Behavioral Health Symptoms, Diagnosis, Dsm-Iv, Etc 560

Front 1

Major Depressive Episode

5 or more of the following sx during the same 2 week period and represents a change
from previous functioning. At least one of the sx must be (1) depressed mood or (2) loss
of interest or pleasure.

Back 1

1. Depressed mood most of the day, nearly every day (can be irritable in kids and teens)
2. Markedly diminished interest in all, or almost all, activities
3. Significant weight loss/gain or decrease/increase in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation (observable by others, not just subjectively)
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Poor concentration or inability to make decisions
9. Recurrent thoughts of death, recurrent SI with or without specific plan

Front 2

MDD-Symptoms

Front 3

MDD and Mental Status Exam

Front 4

MDD: Workup

Front 5

Pediatric MDD Presentation

Back 5

 Kids-may present as lack of wt gain, GI upset, headaches, irritability, malaise, aggression
 Teens-may present as irritability, severe misconduct, poor grades, “wrong crowd”

 60% have first degree relative with MDD

Front 6

MDD in elderly

Back 6

 Agitation and somatic concerns common
 “Pseudodementia
 Don’t neglect psychotherapy
 Don’t undertreat

Front 7

General medical conditions that may biologically cause MDD

Back 7

General medical conditions that can cause MDD

• Autoimmune (SLE)
• Endocrine (hypothyroid, DM, adrenal)
• Postviral infections (influenza, HIV, mono)
• Toxicity (lead, mercury)
• CNS (Parkinson’s, CVA, Alzheimer’s)
• CA
• Metabolic (B12 deficiency)

Front 8

MDD 3 Tx Phases & Goal

Back 8

MDD: 3 treatment phases:
1. Acute
2. Continuation (6-12mos)
3. Maintenance

Goal is full restoration of functioning and prevention of relapse/recurrence

Front 9

MDD: Psychiatry Referral

Back 9

MDD: Psychiatry Referral
• Patient or family request
• Uncertain diagnosis
• Suicidal
• Psychotic features
• Substance abuse
• Other psychiatry comorbidities
• Needs ECT
• Failure of 2 reasonable med trials

Front 10

SAD: Treatment

Back 10

SAD: Treatment
• Mild sx: spend time outdoors, sunlight
• Phototherapy
o Suppresses brain’s secretion of melatonin
o 10,000 lux for 30 minutes in am
o Need prescription; Insurance coverage
• May use antidepressant

Front 11

Dysthymia

Back 11

Dysthymia:
o Extremely chronic, yet milder depression
o Usually “double depression”
o Can be very negative, sarcastic, never happy
o Marriage/friendships not rewarding
o Same sx as MDD, but don’t meet full criteria
o 40% of those with MDD meet criteria
o Sx → clinically sign distress/impairment

Front 12

DYSTHYMIA: Depressed mood for most of the day, for more days than not, for at least 2 years. In kids & teens, mood can be irritable and must be at least 1 year.

Back 12

While depressed, 2 or more of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy, fatigue
4. Low self esteem
5. Poor concentration, difficulty making decisions
6. Hopelessness

Front 13

Postpartum Depression

Back 13

Postpartum Depression
o Within 4 weeks postpartum
o Postpartum “blues” may or may not precede it (<2 wks; 60%)
o Sx are identical to MDD
o Feel inadequate to care for baby
o Most recover in a few months to a year

Front 14

Adjustment Disorders

Back 14

Postpartum Depression
o Within 4 weeks postpartum
o Postpartum “blues” may or may not precede it (<2 wks; 60%)
o Sx are identical to MDD
o Feel inadequate to care for baby
o Most recover in a few months to a year

Front 15

Adjustment Disorders

Back 15

Adjustment Disorders
o Clinically significant emotional or behavioral symptoms that develop in response to a stressor
o Reaction is disproportionate to the nature of the stressor or functioning is sign impaired
o Symptoms must occur within 3 months
o

Front 16

Adjustment Disorders: Treatment

Back 16

Adjustment Disorders: Treatment
o Depends on symptom severity
o Usually supportive
o Medication not normally needed
o Possibly short term psychotherapy
o Encourage exercise, relaxation training, socialization, support groups

Front 17

Depressive Disorder, NOS

Back 17

Depressive Disorder, NOS

Depressive symptoms not meeting criteria for any specific depressive disorder

Front 18

Bipolar Spectrum Mood Disorders

Back 18

Bipolar Spectrum Mood Disorders

o “Manic depression”
o Usually present depressed
o Caution with antidepressants
o High risk of suicide, esp when depressed

Front 19

Bipolar Disorder

Back 19

Bipolar Disorder
o 1-2% of U.S. population
o Late teens-early 20s
o Family history important
o Failure/worsening with antidepressants
o Possible seasonal changes

Front 20

Manic episode: DSM-IV

Back 20

Manic episode: DSM-IV

Distinct period of abnormally and persistently elevated or irritable mood, lasting at least 1 week (or any duration if hospitalization necessary).

