Identification of Symptoms of Mental disorder

 

Identification of Symptoms of Mental disorder

Daniel Chisholm (1996) looks at the nature of mental disorder as being heterogeneous and uncertain as well as chronic. He observes that one of the inherent characteristics of mental disorder is its heterogeneity, in terms of its aetiology and the behavioural symptoms manifested by sufferers. There is a consequent unpredictability and uncertainty surrounding decisions regarding the diagnosis, prognosis and treatment of a person with mental health problems that, if not unique in health care, is far in excess of all but a few somatic disorders. Put another way, whilst there is as much uncertainty in mental health as there is in other health sectors with regard to when illness will occur, the mental health professional — or society in general — faces an unusually high level of intrinsic uncertainty with regard to how a mental disorder is to be defined, assessed and managed. In terms of chronicity, mental disorder tends to be of a more long-standing, chronic nature than all but a few somatic disorders. Episodes of mental disorder can last many months or even years before symptoms diminish, and periods of illness and relapse may be repeated over a lifetime. For instance, people who are depressed and who have experienced two or more episodes in the preceding five years have a 70 to 80 per cent chance of experiencing a further two or more episodes during the subsequent five years (Angst, 1992). Over time, therefore, mental disorder presents a different profile of resource allocation and consumption to many somatic disorders. This long-term, comprehensive view of the costs of illness is most pertinent, and the virtues of prevention or early intervention most apparent, in child psychiatry: the future costs of delinquency may far outweigh the costs of treatment at an early age.

 

Someone with a ―healthy mind has clear thoughts, the ability to solve the problems of daily life, enjoys good relationships with friends, family, and work colleagues, is spiritually at ease, and can bring happiness to others. Mental disorder then can be defined as any illness experienced by a person which cause severe disturbances in life often resulting in an inability to cope with the ordinary demands of life. A person is affected in his emotions, feelings, and relating with others, thoughts or behaviour, is out of keeping with their cultural beliefs and personality, and produces a negative effect on their lives or the lives of their families. Symptoms of illness can appear in the form of persistent changes in mood, perception of reality, or capacity to organize or maintain thoughts. Such changes will interfere with the per-son‘s usual beliefs, personality or social function.

 

These symptoms cause great distress to the person affected. Symptoms vary, and every individual is unique. But all persons with mental disorder have some of the thought, feeling, or behavioural characteristics listed below. While a single symptom or isolated event is not necessarily a sign of mental disorder, professional help should be sought if symptoms increase or persist. Often the symptoms of mental disorder are cyclic, varying in severity from time to time. The duration of an episode also varies; some persons are affected for a few weeks or months while for others the illness may last many years or a lifetime.

 

§  Social withdrawal: Sitting and doing nothing; friendlessness; abnormal self centeredness; dropping out of activities; decline in academic or athletic performance.

§  Depression: coming out of nowhere, unrelated to events or circumstances; loss of interest in once pleasurable activities; expressions of hopelessness; excessive fatigue and sleepiness; inability to sleep; pessimism; perceiving the world as “dead”; thinking or talking about suicide.

§  Thought disorders: Inability to concentrate or cope with minor problems; irrational statements; peculiar use of words or language structure; excessive fears or suspiciousness.

§  Expression of feelings: hostility from one formerly passive and compliant; indifference, even in highly important situations; inability to cry; excessive crying; inability to express joy; inappropriate laughter.

§  Behaviour: hyperactivity or inactivity, or alternating between the two; deterioration in personal hygiene. Noticeable and rapid weight loss; drug or alcohol abuse; forgetfulness and loss of valuable possessions; attempts to escape through geographic change; frequent moves or hitchhiking trips; bizarre behaviour (staring, strange posturing); unusual sensitivity to noise, light, clothing.

 

  The Psychiatric History

 

Mental illness frequently arouses resentment, fear, guilt, shame, and anxiety in patients and relatives. These may manifest themselves by attitudes of defensiveness, anger, or by bewilderment. The health worker should be aware of this and attempt to make each history taking an exercise in psychotherapy. In addition, to obtaining much information from family members, the interviews should orient the family members, allay some of their anxiety and give them a better understanding of the causes of emotional illness. The members of the family should be encouraged through their interest in the patient to share as much information as possible. They can also be told in general terms about some of the problems the patient is facing. With better understanding on the part of the relatives, they will be able to be more cooperative in following through recommendations for further care or hospitalization, changes in the home, and attitudes toward the patient.

