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Mental Health Assessment In Mental Health Assessment In The Ambulatory SettingThe Ambulatory Setting
Thomas E. Franklin, D.O.
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IntroductionIntroduction
• Psychologically impaired individuals frequently consult primary care physician with somatic complaints.
• Minor and major events may cause impaired mental health in previously healthy individuals.
• Primary care physicians need system to identify mental health issues for treatment
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ObjectivesObjectives
• Take pt., social & developmental history• Perform mental status examination• Recognize coping responses, co-morbidities• Determine competence, decision-making
capacity and need for commitment.• Formulate plan to address mental
impairment
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Information GatheringInformation Gathering
• Information from many sources (patient,family, police, EMS, other health care facilities, employer) all valuable
• Current medications, illicit drugs, alcohol
– May cause depression, psychosis, delirium, etc.
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Social & Developmental HistorySocial & Developmental History
• Profile patient’s current life situation
– Marital status, family, education, job
– Family history invaluable
– Conflicts, losses, self view, etc.
• Recent changes in patient’s life
• Patterns & events shaping development
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Social & Developmental HistorySocial & Developmental History
• Substance abuse and/or domestic violence
• Social factors related to psychological symptoms:
– Loss: personal due to death or desertion
– Conflict: interpersonal within family, work
– Change: adolescence, menopause, senescence
– Maladjustment: home, work
– Stress: unexpected event or chronic problem
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Social & Developmental HistorySocial & Developmental History
• Isolation: not due to any recent loss, change
• Failure or frustrated expectations: patient’s life’s goals not realized (e.g. failure at school, loss of job, non promotion).
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Mental StatusMental Status
• Appearance: Grooming, attention to dress, motor activity (quiet versus agitated).
• General level of consciousness: Alert, sleepy, stuporous, obtunded.
• Orientation: Person, place, time, purpose
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Mental StatusMental Status
• Speech: Ability to use customary syntax. Note slurring, inability to find the right word, pressured speech, flight of ideas, looseness of association, muteness.
• Memory: Recent memory-knows recent events, capacity to remember names of current treating physicians. Remote memory-ability to give past medical history.
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Mental StatusMental Status
• Attention and concentration: Ability to understand and follow questions or instructions.
• Intelligence: Can be estimated from level of schooling achieved, vocational history, use of language.
• Mood: Pervasive,sustained emotion described by patient (anger, anxiety, etc.).
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Mental StatusMental Status
• Affect: An observable and immediately expressed emotion (anger, anxiety, sadness, fear, humor, etc.). Is affect consistent with content of speech, thoughts, and behavior?
• Suicidal thoughts: Statements or actions that indicate the patient wishes to harm or kill himself.
• Homicidal or violent thoughts: harm or kill others
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Mental StatusMental Status
• Perceptions: Presence of hallucinations (visual, auditory, or somatic perceptions occurring without external stimuli), delusions (fixed beliefs which are false), paranoid ideas, or persistent phobias (fears directed toward specific objects or situations).
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Mental StatusMental Status
• Judgment: Capacity to understand one’s current situation and/or to demonstrate appropriate compliance with instructions for care.
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Coping ResponsesCoping Responses
• Denial
• Rationalization
• Regression
• Projection
• Displacement
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Recognizing Family Co-morbidityRecognizing Family Co-morbidity
• Assume co-morbidity with chronic problems:
– Alcoholism
– Affective disorders
– Anxiety disorders
– Somatoform disorders
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Determining CompetenceDetermining Competence
• Competence and incompetence
– Legal terms, restricted to formal judicial determinations
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Determining CompetenceDetermining Competence
• Decision-Making Capacity– Capacity to comprehend information
relevant to decision– Capacity to choose re: personal values and
goals – Capacity to communicate (verbally or
nonverbally) with caregivers
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Determining CompetenceDetermining Competence
• Commitment Laws
– Most states require physician examination to determine whether the patient is of danger to self or others
– not necessarily psychiatrist
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Formulation of Mental ImpairmentFormulation of Mental Impairment
• Five-Axis Approach (APA)– Axis I:
• Psychosocial syndrome(s)• Conditions not attributable to a formal
mental disorder e.g. malingering, uncomplicated bereavement, noncompliance with medical treatment, academic or occupational problems, etc
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Formulation of Mental ImpairmentFormulation of Mental Impairment
• Axis II: Personality disorders or styles and specific developmental disorders.
• Axis III: General medical conditions• Axis IV: Psychological and environmental
problems.• Axis V: Global Assessment of Functioning;
current level and highest level for at least a few months during past year.
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SummarySummary
• Systematic approach is needed– History
• Developmental• PMH, medications, alcohol / substance abuse• Marital, family, job history• Recent events, changes, losses
– Mental status examination• FP’s can care for many psychiatric problems
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References:References:
• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Wash DC, American Psychiatric Association, 1994.
• Cadoret RJ: In: Cadoret RJ, King LJ (eds): Psychiatry in Primary Care. St. Louis, CV Mosby, 1983. Chap 2.