12.9 Mental, Neurodevelopmental, Behavioral, and Substance Use Conditions
Key Takeaways
Major depression requires at least five of nine symptoms, including depressed mood or loss of interest, for at least two weeks; mania lasts at least a week, hypomania at least four days.
PTSD symptoms last more than a month after a trauma and include intrusive memories, avoidance, negative mood changes, and hyperarousal.
Alcohol and benzodiazepine withdrawal can cause seizures and delirium and need medical supervision; opioid overdose causes pinpoint pupils and slowed breathing and is reversed with naloxone.
Bulimia can cause low potassium and dangerous heart rhythms; anorexia has one of the highest death rates of any mental illness.
Ask directly about suicidal thoughts; a patient with a plan or intent should not be left alone, and 988 is the national Suicide and Crisis Lifeline.
12.9 Mental, Neurodevelopmental, Behavioral, and Substance Use Conditions
Quick Answer: Acupuncturists see many patients with anxiety, depression, insomnia, and addiction. The BIOM exam expects you to recognize the main DSM-5 conditions, use simple screening tools, understand withdrawal and overdose dangers, and respond correctly to suicidal ideation. Acupuncture can support mental health care, but it does not replace psychiatric assessment, psychotherapy, or medication. Never advise a patient to stop psychiatric medication; changes must go through the prescriber.
Mood Disorders
| Condition | Key features |
|---|---|
| Major depressive disorder | At least 5 of 9 symptoms for 2 weeks or more, including depressed mood or loss of interest (anhedonia); others are sleep change, appetite or weight change, low energy, guilt or worthlessness, poor concentration, slowed or agitated movement, and thoughts of death |
| Bipolar I disorder | At least one manic episode lasting a week or more (or requiring hospitalization): elevated or irritable mood, little need for sleep, racing thoughts, grandiosity, risky behavior |
| Bipolar II disorder | Hypomanic episodes of at least 4 days plus major depressive episodes |
| Persistent depressive disorder | Milder depressed mood on most days for at least 2 years |
Screen with the PHQ-2 (two questions about mood and interest) and the PHQ-9.
Anxiety, OCD, and Trauma-Related Disorders
- Generalized anxiety disorder: excessive, hard-to-control worry on most days for at least 6 months, with restlessness, fatigue, poor concentration, irritability, muscle tension, and poor sleep. Screen with the GAD-7.
- Panic disorder: recurrent, unexpected panic attacks that peak within minutes (pounding heart, chest pain, shortness of breath, fear of dying). First-time chest pain must be evaluated medically because panic attacks can mimic a heart attack.
- Obsessive-compulsive disorder (OCD): intrusive, unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that take more than an hour a day or cause distress.
- Post-traumatic stress disorder (PTSD): after exposure to a traumatic event, symptoms lasting more than one month in four clusters: intrusion (flashbacks, nightmares), avoidance, negative changes in thinking and mood, and changes in arousal (hypervigilance, startle, poor sleep). Use trauma-informed care (Section 10.6).
Psychotic Disorders
Schizophrenia involves delusions, hallucinations, disorganized speech or behavior, and negative symptoms (flat affect, withdrawal) with continuous signs for at least 6 months. New psychotic symptoms, or a patient who stops antipsychotic medication and becomes agitated or confused, needs prompt psychiatric referral.
Neurodevelopmental Conditions
- ADHD: inattention, hyperactivity, or impulsivity, with several symptoms present before age 12, in two or more settings (home, school, work). Stimulant medications are covered in Section 15.2.
- Autism spectrum disorder: differences in social communication plus restricted, repetitive behaviors or interests, present from early childhood. Many autistic patients are sensitive to touch, light, and sound. Use a quiet room, predictable routines, clear explanations, and non-insertive methods if needles are not tolerated.
