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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
Copyright © 2016 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be
reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
ISBN: 978-0-07-184175-7
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Notice
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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.
24 Chapter 3 PSYCHOTIC DISORDERS
Schizophrenia is a psychiatric disorder characterized by a constellation of

abnormalities in thinking, emotion, and behavior. There is no single symp-
tom that is pathognomonic, and there is a heterogeneous clinical presenta-
tion. Schizophrenia is typically chronic, with significant psychosocial and
medical consequences to the patient.
P O S I T I V E, N E GAT I V E, A N D C O G N I T I V E S Y M P T O M S
In general, the symptoms of schizophrenia are broken up into three

categories:
KEY FACT
■■ Positive symptoms: Hallucinations, delusions, bizarre behavior, disorganized
Think of positive symptoms as things speech. These tend to respond more robustly to antipsychotic medications.
that are ADDED onto normal behavior. ■■ Negative symptoms: Flat or blunted affect, anhedonia, apathy, alogia, and
Think of negative symptoms as things lack of interest in socialization. These symptoms are comparatively more
that are SUBTRACTED or missing from often treatment resistant and contribute significantly to the social isolation
normal behavior. of schizophrenic patients.
■■ Cognitive symptoms: Impairments in attention, executive function,
and working memory. These symptoms may → poor work and school
performance.
WARDS TIP
THR E E P HA S E S
Stereotyped movement, bizarre
posturing, and muscle rigidity
Symptoms of schizophrenia often present in three phases:
are examples of catatonia seen in
schizophrenic patients. 1. Prodromal: Decline in functioning that precedes the first psychotic episode.
The patient may become socially withdrawn and irritable. He or she may
have physical complaints, declining school/work performance, and/or new-
found interest in religion or the occult.
2. Psychotic: Perceptual disturbances, delusions, and disordered thought
process/content.
3. Residual: Occurs following an episode of active psychosis. It is marked by
mild hallucinations or delusions, social withdrawal, and negative symptoms.
KEY FACT
D I AG N O S I S O F S CH I Z O P HR E N I A
Clozapine is typically considered
for treating schizophrenia when a DSM-5 Criteria
patient fails both typical and other
■■ Two or more of the following must be present for at least 1 month:
atypical antipsychotics; this is due
1. Delusions
to the potential rare adverse event,
2. Hallucinations
agranulocytosis, which requires patients
3. Disorganized speech
be monitored (WBC and ANC counts)
4. Grossly disorganized or catatonic behavior
regularly.
5. Negative symptoms
Note: At least one must be 1, 2, or 3.
■■ Must cause significant social, occupational, or self-care functional
deterioration.
WARDS TIP ■■ Duration of illness for at least 6 months (including prodromal or residual
periods in which the above full criteria may not be met).
The 5 A’s of schizophrenia (negative ■■ Symptoms not due to effects of a substance or another medical condition.
symptoms):
1. Anhedonia
2. Affect (flat) Mr. Torres is a 21-year-old man who is brought to the ER by his
3. Alogia (poverty of speech) mother after he began talking about “aliens” who were trying to steal
4. Avolition (apathy) his soul. Mr. Torres reports that aliens left messages for him by arrang-
5. Attention (poor) ing sticks outside his home and sometimes send thoughts into his mind.
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"Yes," said Dorothy, a curious mixture of satisfaction and glumness in her
tones; "she did, with her own lips. I didn't say a word, and Lewis wasn't there;
he was talking with Deacon Spalding, just behind us; and John didn't speak, of
course, till he spoke to him."
"Well, I never!" said Mrs. Morgan; then, after a somewhat lengthy pause,
"Seems to me she is taking things into her own hands most amazing fast:
nothing but a stranger herself, and gone to inviting company! Without even
waiting to see if it would be convenient, either! There's extra work, too. I
suppose, though, she thinks she can sit in the front room and entertain him,
and we can do the work."
"I s'pose she is so used to company that she don't think anything about it, and
doesn't know that other folks do. It isn't a dreadful thing to have the minister
come to tea; for my part, I'm glad he is coming."
After this sudden marvellous outburst from Dorothy, her mother turned and
surveyed her again, in bewildered fashion. Who had ever before heard
Dorothy express an outright opinion contrary to her mother's? While she was
meditating how to treat this strange development, the hall door opened, and
Louise, broom and dust-pan in hand, a quaint little sweeping-cap set on her
head, appeared on the scene. She dashed into the subject in mind at once:—
"Mother, has Dorothy mentioned that Mr. Butler is coming to tea? We didn't
think about the extra ironing or we might have chosen some other night.—
Why didn't you remind me, Dorrie?—You must let me do all the extra work, to
pay for my carelessness. I have come down now to put the front room in
order; or shall I help in the kitchen first?"
What was a woman to do who had managed her own household with a high
hand for more than thirty years, thus unceremoniously taken by storm? She
turned her gaze from Dorothy to Louise, and stood regarding her for a second,
