Behavioral Health Exam 1 Study Guide PDF

Behavioral Health Exam 1 Study Guide (what is in red is what the previous class made red, not me) Introduction ​ Mental disorders defined by DSM 5 o​ Clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunctio...

Behavioral Health Exam 1 Study Guide (what is in red is what the previous class made red, not me) Introduction ​ Mental disorders defined by DSM 5 o​ Clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning o​ Associated with significant distress or disability in social, occupation, or other important activities ​ Leading cause of psychiatric disability in the world (Class Q) o​ Depression is the leading cause of disability worldwide, and is a major contributor to the global burden of disease ​ Majority of mental illness begins by what age (Class Q) o​ 24 ​ 1 in 5 US adults experience mental illness (Highlighted Stat) ​ ½ of chronic mental illness by age 14, ¾ by age 24 (Highlighted Stat) ​ 19% of common mental illnesses are anxiety disorders (Highlighted Stat) ​ 32% of adults who report mental illness are mixed/multiracial (Highlighted Stat) ​ LGBTQ diagnosis of psychiatric illness compared to the general population o​ LGBTQ individuals are 2 or more times more likely as straight individuals to have a mental health condition (Class Q) o​ LGBTQ youth are 2 - 3 times more likely to attempt suicide than heterosexual youth (We don’t have this) o​ 11% of transgender individuals reported being denied care by mental health clinics (we don’t have this) o​ 44% of lesbian, gay, and bisexual adults report mental illness (Highlighted Stat) o​ Lesbian, Gay, bisexual group has highest prevalence of mental illness (Class Q) o​ 42% of LGBTQ youth seriously considered attempting suicide, including >50% of transgender and nonbinary youth (Highlighted Stat) ​ Potential problems with using DSM 5 o​ Pathologizes normal, expected behavior ▪​ Disruptive mood disorder (temper tantrum vs. mental disorder) ▪​ Normal grief vs. major depressive disorder ▪​ Minor neurocognitive disorder vs. mild cognitive impairment ▪​ Binge eating vs. enjoying food ▪​ GAD vs. worries of everyday life o​ Encouraging Medication use w/ pressure from pharmaceutical companies ▪​ Misuse of stimulants in ADD o​ Under-diagnosing ▪​ New definition of autism lead to funding loss d/t less people being dx o​ Over-diagnosing ▪​ Possible inflation of PTSD in court o​ The DSM era has not deceased large-scale reduction in the morbidity associated w/ major mental disorders (cardiovascular disease, colon cancer, chronic respiratory disease)​  7. Chronic substance abusers lumped with one time drug user​ 8. Behavioral addiction dx overused ​ Specifiers in the DSM 5 o​ Syntonic vs. Dystonic ▪​ Ego syntonic vs dystonic definition ​ Syntonic: heavily defensive, rationalized behaviors and no motivation to change, angry about being told what to do, resign to his/her fate, sees benefits in current behaviors, lacks insight into the condition-typical for children, resistant to therapy/treatment and often has to be motivated to do so o​ Pt doesn’t think there is a problem ​ Dystonic: experience significant distress, disability or impairment in functioning. Has no capacity to cope with the condition at the current time. Is motivated for treatment/therapy to improve the situation and condition o​ Pt knows there is a problem ​ Good/fair insight = Dystonic ​ Poor insight = ambivalence ​ Absent insight = syntonic ▪​ A mental health pt who is ego dystonic is more likely to: Be motivated for treatment/therapy (Class Q) o​ Correlated Disorders and Suicide Risk: each diagnosis will comment of correlation among disorders o​ Respect for age, gender, and culture: each diagnosis will incorporate developmental symptom manifestation, gender specific disorders, cultural sensitivity in regard to certain behaviors ▪​ Cultural Formulation Review (CFI): way to interact w/ people culturally ​ Exploring the pts way of being in the world (religion, culture, preferences) o​ Severity Index Across Time & Circumstances: time and circumstances essential specifiers, will assure that individual does qualify for mental disorder from definition. Severity ranges are mild, moderate, severe, in partial remission, in full remission, *prior history ▪​ Coding