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