I.
Generalized Anxiety Disorder
a. Diagnostic criteria
i. Excessive worry more days than not for at least 6 months, difficulty
controlling worry, resulting in clinically significant distress or functional
impairment, not due to underlying medical condition.
ii. > 3 symptoms x 6 months
1. Restlessness/ on edge/keyed up
2. Easily fatigued
3. Concentration difficulties
4. Irritability
5. Muscle tension
6. Sleep disturbances
b. History and physical
i. Chief concern
1. Worry and anxiety that are: excessive, persistent, unfocused, hard
to control, clinically significant and distressing
ii. HPI
1. Do you find that you’re a worrier or anxious person
2. When did the anxiety start? Is this something you have
experienced in the past? In the last six months do you find yourself
worrying most of the time (more days than not?)
a. Excessive worry about multiple events or activities most
days > 6 mo.
3. Is there something specific that you find yourself worrying about?
Or is it just kind of anything and everything? How long do the
episode last when you start to feel anxious?
4. How does the anxiety make you feel?
a. Restlessness/ on edge/keyed up
b. Easily fatigued
c. Concentration difficulties
d. Irritability
e. Muscle tension
f. Sleep disturbances
g. Headaches or GI symptoms
5. How is this affecting your life your daily functioning?
6. Do you find yourself avoiding any situations to avoid being
anxious?
a. Little or no avoidance of anxiety provoking situations
suggest underlying medical condition
7. Anything that makes the symptoms worse/better?/ Have you tried
anything to help with anxious feelings?
8. Thoughts of hurting yourself? Plan? Reason for living?
iii. Past Psychiatric History
1. Inpt/outpt (dates/ sites)
a. Have you ever been seen by a therapist or a psychiatric
provider for a mental health reason? If so, when? What
were you treated for?
b. Is there ever a time you were hospitalized overnight for any
mental health reason? If so, when? What were you
hospitalized for?
2. Dx (meds)
a. Have you ever taken any medications for a mental health
condition?
b. If so, which medications have you taken in the past?
c. How long ago did you take the medication?
d. How long did you take the medication?
e. Do you recall the dose of the medication that you took?
f. Do you recall whether the medication was particularly
helpful?
g. Did you notice any side effects?
3. Previous depression/suicide
a. Do you have a history of depression?
b. Ever has any suicidal thoughts? When, how?/ self-injury
4. Mania (hypo), panic attacks
iv. Past medical history
1. Do you or anyone in your family have a history of heart problems,
thyroid problems, stomach issues, cancer, or anything like that?
a. Endocrine, cardiopulmonary, or Neurological disorders
Do any of your relatives have a history of anxiety or any mental
health condition? Did they take any medications you’re aware of?
b. Family history of GAD
2. Anyone in your family with substance abuse concerns?
3. Anyone who has attempted or died by suicide?
v. Social history
1. History of trauma
a. Let’s now explore an umbrella called ‘trauma.’ Usually
under that umbrella fits any form of abuse or anything you
would consider traumatic in your childhood or adult life.”
b. Is there anything that fits under this umbrella that you
would be willing to mention/discuss?
vi. Physical
1. Have you experienced any physical symptoms such as fast heart
beat, chest pain, dizziness, trembling?
