Published: August 2010
Epidemiologic data indicate that over one half of U.S. patients receive mental health care exclusively in the primary care setting.1 The primary care physician who can readily detect and manage behavior problems will be better equipped to manage this growing demand.
The American Psychiatric Association's Practice Guideline for Psychiatric Evaluation of Adults provides a comprehensive overview of elements essential to thorough psychiatric evaluation.2 Expecting the primary care physician's strict adherence to the Guideline is unrealistic and impractical. Time does not permit all areas to be addressed, nor is it necessary in most cases.
The purpose of this chapter, therefore, is to draw on the Guideline as well as other resources3-5 to develop a succinct and targeted summary of elements essential to efficient behavioral assessment by the primary care physician. Developing this skill set is especially important because behavioral disorders are among the most prevalent and treatment-responsive problems encountered in primary care.
A behavioral disorder should be included in the differential diagnosis of any patient who presents with repeated complaints, especially fatigue, insomnia, pain, or just feeling overwhelmed. For a variety of reasons, this demands that the primary care physician maintain a high index of suspicion for behavioral disturbance in her or his patients. The patient and physician typically focus on identifying a physical cause for the problem at hand. Failure to find a physical or physiologic basis can leave one or both with the nagging concern that something has been missed. Physicians' time constraints interfere with recognition, thorough assessment, and optimal management of behavioral disturbances.
Patients themselves are also inclined to minimize or ignore behavioral considerations. Psychological symptoms are typically viewed as evidence of weakness or personal failure, so that even under ideal circumstances, patients are unlikely to entertain or accept a behavioral explanation for their distress. The language used to describe symptoms can therefore be problematic, and labeling with psychiatric symptoms or diagnoses can alienate rather than recruit the patient.
The primary care physician must also be aware of and deal with her or his own misgivings about behavioral disorders. The stigma of mental illness is pervasive and originates in each of us. That is, none of us is comfortable with self disclosure, especially when it can result in being labeled crazy or mentally unfit. The primary care physician must overcome her or his own resistance to engage the patient in self revelation that can trigger fear, embarrassment, or shame.
Ideally, the primary care physician creates an environment that facilitates disclosure of sensitive, personal information. Effective interviewing that achieves this goal also helps maximize data gathering. Effective time management depends on having the skill not only to facilitate but also to tactfully limit patient self-disclosure or somatic preoccupation.
The most comprehensive and accurate information is obtained when the examination begins with open-ended questions and active listening followed by structured inquiry about specific symptoms and events. Open-ended questions give the patient the opportunity to tell things from his or her perspective, and active listening helps verify and enrich the patient's report. Active listening involves periodic feedback to the patient of what the clinician has understood so as to ascertain and clarify what the patient has said. It can also serve to limit and redirect the rambling of an unfocused patient. Active listening facilitates the assimilation of a comprehensive database, and it also conveys to the patient the clinician's sincere effort to understand and to empathize with the patient's circumstances. The clinician's listening attitude helps to establish trust and a collaborative, problem-solving partnership between patient and clinician.
A widely accepted format for organizing the findings of medical examination is the acronym SOAP (subjective, objective, assessment, plan). An alternative that focuses attention on behavior and emotional symptoms occurring in the context of the patient's life circumstances is captured by the acronym BATHE. Proposed by Stuart and Lieberman,3 the relevant terms and questions are listed in Table 1.
|Domain||Recommended Question or Statement||Rationale|
|Background||“What is going on in your life?”||Elicits life circumstances, potential stresses, etc.
Redirects patient from somatic focus
|Affect||“How do you feel about that?” or “How has that affected your mood?”||Allows the patient to report feelings, emotions|
|Trouble||“What about the situation troubles you the most?”||Focuses on the meaning of the circumstances to the patient|
|Handling||“How are you handling that?”||Provides an assessment of functioning and potentially a connection to the somatic complaint|
|Empathy||“That must be difficult for you” or “No wonder you're feeling the way you do”||Normalizes the patient's reaction and demonstrates the physician's understanding|
Adapted from Stuart MR, Libermann JA: The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician, 2nd ed. Westport, Conn: Praeger, 1993.
Although the BATHE technique was designed to help primary care physicians integrate effective, time-limited psychotherapy during a brief office visit, it also helps facilitate information gathering during patient evaluation. Once the patient's attention is directed to affect, behavior, and life circumstances, it may be easier to elicit other symptoms potentially relevant to an underlying behavioral disorder. Fundamentally, BATHEing the patient is a way of skillfully drawing attention to the patient's emotional life, reactions to illness and other potential stressors, and the possible relevance of these reactions to the manifesting problem.
