Chapter Outline
Myths and Stigmas Attached to Psychiatric Illness
The Physician Assistant–Patient Encounter
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
Expectations of Physician Assistant Students on Psychiatric Clinical Rotations
The Role and Future Physician Assistants in Psychiatry
Similar to many physical disorders, mental and behavioral disorders are the result of a complex interaction among biological, psychological, and social or environmental factors. Physician assistants (PAs) must realize that the concept of mental health includes an amalgam of subjective well-being, perceived self-efficacy, autonomy, competence, intergenerational dependence, and self-actualization of one’s intellectual and emotional potential.
Behavioral medicine skills are imperative for the practicing PAs in any specialty field, not just primary care. The goal of this chapter is to help PA providers and students understand the interrelationship among psychological, physical, social, and cultural issues of patients.
In this chapter, the following elements are introduced:
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A brief history of mental illness
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Common myths and stigmas regarding the psychiatric patient
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The importance of empathy and building rapport with patients
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Strategies in approaching psychiatric patients
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Skills necessary for managing mental health needs of patients
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Models to better understand concepts in behavioral medicine
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Treatment and screening tools for specific disorders
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Suggestions on how we might accept challenges in the future
History of Mental Illness
Throughout history, many cultures have viewed mental illness as a form of religious punishment or demonic possession. In ancient Egypt, Greece, and Rome, mental illness was categorized as a religious or personal problem. During the Middle Ages, mentally ill individuals were believed to be possessed or in need of religion. Negative attitudes toward mental illness persisted into the 18th and 19th centuries in the United States, leading to stigmatization of mental illness and unhygienic (and often degrading) confinement of mentally ill individuals. A movement toward deinstitutionalization became popular in many countries, which forced the closure of many asylums and institutions because of mistreated patients, bad management and poor administration, lack of resources, lack of staff, lack of training, and inadequate quality assurance protocols.
Myths and Stigmas Attached to Psychiatric Illness
- 1.
Assume the patient is psychotic, violent, or dangerous.
- 2.
Suspicions that the patient is “faking” symptoms or seeking attention
- 3.
“There is nothing you can do as a provider if symptoms are severe.”
- 4.
Psychiatric illnesses usually do not exist in children and adolescents, but if they do, then unfortunately, they are “ruined for life.”
- 5.
Psychiatric disorders are not “real” medical illnesses.
- 6.
The patients are just plain “crazy.”
- 7.
Depression equates to “mentally weak” (or lazy) or some character flaw. “They just need to snap out of it.”
- 8.
Addiction is the result of a person having “no willpower.”
- 9.
Psychiatric illness is probably the product of nurture versus nature, and thus bad parenting was involved.
- 10.
Assume the psychiatric patient is or will become a criminal. (However, mental health issues do exist in correctional institutions and do present a definite health disparity; this is discussed in a separate chapter.)
Awareness of your Own Biases
What is your personal philosophy on life? How does this balance with your professional life?
When PAs vow to care for the lives of others they are confronted with their own humanity and provided a grave responsibility as a health care provider. They must be mindful of their physical, emotional, and spiritual health in order to be effective clinicians who focus on the well-being of others.
Empathy and Rapport
Everyone makes choices and engages in behaviors that affect their health, whether positive or negative. The key to success in dealing with even challenging or “difficult” patients is to put aside disagreement or any negative judgment and imagine what it must be like from their perspective. The power of empathy allows for an alliance with the provider and patient, which not only increases patient satisfaction but also helps improve patient outcomes. Although empathy is not generally considered a therapeutic tool, in the realm of behavioral medicine, it is one of the most powerful clinical tools to support and encourage healthy behaviors.
The Physician Assistant–Patient Encounter
The Approach to the Patient
The initial psychiatric interview is one of the most important components of a psychiatric diagnostic evaluation. It is a crucial skill that can be learned and developed over time. The encounter begins with nonverbal communication during the very first meeting of a patient in an outpatient clinic or inpatient hospital unit. The PA must observe the patient’s behavior and body language both before and during the encounter. The best way for a provider to begin gathering information from a patient is to start with open-ended, nonfocused questions.
Identifying Information
When documenting the psychiatric patient encounter, begin with identifying information similar to any other medical record. Include the patient’s name, age, marital status, race or ethnicity, gender, occupation, and referral source.
For example, Jane Doe is a 45-year-old single white woman with a history of paranoid schizophrenia who was admitted involuntarily for suicidal ideation. It is important to identify the source of the information whether it is the patient, a family member, a friend, or other. Reliability of the source must be included as well.
