suggestive of mental health disorders • Mental health disorders are commonly masked by other conditions – Associated with substantial psychosocial morbidity and they are all treatable – Look for anxiety and depression in patients with substance abuse – Watch out for underlying psychiatric conditions in difficult encounters and patients with unexplained symptoms – Bear in mind that nearly half of those with any mental disorder meet criteria for two or more disorders with severity strongly related to comorbidity SYMPTOMS AND BEHAVIOR PATIENT SYMPTOMS -symptoms may be psychological (relating to mood or anxiety) or physical (relating to body sensation such as pain, fatigue or palpitations) - Somatic-px manifest physical symptoms - 30% of symptoms are medically unexplained - Functional syndromes- physical symptoms occur in clusters such as irritable bowel syndrome, chronic fatigue Somatoform disorder- px exhibit physical symptoms that are not fully explained by a medical condition, effects of substance abuse, or other mental disorders (described in DSM IV-TR) Medically Unexplained Symptoms - Many patients do not report symptoms of anxiety and depression but focus on physical concerns instead - Failure to recognize the admixture of physical symptoms, functional syndromes and common mental health disorders adds to the burden of patient undertreatment and poor quality of life PATIENT IDENTIFIERS FOR SELECTIVE MENTAL HEALTH SCREENING -Unexplained conditions lasting beyond 6 weeks are recognized as common chronic disorders that should prompt screening for depression, anxiety, or both. - Experts recommend a two-tier approach: brief screening questions with high sensitivity and specificity for patients at risk, followed by more detailed investigation when needed PRACTICAL SCREENING TOOLS FOR DETECTING MENTAL DISORDERS - PRIME-MD (Primary Care Evaluation of Mental Disorders) - DSM IV-TR PERSONALITY DISORDERS (character disorders) - Dysfunctional interpersonal coping styles that disrupt and destabilize their relationships - Co- occur at high frequencies with alcohol and substance abuse BORDERLINE PERSONALITY DISORDERS - Many have co-existing mood, anxiety and substance abuse disorders - 75% are women and shows a strong genetic and familial pattern - Recurrent suicidal threats or acts, combined with fear of abandonement, strongly suggest the diagnosis HEALTH HISTORY COMMON OR CONCERNING SYMPTOMS - Changes in attention, mood or speech - Changes in insight, orientation, or memory - Anxiety, panic, ritualitistic behavior, and phobias - Delirium or dementia HEALTH HISTORY - As illicit the patient’s history, observe the level of alertness and orientation, and mood, attention, and memory - While the history unfolds, learn about the patient’s insight and judgment, as well as any recurring or unusual thought or perceptions - (Terminology: The Mental Status Examination) HEALTH HISTORY ATTENTION, MOOD, SPEECH; INSIGHT, ORIENTATION, MEMORY. - As you listen to the patient’s concerns, assess level of consciousness, general appearance, mood, and ability to pay attention, remember, understand and speak - Patient’s vocabulary and general fund of information often make a rough estimate of intelligence HEALTH HISTORY ATTENTION, MOOD, SPEECH; INSIGHT, ORIENTATION, MEMORY. - Patient’s responses to illness and life circumstances often tell about insight and judgment HEALTH HISTORY ANXIETY, PANIC, RITUALISTIC BEHAVIOR, PHOBIAS. - Worries persisting over a 6-month period suggest anxiety disorder - Panic disorder- recurrent panic attacks followed by a period of anxiety about further attacks - Obsessive-compulsive disorder- intrusive thoughts and ritualistic behaviors - Posttraumatic stress disorder- avoidance, numbing and hyperarousal - Social phobia- marked anticipatory anxiety in social situations HEALTH HISTORY DELIRIUM OR DEMENTIA. - Patients may have subtle behavioral changes, difficulty taking medications properly, problems attending to household chores or paying bills, or loss of interest in their usual activities HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS • - Screening for depression and suicidality • - Screening for alcohol, prescription drug and substance abuse HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS MOOD DISORDERS AND DEPRESSION. - Screen high-risk patients for early signs of depression: low self-esteem, loss of pleasure in daily activities (anhedonia), sleep disorders and difficulty concentrating or making decisions. - Asking two simple questions about mood and anhedonia appears to be effective as screening tool. HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS SUICIDE. Suicide rates are four times higher in men, who are more likely to use firearms and less likely to use poison