Other Behavior/Emotional Disorders-
-Acute Reaction to Stress-
-Acute Stress Disorder is characterized by acute stress reactions that may occur in the initial month after a person is exposed to a traumatic event (threatened death, injury, or sexual violation)
-Treatment of acute stress disorder can have an additional benefit of limited subsequent post traumatic stress disorder (PTSD), which is diagnosed at least 4 weeks after the exposure to the trauma
-Trauma focused cognitive behavior for acute stress disorder include patient education, cognitive restructuring, and exposure
-Benzodiazepines may be helpful to manage acute anxiety
-For acute stress disorder it is recommended CBT for first ling therapy. Short term benzodiazepine use may be helpful
-Child/Elder Abuse-
-Elder Abuse is defined as behavior by someone with an ongoing relationship, that may constitute :
1. Willful infliction of physical pain or injury
2. Willful nonsexual contact
3. Willful infliction of emotional harm
-Elder is the finest person 60 or 65 years of age or older
-neglect is defined as a failure of a person to right needs for the protection of vulnerable order what a person have an ongoing relationship with the Elder, In a duty to provide those needs and protection.
-abandonment is defined as the desertion of a vulnerable when the had an ongoing relationship with the elder
-Elder mistreatment constitutes abuse, neglect, self-neglect, in financial exploitation
-Financial exploitation is a nonconsensual appropriation of an elderly person resources for the benefit of another by someone an ongoing relationship and a duty towards that person
-Community dwelling elders are protected by the adult protective services in all 50 states. This agency is responsible to investigate allegations, Complaints, and provide social and legal and medical intervention to help victims.
-Elderly patients in long-term care facilities are governed by State Long Term Care Ombudsman Programs
-warning signs of elder mistreatment include unexplained bruising a various stages Of healing, fractures that are not explained, malnutrition, dehydration, pressure ulcers, any indicators of sexual abuse such as evidence of venereal diseases.
-elders who are deemed competent may reject services offered by adult protective services. If the person is seemed incompetent courts may intervene and issue an emergency order for an Adult protective services.
-if a healthcare professional fields that there's mistreatment adult protective services should be notified.
-Child Abuse-
-findings that raises suspicion for child abuse on physical examination include: injuries indicate method of infliction such as slap or belt, cigarette burn, spatula burn, or immersion bruises at high tide level.
-other indications of abuse are fractures in various stages of healing
-other signs of abuse and neglect include: bruises and children who cannot cruise, bruises of the trunk, ears and neck. Long bone fractures and children do not walk, in rib fractures in children who are less than one year of age.
-sudden onset of altered mental status not a caused by a medical illness such as hypovolemia, Hypoxemia, hyperglycemia or shock.
-other signs of abuse include injury to genitalia, subdural hematoma in a children less than one year of age, or injuries that are physically impossible.
-parent behavior should be observed carefully and suspicious parenteral behavior may increase the suspicion for abuse.
-Workup for unusual bruising include CBC, PT, PTT, VWF antigen and activity, Factor VIII and IX level
-If intracranial bleeding consider DIC panel including d-dimer and fibrinogen
-Urinalysis should be obtained in children with abdominal trauma.
-Toxicology should be obtained if suspicious for poisoning or malicious materials
-Radiographic workup is dependent on age and physical exam findings. May need a skeletal survey
-Ophthalmologic evaluation is recommended for children less than 5 where head trauma is suspected.
-in the United States, Suspected child abuse is mandated to be reported to the appropriate governmental agency.
-Conduct Disorders-
-conduct disorder overlaps with antisocial personality disorder. Antisocial personality disorder is a pattern of socially irresponsible, exploitative, and guiltless behavior that begins in childhood or early adolescence and is manifested in many areas of a persons everyday life.
-Conduct disorder is a mental disorder of childhood and adolescence. It is diagnosed in children and adolescents with a repetitive and persistent pattern of violating basic rights of others and societies rules
-Conduct disorder is diagnosed with high rates of psychiatric diagnoses, substance misuse, mood disorder, anxiety disorders, ADHD, learning disabilities, pathologic gambling, and borderline personality disorder.
-Pathogenesis is unknown but research suggests both genetic and non genetic causes.
