Lecture 2.2: Behavioral health (5% of final)

Question 1

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?

Answer 1

1) Roughly 1/5
2) Only about 40%
3) Nearly half

Question 2

Why does psych matter?

Answer 2

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)

Question 3

Describe the differences between symptoms and signs

Answer 3

-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)

Question 4

Describe the two types of symptoms

Answer 4

1) Somatic – pertaining to a body sensation like pain, fatigue, or palpitation
2) Psychological – pertaining to a mental state, like anxious or depressed

Question 5

How does the division of symptoms into somatic and psychological hinder care?

Answer 5

Sets up a dichotomy between “Psych” and “Soma”

Question 6

What does the current model suggest about symptoms

Answer 6

Symptoms are interactive and represent “A varying mix of disease and non-disease input from medical to mental disorders”

Question 7

What does evidence show about symptom etiology?

Answer 7

Symptom etiology is often multifactorial, lacking a single cause; often, there are several related symptoms or symptom clusters rather than single complaints.”

Question 8

What does the new approach say about the divisions between psych and somatic?

Answer 8

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

Question 9

Give examples of a little bit of psych and somatic overlap, and examples of a lot of overlap

Answer 9

1) Very little overlap in: straight forward complaints like UTI, URI
2) Prominent overlap in: fibromyalgia patients, IBS, chronic pain syndrome, etc.

Question 10

What is the modern model that integrates psych and somatic?

Answer 10

An integrative continuum model (with 5 nodal points pertaining to patients’ signs/ symptoms)

Question 11

What are the five nodal points pertaining to a patient’s sign/symptom?

Answer 11

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

Question 12

What percent of all symptoms reported are medically unexplained?

Answer 12

30%

Question 13

If psychiatric components can lead to what is characterized as somatic disease, shouldn’t the reverse also happen?

Answer 13

Yes; pts with “distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms”

Question 14

The disorder is not in the symptom itself, but rather in what?

Answer 14

The patient’s response.

Question 15

What should you be aware of in regards to difficult patients that keep coming back with unexplained CCs?

Answer 15

-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

Question 16

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?

Answer 16

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

Question 17

How do you tell a patient you’re considering a psychiatric origin of their symptoms?

Answer 17

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.”

Question 18

1) Define attention
2) Define memory
3) Define orientation

Answer 18

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)

Question 19

1) Define perceptions
2) Define thought processes
3) Define thought content

Answer 19

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

Question 20

1) Define insight
2) Define judgement
3) Define affect

Answer 20

1) Awareness of their own condition
2) The process of evaluating options when making a decision
3) Facial expression

Question 21

1) Define mood
2) Define language
3) Define higher cognitive function

Answer 21

1) Pervasive sustained emotion
2) Language the pt uses
3) Higher cognitive function includes vocab, fund of information, abstract thinking, calculations

Question 22

Give 12 terms important to consider when conducting a psych eval

Answer 22

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

Question 23

What should you do when considering a patient’s fund of knowledge? Give an example

Answer 23

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

Question 24

What are the 6 components of mental assessment?

Answer 24

1) General Appearance
2) Speech and language
3) Mood
4) Thoughts and perceptions
5) Cognition
6) Special tests

Question 25

What 5 things should you consider about a patient's speech and language? Describe each

Answer 25

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

Question 26

1) Define dysarthria 2) Define aphasia, describe what it appears as, and name its two types 3) What does dysphonia result from?

Answer 26

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

Question 27

1) Define fluency 2) What can you best assess here?

Answer 27

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

Question 28

What are some signs of aphasia? (4)

Answer 28

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”

Question 29

How do you test for aphasia? (5 things)

Answer 29

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

Question 30

What should you ask a patient regarding their mood?

Answer 30

-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?”

Question 31

1) What should you be careful about when considering orientation? 2) How do you assess orientation?

Answer 31

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

Question 32

1) How should you assess attention? 2) How should you assess remote memory?

Answer 32

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)

Question 33

What are the 5 elements of cognition?

