Introduction: Psychiatric Disorders
In recent years, a convergence of social, economic, and professional forces has dramatically changed the mental health field. Community and professional organizations, for instance, have established family advocacy programs, substance abuse rehabilitation programs, stress management workshops, bereavement groups, victim assistance programs, and violence shelters. The public education system has established widespread information programs about mental health issues. Mental illness isn’t as stigmatizing as it once was. Self-help and coping books have proliferated, and media attention to mental and emotional disorders has increased. Finally, more effective drugs are available to treat many of these illnesses.
Social changes
Today, more people than ever experience mental health problems. Some researchers blame social changes, which have altered the traditional family structure and contributed to the loss of the extended family. The result: more single parents, dysfunctional families, troubled children, and homeless people.
The loss of effective support systems strains a person’s ability to cope with even minor problems. For example, a working mother may lack the necessary support to meet the demands of her job, her home, her spouse, and her children. When she views herself as ineffective in these roles, her self-esteem falters and her level of stress intensifies.
Furthermore, alcohol and substance abuse are proliferating and their victims are becoming younger. Up to 7% of adolescents are dependent on alcohol, and 15% to 20% of American teens have experienced a serious episode of depression. Isolation, fear of violent crime, and loneliness have contributed to a similar rise in depression among elderly people. Victims of violence, abuse, and social discord struggle to cope with the trauma they have experienced.
Economic forces
Recent cuts in federal funding of mental health programs place future control of mental health services in the hands of state and local authorities, drastically reducing the funds available for training and care. One result of decreased funding is increased collaboration between community psychiatric facilities (short-term inpatient, outpatient, and auxiliary services) and long-term inpatient state facilities. Another result is decreased availability of long-term care and reduced length of stay for acute patient care.
Professional changes
Mental health professionals have experienced enormous changes in perspective, focus, and direction, which are reflected in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). With this system of classifying mental disorders, clinicians must consider many aspects of patients’behavior, mental performance, and history, emphasizing observable data rather than subjective and theoretical impressions.
DSM-IV-TR defines a mental disorder as a clinically significant behavioral or psychological syndrome or pattern that’s associated with current distress (a painful symptom), disability (impairment in one or more important areas of functioning), or a significantly greater risk of suffering, death, pain, disability, or an important loss of freedom. This syndrome or pattern mustn’t be merely an expected response such as grief over the death of a loved one. Whatever its original cause, it must currently be considered a sign of a behavioral, psychological, or biological dysfunction.
To add diagnostic detail, DSM-IV-TR uses a multiaxial approach. It specifies that every patient be evaluated on each of these five axes:
❑ Axis I — clinical disorder, the diagnosis (or diagnoses) that best describes the presenting complaint
❑ Axis II — personality disorders and mental retardation
❑ Axis III — general medical conditions, a description of any concurrent medical conditions or disorders
❑ Axis IV — psychosocial and environmental problems
❑ Axis V — global assessment of functioning (GAF), based on a scale of 1 to 100. The GAF scale allows evaluation of the patient’s overall psychological, social, and occupational functioning.
The first three axes, which constitute the official diagnostic assessment, encompass the entire spectrum of mental and physical disorders. This system may require multiple diagnoses. For example, on axis I, a patient may have a psychoactive substance abuse disorder and a mood disorder. He may even have multiple diagnoses within the same class, as in major depression superimposed on cyclothymic disorder. A patient also may have a disorder on axes I, II, and III simultaneously.
Axis IV documents the effect of psychosocial and environmental stressors on the patient. Examples of such stressors include marital, familial, interpersonal, occupational, domestic, financial, legal, developmental, and medical concerns as well as environmental factors and natural disasters.
Axis V measures how well the patient has functioned over the past year and includes his current level of functioning.
A patient’s diagnosis after being evaluated on these five axes may look like this:
❑ Axis I — adjustment disorder with anxious mood
❑ Axis II — obsessive-compulsive personality
❑ Axis III — Crohn’s disease, acute bleeding episode
❑ Axis IV — recent remarriage, death of father
❑ Axis V — GAF = 65 (current).
Related professional forces
An increased emphasis on holistic care has promoted a closer relationship between psychiatry and the rest of medicine. More hospitalized patients benefit from psychiatric consultations, reflecting a growing recognition of the emotional basis of physical disorders. Advances in neurobiology have revolutionized our understanding of the physiologic basis of mental function. The result: better diagnosis and treatment of mental disorders.
Psychosocial assessment
You’ll encounter patients with mental and emotional problems in all clinical areas and settings. Begin your care of these patients with a psychosocial assessment.
For this assessment to be effective, you need to establish a therapeutic relationship with the patient that’s based on trust. You must communicate to him that his thoughts and behaviors are important. Effective communication involves sending and receiving messages. (See Communication barriers.) Words count, as does nonverbal communication — such as eye contact, posture, facial expressions, gestures, clothing, affect, and even silence. All can convey a powerful message.