The two most important goals of behavioral assessment are accurate formulation of the diagnosis and adequate assessment of risk.
The Guideline lists 16 domains of the clinical evaluation (Table 2). Although thorough psychiatric evaluation demands attention to all domains, targeted assessment by the primary care physician requires attention to history of present illness, past history of similar symptoms and treatment, family history of psychiatric symptoms and diagnosis, substance use, stressors, and level of function. Because most clinically significant behavioral disorders are chronic, recurrent, and familial, attention to the patient's past and family histories can help to confirm suspicion of an underlying behavioral disorder. Also, drug and alcohol abuse commonly accompany primary behavioral illness and cause or mimic secondary behavioral symptoms. Psychiatric diagnostic formulation is discussed more fully later and is summarized in Table 3.
|Domain||Essential*||Details to Explore|
|Reason for evaluation||×|
|History of present illness||×||Precise time and circumstances at onset of symptom(s)|
|Associated behavioral symptoms with special consideration to diagnostic criteria for psychiatric disorders common in primary care: major depression, bipolar disorder, anxiety disorders, eating disorders, substance use disorders, somatization|
|Past psychiatric history||×||Similar symptoms in past|
|Unexplained symptoms in past|
|Response to past treatment(s)|
|Family psychiatric history||×||Actual or suspected psychiatric symptoms or disorders|
|Suicide or suspicious death|
|Substance abuse (alcohol, drug, tobacco, inhalant)||×||Current and/or past use|
|Consequences (legal, physical, marital, interpersonal, vocational)|
|General medical history|
|Developmental, psychosocial, and sociocultural histories|
|Occupational and military histories|
|Review of systems|
|Mental status examination||×||Be vigilant and assess for indications of dangerousness: suicide, homicide, psychosis|
|Functional assessment||×||Can the patient return home, to his or her job?|
|Can the patient perform activities of daily living?|
|Current and baseline global assessments of functioning|
Adapted from American Psychiatric Association: Practice Guideline for the Psychiatric Evaluation of Adults, 2nd ed. Washington, DC, American Psychiatric Association, 2006.
* All domains are important. It is recommended, however, that those identified as essential be included in any rapid behavioral assessment by the primary care physician.
|I||Primary psychiatric disorder|
|II||Personality or developmental disorder|
|IV||Psychosocial or environmental problems that contribute to the current problem||Classification of problems:
Primary support group
|Access to health care|
|Interaction with the legal system; crime|
|Other psychosocial and environmental|
|V||Global assessment of functioning||Current level (0-100)|
|Highest level in the past year (0-100)|
Adapted from American Psychiatric Association: Diagnostic and Statistical Manual, 4th ed, text rev. Washington, DC, American Psychiatric Press, 2000.
Severity rating (based on clinician's judgment):
0 = None
1 = Mild
2 = Mild-to-moderate
3 = Moderate
4 = Moderate-to-severe
5 = Severe
90-100 = Superior functioning
80-89 = Expected response to usual stressors
70-79 = Mild symptoms and/or dysfunction
60-69 = Moderate symptoms and/or dysfunction
50-59 = Severe symptoms and/or dysfunction
40-49 = Elevated risk of harm to self or others
<40 = Acute risk of harm to self or others from psychosis, delirium, or dementia
Among the most important elements of behavioral evaluation is determination of risk of harm to self or others. Risk assessment has a critical impact on immediate treatment and triage decisions. Failure to assess risk adequately can lead to a potentially devastating outcome. Because of this, some clinicians might underreact by overlooking behavioral symptoms. Others might overreact by insisting on emergent psychiatric assessment at any mention of suicidal or homicidal thoughts or impulses. Knowing how to assess risk and when and where to seek emergency psychiatric consultation is important. In general, the clinician should determine whether the patient is safe to leave the office, and if so, whether or not return to work is advisable.
