Getting the Diagnosis Right · 8/8/2018 · Good grades Elementary School, Middle School and even...

Getting the

Diagnosis Right

Susan Caverly, PhD, ARNP, BCTherapeutic Health Services

Seattle ,Washington

King County School Health Clinics 2018

S. Caverly 2018 King County

Thank you to Verdant Health Commission and Snohomish County for grant funding

supporting implementation of the Integrated Cognitive Therapies Program

All pictures and diagrams are the product of this author.


Upon completion of this session participants will be able to describe three (3) strategies for differentiating symptoms to determine diagnoses when working with adolescents.


Consider the most common mental health symptoms teens present in the school setting

Review commonplace strategies for determining diagnoses

Present a structure and options for being more specific

Case Exemplars


The Integrated Cognitive Therapies Program (ICTP) began in 2014 as an outgrowth of a 2010 collaboration between Therapeutic Health Services and the University of Colorado at Denver to launch ENCOMPASS.

ENCOMPASS was developed in a multi-site clinical trial by Paula Riggs, MD, but had not been shown a feasible practice prior to this collaboration.

ICTP has been listed on the Washington State Registry of Research Based, Evidence Based and Promising Practices

ICTP incorporated adaptations that included a model for individual and group Parent Coaching. This model may be adapted with permission and acknowledgement.


Ellen Rosen-McGill, LICSW Cognitive Behavior Therapist and Clinical Supervisor

Seattle

Kara Key, LICSW, CDPT Lead Therapist – Snohomish County

Laura Lamb, LMHC Lead Therapist – Snohomish County

Susan Caverly, PhD, ARNP, BC ICTP Director and Director of Psychiatric Services at THS


What are your most pressing topics related to diagnosis?

Differentiating symptoms Determining what a symptom points to Psychiatric disorder Response to a difficult day Volitional behaviors/secondary gain Learning differences Development Substance use

Engagement in the process of assessment

Often family history is not available and patient doesn’t really know or remember their own complete history

Knowing when to take threats seriously


Time – and awareness that with neuronal development, psychiatric presentation also changes

When feasible, collateral information from parent

Standardized Assessment Measures One time use at initiation of care Repeated use of measure

Ratings Rate your mood on scale of 1-10 (today, best this week and

worst this week)

Color Calendar



Susan’s Color Calendar

Directions: Select no more than 5 colors

Red: Chaotic Day, Angry, Difficult Sleep, Over-eating

Yellow: Wonderful Day, Very Happy Mood, Did not need to sleep, Enjoyed food

Green: Calm Day, Relaxed Mood, Slept well, Appetite fine

Blue: Problems in Day, Sad Mood, Slept too much and still tired, Appetite poor

Black: Horrible Day, Despairing Mood, Can’t sleep at all and exhausted, No

interest in food

Day

Environment

Sleep

Mood Appetite

All New Participants


1. Substance Use (Lifetime) TLFB (28 days) 2. TLFB (28 days) (Timeline Follow-back3. LEC-5 (Lifetime) (Life Events Check List)4. CDRS (28 days) (Child Depression Rating Scale)

(If score indicates depression, ask if/when this may have occurred in the past.)

1. MASC (28 days) (Multidimensional Anxiety Scale for Children)(If score indicates anxiety disorder, ask if/when this may have occurred in the past)

(Past 28 days and prior)

1. Conduct Disorder Screen2. Oppositional Defiant Disorder Screen3. Disrupted Mood Dysregulation Disorder Screen4. Intermittent Explosive Disorder Screen


ASRS –Adult Self-Report Screen for ADHD

YMRS – Young Mania Rating Scale (use clinical judgment)

(Note Anxiety Measure has already been assessed using MASC-2)


If Symptoms Suggest Trauma PCL-5 (PTSD Check List for DSM V)

If Symptoms Suggest a Mood Disorder YMRS – (Young Mania Rating Scale)

If Symptoms Suggest an Eating Disorder Eating Disorder Questionnaire

If Symptoms Suggest Psychotic Disorder Brief Psychiatric Rating Scale


YBOCS for Obsessive Compulsive Disorder

SPIN for Social Phobia/Anxiety

GAD-7

Zung or Beck Depression Inventories


( Although this will not be our focus today!)

