Exam 1 Flashcards
Which state would you go to to study mental Illness?
Utah (22.4% living with mental illness; 5.2% reports of serious mental illness), Oklahoma (5.2% reports of serious mental illness) , West Virginia (5.5% reports of serious mental illness)
What disorders are the most likely to see in the US?
- Anxiety (panic, OCD, PTSD, GAD, phobias): 42 million people, 18.1% - Major Depression: 14.8 million people, 6.7% - Bipolar disorder: 6.1 million people, 2.6% - Schizophrenia: 2.5 million, 1.1%
Psychoanalytic Theory (Sigmund Freud)
Focuses on personality development and unconscious motivations as the cause of behaviors (Oral, Anal, Phallic, Latency, Genital) If an individual receive to ouch or too little gratification in one of the states, they will becomes fixated in that particular development stage.
Attachment Theory
Focuses on the role of the early care giver and child relations. Secure infants/children have more self-esteem and self-reliance as they becomes adults and function better
Diathesis-stress Model
examines the interaction of non-biological or genetic traits (diathesis) and environmental influences (stressors) to produce disorders (e.g. depression, anxiety, schizophrenia)
Axis I (Old)
Clinical Disorders/Affective Disorders: - Schizophrenia - Major depression - Bipolar disorder
Axis II (Old)
Disorders that appeared early in life and persisted: - Personality disorders - Intellectual disabilities, previously called mental retardation
Axis III (Old)
General Medical Conditions: - Diabetes - Hypertension - Epilepsy
Axis IV (Old)
Psychosocial and Environmental Problems - Problems with primary support groups - Problems related to the social environment - Educational Problems - Occupational problems - Housing problems - Economic problems - Problems with access to healthcare services - Problems with related to interaction with the legal system/crime - Other
Axis V (Old)
Global Assessment of Functioning (GAF) –> Old Now use: World Health Organization Disability Assessment Schedule (WHODAS)
Major Types of Classficiations
MAPPSSC Mood Anxiety Psychosis Personality Substances/Addiction Somatic Cognitive
Top 12 Tips on Psych Interview Techniques
- Establish rapport early – start with non-threatening questions, and when possible some common topics.
- Allow the patient to talk freely without interruption (at least 3-4 minutes)
- Determine the patient’s chief complaint – It may not be clear.
- Use open and closed ended questions
- Develop provisional differential diagnosis (DDX).
- Use more focused questions to clarify differential DDx
- Depending on the patient, initially you may not want to try reasoning with them.
- Gradually move to the tougher questions, (drugs, sexual, and criminal behavior, etc.)
- Follow-up on vague responses.
- Always ask about suicidal and homicidal ideations.
- Provide adequate time for the patient to ask questions.
- Convey confidence and hope.
Psych Review of Symptoms (ROS)
MAPPSS-CEETO
Mood – Describe your mood
Anxiety – Do you worry a lot? Is it hard for you to control the worrying?
Psychosis – Do you see things that others don’t
Personality – Any patterns that have caused you problems throughout your life?
Substance/Addiction – How often do you use substances, gamble, etc.?
Somatic – Do you worry about your physical health?
Cognitive/Dissociation –do you often forget things?
Eating/feeding – Do you have concerns with your weight or eating habits? Restrict foods?
Elimination – regularly soil clothing?
Trauma – ever suffered an event you believed threatened your safety/life.
Obsessions/compulsions – Experience unwanted urges, thoughts, repetitive acts?
Past Psych Hx
Family History
- Age and occupation of parents and age of siblings
- Document the family hx of mental disorders as well as their course and outcome.
- Document alcohol and drug use, criminal history, severe depression, suicide, etc., in blood relatives.
- Social, cultural, educational background
Social History = Life History
- Include personal history/demographics
- Birth place, childhood area
- Developmental and social adjustments
- Childhood behavioral concerns (temper tantrums, phobias, cruelty concerns)
- Adolescence: family, peer, and authority relationships, school performance, drug use
- Legal issues
Adulthood:
- Sexual history: sexual development
- Marital and family relationships
- Religious and cultural attitudes
- Education, employment, military service, financial situation, current social/living situation, and support systems
Medical History
Very brief Medical Hx:
- Allergies, hospitalizations
- Chronic diseases, current medications
- History of neurologic disorders or head trauma
Components of MSE
- General Appearance & Attitude
- Motor Activity/behavior
- Levels of Consciousness/orientation
- Speech and language
- Mood and Affect
- Thought form/content
- Perception
- Memory and cognition
- Judgment and Insight
Alert
patient is able to open eyes, look at you, responds fully and appropriately
Lethargic
sluggish, drowsy, but can open eyes, and respond. Falls back to sleep easily
Obtunded
lessened interest in the environment, slowed response to stimulation, sleeps a lot.
