www.thepalife.
com
BEIIAVIORAL MODICINE RE}1EW
Ellen D. Mandel, MPA, MS, PA-C Assistant Professor, UMDNJ Physician Assistant Pro gram
Lecture: Topic Outline .' Commonly Presenting Types
:rAnxie8Disorders
p p
PD
pMoodDisorders
e. Factitious
Disorders :'Eating Disorders p Childhood Disorders Dissociative Disorders p Cognitive Disorders
Somatoform Personalrtv l )lsoKlers
" etPsYchosis
Disorder .
.*
Substance Abuse Domestic Violence
:rsexual Abuse
:o Child Abuse
Learning Objectives
e'1.
Acquire a working knowledge of the major diagnostic criteria developed by the American Psychiatric Association criteria for common DSM-IVTR Classifications seen in PA practice.
:'2.
p 4.
Apply the Multiaxial Classification Schemesymptoms and treaknents for the
s.3. Identi& t]re central
anxiety and panic disorders.
Assess dre symptoms and treatments for dre somatoform disorders-
www.thepalife.com
Learning Objecfives
ar5. Identi& the dissociation disorders.
st 6. Differentiate factitious disorders from the somatoform disonders. z. 7. Identi& Munchausen's syndrome
8. Identi& the personality disorders by ccmmon clusters and related treatment options
z' 9- Identi$ the signs of schizophrenia and those for
good vs. poor prognosis. Determine treatmentar 10. Understand the potential side effects of antipsychotics including tardive dyskinesia.
Learning Objectives
z- I 1. Distinguish between delusions and dementia :o 12. Identi& the criteriaand common heafnents for
depressive vs. bipolar I and
rr
II disorders. 3. Identi& the risk factors for suicide.
s. 14. Know the diagnosis and treatment forADF,trD s.15. Understand the cycle ofabuse"
a. 16. Identifu the signs and symptoms ofsubsance abuse. a, I 7. Recommend appropriate therapylreferral.
THE PSYCHIATRIC DISORDERS
DSM-IV-TR
www.thepalife.com
DSM.IV-TR
Multi axi aI Cl as s irt. c atio n S c h e me zr Axis I: All diagnoses of mental illness including
substance atruse and developmental disorders. Itdoes NOT include penonality disorders or mental
retardation.
pAxis
pAxis
zrAxis
II: III: V:
Personality disorders and mental retardation
General medical conditioas
pAxis IV:
Psychosocial and environmsntal problems
The Global Assessment of Function (GAF). Rafts the overall level of'functioning on a 0-100 scale.
Psychotherapies: Freud et al
unconscious, sexual, - aggressive, primary. (v
:old:
instinctive,
PDefense
Mechanisms are used by the Ego to protect ^-^^^tr'-r --r^^r oneself and relieve anxiety by keeprng conflicts out of awareness.
p Ego: Mediator available
between
the Id.
Id and the world.
Uses defense
mechanisms to tame the
PSuperego: Moral
conscience.
Defense Mechanisms
zrlmmature r Acting Ou! Regressio4 Passive aggressivg
Blocking, Somatization, Schizoid fantasy eoNeruotic
Dissociation, Reaction formation, Repression, Rationalization, Isolation, Displacement Sublimation, Humor, Anticipetion
arMature
r Altruism,
www.thepalife.com
conflicts.
Psycho Eehavioral Cognitiv+ Gmup ealysis Treats Patientsare >zpatients Restus disorders by taughtio with similar unmnscious replacing identi,9 problemsmeet lnsight if not
altematives.
rdo*s
Fmily&
liladtal
lndividual
$oblemssten
oriented. healthy
Works best <aoe 40, stable,
maladaptive maladaptive withthempist" affectthe behaviotswith thoughtsand Alltechniques entirefamilyreplace them may be used. Dy3functioN
psychotic, *ithphobias
wll
wittr
positive
lncludes
Meets4. sx&rkfor yem.
smart.
