Transcript MAPS-O - Virginia Commonwealth University

PIPC® Psychiatry In Primary Care
Educational System
Robert K. Schneider, MD
Departments of Psychiatry, Internal Medicine
and Family Practice
The Medical College of Virginia at
the Virginia Commonwealth University
Richmond, Virginia
“de facto mental health system”
Regier,1978
• 54% of people with mental illness who
seek treatment are exclusively seen in
the “general medical sector”
• 25% of patients in primary care setting
have a diagnosable mental illness
Why Now?
• Great scientific evidence
– Genetic basis for disease
• Twin studies and Human Genome Project
– Neuroscience Research
• CT to MRI to PET to SPECT scanning
• Neurotransmitter basic science
• Somatic Therapies
– Psychiatric Medication Explosion (“SSRI
Surge”)
• Economic pressures (Managed Care)
Perspective
• Psychiatry
Mental illness of sufficient severity that when
treated appropriately symptoms abate
• Mental Health
Psychological aspects of all health issues
• Behavioral Health
Broadest category that pertains to all behaviors
in all disease and health states
PIPC® Goals
• Effectively recognize, diagnose and
treat mental illness in primary care
• Bring the skills and knowledge
base in psychiatry of the primary
care physician on par with other
medical specialty knowledge bases
Hypothesis Driven Interview
• Notice cues from patient
• Collect target symptoms
• Develop differential diagnosis
–pattern recognition
• Ask further questions to rule in
or rule out
Example: Chest Pain
• Target symptoms
– Chest pain, Shortness of Breath
• Differential diagnosis
– Cardiac (ischemic, valvular, cardiomyopathy)
– GI (esophageal spasm, PUD)
– Pulmonary (COPD, pleurisy, pneumonia)
– Musculoskeletal (intercostal spasm, rib fx)
– Panic Attacks
• Further questions
– Age, onset, associated symptoms, etc…..
Example: Depression
• Target symptoms:
– Poor sleep, fatigue, isolation (no enjoyment)
• Differential diagnosis:
– Major Depression (single episode vs recurrent)
– Dysthymia (2 year history)
– Bipolar (mania/hypomania)
– Substance induced mood disorder (mood
during periods of abstinence)
• Further questions:
– Age, onset, associated symptoms, etc…
How can a primary care doc
make a reasonable psychiatric
differential diagnosis?
Schizophrenia
Depression
Panic Disorder
Personality Disorder
Dysthymia
Dementia
Posttraumatic Stress Disorder
Agoraphobia
Bipolar Disorder
Generalized Anxiety Disorder
ADHD
Substance Abuse
Psychosis
Anxiety
Obsessive Compulsive Disorder
Specific Phobia
Mania
Eating Disorders
Somatization Disorder
Schizoaffective Disorder
Panic Attacks
Social Phobia
Mood
Anxiety
Psychosis
Substances
Other
MAPS-O®
• Organizes psychiatric knowledge like other
specialties
• Most prevalent disorders in primary care
• Organized by “organ system” approach
• Makes psychiatric knowledge assessable
• Creates a foundation for the PIPC Interview
Mood Disorders
• Major Depression
– Single episode
– Recurrent
• Dysthymia
• “Double” Depression
• Bipolar Disorder
– Mania
– Hypomania
• Psychotic Depression
Mood Disorders
• Major Depression
– Single episode
– Recurrent
• Dysthymia
• “Double” Depression
• Bipolar Disorder
– Mania
– Hypomania
• Psychotic Depression
Major Depression –
Case Finding Questions:
• Have you been feeling sad, blue or
depressed?
• Have you lost interest in or do you
get less pleasure from the things
you used to enjoy?
Major Depression –
Criteria:
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Weight change
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue
Excessive guilt
Decreased concentration
Hopeless
Recurrent thoughts of death or suicide
Mood Disorders
• Major Depression
– Single episode
– Recurrent
• Dysthymia
• “Double” Depression
• Bipolar Disorder
– Mania
– Hypomania
• Psychotic Depression
Mood Disorders –
Dysthymia: Criteria
• Depressed mood for most of the day,
for more days than not, for at least two
years.
–No episodes of major depression
during the last 2 years
–Symptoms have not gone away for
more than 2 months at a time
–Depressed plus 2 symptoms
Dysthymia –
Questions:
• Same as major depression
• Longitudinal course and symptom
density is the focus of questions
DOUBLE DEPRESSION
NORMAL
MOOD
DYSTHYMIA
2+ years
5-8
DEPRESSION
PARTIAL RECOVERY
6 - 24 months
Stahl S M, Essential
Psychopharmacology (2000)
Mood Disorders
• Major Depression
– Single episode
– Recurrent
• Dysthymia
• “Double” Depression
• Bipolar Disorder
–Mania
–Hypomania
• Psychotic Depression
Mood Disorders –
Mania and Hypomania
Mania
Distinct period of abnormally and
persistently elevated, expansive or
irritable mood, lasting at least one week.
