final - psych Flashcards
(43 cards)
1
Q
Objectives
A
- Detail commonly encountered psychological disorders and treatment for each
- Identify at-risk psychiatric patients who necessitate immediate and emergent referral
- Identify risky behavior, substance abuse screening strategies, and treatment for common substance abuse disorders focusing upon tobacco addiction
- Compare and contrast the spectrum of commonly encountered eating disorders in the family practice setting, initial treatments for each, and subsequent referral patterns
2
Q
Lifetime Prevalence
A
- Anxiety disorders- 28.8%Mood disorders- 20.8%Substance use disorders- 14.6%
- Any disorder-46.4%
3
Q
DSM-VMajor DepressionDisorder (MDD)
A
- > 5 symptoms during the same 2 week period.
- At least one of the symptoms must be depressed mood or anhedonia
- Depressed mood
- Anhedonia (decreased interest/pleasure in all)
- insomnia or hypersomnia
- change in appetite or weight loss or gain
- psychomotor retardation or agitation
- fatigue
- Poor concentration
- Thoughts of worthlessness or inappropriate guilt
- Recurrent thoughts about death or suicide
- In addition must have the following 4:
- Sx impair social, occupational function
- Not attributable to other medical condition
- No other psychotic disorder explains symptoms
- No manic or hypomania
4
Q
Depression in Primary Care
A
- Depression in primary care: common, costly, treatable often unrecognized
- Incidence in Primary care: 15.3%-22%
- 1 of 5 most common conditions in primary care
5
Q
Chronic Illness and Depression
A
- Higher prevalence in patients w/ co-morbidities
- Pain syndromes, Diabetes, Heart Disease, Neurological Disorders, HIV
- Prior depression risk factor for Diabetes (eating food to make someone happy)
- Patients with co-morbid chronic illness and depression have:
- More symptoms
- Worse function
- Impaired self care and adherence
- Higher costs
6
Q
52-year-old mlae small business owner with a history of hypertension and T2DM
He reports 2-3 months of fatigue and chronic, occasionally debilitating back pain treated with OTC analgesics
He feels “frazzled” by his work and does not do anything for fun anymore
He denies feeling sad
Remainder of history is unremarkable
A
Not fitting enough mdd
- Need more info for depression screening
- Could be his chronic condition - reason why he can’t do things he likes anymore
7
Q
A
8
Q
Screening Tools:PHQ2
A
- PHQ2 (Patient Health Questionnaire)
- “First Step Approach”
- During the past 2 weeks, have you had any of the following:
- have you often been bothered by feeling down, depressed, or hopeless?
- have you often been bothered by little interest or pleasure in doing things?\
- If positive needs further evaluation for Major Depressive Disorder, PHQ 9
9
Q
SIG E CAPS mneumonic
A
10
Q
Screening Tools: PHQ-9
A
- Patient self-administered
- Validated in Spanish and Chinese
- Useful for monitoring change over time
11
Q
PHQ 9 Scoring
A
- Significant improvement = 5 point decrease
- Response = 50% decrease or score <10
- Remission = score <5
12
Q
using PH9-9 score for management
A
13
Q
Suicide
A
- Primary care physicians assess for suicide in patients with depression in only about 1/3of visits
- Assess suicide risk
- Ideation, intent, plan, availability, lethality
- Ask: “ This past week, have you had any thoughts that life is not worth living or that you would be better off dead?
- Consider “NO suicide contract” have them write out a contract stating they won’t commit suicide, they will report to the closest hospital to seek help
14
Q
PCP to make Suicide a priority
A
- Rate of Suicide death is increasing
- 45% of individuals who committed suicide visited their PCP 1 month before their death
15
Q
Treatment Options suicide
A
- Watchful waiting and support
- Antidepressants
- Referral for counseling
- Call the MHA they can suggest practitioners in the area
- Best Outcome : Combination of antidepressants and counseling***
16
Q
Cognitive Behavior Therapy
A
- Often includes education, relaxation exercises, coping skills training, stress management, or assertiveness training
- In cognitive therapy, the therapist helps the patient identify and correct distorted, maladaptive beliefs.
- Behavioral therapy uses thought exercises or real experiences to facilitate symptom reduction and improved functioning.
- Can be used to treat:
- Depression, GAD, PTSD, Panic Disorders, eating disorders, and OCD
17
Q
ABC’s ofCBT
A
- Activating Event– the actual event and the client’s immediate interpretations of the event
- Beliefs about the event– this evaluation can be rational or irrational
- Consequences– how you feel and what you do or other thoughts
18
Q
Anxiety Disorders
A
- Approximately 14-36% of patients with anxiety disorders are recognized in PC clinics.
- Approximately 25% receive an adequate trial of pharmacologic treatment.
- Less than 25% receive appropriate counseling/ cognitive therapy.
