Behavioral Disorders: Diagnosis & Treatment

• Objectives
• Exams and questions are needed to accurately determine the correct diagnosis and formulate treatment plans for common behavioral disorders, given a patient scenario

Terminal Learning Objectives

• Determine exams and questions needed to accurately identify the correct diagnosis
• Formulate treatment plans for common behavioral disorders, given a patient scenario

Enabling Learning Objectives

• Accurately identify common signs, symptoms, physical findings, and possible treatments for the behavioral disorders
• Understand the importance and best practices for HPI gathering
• Synthesize anatomy and physiology knowledge to demonstrate understanding of causes and corrections for deviations from baseline human functioning
• Discern relevant red flags from presented cases

Behavioral Disorders

• Adjustment Disorder
• PTSD (Post-Traumatic Stress Disorder)
• Anxiety Disorders
• Depressive Disorders
• Suicide
• Insomnia
• Alcohol Use Disorder
• Drug Overdoses
• Eating Disorders

Initial Patient Assessment

• Apparent state of health
• Level of consciousness
• Signs of distress
• Skin color and obvious lesions
• Dress, grooming, and personal hygiene
• Facial expressions
• Posture, gait, and motor activity

Signs of Distress

• Anxiety or depression is a sign of distress
• Anxious affect or fidgety movements
• Flat affect or psychomotor slowing

Dress, Grooming, and Personal Hygiene

• Evaluate how the patient is dressed
• Evaluate whether clothing is appropriate for the weather
• Assess hair, nails, or use of cosmetics

Facial Expressions

• Evaluate whether the patient's eye contact is natural, sustained, quickly averted, or absent
• Evaluate expressions at rest, during conversation, and throughout the exam

Odors of Body/Breath

• Assess for alcohol, fruity, foul, or uremic odors

Suicidal Ideation/Homicidal Ideation

• Always assess a patient's risk for harm to self or others
• Ask "Do you want to kill yourself?"
• Immediately assign one-to-one direct observation if there is any suspicion
• Do not allow the patient out of sight and do not allow the patient to access anything harmful
• EVAC or transfer to ER or appropriate facility

SIG E CAPS

• S – Sleep changes
• I - loss of Interest in activities
• G - feelings of Guilt or worthlessness
• E – loss of Energy
• C - reduced Cognition, difficult concentration
• A – loss or change in Appetite or weight
• P - Psychomotor agitation or lethargy
• S – Suicidal ideation
• Access to a weapon should be assessed
• PHQ-9 (start with PHQ-2) and GAD-7 (start with GAD-2) should be assessed

Sensitive Exam Potential

• Mental health concerns have a negative stigma for many patients
• Symptoms can be diminished or masked, requiring empathetic listening, close observation, sensitive and careful questions because of this
• It is important to elicit the patient's understanding of the diagnosis to address any internalized false beliefs about the disorder
• Reinforce that psychiatric conditions, like cardiac or pulmonary conditions, are real and treatable

Generalized Anxiety Disorder (GAD)

• Principle components are psychological and somatic
• It is the most common anxiety disorder (women>men)
• It is characterized by excessive and persistent worry or anxiety that is difficult to control
• Anxiety is less tied to the exact timing of a threat, it can be anticipatory, persist after, or occur without an identifiable threat
• It typically appears between ages 20-35
• It is present for more days than not for more than or equal to 6 months to qualify as GAD

Panic and Phobic Disorders

• Panic Disorder is the occurrence of repeated panic attacks, short-lived (<10 minutes), recurrent, unpredictable episodes of intense anxiety accompanied by marked physiologic manifestations
• Phobic Disorders are persistent, unreasonable, intense fears (phobias) of specific situations, circumstances, or objects