a. Tachycardia
b. Chest pain
c. Dizziness, trembling, diaphoresis
c. Differential diagnosis
i. Depression
ii. Bipolar disorder
iii. Delusional disorder
iv. Other anxiety disorders
1. Situational anxiety
2. Panic disorder
3. OCD
4. PTSD
5. Phobias
6. Social anxiety disorder
7. Somatic symptom disorder
8. Separation anxiety
v. Medication induced symptoms
1. Beta-adrenergic agonist
2. Corticosteroids
3. Thyroid hormones
4. Sympathomimetics (i.e phenylephrine)
vi. Substance induced
1. Caffeine
2. Amphetamines
3. Cocaine
4. Herbal supplements (i.e ginseng)
vii. Withdrawal
1. Alcohol
2. Benzodiazepines
3. Opioids
4. Nicotine
5. SSRIs
6. SNRIs
viii. Medical conditions
1. Endocrine disease
a. Hypothyroidism, diabetes, hypoglycemia
2. Cardiopulmonary disorders
a. Asthma
b. COPD
c. CHF
d. Testing
i. CBC
ii. Fasting lipid/glucose
iii. Electrolytes
iv. TSH
v. Liver enzymes
vi. Urine tox
e. Screening
i. GAD-7
1. 0-4 Minimal
2. 5-9 Mild
3. 10-14 Mod
4. 15-21 Severe
ii. HAM-A
1. <0-17 Mild
2. 18-24 Mild to moderate
3. 25-30 moderate to severe
iii. Pediatric RS
1. Pediatric anxiety rating scale
2. Screen for child anxiety related emotional distress
f. Patient education
i. Anxiety is a normal reaction to stress which can be beneficial in some
situations and can motivate people to perform at their best and Alert us to
dangers and help us pay attention however, Anxiety disorders differ from
normal feelings of nervousness or anxiousness and involve excessive fear
or anxiety which can be crippling. Fear is an emotional response to an
immediate threat and is more associated with a fight or flight reaction –
either staying to fight IN A STATE OF TENSION or leaving to escape
danger OR AVOID SIUTATIONS. Either extreme is not good and result
in physical and emotional exhaustion.Anxiety disorders can cause people
to try to avoid situations that trigger or worsen their symptoms. Job
performance, school work and personal relationships can be affected.
ii. There are several types of anxiety disorders, including generalized anxiety
disorder, panic disorder, specific phobias, I believe you may have…
g. Management
i. Therapy
1. CBT
a. Although each anxiety disorder has unique characteristics,
most respond well to two types of
treatment: psychotherapy, or “talk therapy,” and
medications. These treatments can be given alone or in
combination. Cognitive behavior therapy (CBT), a type of
talk therapy, can help a person learn a different way of
thinking, reacting and behaving to help feel less anxious.
CBT has been considered more effective than other
psychotherapies and typically includes 8 to 12 sessions.
2. Relaxation therapy
3. Mindfulness meditation
II.
ii. Medications
1. In terms of medications, Medications will not cure anxiety
disorders, but can provide significant relief from symptoms. The
most commonly used medications are anti-anxiety medications
(generally prescribed only for a short period of time) and
antidepressants. Beta-blockers, used for heart conditions, are
sometimes used to control physical symptoms of anxiety.
a. SSRIs: SELECTIVE SERETONIN REUPTAKE
INHIBITOR
i. Escitalopram (Lexapro) 10-20 mg/day
ii. Paroxetine (Paxil) IR 20-50/d
iii. Sertraline (Zoloft) (off label) 50-200 mg/d
b. SNRIs
i. Duloxetine (Cymbalta) 60-120 mg/d
ii. Venlafaxine (Effexor) XR 75-225 mg/day
c. Second line meds
i. Bupropion, imipramine
ii. Benzodiazepines- Xanax, valium, Ativan (effective
for short term treatment 1- days at max 2-4 wks) b/c
they can be habit forming and lead to misuse and
abuse additionally may lead to rebound anxiety and
can have significant withdrawal effects)
iii. Buspar, Atarax
iii. Lifestyle management
1. There are a number of things people do to help cope with
symptoms of anxiety disorders and make treatment more effective.
Stress management techniques and meditation can be helpful.
Support groups (in-person or online) can provide an opportunity to
share experiences and coping strategies. Learning more about the
specifics of a disorder and helping family and friends to understand
the condition better can also be helpful. Avoid caffeine, which can
worsen symptoms, and check with your doctor about any
medications.
Major Depression
a. Diagnostic criteria
i. Depressed mood and/or anhedonia + > 5 associated symptoms for > 2 wks
that cause clinically significant distress and functional impairment.
