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*** LISTEN TO THE PODCAST HERE ***

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Question

You are asked to evaluate a 23yo male prisoner for underlying psychiatric illness prior to standing trial for his third aggravated assault arrest in 12 months. During your discussion, he discloses that he doesn’t hold jobs down very well because “his bosses are idiots”, does not speak with his family, and prefers to not have friends because “everybody is stupid”. He was expelled from 3 different high schools and finally dropped out at 16. In reviewing his criminal record with his attorney, it is revealed he has been arrested 9 times starting at age 14 for theft, burglary, assault, and intoxication infractions.

1. What condition is high on your differential?
2. What are the DSM-V criteria for this condition?

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Answer

1. This patient is exhibiting the signs and symptoms of Antisocial Personality Disorder
2. To make this diagnosis, the patient must have shown examples of conduct disorder before the age of 15, be olde than 18 years, and have a pervasive pattern of disregard for and violation of the rights of others as evidenced by at least three (3) of the following DSM-V criteria:
   1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
   2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
   3. Impulsivity or failure to plan ahead
   4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
   5. Reckless disregard for safety of self or others.
   6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
   7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

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Question

You are asked to evaluate a 23yo male prisoner for underlying psychiatric illness prior to standing trial for his third aggravated assault arrest in 12 months. During your discussion, he discloses that he doesn’t hold jobs down very well because “his bosses are idiots”, does not speak with his family, and prefers to not have friends because “everybody is stupid”. He was expelled from 3 different high schools and finally dropped out at 16. In reviewing his criminal record with his attorney, it is revealed he has been arrested 9 times starting at age 14 for theft, burglary, assault, and intoxication infractions.

1. What condition is high on your differential?
2. What are the DSM-V criteria for this condition?

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Purpose Behind Screening

• Many of the more common conditions in psychiatry are often “silent”
  • Meaning that it can be difficult to objectively diagnosis
  • Some patient also don’t like talking about their illness with other clinical staff
• These screening tools can be given to any patient to complete without having to talk about it out loud and then reviewed by you to see if there needs to be any further discussion
• Some of these (GAD-7, PHQ-9) can also be used to track changes in the scores during therapy or treatment to see how well it is working

Link to SAMHSA-HRSA Page for Screening Tools

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Generalized Anxiety Disorder 7-item (GAD-7) Scale

• Screening for anxiety
  • Newer validation studies actually show some applicability to panic disorders, social phobias, and PTSD
• Developed in 2006
• Validated in 2008 and 2013
• Series of seven questions asking about symptoms over the past two weeks with four different grades for each question

• Interpretation

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Patient Health Questionnaire Nine Item (PHQ-9) Scale

• Screening for depression
• Developed in 2001
• Validated in 2010
• Series of nine questions asking about symptoms over the past two weeks with four different grades for each question

• Interpretation

• PHQ-2
  • Can be used as a brief screening tool using the first two questions from the PHQ-9
    • Sensitivity – 76% and Specificity – 87%

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Columbia Suicide Severity Rating Scale (C-CSSR)

• Screening for suicidal ideation and behavior
• Developed in 2011
• Validated in 2016
• Series of six questions asking about suicidal thoughts and actions over the past month

• Suicidal Behavior Question
  • No reported suicidal behavior
  • Actual attempt
  • Interrupted attempt
  • Aborted attempt or self-interrupted attempt
  • Preparatory acts or behavior
  • Suicide
• Interpretation

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Alcohol and Substance Misuse

CAGE-AID

• Combined alcohol and illicit drug screening tool
• Developed in 1995
• Series of four questions with “yes/no” answers

• Shorted to a two-item screening in 2001
  • “In the last year, have you ever drunk or used drugs more than you meant to?”
  • “Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?”
    • Sensitivity and Specificity – 80%
    • Positive Likelihood Ratio – 1.93 (yes to one) and 8.77 (yes to both)

Alcohol Use Disorder Identification Test (AUDIT)

• Screening for alcohol only
• Developed by WHO in 1998, but updated in 2001
• Series of ten items asking about alcohol consumption with five grading categories

• Interpretation
  • > 90% sensitivity and specificity for unhealthy alcohol use with a score of ≥ 8
• AUDIT-C
  • Uses the first three questions only (uses 6 or more drinks)
  • Men
    • 86% sensitivity and 89% specificity with a score of ≥ 4
  • Women
    • 73% sensitivity and 91% specificity with a score of ≥ 3

Drug Abuse Screening Test (DAST-10)

• Screening for illegal drugs only
• Developed in 1982
  • Originally 20 items, but condensed to 10
• Simplified to a single item in 2010
• Series of ten questions asking about illegal/illicit drug use over the past 12 months with “yes/no” responses

• Interpretation
  • Score of ≥ 3 suggests drug use with adverse consequences
  • Single Item
    • “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”
    • Yes has a 100% sensitivity and 74% specificity for drug-use disorder and a 93% sensitivity and 94% specificity for past-year drug use

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Intimate Partner Violence

• Think of your standard framing statement prior to jumping right into these scoring systems
  • Massachusetts Medical Society Committee on Violence suggests:
    • “Violence can be a problem in many people’s lives, so I now ask every patient about trauma or abuse they may have experienced in a relationship.”
    • “Many patients I see are coping with an abusive relationship, so I’ve started asking about intimate partner violence routinely.”
    • “When people have the symptom you are experiencing, and the approaches you’ve tried don’t make it better, I wonder if they could have been hurt at some point in their life. Has anything like this ever happened to you?”

