Mental Status Examination PDF - 4th Week Anxiety Disorders

4th WEEK: ANXIETY DISORDERS MENTAL STATUS EXAMINATION It refers to all clinical measurements and observations that begin with the patient entering the session room and indicate important points that the therapist should pay attention to. An effective and comprehensive...

4th WEEK: ANXIETY DISORDERS MENTAL STATUS EXAMINATION It refers to all clinical measurements and observations that begin with the patient entering the session room and indicate important points that the therapist should pay attention to. An effective and comprehensive mental status examination is essential for an effective process to be carried out independently of the diagnosis. Main map: 1. INTRODUCTION 1.1. Status of the examination 1.2. Appearance 2. SPEECH AND COMMUNICATION 2.1. Normal properties 2.2. Abnormal properties 2.3. Communicative skills 3. AFFECT AND MOOD 3.1. Normal properties 3.2. Abnormal properties 4. COGNITIVE SKILLS 4.1. Cognition 4.2. Orientation 4.3. Memory 4.4. Attention 4.5. Perception 4.6. Language 4.7. Intelligence 4.8. Judgment 4.9. Reality testing 5. THOUGHT 5.1. Thought process 5.1.1. Speed 5.1.2. Expediency  5.1.3. Order of associations 5.1.4. Neologism 5.2. Thought content 5.2.1. Normal properties 5.2.2. Delusions 5.3. Obsessions 5.4. Phobias 5.5. Suicidal or homicidal thoughts 6. BEHAVIOR 6.1. Normal properties 6.2. Quantitative disruptions 6.2.1. Decrease 6.2.2. Increase 6.3. Qualitative disruptions 6.3.1. Compulsions 6.3.2. Tics 6.3.3. Postural deterioration 6.3.4. Catatonia In a mental status examination following this map, data from objective and/or projective tests are included, as well as data from clinical observation and interview. Data from a single area is not sufficient for diagnosis and treatment planning. The mental status examination is a whole. It is wrong to insist on points where the patient avoids giving information; the patient’s hesitation is also valuable data. We will begin with affect and mood, which are components of a comprehensive and systematic mental status examination.  ANXIETY DISORDERS ANXIETY DISORDERS Social Anxiety Generalized Separation Selective Specific Disorder Panic Agoraphobia Anxiety Anxiety Mutism Phobia (Social Disorder Disorder Phobia) “ANXIETY” Anxiety is similar to fear. It feels as though something bad is about to happen, as if one is about to receive some terrible news, a sense of unease or worry with no clear cause. The intensity of this distressing emotion can vary. The patient often expresses that “even the most intense physical pain they've experienced up until that moment was not as severe as this”. It is so overwhelming that the patient would “agree to anything just for this distress to end”. The moment right after waking from a nightmare – a feeling experienced while awake. Similar to mood disorders, anxiety disorders are very common in society. They are more prevalent in individuals aged 15-34 and in women. In Western countries, the prevalence is reported to be between 14.5% and 33.7%. The most common anxiety disorders in the general population are specific phobias and social anxiety disorder. Anxiety disorders are about twice as common in women compared to men. The average age of onset for all anxiety disorders is 21.3 years, with the highest risk period being between 10 and 25 years old. Specific phobia, social anxiety disorder, and separation anxiety disorder typically begin in childhood or early adolescence. Generalized anxiety disorder, panic disorder, and agoraphobia usually emerge in late adolescence or early adulthood, most often between the ages of 25 and 30. Patients typically seek clinical help with complaints of physical symptoms.  SEPARATION ANXIETY DISORDER A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. 2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. 3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. 5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. 6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. 7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated. B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. C. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.  SELECTIVE MUTISM A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g. - at school) despite speaking in other situations. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (cannot be during first month of school). D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E. The disturbance is not better explained by a communication disorder (e.g. - childhood- onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.  