1. Depressed mood (irritability in children)
2. Significantly decreased interest of pleasure
3. Insomnia/hypersomnia
4. Changes in weight/appetite
5. Psychomotor agitation or retardation
6. Fatigue
7. Worthlessness/guilt
8. Recurrent thoughts of death or suicide
ii. Absence of mania
iii. Not attributable to any other condition
iv. Severity
1. Mild- minim. Symptom, manageable. and minor fnx impairment
2. Severe- subst. excess of req sxs, serious distress and impairment
v. Specifiers
1. Anxious > responsive to traditional antidepressants
2. Mixed >3 symptoms associated with mania
3. Melancholic sxs worse in morning, early morning wakening,
anorexia, excessive. guilt. [SNRIs more appropriate]
4. Atypical requires mood reactivity + >2 (weigh gain, increased
sleep, leaden paralysis, interpersonal sensitivity.
5. Psychotic features hallucinations and delusions
6. Catatonic psychomotor retardation, dec. engagement,
echolaia/praxia
7. Peripartum onset
8. Seasonal pattern
b. History and physical
i. How have you been feeling about yourself lately?
ii. It must be really difficult to feel like that over such a long period. Can you
tell me a little but more about the way you feel? How does that affect you
(life, work, relationships)?
iii. Have you noticed that your mood improves or gets worse throughout the
day?
iv. On a scale of 1 to 10 if 10 was really, really down, where would you put
yourself?
v. Was there any kind of stressor that happened right before you started to
feel this way?
vi. What kinds of things do you usually enjoy doing? Have you been enjoying
these activities as much as you have in the past?
vii. When is the last time you were involved in (activity)
viii. Managing your home and working must be quit a handful. I wonder how
your energy levels keep up? Do you ever feel restless
ix. How is your concentration, when your watching TV are you able to follow
what you watch? Can you watch a half-hour TV show from start to finish
without losing focus?
x. Have you noticed any changes in your appetite. Gained lost weight? How
much?
xi. How has your sleep been lately? Is that usual for you? Do you find that it
has been difficult to fall asleep or stay asleep at night?
xii. How do you see the future?
xiii. Do you ever blame yourself for what you’re going through?
xiv. Sometimes when people feel low the may have thoughts of suicide. Has it
ever gotten so bad where you’ve felt life is not worth living? What
thoughts have you had? Have you ever come close to acting on any those
thoughts? What stops you?
xv. Past Psychiatric History
1. Inpt/outpt (dates/ sites)
a. Have you ever experienced anything like this in the past?
How often? How severe?
b. Have you ever been seen by a therapist or a psychiatric
provider for a mental health reason? If so, when? What
were you treated for?
c. Is there ever a time you were hospitalized overnight for any
mental health reason? If so, when? What were you
hospitalized for?
2. Dx (meds)
a. Have you ever taken any medications for a mental health
condition?
b. If so, which medications have you taken in the past?
c. How long ago did you take the medication?
d. How long did you take the medication?
e. Do you recall the dose of the medication that you took?
f. Do you recall whether the medication was particularly
helpful?
g. Did you notice any side effects?
3. Previous depression/suicide
a. Do you have a history of depression?
b. Ever has any suicidal thoughts? When, how?/ self-injury
4. Mania (hypo)
a. Has there ever been a time where you felt happier or more
energetic than usual for no particular reason? Did you
notice more rapid thoughts, less need for sleep? More
talkative than usual? How long did this last? Did it affect
your life, work, or relationships.
5. Have you ever experienced any delusions or hallucinations
xvi. Past medical history
1. Do you or anyone in your family have a history of heart problems,
thyroid problems, stomach issues, cancer, or anything like that?
a. Neurological conditions (stroke, parkinsons, dementia, MS)
b. Thyroid conditions
c. Malignancy
d. Infectious disease
Do any of your relatives have a history of mood disturbance or any
mental health condition? Did they take any medications you’re aware
of?
