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, people believed mentally ill individuals were possessed or in need of religion. Negative attitudes toward mental illness persisted into the 18th and 19th centuries in the United States, leading to the stigmatization of mental illness and the unhygienic (often degrading) confinement of mentally ill individuals. Around the mid-20th century, a movement toward deinstitutionalization became popular in several countries and forced the closure of many asylums and institutions because of issues related to mistreated patients, bad management and poor administration, insufficient resources, lack of staff, lack of staff training, and inadequate quality assurance protocols. Today, because of the deinstitutionalization movement, most patients with mental illness receive care in community-based settings.
Like many physical disorders, mental and behavioral disorders are the result of complex interactions among biological, psychological, and social or environmental factors. The terms behavioral health and mental health are often used interchangeably. Behavioral health, however, is a broader designation that includes ways of promoting well-being, as well as ways to prevent or intervene in mental illness. The terms mental illness and psychiatric illness also tend to be used interchangeably. Unless a person has a psychiatric disability, using the term mental illness is generally considered less labeling. Regarding mental health in general, physician assistants (PAs) should be aware 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 health skills are imperative for practicing PAs in any specialty field, not just psychiatry and primary care. One goal of this chapter is to help PA students and providers understand the inter-relationship between patients’ psychological, physical, and social issues. In addition, the chapter provides an overview of the approach to patients in behavioral (or mental) health settings and discusses expectations for PA students completing behavioral health rotations.
Approach to the patient
What is your personal philosophy of life? How does it balance with your professional life? When PAs vow to care for the lives of others, they are entrusted with a profound responsibility. Therefore they must thoughtfully consider their approach to care. To be effective clinicians focused on the well-being of others, they must be mindful of their own physical and emotional health. Before the start of a rotation in a behavioral health setting, it may be useful to reflect on one’s own potential biases by considering myths and stigmas attached to patients with mental illness. They include:
Patients are psychotic, violent, or dangerous.
Patients are “faking” symptoms or seeking attention.
“There is nothing you can do as a provider if symptoms are severe.”
Psychiatric illnesses usually do not exist in children and adolescents. When they do, unfortunately the child or adolescent is “ruined for life.”
Psychiatric disorders are not “real” medical illnesses.
Patients are just plain “crazy.”
Depression equates to being “mentally weak” (or lazy) or having some character flaw. “They just need to snap out of it.”
Addiction is the result of a person having “no willpower.”
Psychiatric illness is probably the product of nurture versus nature, and thus bad parenting is involved.
The psychiatric patient is or will become a criminal. (Disparity in the number of individuals with psychiatric illnesses in correctional institutions is discussed in chapter 49 ).
As you begin to see patients in behavioral health settings, consider how the stigma associated with misconceptions about psychiatric illness affects patients and their care.
A typical day in behavioral health settings
Psychiatry visits are a lot like general medicine visits in an outpatient setting; 1 hour may be allotted for a new patient history (or diagnostic interview) and physical and 15 minutes for follow-up visits, which often consist of medication checks and sometimes supportive psychotherapy. Although the conditions that psychiatric providers manage vary, in adult clinics the most common diagnoses include: major depressive disorder, bipolar disorder, anxiety disorders, borderline personality disorder, attention deficit disorder, schizophrenia, anorexia and bulimia nervosa, and neurocognitive disorders. Evaluating or treating approximately 25 patients per day is common, depending on how many are new patients. Unique aspects of behavioral health encounters are described in the following section on patient encounters.
Patient encounters and essential clinical information in behavioral health
The initial evaluation
The initial psychiatric interview is one of the most important components of a psychiatric diagnostic evaluation. Taking a psychiatric history is an essential skill that one learns and develops 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 (See the Appearance and Behavior section in Box 24.1 ). The best way for a provider to begin gathering information from a patient is to start with open-ended, nonfocused questions, such as “What caused you to come in to be seen today?” Open-ended questions provide patients the opportunity to speak freely, provide pertinent information, and feel heard.
Appearance and behavior
This is a general description of the patient’s appearance. Observe and document whether the patient looks his or her stated age. Note the patient’s eye contact, attire, and facial expressions. Scars, tattoos, or other noteworthy findings may also be included. Describe the patient’s behavior. Is the patient cooperative, guarded, agitated, hostile (especially if brought involuntarily), disinterested, or suspicious?
Activity can be normal, slowed, or increased. Are there any signs of abnormal movements, unusual or sustained postures, pacing, restlessness, or tremor? Extrapyramidal side effects of antipsychotic medications may be noted, such as tardive dyskinesia (lip smacking or tongue protrusion).
Note the fluency, language content, rate, volume, and tone of the patient’s speech.
