Varsha K. Vaidya
Chester W. Schmidt Jr.
Patients with psychological and social problems often consult their general physicians, usually complaining of not feeling well in some physical sense. The problems these patients present range from temporary distress to enduring and disabling conditions.
The temporary disturbances that are most often seen by the generalist are anxiety regarding the meaning of a new symptom (e.g., cancer fear), frustrations attending an illness that interrupts valued activities (e.g., recovery phase after myocardial infarction [MI]), and dysphoric mood related to recent social stress (e.g., anxiety in the mother of a teenager who has run away from home). Such problems are common in people with excellent previous mental health. These disturbances usually resolve when the interviewing and counseling skills discussed inChapters 3, 4, and 20 are used in conjunction with management of the patient's medical problem.
Patients with more persistent psychosocial problems need to be evaluated and treated for common psychosocial syndromes. This chapter andChapter 20 provide general approaches for the evaluation and treatment of such patients. Later chapters cover the specific psychosocial syndromes seen by generalists.
Epidemiology
The publication, Mental Health: A Report of the Surgeon General, completed and disseminated in 1999, describes the importance and the challenges of mental health problems in the United States (1). The report defines mental health as “the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity.” It points out that mental disorders account for more than 15% of the overall burden of disease from all causes. And it recommends a combination of population-focused and patient-focused initiatives as the most important ways to prevent, identify, or treat mental illness.
The Epidemiologic Catchment Area Survey, conducted in 1980 to 1982, identified the frequency of common psychosocial syndromes in arepresentative sample of American communities (1). Table 19.1 lists the four most common disorders in major sex and age subgroups. Approximately 12% of adults reported symptoms of a diagnosable mental disorder during the previous 6 months, and 25% had had a mental illness at some time in their lives. Of subjects meeting criteria for disorders other than alcohol or other drug abuse or dependence, approximately 30% had more than one disorder; of those with alcohol or drug abuse/dependence, 45% and 72%, respectively, had coexisting mental disorders (2). These figures probably underrepresent the true prevalence of mental disorders because the study instrument did not identify patients with two common syndromes: adjustment disorder and generalized anxiety disorder. More than half of those persons with mental illness reported that the only health care providers they
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saw were generalists, and of these people, the majority had not discussed their mental illness with their health care providers (3). In 2001 the National Institutes of Mental Health (NIMH) reported that 22.1% of Americans age 18 or older, about one in five adults suffered from a “diagnosable mental disorder” in a given year. Mental disorders constitute 4 out of 10 “leading causes of disability” (4).
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TABLE 19.1 Four Most Common Psychiatric Disorders by Sex and Age Based on 6-Month Prevalence Ratesa |
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In one multi-institutional study of American primary care settings, one in four patients met full criteria for a specific psychosocial disorder. However, in these settings, 50% to 75% of those patients suffering from a common mental disorder were not diagnosed or treated (5). A World Health Organization (WHO) survey of 14 countries found a similarly high rate of mental disorders among primary care patients; the rates of both occupational and physical disability were higher in patients with mental illness than in other patients (6). These findings, combined with the Epidemiologic Catchment Area community-based data, point to the importance of evaluating patients for mental illness.
Syndromal Diagnosis
Accurate diagnosis of a psychosocial problem is essential for prognosis and management. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision (DSM-IV TR), published in 2000 by the American Psychiatric Association, is a particularly useful resource because it provides diagnostic criteria, epidemiologic information, and prognostic profiles for most of the psychosocial syndromes encountered in office practice. DSM-IV Primary Care Version (PC), also published by the American Psychiatric Association, is a useful tool in the diagnosis of psychiatric disorders in the primary care setting. DSM-IV criteria are stated wherever relevant in the chapters that follow.
Despite the availability of diagnostic criteria, reaching an accurate psychosocial diagnosis in general medical practice can be difficult for several reasons:
After initial information gathering about mental symptoms, it is usually possible to decide which general phenomenon is the dominant problem (e.g., anxiety, depression, somatization, cognitive impairment, maladaptive behavior). To refine the diagnosis, additional information is needed. For example, consider a patient with a depressed mood. With a systematic approach, the diagnosis of depression may be more accurately formulated as one of the following:
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Information Gathering
The order in which information is gathered and the particular information gathered vary depending on the style one has developed with previous patients and the diagnosis being considered. With a minimal amount of prompting, many patients volunteer information that would otherwise require systematic questioning. Both the efficiency and the accuracy of the interview are probably enhanced when this occurs.Chapter 3 describes other interviewing skills useful in eliciting a psychosocial history.
