Differential Diagnosis
PTSD and MDD
PTSD presents intrusive symptoms, persistent avoidance of stimuli, negative alterations in cognition, alterations in arousal and reactivity associated with the traumatic event. MDD does not.
Main components
Presenting issue, family , biological , psychological, social, substance use, safety
PTSD
Modalities: EMDR, TF-CBT, and exposure therapy
Reduced score on the PCL-5 scale
Risperidol (Risperidone)
What is a common medication used for diagnoses with symptoms of psychosis (like schizophrenia) mania (bipolar I), and behavior problems like aggression (some children with ASD)? What has side effects of weight gain, anxiety, nausea and vomiting, rhinitis, erectile dysfunction, orgasmic dysfunction, increased pigmentation?
Level A
Adult
Covered Dx
-Episodic depression, anxiety, or other mental health conditions with NO recent hospitalizations & ltd crisis episodes within the past year
AND ONE of:
- mild fx impairment
- presentation elevated from baseline
Freq: Monthly
Dur: ONE YEAR
Child & Family
- Treatment limited to target a specific behavior
- Covered dx
AND
- Need for maintenance of a med regimen OR
- mild or episodic parent, youth or family system interactional problem triggered by recent transition or event OR
- transition from a higher level of service
AND
- low acuity of presenting symptoms, minimal fx impairment
AND
home, school, community impact is minimal
Freq: MONTHLY
Dur: ONE YEAR
ODD and Conduct Disorder
ODD presents less severe behaviors, and does not present aggression toward people or animals, destruction of property, and a pattern of theft or deceit like Conduct Disorder. ODD also presents emotional dysregulation.
Histories
Presenting illness, family, mental health, physical health, development, milestones, social, and hospitalizations
GAD
Modalities: CBT, systematic desensitization, exposure therapy, and progressive muscle relaxation
Reduced severity on the GAD-7
Lithobid (Lithium)
What is prescribed to treat and prevent episodes of mania in people with bipolar disorder and cyclothimia? What has side effects of cardiac effects (i.e. arrhythmias), gastrointestinal effects (i.e. nausea), weight gain, neurologic effects(i.e. tremors, and cognitive effects (i.e. dysphoria)?
Level B
Adult
time-limited with services discontinued when client's functioning improves.
Covered Dx
At least TWO:
- mod fx impairment in at least 2 areas
- risk of harm to self or others that is escalated from baseline
- at least one hospitalization within the last six months
mult system involvement req coord & case mgmt
- mod-sig current subs abuse
- sig PTSD, anxiety, depression, or other MH symptoms
- extended or repeated crisis episodes
- ind has marginalized ID and/or ltd English lang skills
- Dx and/or age related fx deficits and/or complex med issues
Freq: 1x /week
Dur: 1 year.
Child & Family
time limited with services discontinued as an individual can function more effectively.
- Covered Dx
AND
1. mild to mod fx impairment in at least one area OR
2. mild to mod impairment of parent/youth relationship to meet dvpt and/or safety needs OR
3. mod emotional distress causing chronic fam or other system disruption or somatic/phys complaints not better explained by another med cond OR
4. transition from higher level of service intensity
Freq: 2-3x per month
Dur: 6 months
DMDD and ODD
ODD shares with disruptive mood dysregulation disorder the symptoms of chronic irritable mood and temper outbursts. However, if the irritable mood and other symptoms meet criteria for disruptive mood dysregulation disorder, a diagnosis of ODD is NOT given, even if all criteria for oppositional defiant disorder are met. IOW: DMDD does not have criteria of defiance or vindictiveness.
Mental Status Exam
Appearance, behavior, speech/language, mood, thought process, oriented to person/time/place, intellectual level, developmental level, eye contact, affect, attention, insight, gait, impulse control, memory
MDD
Modalities: CBT, DBT, ACT, and MI
Reduced severity on the PHQ9 scale
Prozac (Fluoxentine)
What is prescribed to treat depression, obsessive-compulsive disorder some
eating disorders, and panic attacks? What is prescribed to relieve the symptoms of premenstrual dysphoric disorder? What is an SSRI? What has side effects of nervousness, anxiety, difficulty falling asleep or staying asleep, nausea and diarrhea?
Level C - Adult
focused and time limited with services discontinued when client's functioning improves.
Covered dx
AND at least TWO of the following must be met:
● Moderate functional impairment in at least two areas (e.g. housing, financial, social, occupational, health, activities of daily living.)
● Risk of harm to self or others or risk of harm to self or others that is escalated from baseline
● At least one hospitalization within the last 6 months
● Multiple system involvement requiring coordination and case management (e.g. PCP, family system, employment, PT, OT, Specialty Health Provider, etc.)