as if in no doubt what to say; then, with a bitterness of tone that Louise did not
in the least understand, said—
"Do just exactly what you please; which I guess is what you are in the habit of
doing, without asking permission."
Then she dashed into the outer kitchen, and set up such a clatter with the pots
and kettles there that she surely could not have overheard a word had many
been said.
Louise, with honest heart, desiring to do what was right, was by no means
infallible, and yet was quick-witted she discovered that she had blundered. It
flashed before her that Mother Morgan thought she was trying to rule the
household and reorganize the home society—trying, indeed, to put her, the
mother, aside. Nothing had been further from her thoughts. She stood
transfixed for a moment, the rich blood rolling in waves over her fair face at
thought of this rude repulse of her cheery effort to play that she was at home
and act accordingly. It was as Dorothy said: she was so accustomed to the
familiar sentence, "Come in and take tea," that it fell from her lips as a matter
of course; especially had she been one of those trained to a cordial heartiness
as regarded her pastor. Her invitation to Mr. Butler had been unpremeditated,
and, she now believed, unwise. Yet how strange a sense of loneliness and
actual homesickness swept over her as she realized this. How difficult it was
to step at all! How she must guard her words and her ways; how sure she
might be of giving offence when nothing in her past experience could
foreshadow such an idea to her! Was it possible that in her husband's home
she was not to feel free to extend hospitalities when and where she chose?
Could she ever hope to grow accustomed to such a trammelled life? She
stood still in the spot where her mother-in-law had transfixed her—the dust-
pan balanced nicely, that none of its contents might escape; the broom being
swayed back and forth slowly by a hand that trembled a little; the fair, pink-
trimmed cambric sweeping-cap, that was so becoming to her, and so useful in
shielding her hair from dust, heightening now the flush on her face. If she had
but known it, in the new mother's eyes that sweeping-cap was one of her
many sins.
"The idea of prinking up in a frilled cap to sweep!" had that lady exclaimed, the
first time she saw it, and she drove the coarse comb through her thin gray hair
as she spoke, regardless of the fact that much dust had settled in it from that
very morning's sweeping.
"It keeps her hair clean, I'm sure," had Dorothy interposed; "and you are
always for keeping things most dreadfully clean."
"Clean!" had the mother exclaimed, vexed again, at she hardly knew what; "so
will a good washing in soap and water, and look less ridiculous besides. What
do you catch me up in that way for whenever I say anything? Attend to the
dishes, and don't waste your time talking about hair; and if you ever stick such
a prinked-up thing on your head as that, I'll box your ears."
What could there have been in the little pink cap to have driven the mother
into such a state? She rarely indulged in loud-voiced sentences. It was
unfortunate for Louise that this episode had occurred but a short time before;
and it was fortunate for her that she did not and could not guess what the
innocent cap, made by Estelle's deft fingers, had to do with Mrs. Morgan's
state of mind. Had she known that such a very trifle had power over the new
mother's nerves, it might have appalled her. We grieve sometimes that we
cannot know other people's hearts, and foresee what would please and what
would irritate. Sometimes in our blindness we feel as if that certainly would
have been the wiser way; yet I doubt if Louise's courage would not have
utterly forsaken her could she have seen the heart of her husband's mother as
she rattled the pots and kettles in the outer kitchen. Hearts calm down
wonderfully sometimes; what need then to know of their depths while at
boiling-point? But what sights must the all-seeing God look down upon—
sights, in tenderness, shut away from the gaze of his weak children.
Poor Louise! It was such a little thing, and she felt so ashamed for allowing
herself to be ruffled. Several states of feeling seemed knocking for
admittance. She almost wished that she could go to that outer kitchen and
slam the door after her, and set the dust-pan down hard before the cross lady,
and say to her,—
"There! take your broom and your dust-pan, and do your own sweeping up in
John's room after this, and let Lewis and me go home to mother. You are not a
mother at all; the name does not fit you. I know what the word means; I have
had a mother all my life, and I begin to think Lewis has never had."
What if she should say something like that? What a commotion she could
make! It was not that she had the least idea of saying it; it was simply that she
felt, "What if I should?"—Satan's earliest and most specious form, oftentimes,
of presenting a temptation. Also, there was that unaccountable tendency to a
burst of tears; she felt as though she could hardly keep them back, even with
Dorothy's gray eyes looking keenly at her. Just a little minute served for all
these states of feeling to surge by; then Dorothy broke the silence, roused out
of her timidity by a struggling sense of injustice.
"You mustn't mind what mother says; she speaks out sometimes sharp.
Anybody who didn't know her would think she was angry, but she isn't; it is just
her way. She isn't used to company either, and it kind of flurries her; but she
will be real glad to have had Mr. Butler here after it is all over."
Such a sudden rush of feeling as came to Louise, borne on the current of

