Behavior and Mental Status

By:

Jimson Rey Q. Intong,M.D.

Department of Family and
Community Medicine
Vicente Sotto Memorial Medical
Center
 Behavior and Mental Status
Empathic listening and close observation
open a unique vista on patient's
outlook,concerns, and habbits

Prevalence of mental disorders:30%

20% of affected patients recieved
treatment
 Behavior and Mental Status
Often patients have more than 1 mental
disorder, with symptoms that mirror
medical illnesses

Difficult patients are frequently those with

multiple unexplained symptoms and
underlying psychiatric conditions that are
amenable to therapy
 Prevalence of Mental Disorders in
Primary Care Setting
Anxiety 20 %

Mood disorders including dysthymia and

25%
depressive and bipolar disorders

Depression 10%

Somatoform Disorders 10-15%

Alcohol and Substance Abuse 15-20%

Patient Identifiers for Mental Health
Screening
Medically unexplained physical symptoms
Multiple physical or somatic symptoms
High severity of the presenting somatic symptom
Persisting pain
Symptoms for more than 6 weeks
Physician rating as a "difficult encounter"
Recent Stress
Low self-rated health
High use of healthcare services
Substance abuse
 The Health History
Common or Concerning Symptoms:

Changes in attention, mood, or speech

Changes in insight, orientation, or memory
Anxiety, panic, ritualistic, behavior, and
phobias
Delerium or dementia
Terminology: The Mental Status
Examination
Alertness or state of awareness of the
Level of Consciusness
environment
The ability to focus or concentrate
Attention
overtime on one task or activity
The prcess of registering or recording
information. Recent or short-term
Memory memory covers minutes, hours, or
days;remote or long-term memory refers
to intervals of years
Awareness of personal identity, place, and
Orientation time; requires both memory and
attention
Sensory awareness of objects in the
environment and their
Perceptions
interrelationships;also refers to internal
stimuli(eg dreams)
The logic, coherence,and relevance of
Thought Processess
patients thoughts or how people think
Terminology: Mental Status
Examination
What the patient thinks about, including
Thought Content
level of insight and judgement

Awareness that symptoms or disturbed

Insight
behaviors are normal or abnormal

Process of comparing and evaluating

alternatives; reflects values that may or
Judgement
may not be based on reality and social
conversations or norms
An observable, usually episodic, feeling
Affect tone expressed through voice, facial
expression and demeanor
A more sustained emotion that may color
Mood a person's view of the world( mood is to
affect as climate is to weather)
 Terminology: Mental Status
Examination
A complex symbolic system for
expressing, recieving, and
Language
comprehending words;essential for
assessing other mental functions

Assessed by vocabulary, fund of

information, abstract thinking,
Higher cognitive functions
calculations, constructions of objects with
two or three dimensions
 Health Promotion and Counseling
Screening for depression and suicidability
Screening for dementia
 Depression
Major Depression
Lifetime prevalence: 16%
Annual prevalence : 6%

Early Clues:
low self-esteem
anhedonia(lack of pleasure in daily activities)
sleep disorders
difficulty concentrating or making decisions
 Suicide
Highest among men older than 85 years
and are increasing among teenagers and
young adults

More than 90% of suicide deaths occur in

patients with depression or or other mental
helath disorders or substance abuse
 Suicide
Risk Factors:
Suicidal or homicidal ideation,intent or plan
access to the means of suicide
current symptoms of psychosis or severe anxiety
any history of psychiatric illness (especially
linked to a hospital admission)
Substance abuse
Personality disorders
prior history or family history of suicides
 Alcohol and Substance Abuse
Alcohol, tobacco, and ellicit drugs account
for more illness, deaths, and disabilities
than any other preventable condition
 Techniques of Examination

Important Areas of Examination

Appearance and behavior

Speech and language
Mood
Thoughts and Perceptions
Cognition, including memory, attention, information and vocabulary, calculations,
abstract thinking, and constructional ability
 Appearance and Behavior
Assess The Following: 1) Level of Consciousness
Observe alertness and response to
verbal and tactile stimuli
2) Posture and Motor
Behavior
Observe pace, range, character,
and appropriateness of movements
3) Dress, Grooming, and
personal hygiene
4) Facial expression
Assess during rest and interaction
5) Manner, affect,and
relation to people and
things
Normal
consciousess,lethargy,obtu
ndation,stupor,coma
Restlessness, agitation,
bizarre
postures,immobility,involunt
ary movements
Fastidiousness,Neglect
Anxiety,depression,elation,a
nger, responses to
imaginary people or
objects,withrawal
 Speech and Language
Note: quantity, rate,loudness, clarity, and
fluency of speech. If indicated, test of
aphasia

Possible Findings:
Aphasia
Dysphonia
Dysarthria
Changes in mood disorders
 Speech and Language
Testing for Aphasia

Ask patient to follow a one-stage

command, such as "point to your nose".
Word Comprehension
Try a two-stage command: Point to your
mouth,then your knee
Ask patient to repeat a phrase of one-
Repetition syllable words (the most difficult
repitition task): No ifs,ands, or buts."
Ask the patient to name the parts of the
Naming
watch