Hypomania
Like mania but less and lasts throughout
at least 4 days. Clearly different from the
usual nondepressed mood.
Mania and HypomaniaQuestions:
• Have there been times, lasting at least a
few days when you felt the opposite of
depressed, that is when you were very
cheerful or high and felt different than
your normal self?
• Did anyone notice there was something
different?
5 Anxiety Disorders
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Generalized Anxiety Disorder
Panic Disorder
Posttraumatic Stress Disorder
Obsessive Compulsive Disorder
Phobias
– Specific
– Social
Anxiety Disorders
• Generalized Anxiety Disorder
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Panic Disorder
Posttraumatic Stress Disorder
Obsessive Compulsive Disorder
Phobias
– Specific
– Social
Generalized Anxiety Disorder
GAD
• Excessive anxiety for 6 months (more days than not)
Difficult to control the worry (a “worrier”)
• Associated with 3 or more of the following:
– Restlessness
– Easily fatigued
– Difficulty concentrating
– Irritability
– Muscle tension
– Sleep disturbance (initial insomnia, fragmented)
GAD –
Screening Questions
• Have you frequently been worried or
anxious about a number of things in
your daily life?
–Do people say you worry about things too
much?
–Do you think your anxiety is unrealistic or
excessive?
• Is it hard for you to control or stop your
worrying?
Anxiety Disorders
• Generalized Anxiety Disorder
• Panic Disorder
• Posttraumatic Stress Disorder
• Obsessive Compulsive Disorder
• Phobias
– Specific
– Social
Panic Attack: 4 or more
Fear of Dying
Sweating
Trembling
SOB
Paresthesias
Chest Pain
Fear of Losing Control
Derealization
Nausea
Choking feeling
Hot flashes
Panic “Attack”
• Do you have episodes (spells) where it
comes at once; the fear (anxiety) and
physical symptoms (choking, chest pain)?
• Often they last only 10 –15 minutes?
• Are they associated with anything or do
they come out of the blue?
• Do you get anxious when you anticipate the
possibility of a panic attack?
Panic Attack  Panic Disorder
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Major Depression
GAD
Panic Disorder
PTSD
OCD
Phobias
Substance Induced
(Intoxication and Withdrawal)
Panic Disorder –
Screening Questions:
• Have you had sudden rushes of intense
fear, anxiety, or discomfort that come on
from out of the blue for no apparent reason
or in situations where you did not expect
them to occur?
• Do you worry a lot about having more of
them?
• Have you changed your behavior since
these attacks began?
Anxiety Disorders
• Generalized Anxiety Disorder
• Panic Disorder
• Posttraumatic Stress Disorder
• Obsessive Compulsive Disorder
• Phobias
– Specific
– Social
Posttraumatic Stress Disorder
PTSD
• Common following life-threatening or
overwhelming experiences
• The person’s response involved intense
fear, helplessness or horror
• Most common “trauma” is the sudden
death of a loved one
• A “civilian” disorder
Symptoms
• Re-experience the trauma
– Flashbacks, Nightmares,Intrusive thoughts
– Intense reaction when exposed to “triggers”
• Avoidance or Numbing
– Avoidance of associated thoughts, feelings, activities,
or places.
– Detachment, restricted range of affect
• Hyperarousal
– Sleep problems, Irritability, Hypervigilance
– Exaggerated startle
PTSD – Stressor Criteria
Screening Questions:
• Have you ever seen or experienced a
traumatic event in which your life was
actually in danger or you thought your
life was in danger?
• How did you react to the trauma?
– Were you frightened or horrified?
– Did you feel helpless and out of control?
PTSD Screening Questions:
• Do memories about the [ ] still bother
you?
• Do you try to block out thoughts or
feelings related to the [ ]?
• Since the trauma have you…
– .. had problems sleeping?
– …been more irritable?
– ….been on the alert?
– …..easily startled?
Anxiety Disorders
• Generalized Anxiety Disorder
• Panic Disorder
• Posttraumatic Stress Disorder
• Obsessive Compulsive Disorder
• Phobias
– Specific
– Social
Obsessive Compulsive Disorder
OCD
Obsessions:
persistent ideas, thoughts, impulses, or
images that are experienced as intrusive,
inappropriate, and increase anxiety
Compulsions:
repetitive behaviors or mental acts that are
aimed at preventing or reducing anxiety
and distress caused by the obsessions
Obsessive Compulsive Disorder
OCD
• Patients are often secretive about
this and have increased shame.