&
conpulsioni
weilwith ildhedback midentifed depressive & from pee6. and mehods anxiety ?ppliedto disrdersreducemn{ict U$fitl riltt ild chilge OCD, ating destruclive somatifom, iorces.
disordere.
ms. Works
M.
of the couple
Gain
bsigtds orlamily mit
Anxiefy Disorders: DSM-IV-TR Diagnoses
pPanic Disorder
e.Agoraphobia
:'Specifrc Phobia :rSocial Phobia
Generalized Anxiety Disorder
p 0bsessive Compulsive Disorder :r Post-traumatic Stress (Ptsd) pAcute Stress Dsorder
Panic
Attack
Discrete Periods
arHeart Cluster
r Palpitations,
Chest pain, Nause4 rumbnesg
tingling arBreathlessness Cluster
Shorhress of breati, Choking sensatiorl Dizziness, Paresthesias, Chills or hot flashes
arFear Cluster r Fearofdying, Fearofgoing crazy, Shaking,
Sweating, Derealization or depersonalization
www.thepalife.com
Panic Disorder: Characteristics
p>Females 2-4x
Pa.,,.,K A\^,K flc.\'.rJe,s Pen,*K )r*nJr,r
t) Storg genetic component with 4-8X greater with
lst degree relative.
Onset late adolescence to 30s
ar Over 65 yr- underreported
p p
Prior stressfirl event within 6 months
78olo
initial panic attack occurs w/o environmental
trigger
Panic Disorder Criteria
p
Spontaneous recurrent panic attacks wlo obvious
precipitant.
:r >1 attack is followed by concern for additional attack, fear ofattack implications and a sisnificert
change in behavior related to the attack.
Should assess for agoraphobia
ar Range of aftacks vary and often last 20-30 minutes
Panic Disorder: Masquerade
:r Think of hyperthyroidism, Bl2 deficiency,
seizures, CAD, anernia, pheochromorytoma,
hypoglycemia
pThink of
exoessive caffeine, amphebmineq withdrawal, heavy metal toxicity, other medication induced anxiety such as allergic
reaction to PCN, sulfa or atypical reaction
agonists.
beta
www.thepalife.com
TIIE PANIC CYCLE
APPRIA.ISAL'-
CATASI'ROPHIC MISINTERPRETATION ,/, \,u
/.tt-
---_--TBELINGS
\,/
B[}T}IIJ
SENSATIONS
Specific & Social Phobias: Criteria
p
The most common mental disonder in US. >5-1ff/o
of population affected.
pAn
irrational fear or situation.
tlat
leads to avoidance of a object
;t Eryosure to situation provokes anxiety p, Recognition of excessive nature of fear pNot
due to substances or other disorder
s, Durafion >6 nronths
Agoraphobia Criteria
:rAnxiety about being in places or situations
.
r r
a:
escape is
difEcult
embarrassment takes place
helpnotavailable
Avoidance of situations erMay require a companion in attendance atAnxiety not due to another mental disorder
www.thepalife.com
Generalized Anxiety Disorder (Gad)
r"rChronic ExcessivdlVorry for >6 months ) pHyper-arousal often with somatization e.Associated with restlessness, fatigue, poor concentation, irritability, muscle tension and sleep disturbance. :rlifetime prevalence *457o ar>Females 2:1, onset age 20
/'
----'\
PANIC DISOKDERS: General Tx
p Benzodiuepines p Antidepressants
o Tricyclics and SSRIs, MAOI
r (CAUTION: p
-20olo experience stimulantlike reaction
"Activafion Syndrome) o Provide Reassumnce: 2-6 weeks for effectiveness
Behavioral interventions
o Cognitive thempy
r r
Combine w/ biofeedback or relaxation Panlc control
tretment (pct)
o Assertiveness training
o Behavioral therapy
Obsessive-Compulsive Disorder
''OBSESSIONS . rrcumt, intrusive ''COMPULSIONS
thoughts, feelings or ideas
to the obsessions
0L
- ?n=^,^,\,L D;< u's
%e s)-qjrlirz- '/e
rj5r=cy"'+?. i
r'r
mnsciou repetitive behavim linked
that when perfomed relieve anxiety
p Full ,.
awareness makes OCD a "Disorder" and differs from the Obsessive-Compulsive
Personality Disorder (OCPD) Ego-syntonic versus ego-dystonic
www.thepalife.com
OCD: Characteristics
,t2-3Vo of population, males: females
er Onset: childhood or early adulthood
AE;r.. t
"Ten:retle,'g
p
zo
Suessful events exacerbate condition Common co-morbid conditions
r
lr
depressiorq panic disorder, eating disorders, tics, separalion anxiety in childhood" phobia
Rate is highsr with I st degree relative with Tourette's
Obsessive-Compulsive Disorder
:r
Obsession
o Contamiration
zt Compulsion
Doubt o Symmetry
o e- Can also have obsessive thoughts
r r
Constanthand*ashing
Checking
o cornPrilsive slow
without a linked
compulsion.
vS At-{e
Posttraumatic Stress Disorder (PTSr))
Silce:rg'
R"'-r{un
\,
?