Humiliation, Afraid, Rape, Kick (HARK)

• Developed in 2007
• 4 questions asking about experiences over the last 12 months
  • Humiliated or emotionally abused in other ways by your partner or your ex-partner?
  • Afraid of your partner or ex-partner?
  • Raped or forced to have any kind of sexual activity by your partner or ex-partner?
  • Kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner?
• Interpretation
  • If answered yes to any of the questions:
    • 81% sensitivity, 95% specificity, 83% PPV, 94% NPV, and 16 positive likelihood ratio

Hurt, Insult, Threaten, Scream (HITS) Scale

• Developed in 1998
• 4 questions graded on a five-point scale of frequency

• Interpretation
  • Score of ≥ 10 indicates likely victimization
    • 91% sensitivity

Woman Abuse Screening Tool (WAST)

• Developed in 2000
• 8 questions that assess physical and emotional IPV with a 3 point graded response based on frequency

• Interpretation
  • WAST-SF (short form) is the first two questions
    • If both “no”, then stop
    • If either “a lot of tension” or “great difficulty”, then proceed with the rest of the WAST

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References

1. Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of internal medicine. 2006; 166(10):1092-7. [pubmed]
2. Löwe B, Decker O, Müller S, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Medical care. 2008; 46(3):266-74. [pubmed]
3. Kertz S, Bigda-Peyton J, Bjorgvinsson T. Validity of the Generalized Anxiety Disorder-7 scale in an acute psychiatric sample. Clinical psychology & psychotherapy. ; 20(5):456-64. [pubmed]
4. Hunot V, Churchill R, Silva de lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007;(1):CD001848. [pubmed]
5. Hendriks GJ, Oude voshaar RC, Keijsers GP, Hoogduin CA, Van balkom AJ. Cognitive-behavioural therapy for late-life anxiety disorders: a systematic review and meta-analysis. Acta Psychiatr Scand. 2008;117(6):403-11. [pubmed]
6. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-13. [pubmed]
7. Arroll B, Goodyear-smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348-53. [pubmed]
8. Manea L, Gilbody S, Hewitt C, et al. Identifying depression with the PHQ-2: A diagnostic meta-analysis. J Affect Disord. 2016;203:382-395. [pubmed]
9. Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266-77. [pubmed]
10. Madan A, Frueh BC, Allen JG, et al. Psychometric Reevaluation of the Columbia-Suicide Severity Rating Scale: Findings From a Prospective, Inpatient Cohort of Severely Mentally Ill Adults. J Clin Psychiatry. 2016;77(7):e867-73. [pubmed]
11. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995;94(3):135-40. [pubmed]
12. Brown RL, Leonard T, Saunders LA, Papasouliotis O. A two-item conjoint screen for alcohol and other drug problems. J Am Board Fam Pract. 2001;14(2):95-106. [pubmed]
13. Bush K, Kivlahan DR, Mcdonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158(16):1789-95. [pubmed]
14. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro M. The Alcohol Use Disorders Identification Test: Guidelines for Use in primary Care. Geneva: World Health Organization, 2001, 2^nd Edition. [link]
15. Skinner HA. The drug abuse screening test. Addict Behav. 1982;7(4):363-71. [pubmed]
16. Smith PC, Schmidt SM, Allensworth-davies D, Saitz R. A single-question screening test for drug use in primary care. Arch Intern Med. 2010;170(13):1155-6. [pubmed]
17. Intimate Partner Violence. Massachusetts Medical Society Committee on Violence Intervention and Prevention. 5th Edition. http://www.massmed.org/AM/Template.cfm?Section=Home6&CONTENTID=36015&TEMPLATE=/CM/ContentDisplay.cfm  (Accessed on August 08, 2012).
18. USPSTF 2018 Recommendation Statement on Screening for Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening
19. Sohal H, Eldridge S, Feder G. The sensitivity and specificity of four questions (HARK) to identify intimate partner violence: a diagnostic accuracy study in general practice. BMC Fam Pract. 2007;8:49. [pubmed]
20. Sherin KM, Sinacore JM, Li XQ, Zitter RE, Shakil A. HITS: a short domestic violence screening tool for use in a family practice setting. Fam Med. 1998;30(7):508-12. [pubmed]
21. Brown JB, Lent B, Schmidt G, Sas G. Application of the Woman Abuse Screening Tool (WAST) and WAST-short in the family practice setting. J Fam Pract. 2000;49(10):896-903. [pubmed]

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Question

A 20yo man, with no significant past medical history, is brought in by his parents for evaluation of concerning behaviors. They state he often feels he “needs” to arrange the items in his room in a certain way and becomes very agitated if they are moved. He also must make sure that there is no dirt on his shoes before he walks in his room and is meticulous in his cleaning endeavors every day. His parents are worried about his level of functioning and ability to move out and maintain his own apartment. He denies any thoughts of self-harm, homicidal ideations, or audio-visual hallucinations. On physical examination, he seems composed, non-distracted, and answers all questions appropriately. When asked about these behaviors, he recognizes that they are a problem, but states he can’t relax and has severe anxiety unless these are taken care of.

1. What is the most likely diagnosis based on this presentation?
2. What criteria must be met per the DSM-V for diagnosis?

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Answer

The most likely diagnosis is obsessive compulsive disorder and is defined by the DSM-V using the below criteria:

A. Presence of obsessions, compulsions, or both

• Obsessions as defined by:
  • Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
  • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (ie, by performing a compulsion).
• Compulsions as defined by:
  • Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
  • The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

B. The obsessions or compulsions are time-consuming (eg, take more than one hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder.

DSM-V Specifiers

• Patient’s degree of insight into the illness
  • With good or fair insight
    • The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
  • With poor insight
    • The individual thinks obsessive-compulsive disorder beliefs are probably true.
  • With absent insight/delusional beliefs
    • The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
• Tic-Related – The individual has a current or past history of a tic disorder.