Presentation on theme: "Welcome to the psychiatry clerkship!"— Presentation transcript:
1Welcome to the psychiatry clerkship! 2012-2013 Clerkship Director: Adriana Foster, MD
2Psychiatry clerkship orientation goals Learn clerkship objectives/ expectationsLearn to use the resources provided on the clerkship websiteIdentify self-study areasBecome familiar with mental status exam, psychiatric interview, basic psychopharmacology and psychodynamic approach to behavior
3Clerkship Objectives (C.O.) C.O. 1. Patient care Perform a thorough psychiatric interview of a patient with mental illnessPerform and describe a mental status examination.Appraise the information obtained in a psychiatric interview.Formulate a psychiatric differential diagnosis including all 5 diagnostic axes.Appraise the appropriate treatment modalities for psychiatric disorders.Demonstrate the ability to educate patients and their families/support systems about diagnoses, and subsequent care or mental disorders.
4C.O. 2 Medical Knowledge A. Recognize the pathophysiology, epidemiology, clinical picture, and principles of treatment for the following disorders: Psychiatric aspects of medical disorders Cognitive disorders (dementia, delirium) Psychotic disorders Mood disorders Anxiety disorders Personality disorders Substance abuse/dependence disorders Childhood and adolescent psychiatric disorders B. Appraise the indications, contraindications, and possible side effects of the following drug classes in formulating a treatment plan: Antipsychotic Anti-anxiety Mood stabilizers Antidepressants Sedative/hypnotics Other drug classes that display psychiatric side effects C. Distinguish the indications for the major types of psychotherapy occurring in individual or group format: supportive; cognitive; behavioral; psychodynamic.
5C.O. 3 Practice-Based Learning and Improvement The students will be able to choose and appraise medical literature that pertains to at least 1 (one) of their patients’ mental illness
6C.O. 4 Interpersonal and Communication Skills The students will be able to:Give an oral presentation of a patient in a succinct and organized manner using findings from the psychiatric interview and mental status exam.Write complete histories and physicals and progress notes in a succinct and organized manner using findings form the psychiatric interview and physical exam. Communicate empathically with patients with mental illness and their families or support system members
7C.O. 5 Professionalism Students will demonstrate utmost respect for all with whom they interact (patients and their families and support system, colleagues and team members)
8Your job during the clerkship Enjoy every day! People will tell you amazing life stories in the next month!!!Study from Day 1: Vista cases and NBME exam can be difficult!!!Log ALL patients seenObserve safety and confidentiality rulesRespect/learn from your team: attending, SW, psychologists; counselors, occupational therapists, peer support specialists, nursesReport any problems EARLY to your attending, clerkship director or coordinator.
10Things to do/not to do on psychiatry clerkship Ask for contact numbers for attending/residentArrive on time or early on wards/clinicsAsk many questionsAsk for feedback on your interviews and write-upsOffer to present cases or short (5 min) literature reviewsLog in all patients seenRespect and advocate for your patientsNOT TO DO:Be lateCall in late after you already missed part of the dayBe overly familiar with patients and staffSelf disclosure (with minimal exceptions)Break any confidentiality barriersContact the site preceptor for appeals
13? Psychiatric Interview ? Skill to encourage disclosure of personal information for a professional purposeEmpathy → rapport → therapeutic alliance
14OUTLINE OF PSYCHIATRIC CASE PRESENTATION Chief Complaint: patient’s words HPI and psychiatric history: course/treatment Psychiatric review of systems: symptoms inventory and duration Mood, psychosis, anxiety, substance & alcohol use, cognitive, personality, somatoform, other d/o. Suicidal: has gun? Dangerous LegalMedical history, Family history, Social history Developmental: pre-natal history/sibs/raised by/family life/events/trauma Mental status exam. MMSE in the last 5 minutes. Presentation DD: most likely 2-3 and why?; specific examples and factors for and against Axis I: R/O mood, psychotic, anxiety, substance& alcohol, cognitive, somatoform, etcAxis II: personality, mental retardationAxis III: current medical conditionAxis IV: stressorsAxis V: global assessment of functionFormulation: Biologic: genetic d/o/ substance/medical Psychologic: relate childhood / development to current conflicts. Social-cultural: +prognosis: function at work, hobbies, stable relationships, faith, volunteer: reflect ego strength - prognosis: poor relationships, impulsivity, bad work history, non-adherence Treatment State goals of each of the following (include patient’s goals): Medication: why / side-effects / complications / compliance problems. Therapy: individual / group supportive / insight: behavioral / cognitive / psychodynamicWHAT KINDS OF THINGS HERE DO YOU SEE THAT YOU DON’T NORMALLY ASK ABOUT IN AN INTERVIEW FOR OTHER SPECIALTY?Setting of the interview will influence how much you ask about:ER: CC, HPI, dangerousness to self/others, substance, MSEC&L: reason for consult, HPI psych and medical, current prescription medication, substance abuse, MSEPsychotherapy evaluation: social, developmental, family , past psych including past psych treatments
15Chief Complaint What brought the patient in? Patient’s own words Why now and not 6 months ago?What happened in the past week?Past 24 hours?