these words—words which she knew cost Dorothy an effort, for she had been
with her long enough, and watched her closely enough, to realize what a
painful hold timidity had gotten on her. But these eager, swiftly-spoken words,
so unlike her usual hesitation, evinced a kindly tenderness of feeling for
Louise herself that the lonely young wife reached after and treasured
gratefully. The tears rolled down her cheeks, it is true—they had gotten too
near the surface to control, and were determined for once to have their way;
but she looked through them with a smile at Dorothy, nay, she set down her
dust-pan suddenly and dropped her broom, and went over to the astonished
girl and kissed her heartily.
"Thank you," she said brightly, "you good sister Dorrie; you have helped me
ever so much. Of course mother doesn't mean to scold me; and if she did,
mothers are privileged, and should be loved so much that little scoldings can
be taken gratefully, especially when they are deserved, as mine is. I ought to
have asked her whether it would be convenient to have company. But never
mind; we'll make the best of it, and have a good time all round. And, Dorothy,
let us be real true sisters, and help each other, and lore each other. I miss my
sister Estelle."
It was the last word she dared trust herself to speak; those treacherous tears
desired again to choke her. She turned abruptly from Dorothy and ran
upstairs, leaving the dust-pan a central ornament of the kitchen floor. Hidden
in the privacy of her own room, the door locked on the world below, Louise sat
down in the little home-rocker and did what would have thoroughly alarmed
her own mother because of its unusualness—buried her head in her hands
and let the tears have their way.
She had managed to control herself before Dorothy, to smile brightly on her,
and to feel a thrill of joy over the thought that she had touched that young
person's heart. But all this did not keep her from being thoroughly roused and
indignant toward her mother-in-law. What right had she to treat her as though
she were an interloper? Was not she the wife of the eldest son, who toiled
early and late, bearing burdens at least equal to, if not greater than, his
father? "What that woman needs," said a strong, decided voice in her ear, "is
to realize that there are other people in this world beside herself. She has
been a tyrant all her life. She manages everybody; she thinks she can
manage you. It is for her good as well as your own that you undeceive her.
You owe it to your self-respect to go directly down to that outer kitchen, where
she is banging the kettles around, and say to her that you must have an
understanding. Are you one of the family, with rights, as a married daughter, to
invite and receive guests as suits your pleasure, or are you a boarder simply?
—in which case you are entirely willing to pay for the trouble which your
guests may make."
Every nerve in Louise's body seemed to be throbbing with the desire to help
her carry out this advice. It was not merely the sting of the morning, but an
accumulation of stings which she felt had been gathering ever since she came
into the house. But who was the bold adviser? It startled this young woman
not a little to realize that her heart was wonderfully in accord with his
suggestions. As usual, there was war between him and another unseen force.
Said that other,—
"It is a trying position, to be sure. You have many little things to bear, and it is
quite probable, your life having been so shielded heretofore, that they seem to
you great trials. But, you will remember, I never promised you should not be
tried; I only pledged myself that your strength should be equal to your day.
And, really, there has no temptation taken you but such as is common to men.
And I am faithful: I will not suffer you to be tempted above that ye are able."
Surely she knew this voice, and recognized this message sent to her so long
ago, and proved true to her experience so many times.
"But," said that other one, "you really are not called upon to endure insults. It
is a perfectly absurd position. If you had gone out as a home missionary, or
were among uncouth people who had had no advantages, and to whom you
were not in any sense related, it would do to talk of bearing trials; but in this
case what right have your husband's family to put trials of this sort upon you?
You have a perfect right to please yourself, and they ought to know it."
"Yes," said that other voice, "there are undoubtedly some things that they
ought to know; but then 'even Christ pleased not himself.'"
"But it is so absurd! She is evidently vexed because you have invited her own
pastor to take tea with her—the most natural and reasonable thing in the
world. She ought to want him to come. The idea of having trouble over such a
trifle as that!"
"Yes; but, after all, are there not two sides to even that? How did you know but
it would be extremely inconvenient for your new mother to see her pastor just
at the time you set?"
"I never thought of such a thing. In our house it was always convenient to see
people."
"Why not tell her that you didn't think of it, omitting the reference to the
different conditions of your own home? Because, you know, you never like to
have people suggest uncomplimentary comparisons to you; therefore, by the
rule which you profess to have accepted, you must not hint them to others."
"But," said that other one, "it is an unnecessary humiliation for you to go to her
and apologize, as though you had done something wrong. The idea! You
should certainly have some regard to your position. Because you came here
full of schemes for usefulness, eager to do her good, is no reason why you
should tamely submit to such treatment as this—least of all, offer an apology
for what you had no idea would be disagreeable; besides, you almost
apologized, and how did she receive it?"
Then that other voice,—
"Remember the word that I said unto you—'The servant is not greater than his
lord.'"
And straightway there surged over Louise Morgan's soul such a sense of
"remembrance" of that other's patience, and meekness, and forgiveness, and
humiliation, such a remembrance of his thirty years of sorrowful cross-bearing
for her, that there surely was verified to her another of the promises: "He shall
bring all things to your remembrance." Moreover, her eyes being opened by
the searching Spirit, she saw who that counsellor was, with his suggestion of
self-respect and wounded dignity and position—always at variance with that
other one, always directly contradicting, always eagerly putting "self" between
Christ and his work. The tears came down in showers; but they were shed in a
lowly attitude, for this troubled young soul sank on her knees.
"O Christ," she said, "thou didst conquer him years ago. He desires to have
me; but, thou mighty One, bid him leave me, for thou art pledged that thou wilt
with the temptation provide a way of escape. And now, dear Christ, help me to
show such a spirit of meekness and unfaltering cheerfulness of spirit before
Lewis's mother that she shall be led, not to me, but to thyself."
It was a very peaceful face which presented itself in the kitchen not many
moments thereafter, and the voice that spoke seemed to Dorothy, who looked
on and listened, the very essence of the morning sunshine.
"Mother, it was certainly very careless in me to invite anybody to tea without

