Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2685_Библиотеки_им_академика_М_И_Перельмана
.pdf
Chapter 3 • Affective Changes 31
https://t.me/med1917
Symptoms suggesting psychological or psychosocial origin
Rule out a physiological/medication cause
Consider
domestic violence
Screen for suicide risk, depression, anxiety, bipolar
FIGURE 3-1 A suggested approach to the visit. There are areas of overlap.
Consider
substance use
disorder
If positive screen, gather
additional data
Evaluate and refer
to mental health
professional for
diagnosable
psychological
disorder
Gather more info
BATHE,
HEEADSSS
Symptoms
Physiological problems often present in the patient
as abdominal pain (Chapter 2), chest pain (Chapter 7),
confusion (especially in the older adult, Chapter 8),
dizziness (Chapter 12), fatigue (Chapter 15), headache
(Chapter 18), and sleep disturbances (Chapter 28).
Refer to the specic chapters that discuss the evaluation of the presenting concern and symptom(s).
Major Illness/Chronic Conditions
Mood disorders can occur secondary to a physiological
condition. Patients who have had a major health event,
such as a myocardial infarction, stroke, or trauma, or
who have chronic symptoms, such as pain, are at risk
for the development of depression.
The mnemonic THINC MED is useful when evalu-
ating for underlying organic causes of changes in mood
or behavior. Box 3-1 identies conditions that are com-
monly associated with anxiety and depression.
Could this be caused by medication?
Key Questions
n What prescribed medications are you currently
taking?
n What over-the-counter (OTC) and/or herbal medicines
do you take?
n What dietary supplements are you taking?
Medication History
Many medications can cause psychiatric symptoms
and mood changes. Box 3-2 lists medications that
can produce symptoms of depression, anxiety, and
mania.
32 Chapter 3 • Affective Changes
https://t.me/med1917
Box 3-1
Major categories of medical conditions that mimic psychological conditions are as follows:
T: Tumors
H: Hormones (e.g., thyroid, adrenal, gonads,
I: Infections and immune diseases (e.g., AIDS,
N: Nutrition
C: Central nervous system (e.g., head trauma,
M: Miscellaneous (e.g., sleep apnea, anemia,
E: Electrolyte abnormalities and toxins (e.g.,
D: Drugs (including nicotine, caffeine, prescribed
From Goolsby MJ, Grubbs L: Advanced assessment: interpreting
findings and formulating differential diagnoses, Philadelphia, 2006,
F.A. Davis.
THINC MED
insulin)
lupus, syphilis, Lyme disease)
seizures, multiple sclerosis, Parkinson’s
disease, dementia)
congestive heart failure)
hypercalcemia, hypo/hyperphosphatemia,
hypo/hypernatremia)
medications, illicit drugs, and alcohol)
OTC Medications, Herbal Medicines,
and Dietary Supplements
Some OTC medications, herbal preparations, and dietary
supplements can contribute to psychiatric symptoms.
A complete list of all preparations that the patient is
taking is a starting point for evaluating side effects and
interactions.
Is this a domestic violence situation?
Box 3-2
Medications Associated with
Changes in Mood
Medications That Can Cause Symptoms of
Depression
• Accutane
• Antabuse
• Anticonvulsants
• Antiparkinsonian medications
• Antivirals
• Barbiturates
• Benzodiazepines
• Beta-adrenergic blockers
• Calcium-channel blockers
• Estrogens
• Fluoroquinolone antibiotics
• Interferon alfa
• Narcotics
• Statins
Medications That Can Cause Symptoms of Anxiety
• Albuterol
• Theophylline
• Thyroid hormones
Medications That Can Cause Symptoms of Mania
• Antabuse
• Anticholinergics
• Antiparkinsonian medications
• Capoten
• Cogentin
• Corticosteroids
• Cyclosporine
• Monoamine oxidase inhibitors (MAOIs)
• Opioids
• Tagamet
• Thyroid hormones
Key Questions
n Have you been hit, kicked, punched, or otherwise
hurt by someone within the past year?
n Do you feel safe in your current relationship?
n Is there a partner from a previous relationship who
is making you feel unsafe now?