Building on the patient's initial account, one should assess relevant aspects of the social history, the patient's mental status, the patient's personality and coping styles, the chronology of the patient's problem, and the family history of psychosocial problems. Given the time limitations, it may not be possible to get all the information at one time. However, it is important not to miss the following (remembered with the mnemonic “SHAPES”): suicidal ideas, homicidal ideas, problems with activities of daily living, psychotic symptoms, emergency medical conditions, and substance abuse.
With the patient's permission, additional information should be obtained from family members, other physicians, and previous medical records whenever possible. Current medications should be identified, because psychological disturbances can be caused or worsened by a large number of drugs (7). Tables in other chapters list drugs that can cause anxiety (Table 22.1), depression (Table 24.3), psychotic symptoms (Table 25.2), delirium (Table 26.3), or sexual dysfunction (Table 6.4).
Chronology
Accurate information about the chronology of a psychosocial problem is important for diagnosis, prognosis, and management. Therefore, as the interview is closing, one should ensure that the patient has provided the following essential information: duration of the present episode; the times and circumstances during which the current symptoms have either improved or worsened (if temporal relationships are unclear, it is helpful to have the patient keep a log of symptoms and events for 1 week or longer); the patient's optimal level of functioning during the past year (when was it and how long did it last?); and the time and circumstances of any previous episode of similar symptoms or of previous mental illness and any previous treatments.
Family History
In the family of a patient with a chronic psychosocial disorder, occurrence in others of the same disorder or of other psychiatric problems is common. Information about psychiatric illness in the family and related beneficial treatments may strengthen one's diagnostic hunches, influence the choice of treatment, and help the patient to recognize the nature of his or her own problem. For example a family history of suicide or substance abuse increases the risk of suicide, major psychiatric illness, and substance abuse in the patient.
Social and Developmental History
The history should always include a profile of the patient's current life situation (e.g., marital status, family structure, household makeup, educational level, occupation, recreational activities, substance use). At times, it is also helpful to know the principal patterns and events that have characterized a patient's development from childhood until the present (e.g., family makeup, interactions, conflicts, losses, relationships in school, service in the armed forces, jobs) and to have patients depict their view of the type of person they are and have been. Some of this information is known already to the patient's personal physician, which makes the assessment of a new psychosocial problem simpler at times. When a psychosocial problem seems likely, the presenting symptom should be re-explored in the context of social interactions (e.g., “Tell me just where you were and who was there the last time you noted the nausea and quivering in your stomach”). The patient should be asked to describe any recent changes in life situation and to discuss the nature of critical relationships (e.g., with spouse, children, work associates). If substance abuse or domestic violence, which is often related to substance abuse, is suspected, skillful inquiry is needed to make a diagnosis (see Chapter 28 on alcoholism and domestic violence and Chapter 29 on illicit drugs).
Much psychosocial illness is related to stressors and maladjustments that are disclosed by the patient during this inquiry. The social factors most commonly related to psychosocial distress were summarized by McWhinney (Table 19.2). The significance of a report of one of these factors becomes clear when it is integrated into the rest of the history. For example, an interpersonal conflict may be the stress causing an adjustment disorder, or it may be a symptom of alcoholism, depression, or sexual dysfunction.
In addition to providing clues to the diagnosis, the social history usually discloses important assets and liabilities in the patient's life. This information is useful in planning treatment for a psychosocial problem.
Personality
Personality is the enduring attitudes and patterns of behavior that typify an individual. Generally a physician becomes acquainted with a patient's personality, particularly the patient's behavior pattern in the face of illness, through caring for that patient during months or years. Some patients exhibit the features of a maladaptive personality, and recognition of this fact may be helpful in planning the patient's care, as discussed in more detail in Chapter 23.
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TABLE 19.2 Common Social Factors Related to Psychological Symptoms |
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Coping Responses
Coping responses are unconscious intellectual maneuvers that people assume in adapting to life stresses. There are several common coping responses that should be recognized because patients may use them to avoid confronting a problem for which help is needed. When maladaptive coping is recognized, the physician can often help the patient to disclose the primary problem and to reach a healthier adaptation to it.
