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MEDEX BEHAVIORAL SCIENCE

Comprehensive Checklist for S stem!tic Appro!ch to "!tient C!re M " L D S M C S S C " # $ Medical Psychosocial Hx Physical Exam Labs Depression Inventory Suicide Assessment MMSE CAGE Sa ety Support Community !esources Patient Education "reatment#!e erral $ollo% &p Complete medical and psychosocial history Complete physical examination Appropriate labs and dia'nostic tests Depression inventory Suicide assessment Mini Mental Status Examination CAGE Sa ety Support System Community resources Patient Education "reatment plan#re erral $ollo%(up

C O D A R A M O A " $ L E A S

H% Chie complaint )nset Duration Associated symptoms !elievin' actors A'revatin' actors Meds )ther )"C#herbals Aller'ies PMHx $Hx LMC E ects on li e Anythin' else Summary

&' Min(te Co(nselin) Sessions "rotocol to *etermine conte%t of visit B *ac+'round A A ect # "rouble H Handlin' E Empathetic statement

,-hat is 'oin' on in your li e./ ,Ho% do you eel about that./ ,-hat troubles you the most about this./ ,Ho% are you handlin' that./ ,"hat must be very di icult or you0/

5 Emp!thetic st!tements ,"hat must be very di icult or you0/ 2"his is a tou'h situation to be in2 2Anybody %ould eel as you do2 23our reaction ma+es sense to me2 Depression +,-. for more th!n / 0eeks1 Depressed mood Anhedonia -ei'ht or appetite chan'e Insomnia#Hypersomnia Psychomotor a'itation or retardation $ati'ue#Loss o ener'y -orthlessness#'uilt Indecisive#decreased concentration !ecurrent thou'hts o death S(ici*e Assessment2 10 -hat is the extent o the patient4s thin+in' and behavior related to suicide. 50 Does the patient demonstrate historical and sociodemo'raphic ris+ actors ore completed suicide. 60 Does the patient meet criteria or a psychiatric disorder that has been associated %ith completed suicide. Screenin) for Alcohol Depen*ence Cut Do%n Ever elt you ou'ht to cut do%n on your drin+in'. Annoyed Have people annoyed you by critici7in' your drin+in'. 3uilty Ever elt bad or 'uilty about your drin+in'. Eye )pener Ever had an eye(opener to steady nerves in the AM. M!nic +4-51 Sel esteem#'randiose Decreased sleep Pressured Speech "hou'hts racin' Distractibility Increased 'oal oriented activity Leads to increased pleasurable activities %ith pain ul conse8uences

Hostile "!tient Sho% empathy !eiterate treatment process As+ %hat they %ould li+e ( o er alternative 9i0e0 5nd opinion: more testin': re erral; Education about situation Su''est treatment options Se*(ctive "!tient As+ %hat patient %ants < alternatives Maintain boundaries 9non(scoldin' %ay; Education about %hat patient eels they need Get Hx o problems: support system: activities ) er Support H pochon*ri!c-Som!ti6in) ) er support and empathy Explain#educate about somatic symptoms and stress Additional history ( !#) depression#anxiety disorders#P"SD !evie% "ests ( reassure about positive aspects o physical exam and testin' # pes of El*er A7(se "h sic!l "he use o physical orce Se%(!l =on consensual sexual contact o any +ind %ith an elderly person Emotion!l +"s cholo)ic!l1 In liction o an'uish: pain: or distress throu'h verbal or nonverbal means Ne)lect !e usal or ailure to ul ill any part o a persons obli'ations or duties to an elder A7!n*onment "he desertion o an elderly person by an individual %ho has assumed responsibility or providin' care or an elder0 $in!nci!l or m!teri!l e%ploit!tion "he ille'al or improper use o an elder4s unds Self8Ne)lect "he behavior o an elderly person that threatens his#her o%n health or sa ety Di!)nosin) An%iet 96 criteria;> S2 Somatic symptoms

A 92 -orries I2 Irritability :2 ?eyed up: on ed'e I2 Initial insomnia R2 !elaxation di iculties An%iet Disor*er Separation Anxiety excessive anxiety about bein' separated rom a ma@or attachment i'ure Panic Disorder Discrete period o intense ear %ith A or more symptoms developin' and pea+in' %ith 1B minutes Symptoms> palpitations cho+in' de(reali7ation or depersonali7ation s%eatin' chest pain ear o losin' control#'oin' cra7y tremblin'#sha+in' nausea#GI distress paraesthesias shortness o breath di77iness ear o dyin' chills or hot lushes Generalized Anxiety Disorder (GAD) Excessive anxiety or C months or more 6o > restlessness# eelin' on ed'e irritability easily ati'ued muscle tension trouble concentratin' poor sleep Early onset - before age 20 Post-Traumatic Stress Disorder (PTSD) Exposure to a traumatic event involvin' actual or threatened death or serious harm to sel or others: A=D reaction o ear: horror: or helplessness Social Phobia Excessive ear o social or per ormance situations: public humiliation

