Unit 4: Behavioral Medicine

Affective, Anxiety, and Somatic Disorders

Elizabeth A. Zeidler Schreiter, Psy.D.Neftali Serrano, Psy.D.

Fairleigh Dickinson UniversityCertificate in Integrated Primary Care

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Affective DisordersLifetime Prevalence

Any Mood Disorder: 21.4%

Bipolar Disorder: BP-I: 1.0% BP-II: 1.1%

Depressive Disorders: MDD: 16.9% Dysthymia: 2.5%

(National Comorbidity Survey [internet]. NCS-R appendix tables 1 and 2. Available at http://www.hcp.med.harvard.edu/ncs/publications.php)

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Depression Screening PHQ-9 is the nine item depression scale of the Patient Health

Questionnaire. PHQ9 Copyright © Pfizer Inc.

PHQ-9 is used to assist in screening and diagnosing depression as well as selecting and monitoring treatment especially in primary care settings.

The PCP or BHC should discuss with the patient the reasons for completing the questionnaire and how to fill it out (Assessing self-reported sx within the past 2 weeks)

There are two components of the PHQ-9: Assessing symptoms and functional impairment to make a

provisional depression diagnosis Deriving a severity score to help select and monitor treatment The PHQ-9 is based directly on the diagnostic criteria for major

depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV).

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Depression Screening PHQ-9 Scoring:

Add up all checked boxes on PHQ-9 For every ✓: Not at all = 0; Several days = 1; More than half

the days = 2; Nearly every day = 3 Interpretation of Total Score

1-4 Minimal Depression 5-9 Mild Depression 10-14 Moderate Depression 15-19 Moderately Severe Depression 20-27 Severe Depression

The MacArthur Foundation Initiative on Depression and Primary Care has created a Depression Tool Kit (http://www.depression-primarycare.org/clinicians/toolkits)

PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. For research information, contact Dr Spitzer at rls8@columbia.edu. The names PRIME-MD® and PRIME MD TODAYTM are trademarks of Pfizer Inc.

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Bipolar Screening Consider use of Mood Disorder Questionnaire or

Bipolar Spectrum Diagnostic Scale (assessment tools reviewed in greater detail in other modules).

Assess for periods of mania/hypermania in the past/present

Consider impacts of substance abuse of sx presentation

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Assessment The format of the 5 A’s model has been strongly recommended for

use in Primary Care and is basis for conceptualization of presenting problems in current presentation Assess: Information gathering (sx, thoughts, feelings, behaviors, and

environmental stressors) Functional Assessment Advise: Discuss options for treatment/intervention and potential

outcomes Agree: PT decides on personal preference for treatment based on

options discussed in Advise phase. May also indicate dislike of all options and then can brainstorm additional options

Assist: Skills acquisition and learning of new information (Formal BHC interventions)

Arrange: Specify follow-up plan if needed and modality (PCP visit, BHC visit, phone check-in, and/or referral for specialty services)

The 5 A’s model can be used in variety of settings and to address numerous presenting problems

(Whitlock et. al., 2002; Goldstein et. al., 2004; and Hunter et. al. 2009)

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Functional Assessment Screening is important, however the typical role of BHC

in primary care is not to diagnosis, but instead assess functional impairment of sx and assist PCP and PT in minimization of such sx

Areas to assess: Duration of problem Triggering events Frequency and intensity of problem Factors associated with problem becoming better or worse

(physical emotional, behavioral, environmental, & cognitive)

Functional Impairment (work performance, work or social relationships, family relationships)

Changes in sleep, energy, appetite, concentration Substance use (caffeine, nicotine, drugs, alcohol)

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Suicidal/Homicidal Patients If clinically appropriate screening for suicidal/homicidal

ideation may be indicated while this is likely not a routine part of every BHC consult there are situations where this is warranted.

Asking directly:

“Do you have any thoughts of harming or killing yourself?”

“Do you have a history of attempting to harm yourself?”

“Do you have thoughts of hurting or killing anyone else?”

Assessing if passive versus active ideation is also important to determine what level of intervention is needed to ensure safety (e.g. current intent or plan?)

