Psychology Flashcards
Psychiatric Exam: Signs and Symptoms
Self-Report measures of mood
Beck Anxiety Inventory
Beck Depression Inventory
Symptom Checklist-90-Revised
Psychiatric Exam: Signs and symptoms
Clinician-Rated Measures
Hamilton Rating Scale for Depression
Mental Status Examination (MSE)
Establishes the reliability of self report, informs rest of exam. Establishes neuro cognitive baseline. Ranges in breadth and depth depending on patient. Data relevant to MSE is available through the clinical encounter (formal MSE may be brief)
Mental Status Exam: Orientation
Self (do they know their name), Place (where they are), Time (day month year), Purpose (why they are here)
Notation patient is oriented x3 (self place time)
Patient is oriented to self, place, time, purpose
Mental Status Exam: Speech and Language
Assessment: amount, rate, tone, volume, fluency, articulation, spontaneity.
Dysprosodic (rhythm), dysarthria (poor articulation of phonemes), dysfluent (can’t find the right words), pressured, slow…
Assument of language: comprehension - direct and simple commands
Expression? - paraphrasais (phonemic or semantic)
MSE: Thought Process and Form
Normal thought is logical and goal directed.
Disordered can be:
Tangential, circumstantial (indirect, winding, tedious), derailed (no connections), flight of ideas, perseverative, clanging, neologistic (making up words combining words), Blocked (going black v often)
DSE: Thought Content
Disordered thought can be
Ruminative (preoccupation)
Obsessive (unwanted concerns)
Delusional (at odds with convention)
MSE: Insight and Judgment
Insight: what brings you here, what is the problem
Judgment: appropriate decisions, if a building were on fire, what would you do?
MSE: Cognition
Attention, concentration distractibility
Memory (short and life)
Intellectual (current president etc)
MSE Categories
ASEPTIC
Appearance, attitude, accessibility, behaviour
Stream of mental activity (inferred from speech)
Emotion, mood affect suicidality homocidality
Psychotic symptoms (hallucinations, delusions)
Thought (and language)
Insight and Judgment
Cognition, orientation, concentration, memory
MSE: Risk Assessment
Suicidality - “What stops you” behavioural control
Chronic or acute?
Risk factors:Prior attempts is the STRONGEST PREDICTOR,psychiatric symptoms (esp BPD and PTSD)
Homocidality - anger?
Protective factors: ie social support, responsibility, coping.
Conditions for involuntary Hospitalization
Patient can be hospitalised without consent by one or two physicians for a time limited period before court hearing.
Conditions: danger to themselves, danger to others.
“Provisional” as a diagnostic descriptor
Used AFTER the name of the specific diagnosis.
Used if one presumes that the criteria will be met but
Patient info is unavailable (and expected to be confirmed upon inquiry)
Required symptoms are present, but the duration criterion is NOT YET (but expected to be) met.
“Unspecified” as a diagnostic descriptor
Patient definitely does NOT meet criteria for a specific disorder, but has significant symptoms within a given diagnostic category
Insert word “unspecified” BEFORE the name of the category
Fluoxetine
Prozac, SSRIs
Venlafaxine (effexor)
SNRI, similar side effects as SSRIS
Side effects of TCAs
Postural hypotension, tachycardia (cardiac side effects)
Treatment of MDD
CBT, TCAs, ECT (ELECTRO, frontotemporal), TMS (transcranial magnetic, for prefrontal cortex), vagus nerve stimulation (VNS, electrical stim).
ECT Contraindications (ELECTROconvulsive therapy)
Vascular disease, due to blood pressure increase during a seizure, not preventative
Procedure: frontotemporal, unilateral, seizure for 30s
Side effectsL cardiac arrhyth, headache and confusion, some mesmory loss around session but usually goes away
Patients bill of Rights
(1972)
Right to receive complete information
Right to refuse treatment
Right to know about a hospital’s financial conflicts of interest
Patient Self-Determination Act
1991
Patients must be given written information about their health care decision making rights and the institutional policy on advance directives (living will and power of attorney)
Benefits of informed patients
Greater sense of control, associated with
Greater ability to tolerate pain, faster recovery, enhanced adjustment, decreased hospital stay
Transference
Relationships schemas (beliefs, expectations, perceptions from the past informing the presence). Unconscious - ie patient transfers feelings onto the physician, can be positive (affectionate) or negative (hostile), or ambivalent.
Countertransference
Physician projecting his relationship schemas onto patient. Ie treat an elderly patient as your own grandmother.
Objectification/dehuminization
Using patient as a teaching tool in direct view of patient, discussing case with colleagues in listening range of the patient
Barriers to treatment adherence
- Poor physician relationship - anger at the physician, unapproachable physician
- Believing time and costs outweigh benefits
- Symptom resolution (ie seizures stop, BP normalises)
- Complex treatment schedule’
- Fears - loss of bodily integrity from side effects, dependency on others, loss of masculinity, loss of work time, fear of losing livelihood.