Signs and Symptoms of Anxiety Disorders

• Apprehension, worry, irritability, difficulty concentrating, insomnia, and/or others
• Somatic complaints include:
• Cardiac: tachycardia, palpitations, increased blood pressure
• GI: increased acidity, epigastric pain, nausea
• Neurologic: headache, dizziness, near-syncope
• Panic Disorder: alarm response or feelings of impending doom: paresthesias, choking, smothering feelings

Focused History for Anxiety Disorders

• Assess patient's risk for harm to self or others (SI/HI)
• Administer SIGECAPS questionnaire
• Inquire about anxiety-producing situations, stressors, and fears
• Inquire about personal or family history of anxiety disorders

Physical Exam for Anxiety Disorders

• There are usually no specific findings
• Important to note mood, affect, dress, and appearance

Differential Diagnoses for Anxiety Disorders

• PTSD: intrusive and avoidance symptoms after exposure to a traumatic event
• Acute stress disorder: occurs after a traumatic event similar to PTSD, but only lasts 2-28 days
• Panic disorder: short-lived, recurrent, unpredictable episodes of intense anxiety accompanied by marked physiologic manifestations
• Substance-induced anxiety disorder
• Anxiety disorder due to a general medical condition, like thyroid issues

Behavioral/Psychological Therapy for Anxiety Disorders

• Engage mental health resources (BHOP, MFLAC, MH, etc.)
• The patient will work on relaxation, desensitization, emotive imagery, individual or group therapy
• Peer Support Groups can be helpful

Medication for Anxiety Disorders

• Use medication for limited, very short-term use only in emergent situations
• Lorazepam or diazepam
• Referral is always appropriate for first-line therapy and is needed for any possible long-term medication (SSRIs, SNRIs, etc.)

Prognosis and Follow-Up for Anxiety Disorders

• Anxiety disorders are usually chronic and difficult to treat, but all can be relieved to varying degrees
• Encourage compliance with psychotherapy
• Return for further evaluation if symptoms worsen or do not improve within 1 month
• SI/HI precautions: call 911, proceed to the ER, or tell supervisor immediately if having thoughts of SI/HI
• Contact Preceptor Immediately (Blue Directive)

Depressive Disorders

• Depressive disorders are characterized by sadness severe and/or persistent enough to interfere with function, and often by decreased interest or pleasure in activities
• Depression is extremely common, with up to 30% of primary care patients having depressive symptoms
• Etiology includes genetic factors, developmental problems (i.e., childhood events), personality problems, psychosocial stressors (divorce, unemployment, financial hardship, etc.)

Major Depressive Disorder

• Major Depressive Disorder is a syndrome of mood, physical, and cognitive symptoms that occurs at any time of life
• For diagnosis, at least 5 of the following must have been present nearly every day during the same 2-week period and one of them MUST be depressed mood or loss of interest or pleasure Symptoms include

Symptoms of Major Depressive Disorder

• Depressed mood most of the day
• Markedly diminished interest or pleasure in all or almost all activities for most of the day
• Significant (>5%) weight gain/loss
• Decreased/increased appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation observed by others
• Fatigue or energy loss
• Feelings of worthlessness or excessive/inappropriate guilt
• Diminished cognitive abilities
• Recurrent thoughts of death or suicide, a suicide attempt, or a plan

Persistent Depressive Disorder (Dysthymia)

• Chronic depressive disturbance of sadness over a period of 2 or more years
• Symptoms are milder but last longer than major depressive disorder

Bipolar Disorder

• Characterized by episodes of mania and depression
• These episodes may alternate, although many patients have a predominance of one or the other -Cycles can be weeks to months, depressive episodes typically last longer
• Manic episode: at least 1 week of a persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or a noticeable increase of energy plus at least 3 additional symptoms

Symptoms of Manic Episodes

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• Greater talkativeness than usual
• Flight of ideas or racing thoughts
• Distractibility
• Increased goal-directed activity
• Over-involvement in activities

Signs and Symptoms of Depressive Disorders

SIGECAPS Questionnaire:

• S – sleep changes
• I - loss of interest in activities
• G - feelings of guilt or worthlessness
• E – loss of energy
• C – reduced cognition, difficult concentration
• A – loss or change in appetite or weight
• P – psychomotor agitation or lethargy
• S – suicidal ideation
• Other: anxiety, loss of sexual drive
• Always ask about access to weapons

Focused History for Depression

• Assess patient's risk for harm to self or others (SI/HI)
• Administer SIGECAPS questionnaire
• Inquire about life situations, stressors, and worries
• Inquire about personal or family history of depressive disorders

Physical Exam for Depression

• Vital signs: note any changes in weight (+/-)
• Appearance:
• Pay attention to personal hygiene
• May demonstrate tearfulness, furrowed brows, slumped posture, poor eye contact, lack of facial expression, little body movement, and/or speech changes (soft voice, use of monosyllabic words)

Differential Diagnoses for Depressive Disorders

• Major depressive disorder: severe depressed mood not due to one specific stressor
• Persistent Depressive Disorder (Dysthymia): chronic sad feelings over a period of two or more years
• Bipolar disorder: depressive and manic symptoms alternating over weeks to months
• Substance induced depressive disorder
• Organic disorders may lead to depressive symptoms, such as endocrine disorders (thyroid, diabetes) or neurologic disorders (cerebral tumors, head trauma)

Treatment for Depressive Disorders

• Behavioral or psychological therapy
• Medication
• Referral is needed for any possible long-term medication (SSRIs, SNRIs, etc.)
• If manic episode, then transfer

Follow-Up Actions for Depressive Disorders

• Encourage compliance with psychotherapy
• Return for further evaluation if symptoms worsen or do not improve within 1 month
• SI/HI precautions: call 911, proceed to the ER, or tell supervisor immediately if having thoughts of SI/HI
• Contact Preceptor Immediately (Blue Directive)

Adjustment Disorder

• Involves anxiety or depression regarding an identifiable stress
• Acute if less than 6 months
• Stress is subjectively defined and the response is a function of personality and physiologic endowment
• Can lead to an impairment in social or occupational functioning
• Can lead to maladaptive behavior(s) such as over-indulgence in alcohol, drugs, overeating, extra-relational affairs, running away, etc.
• Major symptom must be specified in the diagnosis (i.e., adjustment disorder with depressed mood)

Signs and Symptoms of Adjustment Disorder

• Depression and/or anxiety
• May develop a physical symptoms in response to stress, such as pain
• Subjective responses: fear, rage, guilt, shame, irritability, restlessness, fatigue, increased startle reaction, inability to concentrate, sleep disturbances
• Patients must have emotional or behavioral symptoms within 3 months of exposed stressors

Focused History for Adjustment Disorder

• Assess patient's risk for harm to self or others (SI/HI) first
• SIGECAPS questions
• Inquire about stress-producing events
• Inquire about history of personal or family psychiatric disorders

Physical Exam for Adjustment Disorder

• Vital signs: note any changes in weight from review in chart and asking patient (gained or lost)
• Appearance:
• Pay attention to personal hygiene
• May demonstrate tearful eyes, furrowed brows, slumped posture, poor eye contact, lack of facial expression, little body movement, speech changes (soft voice, use of monosyllabic words)

Differential Diagnosis for Adjustment Disorder

• Normal reaction to significant stressor
• Anxiety disorders: feelings of nervousness, uneasiness
• Major depressive disorder: syndrome of mood, physical and cognitive symptoms, more severe and generally more prolonged than adjustment disorder
• Persistent depressive disorder (Dysthymia): chronic sad feelings over a period of 2 or more years, milder than major depressive disorder
• Organic disorders that may lead to depressive symptoms like endocrine disorders (thyroid, diabetes) and neurologic disorders (cerebral tumors, head trauma), etc.