The World Health Organization (WHO) has developed guidelines to assist with this process.4 These are summarized in Box 1. Suicidal and homicidal thoughts, intentions, and planning are addressed in the mental status examination (MSE). More detailed discussion of these issues can be found in the chapter entitled “Management of Office-Based Behavioral Emergencies.”
|Box 1 Referral to Secondary Mental Health Services|
|Circumstances Warranting Referral|
|The patient displays signs of suicidal intent or seems to be a risk of harm to others.|
|The patient is so disabled by the mental disorder that he or she cannot leave the home, look after the children, or fulfill other activities of daily living.|
|The primary care physician requires the expertise of secondary care to confirm a diagnosis or implement specialist treatment.|
|The primary care physician feels that the therapeutic relationship with the patient has broken down.|
|The primary care interventions and voluntary/nonstatutory options have been exhausted.|
|The patient's physical condition has severely deteriorated.|
|A particular psychotropic medication is required (e.g., clozapine, lithium).|
|The patient requests a referral.|
|Considerations in Making a Referral|
|The physician should have access to a local resource directory.|
|The physician should consider coordination issues around the referral (e.g., care program approach, care manager).|
|The physician should consider implications for the continuing care of the physical health of the patient.|
|From: World Health Organization: Integrating mental health services into primary health care. Geneva, World Health Organization, 2007. Available at www.who.int/mental_health/policy/services/en/index.html(accessed March 15, 2009; Mental Health Policy, Planning and Service Development Information Sheet, Sheet 3.)|
Like the physical examination, the MSE is a structured, systematic method for collecting objective data pertinent both to diagnosis and to patient management. The paucity of clinically relevant laboratory, neuroimaging, and other quantifiable markers of psychopathology make effective mental status examination particularly important.
The elements of the MSE performed by psychiatrists are elaborated in the Guideline2; aspects relevant to the primary care physician are discussed here. Much of the patient's cognitive and emotional status can be inferred during the interview. Attention to important details, however, prevents incorrect inference and facilitates diagnostic accuracy and effective triage. Those interested in developing a more thorough understanding of psychiatric MSE should consult the Guideline and other sources.2, 6, 7
Summarized here and in Table 2 are important domains and details of the general mental status examination.
Hygiene and attire can help to distinguish a chronic from an acute process, such as chronic paranoid schizophrenia versus acute mania, acute psychosis, or toxic psychoses, delirium, or encephalopathy secondary to drug toxicity, metabolic disturbance, or an acute neurologic event (e.g., stroke, acute hypoglycemia, herpes encephalitis).
Look for tics, tremors, and other abnormal movements that suggest primary central nervous system disorders (e.g., Parkinson's disease, Tourette's syndrome, Huntington's disease) or extrapyramidal disorders secondary to antipsychotic drugs (e.g., akathisia, dystonia, parkinsonism, tardive dyskinesia).
Mood applies to the prevalent feeling(s) verbalized by the patient, whereas affect refers to the current expression of emotion. Affect is described according to its four features: quality (e.g., depressed, euphoric, silly, anxious, irritable, angry, flat, euthymic), intensity (e.g., bright, blunted), range (e.g., labile, constricted, normal), and congruence (i.e., with mood and thought content). Examples of incongruent mood and affect include the depressed, hopeless individual who intentionally exhibits a bright affect or the bipolar patient whose underlying depression is masked by manic or hypomanic affect.
Dysarthria due to substance-induced toxicity or central nervous system pathology is generally easily detected. Be careful to rule out aphasia in the patient whose disorganized verbal production might create a first impression of being psychotic, crazy, or stressed out. Simple tests that screen language function are included in the Mini-Mental State Examination (MMSE).8
Pressure of speech describes a person's inability to converse in an appropriate give-and-take fashion, to listen and refrain from speaking while another person speaks. Speech is described as pressured when the listener has difficulty interjecting. Pressured speech is a hallmark of mania, but should it not be confused for the nonstop ruminative speech of an anxious person or a patient's manipulative efforts to frustrate the examiner's quest for information. Speech that is both pressured and rapid, however, almost certainly indicates mania.
Abnormal perceptions include hallucinations (sensory experiences occurring in the absence of an identifiable stimulus), illusions (misinterpretation of an identifiable stimulus) and distortions (distorted perception of an identifiable stimulus, e.g., micropsia or macropsia). Well-formed, complex auditory hallucinations are more common than visual hallucinations. Both types of hallucinations can occur in schizophrenia and in depression or mania with psychotic features. However, any type of abnormal perception—especially illusions and distortions—should alert the clinician to a toxic, metabolic, structural or epileptic cause.
A formal thought disorder (i.e., a disorder of thought process or the form of thought) is thinking that is illogical and hard to follow, or concrete and void of meaningful content. Cognitive disturbances due to frontotemporal pathology (e.g., stroke, dementia, multiple sclerosis) typically produce abnormal form of thought that is concrete, overly detailed, or without clear relationship to other thoughts (loose associations). The literature on schizophrenia, whose hallmark is a formal thought disorder, points to underlying frontal cortical and corticothalamic dysfunction.
