PIPC® P sychiatry I n P rimary C are 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
Dec 16, 2015
PIPC® Psychiatry In Primary Care
Educational SystemRobert 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?
Depression
Posttraumatic Stress Disorder
Mania
Psychosis
Generalized Anxiety Disorder
Somatization Disorder
Dysthymia
Obsessive Compulsive Disorder
Bipolar Disorder
Panic Disorder
Schizophrenia
Panic Attacks
Personality Disorder
Substance Abuse
Social Phobia
Specific PhobiaSchizoaffective Disorder
Eating Disorders
Dementia
ADHD
Anxiety
Agoraphobia
MoodAnxiety
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:• 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
6 - 24 months2+ years
DEPRESSION
NORMAL MOOD
DYSTHYMIA PARTIAL RECOVERY
DOUBLE DEPRESSIONDOUBLE DEPRESSION
5-8 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
ManiaDistinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least one week.
HypomaniaLike mania but less and lasts throughout at least 4 days. Clearly different from the usual nondepressed mood.
Mania and Hypomania-Questions:• 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
• Generalized Anxiety Disorder
• Panic Disorder
• Posttraumatic Stress Disorder
• Obsessive Compulsive Disorder
• Phobias– Specific– Social
Anxiety Disorders
• Generalized Anxiety Disorder
• Panic Disorder
• Posttraumatic Stress Disorder
• Obsessive Compulsive Disorder
• Phobias– Specific– Social
Generalized Anxiety DisorderGAD
• 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 Fear of Losing Control
Sweating Derealization
Trembling Nausea
SOB Choking feeling
Paresthesias Hot flashes
Chest Pain
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• 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 DisorderOCD
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 DisorderOCD
• Patients are often secretive about this and have increased shame.
• Starts early in life, adolescence or early adulthood.
Obsessive Compulsive DisorderOCD
• 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
• 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 PhobiasHealth 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
• 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-upRobert 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?
HELLO
DATA GATHERING
NEGOTIATION
3 Parts of ANY Interview
INTRODUCTIONS
PURPOSE OF VISIT
STRUCTURE OF VISIT
FOCUSED OPEN-ENDED QUESTION
HELLO
TARGET SYMPTOMS (CUES)
HYPOTHESES (MAPS-O©)
CASE FINDING QUESTIONS
DIAGNOSTIC CRITERIA (DSM-IV)Comorbidities (ROS)
DATA
GATHERING
DIAGNOSIS
TREATMENTS
PATIENT PREFERENCE
DIAGNOSIS & TREATMENT CHOICE
NEGOTIATION
How can a primary care doc make a reasonable psychiatric differential diagnosis?
Depression
Posttraumatic Stress Disorder
Mania
Psychosis
Generalized Anxiety Disorder
Somatization Disorder
Dysthymia
Obsessive Compulsive Disorder
Bipolar Disorder
Panic Disorder
Schizophrenia
Panic Attacks
Personality Disorder
Substance Abuse
Social Phobia
Specific PhobiaSchizoaffective Disorder
Eating Disorders
Dementia
ADHD
Anxiety
Agoraphobia
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
MAPS-O®
Mood Disorders Major Depression, Dysthymia, Bipolar Disorder
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other
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 Schizophrenia, Schizoaffective
Substance Abuse
Other
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse Alcohol, Cocaine, Nicotine, Other Psychoactive Substances
Other
MAPS-O®
Mood Disorders
Anxiety Disorders
Psychotic Disorders
Substance Abuse
Other “Organic”:
Stroke, Dementia, HIV, TBI
Other Psych:
Personality Disorders, ADHD, Somatization,Eating Disorders
MoodAnxiety
Psychosis
Substances
Other