Mood and affect
Mood is subjective and includes what the patient says he or she feels (e.g., happy, sad, euphoric, depressed, fearful, anxious, or irritable). Affect is objective and is the patient’s outward expression of inner experiences observed by the clinician. Affect can be measured in terms of quality (measure of intensity), quantity range (restricted, normal, labile), appropriateness (affect correlates to the setting), and congruence (with patient’s described mood). Examples of affect include dysphoric, euthymic, irritable, angry, tearful, restricted, flat (severely restricted), full, labile, expansive, or congruent with mood.
There are several components of thought content:
Obsessions are intrusive, repetitive thoughts.
Compulsions are ritualized behaviors that the patient feels compelled to perform to reduce anxiety.
Delusions are false beliefs. Delusions can be either bizarre, meaning they could never occur in reality, or nonbizarre, meaning the thoughts are not out of the realm of possibility. Common delusional themes include persecutory, grandiose, erotomanic, jealous, or somatic beliefs.
Idea of reference is the belief that one is the subject of attention by others or that he or she is receiving special messages, such as through media.
Paranoia can be soft (mild suspiciousness) to severe (worrying about cameras, microphones, or the government monitoring them).
Suicidality must be ruled out. The patient may be nonsuicidal or may have suicidal ideation that is either passive or active. If present, further probe whether the patient has a plan, intent, or access to a means to end her or his life.
Homicidal ideation must also be identified; probe whether the patient has a particular victim, plan, or intent. In this case the clinician is obligated to notify the proper authorities.
This component describes how the patient’s thoughts are formulated, organized, and expressed. Ask yourself if the patient’s ideas logically connect from one to the next. Keep in mind, however, that a patient can have a normal thought process with significantly delusional thought content.
A normal thought process can be described as linear, logical, or goal directed. Some examples of abnormal thought processes include:
Circumstantial, which is the addition of many irrelevant details that impede the patient’s ability of getting to the point, but the patient eventually does.
Tangential, which is when the patient responds to the question without actually answering it. The thoughts go off onto a tangent and do not come back around to the point.
Loose associations or thought derailment, which is a lack of logical connection between the content. The patient may construct sentences, but the sentences do not make sense in sequence.
Flight of ideas, which is when ideas shift abruptly, but the sentences are logically connected, unlike those in loose associations. Flights of ideas often occur in a manic state and are accompanied by rapid, pressured speech.
Perseveration, which is repeating the same word or phrase or focusing on an idea with an inability to progress to other topics.
Thought blocking, which is an abrupt halt in the train of thought so that the patient is unable to complete the thought. Thought insertion is the belief that someone or something is putting thoughts into his or her head. Thought withdrawal is the belief that someone or something is removing thoughts from his or her brain.
Broadcasting, which is the belief that thoughts can be heard by others.
Neologism, which is the invention of new words or phrases (or condensing several words).
Word salad, which is a collection of words that do not make sense.
Clang associations, which involves using words that rhyme.
This category can be subdivided into illusions and hallucinations. Illusions are misperceptions of actual stimuli. Hallucinations are false sensory perceptions without a stimulus. To evaluate this, you may ask the patient if he or she has ever heard sounds or someone talking when no one else is there. Further inquiry can be made regarding when they occur, how often, and if it is uncomfortable for the patient (ego dystonic). Additionally, does the patient hear words, commands, or conversations or recognize the voice?
Auditory hallucinations are the most common. Nonauditory hallucinations (those involving the other senses) may indicate a neurologic or substance intoxication or withdrawal etiology. Visual hallucinations may involve shapes of people and occur commonly in delirium and dementia. Tactile or somatic hallucinations may consist of a burning sensation or feeling like something is crawling on the skin. This is common with cocaine intoxication or delirium tremens. Olfactory hallucinations of unusual smells may be indicative of temporal lobe epilepsy or other seizure etiology.
Depersonalization is feeling like one is standing outside one’s own body observing what is happening. Derealization is feeling that one’s environment has changed, such as not feeling real or not present.
Assessing cognition includes:
Alertness : The patient is alert, drowsy, somnolent, comatose, or other.
Orientation : Assess whether the patient is oriented to person, place, and time.
Concentration : This can be assessed through serial 7s or spelling the word “world” backward.
Memory : Recent memory, or immediate recall, is the ability to repeat three objects that were just stated. Short-term memory is evaluated by asking the patient to recall the three words after 3 to 5 minutes. Long-term memory is assessed by the patient’s ability to recall historical information, from months to years ago.
Calculation : This can be assessed by serial 7s or other examples, such as by asking the number of nickels in a dollar.
Fund of knowledge: Ask the patient to list the last five presidents or describe current events.
