Attachment of the Petition on Legal Separation

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					Managing Psychotic Disorders
 in the Primary Care Setting
       Anne Dohrenwend, Ph.D., ABPP
       McLaren Regional Medical Center

       Heather Kirkpatrick, Ph.D., ABPP
       Genesys Regional Medical Center
     Presentation Outline
Introduction: Facts about Psychosis in
Primary Care

Part I: Case Examples

Part II: Guidelines for Management
      Psychosis Defined

Loss of ego boundaries or gross
impairment in reality testing
     Psychotic Symptoms
Hallucinations
  Auditory or visual
Disorganized speech
Catatonic behavior
Delusions
  Fixed, false beliefs
                            Prevalence
  One study of 1,000 adults in primary
  care found 3.7% of patients being seen
  in the office reported one or more
  psychotic symptoms
  Most common was a belief that others
  were spying on them or following them
Olfson, Weissman, Leon, Farber, Sheehan (1996). Psychotic symptoms in primary
care. Journal of Family Practice. 43(5):481-8.
   Psychotic Disorders …

Psychotic symptoms are the defining
feature
     Psychotic Disorders
Brief Psychotic Dx
Delusional Disorder
Schizoaffective Disorder
Schizophrenia
Schizophreniform
Shared Psychotic Dx
Substance-Induced Psychotic Dx
                 Prevalence
Disorder                   Lifetime prevalence
Schizophrenia +            0.7-1.2%
Schizophreniform
Delusional Disorder        .03%
Brief Psychotic Disorder   unknown, but uncommon
Schizoaffective Disorder   unknown, but less than
                           schizophrenia
Substance Induced          unknown, but probably
Psychotic Disorder         highest
 Disorders with Associated
    Psychotic Symptoms
Alzheimer’s Dementia
Lewy Body Disease/Dementia
Amnesic Disorders
Cognitive Disorders
Mood Disorders with Psychosis
Specifiers
  Major Depression with Psychosis
  Mania with Psychosis
  PART I
Case Examples
              Case I
71 yr old wf known to the PCP. Pt is
always very well groomed, appropriate.
Longstanding complaints re: husband,
e.g. stealing her things, breaking her
things. This appt. pt. tells PCP that
husband has her followed, at all times,
and has bugged the house. Husband is
in the waiting rm.
          Interventions

Cognitive Screen
  Normal range on Folstein
  Ramparts suggested frontal impairment
  Referred for neuropsychological
  assessment
  Referred to neurology
            Interventions
Interviewed daughter
  Non-bizarre delusions noted


Held family meeting and discovered
  driving while taking photos of cars behind her
  disconnecting lights, phones looking for bugs
  purchasing secret storage areas for her belongings
  was hospitalized, briefly once, due to pointing gun
  at husband’s head
          Interventions
MRI
 T2 signal abnormalities in subcortical white
 matter, some periventricular. Mildly
 atrophic frontal lobes and left superior
 parietal lobe
 EEG normal
Frontotemporal Dementia
     Critical Event Occurs
Patient becomes overwhelmed, anxious
in office. Falls to her knees crying
  Sent to ER for inpatient psychiatric
  treatment
  Sent home due to dementia diagnosis,
  e.g., no local psychiatric floor accepting
  patients with dementia
          Interventions
Referred to Cottage Hospital, with
geriatric unit
  pt. has inpatient stay, but psychiatrist
  diagnoses personality disorder; admits he
  did not read neuropsychological testing
  results
  pt sent home with no improvement
          Interventions
Referred pt to geriatric psychiatrist at
Henry Ford
  Frontotemporal Dementia confirmed
  Klonopin, .5 TID prescribed
          Interventions
Educated family
Restricted driver’s license
Suggested separation from husband
Referred husband for counseling
Recommended hospitalization under
geriatric psychologist at next outburst
Recommended family obtain legal
guardianship
                 Results
After two sessions, patient failed to follow
through with geriatric psychiatry

Patient continues to be seen by the PCP who
prescribes Klonopin, which does help to calm
patient. SSRI tried with no positive effect.