E Obsessive-compulsive Disorder (O D) Persistent: irrational thou'hts or ima'es 9obsessions; and#or repetitive behaviors that the patient eels driven to per orm to reduce anxiety

Ad!ustment disorder "ith anxious mood Anxiety due to a medical condition

Psychotherapy - General Principles (This is #rom the role playin$ "e did durin$ the psychotherapy lecture) Greetin' Patient> Small "al+: 'race ul entry Active Listenin'> *ody Lan'ua'e: eye contact: noddin': 'runts: re lectin': paraphrasin': summari7in' Empathetic Comments Dalidatin' in terms o normal unctionin' A'reein'#=e'otiatin' o problem areas As+in' the patient about next steps 9Ho% to eel better: do somethin': have more riends: mobili7e support: 'et meds; Grace ul endin' o intervie% ( transition to next appointment or re erral $o(r topics of clinic!l ethics in c!se !n!l sis MEDICAL INDICA#IONS "A#IEN# "RE$ERENCES 10 -hat is patient4s medical problem. 10 -hat has the patient expressed about history. dia'nosis. pro'nosis. pre erences or treatment. 50 Is problem acute. chronic. critical. 50 Has patient been in ormed o bene its and emer'ent. reversible. ris+s: understood: and 'iven consent. 60 -hat are 'oals o treatment. 60 Is patient mentally capable and le'ally A0 -hat are probabilities o success. competent. -hat is evidence o incapacity. E0 -hat are plans in case o therapeutic A0 Has patient expressed prior pre erences: ailure. e0'0 Advance Directives. C0 In sum: ho% can this patient be bene ited E0 I incapacitated: %ho is appropriate by medical and nursin' care: and harm surro'ate. Is surro'ate usin' appropriate avoided. standards. C0 Is patient un%illin' or unable to cooperate %ith medical treatment. I so: %hy. F0 In sum: is patient4s ri'ht to choose bein' respected to extent possible in ethics and la%. ;<ALI#= O$ LI$E 10-hat are the prospects: %ith or %ithout treatment: or a return to patient4s CON#EX#<AL $EA#<RES 10 Are there amily issues that mi'ht in luence treatment decisions.

C normal li e. 50 Are there biases that mi'ht pre@udice provider4s evaluation o patient4s 8uality o li e. 60 -hat physical: mental: and social de icits is patient li+ely to experience i treatment succeeds. A0 Is patient4s present or uture condition such that continued li e mi'ht be @ud'ed undesirable by them. E0 Any plan and rationale to ore'o treatment. C0 -hat plans or com ort and palliative care. 50 Are there provider 9physicians and nurses; issues that mi'ht in luence treatment decisions. 60 Are there inancial and economic actors. A0 Are there reli'ious: cultural actors. E0 Is there any @usti ication to breach con identiality. C0 Are there problems o allocation o resources. F0 -hat are le'al implications o treatment decisions.

% &oral Principle o# linical 'thics A&")=)M3 *E=E$ICE=CE =)=(MAL$EASA=CE $AI!=ESS#G&S"ICE Consi*er!tion of the fo(r topics pl(s the fo(r principles *efine the ethic!l pro7lem !n* sho(l* s())est ! resol(tion> Imp!irment8 )r'an Dis!7ilit ( $unctional limitation at the level o person Limitations in tas+ per ormance H!n*ic!p ( At the level o the interaction bet%een the person and the environment 9societal vie%; Example - HIV Diagnosis (without disease) reates a signifi ant handi ap without any disability Intervie% the patient as an expert in their o%n body Assess ADLs

Different :in*s of "s chother!p Supportive 9e0'0 Chronic situations: illness: stresses; Investi'ative 9Is there a problem. Is it =ormal.; Problem(Solvin' !esolution o Acute Issue 9Grie ; Investi'ation#!esolution o Lon'standin' Issue Personality Chan'e> Accept Ds0 Chan'e !educe Harm ul *ehaviors !ein orce Positive *ehaviors Limits on Contact or Positive !ein orcement Prepare or Crisis 9Education be ore sur'ery; Education or HealthH Emotional !eactions Substance &se !eduction *ehavioral Intervention A I Antecedents * I *ehavior C I Conse8uences Mo*el of Se% #her!p "LISSI# "ermission Limited In ormation Speci ic Instructions Intensive #herapy Depression Screenin) Sleep decreased 9Insomnia %ith 5(A am a%a+enin'; Interest decreased in activities 9anhedonia; 3uilt or %orthlessness 9=ot a ma@or criteria; Ener'y decreased Concentration di iculties

K Appetite disturbance or %ei'ht loss "sychomotor retardation#a'itation Suicidal thou'hts

