Behavioral Health

Generalized Anxiety Disorder

Generalized Anxiety Disorder, GAD, is an anxiety disorder characterized by chronic anxiety, exaggerated worry and tension, even when there is little or nothing to provoke it.

Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder, OCD, is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Repetitive behaviors such as hand washing, counting, checking, or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called “rituals,” however, provides only temporary relief, and not performing them markedly increases anxiety.

Panic Disorder

Panic disorder is an anxiety disorder and is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, and shortness of breath, dizziness, or abdominal distress.

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder (PTSD) PTSD is an anxiety disorder that some people get after seeing or living through a dangerous event. When in danger, it’s natural to feel afraid. This fear triggers many split-second changes in the body to prepare to defend against the danger or to avoid it. This “fight-or-flight” response is a healthy reaction meant to protect a person from harm. But in PTSD, this reaction is changed or damaged. People who have PTSD may feel stressed or frightened even when they’re no longer in danger.

Social Phobia (or Social Anxiety Disorder)

Social Phobia, or Social Anxiety Disorder, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. Social phobia can be limited to only one type of situation — such as a fear of speaking in formal or informal situations, or eating or drinking in front of others — or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people.

Best Practices

Interventions for the treatment of anxiety disorders categories: Pharmacological and psychosocial interventions. Cognitive behavior therapy (CBT) is a type of psychosocial treatment that helps patients to understand the thoughts and feelings that influence behaviors. Pharmacological management includes, most often, prescribing an Antidepressant, anti-anxiety medications, and beta-blockers.

Screening Tools:

• GAD-7
• www.anxietycentre.com: Anxiety Rating Test, Social Anxiety Test, Anxiety Potential Test, Anxiety Disorder Test, and Degree of Anxiety Condition Test

Resources:

• National Alliance on Mental Illness
• National Institute of Mental Health
• Substance Abuse and Mental Health Services Administration

Autism is one of a group of serious developmental problems called autism spectrum disorder (ASD) that appear in early childhood- usually before age 3. Though symptoms and severity vary, all autism disorders affect a child’s ability to communicate and interact with others.

Symptoms to look for:

Problems in three crucial areas of development: social interaction, language and behavior.

• Fails to respond to his or her name
• Has poor eye contact
• Appears not to hear you at times
• Resists cuddling and holding
• Appears unaware of others’ feelings
• Seems to prefer playing alone
• Starts talking later that age 2
• Loses previously acquired ability to say words or sentences
• Doesn’t make eye contact when making requests
• Speaks with an abnormal tone or rhythm
• May repeat words of phrases verbatim
• Performs repetitive movements such as rocking, spinning, or hand flapping
• Develops specific routines or rituals
• Becomes disturbed at the slightest change in routine or rituals
• Moves constantly
• May be unusually sensitive to light, sound and touch and yet oblivious to pain
• May be fascinated by parts of an object, such as the spinning wheels of a toy car

Best Practices:

No cure exists for autism, and there is no “one–size-fits-all” treatment. The range of home-based and school-based treatments and interventions of autism can be overwhelming. Treatment options may include: behavior and communications therapies, educational therapies and medications. Alternative therapies include: creative therapies, special diets, and chelation therapy.

Screening Tools:

• Due to the complex nature of autism, numerous screening tools exist. Here are some of the links that can be used for screening purposes. www.firstsigns.org/screeings/tools

Resources:

• National Alliance on Mental Illness
• National Institute of Mental Health
• Substance Abuse and Mental Health Services Administration

Bipolar Disorder is a condition characterized by shifts in mood, energy, and activity levels, which can affect one’s ability to carry out daily tasks as well as one’s relationships, job, and school performance. Individuals suffering from Bipolar Disorder experience distinct “mood episodes” that are more extreme than the regular ups and downs that we may all experience from time to time. There are multiple types of Bipolar Disorder that differ in the types of mood episodes experienced, as well as the frequency and intensity of the symptoms. Bipolar Disorder often develops in the late teens or early adult years, but in some cases can begin in childhood or later in one’s adult life. It is usually a long term illness, but there are effective treatments that can allow people to lead full and productive lives.