e. Family history of MDD
2. Anyone in your family with substance abuse concerns?
3. Anyone who has attempted or died by suicide?
xvii. Social history
1. any current social or occupational impairments
2. psychosocial stressors including significant loss/bereavement,
interpersonal conflict, financial difficulties, life changes, abuse,
and trauma or other negative life events
3. social support system
4. use of alcohol or other substances
5. smoking and dietary behavior
6. History of trauma
a. Let’s now explore an umbrella called ‘trauma.’ Usually under
that umbrella fits any form of abuse or anything you would
consider traumatic in your childhood or adult life.”
b. Is there anything that fits under this umbrella that you would be
willing to mention/discuss?
c. Differential Diagnosis
i. Bipolar disorder
ii. Adjustment disorder with depressed mood
iii. Premenstrual dysphoric disorder
iv. Schizoaffective disorder
v. Schizophrenia with depressed mood
vi. PTSD
vii. Medical conditions
1. Parkinsons
2. Dementia, MS
3. Cognitive impairment
4. Hypothyroidism
d. Patient education
i. One thing I like to point out is that depression is a medical condition. It
has to be treated the same way we treat asthma or diabetes and its not
something that a person can be at fault for. You did not cause this to
happen. Depression is typically caused by one or more factors. This
includes genetic, biological, environmental, and psychological causes.
ii. That being said Depression can affect people of all ages and is different
for every person. A person who has depression can’t control his or her
feelings. Symptoms are different for every person. Your symptoms may
appear as emotional, physical, or a combination of both. Ans symptoms
can include Crying easily or for no reason Feeling guilty or worthless.
Feeling restless, irritated, and easily annoyed. Feeling sad, numb, or
hopeless. Physical symptoms include: Changes in appetite (eating more
than usual, or eating less than usual).Feeling extremely tired all the
time.Having other aches and pains that don’t get better with treatment.
Having trouble paying attention, recalling things, concentrating, and
making decisions. Headaches, backaches, or digestive problems.
e. Management
i. Antidepressants
1. SSRIs, SNRI, MAOIs (non-responsive), TCAs
2. They help increase the number of chemical messengers (serotonin,
norepinephrine, dopamine) in your brain.
3. There is no concrete evidence that one antidepressants works better
than another so we usually choose treatment based on side effect
profile, tolerability, and drug interactions.
4. Antidepressants work differently for different people. They also
have different side effects. So, even if one medicine bothers you or
doesn’t work for you, another may help. You may notice
improvement as soon as 1 week after you start taking the medicine.
But usually become effective at 4-6 weeks and t you probably
won’t see the full effects for about 8 to 12 weeks. You may have
side effects at first. They tend to decrease after a couple of weeks.
Its important that if there are any side effects you let me or another
provider know first before you stop taking the medication.
5. potential for increased agitation, anxiety, and suicidal ideation
during initial treatment stages; ensure patient knows how to seek
help promptly if these symptoms occur
ii. Therapy
1. Counseling may be a good treatment option for mild to moderate
depression. For major depression and for some people with minor
depression, counseling may not be enough. A combination of
medicine and talk therapy is usually the most effective way of
treating more severe depression.
2. Types of individual psychotherapies for MDD5
a. cognitive behavioral therapy (CBT) - incorporates
modifying and refocusing dysfunctional beliefs (cognitive
restructuring) to impact behavior and functioning
b. behavioral activation therapy - aims to increase
participation in positive activities that provide sense of
pleasure and mastery, and may focus on identifying and
mitigating avoidance habits
c. psychodynamic therapy - focuses on understanding and
gaining insight into chronic conflicts with a focus on past
experiences and relationships
d. problem-solving therapy (PST) - focuses on developing
structured set of skills for addressing problems creatively to
avoid barriers to goals and make effective decisions
e. interpersonal therapy - aims to help identify and resolve
issues in relationships and social roles
f. mindfulness-based therapy - involves regular meditative
practice focusing on paying non judgmental attention to
thoughts, feelings, and experiences to facilitate acceptance
III.
Bipolar disorder
a. Diagnostic criteria
i. Bipolar 1 – atleast 1 manic episode present for 1 week and associated with
any hospitalizations, impairment in social/occupational functioning, w or
w/o psychotic features. May or may not be associated with depressive
episodes.
