1. Welcome to 2016, and Welcome to Unit III
Unit III Co-leaders: Dr. Heather Maclean Dr. Katherine Allen (replacing Dr. Elliott Lee)

2. Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
WRITTEN (75%)

3. Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
WRITTEN (75%)
Essay (10%) topics and due date to be announced by SIM directors

4. Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
WRITTEN (75%)
Final Practical Examination (13.5%)
ABL (1.5%)
ABL =
Anatomy
Based Learning

5. Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
WRITTEN (75%)
Midterm (15%)
Final (60 %) .

6. Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
WRITTEN (75%)
Midterm (15%)
Final (60 %)
Psychiatry ( 75% )
Eye ( 25% ) .
Ratio of MCQ : CDMQ = 75% : 25%

7. Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
WRITTEN (75%)
Midterm (15%)
Final (60 %)
Eye ( 7% )
Psychiatry ( 25% )
Neurology ( 68% ) .
Ratio of MCQ : CDMQ = 75% : 25%

8. Calculation of overall mark – Unit 3
Eye
1 week
3 weeks
5 weeks
Contribution to overall mark is proportional to # weeks / topic
Psychiatry
Neurology

9. Midterm Weeks Topics #MCQ #CDMQ 1-3 Psychiatry 49
1-3
Psychiatry 49
4 questions = 11 marks (total) 4
Special Senses(Eye) 10
2 questions = 10 marks (total)
Marks out of 80
59 (adjusted to 75%)
21 (adjusted to 25%)

10. Final Exam Weeks Topics #MCQ #CDMQ 1-3 Psychiatry 17
1-3
Psychiatry 17
2 questions = 7 total marks 4
Special Senses (Eye)
1 question = 2.5 total marks
5-9
Neurology 57
3 questions = 11 total marks
Marks out of ~100
78 (adjusted to 75%)
20.5 (adjusted to 25%)

11. Psychiatry Midterm (MCQ)
Mood disorders/tx 20%
Anxiety and related disorders/tx 10%
Psychotic disorders/tx 15%
Geriatric/neurocognitive and tx 15%
Substance use disorders/tx 10%
Sleep/eating 5%
Disorders of childhood/tx 8%
Personality/Somatic/tx(therapy) 10%
Legal %

12. Exam Comments No dosages (for preclerkship) Do not use abbreviations
Please mind the spelling
Read directions carefully (e.g. if it says choose up to 4, don’t choose 5 etc.)

13. Medication Errors 5-81% prescriptions have significant errors
7 commonest errors (Medscape, Oct 2015): 1)* Wrong drug (e.g. brillinta vs brintellix) 2) *Wrong dose/formulation (e.g. XL vs SR) 3) Ignoring alerts 4) Failure to adjust (e.g. age, renal failure) 5) Use of smart phones 6) Units (e.g. lbs instead of kg) 7) *Ambiguous abbreviations

14. Psychiatry DSM-5 was introduced in May 2013
It is highly likely the Licentiate Medical Council of Canada (LMCC) exams will use DSM-5 criteria by 2016
Academically, it would behoove you to know DSM-5
Professionally, DSM-IV-TR will likely come up frequently

15. Introduction to Psychiatry
(Not Psychology)
Elliott Lee MD, FRCPC, D. ABPN Sleep Medicine, Addiction Psychiatry, D. ABSM, F. AASM, F. APA
January 4, 2016

16. No disclosures to declare

17. Objectives
Explain the difference between normal and abnormal emotions, thoughts and perceptions
Describe the broad categories of psychiatric disorders
Describe the basics of the psychiatric interviewing process including listing and defining the components of a psychiatric history

18. List and define the components of a mental status exam
Explain the biopsychosocial model of understanding mental illness
Describe the importance of using a biopsychosocial approach with respect to mental illness with respect to management
Demonstrate awareness of medicolegal and ethical considerations related to psychiatric practice, including involuntary hospitalization and treatment.
Recognize the impact of the stigma of mental illness

19. Objectives/ Outline What is Psychiatry? Diagnosis and Classification
DSM Psychiatric Disorders
The Psychiatric Interview – the basics
Mental Status Examination (components)
Biopsychosocial understanding of mental illness & its use in management plans
Medico-legal/ethical Issues
Stigma

20. What is Psychiatry? ?

21. It’s all about the brain!
Master Watermark Image:

22. What is Psychiatry? A very human branch of medicine
Focuses on the human brain
Ranges from molecular biology to neuroanatomy to concepts of the mind
Defines and recognizes mental disorders
Identifies treatment methods
Explores causes of mental illness
Identifies and implements preventive measures

23. What is a psychiatrist? Completed medical school MD
Completed residency in psychiatry
Successfully passed examination by the Royal College of Physicians and Surgeons of Canada in Psychiatry
May have completed fellowship in a psychiatric subspecialty and a second exam
Not a psychologist!

