Oct15 M1,2- Intro to psychiatry and examination Flashcards
some non pharmaco tx in psych
- psychotherapy
- electroconvulsive therapy (anesthetist present, like day surgery)
psychiatry focus in last century
- 1920-1970 = psychotherapy (psychoanalysis)
- 1980s-today = pharmacotherapy + bio explanations
- best thing is in the middle*
goal of psychiatry
- evaluate and manage complex mental health problems
- talk about management of illness and burden rather than cure
top causes of mental illness burden (life years lost related to alcohol and drug use, disability-adjusted life-years, years lived with disability)
- depression
- anxiety disorders
- substance and alcohol use disorders
- schizophrenia
prevalence of mental illness
17% of population.
lifetime prevalence is 29%
mental illnesses with highest prevalence
- anxiety (50% lifetime prev in Americans. 16% across the world)
- major depression (10% world. 17% US)
- personality disorders (13%)
- alcohol and drug dependence (13%)
dx in psych
- interviewing*
- no PE findings
- no blood tests
- no imaging markers
- no consistent markers yet
main resource used in psych for dx
DSM-V (Diagnostic and Statistical Manual of Mental Disorders)
- dx based on having a minimum set of sx (need to cross a certain threshold) from a list of options
- a minimum timeline is almost always required (can’t be a couple days)
- ro other psychiatric causes
- ro physiologic causes (like substances, other illnesses, etc.)
- must cause functional impairment
DSM-V divisions
- schizophrenia spectrum and other psychotic disorders
- bipolar and related disorders
- depressive disorders
- anxiety disorders
- obsessive-compulsive and related disorders
- trauma and stressor related disorders
good things with DSM
- atheoretical so avoids changing scientific understanding
- same results with diff interviewers
- used for research
bad things with DSM
- etiology not addressed (maybe that there are diff types of depression but are lumped together, etc.)
- 5 of 9 sx on the list just bc is more than half..
- can’t give clear cut off for normality
- high rates of comorbidity (hard to make sure the cause of sx is the psych illness you’re dx)
approach to psych interview
- differs with setting (ER vs f-u vs start of psychotherapy, etc.)
- let pts guide interview
- help guide the pts
part 1 of psych interview
- introduction (yourself + why we’re here + purpose)
- short break between intro and start
part 2 of psych interview
opening
- pt ID (age, living situation, work or school or welfare)
- chief complaint (open ended Q + emphatic statements): goal = get good assessment of mental status + let pt say the most.
- looking for sx, timeline, triggers and psychosocial factors, PHx + social hx, mental status*
part 3 of psych interview
body
- expand HPI (sx duration, severity, primary + assoc sx, triggers, past hx of same sx)
- know the DSM and know what criteria and sx to look for, got an idea in the opening already
- more close ended Qs
- check if pt has insight on their problem (how are you feeling, etc.). if yes = ask them Qs about feelings, etc how it happened. if no, ask what family thinks, etc.
- get collateral (call family and friends, check DSQ, check hospital charts, etc.)
- suicide and homicide screening
- PMHx, past psych hx, meds, allergies, habits, FHx, legal hx
- personal and social hx (childhood, family, work, education, relationship, leisure, etc.) (WORK, LOVE, PLAY)
4th part of psych interview
closing
- give dx
- talk about tx options, SEs, future appointments
- address goal of interview and pt expectations
5th part of psych interview
termination
- closing statement
- end on good note (better pt compliance with tx plan)
interview length in psych
about an hour (less in busy ER, more when talk with family, collaterals, etc.)
scales and measures in psych
- have tests that help dx and improve tx
- are self-reported forms or interviews
- lead to better outcomes
- most famous is MMSE (mini mental status exam)
mental status exam def
- psych equivalent to PE
- attempt to give objective info on the pt
- is not MMSE, which is a test to dx dementia*
components of the MSE
- appearance
- behavior
- cooperation
- mood and affect
- speech
- thought process
- thought content
- perception
- cognition
- judgment
- insight
- risk assessment
appearance in MSE
- clothing
- hygiene
- build (height and weight)
- physical findings
- sleep apnea (obese people) worsens depressive sx
- pt has money = can suggest more expensive tx like psychotherapy
behaviour in MSE
- psychomotor activity
- fidgeting and repetitive movements
- eye contact
- odd behaviour?
cooperation in MSE
- does pt coop?
- evasive or guarded pt?
- hostile? threatening?
- overly coop is also bad
mood def in MSE
self-reported subjective experience
- how are you feeling?
- euthymic = normal mood
- euphoric = elevated mood
affect def in MSE
overall pattern and type of emotional states and expression (what they look like they’re feeling)
- range = can the pt express the full range of emotional expressions (smiling, laughing, anxious, angry, sad)
- variability of expression = how quickly pt changes emotional expression + how intense they are
- how pt look like they’re feeling
diff types of range of affect in MSE
- blunt = reduced range and intensity
- flat = no variation in expression
- restricted = only express some emotions (like depressed pt that can’t be happy)
diff types of variability of expression in affect in MSE
- labile = rapidly shifting + intense emotional expressions
- inappropriate = not matching what is discussed
flat affect think of what dz
schizophrenia
speech in MSE
3 things to describe
- rate = how fast or slow is the speech
- rhythm = monotonous? lyrical (think mania)? diff flow?