first learning whether it would be convenient for you. If you will forgive me this
time I won't do it a 'bit more.' That is what my little sister says when she gets
into trouble. Now, I want to know if you will let me hang some of my pictures in
the parlour; I've been unpacking them, and I don't know what to do with half of
them."
"Of course," said Mother Morgan. "Fix the parlour as you want it. It never was
called a parlour before in its life; but I daresay that is as good a name as any.
The extra ironing is no consequence anyhow; we always have enough to eat.
He might as well come to-day as any time, for all I know."
Then she dashed out at that end door again, and set the outer kitchen door
open, and stood in it looking off toward the snowy hills. Nobody over
apologized to her before; it gave her a queer feeling.
"Well," said Dorothy, addressing the dust-pan after Louise had vanished
again, "I never could have said that in the world. After what mother said to her
too. I don't care; I like her first-rate. There now."
CHAPTER XII.
DIFFERENT SHADES.
THAT front room was square and bare; at least that last word expresses the
impression which it made upon Louise as she stood surveying it. There were
several things that she felt sure she could do to brighten it, but the question
turned on expediency. How much would it be wise to undertake?
It is a curious fact that the people who, from choice or necessity, have
contented themselves with paper window-shades, have also been the people
fated to choose for these ungainly creations colours that would fight with the
shades of carpet and wall-paper. Those in the Morgan household were the
ugliest of their kind, and the initiated know that is saying a great deal. The
ground-work was blue. Who ever saw a tint of blue that would harmonize with
a cheap ingrain carpet? They were embellished by corner pieces, done in
dingy brown, with streaks of red here and there; the design looking like
nothing with sufficient distinctness to be named—the whole being grotesque;
while in the centre was a bouquet of flowers so ugly that it was a positive relief
to remember that nature never produced anything in the least like them. An
old-fashioned piece of furniture, known as a settle, suggested possibilities of
comfort if it had not been pushed into the coldest corner of the room and been
disfigured by a frayed binding and a broken spring. The chairs, of course,
were straight-backed and stiff; and set in solemn rows. But the table, with its
curious clawed legs and antique shape, filled Louise's heart with delight.
"What a pity," she said aloud, "that they couldn't have put some of the grace
into the old-fashioned chairs which they lavished on those delightful old
tables! How that bit of artistic twisting would delight Estelle's heart!"
This deliberate survey of her present field of operations was being taken after
the sweeping and dusting were over, and she was trying to settle the
momentous question of "What next?"
The door leading into the kitchen was swung open, and Mother Morgan
presented herself in the doorway, her arms still in their favourite reflective
attitude, holding to her sides.
"The curtains do look scandalous," she said, her eyes lighting on them at
once. "I've been going, for I don't know how long, to get new ones, but I never
seem to get at such things. I declare I didn't know they was so cracked."
Instantly Louise's wits sprang to grasp this opportunity. Who could have
expected such an opening in accord with her present thoughts?
"Oh, I hope you won't get new ones. I have a set of curtains that my mother
gave me for my room, so I might have a reminder of home, and they are
altogether too long for my windows; but I think they will just fit here. I should
so like to see them in use. May I put them up?"
What was the mother to say? She possessed that unfortunate sort of pride
which is always hurt with the suggestion of using other people's things. Yet
she had herself opened the door to this very suggestion. How was she to
close it?
"Oh, it isn't necessary to bring your curtains down here. I mean to get new
ones, of course. I've just neglected it, that's all; there's been no need for it."
"I'm so glad then that you have neglected it," Louise said quickly. "It has made
me feel sort of lonely to see those curtains lying idle in my trunk. I wanted to
put them somewhere. How fortunate it is that they are just the right colour to
match nicely with the carpet. You are really good to let me have them up
here."
Whereupon Mrs. Morgan, with a vague feeling that she had been "good"
without in the least intending it, kept silence.
Louise gave her little chance for reflection.
"You can't think how much I like that sofa. Wouldn't it be nice if they made
such shaped ones nowadays, so long and wide? It suggests rest to me right
away. I can't think of anything more comfortable than this corner when the fire
is made, with that nice, hospitable sofa wheeled into it."
This sentence brought Dorothy from the kitchen, to gaze, with wide-eyed
wonder, first at the lounge and then at the speaker. The object of her
intensified hatred, for many a day, had been that old, widespread, claw-footed
settle. Not being accustomed to seeing such an article of furniture anywhere
else, and being keenly alive to the difference between her home and that of
the few other homes into which she had occasionally penetrated, she had,
unconsciously to herself, singled out the old lounge and the old table, and
concentrated her aversion to the whole upon them.
There was something about Louise that gave to all she said the stamp of
sincerity. Dorothy found herself believing implicitly just what had been said;
therefore this surprising eulogy of the old settle was the more bewildering.
Louise's next sentence completed the mystification.
"But the prettiest thing in this room is that table. I never saw anything like that
before; it must be very old, isn't it? And it looks like solid mahogany."
