Webinar Objectives. Differential diagnosis: Navigating difficult diagnostic dilemmas. Diagnostic Assessment Workflow. Diagnostic Assessment Workflow

Transcription

1 Webinar Objectives Differential diagnosis: Navigating difficult diagnostic dilemmas Anna Ratzliff, MD, PhD Integrate a structured diagnostic work flow into the assessment process. Use diagnostic screeners to aid in developing a differential diagnosis. Describe an approach to differentiation of common diagnostic dilemmas. Apply communication strategies to discuss provisional diagnosis with other team members Diagnostic Assessment Workflow Diagnostic Assessment Workflow Interview Develop a Differential Additional Assessment Diagnosis Interview Develop a Differential Additional Assessment Diagnosis The Diagnostic Interview Systematic information gathering about the patient s presenting complaints, symptoms and other relevant history Will lead to a formulation of the patient s problems and diagnoses Essential part of building therapeutic alliance Best done at the first meeting Why do we care about the diagnosis? Guides treatment and clinical decision making! The Diagnostic Interview Get Organized! Give an orientation to the structure of the interview Introduce the concept of the assessment being an important part of getting them the right help Start with open-ended question Let the patient talk for 3-5 minutes Keep a checklist in mind of the questions you need to ask, and get focused. History of Present Illness Past Psychiatric History Social History and Functional Assessment 1

2 Mood:, Mania/Hypomania : Generalized anxiety, Panic attacks,, : Primary, Secondary Substance Use: Alcohol, Illicit, Prescription Organic: Cognitive impairment, Relevant medical history Screen Five Major Diagnostic Areas HPI Mood Card Mood Duration, trigger Sleep Appetite Energy level Suicidal ideation Mania/hypomania Has there ever been a period of time in your life that lasted for at least a few days in a row when you felt unusually happy or energized for no particular reason? For how long did you feel that way? How was your sleep during that time? How often does an episode like this occur? Inquire about pertinent substance use HPI Card Generalized anxiety Do you find yourself feeling nervous or on edge for no particular reason? Are you a worrier? Panic attacks Inquire about the presence of unprovoked attacks Has there been anything that felt particularly traumatic and still comes back to haunt you? Reassure the patient that you don t have to know the details of the trauma while trying to understand the basic nature of the trauma Nightmares, flashbacks, hypervigilance, avoidance Washing/cleaning Checking Ordering/counting Hoarding HPI Card Questions may need to be tailored to the specific patient Be alert to signs of possible psychosis: Thought/behavioral disorganization, vagueness of speech, bizarre mannerism, response to internal stimuli Common ways to phrase your question: Have you ever had strange experiences such as hearing voices when no one is around, or seeing things that aren t there? (When suspecting psychotic depression) Sometimes when people feel very depressed, they can have strange experiences such as hearing voices when no one is around. Has something like this ever happened to you? Inquire about possible delusions when appropriate: Have you ever felt that other people (such as your neighbors, or government organizations) are out there to get you? HPI Substance Use Card Ask about each substance individually and don t be shy Alcohol How often do you use alcohol? How many drinks do you usually have in a day? When was the last time you had anything to drink? Marijuana Heroin Cocaine Methamphetamine Have you ever used? For long did you use it on a regular basis? When was the last time you used it? Prescription drugs, such as benzos and opioids HPI Organic Card Be alert to signs of possible cognitive impairment: forgetfulness, word-finding difficulty, difficulty tracking conversation Pertinent medical history: Head trauma Seizures Thyroid problems Chronic pain Medications Other neurologic disorders 2

3 Past Psychiatric History Psychiatric hospitalizations Suicide attempts Past medication trials Which medications? For how long? Tolerability? Efficacy? Making a Diagnosis Symptoms Functional Impairment Disorder Social History and Functional Assessment Start with the present Focus on pieces relevant to determining the patient s functional status Housing situation Social support Lives alone? Married? Family? Friends? Education attainment Employment history Legal history This is also relevant to assessing violence risk Functional Assessment: Activities of Daily Living This is only relevant when you suspect the patient may have difficulty handling common daily tasks Ask how the patient normally spends his/her day, and his/her ability to: Bath/dress self Prepare meals Perform common household chores, e.g., cleaning, laundry Manage money Screeners as Vital Signs Screeners are like monitoring blood pressure! Identify that there is a problem Need further assessment to understand the cause of the abnormality Help with ongoing monitoring to measure response to treatment Diagnostic Assessment Workflow Interview Develop a Differential Additional Assessment Diagnosis 3