16HPI: Course & treatment When started: child, adolescent, adultWhat led to first treatment:--Suicide attempt?Hospitalization?Who initiated it: Patient? Family? School? Legal system? Military? Social services?What worked best: medication; ECT; psychotherapy; peer groups; AA; alternative medicine?Is family or other support involved?Take a detailed account of previous treatments; it will show not only medication refractory status but patterns of behavior…non-adherence with drugsListen to the patient: some people (5-7 % of Caucasians ) may be poor CYP450 metabolizers and they can only take very small amounts of meds w/o developing side effects. A man stated he will only take reserpine for his schizophrenia: reserpine blocks DA receptors.
17Psychiatric review of systems = symptom inventory, sequence & durationMoodPsychosisAnxietySubstance & alcoholCognitive: dementia, delirium, head injuryOther disorders: Learning, Somatoform, Factitious, Impulse control, Dissociative, Sexual, Eating, SleepPersonalityExplore temporal relationships: cause vs. co-morbidity.This is the new part that students will need to master in this clerkshipKnowing the major characteristics of these diseases and their treatment = meeting clerkship objectives!!!!Which illness came first? examples of stereotypes; avoid labeling people as drug users only…alcohol and drug dependence as co morbidity of bipolar d/o (risk is 7X higher to have substance abuse);if you use hallucinogens (LSD, PCP) and you persist having psychotic sy more than one mo. from the drug use, you likely have primary psychosisAdolescents treated for ADHD with stimulants do not have more substance abuse than non-ADHD adolescents.
18Ask about development Early childhood: who raised the patient? School years: academic –special education or high achiever, activities, drugs, legal system, missing school due to illness…How available were the parents?AbuseAway from home: job, college, marriageRelationships throughout development
19Ask about strengths and illness experience What did you use to enjoy before you became ill?What are you good at?How has your illness and its treatment affected yourphysical activitiesrelationships with family and friendsjob and hobbiesfeelings about yourselfspiritual/religious beliefsWhat is the most difficult thing about your illness and its treatment?Is there anything positive that has come out of the experiences with your illness and its treatment?This will help understand the whole person and allow you to do the bio-psycho-social-cultural formulation
20Interventions Affirmation =”I see” Advice/praise =“I’m so proud of you that you stopped smoking!”Empathic validation: “It hurts to be treated that way”Encouragement to elaborate: “tell me more about your mother”Clarification = pull together patient’s verbalizations into a more coherent wayConfrontation = addresses something patient does not want to accept. Reflects back to patient a denied or suppressed feeling.Interpretation = one of most expressive forms of treatment; therapist’s decision making; makes something conscious that was previously unconscious.
24Q2: The therapist is offering: check all correct answers A confrontationAn interpretationEmpathic validationRe-framingEncouragement to elaborateAnswer: confrontationAffirmation=”I see”Advice/praise=“I’m proud of you that you stopped smoking”Empathic validation: “It hurts to be treated that way”Encouragement to elaborate: “tell me more about your mother”Clarification=pull together patient’s verbalizations into a more coherent wayConfrontation=addresses something patient does not want to accept. Reflects back to pt a denied or suppressed feeling.Interpretation= one of most expressive forms of treatment; therapist’s decision making; makes something conscious that was previously unconscious.
