OMS2 Semester 1 Psychiatry

Court ordered (worker's compensation)
Malpractice case
Elder or Child abuse
Tarasoff issues (threats)

Open ended questions
Developing rapport (mutual trust)
Facilitation (encourage communication)
Summarize

Permitting too much silence
Confrontation
Overly direct questions

Being empathic, identifying with or experiencing feelings/thoughts/attitudes of the patient, can enhance the effectiveness of care, patient satisfaction.

The relationship between the clinician and patient in which both commit to look at the patient’s problems and establish mutual trust, cooperate with each other in order to achieve a realistic goal of cure or amelioration of symptoms.

Naming the emotion, reflecting it back to the patient, makes feelings explicit, allows them to speak at length.

Informs the patient you understand the reason for their emotions, they feel less isolated, you seem like equals in the human condition.

Non-verbal and verbal ways of showing that the physician cares about the patient.

Implies a team approach where the doctor and patient work together toward the same goal, use of "we" "us"

"snapshot" - a cross-sectional description of a patient's mental state at a single point in time.

Informal - starts as soon as the patient enters the office, includes appearance, behavior, etc.

Formal - attitude toward examiner, psychomotor activity, speech...

Mood - more subjective, pervasive sustained emotion experienced by the patient.

Affect - more objective, how the patient appears to be feeling, speaks, appropriateness of emotions.

Sudden anger or tears in an organic patient in response to something they can't do.

The inability to discuss emotions despite coaching.

Changes in appetite, energy, or sleep, difficulty concentrating, decreased feelings about self, feelings of hopelessness, desire to hurt oneself

Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness

Distortions of reality without external stimulus - include auditory, visual, tactile, gustatory, olfactory, and command.

Hypnagogic - upon going to sleep
Hypnapompic - upon arising from sleep
Kinesthetic - feel movement when none occuring
Tactile - withdrawal, drug abuse

Definition: misinterpretation or misrepresentation of real external stimuli.

Patient sees something real and interprets it as a threat.

"Loose associations" = no connection of the ideas
"Circumstantial thinking" = connection to question but takes a while to get there.
"Blocking" = mind often goes blank mid-sentence
"Perseveration" = repetition of the same words or phrases
"Echolalia" = direct repetition of interviewer's words
"Flight of Ideas" = Rapid speech/quick charge in ideas
"Clang Associations" = words rhyme
"Insight" = Patient able to understand themselves and their condition in the context of their treatment
"Judgment" = Gives idea of the patient's educational level and ability to handle simple problems
"Confabulation" = Effort to give correct answers when memory is impaired.

"____ is making me do/say _____"

The belief that others can hear your thoughts

The idea that other things (TV, radio, people) are talking about you.

Recurrent thoughts/impulses, increases anxiety to fight it (rarely successful), examples: concern about germs/waste, need for exactness, forbidden sexual thoughts, fear that something bad will happen.

Repetitive behaviors – hand washing and grooming, checking, cleaning to rid of germs, touching, counting, repeating rituals (up/down from chair)

Abstract vs Concrete thinking

Orientation - year, name, etc.
Registration - repeat 3 common things
Attention/calculation - Serial 7's or DLROW
Recall - Repeat those first 3 common items
Language - various naming

Points < 25 = bad

Alert – responds appropriately to all perceptual input
Drowsy – sleepy but aroused by aversive stimuli
Stupor – repeated energetic stimulation to be aroused
Coma – neither verbal nor motor response in spite of noxious stimuli.

patient unconsciously projects his/her emotions/thoughts/wishes related to certain significant persons in the past onto the psychiatrist

The physician unconsciously projects his/her own emotions from the past onto the patient, or what the patient is presenting. Represents unresolved needs of the psychiatrist.

Childhood, lasting disorders, everything not in Type II

This includes most disorders

Personality disorders and mental retardation (inherent)

General medical conditions (diabetes, etc)

Psychosocial and environmental problems

Global assessment of functioning - scale 0-100; Higher rating = good

A sustained, pervasive emotional state that colors the whole personality and psychic life.