Answer 33

1) Orientation 2) Attention 3) Remote memory 4) Recent memory 5) New learning ability

Question 34

1) How should you assess recent memory? What is this seen in? 2) How should you assess new learning ability?

Answer 34

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

Question 35

What are the 7 concerning psych symptoms and how to spot them?

Answer 35

1) Changes in attention, or speech -In your mental assessment 2) Changes in insight, orientation, or memory -In your mental assessment 3) Anxiety, panic, ritualistic behavior, and phobias -In your mental assessment 4) Delirium or dementia -MMSE 5) Change in Mood -in your mental assessment + depression screening questions 6) Signs of Suicide -your mental assessment + suicide screening and direct questioning 7) Signs of substance use disorders -your direct questioning in medical history + CAGE score if needed

Question 36

1) What is a concerning Sx regarding anxiety, panic, and ritualistic behavior? 2) What are some mimickers?

Answer 36

1) Persistent worry for 6 months = anxiety 2) Has many mimickers: PTSD: marked by reliving and avoidance -Panic disorder: recurrent attacks followed by period of anxiety about further attacks -OCD: intrusive thoughts and ritualistic behavior -Social anxiety disorder: anticipatory anxiety in social situations

Question 37

1) Define delirium 2) Define dementia 3) Give some causes of dementia 4) Who is usually the first to notice dementia?

Answer 37

1) An acute and transient change in mental status marked by confusion and emotional disruption 2) Long-term progressive cognitive decline 3) Alzheimer’s, Parkinson’s disease, Lewy-Body Dementia, among others 4) Pt’s with dementia are often the first to notice a change in their memory; “If I didn’t tell ya’, you’d never know”

Question 38

1) What should you watch for when looking for dementia? (2 things) 2) How is it screened?

Answer 38

1) -Watch for subtle behavior changes, difficulty taking medicines or performing routine chores -Loss of interest in usual activities (though this is also very common with depression) 2) With MMSE

Question 39

What is an acute and transient change in mental status marked by confusion and emotional disruption?

Answer 39

Delirium

Question 40

1) How common is depression? 2) What is it often comorbid with? 3) What increases risk for depression? 4) Who is it most common in, men or women?

Answer 40

1) Very common – affecting 16 million Americans 2) Anxiety, substance abuse, and chronic medical conditions 3) Family history increases risk 4) Twice as common in women

Question 41

1) How common is suicide in the US? 2) How common is it in 15-24 year olds? 3) What age range are suicide rates the highest in? 4) Is suicide more common in men or women?

Answer 41

1) 10th leading cause of death in USA 2) Second leading cause of death in 15-24-year-olds 3) Between 45-55 4) Four times more common in men

Question 42

List 4 suicide screening questions

Answer 42

1) Do you feel discouraged or depressed? 2) How low do you feel? 3) What do you see for yourself in the future? 4) Do you ever feel that life isn’t worth living? OR that you want to be dead?

Question 43

1) Is asking about suicidal thoughts your responsibility if you have any suspicion? 2) How do you need to ask about it?

Answer 43

1) It is absolutely your responsibility to ask directly about suicidal thoughts if you have any suspicion. 2) You can not substitute a different word. You have to say, "Have you thought about killing yourself?”

Question 44

If they are considering suicide what do you need to ask next?

Answer 44

You need to dig further: “How do you think you would do it? Do you have a plan?”

Question 45

What do you need to do if a patient is suicidal AND has a plan?

Answer 45

If they are suicidal and they have a plan, your whole day just stopped: get them help before they leave your care.

Question 46

Who should you ask about drug and alcohol use, and abuse/ misuse of prescription drugs?

Answer 46

Every patient

Question 47

What is the CAGE questionnaire? List its questions

Answer 47

The questionnaire regarding SUDs: -Have you ever felt you should Cut down on your drinking? -Have people Annoyed you by criticizing your drinking? -Have you ever felt bad or Guilty about your drinking? -Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover: Eye opener

Question 48

1) Define circumstantiality 2) Give an example

Answer 48

1) Speech has unnecessary detail, indirection, delay in reaching the point 2) Some folks without disorders demonstrate speech with circumstantial quality, but it also occurs in people with obsessions

Question 49

1) Define derailment 2) Are patients aware they're doing this? 3) What is this seen in?