Rapid flow (rate) of thought is often described as flight of ideas and suggests mania. Psychomotor retardation describes the paucity and slowing of thought (and movement) associated with clinically significant major depression (see elsewhere in this section, “Recognition and Treatment of Depression”).
It is especially important, but often difficult, to examine the content of thought, because the validity of findings depends almost exclusively on the patient's openness and cooperation. Suicidal, homicidal, paranoid, and obsessive thoughts are examples of abnormal thought content whose disclosure is essential to accurate diagnosis and triage. Any indication that a patient has thoughts of harming himself or herself or someone else requires careful assessment of the intensity and frequency of such thoughts, the degree to which the patient intends to follow through, and the availability of means and circumstances that would permit follow-through (see the later chapter “Psychiatric Emergencies.”).
Often used as a synonym for “sensorium,” cognition technically refers to ability to reason, abstract, and calculate. Sensorium includes mental processes that regulate level of consciousness, attention, and memory (orientation, registration, and short- and long-term memory). Tests of attention and memory are included in the Mini-Mental State Examination,8 as are tests of speech and language (repetition, reading, writing, and comprehension) and constructional ability.
Level of insight is judged by the patient's ability to recognize whether or not he or she has an illness, and the degree to which it might or might not compromise the patient's function.
Judgment is determined by the patient's ability to register, process, manipulate, and act on information in a socially appropriate manner. Abnormalities of cognition, sensorium, behavior (e.g., agitation, combativeness), or affect (severe depression or mania) can interfere with sound judgment.
Although not included in the Guideline, executive functions include anticipating, planning, and organizing and executing tasks, functions that depend on an intact dorsolateral prefrontal cortex. Normal impulse control depends on intact orbitofrontal cortex function; high impulsivity can interfere with otherwise normal executive functioning. A quick and effective screen of higher cortical function is clock drawing.9
Physician-rated behavioral scales and structured interviews10 are largely relevant to research and not commonly employed in clinical practice. In contrast, patient-rated screening instruments can be a valuable source of data obtained at no cost of physician time (Table 4). Once collected, however, the patient's responses must be reviewed. Failure to review patients' responses can introduce potential liability if, for example, a patient makes a suicide attempt or successfully commits suicide after endorsing “suicidal ideation” on a screening form that was never reviewed by a professional.
|Depressed mood or loss of interest||Major depressive episode (single or recurrent) or Adjustment disorder with depressed mood||Beck Depression Inventory (BDI-II)||≥10 suggests at least mild clinically significant depression|
|Severity correlates positively with score|
|11-17 = mild|
|18-23 = moderate|
|≥24 = severe|
|Center for Epidemiologic Studies Depression Scale (CES-D)||≥16 compatible with clinically significant DSM-IV depression|
|Severity correlates positively with score|
|Zung Depression Scale||≥50 compatible with clinically significant depression|
|Patient Health Questionnaire 9 (PHQ-9)|
|Geriatric Depression Scale (short form)||3 ± 2 = normal|
|7 ± 3 = mildly depressed|
|12 ± 2 = very depressed|
|Depression with history of mania or hypomania||Bipolar disorder I or II; cyclothymia||Mood Disorder Questionnaire (MDQ)|
|Excessive worry/arousal||Generalized anxiety disorder||Zung Self-rating Anxiety Scale||>20 suggests clinically significant anxiety|
|Highest score = 80. Severity correlates positively with score|
|Anxiety attacks, unexplained episodic pain||Panic disorder||Resources available at http://www.neurotransmitter.net||None validated or normed|
|Withdrawn, shy||Social anxiety disorder||Liebowitz Social Anxiety Scale* http://www.socialanxietysupport.com/liebowitz.php|
|Flashbacks, social withdrawal||Posttraumatic stress disorder||Resources available at http://www.ptsd.va.gov/|
|Intrusive, unwanted thoughts and/or repetitive or ritualistic activity||Obsessive-compulsive disorder obsessive-compulsive personality disorder||Resources available at http://www.neurotransmitter.net||None validated or normed|
|Life-long trouble staying focused, getting things done, ± hyperactivity||Attention-deficit/hyperactivity disorder||Wender-Utah Rating Scale|
|Adult ADHD Self-Report Scale (ASRS)|
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision.
