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BEHAVIOR AND MENTAL STATUS

• Introduces common symptoms and behaviors


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