Key to Diagnosis of Adjustment Disorder

• Emotional or behavioral symptoms in response to an identifiable stressor
• OR significantly impacts/impairs social or occupational function

Treatment for Adjustment Disorders

• Stress reduction techniques - meditating, exercise, connecting with community, etc.
• Supportive psychotherapy
• Engage mental health resources (BHOP, MFLAC, MH, chaplain etc.)
• Emphasis on strengthening existing coping mechanisms
• Medication
• For limited, short-term use only in emergency situations:
  • Lorazepam- only helps anxiety/panic symptoms
• Referral is always appropriate for first-line therapy and is needed for any possible long-term medications (SSRIs, SNRIs, etc.)

Prognosis and Follow-Up for Adjustment Disorders

• The longer the symptoms persist unaddressed, the more likely the progression to a long-term problem
• Encourage compliance with psychotherapy
• Return for further evaluation if symptoms worsen or do not improve within 1 month
• SI/HI precautions: call 911, proceed to the ER, or tell supervisor immediately if having thoughts of SI/HI
• Discuss weapon removal if indicated
• Contact Preceptor Immediately (Blue Directive)

PTSD

• Direct or indirect exposure to a traumatic, overwhelming event (based on patient's perception)
• Most events leading to PTSD are those that invoke feelings of fear, helplessness, or horror
• May develop based on witnessing event(s) firsthand
• Learning of traumatic events occurring to close family or friends can also produce PTSD
• PTSD can also arise From repeated exposure to adverse details of traumatic events (first responders)

Characteristics of PTSD

• Can be characterized by Re-experiencing a traumatic event
• Recurrent or prolonged distress at exposure to cues
• Nightmares or Flashbacks
• Avoidance of potential stimuli that remind the individual of the trauma
• Avoiding thoughts, locations, people, situations, or conversations
• Negative alterations in cognition and mood
• Feelings of detachment or Persistent negative state
• Persistent exaggerated negative beliefs (“No one can be trusted”) or Self-blame
• Alterations in memory of event

Veterans, Problems, and Cases

• Veterans' PTSD data: 13% Iraq, 6% Afghanistan
• Associated problems (20-40%): divorce, parenting problems, difficulties with law, substance abuse
• 75% of cases include comorbid depression or panic disorder

Signs and Symptoms of PTSD

• Intrusive symptoms: flashbacks, nightmares
• Avoidance symptoms: Avoid locations, people, situations, conversations and become withdrawn
• Physiologic hyperarousal: startle reactions, intrusive thoughts, sleep problems, nightmares, hyper-alertness, irritability
• DSM-5 criteria: symptoms must last for more than 1 month and cause significant distress or impairment in function
• Symptoms may be precipitated or exacerbated by events that are a reminder of the original event
• Symptoms frequently arise after a long latency period

Focused History for PTSD

• Assess patient's risk for harm to self or others (SI/HI)
• Administer SIGECAPS questionnaire
• Inquire about traumatic events, disturbing memories, nightmares, flashbacks (reliving the moment), awareness of being hyper-alert
• Personal or family history of psychiatric disorders
• Access to weapons

Physical Exam for PTSD

• Usually, no specific positive findings on exam
• Note mood, affect, dress, and appearance

Differential Diagnosis for PTSD

• Acute stress disorder: occurs after a traumatic event similar to PTSD, but only lasts 2-28 days
• Anxiety disorders: feelings of nervousness, uneasiness
• Panic disorder: short-lived, recurrent, unpredictable episodes of intense anxiety accompanied by marked physiologic manifestations

Key to Diagnosis for PTSD

• History of exposure to overwhelming event
• Followed by intrusive or avoidance symptoms

Medication for PTSD

• Psychotherapy Engage mental health resources as soon as possible
• Involves the patient confronting the traumatic event and learning to view it with less reactivity
• Medications SSRIs are pharmacotherapy of choice: referral is needed