● Risk of loss of current living situation, in an unsafe living situation, or currently homeless due to symptoms of mental illness
● Moderate-significant current substance abuse for which integrated treatment is necessary
● Significant PTSD, anxiety, depression or other mental health symptoms, ongoing systemic oppression, trauma and/or major life change, multiple losses
● Extended or repeated crisis episode(s) requiring increased services
● Individual has a marginalized identity which creates barriers to receiving appropriate services, and/or individual's level of English language skill and/or cultural navigation barriers is not sufficient to achieve symptom or functional improvement without additional supports
● Diagnosis and/or age-related functional deficits and/or complex medical issues requiring substantial coordination
Frequency: 1x/week
Duration of treatment: 1 year
GAD and OCD
In GAD, the focus of the worry is about forthcoming problems and it is the excessiveness of the worry about future events that is abnormal. In OCD, obsessions are inappropriate ideas that take the form of intrusive and unwanted thoughts, urges, or images.
Environmental
Socioeconomic, military service, addictions/substance abuse
Bipolar
Modalities: CBT, interpersonal and social rhythm therapy (IPSRT), and family-focused therapy
BDRS (Bipolar Depression Rating Scale)
Bupropion (Aplenzin, Wellbutrin, Wellbutrin SR, Wellbutrin XL)
What is used to treat depression and seasonal affective disorder, and to aid in smoking cessation? What is an antidepressant? What has side effects of headache, insomnia, dry mouth, tremor and nausea?
Level C - Child and Family
Designed to prevent the need for a higher level of care, or to sustain the gains made in a higher level of care, and which cannot be accomplished in either routine outpatient care or other community support services.
Covered dx
AND At least ONE of the following:
∙ Significant risk of harm to self or others
∙ Moderate to severe impairment of parent/youth relationship to meet the developmental and/or safety needs
∙ Moderate to severe functional or developmental impairment in at least one area of daily living (for example, sleep, eating, self-care, relationships, school behavior or achievement)
AND For School-Age and Adolescents at least ONE of the following:
-Risk of out of home placement or has had multiple transition in placement in the last 6 months due to symptoms of mental illness
-Risk of school or daycare placement loss due to mental illness or development needs.
-Multiple system involvement requiring coordination and case management (e.g. school, family, PCP, legal, DHS, PT, OT, Speech, etc.)
-Moderate to severe behavioral issues that cause chronic family or other system disruption (e.g. school, foster care, legal, etc.)
-Moderate to severe emotional distress causing chronic family or other system disruption or somatic/physical complaints that are not better explained by another medical condition
-Extended crisis episode requiring increased services
-Recent acute or subacute admission (e.g. inpatient, IOP or residential tx within the last 6 months)
-Moderate-significant current substance abuse for which integrated treatment is necessary
-Transition from a higher level of service intensity (stepdown) to maintain treatment gains
-Youth and/or family's level of English language skill and/or acculturation is not sufficient to achieve symptom or functional improvement without case management
Frequency: 1x/week
Duration of treatment: 6 months
Bipolar I and Bipolar II
Bipolar I: includes manic episode. may include major depressive episode but is not required.
Bipolar II: no manic episodes, instead hypomanic episodes. have had at least one depressive episode.
Treatment
Quantitative scores and instruments used, dx, treatment plan, level of care analysis
Schizophrenia
Modalities: ACT (acceptance and committment therapy), DBT (dialectical behavior therapy), CBT Also -- a combination of psychosocial therapies with medication (such as risperidone, abilify, or clozapine)
PANSS can be used to rate both positive and negative symptoms. CAINS is a newer scale that focuses on negative symptoms only.
Methylphenidate (Concerta, Ritalin)
What is prescribed to treat ADHD? What has side effects of decreased appetite, insomnia, and headache?
Level D
Adult / SPMI:
Services are designed to promote recovery and rehabilitation for adults with severe and persistent symptoms of mental illness. Emphasis on linkages with access and coordination of care.
Two of the following:
∙ Covered diagnosis
∙ Significant assistance required to meet basic needs such as housing and food
∙ Significant PTSD or depression symptoms as a result of torture, ongoing systemic oppression, trauma or multiple losses
AND at least two of the following:
∙ At least one hospitalization within the past year ∙ Symptoms related to the mental illness result in a moderate to significant functional impairment and are only partially controlled
∙ Risk of harm to self or others or risk of harm to self or others that is escalated from baseline
∙ Multiple system involvement requiring substantial coordination
∙ Extended or repeated crisis episode(s) requiring increased services
∙ Significant current substance abuse for which treatment is necessary
∙ Risk of loss of current living situation, in an unsafe living situation, or currently homeless due to symptoms of mental illness
∙ Individual has a marginalized identity which creates barriers to receiving appropriate services, and/or individual's level of English language skill and/or cultural navigation barriers is not sufficient to achieve symptom or functional improvement without additional supports ∙ Diagnosis and/or age-related functional deficits and/or complex medical issues requiring substantial coordination
Authorization length: 1 yr
Child and family -- 0-5 -- Covered dx. Severe impairment. Severe risk of harm to self or others. Severe risk of disruption from current living situation. Frequency: intensive. Duration: three months.
Child and family 6-17: REFER OUT