 

Discussions with the relatives should avoid the extremes of alarmism or undue optimism. In speaking to them, language should be used which is understandable in terms of their own culture pattern. Special care should be exercised to protect the patient's interests and not give information to the relatives that could be used against him or that could be misinterpreted by the family. After the initial interview, the family should be seen whenever necessary or at their request. They should be kept informed of the patient's progress. Any communication with the family members or with others concerned with the patient's welfare should be undertaken with the full knowledge of the patient. There must be no question in the patient's mind about the confidentiality of what transpires between him and his health worker.

 

Therefore , the psychiatric history is used to identify the existence of psychological distress and symptoms of illness. Information obtained can be used to guide the healthcare provider‘s impressions and therapeutic interventions. Psychological distress and mental disorder may be influenced by past and present experiences and circumstances. A psychiatric history is a description of the habits, activities, relationships, and physical conditions that have shaped the way one feels, thinks, and behaves. The psychiatric history is obtained by interviewing the individual or asking a series of questions associated with their psychological function. In taking a psychiatric history and assessing the mental state, it is crucial both to establish and maintain rapport and to be systematic in obtaining the necessary information. The outline below is intended as a schema for written documentation. Greater flexibility is clearly required during the interview.

 

The history begins with an introduction noting the patient’s name, age, marital status, occupation, ethnic origin, religion and circumstances of referral. Then follows the Chief complaint (a concise statement of the patient‘s psychiatric problem in his or her own words) and the history of the present illness (current circumstances in which current psychiatric symptoms have occurred covering; duration, precipitating factors, effect on interpersonal relationships, working capacity and details of treatment to date). In the family history, note parents’/siblings’ ages, occupations, physical and mental health and relationships with the patient. If a relative is deceased, note the cause of death and the patient’s age at the time of death. Enquiry is made into any blood relatives with history of psychiatric symptoms, like nervous breakdowns’ suicide, drug/alcohol abuse and forensic encounters, treatment, or psychiatric hospitalizations.

 

The personal history begins with the patient’s early life and development including details of the pregnancy (? planned) and birth (especially complications). Any serious illnesses, separations in childhood or delays in development are noted. History of alcohol or substance abuse or dependence – length or period of abuse/dependence; date and amount of last use; history of drug treatment or rehabilitation programs. The childhood home environment is described (geographical situation, atmosphere) as are details of school (academic achievements, relationships with peers, teachers). The occupational history should list jobs, reasons for change, work satisfaction, relationships with colleagues. Document details of sexual practices (past/present abuse, sexual orientation, difficulties, satisfaction), relationships, marriage (duration, details of partner, children) and, in the case of women, menstrual pattern, contraception, miscarriages, stillbirths and terminations of pregnancy.

 

Previous psychiatric history. An inquiry is made of any prior psychiatric symptoms, treatment (therapy or medication); prior psychiatric hospitalizations (dates of illnesses, symptoms, diagnoses, treatments, hospitalizations) and past medical and surgical history are obtained. The medical history should address significant medical conditions, treatments/surgeries; current medications; history of allergies to medications or other agents; history of head injuries; seizures; loss of consciousness or other neurological disorders.

 

Social history – place of birth; description of family members; marital status; education obtained; occupations past and present. The patient’s alcohol, drug (prescribed and recreational) and tobacco consumption and any forensic history are recorded. The patient’s attitude to and practice of religion, politics and hobbies are noted.

 

The premorbid personality (e.g. character, social relations) and finally, details of the present circumstances (accommodation, occupation, financial details), are described.

 

 Mental State Examination (MSE)

 

A record of the patient's mental status is part of every completely recorded history of illness. In the form here suggested, it follows the record of the Physical Examination. How much of the complete MSE is administered and at what point or points in the total relationship with the patient this is done, depends on each individual case. In many instances, as will be elaborated below, much necessary minimum information can be elicited in the course of taking the patient's history and during the physical examination. This may be sufficient to give adequate data for an estimate of the status of the patient's mental functioning and may provide adequate material for a useful record. In instances where no further formal examination may be necessary a number of areas of mental functioning will have been found to be grossly intact in the course of history-taking and other initial contacts with the patient. These might include the formal headings of:

