8: Neurocognitive Disorders 97

Chapter 9: Geriatric Psychiatry 113

Chapter 10: Psychiatric Disorders in Children 121

Chapter 11: Dissociative Disorders 133

Chapter 12: Somatic Symptom and Factitious Disorders 139

Chapter 13: Impulse Control Disorders 145

Chapter 14: Eating Disorders 151

Chapter 15: Sleep-Wake Disorders 159

Chapter 16: Sexual Dysfunctions and Paraphilic Disorders 171

Chapter 17: Psychotherapies 179

Chapter 18: Psychopharmacology 189

Chapter 19: Forensic Psychiatry 209

How to Succeed in the

Why Spend Time on Psychiatry? 2 Keep Patient Information Handy 3

How to Behave on the Wards 2 Present Patient Information in an Organized Manner 3

Why Spend Time on Psychiatry?

Being aware of and understanding the features of mental dysfunction in psy-

Psychotropic medications are frequently prescribed in the general popula-

Because of the unique opportunity to spend a great deal of time interacting

How to Behave on the Wards

Always maintain professionalism and show the patients respect. Be respectful

■■ Regardless of your interest in psychiatry, take the rotation seriously.

Be enthusiastic and self-motivated. Volunteer to help with a procedure or a

Use a clipboard, notebook, or index cards to keep patient information, includ-

Here is a template for the “bullet” presentation:

“This is a [age]-year-old [gender] with a history of [major history such

The newly admitted patient generally deserves a longer presentation following

How to Prepare for the Clerkship (Shelf ) Exam

Other helpful studying strategies include:

STUDY WITH FRIENDS

STUDY IN A BRIGHT ROOM

Mental Status Exam

Appearance/Behavior: apparent age, attitude and cooperativeness, eye

Speech: rate, rhythm, volume, tone, articulation

Mood: patient’s subjective emotional state—depressed, anxious, sad,

Affect: objective emotional expression—euthymic, dysphoric, euphoric,

Thought process: logical/linear, circumstantial, tangential, flight of

Thought content: suicidal/homicidal ideation, delusions, preoccupa-

(hypnagogic hallucination) or upon awakening (hypnopompic hal