NIDA SBIRT

Screen ALL Patients

in Drug Treatment

for Mental Illness

Screen ALL Patients

for Substance Use

Disorders

Screening, Brief Intervention & Referral to Treatment


We have Evidence of the Impact of adolescent SUD

Co-Morbidity is becoming the Norm

Perceptions of Substance Risk & Adolescent Addiction are problematic

Treatment Outcomes are Disappointing

We have Information that can Improve Outcomes


National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. Updated December 2016


S. Caverly 2018 King

County

58.50%

52.10%

10.60%

10.30% 9.50%

Substances Most Often Combined with RX Opioids by Teens

Usng Cannabis

Using Alcohol

Using cocaine

Using Tranquillizers

Using Amophetamines


Trouble concentrating and getting work done improved when she tried a friend’s Adderall…

She worries a lot about school and failing.

She thinks she has ADHD.

The Child Behavior Checklist has indicated that she struggles with attention and ability to sustain effort on a task, she is also forgetful and loses things frequently


What are the key symptoms that concern her

What more do we need to know


What are the key symptoms that concern her Focus and concentration

Worry

Using Friend’s RX

What more do we need to know School performance history?

Recent life events? Has there been a change?

Family history of mental health diagnoses?

Past therapy or psychopharmacology interventions?

Substance use?

Would assessment tools be helpful?


Adjustment Disorder

Social Phobia

Generalized Anxiety Disorder

PTSD

Obsessive Compulsive Disorder

Bipolar Disorder II

Major Depressive Disorder

Substance Use History

Sleep Apnea

Diabetes


Symptom Specifics

Trajectory of symptoms – escalating, static, cycling, circumstantial

Age of onset

Factors associated with onset or mitigation

Family History

Recent Stressors


Sleep – amount, stability, interruptions nightmares, sleep apnea/snoring

Appetite - stability, weight changes

Energy – stability, excessive, low

Libido – stability, excessive, low

Caffeine – amount, frequency, reaction, impact on sleep

Nicotine – amount, frequency, timing of initiation in relation to symptoms

Other Substances

Living situation


Claire has always struggled to fall asleep, she lies in bed and struggles to turn her thoughts off….

Thoughts are commonly about getting ready for the next day, or repetitive review of the prior day – events and how she behaved or what she wishes she had done differently, or worry about failure.

She wakes up at night and can’t fall back to sleep.

Claire gets up for school even when tired.

All of Claire’s sleep problems predated Adderall.


No psychiatric HX

Good grades Elementary School, Middle School and even high school have been consistent. Social experience has been becoming more problematic. High School has been “super hard”.

Parents separated when she was 12 and she had to move from family home, and away from friends.

Mother HX of anxiety and panic disorder.

Brother has been diagnosed with OCD.

Father “drinks”.

Paternal grandmother is “crazy”.

Claire recently began to “vape” “just nicotine” so that she could fit in with friends. Caffeine causes her to feel panic symptoms.


What tools might help clarify

ADHD onset should have occurred prior to middle school? And grades have been good…

Middle school and high school socially more challenging– did move create more difficulties?

Family history of anxiety seems important.

Vaping nicotine may be making things worse?

Trying Adderall from friend is a red flag…


Probable Social Anxiety Disorder.

Possibly Generalized Anxiety Disorder?

Explore for symptoms of Obsessive Compulsive Disorder.

Might rule out PTSD and Panic Disorder – but unlikely.

ADHD Highly Unlikely.


Peter is 14 years old

He has a very sweet demeanor and is well liked by teachers and peers

Mood has always been a bit subdued, but he is someone others always count on and he does well in school

Peter recently told a friend he had a plan to hang himself and that friend asked for help for Peter


Specific information regarding risk

Intention?

Access to means?

Resources/adults he is able and willing to access?