- Nearly 1⁄2 patients screened in primary care
19
Q
types of anxiety disorders
A
- Anxiety Disorders
- Specific Phobia
- Situational
- Social Anxiety Disorder
- Panic Disorder
- Agoraphobia
- Generalized Anxiety Disorder seen MC*
20
Q
Caveats when dealing with an anxious patient:
A
- 1) Include history & physical examination, including neurologic evaluation to evaluate for medical causes.
- Pursue adequate evaluation of other physical symptoms or examination findings.
- 2) Consider CBC, routine chemistries, TSH, magnesium, calcium, EKG and screening for substances.
- 3) “Collateral history” from a family member can be helpful.
21
Q
Caveats when dealing with an anxious patient:
A
- 4) Consider all medications, withdrawal syndromes, caffeine and other OTC’s.
- 5) Anxious patients are further stressed by diagnostic uncertainty; try to be reassuring even when uncertain.
- 6) Rates of anxiety symptoms are commonly increased in patients with COPD, asthma, PE, Parkinson’s, post- CVA
- Many patients with anxiety disorders have more than one mental health disorder: 1/3 to 2/3 in many series**
22
Q
Screening for anxiety disorders:
A
- Many different tools
- GAD- 7 item scale
23
Q
tx for anxiety ds
A
CBT is more immediate
SSRI will take a few weeks to build up
24
Q
Generalized Anxiety Disorder prognosis, tx
A
- Prognosis varies with severity of symptoms, presence of comorbidities (especially depression, substance abuse or other anxiety disorders), and social factors.
- Response rates vary
- Start low dose, monitor closely for adverse effects and benefit and titrate dose.
- Cognitive Behavioral Therapy is first-line therapy if available, generally equal to medications and longer lasting.
25
Why should PCPs integrate MH in their practice?
- 1) Patients prefer it.
- 2) Mental health problems are missed or misattributed to physical illnesses, particularly in elderly patients.
- 3) Patients are more likely to receive care for MH problems when it’s identified and able to be treated in a PC setting.
- 4) Receiving MH care in the primary care context enables better integration of care.
- 5) Treating MH issues in PC setting can help destigmatize mental illness and MH care.
26
Tobacco Abuse
- Cigarette smoking is the leading preventable cause of mortality.
- Approximately 2/3rds of smokers say that they want to quit
- 50 percent of smokers report that they tried to quit in the past year
- Only 3 to 6 percent of smokers who make an unaided quit attempt are still abstinent one year later.
27
Tobacco Abuse
- Full assessment
- Frequency of use
- The products used
- Degree of nicotine dependence
- History of previous quit attempts
- Including methods used and their effectiveness
- Readiness to stop smoking at this time
- It is important to ask a patient if he or she EVER smokes cigarettes, because non-daily or intermittent smokers may not identify themselves as smokers when questioned
28
Assisting Smokers Ready to Quit
- Setting a quit date
- Addressing barriers to quit
- Nicotine withdrawal syndrome -- Primary barrier
- Triggers – morning coffee, alcoholic drink, end of meal
- Weight gain
- Depression
- Treatment options
- Combo of behavioral and pharmacologic treatments
- Nicotine replacement agents (patch, gum, lozenges)
- Varenicline (chantix) or bupropion (zyban)
29
Alcohol Abuse
- Risky Behavior
- Binge Drinking
- Alcohol Use Disorders
30
Risky Use
- Consumption of an amount of alcohol that puts an individual at risk for health consequences.
- Not so severe as to meet diagnostic criteria for an alcohol use disorder.
- May go on to develop an alcohol use disorder
- Men < 65 y/o
- > 14 drinks/week, or >4 drinks/day
- Women and adults > 65 y/o
- > 7 drinks/week, or > 3 drinks/day
31
Binge Drinking
- “Drinking so much within about two hours that blood alcohol concentration (BAC) levels reach 0.08g/dL“
- Women >four standard drinks
- Men > five standard drinks
- Binge drinking is associated with acute injuries due to intoxication and may be associated with an increased cardiovascular risk
32
Alcohol use disorder
- Problematic pattern of alcohol use leading to clinically significant impairment or distress
- multiple psychosocial, behavioral, or physiologic features
- Recommended that all adult primary care patients be screened for unhealthy ETOH use
33
CAGE Questionnaire
- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?