Answer 49

1) “Tangential” speech with shifting topics that are only loosely related, if at all 2) Patient does not realize they are doing this 3) Seen in schizophrenia, manic episodes of bipolar, psychotic features of other disorders (including depression)

Question 50

1) Define flight of ideas 2) Give examples of what is seen during this phenomenon 3) What condition is this seen in?

Answer 50

1) Almost continuous flow of fast speech with abrupt changes in topic; The ideas are understandably related 2) Plays on words, loose associations, distracting events 3) Seen very often in manic episodes

Question 51

1) Define neologisms 2) What is this seen in?

Answer 51

1) The creation of new words 2) Schizophrenia, psychotic disorders, and aphasia

Question 52

1) Define incoherence 2) What is it characterized by? 3) What is it seen in?

Answer 52

1) Speech that is incomprehensible and illogical 2) Abrupt changes in topic with no meaningful connections; disordered grammar and word use 3) Severe psychotic disturbance or acute traumatic brain injury

Question 53

1) Define blocking 2) What does it occur in?

Answer 53

1) Sudden interruption of speech in midsentence or before the ideas completed; “loosing the thought” 2) Occurs in normal mentation sometimes, but also may occur in schizophrenia or dementia

Question 54

1) Define confabulation 2) What is this seen in?

Answer 54

1) Fabrication of facts or events in order to “cover” for gaps in memory; “faking it” 2) Seen in dementia and Korsakoff syndrome

Question 55

1) Define perseveration 2) What does it occur in?

Answer 55

1) Persistent repetition of words or ideas; being “fixated” on an idea or word 2) Occurs in schizophrenia, autism, and other psychotic disorders

Question 56

1) Define echolalia 2) What is it seen in?

Answer 56

1) Repetition of the words and phrases of others 2) Manic episodes, psychosis, and Tourette’s syndrome

Question 57

1) Define clanging 2) Give an example 3) What is it seen in

Answer 57

1) Choosing words based on sound than meaning 2) Punning and rhyming with no concern for content 3) Schizophrenia and manic episodes

Question 58

How do you go about assessing abnormality in thought content of a patient?

Answer 58

Follow the patient’s lead…take their cues. “You mentioned earlier that your neighbors have been causing your illness. Tell me more about that.”

Question 59

1) Define compulsions 2) What are compulsions aimed at? 3) Differentiate compulsions from perseveration 4) What is it seen in?

Answer 59

1) Repetitive behaviors that the person is driven to perform in response to an obsession 2) Aimed at reducing anxiety, or aimed at preventing something feared from happening 3) Broader than perseveration, can include images 4) Phobias and OCD

Question 60

1) Define obsessions 2) Can obsessions be ignored?

Answer 60

1) Recurring, persistent thoughts, images, or urges experienced as intrusive 2) Pts try to ignore these but cannot

Question 61

Define Phobias

Answer 61

Persistent irrational fears (accompanied by avoidance)

Question 62

Define anxieties

Answer 62

Anticipation of future danger accompanied by worry

Question 63

1) Define "feeling of unreality" 2) What is it associated with?

Answer 63

1) A sense that the environment is strange, unreal, or remote 2) Psychotic disorders

Question 64

Define "feeling of depersonalization"

Answer 64

1) Sense that self or identify is different or changed; unreal or lost 2) Associated with psychotic disorders

Question 65

1) Define delusions 2) What are they seen in?

Answer 65

1) False, fixed, personal belief that will not change when shown to be false 2) Seen in psychosis, severe mood disorders, dementia

Question 66

What are the 6 flavors of delusions? Give an example of each

Answer 66

1) Persecutory: “They’re out to get me” 2) Grandiose: “I’m one of a kind” 3) Jealous: “They’re cheatin’ on me” 4) Erotomaniac: “They’re in love with me” 5) Somatic: “Something’s wrong with my x,y,z” 6) Unspecified: unusual personal significance. . . “The radio is talking to me”

Question 67

1) Define illusions 2) Give an example 3) What can they occur in?