-clinical manifestations include: fights with peers, conflict with parents and authority figures, stealing, vandalism, fire setting, cruelty to animals, Poor academic performance, and ran away from home.
-Domestic Violence-
-Domestic violence is referred to intimate partner violence (IPV). The term describes actual or threatened psychological, physical, or sexual harm to a current or former partner or spouse.
-clinical presentation can include: inconsistent explanation of injuries, a delay in seeking treatment, frequent emergency department or urgent care visits, pregnant women may have delayed initiation in prenatal care, repeated abortions, medication noncompliance, inappropriate affect, over a attentive or verbally abusive partner, apparent social isolation, reluctance to undress, or refusal of genital or rectal examination.
-careful questioning must be done by the clinician to get an accurate and truthful history.
-These patients must be referred to social service and appropriate community resources to make sure they are in a safe environment.
-Grief Reaction-
-immediately after following death, survivors often experience feelings of numbness, shock, or disbelief.
-sleeplessness, appetite disturbances, agitation, chest tightness, sighing, exhaustion, and other somatic complaints are common
-shock, numbness, intense feelings of sadness, yearning for the deceased, anxiety for the future, disorganization, and emptiness often commonly arise in weeks after death.
-grief often comes in waves precipitated by Reminders of the deceased. The survivor may feel fine one moment and be overwhelmed with sadness and grief in the next moment. Feelings of pleasure or often experience as a betrayal of the relationship with the person who has died.
-these symptoms are all considered normal grief reaction.
-Rates of depression during the first year after loss of a spouse are 4-9 times higher than in the general population.
-patients with complicated grief reactions should be referred to a psychiatrist. It is difficult to differentiate between major depression and a complicated grief reaction by most primary care clinicians.
-Complicated grief treatment is a psychotherapeutic approach that includes behavioral methods similar to those with posttraumatic stress disorder.
-treatment with antidepressants is associated with improvement of symptoms associated with depression but it appears to be ineffective in treating symptoms associated with grief.
-Suicide-
-there is no data to support screening for suicide in primary care reduces mortality. Additionally, predicting which patients with suicidal thoughts will go on to attempt suicide cannot be achieved with a high degree of certainty.
-over twice as many patients who attempt suicide contact their primary care provider versus a psychiatrist one month prior to attempting suicide.
-Several risk factors have been associated with suicide: hopelessness and impulsivity, history of previous attempts, increasing age, female sex, white elderly men over 85, marital status, occupation, health, adverse childhood experience, family history of suicide, and accessibility to weapons.
-There is an increase of suicide with age, but young adults attempt suicide more often then younger adults.
-Females attempt more often but men are 3 times more successful than women
-Suicide is greater in patients who have unskilled occupations
-Management of the acutely suicidal patient includes: reduce immediate risk, manage underlying factors, and monitoring and follow up
-If the patient is threatening to leave, in most jurisdictions the police can be called to detain the patient or the patient can be placed under a psychiatric hold for 72 hours
-If patients are going to be discharged, contracting for safety is assessing family support to maintain the patients safety.
-Lithium has been showed in patients with mood disorder to prevent suicide
-Psychotherapy may prevent subsequent suicide attempts
Thursday, February 19, 2015
Sunday, February 15, 2015
Substance Use Disorders
Substance Use Disorders-
-Abuse-
-Substance use disorder can be recognized when a patient requests help to discontinue the use of alcohol or drugs
-Risky use of alcohol or other drugs when consumption amounts that increase the likelihood of health consequences
-Substance Use Disorder replaced the psychiatric diagnoses once known as substance dependence and substance abuse
-Physical dependence is a state of adaption manifested by a withdrawal syndrome that is produced with an abrupt cessation of a substance or by tolerance to a substance
-Addiction-is a primary, chronic, neurologic disease, with genetic psychosocial and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include impaired control over substance abuse, compulsive use, and continue despite harm and craving
-Unhealthy Alcohol or Other Drug Use-refers to the spectrum that can result in health consequences
-Various types of substance use and approach to treatment
-Cocaine use and intoxication is treated with supportive care such as benzodiazepines to control agitation.