E,;l.:e
lt.
)nr
elResponse to a catastrophic (life threatening event) with intense fear or horrorer>1 month of increased arousal, avoidance of stimuli, persistent reJiving of event, dreams, flashbacks, poor sleep, exaggerated
startle response, anger
www.thepalife.com
Acute Stress Disorder
a,Similar to PTSD
e.Symptoms start within I month of event and resolve within I mont-h
Sexual Violence: Rape
arRape is legally defined as "carnal knowledge ofa person by force and against [her] will". arOccurs every 2 minutes and9ff/aare unreported pBetter prognosis if seek immediate care
pMust
attend to the medical and psychological aspects of care
Coping Of Rape Victims: Reaction Phases
?d
Acute Phase: lasts several weeks to months Reorgaaization Phase: longerterrn of reorganization lasting as long as several years
:. Initial Presentation:
generally overwhelmed, labile, anxious. suspicious, guilty, degraded or depressed. May depersonalize the event. calm think "shock" with risk of later symptoms z.Longer Term Problems: difficulty with relationships, jobs, regressio4 dependency.
:'If
www.thepalife.com
Parfner Violence: Phases
ar
1. Verbal abuse and hostility phase r Systematic isolation
o
Undermining self-esteem
phase
ar2. Violent
o Assault
:t3.
o
Honeymoon phase Remorseful of reform
o Promises
Domestic Violence: Screening Radar
*Routine screening of female patients
pz4sk direct questions erDocument your findings
:r,4ssess patient' s safefy
,pReview options and do referrals
Battering only takes place among minorities and in lower socioeconomic
groups.
Batterers are drunk or out
of control
www.thepalife.com
Domestic Violence: Abuser ProfiIe
pl.ow
self-esteem
z.rUse tlreats, force for control
arAlcohol or substance abuse
:vJealous of parhrer's relationships
erBlame partner for violence
e-90Vo deny problem exists
zrProduct of abusive home
Child Abuser: Characteristics
:rFear of spoiling children
p>Value
on punishment
arFalse expectations of children
e Umealistic demands of love or behavior e*Lack of empathy :eFelt misunderstood as child
erFelt unrewarded and criticized
as
child
Somafoform Disorders:
DSM-IV-TR Diagnoses
p Somatization Disorder
pConversion Disorder
eePain Disorder
zrHypochondriasis
:rBody Dysmorphic Disorder
www.thepalife.com
" Somatizafion Disorder:
Criteria
5-10Yo
zt > 2 GL >1 sexual/reproductive,
>l
neurologic,
>4 pain symptoms, onset < 30 years
:r :r
in general medical practice
zt Females 5-20X greater incidence
50p/o
with co-morbid mental disorder
frequent visits
pNO CURE: schedule
fol
reassuranc
Somatization: Common Complainfs
a'"'sickliness" urination diffrcultie s p double visionlblurred vision ermemory loss
ar
p diarrhea/vomitinglnausea
pabdominal pain
a*menstrual complaints
. Conversion Disorder
er>l newological symptom
erCannot be explained medically
p Causes sip,ificant distress/impairrnent
p"La Belle Indifference"
pCommon, 20-25% incidence in medical
setting arOnset teens, more common in females zoCo-morbid with schizophrenia" major
depression and anxiety.
www.thepalife.com
Pain Disorder
arPain in one or more anatomic sites arPain causes distress e'Psychological NOT Medical, FactitiousAvlatingering
arFemales, 30s and 50s peak
erPoor Prognosis Litigation Concerns
Hypochondriasis
(- t6 \*
rnnn11tr of fear]of serious medical condition.
e.Bases on misinterpretation of bodily functions/disease
e. Fear persists despite medical tratment
:d Sympto;ns may wax and wane and 5fflo imp'rove
r4{7o
of general medical pop.