Stuporous
Wakens only with painful stimuli. Verbal responses slow or absent. Falls back into unresponsive state when stimuli ceases
Comatose
unarousable to any stimuli
Mood
emotional attitude that is relatively persistent; and usually reported by the patient.
Depressed, euphoric, anxious, irritable, apathetic, anhedonic, bored, “sad/happy
To assess mood, you need to ask the patients how they are feeling:
- “How are your spirits these days?”
- Labile mood?
- Intensity of mood?
- Is the patient suicidal?
- Is the mood appropriate to the patient’s situation?
Affect
Inferred from the patient’s emotional response. It is what you see or observe (objective). Full range, inappropriate, labile, flat or blunted.
The external expression of emotion visible to the clinician:
- Are the pts responses and body language devoid of emotion?
- Are their responses hyper-emotional?
- Do their responses change dramatically through the interview?
- Are the responses appropriate to the patient’s situation or what they are saying?
Patterns of Speech: Derailment or loose associations
Pattern of Speech: Tangentiality
only partially relevant or irrelevant responses to questions that don’t answer the question. Totally digress…
Pattern of Speech: Circumstantiality
Speech Patterns: Word salad/Incoherence
speech makes no sense at all. Words joined don’t convey a message, i.e., Wernicke’s aphasia…. Need to rule out stroke.
Speech Pattern: Pressured speech
Fast and difficult to interrupt/understand; seen in bipolar-mania.
Speech Pattern: Flight of ideas
rapid, continuous, shift of ideas either unrelated or based upon minimal associations, distractions, play on words; (seen in mania).
Patterns of Speech: Distractible speech
During the course of a discussion, pt changes subject in response to something unrelated in the environment.
Patterns of Speech: Perseveration
persistent repetition of specific words or ideas; in absence of stimuli
Pattern of Speech: Clanging
word choice don’t make sense. Words are chosen based on the sound they make (often rhyming), not their meaning.
Thought Content: Preoccupations
obsessive, phobic, suicidal, homicidal, paranoia/suspicious
Thought Content: Delusions
False, fixed personal beliefs that are not shared by others in the pts community. (Occur in psychotic d/o).
- Persecution
- Grandiosity
- Delusion of being controlled externally
- Somatic delusions
- Jealousy, Religious
- Ideas and delusions of reference
- Thought insertion/withdrawal/broadcasting
Alogia
Poverty of thought, no depth, minimal responses, very concrete (vs. abstract). Often seen in schizophrenia.
Manifests as:
- Non-fluent empty speech (poverty of speech)= few spontaneous words, very concrete
- Fluent empty speech (poverty of content of speech) = conveys little information, overly abstract or concrete.
Preception: Illusions
misperception of real external stimuli
Preceptions: Hallucinations
Abnormal perceptions. Pt hears, sees, smells or feels something others cannot.
- Visual
- Auditory – One voice or more? Conversing?
- Tactile, olfactory, gustatory
Preceptions: Derealization
is the sense that the world around the person is somehow not real
Preceptions: Depersonalization
is the sense that the person is somehow not real
Memory: Registration
Can pt. learn something new and immediately repeat it back?
Memory: Recent/short term memory
Can the patient correctly remember things that happened today?
Memory: Remote/long-term memory
Can the patient correctly remember things that happened or information from long ago?
Attention
Can the patient focus enough to be able to perform tasks?
- Attentive
hypervigilant - distractible
- difficulty following conversation
Cognition
Assess patient’s apparent cognition/intelligence by assessing the degree to which they are informed, can problem solve, capacity for abstract thinking, simple math, complexity of their vocabulary, etc.
Abstract Thinking:
- Proverbs: Ask the patient to interpret a commonly used proverb
- Similarities: Ask the patient to tell you how two things are alike
Judgement
Judgment is the ability to evaluate a situation and make a reasoned decision. Two ways to assess:
- Ask patients to propose a solution to their current problems: “How will you get follow up care after you leave here today?”