There was no resisting the impulse. Mother Morgan's heart swelled with a
sense of gratified pride (if it were not a nobler feeling than pride).
"It is solid," she said quickly, "every inch of it; it belonged to my mother; it was
one of her wedding presents from my grandfather. There isn't another table in
the country as old as this."
"Isn't that delightful?" said Louise, genuine eagerness in tone and manner. "To
think of your having one of your own mother's wedding presents! My sister
Estelle would like to see that; she has such a wonderful feeling of reverence
for old things, especially when she can hear about the hands that have
touched them long ago. Did your mother die a good many years ago?"
"She died when I was a girl like Dorothy there," said Mrs. Morgan, her voice
subdued, and she gathered a corner of her large apron and carried it to her
eyes.
"I always set great store by that table. I've seen my mother rub it with an old
silk handkerchief by the half-hour, to make it shine. She thought a great deal
of it on grandfather's account, let alone its value, and it was thought to be a
very valuable table in those days. I have always thought I would keep it for
Dorothy. But she don't care for it; she thinks it is a horrid, old-fashioned thing.
She would have it put into the barn-loft, along with the spinning-wheel, if she
could. Your sister must be different from other girls, if she can stand anything
old."
Poor Dorothy, her cheeks aflame, stood with downcast eyes; too honest was
she to deny that she had hated the claw-footed table as one of the evidences
of the life to which she was shut up, different from others. Louise turned
toward her with a kindly smile.
"I think Estelle is different from most girls," she said gently. "Our grandmother
lived until a short time ago, and we loved her very clearly, and that made
Estelle like every old-fashioned thing more than she would. Mother says that
most girls have to get old and gray-haired before they prize their girlhood or
know what is valuable."
"That is true enough," said Mother Morgan emphatically.
Then Louise—
"I wonder if I can find John anywhere? I want him to help me to hang pictures
and curtains. Do you suppose father can spare him a little while?"
"John!" said the wondering mother. "Do you want his help? Why, yes, father
will spare him, I daresay, if he will do anything; but I don't suppose he will."
"Oh yes," said Louise gaily, "he promised to help me; and besides, he invited
the minister here himself, or at least seconded the invitation heartily, so of
course he will have to help to get ready for him."
"Well, there he is now, in the shed. You get him to help if you can; I'll risk his
father. And move things about where you would like to have them; I give this
room into your hands. If you can make it look as pleasant as the kitchen, I'll
wonder at it. It was always a dreadful dull-looking room, somehow."
And the mollified mother went her way. An apology was a soothing sort of
thing. It was very nice to have the long-despised old settle and table (dear to
her by a hundred associations, so dear that she would have felt it a weakness
to own it) not only tolerated but actually admired with bright eyes and eager
voice; but to engage, in any enterprise whatever, her youngest son, so that
there might be hope of his staying at home with the family the whole of
Tuesday evening—an evening when, by reason of the meeting of a certain
club in the village, he was more than at any other time exposed to temptation
and danger—was a thought to take deep root in this mother-heart. She did not
choose to let anybody know of her anxiety concerning this boy; but really and
truly it was the sore ache in her heart, and the thinking of the brightness of
Louise's care-free face in contrast with her own heavy-heartedness, that
developed the miseries of the morning. After all, to our limited sight, it would
seem well, once in a while, to have peeps into each other's hearts.
Greatly to his mother's surprise, and somewhat to his own, John strode at first
call into the front room, albeit he muttered as he went: "I don't know anything
about her gimcracks; why don't she call Lewis?"
"Are you good at driving nails?" Louise greeted him with; "Because Lewis isn't.
He nearly always drives one crooked."
"Humph!" said John disdainfully. "Yes, I can drive a nail as straight as any of
'em; and I haven't been to college either."
"Neither have I," said Louise, accepting his sentence in the spirit of banter;
"and I can drive nails, too. If I were only a little taller I'd show you. But how are
we going to reach away up to the ceiling? Is there a step-ladder anywhere?"
"Yes; make one out of the kitchen table and the wood-box."
And he went for them. Then the work went on steadily. John could not only
drive nails, but could measure distances with his eye almost as accurately as
with a rule, and could tell to the fraction of an inch whether the picture hung
"plum" or not. Louise, watching, noted these things, and freely commented
upon them, until, despite himself, John's habitual gruffness toned down.
"Who is this?" he asked, and he, perched on his table and wood-box, stopped
to look at the life-size photograph of a beautiful girl.
"That," said Louise, pride and pleasure in her voice, "is my sister Estelle; isn't
she pretty? With the first breath of spring I want her to come out here; and I
want you to get ready to be real good to her, and show her all the interesting
things in field and wood."
"I!"
"Yes, you. I look forward to your being excellent friends. There are a hundred
delightful things about nature and animal life of which she knows nothing, and
she is eager to see and hear and learn. I look to you for help."
At this astounding appeal for "help" John turned and hung the picture without
a word. What was there to say to one who actually expected help from him for
that radiant creature!
Louise, apparently busy in untangling cord and arranging tassels, watched