25Content vs.. Process Diagnostic vs.. dynamic What information we get vs..How we get it ….Diagnostic vs.. dynamicDiagnostic: happens earlyDynamic interview = extended process; elicits bio-psycho-social and cultural aspects of the illness
34Thought Process Speed: RapidSlow Linear/Goal directed/Logical TangentialCircumstantialFlight of ideasLooseness of association/DerailmentIncoherent/Word saladClang associationsNeologismsPerseverationEcholaliaThought blocking
37Insight & Judgment Insight Judgment Patient’s understanding of their illnessJudgmentExamples of harmful behaviorsTest an imaginary situationStamped addressed envelopeAbstractionProverb
38Memory, Attention & Concentration Serial 7’sWORLD DLROWImmediate and delayed recall
39MINI-MENTAL STATE ORIENTATION What is the (year) (season) (date) (day) (month)?Where are we: (state) (county) (town) (hospital) (floor)?REGISTRATION TemporalName 3 objects: One second to say each. Ask the patient all three after you have said them. Give 1 point for each correct answer. Then repeat them until he/she learns all three. Count trials and record:ATTENTION AND CALCULATION FrontalSerial 7’s. One point for each correct. Stop after five answers. Alternatively spell “world” backwards.RECALL TemporalAsk for the three objects repeated above. Give one point for each correct.LANGUAGE Fronto-temporalRepeat the following “No ifs, ands or buts.” (1 pt.) Follow a 3-stage command: “Take a paper in your right hand, fold it in half, and put it on the floor” (3 pts.)Name a pencil, and watch (2 pts.) OccipitalRead and obey the following: Close your eyes (1 pt.) Write a sentence (1 pt.) Copy design (1 pt.) ParietalCONSCIOUSNESS RASAlert; drowsy; stupor ; coma.Attn and Conc are frontalFronto-temporal: fluency, comprehension, repetition, naming, reading comprehension and writing, prosody (intonations that accompany language)RAS maintains consciousness, alertness
40Executive function - frontal = ability to think abstractly, plan, initiate and sequence, monitor and stop complex behavior; insight, judgmentBedside measuresLuria Motor Test: alternate hand movements; fist, cut; slap.Word Fluency Test: “tell me 5 words starting with the letter “A”Similarities: ability to apply abstract concepts.Proverb interpretation: conceptual thinking abilityClock Drawing: “This circle represents a clock face. Please put the numbers, so that it looks like a clock and then set the time to 10 minutes past 11” (parietal and frontal lobes involved)Clock drawing: 85% sensitivity and specificity, good inter-rater reliability, good concurrent and predictive validity, In combination with MMSE, verbal fluency test and informant reports: detection of early dementia. It will show neglect if parietal lobe lesion is present. Frontal/executive function is responsible for the sequence of drawing the numbers, and showing the time, it is a complex task.