Plan for safety?

Parental ability to be supportive in seeking help?

History of self harm?

Identifiable triggers?

Any substance use, including nicotine, caffeine?


Peter’s older brother committed suicide 7 years ago, Peter was 7 y/o

Mother has been distraught and father has been working a lot

Maternal grandfather died in a way that family suspects was suicide

Maternal aunt is treated for depression

Paternal grandfather is described as alcoholic

Paternal uncle has been missing for years, and is believed by family to be addicted to opioids



Adjustment Disorder

PTSD

????


Engage and focus on safety

Include adult residing with Peter - ? Father

Clarify diagnosis

CDRS

PCL

Ask about substance use

Likely start SSRI, Monitor and titrate dose


William is 17 y/o and unlikely to graduate on time, he has been told he can’t play football due to his grades

He has been sleeping in class and missing school

He has been putting on weight, but denies he has been eating differently

He denies there is anything wrong, but he has been in fights at school, irritable, and his affect is flat when not angry

He has been forgetting things



Intermittent Explosive Disorder

Traumatic Brain Injury

Adjustment Disorder with Depression

Metabolic Disorder, i.e. Diabetes


Has he had a head trauma related to either football or fighting?

When did the irritability begin? Has it been in place for some time?

What is his sleep like at home? Has this changed? Does he snore?

Does he need to have labs to evaluate for diabetes or other metabolic or hematologic disorder?

What seems related to the fights?

What is his family history?


Still not certain!

Need to Consult more with family and with primary care or neurology.


New to the school due to problems at her prior school.

Self reported Bipolar Disorder and Hx suicide attempts

Maternal instability and reported Bipolar Disorder/Neglect

Hx of Abilify RX she “hated”

Anger dyscontrol – verbally raged intermittently for an hour.

Became angry, raged, bit her arm and threw an object carefully when Bipolar Disorder was not immediately “believed” “No one ever listens”


More psychosocial background.

More about psychiatric HX if possible – for Becky and her family. What is her supervision like?

Age of onset of self inflicted harm, mood lability and irritability.

Sleep quality and consistency.

What is the meaning of the DX Bipolar Disorder for Becky?


Becky’s parents were never married. Parents live separately.

Raised by her father and despises her mother, rages toward father.

Few friends and commonly in conflict with slightly older sisters School and social interaction has been a challenge.

Affect brightens when talking about how terrible her life has been and sharply switches when she is not given complete attention or is questioned in any way.

Frequent threats of and minor actions to harm self. Frequent trips to ER or in-patient care.

Sleeps 8-10 hours soundly on a regular basis and restricts food.


Do We Know?

Is it Bipolar Disorder?

How Do We Proceed?

Disruptive Mood Dysregulation Disorder – Most Likely due to ODD symptoms coupled with chronic, frequent, severe negative mood and temper outbursts

Reactive Attachment Disorder – Maternal relationship distant due to mother’s inability to bond with her, separation from siblings

Oppositional Defiant Disorder – Ruled out in favor of DMDD

PTSD – Possibly some as yet undisclosed trauma other than abandonment

Bipolar Disorder – Unlikely – Cycling seems unrelated and sleep not a primary concern – commonly tired


Severe recurrent tempter outbursts manifested verbally (rages), and or behaviorally, that are grossly out of proportion in intensity or duration to situation or provocation.

Temper outbursts that are inconsistent with developmental level.

Temper outbursts occurs on average three or more times per week.

Mood between temper outbursts is persistently irritable or angry most of the day nearly every day and is observable by others (parents, teachers, peers)

Age of onset before 10 y/o.S. Caverly 2018 King County

Take enough time to obtain full history.

Whenever possible obtain collateral information.

Incorporate standardized measures whenever feasible. When not, use quick rating scales.

Consult!


Getting the Diagnosis Right · 8/8/2018 · Good grades Elementary School, Middle School and even...

Documents

Transcript of Getting the Diagnosis Right · 8/8/2018 · Good grades Elementary School, Middle School and even...