Eating Disorders
| Condition | Key features | Medical risks |
|---|---|---|
| Anorexia nervosa | Restricted intake, low body weight, intense fear of weight gain, distorted body image | Slow heart rate, low blood pressure, missed periods, osteoporosis, fine body hair (lanugo); one of the highest death rates of any mental illness |
| Bulimia nervosa | Binge eating with compensatory behavior (vomiting, laxatives, fasting, exercise) at least weekly for 3 months; weight often normal | Low potassium and heart rhythm problems, calluses on the knuckles (Russell's sign), swollen salivary glands, dental erosion |
| Binge-eating disorder | Recurrent binges without compensatory behavior | Obesity, diabetes, depression |
Substance Use Disorders
DSM-5 rates severity by the number of 11 criteria met: 2-3 mild, 4-5 moderate, 6 or more severe. Screening tools include the AUDIT-C and the CAGE questions (felt you should Cut down, been Annoyed by criticism, felt Guilty, needed an Eye-opener; two or more "yes" answers suggest a problem).
| Substance | Withdrawal | Overdose and emergencies |
|---|---|---|
| Alcohol | Tremor, sweating, anxiety, and nausea from about 6-24 hours; seizures usually within 48 hours; delirium tremens (confusion, hallucinations, fever, high pulse) around days 2-4, which can be fatal | Medical detoxification is needed for heavy daily drinkers |
| Benzodiazepines | Anxiety, insomnia, seizures; never stop abruptly | Dangerous breathing depression when combined with opioids or alcohol |
| Opioids | Yawning, sweating, runny nose, dilated pupils, diarrhea, gooseflesh, cravings; very unpleasant but rarely life-threatening | Overdose triad: pinpoint pupils, slow or stopped breathing, unresponsiveness. Call 911 and give naloxone, which is now available over the counter as a nasal spray |
| Nicotine | Irritability, anxiety, poor concentration, increased appetite, cravings, worst in the first few days | Smoking cessation medications are covered in Section 15.2 |
The NADA ear protocol (Section 10.2) is widely used to support recovery, alongside medical and behavioral treatment.
Suicidal Ideation
- Ask directly: "Are you thinking about killing yourself?" Asking does not plant the idea and often brings relief.
- Assess plan, intent, means, and timing, and protective factors.
- Imminent risk (a plan, intent, or access to means): do not leave the patient alone, remove access to means if safe, and call 911 or arrange emergency evaluation.
- No imminent risk: provide the 988 Suicide and Crisis Lifeline (call or text 988), arrange prompt mental health follow-up with the patient's consent, and document the assessment.
- Confidentiality does not prevent you from acting to protect a patient at serious risk; see Section 16.1 for duty-to-warn rules.
A patient describes four days of very little sleep without feeling tired, racing thoughts, rapid speech, and unusual spending, followed months earlier by weeks of depression. Which diagnosis do these episodes most suggest?
Generalized anxiety disorder
Bipolar II disorder
Persistent depressive disorder
Obsessive-compulsive disorder
A patient who drinks heavily every day says he will stop drinking completely starting tonight, without medical help. What is the main safety concern?
Withdrawal can cause seizures and delirium tremens, so refer him for supervised withdrawal
Alcohol withdrawal is always mild and harmless, so he can safely stop on his own tonight
Stopping alcohol suddenly causes pinpoint pupils and slowed breathing within hours
He should replace the alcohol with benzodiazepines bought online to ease the withdrawal symptoms
A friend brings a patient into the clinic who is unresponsive, breathing very slowly, and has pinpoint pupils. What is the most likely cause, and what is the immediate response?
Hypoglycemia; give orange juice by mouth and recheck in 15 minutes
Opioid overdose; call 911, give naloxone, and support breathing
Panic attack; coach slow breathing into a paper bag
Alcohol withdrawal; give fluids and keep the patient warm
During a visit, a patient says, "Sometimes I think everyone would be better off without me." What should the practitioner do first?
Ask directly about suicidal thoughts, plus any plan, intent, and access to means
Change the subject gently to avoid putting the idea of suicide in the patient's mind
Add Shen-calming points such as HT 7 and Yintang, then end the visit as planned
Reassure the patient that everyone feels this way at times and it will soon pass
Sections you finish are checked off in the contents.