Diagnose me, baby!
A 52y/o female presents to establish care with you. She reports a history of sexual abuse as a child and believes she has PTSD, but she's never talked to anyone about this before and has never been formally diagnosed. What screening can you use for PTSD and what are the criteria for diagnosis?
Screening: Primary care PTSD screen for DSM-5 (PC-PTSD-5) or or Clinician Administered Posttraumatic Scale (CAPS) interview. Be sure to assess suicide risk!!
DSMV Criteria:
1. exposure to an actual or threatened trauma
2. experiencing memories that are recurrent, involuntary, and intrusive, dreams that are distressing, reactions that are dissociative (such as flashbacks), and/or distressing psychological or physiologic reactions to reminders of the trauma
3. avoidance of stimuli associated with the trauma
4. 2 or more mood or cognitive changes associated with the trauma such as an inability to recall details of the trauma, detachment and estrangement from others, distorted blame, negative beliefs that are persistent, negative emotional state, and decreased interest in activity participation
5. 2 or more symptoms indicating a change in arousal and reactivity associated with trauma including aggressiveness or irritableness, recklessness, increased vigilance, increased startle response, concentration problems, and sleep disturbances
6. persistence of symptoms which cause significant functional impairment and distress for ≥ 1 month
Your patient reports they have SI - on further discussion, they report thinking about using pills to kill themself. They have the pills at home, live alone, are not in contact with family and don't feel they would reach out to anyone in a moment of crisis. Who ya gonna call?
Involuntary commitment - active planning, unable to adhere to a safety plan. Ensure safety, transfer to ED...
Your patient is a 21y/o female with a h/o depression, anxiety, PTSD, on sertraline which has helped improve her mood and she no longer has passive SI, also on buspirone for anxiety. However, she is having trouble sleeping due to nightmares and flashbacks of when she saw her best friend killed. She has been practicing good sleep hygiene but it has not helped. What medication(s) do you offer and why?
Prazosin - conflicting evidence but some indications that it helps with PTSD nightmares; beware of BP
Trazodone - can help with insomnia, cautious with multiple serotonergic agents
Zolpidem - only for short term, and even then...bleh.
Others - clonidine, gabapentin, atypical antipsychs (Seroquel)
What is the difference between:
Malingering
Factitious Disorder
Munchausen's Syndrome
Malingering: falsifying illness for external rewards (disability, worker's comp, etc.)
"The DSM-5 criteria for factitious disorder imposed on self includes fulfillment of all of the following:
"Munchausen syndrome is a type of factitious disorder characterized by pseudologia fantastica, or a chronic pattern of deceit involving fantastical, self-aggrandizing events."
A 31y/o male establishes care with you. He reports difficulty focusing and completing tasks, he believes he has ADHD but has never been diagnosed. He has no known FHx of ADHD, but reports his parents "didn't believe that ADHD was a real thing". What screening tools can you use and what are the diagnostic criteria for ADHD in adults?
Screening: Adult ADHD Self-Report Scale (ASRS) - just the pt fills it out; Conners’ adult ADHD rating scale (CAARS) - self-report and observer-report.
Diagnosis:
*Screenings/Scales not terribly reliable, must be within context of clinical assessment*
*r/o other medical or BH causes of symptoms*
1. at least 5 symptoms from the specific subtype category to diagnose ADHD inattention or hyperactivity/impulsivity subtypes and ≥ 5 symptoms from each category to diagnosis ADHD combined type
2. several symptoms present before age 12 years (if undiagnosed in childhood, this is established by a retrospective assessment of childhood symptoms)
3. criteria met in ≥ 2 settings (home, school, or work, or with friends or relatives)
4. clear evidence that symptoms interfere with or reduce the quality of social, academic, or occupational functioning
5. symptoms present for ≥ 6 months, symptoms more frequent than expected, and if they directly affect social, academic, or occupational activities
During a follow-up appointment discussing depression and SUD (currently using meth), your patient reports thinking about harming others - owns firearms, contemplates shooting people. They do not identify any specific people they would target. Who ya gonna call?
Involuntary commitment - "(1) suffers from a mental disorder; and (2) the individual is either a danger to themselves, others or property."
Duty to warn - "patient has communicated an actual threat of physical violence against a reasonably identifiable victim", "In Volk, the Supreme Court held that, in the outpatient and voluntary inpatient treatment setting, the duty of health care providers to warn or protect potential victims of violence extends to all individuals who may be “foreseeably” endangered by a patient, even if no specific target was identified."
