Sydenham's chorea

The literature highlights the prevalence of mental disorders and physical comorbidity.1-4 A mental disorder is a clinically significant behavioral or psychological syndrome associated with impairment in one or more important area(s) of functioning, or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.5

Among patients diagnosed with mental disorders, between 24% to 60% have known physical disorders6 and many more have unrecognized and untreated physical comorbidity. It is important to screen for these as they can cause or worsen psychiatric symptoms and, in some patients, increase suicidal attempts.1,6 Physical conditions such as obesity, diabetes, dyslipidemia, and cardiovascular disease may be induced or worsened by prescribed psychopharmacologic regimens and lifestyle patterns such as smoking.7-10 Persons with persistent mental illness (disorders persisting over time with remissions and recurrence of severe symptoms) form a disenfranchised group whose access to medical care has been limited, leading to greater mortality1,4 as demonstrated by statistics showing that individuals with schizophrenia have a life expectancy 20% lower than the general population.6,7

Managed care guidelines, psychiatric hospital closings, and expanded community treatments have resulted in more people with mental illness being treated in nonpsychiatric settings such as primary care, prisons, and emergency rooms.11-13 Historically, physical disorders and mental disorders have been treated in separate facilities. When they co-occur in the primary care setting, a mental disorder tends to get less attention, even though it may cause the greater disability.14,15

Recognition and treatment of mental disorders is more complex in nonpsychiatric settings than in psychiatric settings due to patient and clinician factors.11 Patients' cognitive or interpersonal impairments may make them unwelcome. Elderly persons often somatize mental health symptoms and resist psychiatric etiologies and interventions.

Some patients' perceptual or cognitive deficits prevent them from recognizing or communicating their own mental health symptoms or problems.9,10

Clinician obstacles to assessing health care of the persistently mentally ill include poor communication between the primary care provider and the mental health clinician and primary care providers' lack of skill. Additionally, some clinicians are uncomfortable with difficult behaviors in their patients.9,10 This article notes the interrelations between mental and physical disorders and suggests an assessment approach to improve health outcomes for persons with persistent mental illness who are seen in primary care.

* Collecting Assessment Data

To provide a comprehensive physical assessment of a patient with a mental disorder, it is important to collect relevant data from multiple sources. The approach described here begins with an intake interview that incorporates data gleaned from observation and a Review of Systems (ROS), including past and present subjective symptoms. Data from previous health records, laboratory findings, physical examination, and collateral sources are also used. It may be necessary to add follow-up sessions with the patient and (with the patient's permission) family and other care providers in order to obtain a complete data base.6

* Family Interview

Many psychiatric symptoms are beyond the awareness of the patient, but a family member who sees the patient regularly can give significant diagnostic clues not available to the health care provider.16

During the intake interview, observe the patient and collect verbal, behavioral, and physiologic data. Inquire about the history of the present physical illness, past medical and psychiatric illnesses in the patient and patient's family, surgeries, the patient's developmental/social history, and present functioning. Explore all medications the patient possesses-those currently and previously prescribed, as well as their dosage schedules, along with over-the-counter drugs, herbs, vitamins and recreational drugs.

The patient's presenting behavioral symptoms may be the result of prescribed and/or nonprescribed medications, herbs, or other substances.6 Research has shown that persons with psychiatric disorders abuse drugs such as nicotine, caffeine, marijuana, hallucinogens, and cocaine more than the general population.10 Prescription drugs that commonly produce behavioral or emotionally related problematic symptoms include psychotropics, anticholinergics, steroids, antihistamines, antiarrhythmics, and beta-adrenergic blockers. Anxiolytics and hypnotics can produce confusion during withdrawal, especially in the elderly.17

Inquire about the patients' emotional state, particularly depressive and suicidal thoughts. If the patient expresses suicidal ideation, a brief assessment of lethality may indicate need for referral to more appropriate services. Among those who commit suicide, physical illness is a contributing factor in 11% to 51% of cases, increasing with the person's age.6 Studies indicate that 70% of people who committed suicide had seen a primary care provider within the previous 4 to 6 weeks.18-20 Patients are not likely to volunteer suicidal intent, but the office visit itself may be a call for help. An inquiry such as, "How would you describe your predominant mood over the past 2 weeks?" may encourage the patient to discuss depression or suicidal ideation. Among a group of people who survived serious suicide attempts, 70% reported they had not been asked about their emotional state when they saw their primary care provider.20