-Cocaine symptoms are best treated by allowing the patient to sleep and eat as needed in a supportive environment
-No medication has shown to be effective in cocaine withdrawal syndrome
-Psychosocial treatment is best for cocaine use and have shown to lead to mean reductions in cocaine use. No medication has been shown to be effective in cocaine dependence
-Patients with opioid use disorder wan achieve abstinence though medically supervised withdrawal often require long treatment to prevent relapse
-Long term treatment of opioid use disorder may take several forms:
1. Psychosocial treatment and abstinence based treatment can be provided in the outpatient setting
2. Opioid antagonist treatment-naltrexone base therapies exist that are antagonistic to opioids
3. Opioid agonists treatment with methadone, buprenorphine can be given to patients and then wean them down. Not ideal
-Opiate withdrawal is characterized by pupillary dilation, yawning, increased bowel sounds, and piloerection. Patients may have severe distress, heart rate, blood pressure and respiratory rate may be increased. Patients may present with volume depletion from vomiting and diarrhea.
-Other symptoms of opiate withdrawal include rhinorrhea and lacrimation, myalgia, arthralgia, and abdominal cramping
-Opiate withdrawal can occur within 6 hours of discontinuation of use
-Abstinence detoxification from opioids is largely supportive with hydration and control of symptoms such as vomiting, and agitation. Phenergan and Atarax are commonly used for control of symptoms.
-Benzodiazepine withdrawal onset may vary from the half life of the particular benzodiazepine involved. Symptoms may be delayed up to three weeks after discontinuation
-Symptoms of benzodiazepine withdrawal can include tremors, anxiety, perceptual disturbances, dysphoria, seizures, and psychosis
-BZD withdrawal is treated with a BZD that has a prolonged clinical effect, such as valium IV and titrated to the desired effect
-The BZD does should be tapered gradually over a period of months. BZD withdrawal can be fatal if not treated appropriately
-Alcohol withdrawal can present with a variety of symptoms
-Minor alcohol withdrawal symptoms include insomnia, tremulousness, mild anxiety, gastrointestinal upset, anorexia, headache, diaphoresis and palpitations
-Alcohol withdrawal seizures are generalized tonic clonic seizures and usually occur within 12-48 hours of their last uses
-Alcohol hallucinosis and delirium tremens (DT) are not synonymous. Hallucinations are usually visual, although auditory may occurred can develop within 12-24 hours of last use and usually resolve within 24-48 hours
-DT is associated with global clouding of the sensorium with specific hallucinations and vital signs are normal
-Treatment of psychomotor can be done with benzodiazepines such as librium, ativan, or valium
-Thiamine and glucose should be administered to prevent Wernicke's encephalopathy
-Ativan or Serax should be used of patients with cirrhosis or acute alcoholic hepatitis
-Patients with moderate to severe alcohol withdrawal should be admitted to the ICU for monitoring and treatment
-Antipsychotics including haldol should not be used because they lower seizure threshold
-Abuse-
-Substance use disorder can be recognized when a patient requests help to discontinue the use of alcohol or drugs
-Risky use of alcohol or other drugs when consumption amounts that increase the likelihood of health consequences
-Substance Use Disorder replaced the psychiatric diagnoses once known as substance dependence and substance abuse
-Physical dependence is a state of adaption manifested by a withdrawal syndrome that is produced with an abrupt cessation of a substance or by tolerance to a substance
-Addiction-is a primary, chronic, neurologic disease, with genetic psychosocial and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include impaired control over substance abuse, compulsive use, and continue despite harm and craving
-Unhealthy Alcohol or Other Drug Use-refers to the spectrum that can result in health consequences
-Various types of substance use and approach to treatment
-Cocaine use and intoxication is treated with supportive care such as benzodiazepines to control agitation.