him furtively. He studied the picture after it was in place; he had difficulty in
getting it to just the right height, and tied and untied the crimson cord more
than once in his precision. The bright, beautiful, girlish figure, full of a
nameless witchery and grace that shone out at you from every curve! She
hardly knew how much she wished for the influence of the one over the other.
If Estelle could help, would help him in a hundred ways, as she could; and if
he would help her! Yes, Louise was honest; she saw ways in which this
solemn-faced boy could help her gay young sister, if he only would.
"Oh!" she said to herself, with great intensity of feeling, "if people only would
influence each other just as much as they could, and just as high as they
could, what a wonderful thing this living would be!"
It was for this reason among others that she had selected from her family
group, hanging in her room, this beautiful young sister, and sacrificed her to
hang between the windows in the front room. There were other pictures, many
of them selected with studied care, with an eye to their influence. Among
others, there was a brilliant illuminated text worked in blues and browns, and
the words were such as are rarely found in mottoes. In the centre was a great
gilt-edged Bible, and circling over it: "These are written that ye might believe
on the Son of God." Then underneath, in smaller letters: "And that believing,
ye might have life through his name."
"That is Estelle's work," his companion said. "Isn't it pretty?"
"I suppose so. I don't know anything about pretty things."
"Oh yes you do; you know perfectly well what you think is pretty. I venture to
say that you know what you like, and what you dislike, as well as any person
in this world."
He laughed, not ill pleased at this; and Louise, with no apparent connection,
branched into another subject.
"By the way, where is that church social that was announced for Friday night?
Far-away?"
"No; just on the other hill from us, about a mile, or a trifle more."
"Then we can walk, can't we? I'm a good walker, and if the evening is
moonlight, I should think it would be the most pleasant way of going."
And now John nearly lost his balance on the wood-box, because of the
suddenness with which he turned to bestow his astonished gaze on her.
"We never go," he said at last.
"Why not?"
"Well," with a short laugh, "that question might be hard to answer. I don't, I
suppose, because I don't want to."
"Why don't you want to? Aren't they pleasant gatherings?"
"Never went to see. I grew away from them before I was old enough to go.
Mother and father don't believe in them, among other things."
There was a suspicion of a sneer in his voice now. Louise was a persistent
questioner.
"Why don't they believe in them?"
"Various reasons. They dress, and mother doesn't believe in dressing. She
believes women ought to wear linsey-woolsey uniform the year round. And
they dance, and neither mother nor father believe in that; they think it is the
unpardonable sin mentioned in the Bible."
"Do they dance at the church socials?"
"Yes," an unmistakable sneer in his tones now, "I believe they do; we hear so
anyhow. You will look upon the institution with holy horror after this, I
suppose?"
"Does Mr. Butler dance?"
"Well, reports are contradictory. Some say he hops around with the little girls
before the older ones get there, and some have it that he only looks on and
admires. I don't know which list of sinners he is in, I'm sure. Do you think
dancing is wicked?"
"I think that picture is crooked," said Louise promptly; "isn't it? Doesn't it want
to be moved a trifle to the right? That is a special favourite of mine. Don't you
know the face? Longfellow's 'Evangeline.' Lewis don't like the picture nor the
poem; but I can't get away from my girlhood liking for both. Don't you know the
poem? I'll read it to you some time and see if you don't agree with me. Now,
about that social: let's go next Friday, and see if we can't have a good time—
you and Lewis, and Dorothy and I. It is quite time you introduced me to some
of your people, I think."
"You don't answer my question."
"What about? Oh, the dancing? Well, the truth is, though a short question, it
takes a very long answer, and it is so involved with other questions and
answers that I'm afraid if we should dip into it we shouldn't get the curtains
hung by tea-time. Let me just take a privilege and ask you a question. Do you
expect me to believe in it?"
"No."
"Why not?"
"Because—well—because you religionists are not apt to."
"Don't you know any religionists who seem to?"
"Yes; but they are the counterfeit sort."
"Then you think real, honest Christians ought not to believe in dancing?"
"I didn't say any such thing," returned John hotly; then, being quick-witted, he
realized his position, and despite his attempt not to, laughed. "I think we had
better go after those curtains now," he said, significantly. And they went.
CHAPTER XIII.
BUDS OF PROMISE.
"WELL," said Dorothy, and she folded her arms and looked up and down the
large room, a sense of great astonishment struggling with one of keen
satisfaction on her face, "who ever thought that she could make this look like
this!"
Which mixed and doubtful sentence indicates the bewilderment in Dorothy's