Sociodemographic risk factors for suicide include being male, Caucasian or Native American, living alone, and having a chronic physical or mental disorder. Among current mental disorders, affective disorders and substance abuse pose greater risk.19,20 Suicide risk maybe assessed by identifying feelings of hopelessness, past suicidal attempts, recent loss or rejection, level of external support, the seriousness of intent, the extent of planning, and the ability and means to carry out the plan.16 Hopelessness, little external support, having an affective disorder, substance abuse, and specific planning are associated with greater suicide risk (see Table: "Suicide Risk Assessment Questions").20,21

* Review of Systems

As with all patients, a ROS in patients with mental disorders notes the absence or presence of symptoms in the major body systems, aids in developing differential diagnoses, and guides further diagnostic and treatment choices.16,17 Clinicians may have to work harder to discover comorbid conditions, as the patient with a mental illness may be reluctant or unable to describe physical problems. It has been noted that patients suffering from schizophrenia are less sensitive to pain from myocardial infarction, fractures, and other serious conditions. Using a structured format during each patient contact fosters comprehensive assessment.10

* Neurological

During the interview, attend to the patient's level of alertness, responsiveness, and motor agitation or retardation. Drowsiness or inattentiveness may be due to brain dysfunction or drug overdose. Inquire about sleep patterns, because sleep pattern disturbance may herald the beginning or recurrence of a mental disorder.6

The patient's gait and movements are telling. Ataxia (awkwardness of posture or gait) may be caused by cerebellar disorder or substance intoxication. Basal ganglia disorders may present with the rigidity, bradykinesia, and shuffling gait of Parkinson's disease, or the purposeless movements of Huntington's disease or Sydenham's chorea.6 Abnormal involuntary movements may result from the extrapyramidal side effects of psychotropic drugs.18

Inquire about the presence, frequency, duration, character, location, and severity of headaches. Headaches may suggest etiologies as diverse as substance abuse, stress, brain tumor, head trauma, and subarachnoid hemorrhage. Multi-infarct dementia, subdural hematoma, normal pressure hydrocephalus, tumors, and human immunodeficiency virus all may produce dementia that must be differentiated from Alzheimer's disease and psychotic disorders. Ask about developmental milestones, seizures, head trauma, any periods of loss of consciousness, and substance abuse.6

* Eye, Ear, Nose, and Mouth

Reports of symptoms affecting the eye, ear, nose, and mouth provide information about risk factors, the need for medication review, and future medication prescription. A history of glaucoma is a contraindication for prescribing anticholinergic drugs. Certain psychotropic medications cause blurred vision. Unusually frequent blinking is associated with schizophrenia. Pupillary constriction suggests use of opioids and pupillary dilation may result from anticholinergic agents or hallucinogens.6 Dilated pupils may also result from overactivity of norepinephrine, which occurs in anxiety.18 The symptoms constellation of rhinorrhea, lacrimation, midriasis and yawning may indicate opiate withdrawal.18 Abnormal saccades (volitional eye movements) are seen in some patients with schizophrenia, mood disorders, and drug induced states.6 One group of researchers reported that visual hallucinations and illusions were the psychiatric symptoms most indicative of physical disorders such as alcohol withdrawal, temporal lobe epilepsy, and conditions that impair visual acuity.6

Hearing-impaired individuals can be more vulnerable to delusional disorder than persons with normal hearing. Perforation of the nasal septum with breathing difficulty can be caused by cocaine abuse. Perioral twitching may point to an early stage of antipsychotic-induced tardive dyskinesia.6

* Respiratory System

Abnormal respiration may be affected by emotions. Psychogenic hyperventilation is suggested if the patient's history includes apprehension, onset at rest, anxiety, depersonalization, palpitations, and numbness of the feet and hands. Dyspnea caused by depression differs from that caused by airway obstruction. In depression, dyspnea fluctuates, coincides with mood, is most prominent upon inspiration, and may be accompanied by vertigo, perspiration, palpitations, and paresthesias. In obstructive airway conditions, the onset is often insidious, with the greatest difficulty on expiration.6

* Cardiovascular System

Cardiac complaints require differential diagnosis. Common signs of anxiety include tachycardia, palpitations, and cardiac arrhythmias. Pheochromocytoma commonly produces symptoms mimicking anxiety. Mitral valve prolapse often coexists with panic attack. Because psychological stress can cause angina-like pain, a history of substernal pain should be investigated. Recognizing and treating psychological risk factors for developing cardiac problems, such as anger, trauma, or depression, and treating anxiety associated with cardiac problems will contribute to a decline in patient morbidity and mortality.5,22

