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Chapter 3 • Abdominal Pain
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29
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Acute Abdominal Pain — cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Peritonitis Occurs more often in elderly;
sudden onset of severe pain
that is diffuse and worsens
Acute pancreatitis History of cholelithiasis or
Mesenteric adenitis Fever, pain in RLQ, other
Cholecystitis/ lithiasis Appears in adults more than
Ureterolithiasis Sudden onset, excruciating
Urinary tract infection
(UTI)/pyelonephritis
Pelvic inflammatory
disease (PID)
with movement or coughing
excessive alcohol use; pain
is steady and boring in
quality and is unrelieved by
change of position; located
in LUQ and radiates to
back; nausea, vomiting,
and diaphoresis
symptoms suggestive of
appendicitis
in children, females more
than males; colicky pain
with progression to constant
pain; pain in RUQ that can
radiate to right scapular
area; pain of cholelithiasis
is constant, progressively
rising to plateau and falling
gradually; nausea, vomiting,
history of dark urine and/or
light stools; may be aggravated by certain foods
intermittent colicky pain that
can progress to constant
pain; pain in lower abdomen
and flank and radiates to
groin; nausea, vomiting,
abdominal distention,
chills, and fever; increased
frequency of urination
Urinary symptoms with UTI,
back pain with pyelonephritis; infants present with
fever, failure to thrive,
irritability; toddlers report
pain in abdomen; may not
report dysuria or frequency
Lower abdominal pain that
becomes progressively more
severe; can have irregular
bleeding, vaginal discharge,
and vomiting; most
common in sexually
active women
Guarding; rebound tender-
ness; bowel sounds decreased or absent
Patient appears acutely ill;
abdominal distention,
decreased bowel sounds,
diffuse rebound tenderness; upper abdomen can
show muscle rigidity; can
have limited diaphragmatic
excursion of lungs
Pain on palpation in RLQ;
there can be pharyngitis,
cervical adenopathy
Tender to palpation or
percussion in RUQ;
gallbladder palpable in
about half cases of
cholecystitis; positive
Murphy sign
CVA tenderness; increased
sensitivity in lumbar and
groin areas; hematuria
Altered voiding pattern,
malodorous urine, fever
Abdominal tenderness, CMT
and adnexal tenderness
(usually bilateral); with
peritonitis can also have
guarding and rebound
tenderness; fever and
vaginal discharge common
CBC with differential,
abdominal radiographs
CBC with differential,
serum amylase and
lipase levels, triglyceride
level, calcium level,
and liver chemistries;
ultrasonography; CT
CBC with differential;
adenovirus found in tissue of surgical specimen
CBC with differential,
ultrasonography,
radiographs, serum
amylase and lipase
levels
U/A, noncontrast-enhanced
helical CT
U/A and culture
WBC and ESR usually
elevated; DNA testing,
cultures and Gram
staining for STIs
Continued
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Chapter 3 • Abdominal Pain
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Acute Abdominal Pain — cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Obstruction Sudden onset of crampy pain
usually in umbilical area of
epigastrium; vomiting occurs
early with small intestinal
obstruction and late with
large bowel obstruction;
Ileus Abdominal distention, vomit-
Intussusception Sudden-onset pain in infant;
Malrotation/volvulus Seen in infants up to 1 mo
Henoch-Schönlein
purpura
Incarcerated hernia More common in elderly;
Pneumonia Children age 2-5 yr can
Irritable bowel
syndrome (IBS)
Crohn disease Abdominal pain with chronic
Lactose intolerance Crampy pain after eating milk
Diverticular disease Localized pain, usually LLQ;
Simple constipation Colicky or dull and steady pain
Habitual constipation Lifelong history; younger