1. Mania
a. Distractibility
b. Impulsivity
c. Grandiosity
d. Flight of ideas
e. Increased activity
f. Decreased need for sleep ( not tired)
g. Talkative (pressured speech)
ii. Bipolar 2- hx of MDE and hypomanic (4 day/no-significant impairment/
psychosis or hospitalization) but no episodes of mania.
1. MDE
SIGECAPS (5 for 2 weeks)
a. Mild > 4. Mod > 6. Severe >8 sxs
b. Atypical – hypersomnia, inc. appetite, heaviness in limbs.
c. Psychomotor retardation, multiple suicide, refractory to 3
antidepressant trials.
iii. Specifiers may include anxious distress, mixed fx, melancholic, atypical,
mood-congruent/incongruent psychotic fx, catatonia, peripartum onset and
seasonal pattern (mixed fx mania and depression at the same time)(rapid
cyc. 4 episodes in 12 months)
iv. Cyclothymia- 2 y adult (1y children) of MDE and hypomanic symptoms
that do not meet full criteria. No symptom free period for > 2 months.
b. History and physical
i. Chief concern
1. patients typically present with depression or mixed state of
depressed mood plus increased energy, restlessness, and racing
thoughts
ii. HPI
1. Have you ever has the opposite of depression, when you’ve been
extremely happy, over the top, doing things out of character or
talking to fast?
2. How long did it last?
3. During this period did you feel especially confident. Like you were
on top of the world? How do you compare yourself to others?
4. Did you find it difficult to keep track of your thoughts?
5. Have your friends or family commented on the way you are
talking?
6. Have you needed much less sleep than usual?
7. Have you taken on new activities lately?
8. Have you been doing things that are out of character for you or
getting in trouble with the police or your family?
9. Have you ever had any unusual experiences such as hearing voices
talking to or about you when no one else was around? Where do
they come from? Inside your head or through your ears? Do you
have any unusual ideas such as people are plotting against you?
10. When did this start? Is this something you have experienced in the
past? How often are you experiencing these drastic changes is
mood.
iii. Past Psychiatric History
1. Inpt/outpt (dates/ sites)
a. Have you ever been seen by a therapist or a psychiatric
provider for a mental health reason? If so, when? What
were you treated for?
b. Is there ever a time you were hospitalized overnight for any
mental health reason? If so, when? What were you
hospitalized for?
2. Dx (meds)
a. Have you ever taken any medications for a mental health
condition?
b. If so, which medications have you taken in the past?
c. How long ago did you take the medication?
d. How long did you take the medication?
e. Do you recall the dose of the medication that you took?
f. Do you recall whether the medication was particularly
helpful?
g. Did you notice any side effects?
i. Antidepressants causing mania or agiatation
3. Previous depression/suicide
a. Do you have a history of depression?
b. Ever has any suicidal thoughts? When, how?/ self-injury
4.
iv. Past medical history
1. Do you or anyone in your family have a history of heart problems,
thyroid problems, stomach issues, cancer, or anything like that?
Do any of your relatives have a history of bipolar any mental
health condition? Did they take any medications you’re aware of?
2. Anyone in your family with substance abuse concerns?
3. Anyone who has attempted or died by suicide?
v. Social history
1. History of trauma
a. Let’s now explore an umbrella called ‘trauma.’ Usually
under that umbrella fits any form of abuse or anything you
would consider traumatic in your childhood or adult life.”
b. Is there anything that fits under this umbrella that you
would be willing to mention/discuss?