- volume = loud or quiet
thought process in MSE (least to most severe)
how thoughts are expressed and connected to each other
- linear thought process = normal
- overinclusive = almost normal (direct connection, give answer) but too many details
- circumstantial thought process = go off on many tangents but pt ends up giving answer
- tangential = never answer the question
- loosening of associations = sentences disconnected, more severe
- word salad = every word is disconnected from the next (clang associations = connecting words bc they sound similar. neologisms = creating new words)
other charact of thought process
also refers to speed of mvmt form one thought to other
- thought blocking = delay or absence, thoughts get stuck. (often bc intense auditory halluc)
- poverty of thought = minimal mvmt from one thought to another. keep info very basic and minimal
- concrete = thought expanded a little bit. only superficial
- flight of ideas = move too rapidly between ideas without expanding on them
thought content in MSE
what person is thinking about
- suicidal and homicidal thought assessment
- obsession; recurrent, unwanted, disturbing thoughts or images (like someone breaking in the house, killing family). a COMPULSION is how they deal with an obsession
- overvalued ideas (thoughts that are hard to shake)
- idea of reference (thought that something that is neutral is actually connected to you)
- delusions (fixed, false beliefs, can’t convince someone out of it)
4 most common types of delusions
- persecutory delusion (you’re being targeted by someone, something)
- grandiose delusion (belief you have special power, you’re imp) (mania)
- religious delusion = belief you have special connection with god(s)
- somatic delusions = belief that something is happening in or with your body
important questions to ask when see delusions and WHY
- ever feel like being instructed?
- able to ignore instructions?
- ever forced to do things that put them or others at risk?
- *bc these are most assoc with psychotic pts being violent and suicidal**
link between mental illness and violence
- NO increased risk of violence except psychosis (but this is mostly due to their assoc use of drugs and alcohol)
- increased risk of being VICTIM of violence
perception in MSE
- illusion = misperception of real sensory stimulu
- hallucination
- dissociation = being disconnected from self or external world (depersonalization = feeling of disconnection with your own body, derealization = feeling of disconnection with reality)
perceptions charact
- common
- auditory = schizophrenia
- visual = consider medical causes like classical delirium (but think schizo too)
- tactile, olfactory, gustatory also possible
- dissociation = borderline personality disorder + panic attacks
cognition in MSE
rarely described or tested -often write alert and oriented x 3 (3 = time, place, orientation) Can include the following: -lvl of consciousness -orientation -attention -memory -overall ingelligence
how to test cognition
- MMSE: poor test assessment properties
- MOCA (mtl cognitive assessment): better but longer to give
- MOST IMP: report score
judgement in MSE
ability to make reasonable decisions
- check justifications for decisions
- ask std question
- rate as good, average, fair, poor, etc.
- point out if impaired by delusions, hall, etc.
insign in MSE
understanding of illness
- also rate as good, avg, fair, poor, etc.
- can have superficial or partial insight
risk assessment in MSE
comment on suicide and violence risk
- passive death wishes
- suicidal homicidal ideation
- intent
- plan
- preparation
extrapyramidal sx meaning
movement disorders caused by antipsychotic meds
- acute distonia = painful rigid muscle mvmt
- tardive dyskinesia = slow, rhythmic mvmts
- parkinsonism = slowing, rigidity, cogwheeling (antipsychotics)
- akathisia = internal sense of restlessness
catatonia def
motor changes characterized by mutism, immobility (not talking not moving) can include purposeless hyperactivity
confinement rules in Qc and Canada (key things throughout provinces)
key requirements for confinement
- serious and imminent risk to others
- serious and imminent risk to self
- may be due to disorganization (disorganized behaviour) and not direct intent
confinement in Quebec
- garde preventive: can be ordered by physicians
- garde provisoire: refusal to comply with psychiatry eval, judge can force pt to comply
- garde en etablissement: confinement for longer period (usually 30 days). ordered by 2 psychiatrists + presented to judge
other legal issues in Qc psychiatry
- compulsory tx = doctors can force pt to receive tx against their will
- tribunal administratif du quebec = legal system responsible for people who are declared not criminally responsible (of murder for ex) due to mental illness
how to formulate (formulation) a patient’s state
biopsychosocial model (why does this person have this problem today). the diff factors in their life
- 4x3 grid
- 4 rows = predisposing, precipitating, perpetuating and protective factors
- 3 columns = biological, psychological and sociocultural factors
why is the psychosocial model helpful
helps ID areas that can be modified to improve current problems and reduce risk of relapse + guide therapists of the psychotherapy
biopsychosocial tx
- bio = meds or ECT ?
- psycho = psychotherapy (suggest type and focus)
- social = support network involvement, outside activities, changing difficult social situations
schizophrenia tx
- acute decompensation = antipsychotic med, consider clozapine if tx refractory + consider injectable meds
- chronic = psychotherapy (cognitive behavior therapy = CBT), supported employment, social skills
- family psychoeducation
major depressive disorder tx
- antidepressant and-or psychotherapy (mild-moderate = ask the pt)
- more severe = combine both
- can consider ECT (if really tx refractory)
bipolar disorder tx
- when manic = lithium/mood stabilizer + antipsychotic
- when depressed: lithium/mood stabilizer, maybe antipsychotic, psychotherapy. NO antidepressant
- for maintenance = mood stabilizer
- psychoeducation and relapse prevention
anxiety disorders tx
- psychotherapy (CBT)
- possibly antidepressants (SSRIs, SNRIs)
personality disorders tx
- psychotherapy (specialized for more chronic or severely ill pts)
- meds RARELY
substance use tx
- psychotherapy and counselling programs
- peer support programs (ex. AA)
- meds DEPENDING on drug