Dysmenorrhea Typical premenstrual pain
obstipation or diarrhea
ing, obstipation, and
cramps
occurs with sudden relief,
then pain again
old; irritability, pain
Seen in children age 2-8 yr Rash on lower extremities/
constant severe pain in RLQ
or LLQ that worsens with
coughing or straining
present with only abdominal
pain and fever
Begins in adolescence or as
young adult; hypogastric
pain; crampy, variable
infrequent duration;
associated with bowel
function; associated with
gas, bloating, distention;
relief with passage of flatus,
feces
bloody diarrhea
or milk products
older patient
that does not progress and
worsen
patient
onset soon after menarche,
gradually diminishing
with age
Hyperactive, high-pitched
bowel sounds; fecal mass
can be palpated; abdominal
distention; empty rectum
on digital examination
Minimal or absent peristalsis
on auscultation
Fever, vomiting, currant jelly
stools
Bilious emesis, abdominal
distention
buttocks; arthralgias;
hematuria
Hernia or mass that is
nonreducible
Tachypnea, retractions, pallor,
nasal flaring, crackles
Normal examination;
heme-negative stool
Abdominal tenderness; weight
loss
Negative physical examination Trial elimination of
Abdominal tenderness; fever CT, contrast enema,
Fecal mass palpable, stool in
rectum
Normal examination;
heme-negative stool
Normal pelvic examination Gynecology consult; pelvic
Diagnosis confirmed with
CT, abdominal radiographs
Gaseous distention of
isolated segments of both
small and large intestines
shown on radiographs
Abdominal films, ultrasound
Abdominal films
CBC, ESR, serum IgA
MRI, CT, ultrasound
CBC, chest radiograph
demonstrating
infiltrations
Proctosigmoidoscopy,
colonoscopy if onset at
middle age/older, stool
positive for blood, family
history of colorectal
cancer or polyps, failure
to improve after 6-8 wk
of therapy
offending foods
cystography, ultrasound,
colonoscopy sometimes
useful but not used
during acute attack
None
Sigmoidoscopy, anorectal
manometry, colonoscopy
if symptoms are alarming
ultrasound if secondary
dysmenorrhea, increasing
disability, or abnormal
pelvic examination
Chapter 3 • Abdominal Pain
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31
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Acute Abdominal Pain — cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Uterine fibroids Pain related to menses,
intercourse
Hernia Localized pain that increases
with exertion or lifting
Ovarian cyst(s) Young woman Adnexal pain and palpable
Abdominal wall
disorder
Esophagitis/GERD
(see Chapter 20)
Peptic ulcer Burning or gnawing pain;
Gastritis Constant burning pain in
Gastroenteritis Occurs at any age and produces
Functional dyspepsia Vague reports of indigestion,
History of trauma Visible ecchymosis or
Burning, gnawing pain in
midepigastrium that
worsens with recumbency;
water brash; pain occurs
after eating and can be
relieved with antacids; in
infant: failure to thrive,
irritability, postprandial
spitting and vomiting
soreness, empty feeling, or
hunger; occurs most often
with empty stomach, stress,
and alcohol, and relieved by
food intake; pain steady,
mild, or severe and located
in epigastrium; can be atypical in children and minimal
in elderly
epigastric area that can be
accompanied by nausea,
vomiting, diarrhea, or fever;
alcohol, NSAIDs, and
salicylates make pain worse
diffuse crampy pain accompanied by nausea, vomiting,
diarrhea, and fever; can
have history of recent travel,
family members ill
heartburn, gassiness, or
fullness; belching,
abdominal distention,
and occasionally nausea
Palpable myomas; no
suspicion of other pelvic
disorder
Physical examination
documents hernia
ovarian cysts, especially in
late cycle (corpus luteum)
swelling; palpable hernia
pain with rectus muscle
stress; no GI/genitourinary
symptoms
Physical examination negative;
in infants: weight loss, in
some cases aspiration
pneumonia