A positive response to any one of these three
questions constitutes a positive screen for partner
violence (Feldhaus et al, 1997). The rst question,
which addresses physical violence, has been validated in studies as an accurate measure of 1-year
prevalence rates. The latter two questions evaluate
the perception of safety and provide estimates of
the short-term risk of further violence and the need
for counseling, but reliability and validity evaluations have not yet been established. A positive screen
requires further assessment and clinical followup,
including ascertaining patient safety.
Could this be situational stress or normal
grief?
The BATHE model provides a framework for understanding the patient in the context of his/her total life
situation (Lieberman, 1997). BATHE is a mnemonic
for Background, Affect, Trouble, Handling, Empathy.
Key Questions
Background—ascertains the context of the visit
n What is going on in your life?
n What is going on right now?
n Has anything changed recently?
Chapter 3 • Affective Changes 33
https://t.me/med1917
Affect—elicits the emotional response and allows the
patient to label the feeling
n How do you feel about that?
n What is your mood?
Trouble—determines the symbolic meaning of the
situation for the patient
n What about the situation troubles you most?
n What worries or concerns you?
Handling—helps to assess patient resources and re-
sponses to the situation
n How are you handling that?
n How are you coping?
Empathy—reects an understanding that the patient’s
response is reasonable under the circumstances
n That must be very difcult for you.
n I can understand that you would feel that way.
BATHE Model
This model provides a patient-centered technique
that helps establish a relationship with the patient;
serves as a rough screening test for anxiety, de-
pression, or situational stress disorders; and takes
minimal time.
Could this be a result of substance abuse?
Key Questions
n In the past year, have you used alcohol or drugs
more than you meant to?
n Have you wanted or needed to reduce your drinking
or drug use in the past year?
A positive response to one question indicates a substance use concern. When the screen is positive, the
CAGE questions can be used to detect alcoholism.
Other substances can be substituted for alcohol in the
CAGE questionnaire (Box 3-3). Other questionnaires,
T-ACE and RAFFT, for alcohol use are also available
(Box 3-4 and Box 3-5).
How can I narrow my diagnosis?
Box 3-3
A Framework for Detecting Alcoholism*
C: Concern, Cut
A: Annoyed Have people annoyed you by
G: Guilt Have you ever felt bad or guilty
E: Eye-opener Have you ever had an eye-
From Ewing JA: Screening for alcoholism using CAGE. Cut down,
annoyed, guilty, eye opener, JAMA 280:1904, 1998.
*Answering yes to one or more of the four questions raises a high index
of suspicion for alcohol abuse and dependence. The CAGE questionnaire has been used and tested extensively in many populations. It is
considered to be a reliable method of screening for alcohol abuse in
adults. It has reported sensitivities of 43% to 94% and specificities
ranging from 70% to 97%.
Box 3-4
A Framework for Prenatal Detection of Risk
Drinking*
T: Tolerance How many drinks does it take
A: Annoyed Have people annoyed you by
C: Cut down Have you felt you ought to cut down
E: Eye-opener Have you ever had an eye-opener
From Sokol RJ, Martier SS, Ager JW: The T-ACE questions: Practical
prenatal detection of risk-drinking, Am J Obstet Gynecol 160:863,
1989.
*A positive answer to T alone or to two of A, C, or E can signal a
problem with a high degree of probability, and positive answers to all
four indicates great certainty of a problem.
CAGE Questionnaire
Have you ever felt you should
down
cut down on your drinking?
criticizing your drinking?
about your drinking?
opener drink first thing in the
morning to steady your nerves
or get rid of a hangover?
T-ACE Questionnaire
to make you feel high?
(Positive 5 more than 2)
criticizing your drinking?
on your drinking?
drink first thing in the morning to
steady your nerves or get rid of a
hangover?
Begin with broad screening questions. If the patient’s
response to the screening question(s) is positive, proceed to elicit more specic symptoms. Although a
negative response to a given screening question decreases the likelihood of a disorder, the sensitivity of
such screening is not perfect, and answers should be
interpreted within the context of the patient’s entire
history and physical examination.
Key Questions
n Is there a personal or family history of mental illness?
n Is there a family history of autism?
n Over the past 2 weeks, have you felt down,
depressed, or hopeless?
n Over the past 2 weeks, have you had little interest
or pleasure in your daily activities?
