Lecture 2.2 (10/10) Flashcards
1) What fraction of Americans have a mental illness?
2) What percent of those receive treatment?
3) How many pts who are mentally ill have more than one mental illnesses?
1) Roughly 1/5
2) Only about 40%
3) Nearly half
Why does psych matter?
1) Mental illness is highly prevalent and treatable
2) There is a shortage of mental health providers
-Therefore, those in primary care should be especially competent in picking up mental illness (and those in specialties are not immune)
Describe the differences between symptoms and signs
-We often describe symptoms as subjective and signs as demonstrable
-A symptom is therefore a psychiatric phenomenon, under this model and something experienced by a patient (somatic or psychological)
Describe the two types of symptoms
1) Somatic – pertaining to a body sensation like pain, fatigue, or palpitation
2) Psychological – pertaining to a mental state, like anxious or depressed
How does the division of symptoms into somatic and psychological hinder care?
Sets up a dichotomy between “Psych” and “Soma”
What does the current model suggest about symptoms
Symptoms are interactive and represent “A varying mix of disease and non-disease input from medical to mental disorders”
What does evidence show about symptom etiology?
Symptom etiology is often multifactorial, lacking a single cause; often, there are several related symptoms or symptom clusters rather than single complaints.”
What does the new approach say about the divisions between psych and somatic?
There is an overlap between the psychological component of the patient’s history and the purely “medical” aspect of their care:
-Often, the experience of the patient is not easily divided into “psych complaints” and “medical complaints”
-Mental activity shows up in the body, and illness of the body manifest in the patient’s psychiatric makeup
-One might say this leads to a type of merger between sign and symptom
Give examples of a little bit of psych and somatic overlap, and examples of a lot of overlap
1) Very little overlap in: straight forward complaints like UTI, URI
2) Prominent overlap in: fibromyalgia patients, IBS, chronic pain syndrome, etc.
What is the modern model that integrates psych and somatic?
An integrative continuum model (with 5 nodal points pertaining to patients’ signs/ symptoms)
What are the five nodal points pertaining to a patient’s sign/symptom?
1) Clear Cause: wheezing (obstructive disease)
2) Functional somatic syndrome: IBS, etc. AKA “Functional syndromes”
3) Symptom only dx: low back pain, nonspecific GI pain
4) Psych conditions: anxiety, depression
5) Unexplained sx: etiology unknown
What percent of all symptoms reported are medically unexplained?
30%
If psychiatric components can lead to what is characterized as somatic disease, shouldn’t the reverse also happen?
Yes; pts with “distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms”
The disorder is not in the symptom itself, but rather in what?
The patient’s response.
What should you be aware of in regards to difficult patients that keep coming back with unexplained CCs?
-Try not to label them as “crazy” or “difficult”; instead, up your game
-And remember that two thirds of pts with depression present with physical complaints
-Often, there may be an element of psychiatric disease to the unexplained symptom
We fail our patients if we simply write them off when we don’t understand the cause of their CC, so when is it time to consider screening for psych illness?
Consider:
-Medically unexplained physical symptoms
-Multiple physical or somatic symptoms (high symptom count)
-High severity of the presenting somatic symptom
-Chronic pain
-Last more than 6 weeks
-Recent stress
-Low self rating of overall health
-Frequent use of healthcare services
-Substance use
How do you tell a patient you’re considering a psychiatric origin of their symptoms?
Very carefully; you need to simultaneously plant the seed that psych could be a component of their disease process, without telling them “it’s all in your head.”