Symptoms to look for:

Signs of a Manic Episode:

• Excessive happiness or excitement
• Irritability
• Restlessness or increased energy
• Racing thoughts
• Grandiosity
• Impulsive or reckless behaviors

Signs of a Depressive Episode:

• Sadness
• Decreased energy or motivation
• Difficulty concentrating
• Hypersomnia
• Appetite changes
• Hopelessness

Best Practices

Often, people respond best to a combination of medication and therapy aimed at learning to manage symptoms. There are a variety of medications used to treat Bipolar Disorder and people may need to try different types before they find that ones that work best for them. Mood stabilizers, anticonvulsants, and antipsychotics are often used to treat this disorder. In addition, the depressive symptoms may be treated with antidepressants, but are usually taken with a mood stabilizer due to the risk of triggering a manic episode. Individuals with Bipolar Disorder are also at high risk for suicide whether they are in a manic or depressive episode, so it is important to assess for this and plan for emergencies.

• Conduct client education and family education as appropriate
• Increase recognition of symptoms and signs of episodes
• Confirm diagnosis of co-morbid conditions and treat accordingly
• Monitor medication compliance and side effects
• Regulate daily routines for sleep, activity, and relaxation
• Increase awareness of interactions between medications and various foods, over-the-counter medications, as well as alcohol and caffeine
• Identify stressors that trigger manic or depressive moods/episodes
• Develop effective stress management skills
• Identify positive coping skills for managing emotions
• Increase awareness of signs of relapse
• Develop personal support system and a plan for emergencies with support persons
• Stress the need for continued medication compliance after stabilization

Screening Tools:

• The Mood Disorders Questionnaire

Resources:

• National Alliance on Mental Illness
• National Institute of Mental Health
• Depression and Bipolar Support Alliance
• Substance Abuse and Mental Health Services Administration

Borderline personality disorder is a serious mental illness marked by unstable moods, behavior, and relationships. Because some people with severe borderline personality disorder have brief psychotic episodes, experts thought of this illness as atypical, or borderline, versions of other mental disorders. While mental health experts now generally agree that the name “borderline personality disorder” is misleading, a more accurate term does not exist yet. Most people who have borderline personality disorder suffer from:

• Problems with regulating emotions and thoughts
• Impulsive and reckless behavior
• Unstable relationships with other people.

People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides. Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia. These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat borderline personality disorder and other mental disorders.

Symptoms to look for:

• According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:
• Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
• A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
• Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
• Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
• Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
• Intense and highly changeable moods, with each episode lasting from a few hours to a few days
• Chronic feelings of emptiness and/or boredom
• Inappropriate, intense anger or problems controlling anger
• Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

Best Practices

Psychotherapy is usually the first treatment for people with borderline personality disorder. Types of psychotherapy include Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT) and Schema-focused therapy.

Screening Tools:

• The McLean Screening Instrument

Resources:

• National Alliance on Mental Illness
• National Institute of Mental Health

Depression is a medical illness that involves the mind and body. It affects how someone feels, thinks and behaves. It can lead to a variety of emotional and physical problems. Someone may have trouble doing normal day-to-day activities, and depression may make someone feel as if life isn’t worth living. More than just a bout of the blues, depression isn’t a weakness, nor is it something that someone can simply “snap out” of. Depression is a chronic illness that usually requires long-term treatment but most people with depression feel better with medication, psychological counseling or other treatment.

Symptoms to look for:

Adults

• Persistent sad, anxious, or “empty” feelings
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness irritability, restlessness
• Loss of interest in activities or hobbies once pleasurable
• Fatigue and decreased energy
• Difficulty concentrating, remembering details, and making decisions
• Insomnia, early-morning wakefulness, or excessive sleeping
• Overeating, or appetite loss
• Thoughts of suicide, suicide attempts
• Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment.

Children and Adolescents

• Frequent sadness, tearfulness, crying
• Decreased interest in activities; or inability to enjoy previously favorite activities
• Hopelessness
• Persistent boredom; low energy
• Social isolation, poor communication
• Low self-esteem and guilt
• Extreme sensitivity to rejection or failure
• Increased irritability, anger, or hostility
• Difficulty with relationships
• Frequent complaints of physical illnesses such as headaches and stomachaches
• Frequent absences from school or poor performance in school
• Poor concentration
• A major change in eating and/or sleeping patterns
• Talk of or efforts to run away from home
• Thoughts or expressions of suicide or self-destructive behavior

Best Practices

Interventions for the treatment of depression falls into two main categories: Pharmacological and psychosocial interventions. Psychosocial interventions such as Cognitive Behavioral Therapy, Interpersonal Therapy, Psychodynamic Therapy, and Dialectical Behavior Therapy, can be useful. Pharmacological management includes, most often, prescribing Antidepressants- including SSRI’s, SNRI’s, MAOI’s, Atypical, Tricyclic and Tetracyclic. A follow up appointment should occur within 12 weeks of diagnsosing and initiating treatment of an adult with an antidepressant medication. Another follow up appointment should occur within the next 90 days to ensure effective continuation of treatment.

