Special Clinical Topics



Special Clinical Topics






ADHD: DIAGNOSIS




























































DIFFICULTY PAYING ATTENTION AND/OR SITTING STILL


Adult-onset ADHD does not exist, only residual childhood ADHD Treatment of childhood ADHD decreases risk of adult pathology


Evaluation: 5 components which may take 2-3 visits


Medical


Psychiatric


Educational


Records


Testing


Screen for anemia, thyroid, cardiac, or seizure risk


Mood, anxiety, psychosis, substance, sleep, family


To identify school, work, and social difficulties


From previous evaluations, providers, prescribers


Neuropsychologist > computer > scales > self-report


SYMPTOMS


DIAGNOSIS


Minimum Criteria


Difficulty paying attention


Inattentive


6 problems (6 months)


Attention, listening, follow-through, organizing, distraction, memory, losing things, sustained mental effort


Adults only require 5 symptoms


Difficulty sitting still


Hyperactive-impulsive


6 problems (6 months)


Running about, playing quietly, talking too much, waiting turn, blurting out answers, interrupting or intruding, feeling “driven by a motor”


Adults only require 5 symptoms


Both


Combined


6 of each type (6 months)


Adults only require 5 symptoms


Symptoms must occur in 2 settings and be present by 12 years of age


ASRSa


Adult Symptom Rating Scale


4 in the shaded area of part A (part B is additional info)


VADRSa


Vanderbilt ADHD Diagnostic Rating Scale


Includes parent and teacher assessments


≥6 often/very often scores on inattentive/hyperactive


+ ≥4 on any impairment in performance scale


Additional Neurodevelopmental Disorders


Intellectual disability


Intellectual and adaptive deficits


Communication disorder


Language, speech, stuttering, social


Specific learning disorder


Reading, written, math


Motor disorder


Coordination, stereotypic, tic


Autism spectrum disorder


Social/communication/relationships


a Validated: but not listed in AIMS/SAMHSA/AHRQ recommendations




ADHD: TREATMENT

























































Simple ADHD


Titrate stimulants and add alpha-blockers as needed for augmentation


Inattentive


1) Stimulant 10-60 div daily-TID


2) If SUD/cardiac concerns: atomoxetine 40-80


Hyperactive or combined


1) Stimulant 10-60 div daily-TID


2) If SUD/cardiac concerns: atomoxetine 40-80


3) Add/use clonidinea 0.05-0.2 BID or ER 0.05-0.4 HS or less sedating guanfacinea 0.5-2 BID or ER 1-4


Amphetamine-related stimulants: weakest to strongest in effect and side effects: methylphenidate < amphetamine < dextroamphetamine


Side effects: anxiety, tremor, insomnia, ▼ appetite, rare seizure


EKG: only needed if cardiac history in patient or first-degree relative


ADHD and a Co-occurring Disorder


Treat severe co-occurring disorders first or simultaneously with ADHD


MDD


1) Bupropion ER-24 150-450


2) Bupropion/SSRI/SNRI + ADHD meds


Anxiety


1) Buspirone 10-30 BID or SSRI/SNRI, + ADHD meds


2) Guanfacinea or clonidinea ± other ADHD meds


Tic


1) If MDD/anxiety also present: SSRIa + ADHD meds


2) Guanfacinea or clonidinea ± other ADHD meds


3) Tetrabenazinea 12.5-25 BID or SGA,a + ADHD meds


Insomnia


Avoid long-acting meds or add clonidinea 0.05-0.2 HS


History SUD


1) Bupropion ER-24a 150-450 or atomoxetine 40-80


2) Methylphenidate ≤30 mg (with SUD monitoring)


PSYCHOTHERAPY & RESOURCES


Education, study skills, CBT (anxiety/depression), and HRT (tics)


Delivered from Distraction—Hallowell/Ratey


Mindful Parenting for ADHD—Bertin


The ADHD Workbook for Kids—Shapiro


ADHD and Me—Taylor


Chadd.org—Children and Adults with ADHD


CONTRAINDICATIONS & MONITORING


Stimulants, bupropion, SGAs, tetrabenazine


See safety and monitoring in appendix for additional information


a Off-label: evidence-based but no FDA indication




SUICIDE & VIOLENCE


























































SUICIDE ASSESSMENT


Suicidal risk escalation: ideation-plan-intent-means-attempt


1) Determine non-modifiable risk factors




  • Sex is male



  • Age over 65 years



  • Depression history



  • Past attempt



  • Etoh history




  • Rational thought loss



  • Social support lacking



  • Organized plan



  • No spouse



  • Sickness




  • Caucasian



  • Native American



  • Unemployed



  • Childhood abuse



  • Family suicide


2) Determine modifiable risk factors




  • Depression



  • Anxiety




  • Access to lethal means



  • Suicidal ideation/plan




  • Hopelessness



  • Alcohol use


3) Determine protective factors




  • Children



  • Social network




  • Religion/cultural beliefs



  • Therapeutic alliance




  • Positive affect



  • Hope for future


4) Intervene & document


Determine risk level for imminent harm (high/intermediate/low)