34 Chapter 3 • Affective Changes
https://t.me/med1917
Box 3-5
A Framework for Detecting Substance Use Disorders
in Adolescents
R: Relax Do you drink or take drugs to relax, feel
A: Alone Do you ever drink or take drugs while you
F: Friends Do any of your closest friends drink or use
F: Family Does a close family member have a
T: Trouble Have you ever gotten into trouble from
From Bastiaens L, Francis G, Lewis K: The RAFFT as a screening tool
for adolescent substance use disorders, Am J Addict 9:10, 2000.
n Do you tend to be an anxious or nervous person?
n Have you had periods of feeling so happy or ener-
The RAFFT Questionnaire
better about yourself, or fit in?
are alone?
drugs?
problem with alcohol or drugs?
drinking or taking drugs?
getic that your friends told you were talking too fast
or that you were too “hyper”?
Prior Mental Illness, Family History
A personal or family history of prior mental illness
increases the likelihood of a current mental illness.
Studies support the inuence of both behavioral and
biological factors in the development of mental health
conditions.
Family history of another child with autism in-
creases the risk of autism in a sibling.
Box 3-6
Neurovegetative Signs In Depression
S: Sleep disorder (either increased or
I: Interest deficit (anhedonia)
G: Guilt (worthlessness, hopelessness, regret)
E: Energy deficit
C: Concentration deficit
A: Appetite disorder (either decreased or
P: Psychomotor retardation or agitation
S: Suicidality
From Carlat DJ: The psychiatric review of symptoms: a screening tool
for family physicians, Am Fam Physician 58:1617, 1998.
SIG E CAPS
decreased sleep)
increased)
A positive response to a question about anxiety or
nervousness can prompt further screening:
n Do you have anxiety or panic attacks?
n Have you had to limit your activities because of
your anxiety?
The rst question helps to differentiate anxiety from
panic attacks. The second question points toward panic
with agoraphobia. If the patient is not certain what you
mean by the term “panic attacks,” you can provide a
simple description to clarify: “A panic attack is a sudden rush of fear and nervousness that makes your heart
pound and makes you afraid you’re going to die or go
crazy” (Carlat, 1998).
Down, Depressed, Hopeless, Loss of Interest
or Pleasure
These are cardinal symptoms for depression, and the
presence of at least one of these symptoms is required to
diagnose clinically signicant depression. Research suggests that these two questions (Over the past 2 weeks,
have you felt down, depressed, or hopeless? and Over the
past 2 weeks, have you felt little interest or pleasure in
your daily activities?) are as effective as longer inventories. If screening is positive, conrm with a more thorough assessment of neurovegetative signs (Box 3-6).
Anxious or Nervous
Although there are no validated screening questions for
anxiety, asking patients whether they feel anxious or
nervous is useful as a general screen. Clinical experts
suggest that unexplained somatic symptoms along with
reports of agitation and difculty maintaining concentration suggest anxiety rather than depression.
Happy, Energetic, Hyper
In the presence of depressive symptoms, a positive response to the last key question is helpful in screening
for bipolar disorder. If the screen is positive, the mnemonic DIG FAST can be used to conrm the cardinal
symptoms of mania (Box 3-7).
What about special considerations for
adolescents?
For adolescents, a psychosocial review of systems can
serve as a screen for areas that could be of concern
or that have the potential to create problems. The
HEEADSSS method of interviewing provides structure and a framework for focusing assessment of the
following (Goldenring & Rosen, 2004):
Home environment
Education and employment
Eating
Chapter 3 • Affective Changes 35
https://t.me/med1917
Box 3-7
Cardinal Symptoms of Bipolar Disorder
D: Distractibility
I: Indiscretion (excessive involvement in pleasur-
G: Grandiosity
F: Flight of ideas
A: Activity increase
S: Sleep deficit (decreased need for sleep)
T: Talkativeness (pressured speech)
From Carlat DJ: The psychiatric review of symptoms: a screening tool
for family physicians, Am Fam Physician 58:1617, 1998.
DIG FAST
able activities)
Activities that are peer-related
Drugs
Sexuality
Suicide/depression
Safety from injury and violence
Key Questions
The HEEADSSS interview progresses from less
intimidating questions about home, family members,
and the past to more personal and private issues
(Table 3-1). Although the HEEADSSS interview is
designed to be used in a reasonably short period
of time, you often will not have enough time for
the adolescent to respond to all questions. Some
questions are considered essential; other questions
can be asked as time permits or as the situation
demands.