Chief Complaint and History of Present Illness
The chief complaint is a brief statement using the patient’s own words and states the reason for presentation. For example, “I don’t know why I am here; the sheriff brought me into the hospital.” As in any medical history, the history of present illness outlines the current symptoms and identifies reasons leading up to patient presentation. The description of the patient’s illness must be balanced in the documentation so as to not include extraneous details but rather lead to a pointed diagnosis and treatment plan. If the patient’s condition is chronic, begin with the most recent onset of the episode. Inquire about the course of illness, including aggravating and alleviating factors. Elicit any triggers or stressors that precipitated this episode, such as work, school, legal, medical, financial, or interpersonal problems. Document symptoms, severity, and associated factors for each diagnosis. For the psychiatric history, it is extremely important to quote the patient’s own words, especially if hallucinations or delusions are present. In considering a diagnosis, inquire and document pertinent positive and negative symptoms to construct the appropriate differential diagnosis.
Past Psychiatric History
This section should encompass the first psychiatric onset of symptoms and further review in detail any past or current diagnoses. Past pharmacologic treatments should be well documented, including details of medication doses, length of trial, reason for discontinuation, and response to the medication. Previous hospitalizations should also be included, with dates, lengths of stay, and reasons for admission. Inquire about past (or present) suicidal behavior (ideation, intent, plan, attempts) and self-harm behaviors (cutting or burning for relief of distress). Finally, obtain patient information regarding past visits to psychologists, counselors, and psychiatrists.
Social History
It is important to learn details about the patient’s personal and social life. Review the patient’s developmental history, home environment, relationships with parents and siblings, academic and behavioral performance in school, highest level of education, legal issues, traumatic events, past and current employment, marital or relationship status, sexual history, children, religion, hobbies, diet and exercise, and any military service. Learn about the patient’s support system. Discover the patient’s expectations and if there are any safety concerns. The PA must establish whether the patient has an addictive personality or history of substance use, including caffeine, tobacco, alcohol, or illicit drug use. Additionally, have there been any consequences because of substance misuse such as legal issues? It is important to note the patient’s history of seizures or delirium tremens because it could indicate recurrent behavior and withdrawal symptoms. Discuss with the patient previous attempts for treatment, such as rehabilitation or self-help groups and whether they were found valuable.
Family History
Many psychiatric illnesses have a genetic predisposition. Family history should include any mental illness, hospitalizations, or suicide in family members. Family history of suicide attempts is a significant risk factor for suicide in psychiatric patients. Document the family history of substance abuse and medications that have worked for family members. If a medication has worked for a family member with the same disease, there is an increased chance it will be efficacious for the patient.
Past Medical History
Although the priority may be focused on the psychiatric history, the clinician should detail a comprehensive past medical history as well. Certain comorbidities have increased risk for mental illness, including seizures, traumatic brain injuries, episodes of unconsciousness, and other central nervous system disorders. Other conditions may affect mental health such as diabetes, metabolic syndrome, hepatic or renal disease, or reproductive dysfunction.
Psychiatric Review of Systems
It is good medical practice to screen for other psychiatric illnesses. Major depression is one of the most common mental illnesses, with a worldwide lifetime prevalence of approximately 12%. The PA should be aware that in most countries, the majority of cases of depression go unrecognized in primary care settings and that in many cultures, somatic symptoms are very likely to constitute the presenting complaint. An excellent screening tool for major depressive disorder is to use the classic mnemonic SIGEMCAPS ( Box 29.1 ). If the patient admits to five of nine symptoms, this should give the PA reason to suspect a major depressive disorder.
S leep changes: insomnia or hypersomnia
I nterest: loss of interest (anhedonia) in activities previously enjoyed; lack of motivation
G uilt: feelings of guilt or hopelessness or worthlessness
E nergy: lack of energy; fatigue is a common complaint
M ood: depressed, sadness
C oncentration: difficulty concentrating, up to memory loss
A ppetite: change in appetite may include an increase or decrease, which may lead to weight gain or weight loss
P sychomotor: retardation or agitation
S uicidal ideation: preoccupation with death
The psychiatric review of systems should also include screening for history of mania, psychosis (hallucinations or delusions), anxiety (generalized, panic, social), obsessions or compulsions, posttraumatic stress disorder, substance use disorders, personality disorders, eating disorders, attention or impulsive symptoms, and cognitive impairments. For example, when screening for bipolar disorder, ask the patient if (at any point in his or her life) for more than 4 to 7 days, felt on “top of the world” and not his or her usual self. Consider other disorders that may have overlapping symptoms. For example, a patient might have concerns about attention deficit hyperactivity disorder because she or he has problems concentrating or concerns with Alzheimer disease because he or she is experiencing memory loss. However, it is important to note that depression and anxiety may also include these symptoms.
Mental Status Examination
The mental status examination (MSE) is an important clinical assessment tool in which the provider may determine the patient’s state of mind through observation and open-ended questioning under several domains including appearance, behaviors, speech, mood/affect, thought content, thought process, perception, cognition, insight and judgment. Information on the MSE can be found in Box 29.2 . The clinician should be careful to not misinterpret low education level, poor language skills, impaired vision, or cultural diversity.
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