Denial is a common response by which a distressing problem is avoided. Denial may be silent (e.g., a patient with bloody stools may withhold this information to avoid confronting the fear of cancer), or it may be voiced openly (e.g., a man who greatly fears sudden death during convalescence from a MI may boast of robust health and deny angina or other symptoms he is experiencing).
Rationalization serves the same function as denial. It is a process in which a patient gives plausible explanations for behavior designed to avoid unpleasant realities (e.g., a relapsing alcoholic explains that demands at work increased so much lately that it was impossible to continue to go to Alcoholics Anonymous meetings).
Regression is reversion to dependent behavior typical of childhood. Regressive behavior is a common response to major illness or other circumstances that threaten a person's autonomy (e.g., a man who is recovering slowly from a hip fracture complains excessively about small problems at home, gets upset when his son cannot continue to visit daily, and expects his wife to order for him when they go out to a restaurant on the weekend).
Projection is a process in which an unpleasant aspect of one's self is ascribed to another person (e.g., a teenager who is angry about limits set by her mother criticizes her older sister for being hostile to their mother).
Displacement is a process in which feelings toward one person are directed toward another (e.g., a researcher who is furious at a colleague who has beaten him to an important finding becomes irritable toward his wife for no apparent reason).
Mental Status
When the patient's behavior is the principal problem or when psychological symptoms are causing a great deal of subjective distress (e.g., marked anxiety or depression) or suggest a major psychiatric disorder (e.g., dementia, schizophrenia, manic-depressive illness), a brief mental status examination should be performed.
The mental status examination is a systematic assessment of the patient's current mental functioning. The elements of the mental status examination most useful for the general physician are the following:
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Most of the data needed for a brief mental status examination are observable while the patient gives the history. Depending on the cues the patient provides, the practitioner should question the patient more about his or her mental status and other features of the syndromes suggested by the history. For patients whose mental status suggests focal or global cognitive impairment, a more formal cognitive examination can be administered in a few minutes (see Table 26.1 in Chapter 26). For those who describe cardinal symptoms of anxiety, affective disorders, or psychotic disorders, focused interviewing is necessary (see Chapters 22, 24, and 25, respectively).
Overall Formulation of the Problem
When the essentials of a patient's psychosocial history have been collected, a useful way to formulate the problem is the five-axis approach recommended by the American Psychiatric Association.
Case Study
Mr. J, a 60-year-old married security guard, underwent coronary artery bypass graft (CABG) surgery in January 1998. His postoperative hospital course was uneventful. Shortly after discharge, he came twice in the same day to the emergency department (ED) complaining of severe chest pain and cold upper extremities. Evaluation revealed mild tenderness at the location of his sternotomy scar. The next day he returned, this time describing inability to sleep in addition to the previous symptoms. A thorough evaluation, including an exercise stress test, did not disclose a physical basis for his symptoms.
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TABLE 19.3 Axis IV: Categories for Psychosocial and Environmental Problems |
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The patient's wife described regressive behavior since the patient returned home (e.g., he wanted her to bring his meals to him in bed, asked her to pick his clothes for him each day, was having occasional urinary incontinence, and had put her in charge of dispensing all of his medicines). He was not sleeping well and awakened his wife whenever he could not sleep. Additional inquiry and observation revealed a somewhat diminished sense of self-worth and some doubts regarding his future. He was worried specifically that he would not return to work, as he had expected to preoperatively, and his calculations suggested that his income would be significantly lower if he applied for Social Security benefits.
The patient eventually disclosed that he was sure that he had been on the pump too long and that he feared that his incision would break down (this had happened to a friend after CABG).
Mr. J had always seemed to be a self-reliant man. He had worked as a security guard, while receiving medical therapy for his angina, for several years. The CABG was recommended when his angina worsened in November 1997, making it difficult for him to walk the distances required at his job. He had never developed markedly regressive behavior in the past, although he had depended on his wife to make decisions about almost all purchases they made, had never been separated from her for a full day during their long and tranquil marriage, and often referred to her as “Mother.” There was no history of significant psychiatric illness in his family.