2. Drug alcohol use
3. High-risk sexual behaviors?
4. Legal or financial difficulties
5. Recurrent job stress
6. Interpersonal relationships
c. Differential diagnosis
i. Secondary Mania in patients presenting with first manic episode before
puberty or after 40.
ii. Medication induced
1. Cardiovascular agents (catapril, hydralazine)
2. Endocrine agents ( steroids or bromocriptine)
3. Neuro agent levodopa
4. Antidepressants, disulfiram, methylphenidate or MAOIs
5. Baclofen, cimetidine, or isoniazid
iii. Medical conditions
1. Neuro (seizures, huntingtons, MS, migrains, stroke, TBI, wilsons)
2. Cerebrovascular disease
3. Dementia
4. Endocrine (Cushings, hypo/hyperthyroidism)
5. Vitamin deficiency (b12, folate, niacin, thiamine)
6. SLE
7. Infx dx( Herpes simpl. Encephalitis, neurosyphilis)
iv. Substance use disorders
1. AUD, OUD, amphetamine/cocaine/hallucinogens abuse
v. Mania secondary to
1. ADHD, personality disorders/traits
2. Schizophrenia/schizoaffective
3. Hyponatremia
d. Patient education
i. Bipolar disorder is a brain disorder that causes changes in a person’s
mood, energy, and ability to function. People with bipolar disorder
experience intense emotional states that typically occur during distinct
periods of days to weeks, called mood episodes.
ii. People without bipolar disorder experience mood fluctuations as well.
However, these mood changes typically last hours rather than days. Also,
these changes are not usually accompanied by the extreme degree of
behavior change or difficulty with daily routines and social interactions
that people with bipolar disorder demonstrate during mood episodes.
Bipolar disorder can disrupt a person’s relationships with loved ones and
cause difficulty in working or going to school.
iii. Bipolar disorder usually runs in families and environmental factors such as
stress, sleep disruption, and drugs and alcohol may trigger mood episodes
play a role in vulnerable people. It is also thought to have a basis in
imbalance of brain chemicals that lead to dysregulated brain activity.
iv. Bipolar disorder symptoms commonly improve with treatment. And
people can lead full and productive lives. Medication is the cornerstone of
bipolar disorder treatment, though talk therapy (psychotherapy) can help
many patients learn about their illness and adhere to medications,
preventing future mood episodes.
v. Medications known as “mood stabilizers” (e.g., lithium) are the most
commonly prescribed type of medications for bipolar disorder. These
medications are believed to correct imbalanced brain signaling. We may
also use dopamine antagonist/partial agonist may also Because bipolar
disorder is a chronic illness in which mood episodes typically recur,
ongoing preventive treatment is recommended. Bipolar disorder treatment
is individualized; people with bipolar disorder may need to try different
medications before finding what works best for them.
vi. Some important lifestyle management includes sticking to a schedule, pay
attention to your sleep habits (being sleep deprived can trigger mania and
also be a sign of pending episodes) and then follow the guidelines for any
particular healthy lifestyles such as exercise and nutrition Limiting
caffeine and alcohol, decrease stress
e. Management
i. Medications
1. Lithium
2. Valproate (avoid in pregnant patients (carbamazepine)
3. Second- generation antipsychotics
4. Acute mania
a. hospitalization if risk of harm
b. Taper and cease agents with mood elevating properties (
antidepressants/ stimulants)
c. IM benzo or antipsychotic
d. ECT suicidal
e. Mania w/o mixed fx
i. Lithium 1st , Seroquel, SGA
f. Rapid cycling
i. Aripiprazole or Seroquel 1st
5. Acute depression
a. Psychotic fx – Latuda or Seroquel
b. Latuda, Zyprexa + Prozac, Seroquel, VRAYLAR
IV.
Attention hyperactive disorder
a. Diagnostic criteria
i. At least 5 sxs from specific subtype category to diagnoses ADHD
inattention or hyperactivity/impulsivity and >5 sxs from each to dx
combined type
ii. Several sxs present before age 12 y
iii. Criteria met in>2 settings (home, school, work, or with relationships)
iv. Sxs interfere with social, academic, or occupational functioning
v. Symptoms present for > 6 mo
vi. Symptoms of inattention subtype
1.
vii. symptoms of hyperactivity/impulsivity subtype
1. often fidgets with or taps hands or feet or squirms in seat
2. often leaves seat in situations in which one is expected to remain
seated
3. often runs about or climbs in inappropriate situations (may be
limited to feeling restless)
4. often is unable to play or engage in leisure activities quietly
5. often is "on the go," acting as if "driven by a motor"
6. often talks excessively
7. often blurts out an answer before a question has been completed
8. often has difficulty awaiting turn
9. often interrupts or intrudes on others
viii. symptoms do not occur exclusively during course of schizophrenia or
another psychotic disorder and are not better accounted for by another
mental disorder (mood disorder, anxiety disorder, dissociative disorder, or
personality disorder)
b. History and physical
i. I’m here to learn as much as I can about you. What brought you in?
ii. What is your day to day like. Do you work, what are your interest and
hobbies?
iii. How where things for you growing up?