Depression

Mania

A clinical “syndrome” consisting of a lowering of mood tone (feelings of painful dejection or an irritability), loss of interest or pleasure in comparison with the patient’s pre-morbid state, psychomotor retardation or agitation, and difficulty in thinking and/or concentration

A clinical “syndrome” consisting of an elevated mood (may be irritable at times) characterized by inflated self-esteem, increased psychomotor activity, and an increase in the number of ideas (grandiose quality) and the speed of thinking and speaking

A patient dips clinically into one pole or the other, depression or mania.

Unipolar mood disorder

Person fluctuates clinically from one pole to the next, extreme depressive episodes and extreme mania episodes.

2x as common in women

Late 20's to mid-40's

The occurrence of one or more Manic Episodes. Depressive Episodes may also occur and almost always do, but are not required for diagnosis.

Late teens to early 20's

Chromosome 3

Having primary relatives with MDD increases risk of MDD by 2-3x, and with BD increases risk by 4-18x

In monozygotic twins, rate of MDD (54%), BD (60%); dizygotic rate of MDD (24%), BD (19%)

Five or more of the following symptoms have been present during the same 2 week periods and represent a change from previous functioning - at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure.

1) Depressed mood for most of the day, nearly every day, indicated by subjective or objective reports
2) Marked diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (subjective, objective)
3) Significant weight loss when not dieting or weight gain, change of 5% of weight, decrease in appetite nearly every day
4) Insomnia or hypersomnia nearly every day
5) Psychomotor agitation or retardation nearly every day (observed, not just subjective)
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day
8) Diminished ability to think or concentrate, indecisiveness, nearly every day
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Symptoms do not meet the criteria for a Mixed Episode, symptoms cause clinically significant distress or impairment, symptoms are not due to the direct physiological effects of a substance or other medical condition

Moderate to severe depression persisting for more than 1 month

Mild-moderate depression that is chronic and significantly interferes with routine functioning in social or occupational roles.

Patients with multiple episodes of major depressive disorder, any patient with three or more episodes of MDD is a candidate for continuous treatment.

Anemia - especially B12 deficiency
Cancer - pancreatic, "oat cell" carcinoma of the lung, ovarian, thyroid
Endocrine - especially thyroid
Cardiovascular - any cause of cardiac insufficiency
Chronic pain - any type is associated with depression
Drug induced - alcohol, narcotics, antihypertensives, oral contraceptives, anti-neoplastics, glucocorticoids, etc.
Infections - TB, HIV, mono, viral syndromes
Neurological - CVA, Parkinson's Disease, Alzheimer's Disease

Psychological treatment - cognitive therapy, intensive interpersonal therapy, healthy lifestyle

Antidepressant therapy

Combination

50% reduction in symptoms sustained for 2 weeks

The virtual absence of depressive symptoms

A state of remission for at least 4 months

A return of the major depressive episode prior to recovery

The occurrence of a new major depressive episode after recovery

Side effect profile, history of prior response, coexisting medical problems, potential drug-drug interactions, cost;

Give adequate dosage for adequate duration - 3-4 weeks to start, at least 6 weeks. Combine with counseling sessions. Lifestyle changes may also help.

4 months at minimum, to ensure remission

Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Presence, while depressed, of two (or more) of the following – poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, feelings of hopelessness. Disturbance is not better accounted for by MDD chronic or in remission, never been without the symptoms for more than 2 months.

Occurs in 50-80% of women after giving birth and typically last 3-7 days. Diagnosed with same DSM criteria for a MDD, within 4 weeks of birth, women may feel guilty because they think they should be happy and be reluctant to bring up their symptoms or negative feelings toward the child.

Risk of recurrence is 30-50% at subsequent deliveries.
Treat depressive symptoms lasting more than 2 weeks.

Psychotic features occur in roughly 1/500 to 1/1000 deliveries – in such cases hospitalization is usually necessary to protect infant and mother. Prior episodes make patient at higher risk.