Reading Comprehension Ask patient to read a paragraph aloud

Writing Ask patient to write a sentence

 Mood

Ask about the patients spirits

Note nature, intensity, duration, and
stability of any abnormal mood. Happiness, elation, depression, anxiety,
anger, indifference

If indicated, assess the risk of suicide

 Thought and Perceptions
Thought Processes.
Derailments, flight of
Assess logic, relevance, organization and ideas,incoherence,confabulation,blocking
coherence

Thought Content: Ask about and explore Obsessions, compulsions, delusions,

any unusual or unpleasant thoughts feelings of unreality

Perceptions.
Ask about any perceptions (eg. seeing or Illusions, hallucinations
hearing things)
Insight and judgement.
Recognition or denial of mental cause of
Assess patients insight into the illness and symptoms, bizarre, impulsive, or
level of judgement used in making unrealistic judgement
decisions or plans
 Cognitive Functions
Orientation to time, place, and person Disorientation

Attention
Digit Span--ability to repeat series of numbers Poor performance of digit span, serial 7s,
forward and then backward and spelling backward are common in
Serial 7s--ability to subtract 7 repeatedly, starting
with 100
dementiaand delirium but have other
Spelling backward of a five-letter word such as W-O-
causes too
R-L-D
Remote Memory(birthdays,
anniversaries, social security number, Impaired in late stages of dementia
schools, jobs, wars
Recent memory and new learning ability
Recent Memory (events of the day) impaired in dementia, delirium, and
amnestic disorders
New Learning Ability--ability to repeat
three or four words after a few minutes of
unrelated activity
 Higher Cognitive Functions
Examination Techniques
Information and Vocabulary.
Note the range and depth of patients
information, complexity of ideas
expressed, and vocabulary used. For the
fund of information,you also may ask
names of presidents,other political figures
,or large cities
Calculating Abilities, such as addition,
subtraction, and multiplication
Abstract Thinking--ability to respond
abstractly to questions about
The meaning of proverbs, such as "A stitch in time
saves nine"
The similarities of beings or things such as cat and a
mouse or a piano and a violin
Possible Findings
These attributes reflect intelligence,
education, and cultural background. They
are limited by mental retardation but are
fairly well preserved in early dementia
Poor calculation in mental retardation and
dementia
Concrete responses (observable details
rather than concepts) are common in
mental retardation, dementia, and
delerium. Responses are sometimes
bizarrein schizophrenia
 Higher Cognitive Functions

Constructional Ability. Ask patient

To copy figures such as circle,cross,

diamond,and box, and two intersecting Impaired ability common in dementia
pentagons, or and with parietal lobe damage.

To draw a clock face with numbers and

hands
 Special Technique
Mini-Mental State Examination (MMSE)

brief test useful in screening for cognitive

dysfunction and dementia and following
their course over time
 Mini-Mental State Exam
Orientation to time
Sample Item:
"What is the date?"

Registration
" Listen carefully; I am going to say three words. You say them back after
I stop. Ready? Here they are...
House(pause),Car(pause),Lake(pause). Now repeat those words back o
me." ( Repeat up to five times, but score only the first trial.)

Naming
"What is This?" (Point to a pencil or pen.)

Reading
"Please read this and do what it says." (Show examinee the words on the
stimulus form)
Close your eyes
 Mini-Mental State Exam
Recording the Examination-Mental Status
Mental Status: The patient is alert, well-
groomed, and cheerful. Speech is fluent
and words are clear. Thought processess
are coherent,insight is good. The patient is
oriented to person, place and time. Serial
7s accurate;recent and remotememory
intact. Calculations intact
 Mini-Mental State Exam
"Mental Status; the patient appears sad
and fatigued;clothes are wrinkled. Speech
is slow and words are mumbled. Thought
processesare coherent but insight into
current current life reverses is limited. The
patient is oriented to person, place and
time. digit span, serial 7s, and calculations
accurate but responses delayed. Clock
drawing is good."
 Somatoform Disorders: Types and
Approach
Management Guidelines
for Patients with
Unexplained Medical
Symptoms
Show empathy and understanding for the complaints and
frustrating experiences the patient has had so far
General Aspects
Develop a good patient-physician relationship;try to be
the coordinator of diagnostic procedures and care

Explore not only the history of complaints and former

treatments,but impairment,anxiety,psychosocial issues
When the patient presents with new symptoms, examine
the relevant organ system
Diagnosis
Show the results of investigations to explain the absence
of pathology and to give clear reassurance that there is no
serious physical disease
Avoid unnecessary diagnostic tests or surgical procedures
 Somatoform Disorders: Types
and Approach
Provide regularly scheduled visits, especially in the case of a
history of very frequent health care utilization
Treatment Explain that treatment is coping, not curing
Suggest coping strategies like regular physical activity,
relaxation,distraction

If referral is necessary to start psychotherapy or

Referral psychopharmacotherapy,prepare the patient for the treatment and
reassure him/her that you will continue to be his/her "doctor"
 Disorders of Mood
Major Depressive Episode Manic Episode

A distinct period of abnormally and

persistently elevated, expansive, or irritable
At least five of the symptoms listed
mood must be present for at least a
below(including one of the first two) must
week(any durationif hospitalization is
be present during the same two week
necessary). During this time,at least three of
period;they must represent a change from
the symptoms listed below have been
the person's previous state.
persistent and significant.( Four symptoms
are required if the mood is only irritable.)