Family failed to follow through with
recommendations for guardianship
              Case II
56 yr old white female sees her PCP for
for reoccurring abdominal pain (8 out of
10, sharp, transient, interferes with
eating). She believes tubing was left in
her stomach during surgery years ago.
Pt. had several studies (x-ray,
ultrasound) showing no object in the
abdomen. Accompanied by her newly
wed husband. No known psych hx.
Delusional Disorder
         Interventions
Obtained permission to have a meeting
where x-ray results were viewed with
both husband and pt, together
Asked psychologist to join and attend
this meeting
Confronted patient with delusional
diagnosis and need for treatment
              Results
Husband believed wife who explained
that the tubing moved around and was
not always visible in the abdomen
Strongly urged pt to see psychiatrist for
evaluation, but she refused
Decided on close f/u with PCP
Other Possible Interventions
Involuntary Hospitalization
MRI
Attempt to contact alternative family
member
                 Case III
19 yr old AA male, HS graduate, unemployed,
 living with older sister. Sister says pt. has had
 slow decline in function over a year. Says he
 plays videos all day. Mood is sad or flat. Can’t
 make decisions, “like whether to turn the
 light switch on or off.” Sister took pt to the
 ER. They diagnosed Major Depression, urged
 her to bring the pt to his PCP for treatment.
       Case III, Continued
Explored possible reasons for poor function
  No history of learning disability or MR
  No head injury
  Mild to moderate depression
     No homicidal or suicidal ideation
  Psychosis
     Pt. vague about hearing voices
     Ideas of reference: music had a special messages for
     him
       New Onset
Schizoaffective Disorder,
    Depressive Type
         Interventions
Made appt. to see psychiatrist in one
month (first available appointment)
Treated with Seroquel, (50mg daily for
one week, increased to 100mg)
F/u on a weekly basis until pt saw
psychiatry
              Results
Dramatic improvement in behavior
Psychotic symptoms controlled
Pt care successfully transferred to
psychiatry
                Case IV
50 yr old wf arrives to appt. with her
husband. Husband says he has taken her to
the ER multiple times, thinking she would be
hospitalized, but she is repeatedly sent home.
He is concerned because she is sleeping in
the car. The patient appears unkempt, dirty.
She rocks back and forth. Speech is
tangential. Affect and mood are very anxious.
      Case IV, Continued
Evaluated anxiety
  cleanliness rituals
    Resulting in inability to touch or move through
    certain areas
  fear of losing things
    Husband reveals that pt checks and rechecks
    garbage to be sure nothing is unintentionally
    thrown out
  Obsessive Compulsive
Disorder, with Poor Insight
           Interventions

Paged psychiatry on call
Clarified pt hx in ER
Established risk to self due to
functionality debilitation
  inability to enter home, poor hygiene, poor
  nutrition, poor insight (specifier)
              Results
Psychiatry arranged for direct admit to
floor-pt stayed 2 weeks
Important Points Re: Transfer
We contacted patient registration and
told them to expect the patient and her
husband
Faxed psychiatry our notes and recent
labs
               Case V
45 yr old wm makes appt. with PCP for
psych medication refills. He says he is
schizophrenic, new to the area, on no
medications. Thinks he knows med
names, but not doses. Hx of multiple
suicide attempts. Affect is flat. Behavior
is cooperative. Reports anxiety and
hearing voices.
Schizophrenia, (did not
    establish type)
         Interventions
Did not treat this patient due to
seriousness of symptoms, e.g. suicide
attempts

Referred to the ER
              Results
Pt. accepted for inpatient treatment
  Guidelines for Management
When confronted with psychotic symptoms:


 Know legal standards
 Attempt to determine onset of
 symptoms
 Rule out medical causes
 Form collaborative treatment plan
        Part II
Guidelines for Management
 Guidelines for Mangement
Know the legal standards
           Legal Standards
HIPPA allows for disclosure
  “SPECIAL SITUATIONS”
  We may use or disclose health information about you
  without your permission for the following purposes, subject
  to all applicable legal requirements and limitations:

  To Avert a Serious Threat to Health or Safety. We may use
  and disclose health information about you to prevent a
  serious threat to your health and safety or the health and
  safety of the public or another person.”