mind. Yet there had been no wonderful thing done. But Dorothy belonged to
that class of people who do not see what effects little changes might produce.
Still, she belonged, let us be thankful, to that class of people who can see
effects when the changes have been produced. There are not a few in this
world who are as blind as bats about this latter matter.
The place in question was the large square front room of the Morgan family.
The heavy crimson curtains, of rare pattern and graceful finish, hung in rich
waves about the old-fashioned windows, falling to the very floor, and hiding
many a defect in their ample folds. The walls were hung with pictures and
brackets and text-cards. The brackets were furnished—one with a pretty
antique vase, hiding within itself a small bottle of prepared earth, which
nourished a thrifty ivy. One held a quaint old picture of Dorothy's mother's
mother, for which Louise's deft fingers had that morning fashioned a frame of
pressed leaves and ferns. The old-fashioned settee was drawn into exactly
the right angle between the fire and the windows. The torn braid had been
mended, and John, of his own will, had repaired the broken spring.
The heavy mahogany table rejoiced in a wealth of beautifully bound and most
attractive-looking books; while a little stand, brought from Louise's own room,
held a pot of budding and blossoming pinks, whose old-fashioned spicy breath
pervaded the room. Perhaps no one little thing contributed to the holiday air
which the room had taken on more than did the tidies of bright wools and clear
white, over which Estelle had wondered when they were being packed, Louise
thought of her and smiled, and wished she could have had a glimpse of them
as they adorned the two rounding pillow-like ends of the sofa, hung in graceful
folds from the small table that held the blossoming pinks, adorned the back
and cushioned seat and arms of the wooden rocking-chair in the fireplace
corner, and even lay smooth and white over the back of Father Morgan's old
chair, which Louise had begged for the other chimney-corner, and which Mrs.
Morgan, with a mixture of indifference and dimly-veiled pride, had allowed to
be taken thither.
Little things were these, every one, yet what a transformation they made to
Dorothy's eyes. The crowning beauty of the scene to Louise was the great
old-fashioned artistic-looking pile of hickory logs which John built up
scientifically in the chimney-corner, the blaze of which, when set on fire,
glowed and sparked and danced, and burnished with a weird flame every
picture and book, and played at light and shade among the heavy window
drapery in a way that was absolutely bewitching to the eyes of the new-comer.
"What a delightful room this is!" she said, standing with clasped hands and
radiant face, gazing with genuine satisfaction upon it when the fire was
lighted. "How I wish my mother could see that fire! She likes wood fires so
much, and she has had to depend on 'black holes in the floor' for so long a
time. I do think I never was in a more home-like spot."
It was fortunate for Louise that her education had been of that genuine kind
which discovers beauty in the rare blending of lights and shades and the
tasteful assimilation of furnishings, rather than in the richness of the carpet or
the cost of the furniture. It was genuine admiration which lighted her face. The
room had taken on a touch of home and home cheer. Mrs. Morgan, senior,
eying her closely, on the alert for shams, felt instinctively that none were veiled
behind those satisfied eyes, and thought more highly of her daughter-in-law
than she had before.
As for Dorothy, she was so sure that the fairies had been there and bewitched
the great dreary room that she yielded to the spell, nothing doubting.
It seemed almost strange to Louise herself that she was so deeply interested
in this prospective visit from the minister. She found herself planning eagerly
for the evening, wondering whether she could draw John into the
conversation, whether Dorothy would rally from her shyness sufficiently to
make a remark; wondering whether the bright-eyed young minister would
second her efforts for these two. During a bit of confidential chat which she
had with her husband at noon, she said,—
"I can't help feeling that there are serious interests at stake. Mr. Butler must
get hold of the hearts of these young people; there must be outside influences
to help us or we cannot accomplish much. I wonder if he has his young people
very much at heart?"
"I may misjudge the man," Lewis said, leisurely buttoning his collar and
speaking in an indifferent tone; "but I fancy he hasn't a very deep interest in
anything outside of having a really good comfortable time."
"O Lewis!" and his wife's note of dismay caused Lewis to turn from the mirror
and look at her inquiringly. "How can you think that of your pastor? How can
you pray for him when you are composedly saying such things?"
"Why," Lewis said, smiling a little, "I didn't say anything very dreadful, did I,
dear? He really doesn't impress me as being thoroughly in earnest. I didn't
mean, of course, that he is a hypocrite. I think him a good, honest-hearted
young man; but he hasn't that degree of earnestness that one expects in a
minister."
"What degree of earnestness should a minister have, Lewis?"
"More than he has," said her husband positively. "My dear wife, really you
have a mistaken sort of idea that because a man is a minister therefore he is
perfect. Don't you think they are men of like passions with ourselves?"
"Yes, I do; but from your remark I thought you were not of that opinion. No,
really, I think I am on the other side of the argument. I am trying to discover
how much more earnest a minister should be than you and I are, for instance."
"Rather more is expected of him by the Church," her husband answered,

