Chapter 33Assessment of Mood and Anxiety

• Medportal eLearning Course Modules (requires Medportal Login): Mood and Anxiety Assessment.
• ADMSEP eModules (requires Medportal Login): Adjustment Disorders; Anxiety Disorders, Bipolar Disorder.
• Archived Lecture: Clinical Skills LGS on Assessment of Mood and Anxiety (requires Medportal Login)

• During the past 4 weeks, have you been bothered by feeling worried, tense or anxious most of the time?
• Are you frequently tense, irritable, and having trouble sleeping?

• Does fear of embarrassment cause you to avoid doing things or speaking to people?
• Do you avoid activities in which you are the center of attention?
• Is being embarrassed or looking stupid among your worst fears?

• Do you have sudden episodes/spells/attacks of intense fear or discomfort that are unexpected or out of the blue? → If yes, ask follow-up questions:
  • Have you had more than one of these attacks?
  • Does the worst part of these attacks usually peak within several minutes?
  • Have you ever had one of these attacks and spent the next month or more living in fear of having another attack and worrying about the consequences of the attack?

• Are there any specific things (such as heights, animals or closed spaces) that you fear or avoid?
• Do you think that your fear is excessive?
• Do you have any special fears such as flying or spiders?

Obsessions:

• Are you bothered by repeated and unwanted thoughts of any of the following types: Thoughts of hurting someone else; Sexual thoughts; Excessive concern about contamination/germs/disease; Preoccupation with doubts (“what if” questions) or an inability to make decisions; Mental rituals (e.g., counting, praying, repeating); Other unwanted intrusive thoughts
• If you answered “YES” to any of the above… Do you have trouble resisting these thoughts, images, or impulses when they come into your mind?

Compulsions:

• Do you feel driven to perform certain actions or habits over and over again, or in a certain way, or until it feels just right? Such as: Washing, cleaning; Checking (e.g., doors, locks, appliances); Ordering/arranging; Repeating (e.g., counting, touching, praying); Hoarding/collecting/saving
• If you answered “YES” to any of the above… Do you have trouble resisting the urge to do these things?

• Have there been times lasting at least several days when you feel high, on top of the world, euphoric, or overly cheery?
• Have you had periods when you are more energetic or active than usual?
• Have you ever had a period of a week or so when you felt so happy and energetic that your friends told you that you were talking too fast or that you were behaving differently or strangely?
• Has there been a period when you were so hyper and irritable that you got into arguments with people?

• Have you experienced or seen a life-threatening or traumatic event such as a rape, accident, someone badly hurt or killed, assault, natural or man-made disaster, war, or torture? → If yes, then continue:
  • Do you re-experience the event in disturbing (upsetting) ways such as dreams, intrusive memories, flashbacks, or physical reactions to situations that remind you of the event?

M- SIG E CAPS – 5 of 9, one must be ↓ mood or anhedonia

• Mood
• Sleep → Hypersomnia or Insomnia
• Interest → Anhedonia
• Guilt
• Energy → Fatigue
• Concentration
• Appetite → ↑ or ↓
• Psychomotor → Agitation or Slowing
• Suicidal

DSM-5 Correlation Highlights: Must be present nearly every day for a period of at 14 days; Change from baseline (e.g. chronic insomnia or daytime fatigue); Causing significant impairment in social, occupational or other areas of functioning; Must never have had manic or hypomanic episode

HE’S 2 SAD – 3 of 7, one must be ↓ mood

• Hopelessness
• Energy → Low energy or fatigue
• Self Esteem → Low
• 2 years minimum ↓ mood for most of day, more days than not
• Sleep → Hypersomnia or Insomnia
• Appetite → ↑ or ↓
• Decision making or concentration impaired

DSM-5 Correlation Highlights: Depressed mood must be present for most of the day, for more days than not for at least 2 years; No remission → never a 2-month period free of symptoms; Causing significant impairment in social, occupational or other areas of functioning; Must never have had manic or hypomanic episode