- Ask patients to propose a solution to a hypothetical problem: “What would you do if you found a stamped, addressed letter on the ground?”
Insight
Insight is the ability of patients to understand and acknowledge factors that influence a situation (such as their illness).
Patients with mental disorders or have dementia often lack insight and may deny their illness. They may also refuse to take medications for their illness or engage in needed therapy
SIG E CAPS
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicidal thoughts
Major Depression: 5 of 9 criteria, most of every day for two weeks, with impairment
Sad, empty, hopeless (need one of these)
OR
Lost of interest or pleasure (apathy, anhedonia)
Weight change
Insomnia or hypersomnia
Psychomotor slowing or agitation
Fatigue
Worthlessness, guilt
Decreased concentration
Thoughts of death or suicide
How to believe a DSM diagnosis
(Not in DSM but the smart thing)
Right patient: female of reproductive age
Right Symptoms: meets criteria
Right backstory: social stressors, current and past
Right family history: alcoholic father but not clear
Right prior treatment response: yes, sort of
Screening Questions
” Have you ever been treated for depression in the past?”
“In the past two weeks have you been feeling sad, down, or depressed most days?”
“In the past two weeks have you noted loss of interest or that you can’t enjoy things as much as usual?”
Use Medicine to help you answer questions
Thyroid
Vitamin D
General chemistries, CBC
Age appropriate for specific symptoms or unusual presentation (age, gender, context)
Fatigue: cardiovascular, autoimmune, metabolic
Sleep: Sleep apnea
Weight loss: abdominal cancer
Presence of serious medical condition doesn’t rule out depression as a co factor requiring treatment
***SUBSTANCE ABUSE!***
Helps calculate suicidal Risk
“SAD PERSONS”
S – Sex: 1 if male; 0 if female; (more females attempt, more males succeed)
A – Age: 1 if < 20 or > 44
D – Depression: 1 if depression is present*
P – Previous attempt: 1 if present
E –Ethanol abuse: 1 if present*
R – Rational thinking loss: 1 if present*
S – Social Supports Lacking: 1 if present*
O – Organized Plan: 1 if plan is made and lethal
N – No Spouse: 1 if divorced, widowed, separated, or single
S – Sickness: 1 if chronic, debilitating, and severe*
*=modifiable
Total points
Proposed clinical action
0 to 2
Send home with follow-up
3 to 4
Close follow-up; consider hospitalization
5 to 6
Strongly consider hospitalization, depending on confidence in the follow-up arrangement
7 to 10
Hospitalize or commit
Suicide risk: Clinical
Addicted or chronically ill
Prior attempts Planning
Hopelessness a critical predictor
Anxiety or agitation; panic while depressed
Anxiety induced by antidepressants (esp adolescents)
Psychotic symptoms
Suicide Assessment Five-Step
“SAFE-T”
IDENTIFY RISK FACTORS
Note those that can be
modified to reduce risk
2
IDENTIFY PROTECTIVE FACTORS
Note those that can be enhanced
3
CONDUCT SUICIDE INQUIRY
Suicidal thoughts, plans
behavior and intent
4
DETERMINE RISK LEVEL/INTERVENTION
Determine risk. Choose appropriate
intervention to address and reduce risk
5
DOCUMENT
Assessment of risk, rationale,
intervention and follow-up
eAssessment SAFE-T
NATIONAL SUICIDE PREVENTION LIFELINE
1.800.273.TALK (8255)
Integration Care
- Start with one medication, used in appropriate doses, follow with measures (Like PHQ9)(Implement “disease management” if available)
- Switch within class or to another class/enlist mental health practitioner
PA: may continue to manage medication while psychotherapy provided by MSW, PHD
Clinically Participating in their care
SAD PERSONS: Low sensitivity (19%) and minimal positive predictive value
Single question: Do you wish to be dead?
Instill hope
Impulsive suicide (esp, psychosis, personality disorders, dementia) is much harder to predict (people who can’t plan)
Access to means (GUNS)
Active preparation
Treat or Refer?
TREAT
Prior treatment response
Medically complicated
Pain and MUPS
Preference for medication
PMDD
Seasonal disorder (“atypical” : hypersomnic, weight gain, not densely anhedonic) (use light)
REFER
Moderate or mild: wants or open to psychotherapy
Severe, Bipolar, psychotic sx
Wish to be dead/ history of suicide attempts
Treatment non responsive
Intolerance to side effects or meds