Specifiers: F31.9 = Unspecified (He put this in red?) Psychiatric History ​ Pacing the Interview o​ Convey collaboration, free expression, trust, and self-exploration o​ Interviewer should be relaxed, receptive, NOT preoccupied, rushed, abrupt, or irritable ​ Normalizing o​ Introduce topic by first making a statement that the behavior is a normal, or understandable, response to a mood or situation o​ Decreases pts shame about certain thoughts + behaviors o​ Use scripts to normalize: suicidal ideation, substance abuse (overestimate amount of drug use), depression, hallucinations ​ Emotive o​ Create space (container) for emotions and be with them and the pt o​ Allow time for pt to cry, be angry, sad  o​ NOT time for you to express emotions ​ Safety o​ Always keep a path open you should be between the door and the pt o​ Watch for escalation + know when to leave ​ RESPECTFULL Model o​ Religious/spiritual identity o​ Economic class/background o​ Sexual Identity / Safety (must always include abuse in SOAP) o​ Psychological maturity o​ Ethnic/ Cultural/ Racial ID o​ Chronological / developmental Challenges o​ Trauma and threats to well being o​ Family history o​ Unique physical characteristics (tattoos, scars) o​ Location of residence o​ Language differences ​ HPI (use OLDCARTS) ​ Past Psychiatric History o​ Anything not described in HPI o​ Tx interventions (hospitalizations, Baker Acts, suicide attempts) ​ Family History o​ Psychiatric + substance abuse in relative o​ Abuse/domestic violence hx (present and past) o​ Pertinent medical conditions (CAD can cause depression) ​ History of Substance Use or Abuse o​ Use = experimental, low frequency use o​ Abuse = regular / compulsive use (includes caffeine and nicotine) o​ Current substance use can be in HPI ​ Social History o​ Occupation, military (very important), legal history/incarcerations, relationships, religion, pets, libido, appetite, activity (ADLs, socializing, exercise), sleep ​ Mental Status Exam (MSE) aka Psychiatric Exam vs Mini Mental Status Exam (MMSE) o​ MSE is psychological equivalent of a PE (describes mental state + behaviors) o​ MMSE screens pt for cognitive impairment, including dementia ​ MSE ABC STAMPLICKER o​ Appearance ▪​ physical characteristics of the patient: attire + grooming, eye contact, physical characteristics, facial expression (Sad, happy, flat) ▪​ attentiveness ▪​ position + posture o​ Behavior ▪​ Level and quality of pts physical/motor movement  ▪​ Fidgeting, voluntary movements, involuntary movements, pacing o​ Cooperation ▪​ Attitude, pts approach to interview + interaction w/ examiner + staff ▪​ Friendly, uncooperative, hostile, arrogant, guarded, etc. o​ Speech ▪​ Quantity (hyperverbal vs poverty of speech (Alogia- not talking a lot) vs poverty of content (many words, little info) ▪​ Rate (normal vs slow vs rapid) ▪​ Intonation, tone, stress, rhythm, audible ▪​ Pressured speech = can’t get words out fast enough ▪​ Echolalia = repeating, only able to repeat question and not able to answer ▪​ Word salad = nonsensical combo of words ▪​ Blocking = stops talking ▪​ Neologisms = made up words, usually non-sensical and unrecognizable o​ Thought Processes/ content ▪​ Relevant, organized, coherent ▪​ Linear/goal directed ▪​ Obsessions (Distressing, obtrusive thoughts) ▪​ Ruminations (over contemplating to solve a problem) ▪​ Compulsions (Actions) ▪​ Phobias/anxieties ▪​ Can also include hallucinations and delusions ▪​ Confabulations = memory disturbance, person confuses imagined scenarios w/ actual memories w/ NO intent to deceive ▪​ Circumstantial = includes many irrelevant details and frequent diversions, but remains focused on broad topic ▪​ Tangential = moves from thought to thought but never gets to main point. Connection from one thought to the next ▪​ Flight of ideas = rapid movements from one subject to another. Loose connections ▪​ Perseveration = continues talking about topic even when the conversation has moved on ▪​ Clanging = groups of (usually rhyming) words that are based on similar-sounding sounds even though words don’t have logical connection o​ Affect ▪​ The way the pt is at that moment, how the pt presents their emotional state, how they appear to feel ▪​ Appropriate, inappropriate, Constricted, blunted, flat (nothing), labile (rapid change in emotion), incongruent o​ Mood ▪​ How they usually are/baseline, how they feel ▪​ Depressed, euthymic (everything’s fine), anger, anxious, dysphoria, elevate, irritable, impatient, cheerful, emotionless (alexithymia – I don’t feel anything) o​ Perceptions ▪​ Healthy – based in reality ▪​ Abnormal = hallucinations, illusions, delusions, derealization/depersonalization  ​ Delusions = rigid belief in something that is likely not true (grandiose, persecutory, jealous, somatic, erotomanic, mixed) ​ Depersonalization = you don’t feel real ​ Derealization – everything outside the person seems unreal o​ Level of Consciousness ▪​ Alertness, Lethargy, Obtundation, Stupor, Coma o​ Insight and Judgement ▪​ Insight = ability to be self-aware + understand one’s condition ▪​ Judgement = process of considering and formulating a decision or action and intended/ expected consequences/outcomes o​ Cognitive Functions ▪​ orientation, conception/language, attention and concentration (spell WORLD backwards), registration and short-term memory, long term memory, constructional and visuospatial ability, abstraction and conceptualization o​ Knowledge fund/base ▪​ Amount of general info an individual stores in their long-term memory ▪​ Ask about something they know o​ Endings (Suicidal/Homicidal) ▪​ “Are you thinking about hurting yourself or someone else?” ▪​ Previous attempts, weapons in the home or other means o​ Reliability ▪​ Ability to state accurate medical/psychosocial history ​ Important Miscellaneous History o​ Coping mechanisms, values/ideal, aspirations ​ Class Q o​ What part of cognition is tested by asking the pt to spell world backwards? (concentration) o​ Which of these describes an obsession? (Need for symmetry) o​ You ask a pt if they use an illicit drug and they say “Drugs are an interesting thing. There are so many drugs from A-Z, and I bet aardvarks and zebras don’t take any and neither do I”. This is an example of: (circumstantial) o​ A person who hears voices telling him to “go find fire under the house” is having: (hallucination) o​ What part of cognition is tested by asking pt to explain “a stitch in time saves nine”? (abstraction) o​ How would yfou assess a patients fund of knowledge? (ask the pt how to drive a car) o​ You ask a pt why they think they are having visual hallucinations and they answer it is bc the aliens are broadcasting into their brain. This is an example of: (poor insight) ​ What is the greatest predictor of suicide? o​ Previous suicide attempt Psychotherapy, Cognitive Behavioral Therapy, Group Therapy ​ Multidisciplinary VS Interdisciplinary Care (*know diff.) o​ Multidisciplinary = intentional communication btwn a variety of healthcare providers to support pt health and safety.  o​ Participants include direct care providers + the patient. Sometimes case manager closes the loop. o​ Most commonly outpatient care o​ Interdisciplinary = intentional care planning by a team of healthcare providers. o​ Include psychiatrists, psychologists, counselors, RNs, PAs, social worker/case manager and the patient and family. Loop is closed through discussion, feedback, agreement. o​ Commonly inpatient/residential care ​ Which is best: meds, therapy, or both o​ Always both! o​ Medications reduce/resolve symptoms o​ Therapy is a healing process that assists individuals to understand themselves and develop skills toward improving pt and family mental health ​ Therapeutic Interventions o​ Evidence Based Therapy o​ Respective, non-coercive, non-abusive, pts/clients best interest o​ Individual Therapies (focuses on trusting relationship btwn patient/client and a therapist) o​ Psychoanalytic ​ Involves talking more about how a patient’s past, influences what happens in the present and the choices they make ​ Lasts longer than CBT and counseling, sessions are usually an hour long ​ Advantages: Explores early life experiences: childhood, parental relationships, Acknowledges the role of the unconscious: “Freudian slips,” dream analysis, free association, Rorschach test ​ Disadvantages: Takes many months-years, expensive. Inappropriate for: actively psychotic patients, patients with poor insight, limited by finances and insurance benefits o​ Brief Insight-Oriented Psychotherapy ​ Short-term: 10-40 sessions for a period of usually 1 year ​ Goal: develop insight into issues and conflicts which will then lead to psychological and behavior changes ​ Beneficial treatment for depressed, anxious, or experiencing adjustment reactions to stress ​ Not useful for clients: poor impulse control, borderline personality, substance, antisocial personality o​ Therapy You Can Use- Unconditional Positive Regard ​ Active listening, empathetic, supportive, patient-centered, genuine, eye contact, therapeutic touch ​ Disadvantages: not always appropriate psychosis + paranoia, history of physical/sexual abuse, mania, need for skills training/directions, time consuming, expensive ​ Role Play Practice: When ____ happens, I feel ______. ​ Reframing: Use alt. ways to remember and think about a problem or event o​ Jungian Psychology  ​ Explore and integrate the unconscious to become “Whole” ​ Integration of shadow and projections: shadow = unacceptable aspect, projection = hero worship ​ Uses ritual and symbolism ​ Archetypes: thematic personalities hero, villain, healer, trickster, etc. ​ Disadvantages: same as psychoanalytic o​ Counseling ​ Client encouraged to talk about feelings, works in emoting and finding solutions, not as “past” based as psychoanalytic o​ Behavior Therapies ​ Change or reduce maladaptive behavior/actions (vs examining unconscious conflicts or aspects) ​ Goal: eliminate the behavior (past doesn’t matter) ​ Ex: learned helplessness, behavioral activation for depression (focus on pleasurable activities) ​ Positive reinforcement: pleasant stimulus increases frequency of particular behavior: reward o​ To reinforce behavior, >5 positive to 1 negative ratio ​ Systematic Desensitization or Exposure Therapy o​ For phobias, fears, aversions o​ Training to replace feelings of anxiety w/ feelings of relaxation o​ Cognitive Behavioral Therapy (CBT) ​ The present is more important than the past, how one thinks of an event/situation determines how one feels, which influences behavior ​ Our feelings do not have to be dictated by the event but can be changed by the way we think about our situation. Automatic strong feelings are made aware ​ Thought→Behavior→Emotion all connected ​ Therapy lasts 12-20 weeks, time efficient ​ Used for a variety of disorders: anxiety, insomnia, depression, phobias ​ Effective, sometimes superior to meds ​ Promotes pt autonomy ​ Psychoanalytic Concepts: o​ Transference: patients begin to transfer their feelings of a particular person in their lives to the therapist/provider (patient falls in love with their therapist), feelings could be positive or negative, part of the therapeutic process and therapist facilitates patient “working through” unresolved feelings. You could use the role-playing technique or the “chair technique” to help with this o​ Countertransference: The therapist develops positive or negative feelings toward the patient. Therapist’s unconscious feelings are stirred up during therapy which the therapist directs toward the patient. Therapist starts feeling unhappy with the way therapy is going, or unhappy with themselves. Very common: the therapist seeks “supervision” to process their feelings o​ Resistance: a disruptive response by the client to some topic they find sensitive which is the source or close to the source of anxiety  o​ Example the client might make an off-handed remark or joke, claim they forgot the information, or pick a fight with the therapist o​ The therapist is getting closer to the root of the problem o​ Attachment Theory: quality of a child’s attachment during the formative years affects the quality of relationships throughout life. As the caregiver affects the child, the child also affects the caregiver. o​ Proximity maintenance: wanting to be physically close to the therapist o​ Separation distress: separation anxiety o​ Safe haven: retreating to the therapist when sensing danger/feels anxious o​ Secure base: exploration of the world knowing that the therapist will protect them o​ Dependence, then healthy independence, interdependence, and connection ​ Other Therapies o​ Meditation: paying attention in a particular way, on purpose, being present in the moment. o​ 3 core skills: concentration, sensory clarity, equanimity o​ Mindfulness