-Cocaine symptoms are best treated by allowing the patient to sleep and eat as needed in a supportive environment
-No medication has shown to be effective in cocaine withdrawal syndrome
-Psychosocial treatment is best for cocaine use and have shown to lead to mean reductions in cocaine use. No medication has been shown to be effective in cocaine dependence
-Patients with opioid use disorder wan achieve abstinence though medically supervised withdrawal often require long treatment to prevent relapse
-Long term treatment of opioid use disorder may take several forms:
1. Psychosocial treatment and abstinence based treatment can be provided in the outpatient setting
2. Opioid antagonist treatment-naltrexone base therapies exist that are antagonistic to opioids
3. Opioid agonists treatment with methadone, buprenorphine can be given to patients and then wean them down. Not ideal
-Opiate withdrawal is characterized by pupillary dilation, yawning, increased bowel sounds, and piloerection. Patients may have severe distress, heart rate, blood pressure and respiratory rate may be increased. Patients may present with volume depletion from vomiting and diarrhea.
-Other symptoms of opiate withdrawal include rhinorrhea and lacrimation, myalgia, arthralgia, and abdominal cramping
-Opiate withdrawal can occur within 6 hours of discontinuation of use
-Abstinence detoxification from opioids is largely supportive with hydration and control of symptoms such as vomiting, and agitation. Phenergan and Atarax are commonly used for control of symptoms.
-Benzodiazepine withdrawal onset may vary from the half life of the particular benzodiazepine involved. Symptoms may be delayed up to three weeks after discontinuation
-Symptoms of benzodiazepine withdrawal can include tremors, anxiety, perceptual disturbances, dysphoria, seizures, and psychosis
-BZD withdrawal is treated with a BZD that has a prolonged clinical effect, such as valium IV and titrated to the desired effect
-The BZD does should be tapered gradually over a period of months. BZD withdrawal can be fatal if not treated appropriately
-Alcohol withdrawal can present with a variety of symptoms
-Minor alcohol withdrawal symptoms include insomnia, tremulousness, mild anxiety, gastrointestinal upset, anorexia, headache, diaphoresis and palpitations
-Alcohol withdrawal seizures are generalized tonic clonic seizures and usually occur within 12-48 hours of their last uses
-Alcohol hallucinosis and delirium tremens (DT) are not synonymous. Hallucinations are usually visual, although auditory may occurred can develop within 12-24 hours of last use and usually resolve within 24-48 hours
-DT is associated with global clouding of the sensorium with specific hallucinations and vital signs are normal
-Treatment of psychomotor can be done with benzodiazepines such as librium, ativan, or valium
-Thiamine and glucose should be administered to prevent Wernicke's encephalopathy
-Ativan or Serax should be used of patients with cirrhosis or acute alcoholic hepatitis
-Patients with moderate to severe alcohol withdrawal should be admitted to the ICU for monitoring and treatment
-Antipsychotics including haldol should not be used because they lower seizure threshold
Somatoform Disorders
Somatoform Disorders-
-Somatoform Disorders-
-Somatization is a syndrome of physical symptoms that are distressing and may not be explained by a medical condition after a full workup
-Somatoform disorders is an illness with symptoms that were not explained by a general medical condition
-Risk factors for somatization include: female sex, fewer years of eduction, minority ethnic status, and low socioeconomic status
-Somatization increases the use of medical services independent of any accompanying psychiatric or non psychiatric medical disorder
-Somatization patients present with a wide array of symptoms including pain, GI symptoms, cardiopulmonary symptoms, neurologic symptoms, and reproductive organ symptoms
-Somatoform Disorders include:
1. Somatization disorder
2. Pain disorder
3. Undifferentiated Somatoform Disorder
4. Hypochondriasis
5. Somatoform Disorder NOS
6. Conversion disorder
7. Body Dysmorphic Disorder
8. Somatofrom Autonomic Dysfunction
9. Other somatoform disorders
10. Factitious Disorder
11. Maligering
12. Abridged somatization
13. Multi-somatoform disorder
-Psychotherapy and pharmacologic therapy are each beneficial for patients with somatization
-These treatments may also be combined
-SSRI's have been shown to be beneficial in somatization disorder
-Clinicians should avoid giving opioid analgesics for pain complaints
-Cognitive behavior therapy (CBT) to treat somatization is most helpful to treat somatization more so than any other psychotherapy
Tuesday, February 10, 2015
Psychoses
Psychoses-
-Delusional Disorder-
-Delusional disorder is characterized by the presence of one or more delusions for a month or longer in the absence of meeting the criteria for schizophrenia
-There is also a lack of being attributed to a manic or depressive episodes, and other medical conditions other than a medical disorder