Can be epigastric tenderness
on palpation
Physical examination negative No diagnostic testing
Hyperactive bowel sounds will
be heard on auscultation;
dehydration if severe
Physical examination negative H. pylori testing; consider
Pelvic ultrasound if ovarian
or uterine neoplasm
cannot be excluded;
gynecology consult if
abnormal bleeding or
severe symptoms
MRI, CT, ultrasound, BE if
suspect strangulation or
bowel obstruction
Pelvic ultrasound
CT if internal disease
cannot be excluded
Endoscopy if symptoms are
severe or do not respond
to therapy; manometry,
pH monitoring
H. pylori testing; endoscopy
if no response to therapy
necessary if patient
responds to therapy
No diagnostic testing
needed
endoscopy if no response
to empiric treatment;
CBC, FOBT, or FIT
Continued
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Chapter 3 • Abdominal Pain
DIFFERENTIAL DIAGNOSIS OF
Common Causes of Acute Abdominal Pain — cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Abdominal migraine Females age 7-10 yr; episodic
periumbilical pain lasting
more than 1 hr accompanied by nausea, photophobia, headache, and
vomiting; family history
Recurrent abdominal
pain (RAP)
CBC, Complete blood count; CMT, cervical motion tenderness; CT, computed tomography; CVA, costovertebral angle; ECG, electrocardiography;
ESR, erythrocyte sedimentation rate; FIT, fecal immunochemical test; FOBT, fecal occult blood test; GERD, gastroesophageal reflux disease; GI,
gastrointestinal; GYN, gynecological; hCG, human chorionic gonadotropin test; LLQ, left lower quadrant; LUQ, left upper quadrant; MRI, magnetic
resonance imaging; NSAIDs, nonsteroidal anti-inflammatory drugs; O&P, ova and parasites; RLQ, right lower quadrant; RUQ, right upper quadrant;
WBC, white blood cell count.
of migraines
Children age 5-10 yr; history
of environmental or psychological stress
References and Readings
AGA Institute on “Management of Acute Pancreatitis” Clinical Prac-
tice and Economics Committee, AGA Institute Governing Board:
AGA Institute medical position statement on acute pancreatitis,
Gastroenterology 132:2019, 2007.
Alvarado A: A practical score for the early diagnosis of acute
appendicitis, Ann Emerg Med 15:557–564, 1986.
Brown EL, Brown DF, Nadel ES: Pediatric abdominal pain, J Emerg
Med 36:1, 2009.
Carsen L, Lewis D: Abdominal migraine: An underdiagnosed cause
of recurrent abdominal pain in children, Headache 51:5, 2011.
Cartwright SL, Knudson MP: Evaluation of acute abdominal pain in
adults, Am Fam Physician 77:971, 2008.
Fass R, Longstreth GF, Pimentel M, Fullerton S, Russak SM, Chiou
CF et al: Evidence- and consensus-based practice guidelines for
the diagnosis of irritable bowel syndrome, Arch Intern Med
161:2081, 2001.
Incesu L, Taylor CR: Appendicitis imaging. Medscape emedicine, 2014.
Retrieved from http://emedicine.medscape.com/article/363818.
Jacobs DO: Clinical practice: Diverticulitis, N Engl J Med 357:2057,
2007.
Kahrilas PJ, Shaheen NJ, Vaezi MF, et al, American Gastroentero-
logical Association: American Gastroenterological Association
medical position statement on the management of gastroesophageal reux disease, Gastroenterology 135:1383, 2008.
Levy J: Gastroesophageal reux and other causes of abdominal pain,
Pediatr Ann 30:42, 2001.
Lyon C, Clark DC: Diagnosis of acute abdominal pain in older
patients, Am Fam Physician 74:1537, 2006.
Physical examination negative Rule out other causes of
episodic pain
Physical examination negative CBC, U/A, ESR, FOBT, or
FIT, stool for O&P
Marin J, Alpern E: Abdominal pain in children, Emerg Med Clin
North Am 29:2, 2011.
Matthews PJ, Aziz Q: Functional abdominal pain, Postgrad Med
81:448, 2005.
McCollough M, Sharieff G: Abdominal surgical emergencies in
infants and young children, Emerg Med Clin North Am 21:909,
2003.
McFerron BA, Waseem S: Chronic recurrent abdominal pain, Pediatr
Rev 33:11, 2012.
