Chapter Twelve: Other Psychiatric Considerations

1. Chapter Twelve: Other Psychiatric Considerations

2. points to consider • Suicide evaluation and prevention • Mental status examination • Categories of psychiatric illness • Psychotropic medications

3. suicide • More common in alcoholics • More common when drinking • 65% involve drinking • alcoholics and non-alcoholics • alcohol effects judgment

4. suicide: types Completers  isolated secretive lonely violent methods  calculated  lonely teens or white males 50+ Attempters  impulsive  pills  women  die by mistake

5. suicide: types (cont.) Threateners  as “weapon” in relationships  usually don’t follow through Parasuicide  a different class  to relieve emotional pain  die through miscalculation

6. suicide: high-risk factors Recent loss Single, widowed, childless Emotional constellations anger + hopelessness poor family communications isolation in a relationship Chronic illness Entering or leaving depression

7. suicide: clinical tips Ask all clients Be explicit If suicidal thoughts . . . What was going on then? Is there a plan?

8. responding to suicidal patients • Diffuse psychologically and concretely • Offer alternatives • Reinforce reasons to live • Make a referral • Get weapons • Assure not leaving office to go home alone

9. emergency situations • Someone threatening to jump or shoot themselves • Police departments have trained emergency personnel • In the meantime . . . • keep voice down • non-threatening topics • ask practical questions

10. mental status exam • Purpose • secure information on mental functioning • Three components • mood and affect • thought processes • cognitive functioning

11. major categories of of psychiatric illness • Substance use, most common psychiatric disorder • Alcoholism, the great mimicker • can mask other disorders • Need to assess contribution of alcohol and other psychiatric disorders to problems • Substance use problem  another psychiatric condition termed “co-morbidity” or “co- occurring disorders”

12. mood disorders • Depression • Mania • Bipolar • Relation to alcohol use • can worsen depression • can contribute to suicide attempts • possible use to self-medicate in mania

13. mood disorders (cont.) • Relationship to alcohol dependence • depression common in alcoholism • diagnosis of depression in sober state by history, depression prior to alcohol

14. disorders with psychosis • Disturbed thought and perceptions • Schizophrenia • debilitating • positive symptoms additions to usual behavior delusions, hallucinations • negative symptoms loss of usual functions withdrawal, difficulty communicating, depressed mood

15. disorders with psychosis (cont.) • Alcohol-induced conditions can mimic schizophrenia • Wernicke-Korsakoff syndrome • alcoholic hallucinosis • Alcohol use in schizophrenia • modest use can cause problems

16. anxiety disorders • Steady or episodic • Different types • fear of places/situations (agoraphobia) • fear of specific object (simple phobia) • unrelenting thoughts (obsessions) • repetitive acts (compulsions) • Physical symptoms • No alteration of mood , thought, or judgment

17. anxiety disorders (cont.) • Diagnose in abstinent state • Benzodiazepines used to treat • high abuse potential • other medications available • Primary or secondary to alcohol problems

18. personality disorders • Ten different types • Types common with alcohol • Antisocial Personality Disorder • interpersonal problems problems with authority con others for personal benefit • risk factor for alcohol disorders • drinking can induce antisocial behaviors

19. personality disorders (cont.) • Borderline Personality Disorder • inappropriate emotions • feelings of boredom, emptiness • chaotic life situations • impulsive • evoke negative feelings in helpers • diagnose in sober state

20. attention deficit hyperactivity disorder • First seen in childhood • 3% to 5% of children • Increased risk for alcohol/drug use problem • Diagnosis difficult in alcoholism • Consider when a series of treatment failures • By history, childhood

21. attention deficit (cont.) hyperactivity disorder • Treatment with medication • Stimulants common • Stimulants paradoxical action • Suggests brain anomalies • Implications for prevention • children with ADHD

22. medical illness causing psychiatric illness • Variable causes examples: brain tumor, stroke, infections • Permanent or reversible reversible = delirium irreversible = dementia • Treatment of underlying condition • Elderly especially susceptible

23. alcohol problems and homelessness • Every evening, 600,000 people without shelter • 2/5ths of homeless have alcohol problems • Multiply disadvantaged • medical problems  psychiatric illness • social isolated  victims of crime • transient  Tx revolving door

24. other addictive behaviors • Non-alcohol/drug addictions • seen as disorders of impulse-control • gambling • eating disorders • computer/internet • Alcohol often part, non-substance addictions

25. psychotropic medications • Different types of psychotropic medications • Different properties • Differ in abuse potential • Four major classes • anti-psychotic  mood stabilizers • anti-depressants  anti-anxiety

26. psychotropic medications: anti-psychotic agents • Used to treat severe mental illness • In addition to anti-psychotic effects also sedating • Little likelihood of abuse • Effects not considered “pleasurable” • Two different types of anti-psychotic drugs

27. psychotropic medications: anti-depressants • For biological component of depression • Take for 2 or more weeks before full effects • Different types of anti-depressants • Rarely subject to abuse • But overdose can be lethal

28. psychotropic medications: mood stabilizers • Used to treat bipolar disorder, mania, and depression • Different types of drugs in category • Alcohol contraindicated additive effects and possible liver damage • Little likelihood of abuse

29. psychotropic medications: anti-anxiety agents • Effects similar to alcohol • invite abuse and dangerous with alcohol • Uses: treat anxiety disorders managing alcohol withdrawal • Two different types • benzodiazepines • “non-benzodiazepines”less abuse (e.g. Atarax, Buspar) • Associated with abuse • Librium Valium Xanax Rohypnol(not available in U.S.)