24. What is mental illness/ a mental disorder ?
Alteration in thinking, mood or behavior associated with
significant distress and
impaired function

25. Why focus on mental illness?
World Health Organization (WHO) reports that Major Depressive Disorder is the costliest illness in the world
4/top 10 global burden of disease (5/10 if include suicide) are mental illness
21% of Canadians have life time risk of mental illness
6% mood, 1% schizophrenia, 3% of women eating disorder

26. The good physician knows the disease the patient has; the great physician knows the patient who has the disease. William Osler

27. Top 5 Mental Health Myths
Mental health problems are uncommon - False: 1/5 Canadians affected
People with mental illness are violent - False: more likely to be victims
People with mental illness are poor/less intelligent - False – average/above average
Mental illness is caused by personal weakness*
Mental illness is a single, rare disorder*
* Hopefully addressed in psychiatry block

28. MENTAL ILLNESS IS NOT MENTAL WEAKNESS

30. Phineas Gage: Phineas Gage was a railroad worker in the 19th century living in Cavendish, Vermont. One of his jobs was to set off explosive charges in large rock in order to break them into smaller pieces. On one of these instances, the detonation occurred prior to his expectations, resulting in a 42 inch long, 1.2 inch wide, metal rod to be blown right up through his skull and out the top. The rod entered his skull below his left cheek bone and exited after passing through the anterior frontal lobe of his brain.
Frontal

31. Structures to know Amygdala Prefrontal cortex Hippocampus
Ventral Tegmental Area
Nuclei/Tracts (clusters of neurons with a common function) - Nucleus Accumbens - Dorsal Raphe Nucleus - Locus Coeruleus - Dopaminergic Nuclei

32. Normal or Abnormal
Where does “normal” end and clear psychopathology begin?

33. Diagnosis and classification
Introduces order and structure, “not just a label”
Facilitates communication between clinicians
Helps decide on appropriate treatment
Helps predict outcome
Helps to monitor treatment
Assists in search for pathophysiology and etiology
Used by epidemiologists to determine incidence and prevalence

34. DSM – Diagnostic and Statistical Manual of Mental Disorders
Current - DSM-5, 2013 (May)
Diagnostic criteria are provisional agreements, consensus by experts
Useful but arbitrary
Improves reliability, facilitates history taking and making a differential diagnosis

35. Psychiatric Disorders
Depressed Patients Sound Anxious; So Claim Psychiatrists - Depressive/Bipolar Disorder - Psychotic Disorders (e.g. Schizophrenia) - Substance Use Disorders - Anxiety Disorders and related disorders (Panic, Social, GAD, PTSD) + OCD - Somatic Symptom disorders (Illness anxiety etc.) - Cognitive – neurocognitive, delirium - Personality disorders

36. DSM Psychiatric Disorders
Disorders usually evident in infancy, childhood or adolescence
Delirium, neurocognitive disorders
Substance use disorders
Schizophrenia and other psychotic disorders
Mood Disorders

37. Psychiatric Disorders cont’d
Anxiety Disorders
Personality Disorders
Somatic Symptom Disorders
Dissociative and related disorders
Eating Disorders
Sleep Disorders
Adjustment Disorders
Sexual and Gender Identity Disorders

38. What is Psychosis? The disjunction of thinking from reality
The presence of delusions and/or hallucinations – not a diagnostic category
Delusions are false fixed beliefs that are
Inconsistent with cultural norms, not altered by proof to the contrary, tend to pre-occupy
Hallucinations are sensory perceptions that occur with no external stimulus – visual, auditory, olfactory, tactile, gustatory

39. The Psychiatric Interview: Components
Chief Complaint/Reason for Referral
Identification - Age, Marital status, Job, Gender, Living arrangements
History of Present Illness
Current Medications
Past Medical History
Past Psychiatric History
Family Psychiatric History