Based on this story and additional inquiry, the formulation of Mr. J's illness was as follows:
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TABLE 19.4 Global Assessment of Functioning (GAF) Scale |
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Comorbid Substance Abuse
In a patient with comorbid substance abuse, it is often difficult to tease out which came first: Is the patient depressed or hypomanic because he or she is using drugs, or is the patient using drugs to “self-medicate” his or her symptoms? It is important to obtain a history of substance abuse, as detailed in Chapter 29. Information from the patient about how long he or she was abstinent from drugs is of special relevance. If the patient had symptoms during a reasonably long “clean” or drug-free period and relapsed when depressed, then he or she is more likely to need and benefit from psychotropic medication. There will remain a subgroup of patients for whom the chronology is unclear or who have had no clean time; it may be reasonable to treat the symptoms if they persist beyond the initial withdrawal dysphoria (8,9).
Comorbidity in the Patient's Family
Psychosocial problems create substantial stress for the spouse, children, and other people with close ties to the affected patient. This is particularly true of chronic problems such as alcoholism, affective disorders, anxiety disorders, and the somatoform disorders. The impact of the patient's illness on others should always be considered in the evaluation of psychosocial problems. As pointed out in other chapters in this section, there are important ways in which the comorbidity of the family can be alleviated as part of the overall approach to these trying problems. Chapter 3 describes how to conduct a family meeting that focuses on a specific problem, and Chapter 20 describes the process for formal family counseling.
Screening for Mental Illness in Primary Care Settings
The questionnaire known as the Primary Care Evaluation of Mental Disorders (PRIME MD) is a useful and well-validated tool that can be used to screen patients in primary care settings. It is relatively brief and covers the spectrum of psychiatric disorders inclusive of alcoholism (Fig. 19.1). In terms of specific psychiatric disorders, the U.S. Preventive Task Force recommends screening adults
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for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and appropriate followup (10,11) (see Chapter 24 for details regarding screening for depression).
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FIGURE 19.1. PRIME-MD (Primary Care Evaluation of Mental Disorders) one-page patient questionnaire that is to be completed by the patient before seeing the physician. (From Spitzer R, Williams J, Kroenke K. Utility of a new procedure for diagnosing mental illness in primary care: the PRIME-MD 1000 Study. JAMA 1994;272:1749. Reproduced with permission of the American Medical Association. ) |
Assessment of Competence, Decision-Making Capacity, and Need for Commitment
The three situations covered here require input by a physician or multiple physicians who know or have examined the patient. A physician assesses the patient's competence and decision-making capacity implicitly at every medical encounter. At times, the assessment must be done explicitly.
Competence and incompetence are legal terms, and their use should generally be restricted to situations in which a formal determination has been made. Under the law, people are presumed competent to manage their own affairs until a judicial determination has been made. A physician may be called on to provide evidence to be used in such a determination. Common civil issues that require determination of mental competence include competence to accept or refuse medical care, commitment to hospitals, contesting of wills, and guardianship decisions. In the ambulatory setting, perhaps the most common problem presented by marginally competent patients is unreliable self-care; here, the assistance of a reliable household member or visiting nurse is essential, in addition to the measures needed to obtain a legal decision about competence.
Decision-making capacity is a clinical term referring to the capacity of the patient to make a particular decision. It is also called clinical competency. Judgments regarding such capacity are made by clinicians every day, particularly when informed consent is sought for performing medical procedures. Decision-making capacity is said to be present when the patient demonstrates the following:
Patients may have the capacity to make one decision (e.g., to assign power of attorney to a relative) but not another (e.g., to decide whether to undergo an experimental surgical procedure), so decision-making capacity must be addressed each time a decision is required. The presence of a psychiatric or neurologic disorder does not necessarily imply incapacity. Although patients who are demented,
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delirious, delusional, or hallucinating often lack decision-making capacity, they may actually be able to make some decisions themselves. Therefore, they require the same assessment as patients without these disorders or symptoms.
Commitment laws in most states require examination by a physician and do not specify examination by a psychiatrist. Therefore, the patient's primary physician is occasionally required to assist in a commitment determination. A complete psychiatric evaluation, including a complete mental status examination, is necessary to determine whether a patient is dangerous to himself or herself or to others, which is the usual test for commitment.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.