Behavioral Health and Medical Conditions

Medical and behavioral health conditions can have many symptoms in common and may coexist or mimic each other:

• Some medical conditions have symptoms that make them look like behavioral health problems.
• Some medical conditions may be caused or worsened by behavioral health problems.
• Medical and behavioral conditions can coexist and have a direct effect on each other.

It is important to know enough about the symptoms of medical illnesses that look like behavioral health issues to determine if further assessment is necessary. A thorough medical or psychological assessment could provide a more accurate diagnosis and save months or years of frustration and ineffective treatment. For example:

• A depressed patient may have an underactive thyroid gland, meaning the body is not producing enough adrenaline to maintain adequate energy levels. Treatment for the underactive thyroid could resolve the symptoms of depression.
• A client with panic attacks or attention problems may have a condition where the body produces excess adrenaline. Treatment to decrease levels of adrenaline could reduce or resolve attention and panic issues.
• A client may have a medical condition that causes her a lot of pain, which makes her irritable and has caused problems in her relationships. Treatment for the medical condition or to learning how to better cope with the pain could help the client be less irritable.

Definitions

Mental health includes our emotional, psychological, and social wellbeing. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood and elder years.

A person who has good emotional health has the ability to live a full and creative life and the flexibility to deal with life’s challenges.

Having good physical health is more than not being sick; it refers to a person's overall physical wellness and ability to live life fully based on their body's functionality.

For information on supporting wellness, see Chapter C-3: Wellness and Prevention.

Physical health problems can contribute to behavioral health problems and vice-versa. While these mind-body relationships may seem obvious, often the source of the problem is far less clear, with the physical health problem being masked by psychosocial concerns.

Behavioral health problems may also increase the risk of some medical conditions. For example, people who have depression often find it hard to take care of their bodies, which can lead to health problems. They tend to eat poorly and get less exercise, and are at a greater risk of smoking. During the screening and intake process, it is important to ask clients if they have a regular medical provider or had a physical exam completed recently. Refer your client to a medical provider or CHA/P if he describes any new, recent, or untreated physical symptoms that appear to affect his daily functioning

It takes a team. Determining if a person has a behavioral health disorder or a physical condition requires a comprehensive overview of the individual’s history to help identify what may be causing symptoms. A client’s treatment is more likely to be effective if the behavioral health and medical providers have as much information as possible.

You are key to making sure clients receive holistic health care. Medical providers typically spend less than 15 minutes with each patient to collect a history, do a physical, order tests, and make notes. Given the limited amount of time medical providers get to spend with clients, they can miss or never receive critical information related to their patients’ presenting problems. As such, it is important for you to advocate for your client by working with all members of the medical team. This team may include primary care providers, CHA/Ps, and nurses, all of whom can help to better identify, diagnose, and treat complex and often overlapping medical and behavioral health conditions.

Before contacting a medical provider, ask yourself:

• What symptoms are you and your client most concerned about?
• What kind of information, guidance, or answers do you want from the medical provider? For example, do you (as the BHA/P) want to consult with the provider about the case? Does your client need an appointment to discuss her symptoms or have her medications reviewed?
• What essential information will the medical provider need in order to respond to the client's needs?
  • Take care to organize and document the information so you can share it with the provider, Remember to only share information that is relevant to the concerning symptoms. See Chapter B-4: Confidentiality and Release of Information for more specifics related to the sharing of client information.

Obtain Releases of Information that will allow you to speak with other providers, agencies, and people who know the client well and could provide critical information about their symptoms and behaviors.

• If you cannot obtain an ROI and believe it is critical to consult with a medical professional, consult with your supervisor and follow your organizational policies and procedures.

• Collaborate with the local CHA/P and/or medical provider to develop holistic plans that address your client’s needs. As it relates to each provider:
  • Identify the symptoms you are most worried about.
  • Provide the information you have about the client’s symptoms; be specific. Report how long the symptoms have persisted and how the symptoms are affecting the client’s functioning.
  • Clearly state what kind of answer, information, or treatment directives you want from the medical provider.
  • Identify a plan and schedule for each provider to monitor and share updates on the client’s condition and treatment.

Advocate for your client's needs. When you work with other providers, it is possible that they will overlook the medical causes of behavioral health problems. Be aware of some of the reasons for this and aim to advocate for your client's treatment needs:

• Medical providers are often uncomfortable around people with behavioral health problems because it is not their main area of training or expertise.
• Behavioral health problems are often invisible, and providers may dismiss the complaints of behavioral health patients or blame complaints on a patient’s character.
• Patients with behavioral health problems may behave in ways that make evaluation more difficult.
• Providers may associate certain symptoms (e.g., psychosis) with a behavioral health problem and overlook medical causes for the symptoms.
• Some patients may be either unwilling to give a full history or unable to accurately describe symptoms.
• Patients may be too frightened to allow a full physical examination.
• Adults who are elders, are hard of hearing, have communication challenges, are less organized, or think less clearly than typical adults may not communicate important information to the medical provider when time is limited.

You can help overcome these challenges when interacting with clients and their medical providers.