40. The Psychiatric Interview: Components (cont’d)
Personal/Social history, including legal problems
Mental Status Examination *
Physical and Neurologic exam
Relevant lab/diagnostic test results
Formulation, Treatment and Management Plan

41. Mental Status Examination ABC STAMPLICKER
Appearance, Attitude and Motor Activity
Behavior: calm, agitated
Cooperation?
Speech (volume, prosody, fluency)
Thought Form (organization, logic)
Thought Content (topics, ideas, issues)
Affect (observed, external manifestation of emotional state )

42. Mental Status Examination (cont’d)
Mood (patient report of internal feeling state)
Perceptions (sight, hearing, taste, smell, touch)
(Level of Consciousness)
Insight and Judgment
Cognition: orientation, memory, language, calculation, visuospatial ability, executive function)

43. Mental Status Examination (cont’d)
Knowledge
Emptiness/Suicide/Homicide
Reliability - assess with others

44. video Shine, released by First Line Features, 1996
I did. I did. I-I-I thought I was a cat. Ooh. Well, kind of, kind of. I-I identified with cats. Well, I kind of did. I wonder why that was. They make sure you try to stroke them. Is that right? So maybe I was a sad cat. Was I a sad cat? Because I wonder. Yeah, yeah, yeah, I wonder about cats. Truly, I did. I did. I did. I did. 'Cause I was a fuddy-duddy. Fuddy-duddy. I kissed them all. Kissed them. I will always kiss cats. Always did. If a cat'd let me kiss it, I'd kiss it. You know, if I see a cat on a fence, I'll kiss it. Always, always. I will, didn't I? Ooh. Life's a perpetual risk, isn't it? That's right. I think it is. Because the point is, I was different in those days, wasn't I? I was. I was. I was. I've got... I've got to be different again. Different again. But can a leopard change its spots? Who knows? Ooh. It's a blood sport. I think it's a blood sport. It's true. It seems to be true. Or is it a blank? Bit of a scrabble. Hoo hoo. You've got to put all the pieces together. See if you can make a word. Ho ho, that's very... That's very funny. It's a mystery. It's a mystery. - Bye. - Take care. Bye-bye. We're closed. - What's the problem, mate? - Sorry, sorry, sorry, sorry, mate. I'm the problem. I think I'm the problem. Oh, such a problem. And wet! Oh. But it's not an ideal world. Is it an ideal world? I mean, we just have to make the most of it. This is the way we find it, isn't it? Yeah, yeah. But I mean, it's more ideal than it was because... I mean, you know, I mean we're privileged, we're privileged. We're privileged, aren't we, because not long ago people would be burned to a stake. - Wouldn't they, Moby? Moby, yea! - No, no. It's Tony. Hey... Tony, Tony, Tony. Not Moby. Tony, Tony, Tony. Who am I, Tony? Who knows Tony? I don't know myself. Ahh! I'm David. I'm David, Tony. I'm David. How does that sound? - Hi, David. How can Sylvia help? - Sylvia. Is it Sylvia? Sylvia! Ah, hi, Sylvia. Pleased to meet you, Sylvia. Oh. - Schubert, Schubert, Schubert, wasn't it? He said, "Who is Sylvia? What is she?" - What... - 'Course he did. 'Course he did. - What can we do for you, David? - Do for me. Do for me. What... Ahh... Got to... Got to... I got to stop talking. Got to stop talking. - It's a problem, isn't it? It's a problem. - No, no, no. It's all right. - You just tell Sylvia why you're here. - Oh, well, ah, it's a mystery. - Are you lost? - It's a mystery. Am I lost? Perhaps that's it. - Yes? - Perhaps I am lost. I'm lost. How does that sound? How's that sound? Oh, is that your piano, Sylvia? Beautiful Sylvia. Oh, isn't Sylvia beautiful, Toby? Not Toby, Tony. Tony. You're Tony. You're beautiful too, Tony. Oh, perhaps I could play it. Could I play it? Could I play it? - You say. You say. You say. - Oh, like hell, baby. Go on. - Shut up, Sam. - Hell, baby. Whoa ho, the devil. Diablerie. Oh, Sam. - David. David. - Get out of here. Go on. - Sylvia, Sylvia, Sylvia, Sylvia, Sylvia, Sylvia. - You just te... You just tell us who you are and where you live. Could I play? Live, live, live, Sylvia. Live and let live. That's important, isn't it? Molto, molto. But then again, it's a lifelong struggle. Isn't it, Sylvia? Tony. Tony. Tony. Tony. Sylvia. To-To survive. To-To live. To survive. To survive undamaged and not to destroy any living, breathing creature. I mean, the point is, if you do something wrong, you can be punished the rest of your life. - So I think it's a lifelong struggle. Is it a lifelong struggle? - Yes. I mean, whatever you do, I think it's a struggle. A struggle. A struggle to keep your head above water and not get it chopped off. - I'm not disappointing you, am I, Sylvia, Tony, Tony, Sylvia? - Oh, no. Oh, get off! Helfgott! What a name.
Shine, released by First Line Features, 1996