ERPO - family/household member or law enforcement can file "a court order that temporarily suspends a person’s access to firearms if there is evidence that the person is threatening to harm him or herself or others "
Your patient is a 36y/o combat veteran with PTSD, has not sought out treatment until now - his spouse pressured him to be seen for this and he now recognizes that his flashbacks, panic attacks, anger, and depression are not under control. What is the first line treatment for this patient?
"individual trauma-focused psychotherapy over other pharmacologic and non-pharmacologic interventions, as recommended by Department of Veteran Affairs/Department of Defense 2017 clinical practice guidelines" (cognitive processing therapy, EMDR, etc.)
First line pharmacotherapy: SSRIs (sertraline, paroxetine, fluoxetine, venlafaxine)
What is the prevalence of conversion disorder in neurologic and psychiatric settings?
"The exact prevalence of conversion disorder is unknown but it is estimated to be 2-22 per 100,000 persons annually in United States and affects up to 20% of patients in neurological and psychiatric settings."
A 32y/o female presents for follow up of mental health concerns. She reports severe anxiety present consistently since she was a teenager, has worries/concerns she can't control. Worries about her loved ones getting hurt or dying, to the extent that she spends several hours per day praying for their safety - she feels if she does not do this something terrible will happen to them, and it causes her great distress. Her family members have also expressed frustration at how often she texts/calls them to make sure they are okay - once again, she feels if she does not do so that something terrible will happen. What is the most likely diagnosis, and what screening tools can you use to help in making the diagnosis?
OCD - can use Yale-Brown Obsessive Compulsive Scale (Y-BOCS) [for kids it's the CY-BOCS]; include risk assessment for harm of self or others, often have comorbid BH disorders; different levels of insight into obsessions/compulsions; sometimes associated with past/present tic disorder
DSMV Criteria:
1. Presence of obsessions, compulsions, or both.
2. obsessions/compulsions are time-consuming (>1hr/day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.
4. not better explained by another mental disorder
16y/o male held in the ED after violently attacking his family members. Continues to have auditory hallucinations and intrusive thoughts of harming others. Who ya gonna call?
Social Work will coordinated with MBSW and work on inpt transfer. ...?
You diagnose an adult patient with OCD - what is the first line treatment?
CBT &/or SSRI
"Consider clomipramine as an alternative if not responding to an SSRI or if there has been a previous good response to clomipramine " - TCA, may have more side effects
What is the lifetime prevalence of dissociative disorders?
"5.5%-18.3% reported lifetime prevalence in general population in the United States, Canada, Finland, and Turkey between 1991 and 2008"
You have a patient in the hospital you are sure has borderline personality disorder -- what are the actual diagnostic criteria?
DSM-5 criteria: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (eg, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (eg, frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
*Don't over-diagnose it just because a patient is difficult*
*Don't under-diagnose it just because you're afraid to attach stigma to a patient - remember high risk of self-harm*
*Often exists with comorbid BH conditions - doesn't preclude diagnosis*
Your patient has severe depression exacerbated by the recent death of a loved one. They report often wishing they were dead, and have thought about falling off a cliff or just not waking up in the morning. They have no plans of self harm, and call their best friend when they feel down. Who ya gonna call?
Lauren!
- dot phrase in your note, discuss with patient
- same BH23 referral with Lauren B at EPFM in comments
- route to Lauren as FYI
Crisis lines, psychologytoday.com, openpathcollective.org, mindfulness/meditation, CBT workbooks.
28y/o female presents to discuss depression. Symptoms are severe on PHQ9 and she reports passive SI but no active SI/HI. Also reports feelings of guilt and shame related to her body weight. Describes periods of binge eating, after which she feels so bloated that she makes herself puke to feel better. Exercising for long periods also helps her to feel better after she's eaten too much. First line treatment?
CBT is first-line
Can add medication, but never as monotherapy (must be adjunct to CBT). "fluoxetine is only pharmacologic agent with FDA approval for treatment of bulimia nervosa, although other selective serotonin reuptake inhibitors (SSRIs) may also be effective"
Your patient has had tremors and muscle spasms with a thorough and unremarkable workup. What are the criteria to diagnose functional movement disorder?
DSMV criteria:
"DSM-5 criteria no longer require identification of precipitating stressors for diagnosis of functional neurologic symptom disorder"