Prognosis and Follow-Up for PTSD

• The sooner therapy is initiated the better the prognosis
• Better prognosis in those with good premorbid psychiatric functioning
• Encourage compliance with psychotherapy
• Return for further evaluation if symptoms worsen or do not improve within 1 month
• SI/HI precautions: call 911, proceed to the ER, or tell supervisor immediately if having thoughts of SI/HI
• Discuss weapon removal if indicated
• Contact Preceptor Immediately (Blue Directive)

Suicide

• It is the most serious complication for psychiatric disorders
• The lifetime risk includes:
• Hospitalized for depression: 10-15%
• Bipolar Disorder: 20%
• Women more likely to attempt, men are more likely to complete

Suicide Risk Factors

• Alcohol usage is a significant factor in many attempts
• Higher risk: depression (especially when associated with severe anxiety or part of bipolar depression), acute situational problems, other comorbid psychiatric or personality disorders, family history of suicide

Signs and Symptoms of Suicidal Individuals

• Severe depression
• Anxiety, pain, fear
• A dramatic improvement in mood may be noted right before the suicide as the individual is at peace with their decision to end their own life

Focused History Concerning Suicide

• SIGECAPS Questionnaire
• Personal or family history of psychiatric disorders
• Suicide attempts or family history of completed suicides
• Access to means of physical harm
• Columbia Suicide Severity Rating Scale

Physical Exam

• Evaluate patient's mood status
• Direct evaluation:
• Plans or concerns about the future
• Personal reactions to attempting suicide
• Thoughts about the reactions of others
• Assess risk by inquiring about:
• Intent, plans, means; possible rehearsals or preparations
• Suicide-inhibiting factors such as strong ties to children, family, or church

Differential Diagnosis of Suicide

• Consider co-morbid disorders
• Anxiety disorders: feelings of nervousness, uneasiness
• Major depressive disorder: severe depressed mood not due to one specific stressor
• Adjustment disorder: anxiety or depression regarding an identifiable stress
• Bipolar disorder: depressive and manic symptoms Persistent Depressive Disorder (Dysthymia)
• chronic sad feelings over a period of 2 or more years

Actions for a Pt with suicidal ideation

• EVAC or transfer to ER or appropriate facility
• If any suspicion, immediately assign one-to-one direct observation
• Do not allow the patient out of sight and do not allow patient to access anything potentially harmful
• Guns and medications should be removed

Actions for a Pt with a suicide attempt

• Render emergency treatment required to stabilize patient (treat for drug overdose, physical injury, etc.)
• Initiate 24-hour surveillance with patient in protective custody
• Employ appropriate physical and/or chemical restraint if necessary, until evacuation can occur
• If the patient is severely agitated then subdue with diazepam (Valium®) 5 mg IM
• CONTACT PHYSICIAN PRECEPTOR- MEDICATION prior to use if possible

Education for Any Psychiatric Disorder

• Always provide the following education: SI/HI precautions: call 911, proceed to the ER, or tell supervisor immediately if having thoughts of SI/HI
• Immediate Evacuation; Contact preceptor ASAP (Red Directive)

Insomnia

• Insomnia includes difficulty getting to sleep, staying asleep, intermittent wakefulness, early awakening
• Common factors:
• Stress, caffeine, physical discomfort, daytime napping, early bedtime
• Psychiatric disorders may be associated with persistent insomnia: depression, manic disorders
• Insomnia is a side effect of many medications: Corticosteroids, Pseudoephedrine, Stimulants

Additional Influences on Insomnia

• Other contributing factors: Alcohol abuse, heavy smoking, withdrawal from sedatives (benzodiazepines)
• Contributing medical conditions: Pain disorders, asthma, thyroid disorders, sleep apnea, restless leg syndrome