1. I’m going to ask some questions that relate more to your symptoms
within the diagnostic criteria.
iv.
v.
vi.
vii.
Have you always had these symptoms (present before 7 yrs old)
How frequently are you experiencing these symptoms?
How do you manage the restlessness/inattention?
In which areas do these issues affect you? Word/education,
relationship/family, social contacts, free time/hobbies, self confidence.
c. Past Psychiatric History
i. Inpt/outpt (dates/ sites)
1. Have you ever been seen by a therapist or a psychiatric provider
for a mental health reason? If so, when? What were you treated
for?
a. Depression, mania, anxiety, tic disorder, learning
disabilities)
2. Is there ever a time you were hospitalized overnight for any mental
health reason? If so, when? What were you hospitalized for?
3. Where you ever dx with ADHD in childhood
ii. Dx (meds)
1. Have you ever taken any medications for a mental health
condition?
2. If so, which medications have you taken in the past?
3. How long ago did you take the medication?
4. How long did you take the medication?
5. Do you recall the dose of the medication that you took?
6. Do you recall whether the medication was particularly helpful?
7. Did you notice any side effects?
a. Antidepressants causing mania or agitation
iii. Previous depression/suicide
1. Do you have a history of depression?
2. Ever has any suicidal thoughts? When, how?/ self-injury
iv. Past medical history
1. Do you or anyone in your family have an medical history?
a. Thyroid disorder, head injury, liver disease, sz disorder,
lead exposure
b. Cardiovascular disease, autism, tourettes, dsylexia
2. Any substance abuse concerns?
v. Social history
1. Educational and occupational history
a. Conduct, displinary action
b. Frequent job changes and absenteeism
c. Poor school performance
2. Socioeconomic status
3. Legal or financial difficulties
4. Recurrent job stress
5. Interpersonal relationships
6. Drug alcohol use
d. Differential diagnosis
i. Psych
1. Bipolar, GAD, MDD, BPD, OCD, autism
ii. Neuro
1. Learning disabilities, tic disorder, seizures, acquired brain injury
iii. Sleep
1. OSA
e. Patient education
i. Attention-deficit hyperactivity disorder (ADHD) is a group of behaviors
common in both chhildrens and adult which cause difficulties with
concentration and attention. Most of what we hear about ADHD is how it
affects children. Not as much is known about the way ADHD affects
adults. For adults to be diagnosed, they must have developed symptoms
prior to age 12. ADHD may run in families.
ii. People who have ADHD do not make enough chemicals in certain areas in
the brain that are important for organizing thoughts. Without enough of
these chemicals, the organizing centers of the brain don’t work well. This
is thought to be the cause of ADHD. The shortage of chemicals may be
due to a person’s genes (research shows that ADHD is more common in
people who have a close family member with the disorder), environment,
or physical development. Recent research also links smoking and other
substance abuse during pregnancy to ADHD. Exposure to environmental
toxins, such as lead, can also be a factor.
iii. Some of the medicines used to treat ADHD are called psychostimulants.
They include methylphenidate, dextroamphetamine, and while these
medicines have a stimulating effect in most people. However, they have a
calming effect in people who have ADHD. These medicines improve
attention and concentration and decrease impulsive and overactive
behaviors. Non-stimulants such as atomoxetine and bupropion may also be
used.
iv. Psychostimulants may decrease your appetite and cause a stomachache or
a headache. The loss of appetite can cause weight loss in some people.