Know your state’s statutes for involuntary admission
        Legal parameters
Depend upon state mental health code

Fairly standard, but should check

“Mental health statutes” as search term

HIPAA
Michigan’s Mental Health Statute
 330.1401 “Person requiring treatment” defined; exception.
 Sec. 401. (1) As used in this chapter, “person requiring treatment” means (a), (b), or (c):
 (a) An individual who has mental illness, and who as a result of that mental illness can reasonably be
 expected within the near future to intentionally or unintentionally seriously physically injure himself or
 herself or another individual, and who has engaged in an act or acts or made significant threats that are
 substantially supportive of the expectation.
 (b) An individual who has mental illness, and who as a result of that mental illness is unable to attend to
 those of his or her basic physical needs such as food, clothing, or shelter that must be attended to in order
 for
 the individual to avoid serious harm in the near future, and who has demonstrated that inability by failing
 to
 attend to those basic physical needs.
 (c) An individual who has mental illness, whose judgment is so impaired that he or she is unable to
 understand his or her need for treatment and whose continued behavior as the result of this mental illness
 can
 reasonably be expected, on the basis of competent clinical opinion, to result in significant physical harm to
 himself or herself or others. This individual shall receive involuntary mental health treatment initially only
 under the provisions of sections 434 through 438 of this act.
 (2) An individual whose mental processes have been weakened or impaired by a dementia, an individual
 with a primary diagnosis of epilepsy, or an individual with alcoholism or other drug dependence is not a
 person requiring treatment under this chapter unless the individual also meets the criteria specified in
 subsection (1). An individual described in this subsection may be hospitalized under the informal or formal
 voluntary hospitalization provisions of this chapter if he or she is considered clinically suitable for
 hospitalization by the hospital director.
 History: 1974, Act 258, Eff. Nov. 6, 1974;¾Am. 1975, Act 179, Eff. Aug. 6, 1975;¾Am. 1995, Act 290,
 Eff. Mar. 28, 1996.
Michigan’s Mental Health Statute
A. expected within the near future to intentionally or unintentionally seriously
physically injure himself or herself or another individual, and who has engaged
in an act or acts or made significant threats that are substantially supportive of
the expectation.

B. unable to attend to those of his or her basic physical needs such as food,
clothing, or shelter
C. whose judgment is so impaired that he or she is unable to understand his or
her need for treatment and whose continued behavior as the result of this
mental illness can reasonably be expected, on the basis of competent clinical
opinion, to result in significant physical harm to himself or herself or others.
An individual whose mental processes have been weakened or impaired by a
dementia, an individual with a primary diagnosis of epilepsy, or an individual
with alcoholism or other drug dependence is not a person requiring treatment
under this chapter unless the individual also meets the criteria specified in
subsection (1). A, B or C.
 Illinois Mental Health Code
405 ILCS 5/3-600) (from Ch. 91 1/2, par. 3-600)
   Sec. 3-600. A person 18 years of age or older who is subject to involuntary
admission and in need of immediate hospitalization may be admitted to a
mental health facility pursuant to this Article.
(Source: P.A. 80-1414.)
   (405 ILCS 5/3-601) (from Ch. 91 1/2, par. 3-601)
   Sec. 3-601. Involuntary admission; petition.
   (a) When a person is asserted to be subject to involuntary admission and in
such a condition that immediate hospitalization is necessary for the protection of
such person or others from physical harm, any person 18 years of age or older
may present a petition to the facility director of a mental health facility in the
county where the respondent resides or is present. The petition may be
prepared by the facility director of the facility.
   (b) The petition shall include all of the following:
      1. A detailed statement of the reason for the     assertion that the
respondent is subject to involuntary admission, including the signs and
symptoms of a mental illness and a description of any acts, threats, or other
behavior or pattern of behavior supporting the assertion and the time and place
of their occurrence.
          Missouri MH Statutes
9) "Likelihood of serious harm" means any one or more of the following but
does not require actual physical injury to have occurred:
(a) A substantial risk that serious physical harm will be inflicted by a person
upon his own person, as evidenced by recent threats, including verbal threats,
or attempts to commit suicide or inflict physical harm on himself. Evidence of
substantial risk may also include information about patterns of behavior that
historically have resulted in serious harm previously being inflicted by a person
upon himself;
(b) A substantial risk that serious physical harm to a person will result or is
occurring because of an impairment in his capacity to make decisions with
respect to his hospitalization and need for treatment as evidenced by his current
mental disorder or mental illness which results in an inability to provide for his
own basic necessities of food, clothing, shelter, safety or medical care or his
inability to provide for his own mental health care which may result in a
substantial risk of serious physical harm. Evidence of that substantial risk may
also include information about patterns of behavior that historically have
resulted in serious harm to the person previously taking place because of a
mental disorder or mental illness which resulted in his inability to provide for his
basic necessities of food, clothing, shelter, safety or medical or mental health
care; or
Cont. of Missouri MH Statutes

