Friday, April 22, 2016

Introduction to Behavioral Health

Introduction to Behavioral Health
Updated: 04/22/2016
The Multiaxial System - used previously in DSM 4 (now DSM 5 is used, but we should still understand and recognize the importance of these axes).
  1. Axis I – serious mental illnesses (mood, anxiety, eating, sleep, impulse-control, adjustment)
  2. Axis II – personality disorders +/- mental retardation
  3. Axis II – general medical conditions (neoplasms, injury, poisoning)
  4. Axis IV – psychosocial and environmental problems (educational problems, economic, housing, access to healthcare)
  5. Axis V – GAF (1-100) = global assessment of functioning

AFFECT - The patient’s present emotional responsiveness, inferred from patient’s facial expression, including amount and range of expressive behavior [objective: what you observe about pt]

Appropriate amount of eye contact, facial expression, responsiveness, etc.
Incongruent with content or social norms
Psychotic content consistent with patient's mood
Psychotic content inappropriate to patient's mood

Reduced intensity of affect – lesser degree than blunted
Restricted affect
Severe reduction in intensity of affect

Virtually no signs of affective expression, no facial expression, monotonous voice
Dramatic, overly expressive
Fluctuating, rapid changes in emotion unrelated to external stimuli

MOOD - Pervasive & sustained emotion that colors the person’s perception of the world
Pertaining to a normal mood in which the range of emotions is neither depressed nor highly elevated.
Depressed (a state of unease or generalized dissatisfaction with life.)
Elevated mood
Inability to feel or express emotion
Clang Associations
Thoughts associated by sound vs meaning
(rhyming tangent)
Ex. Disturbance in thought – person selects words that are similar by sound, but do not mean the same; sometimes they rhyme the words
Pattern of speech wherein pt fixates on one topic; repetition or words, phrases, ideas
Persistent repetition of words or concepts in the process of speaking – seen in cognitive disorders, schizophrenia, etc.
-Depth or extent of patient’s awareness and understanding of himself
-Begins with patient’s recognition of problem and relationship to problem
-Intellectual insight = when patient’s can admit they are ill and acknowledge their failures to adapt are due in part to their own irrational feelings/thoughts
-Emotional insight = patient is aware of their own motives and feelings that lead to change in personality and/or behavior
-Understanding about being ill:
  • May be aware
  • May blame others
  • May blame other external factors
  • Attribute to organic factors
  • May acknowledge being ill but attribute to something unknown or mysterious
-Capacity for social judgment
-Understanding of consequences of behavior – long/short term
-Influences behavior – setting priorities
-Can patient predict his or her own behavior in a given situation?  ie. Smelling smoke in a theater; find a stamped envelope
Thought Insertion
Thought blocking (thought latency)
Thought withdrawal
Thought broadcasting
Flight of ideas
The delusion that thoughts that are not one's own are being inserted into one's mind.
Disruption of flow of ideas; a phenomenon that occurs in people with psychiatric illnesses (usually schizophrenia), occurs when a person's speech is suddenly interrupted by silences that may last a few seconds to a minute or longer.
The delusional belief that thoughts have been 'taken out' of the patient's mind, and the patient has no power over this. It often accompanies thought blocking.
The belief that others can hear or are aware of an individual's thoughts or thoughts are being broadcasted over radio or other media. This differs from telepathy in that the thoughts being broadcast are thought to be available to anybody. Thought broadcasting is considered a positive symptom of schizophrenia.
Over inclusion of trivia, which is not all relevant
Person has a point and eventually gets to that point, but with delay in the thought process
Responds generally but doesn’t answer the question
Succession of multiple associations (jumps from topic to topic) with rapid speech, but topics tend to be CONNECTED
Looseness of Association
Word Salad
Person changes subjects, but there is NO CONNECTION between the subjects
Mixture of words that have no sense to them
Disturbance in thought causing a person to start a train of thought, but never getting to the point
Person skips to another subject – occurs if a topic comes up that a person does not wish to discuss
Disturbances in Language
The inability to use language appropriately and may include problems speaking, hearing, and reading. Some with aphasia are able to read properly, but can't speak the language, speak the language but not be able to read it, or read letters but not numbers. Aphasia usually results from damage to parts of the brain such as Broca's (speaking problems) area or Wernicke's area (understanding language problems).
Inability to speak; prolonged failure to speak without an underlying physical cause
Invention of new words or phrases
Describe disorders of thought processing and thought content
Formal thought disorders (disorder of process)
  • Circumstantiality = over inclusion of trivia
  • Clang Associations = thoughts associated by sound vs meaning [endings of words the same … example: pschitzo]
  • Derailment = disconnect between logic and goal directedness [speech with loose associations and sentences that do not make sense]
  • Flight of ideas = succession of multiple associations [manic phase of bipolar]
  • Neologisms = invention of new words or phrases
  • Perseveration = repetition or words, phrases, ideas [alcoholics; elderly ppl]
  • Tangentiality = responds generally but doesn’t answer the question
  • Thought Blocking = disruption of flow of ideas [elderly]

Thought Context
  • Delusions = fixed false beliefs, out of keeping with patients cultural background
    • Persecutory, grandiose, paranoid (sx: scanning, fidgety, uneasy), jealous, somatic [sense that body parts are changing or sense that something’s wrong with one’s body]. Guilty, nihilistic, erotic
    • Ideas of Reference [to know another’s thoughts without speaking. when a pt thinks that they can get special messages from the tv or the way the things are arranged. “I know what you’re thinking”]; hallmark in schizophrenia
    • Ideas of Influence [think they can influence other people’s behavior or thoughts that influence them – i.e. behavior]

Common Definitions
Mania (Manic Episode)
Not sad
Abnormally and persistently elevated, expansive, or irritable mood lasting >= 1 week, requires 3+ symptoms
-DIG FAST: Distractibility, Insomnia, Grandiosity
-Flight of ideas, Activity/Agitation, Speech, Thoughtlessness
-Hallmark: irritability
-Causes marked impairment (hospitalization)
-Not substance/ medication-induced, due to another medical condition, or better accounted for by another mental disorder
- TX: Olanzapine, lithium, valproate
-Less severe than mania
-4+ days, requires 3+ symptoms
-Shorter time frame than mania
-Does not cause marked functional impairment but is an unequivocal change in usual functioning and behavior – no psychotic attributes
-Not substance/ medication-induced, due to another medical condition, or better accounted for by another mental disorder
Dysthymia (PDD)
Mild, chronic depression >=2 years in an adult, >=1 year in a child.
Numerous hypomanic periods and mild depressive periods for >=2 years                                 

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