Transcript The Anxiety Disorders Some Practical Questions & Answers

The Attention Deficit Hyperactivity
Disorder (ADHD) Patient
A Patient-Centered, Evidence-Based Diagnostic and
Treatment Process1,2,3
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DFAPA
September 17, 2010
I intend to offer practical information you can use in your work with patients tomorrow.
let me know whether I succeeded on your evaluation forms.
3Please stop me in the hall, contact me on Facebook or email me with any questions or suggestions for improvement.
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2Please
Why is this important?
• Around 5% of young children
and 4% of adults struggle with
ADHD.
• These patients are impaired (in
at least two settings) from
inattention, hyperactivity or
impulsivity.
• These children and adults
underperform, and they place
great demands on their
families, teachers and
coworkers.
• ADHD and its treatment are
controversial, but early
recognition and successful
treatment can make a huge
difference in these sufferer’s
lives—and in the lives of those
closest to them.
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Refer to the presentation notes for additional information.
• After listening to this
presentation, you will be able to
answer the following questions:
– Why is this important?
– How do these patients
present?
– What are the diagnostic
criteria?
– What is the differential
diagnosis?
– What is the treatment?
– What are some of the
treatment challenges?1
How do these (adult) patients
present?1
• “I’m frustrated with
myself.”
• “I can’t get anything
done.”
• “I just can’t stay
focused.”
• “I can’t finish
anything.”
• “I’ve been this way
my whole life.”
• “I thought this was
just my personality.”
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Here are a few patient stories on YouTube.
• “My brother acts the
same way, and the
doctor started him on
some medication that
he says has really
helped.”
• “I lose important stuff
all the time.”
• “My boss tells me I
have to pay attention;
I try but my mind just
wanders.”
What are the diagnostic criteria?1,2,3
• Attention Deficit
– Often fails to pay
attention to details
– Often cannot sustain
attention
– Often does not appear to
listen
– Often does not follow
through
– Often disorganized
– Often avoids tasks that
require sustained
attention
– Often is easily distracted
– Often forgetful
• Hyperactivity or
Impulsivity
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Often fidgets
Often leaves seat
Often appears restless
Often has difficulty in
engaging in leisure
activities quietly
– Often “on the go”
– Often has trouble waiting
turn
– Often interrupts or
intrudes
Some symptoms must be present before age 7.
must be evidence of significant impairment.
3These symptoms must not be better accounted for by another mental disorder.
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2There
What is the differential diagnosis?1,2
• Normal behavior
• Pervasive Developmental
Disorder
• Schizophrenia
• Another Psychotic Disorder
• Mood Disorder
• Anxiety Disorder
• Dissociative Disorder
• Personality Disorder
• Intoxication
• Withdrawal
1Patients
2A
come in with whatever disorder is currently being discussed in what they are watching and reading.
tenured professor came in to see me for his “learning disability.”
What is the treatment?
• Medication
– CNS stimulants are the first
treatments of choice.
– Once-a-day dosing is
preferred for obvious reasons.
– These drugs are usually safe
and effective.
– Common side effects include
• Decreased appetite
• Insomnia
• Headache
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• Psychotherapy
– Obtain a careful history from
the patient and social
networks.1,2
– Provide practical education.
– Stress that medication alone
is usually not sufficient.
– Suggest social skills training
for children.
– Explore the child’s feelings.
– Recommend parental
training.
– Suggest the design and
implementation of a
reasonable structure.
– Recommend reputable selfhelp groups.
– Use the Internet.
I depend a great deal on the reports of family members.
asked a wife to send in a list of exactly what behaviors had improved on medication.
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What are some of the treatment
challenges?
• Parents (and adult) patients can be demanding of
a miracle cure.
• A dispassionate comparative history may be
difficult to obtain.
• Unrealistic expectations for a pill fix are common.
• The temptation to prescribe too quickly is great. 1
• The effect of advertizing on the public is great.
• Anti-medication advocates may put the child’s
learning at risk.
• This disorder is often used as an excuse for bad
behavior; some will expect you to collude in this
fraud.
• As always, motivation—or the lack of it—is a key
factor in how things turn out.
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A man came in requesting that I change his antidepressant to the one his daughter was selling.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have
made.
Reassure me.
Outline your recommended treatment
plan while making sure that I
understand.
Repeatedly invite my clarifying
questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any
additional questions I may have.
Make a follow up appointment.
Communicate with my other
physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical
Psychiatry, Third Edition, 20081
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of
Neurology, April 20072
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry
Clerkship, Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and
Review, Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the
Brain, January 2008
Median, John, Brain Rules: 12 Principles for Surviving and Thriving
at Home, Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Jacobson and Jacobson, Psychiatric Secrets, 2nd Edition, 2001
Where can you find evidence-based
information about mental disorders?1
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties
of your choice here.
Subscribe to Evidence-Based Mental Health and search a database at
the National Registry of Evidence-Based Programs and Practices
maintained by the Substance Abuse and Mental Health Services
Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Sarah Ann Flaherty, DO
OUCOM 2003
www.somc.org
Jason Cheatham, DO
OUCOM 2002
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