1) Define attention
2) Define memory
3) Define orientation
1) Ability to concentrate over time
2) Memory: ability to remember things
3) Orientation: Awareness of personal identity, place, and time (requires both memory and attention)
1) Define perceptions
2) Define thought processes
3) Define thought content
1) Sensory awareness of objects in the environment and their interrelationships
2) Logic, coherence, and relevance of people’s thought “how people think”
3) What you think about
1) Define insight
2) Define judgement
3) Define affect
1) Awareness of their own condition
2) The process of evaluating options when making a decision
3) Facial expression
1) Define mood
2) Define language
3) Define higher cognitive function
1) Pervasive sustained emotion
2) Language the pt uses
3) Higher cognitive function includes vocab, fund of information, abstract thinking, calculations
Give 12 terms important to consider when conducting a psych eval
1) Attention
2) Memory
3) Orientation
4) Perceptions
5) Thought processes
6) Thought content
7) Insight
8) Judgement
9) Affect
10) Mood
11) Language
12) Higher cognitive function
What should you do when considering a patient’s fund of knowledge? Give an example
Place vocab and fund of knowledge within the patient’s cultural context
-Asking “Do you know who the president is?” might not be appropriate for some patients who aren’t super in-touch with current events
What are the 6 components of mental assessment?
1) General Appearance
2) Speech and language
3) Mood
4) Thoughts and perceptions
5) Cognition
6) Special tests
What 5 things should you consider about a patient’s speech and language? Describe each
1) Quantity: Talkative or silent. Are comments spontaneous or limited to your questioning?
2) Rate: Is the speech itself fast or slow
3) Volume: Loud or soft
4) Articulation: Clear and distinct? Is the tone normal or odd?
5) Fluency: Ties in the rate, flow, and melody of speech – along with the content and use of words
1) Define dysarthria
2) Define aphasia, describe what it appears as, and name its two types
3) What does dysphonia result from?
1) Defective articulation
2) Inability to understand or express speech
-Speak in short or incomplete sentences, speak in sentences that don’t make sense, use unrecognizable words
-Usually either receptive (Words don’t go in – Wernicke’s area) or expressive (Can’t get words out – Bocca’s area)
3) Impaired volume, quality, or pitch
1) Define fluency
2) What can you best assess here?
1) Ties in the rate, flow, and melody of speech, along with the content and use of words
2) This is where you best asses for aphasia
What are some signs of aphasia? (4)
1) Hesitancy
2) Disturbed inflections
3) Circumlocution: “What you write with” instead of “pen”
4) Paraphasia (malformed words): “I write with a bar” “I write with a den”
How do you test for aphasia? (5 things)
1) Word comprehension: ask patient to follow one-stage command, then two-stage
-Touch your nose
-Touch your mouth, then your nose
2) Repetition
-Repeat a phrase of one-syllable words
-“No iffs, ands, or buts”
3) Naming
-Ask pt to name parts of a watch
4) Reading
-Ask patient to read a something out loud
5) Writing
-Ask patient to write a sentence
What should you ask a patient regarding their mood?
-Ask them to describe their mood, and have them describe how their mood fluctuates with life events
-“How did you feel when that happened?” or “With all that going on, how did you do?”
1) What should you be careful about when considering orientation?
2) How do you assess orientation?
1) May be assessed during the interview, but some patients converse well until you find out they are out of touch
2) Ask them for:
Person: name, name of relatives, professional personnel
Place: residence, names of hospital, city, state
Time: time of day, week, month, season, date, year, duration of hospitalization
1) How should you assess attention?
2) How should you assess remote memory?
1) Have the patient repeat numbers back to you; start one at a time, then build
-Either write them down where you can see them or use numbers that you know, in order to ensure accuracy
-Pt should be able to recite at least five
2) Ask about birthdays, anniversaries, social security number, schools attended (impaired in advanced dementia)
What are the 5 elements of cognition?
1) Orientation
2) Attention
3) Remote memory
4) Recent memory
5) New learning ability
1) How should you assess recent memory? What is this seen in?
2) How should you assess new learning ability?
1) Ask for events of the day; be careful of confabulation
-Seen in early dementia
2) Give the patient three or four odd words and ask them to repeat them to you. Several minutes later, see if they are remembered