BH E3- Review

What are the exceptions to confidentiality?

*Five “C”s

Consent- pt legally authorizes

Court order- subpoena or legal request

Continued treatment- minimum necessary rule, pt transfer

Comply with law- mandatory reporting for abuse

Communicate a threat- duty to protect or warn

What statute allows judges, law enforcement officers, physicians, PAs, or mental health professionals to involuntary admit a patient to prevent harm to self or others?

*maximum 72 hours for evaluation

Baker act (Florida mental health act of 1971)

What must there be evidence of before a baker act is placed?

Behavioral health diagnosis, harm to self or others or is self neglectful

What is the MC mental health emergency in the US?

Suicide

What are most suicides due to?

Firearms

What are RF for suicide?

Prior attempt (greatest RF), men > 65 & 45-54 y/o, veterans, isolation

What gender is more likely to overdose & more likely to attempt suicide (not successful)?

Women

What gender is more likely to commit suicide by firearms, jumping, hanging, MVA and is more likely to be successful?

Men

In order, what ages are more likely to commit suicide?

Males > 65, males 45-54, females 45-54, females 55-64

What psychological factor is the single best indicator of long term suicidal risk?

Hopelessness

What psychological factors contribute to suicide?

Hopelessness, helplessness, depression with psychotic features, substance use disorders, isolation & loss of social support, & recent significant loss

What are the stages of change in motivational interviewing?

Precontemplation (unaware of problem) → contemplation (acknowledges problem & considers action) → planning (prepares to take action) → action (actively modifies behavior) → maintenance (sustains new behavior) → relapse (returns to old patterns)

What is the following an example of?

• pt doesn’t know they have depression

• pt is sad & empty, thinks they might have depression, needs to make appointment

• pt goes to PCM, plants to control depression & keep journal

• initiates action to control depression - takes meds, keeps journal

• depression is controlled & pt continues activities that control it

• pt stops something & depression returns

Stages of change model

The following criteria is for what condition?

• Intentional self injury ≥ 5 days in past year WITHOUT suicidal intent

• self-harm with expectation of:

  • relief from negative feelings

  • resolving interpersonal difficulties

  • inducing positive feelings

• associated with interpersonal difficulties or negative emotions

Nonsuicidal self-injury disorder

What population is nonsuicidal self injury MC?

Females in their 20s, BPD

What are the most common psychiatric diagnosis in the ED?

*40% require admission

Mood disorders & alcohol dependence

What patients should be screened for DV?

All patients ≥ 14 y/o

What is the MC population for somatic disorders?

F > M

What clues might suggest somatic disorders?

Excessive or chronic pain, chronic multiple sx w/o adequate explanation or no correlation, sx don’t improve despite treatment, & excessive concern with health

What is a disorder in which an individual experiences high levels of anxiety & persistent worry about bodily signs and symptoms that are misinterpreted as having a known medical disorder?

Somatic symptom disorder

The following key diagnostic features are associated with what condition?

• distressing physical sx + excessive thoughts & anxiety

• persistent ≥ 6 mos

• multiple physical complaints affecting various body systems

• sx lead to significant functional impairment

• pts believe sx indicated serious illness

  • sx may involve pain, GI, cardio, pulm

Somatic symptom disorder

What is the treatment for somatic symptom disorder?

Regularly scheduled PCP visits (4-8 wks) & discuss overall health, SSRIs to tx cormorbid anxiety & depression symptoms, refer to psych if refractory

What factors are associated with a good prognosis in somatic symptom disorder?

Sudden onset, short course of sx, treatment responsive anxiety or depression, absence of personality disorder

What should be done at the initial visit with somatic symptom disorder?

Establish therapeutic alliance → legitimize sx, eval & tx diagnosable medical conditions, limit tests & referrals, reassure, pt education, slow d/c unnecessary meds

What is a disorder in which a person has a preoccupation with and fear of having/acquiring a serious illness?

*formerly called hypochondriasis

Illness anxiety disorder

What condition?

• symptoms (abd pain, D, etc) → severe emotional distress → multiple doctors visits → impairment in functioning → progression into depression & long term anxiety disorder

Somatic symptom disorder

What condition?