Is this patient at risk for suicide?
Key Questions
n Have you been feeling that life is not worth living
or that you are better off dead?
n Sometimes when a person feels down or depressed
he or she might think about dying. Have you been
having thoughts like that?
If patient answers yes to the preceding questions,
then ask the following:
n Do you have a plan?
n What is the plan?
n Do you have the means to carry it out?
n What would cause you to carry out your plan or
keep you from carrying it out?
n Have you ever attempted suicide in the past?
Initial Questions
The rst set of questions helps determine whether the
patient is at risk. Patients rarely volunteer thoughts
of suicide, so it is important to ask directly. There is no
evidence to suggest that asking about suicide precipitates
suicidal thinking or acts.
Follow-Up Questions
The second set of questions helps you evaluate how
imminent the risk is. Patients at high risk for suicide
should be referred for psychiatric evaluation; those at
imminent risk should be admitted for evaluation and
treatment. Major risk factors for suicide include hope-
lessness, substance abuse, and prior suicide attempts.
How do I evaluate for a diagnosable
psychological disorder?
All positive screening tests for mental health disorders
require a full diagnostic follow-up interview using
standard diagnostic criteria, such as those from the
Diagnostic and Statistical Manual of Mental Disor-
ders, Ed 4, Text Revision (DSM-IV-TR), to determine
the presence or absence of specic disorders. The
manual describes specic symptom criteria for mental
disorders and psychosocial problems. Although pri-
mary care providers often diagnose and treat patients
with symptoms of depression and anxiety, serious
impairment of mental or emotional functioning, psy-
choses, bipolar disorder, and substance abuse disor-
ders require evaluation, diagnosis, and treatment by
qualied mental health specialists. Primary care is not
a substitute for psychiatric care. When a patient has
been screened and is suspected to be at high risk for a
condition, the primary care practitioner has a respon-
sibility to refer the patient to an appropriate resource.
See the differential diagnosis table at the end of this
chapter for the diagnostic criteria for some common
psychological disorders.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Physical examination can yield little additional data
that are of diagnostic value. No physical nding is
specic for any psychological disorder. The physical
examination should be directed at identifying organic-
based conditions that mimic psychological disorders.
Perform a comprehensive and thorough physical ex-
amination if the patient has not had one since the onset
36 Chapter 3 • Affective Changes
https://t.me/med1917
Table 3-1
ESSENTIAL QUESTIONS AS TIME PERMITS FOR MORE IN-DEPTH
Home
Who lives with you?
Where do you live?
Do you have your own room?
What are relationships like at home?
To whom are you closest at home?
With whom can you talk at home?
Is there anyone new at home?
Has someone left recently?
Have you moved recently?
Have you ever had to live away from
home? (Why?)
Education and Employment
What are your favorite subjects at
school?
Your least favorite subjects?
How are your grades?
Any recent changes?
Any dramatic changes in the past?
Have you changed schools in the past
few years?
What are your future education/
employment plans/goals?
Are you working? (Where? How much?)
Eating
What do you like and not like about your
body?
Have there been any recent changes in
your weight?
Have you dieted in the last year?
(How? How often?)
Have you done anything else to try to
manage your weight?
How much exercise do you get in an
average day? Week?
What do you think would be a healthy
diet?
How does that compare to your current
eating patterns?
Activities
What do you and your friends do for
fun? (With whom, where, and when?)
What do you and your family do for fun?
(With whom, where, and when?)
Do you participate in any sports or other
activities?
Do you regularly attend a church group,
club, or other organized activity?
The HEEADSSS Psychosocial Interview for Adolescents
Have you ever run away? (Why?)
Is there any physical violence at home?
Tell me about your friends at school.
Is your school a safe place? (Why?)
Have you ever had to repeat a class?
Have you ever had to repeat a grade?
Have you ever been suspended or
expelled?
Have you ever considered dropping out?
How well do you get along with people at
school and work?
Have your responsibilities at work
increased?
Do you worry about your weight? How
often?
Do you eat in front of the TV or
computer?
Does it ever seem as though your eating
is out of control?
Have you ever made yourself throw up on
purpose to control your weight?
