Psychiatry for the Lay Counselor:
When to Refer for Professional Help
By Jeff Gordon, M.D.
[This brief orientation to Psychiatric terminology and conditions was written in
1989. It is intended to help lay counselors understand the appropriate limitations to
their efforts to help people]
Introduction
The goal of this discussion is to identify the individuals who need psychiatric
evaluation. This is NOT intended to encourage the layman to attempt making a psychiatric
diagnosis. That would be inappropriate as it could threaten the well-being of the person
involved if misdiagnosis and treatment were performed. Keep in mind that the information
contained here is meant to make the layman able to identify the person who may be
endangered due to his psychological condition or the person who may derive benefit from
further evaluation. The discussion will include the following:
- A method for basic psychological evaluation.
- Definitions of common terms used in psychiatry.
- Description of a limited selection of common psychological disorders including:
- Schizophrenia.
- Depression
- Bipolar disorder.
- Personality disorders
Psychological Evaluation for the Counselor
To reach the proper conclusions, correct information must be gathered. Many of the
tell-tale signs of mental illness will not be uncovered unless particular questions are
asked. A central role of the counselor is to obtain various historical details and
information regarding the person's current psychological state. This allows the counselor
to either move ahead with his job or to refer the person on for further evaluation by a
psychiatrist.
Chief complaint and history of present situation:
The goal here is to understand first of all, what has brought this person to the point
of seeking out counsel and secondly what has led up to this event. The present situation
could have been brought out by a recent event or could be a long-standing problem.
Past history may be obtained over several sessions and should include the following:
- A listing of any medical conditions (past or present) as many psychological problems are
caused by medical problems (e.g., thyroid disease).
- The person's childhood should be explored including early memories, punishments, early
friendships, parental relationships, and school experiences. Their adolescence should be
investigated as well including school, relationships with teachers, peers, and parents,
hobbies, feelings of inferiority, and role models.
- The adult life should be examined including their occupational, social, and marital
history. Current or previous history of substance abuse should be addressed as well. The
counselor must ask direct questions at this point (e.g., "How many beers a
day?").
- Sexual history is very important to obtain because sexual abuse is relatively common and
often leads to a tremendous amount of emotional damage.
Family history of psychiatric illness and their relationship to that person should also
be explored. Was the relative hospitalized, on medication, suicidal, etc.?
Mental Status Examination
As implemented by the professional, the complete mental status exam is quite extensive.
Presented below are some portions of this evaluation which will help the counselor
identify those persons in need of psychiatric evaluation. Obviously, these questions need
not be addressed with every person you might counsel, but in the case of those that seem
unresponsive to input or seem particularly bizarre, the evaluation suggested below may be
helpful.
The key to this evaluation is close observation and careful questioning. The following
items may be addressed:
- Attitude toward examiner: Some examples of various attitudes would be
cooperative, friendly, attentive, interested, frank, seductive, defensive, hostile,
playful, and evasive.
- Affective expression: Normal expression includes a variation in facial
expression, tone of voice, use of hands, and body movements. Affect may be normal,
elevated, or depressed. When affect is depressed, there is a clear reduction in the range
and intensity of the expression. It may be characterized as blunted, shallow, or flat,
with flat being the most impaired state. On the other hand affect can be elevated and in
the extreme case mania (described below) results. Affect may be described as depressed,
proud, angry, fearful, anxious, guilty, euphoric, or expansive.
- Appropriateness: Is the emotion expressed suitable or proper for the situation
addressed (e.g., "My dog was run over by a Mack truck! HA, HA, HA!!!")? This
obviously is an inappropriate emotional response.
- Perception: Hallucinations or illusions (defined under "Terminology in
Psychology") may be present in various conditions. These are signs of serious
psychological disorders and all patients with hallucinations should be referred to a
psychiatrist. Some individuals may volunteer the information but others will have to be
asked specifically about the presence of hallucinations. Questions such as, "Do you
ever hear voices that no one else hears?" may be asked. The counselor should explore
the content of the hallucination as far as possible.
- Content of thought: Abnormalities in the thought process including
preoccupations, obsessions, compulsions, phobias, and delusions. These are defined below
and in most cases indicate the need for psychiatric evaluation. One may also assess the
counselee's abstract thinking ability by giving a parable. For example, "A rolling
stone gathers no moss." A response such as, "Don't wash your dirty underwear in
public," would indicate a problem.
- Judgement: Social appropriateness may be impaired in a variety of conditions.
Consider asking questions to assess this such as, "What would you do with a stamped
letter that you found?"
Terminology in Psychiatry
- Affect refers to the experience of emotion expressed by an individual and
observed by others.