Review protective factors (e.g. family, friends, faith)

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Ensuring Safety Discuss safety plan if SI continues or intensifies (call

clinic, call 9-1-1, present to ED)

Consider closer follow-up until mood stabilizes (phone call, office visits)

Enlist support of family members

If PT is in immediate risk of harming self or others send PT to ED for further evaluation and possible admittance to inpatient psychiatric unit to ensure safety.

Coordinate care with ED and notify of PT impending arrival and provide pertinent information

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Treatment Options for Mood Disorders

Pharmacological: Antidepressants (depressive disorders) Mood Stabilizers (bipolar spectrum disorders)

Behavioral

Combination Treatment

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BHC Interventions for Mood Disorders

Self-management and emotional regulation skills training Provide mood monitoring charts

Strength based approach with assisting PT in identifying personal strengths and periods in which PT feels the best

Use patient education handouts and materials to support behavioral change

Have PT consider set or planned times for exposure to unpleasant/avoided thoughts or feelings

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Interventions Continued Address specific sx that are problematic (e.g sleep, thought

rumination, low energy) then use specific strategies and handouts (sleep hygiene, challenging cognitive distortions, behavioral activation)

Direct focus to areas within the PT locus of control (e.g. reaction to spouse instead of changing spouse’s behaviors)

Behavioral Activation/Change Plan

Set small specific behavior change goals to increase self-efficacy for more widespread changes in the future

Provide information about additional community supports and group offerings (NAMI, exercise classes, faith based, etc.)

(Robinson, P.J., Reiter, J.T. 2007)

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Anxiety Disorders According to the National Comorbidity Survey Replication (NCS-R),

anxiety disorders are the most common psychiatric disorders in the general population.

12-month incidence is 19% with lifetime incidence being 31%.

Among anxiety disorders the most prevalent include: generalized anxiety disorder (GAD) panic disorder (PD) post-traumatic stress disorder (PTSD) social anxiety disorder (SAD) specific phobia

The prevalence of anxiety disorders (GAD, PD, PTSD, and social phobia) in primary care are similar to that in the general population (Harman JS, Rollman BL, Hanusa BH, et al. 2002).

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Screening and Evaluation Medical evaluation by PCP to rule out organic basis for sx

Assess, Advise, Agree, Assist, Arrange

The GAD 7-Item Scale (GAD-7) GAD7 Copyright © Pfizer Inc. is primarily used for screening of generalized anxiety disorder, but is also sensitive to detect other anxiety disorders

Self-report measure that provides assistance with sx detection, needs further inquiry as far as functional impact of sx as this is not assessed by screener

Can be completed quickly in primary care setting

Effective tool to assist with monitoring response to treatment.

Scoring: Total score of 8 or greater is highly suggestive of an anxiety disorder, 10 or greater suggestive of probable GAD

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Causes and Contributors of Anxiety

Life stressors

Uncertainty regarding medical prognosis/outcomes

Anxiety about one’s body

Fears regarding death

Anxiety about the functional impact of illness

Anxiety regarding response from physician

Substance induced

Secondary to medical condition

(Hicks et. al., 2010)

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Treatment Options Collaboration with PCP and PT to make shared

decisions regarding treatment is key

Pharmacological and behavioral treatments are found to be effective

Pharmacological treatment options include: Antidepressants (SSRIs and SNRIs) Benzodiazepines Buspirone Antihypertensives

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BHC Interventions for Anxiety

Cognitive coping: Discuss ways to challenge anxious thinking and engage in positive self-talk

Psychoeducation regarding the stress-coping-vulnerability model

Exposure to sx and assist with coping skills application

Brainstorm possible solutions and coping to psychosocial stressors

Relaxation Skills Training and Increased Mindfulness PMR Diaphragmatic breathing Exercise

Anticipate and plan for resurgence of sx and be proactive regarding plan to cope in order to address sx

(Robinson, P.J., Reiter, J.T. 2007)

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Somatic Disorders Somatization describes a tendency to experience and communicate psychological

distress in the form of physical symptoms. Some patient’s experience continuing somatic symptoms and begin to attribute them to physical illness despite the absence of medical findings and continually seek medical care for such sx.

Somatization may also coexist with a medical disease, but when it does the symptoms are out of proportion to the demonstrable medical findings.

Patients with multiple unexplained somatic symptoms have significantly higher rates of depressive and anxiety disorders.