than women. HEALTH PROMOTION AND COUNSELING: EVIDENCE AND RECOMMENDATIONS ALCOHOL, PRESCRIPTION DRUG,AND SUBSTANCE ABUSE. - Interaction between mental disorders and alcohol and substance abuse is profound. - The Centers for Disease Control and Prevention reports that prescription drug abuse now kills more people than illicit drugs, reversing trends of even 10-15 years ago - Screening for alcohol and substance abuse and misuse of prescription drugs should be part of every patient history. TECHNIQUES OF EXAMINATION The mental status examination - Appearance and behavior - Speech and language - Mood - Thoughts and perceptions - Cognition, including memory, attention, information and vocabulary, calculations, abstract thinking and constructional ability TECHNIQUES OF EXAMINATION APPEARANCE AND BEHAVIOR. - Level of Consciousness- If the patient does not respond to questions; - speak to the patient by name and in a loud voice - Shake the patient gently, as if awakening a sleeper TECHNIQUES OF EXAMINATION APPEARANCE AND BEHAVIOR. - Posture and Motor Behavior- Observe the pace, range and character of movements - Agitated depression - Depression - Manic episode TECHNIQUES OF EXAMINATION APPEARANCE AND BEHAVIOR. - Dress, Grooming and Personal Hygiene- Note the patient’s hair, nails, teeth and skin. - compare patient’s grooming with those of other people of comparable age, lifestyle and socioeconomic group - Compare one side of the body with the other - Depression, schizophrenia and dementia - Obsessive-compulsive disorder - Lesion in the opposite parietal cortex TECHNIQUES OF EXAMINATION APPEARANCE AND BEHAVIOR. - Facial Expression – Observe the face, both at rest and when the patient interacts with others - Parkinsonism TECHNIQUES OF EXAMINATION APPEARANCE AND BEHAVIOR. - Manner, Affect, and relationship to People and Things- Assess patient’s affect, or external expression of the inner emotional state. - Note the patient’s openness, approachability and reactions to others and to the surroundings - Paranoia - Mania - Schizophrenia - Dementia - Anxiety or depression TECHNIQUES OF EXAMINATION SPEECH AND LANGUANGE. - Quantity- talkative or relatively silent - Rate- speech fast or slow - Volume- speech loud or soft - Articulation of Words- words spoken cleary and distinctly? Is there nasal quality to the speech? - Fluency TECHNIQUES OF EXAMINATION SPEECH AND LANGUANGE. -Fluency- rate, flow and melody of speech and content and use of words. Be alert for abnormalities such as: - Hesitancies and gaps - Disturbed inflections, such as monotone - Circumlocations - Paraphasias, wrong, or invented TECHNIQUES OF EXAMINATION SPEECH AND LANGUANGE. Testing for Aphasia - Word Comprehension - Repetition - Naming - Reading Comprehension - Writing TECHNIQUES OF EXAMINATION MOOD. - Include sadness and deep melancholy, contentment, joy, euphoria, and elation; anger and rage; anxiety and worry; and detachment and indifference - If you suspect depression, assess its depth and any associated risk of suicide. - By open discussion, you demonstrate your interest and concern for a possibly life- threatening condition TECHNIQUES OF EXAMINATION THOUGHT AND PERCEPTIONS. THOUGHT PROCESSES. Variations and Abnormalities - circumstantiality - derailment (loosening of associations) - flight of ideas - neologisms - incoherence TECHNIQUES OF EXAMINATION THOUGHT AND PERCEPTIONS. THOUGHT PROCESSES. Variations and Abnormalities - blocking - confabulation - perseveration - echolalia - clanging TECHNIQUES OF EXAMINATION THOUGHT AND PERCEPTIONS. THOUGHT CONTENT. Abnormalities of Thought Content - compulsions - obsessions - phobias - anxieties - feelings of unreality - feelings of depersonalization - delusions TECHNIQUES OF EXAMINATION THOUGHT AND PERCEPTIONS. PERCEPTIONS. Abnormalities - Illusions - Hallucinations TECHNIQUES OF EXAMINATION THOUGHT AND PERCEPTIONS. INSIGHT AND JUDGMENT. - Insight- “What brings you to the hospital?” - Judgment- noting the patient’s responses to family situations, jobs, use of money and interpersonal conflicts TECHNIQUES OF EXAMINATION COGNITIVE FUNCTIONS. ORIENTATION- determine the px orientation to time, place and person ATTENTION- - digit span - serial 7s - spelling backward TECHNIQUES OF EXAMINATION COGNITIVE FUNCTIONS. REMOTE MEMORY-relevant to px past RECENT MEMORY- events of the day NEW LEARNING ABILITY TECHNIQUES OF EXAMINATION HIGHER COGNITIVE FUNCTIONS. INFORMATION AND VOCABULARY- provide a rough estimate of a person’s intelligence CALCULATING ABILITY ABSTRACT THINKING - Proverbs - Similarities CONSTRUCTIONAL ABILITY SPECIAL TECHNIQUES MINI-MENTAL STATE EXAMINATION (MMSE)- useful in screening for cognitive dysfunction or dementia - Sample items - orientation to time - registration - naming - reading