Front 21

Manic Episode

Back 21

Besides mood disturbance, > 3 of the following:
– Inflated self esteem or grandiosity
– Decreased need for sleep
– More talkative than usual; pressure to keep talking
– Flight of ideas; racing thoughts
– Distractibility
– ↑ goal directed activity or psychomotor agitation
– Excessive involvement in activities that are high risk

Front 22

Manic Episode

Back 22

Manic Episode
o Mood disturbance is sufficiently severe to cause marked impairment, to necessitate hosp to prevent harm to self or others, or psychotic features
o Manic-like episodes that are clearly caused by antidepressant treatment (meds, ECT, light
therapy) should not count toward dx of bipolar disorder

Front 23

Hypomanic Episode

Back 23

Hypomanic Episode

o Distinct period of persistently elevated or irritable mood lasting > 4 days that is clearly different form the usual mood
o Need 3 or more of same 7 sx of mania
o Episode associated with an unequivocal change in functioning that is uncharacteristic of the person
o Disturb in mood and change in funct is observable by others
o Episode is not severe enough to cause marked impairment, to necessitate hospitalization, and no psychotic features

Front 24

Cyclothymia

Back 24

Cyclothymia
o For at least two years, the presence of numerous periods with hypomanic sx and numerous periods with depressive sx that do not meet criteria for a MDE
o During the two year period, the person cannot be without sx for more than 2 mos

Front 25

Anxiety Disorder Prevalence

Back 25

Anxiety Disorders

o Up to 25% lifetime prevalence rate
o Most common ages 20-45
o Female > Male
o Start earlier in childhood/adolescence
o 1 in 7-8 kids/teens

Front 26

Anxiety Disorders

Back 26

Anxiety Disorders
o Frequent visits to primary care provider
o Majority are untreated (unrecognized as anxiety)
o Often is a comorbid mood disorder: anxious depression
o ETOH 2-4x more common with anxiety dx

Front 27

Hallmarks of Anxiety Disorders

Back 27

HALLMARKS OF ANXIETY DISORDERS
o Physiological Arousal
o Sweating, flushing, shortness of
breath, GI upset/diarrhea, palpitations/chest pain, insomnia, shaking, dizziness
o Subjective Apprehension (aware of feeling nervous)
o Worry, tension, inability to concentrate,
restlessness, feelings of fear/dread

Front 28

Anxiety Disorder Etiology

Back 28

Anxiety disorder etiology
 Genetic
 Biologic
o ANS: excessive response to moderate stimuli
o GABA, Serotonin, and Norepinephrine
 GABA & serotonin are calming agents
 Psychosocial: Modeling from parents
 Learned: Conditioned response, parents

Front 29

Anxiety Disorder: 1st Must R/O -

Back 29

Anxiety Disorder: 1st Must R/O
• Hyperthyroidism
• Hypoglycemia
• COPD
• Hyperparathyroidism
• Cardiac arrhythmias

Front 30

Drugs that Can Induce Anxiety

Back 30

Drugs that can induce anxiety:
B-adrenergic agonists
Steroids
Thyroid hormone, etc
Caffeine
Amphetamines
Cocaine
Withdrawal from alcohol or sedatives

Front 31

Panic Disorder

Back 31

Panic Disorder
• 2-3x higher in females
• Usually begins early adulthood
• Major life transitions can precipitate
• 4-8x increased risk in first degree relative
• Chronic, relapsing nature
• Recurrent panic attacks (5-30min)
• Panic” vs. panic attack
• Usually no trigger
• May avoid normal activities
• Attacks may occur daily or rarely

Front 32

Panic Disorder Hallmark

Back 32

Panic Disorder Hallmark:

Worry about future panic attacks

Front 33

PANIC ATTACK - Intense fear or discomfort in which 4 or more of 13 sx abruptly appear and reach peak within ten minutes

