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Bloc J - Neuro > Oct15 M1,2- Intro to psychiatry and examination > Flashcards

Oct15 M1,2- Intro to psychiatry and examination Flashcards

1
Q

some non pharmaco tx in psych

A
  • psychotherapy

- electroconvulsive therapy (anesthetist present, like day surgery)

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2
Q

psychiatry focus in last century

A
  • 1920-1970 = psychotherapy (psychoanalysis)
  • 1980s-today = pharmacotherapy + bio explanations
  • best thing is in the middle*
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3
Q

goal of psychiatry

A
  • evaluate and manage complex mental health problems

- talk about management of illness and burden rather than cure

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4
Q

top causes of mental illness burden (life years lost related to alcohol and drug use, disability-adjusted life-years, years lived with disability)

A
  • depression
  • anxiety disorders
  • substance and alcohol use disorders
  • schizophrenia
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5
Q

prevalence of mental illness

A

17% of population.

lifetime prevalence is 29%

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6
Q

mental illnesses with highest prevalence

A
  • anxiety (50% lifetime prev in Americans. 16% across the world)
  • major depression (10% world. 17% US)
  • personality disorders (13%)
  • alcohol and drug dependence (13%)
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7
Q

dx in psych

A
  • interviewing*
  • no PE findings
  • no blood tests
  • no imaging markers
  • no consistent markers yet
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8
Q

main resource used in psych for dx

A

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
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9
Q

DSM-V divisions

A
  • schizophrenia spectrum and other psychotic disorders
  • bipolar and related disorders
  • depressive disorders
  • anxiety disorders
  • obsessive-compulsive and related disorders
  • trauma and stressor related disorders
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10
Q

good things with DSM

A
  • atheoretical so avoids changing scientific understanding
  • same results with diff interviewers
  • used for research
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11
Q

bad things with DSM

A
  • 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)
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12
Q

approach to psych interview

A
  • differs with setting (ER vs f-u vs start of psychotherapy, etc.)
  • let pts guide interview
  • help guide the pts
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13
Q

part 1 of psych interview

A
  • introduction (yourself + why we’re here + purpose)

- short break between intro and start

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14
Q

part 2 of psych interview

A

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*
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15
Q

part 3 of psych interview

A

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)
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16
Q

4th part of psych interview

A

closing

  • give dx
  • talk about tx options, SEs, future appointments
  • address goal of interview and pt expectations
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17
Q

5th part of psych interview

A

termination

  • closing statement
  • end on good note (better pt compliance with tx plan)
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18
Q

interview length in psych

A

about an hour (less in busy ER, more when talk with family, collaterals, etc.)

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19
Q

scales and measures in psych

A
  • 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)
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20
Q

mental status exam def

A
  • psych equivalent to PE
  • attempt to give objective info on the pt
  • is not MMSE, which is a test to dx dementia*
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21
Q

components of the MSE

A
  • appearance
  • behavior
  • cooperation
  • mood and affect
  • speech
  • thought process
  • thought content
  • perception
  • cognition
  • judgment
  • insight
  • risk assessment
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22
Q

appearance in MSE

A
  • 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
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23
Q

behaviour in MSE

A
  • psychomotor activity
  • fidgeting and repetitive movements
  • eye contact
  • odd behaviour?
24
Q

cooperation in MSE

A
  • does pt coop?
  • evasive or guarded pt?
  • hostile? threatening?
  • overly coop is also bad
25
Q

mood def in MSE

A

self-reported subjective experience

  • how are you feeling?
  • euthymic = normal mood
  • euphoric = elevated mood
26
Q

affect def in MSE

A

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
27
Q

diff types of range of affect in MSE

A
  • blunt = reduced range and intensity
  • flat = no variation in expression
  • restricted = only express some emotions (like depressed pt that can’t be happy)
28
Q

diff types of variability of expression in affect in MSE

A
  • labile = rapidly shifting + intense emotional expressions

- inappropriate = not matching what is discussed

29
Q

flat affect think of what dz

A

schizophrenia

30
Q

speech in MSE

A

3 things to describe

  • rate = how fast or slow is the speech
  • rhythm = monotonous? lyrical (think mania)? diff flow?
  • volume = loud or quiet
31
Q

thought process in MSE (least to most severe)

A

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)
32
Q

other charact of thought process

A

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
33
Q

thought content in MSE

A

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)
34
Q

4 most common types of delusions

A
  • 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
35
Q

important questions to ask when see delusions and WHY

A
  • 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**
36
Q

link between mental illness and violence

A
  • 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
37
Q

perception in MSE

A
  • 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)
38
Q

perceptions charact

A
  • 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
39
Q

cognition in MSE

A 
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
40
Q

how to test cognition

A
  • MMSE: poor test assessment properties
  • MOCA (mtl cognitive assessment): better but longer to give
  • MOST IMP: report score
41
Q

judgement in MSE

A

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.
42
Q

insign in MSE

A

understanding of illness

  • also rate as good, avg, fair, poor, etc.
  • can have superficial or partial insight
43
Q

risk assessment in MSE

A

comment on suicide and violence risk

  • passive death wishes
  • suicidal homicidal ideation
  • intent
  • plan
  • preparation
44
Q

extrapyramidal sx meaning

A

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
45
Q

catatonia def

A

motor changes characterized by mutism, immobility (not talking not moving) can include purposeless hyperactivity

46
Q

confinement rules in Qc and Canada (key things throughout provinces)

A

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
47
Q

confinement in Quebec

A
  • 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
48
Q

other legal issues in Qc psychiatry

A
  • 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
49
Q

how to formulate (formulation) a patient’s state

A

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
50
Q

why is the psychosocial model helpful

A

helps ID areas that can be modified to improve current problems and reduce risk of relapse + guide therapists of the psychotherapy

51
Q

biopsychosocial tx

A
  • bio = meds or ECT ?
  • psycho = psychotherapy (suggest type and focus)
  • social = support network involvement, outside activities, changing difficult social situations
52
Q

schizophrenia tx

A
  • acute decompensation = antipsychotic med, consider clozapine if tx refractory + consider injectable meds
  • chronic = psychotherapy (cognitive behavior therapy = CBT), supported employment, social skills
  • family psychoeducation
53
Q

major depressive disorder tx

A
  • antidepressant and-or psychotherapy (mild-moderate = ask the pt)
  • more severe = combine both
  • can consider ECT (if really tx refractory)
54
Q

bipolar disorder tx

A
  • when manic = lithium/mood stabilizer + antipsychotic
  • when depressed: lithium/mood stabilizer, maybe antipsychotic, psychotherapy. NO antidepressant
  • for maintenance = mood stabilizer
  • psychoeducation and relapse prevention
55
Q

anxiety disorders tx

A
  • psychotherapy (CBT)

- possibly antidepressants (SSRIs, SNRIs)

56
Q

personality disorders tx

A
  • psychotherapy (specialized for more chronic or severely ill pts)
  • meds RARELY
57
Q

substance use tx

A
  • psychotherapy and counselling programs
  • peer support programs (ex. AA)
  • meds DEPENDING on drug

Bloc J - Neuro (60 decks)

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