Items in AFP with MESH term: Behavior Therapy
Tourette's Syndrome - Article
ABSTRACT: Tourette's syndrome is a movement disorder most commonly seen in school-age children. The incidence peaks around preadolescence with one half of cases resolving in early adulthood. Tourette's syndrome is the most common cause of tics, which are involuntary or semivoluntary, sudden, brief, intermittent, repetitive movements (motor tics) or sounds (phonic tics). It is often associated with psychiatric comorbidities, mainly attention-deficit/hyperactivity disorder and obsessive-compulsive disorder. Given its diverse presentation, Tourette's syndrome can mimic many hyperkinetic disorders, making the diagnosis challenging at times. The etiology of this syndrome is thought to be related to basal ganglia dysfunction. Treatment can be behavioral, pharmacologic, or surgical, and is dictated by the most incapacitating symptoms. Alpha2-adrenergic agonists are the first line of pharmacologic therapy, but dopamine-receptor-blocking drugs are required for multiple, complex tics. Dopamine-receptor-blocking drugs are associated with potential side effects including sedation, weight gain, acute dystonic reactions, and tardive dyskinesia. Appropriate diagnosis and treatment can substantially improve quality of life and psychosocial functioning in affected children.
ABSTRACT: Bulimia nervosa is characterized by binge eating and inappropriate compensatory behaviors, such as vomiting, fasting, excessive exercise and the misuse of diuretics, laxatives or enemas. Although the etiology of this disorder is unknown, genetic and neurochemical factors have been implicated. Bulimia nervosa is 10 times more common in females than in males and affects up to 3 percent of young women. The condition usually becomes symptomatic between the ages of 13 and 20 years, and it has a chronic, sometimes episodic course. The long-term outcome has not been clarified. Other psychiatric conditions, including substance abuse, are frequently associated with bulimia nervosa and may compromise its diagnosis and treatment. Serious medical complications of bulimia nervosa are uncommon, but patients may suffer from dental erosion, swollen salivary glands, oral and hand trauma, gastrointestinal irritation and electrolyte imbalances (especially of potassium, calcium, sodium and hydrogen chloride). Treatment strategies are based on medication, psychotherapy or a combination of these modalities.
Chronic Insomnia: A Practical Review - Article
ABSTRACT: Insomnia has numerous, often concurrent etiologies, including medical conditions, medications, psychiatric disorders and poor sleep hygiene. In the elderly, insomnia is complex and often difficult to relieve because the physiologic parameters of sleep normally change with age. In most cases, however, a practical management approach is to first consider depression, medications, or both, as potential causes. Sleep apnea also should be considered in the differential assessment. Regardless of the cause of insomnia, most patients benefit from behavioral approaches that focus on good sleep habits. Exposure to bright light at appropriate times can help realign the circadian rhythm in patients whose sleep-wake cycle has shifted to undesirable times. Periodic limb movements during sleep are very common in the elderly and may merit treatment if the movements cause frequent arousals from sleep. When medication is deemed necessary for relief of insomnia, a low-dose sedating antidepressant or a nonbenzodiazepine anxiolytic may offer advantages over traditional sedative-hypnotics. Longterm use of long-acting benzodiazepines should, in particular, be avoided. Melatonin may be helpful when insomnia is related to shift work and jet lag; however, its use remains controversial.
Insomnia - Article
ABSTRACT: Insomnia is a common complaint with potentially significant medical and psychologic complications. In some cases insomnia presents as a symptom of another underlying medical, psychiatric or environmental condition. In these cases, management of insomnia depends on accurate diagnosis and successful treatment of the underlying condition. In other cases, insomnia is a primary disorder requiring direct treatment. Pharmacologic treatments include nonprescription medications, sedating tricyclic antidepressants, benzodiazepines and related drugs. Behavior management methods that may be administered in the office setting include stimulus control therapy, sleep restriction therapy and sleep hygiene education. Although prescription medications and behavior therapy have similar short-term efficacy, behavior interventions are recommended as the first line of treatment for primary insomnia because of their greater safety and long-term efficacy.
ABSTRACT: Patients with insomnia may experience one or more of the following problems: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning and nonrefreshing sleep. In addition, daytime consequences such as fatigue, lack of energy, difficulty concentrating and irritability are often present. Approximately 10 percent of adults experience persistent insomnia, although most patients do not mention it during routine office visits. Asking sleep-related questions during the general review of systems and asking patients with sleep complaints to keep a sleep diary are helpful approaches in detecting insomnia. Behavior and pharmacologic therapies are used in treating insomnia. Behavior approaches take a few weeks to improve sleep but continue to provide relief even after training sessions have ended. Hypnotic medications are safe and effective in inducing, maintaining and consolidating sleep. Effective treatment of insomnia may improve the quality of life for many patients.