Pepper VR, Stanll AB, Pearl RH: Diagnosis and management of
pediatric appendicitis, intussusception and Meckel diverticulum,
Surg Clin North Am 92:3, 2012.
Ros PR, Huprich JE, Bree RL, et al, Expert Panel on Gastrointestinal
Imaging: Suspected small bowel obstruction. Reston, Va., 2005,
American College of Radiology (ACR).
Ross A, LeLeiko N: Acute abdominal pain, Pediatr Rev 31:135,
2010.
Sachs CJ, Abdominal pain: A rational approach, Consultant,
November 2005.
Talley NJ, American Gastroenterological Association: American
Gastroenterological Association medical position statement:
Evaluation of dyspepsia, Gastroenterology 129:1753, 2005.
Ternent CA, Bastawrous AL, Morin NA, et al, Standards Practice
Task Force of The American Society of Colon and Rectal Surgeons: Practice parameters for the evaluation and management of
constipation, Dis Colon Rectum 50:2013, 2007.
Tsipouras S: Nonabdominal causes of abdominal pain—nding your
heart in your stomach! Aust Fam Physician 37:620, 2008.
CHAPTER
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4
large percentage of primary care visits have psy-
A
chological or psychosocial origins. A practitioner
must rst rule out organic causes for symptoms, mood
changes, and behavior changes. Some patients are
able to express that their symptoms could be related to
situational stress or a psychosocial cause. Others can
identify that psychological or emotional difculties
are causing worrisome symptoms or symptoms that
interfere with their ability to function. Often the practitioner suspects an underlying psychological or psychosocial disturbance that the patient is not able to
articulate. In some cases a parent has concerns about a
child’s or adolescent’s behavior. This chapter focuses
on commonly encountered psychological conditions
and psychosocial concerns, and provides an approach
to elicit more information, determine suicide risk, and
evaluate for a diagnosable psychological disorder
(Figure 4-1).
Do not assume that an emotional symptom has a
psychosocial cause until physical causes have been
fully explored. Anxiety and depression are prevalent
in the primary care setting. Although they are distinct diagnoses, they often co-occur. Substance use
is either a primary condition that is the cause of
psychological concern or a comorbid condition that
is a consequence of a psychological or psychosocial
condition.
Affective Changes
DIAGNOSTIC REASONING: FOCUSED
HISTORY
common in patients experiencing situational stress, depression, anxiety, or substance use problems. Prolonged
somatic symptoms that have not been diagnosed, such as
headache, chest pain, abdominal pain, low back pain, or
dizziness, can suggest a psychosocial or psychological
cause. It is imperative that you consider these clues as
you rule out an organic cause. Also see specic chapters
that address these symptoms.
A parent may relate that a child’s behavior is different from that of other children. On developmental
screening, the very young child may have decits in
social skills and in preverbal language.
Behavioral Cues
A history of frequent primary care or emergency department visits for unexplained symptoms can point
to a psychosocial cause. Sometimes the patient’s behaviors and general appearance do not match the
presenting concern. An emotional response that is
not consistent with the severity of the presenting
problem or situation can point to a psychosocial
problem.
Agitation and restlessness are common manifestations of depression, anxiety, and/or substance abuse.
Changes in personality or in relationships may be
associated with substance abuse, depression, and
anxiety.
Language and social skills that seem out of sync
with general development are important cues that
might indicate a more serious condition.
Is this a psychosocial problem?
Key Questions (to self)
l
Does the presenting concern provide any clues?
l
Are behavioral cues present?
Presenting Concern
Fatigue, lack of energy, sleep disturbance, and an inability to concentrate are symptoms that can bring a
patient to the primary care setting. These symptoms are
Could this be a result of a physiological problem?
Key Questions
l
Can you describe the symptoms you are having?
l
Have you had a major illness recently?
l
How long have you had these symptoms?
