MDT presentation and tx Flashcards
Clinical Manifestations of what disorder?
(1) Some response to trauma is considered to be normal but in patients with this issue the symptoms go beyond the realm of normal with multiple impairments:
-(a) Affective dysregulation (anger common)
-(b) Cognitive impairment
-(c) Several behavior responses in response to regular stimuli:
–1) Flashbacks
–2) Severe anxiety symptoms
–3) Fleeing
–4) Combative behaviors
(2) These symptoms lead to compensatory behaviors by the individual
-(a) We call this an avoidance of triggering experiences
–1) Avoidance leads to furthering of symptoms such as emotional
Post-Traumatic Stress Disorder (PTSD)
Treatment for PTSD
1) Therapy and medication are both useful and can be used either alone or in combination
(a) Psychotherapy
(b) Since marital problems and substance abuse are commonly seen with PTSD, consider referral sources for counseling
(d) Medications
–1) Antidepressant medications (SSRIs) are the first line therapy of choice
-2) Other adjuncts may be used based on symptoms
–a) Prazosin for nightmares
–b) Beta blockers for tremors and sympathetic responses
–c) Antipsychotics for comorbid psychosis if needed
What is the focus of the Independent Duty Corpsman is screening for PTSD?
Symptoms must be present for at least four weeks following trauma for psychiatry to make the diagnosis
What issue?
1) Pathophysiology
-(a) Neuroimaging studies have shown structural brain changes
-(b) Deficits in dopaminergic function and serotonergic function
–1) Dopamine: Eating behavior, motivation and reward
–2) Serotonin: Mood, impulse control, obsessive behavior
2) Diagnostic Criteria (DSM V)
-(a) Restriction of energy intake that leads to low body weight
–1) Taking into account the sex, age, developmental trajectory, and physical health
-(b) Intense fear of gaining weight or becoming fat or persistent behavior that
prevents weight gain, despite being underweight
-(c) Distorted perception of body weight and shape, undue influence of weight and shape on self-worth, or denial of the medical seriousness of one’s own low body weight
3) Common physical exam findings
-(a) Low BMI (<17.5)
-(b) Emaciation
-(c) Hypothermia
-(d) Bradycardia
-(e) Hypotension
-(f) Hypoactive bowel sounds
-(g) Xerosis (dry and scaly skin)
-(h) Brittle hair and hair loss
-(i) Lanugo body hair
-(j) Abdominal distent
Anorexia Nervosa
What issue?
Diagnostic Criteria
(a) Recurrent episodes of binging and purging and inappropriate compensatory behavior to prevent weight gain
-1) Self-induced vomiting
-2) Misuse of laxatives
-3) Diuretic use
-4) Enemas
-5) Fasting
-6) Excessive exercise
-7) Occurring on average at least once per week for three months
Clinical findings
(a) Dehydration
(b) Menstrual irregularities
(c) Mallory-Weiss syndrome
(d) Pharyngitis
(e) Erosion of dental enamel
(f) ECG changes may occur
Bulimia nervosa
What Issue?
(a) Episodes of binge eating
(b) Eating is associated with:
-1) Uncomfortably full
-2) Eating when not hungry
-3) Feelings of embarrassment
-4) Feelings of disgust, depression
Binge eating disorder
What Issue?
(a) Eating of nonfood substances
-1) Chalk, dirt, hair, metal, etc
(b) Inappropriate eating behavior for developmental level
(c) Not culturally, socially normal eating
(d) Associated with iron deficiency anemia
PICA
What issue?
(a) Repeated regurgitation of food
-1) May be rechewed, reswallowed, or spit out
(b) The regurgitation is not due to GERD, pyloric stenosis, or another medical condition
Rumination Disorder
What issue?
Variable presentation
(1) Changes in mood
-(a) Sadness, distress, numbness, anxiety, irritability
(2) Cognitive problems
-(a) Changes in work performance
(3) Neuro-vegetative symptoms
-(a) Loss of energy, changes in sleep, appetite, or weight gain
(4) Somatic symptoms
-(a) Headache, abdominal pain, pelvic pain, back pain, other physical complaints
Depression
Treatment of depression
psychotherapy, pharmacotherapy, or both
-Pharmacotherapy
1) SSRIs: Selective Serotonin Reuptake Inhibitors
-a) Fluoxetine, paroxetine, sertraline, escitalopram, citalopram
2) SNRIs: Serotonin- Norepinephrine Reuptake Inhibitors
-a) Venlafaxine, duloxetine
What issue?
1) Commonly seen in the Navy
2) May look similar to a major depressive disorder but does not meet criteria
3) Occurs in the context of a recent stressor
-a) Deployment, marital problem, recruit training, financial concerns, increasing responsibilities with rank
-b) Specifically NOT diagnosed in the context of bereavement
4) Resolves within six months when the stressor is removed
Adjustment Disorder
What issue?
1) Very common
2) Occurs in the context of childbirth
3) Usually occurs within 12 months after delivery
4) Same diagnostic criteria as depression
5) Likely due to genetic susceptibility and hormonal changes in addition to increased stressor
Post-Partum Depression
Treatment Post partum depression
(1) For mild to moderate, recommend psychotherapy such as CBT as initial treatment; especially useful for breastfeeding moms as they won’t expose children to antidepressants.
2) If CBT is unsuccessful or depression is more severe, antidepressants (SSRIs, Bupropion (Wellbutrin), Mirtazapine (Remeron)) are useful.
(3) SSRIs: Paroxetine (Paxil) or Sertraline (Zoloft) appear to have lowest adverse effects on infants.
Clinical Manifestations of what issue
Occurs more days than not, for at least six months
(a) Most do not present with “excessive worry”
-1) If asked typically will admit to worrying excessively about minor matters
(b) Hyperarousal and muscle tension common
(c) Poor sleep
(d) Fatigue
(e) Difficulty relaxing
(f) Headaches
(g) Pain in the neck, shoulder, and back
Generalized Anxiety Disorder (GAD)
GAD Treatment
1) Benzos for Panic attacks
2) Hydroxyzine
-long term maintenance
–a) SSRI’s
–b) SNRI Venlafaxine
