Behavioral Medicine

medical conditions involving a change in emotion, thinking, and/or behavior. Associated with distress and/or difficulty functioning in social, work, and/or family life

mental illness

interdisciplinary field that integrates behavioral, psychosocial, and biomedical science knowledge and techniques

behavioral medicine

medical specialty for the diagnosis, treatment, and prevention of mental disorders

psychiatry

what model is used to show the etiology and risk factors of mental illness

biopsychosocial model

DSM-5

Diagnostic and Statistical Manual and Mental Disorders, Fifth Edition

who published the DSM-5

American Psychiatric Association (APA)

parts of assessment of the psychiatric patient

introduction

medical conditions causing psychiatric symptoms

most important components

history

mental status exam

physical exam

diagnostic tests

introduction during assessment of a psychiatric patient

will differ by setting and patient

people with a substance or eating disorder will often claim that nothing is wrong

most important components of assessment of a psychiatric patient

history

mental status exam

physical exam

diagnostic tests

history during assessment of a psychiatric patient

how most diagnoses are made

chief complaint

subjective history

what is included in subjective history

past medical history

social history

family history

mental status exam during assessment of a psychiatric patient

subjective and objective components

observations and questions at the time of interview

essential part of documentation

only accurate at the time of the exam

general description of mental status exam

appearance and attitude

mood

subjective

emotion reported by patient

affect

objective

observed expression

what can tell a lot about a patient in the general description of a mental exam

speech

components of a mental status exam

general description

mood and affect

speech

thought

sensorium and cognition

what can be indicators of a mental disorder or substance use through speech

volume

cultural differences

slurred

pressured

perception in a mental status exam

hallucinations

false sensory perception, not associated with real external stimuli

hallucination

what can hallucinations be caused by

psychiatric problems

underlying medical problem

most common hallucination

auditory

which hallucination is common in elderly patients with dementia

visual

what hallucinations are typically due to underlying medical issues

olfactory

tactile

gustatory

thoughts in mental status exam

delusion

obsession

phobia

suicidal ideation and homicidal ideation

false belief that cannot be changed by reasoning

delusion

pathological persistence of a thought or feeling

cannot be eliminated by logical effort

obsession

persistent, irrational, or exaggerated fear

phobia

thoughts of harm to self or others

suicidal ideation

homicidal ideation

sensorium and cognition in mental status exam

consciousness

orientation

memory

concentration

what is sensorium and cognition tied into

mini-mental exam

when should a physical exam be done

with any evaluation

purpose of diagnostic tests

to establish normal

look for abnormalities

rule outs

standard laboratory tests

CBC

glucose

chemistries

TSH

tox screen

drug levels

HIV

other diagnostic tests

CXR
EKG
EEG
CT
MRI

psychological evaluations

intelligence tests

personality tests

criteria for major depressive disorder

have either a depressed mood or loss of interest for a two-week period, most of the day, nearly every day and at least four symptoms

loss of interest or pleasure

anhedonia

symptoms of major depressive disorder

suicidal ideation, thoughts of death/plan/attempt

interest

guilt/worthlessness

psychomotor agitation/retardation

what can symptoms of major depressive disorder cause

distress or impairment in areas of functioning

specifiers of major depressive disorder

with peripartum onset

with seasonal pattern

when must symptoms be present for peripartum onset major depression

within 4 weeks of delivery

what can depressed mood be

sad, hopeless, down

somatic complaints

loss of interest

depression inventories

screening assessments

subjective

major depressive disorder in children

irritability

school

acting out

weight change

major depressive disorder in the elderly

somatic complaints

asses co-morbid symptoms

pathophysiology of major depressive disorder

genetic/biological (neurotransmitters)

environmental

secondary to other diseases/conditions

what gender is major depressive disorder more common in

women

when is major depressive disorder typically onset

mid 20s

what does major depressive disorder have a high rate of

recurrence (60%)

treatment for major depressive disorder

pharmacotherapy

psychotherapy

pharmacotherapy for major depressive disorder

antidepressants

• selective serotonin reuptake inhibitors (SSRIs)

