Red flag symptoms
- Changes of mood, behaviour or functioning in more than one area of life, even if this change may be relatively subtle
- Potentially aggravating social or occupational factors
- Potential risk of harm or neglect for patient or others owing to mood and behavioural change
- Unexplained onset or persistent/disruptive mood changes in vulnerable groups such as adolescents, children, patients with disabilities or chronic physical or mental health conditions
Physical and mental illness (including more severe conditions, such as schizophrenia and bipolar disorder) rarely appears without early signs.
Patients themselves, or people around them (family, friends, colleagues, neighbours, teachers or others) typically recognise a period of change before a clearer onset of symptoms. This may become more apparent retrospectively and can include mood, thinking, feeling or behaviour.
Although `mood' is not easy to define, there tend to be cultural or collective norms and expectations or `typical' benchmarks, and if an individual starts to deviate from these, it is likely to be noticed. There could be a slow, progressive change, or a sequence of more erratic, unpredictable changes.
Mood has elements of stability and fluidity in the individual. We may sometimes use the word `temperament' for the more fundamental and continuous features of an individual's mood. The more flexible element of mood could be regarded as the part that is more immediately influenced by external elements, such as social context, environmental surroundings and other circumstances, and may even be mostly dependent on them.
It is often more important to recognise and identify minor changes, particularly if they occur in several arenas of the patient's life situation, rather than only looking for a significant change in one area alone. These changes may include:
- Loss of interest in, or concern about, others as well as oneself
- Apathy or overactivity
- Unexplained development of persisting seriousness or euphoria
- Unusual or unexpected disengagement from previous involvements (sports, clubs, volunteering, hobbies), or the development of a significant change of focus, interest and preoccupation with new activities that seem to be unusual for the individual. For example, these might include a sudden spiritual or religious interest, or a concern regarding politics or conspiracies.
- Onset of dysfunctions and difficulties with intellectual or practical tasks or procedures which were familiar
- A vague sense of unreality or disconnection from things or people; illogical interpretations of events or influences
- Onset of unexplained rapid mood swings, with irritability, anger, fear, panic, agitation, suspicions or changes of a sense of boundaries (withdrawal/disinhibition), significantly increased overall sensory responses or fragility, unexplained changes in sleep patterns, appetite, personal hygiene or speech
- A degree of insight or denial regarding such changes
When taking the history, gathering information from third parties can be at least as important as information from patients themselves.
The patient's or relatives' concerns and ideas may give helpful hints regarding triggering events, as well as the impact of the mood changes on the patient's life and functioning.
The medical notes review would need to include previous mental and physical conditions (even if seemingly controlled or resolved), current medication and social factors, if known.
|Possible causes of mood change|
Consider the presentation to be possibly the tip of an iceberg. Therefore, the opportunity to gather information now is precious.
In interaction, are there any signs of thought disorders, delusions, hallucinations, intense preoccupation with a topic and elements of `pontification', memory problems, inability to engage or fluctuating engagement and disengagement, agitation or aggression, fear, suspicion, flatness, or suicide risk?
On physical examination, is there restlessness and rigidity, possible intoxication, neurological deficits or abnormalities, fever, BP, pulse, urine dipstick, BMI or blood sugar?
Start with open questions but do not omit some closed questions for specific aspects.
Consider a brief memory test, such as the GP Assessment of Cognition. If possible, gather extra information from sources who know the patient, if considerations of consent or confidentiality and privacy allow this.
Consider baseline blood tests to check for signs of inflammation or infection or apparent deficiencies (anaemia), as well as metabolic dysfunction (liver, renal, thyroid function, random glucose).
Think carefully about an appropriate active follow-up consultation in the right setting, and about mechanisms so that this cannot be changed or missed without being flagged up and noticed.
When to refer
Immediately refer or admit the patient if there could be a potential risk of physical harm to them or others. Consider social services involvement, for children as well as adults. Keep a low threshold for obtaining a rapid second opinion from a specialist in cases of concern, even though (or especially when) the situation does not fit a clear referral pathway. A brief telephone discussion with a local psychiatric crisis team or similar facility for advice, if available, may be useful.
- Dr Tillmann Jacobi is a GP in York
This is an updated version of an article first published in October 2014.