Today we will cover elements of the mental status exam that are particularly important in depressive disorders. 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
•There is no one-size-fits-all when it comes to appearance and behavior of patients with anxiety.
•Many patients with anxiety are suffering on the inside but still able to present themselves as well-kept. On the other hand some patients with debilitating agoraphobia or generalized anxiety may lack the ability and focus to bathe or properly groom and dress themselves or appear disheveled.
•Write this section with the goal of later being able to reconjure the person's most salient features on physical appearance and their behavior.
•Socially anxious patients may have poor eye contact and averted gaze.
•May have psychomotor agitation which is a term used to describe excessive motor activity associated with a feeling of inner tension. Behaviors seen include hand wringing, hair pulling, pulling of clothes, pacing, fidgeting, hand or voice tremor, and inability to sit still.
SPEECH / LANGUAGE
•Speech and language tends to be less affected in anxiety disorders compared to other conditions such as psychotic, bipolar, or depressive disorders. Pay attention to rate, tone, volume, and rhythm.
•Patients with severe anxiety or those in the middle of a panic attack may have difficulty speaking such as stammering or a vocal tremor.
MOOD / AFFECT
•Patient's may describe their mood as anxious, nervous, worried, afraid, tense, exhausted, frustrated, "on edge", or irritable. Patient's experiencing a panic attack may say they feel like they are dying.
•Anxiety is obviously the core clinical feature, however it is important to realize that some patients primarily choose to discuss a particular somatic complaint (insomnia, GI distress, etc...) or may describe depressed mood as their primary symptom.
•Other patients may deny any problems and may not appear to be particularly anxious at first glance. Family members or employers may suggest they come in for treatment due to social withdrawal, avoidance behaviors, ruminations, decreased activities, or other behaviors.
•The emotional range can vary. Those with social anxiety or generalized anxiety may presents as more blunted or restricted which are a reduction 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 panic disorder or agoraphobia might show more lability and higher emotional expression when experiencing acute anxiety.
•Remember that anxiety disorders and depressive disorders are highly comorbid and thus patients may present more like a depressed patient. See MSE in depressive disorders.
THOUGHT PROCESS / THOUGHT CONTENT
•Anxious patients, like depressed patients, sometimes have negative views of themselves and of the world.
•Thought content frequently includes perseverations and ruminations which is described as continuous brooding or worry about past or future negative events.
The content of these perseverations will vary somewhat among anxiety disorders. Examples include:
Panic disorder: During an attack they will experience extreme fear and a sense of impending death and doom. They have often are unable to name the source of their fear. Between attacks they may have anticipatory anxiety about having another attack.
Specific phobia: Irrational and ego-dystonic fear of a specific situation, activity, or object.
Social anxiety: Preoccupation with fear of embarrassment, judgement, or rejection in social situations.
Generalized anxiety: May be hyper-focused on their anxiety and difficulty controlling their worries. Their concerns will be broad and mostly about future unknowns. However, commonly they may be more focused on somatic symptoms (insomnia, chronic diarrhea, muscle pain, etc..).
•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. We will discuss this in depth in a later article.
•Commonly obtained through a general sense of cognitive functioning obtained through conversation, however additional tests (MMSE, MoCA) can expand this exam if needed.
•Severe anxiety can lead to difficulty concentrating and may also lead to confusion. Notable examples include panic disorder and generalized anxiety disorder. Both can lead to difficulty concentrating, their mind "going blank", and difficulty focusing on anything other than their anxious ruminations.
INSIGHT / JUDGEMENT
•Does the patient attribute their symptoms to a mental disorder? Are they unconvinced of a problem?
•Anxiety disorders, particularly social anxiety disorder and other phobia's, are typically ego-dystonic. In this context this means they often have good insight into the fact that their fears and anxiety are out of proportion to the actual threat. This does not make it any easier, however, to control their symptoms.
•A hallmark of anxiety disorders are avoidance behaviors. Even though they are often aware their fears are out of proportion to the actual threat they still often find the anxiety 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 anxiety disorders. Next lesson will be a discussion on the medical workup for anxiety.
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