Answer 67

1) Misinterpretations of real external stimuli 2) Ex: mistaking rustling leaves for sound of voices 3) Can occur in grief reactions (mistaking persons for the deceased), or delirium, PTSD, and schizophrenia

Question 68

1) Define hallucinations 2) What conditions are they seen in?

Answer 68

1) Perceptions that seem real but are not at all 2) Delirium, dementia, alcohol withdraw, schizophrenia

Question 69

Define insight

Answer 69

Whether they seem to be able to identify what is wrong or seem oblivious to variation/abnormality

Question 70

1) Define judgement 2) How may it be assessed? 3) What may affect it?

Answer 70

1) The formulation of decisions 2) Asking how the pt would plan to deal with a certain scenario, like job-loss, illness, or even leaving the hospital 3) Intellectual disability, thought disorder, and culture

Question 71

1) What does information and vocabulary provide us knowledge of? 2) How can a pts fund of knowledge be tested? 3) Is this affected by psychiatric illness?

Answer 71

1) Provides baseline of pts abilities 2) By asking about hobbies, TV, current events 3) Virtually unaffected by psychiatric illness

Question 72

1) Define calculating ability 2) What should you consider when evaluating this? 3) What affects this ability?

Answer 72

1) Serial addition 2) A patient’s baseline and education 3) TBI, CVA, and dementia

Question 73

1) How is abstract thinking often tested? 2) How else can it be tested? 3) What conditions may alter a pts ability to think abstractly?

Answer 73

1) By interpreting proverbs 2) By making similarities: what are the things in common? 3) Psychosis, dementia, delirium, intoxication, intellectual disability

Question 74

Asking a patient to tell you the similarities between an orange and an apple is testing what?

Answer 74

Abstract thinking

Question 75

1) How do you test constructional ability? 2) What should you suspect if it's impaired?

Answer 75

1) Asking pts to copy figures of increasing complexity 2) Dementia, parietal lobe damage, or intellectual disability

Question 76

What is the MMSE “Mini Mental Status Exam” used often to assess for dementia?

Answer 76

1) Orientation to time -What is the date 2) Registration -Repeat 3 words 3) Naming -Pencil or pen 4) Reading -Pt reads instructions and performs their directive

Question 77

List the groups of personality disorders

Answer 77

1) A: Odd or eccentric: paranoid, schizoid, or schizotypal 2) B: Dramatic: Antisocial, borderline*, histrionic 3) C: Anxious: avoidant, dependent, and obsessive-compulsive

Question 78

Name 3 disorders that fall under the A/ odd or eccentric class of personality disorders

Answer 78

1) Paranoid 2) Schizoid 3) Schizotypal

Question 79

Name 4 disorders that fall under the B/ dramatic class of personality disorders

Answer 79

1) Antisocial 2) Borderline* 3) Histrionic 4) Narcissistic

Question 80

Name 3 disorders that fall under the C/ anxious class of personality disorders

Answer 80

1) Avoidant 2) Dependent 3) Obsessive-compulsive

Question 81

What kind of patients may appear especially demanding, disruptive, or manipulative?

Answer 81

Borderline

Question 82

What are schizoid patients like?

Answer 82

Usually hermits, probably won't see them often

Question 83

What are histrionic patients like?

Answer 83

Dramatic, considered the female twin of the narcissist (which is the personality disorder that's skewed male)

Question 84

1) What does an antisocial diagnosis come from? 2) What are antisocial patients like? 3) How many people have it?

Answer 84

1) Comes from pediatric diagnosis of conduct disorder; think of being born without a conscience. 2) Pts just don't see the value of other's wants and desire. 3) 2-3% of population

Question 85

What are avoidant patients like?

Answer 85

They stay home but feel bad about it

Question 86

What are obsessive-compulsive patients like?

Answer 86

-Different from OCD -A personality disorder characterized by excessive tidiness and organization that hinders daily life, but does not have compulsions.