(c) A substantial risk that serious physical harm will be inflicted by a
person upon another as evidenced by recent overt acts, behavior or
threats, including verbal threats, which have caused such harm or
which would place a reasonable person in reasonable fear of sustaining
such harm. Evidence of that substantial risk may also include
information about patterns of behavior that historically have resulted in
physical harm previously being inflicted by a person upon another
person;
New York Mental Health Statutes
 "in need of care and treatment" means that a person has a mental
 illness for which in-patient care and treatment in a hospital is
 appropriate.
 "in need of involuntary care and treatment" means that a person has a
 mental illness for which care and treatment as a patient in a hospital is
 essential to such person`s welfare and whose judgment is so impaired
 that he is unable to understand the need for such care and treatment.
 "likelihood to result in serious harm" or "likely to result in serious harm"
 means (a) a substantial risk of physical harm to the person as
 manifested by threats of or attempts at suicide or serious bodily harm
 or other conduct demonstrating that the person is dangerous to himself
 or herself, or (b) a substantial risk of physical harm to other persons as
 manifested by homicidal or other violent behavior by which others are
 placed in reasonable fear of serious physical harm.
  Guidelines for Management
 Know legal standards
 Attempt to determine onset of
 symptoms
Attempt to determine onset of
         symptoms

 Chronic course—more likely to be
 psychiatric
 Acute—could be medical or psychiatric in
 origin
 Late life onset—more likely to be related to
 dementia
    General Treatment Plan
 Know legal standards
 Attempt to determine onset of
 symptoms
 Rule out medical causes
             Rule out

Head Injury
substance use/intoxication
Cognitive limitations
Delirium
 Medical Tests for evaluation of late-onset psychosis
                                    In absence of delirium             With delirium/dementia
                                                                       present
  Blood chemistries                 Yes                                Yes
  Thyroid Function Tests            Yes                                Yes
  CBC with differential             Yes                                Yes
  Drug levels                       Yes                                Yes
  ABG or oximetry                   Only if clinically indicated       Yes
  UA (culture as needed)            Yes                                Yes
  EKG                               Only if clinically indicated       Yes
  Chest X-ray                       Only if clinically indicated       Yes
  EEG                               Not indicated                      If needed
  LP                                Not indicated                      If needed
  CT or MRI                         May be needed                      Yes
  Heavy metal urine analysis        Usually not needed                 Yes
  Neuropsychological test           Only if clinically indicated       Only if clinically indicated

Khouzam, Battista, Emes, and Ahles (2005). Psychoses in late life: Evaluation and management of
disorders seen in primary care. Geriatrics 60(3); 26-33.
    General Treatment Plan
 Know legal standards
 Attempt to determine onset of
  symptoms
 Rule out medical causes
  Form collaborative treatment plan
Collaboration with others
Obtain info from source other than pt
Make a special effort to share information
with other providers
Be sure the patient is safe
Persist until the patient is treated
 Collaboration with others
Involve
  Neurology
    Order necessary studies
  Psychiatry
  Psychology
    Neuropsychology
            In Summary
Presentation of psychosis in PC may increase
with poor economic conditions and fiscally
constrained mental health resources
Management of psychosis in PC may involve
temporary medical management or
involuntary hospitalization
And so, we need to prepare our residents for
managing psychosis, the third reason for
hospitalization
Thanks for the opportunity to
      present to you!

				
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