GST PAID (3 of 7, or 4 of 7 if mood is only irritable)

• Grandiosity → Inflated self-esteem
• Sleep Deficit → Decreased need (e.g. rested on 3 hours’ sleep)
• Talkativeness→ more than usual or pressure to keep talking
• Pleasurable activity, painful consequence→Impulsive/foolish/reckless
• Activity ↑ → Goal-directed (social, work, sex) or psychomotor
• Ideas → Flight of ideas
• Distractibility → attention drawn to irrelevant external stimuli

DSM-5 Correlation Highlights: Requires a distinct period of abnormally, persistently ↑, expansive/irritable mood and abnormally/persistently ↑ goal-directed activity or energy, lasting ≥1 week present most of day, nearly every day (or any duration if requiring hospitalization); Episode causes significant impairment in function, or necessitates hospitalization

*Note: To be diagnosed with Bipolar Affective Disorder Type 1, patient must meet criteria for a manic episode, which may have been preceded and may have been followed by a hypomanic or major depressive episode (MDE – follows same M-SIGECAPS as above)

TAD HIGH

• Talkative
• Attention deficit
• Decreased need for sleep
• High self-esteem/Grandiosity
• Ideas that race
• Goal-directed activity increased
• High-risk activity

DSM-5 Correlation Highlights: Minimum 4 consecutive days of symptoms most of the day, nearly every day; Hospitalization or psychotic features exclude hypomania

*Note: To be diagnosed with Bipolar Affective Disorder Type 2, patient must meet criteria for a current or past hypomanic episode, and must meet criteria for a current or past major depressive episode (MDE – follows same M-SIGECAPS as above)

WATCHERS

• Worry → Apprehensive expectation about number of activities
• Anxiety → about a number of activities
• Tension in muscles
• Concentration difficulty → or “mind going blank”
• Hyperarousal (irritability)
• Energy → Easily fatigued
• Restlessness → feeling keyed up or on edge
• Sleep disturbed → falling or staying asleep, or restless unsatisfying

DSM-5 Correlation Highlights: Required excessive Worry and Anxiety that is difficult to control, more days than not for ≥6 months about number of activities, plus 3 of 6 of other items in mnemonic (TCHERS); Anxiety, worry or physical symptoms cause clinically significant impairment in functioning

Panic Attacks: STUDENTS FEAR the 3 Cs – 4 of 13

• Sweating
• Trembling (shaking)
• Unsteadiness (dizziness)
• Depersonalization or Derealisation
• Excessive HR, Palpitations
• Nausea
• Tingling
• Shortness of Breath

FEAR: 2 criteria → Losing Control; and Dying

3 C’s: 3 Criteria → Chest Pain, Choking, and Chills

DSM-5 Correlation Highlights: Panic attacks: Intense fear and discomfort that peaks in minutes; Attacks are recurrent with at least 2 unexpected attacks; 1 month + of persistent worry of additional panic attacks, significant maladaptive changes to avoid them (e.g. avoiding exercise or unfamiliar situations)

TRAUMAS – 6 of 6 criteria

• Traumatic event
• Re-experiencing the traumatic event (nightmares, flashbacks, etc.)
• Avoidance of stimuli associated with traumatic event
• Unable to function – distressing, significant impairment
• Month – lasts >1 month
• Arousal – startle reaction, poor concentration, hypervigilance
• Self – significant alterations in cognitions and mood

DSM-5 Correlation Highlights: Duration of the disturbance is > 1 month

TIRED

• Thoughts – obsessions recurrent, persistent, intrusive, unwanted
• Ignore, suppress or neutralize obsessions – e.g. via compulsions
• Repetitive – compulsive behaviours or mental acts
• Excessive – behaviours not realistically connected with what they’re designed to prevent or neutralize
• Distressing – excessive time use (>1 hr/day) or impairment

DSM-5 Correlation Highlights: Presence of Obsessions (thoughts to ignore, suppress or neutralize), Compulsions (repetitive behaviours that are excessive and disconnected with what they’re designed to prevent), or both