ABSTRACT: Helping patients change behavior is an important role for family physicians. Change interventions are especially useful in addressing lifestyle modification for disease prevention, long-term disease management and addictions. The concepts of "patient noncompliance" and motivation often focus on patient failure. Understanding patient readiness to make change, appreciating barriers to change and helping patients anticipate relapse can improve patient satisfaction and lower physician frustration during the change process. In this article, we review the Transtheoretical Model of Change, also known as the Stages of Change model, and discuss its application to the family practice setting. The Readiness to Change Ruler and the Agenda-Setting Chart are two simple tools that can be used in the office to promote discussion.
Evaluation and Treatment of Enuresis - Article
ABSTRACT: Enuresis is defined as repeated, spontaneous voiding of urine during sleep in a child five years or older. It affects 5 to 7 million children in the United States. Primary nocturnal enuresis is caused by a disparity between bladder capacity and nocturnal urine production and failure of the child to awaken in response to a full bladder. Less commonly, enuresis is secondary to a medical, psychological, or behavioral problem. A diagnosis usually can be made with a history focusing on enuresis and a physical examination followed by urinalysis. Imaging and urodynamic studies generally are not needed unless specifically indicated (e.g., to exclude suspected neurologic or urologic disease). Primary nocturnal enuresis almost always resolves spontaneously over time. Treatment should be delayed until the child is able and willing to adhere to the treatment program; medications are rarely indicated in children younger than seven years. If the condition is not distressing to the child, treatment is not needed. However, parents should be reassured about their child's physical and emotional health and counseled about eliminating guilt, shame, and punishment. Enuresis alarms are effective in children with primary nocturnal enuresis and should be considered for older, motivated children from cooperative families when behavioral measures are unsuccessful. Desmopressin is most effective in children with nocturnal polyuria and normal bladder capacity. Patients respond to desmopressin more quickly than to alarm systems. Combined treatment is effective for resistant cases.
Oppositional Defiant Disorder - Article
ABSTRACT: Oppositional defiant disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., as a recurrent pattern of developmentally inappropriate, negativistic, defiant, and disobedient behavior toward authority figures. This behavior often appears in the preschool years, but initially it can be difficult to distinguish from developmentally appropriate, albeit troublesome, behavior. Children who develop a stable pattern of oppositional behavior during their preschool years are likely to go on to have oppositional defiant disorder during their elementary school years. Children with oppositional defiant disorder have substantially strained relationships with their parents, teachers, and peers, and have high rates of coexisting conditions such as attention-deficit/hyperactivity disorder and mood disorders. Children with oppositional defiant disorder are at greater risk of developing conduct disorder and antisocial personality disorder during adulthood. Psychological intervention with both parents and child can substantially improve short- and long-term outcomes. Research supports the effectiveness of parent training and collaborative problem solving. Collaborative problem solving is a psychological intervention that aims to develop a child's skills in tolerating frustration, being flexible, and avoiding emotional overreaction. When oppositional defiant disorder coexists with attention-deficit/hyperactivity disorder, stimulant therapy can reduce the symptoms of both disorders.
ABSTRACT: Delirium is common in hospitalized older patients and may be a symptom of a medical emergency, such as hypoxia or hypoglycemia. It is characterized by an acute change in cognition and attention, although the symptoms may be subtle and usually fluctuate throughout the day. This heterogeneous syndrome requires prompt recognition and evaluation, because the underlying medical condition may be life threatening. Risk factors for delirium include visual impairment, previous cognitive impairment, severe illness, and an elevated blood urea nitrogen/serum creatinine ratio. Interventions that have been shown to reduce the incidence of delirium in at-risk hospitalized patients include repeated reorientation of the patient to person and place, promotion of good sleep hygiene, early mobilization, correction of dehydration, and the minimization of unnecessary noise and stimuli. The treatment of delirium centers on the identification and management of the medical condition that triggered the delirious state. Nonpharmacologic interventions may be beneficial, but antipsychotic agents may be needed when the cause is nonspecific and other interventions do not sufficiently control symptoms such as severe agitation or psychosis. Although delirium is a temporary condition, it may persist for several months in the most vulnerable patients. Patient outcomes at one year include a higher mortality rate and a lower level of functioning compared with age-matched control patients.
Fatigue: An Overview - Article
ABSTRACT: Fatigue, a common presenting symptom in primary care, negatively impacts work performance, family life, and social relationships. The differential diagnosis of fatigue includes lifestyle issues, physical conditions, mental disorders, and treatment side effects. Fatigue can be classified as secondary to other medical conditions, physiologic, or chronic. The history and physical examination should focus on identifying common secondary causes (e.g., medications, anemia, pregnancy) and life-threatening problems, such as cancer. Results of laboratory studies affect management in only 5 percent of patients, and if initial results are normal, repeat testing is generally not indicated. Treatment of all types of fatigue should include a structured plan for regular physical activity that consists of stretching and aerobic exercise, such as walking. Caffeine and modafinil may be useful for episodic situations requiring alertness. Short naps are proven performance enhancers. Selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, or sertraline, may improve energy in patients with depression. Patients with chronic fatigue may respond to cognitive behavior therapy. Scheduling regular follow-up visits, rather than sporadic urgent appointments, is recommended for effective long-term management.