• Help clients find the words to communicate to the medical providers when symptoms are vague. For example, you could help your client make a list of important symptoms to share.
• Use specific language with medical providers. Be detailed.

Depression and medical conditions

People who have chronic diseases such as arthritis, asthma, diabetes, cancer, heart disease, hepatitis C, and stroke often also have depression. Depression also often occurs with chronic pain. Depression may occur with these conditions because:

• The everyday stress of dealing with a chronic disease causes depression or makes it worse.
• Severe depression may lead to suicidal thoughts. See Chapter D-6: Suicidal Thoughts and Plans.
• People dealing with chronic conditions are at a greater risk of substance abuse.
  • If your client is using alcohol or drugs to cope with the effects of a medical condition, see Chapter D-2: Substance Use and Abuse and consult with your supervisor.
• Some chronic diseases change body and brain chemistry (e.g., increase or decrease hormone levels or change functioning of bodily systems) and contribute to depression. Cushing's syndrome and an underactive thyroid ( hypothyroidism ) are examples of two conditions that may cause depression.
• Depression is linked with some chronic diseases. For example, depression makes coronary artery disease (CAD) and death from heart disease more likely.
• People learning to live with diabetes are more likely to experience depression and people with depression are more likely to develop diabetes, as diet and exercise are often lacking in depressed people’s lives.
• Some medications may cause depression, while medications taken to treat depression can make other health problems worse. For more information on medications used to treat mental health conditions, see Chapter E-4: Medication Management.
• A client with a diagnosis of depression but whose symptoms don’t seem to be fully attributable to depression may have a medical illness contributing to or causing the depression.
• A client with a history of thyroid issues who complains of depression with decreased energy levels, increased weight, decreased libido, and dry skin may need to be evaluated for reoccurring thyroid problems.
• Similarly, a new mother’s exhaustion and disinterest in her baby seem like postpartum depression but really be caused by a postpartum thyroid imbalance that medication can correct.
• Deficiencies of vitamins (D, B-12, and folate), hormonal changes, and sleep disorders have been linked to depression.
• A person’s sudden depression might turn out to be a side effect of high blood pressure medication.

Anxiety and Medical Conditions

It is possible that anxiety may be due to a medical condition if:

• The person does not have a parent or sibling with an anxiety disorder.
• The person did not have any anxiety as a child.
• The person does not avoid certain things or situations because of the anxiety.
• There is a sudden occurrence of anxiety that seems unrelated to life events with no previous history of anxiety.

Sometimes, anxiety is linked to an underlying health issue. Anxiety signs and symptoms are the first indicator of some medical illnesses. As a BHA/P, being aware of medical conditions will help you be aware of when medical conditions could be causing anxiety symptoms. For example:

• A person who has angry outbursts and frequently feels “ready to explode” might have high blood pressure or diabetes that causes anxiety-like reactions.
• People who have asthma can have panic attacks and may feel "jittery" after using an inhaler or breathing treatment.
• Back pain, stiffness, and spasms may go before, accompany, or follow an escalation of anxiety sensations and symptoms. If these symptoms are not otherwise explained, the client should be referred for a medical evaluation.
• Anxiety symptoms can happen suddenly and without warning, as can heart attack symptoms. As a result, patients sometimes go to the emergency room thinking they are having a heart attack when they are really having anxiety symptoms, which do not often get properly addressed in the emergency room.
• The following symptoms of anxiety can also be signs of physical conditions:
  • Chest pain, shortness of breath, fatigue, or racing heart can be a sign of heart problems or a heart attack.
  • Breathing difficulties may be a sign of conditions such as bronchitis, emphysema, ovarian cancer, or cardiac problems.
  • Lack of concentration and chest pain may be a sign of coronary artery disease, chronic fatigue syndrome, Alzheimer’s disease, or brain cancer.
  • Irritability, being tired, changes in eating, frequent urination, and underlying feelings of anxiety may be a sign of diabetes mellitus.

People who have endured abuse or trauma or who have witnessed traumatic events are at a higher risk of developing an anxiety disorder at some point in life.

Stress due to illness or a serious health condition may cause significant worry about issues such as treatment and the future, creating anxiety.

Traumatic Brain Injuries (TBI)

A traumatic brain injury (TBI) is an injury to tissue in the brain that may result in physical disabilities and to sensory and speech impairments that are classified as medical.

• A person with a TBI may have symptoms that affect mental, cognitive, behavioral, or emotional functioning.
• A person with a TBI can appear intoxicated, have aggression issues, or have memory problems.
• TBIs have a wide range of physical and psychological effects.
• Mood swings and emotional instability are often caused by damage to the part of the brain that controls emotions and behavior.
• Someone with a TBI may show outbursts of anger, impulsivity, and irritability or have sudden episodes of crying or laughter. Such emotional responses can be alarming to the person experiencing the symptoms or people who observe the symptoms.

Behavioral health treatment can be helpful in guiding the person to develop routines and strategies for coping with the effects of the TBI. The client may need additional advocacy and case management to connect her with the resources needed to address her treatment goals.