Depressed mood (maybe an irritable mood

in children and adolescents) most of the Inflated self-esteem or grandiosity
day,nearly every day
Markedly diminished interest or pleasure in
Decreased need for sleep (feels rested
almost all activities most of the day,nearly
aftersleeping 3 hours)
every day
Significant weight gain or loss (not dieting)
More talkative than usual or pressure to
or increased or decreased appetite nearly
keep talking
everyday
 Disorders of Mood
Major Depressive Episode Manic episode

Insomnia or hypersomnia nearly

Flight of ideas or racing thoughts
everyday

Psychomotor agitation or retardation

Distractibility
nearly everyday

Increased goal-directed activity (either

Feelings of worthlessness or inapropriate
socially at work or school,or sexually) or
guilt nearly everyday
psychomotor agitation
excessive involvement in pleasurable
Recurrent thoughts of death or suicide,
high-risk activities (buying sprees,foolish
or a specific plan for or attempt at suicide
usiness ventures, sexual indiscretions)
 Disorders of Mood

Mixed Episode Hypomanic Episode

The mood and symptoms resemble those

A mixed episode,which must last at least in a manic episode but are less impairing,
1 week,meets the criteria for both major do not require hospitalization, do not
and manic episodes depressive episodes. include hallucinations or delusions, and
have a shorter minimum duration -4 days
 Disorders of Mood
Dysthymic Disorder
A depressed mood and symptoms for
most of the day, for more days than not,
over at least 2 years ( 1 year in children
and adolescents).
Freedom from symptoms lasts no more
than 2 months at a time.
Cyclothymic Episode
Numerous periods of hypomanic and
depressive symptoms that last for at least
2 years(1 year in children and
adolescents). Freedom from symptoms
lasts no more than 2 months at a time.
 Anxiety Disorders
Panic Disorder
recuurent,unexpected panic attacks, at
least one of which has been followed by a
month or more of persistent concern about
further attacks, worry over their
implications or consequences, or a
significant change in behavior in relation to
the attacks
 Anxiety Disorders
Panic Attack
is a discrete period of intense fear or discomfort that develops abruptly and peaks
within 10 minutes.

involves at least four of the following symptoms:

1) Palpitations,pounding heart,accelerated heart rate

2) Sweating
3) Trembling or shaking
4) Shortness of breath or a sense of smothering
5) Feeling of choking
6) Chestpain or discomfort
7) Nausea or abdominal distress
8) Feeling dizzy,unsteady,lightheaded,or faint
9) Feelings of unreality or depersonalization
10) Fear of dying
12) Paresthesias (numbness or tingling)
13) Chills or hot flushes
 Anxiety Disorders
Agorophobia
Anxiety about being in places or situations where escape
may be difficult or embarassing or help for sudden
symptoms unavailable

Specific Phobia
A marked, persistent, and excessive or unreasonable
fear that is cued by the presence or anticipation of a
specific object or situation, such as dogs,injections, or
flying
The person recognizes the fear as excessive or
unreasonable,but exposure to the cue provokes
immediate anxiety
 Anxiety Disorders
Social Phobia
A marked, persistent fear of one or more social or
performancesituations that involve exposureto unfamiliar
people or to scrutiny by others

Obsessive-Compulsive Disorder
Obsessions or compulsions that caused marked anxiety
or distress.
Although recognized as excessive or unreasonable, they
are time consuming and interfere with the person's
normal routine relationships
 Anxiety Disorders
Acute Stress Disorder
Exposure to a traumatic event that involved actual or
threatened deathnor serious injury to self or
others,leading to intense fear,helplessness, or horror
During or immediately after this event ,the person has at
least three dissociative symptoms:
1) A subjective sense of numbing,detachment,or absence
of emotional responsiveness
2) A reduced awareness or sorroundings as in a daze
3) Feelings of unreality
4) feelings of depersonalization
5) Amnesia for an important of the event
 Anxiety Disorders
Posttraumatic Stress Disorder
The event, fearful response, and persistent
reexperiencing of the traumatic event
Hallucinations may occur
The person has increased arousal,tries to avoid
stimuli related to the trauma,and has numbing of
general responsiveness
Causes marked distress and impaired social or
occupational function, and lasts for more than a
month
 Anxiety Disorders
Generalized Anxiety Disorder
Lacks a specific traumatic event or focus
for concern
Excessive anxiety and worry are hard to
control and generalized to a number of
events or activities
 Anxiety Disorders
Generalized Anxiety 1) feeling restless, keyed up, or on edge
Disorder
2) being easily fatigued
At least three of the
following symptoms 3) difficulty in concentrating or mind
are associated: going blank

4) irritability

5) muscle tension

6) difficulty in falling or staying asleep, or

restless, unsatisfying sleep