neuro – mental status exam (chapter 1)

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mental status exam
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Combine the patient’s report of the current cognitions and emotions with the clinicians observation of the patient’s behavior serves as a snapshot of the patient’s current mental state tool for communication among clinicians
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generating differential diagnosis
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medical related etiologies
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Hypothyroidism, cancer, congestive heart failure, Addison’s disease
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substance related etiologies
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Alcohol dependence, stimulant withdrawal, use of steroid medications
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emotion
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Complex feeling states with psychological, somatic, and behavioral components that function to guide adaptive behavioral responses and decision-making allow for rapid, complex, and organized responses to environmental stimuli: fear for example essential for survival and effective social behaviors
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behavior
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arise from the interplay of motivations, cognitive processes and emotional state psychiatric disorders are often disabling because the cognitive and emotional symptoms interfere with adaptive behaviors
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axis I DSM criteria
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clinical disorders -delirium, dementia, and other cognitive disorders -substance related disorders -schizophrenia and other psychotic disorders -mood disorders -anxiety disorders -somatoform disorders -eating/sleep disorders -disorders usually 1st diagnosed in childhood or adolescence
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Axis II DSM criteria
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Personality disorders mental retardation
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Axis III DSM criteria
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General medical conditions
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Axis IV DSM criteria
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Psychosocial and environmental stressors -primary support group -related to social environment -educational -occupational -housing -economic -access to healthcare services -interactions with the legal system
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Axis V DSM criteria
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Global assessment of functioning
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Biological contributions to psychiatric illness described by the biopsychosocial model
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anatomical, molecular, and genetic substrates of disease
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Psychological contributions to psychiatric illness described by the biopsychosocial model
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Personality traits, methods of coping with stress, perception of relationships with others, meeting of illness, and internal experience of emotion
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Social contributions to psychiatric illness described by the biopsychosocial model
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Cultural, environmental, and spiritual influences
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Purposes of these psychiatric interview
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-Establishing a relationship -gathering clinical information -determine the risk of unwanted outcomes such as suicide -attempting to understand the patient -developing a diagnosis -develop a biopsychosocial formulation – treatment plan
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Elements of the mental status exam
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appearance behavior speech mood and affect thought process thought content cognition insight and judgment
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Conduct of the mental status exam
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Not separate from the rest of the psychiatric interview but rather is collected over the course of the interview
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Abnormalities of the mental status exam and their associated psychiatric diagnoses
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4 of the 10 most disabling this orders worldwide are mental illnesses
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Maj. depressive disorder alcohol abuse/dependence bipolar disorder schizophrenia
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2 fundamental challenges of determining psychiatric illness
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1. Determining whether or not a psychiatric disorder is present 2. If so, determining which psychiatric disorder is present
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Instrument used to make psychiatric diagnosis and to develop a biopsychosocial formulation
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Psychiatric interview with mental status examination
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Disorders of cognition
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Dementia and delirium
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disorders of emotion
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Mood disorders -major depressive disorder -bipolar disorder anxiety disorders -posttraumatic stress disorder
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DSM-IV diagnostic classification
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A. 5 or more of the following symptoms have been present in the same two-week period and present a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure -depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others -markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day -significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day -insomnia are hypersomnia nearly everyday -fatigue or loss of energy nearly every day -feelings of worthlessness or excessive or inappropriate guilt nearly every day -diminished ability to think or concentrate, or indecisiveness, nearly every day -recurrent thoughts of death, recurrent suicidal iteration without a specific plan, or a suicide attempt or a specific plan for committing suicide B. Symptoms to not meet the criteria for a mixed episode C. Symptoms cause clinical significant distress or impairment in social, occupational, or other important areas of functioning D. Symptoms are not due to the direct psychological effects of a substance or a general medical condition capital E. Symptoms are not better accounted for by bereavement
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Diagnosis of major depressive episode
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A patient must demonstrate some combination of symptoms in DSM IV criterion A for 2 weeks or more, must not meet criteria for another condition (B, D, E) and must have functional impairment due to the symptoms (C)
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Multiaxial system
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Clinicians are encouraged to imply a holistic approach, simultaneously assessing psychiatric disorders, personality, health status, stressors, and overall functioning
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Psychiatric disorders
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Axis I
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Personality disorders
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Axis II
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Health status
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Axis III
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Stressors
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Axis IV
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Overall functioning
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Axis V
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Axis II disorders
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Conditions that arise early in life and are persistent
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Personality disorder
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Enduring pattern of cognitions, emotions, and behaviors that leads to interpersonal and functional problems
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Axis I disorders
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Less persistent and more episodic; all psychiatric disorders that are not personality disorders or mental retardation
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Substrate of mental illness
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the brain
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Cognition
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Refers to processes such as: -memory -attention -language comprehension and production -sensory perception -executive function (impulse control, sequencing, planning, and decision-making)
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appearance
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describes the patient’s general appearance, including grooming and hygiene, dress, posture, and facial expression note stigmata of physical illness such as track marks, pinpoint pupils, spider angiomate, masked facies, self-harm
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Poor grooming and hygiene
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Due to poor self-care associated with depressive disorder or psychotic disorder or dementia
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Protective clothing or excessive or garish makeup
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Associated with hypomania or mania
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odd clothing or clothing inappropriate for the weather
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Schizophrenia
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Behavior
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Describe the motor behavior of the patient including psychomotor agitation (restlessness) or psychomotor retardation, any abnormal involuntary movements, gait, gaze, attitude
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Tremor
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Resting or intentional, coarse or fine, high or low frequency, location in the body, symmetrical or asymmetrical
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tic
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Sudden, jerking movement or vocalization
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Dyskinesia
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Slower, writhing movements of lips, tongue, job, or trunk