* Social phobia scoring scale 55-65 Moderate
>95 Very Severe
Patient-rated screening instruments can be valuable when used on an ad hoc basis to verify a clinical impression and to follow treatment progress. For example, the physician who suspects a clinically significant behavioral disorder can ask the patient to complete a patient-rated questionnaire or survey. The same instrument can be used at subsequent visits as a metric of progress. These instruments can assist with diagnostic verification and symptom measurement, and they provide a time-effective way of collecting and documenting clinically relevant data.
Self-reported behavioral symptoms can also be processed by computer to generate a valid behavioral diagnostic profile. Data that are entered into the computer by the patient manually or by telephone are rapidly analyzed so that valid diagnostic information is available within minutes. Shedler's Quick PsychoDiagnostic Profile5 and the Patient Health Questionnaire11 are based on DSM IV diagnostic criteria, have computerized formats, and deliver data analysis on five or more psychiatric disorders commonly seen by primary care physicians (major depression, dysthymia, panic disorder, generalized anxiety disorder, eating disorders, substance-use disorders, and somatization). The Patient Health Questionnaire 9 (see Table 4) is an abridged version of the Patient Health Questionnaire that focuses specifically on criteria for depression.
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM IV-TR)12 employs a multiaxial system to formulate a diagnosis of behavioral disorders. The five-axis system is depicted in Table 3. It is designed to capture the multiple variables that can contribute to the genesis, severity, and persistence of behavioral symptoms. Although not designed specifically for primary care practice, it is a standard format used by psychiatrists. Familiarity with it can facilitate communication between the primary care physician and mental health professionals.
Axis I codifies the primary psychiatric disorder (e.g., major depression, panic disorder, alcohol dependence, conversion disorder). In general, Axis I disorders have a discrete onset, are episodic, and dominate the clinical picture. A patient can have more than one primary psychiatric disorder (e.g., one patient can have major depression, panic disorder, alcohol dependence, and conversion disorder all at once).
Axis II codifies personality disorders. Personality is defined by typical, persistent, and predictable patterns of behavior, thinking, and feeling that characterize an individual person. Personality disorder is diagnosed when these distinctive patterns are maladaptive and cause significant conflict, distress, or dysfunction. Personality disorders often accompany Axis I disorders and can be difficult to differentiate. A core characteristic of personality disorder is a lack of insight that contributes to ongoing conflict with others and a profound sense of being misunderstood.
Axis III codifies current medical problems that may be relevant to the Axis I disorder (e.g., acute myocardial infarction followed by onset of a major depressive episode).
Axis IV codifies categories of stress and their severity. Fundamental to accurate formulation of the diagnosis is the recognition that diagnostic criteria (relevant symptoms, duration, and intensity) determine diagnosis—not the stressor(s) that might have triggered the Axis I disorder. For example, a common error is to assume that depressive symptoms and a difficult adjustment constitute a normal reaction in the wake of catastrophic or debilitating medical illness and therefore does not require specific treatment. If the patient meets symptom criteria for a diagnosis of major depression, then regardless of the type and intensity of stress, a diagnosis of major depressive episode is warranted. Symptom burden—not stress—is the principal determinant of diagnosis.
Axis V quantifies the current level of function and the highest level in the past year.
Some patients overuse or misuse the primary care physician's time and services. Many such patients have a behavioral disorder. Occasionally, effective treatment of a previously undiagnosed behavioral disorder solves the problem. In other instances, a multitude of medical and either primary or secondary behavioral disorders can complicate management. Some patients present repeatedly with multiple, often changing somatic complaints, and others manufacture complaints for secondary gain. Many of the most troublesome patients suffer from Axis I disorders (e.g., somatization disorder hypochondriasis, or factitious disorder) or Axis II disorders (e.g., borderline, dependent). These patients require special attention that entails limit-setting and delineation of clear, reasonable expectations. This important topic is discussed further elsewhere.13
Some chronic debilitating medical illnesses are associated with a high risk of secondary behavioral disorder (Box 2). The primary care physician should be alert to such patients and anticipate their need for specific behavioral treatment or referral.
|Box 2 Illnesses Commonly Associated with Behavioral Comorbidity|
|Cancer (especially pancreatic)|
|Chronic obstructive pulmonary disease|
|Congestive heart failure|
|Hepatitis C and its treatment with interferon|
|Human immunodeficiency virus infection or acquired immunodeficiency syndrome|
|Parkinson's disease and other movement disorders|
Patients who make threats or behave in ways that potentially endanger themselves or others must be identified and triaged appropriately. Access to appropriate services is often problematic and requires advance planning.
The pregnant patient with a behavioral disorder might require consultation with a psychiatrist to determine her optimal behavioral treatment program.