Symptoms
Physiological problems often present in the patient
as abdominal pain (see Chapter 3), chest pain (see
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Chapter 4 • Affective Changes
Symptoms suggesting psychological or psychosocial origin
Rule out a physiological/medication cause
Consider
domestic violence
Screen for suicide risk, depression, anxiety,
FIGURE 4-1 A suggested approach to the visit. There are areas of overlap.
Consider
substance use
bipolar disorder
If positive screen, gather
additional data
Evaluate and refer
to mental health
professional for
diagnosable
psychological
disorder
Gather more info
BATHE,
HEEADSSS
Chapter 8), confusion (especially in the older adult,
see Chapter 9), dizziness (see Chapter 13), fatigue
(see Chapter 16), headache (see Chapter 19), and
sleep disturbances (see Chapter 31). Refer to the
specic chapters that discuss the evaluation of the
presenting concern and symptom(s).
Major Illness/Chronic Conditions
Mood disorders can occur secondary to a physiological
condition. Patients who have had a major health event,
such as a myocardial infarction, stroke, or trauma, or
who have chronic symptoms, such as pain, are at risk
for the development of depression.
The mnemonic THINC MED is useful when evaluating for underlying organic causes of changes
in mood or behavior. Box 4-1 identifies conditions
that are commonly associated with anxiety and
depression.
Box 4-1
Major categories of medical conditions that mimic psychological conditions are as follows:
T Tumors
H
I Infections and immune diseases (e.g., AIDS, lupus,
N Nutrition
C
M Miscellaneous (e.g., sleep apnea, anemia, congestive
E Electrolyte abnormalities and toxins (e.g., hypercalce-
D Drugs (including nicotine, caffeine, prescribed medi-
From Goolsby MJ, Grubbs L: Advanced assessment: Interpreting findings
and formulating differential diagnoses,
Davis.
THINC MED
Hormones (e.g., thyroid, adrenal, gonads, insulin)
syphilis, Lyme disease)
Central nervous system (e.g., head trauma, seizures,
multiple sclerosis, Parkinson disease, dementia)
heart failure)
mia, hypo/hyperphosphatemia, hypo/hypernatremia)
cations, illicit drugs, and alcohol)
ed. 2, Philadelphia, 2011, F.A.
Chapter 4 • Affective Changes
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35
Could this be caused by medication?
Key Questions
l
What prescribed medications are you currently
taking?
l
What over-the-counter (OTC) and/or herbal medi-
cines do you take?
l
What dietary supplements are you taking?
Medication History
Many medications can cause psychiatric symptoms and
mood changes. Box 4-2 lists medications that can pro-
duce symptoms of depression, anxiety, and mania. The
Beers criteria identies potentially inappropriate medica-
tions for older adults (available at www.american geriatrics.
org/health_care_professionals/clinical_practice/clinical_
guidelines_recommendations/2012).
OTC Medications, Herbal Medicines, and Dietary
Supplements
Some OTC medications, herbal preparations, and dietary
supplements can contribute to psychiatric symptoms.
A complete list of all preparations that the patient is
taking is a starting point for evaluating side effects and
interactions.
A positive response to any one of these three questions
constitutes a positive screen for partner violence
(Feldhaus et al, 1997). The rst question, which addresses physical violence, has been validated in studies
as an accurate measure of 1-year prevalence rates. The
latter two questions evaluate the perception of safety,
and provide estimates of the short-term risk of further
violence and the need for counseling, but reliability and
validity evaluations have not yet been established. A
positive screen requires further assessment and clinical
follow up, including ascertaining patient safety.
Could this be situational stress or normal grief?
The BATHE model provides a framework for understanding the patient in the context of his/her total
life situation (Lieberman, 1997). BATHE is a mnemonic for Background, Affect, Trouble, Handling,
and Empathy.
Key Questions
Background: ascertains the context of the visit.
l
What is going on in your life?
l
What is going on right now?
l
Has anything changed recently?
Is this a situation of domestic or partner violence?
Key Questions
l
Have you been hit, kicked, punched, or otherwise
hurt by someone within the past year?
l
Do you feel safe in your current relationship?
l
Is there a partner from a previous relationship who is
making you feel unsafe now?
