Reaching Rural Veterans Initiative Applying Psychiatric Principles To Improve Patient Outcomes

1. Reaching Rural Veterans Initiative Applying Psychiatric Principles To Improve Patient Outcomes John K. Findley, M.D. Geisinger Medical Center Danville, Pennsylvania 17822

2. Chronic Pain Opiates Depression DT SI Alcohol Dependence Family & Marital Problems PCP PTSD Anxiety Individual Therapy Personality Disorders Rx Mental Health Issues Limbic System “The difficult patient” Biology

3. The Limbic System

4. Psychiatry is the medical application of limbic dysregulation • Neurology/Psychopharmacology • Mood/Anxiety/ Psychosis • Delirium/Capacity/Mental Status • Pain/Sedation/Agitation

5. The Brain

6. Limbic Probes & Chum • In-suck of breath • Answers to questions NOT asked • Listening with the 3rd ear • AA vs. methadone

7. Chronic Pain Alcohol Dependence Opiates Depression DT SI Family & Marital Problems PCP PTSD Anxiety Individual Therapy Personality Disorders Rx Mental Health Issues Limbic System “The difficult patient” Biology

8. Taking care of the hateful patient JE Groves Abstract "Hateful patients" are not those with whom the physician has an occasional personality clash. As defined here they are those whom most physicians dread. The insatiable dependence of "hateful patients" leads to behaviors that group them into four stereotypes: dependent clingers, entitled demanders, manipulative help-rejecters and self-destructive deniers. The physician‘s negative reactions constitute important clinical data that should facilitate better understanding and more appropriate psychological management for each. Clingers evoke aversion; their care requires limits on expectations for an intense doctor-patient relationship. Demanders evoke a wish to counterattack; such patients need to have their feelings of total entitlement rechanneled into a partnership that acknowledges their entitlement--not to unrealistic demands but to good medical care. Help-rejecters evoke depression; "sharing" their pessimism diminishes their notion that losing the symptom implies losing the doctor. Self-destructive deniers evoke feeling of malice; their management requires the physician to lower Faustian expectations of delivering perfect care. NEJM 1978 April 20

9. Hateful Patients Stereotype • Dependent clingers • Entitled demanders • Manipulative help-rejecters • Self-destructive deniers Feelings Evoked Aversion Counter Attack Depression Malice Strategy Limit expectations Re-channel into partnership Share their pessimism Lower expectation of appropriate care

10. Personality Pervasive chronic patterns of thinking, feeling, acting and reacting

11. Transferencevs.Counter Transference

12. Cluster BDramatic, Emotional, Erratic Narcissistic Antisocial Borderline

13. Self-Inflicted Wounds Coping Strategy Psychosis (Therapy) (Medication)

14. Cognitive Behavioral Therapy(CBT) • Based on interplay between cognition, mood and behavior • Assumes psychopathology, in part, based on distorted thinking, in turn has negative impact on mood and behavior • Structured based; teaches methods/skills to become their own therapist Thoughts Feelings Behavior

15. Application of CBT • Depression • Panic • Substance Abuse (AA) • Personality (DBT) • Eating Disorders

16. Chronic Pain Alcohol Dependence Opiates Depression DT SI Family & Marital Problems PCP PTSD Anxiety Individual Therapy Personality Disorders Rx Mental Health Issues Limbic System “The difficult patient” Biology

17. NEJM Ballentine

18. Chronic Opiates • Increase pain • Decrease immunity • Lead to addiction

19. Medication Effects of Narcotics

20. $ Street Dilaudid Fentanyl Oxycontin Morphine Percocet Vicodin Ultram Methadone Euphoria

21. Pain Sleep Appetite Euphoric Dysphoria Mood

22. Evaluation of Pain • Sleep and Appetite • Complaints of pain vs. Clinical Syndrome • Drug seeking behavior

23. Fibromyalgia • Uncertain pathology; normal muscle biopsy • Without objective clinical or laboratory abnormalities • Inheriting a patient with diagnosis & on opiates • High psychiatric comorbidity

