CCFP Topic: Behavioural Problems

Include medical, social and psychiatric  causes:

Use the DIMS (Drugs, Infectious, Metabolic, Structural) mnemonic or similar for delirium if it’s an acute change, or look for some of the more chronic conditions that can affect behaviour. Consider:

• hearing and vision impairment in both the young and elderly
• central causes like head trauma and seizures
• metabolic disorders like hypo or hyperthyroid, electrolyte abnormalities or DKA
• Toxins like lead, carbon monoxide, or other ingestions or drugs
• Anemia
• Perinatal or genetic causes
• Neurodegenerative disorders

Psychosocial factors can play a large role in a presentation of behavioural issues, that can be an aberrant behaviour from the patient, or unusual expectations or parenting styles. Keep in mind:

• Child abuse or neglect
• Housing and food security
• Substance use
• Stressful situations
• Peer conflict.

After ruling out medical or social issues, look toward psychiatric diagnoses. This is really going to be driven by the presenting complaint, as well as the age of the patient. In the younger patients think about:

• Autism spectrum disorder (ASD)
• Learning disorders
• Attention deficit hyperactivity disorder (ADHD)
• Oppositional defiant disorder (ODD)/Conduct disorder (CD)

In adolescents and adults think about:

• Mood disorders like bipolar and depression
• Psychotic disorders like schizophrenia
• Anxiety spectrum disorders including generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD)
• Eating disorders
• Self-harm behaviours as a maladaptive coping strategy
• Personality disorders

In adults and the elderly, these same conditions may be present, but new onset symptoms are more likely related to

• Neurocognitive disorder
• Depression
• Medication
• Secondary to a medical structural cause
• Personality disorders (covered in future episode)

Tools for screening and diagnosing ADHD and ASD are standard in their workup. These include things like the SNAP-4 and Vanderbilt scales for ADHD, and the MCHAT or ADI-R for ASD. Be aware when using these tools and ensure you’re using the appropriate questionnaire, whether that’s for screening or diagnosis.

Other useful screening tools include the Beck Depression Scale, PHQ9, GAD7, and mood disorder questionnaire.

The CPS website has a really good page of screening tools available here: https://www.cps.ca/en/mental-health-screening-tools

This may go without saying, but you will need more than one side to get the full story. This includes talking with the patient alone, if appropriate, as well as with just the caregiver, if the patient is ok with that. Getting information from the teacher or school, nursing home or other community members may be challenging, but this is vital to the diagnosis of a number of conditions that require the symptoms be present in more than one setting, or where the symptoms are only present in certain situations. The things that come to mind are ADHD in the younger patients, and sexual disinhibition in the elderly as a result of dementia, respectively.

Gather info from both the patient and their caregiver, ideally separately. You may get very different stories, or pick up on other issues.

ADHD is a common concern in children – parents can be quite anxious about it, and the patient can be quite affected by it if left untreated. The biggest Canadian guidelines covering this are the CADDRA Guidelines. https://www.caddra.ca/wp-content/uploads/CADDRA-ADHD-Practice-Guidelines-4.1-English.pdf In these they suggest that Patients with ADHD can be managed in a primary care setting, but first a diagnosis needs to be made.

Some red flags that should prompt you to consider ADHD in your young patients include:

• Poor organizational skills be it time management like missed appointments, frequent late and unfinished projects
• Erratic work/academic performance
• Anger control problems and Family/marital problems
• Difficulty in maintaining organized household routines, sleeping patterns and other self-regulating activities including finances
• Addictions such as substance use, compulsive shopping, sexual addiction, overeating, compulsive exercise, video gaming or gambling
• Frequent accidents either through recklessness or inattention.
• Problems with driving (speeding tickets, serious accidents, license revoked).
• Having a direct relative who has ADHD.
• Having to reduce course load, or having difficulty completing assignments in school.
• Low self-esteem or chronic under-achievement.