- Denial/avoidance
- Regression
Sick Role
Parsons, 1951
Sanctioned deviance - sick person exempt from normal social roles, not responsible for condition, work toward return to health
1980s: onus moved to patient, obligation to behave think and feel healthily, sick leave de-legitimised. Responsible for your own care.
ICD 10 Post-Concussional Syndrome
history of head trauma with LOC preceding symptom onset by max of 4 weeks
3 or more: headache, dizziness, malaise, fatigue
Irritability
Self reported cog difficulties with no evidence of impairment on formal testing
Insomnia
Reduced alcohol too
Pre-occupation with symptoms, adoption of sick role
Nocebo effect
Various inherently inert factors that may create negative expectancies for recovery, and therefor impede a given patient’s progress and recover
SPIKES - 6 step protocol for conveying bad news to patients
S - setting up the interview - privacy, so’s, eye contact, silence pager
P - reception of the patient - find out what patient understands, determine thinking, expectations
I - invitation - find out how would like to receive diag, detail wanted, offer to answer qs, talk to relatives
K - knowledge - prepare patient for bad news, give positive news first, bad news clearly, info in small doses, nontechnical, avoid conveying hopelessness
E - emotion/empathy - connect emotion and reason, tolerate discomfort, ask if need someone called.
S - strategy/summary - ask if ready to disc treatment, evaluate understanding and hopes, share decision making, understand goals ie pain ctrl, state plans, schedule follow ups.
Medical Interview
Start with open-ended questions, add direct questions. Avoid leading questions, or compound questions.
Interruption: redirecting patient if rambling, restructuring.
Transition - politely changing topics to gather relevant info
Reflection - paraphrasing to show understanding
3 key components of medical encounter
History
Signs (physical exam)
Symptoms (physical exam)
/ lab tests
Clinical Decision making (6 steps)
- Define the problem - problem list, hypotheses, iterative refinement to diagnosis
- Define outcome goals - desired condition after treatment
- General alternative treatment solutions - consider how to alter bio fnxn, modify behaviour, changes in enviro, utilise social resources
- Finalize treatment plan - optimal interventions, priorities, clear goals, confirm understanding and commitment, oral and written comm.
- Implement treatment plan - establish method for comm unexpected obstacles to implement ie side effects, insurance denial, follow-up appt to review progress
- Evaluate outcome - symptoms resolved/reduced?
SOAP Note
Subjective - incl chief complaint “stomach pain for 3 days”. HPI (if first visit), status of existing or new sympas, status of health behaviours (sleep, diet)
Objective - vital signs, measurement, physical exam findings, lab tests, medication list
Assessment - summary, differential diag, rule out
Plan - labs ordered, referrals, procedures performed, mess given, eduacation provided, treatment goals, monitoring parameters
Obstacles that can arise in psychiatric interviewing
- Poor insight - don’t realise they have a disorder
- Positive impression management
- Self-deception - ie in denial
- Symptoms as adaptations
MSE: Orientation
Oriented to self, place, time, and purpose.
Dyskenisias
Unable to perform voluntary movement (part of motor behaviour of MSE)
Dystopias
Part of Motor Behaviour of MSE - weak muscle tone and posture
MSE: Mood
Sustained subjective emotional state as reported by patient
Time scale: weeks
MSE: Affect
Observed emotional state
Time scale: minutes
Assess: appropriate, fluctuate, broad range
Dysprosodic speech
Disruption of prosody (rhythm, body, intonation, pauses, stresses) of speech
Dysarthric speech
Slurred slow speech, difficult to understand. Commonly nervous system disorders
Dysfluent speech
Stuck, unable to move ahead in speech/ Can’t find the words, stutter
Phonemic paraphasia
Substitution of a word with nonproductive that preserves at least half of the segments and or number of syllables of intended word.
Semantic Paraphasia
Sub of one word for another on the basis of a meaning relationship between the two.
ASEPTIC (MSE)
Appearance, attitude, accessibility, behaviour
S - stream of mental activity
E - emotion, mood, affect, suicidality, homocidality
P - psychotic symptoms
T - thought and language
I - insight and judgment
C - ignition, orientation, concentration, memory
V Code conditions
Other conditions that may be a focus of clinical attention, but are not mental disorders
Ie V61.7 problems related to unwanted preg
Exposure to disaster, war
Problems related to release from prison
DSM 5 conditions for further study
Proposed criteria sets for 8 disorders ie internet gaming
Common language for studying, NOT for clinical use, research guid future DSM decisions.
Unspecified Disorders
Diagnosed when a patient definitely does NOT meet criteria for a specific disorder, but has significant symptoms within a given diagnostic category. Insert word unspecified BEFORE the name of the category.