- Mood is a pervasive and sustained emotion which is subjectively experienced and
reported by the patient. This includes depression, anger, etc.
- Neurosis is a condition in which the patient remains in touch with reality and
symptoms are experienced as distressing. For example, the obsessive hand washer knows that
what he is doing is weird, but he is not able to curtail the behavior. The behavior does
not violate gross social norms.
- Psychosis is characterized as an inability to distinguish reality from fantasy
such that a "new reality" is created in the person's mind. When a person is
psychotic, he incorrectly evaluates the accuracy of his perceptions and thoughts and makes
incorrect inferences about external reality, even in the face of contrary evidence. Direct
evidence of psychosis is the presence of delusions or hallucinations.
- Delusion is an alteration in the thought process and is characterized by false
beliefs, based on incorrect inferences about external reality. These are not consistent
with patient's intelligence and cultural background (NOTE: religious ideas that are
consistent with one's culture are not considered delusional simply because they cannot be
scientifically proven). Delusions cannot be corrected by reasoning. A list of various
types of delusions includes:
- Bizarre (obsession with UFO's)
- Nihilistic ("The world is coming to an end!")
- Somatic ("My brain is rotting!")
- Paranoid persecution (feels harassed or mistreated and often takes inappropriate legal
action)
- Grandeur ("I am the Messiah.")
- Reference (e.g., believes he is getting a personal message form the evening news)
- Control (others are in control through a variety of means)
- Erotomania (belief in women that a man is in love with them)
- Hallucinations are false sensory perceptions not associated with real external
stimuli. They may be manifest in any one of the senses including, auditory, visual,
gustatory, olfactory, tactile, or somatic.
- Illusions are misperceptions of a real external stimulus (e.g., hearing voices in
the wind.)
- Phobia refers to persistent, irrational, exaggerated, and invariably pathological
dread of some specific type of stimulus or situation. This results in a compelling desire
to avoid the situation or stimulus.
- Compulsion is the uncontrollable impulse to perform an act repetitively. Examples
include kleptomania, nymphomania, and trichotillomania (pulling out hair). Ritualistic
behavior, such as counting, checking, or hand-washing, is also considered compulsive
behavior.
- Obsession is a recurrent and intrusive mental event, which can be a thought, a
feeling, an idea, or a sensation (e.g., that one's spouse is having an affair).
- Obsessive-compulsive disorder is the presence of obsessions or compulsions in the
absence of other mental disorders that may cause alterations in the thought patterns.
There must be significant alteration in the person's lifestyle with at least one hour
daily being consumed with the obsessions or compulsions.
Selected Common Mental Illnesses
Schizophrenia
This condition is characterized by the presence of psychosis for at least six months in
which organic and other mental disorders have been ruled out. These patients' capacity to
function in society is impaired.
The lifetime prevalence is about 1%, so that about 2 million Americans suffer from this
disease. It usually develops by age 25 and there is an increased risk of schizophrenia if
one member of family is schizophrenic. Suicide is attempted in 50%, with 10% succeeding in
a 20 year follow-up period.
Clinical signs and symptoms
NOTE: Every sign seen in schizophrenia may be seen in other psychiatric disorders so a
careful history must be taken.
1. Mood and affect
- - Reduced emotional response or anhedonia
- - Overly active and inappropriate emotions of extreme rage, happiness, or anxiety.
2. Perceptual disturbances
- - Hallucinations in any of the five sensory categories with auditory hallucinations
being most common.
- - Illusions
3. Thought process
- - Content: Delusions which can be quite varied. These patients have lost a clear
sense for where their influence and self end and the rest of the world begins. for
example, they may believe that a news story is about them or may believe that they can
influence the weather.
- - Form: Objectively observed in the spoken and written language of the patient.
Includes looseness of associations, neologisms, echolalia, "word salad," and
mutism.
- - Process: How ideas and language are formulated. This includes flight of ideas,
thought blocking, impaired attention, poverty of thought, poor memory, illogical ideas.
4. Impulse control is limited such that their social sensitivity is decreased.
5. Orientation is intact.
6. Judgement and insight into their own problems is impaired.
Differential Diagnosis of Schizophrenia: Other disorders which may mimic
schizophrenia include:
- Many medical conditions
- Autistic disorder
- Mood disorders
- Schizoaffective disorder
- Schizophreniform disorder
- Brief reactive psychosis
- Delusional disorder
- Personality disorder
Major Depression
The symptoms of major depression as outlined below must be present continually for at
least a two week period. This is a common disorder with a lifetime prevalence of 10% in
males and 20% in females. The mean age of onset is 40 years of age and the cause of major
depression is unknown.