• Develop and practice healthy stress management and coping skills
• Develop and practice healthy problem-solving and communication skills (Including how to effectively negotiate and compromise)
• Develop and practice healthy ways to monitor and control impulses
• Identify the connection between thoughts, feelings, and actions
• Identify and replace cognitive distortions and negative self-talk (avoid all-or-nothing, black-or-white, and catastrophic patterns of thinking)
• Develop and practice a routine of physical exercise, activity, and social involvement
• Identify, verbalize, and address any unresolved grief or loss issues
• Acknowledge the presence of any self-harm thoughts or suicidal thoughts and develop a personal safety plan to avoid acting on them (suicide is among the three leading causes of death for people ages 15-44)
• Participate in a psychiatric evaluation and take all prescribed medications as instructed
• Rule out other psychiatric disorders (e.g., grief reaction, personality disorders, Dysthymia)
• Rule out medical disorders (e.g., hypothyroidism)
• Rule out depression-inducing medications (e.g., steroids)
• Rule out Substance Use Disorder

Screening Tools:

• PHQ-9

Resources:

• National Alliance on Mental Illness
• National Institute of Mental Health
• Substance Abuse and Mental Health Services Administration
• National Suicide Prevention Lifeline 1-800-273-TALK (8255)

Best-Practice Intervention Strategies

• Participate in a psychiatric evaluation and take all medications as prescribed
• Use a thought stopping strategy to interrupt cognitive obsessions
• Practice relaxation techniques such as deep breathing
• Consider learning and practicing the Exposure and Response Prevention (ERP) technique by confronting feared situations and objects (exposure) and resist performing compulsive rituals (response prevention)
• Recognize, discuss, and refute dysfunctional beliefs (e.g., magical or catastrophic thinking patterns)
• Develop and practice a daily ritual to interfere with the current compulsive pattern
• Identify, verbalize, and address unresolved life issues
• Provide psycho-education for family members and encourage their support for the patient during treatment
• Develop and practice positive self-talk

Oppositional Defiant Disorder/Conduct Disorder

Best-Practice Intervention Strategies

• Train parents in behavior modification techniques
• Confirm diagnosis to rule out similar diagnoses that mimic ODD symptoms
• Review parenting techniques to assess effectiveness of training
• Monitor medications if prescribed for co-morbidity (e.g., ADHD, Depression)
• Develop effective problem-solving skills
• Develop appropriate assertiveness skills
• Increase anger management skills
• Assist parents in developing contracts/reward system for positive behavior
• Increase acceptance of responsibility for behaviors
• Decrease impulsivity and identify alternate appropriate behaviors
• Maintain communication between all contexts: parents, school, and community

Psychosis is used to describe conditions that affect the mind in which there has been some loss of contact with reality. Some of the diagnostic psychotic disorders identified in the DSM IV TR are: Schizophrenia, Schizoaffective, Delusional Disorder, Brief Psychotic Disorder, Substance Induced Psychotic Disorder, and Psychotic Disorder NOS. Consider the following:

• Symptoms usually start between ages 16- 30. Men tend to experience symptoms a little earlier than women.
• Has the patient had a major traumatic event happen in his/her life?
• Is there family history of mental illness?

Symptoms to look for:

• Hallucinations auditory and visual are most common
• Delusions
• Social withdrawal
• Reduced concentration and attention
• Sleep disturbances
• Irritability
• Suspiciousness
• Not caring for ADL’s
• Anedonia (lack of interest)

Best Practices

Interventions for the treatment of schizophrenia and other psychotic disorders falls into two main categories: Pharmacological and psychosocial interventions. Pharmacological management includes, most often, prescribing a typical and/or atypical antipsychotic when a person is experiencing psychotic symptoms. Psychosocial interventions such as cognitive behavioral therapy (CBT), family therapy, or education, and problem solving therapy, can be useful in management of recovery and the prevention of relapse.