Compare scores to gut feeling balancing objective/subjective, then document clear reasons for risk level and treatment choices


C-SSRS


Columbia-Suicide Severity Rating Scale


The Screen Version is a 6-question triage scale


Yes on 1 or 2 = refer for routine treatment


Yes on 3 = nonemergency consult


Yes on 4 or 5 (<30 days) = emergency consult


Yes on 6 (<90 days) = emergency consult


VIOLENCE ASSESSMENT


1) Determine individual risk factors




  • Past violence




  • Recent aggression




  • Substance history


2) Look for imminent risk factors




  • Agitation/threats



  • Failing alliance




  • Acute psychosis



  • Intense staring




  • Angry affect



  • Attacks on objects


3) Deescalate violence


Recognize escalation


Read the situation


Connect


Empathize and validate


Depersonalize situation


Give choices


Verbal abuse, agitation, hostility, staring


Frustration about feeling disrespected


Approach cautiously and speak calmly


Apologize and agree with frustration


Explain the situation


Offer water, a walk, or to reschedule




SUICIDE & VIOLENCE











































































INFORMED CONSENT


For specific treatment provider must present RRR


Reason


For test or treatment


R/B/A


Risks, benefits, and alternatives


Refusal


Consequences


CAPACITY


For specific treatment patient must show that they CURV


Choose


Able to express their choice consistently


Understand


The basic facts of informed consent


Reason


Demonstrated by explaining situation in own words


Values


Verified/documented and consistent with decision


EMERGENCY HOLDS


A patient can be held against their will if they are…


Mental


Imminently a danger to self/others or gravely disabled


Medical


Expected to imminently diea if released + lack capacity


Pregnant


Pregnant and the fetus is expected to imminently diea if released + any question of patient’s capacity


Legal


Represented by a legal decision-maker/parent (with capacity) or court that has already agreed to the hold


EMERGENCY TREATMENT


A patient can be treated against their will if they are…


Mental


Immediately a danger to self/others


Medical


Expected to immediately dieb without it + lack capacity


Pregnant


Pregnant and the fetus is expected to immediately dieb without it + any question of patient’s capacity


Legal


Represented by a legal decision-maker/parent (with capacity) or court that has already agreed to the treatment


RESOURCES


1-800-SUICIDE or 1-800-273-TALK (8255)


www.suicidepreventionlifeline.org—National Suicide Prevention Lifeline


a Evidence supports permanent/significant injury or death within 1 day

b Evidence supports permanent/significant injury or death within 1 hour




SOMATIC & PAIN: DIAGNOSIS























































EXAGGERATED FOCUS ON PHYSICAL SYMPTOMS


In factitious disorder and malingering the patient is intentionally exaggerating or creating symptoms (for primary/secondary gain)


In somatic symptom and conversion disorders the patient believes that the symptoms are real and experiences them fully


SYMPTOMS


DIAGNOSIS


MINIMUM CRITERIA


General medical or pain


Somatic symptom disorder


Physical symptoms (6 months)


With excessive thoughts, feelings, or behaviors around symptoms


Mild/moderate/severe, with prominent pain, persistent


Only neuro symptoms


Conversion disorder


Neuro symptoms (6 months)


Unexplainable voluntary motor or sensory deficits


With [symptom], acute/persistent, with/without stressor


Only fear of illness


Illness anxiety disorder


Fear of illness (6 months)


Preoccupation with having or acquiring a serious medical condition


With [symptom], acute/persistent, with/without stressor


Mental factors worsening medical care


Psychological factors affecting other medical conditions


Psychological factors


Which worsen a condition or conflict with medical care


Mild/moderate/severe/extreme


Faked


Factitious disorder


Intentional falsification of illness


To assume the sick role


Malingering


Intentional falsification of illness


For personal gain


PHQ-15


Patient Health Questionnaire-15


Score all symptoms (with/without identified causes)


10-14 medium, 15-30 high level of severity


FPSa


Functional Pain Scale


5 intolerable, 6 severe, 8 very severe, 10 worst possible


a Validated: but not listed in AIMS/SAMHSA/AHRQ recommendations

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May 8, 2019 | Posted by in PSYCHOLOGY | Comments Off on Special Clinical Topics
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