Cross-cultural studies indicate that individuals from some ethnic groups, such as Hispanics, have a higher tendency to exhibit somatic symptoms when experiencing depression.

Patient evaluation should include a complete history, physical examination, and appropriate laboratory tests in order to exclude underlying physical disease.

(Feder, A. www.medicineclinic.org. Accessed online January 20, 2011)

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Interventions by PCP and BHC

Acknowledge the reality of the patient’s symptoms and current level of impairment/suffering. Provide empathy.

Assess and arrange treatment for any underlying mood or anxiety disorder.

Provide psychoeducation regarding impact of mood on physical health (Mind-body connection). Gradually discuss role that stress may play in current presentation, but ensuring that you do not communicate it is the exclusive cause of the symptoms

Focus on adherence to medication regimens as sx may persist or appear to not respond to treatment if poor compliance.

Focus on management of the somatic sxs instead of a cure and increasing functioning in an effort to minimize impairment.

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Interventions Continued Schedule more regular and frequent follow-ups with both

BHC and PCP. (May consider PT seeing BHC in 2 weeks and PCP in 1 month etc.)

Provide positive reinforcement for non-illness behaviors and use behavioral prescriptions

Review benefits of a “medical home” and discourage PT from seeing numerous providers and limit ED presentations (use clinic first).

Provide support to PCP as these PTs can at time elicit frustration response. Formulate clear boundaries for treatment while also validating patient reactions and expectations

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Functional Impairment Persistent somatization is associated with increased

rates of disability and health care utilization

Becomes cycle in which PT gains reinforcement for illness based behaviors

Collaboration is key to minimize negative consequences (unwarranted tests or procedures)and sx exacerbations

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Additional BHC Interventions for Somatic Complaints

• Teaching of stress reduction/management skills

Diaphragmatic breathing

PMR

Increased mindfulness and acceptance based strategies

Cognitive restructuring skills training

(Robinson, P.J., Reiter, J.T. 2007)

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ReferencesFeder, A. [Internet] Available at: www.medicineclinic.org. Accessed online January 20,

2011

Goldstein, M.G., Whitlock, E. P., & DePue, J. (2004). Multiple behavior risk factor interventions in primary care: Summary of research evidence. American Journal of Preventative Medicine, 27 (Suppl. 2), 61-79.

Harman JS, Rollman BL, Hanusa BH, et al. Physician office visits of adults for anxiety disorders in the United States, 1985–1998. Journal of General Internal Medicine 2002;17:165–72.

Hicks, D., Cummings, T., & Epstein, S.A. (2010). An Approach to the patient with anxiety. Medical Clinics of North America, 94: 1127-1139

Hunter, C.L., Goodie, J.L., Oordt, M.S., & Dobmeyer, A.C. (2007). Integrated behavioral health in primary care. Washington, DC: APA Books.

Jonas BS, Franks P, Ingram DD. Are symptoms of anxiety and depression risk factors for hypertension? Longitudinal evidence from the national health and nutrition examination survey I epidemiologic follow-up study. Archives of Family Medicine 1997;6:43–9.

Kessler, R.C., Gruber, M., Hettema, J.M., Hwang, I., Sampson, N., Yonkers, K.A. (2008). Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up. Psychological Medicine, 38(3), 365-374.

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ReferencesKroenke K, Spitzer RL, Williams JB, et al. Anxiety disorders in primary care:

prevalence,impairment, comorbidity, and detection. Ann Intern Med 2007;146(5): 317–25.

National Comorbidity Survey [internet]. NCS-R appendix tables 1 and 2. Available at: http://www.hcp.med.harvard.edu/ncs/publications.php. Accessed January 10, 2011.

O’Donohue, W.T., Cummings, N.A, Cucciare, M.A. et al. (2006). Integrated behavioral health care a guide to effective intervention. New York: Humanities Books.

Robinson, P.J., Reiter, J.T. (2007). Behavioral consultation and primary care: A guide to integrating services. New York: Springer.

Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 1737-1744.

Whitlock, E. P., Orleans, C.T.. Pender, N., & Allan, J. (2002). Evaluating primary care behavioral counseling interventions: An evidence based approach. American Journal of Preventative Medicine, 22, 267-284.

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