According to DSM-5, the diagnostic tasks are to ensure: 

1. Current symptoms must meet criteria for Inattentive or Hyperactive-Impulsive subtypes, or both (Table below). That is 6 of 9 of either of the criteria.
2. Age of onset of these symptoms is by age 12. 
3. Impairment in two or more roles due to these symptoms has been present for the last six months or more. This means issues in 2 or more of work, or school or home.
4. A lack of alternate explanation for the symptoms or impairment,including a broad range of alternate medical (including mental health) and circumstantial conditions.

Treatment for ADHD includes both environmental changes and medications – typically long acting stimulants. The main side effects you should know about for these can be anorexia, weight loss and sometimes impaired sleep. Again, CADDRA has complete recommendations for this: https://www.caddra.ca/resources/medication-chart/

Schizophrenia: This can present with a prodromal phase of negative or positive symptoms. Often this happens in the later teen years, and can last a couple of years prior to onset of the typical symptoms. On the negative side there may be social isolation, decreased emotions, avolition, decreased ideas and deterioration in social roles. On the positive side there may be unusual thoughts, paranoia, grandiosity, and perceptual disturbances.

https://www.uptodate.com/contents/schizophrenia-in-adults-clinical-manifestations-course-assessment-and-diagnosis

Assess each of these domains using the HEADSS mnemonic

• Home
• Education and Employment
• Activities
• Drugs and alcohol
• Safety and Sexuality
• Suicidality.

It’s important to emphasize the terms of confidentiality with adolescents – nothing you discuss will be discussed with their parents without the patient’s consent, EXCEPT if there is suicidality or concerns for safety.

Evaluate the impact of the behaviour: For this you will need to explore how the patient feels about their behaviour and how those around them feel, or how it has objectively affected work or school or relationships. Remember to implement FIFE (Feelings, Ideas, Function, Expectations).

Explore any underlying emotional distress with the patient: Continue with your FIFEing and figure out how they feel about the situation.

Destigmatize embarrassing behaviours: Normalization is often key to building rapport, getting a complete history of the behaviour and to helping treat the patient’s discomfort or anxiety about the situation.

This is important to remember – patients can have some signs or symptoms or traits of a disorder without meeting diagnostic criteria. Or you may not have enough information to make that diagnosis, or perhaps referral to a psychiatrist is warranted. In any case, feel free to use language that leaves room for diagnostic uncertainty. You can tell them what their symptoms are often seen in, or perhaps what things you’re thinking about, but need more information. You don’t always need to have a diagnosis.

Close follow-up is useful for these cases regardless of a diagnosis being made, or what that happens to be.  

Here we need to assess for suicidality – that is ideation, passive or active, whether a plan is present, whether there is the means to do it, preparatory actions like notes or putting affairs in order, and any history of the same. You should also assess risk to others via homicidal ideation with all the same points as with suicidality, as well as possible unintentional risk to others. This would include things like driving while manic or impaired due to drugs or a medical condition, or the presence of small children and inattentive caregivers.

The environmental aspects of ADHD treatment have been shown to be helpful, either alone or in addition to medical treatment, and this should be considered first line even prior to a diagnosis.

Similarly CBT has been shown to be useful in several psychiatric disorders and should be first line or in conjunction with medication.

Begin all patient encounters and relationships with an open mind, being sure not to openly judge patients based on the information they are telling you. Our job is to hear them and help them. We can’t do that if our own prejudices are clouding our judgement, or if we’re busy telling them how their decisions are a terrible idea – they probably already know that. 

Further, not all patients are forthcoming with information or cooperative with interviews or treatment. Maintaining a professional approach while dealing with patients that are uncooperative, belligerent or angry for one reason or another can be tough. Being aware of how the patient is making you feel is the first step to reacting in an appropriate and constructive manner. This is the whole transference/countertransference thing. Overall, I think this objective touches on one of the hardest challenges we’ll face in our careers.