 

• Appearance and Behaviour
• Speech
• Mood
• Thought Content
• Perception
• Orientation as to time space and person

 

It should be remembered that a patient may be too ill to be subjected to a prolonged MSE. Here again, many pertinent data can be obtained during the necessary initial contact with the patient and more formal examination, if deemed indicated, may be postponed. The fact of the patient's refusal to cooperate in some of the more specific areas of the MSE is not in itself a contraindication to pursuing the examination further. Such refusal needs to be understood on its own terms and may be an important datum towards establishing, for instance, the presence of a sensorial defect. The patient in this case may be reacting to his anxiety about the presence of such a defeat by refusal to participate in its demonstration. The skillful examiner then seeks other avenues through his developing relationship to the patient to obtain the needed confirmation. When, early in the course of examination of the patient, defects are detected in some of the areas mentioned above (or in others elaborated below), more formal and detailed examination is in order. This is also almost always the case in any patient whose complaints when first seen are primarily in the area of mental functioning.

 

A written record of the MSE should always be made regardless of factors limiting the extent of the examination itself. No matter how scattered the sources from which the information has been gathered in the course of the total contact with the patient, the accumulated data should be recorded in an organized fashion. One possible form of organizing them is suggested below.

 

 The Technique of Performing the Mental Status Examination

 

Much of the success and validity of this examination will depend on the way the examiner approaches the patient. All aspects of the patient's behaviour are data, including his reaction to the examination itself. Much depends on the examiner's attitude towards this part of the total examination of the patient. The patient senses quickly if the examiner considers his task in this area a routine, which has to be performed for the sake of "completeness" of the record. Perfunctoriness on the part of the examiner, lack of understanding of the purpose of the examination, defensiveness about administering various parts of the examination - all these are reflected in the test results and their validity. As many as possible of the items enumerated below should be obtained during the course of general history taking. Those parts of the MSE, which require specific questioning, should be done with thorough knowledge of their purpose. This should be done in the same matter-of-fact manner as one examines those areas of the body which often are invested with special significance by the patient, but the thorough examination of which are usually accepted by the patient as a matter of necessity. By the time MSE is begun, after initial history taking, certain background facts about the patient will be known which will, to some extent, determine the choice of some of the specific items in the examination (e.g., in the area of "general information"). These background facts include education, occupation, socioeconomic status, age, sex and marital status.

 

Conditions, at the time of examination, also have a great potential influence on the results and their validity. These conditions should be established and later recorded (e.g., patient's experiences with regard to drugs, alcohol, recent sleep disturbances, acuteness of present illness, time of day of the examination , and the physical surroundings in which it was given--on the hospital division, in the physician's office, etc.).

 

So what see is that the mental status examination is an organized systematic framework for noting observations that are made while interviewing individuals. In general, it involves categorizing observations in terms of behaviour and appearance; thought, feelings, judgment, insight, and other functions such as memory and concentration. The elements making up a complete mental status examination are outlined below.

 

Elements of the Mental Status Examination (MSE)

 