• minimal or nonexistent sx → preoccupation of being sick or having disease → extreme anxiety, distress & out of proportion belief of worst possible outcome

• ex: thinking a HA is a brain tumor; may seek or avoid care

Illness anxiety disorder

The following key diagnostic features are for what condition?

• preoccupation with having or acquiring serious illness

• minimal or absent somatic sx

• excessive health related anxiety & behaviors

• behavior persists at least 6 mos

• 2 types: care-seeking or care-avoidant

Illness anxiety disorder

What clues might indicate illness anxiety disorder?

Multiple doctor visits & medical tests (watch for same complaint), repetitive checking of body for sx of alleged medical condition, habitual internet searching about illness or sx (cyberchondria)

What is a disorder in which an individual “converts” psychological distress into an actual neurological symptom?

*formerly conversion disorder

Functional neurological symptom disorder

The following key diagnostic features are associated with what condition?

• altered voluntary motor or sensory function

• incompatible with recognized neurological conditions

• not explained by medical condition or substance absue

• significant distress or impairment

• pts appear calm & unconcerned when describing sx, lack of concern (la belle indifference)

Functional neurological symptom disorder

What are common presentations of functional neurological symptom disorder?

Paralysis, seizures, blindess, mutism

What PE findings may be seen in functional neurological symptom disorder?

Sensory loss that doesn’t match dermatome patterns, normal reflexes with paralysis, no pupillary defect with blindness, normal EEG with “seizures”, & common comorbidities → depression, anxiety, personality disorders

What factors are associated with a poor prognosis in functional neurological symptom disorder?

Symptoms of tremors or seizures

*< 50% improvement if sx persist past 6 mos

What is the treatment for functional neurological symptom disorder?

1st line: patient education

2nd line: motor-PT & CBT; sensory- CBT & stress management

3rd line (refractory): Citalopram, duloxetine, or nortriptyline

What is a disorder in which an individual falsifies physical or psychological symptoms in order to receive medical care?

*formerly munchausen syndrome

Factitious disorder

The following key diagnostic features are associated with what condition?

• falsification or exaggeration of physical or psychological symptoms

• deception- even w/o obvious external rewards

• goal is to assume “sick role”

• may go to extreme measures that can cause legitimate danger

  • insulin injections, tampering with medical instruments, tests, lab specimens

Factitious disorder

What are red flags that might signal factitious disorder?

Dramatic or atypical sx, extensive medical history, multiple drug “allergies,” knowledge of medical terminology, & sx that don’t respond to tx

The following presentations are likely to be associated with what disorder?

• burns: unnatural shape, chemical streaks, or minor injury to fingers → self inflicted

• cuts: accessible parts of body or preponderance of L sided lesions in R handed person → self inflicted

• thyroid: 24 hr I-131 uptake → thyroxine or l-iodothyronine

• etc

Factitious disorder

The following key diagnostic features are seen with what condition?

• caregiver falsifies or induces illness in someone under their care

• caregiver enjoys medical environment & seeks sympathy from staff

• sx are only present when caregiver is present

• *formerly munchausen by proxy

Factitious disorder imposed on another

What population is factitious disorder MC in?

Mothers

What term refers to individuals who falsify symptoms and illness to obtain external rewards such as money, time off work, & avoidance of duties?

Malingering

The following key features are associated with what condition?

• intentionally produce false sx for external gain such as financial compensation, avoiding work or legal consequences, or obtaining drugs

• stops producing ssx when no longer profitable or when the risk becomes too great

• *not considered to be a mental illness

Malingering

What condition might Waddell’s sign be positive?

Malingering - back pain cases

What are the 3 presentations of ADHD?

Predominantly inattentive, predominantly hyperactive/impulsive, or combined

What population is ADHD MC in?

M > F, school aged children

What is the etiology of ADHD?

Genetics, neuroanatomical aspects, neurochemical (DA), developmental factors, psychosocial factors

Which subtype of ADHD?

• ≥ 6 sx (≥ 5 if 17 y/o) for 6 mos:

• careless mistakes in school work

• difficulty sustaining attention in tasks or play

• does not listen when spoken to

• fails to complete tasks

• difficulty organizing tasks

• avoids tasks that require mental effort

• often loses things necessary for tasks

• easily distracted

• forgetful in daily activities

Inattentive

Which subtype of ADHD?