Abstract reasoning: Ask the patient to interpret proverbs or similarities.
Insight is a patient’s conception and understanding of his or her current state or illness. Assess whether the patient realistically understands his or her illness and expresses a need or desire for treatment.
A patient’s ability to make decisions and act on them demonstrates that he or she can use problem-solving skills and good judgment. Ask the patient: What would you do if you found a stamped, addressed envelope on the sidewalk? What would you do in a movie theater if you smelled smoke?
When documenting the psychiatric patient encounter, begin with identifying information similar to that found in any other medical record. Include the patient’s name, age, marital status, race or ethnicity (when relevant), gender, occupation, and referral source. For example, “Jane Doe is a 45-year-old single woman with a history of paranoid schizophrenia being admitted involuntarily for suicidal ideation.” It is important to identify whether the source of the information is the patient, a family member, a friend, or someone else. The reliability of the source must be included as well. An example of a source that may be unreliable is a patient experiencing psychosis or a patient with a history of manipulative behavior.
History of present illness
The history of present illness (HPI) for patients in behavioral health settings outlines the current symptoms and identifies reasons leading up to the patient’s presentation. Similar to the history for other encounters, the HPI should include information about the onset and severity of symptoms, such as whether a patient considers his or her depression to be very mild (e.g., 1/10 in severity) or severe (e.g., 8/10 in severity). 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 include quotes of the patient’s own words, especially if hallucinations or delusions are present. When considering a diagnosis, inquire and document pertinent positive and negative symptoms to construct the appropriate differential diagnosis, consistent with criteria found in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), the standard guide for diagnosing mental disorders (described in a later section).
Past psychiatric history
This section should encompass the first onset of psychiatric symptoms and review in detail any past mental health diagnoses, including any history of a substance use disorder. Past pharmacologic treatments should be well-documented, including prior medication doses, length of medication trials, response, and reasons for discontinuation. Previous hospitalizations should also be included, with dates, lengths of stay, and reasons for admission. Inquire about past suicidal behavior (ideation, intent, plan, attempts) and self-harm behaviors (cutting or burning for relief of distress). Finally, obtain and document information about past visits to psychologists, counselors, or psychiatrists.
Many psychiatric illnesses have a genetic predisposition. Family history should include any mental illness, hospitalizations, or suicide attempts or completions in family members. Family history of suicide is a significant risk factor for suicide, especially in patients with mental illness. Document any family history of substance abuse and ask about medications that have worked for family members. If a medication has worked for a family member with the same condition, there is an increased likelihood it will be efficacious for the patient.
It is important to obtain details about the patient’s personal and social life. Discuss the patient’s upbringing, 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 routine, and any record of military service. Inquire about the patient’s support system and any safety concerns they have, and discuss their expectations for treatment. To determine whether the patient has a history of substance abuse or may be prone to addiction, ask about current or past caffeine, tobacco, alcohol, or illicit drug use. Discovering any consequences of substance misuse, such as legal issues, is also important. Additionally, any history of seizures or delirium tremens should be noted because of the potential for recurrent behavior or withdrawal symptoms (e.g., delirium tremens associated with alcohol withdrawal). Discuss previous attempts at treatment with the patient, such as rehabilitation or self-help groups and whether they were helpful.
Past medical history
Although focusing on a patient’s psychiatric history is usually the priority, the clinician should obtain a comprehensive past medical history as well. Certain comorbidities, including seizures, traumatic brain injuries, episodes of unconsciousness, and other central nervous system disorders, are associated with an increased risk for mental illness. Other conditions, such as diabetes, metabolic syndrome, hepatic or renal disease, or reproductive dysfunction may affect mental health or impact what medications the patient can take. Questioning a patient (or obtaining records) about abnormal birth or development is also important, particularly when the patient is a child or young adult. Premature birth is associated with an elevated risk of mental illness. In addition, exposures in utero, such as exposure to high levels of stress, inflammation, toxins, alcohol, or drugs, can also contribute to an increased risk of developing a mental health condition.
Psychiatric review of systems
Good medical practice includes screening behavioral health patients for other psychiatric illnesses. Major depression is one of the most common mental illnesses, with a worldwide lifetime prevalence of approximately 12%. Moreover, the U.S. Preventive Services Task Force recommends screening any adult for depression when adequate systems are available to ensure appropriate follow-up. An excellent screening tool for major depressive disorder is to use the classic mnemonic MSIGECAPS ( Box 24.2 ). When a patient admits to five or more of the nine symptoms for most of the day nearly every day for 2 weeks, the PA should suspect a major depressive disorder. The Patient Health Questionnaire (or PHQ-9) is another commonly used depression screening tool (See the online resources for this chapter for a link to the PHQ-9).