1. Assessment of The patient’s Initial Appearance and Behaviour e.g. gait; grooming; posture, including general health, demeanour, manner, rapport, eye contact, degree of cooperation, cleanliness, clothing, self-care, facial expression, posture, motor activity, which may be excessive (agitation) or decreased (retardation), abnormal movements (tics, chorea, tremor), stereotypy (purposeless), mannerisms (goal-directed, understandable), gait abnormality or striking physical features are documented.
2. Assessment of Motoric behaviour –e.g. physical agitation or retardation; tremors; anxiety.
3. Assessment of Speech is described in terms of rate slow; rapid; loud; soft/inaudible; stuttering; slurring; paucity; over-inclusive, quantity. (When increased = pressure [often with associated ‘flight of ideas’]; decreased = poverty), and pattern (spontaneity, coherence, rationality, directness [to the point or discursive] and perseveration [repeating words or topics]). Abnormal words (neologisms), puns or rhymes should be noted, giving verbatim examples if abnormal. Abnormal form of thought may be deduced, for example where connections between statements are difficult to follow (‘loosening of associations’). The patient’s subjective experience of thought may be abnormal as in thought block (thoughts disappear: ‘my mind goes blank’) slow; rapid; loud; soft/inaudible; stuttering; slurring; paucity; over-inclusive.
4. Assessment of Attitude –e.g. cooperative; irritable; angry; aggressive; defensive; guarded; apathetic.
5. Assessment of Changes in mood and affect are the commonest symptoms of psychiatric disorder, but also occur in physical illness and in healthy people at times of adversity. Mood refers to subjective emotion as experienced by the individual. Abnormal mood states include: sadness, happiness, irritability, depression, elation, euphoria (unconcerned contentment), anxiety and anger. It should be noted whether mood is consistent with thoughts and actions, or ‘incongruous’, while affect is the observed (and often more transient) external manifestation of that emotion. Mood has been compared to climate, and affect to weather. Abnormalities of affect include blunting, lability, perplexity and suspiciousness.
6. Assessment of Disorders of thought content and processing include non-psychotic phenomena such as obsessional ideas (recurrent thoughts, feelings, images or impulses which are intrusive, persistent, senseless, unwelcome but recognized as the patient’s own [in contrast to delusions which are persistent beliefs that is inconsistent with reality] and phobias (fear/anxiety which is out of proportion to the situation, cannot be reasoned or explained away and leads to avoidance behaviour). Suicidal or homicidal ideation (thoughts) and intent (plans) are crucial.
7. Assessment of Abnormalities of perception include illusions (distortions of perception of an external stimulus, e.g. interpreting a curtain cord as a snake); hallucinations (perceptions in the absence of an external stimulus which are experienced both as true and coming from the outside world); and pseudo-hallucinations (internal perceptions with preserved insight). Hallucinations can occur in any sensory modality, although auditory and visual are commonest. Some auditory hallucinations occur in normal individuals, when falling asleep (hypnagogic) or on waking (hypnopompic). Hallucinations may be auditory, visual, tactile, or olfactory hallucinations.
8. Assessment of Judgment – ability to understand relationships between facts and to draw appropriate conclusions.
9. An assessment of the patient’s insight (degree of correct understanding a patient has of his/her condition and its cause as well as his/her willingness to accept treatment) is made, after which the examiner notes his/her reaction to the patient. Is the patient able or willing to understand his or her condition.
10. Assessment of Cognition:

·     Level of consciousness – alert; cloudy; confused.

·     Orientation. Within the cognitive assessment, the following are noted: level of consciousness, memory (long- and short-term, immediate recall), orientation in time (day, date, time), place, person, attention and concentration, general knowledge and intelligence. Educational background must be taken into account.

·     Memory – long-term (events of the past such as place of birth; date of marriage or graduations); recent (events of yesterday or last week); short-term (test recall of 3 items after a period of 5 minutes).

·     Concentration or attention (You may do a serial 5 test – start at 100 and count backwards by 5).

·     Executive function or ability to reason – abstraction – how are an apple and banana similar? Interpretation of a proverb appropriate to culture; test naming or word finding skill (e.g. can the individual name different parts of a watch/time-piece).

·     visual-motor coordination, in basic terms, may be defined as the brain‘s ability to coordinate information perceived by a sensory organ (the eyes) with complex motor functions (such as writing). Visual-motor coordination is tested by asking the individual to draw an object or figure visualized. For example, draw a circle that is connected to a rectangle and ask the individual to copy the figure. An inability to copy the figure accurately may be an indication of conditions such as brain damage due to medical disease or drug abuse (e.g. Alzheimer‘s disease; alcohol dementia;), schizophrenia, or mental retardation.

11. Assessment of Abnormal beliefs include overvalued ideas (abnormal beliefs or intense preoccupations, firmly held but comprehensible in the light of the subject’s past experience and culturally shared belief systems). An example of this would be an intense but non-delusional feeling of guilty responsibility following bereavement. Ideas of reference are when the patient feels that other people look at or talk about him/her because they notice things about him/her, but insight (see below) is retained. Delusions (fixed, false, firmly held beliefs out of keeping with the patient’s culture, unaltered by evidence to the contrary, and for which the patient has no insight) may be primary (no discernible connection with any previous experience or mood; autochthonous) or secondary (e.g. to mood). Passivity feelings are when the patient experiences outside control of or interference with his/her actions, feelings, perceptions and thoughts (thought interference). The latter may involve thought insertion or withdrawal (thoughts being put into and taken out of the person’s mind) and thought broadcast (the experience that others can hear or read the individual’s mind/thoughts).