Mental disorders are common in medical practice and may present either as a primary disorder or as a comorbid condition. The prevalence of mental or substance use disorders in the United States is approximately 30%, only one-third of whom are currently receiving treatment. Global burden of disease statistics indicate that 4 of the 10 most important causes of disease worldwide are psychiatric in origin.
The revised fourth edition for use by primary care physicians of the Diagnostic and Statistical Manual (DSM-IV-PC) provides a useful synopsis of mental disorders most likely to be seen in primary care practice. The current system of classification is multiaxial and includes the presence or absence of a major mental disorder (axis I), any underlying personality disorder (axis II), general medical condition (axis III), psychosocial and environmental problems (axis IV), and overall rating of general psychosocial functioning (axis V).
Changes in health care delivery underscore the need for primary care physicians to assume responsibility for the initial diagnosis and treatment of the most common mental disorders. Prompt diagnosis is essential to ensure that patients have access to appropriate medical services and to maximize the clinical outcome. Validated patient-based questionnaires have been developed that systematically probe for signs and symptoms associated with the most prevalent psychiatric diagnoses and guide the clinician into targeted assessment. Prime MD (and a self-report form, the PHQ) and the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) are inventories that require only 10 minutes to complete and link patient responses to the formal diagnostic criteria of anxiety, mood, somatoform, and eating disorders and to alcohol abuse or dependence.
A physician who refers patients to a psychiatrist should know not only when doing so is appropriate but also how to refer, since societal misconceptions and the stigma of mental illness impede the process. Primary care physicians should base referrals to a psychiatrist on the presence of signs and symptoms of a mental disorder and not simply on the absence of a physical explanation for a patient's complaint. The physician should discuss with the patient the reasons for requesting the referral or consultation and provide reassurance that he or she will continue to provide medical care and work collaboratively with the mental health professional. Consultation with a psychiatrist or transfer of care is appropriate when physicians encounter evidence of psychotic symptoms, mania, severe depression, or anxiety; symptoms of posttraumatic stress disorder (PTSD); suicidal or homicidal preoccupation; or a failure to respond to first-order treatment. Eating disorders are discussed in Chap. 79, and the biology of psychiatric and addictive disorders in Chap. 390.
Anxiety disorders, the most prevalent psychiatric illnesses in the general community, are present in 15–20% of medical clinic patients. Anxiety, defined as a subjective sense of unease, dread, or foreboding, can indicate a primary psychiatric condition or can be a component of, or reaction to, a primary medical disease. The primary anxiety disorders are classified according to their duration and course and the existence and nature of precipitants.
When evaluating the anxious patient, the clinician must first determine whether the anxiety antedates or postdates a medical illness or is due to a medication side effect. Approximately one-third of patients presenting with anxiety have a medical etiology for their psychiatric symptoms, but an anxiety disorder can also present with somatic symptoms in the absence of a diagnosable medical condition.
Panic disorder is defined by the presence of recurrent and unpredictable panic attacks, which are distinct episodes of intense fear and discomfort associated with a variety of physical symptoms, including palpitations, sweating, trembling, shortness of breath, chest pain, dizziness, and a fear of impending doom or death (Table 391-1). Paresthesias, gastrointestinal distress, and feelings of unreality are also common. Diagnostic criteria require at least 1 month of concern or worry about the attacks or a change in behavior related to them. The lifetime prevalence of panic disorder is 1–3%. Panic attacks have a sudden onset, developing within 10 minures and usually resolving over the course of an hour, and they occur in an unexpected fashion. The frequency and severity of panic attacks vary, ranging from once a week to clusters of attacks separated by months of well-being. The first attack is usually outside the home, and onset is typically in late adolescence to early adulthood. In some individuals, anticipatory anxiety develops over time and results in a generalized fear and a progressive avoidance of places or situations in which a panic attack might recur. Agoraphobia, which occurs commonly in patients with panic disorder, is an acquired irrational fear of being in places where one might feel trapped or unable to escape (Table 391-2). Typically, it leads the patient into a progressive restriction in lifestyle and, in a literal sense, in geography. Frequently, patients are embarrassed that they are housebound and dependent on the company of others to go out into the world and do not volunteer this information; thus physicians will fail to recognize the syndrome if direct questioning is not pursued.
Table 391-1 Diagnostic Criteria for Panic Attack
| Save Table
Table 391-1 Diagnostic Criteria for Panic Attack
|A discrete period of intense fear or discomfort, in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes:|
|1. Palpitations, pounding heart, or accelerated heart rate|
|3. Trembling or shaking|
|4. Sensations of shortness of breath or smothering|
|5. Feeling of choking|
|6. Chest pain or discomfort|
|7. Nausea or abdominal distress|
|8. Feeling dizzy, unsteady, lightheaded, or faint|
|9. Derealization (feelings of unreality) or depersonalization (being detached from oneself)|
|10. Fear of losing control or going crazy|
|11. Fear of dying|
|12. Paresthesias (numbness or tingling sensations)|
|13. Chills or hot flushes|
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