Have you ever taken diet pills?
Do you have any hobbies?
Do you read for fun? (What?)
How much TV do you watch in a week?
How about video games?
What music do you like to listen to?
Do you feel connected to your
school?
Do you feel as if you belong?
Are there adults at school you
feel you could talk to about
something important? (Who?)
What would it be like if you
gained (lost) 10 pounds?
Chapter 3 • Affective Changes 37
https://t.me/med1917
Table 3-1
ESSENTIAL QUESTIONS AS TIME PERMITS FOR MORE IN-DEPTH
Drugs
Do any of your friends use tobacco?
Alcohol? Other drugs?
Does anyone in your family use
tobacco? Alcohol? Other drugs?
Do you use tobacco? Alcohol? Other
drugs?
Is there any history of alcohol or drug
problems in your family?
Does anyone at home use tobacco?
Sexuality
Have you ever been in a romantic
relationship?
Tell me about the people that you’ve
dated. OR Tell me about your sex life.
Have any of your relationships ever
been sexual relationships?
Are your sexual activities enjoyable?
What does the term “safer sex” mean to
you?
Suicide and Depression
Do you feel sad or down more than
usual?
Do you find yourself crying more than
usual?
Are you bored all the time?
Are you having trouble getting to sleep?
Have you thought a lot about hurting
yourself or someone else?
The HEEADSSS Psychosocial Interview for Adolescents—cont’d
Do you ever drink or use drugs when you
are alone?
(Assess frequency, intensity, patterns of
use or abuse, and how youth obtains or
pays for drugs, alcohol, or tobacco.)
(Ask the RAFFT questions, Box 3-5.)
Are you interested in boys? Girls? Both?
Have you ever been forced or pressured
into doing something sexual that you
didn’t want to do?
Have you ever been touched sexually in a
way that you didn’t want?
Have you ever been raped, on a date or
any other time?
How many sexual partners have you had?
Have you ever been pregnant or worried
that you could be pregnant? (females)
Have you ever gotten someone pregnant
or worried that this could have
happened? (males)
What are you using for birth control?
Are you satisfied with your method of
birth control?
Do you use condoms every time you have
intercourse?
Does anything ever get in the way of
always using a condom?
Have you ever had a sexually transmitted
infection (STI) or worried that you had
an STI?
Does it seem that you’ve lost interest in
things that you used to really enjoy?
Do you find yourself spending less and
less time with friends?
Would you rather just be by yourself most
of the time?
Have you ever tried to kill yourself?
Have you ever had to hurt yourself (by
cutting yourself, for example) to calm
down or feel better?
Have you started using alcohol or drugs
to help you relax, calm down, or feel
better?
Continued
38 Chapter 3 • Affective Changes
https://t.me/med1917
Table 3-1
ESSENTIAL QUESTIONS AS TIME PERMITS FOR MORE IN-DEPTH
Safety (Savagery)
Have you ever been seriously injured?
(How?)
How about anyone else you know?
Do you always wear a seatbelt in the
car?
Have you ever ridden with a driver who
was drunk or high? When? How
often?
Do you use safety equipment for sports
and/or other physical activities (for
example, helmets for biking or
skateboarding)?
Is there any violence in your home?
Does the violence ever get physical?
Is there a lot of violence at your school?
In your neighborhood? Among your
friends?
Have you ever been physically or
sexually abused? Have you ever been
raped, on a date or at any other time?
(If not asked previously.)
From Goldenring J, Rosen D: Getting into adolescent heads: an essential update, Contemp Pediatr 21:64, 2004.
The HEEADSSS Psychosocial Interview for Adolescents—cont’d
Have you ever been in a car or
motorcycle accident? (What happened?)
Have you ever been picked on or bullied?
Is that still a problem?
Have you gotten into physical fights in
school or your neighborhood? Are you
still getting into fights?
Have you ever felt that you had to carry a
knife, gun, or other weapon to protect
yourself? Do you still feel that way?
of symptoms. This chapter presumes that you have
performed the physical evaluation for specic presenting symptoms as part of your process to rule out a
physiological cause.
Assess Vital Signs
When substance abuse is suspected, vital signs can
quickly conrm the presence of an organic condition
related to substance intoxication or withdrawal. Abnormal values for body temperature, blood pressure, heart
rate, or respiratory rate indicate a need for a thorough
evaluation.
