Other Behavior/Emotional Disorders

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