415 point scale (Shulman): 5 points: perfect clock4: minor visual-spatial errors3: inaccurate representation of 10 past 11 with good visual-spatial representation2: moderate visual-spatial disorganization, such as accurate representation of 10 past 11 is impossible1: severe visual-spatial disorganization0: no reasonable representation of a clock
42MSE ExampleID/Appearance/Behavior: 30-something obese WM with well-groomed beard casually and appropriately dressed in sports jersey and backwards cap; cooperative with interviewer, poor eye contact; inappropriate laughterOrientation: Not assessed, however most likely oriented to person and place at leastPsychomotor: No abnormal movements, no psychomotor agitation/retardation
43Speech: Spontaneous w/ normal volume, rate, tone; normal articulation Mood: Variable – euthymic to broad at beginning, dysphoric (“life sucks”) towards endAffect: Variable but appropriate and mood-congruent – full at beginning, restricted at endThought Process: + looseness of associations; + clang associations; + neologisms
46Antidepressants: SSRIs Action: inhibit 5HT reuptakeSide Effects:GI 5HT3 receptors activationSexual D2, Ach blockade, 5HT reuptake inhibitionEndocrine SIADH; hyponatremia more frequent in older ♀Discontinuation sdr.Pregnancy paroxetine - class DIncreased suicidal behavior in children & adolescentsSerotonin syndrome with other serotonergic agents: neuromuscular-myoclonus, autonomic instability, mental status, GI symptomsCYP450 interactions: fluoxetine, paroxetine, fluvoxamine-most, citalopram and sertraline-leastThere will be increased serotonin available in the presynaptic neuronsParoxetine : risk of cardiovascular and other congenital malformations may be higher with paroxetine than with other antidepressants
47AntidepressantsSNRIs: venlafaxine, duloxetine, desvenlafaxine BP elevation at higher dose NDRI (NE, DA reuptake inhibitor): Bupropion: dose dependent seizures; CI in eating d/o Mirtazapine: Selective α2 adrenergic antagonism with increase in serotonergic and noradrenergic activity; 5HT2c and 5HT3 receptor blockade → 5HT1A activation; sedation, weight gain, neutropenia 5HT2 antagonists/reuptake inhibitors: Nefazodone: sedation, visual trails, MANY drug interactions CYP450 3A4, hepatic failure-rare Trazodone (metabolite mCPP a strong serotonin agonist-anxiogenic and induces anorexia), priapism-m-CPP (meta-chlorophenyl)piperazine 5HT2A/2C agonist/antagonist MDMA similarities
48Antidepressants TRICYCLICS: inhibit NE and 5HT uptake and less DA Sedation, anticholinergic toxicity (treat with bethanechol), CV-arrhythmias (order EKG >40 years old, avoid in heart disease)Lethal in overdose: wide-complex arrhythmia, seizure, hypotensionNortriptyline therapeutic window: ng/mlMAOIs: Inhibit MAO-A and B which metabolize NE, 5HT and DA; nonselective-phenelzine, tranylcypromine (selective: selegiline; reversible-RIMA: moclobemide)Serotonin syndrome with SSRIs, SNRIs, triptansHypertensive crisis with adrenergic agents, meperidine and high monoamine content foods; treat with phentolamine, chlorpromazine, nifedipine; DO NOT GIVE β BLOCKERSRequire low monoamine diet
50Antipsychotics 1st generation DISCUSS/MONITOR RISK D2 blockade Movement d/o: Parkinsonism (at 80% blockade) treat with anticholinergics, akathisia (tx with β blockers or benzos), acute dystonia (IM antichol.), tardive dyskinesia (eliminate offending agent)NMS: rigidity, hyperthermia, tachycardia, ↑CPK, AMS, potentially lethal! – supportive measuresAnticholinergicSexual (increased prolactin)Retinitis pigmentosa: chlorpromazine and thioridazineQT prolongation black box: thioridazineMovement - nigrostriatal pathwayFlow of information in frontal lobe - mesocorticalPleasure and reinforcement pathways in nucleus accumbens and striatum (cocaine) mesolimbic.Tuberoinfundibular - prolactin-inhibitingSchizophrenia: Overstimulation of D2 receptors in mesolimbic and mesocortical systems (“dopamine excess” theory).
51Antipsychotics 2nd generation DISCUSS RISK/MONITOR Risperidone, paliperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, iloperidone, asenapineD2 (also D3 and D4) , 5HT2 blockade, glutamate?Metabolic: wt gain and direct effect on triglycerides, serum leptinSexualMovement: risperidone anticholinergic treatmentOrthostatic hypotension: titrate slowly (quetiapine, iloperidone)QT prolongation: ziprasidone, iloperidoneThese drugs are approved by FDA to treat schizophrenia as well as bipolar disorder, to address acute manic or mixed episodes (olanzapine, risperidone, aripiprazole, ziprasidone, asenapine, quetiapine) or maintenance (olanzapine, risperidone, aripiprazole, ziprasidone, quetiapine). Quetiapine and aripiprazole are also approved as adjunctive treatment of major depressive disorder!!! One will have the balance the risk of metabolic syndrome with using this drugs. They are a safer alternative than Li and antiepileptics for bipolar women who are pregnant.