This side effect seems to be more common in children. Some people have
insomnia (trouble sleeping). Other possible side effects include fast
heartbeat, chest pain, or vomiting. To avoid or reduce the side effects of
psychostimulants, follow these tips:
1. Use the lowest possible dose that still controls the hyperactivity or
inattention.
2. Take the medicine with food if it bothers your stomach.
3. Take the medicine 30 to 45 minutes before a meal.
v. You can learn ways to change your work environment and keep
distractions to a minimum. Organizational tools can help you learn how to
focus on activities at work and at home. Many people who have ADHD
find counseling helpful. A lifetime of ADHD behaviors and problems can
cause low self-esteem and problems with relationships. Individual
counseling and support groups may help you with these problems.
f. Management
i. f/u q 6-12 months
ii. Conservative management approach
1. Psychoeducation programs to increase knowledge
2. Maintenance of healthy life-style including a balanced, nutritious
diet and regular exercise
3. Low stimulation, reducing distractions, reinforcing verbal request
with written request, optimizing schedule to have shorter periods to
focus with movement breaks.
iii. Medication
1. Stimulant 1st
a. stimulants have high potential for abuse and diversion, and
most are class II controlled substances
b. stimulants are contraindicated if agitation, glaucoma, motor
tics (controversial), or monoamine oxidase (MAO)
inhibitors within 14 days
c. determining contraindications for medication
d. cardiovascular assessment, including electrocardiogram
(ECG) if treatment may affect the QT interval
e. referral to cardiologist for patients with cardiac history may
cause sudden death and serious cardiovascular adverse
events
decreased appetite, insomnia, and dry mouth
f.
g. Controlled release
i. lisdexamfetamine 30 mg orally once daily initially
in the morning, may be titrated weekly by 10-20
mg/day to maximum 70 mg/day 12-13h
ii. methylphenidate 10-72 mg/day orally, depending
upon brand
iii. dexmethylphenidate 10 mg orally once daily
initially, may titrate weekly by 10 mg/day to
maximum 40 mg/day
iv. dextroamphetamine/amphetamine XR 20 mg orally
once daily initially in the morning (for those
switching from immediate release, start at current
total daily dose), may be titrated up to standard dose
5-60 mg/day
v. dextroamphetamine 5-60 mg/day orally in divided
doses
h. Immediate release
i. methylphenidate 10-60 mg/day orally in divided
doses
ii. dexmethylphenidate 2.5 mg orally twice daily
initially, may titrate weekly by 2.5-5 mg/day to
maximum 20 mg/day
iii. dextroamphetamine/amphetamine 10 mg/day orally
initially, may titrate weekly by 10 mg/day to
standard dose 5-60 mg/day
iv. dextroamphetamine 10 mg/day orally initially, may
titrate weekly by 10 mg/day to standard dose 5-60
mg/day in divided doses
2. Non-stimulants
a. Atomoxetine (C/I glaucoma)
i. 40 mg/d initially x 7 days up 80 mg qam or
divided; after 2-4 wk can increase to 100 mg/d if
necessary max 100
ii. Onset 1-2 wks full benefits 6 months
b. Bupropion (C/I sz disorder)
iv. CBT (when drug tx partially or ineffective)
1. most programs are skills-based, focusing on emotional
regulation/control, social skills, organizational and time
management skills, problem solving, and strategies to improve
attention and impulsivity1
2. CBT may reduce ADHD symptoms and functional impairments
across different areas of daily life in adults
I.
Follow up medication management
a. How have you been doing these last few weels?
i. Follow up on stressor presented in previous encounter?
b. Physical changes
c. Any changes you’ve noticed. Anyone in your family noted any changes
d. Any current stressors?
e. Support system?
f. Its only been 2 it usually takes about 4-6 weeks to feel changes?
g. Has there been any side effects. How does it impair quality of life.
h. Everyone responds to medications differently. It really has to do with brain
chemistry which unfortunately is something you and I cant manage on our own.
So finding the right medication is a process. Research can show what has been
shown to be most effective in the general population but there are so many
factors.
i. Screening tool/scale