Back 33

1. Fear of losing control
2. Palpitations, tachycardia
3. Trembling, shaking
4. Shortness of breath
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or GI distress
8. Feeling dizzy, lightheaded
9. Derealization or depersonalization
10. Sweating
11. Chills/hot flushes
12. Paresthesias
13. Fear of dying

Front 34

Agoraphobia

Back 34

Agoraphobia
o At least one of the attacks has been followed by > 1 month > 1 of the following:
1. Persistent concern about having another attack
2. Worry about implications of the attack or its consequences (e.g., losing control, having an MI, “going crazy”)
o Signif change in behavior related to the attacks

Front 35

Panic Disorder: DSM-IV

Back 35

Panic Disorder: DSM-IV
o Recurrent unexpected panic attacks
o > 1 of the attacks has been followed by > 1 of these:
1. Persistent concern about having another attack
2. Worry about the implications of the attack or its consequences (e.g., losing control, having
an MI, “going crazy”)
o Significant change in behavior related to the attacks

Front 36

Post Traumatic Stress Disorder

Back 36

Post Traumatic Stress Disorder
 Males-combat exposure
 Females-sexual abuse, assault
 Acute-sx <3 months
 Chronic-sx >3months
 Delayed onset-sx manifest after 6months
 Intense guilt, feeling “dead inside” common

Front 37

PTSD: DSM-IV: Exposure to a traumatic event where both of the following are present -

Back 37

PTSD: DSM-IV: Exposure to traumatic event where –

1. The person experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury
2. The response involves a sense of helplessness or fear (in kids, may manifest as disorganized or agitated behavior)

Front 38

PTSD: DSM-IV:
Three symptom clusters:

Back 38

PTSD: DSM-IV: 3 symptom clusters:
1) Reexperiencing the trauma
2) Avoidance of stimuli
3) Hyperarousal

Front 39

PTSD: DSM-IV
Traumatic event is “relived” by experiencing at least one:

Back 39

1. Intrusively distressing recollections of event (in kids, may be repetitive play that involves specific aspects of the trauma)
2. Recurrent distressing dreams about the event
3. Sense that the event is recurring via “flashback” episodes
4. Intense psychological distress in response to cues that recall the event
5. Physiological sx cued by remembering the event

Front 40

PTSD: DSM-IV: Persistent avoidance of stimuli associated with the trauma and “numbing” of general responsiveness.
At least three of the following:

Back 40

1. Avoidance of thoughts, feelings, or conversations associated with the event
2. Avoidance of activities, places, or people that arouse memories of the event
3. Inability to recall an important aspect of event
4. Diminished interest in previously enjoyed activities
5. Feeling of detachment from others
6. Blunted affect (e.g., unable to have emo bonding)
7. Negative view of future

Front 41

PTSD: DSM-IV, cont: Persistent symptoms of hyperarousal as indicated by at least 2 of the following:

Back 41

1. Insomnia
2. Explosive behavior
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response
• Symptoms have persisted for > 1month
• Symptoms result in clinically significant impairment in social or occupational functioning

Front 42

GAD
Generalized Anxiety Disorder:
Anxiety associated with > 3 of the following: (only 1 required for kids)

Back 42

– Restlessness, keyed up, on edge
– Easily fatigued
– Difficulty concentrating or mind going blank
– Irritability
– Muscle tension
– Insomnia

Anxiety or physical sx cause clinically signif distress or impairment in social, work, or other functioning

Front 43

Social Anxiety: DSM-IV

Back 43

• Marked and persistent fear of > 1 social or performance situation where the person is exposed to unfamiliar people or to possible scrutiny by others.
• Fears that he/she will act in a way (or show anxiety sx) that will be humiliating. (In kids, anxiety must occur
with peers, not just with adults)
• Exposure to feared situation almost always provokes anxiety, which may present as panic attack.
• Person recognizes fear as unreasonable

Front 44

Social Anxiety: DSM-IV

Back 44

Social Anxiety: DSM-IV
• Feared situation is avoided or else endured with intense anxiety
• Avoidance, anxious anticipation, or distress interferes significantly with the person’s normal routine, occupational functioning, or social activities/relationships
• If under age 18, duration is at least 6 mos

Front 45

Social Anxiety
Premorbid Risk Factors

Back 45

Social Anxiety Premorbid Risk Factors:
 Childhood shyness
 Overprotective or rejecting parents
 Exposure to domestic violence
 Death in family
 Early parent/child separation
 Other childhood trauma

Front 46

Anxiety Disorder, NOS

Back 46

Anxiety Disorder, NOS

Anxiety symptoms that don’t meet criteria for any specific anxiety disorder