SPECIFIC PHOBIA A. Marked fear or anxiety about a specific object or situation (e.g. - flying, heights, animals, receiving an injection, seeing blood – the specific object or situation is called a phobic stimulus). B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object, or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder, including: fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (agoraphobia); objects or situations related to obsessions (obsessive-compulsive disorder); reminders of traumatic events (posttraumatic stress disorder); separation from home or attachment figures (separation anxiety disorder); social situations (social anxiety disorder). Specifiers: Specify based on the phobia: Animal (e.g. - spiders, insects, dogs). Natural environment (e.g. - heights, storms, water). Blood-injection-injury (e.g. - needles, invasive medical procedures). Situational (e.g. - airplanes, elevators, enclosed places). Other (e.g. - situations that may lead to choking or vomiting: in children, e.g. - loud sounds or costumed characters).  SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) A. Marked fear or anxiety about 1 or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g. - having a conversation, meeting unfamiliar people), being observed (e.g. - eating or drinking), and performing in front of others (e.g. - giving a speech). NOTE: In children, the anxiety must occur in peer settings and not just during interactions with adults. B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. - will be humiliating or embarrassing: will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. NOTE: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. D. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication) or another medical condition. H. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder. İ. (Actually J) If another medical condition (e.g. - Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.  PANIC DISORDER A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur: NOTE: The abrupt surge can occur from a calm state or an anxious state. 1. Sweating 2. Trembling and shaking 3. Unsteady, dizziness, light-headed, or faint 4. Derealization (feelings of unreality) or depersonalization (being detached from one self) 5. Excessive/accelerated heart rate, palpitations, or pounding heart 6. Nausea or abdominal distress 7. Tingling, numbness, parathesesias 8. Shortness of breath 9. Fear of losing control or “going crazy” 10. Fear of dying 11. Choking feelings 12. Chest pain or discomfort 13. Chills or heat sensations B. At least 1 of the attacks has been followed by at least 1 month of at least 1 of the following: 1. Persistent concern or worry about additional panic attacks or their consequences (e.g. losing control, having a heart attack, “going crazy”). 2. A significant maladaptive change in behavior-related to the attacks (e.g. behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). C. The disturbance is not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication) or another medical condition (e.g. - hyperthyroidism, cardiopulmonary disorders). D. The disturbance is not better explained by another mental disorder.  AGORAPHOBIA A. Marked fear or anxiety about at least 2 of the following 5 situations: 1. Public transportation (e.g. - automobiles, buses, trains, ships, planes) 2. Open spaces (e.g. - parking lots, malls, marketplaces, bridges) 3. Enclosed places (e.g. - rooms, shops, theatres, cinemas) 4. Crowds or standing in line 5. Being outside of home alone B. The individual fears or avoids these situations because of thoughts that escape might be difficult, or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g. - fear of falling or fear of incontinence in the elderly). C. The agoraphobic situations almost always provoke fear or anxiety. D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. If another medical condition (e.g. - inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive. İ. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder.  GENERALIZED ANXIETY DISORDER A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The person finds it difficult to control the worry. C. The anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months)Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection): 1. Restlessness or feeling keyed up or on edge 2. Being easily fatigued 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder. F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).  SYMPTOMS AND FINDINGS General Appearance and Behavior: A general sense of distress, a worried facial expression, agitation in movements, irritability, quick temper, impatience, sometimes an inability to sit still. Speech and Communication: A trembling excitement in the voice, perhaps difficulty speaking, but speech remains coherent. An anxious, restless, tense state in forming relationships. Affect: The patient expresses feeling a sense of something similar to fear, as though something bad is about to happen. They do not know the cause or the object of their fear. “An ox sitting on the chest”. In cases of prolonged anxiety, states of depression may also accompany the condition. Cognitive Skills: No major defect. Due to excessive and intense distress, attention may easily become distracted, it can lead to temporary amnesia. Comprehension and learning may decrease. Thought Process and Content: No major disturbance in the thought