34
ETOH Abuse
- Treatment:
- May be beneficial to perform some counseling in office, especially for patients with “risky use” or “binge drinking”
- However patients with alcohol use disorder will likely need referral out to psych, Detox clinics, and even rehab
CIWA-Ar scale revises
Look for alcohol withdrawal sx
35
Eating Disorders
- Characterized by a persistent disturbance of eating that impairs health or psychosocial functioning
- Disorders include:
- Anorexia nervosa
- Avoidant/restrictive food intake disorder
- Binge eating disorder
- Bulimia nervosa
- Pica
- Rumination disorder
## Footnote
🧠 Eating Disorders Overview
1. Anorexia Nervosa
Core feature: Restriction of energy intake → significantly low body weight
Key signs:
Intense fear of gaining weight
Distorted body image
May be restricting type or binge/purge type
Risks: Amenorrhea, bradycardia, osteoporosis, lanugo, electrolyte imbalance
2. Bulimia Nervosa
Core feature: Recurrent binge eating followed by compensatory behaviors
E.g., vomiting, laxatives, fasting, excessive exercise
Patients are usually normal weight
Risks: Electrolyte disturbances, parotid gland swelling, dental erosion, metabolic alkalosis
3. Binge Eating Disorder
Core feature: Recurrent episodes of eating large amounts of food with a sense of loss of control
No compensatory behaviors (unlike bulimia)
Often associated with distress, shame, and obesity
4. Avoidant/Restrictive Food Intake Disorder (ARFID)
Core feature: Avoidance of food intake not driven by body image concerns
Reasons may include:
Sensory sensitivity
Fear of choking or vomiting
Lack of interest in eating
Leads to nutritional deficiency, weight loss, or dependence on nutritional supplements
5. Pica
Core feature: Persistent eating of non-nutritive, non-food substances (e.g., dirt, paper, chalk) for >1 month
More common in:
Children
Pregnant women
Individuals with intellectual disabilities
6. Rumination Disorder
Core feature: Repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out
Not due to a GI condition
Often occurs in infants or individuals with developmental delay
36
SCOFF
- SCOFF, which consists of five clinician administered questions
- Do you make yourself Sick because you feel uncomfortably full?
- Do you worry you have lost Control over how much you eat?
- Have you recently lost more than One stone (14 pounds or 6.35 kg) in a three month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Would you say that Food dominates your life?
37
Anorexia Nervosa
- Restriction of energy intake that leads to a low body weight, given the patient’s age, sex, developmental trajectory, and physical health.
- BMI <18.5
- Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight.
- Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one’s low body weight.
38
Avoidant/ Restrictive Food Intake Disorder
- Avoiding or restricting food intake, which may be based upon
- lack of interest in food, the sensory characteristics of food, or a conditioned negative response associated with food intake following an aversive experience (eg, choking).
- The eating behavior leads to a persistent failure to meet nutritional and/or energy needs
39
Bulimia Nervosa
- Recurrent episodes of binge eating characterized by both of the following:
- Eating in a discrete period of tie
- Lack of control over eating during episode
- Inappropriate compensatory behaviors to prevent weight gain
- Self-induced vomiting
- Misuse of laxatives, diuretics, enemas
- Excessive exercise, fasting, strict diets
- Occur on average once a week for 3 months
- Self-evaluation is unduly influenced by body shape and weight
- Disturbance does not occur exclusively during episodes of anorexia nervosa
40
Binge Eating Disorder (BED)
- DSM-V Binge Eating Disorder
- Every episode of binge eating must include:
- Eating larger amount of food that most people would not finish in similar time
- 2. Loss of control during the episode
- Episode must have >3 of the following:
- Eating more rapidly than normal
- Eating until felling uncomfortably full
- Eating when not hungry
- Eating alone because your embarrassed
- Feeling disgusted with oneself, depressed, guilty
- Additional required criteria:
- Distress regarding binge eating
- Once a week for 3months
- Not associated with bulimia or anorexia
41
Eating Disorders: Management
- Eating disorders can be life-threatening due to general medical complications and suicide, and patients often refuse treatment
- Treatment of eating disorders generally involves an interdisciplinary team with experience in treating
- Mental health clinician
- Dietitian
- General medical clinician
- If malnourished, or worried about immediate decompensation ED
42
- A 31-year-old woman seeks evaluation for episodic waves of terror and anxiety. She frequently awakens from a sound sleep due to a rush of anxiety accompanied by palpitations, dyspnea, chest pain, and numbness in her fingers and toes. Which of the following is the most appropriate initial therapy for this patient?
- A. Fluvoxamine (Luvox)
- B. Amitriptyline (Elavil)
- C. Phenelzine (Nordil)
- D. Fluoxetine (Prozac)
Panic disorders - SSRI
- Luvox - OCD
- PROZAC
TCA not the best choice
Know the meds
43
- A 48-year-old man comes to the office for annual physical examination. The patient has smoked one pack of cigarettes daily for the past 20 years and says he wants to quit. He has tried to quit several times, but every time he does, he has depressed mood, difficulty sleeping, anxiety, restlessness, and increased appetite. The patient says these symptoms are so severe that he is unable to function well at work. Which of the following is the most appropriate therapy to aid in smoking cessation for this patient?
- (A) Alprazolam (B) Diazepam (C) Nicotine transdermal patches
- (D) Nicotinic acid (E) Varenicline
What is the pt fagerstrom test score?
- To see severity
- His score is around 5-6 -> severe so give E
VARENICNICLINE