4 Additional assessment? Unipolar : Diagnostic Assessment Workflow Pervasive /worry Generalized Disorder Re experiencing Obsessions or Interview Develop a Differential Additional Assessment Diagnosis Organic and Cognitive Chronic: Dementia, Psychotic Disorders Mood Disorders Pervasive /worry Re experiencing Obsessions or Unipolar : Generalized Disorder PHQ-9 Positive: Don t assume it is unipolar depression! Distress Unipolar Major Depressive Disorder Adjustment Bipolar Disorder: Hypomania/mania Substance abuse/dependence Disorder Organic causes Organic and Cognitive Chronic: Dementia, Psychotic Disorders Mood Symptom Summary Symptom Cluster Consider Screeners Unipolar : Only depression Bipolar Disorder: PHQ9 CIDI or MDQ Bipolar Disorder Diagnosis Diagnosis = Screening Tool (e.g., MDQ, or CIDI-3) + Follow-Up Questions Follow-Up Questions are key to eliminating false positives (e.g., mood episodes from substance abuse). May also need observation over time and collateral information (e.g., from family) 4

5 Bipolar Disorder: Follow-up Questions How long do the hypomanic/manic episodes last? How frequently do the hypomanic/manic episodes occur? During periods of sobriety have you had hypomanic/manic episodes? Do you have a family history of bipolar disorder or schizophrenia? Have you been previously diagnosed with bipolar disorder, and if so, by whom? Have you previously been treated with antidepressants? How did you respond? Still stuck? Describe most recent mood episode When did it start? How long did it last? How was your sleep? Were you using substances? How would your friends and family describe your behavior? Disorders Unipolar : University of Washington 2011 Summary Pervasive /worry Generalized Disorder Generalized Disorder: Pervasive /worry GAD-7 Re experiencing Obsessions or : : Re experiencing PCL-C : Obsessions or Y-BOCS Organic and Cognitive Chronic: Dementia, Psychotic Disorders GAD-7 Postive: Don t assume it is anxiety Major Depressive Disorder Bipolar Disorder: Hypomania/mania Substance abuse/dependence ADHD Psychotic Disorders Pervasive /worry Re experiencing Obsessions or Unipolar : Generalized Disorder University of Washington 2011 Organic and Cognitive Chronic: Dementia, Psychotic Disorders 5

6 Differential for Substance Use Disorders Unipolar : Primary Psychotic Mood Disorder Substance Induced Medical Conditions Other Pervasive /worry Generalized Disorder Schizophrenia Bipolar Disorder Intoxication Delirium Dementia Brief Psychotic Disorder Re experiencing Obsessions or Schizoaffective disorder Major Withdrawal Other Delusional Disorder Cognitive Impairment Chronic: Dementia, Psychotic Disorders The great masquerader: Substance use Diagnostic Assessment Workflow Past use? Drugs of choice? Treatment? Relapse prevention? Signs of use? Current Use? Interview Develop a Differential Additional Assessment Diagnosis Diagnosis Diagnosis Most common disorders are most common Mood disorders and anxiety are most common Assessment by CM and PCP Use your diagnosis to guide treatment planning Ex. Bipolar disorder will need a mood stabilizer Diagnoses can change over time as you gather more information and observations Screeners filled out by patient diagnosis and treatment plan Psychiatric Consultant Case Review or Direct Evaluation 6

7 Assessment and Diagnosis in the Primary Care Clinic Provide intervention Gather information Generate a treatment plan Exchange information -Diagnosis can require multiple iterations of assessment and intervention -Advantage of population based care is longitudinal observation and objective data -Start with diagnosis that is your best understanding Case 1 The patient is a 35-year-old male presenting to his primary care clinic complaining of depression. Patient reports a history of worsening depression over the 3 months. Patient reports difficulty sleeping, irritability, poor energy, poor appetite, feelings of worthlessness and hopelessness, passive suicidal ideation and depression. What do you think about when getting ready for his assessment? Differential Diagnosis Unipolar : Mood Symptom Summary Pervasive /worry Generalized Disorder Symptom Cluster Consider Screeners Re experiencing traumatic events Obsessions or Unipolar : Only depression Bipolar Disorder: PHQ9 CIDI or MDQ Organic and cognitive Chronic: Dementia, Psychotic Disorders HPI Mood Card Mood Duration, trigger Sleep Appetite Energy level Suicidal ideation Mania/hypomania Has there ever been a period of time in your life that lasted for at least a few days in a row when you felt unusually happy or energized for no particular reason? Inquire about pertinent substance use Case 1 continued When the patient is asked about bipolar symptoms, the patient has a positive CIDI screener. Patient reports a previous history of heavy alcohol use. How would you ask about his previous episodes of mania? 7