52CLOZAPINE minimal D2 blockade (D1, D2, D3, D4), 5HT2A (also 5HT2C, H1, M1, α1) Five black box warningsAgranulocytosis: do not give or d/c if WBC is <3,500 or ANC < 2,000, MONITOR these numbers weekly x 6mo, twice/mo x 6 mo., then monthly for lifetimeCardiovascular events: myocarditis, pulmonary emboliDementia patients: increased risk of death –blanket warning for ALL 2nd generation antipsychoticsOrthostatic hypotensionSeizuresAdvantagesIndicated in refractory schizophrenia (failed ≥ 2 antipsychotics)Improvement continues long term: at 6 mo., one year and 5 yearsIt decreases suicide risk and violence in patients with schizophreniaAlong with quetiapine, used in psychosis in Parkinson’s patients because it does not induce EPS
54Mood stabilizers Lithium: Serotonin effect; Li protects rat cerebral cortex and hippocampus from glutamate induced cell deathAnti-suicidal effect in bipolar d/oSide effects:Lethal in overdose: therapeutic window MEq/L; > 3.5 mEq/l fatalLong term: hypothyroidism, renal insufficiencyNSAIDs, ACE inhibitors, thiazide diuretics, tetracycline, salt restriction ↑ levelsTheophylline, caffeine, osmotic diuretics ↓ levelsCan use K sparing diuretics to treat nephrogenic diabetes insipidus (amiloride)Pregnancy class D: Ebstein anomaly rare 1/2,000 birthsIn Ebstein malformation of the tricuspid valve, the septal leaflet of the tricuspid valve is displaced toward the apex of the heart and is attached to the endocardium of the RV rather than at the tricuspid annulus. As a result, the upper portion of the RV is physiologically within the right atrium. This "atrialized" portion of the RV is thin-walled and does not contribute to RV output. The portion of the ventricle below the displaced tricuspid valve is diminished
55Mood stabilizers Valproate Increases brain GABA levels, modulates glutamateRisk of pancreatitis and liver failureDrug interactions: increases levels of drugs metabolized through glucuronidation (lamotrigine, lorazepam)Pregnancy class D: neural tube defects (3-5% spina bifida risk )LamotrigineInhibits Na channels; stabilizes neuronal membranes; modulates glutamateRisk of Stevens Johnson sdr 3/1,000CarbamazepineBlocks Na channels, modifies adenosine receptors; inhibits glutamate; increases extracellular serotoninAgranulocytosis, hyponatremia, induction of other drugs’ hepatic metabolismPregnancy class D: neural tube defects
56Benzodiazepine Anxiolytics GABA-A agonistsEffects:Anxiolytic: anxiety, insomnia, acute agitation, withdrawal syndromesHypnotic: useful in anesthesiaAnticonvulsant: seizure controlMuscle relaxationAll are pregnancy category D drugs; fetus with possible congenital abnormalities; fetus may suffer withdrawalDependence, tolerance, withdrawalIn patients with liver failure give lorazepam, oxazepam, temazepam metabolized by glucuronidation only
58Other medications used in psychiatry: generic/brand names ModafinilProvigilAtomoxetineStraterraMethylphenidateRitalin (LA, SR), Concerta, Metadate (CD, ER), Methylin, DaytranaDextroamphetamine/AmphetamineAdderallDextroamphetamineDexedrineLysdexamphetamineVyvanseHydroxyzineVistarilBenztropineCogentinDiphenhydramineBenadrylGuanfacineTenexBuspironeBusparNaltrexoneReviaDisulfiramAntabuseBuprenorphine and NaloxoneSuboxoneLisdexamfetamine dimesylate is a prodrug that is converted to the active component dextroamphetamine (a noncatecholamine, sympathomimetic amine). Amphetamines are noncatecholamine, sympathomimetic amines that cause release of catecholamines (primarily dopamine and norepinephrine) from their storage sites in the presynaptic nerve terminals. A less significant mechanism may include their ability to block the reuptake of catecholamines by competitive inhibition.