45. Two Major Traditions in Psychiatry
Biomedical Model
Closely allied with general medicine
Stressed diagnosing discrete illnesses and disorders
Psychodynamic Model
Understand in terms of underlying psychological processes
Once were polarized, now integrated into the BIOPSYCHOSOCIAL MODEL

46. Biopsychosocial Understanding of Mental Illness
Biological
Genetic predisposition (or not)
Brain Injury, Toxins (or none)
Medical conditions (or none)
Psychological
Personality structure, coping style, defense mechanisms
Social
Poverty/ financial means
Isolation/ integration
Education/ school success
Access to medical care

47. Biopsychosocial Model of Understanding Health and Illness

48. BPS Model of Management of Mental Disorders
Biological
Medication
Electroconvulsive Therapy (ECT)
Surgery
Transcranial Magnetic Stimulation (TMS)
Psychological
Psychotherapy (most evidence for Cognitive Behavioral Therapy (CBT)/ Interpersonal Therapy (IPT)
Social
Money, Education, Employment, Housing, Social Supports

49. Psychiatry Essay Competition
Natasha Fernandes, COUPE 2015 Essay Winner, University of Ottawa Class of 2016
Canadian Organization of Undergraduate Psychiatry Educators (COUPE) holds an annual national essay competition
Winner receives paid trip to Canadian Psychiatric Association (CPA) meeting
250$, 2000 word limit, + 750$ paid trip to CPA meeting. Next CPA meeting September 2016 – Toronto
Due End of April 2016

50. Medicolegal Issues Civil Private Involuntary hospitalizations
Presence of a mental illness
Dangerousness
Disability
Treatment acceptance/refusal (capacity)
Community Treatment Orders (CTO)
Private
Confidentiality

51. Ethical Issues Capacity
Closure of psychiatric hospitals w/o investment in community supports
Stigma and discrimination

52. Stigma

54. 1988 Olympics, Calgary Figure Skating – favorites to win gold:
Katarina Witt (East Germany)
Debi Thomas (United States) “Battle of the Carmens”

55. video

56. Elizabeth Manley
Went on to win the silver medal at the 1988 Winter Olympics
Best ever medal for a Canadian woman figure skater to this day
Many thought she should have won gold
What does this have to do with psychiatry and stigma?

57. Let’s find out….

58. Epilogue
As physicians, your attitudes, beliefs and behaviors will have a significant impact on those you treat
Intelligence is knowing that a tomato is a fruit; wisdom is knowing that a tomato shouldn’t go in a fruit salad
Everybody has a story behind their history/symptoms

59. Outline What is Psychiatry? Diagnosis and Classification
DSM Psychiatric Disorders
The Psychiatric Interview – the basics
Mental Status Examination (components)
Biopsychosocial Understanding of Mental Illness & its use in management plans
Medicolegal/ethical Issues
Stigma

60. Questions?

61. Back to the brain…

62. Neuroanatomy CNS = Brain + spinal cord
Brain – divided into numerous structures - Cortical /grey matter (unmyelinated) - Cerebrum (frontal, parietal, temporal, occipital) - memory, attention, awareness - Subcortical / white matter (myelinated) Limbic System, thalamus, basal ganglia, amygdala, - Connected by numerous tracts

63. Click the Region to see its Name
Korbinian Broadmann - Learn about the man who divided the Cerebral Cortex into 52 distinct regions:
Modified from:

73. x

74. Neuroanatomy 101

76. Thalamus (anterior nuclei)
Thalamus (lateral nuclei)
Ventricle (3rd ventricle)
Internal Capsule
Midbrain
Hypothalamus
Pons
Pituitary Gland
Mamillary body
Medulla