Symptoms and Questionnaires

• Signs and Symptoms: Difficulty getting to sleep, staying asleep, intermittent wakefulness, early awakening
• Focused History: SIGECAPS, STOP BANG Questionnaires, Stressors, Medications, Medical history, Caffeine intake, Use of nutritional or workout supplements (many contain caffeine or other stimulants)

Physical Exam

• Usually, no specific positive findings on exam.
• Evaluate for possible signs of sleep apnea: obesity, large neck circumference, nasal obstruction, enlarged tonsils, tongue
• Full physical should be performed, including a neurological examination

Insomnia Differentials

• Primary insomnia
• No identifiable etiology appreciated
• Secondary or acute insomnia
• Acute distress such as grief reaction
• Depression and all psychiatric disorders
• Sleep apnea
• Daytime fatigue, snoring
• Medical conditions (Hyperthyroidism, Nocturia, Chronic pain), and Medications

Treatment

• Determine and treat primary underlying cause
• Psychological therapy:
• Helpful for any type of insomnia
• Sleep hygiene counseling with BHOP or MH
• Cognitive Behavioral Therapy by a licensed provider MH frequently recommends CBTi App to help address insomnia

Medical Therapy

• Zolpidem IR (use minimum effective dosage)
  • Female initial dosage: 5 mg, max 10mg
  • Male initial dosage: 5-10 mg, max 10mg - May dispense 5 tabs maximum

Sleep Hygiene

• Go to bed only when sleepy
• Use bedroom only for sleeping and sex (don't read, watch TV, eat, etc.)
• if still awake after 20 minutes, leave, and return when sleepy
• Avoid caffeine/nicotine/alcohol/nighttime fluids too close to bedtime
• Daily exercise (at least 6 hours BEFORE bedtime
• Relaxation techniques + bedtime ritual
• Follow-up Actions: Return for further evaluation if symptoms do not improve within 1 month - SI/HI precautions: call 911, proceed to the ER, or tell supervisor immediately if having thoughts of

Alcohol Use Disorder

• Pattern of alcohol use that typically includes craving and signs of tolerance and or/withdrawal + adverse psychosocial consequences
• CDC defines it as 12 oz. beer, 8 oz. malt liquor, 5 oz. wine, or 1.3 oz. "shot"

Criteria for diagnosing Alcohol Use Disorder (DSM -5)

Criteria per DSM -5 (≥ 2 of the following over a 12-month period):

1. Physical dependence as manifested by evidence of withdrawal
2. Tolerance to alcohol
3. Continued use despite evidence of alcohol-associated physical or mental illnesses, such as alcoholic liver disease, cerebellar degeneration, delirium tremens, etc.
4. Continued use despite recurrent medical and/or social problems and life disruptions
5. Impairment in social and/or occupational functioning -This list is not exhaustive

Alcohol Use Differentials

• Anxiety disorders
• Bipolar disorder
• Depression or Persistent Depressive Disorder
• PTSD
• Insomnia
• Panic or social phobia Alcohol withdrawal could also be mistaken for other sedative withdrawals (benzodiazepines)

Alcohol Use - Signs and Symptoms

• Signs and Symptoms:
• Intoxication: drowsiness, errors of commission, disinhibition, dysarthria
• Overdose: respiratory depression, stupor
• Withdrawal: --Mild withdrawal: 8 hours after the last drink, tremors, anxiety, weakness, headache, nausea, and vomiting
• Withdrawal Cont: -Delirium tremens: may occur in the first 24-72 hours Acute psychosis with mental confusion, tremor, sensory hyperacuity, visual hallucinations (bugs are common), diaphoresis, dehydration, electrolyte disturbances, seizures, cardiovascular abnormalities