Observe General Appearance
Look for signs of depression or substance abuse,
such as an unkempt personal appearance, unusual
dress, and general state of poor nutrition (skin condition and appearance of hair and nails). Observe the
patient’s demeanor and appearance for signs of
neglect or a facial expression that might indicate
depression. Observe for such behaviors as nger
tapping and pacing that indicate anxiety. Methamphetamine users will often have self-induced facial
lesions secondary to scratching.
Adolescents who are abusing substances sometimes
wear clothing or jewelry that displays drug-oriented
grafti.
Observe the infant or child’s engagement. Autistic
children make few if any attempts to contact socially
with others, prefer to be alone, and ignore attempts
to seek attention, affection, or a connection with their
surroundings.
Observe Mental Status
Perform a mental status examination. Assess general
behavior. Irritability can occur in patients with anxiety.
Note body posture, movement, and facial expressions.
Assess thought content for suicidality or delusions,
which can occur with substance abuse or psychotic disorders. Determine affect for emotional range (broad or
restricted), intensity (blunted, at, or normal), stability,
and congruence with the patient’s stated mood. Evaluate
Chapter 3 • Affective Changes 39
https://t.me/med1917
the patient’s cognitive abilities, including attention,
concentration, and memory.
Note Speech and Thought Process
Speech tone, quality, and rate reect mental status. In
depression, the speech can be soft and monotonous
with little spontaneity. In mania, the speech can be
rapid, pressured, and loud, and the speech content consists of a ight of ideas.
Language delay that is not consistent with development should be noted. In some children with autism,
language begins to regress instead of increase in skill
level.
Examine the Eyes
Substance abusers can have eyes that are injected,
jaundiced, puffy, or glassy. Pupils may be dilated or
constricted. The patient may have droopy eyelids and a
sleepy appearance or a xed stare. The patient may
have difculty controlling eye movements.
Examine the Ears, Nose, and Mouth
Ears should be examined. If language delay is suspected, hearing loss or deafness should be ruled out.
Substance abusers may have chronic rhinorrhea,
frequent nosebleeds, or lesions in the nose or around
the nostrils. The patient may have dry lips, halitosis, or
an odor of alcohol, marijuana, or tobacco.
Examine the Skin
Look for skin lesions that reect depression or anxiety,
such as neurogenic scratching, nail biting, and hair
pulling. Look for evidence of attempted self-injury or
suicide. Adolescents may show evidence of cutting
scars or supercial cuts on areas of the body. Although
typically not suicide attempts, cutting serves as a
coping mechanism for unrelieved feelings.
In substance abusers, the skin may be cold and
clammy, itching and burning, tight, swollen, or puffy.
The person may perspire excessively and have discolored ngers or injection marks along the veins. Tattoos
or burn marks, possibly done while under the inuence, can disguise injection marks. The patient may
have injuries or bruises from falling or ghting.
Assess Balance and Gait
The patient who has a substance abuse problem may
have a slow gait or poor balance.
LABORATORY AND DIAGNOSTIC
STUDIES
There are no laboratory tests to assist in the diagnosis
of most psychological conditions. Base the laboratory
and diagnostic studies on the presenting reports (see
specic chapters).
Commonly performed tests to help identify underlying conditions include the following: complete blood
count (CBC), serum electrolytes, thyroid function,
toxicology/blood alcohol levels.
Complete Blood Count with Indices
and Differential
The complete blood count (CBC) will provide information about the presence of infection or anemia.
Serum Electrolytes
Hyponatremia or hypernatremia can exacerbate symptoms of depression. Hypercalcemia and hyperphosphatemia can exacerbate depression.
Thyroid Function Tests
An elevated level of thyroid-stimulating hormone
(TSH) is related to chronic symptoms of depression.
A hyperthyroid state can be associated with anxiety.
Toxicology Screen and Blood Alcohol
Level
Urine and blood screening tests can be used to determine
alcohol or drug intoxication as a cause of psychological
symptoms.
DIFFERENTIAL DIAGNOSIS
Normal Stress
Stress is the nonspecic response of the body to
any demand. The perception of a demand as stressful
depends on the individual’s experience of how much
demand for adaptation an event or situation requires.