Anxiety Disorders
Panic Disorder Agoraphobia Specific Phobia Social anxiety disorder Generalised anxiety Separation anxiety Selective mutism
Panic Disorder
Recurrent and unexpected panic attacks (number not specified)
For > 1 MONTH shows fear of future panic attacks, or sig change in behaviour related
Can be learned by classical conditioning - physical symptom alone can now trigger full fear response
Agoraphobia
> or equal to 2 of these situations are feared/avoided:
using public transp, open spaces, enclosed spaces, standing in line or being in crowd, being outside of home alone
– feared because of thoughts that escape might be difficult if embarrassing symptoms develop
– Agoraphobia often develops in PD patients.
Social Anxiety Disorder
Excessive, persistent, and unrealistic fear of social situation involving possible scrutiny by other due to fear of negative evaluation.
Specify “performance only” if fear is restricted to speaking or performing in public.
Generalised Anxiety Disorder
Persistent uncontrolled anxiety about multiple events for >6 months.
Accompanied by sypmtmos such as: restless, decreased conc, muscle tension, fatigued, irritable, insomnia.
Separataion anxiety disorder
Developmentally inappropriate and excessive concerning separation from major attachment figures Marked distress (mental and physical) about anticipated or actual separataion, harm befalling attachment figures, going out because of separation fears
Selective Mutism
Refusal to speak in specific situations despite fluent speech in other contexts - written comm and social play may also be affected
Symptoms persist for >1 month (not the first month of school)
NOT due to lack of language of comm disorder ie stuttering.
Neuroanatomical Correlates of Anxiety
Amyglda - initiates fear response via activation of hypothalamic - Pituitary - adrenal axis
Prefrontal cortex - SHOULD inhibit amygdala when fear response is no longer necessary
Hippocampus - should track the context in which a fear response is learned and help to suppress fear when in safe contexts
Treatment of anxiety disorders
- CBT - modifying thought (cognitive), using exposure techniques (behavioural)
- Anxiolytics - Try CBT first or use together. Benzos (GABA agonists), antidepressants (monoamine agonists)
OCD
Recurrent obsessions or compulsions
1. Obsessions: intrusive recurrent thoughts, urges, or images that increase distress
Compulsions: repetitive behaviours/mental acts performed to decrease distress. Not always logically related to obsession
2. Obsessions/compulsions are time consuming, disrupt fuel
3. Not explained by another Disorders (ie weight in eating d)
- OCD with absent insight (delusional beliefs). - convinced their OCD beliefs are true.
- -etiology: cortico-striato-thalamo-cortical (CSTC) circuit OVERACTIVITY - cingulate to striatum to thalamus to orbital frontal loop, serotonin def
Treatment: Behavioural ERP - exposure and response prevention - expose to obsession without allowing to engage in compulsion
SSRIs
If refractory: cingulotomy, capsulotomy
Deep brain stimulation - electrical
PANDAS
Rare case, OCD beings suddenly after streptococcal infections
Paediatric Autoimmune Neuropsychiatric Disorders associated with Streptococcal infections
Hyp: autoimmune run affects neurons in basal ganglia, activating CSTC loop (cortico-striato-thalamo cortical path)
Treat w antibiotics and OCD treatment
Yale Brown OC Scale (Y-BOCS)
Objective scale used after OCD Diagnosis to:
Qualify and quantify symptoms and severity
Monitor changes in symptoms over time
Hoarding Disorder
Difficulty parting with possessions. Hoarding causes distress/impairment and is not better explained.
Specify whether HD is “with absent insight (delusional beliefs) - ie certain that HD beliefs are not problematic despite contrary evidence.
Body Dysmorphic Disorder
Preoccupation with perceived flaw in physical appearance (flaw is minimal, on-observable). Repetitive behaviours, mental acts performed in response.
Preoccupation not better accounted for by an eating disorder. Must cause functional impairment (ie sequestering oneself), otherwise considered normal vanity
- specify if with “muscle dysphasia” - preocc belief that body is too small or too little muscle
- or with absent insight (delusional beliefs) - convinced that BDD beliefs are true
Excoriation Disorder
Recurrent skin picking resulting in lesions
Attempts to stop
Picking results in distress/impairment
Not better explained by another disorder
Trichotillomania
Recurrent pulling out of one’s hair - episodes vary in freq, duration, and intensity
Attempts to stop hair pulling,
Pulling causes distress/impairment
Pulling is not better explained by another disorder
PTSD
Exposure to traumatic stressor
>orequalto 1 symptom from EACH of the 4 categories.
(4 symptoms or more)
1. Intrusion symptoms - dreams, recollections, feeling event reoccur, psych distress when encounter symbols
2. Avoidance symptoms - avoid thoughts, places, convos, that are reminders
3. Negative alterations in cognition and mood - persistent neg beliefs, emotion, inability to exp positive emotion, diminished interest, detachment, dissociative amnesia.
4. Alterations in arousal and activity - sleep disturbance, irritable outbursts, reckless self destructive, concentration probs, hypervigilance, exag starte response.
> 1 month. Usually beigin within 3 months of trauma but can be ANYTIME.