process. Thoughts may appear to be accelerated because they want to express their complaints urgently and impatiently. Bodily and Physiological Symptoms: Along with the subjective feeling of anxiety, the most important symptoms are related to autonomic arousal: increased blood pressure, rapid heart rate, palpitations, muscle tension, dry mouth, paleness or flushing of the face, sweating, difficulty breathing, a lump in the throat, coldness in the extremities, sweating, numbness, or tingling. These reactions are natural fear responses to a dangerous situation. However, in generalized anxiety disorder, the nature and source of the danger are unknown to the person! In these patients, anxiety can arise quickly in response to normal life events and interpersonal relationships. Symptoms may include worry, restlessness, excessive sweating, hot and cold flashes, startle responses, difficulty concentrating, sleep disturbances, irritability, and moodiness. Physical symptoms that cannot be medically explained (such as chest or abdominal pain, fatigue, headaches) may lead these patients to seek help from other doctors, aside from mental health professionals. Suicidal thoughts and/or behaviors may also be observed.  ANXIETY AND NEUROANATOMY The amygdala is at the center of the anxiety network. Increased amygdala activity has been specifically confirmed in social anxiety disorder. Its activity decreases with serotonergic medications. There are pathways from the amygdala to the hypothalamus, locus caeruleus (LC), and periaqueductal gray matter; these pathways play a role in the manifestation of anxiety symptoms. In specific phobias, functional imaging studies with exposure to stimuli have shown early increases in the activity of areas related to emotional processing, such as the amygdala, anterior cingulate cortex, thalamus, and insula. The involvement of limbic regions is more pronounced, especially in individuals with a strong autonomic response. Abnormalities in the activity of the prefrontal, orbitofrontal, and visual cortices have also been observed after encountering phobic stimuli. PSYCHOANALYTICAL PERSPECTIVE ON ANXIETY The basic paradigm for the formation of anxiety and phobia was shaped based on Freud's psychoanalytic theory until the mid-1970s. Anxiety is essentially a product of intrapsychic conflict. This internal conflict occurs between the “ego-id” or between the “ego-superego”. If the ego weakens in its attempt to maintain balance against the unconscious impulses specific to the id, or if the power of these impulses increases, a conflict between the ego and the id emerges. This conflict indicates that the ego has failed to find a solution to the impulses. Anxiety serves as a signal of danger within the ego, a kind of alarm. The ego, faced with conflict, activates 'defense mechanisms' against anxiety. One of these mechanisms, displacement, allows anxiety to be redirected from its original source to another object or situation. In this way, phobia is formed. According to the psychoanalytic view, there are four types of anxiety based on their sources: Superego anxiety, castration anxiety, separation anxiety, id anxiety. According to psychoanalytic theory, the fundamental pathology in neuroses is anxiety.  COGNITIVE PERSPECTIVE ON ANXIETY The cognitive approach to anxiety has recently focused on the concept of 'worry.' It refers to the importance of certain cognitive processes in the onset and persistence of disorders: cognitive avoidance, metacognition, intolerance of uncertainty, and the cognitive theory of panic. Panic attacks are explained as the patient interpreting the physical symptoms of anxiety as a severe threat or catastrophe. This misinterpretation leads to an increase in the intensity of the symptoms. Palpitations – interpretation as a heart attack – intense anxiety – physiological arousal – intensification of symptoms, confirming the initial interpretation – increasing severity of symptoms BEHAVIORAL PERSPECTIVE ON ANXIETY Anxiety and phobias are learned behaviors. If a person is repeatedly exposed to an object that does not initially evoke fear, but is simultaneously paired with a painful or aversive stimulus, avoidance behavior will develop toward this object, even though it was not feared at first. = conditioned fear response. This is a learned phobia. Children growing up in a family where parents constantly exhibit a fear of illness may develop illness phobias through “modeling” or observational learning. ANXIETY AND TREATMENT In specific phobia, no place for medication; other anxiety disorders, medication + psychotherapy. PSYCHOTHERAPY The most common psychotherapy approach is CBT (Cognitive Behavioral Therapy). Techniques include exposure and systematic desensitization. PHARMACOTHERAPY Antidepressant (AD) medications are effective. Initially, they can increase anxiety! Benzodiazepines (Xanax, Rivotril, Rivoclon, Diazem, Nervium, Ativan) quickly alleviate anxiety in panic disorder (PD), but there is a risk of addiction!