Box 4-2
MEDICATIONS THAT CAN CAUSE
SYMPTOMS OF DEPRESSION
• Accutane
• Antabuse
• Anticonvulsants
• Antiparkinsonian medications
• Antivirals
• Barbiturates
• Benzodiazepines
• Beta-adrenergic blockers
• Calcium-channel blockers
• Estrogens
• Fluoroquinolone antibiotics
Medications Associated With Changes in Mood
• Interferon alfa
• Narcotics
• Statins
MEDICATIONS THAT CAN CAUSE
SYMPTOMS OF ANXIETY
• Albuterol
• Theophylline
• Thyroid hormones
MEDICATIONS THAT CAN CAUSE
SYMPTOMS OF MANIA
• Antabuse
• Anticholinergics
Affect: elicits the emotional response and allows the
patient to label the feeling.
l
How do you feel about that?
l
What is your mood?
Trouble: determines the symbolic meaning of the situation for the patient.
l
What about the situation troubles you most?
l
What worries or concerns you?
• Antiparkinsonian medications
• Capoten
• Cogentin
• Corticosteroids
• Cyclosporine
• Monoamine oxidase inhibitors
(MAOIs)
• Opioids
• Tagamet
• Thyroid hormones
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Chapter 4 • Affective Changes
Handling: helps to assess patient resources and responses to the situation.
l
How are you handling that?
l
How are you coping?
Empathy: reects an understanding that the patient’s
response is reasonable under the circumstances.
l
That must be very difcult for you.
l
I can understand that you would feel that way.
BATHE Model
This model provides a patient-centered technique that
helps establish a relationship with the patient; serves as
a rough screening test for anxiety, depression, or situational stress disorders; and takes minimal time.
Could this be a result of substance abuse?
Key Questions
l
In the past year, have you used alcohol or drugs more
than you meant to?
l
Have you wanted or needed to reduce your drinking
or drug use in the past year?
A positive response to one question indicates a substance use concern and the need for further investigation. When the screen is positive, the CAGE questions
can be used to detect alcoholism. Other substances can
be substituted for alcohol in the CAGE questionnaire
(Box 4-3). Other questionnaires, T-ACE and CRAFFT,
for alcohol use are also available (Box 4-4 and
Box 4-5).
Box 4-3
The CAGE questionnaire developed in 1984 includes four
interview questions designed to help diagnose alcoholism. Answering yes to one or more of the four questions
raises a high index of suspicion for alcohol abuse and
dependence. The acronym “CAGE” helps practitioners
quickly recall the main concepts of the four questions
(Cutting down, Annoyance by criticism, Guilty feeling,
Eye-openers).
The CAGE questionnaire has been used and tested
extensively in many populations. It is considered to be a
reliable method of screening for alcohol abuse in adults. It
has reported sensitivities of 43% to 94% and specificities
ranging from 70% to 97%.
The complete questionnaire can be found at http://
addictionsandrecovery.org/addiction-self-test.htm.
From Ewing JA: Screening for alcoholism using CAGE: Cut down,
annoyed, guilty, eye opener, JAMA 280: 1904, 1984.
CAGE Questionnaire
Box 4-4
This questionnaire provides a brief screening for prenatal
detection of risk-drinking. The acronym stands for Tolerance,
Annoyed, Cut down, Eye-opener. A positive answer to T alone,
or to two of A, C, or E can signal a problem with a high degree
of probability, and positive answers to all four indicates
great certainty of a problem. The complete questionnaire
can be found at www.acog.org/Resources_And_Publications/
Commi tt ee_Opinio ns/Commi t te e_on_Heal th_Care_for _
Un de rserv ed _Wom en/At -R isk_D ri nking _and_ Al cohol _
Dependence_-_Obstetric_and_Gynecologic_Implications.
From Sokol RJ, Martier SS, Ager JW: The T-ACE questions: Practical
prenatal detection of risk-drinking. Am J Obstet Gynecol 160:863,
1989.