Stressors can be acute or chronic. External stressors
include adverse physical conditions (such as pain) or
stressful psychological environments (such as poor
working conditions, abusive relationships, or major life
events). Internal stressors can be physical (such as infections or inammation) or psychological (such as
worry). Daily hassles or situational factors inuence the
stress load because minor annoyances that happen daily
can accumulate. Situational factors can exacerbate a
40 Chapter 3 • Affective Changes
https://t.me/med1917
depressive disorder in signicant ways. Symptoms of
stress include mental, physical, and behavioral symptoms. Common physical symptoms include responses
of the autonomic nervous system and musculoskeletal
system.
Normal Grief
Grief is a subjective feeling precipitated by the loss
of someone or something important to the individual.
Normal grief is a process of emotional upheaval, distress, and eventual resolution. Individuals who are
grieving often experience both physical and psychological symptoms and can have difculty functioning.
Grief and depression share many of the same characteristics, and normal grief can become clinical depression.
An individual with a history of depression is at risk of
becoming depressed in times of signicant loss. The
mood disturbance in depression is typically pervasive
and unrelenting. In normal grief, uctuations in mood
are common. Although the pain of grief is intense, the
individual is able to experience moments of less intensity or even happiness.
Domestic Violence
Domestic violence is a pattern of assaultive and coercive behaviors that include physical, sexual, psychological, and economic attacks by adults or adolescents
against their intimate partners. Individuals who have
experienced abuse could present with an injury that is
not consistent with the description of how the injury
occurred. The individual may be seen frequently for
undiagnosed psychosomatic concerns. This patient can
appear depressed or show evidence of suicide attempts.
Substance Use Disorders
Substance use disorders are divided into two groups:
substance abuse and substance dependence. The
categories of substances included are alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, opioids, phencyclidines, sedatives, and hypnotics. Substance abuse occurs when repeated use of
alcohol or other drugs leads to signicant impairment in functioning and relationships, but does not
include compulsive use or addiction, or withdrawal
symptoms when stopping the substance. Substance
dependence includes a history of substance abuse
plus continued use despite related problems, an
increase in substance tolerance, and withdrawal
symptoms if the substance use is stopped.
Autism Spectrum Disorder
Autism spectrum disorder is a difcult disorder to diagnose because there are no laboratory tests and the
clinical signs can be subtle. Infants under the age of
18 months are very difcult to diagnose because the
DSM-IV-TR does not have criteria suitable for children this young. Noting a lack of social interaction can
be the rst sign. After age 3 years the autism diagnostic
observation schedule is more useful. Generally children with autism spectrum disorder exhibit mild to
severe decits in social interaction, verbal and nonverbal communication, and have repetitive behaviors or
interests. Box 3-8 describes a screening checklist for
toddlers.
Adjustment Disorders
There are several adjustment disorder diagnoses. All of
the disorders in this category relate to a signicantly
more difcult adjustment to a life situation than would
normally be expected considering the circumstances.
The condition is acute if the disturbance lasts less than
6 months and chronic if it lasts for 6 months or longer
Box 3-8
The Five Key Items on The
CHAT* Screen
Ask the Parent:
1. Does your child ever pretend (for example, to make a
cup of tea using a toy cup and teapot) or pretend with
other things?
2. Does your child ever use an index finger to point, to
indicate interest in something?
Health Practitioner Observation:
3. Gain child’s attention, then point across the room at
an interesting object and say “Oh look! There’s a
(name of toy)!” Watch child’s face. Does the child look
across to see what you are pointing at?
4. Gain child’s attention, then give child a toy cup and
teapot and say “Can you make me a cup of tea?”
Does the child pretend to pour out tea, drink it, etc.?
5. Say to the child “Where’s the light?” or “Show me the
light.” Does the child point with an index finger at the
light? To record “yes” on this item, the child must
have looked up at your face around the time of
pointing.
*CHAT 5 Checklist for Autism in Toddlers.
Reprinted with permission from Baird G, Charman T, Cox A,
Baron-Cohen S, Swettenham I, Wheelwright S, et al: Current topic:
screening and surveillance for autism and pervasive and developmental disorders, Arch Dis 84:471, 2001.
Соседние файлы в папке Библиотека им академика М.И. Перельмана