Meditation is for 8 weeks associated with changes in gray matter concentration in brain regions involved in learning and memory processes. o​ PTSD and MDD associated with decreased density or volume of the hippocampus o​ *helps brain, improves brain function, changes it physiologically o​ Guided imagery + Hypnosis: a suggestion given during a time of receptivity and focused attention, a relaxed-trusting state or given in a stressed state o​ Useful in giving injection or burn patients o​ Disadvantages: painful, distressing memories o​ Avoid in: actively psychotic pts, depersonalization, derealization o​ Spiegel eye roll test for hypnotic susceptibility o​ Metaphors: stories, images, idioms, analogies, which describe a person’s feelings or situation o​ What you don’t say is as important as what you do say o​ Body therapy biofeedback: behavior therapy involving relation and the power of suggestion. Uses biometrics to monitor the patients progress so they know they are accomplishing their goals (migraines, asthma, chronic pain, GI) o​ Talk therapy that is combined with physical “work” (yoga, breathing) o​ Eye Movement Desensitization and Reprocessing (EMDR) o​ Uses eye movements to facilitate brain retraining and reprocessing o​ Bibliotherapy: literature which explains psychological issues and dealing effectively o​ Affirms the patient and their condition and “normalizes,” decreasing a sense of isolation and being “different,” can be done on their own or in conjunction with therapy. Offers solutions, one time cost o​ Family therapy: focuses on the family as a unit, systems theory, development of individual insights and the development of skills to promote communication, empathy, roles, responsibilities and the success of the family unit o​ Role playing, assignments o​ Marriage/ Couples/ Relationship Therapy: to improve communication, identify shared goals, confront concerns honestly, honor individual needs. Develop plans to continue, change, modify, or dissolve the relationship in a respectful manner that reduces harm and collateral damage  o​ Group Therapy: effective for persons dealing with the same issues, being with others who may better understand the problem (drug abuse, loss of loved one), peer support, confrontation, recognizes ineffective behavior and practices effective. Can be topic driven, time limited or ongoing. Focuses on education, skill development, emotional support, support independent and well being ​ Class Q o​ Which therapy should be avoided in psychotic patients? (hypnotherapy) o​ Which therapy is based on systems theory? (family therapy) o​ Changing one’s thoughts and taking different actions are characteristic of which therapy? (cognitive behavioral therapy) Defense Mechanisms ​ Defense Mechanisms o​ Defense Mechanisms: process of thinking and acting developed by the “ego” to protect from physical and/or emotionally painful/dangerous situations ▪​ Can be unconscious or partially conscious (mostly unconscious) ▪​ Automatic ▪​ Used when one is not able to cope/did not learn how o​ What Triggers Defense Mechanisms ▪​ external pressures, tensions with one’s personality, fear of losing respect, other people’s judgment, fear of violence o​ Everyone uses defense mechanisms; they are identified as mature or neurotic/primitive o​ Under duress people tend to use less mature defense mechanisms ​ Coping Mechanisms o​ Conscious and intentional (M&Ms), flexible, health promoting: well-being, quality of life, net reduction of suffering, better able to handle future conflicts, honest, deals with source of anxiety ​ Defense Mechanisms o​ Primitive/Neurotic: ▪​ Affiliation: turn to others for support (healthy), being “right” or superior (unhealthy) ▪​ Acting out: engage in inappropriate behavior without consideration of consequences, usually as a reaction to a situation (unprotected sex, rock and roll persona, unapproved relationships, self-demeaning) ▪​ Autistic fantasy: excessive daydreaming, unwilling /unable to sequester resources to create reality (actor or fantasy). Thinking about doing something but never doing anything to make it happen. ▪​ Compensation: build up other aspects of themselves to adjust for any perceived/real shortcomings (a person who believes that they are not good at sports may