24. Chronic Pain Alcohol Dependence Opiates Depression DT SI Family & Marital Problems PCP PTSD Anxiety Individual Therapy Personality Disorders Rx Mental Health Issues Limbic System “The difficult patient” Biology

25. Alcohol Withdrawal • History (CAGE) • Behavioral changes • Biological Markers; MCV/SGOT • Delirium versus tremens • Dual Diagnosis vs. Comorbidity

26. The CAGE Questionnaire

27. The Stages of Behavioral Change

28. Laboratory Tests Simple routine laboratory tests that predict the likelihood of DT

29. Delirium Tremens • No tremor or diaphoresis; no benzo’s • Long Acting (Librium) vs. Short Acting (Ativan) • Aggressive “In and Out” • Neuroleptics for Agitated Delirium

30. Clinical distinctions betweenComorbidity and “Dual Diagnosis” IA: Mood, Anxiety or Psychotic DisorderIB: Substance Abuse Disorder II: Personality Disorder

31. Chronic Pain Alcohol Dependence Opiates Depression DT SI Family & Marital Problems PCP PTSD Anxiety Individual Therapy Personality Disorders Rx Mental Health Issues Limbic System “The difficult patient” Biology

32. Shell Shock Syndrome to PTSD(Battle fatigue, war neurosis, railway spine) • Homer's Odyssey • British Doctors first described psychiatric illness in 1914

33. Post Traumatic Stress vs. Acute Stress • Exposed to traumatic event that involved actual or threatened serious injury or death • Persons response involved intense fear, helplessness or horror

34. Diagnostic Criteria • Sleep disturbance • Recurrent/intensive distressing memories • Flashbacks • Avoidance • Hypervigilance

35. Signs and Symptoms ofPTSD vs. Time

36. Treatment • Benzodiazepines • SSRI’s • Neuroleptics

37. Chronic Pain Alcohol Dependence Opiates Depression DT SI Family & Marital Problems PCP PTSD Anxiety Individual Therapy Personality Disorders Rx Mental Health Issues Limbic System “The difficult patient” Biology

38. Diagnostic Criteria S sleep I interests G guilt E energy C concentration A appetite P psychomotor, agitation or retardation S suicidal ideation

39. Clinical Observations • Mood vs. Affect • Congruent • Incongruent • Affect Extinction Rates • Importance of general appearance

40. Evaluating Suicidal Ideation • Cultural considerations • When used as a coping strategy • Imminent vs. Non-imminent • Lethality vs. Recovery

41. Dopaminergic Hypothesis • Consider stimulants • Medically ill • Elderly

42. Special Considerations • Elderly Patient’s adjustment to mortality • End of Life: • “I’m sorry, I forgive you, I love you, good-bye”

43. Chronic Pain Alcohol Dependence Opiates Depression DT SI Family & Marital Problems PCP PTSD Anxiety Individual Therapy Personality Disorders Rx Mental Health Issues Limbic System “The difficult patient” Biology

45. Return of the Alpha Male • Difficulty assimilating back to their pre-existing family role • Seeing psychiatrist is often egodystonic • Continuous conflict with spouse • Struggle to assert themselves

46. When defense mechanisms & coping strategies don’t work anymore…will psychotherapy work? Rationalization Adaptive Maladaptive Denial Regression Coping Strategies In / Out Humor Suppression Projection Splitting Intellectualization

47. Chronic Pain Alcohol Dependence Opiates Depression DT SI Family & Marital Problems PCP PTSD Anxiety Individual Therapy Personality Disorders Rx Mental Health Issues Limbic System “The difficult patient” Biology

48. Receptor Binding Profiles

49. Mood Stabilizers • Valproic Acid • Tegretol • Lithium

50. Antidepressants SSRI’s vs. Stimulants Transitional Objects