"The Psychiatric Review of Symptoms: A Screening Tool for Family Physicians" My Synopsis of an Article from AFP

The Psychiatric Review of Symptoms: A Screening Tool for Family Physicians
DANIEL J. CARLAT, M.D., Anna Jacques Hospital, Newburyport, Massachusetts
Am Fam Physician. 1998 Nov 1;58(7):1617-1624.
http://www.aafp.org/afp/1998/1101/p1617.html

     This article describes a really nice way to go over a psychiatric review of systems (PROS) when interviewing the patient. Even though time is limited when the doctor is with the patient, this is an important part of the physical exam that should not be ignored. The mnemonic is  "depressed patients seem anxious, so claim psychiatrists". The mnemonic stands for;
Depression (bipolar disorder, dysthymia)
Personality disorder (borderline personality disorder)
Substance abuse
Anxiety (panic with agoraphobia, OCD)
Somatization and eating disorders
Cognitive disorder (dementia, delirium)
Psychotic disorders (schizophrenia, delusional disorder)
     When interviewing the patient, it is important to try to build a rapport before beginning the psychiatric questions. Patients may feel embarrassed or ashamed. Normalization is an interviewing technique where the clinician lets the patient know that the behavior in question is normal or an understandable reaction to the situation. Symptom assumption is phrasing the question in such a way that the clinician assumes the behavior is occurring (like saying "how much do you drink" instead of "do you drink". Transitional technique is a way to create a smooth flow between questions, rather than jumping around from topic to topic. It expedites the interview process.
     D. For depression, the clinician can simply ask "are you depressed?" If the patient says yes, then the clinican can go into the neurovegetative symptoms of SIGECAPS (sleep, interest, guilt, energy, concentration, appetite, psychomotor, and suicide). Depression is diagnosed by having 4 symptoms plus a depressed mood for for at least 2 weeks. Dysthymia is having two of the following symptoms (sleep, guilt, energy, concentration, appetite) plus two years of depression.  A great question can be "when was the last time you WEREN'T depressed". For suicide, the questions should be asked in levels. The clinician should ask if the patient had ever thought about suicide. If the patient says yes, the questions can progress to questions about if there is a plan in place, if preparations have been made (getting bullets, pills, etc) and if the patient has ever attempted suicide. If the threat is significant, an urgent psychiatric evaluation may be needed.      Bipolar disorder can be screened for by asking "do you ever get so happy/ energetic that you begin to speak too fast or become too hyper". If so, then the mnemonic "DIGFAST"
(Distractibility,
Indiscretion,
Grandiosity,
Flight of ideas,
Activity increase,
Sleep deficit,
Talkativeness) can be used to look for a manic episode. A manic episode is defined as having three of the seven symptoms from the mnemonic with an elevated or irritable mood for one week.
      P. Borderline personality disorder is a fear of being abandoned after being rejected. Red flags include a history of doctor shopping, legal suits against doctors (or other professionals), attempted suicides, multiple brief relationships and marriages, and categorizing people into either "all good" or "all bad". The mnemonic is "I DESPAIRR"
(Identity problem,
Disordered affect,
Empty feeling,
Suicide behavior,
Paranoia or dissociative symptoms,
Abandonment terror,
Impulsivity,
Rage,
Relationship instability).
     S. Substance abuse can be discovered with the classic "CAGE" questions. The questions should be asked in a nonjudgmental way. Open ended questions such as "do you have a drink occasionally?" has shown to be way more sensitive over close ended questions like "how much do you drink?" A quick two question drinking test ("have you ever had a drinking problem?", and "when was your last drink?") is a simple and effective screener. Positive answers will be "yes" and "within the last 24 hours". Other drugs can be asked about in a similar fashion.
     A. Anxiety disorders can be screened for by asking  "are you an anxious or nervous person?"  These patients can also be screened for panic disorder, agoraphobia, and OCD. The clinician can ask about a history of panic attacks, limiting where the patient goes because of anxiety, and excessive compulsions or repetitive actions that interfere with normal activities.
     S. The mnemonic for somatization disorder is "Recipe 4 pain: Convert 2 Stomachs to 1 Sex". It means that somatization disorder is diagnosed by the presence of 4 pain symptoms, 1 conversion symptom, 2 GI symptoms, and 1 sexual symptom.  Eating disorders can be screeened for by asking if the patient has ever felt like they were overweight. If yes, then other behaviors, such as binging, extreme dieting, laxative use, vomiting, can be asked about.
     C. Cognitive disorders, such as dementia, can be determined by conducting formal cognitive testing if the patient has a possible history or impairment. Screening with the MMSE is ineffective in low risk patients. A rapid screen for memory problems can be done by asking the patient about the date and place, repeating 3 words now and later, and asking general questions that people would normally know (first president, who is Abe Lincoln, etc). Patients who struggle may need a more expansive evaluation.
     P. Psychotic symptoms include delusions, hallucinations, and looseness of association. Psychotic patients may also have concomitant depression, substance abuse, and dementia. These symptoms may be subtle and may take a little more investigation to discover. The clinician may ask quaestion such as "do you think that people must have stolen objects that are misplaced?", "does your mind play tricks on you?" or "do you ever think that you hear people in your home, coming for you?" Paranoia is another symptom which can be asked about.
      In any case, a quick screen is not absolute and should lead the clinician to a more detailed examination.