• ≥ 6 sx (≥ 5 if 17 y/o) for 6 mos:

• often fidgets

• leaves seat when expected to remain seated

• inappropriate running & climbing

• unable to play & engage quietly

• often on the go / “driven by a motor”

• talks excessively

• blurts out answers

• often interrupts & intrudes on others

Hyperactivity & impulsivity

What additional criteria must be met for ADHD DSM-5 diagnosis?

Onset of sx before age 12

Sx present in ≥ 2 settings (home, work, school, clubs)

Interferes w/ or reduces quality of functioning

Sx do not occur exclusively during course of psychotic d/o (schizophrenia)

Which aspect of ADHD is most likely to decrease as the patient gets older?

Hyperactivity

What are the 1st line treatment options for ADHD?

CNS stimulants → methylphenidate (ritalin, concerta), amphetamine (adderall, Vyvanse)

What are the 2nd line treatment options for ADHD?

Non stimulants → Atomoxetine (Strattera), Buproprion (Wellbutrin), a2 adrenergic agonists (Clonidine, Guanfacine)

What are CIs to CNS stimulants?

Cardiac risk & abnormalities

What stimulants can be used in the treatment of ADHD in children 6 and older?

Ritalin, Concerta, Focalin, Adderall XR, Vyvanse

What stimulants can be used in the treatment of ADHD in children 3 and older?

Adderall

What ages can atomoxetine (Strattera) be used for ADHD?

≥ 6 y/o

What is the MOA of methylphenidate?

Block re-uptake of DA

What is the MOA of amphetamines?

Block re-uptake & stimulate release of DA

What is the MOA of atomoxetine?

Block re-uptake of DA (in the prefrontal cortex) & NE (throughout the brain)

What is the MOA of Wellbutrin?

Block re-uptake of DA

What ADHD medication is effective in reducing behavioral symptoms (frustration, high activity, agitation, aggression) & may take up to 2 weeks for initial response?

*monotherapy or adjunct to stimulants

A2-adrenergic agonists

What medication can be used to treat ADHD if comorbid anxiety or substance abuse and has modest efficacy in decreasing hyperactivity & aggressive behavior?

Wellbutrin

What SEs are seen with stimulants?

*typically mild, transient & respond to changes in dose/ timing/ med change

Anorexia, weight loss, insomnia, HA, stomach pain, poor growth, tachycardia, jitteriness, tics, dizzy, priapism, irritability & anxiety, abuse potential

What SEs are seen with atomoxetine (Strattera)?

Hepatotoxicity, suicidal behavior in pts < 25 y/o

What medications should be used for patients with ADHD & Tourette’s?

Guanfacine (preferred) or clonidine

How is ADHD medication monitored?

1 mo after initiation: eval mood, adherence, vitals

Monthly visits until optimal dose, FU q 3 mos once stable, consider medication holidays if adverse effects

The following key diagnostic features are for what condition?

• Persistent deficits in

  • social communication & interaction

  • restricted, repetitive patterns of behavior / interests

• sx present in early childhood

• causes functional impairment

• *specifier with or without intellectual impairment

ASD

What 3 areas does every child with ASD have some problem with, to a degree?

Speech & language, social, movement

What severity of autism?

• needs support

• social & communication skills and repetitive behaviors only noticeable w/o support

Level 1 (high functioning)

What severity of autism?

• needs substantial support

• social & communication skills and repetitive behaviors obvious to casual observer, even with support in place

Level 2

What severity of autism?

• needs very substantial support

• social & communication skills and repetitive behaviors severely impair daily life

Level 3 (severe)

What are signs of ASD at 6 mos old?

No smiles or warm / joyful expressions

What are signs of ASD at 9 mos?

No back & forth sharing of sounds, smiles or other facial expressions

What are signs of ASD at 12 mos?

Lack of response to name, no babbling, baby talk, or back & forth gestures (pointing, showing, reaching, waving)

What are signs of ASD at 16 mos?

No spoken words

What are signs of ASD at 24 mos?

No meaningful 2 word phrases that don’t involve repeating or imitating

What might repetitive behaviors, sensory sensitivities, rigid routines, or restricted interests indicate?

ASD

The following criteria is for what condition?