59OTHER SOMATIC TREATMENTS FDA approvedECT: triggers seizures in normal neurons by application of pulses of current through the scalp that propagate to the entire brain.VNS: stimulation of left vagus nerve; pulse generator in L chest wallTMS: pulsatile high-intensity electromagnetic field induces focal electrical currents in the underlying cerebral cortexNot FDA approvedLight therapy, neurosurgery in OCD, deep brain stimulation for OCD and refractory depressionECT syncronous firing of brain neurons with cellular mechanisms coming into play to end the seizureVNS affects limbic structures and thus monoamine equilibrium in the brainDBS wire through small hole in the skull, internal capsule for OCD, researched in depression; stimulus issued through a pacemaker like device in the chestTMS reaches primarily frontal cortex (approx 2 cm under the scalp)
60Foster personal EEG collection Applying a current leading to synchronous firing of all neurons in the brain. The cellular mechanisms that come into play to end the seizure are believed to lead to ECT effectiveness (75% ECT CORE study on >400 pts vs 33% medication effectiveness in STAR*D study step 1 citalopram)
61Vagus Nerve Stimulation (VNS) FDA approved for epilepsy; FDA approved for Treatment Resistant Depression 2005Pulse generator implanted in left chest wall area, connected to leads attached to left vagus nerveMild electrical pulses applied to CN X for transmission to the brainAffects limbic structures and thus the monoamine balance in the brainFink-ASCP2003.ppt
62Case vignetteA 28 years old man with schizophrenia is brought to the ER by family due to refusal to eat and to leave his room, agitation and paranoia. He is treated in the hospital and he is placed in a personal care home. His antipsychotic medication is changed within the month after discharge due to side effects. Within the same week he completes suicide by hanging.To tie this over to the next topic, MEDICATION is only ONE PIECE of the puzzle and alone is not the most important part of psychiatric treatment.
63Suicide risk 95% of suicide completers are mentally ill: 80% have mood d/o10% have schizophrenia5% have delirium/dementia25% alcohol dependence + other illnessCompleters: male, >60 yo, high lethalityAttempters: ♀, <35 yo, low lethality10% of attempters will complete suicideCaucasian>Native American>African American>Asian↓ CSF 5-HIAA (serotonin metabolite) associated with violent suicide
64Suicide Risk Mood disorders: 15-20% Bipolar mixed highest riskDelusional depressionSchizophrenia: 5-10% (young male, insight, high IQ, command hallucinations)3 wks -3 mo. from hospitalizationSubstance abuse:Young male, multiple substances, recent loss, co-morbid, previous ODWHAT WORKS TO DECREASE RISK: LI, CLOZAPINE, ECT, psychotherapy!!
65SUICIDE RISK ASSESSMENT Current suicidal presentation Suicidal thoughts, plans, behaviors, and intent (Have you wished you were dead? or Wished that you could go to sleep and not wake up? or Have you actually had any thoughts of killing yourself?Methods, lethality, access to firearmsHopelessness, impulsiveness, anhedonia, anxietyReasons for living and plans for the futureAlcohol or other substance useThoughts, plans, or intentions of violence toward othersPsychiatric illnessMood disorders, schizophrenia, substance use disorders, anxiety disorders, and personality disorders (primarily borderline and antisocial)Questions adapted from Columbia Suicide Severity Rating Scale Posner et al 2003
67Sources:Allen Frances, MD, Ruth Ross, MA, DSM IV case studies, A clinical guide to differential diagnosis, American psychiatric press, 1996.Glen O. Gabbard, MD, Psychodynamic Psychiatry in Clinical Practice, Fourth Edition, American Psychiatric Publishing, 2005.Harold Kaplan, MD, Benjamin Sadock, MD, Kaplan and Sadock’s Synopsis of Psychiatry, 10th edition, Williams and Wilkins, 2007.Davidson B et al, Assessment of the Family, Systemic and Developmental perspectives, Child and Adolescent Psychiatric Clinics of North America, 10(3), , 2001.Wedding, D, Stuber, M, Behavior and Medicine, 5th edition, Hogrefe Publishing, 2010.Posner K et al, Columbia-Suicide Severity Rating Scale from Oquendo et al Risk Factors for Suicidal Behavior: Utility and Limitations of Research Instruments, in M.B. First [Ed] Standardized Evaluation in Clinical Practice, pp , 2003.