throw themselves into studying) ▪​ Compliance: acquiescing to the desires of someone else to “keep the peace” ▪​ Controlling: trying to make a person act/think/feel a certain way (rejected lover homicide, arguing, micromanaging) ▪​ Denial: refuse to acknowledge aspect of reality (HIV/STDS, Alcoholism)  ▪​ Displacement: transfer negative feelings about one object to another (Kicking the dog or spouse) ▪​ Dissociation: lack of connection in a person’s thoughts, memory and sense of identity (Movies, PTSD, severe abuse, driving somewhere and you don’t know how you got there) ▪​ Externalization: blame problems on another (applicants + low grades) ▪​ Intellectualization: rely excessively on details/facts to maintain distance from painful emotion (“a great case”) ▪​ Inhibition: Involuntary decrease or loss of motivation to engage in goal directed activity to prevent arising anxiety from conflicts with “unacceptable” impulses (religious prohibitions against sex, become a lawyer instead of an actor) ▪​ Introjection (or Identification): internalizing the qualities of an object or person. Advertising strategy. (Identify w/ the quality of something else) Can be healthy if quality is integrated. ▪​ Isolation: being alone to avoid uncomfortable feelings and interactions (“I need some down time”) ▪​ Passive-aggressive: indirectly express aggressive feelings/anger towards other (walking in late on purpose) ▪​ Projection: falsely attribute unacceptable feelings to another (falling in love, scapegoat) ▪​ Projection identification: the person accepts and “takes on” the projection of another- positive or negative (“dumb blonde”) ▪​ Rationalization: not getting the job it didn’t pay enough ▪​ Regression: acting like a younger, less mature person (baby talk) ▪​ Repression: expel disturbing thoughts from consciousness, act like something else is going on bc they don’t even know it (repressed memories of sexual abuse) ▪​ Reaction formation: do opposite of what you feel (older sibling becomes loving to younger baby, but wants to kill them/ Helga bullying Arnold even though she likes him) ▪​ Ritual and undoing: superstitious behavior and thoughts (pregame rituals, full moon, “you’re gonna jinx it”, OCD) ▪​ Sexualization: inappropriate imposition of sexuality on a person, through objectification or emphasizing the person’s appearance ▪​ Splitting: “good” or “bad”, no middle ground (politics, Hallmark of Borderline Personality Disorder) o​ Mature (Defense Mechanisms/Coping Skills: ▪​ Oh, I have a healthy SA2SH (usually conscious or somewhat conscious) ​ Objectivity, Integration, Sublimation, Altruism/Anticipation, Suppression, Humor ▪​ Sublimation: channeling of an unacceptable and potentially disruptive impulse, thoughts or emotions, into a socially acceptable behavior. Dealing with emotional stressors by using energy (punching bag to channel anger impulses) ▪​ Altruism: deal with stress or conflict through dedication to meeting others (sponsor in AA, enneagram- need to be needed, volunteer) ▪​ Affiliation: turn to other for support (sports teams)  ▪​ Anticipation: think about and prepare for possible adversity (boy scout motto be prepared) ▪​ Suppression: avoid thinking about a stressor (trauma patient) ▪​ Humor: deal with stress by seeing ironing, dark humor (medical talk) ​ Defense Mechanisms VS Coping o​ Defense Mechanism: what parts of the distressing events, feelings, and “Self” story must be distorted o​ Coping: how the events/feelings can be managed Medical causes of psychiatric illnesses (this is from the previous class) ​ What factors make it more likely for a psychiatric illness to be caused by a physical condition? o​ Cancer; Cancer treatments, including interferon; Cushing syndrome; Dementing illnesses; Huntington disease; Hypothyroidism; Multiple sclerosis; Parkinson disease; SLE; Sleep apnea; Stroke; traumatic brain injury; hypo/hyperglycemia, DM, Electrolyte abnormality, Meningitis, vitamin B12 insufficiency, UTI ​ How would one work up a patient for a medical cause of a psychiatric illness? o​ Thorough H and P: Family history, including (controversial) race/ethnicity, Social history, Environmental exposures; work/hobbies/home; History of abuse/trauma/military experience; Sleep apnea screen: Epworth sleepiness scale