* Gastrointestinal System

The gastrointestinal system is the source of problems of both iatrogenic and psychologic origins. The practitioner should assess appetite, eating patterns, avoidance of food, dysphagia, xerostomia (dry mouth from salivary gland dysfunction), vomiting, diarrhea, constipation, laxative use, and weight. Primary illnesses related to maladaptive eating patterns include anorexia nervosa, bulimia nervosa, and binge eating disorder. Laxative abuse and induced vomiting are seen in bulimia.6 Incorporate the following questions to identify women with eating disorders: "Are you satisfied with your eating patterns?" and "Do you ever eat in secret?" If screening data is positive, follow up with a full medical workup.25

Research demonstrates a higher prevalence of obesity among those who are mentally ill than the general population due to a frequent sedentary life style and side effects of psychotropic medications. Psychiatric inpatients who understand the need for weight reducing practices may find behavioral change difficult because of their limited ability to make dietary choices within a hospital setting.24 At spaced intervals, plan to encourage weight reduction with these obese patients.

Depression may cause changes in appetite and be accompanied by weight gain or loss. Weight loss may be caused by anorexia nervosa, stimulant abuse, dementia, or infectious conditions. Constipation can be caused by opiates and by psychotropic drugs with anticholinergic properties.6 Lithium toxicity may be manifested with diarrhea.18 Food avoidance may be associated with phobia or an obsessive ritual. Among the elderly, dysphagia and xerostomia may impair eating and, combined with exposure to tardive dyskinesia inducing antipsychotics, may cause choking.16 One group of researchers found the incidence of irritable bowel syndrome higher in patients with schizophrenia than the control group, although patients with schizophrenia seldom reported the symptoms.10

* Integumentary System

Nutritional deficits associated with alcoholism may result in spider nevi over chest, face, and neck. Depression may be mimicked or worsened by hypothyroidism, and present with cool dry skin, coarse hair, loss of lateral third of eyebrows, brittle nails, and alopecia.25 Thinning scalp hair or eye lashes may be caused by trichotillomania (excessive hair pulling). Alopecia may be reported by psychiatric patients exposed to certain psychiatrie drugs (e.g. valproic acid (Depakote) and buspirone (BuSpar). A severe bullous rash of StevensJohnson syndrome might be caused by exposure to lamotrigine (Lamictal).6

Cigarette burn-patterned laceration scars, or other nonsurgical types of scars may indicate a history of self-mutilation or victimization. Ask, "What is this from?" If you suspect self-mutilation, the patient should be referred to an appropriate mental health specialist. If you suspect victimization, you must follow the appropriate steps in reporting and following up your suspicions.26

* Genitourinary System

Exposure to certain drugs results in some genitourinary problems. Many antipsychotics and tricyclic antidepressants cause urinary retention and, less commonly, prostate hypertrophy. The antidepressant trazodone (Desyrel) is associated with priapism, which requires immediate drug cessation and referral for possible surgical intervention. Inquire about incontinence, sexual activity, and history of sexually transmitted disease.6

* Hormonal Systems

A menstrual history should include the age of menarche and menopause, regularity, irregular bleeding, dysmenorrhea, amenorrhea, and any associated treatments. Note premenstrual mood changes such as irritability, depression, and dysphoria. Amenorrhea occurs in anorexia nervosa, extreme stress, and pseudocyesis (false pregnancy). Note significant mood changes associated with abortion and pregnancies. Referral to a mental health clinician may be indicated.6

Antipsychotic-induced hyperprolactinemia may result in gynecomastia and impotence in men, and amenorrhea, galactorrhea, and osteoporosis in women. Marked weight gain is associated with increases in diabetes, cholesterol, and triglycérides, especially among patients taking clozapine (Clozaril) and olanzapine (Zyprexa).6,7,10

* Diagnostic Tests

Order routine laboratory tests to screen for concurrent disease, illicit drug use, pregnancy for women with child bearing potential, and to establish baseline values of functions that will be monitored. Such laboratory tests include complete blood count, electrolytes, blood sugar, renal, liver and thyroid function, urine drug screen, blood alcohol level, and pregnancy test if appropriate. Neuroimaging is the most efficient means for detecting or ruling out major neurological pathologies, but is not indicated routinely. Many psychiatric patients smoke excessively, so an evaluation of pulmonary and cardiac status may be indicated. Ordering laboratory tests is guided by the clinical presentation and risk factors. Tests should be ordered judiciously, but not avoided because of costs.6,17