Box 4-5
The CRAFFT questionnaire was developed as a screening tool
for alcohol and substance abuse in adolescents. The CRAFFT
acronym helps practitioners remember the main concepts of
the six questions: Car, Relax, Alone, Forget, Friends, Trouble.
It is considered a valid screening test among all demographic
subgroups of adolescents with reported sensitivities of 76%
to 92% and specificities of 80% to 94%
The complete questionnaire can be found at: http://
archpedi.jamanetwork.com/article.aspx?articleid5203511.
Reference: Knight JR, Sherritt L, Shrier LA, et al: Validity of the CRAFFT
substance abuse screening test among adolescent clinic patients. Arch
Pediatr Adolesc Med
T-ACE Questionnaire
The CRAFFT Questionnaire
156:607, 2002.
How can I narrow my diagnosis?
Begin with broad screening questions. If the patient’s
response to the screening question(s) is positive, proceed to elicit more specic symptoms. Although a
negative response to a given screening question decreases the likelihood of a disorder, the sensitivity of
such screening is not perfect, and answers should be
interpreted within the context of the patient’s entire
history and physical examination.
Key Questions
l
Is there a personal or family history of mental illness?
l
Is there a family history of autism?
l
Over the past 2 weeks, have you felt down, depressed,
or hopeless?
l
Over the past 2 weeks, have you had little interest or
pleasure in your daily activities?
l
Do you tend to be an anxious or nervous person?
l
Have you had periods of feeling so happy or ener-
getic that your friends told you were talking too fast
or that you were too “hyper”?
Chapter 4 • Affective Changes
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37
Prior Mental Illness, Family History
A personal or family history of prior mental illness increases the likelihood of a current mental illness. Studies
support the inuence of both behavioral and biological
factors in the development of mental health conditions.
Family history of another child with autism increases
the risk of autism in a sibling.
Down, Depressed, Hopeless, Loss of Interest
or Pleasure
These are cardinal symptoms for depression, and the
presence of at least one of these symptoms is required
to diagnose clinically signicant depression. Research
suggests that asking the following two questions is as
effective as longer inventories (Whooley et al, 1997):
l
Over the past 2 weeks, have you felt down, de-
pressed, or hopeless?
l
Over the past 2 weeks, have you felt little interest or
pleasure in your daily activities?
If screening is positive, conrm with a more thorough
assessment of neurovegetative signs (Box 4-6), and
further investigation.
Box 4-6
Neurovegetative Signs In Depression
S
I Interest deficit (anhedonia)
G Guilt (worthlessness, hopelessness, regret)
E Energy deficit
C Concentration deficit
A Appetite disorder (either decreased or increased)
P Psychomotor retardation or agitation
S Suicidality
From Carlat DJ: The psychiatric review of symptoms: A screening tool
for family physicians. Am Fam Physician 58:1617, 1998.
SIG E CAPS
Sleep disorder (either increased or decreased sleep)
Anxious or Nervous
Asking patients whether they feel anxious or nervous
is useful as a general screen. Clinical experts suggest
that unexplained somatic symptoms along with reports
of agitation and difculty maintaining concentration
suggest anxiety rather than depression.
A positive response to a question about anxiety or
nervousness can prompt further screening:
l
Do you have anxiety or panic attacks?
l
Have you had to limit your activities because of your
anxiety?
The rst question helps to differentiate anxiety from
panic attacks. The second question points toward panic
with agoraphobia. If the patient is not certain what you
mean by the term “panic attacks,” you can provide a
simple description to clarify: “A panic attack is a sudden rush of fear and nervousness that makes your heart
pound and makes you afraid you’re going to die or go
crazy” (Carlat, 1998).
Happy, Energetic, Hyper
In the presence of depressive symptoms, a positive response to the last key question is helpful in screening
for bipolar disorder. If the screen is positive, the mnemonic DIG FAST can be used to conrm the cardinal
symptoms of mania (Box 4-7).
What about special considerations for adolescents?