-Delusions are classified as erotomaniac type, grandiose type, jealous type, persecutory type, somatic type, mixed type or unspecified type
-They are also classified by rather than have bizarre content
-Treatment of choice for delusions is antipsychotic medication
-Needs a medical evaluation especially with initial episode to exclude this as being attributed to medical disorder
-Schizophrenia-
-The DSM 5 Criteria for Schizophrenia is as follows:
A. Characterized by two or more of the following:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Gross disorganized or catatonic behavior
5. Negative symptoms (affective flattening, alogia, or avolition)
B. For a significant portion of the time since the onset of the disturbance, one or more of the major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset. When onset is in childhood or adolescence: failure to achieve expected level of interpersonal, academic, or occupational achievement
C. Continuous signs of disturbance persist for at least 6 months. The six months of symptoms must include one mont of symptoms that meet criterion A
D. Schizoaffective disorder and mood disorder with psychotic features have been ruled out
E. The disturbance is not due the direct physiologic effects of a substance such as drug abuse or medication or due to a general medical condition
F. If the patient has a history of autistic disorder or other pervasive developmental disorder, the diagnosis of schizophrenia is is made only if prominent delusions or hallucinations are also present for at least one month
-People with schizophrenia present with several areas of symptoms such as:
1. Positive symptoms (exaggeration of normal processes, distortion of symptoms, hallucinations, and delusions)
2. Negative symptoms (conceptualized as an absence or diminution of normal processes, decreased expressiveness, apathy, flat affect, and lack of energy)
3. Cognitive impairment
4. Mood symptoms
5. Anxiety
-Anti-psychotic medications are first line treatment for schizophrenia and have been shown to reduce positive symptoms
-Patients should be observed on a stable dose of antipsychotic medications for 2-6 weeks before concluding the medication is ineffective
-Antipsychotic medication should be continued indefinitely after the acute phase is passed at the lowest effective dose
-Delusional Disorder-
-Delusional disorder is characterized by the presence of one or more delusions for a month or longer in the absence of meeting the criteria for schizophrenia
-There is also a lack of being attributed to a manic or depressive episodes, and other medical conditions other than a medical disorder
-Delusions are classified as erotomaniac type, grandiose type, jealous type, persecutory type, somatic type, mixed type or unspecified type
-They are also classified by rather than have bizarre content
-Treatment of choice for delusions is antipsychotic medication
-Needs a medical evaluation especially with initial episode to exclude this as being attributed to medical disorder
-Schizophrenia-
-The DSM 5 Criteria for Schizophrenia is as follows:
A. Characterized by two or more of the following:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Gross disorganized or catatonic behavior
5. Negative symptoms (affective flattening, alogia, or avolition)
B. For a significant portion of the time since the onset of the disturbance, one or more of the major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset. When onset is in childhood or adolescence: failure to achieve expected level of interpersonal, academic, or occupational achievement
C. Continuous signs of disturbance persist for at least 6 months. The six months of symptoms must include one mont of symptoms that meet criterion A
D. Schizoaffective disorder and mood disorder with psychotic features have been ruled out
E. The disturbance is not due the direct physiologic effects of a substance such as drug abuse or medication or due to a general medical condition
F. If the patient has a history of autistic disorder or other pervasive developmental disorder, the diagnosis of schizophrenia is is made only if prominent delusions or hallucinations are also present for at least one month
-People with schizophrenia present with several areas of symptoms such as:
1. Positive symptoms (exaggeration of normal processes, distortion of symptoms, hallucinations, and delusions)
2. Negative symptoms (conceptualized as an absence or diminution of normal processes, decreased expressiveness, apathy, flat affect, and lack of energy)
3. Cognitive impairment
4. Mood symptoms
5. Anxiety
-Anti-psychotic medications are first line treatment for schizophrenia and have been shown to reduce positive symptoms
-Patients should be observed on a stable dose of antipsychotic medications for 2-6 weeks before concluding the medication is ineffective
-Antipsychotic medication should be continued indefinitely after the acute phase is passed at the lowest effective dose
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