* Physical Examination

A physical examination for persons with a mental disorder may require increased sensitivity to patient response. The examination may evoke adverse reactions in patients who have a history of rape or sexual abuse, as well as patients who are delusional. Occasionally it is wise to defer or reschedule the physical examination because of the patient's mental state. Using a calm, matter of fact manner with a running account of what is being done allays anxiety. Lingering over one aspect of the examination may arouse the patient's concern. Beginning with familiar procedures such as measuring weight and vital signs may be helpful.6

The physical examination should be customized based on the patient's behavior, the ROS, and patient and family history. Assessment of the neurological system is particularly important, because disorders in the brain may cause psychiatric symptoms. For patients with persistent mental illness, it is important to note neurological findings that are commonly associated with psychiatric disorders and/or psychotropic medications such as posturing, asterixis, dyskinesia, tremor, paresthesia, subtle dysarthria, and gait disturbance.6

* Differential Diagnosis

Evaluation through history, physical examination and laboratory findings leads to diagnosis. When symptoms are identified, the clinician must determine if they are real or delusional, and if the etiology is psychogenic, physiological, or iatrogenic.10 In making a differential diagnosis, physiological etiologies should be considered first. The Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition, describes general medical conditions in which there is a known physiological link between a medical condition and psychiatric symptoms, such as seizures and psychosis or Cushing's syndrome and depression.5 Researchers have noted that the most common general medical conditions that cause psychiatric symptoms are from the cardiovascular, endocrine, immune, and neurological systems6 (see Tables: "Conditions Associated with Psychosis" and "Conditions Associated with Depression").

* Conclusion

The health needs of the population with physical and mental comorbid conditions are not adequately met. The goal of reducing morbidity and mortality among persons with mental and physical comorbidity can be addressed by NPs who are vigilant assessors. Obstacles to assessment of persons with comorbid disorders can be diminished by: 1) developing greater awareness of their needs, 2) increasing sensitivity to their responses, 3) accommodating their behaviors, 4) forming therapeutic alliances with them, and 5) partnering with formal and informal care providers.

DISCLOSURE

The author has disclosed that she has no significant relationship or financial interest in any commercial companies that pertain to this education activity.

CE Test

Assessing Adults with Mental Disorders in Primary Care

Instructions:

* Read the article beginning on page 19.

* Take the test, recording your answers in the test answers section (Section B) of the CE enrollment form. Each question has only one correct answer.

* Complete registration information (Section A) and course evaluation (Section C).

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This Continuing Nursing Education (CNE) activity for 2.0 contact hours and 1.0 pharmacology contact hour is provided by Lippincott Williams &Wilkins, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 11696, CERP Category A).This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.0 contact hours and 1.0 pharmacology contact hour. LWW is also an approved provider of CNE in Alabama, Florida, and Iowa and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified forTexas nursing continuing education requirements asType I.

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Assessing Adults with Mental Disorders in Primary Care

General Purpose: To provide nurse practitioners with the understanding of the prevalence of mental illness and its impact during management of patients in a primary care setting. Learning Objectives: After reading the preceding article and taking the following test, you will be able to: 1. Discuss the significance of mental illness and co-morbid conditions in primary care settings. 2. Identify pharmacologie factors that influence data collection during a primary care interview with a patient who has an existing mental health disorder.

1. Among patients diagnosed with mental disorders, approximately how many have known physical disorders?

a. 5% to 15%

b. 15% to 25%

c. 24% to 60%

d. 45% to 80%

2. What is the life expectancy of an individual with schizophrenia compared to the general population?

a. 10% lower

b. 20% lower

c. 30% higher

d. the same

3. Which of the following comorbid conditions might you find in a patient presenting with depression?

a. delirium

b. folic acid deficiency

c. dementia

d. asthma

4. A condition associated with psychosis that may be present with a mental health illness includes

a. AIDS

b. insomnia

c. lupus

d. ulcerative colitis

5. Chronic alcohol use can cause

a. alopecia

b. severe bullous rash

c. dyspnea with onset of rest

d. spider nevi on face, neck, and chest

6. Common signs of anxiety include

a. palpitations

b. bradycardia

c. constricted pupils

d. hearing impairment

7. Among those who commit suicide, physical illness is a contributing factor in how many cases?

a. 5% to 10%

b. 11% to 51%

c. 45% to 70%

d. 80% to 90%

REFERENCES

1. Geffkcn GR, Ward HE, Stabb JP: Psychiatric morbidity in endocrine disorders. Psychiatr Clin North Am 1998;21(2):473-489.

