Clinical Psychiatry An Introduction to the Psychiatry Block1,2,3 A Presentation for the Students of Ohio University Heritage College of Osteopathic Medicine Kendall L. Stewart, MD, MBA, DFAPA November 28, 2011 1 This is problem-oriented learning. Reinforce what you’ve read by answering the questions to yourself before I do. 2 Please master the recommended sections of the text to reinforce these introductory lectures. 3 Let’s begin with a basic overview of this medical specialty.

Why is psychiatry important? Mental illnesses are serious illnesses. According to the World Health Organization, 4 out of 10 of the leading causes of disability are mental illnesses. Inadequately treated, the costs of these illnesses to individuals and society are staggering. The best treatments for serious mental illness are highly effective. Because of a critical shortage of psychiatrists, most mental illnesses are treated by other medical specialists. Begin preparing yourselves now.1,2 After mastering the information contained in this block, you will be able to Give a brief overview of this medical specialty, Detail the major categories of psychiatric diagnoses. Explain the key diagnostic criteria for the major mental disorders, Outline a treatment plan for some of these disorders, Identify the principal medications used to treat the mental disorders, and Reflect on some of the clinical challenges you will face in treating patients with primary and comorbid mental illness. 1It’s perfectly okay to like some specialties better than others. 2Just don’t let on. A medical student introduced himself and told me he hated psychiatry.

What are the scientific (brain) pillars of psychiatry? Neuroscience Neuroanatomy Neurophysiology Neurochemistry Psychopharmacology Neurology Molecular biology Genetics And others

What are the scientific (mind) pillars of psychiatry? Psychoanalysis Psychotherapy The unconscious Psychodynamics The mind Psychology Psychometrics And others 1Let me illustrate this with a couple of typical cases.

What does the typical psychiatrist do? Talks with troubled people Reviews records Makes accurate diagnoses Prescribes treatment Lifestyle changes Medication Psychotherapy Consults colleagues Arranges for appropriate follow up Manages chronic illnesses Takes enormous satisfaction in watching most patients improve dramatically What are some of the typical work environments? Group or solo private practice Academic position Mental health center employment Psychiatric hospital employment General hospital employment Prison employment The average psychiatrist currently makes about $200,000 per year.1,2 And there are plenty of jobs. It’s a very satisfying career. You can make a difference. 1Pick something you would do for nothing. 2Deal with the disparity in incomes right now.

What are the major categories of psychiatric disorders? Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Delirium, Dementia, and Amnestic and Other Cognitive Disorders Mental Disorders Due to a General Medical Condition Note Elsewhere Classified Substance-Related Disorders Schizophrenia and Other Psychotic Disorders Mood Disorders Anxiety Disorders Somatoform Disorders Factitious Disorders Dissociative Disorders Sexual and Gender Identity Disorders Eating Disorders Sleep Disorders Impulse Control Disorders Not Elsewhere Classified Adjustment Disorders Personality Disorders Other Conditions That May Be a Focus of Clinical Attention

How do physicians make psychiatric diagnoses? They interview Patients, Families, Friends, Coworkers, and Referring professionals They review records. They conduct a mental status examination. Using the patient’s problem list, they probe for more details. It is not always possible to make an accurate diagnosis after just one interview. The initial interview usually provides some ventilation relief and sets the tone for the therapeutic relationship. Using the latest version of the Diagnostic and Statistical Manual (DSM), they rule in or out specific diagnoses with the appropriate diagnostic criteria. We make a multiaxial assessment. Axis I Clinical Disorders Axis II Personality Disorders and Mental Retardation Axis III General Medical Conditions Axis IV Psychosocial and Environmental Problems Axis V Global Assessment of Functioning Most psychiatric patients have multiple psychiatric and general medical diagnoses.

The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process Introduce yourself using AIDET1. Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. 1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

What is included in the typical mental status examination? Appearance and behavior Dress and grooming Posture and gait Physical characteristics Facial expression Eye contact Motor activity1 Specific mannerisms Speech Rate Pitch, volume, clarity Abnormalities Emotions Mood Affect Thought Process Content (distortions, preoccupations) Perception Illusions Hallucinations Sensorium and intellectual function Consciousness Orientation Concentration Memory Fund of knowledge Abstraction Judgment, insight 1I once got too close to a withdrawn paranoid patient and paid the price.

What can I expect from the lectures? My lectures are intended to introduce you to clinical psychiatry.1 These lectures will not cover everything you need to know. The lectures will provide an introduction to The major mental illnesses, The biochemical foundations of psychiatry, Diagnosis, Differential diagnoses, Some treatment challenges, and An overview of practical treatment plans. In addition, we will introduce The major classes of psychiatric medication. 1Click on the hyperlinked text in my presentations to review additional background material.

What process should I follow to do well on the exam? Exercise vigorously every day. Attend and pay attention to the lectures. Ask clarifying questions. Complete the referenced reading assignment as soon as possible after each class. Make flash cards for the major mental disorders. Diagnostic criteria Common differential diagnoses Treatment Make flash cards for the major classes of psychiatric medications. Mechanisms of action Side effects Quiz each other using the flash cards Take sample examinations and pay careful attention to the questions you miss. Use the testing strategies you are already perfecting.

What should I read? Consider reading and mastering the recommended text. You can read it online. Any standard one-volume psychiatry text will do. You will be tempted to use an easy shortcut text. These texts are not as complete, but reading one of these is better than reading nothing. I’ve listed a medical student favorite at the end of this presentation. Go over some sample questions carefully. Study only those questions that begin with a clinical vignette and focus on diagnosis and treatment. I’ve appended a couple of those books too. The lecture handouts will be helpful to organize your studying efforts, but depending on them exclusively will be a serious mistake.

Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000 Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008 Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here. Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007 Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005 Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093 Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007 Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008 Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008 Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here. Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here. Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here. Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here. Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org. Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.

How can you contact me?1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1Speaking and consultation fees benefit the SOMC Endowment Fund.

 Safety  Quality  Service  Relationships  Performance  Are there other questions? Sarah Ann Flaherty, DO OUCOM 2003 Thomas Carter, DO OUCOM 2004  Safety  Quality  Service  Relationships  Performance 