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Rigidity
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Often visible but also elicited by checking for cogwheel rigidity in which the examiner extends and flexes each arm at the elbow-normally the movement is smooth, but ratcheting is present in cogwheel rigidity
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Odd behaviors
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Waxy flexibility (patient is awake, not normally responsive, and maintains postures into which she or he has been placed), posturing, stereotypy (purposeless, repetitive movements)
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Speech
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Describe rate, rhythm, and volume
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Pressured speech
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A cardinal symptom of mania in which the patient speaks rapidly and is difficult to interrupt
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Latent speech
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Patients with depression often speak slowly, softly, and monotonously and there is a delay in answering questions
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echolalia
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Repeating what someone else is saying
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Clang associations
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rhyming speech patterns
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Mood
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Subjective experience of any motion
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Affect
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Outward manifestation of that emotion; for example a smile
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alexithymia
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Difficulty describing one’s mood
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Included in a description of affect
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Content congruence range intensity consistency
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Examples of content
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Dysphoric apathetic anxious irritable euphoric euthymic
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Examples of congruence
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Does affect match the patient’s mood? For example laughing while describing tragic events = inappropriate affect
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Examples of range
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Full-ranging from sad to anxious to irritable restricted-displaying only one or 2 emotions flat-showing almost no emotional response
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Examples of intensity
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Blunted or intense
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Examples of consistency
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Labile affect-one that says suddenly and perhaps unexpectedly over several seconds
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Abnormal thought processes
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Tangentiality circumstantiality loosening of associations flight of ideas thought blocking perseveration thought poverty
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Tangentiality
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Responding to questions in an oblique way that moves further and further from the question
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circumstantiality
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responses are indirect and delayed in reaching the goal
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Loosening of associations
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Links between patient thoughts are not clear or logical and the patient appears to get derailed easily
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Flight of ideas
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Lease and associations that are accompanied by pressured speech often seen in patients with mania
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Thought blocking
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Sudden disruption of thought processes often midstream seen in patients with psychosis
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perseveration
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Patient repeats particular phrases or questions
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Thought poverty
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Little or no spontaneous speech and/or response to questions tersely says only yes or no may be severe depression, psychosis, or dementia
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thought content
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Suicidal ideation homicidal ideation hallucination delusions
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Passive suicidal ideation
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the belief that life is not worth living or wishing to be dead
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Active suicidal ideation
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Includes an intent to harm oneself and/or a plan for doing so and/or access to the means of self harm
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Determining if suicidal ideation exists
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Asked the following questions: 1. Do you ever feel like life is not worth living or that you’d be better off dead? If yes then… 2. Do you want to harm yourself in any way? If yes then… 3. How would you hurt yourself? If a plan exists then… 4. Do you have access to guns, pills, knife, etc.
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Hallucinations
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sensory perceptions in the absence of associated environmental stimuli
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Illusions
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Misperceptions of an actual stimulus, not necessarily pathological
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hypnopompic
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Hallucinations that occur only upon awakening; typically not pathological
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hypnogogic
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Hallucinations that occur only upon falling asleep; typically not pathological
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Auditory hallucination
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most common type of hallucination found in psychiatric disorders
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Command auditory hallucinations
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Voices that tell a patient what to do; hearing commands to hurt oneself or others constitutes a psychiatric emergency
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Visual hallucinations
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Include people, shapes, colors, or characters of a religious nature most often seen in dementia, delirium, and substance intoxication or withdrawal
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Tactile hallucinations
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Less common, involve feelings and olfactory hallucinations gustatory hallucinations are rare
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Delusion
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A fixed false belief that cannot be explained on the basis of the patient’s cultural or spiritual background
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Persecutory and paranoid delusions
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Include the belief that others are conspiring against, spying on, or otherwise attempting to harm the patient most common instinctive for any a and other psychotic disorders can also present with major depressive disorder and dementia
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Grandiose delusions
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Common in patients with schizophrenia or mania
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Religious delusions
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A preoccupation with religious matters-must be outside the range of beliefs considered normal for the patient’s cultural and spiritual background
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Somatic delusion
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Belief that one’s body is diseased or abnormal despite ample evidence to the contrary microchip in the brain
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Schizophrenia is associated with a number of specific delusions including:
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Idea of reference thought broadcasting thought insertion and withdrawal delusion of activity
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Idea of reference
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Believe that remarks, newspapers, TV Internet, or other events refers specifically to the patient and are intended for the patient
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thought broadcasting
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Belief that one’s thoughts are being broadcast for others to hear
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Thought insertion and withdrawal
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Believe that thoughts are being inserted and withdrawn from one’s mind
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Delusions of passivity
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Belief that one’s thoughts or actions are being controlled by someone else or something else
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Patient health questionnaire 9
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Rating scale used for depression screening
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General anxiety disorders assessment (GAD-7)
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Rating scale used for assessment of anxiety
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St. Louis University mental status examination (SLUMS)
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Rating scale used for cognitive assessment
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Major categories of mental illness
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Depression mania anxiety psychosis dementia and delirium substance related disorders personality disorders
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Psychiatric related etiologies
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Major depressive disorder, bipolar disorder, adjustment disorder, bereavement

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