2. Felker B, Yazel JJ, Short, D: Mortality and medical comorbidity among psychiatric patients: A review. PsyServ I996;47:1356-1363.

3. Takesita J, Masaki K, Ahmed I, et al: Are depressive symptoms a risk factor for mortality in elderly Japanese American men? The Honolulu-Asia Aging Study. Am J Psychiatry 2002;159:1127-1132.

4. Harris E, Barraclough B: Excess mortality in mental disorder. Br J Psychiatry 1999;173:ll-53.

5. American Psychiatric Association: Diagnostic and statistical manual of mental disorder-Text revision, 4th Ed. Washington DC, 2000.

6. Kaplan HI, Sadock BJ: Synopsis of psychiatry: Behavioral sciences/clinical psychiatry, 9th edition. Baltimore, MD: Lippincott Williams and Wilkins, 2002.

7. Bailey KP: Choosing between atypical antipsychotics: Weighing the risks and benefits. Arch Psych Nrsg 2002;16(3):[Suppl 1],S2-S11.

8. casey DE: Atypical antipsychotics: Enhancing healthy outcomes: Arch Psych Nrsg, 2002; 16,(3)[Suppl 1]S12-S19.

9. Hodges B, Inch C, Silver I: Improving the psychiatric knowledge, skills and attitudes of primary care physicians, 1950-2000: A review. Am J Psychiatry 2001;158:1579-1586.

10. Dixon L, Fischer PJ, Lehman A: The association of medical comorbidity in schizophrenia with poor physical and mental health. J Nerv Ment Dis 1999; 187: 496-502.

11. Goldman LS: Medical illness in patients with schizophrenia. J Clin Psychiatry 1999;60[Suppl 21], 10-15.

12. National Rural Health Assoc; Mental health in rural America: The scope of mental health issues in rural America, 2002. Found at http://www.nrharural. org/dc/issuespapers.

13. Talley S: Improving outcomes: Clinical and educational challenges for psychiatric nurses. Arch Psych Nrsg 2002;16(3):520-526.

14. Rost K, Nutting P, Smith J, et al: The role of competing demands in the treatment provided primary care patient with major depression. Arch of J:am Med2000;9:150-154.

15. Scharer K, Boyd M, Williams CA: Blending specialist and practitioner roles in psychiatric nursing: Experiences of graduates. J Amer Psych Nurs Assoc 2003;9(4):136-144.

16. Boyd MA: Psychiatric nursing contemporary practice, 2nd edition. Philadelphia: Lippincott. 2002.

17. Andreasen NC, Black DW: Introductory textbook of psychiatry, 2nd Ed. Washington DC: American Psychiatric Publishing, Inc., 2001.

18. Stahl SM: Essential psychopharmacology. New York, New York: Cambridge Press, 2000.

19. Hirschfield AMA, Russell JM: Assessment and treatment of suicidal patients. N Engl J Med 1997/337:910-915.

20. Hall RCW, Platt DE: Suicide risk assessment : A review of risk factors for suicide in 100 patients who made severe suicide attempts. Psychosomatics 1999; 40:18-27.

21. Fenton WS, McGlashan TH, Victor BJ: Symptoms, subtype, and suicidality in patients with schizophrenia spectrum disorders. Am J Psychiatry 1997; 154:2,199-204.

22. Cowan MJ, Pike KC, Budyzynski HK: Psychosocial therapy reduced the risk of cardiovascular at two years after out of hospital sudden cardiac arrest. NursgRes2001;50,68-76.

23. Freund K, Graham SM, Lesky EG: Detection of bulimia in a primary care setting. J Gen Im Med 1993;8:236.

24. Meyer JH: Awareness of obesity and weight among chronically mentally ill in-patients: A pilot study. An Cl Psych 2002;14(l):34-45.

25. Dunphy LM, Winland-Brown JE: Primary care: The art and science of advance practice nursing. Philadelphia: FA Davis,2000;903.

26. Gallop K: Failure of the capacity for self-soothing in women who have a history of abuse and self-harm. J Amer Psych Nrs Assoc 2002;8(1):20-26.

27. Hahn RK, Reist C, Albers LJ: Psychiatry -A current clinical strategies medical book. 2003-2004 Laguna Hills CA: Clinical Strategies Publishing.

Bonnie Davis, RN, DNS, APRN, BC

ABOUT THE AUTHOR

Bonnie Davis is an Associate Professor at the University of Mississippi School of Nursing, Jackson, Miss.

Copyright Springhouse Corporation May 2004
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