Clinical signs and symptoms
The key symptoms are loss of usual interests and a depressed mood. This often leads to
a feeling of worthlessness and suicidal ideation is common (two-thirds contemplate suicide
and 10-15% succeed). These people lack motivation, have a reduced level of energy, and are
often burdened with guilt. As a result, they cry easily. They may suffer from hypersomnia
or insomnia and they are frequently alcohol abusers. Somatic complaints are common. It is
important to note that in some cases the patient may be unaware of their depression such
that they would not seek out counseling.
Mental status exam
Perceptual disturbances such as delusions and/or hallucinations are quite rare. If
these occur, the diagnosis is psychotic depression. Perceptual disturbances typically take
two forms:
- Mood-congruent: guilt, failure, worthlessness, terminal medical illnesses (e.g., rotting
brain), etc.
- Mood-incongruent: exaggerated power, knowledge, and worth (e.g., Messiah)
Thought processes
- The person may have a negative view of himself and/or the world.
- Very slow speech and thoughts may be present.
- Insight into his problems may be extensive.
Course and prognosis
Depression is characterized by periods of depression which last from 6 to 13 months (3
months with treatment) followed by periods of mental health. The risk of relapse is higher
with anxiety symptoms, older age at onset, alcohol and drug abuse, and/or a history of
more than one previous episode.
Bipolar Disorder
Clinical signs and symptoms
Along with depression, the bipolar disorder is a mood disorder. A person is considered
bipolar if they have had mania in the past. Mania is a distinct period of abnormally and
persistently elevated, expansive, or irritable mood. Therefore, mania could be considered
the opposite of depression. The bipolar disorder includes both periods of mania as well as
depression. However, the strict diagnostic criteria state that an individual with periods
of mania is considered bipolar even if depression has not occurred. Manics can be quite
difficult to distinguish from schizophrenics because they may be delusional, experience
hallucinations, and have very disorganized behavior.
A manic episode would include at least three of the following characteristics:
- Inflated self-esteem
- Decreased need for sleep with lack of fatigue
- More talkative and pressured speech
- Flight of ideas
- Distractible by insignificant stimuli
- Increase in goal-directed activity or psychomotor agitation
- Seeking excessive involvement in pleasurable activity
Additional characteristics include profound social impairment (work, family, requires
hospitalization, etc.), does not meet criteria for schizophrenia (see above), and is not
on any drugs that may cause mania.
Mental status
- General appearance is excited, talkative, and hyperactive. The person may be psychotic
and disorganized.
- Affect is rapidly changing. The person tends to be easily frustrated and may become
violent.
- Perceptual disturbances are common and delusions are present in 75% of cases.
- Cognitive functioning is unrestrained and the accelerated flow of ideas leads to
pressured speech.
- 75% are threatening in some way and may be assaultive.
- Judgement impairment is a hallmark as they tend to break all the rules without regard.
Course and prognosis
Most bipolar disorders start with a bout of depression. Most experience both depression
and mania, while about 10-20% experience only mania. This is a recurring illness with
periods of mental health between periods of depression or mania. The usual episode lasts
about three months (untreated), but some individuals have a chronic manic state that
resembles schizophrenia. The prognosis is not as good as depression, but this is a
treatable condition. Big strides have been made in treatment effectiveness with the use of
lithium.
Personality Disorders
Personality disorders are quite common and yet very difficult to deal with. These
people are very difficult to relate to and can be the most abrasive human beings around.
They demonstrate deeply ingrained and inflexible patterns of relating to others. As a
result, they alienate people and become caught in a cycle in which fragile relationships
become shattered by their behavior.
A distinction should be drawn between those with personality disorders and those who
are neurotic. The neurotic sees his behavior as unacceptable both to himself and to
society. He is aware that problems exist and tries to change himself. Much of his
frustration stems from this fact. Unfortunately, those with personality disorders do not
view themselves as at fault and therefore do not consider themselves as needing help.
These disorders are classified into three clusters.
- The odd and eccentric disorders: paranoid, schizoid, and schizotypal.
- Extroverted disorders are dramatic and emotional. This includes the histrionic,
narcissistic, antisocial, and borderline personality disorders.
- Introverted disorders are anxious and fearful. This includes the avoidant, dependent,
obsessive-compulsive, and passive-aggressive disorders.
References
Diagnostic and Statistical Manual of Mental Disorders, ed 3, revised.
Kaplan, H. I., and Sadock, B J. Synopsis of Psychiatry, ed 5. Baltimore:
Williams & Wilkins, 1988.
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