For adolescents, a psychosocial review of systems can
serve as a screen for areas that could be of concern or that
have the potential to create problems. The HEEADSSS
method of interviewing provides structure and a framework for focusing assessment. The acronym stands
for Home, Education/employment, Eating, peer-group
EVIDENCE-BASED PRACTICE
The USPSTF recommends screening adul ts for depression
in clinical practices that have systems in place to assur e
accurate diagnosis, effective treatment, and f ollow up. In
primary care setti ngs, the point prevalence of major depres-
sion ranges from 5% to 9% among adults, an d up t o 5 0%
of depressed patients are not recognized. Several depres-
sion screening i nstruments are available and most instru-
ments have relativ ely good sensitivity (80% to 90%) but
only fair specificity (70% to 85%). Most instruments are
Data from U.S. Preventive Services Task Force (USPSTF): Depression in adults: Screening, and Depression in children and adolescents:
Screening,
Drummond R (Eds): The rational clinical examination: Evidence-based clinical diagnosis. New York, 2009, McGraw Hill.
2009. Ret rieved from www.uspreventiveservicestaskforce.org/: Williams JW , Steffens D: Update Depression, in Simel DL,
Screening for Depression
easy to use and can be administere d in less than 5 minutes.
The evidence demonstrates that shorter screening t ests, i ncluding simply asking questions about depressed m ood
and anhedonia, appear to detect a majority of depressed
patients, with results comparable to longer depression questionnaires. Ultrashort que stionnaires can be administered
easily in writing or verbally. There are no brief validated
depression screening questionnaires for children in prima ry
care settings.
38
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Chapter 4 • Affective Changes
Box 4-7
Cardinal Symptoms of Bipolar Disorder
D Distractibility
I
G Grandiosity
F
A Activity increase
S Sleep deficit (decreased need for sleep)
T Talkativeness (pressured speech)
From Carlat DJ: The psychiatric review of symptoms: A screening tool
for family physicians. Am Fam Physician 58:1617, 1998.
DIG FAST
Indiscretion (excessive involvement in pleasurable
activities)
Flight of ideas
the past to more personal and private issues. The essential questions should be asked of all adolescents.
The next in importance are those questions that should
be asked of most adolescents if time permits. Finally,
the in-depth questions can be asked when time allows
or the situation demands it. Table 4-1 provides sample
items.
Is this patient at risk for suicide?
Key Questions
l
Have you been feeling that life is not worth living or
that you are better off dead?
l
Activities, Drugs, Sexuality, Suicide/depression, and
Safety.
Key Questions
The HEEADSSS interview progresses from less intimidating questions about home, family members, and
Table 4-1
ESSENTIAL QUESTIONS AS TIME PERMITS FOR MORE IN-DEPTH
The HEEADSSS Psychosocial Interview for Adolescents
Sometimes when a person feels down or depressed,
he or she might think about dying. Have you been
having thoughts like that?
l
If the patient answers yes to the preceding questions,
then ask the following:
l
Do you have a plan?
HOME
What are relationships like at home? Have you ever run away? (Why?) —
EDUCATION AND EMPLOYMENT
What are your favorite subjects at school? Tell me about your friends at school. Do you feel connected
to your school?
EATING
What do you like and not like about your body? Do you worry about your weight? How
often?
ACTIVITIES
What do you and your friends do for fun? (With whom) Do you have any hobbies? —
DRUGS
Do any of your friends use tobacco? Alcohol? Other
drugs?
SEXUALITY
Have you ever been in a romantic relationship? Are you interested in boys? Girls? Both? —
SUICIDE AND DEPRESSION
Do you feel sad or down more than usual? Does it seem that you’ve lost interest in
SAFETY (SAVAGERY)
Have you ever been seriously injured? (How?) Have you ever been in a car or motorcycle
Copyrighted 2015. UBM Advanstar. 116284:0315DS
Do you ever drink or use drugs when
you are alone?
things that you used to really enjoy?
accident? (What happened?)
What would it be like
if you gained (lost)
10 pounds?
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