Depression Screenin) 8 Jun' Depression Scale *ec+ Depression Inventory Depression #%2 Appropri!te L!7s2 Screen "SH !#) Substance Abuse C*C !#) )r'anic Causes L$"s Dia'nosis CMP Consider Psychotherapy !P! Pharmacotherapy !e er i Indicated luster A "erson!lit Disor*ers Paranoid Personality Disorder S<S"EC# 9A criteria; S2 Spouse idelity suspected <2 &n or'ivin' 9bears 'rud'es; S2 Suspicious o others "2 Perceives attac+s 9and reacts 8uic+ly; E2 2Enemy or riend2 9suspects associates: riends; C2 Con idin' in others eared #2 "hreats perceived in beni'n events Schizotypal Personality Disorder ME "EC<LIAR 9E criteria; M2 Ma'ical thin+in' or odd belie s E2 Experiences unusual perceptions "2 Paranoid ideation E2 Eccentric behavior or appearance C2 Constricted 9or inappropriate; a ect <2 &nusual 9odd; thin+in' and speech

Shizoid Personality Disorder DIS#AN# 9A criteria; D2 Detached 9or lattened; a ect I2 Indi erent to criticism and praise S2 Sexual experiences o little interest #2 "as+s 9activities; done solitarily A2 Absence o close riends N2 =either desires nor en@oys close relations #2 "a+es pleasure in e% activities

N L2 Lac+s close riends I2 Ideas o re erence A2 Anxiety in social situations R2 !ule out psychotic disorders and pervasive developmental disorder

luster ( Dramatic) 'rratic Group Antisocial Personality Disorder CORR<"# 96 criteria; C( Con ormity to la% lac+in' O8 )bli'ations I'nored R8 !ec+less disre'ard o sa ety or sel or others R8 !emorse lac+in' <8 &nderhanded 9deceit ul: lies: cons; "( Plannin' Insu icient 9Impulsive; #( "emper 9Irritable and a''ressive;

(orderline Personality Disorder AM S<ICIDE 9E criteria; A8 Abandonment M8 Mood instability S8 Suicidal or sel mutilatin' behavior <8 &nstable and intense relationships I8 Impulsivity 9 L 5 sel dama'in' areas; C8 Control o An'er I8 Identity Disturbance D8 Dissociative 9or paranoid; symptoms E8 Emptiness 9chronic eelin's o ; +arcissistic Personality Disorder S"ECIAL 9E criteria; S 8 Special 9believes is special or uni8ue; " 8 Preoccupied %ith antasies 9o unlimited success E 8 Entitlement po%er: beauty: etcM; C 8 Conceited 9'randiose sense o sel importance; I 8 Interpersonal Exploitation A 8 Arro'ant 9hau'hty; L 8 Lac+s empathy

*istrionic Personality Disorder "RAISE ME 9E criteria; " ( Provocative behavior 9or seductive; R ( !elationships 9more than they are; A ( Attention 9uncom ortable %hen not center; I ( In luenced Easily S ( Style o speech 9impressionistic: lac+s det0; E ( Emotions 9rapidly shi tin' and shallo%; M ( Made &p 9physical appearance to dra% attention to sel ; E ( Emotions exa''erated 9theatrical;

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luster Anxious) ,ear#ul Group Avoidant Personality Disorder CRIN3ES 9A criteria; C ( Certainty 9o bein' li+ed be ore %illin' to 'et involved %ith others; R ( !e@ection 9or criticism; preoccupies ones thou'hts in social situations I ( Intimate relationships 9restraint in intimate relationships due to ear o bein' shamed; N ( =e% interpersonal relationships 9is inhibited in; 3( Gets around occupational activity 9involvin' si'ni icant interpersonal contact; E ( Embarrassment 9potential; prevents ne% activity or ta+in' personal ris+s S ( Sel vie%ed as unappealin': inept: or in erior Dependent Personality Disorder RELIANCE 9E criteria; R8 !eassurance re8uired or decisions E 8 Expressin' disa'reement di icult 9 due to ear o loss o support or approval; L 8 Li e responsibilities 9need to have these assumed by others; I 8 Initiatin' pro@ects di icult 9due to lac+ o sel (con idence; A 8 Alone 9 eels helpless and discom ort %hen alone; N 8 =urturance 9'oes to excessive len'ths to obtain nurturance and support; C 8 Companionship 9another relationship; sou'ht ur'ently %hen close relationship ends E 8 Exa''erated ears o bein' le t to care or sel Obsessive ompulsive Personality Disorder LA9 $IRMS 9A criteria; L 8 Loses point o activity 9due to preoccupation %ith detail; A 8 Ability to complete tas+s 9compromised by per ectionism; 9 8 -orthless ob@ects 9unable to discard; $ 8 $riendships 9and leisure activities; excluded 9due to a preoccupation %ith %or+; I 8 In lexible: scrupulous: over conscientious 9on ethics: values: or morality: not accounted or by reli'ion or culture; R 8 !eluctant to dele'ate 9unless others submit to exact 'uidelines; M 8 Misery 9to%ard sel and others; S 8 Stubbornness 9and ri'idity;

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