Screening Tools:

• Psychosis: What is it and How to Treat it

Resources:

• National Alliance on Mental Illness
• National Institute of Mental Health

For information regarding the United States Department of Veterans Affairs’ resources for Post Traumatic Stress Disorder, please go to the National Center for PTSD on the United States Department of Veterans Affairs’ website.

PTSD 101 is a web-based curriculum that offers courses related to PTSD and trauma. The goal is to develop or enhance practitioner knowledge of trauma and its treatment. Continuing Education (CE) credits are available for most courses — newer courses will offer CEs soon.

• presented by a faculty of recognized experts in the field of traumatic stress.
• developed specifically for busy clinicians who provide services to individuals who have experienced trauma.
• appropriate for both seasoned PTSD professionals and those new to PTSD treatment or military personnel.

Best-Practice Intervention Strategies

• Conduct client education about PTSD
• Confirm proper diagnosis and presence of additional diagnosis (e.g., Depression, Anxiety)
• Increase awareness of symptoms
• Identify events that trigger stress
• Decrease guilt, shame, or anger
• Confirm compliance with medications and monitor for side effects
• Develop effective relaxation skills
• Increase coping skills to manage anxiety
• Develop or increase anger management skills
• Increase social/communication skills
• Conduct education on relapse prevention and warning signs
• Consider appropriate medication for repetitive nightmares, flashbacks, and mood lability

Somatoform disorders are a category of mental illnesses that cause pain or other symptoms that would suggest a medical condition but where no physical explanation can be found. These symptoms must cause the patient significant distress or impairment in functioning. Somatoform disorders differ from malingering in which symptoms are intentionally feigned for external gain, or factitious disorder in which symptoms are adopted or exaggerated due to an unconscious desire for sympathy or other internal gain. In somatoform disorders, the sufferer perceives the illness as real and they can cause the person to become extremely worried and preoccupied with their physical health. The types of somatoform disorders include Somatization Disorder, Pain Disorder, Hypochondriasis, Body Dysmorphic Disorder, and Conversion Disorder.

Symptoms to look for:

• Physical pain with no apparent cause
• Multiple symptoms occurring in different organ systems
• Symptoms affecting motor or sensory function that are preceded by a psychological stressor
• Preoccupation with fears of having a serious illness
• Obsessions over physical imperfections or deformity that may or may not exist.

Best Practices

Diagnosing somatoform disorders can be difficult and requires a thorough medical examination and review of medical records to rule out any possible physical cause. Treatment for somatoform disorders should include therapy, and cognitive behavioral therapy has been shown to be one of the more effective treatments. Ongoing medical treatment is also necessary and psychosocial interventions guided by the physician seem to be most successful. A good relationship between the primary care physician is critical and psychoeducation about how symptoms can be exacerbated by stress and other psychological disturbances can help as well. Regular follow up visits and ongoing assessment of the patient’s condition will help reduce anxiety and limit emergency visits.

Screening Tools:

• SOMS-7

Resources:

• National Alliance on Mental Illness
• National Institute of Mental Health
• Family Doctor
• Association for Behavioral and Cognitive Therapies
• Psychosomatic Medicine

Substance Abuse is the excessive consumption or misuse of a substance for the sake of its nontherapeutic effects on the mind or body, especially drugs or alcohol.

Possible signs of substance abuse:

• Behavioral Changes: agitation, fits of violence or anger, paranoia or depression, apathy, forgetfulness, sudden need for money, lying
• Physical Changes: any dramatic increase or decrease in weight, poor coordination, tremors, scent of substance, insomnia or hypersomnia
• Social Changes: will withdraw from friends and family, suddenly socialize with those significantly younger or older

Best Practices

Current research-based best practices tend to merge the biopsychosocial, theoretical perspective of addictive disorders. This includes supportive counseling, motivating client readiness for change, and coping-skills training techniques. The goals of treatment are:

• To establish and maintain abstinence from the illicit use of all psychoactive drugs;
• To foster development of (non-chemical) coping and problem-solving skills;
• To stop and ultimately eliminate impulses to “self-medicate” with psychoactive drugs; and
• To enhance and sustain client motivation for change.

Screening Tools:

• Screening for Drug Use in General Medical Settings(Quick Reference Guide)
• Patient Health Questionnaire (PHQ)

Resources:

• National Institute on Drug Abuse
• Substance Abuse and Mental Health Services Administration