Choose a quiet, private setting for the assessment interview. Interruptions and distractions threaten confidentiality and interfere with effective listening. If you’re meeting the patient for the first time, introduce yourself and explain the interview’s purpose. Sit at a comfortable distance from the patient, and give him your undivided attention.
During the interview, adopt a professional but friendly attitude, and maintain eye contact to the level that the patient can tolerate. A calm, nonthreatening tone of voice will encourage the patient to talk more openly. Avoid value judgments. Don’t rush through the interview; building a trusting therapeutic relationship takes time.
Patient history
A patient history establishes a baseline and provides clues to the underlying or precipitating cause of the current problem. Remember that the patient may not be a reliable source of information, particularly if he has a mental illness. If possible, verify his responses with family members, friends, or health care personnel. Also check facility records from previous admissions, if possible, and compare his past behavior, symptoms, and circumstances with the current situation.
Explore the patient’s chief complaint, current symptoms, psychiatric history, demographic data, socioeconomic data, cultural and religious beliefs, medication history, and physical illnesses.
❑ Chief complaint. The patient may not voice his chief complaint directly. Instead, you or others may note that he’s having difficulty coping or is exhibiting unusual behavior. If this occurs, determine whether the patient is aware of the problem. When documenting the patient’s response, write it verbatim and enclose it in quotation marks.
❑ Current symptoms. Find out about the onset of symptoms, their severity and persistence, and whether they occurred abruptly or insidiously. Compare the patient’s condition with his normal level of functioning.
❑ Psychiatric history. Discuss past psychiatric disturbances, such as episodes of delusions, violence, depression, attempted suicides, drug or alcohol abuse, and previous psychiatric treatment.
❑ Demographic data. Determine the patient’s age, sex, ethnic origin, primary language, birthplace, religion, and marital status. Use this information to establish a baseline and validate the patient’s record.
❑ Socioeconomic data. Obtain information about the patient’s educational level, housing conditions, income, current employment status, and family, because these data may provide clues to his current problem. Determine current stressors from a holistic perspective.
❑ Cultural and religious beliefs. A patient’s background and values affect his response to illness and his adaptation to care. Certain questions and behaviors considered acceptable in one culture may be inappropriate in another. Determine the extent to which the patient may utilize cultural rituals, treatments, and healing practices.
❑ Medication history. Certain drugs can cause symptoms of mental illness. Review any medications the patient may be taking, including over-the-counter drugs and herbal supplements or remedies, and check for interactions. If he’s taking an antipsychotic, antidepressant, anxiolytic, or antimanic drug, ask if his symptoms have improved, if he’s taking the medication as prescribed, and if he has had any adverse reactions.
❑ Physical illnesses. Find out if the patient has a history of medical disorders that may cause distorted thought processes, disorientation, depression, or other symptoms of mental illness. For instance, does he have a history of renal or hepatic failure, infection, thyroid disease, increased intracranial pressure, or a metabolic disorder? Additionally, has the patient suffered recent head trauma, infection, or physical illness?
Patient appearance, behavior,
and mental status
Assess the patient’s appearance, behavior, mood, thought processes, cognitive function, coping mechanisms, and potential for self-destructive behavior, and record your assessment.
❑ General appearance. The patient’s appearance helps to indicate his emotional and mental status. Specifically, note his dress and grooming. Is his appearance clean and appropriate for his age, sex, and situation?
Is the patient’s posture erect or slouched? Is his head lowered? What about his gait? Is it brisk, slow, shuffling, or unsteady? Does he walk normally? Note his facial expression. Does he look alert or does he stare blankly? Does he appear sad or angry? Does the patient maintain direct eye contact? Does he stare at you for long periods?
❑ Behavior. Note the patient’s demeanor and overall attitude as well as any extraordinary behavior such as speaking to a person who isn’t present. Also record mannerisms. Does he bite his nails, fidget, or pace? Does he have any tics or tremors? How does he respond to the interviewer? Is he cooperative, friendly, hostile, or indifferent?
Behavior should be evaluated also in light of the patient’s culture. For instance, making eye contact is considered respectful and attentive behavior in most Western cultures. However, eye contact may be considered rude and aggressive in several Asian-American and Native American cultures, and avoiding eye contact is considerate and respectful. Blacks may be more actively verbal within their culture group, where oral tradition and multiparty conversations are common. In a traditional medical setting, this patient may be restrained or silent.
❑ Mood. Does the patient appear excited or depressed? Is he crying, sweating, breathing heavily, or trembling? Ask him to describe his current feelings in concrete terms and to suggest possible reasons for these feelings. Note inconsistencies between body language and mood (such as smiling when discussing an anger-provoking situation).
❑ Thought processes and cognitive function. Evaluate the patient’s orientation to time, place, and person, noting any confusion or disorientation. Look for delusions, hallucinations, obsessions, compulsions, fantasies, and daydreams.