• serotonin norepinephrine reuptake inhibitors (SNRIs)

psychotherapy for major depressive disorder

counseling

coping skills

techniques

other treatments for major depressive disorder

exercise

limit drugs/alcohol

get sleep

electroconvulsive therapy

brain/vagus nerve stimulation

what is persistent depressive disorder also know as

dysthymic disorder

criteria for persistent depressive disorder

depressed mood for most of the day, more days than not, for at least 2 years, by subjective or objective account and at least 2 symptoms

symptoms of persistent depressive disorder

low self-esteem

hopelessness

presence of major depression and mania

bipolar disorder

criteria for bipolar disorder

distinct period of abnormally and persistently elevated, expansive, or irritable mood that lasts at least 1 week and 3 or more symptoms

symptoms of bipolar disorder

inflated self-esteem

more talkative/pressure to talk

flight of ideas or racing thoughts

decreased need for sleep

increase in goal directed activity or psychomotor agitation

excessive involvement in pleasurable activities that have a high potential for painful consequences

what do symptoms of bipolar disorder cause

marked impairment of functioning

necessitate hospitalization

psychotic features

what is bipolar disease not caused by

substance use

medical condition

when is typical onset of bipolar disorder

early 20s

what is poor in patients with bipolar disorder

insight

they don’t realize that anything is wrong

treatment of bipolar disorder

pharmacotherapy

psychotherapy

pharmacotherapy of bipolar disorder

mood stabilizers

antidepressants

antipsychotics

psychotherapy for bipolar disorder

counseling

coping skills

techniques

other treatments for bipolar disorder

hospitalization

limit/eliminate triggers

other mood disorders

mood disorders due to a general medical condition

substance induced mood disorder

assessing suicide risk

ask about thoughts

intent, plan, access

what keeps them from attempting

need to directly ask if they have had thoughts of suicide

risk factors for suicide

older age

male

single/widowed/divorced

substance abuse

poor social supports

unemployed or retired

poor physical health/serious health problem

prior history/family history

response to suicidal ideation

inpatient treatment should be recommended

apprehension, tension or uneasiness from anticipation of danger/threat

anxiety

common physical symptoms of normal anxiety

chest pain

nausea/vomiting

numbness/tingling

dizziness

shortness of breath

when anxiety interferes with effectiveness in living, achievement of desired goals or satisfaction, or reasonable comfort

pathological anxiety

most common DSM diagnosis

pathological anxiety

lifetime prevalence of pathological anxiety

10-15%

what percentage of pathological anxiety patients meet the criteria

25%

diagnosing anxiety

history

mental status exam

physical exam

laboratory tests/diagnostics as needed

psychological tests as needed

criteria for panic disorder

recurrent, unexpected panic attacks and at least 4 symptoms

persistent concern or worry about additional attacks or their consequences

a significant maladaptive change in behavior related to the attacks

an abrupt surge of intense fear or discomfort

panic attack

symptoms of panic disorder

feeling of choking

trembling

depersonalization

fear of dying

who is panic disorder more common in

female

onset of panic disorder

between adolescence and mid 30s

etiology of panic disorder

neurotransmitters

genetics

psychological factors

criteria for specific phobia

marked fear or anxiety about a specific object or situation

out of proportion to the actual danger posed and to the context

the phobia is actively avoided/or endured with intense fear or anxiety

symptoms persist, typically lasting for 6 months or more

criteria for social anxiety disorder

marked fear or anxiety about social situation in which there is potential scrutiny by others

fear that will act in a way/display anxiety that will be negatively evaluated

out of proportional to actual threat

social situations avoided or endured with intense fear or anxiety

symptoms persist, typically lasting 6 months or more

criteria for generalized anxiety disorder

excessive anxiety and worry about a number of events or activities occurring more days than not for at least 6 months

difficult to control worry

at least 3 symptoms (1 in children)

symptoms of generalized anxiety disorder

restlessness

fatigue/sleep disturbance

difficulty concentration

irritability

muscle tension

what can be common in generalized anxiety disorder

somatic symptoms

what is exaggerated in generalized anxiety disorder

startle response

criteria for post-traumatic stress disorder

exposure to actual or threatened death/injury or sexual violence

intrusion symptoms

persistent avoidance of stimuli, associated with trauma

negative alteration in cognition/mood

alteration in arousal

duration of symptoms greater than 5 months

clinically significant impairment/distress in social, occupational, other functioning

intrusion symptoms

memories

dreams

dissociative reactions (flashbacks)

persistent avoidance of stimuli associated with trauma

avoid memories/thoughts/feelings, or external reminders

negative alteration in cognition/mood

inability to recall important aspect of trauma

negative beliefs/emotional state. Unable to experience positive emotions

diminished interest/participation in significant activities

feeling detached/estranged from others

alterations in arousal

irritability, angry outbursts

reckless/self-destructive behavior

hypervigilance

exaggerated startle response

difficulty concentrating

sleep disturbances

what are there high rates of in post traumatic stress disorder

co-morbid mood disorders

criteria for obsessive compulsive disorder

presence of obsessions, compulsions, or both

the obsessions/compulsions are time-consuming or cause clinically significant distress

obsessions

thoughts

compulsions

actions