• multiple motor & vocal tics

• tics must occur many times a day, almost every day or intermittently for > 1 yr

• onset before 18 y/o

• involuntary movement not d/t substance of medical condition (Huntington, post viral encephalitis)

Tourette syndrome

What DA receptor blocker is the drug of choice for troublesome tics & does NOT cause tardive dyskinesia?

Tetrabenazine

The following criteria if associated with what condition?

• 4+ of 8 behaviors from the 3 categories for ≥ 6 months w/ a non sibling

  • angry/irritable mood (3 behaviors)

  • argumentative/defiant behavior (4 behaviors)

  • vindictiveness (1 behavior)

• children under 5: behavior occurs most days for ≥ 6 mos

• children 5 & older: at least once per week for ≥ 6 mos

ODD

What is the MC population & age of onset for ODD?

Boys until puberty; first sx appear in preschool years

What can more serious forms of ODD evolve into?

Conduct disorder

ODD or conduct disorder?

• more severe, has aggressive or cruelty towards people or animals, destruction of property or patterns of theft

Conduct disorder

The following criteria if associated with what condition?

• ≥3 in the past 12 mos, w/ atleast 1 in the last 6 mos:

  • aggression to people & animals

  • destruction of property

  • deceitfulness or theft

  • serious violation of rules

• childhood (before age 10) or adult onset (after age 10)

Conduct disorder

What do individuals with conduct disorder have a high risk of developing as an adult?

*even higher risk of comorbid ADHD

Antisocial personality disorder

The following criteria is associated with what condition?

• marked fear or anxiety of social situations where scrutiny is possible

• fear of negative evaluation or rejection

• social situations provoke immediate anxiety & are avoided or endured with intense fear

• fear out of proportion to actual threat

• sx ≥ 6 mos

• significant impact on functioning

Social anxiety disorder

The following criteria is associated with what condition?

• ≥5 sx for most of the day, nearly everyday, for at least 2 weeks (must have #1 or 2)

  • depressed or irritable mood

  • anhedonia

  • significant wt loss or gain, change in appetite

  • insomnia or hypersomnia

  • psychomotor agitation or retardation

  • fatigue or loss of energy

  • worthlessness or guilt

  • diminished ability to think, concentrate or indecisiveness

  • recurrent thoughts of SI or death

MDD

How does MDD often manifest in children?

Irritability instead of depression

What are common pediatric presentations of MDD?

Somatic complaints (abd pain), sudden decline in school performance, social withdrawal, sleep problems, anhedonia (“im bored”)

What should be r/o when evaluating MDD in children?

Hypothyroidism

What is the treatment for pediatric MDD?

Refer to psychiatrist → cognitive, interpersonal, group or family therapy

Mod-severe → fluoxetine or citalopram

What SSRI is first line for pediatric MDD can be used in children > 8 y/o?

Fluoxetine

What SSRI can be used for pediatric MDD in children > 12 years?

*he did not have this in his lecture but its on the review lol

Escitalopram

The following criteria is associated with what condition?

• persistent eating of nonnutritive, nonfood substances ≥ 1 mo

• inappropriate for developmental level

• not part of culturally supported normative practice or other mental disorder

• ex: paper, soap. hair, chalk, soil, paint

Pica

What should be r/o when evaluating pica?

Iron or zinc deficiency, pregnancy, anemia, celiacs, renal dialysis, starvation

The following criteria is associated with what condition?

• restriction of energy intake relative to requirements leading to low body wt (BMI < 18.5)

• intense fear of gaining weight; significant behavior that interferes with gaining wt even though low BMI

• disturbance in way body wt/ shape is perceived;

• persistent lack of recognition of seriousness of low BMI

Anorexia Nervosa

What subtype of anorexia is classified as no binge eating or purging in the last 3 months, just refusal to ingest appropriate amount of calories?

Restrictive type

What subtype of anorexia is classified as binge eating then purging in the last 3 months (vomiting, laxatives, diuretics, enemas, exercising)?

Binge-eating / purging type

The following criteria is associated with what condition?

• recurrent episodes of binge eating

  • eating in discrete period of time (2 hrs) an amt of foot larger than normal

  • sense of lack of control

• recurrent inappropriate compensatory behaviors to prevent wt gain

• normal BMI

• average once per week for 3 months

Bulimia nervosa