Psychosis and Medical Conditions

People can experience psychosis as a symptom of a mental illness or a physical illness. Individuals who experience psychosis can have medical illnesses that impact their ability to manage their health and behaviors, or vice-versa: their psychosis can make it difficult for them to manage their physical health needs. For more information about psychosis, see Chapter D-13: Hallucinations and Delusional Thoughts (Psychosis).

Medical problems that may cause psychosis include:

• Brain tumors or cysts.
• Dementia and Alzheimer disease.
• Certain types of epilepsy.
• Stroke.
• Brain diseases like Parkinsons.

Alcohol and some illegal drugs, both during use and during withdrawal, may cause psychosis.

Individuals who experience psychosis are often prescribed an antipsychotic medication to manage their symptoms. For more information on medications used to treat mental health conditions, see Chapter E-4: Medication Management. These medications typically require the client to take them on a regular and consistent schedule, though there are many reasons why this may not happen:

• A person who is taking psychiatric medications will sometimes think the medication is causing certain symptoms. You can help by researching the side effects of your client’s medication and by encouraging your client to attend follow-up medical appointments.
• Some of the medications have unpleasant side effects, such as Tardive Dyskinesia, a condition that cause uncontrollable muscle movements, typically around the mouth. If your client may be experiencing this side effect, encourage your client to make a follow-up medical appointment to discuss options.
• The client has a hard time creating and following a schedule and may not have the skills to plan to get prescriptions refilled. Help your client establish a consistent, achievable plan for taking medication on schedule and requesting refills.

Refer clients to a medical provider or CHA/P if they describe any new, recent, or untreated physical symptoms that appear to affect their daily functioning. When considering whether to refer a client for a medical consult, evaluation, or treatment, ask about and document the client's responses to the following, when relevant:

• When did the symptoms begin?
• Have the symptoms gotten better or worse with time?
• Have you ever had these symptoms before?
• Have you had past hospitalizations and surgeries?
• What is your family history with both medical and behavior health?
• Do you have or have you ever had chronic conditions, such as diabetes, thyroid disease, or high blood pressure?
• Have you ever had a head injury, concussion, periods of unconsciousness, or seizures?
• What medications and vitamins are you taking?
• Are you taking any drugs without your doctor’s approval, including prescription medicines, over-the-counter medicines, or illegal drugs?
• How often do you exercise?
• How is your sleep? How often do you get a restful night of sleep?
• Do you use helmets when on snow machines/four wheelers?
• When, what, and how often do you eat?
• Do you use tobacco of any kind? Are you around secondhand smoke?
• How often do you use sugar, salt, and alcohol? Do you use them in moderation?

In addition to documenting the client's responses to the questions you ask, be sure to document and share your observations about the following:

• Does the person look ill?
• How is the person dressed? Is this how the person normally dresses?
• Does the person appear to experience uncontrollable ticks, muscle spasms, or an inability to move parts of their face or body?
• Is the skin very dry or abnormally colored (e.g., yellow or pale)?
  • Dry skin and hair may signal hypothyroidism.
  • Pale skin, eyelids, or lips may indicate anemia.
  • Yellow skin may indicate jaundice or liver disease.
• Does the person appear to be able to focus on objects and people in the room, including yourself? Do the pupils appear to be exceptionally large or small?
  • Dilated (large) pupils may indicate the use of drugs such as hallucinogens or stimulants.
  • Constricted (small) pupils may indicate the use of opiates.
  • Bulging eyes may be a sign of hyperthyroidism.
• Is there any disturbance in the way the client moves, holds himself, positions his body, or touches his nose? Are his movements jerky or does he tremble?
• Is there any difficulty in speaking, including slurred speech or difficulty finding the right words?

If your client reports the presence or history of the following, be sure to inform the medical providers, because these may be important in helping the medical provider make a diagnosis:

• Over the age of 40
• No previous psychiatric history that presents with mental confusion
• No history of similar symptoms
• Coexistence of chronic disease
• History of head injury
• Changes in frequency of headaches
• Headaches associated with vomiting
• Symptoms worsen when taking antipsychotic or anti-anxiety medications
• Double vision or partial visual loss
• Seeing or responding to things that others cannot see or hear
• Recently developed speech problems (e.g., difficulty making speech sounds or problems comprehending or using words)
• Problems regulating blood pressure, pulse, or temperature
• Disorientation and/or memory impairment
• Abnormal body movements, such as tremors, involuntary movements, and/or reduced facial expression
• Blood or pus in urine
• Losing control of urine or stool
• Chest pain while at rest
• Inability to perform daily tasks like taking care of children or getting to work or school

Behavior

• Eating or sleeping too much or too little
• Pulling away from people and usual activities
• Low or no energy
• Smoking, drinking, or using drugs more than usual
• Yelling or fighting with family and friends
• Intentionally causing harm to self

Emotions

• Feeling numb or like nothing matters
• Helplessness or hopelessness
• Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared
• Severe mood swings that cause problems in relationships

Problematic thinking and psychosis

• Persistent, unwelcome thoughts and memories
• Thoughts of suicide
• Visual hallucinations that are vivid in color and change rapidly
• Olfactory (smell) hallucinations
• Illusions (distortion of environment)
• Hearing voices or believing things that are not true