• Starts early in life, adolescence or
early adulthood.
Obsessive Compulsive Disorder
OCD
• Do you have thoughts that you obsess
on and find hard to control?
– Contamination, germs
– Sex
• Do you have rituals that you do over and
over again that are difficult to control?
– Counting
– Washing
– Checking
Anxiety Disorders
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Generalized Anxiety Disorder
Panic Disorder
Posttraumatic Stress Disorder
Obsessive Compulsive Disorder
• Phobias
–Specific
–Social
Social Phobia Screening Questions:
• Fear of embarrassment, and social interaction
• Some people have very strong fears of
being watched or evaluated by others.
Do you worry that you might do or way
something that would embarrass you in
front of others, or that other people might
think badly of you?
• …what about the situation bothers you?
Specific Phobias
Health care-related phobias
• Examples of health care-related phobias
– needles
– the sight of blood or open wounds
– pain
– anesthesia
– dental procedures
• Effectively treated with systematic
desensitization
Psychotic Disorders
• Schizophrenia
• Schizoaffective Disorder
Screening Questions:
Psychotic Disorders
• Does your mind play tricks on you?
• Do you hear or see things others don’t,
that are difficult to explain?
• Do you have experiences that are hard
to explain?
Substance Induced
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Caffeine
OTC
Herbs
Alcohol
Cocaine
MJ
Heroin
Prescription Drugs
Screening Questions:
Substance Abuse
Remember:
Ask about ALL psychoactive
substances, not just ones of abuse.
– Caffeine
– Herbals
– Nonprescription drugs
Other
• “Organic”
– Dementia
– TBI
– HIV
• Other Psych
– Personality Disorders
– Somatization
– ADHD
Screening Questions:
Other – “Organic”
• Have you or others noticed any
changes in your memory?
• Have you ever had an injury where you
have lost consciousness?
• High risk behaviors that may increase
your risk of HIV infection?
• Always review the list of medications.
Screening Questions:
Other Psych
• Have you ever received treatment for
your nerves or a psychiatric condition?
• Has anyone in your family?
• Should anyone have received treatment
and didn’t?
• Questions specific to the “other”
psychiatric diagnosis
PIPC® Psychiatry In Primary Care
Wrap-up
Robert K. Schneider, MD
Departments of Psychiatry, Internal Medicine
and Family Practice
The Medical College of Virginia at
the Virginia Commonwealth University
Richmond, Virginia
SP Cases Wrap-up
• Dysthymia, Major Depression
(“Double Depression”) and PTSD
• GAD, Psychoactive substance use
(EtOH abuse/dependence)
–Effective?
–Problems?
–Changes in the cases?
3 Parts of ANY Interview
HELLO
DATA GATHERING
NEGOTIATION
INTRODUCTIONS
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PURPOSE OF VISIT
STRUCTURE OF VISIT
FOCUSED OPEN-ENDED QUESTION
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TARGET SYMPTOMS (CUES)
HYPOTHESES (MAPS-O©)
G
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CASE FINDING QUESTIONS
DIAGNOSTIC CRITERIA (DSM-IV)
Comorbidities (ROS)
DIAGNOSIS
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TREATMENTS
PATIENT PREFERENCE
DIAGNOSIS & TREATMENT CHOICE
How can a primary care doc
make a reasonable psychiatric
differential diagnosis?
Schizophrenia
Depression
Panic Disorder
Personality Disorder
Dysthymia
Dementia
Posttraumatic Stress Disorder
Agoraphobia
Bipolar Disorder
Generalized Anxiety Disorder
ADHD
Substance Abuse
Psychosis
Anxiety
Obsessive Compulsive Disorder
Specific Phobia
Mania
Eating Disorders
Somatization Disorder
Schizoaffective Disorder
Panic Attacks
Social Phobia
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Major Depression, Dysthymia,
Bipolar Disorder
MAPS-O®
Mood Disorders
Anxiety Disorders
GAD, Panic Disorder, PTSD,
OCD, Phobias (Social/Specific)
Psychotic Disorders
Substance Abuse
Other
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Schizophrenia, Schizoaffective
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
Alcohol, Cocaine, Nicotine,
Other Psychoactive Substances
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
“Organic”:
Stroke, Dementia, HIV, TBI
Other Psych:
Personality Disorders, ADHD,
Somatization,Eating Disorders
Mood
Anxiety
Psychosis
Substances
Other