moving cautiously, and becoming suddenly aware that he was on slippery
ground.
"By the Church possibly; but is more really expected of him by the Lord?
Sometimes I have heard persons talk as though they really thought there was
a different code of rules for a minister's life than for the ordinary Christian's.
But, after all, he has to be guided by the same Bible, led by the same Spirit."
"There's a bit of sophistry in that remark," her husband said laughing; "but I
shall not stay to hunt it up just now. I expect father is waiting for me to help
about matters that he considers more important."
"But, Lewis, wait a moment. I don't want to argue; I just want this: Will you this
afternoon pray a good deal about this visit? I do feel that it ought to be a
means of grace to our home and to the pastor; for there should certainly be a
reflex influence in visits between pastor and people. I have been for the last
two hours impressed to almost constant prayer for this, and I feel as though I
wanted to have a union of prayer."
Her husband lingered, regarding her with a half-troubled, half-curious
expression.
"Sometimes," he said slowly, "I am disposed to think that you have gone away
beyond me in these matters, so that I cannot understand you. Now, about this
visit. I can see nothing but an ordinary social cup of tea with the minister. He
will eat bread and butter, and the regulation number of sauces and cakes and
pickles, and we will keep up a flow of talk about something, it will not matter
much what to any of us, so we succeed in appearing social; then he will go
away, and the evening will be gone, and, so far as I can see, everything will be
precisely as it was before."
"No," she said, with a positive setting of her head. "You are ignoring entirely
the influence which one soul must have over another. Don't you believe that
all of our family, by this visit, will have been drawn either to respect religion
more, to feel its power more plainly, or else will have been repelled from the
subject? They may none of them be aware that such is the case, yet when
they come in contact with one so closely allied to the church and prayer-
meeting, I think, that either one influence or the other must have its way."
"New thought to me put on that broad ground. But if it is true, it proves, I think,
that the minister has more influence over the community than private
Christians have; because, certainly, it is possible for you and me to go out to
tea and have a pleasant social time, and not change any person's opinion of
religion one-half inch."
She shook her head. "It proves to me that the outward position helps the
minister by the law of association to make a more distinctly realized
impression; but, dear Lewis, the question is, is it right for any servant of the
King to mingle familiarly for an afternoon with others, who either are or should
be loyal subjects, and not make a definite impression for the King?"
"I don't know," he said slowly, gravely; "I don't believe I have thought of social
gatherings in that light."
And Louise, as he went away, realized, with a throb of pain, that she wanted
the minister to make a definite impression for good, not only on Dorothy and
John, but on her husband. Perhaps she never prayed more constantly for the
success of any apparently small matter than she did for this tea-drinking. Her
interest even extended to the dress that Dorothy wore. She knew well it would
be a somewhat rusty black one; but the door of that young lady's room being
ajar, and she being visible, in the act of adding to her toilet an ugly red necktie
that set her face aflame, Louise ventured a suggestion.
"O Dorrie, if you would wear some soft laces with that dress, how pretty it
would be!"
"I know it," said Dorothy, snatching off the red tie as she spoke. "But I haven't
any. I hate this necktie; I don't know why, but I just hate it. Mother bought it
because it was cheap!"—immense disgust expressed in tone and manner.
"That is surely the only recommendation it has."
"I have some soft laces that will be just the thing for you," Louise said in
eagerness, and she ran back to her room for them.
"These are cheap," returning with a box of fluffy ruchings. "They cost less than
ribbon in the first place, and will do up as well as linen collars."
New items these to Dorothy. The idea that anything so white and soft and
beautiful could also be cheap! A mistaken notion had this young woman that
everything beautiful was costly.
"Let me arrange them," Louise said in a flutter of satisfaction, lifting her heart
in prayer as she worked.
Praying about a lace ruffle! Oh yes, indeed; why not? If they are proper to
wear, why not proper to speak of to the Father who clothes the lilies and
numbers the very hairs of our head? Actually praying that the delicate laces
might aid in lifting Dorothy into a reasonable degree of self-appreciation, and
so relieve, somewhat, the excessive timidity which Satan was successfully
using against her. I wonder, has it ever occurred to young people that Satan
can make use of timidity as well as boldness?
"There," said Louise, as she arranged the puffy knots, giving those curious
little touches which the tasteful woman understands so well and finds so
impossible to teach.
"Aren't they pretty?" And she stood back to view the effect.
The pink glow on Dorothy's cheeks showed that she thought they were.
With the details of the supper Louise did not in the least concern herself; she
knew that food would be abundant and well prepared, and the linen would be
snowy, and the dishes shining. What more need mortal want?
As for the minister, truth to tell, he spent his leisure moments during the day in
dreading his visit. He had heard so much of the Morgans—of their coldness
and indifference, of their holding themselves aloof from every influence, either
social or spiritual. The few sentences that had ever passed between himself
and Farmer Morgan had been so tinged with sarcasm on the latter's part, and
had served to make him feel so thoroughly uncomfortable, that he shrank from
all contact with the entire family, always excepting the fair-faced, sweet-voiced
stranger; not her husband, for something about the grave, rather cold face of
Lewis Morgan made his young pastor pick him out as merciless intellectual
critic. However, it transpired that most of his forebodings were unrealized.
It suited Mrs. Morgan, senior, to array herself in a fresh calico, neatly made,
relieved from severe plainness by a very shining linen collar; and though her
manner was nearly as cold as the collar, yet there was a certain air of
hospitality about it that made the minister feel not unwelcome. Dorothy, under
the influence of her becoming laces, or some other influence, was certainly
less awkward than usual. And fair, curly-haired, sweet-faced Nellie caught the
young man's heart at once, and was enthroned upon his knee when Farmer
Morgan came to shake hands before proceeding to supper. If there was one
thing on earth more than another that Farmer Morgan did admire, it was his
own beautiful little Nellie. If the minister saw that she was an uncommon child,
why, in his heart, he believed it to be a proof positive that the minister was an
uncommon man. Altogether, Mr. Butler's opinion of the Morgan family was
very different by six o'clock from what it had been at four. Just a word alone
with him Louise had, when Farmer Morgan suddenly remembered an
unforgotten duty and went away, while Mrs. Morgan and Dorothy were putting
the finishing touches to the supper-table. Lewis was detained with a business
caller at one of the large barns, and John had not presented himself at all.
This was one of her present sources of anxiety. She turned to the minister the
moment they were alone.
"We need your help so much," she began eagerly. "My husband and I are the
only Christians in this family. I am specially and almost painfully interested in
both John and Dorothy; they need Christ so much, and apparently are so far
from him. Is the Christian influence of the young people decided in this
society?"
"I hardly know how to answer you," he said hesitatingly. "If I were to tell you
the simple truth, I seem better able to influence the young in almost any other
direction than I do in anything that pertains to religion." And if the poor young
man had but known it, he was more natural and winning in regard to any other
topic than he was with that one. "I have hardly a young man in my
congregation on whom I can depend in the least," he continued sadly, "and I
do not see any gain in this respect."

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Tips on what to know to IMPRESS

LATHA GANTI, MD, MS, MBA, FACEP Sean M. Blitzstein, MD

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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-

Perceptual disturbances: hallucinations, illusions, derealization, deper-

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-

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

Etiology: drugs (narcotics, benzodiazepines, anticholinergics, TCAs, ste-

Management: identify/correct underlying cause, simplify Rx regi-

(hypnagogic hallucination) or upon awakening (hypnopompic hal