8 Bipolar Disorder: Follow-up Questions How long do the hypomanic/manic episodes last? How frequently do the hypomanic/manic episodes occur? During periods of sobriety have you had hypomanic/manic episodes? Do you have a family history of bipolar disorder or schizophrenia? Have you been previously diagnosed with bipolar disorder, and if so, by whom? Have you previously been treated with antidepressants? How did you respond? Case 1 continued The patient reports that sometimes he has mood episodes that go up and down over a day. However, he notes two previous episodes of increased energy after little sleep. During these periods of time, he reported "working on a book", spending money to develop a tour to sell his book, impulsive travel to another state and increased sexual promiscuity. He notes these happened during a period of sobriety. The patient also reports periods of approximately one week lasting up to one month of increased irritability, agitation with a depressed mood. What is your working diagnosis? Are there other questions you would ask? Case 1 conclusion Communication: How and When? Be sure to ask about psychosis and other physical symptoms diagnosis: Bipolar I disorder, current episode depressed Consider Bipolar I disorder, mixed episode; Substance induced mood disorder and Mood disorder secondary to medical condition Treatment implications Helpful if can ask about previous treatment response Communication is key to team function! Consider modality In person Staff (MA or nurse) Phone Fax (careful with confidential info) EMR Frequency Scheduled As needed PCP Patient CM Other Behavioral Health Clinicians Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Core Program Psychiatric Consultant Additional Clinic Resources Outside Resources Key Elements for Talking to PCP PCP Discussion Template Understand any concerns they have about the patient Baseline Clinical measures e.g., PHQ-9 Score Current Symptoms Symptoms that aren t improving Current treatment(s) and length of time Problematic side effects Psychiatric consultant recommendations (if relevant) 8

9 Communicating with Psychiatric Consultant Model Consultation Hour Care Manager Weekly consultation -review caseload -create recommendations -track outcomes Psychiatric Consultant Each 0.5 FTE care manager = 1 hour/week with consultant 4-6 patients per hour Brief check in Changes in the clinic Systems questions Identify patients and conduct reviews Flagged by CM Not improved w/o note Severity of presentation Disengaged from care Wrap up Confirm next consultation hour Educational resources discussed Consulting Psychiatrist Review Template ID Current symptoms and functional impairment Mood Substance use Organic and Cognitive Suicidality/Safety Medical problems Behavioral health history Psychosocial factors Not Just Meds! Psychiatric consultant can help: Clarify diagnosis Suggest psychotherapeutic interventions Brainstorm strategies when patient not improving Provide emotional support to Care Manager Thank you! Questions? Anna: annar22@uw.edu Questions Personality Disorders ADHD Malingering 9

10 Personality Disorders Often co-exist with other psychiatric disorders Be sensitive to personality traits/disorders for guiding therapeutic stance Observation over time is especially important to make these diagnoses May consider a personality disorder when do not respond to treatment or have significant interpersonal difficulties ADHD Diagnosis of exclusion Inattention and difficulty with concentration are common in many mood, anxiety and psychotic disorders Treat other psychiatric disorders first, then re-assess attention Obtain additional function impairment history What can t they do right now because of poor attention? Educational and work functioning history are informative Factitious Disorder and Malingering Factitious disorder The essential feature of factitious disorder is intentionally faking symptoms in order to assume the sick role, ie, to be a patient Malingering The essential feature of malingering is intentionally faking or grossly exaggerating symptoms for an obvious, external incentive such as avoiding work, avoiding criminal prosecution, obtaining financial compensation, or obtaining medications Clinicians should suspect malingering when any combination of the following is present: medical-legal context (eg, patient is referred by an attorney for evaluation) marked discrepancy between the patient's claimed distress or disability and the objective findings; pan-positive symptoms across many categories! noncompliance with diagnostic evaluation or treatment antisocial personality disorder Social Innovation Fund Applying these principles within the eligibility criteria for SIF is the topic for the next care manager call Wednesday, May 21 Bring questions about SIF eligibility to that call University of Washington