Assess the patient’s attention span and ability to recall events in the distant and recent past. For example, to assess immediate recall, ask him to repeat a series of five or six names of objects. Test his intellectual functioning by asking him to add a series of numbers and his sensory perception and coordination by having him copy a simple drawing. Inappropriate responses to a hypothetical situation (“What would you do if you won the lottery?”) can indicate impaired judgment. Keep in mind that the patient’s cultural background and personal values will influence his answer.
Note speech characteristics that may indicate altered thought processes, including monosyllabic responses; irrelevant or illogical replies to questions; convoluted or excessively detailed speech; repetitious, accelerated, or slowed speech patterns; flight of ideas; and sudden silence with an obvious reason.
Finally, assess the patient’s insight by asking if he understands the significance of his illness, the plan of treatment, and the effect it will have on his life.
❑ Coping mechanisms. The patient who’s faced with a stressful situation will utilize coping, or defense, mechanisms — behaviors that operate on an unconscious level to protect the ego. Examples include denial, regression, displacement, projection, reaction formation, and fantasy. Look for an excessive reliance on these coping mechanisms. (See Coping mechanisms defined, page 411.)
❑ Potential for self-destructive behavior. Mentally healthy people may intentionally take death-defying risks such as participating in dangerous sports. The risks taken by self-destructive patients, however, aren’t death-defying but rather death-seeking.
Not all self-destructive behavior is suicidal in intent. The patient may engage in self-destructive behavior because it helps him feel alive. A patient who has lost touch with reality may cut or mutilate body parts to focus on physical pain, which may be less overwhelming than emotional distress.
Assess patients for suicidal tendencies, particularly if they report signs and symptoms of depression. (See Suicide’s warning signs.) Not all such patients want to die; however, the incidence of suicide is higher in depressed patients than in patients with other diagnoses.
Diagnostic tests
The laboratory tests, psychological tests, and EEG and brain imaging studies summarized here provide information about the patient’s mental status and possible physical causes of his signs and symptoms.
Laboratory tests
Urinalysis, hemoglobin level, hematocrit, serum electrolyte and serum glucose levels, and liver, kidney, and thyroid function tests screen for physical disorders that can cause psychiatric signs and symptoms. Toxicology studies of blood and urine can detect the presence of many drugs, and current laboratory methods can quantify the blood levels of these drugs. Patients on psychoactive drugs may need routine toxicology screening to ensure that they aren’t receiving a toxic dose. (See Toxicology screening.)
Psychological and mental
status tests
These tests evaluate the patient’s mood, personality, and mental status. Commonly used tests include:
❑ The Mini–Mental Status Examination measures orientation, registration, recall, calculation, language, and graphomotor function.
❑ The Cognitive Capacity Screening Examination measures orientation, memory, calculation, and language.
❑ The Cognitive Assessment Scale measures orientation, general knowledge, mental ability, and psychomotor function.
❑ The Global Deterioration Scale assesses and stages primary degenerative dementia, based on orientation, memory, and neurologic function.
❑ The Functional Dementia Scale measures orientation, affect, and the ability to perform activities of daily living.
❑ The Beck Depression Inventory helps diagnose depression, determine its severity, and monitor the patient’s response during treatment.
❑ The Eating Attitudes Test detects patterns that suggest an eating disorder.
❑ The Minnesota Multiphasic Personality Inventory helps assess personality traits and ego function in adolescents and adults. Test results include information on coping strategies, defenses, strengths, gender identification, and self-esteem. The test pattern may strongly suggest a diagnostic category, point to a suicide risk, or indicate the potential for violence.
EEG and brain imaging studies
To screen for brain abnormalities, the physician may order tests that visualize electrical brain-wave pattern disturbances or anatomic alterations.
❑ An EEG graphically records the brain’s electrical activity. Abnormal results may indicate organic disease, psychotropic drug use, or certain psychological disorders.
❑ A computed tomography (CT) scan combines radiologic and computer analysis of tissue density to produce images of intracranial structures not readily seen on standard X-rays. This test can help detect brain contusions or calcifications, cerebral atrophy, hydrocephalus, inflammation, space-occupying lesions, and vascular abnormalities.
❑ A magnetic resonance imaging (MRI) scan is a noninvasive imaging technique. MRI localizes atomic nuclei that magnetically align and then fall out of alignment in response to a radio-frequency pulse. The MRI scanner records signals from nuclei as they realign; it then translates the signals into detailed pictures of anatomic structures. Compared with conventional X-rays and CT scans, the MRI scan provides superior contrast of soft tissues and sharper differentiation of normal and abnormal tissues. It also provides images of multiple planes, including sagittal and coronal views, in regions where bones usually interface.
❑ A positron emission tomography (PET) scan provides colorimetric information about the brain’s metabolic activity by detecting how quickly tissues consume radioactive isotopes. PET scanning is used mainly for diagnosing neuropsychiatric problems, such as Alzheimer’s disease, and some mental illnesses.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Cognitive impairment
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