77. Thalamus – a relay station for motor and sensory information for the brain – lots of connections to cortical structures. Also plays an important role in sleep and wakefulness.
Thalamus (anterior nuclei)
Thalamus (lateral nuclei)

78. Part of the ventricular system of the CNS, this contains cerebrospinal fluid, and is thought to give the brain buoyancy, physical support, and chemical stability
Ventricle (3rd ventricle)
Internal Capsule
Internal capsule consists of numerous neurons; separates caudate and thalamus, from lentiform nucleus (putamen and globus pallidus). This is the major group of nerves through which cerebral cortex is connected to brain stem and spinal cord

79. Hypothalamus – part of the neuroendocrine system, with strong connections to the pituitary gland. Helps to regulate various metabolic processes (thyroid, stress, glucose control, sexual function, fluid balance), as well as sleep, appetite, body temperature, circadian cycles.
Hypothalamus
Pituitary Gland
Mamillary body

80. Hypothalamus
Pituitary Gland
Mamillary body
Mamillary bodies – play an important role in memory. Damaged with thiamine (vitamin B1) deficiency – leading to Wernicke Korsakoff syndrome)

81. Brain stem divisions – midbrain, pons, medulla
Brain stem divisions – midbrain, pons, medulla. Within the brainstem are numerous nuclei/tracts. Important ones in psychiatry:
Midbrain
Pons
Medulla
5-HT = serotonin

82. M I D B R A I N
- Dorsal Raphe Nuclei (midbrain) – 5HT neurons originate here; project to various parts of the brain - Dopaminergic neurons Substantia Nigra- (midbrain) – coordinate movement, may play a role in addictions Ventral Tegmental Area ( midbrain) – dopaminergic neurons originate and project to various parts of the brain mesolimbic pathway mesocortical pathway
Midbrain
Pons
Medulla
5-HT = serotonin

83. Midbrain
Pons
- Locus Coeruleus (pons) – noradrenergic neurons originate from here; project to various parts of the brain, mediate arousal, anxiety, emotional context to memories
Medulla
5-HT = serotonin

84. Cerebral Fornix
Cerebellum
Basal Nuclei (globus pallidus)
Globus pallidus - Regulates voluntary movements
Hippocampus
Plays an important role in memory consolidation (converting short term to long term memories)

85. Cerebral Fornix
Thalamus (anterior nuclei)
Hippocampus
Hypothalamus
Amygdala
Mamillary body
Limbic System: Hippocampus, amygdala, mammillary bodies, anterior thalamic nuclei, hypothalamus, cingulate gyrus, cerebral fornix – together form limbic system→ important for control of emotion, memory, and motivation. Tightly connected with the prefrontal cortex, nucleus accumbens

86. Lateral ventricles
Contains cerebrospinal fluid (CSF) Gives brain buoyancy, physical support, and chemical stability (CSF transports nutrients/carries waste away)

87. Basal Ganglia – important for coordination of movements, procedural motor control. Dysfunction is seen in movement disorders such as Parkinson’s, Huntington’s. Also – Tourette’s, schizophrenia, OCD
Basal Nuclei (caudate nucleus)
Basal Nuclei (putamen)
Amygdala

88. Basal Ganglia includes striatum (putamen, caudate, nucleus accumbens), lentiform nucleus (putamen, globus pallidus) and substantia nigra.
Striatum - Dorsal = putamen, caudate - Ventral = nucleus accumbens, olfactory tubercle
Lentiform nucleus = putamen and globus pallidus
Basal Nuclei (caudate nucleus)
Basal Nuclei (putamen)
Amygdala

89. Cerebellum
Coordination of movements

90. Corpus Callosum (white matter)
Corpus Callosum – connects two hemispheres; important for interhemispheric communication

92. Cingulate gyrus
important in emotion learning, processing, memory, motivation

93. The Reward Circuit – consists of Ventral Tegmental Area, Nucleus Accumbens and Prefrontal Cortex (all bidirectionally connected; important in mediating addictions

94. Nucleus Accumbens
important part of reward circuit; involved in feelings of pleasure (near where head of caudate and putamen meet)
Prefrontal Cortex:
cognitive analysis, executive functioning, planning, abstract thought. One of the last areas to mature (maybe why teens can make very poor judgements)
Corpus Callosum (white matter)

95. Cerebrum