p Males : females p Most common during 20-30 yrs. pNO CURE: Frcquent visits, Group therapy
erFacial Flaws, physical imperfections PAverage of 4 Flaws zrOnset is 15-20 years arMore common in the unmarried
er907o
with co-morbid depressiorg 70%o with anxietv- 30% wiLh pwchotic disorder
*Treatoaerl(-QlB5-J
www.thepalife.com
4' J)
/----
Factitious Disorder
e.Intentionally produced symptoms e"Primary gain
sense
"4\e N, r$C,
Y4::)background, poor arMedical
poor sexual adjushnent
zo 3
of identity,
-9Yo
hospital admissions
pSick role
Munchausents Syndrome
TRIAD
SIMI,ILATION OF DISEASE
,'
/ ./
ffi\
*ti + j!
..-
\\ \
r-rNc
//\
,,'
PATHOLOGICAL
LIfNG
!D:r
Dissociative Disorders
Loss of memory, identity, self, onset of amnesia, detachmen! can arise suddenly
zr Dissociative Amnesia:
>l
Important Infonnatioa
no
Inolving
Episode of Imbility to Recall a Traumatic Event.
Dissociative Fugue: Wherelwho Am I? Dissociative ldentity Disorder:
>l
Identity
Depersonalizaticn Disorder: Out of Body
www.thepalife.com
Personalify Disorders
Personality is one's set of stable, pre di ct ab I e, etn o ti onal snd
)raso"d*y'}^'\s vg
bla,-,.,.\ p,"s'
behwioral traits. l::=liiffi
gitdj#ri3$rdBi.ri:lA)fiiibr,?#t
ingrained, iflerib le patterns re lating to olhers that are maladaptive and cause significant impairment in social or o c cap ati onal ftn ct i arcing.
Ego-syntonic & Stable
Personality Disorders : Diagnosis
grDSM-IV-TR: Code cn Axis pMisdiagnosis is common
II
Lackofprecision
r Overlapofcriteria r Dimensions in nulny prs{ms
pDisorders grouped into Clusters A, B, & C
Personality Disorders: Clusters
lCLUSTER A : Schizoid, Schizotypal and Paranoid o Social Detachment W Unusual Behavim e. CLUSTER B: Antisocial, Borderline, Histrionic and
Narcissistic
e Drama
o Emotional & Impulsivity
p'CLUSTER C: Avoidanq Deperrden! aud ObsessiveCompulsive o Arxiety e Fearfirlness
www.thepalife.com
Cluster,4; Schizoid PD -qIgBNrr
r Detached r lndifferent To Criticism
Or Praise
r r Absence Of Close Friends r Neither Desires Nor Enjoys Relations
$exual Experiences Oflittle Interest lasks Performed Alone
Iakes Pleasure In FewActivities
SchizotypalPD: ME PECULIAR
'"r
i
i
i
I I i I
!-{agical ftriiti"g r Experiences Uoo*uut Perceptio*s . laranoid Ideation r Eccentric
Behavior
r Unusual Thinking r lacks Close
Friends
ldeasOfReference
r .Apxiety In Social r Bule Out Psychosis
r Qgnstructed
Affect
Paranoid PD : SUSPECT
r $pusal Infidelity Suspected r Unforgiving r $uspicious r lerceives Attacks r pnemy Or Friend r Confiding In Odrer Feared r ThreatsPerceived
www.thepalife.com
Anfisocial PD
CORRUPT
ar9onformity Lacking pObligations Ignored
pReckless Disregard For Self Or Odrers
atRemorse Lacking
pUnderhanded p Planning Insufficient (Impulsive)
avTemper
Borderline: I DESPAIRR
:rldentiVProblem
erAbandonment
Affect e"Empty Feeling
erDisordered
Terror
a'Impulsivity
aYRage
e.suicidalBehavior
erParaaoia
Or Dissociative
e'Relationship Instability
Borderline PD
e.Red Flags
r Doctor Shopprng r Legal Suits r Suicide Attempts r Several Brief Marriages r Doctor Idealization
o Excessive Interest
www.thepalife.com
Histrioni c PD : Pft.4l,St' ME
zrProvocative
:rRelationships
auAttention Center
er
Of
a.rlnfluenced Easily
Etyle Impressionistic arEmotions Shiftrng
er
