Today we will cover elements of the mental status exam that are particularly important in PTSD. These are important clues that will help you with diagnosis as well as gauge treatment response. Let's get started.
Today's Content Level: Beginner; Intermediate
REMINDER OF THE MENTAL STATUS EXAM COMPONENTS
APPEARANCE & BEHAVIOR
•Write this section with the goal of later being able to reconjure the person's most salient features on physical appearance and their behavior.
•There is no one-size-fits-all when it comes to appearance and behavior of patients with PTSD. Many patients with PTSD are suffering on the inside but still able to present themselves as well-kept and presentable. On the other hand some patients with debilitating PTSD may lack the focus and energy to bathe or properly groom and dress themselves or appear disheveled.
Some patients may have comorbid anxiety and present with "psychomotor agitation" associated with feelings of inner tension (hand wringing, hair pulling, pulling of clothes, pacing, fidgeting, hand or voice tremor, and inability to sit still).
Some patients may have comorbid depression and present with "psychomotor depression" which can be seen as generalized slowing of movements and speech (stooped posture, minimal spontaneous movements, downcast gaze, minimal eye contact with interviewer). Also observe for evidence of self-harm such as cut marks, burns, or scars.
•You may or may not observe hyper-vigilance as evidenced by an exaggerated startle response, frequently checking their surroundings, and overacting to things happening around them. In other patients you may observe more guarded or avoidance behaviors.
SPEECH / LANGUAGE
•Speech and language tends to be less affected in PTSD compared to other conditions such as psychotic, bipolar, or depressive disorders. Pay attention to rate, tone, volume, and rhythm.
•Patients with severe anxiety may have difficulty speaking such as stammering or a vocal tremor. Patients with comorbid depression may have decreased rate and volume and variation in tone of speech (slow, soft, and monotone).
MOOD / AFFECT
•Patient's may describe their mood in a number of ways such as angry, anxious, afraid, tense, hopeless, depressed, worthless, guilty, miserable, or exhausted.
•Other patients may deny any problems and may not appear to be particularly anxious or depressed at first glance. Family members or employers may suggest they come in for treatment due to social withdrawal, avoidance behaviors, insomnia, anger outbursts, or other behaviors.
•The emotional range can vary. They my present as blunted or restricted which are reductions in the range and intensity of emotional expression. They may also be guarded, which means filtering their emotional expression and using caution in disclosing information. Those with significant increased arousal may show more lability and higher emotional expression when experiencing acute anxiety.
THOUGHT PROCESS / THOUGHT CONTENT
•Disorders in thought process relate to the way in which ideas and languages are formulated and organized. PTSD alone does not typically cause a disorganized thought process.
•Thought content can commonly include negative beliefs about themselves or the world, distorted sense of self-blame, feelings of guilt or anger, and perseverations or worry about about the traumatic event. They may focus on feeling detached from others and inability to experience positive emotions.
•If present, clearly describe in your documentation the extent of their suicidal (and homicidal) thoughts and include their specific thoughts, their intent, plans, research, preparatory actions, etc. This will weigh heavily in your risk assessment and safety plan. Risk assessments are discussed in detail here and here.
"Flashbacks", dissociation, and other intrusive symptoms are not considered symptoms of psychosis, however they do share some common features.
Dissociation = depersonalization (feeling of being detached from your mental process or body) and derealization (feeling of unreality of surroundings). Some experts believe this is a modification of one's character/identity that facilitates avoidance of emotional distress and can be a common numbing response to trauma.
Flashback = a type of dissociative reaction where you may temporarily lose connection with your present situation and feel like you are actually transported back to the traumatic event. In severe flashbacks you may see, hear, or smell things that are not actually present (compare with psychosis).
•Commonly obtained through a general sense of cognitive functioning obtained through conversation, however additional tests (MMSE, MoCA) can expand this exam if needed.
•Severe PTSD can lead to difficulty concentrating and even amnesia regarding certain events. Additionally, preoccupation on the effects of the trauma may leave little mental energy for other tasks.
INSIGHT / JUDGEMENT
•Does the patient attribute their symptoms to a mental disorder? Are they unconvinced of a problem?
•A hallmark of PTSD, among other anxiety disorders, is avoidance behaviors. Even though they are often aware their fears are out of proportion to the actual threat they still often find the symptoms to be intolerable and thus they leave/avoid situations where they have come to expect these symptoms.
•Judgment is best assessed by reviewing patients' actions in the recent past and their behaviors during the interview.
Nice work today. We covered some important factors regarding the mental status exam in patients with PTSD. Next lesson will be a discussion on trauma-focused psychotherapy.
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