Diagnosing and assessing Alcohol Use, treatment, and follow up

Physical Exam

• Physical findings of Alcohol Use includes: Chronic findings: Dupuytren's contractures of palmar fascia, vascular spiders, signs of hypogonadism and feminization in men (gynecomastia, testicular atrophy
• Intoxication: drowsiness, psychomotor dysfunction, dysarthria, ataxia, nystagmus.
• Mild Withdrawal (8 hours after last drink): elevated vital signs, tremor, sweating, hyperreflexia
• Seizures (24-72 hours after last drink)
• Delirium tremens (24-72 hours after last drink in severe withdrawal) -Autonomic liability: tachycardia, increased temperature -Marked tremors and ataxia
• Overdose: Loss of consciousness
  • Arrhythmias
• Respiratory depression Seizures, coma, & deaths

Focused History

• SIGECAPS questionnaire
• Family history of Alcohol Use Disorder or other psychiatric disorder
• CAGE questions:
• C: have you ever felt the need to Cut down on your drinking?
• A: have people Annoyed you by criticizing your drinking?
• G: have you ever felt Guilty about your drinking?
• Specifically ask about the amount and frequency of alcohol Patient may say they have a beer or two a night. - Patient may say they have a beer or two a night. Get them to specify- size of the beer,(oz.), exactly how many and how often, etc.

Diagnostics

• Consider co morbid disorders
• Anxiety disorders
• Bipolar disorder -Depression or Persistent Depressive Disorder -PTSD -Insomnia -Panic or social phobia

Treatment and Followup

Treatment Includes:

• Psychic Referral
• Psychological counseling Social support (AA) -Stabilize Withdrawal - (Benzodiazepines (IV only for very severe withdrawal symptoms- Evac or transfer

Followup

Ensure -

• Encourage compliance with all medical recommendations
• Safety (SI/HI) Ensure RED DIRECTIVE - Immediate Evacuation CONTACT PREDATOR

Drug Overdoses

Overdose causes

Opioids - CNS and sympathetic outflows Benzo CNS depressants Stim CNS activators - (amphetamines)

Symptoms

• Signs of physical Exam
• Vital Signs are all affected because, after OD the rate of the pt changes: -Physical Exam- Opioid overdose Decreased respiratory rate and pinpoint pupils, pulmonary edema, coma, and death. -Physical Exam- Benzo - respiratory depression, stupor shock syndome, coma and death -Physical Exam- Stim OD = Cardiovascular collapse, hypertension and taci, Hypertermia, seizures, arrhythmias, and death

Diagnosing

• Consider co-morbod
• Anxiety Bipolar disorder
• Persistant depressive or PTSD
• Panic
  • Alcohol and other sedative w/ Draws

Treatment

MISUSE

• UTILIZE MENTAL HEALTH RESOURCES TO TAPER SAFE

OVERDOSE

• EVAC or Transfer
• Meds: Opioids IV/IM/intranasal naloxone Benzo - IV flumazenil ( Controversial) STIM - IV

Eating Disorders

Eating habits and the body are drastically changing from the normal or previously known baseline for one and are altered enough to cause personal life concerns. Examples include:

• Anorexia and Bulimia Nevosa*
• Body shape dismorphiea: -Body weight can be 15% below expected
• Bulimia Nervosa Recurrent episodes of binge eating followed by inappropriate exercise and poor diets
• -Depression and/ or anxiety may be displayed or in the background
• ---Signs will present on the upper class Female

The Physical signs

• Anorexia
• Brady cardia & HOTNia, Thermia -Loss of body fat, dry- scaly skin and lanugo body hair with:
• Bulimia Dental and parotid gland inflammation and issues

Focused history

• Harm to self of others ( SI/HI issues) -Use the Sigcaps

Differentials (DDx)

Ddx - -Other Endo and Metabolic disorders tumors and Type I DM Sub Abuse of amphetamines

Treatment goals:

Stabilize the patient via: Behavioral and psychological management and the patient will then proceed for medication ( to proceed a evaluation is then required followed by EVAC / TRANSFER to MENTAL HEALTH RESOURCES )

Followups:

Follow the RED DIRECTIVE that: 100/call 91/ SUPERVISOR