Transcript Introduction to Psychiatry

Welcome to 2016, and
Welcome to Unit III
Unit III Co-leaders:
Dr. Heather Maclean
Dr. Katherine Allen (replacing Dr.
Elliott Lee)
Calculation of overall mark – Unit 3
SIM (10%) LAB (15%)
WRITTEN (75%)
Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
WRITTEN (75%)
Essay (10%)
topics and due date to be announced by SIM directors
Calculation of overall mark – Unit 3
SIM (10%) LAB (15%)
WRITTEN (75%)
Final Practical Examination (13.5%)
ABL (1.5%)
ABL =
Anatomy
Based
Learning
Calculation of overall mark – Unit 3
SIM (10%)
Midterm (15%)
LAB (15%)
WRITTEN (75%)
Final (60 %)
Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
WRITTEN (75%)
Midterm (15%)
Final (60 %)
Psychiatry Eye
( 75% ) ( 25% )
Ratio of MCQ : CDMQ =
75% : 25%
Calculation of overall mark – Unit 3
SIM (10%)
LAB (15%)
Midterm (15%)
Eye
( 7% )
WRITTEN (75%)
Final (60 %)
Psychiatry
( 25% )
Ratio of MCQ : CDMQ =
Neurology
( 68% )
75% : 25%
Calculation of overall mark – Unit 3
Eye
1 week
Psychiatry
3 weeks
Neurology
5 weeks
Contribution to overall mark
is proportional to
# weeks / topic
Midterm
Weeks
Topics
#MCQ
#CDMQ
1-3
Psychiatry
49
4 questions
= 11 marks (total)
4
Special
Senses(Eye)
10
2 questions
= 10 marks (total)
Marks
out of 80
59
21
(adjusted to 75%)
(adjusted to 25%)
Final Exam
Weeks
Topics
#MCQ
#CDMQ
1-3
Psychiatry
17
2 questions
= 7 total marks
4
Special Senses (Eye) 4
1 question
= 2.5 total marks
5-9
Neurology
57
3 questions
= 11 total marks
Marks
out of ~100
78
20.5
(adjusted to 75%)
(adjusted to 25%)
Psychiatry Midterm (MCQ)
•
•
•
•
•
•
•
•
•
Mood disorders/tx
Anxiety and related disorders/tx
Psychotic disorders/tx
Geriatric/neurocognitive and tx
Substance use disorders/tx
Sleep/eating
Disorders of childhood/tx
Personality/Somatic/tx(therapy)
Legal
20%
10%
15%
15%
10%
5%
8%
10%
7%
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.)
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
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
Introduction
to Psychiatry
(Not Psychology)
Elliott Lee MD, FRCPC, D. ABPN Sleep Medicine,
Addiction Psychiatry, D. ABSM, F. AASM, F. APA
January 4, 2016
No disclosures to declare
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
 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
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
What is Psychiatry?
?
It’s all about the brain!
Master Watermark Image:
http://williamcalvin.com/BrainForAllSeasons/img/bonoboLH-humanLH-viaTWD.gif
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
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!
What is mental illness/ a
mental disorder ?
 Alteration in thinking, mood or behavior
associated with


significant distress and
impaired function
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
The good physician knows the disease the
patient has; the great physician knows the
patient who has the disease.
William Osler
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
MENTAL ILLNESS IS NOT MENTAL WEAKNESS
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
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
Normal or Abnormal
 Where does “normal” end and clear
psychopathology begin?
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
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
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
DSM Psychiatric Disorders
 Disorders usually evident in infancy,
childhood or adolescence
 Delirium, neurocognitive disorders
 Substance use disorders
 Schizophrenia and other psychotic
disorders
 Mood Disorders
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
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
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
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
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 )
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)
Mental Status Examination
(cont’d)
 Knowledge
 Emptiness/Suicide/Homicide
 Reliability
- assess with others
video
Shine, released by First Line Features, 1996
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
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
Biopsychosocial Model of
Understanding Health and Illness
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
Psychiatry Essay Competition
 Canadian Organization of
Undergraduate Psychiatry Educators
(COUPE) holds an annual national
essay competition
 Winner receives paid trip to Canadian
Psychiatric Association (CPA) meeting
Natasha Fernandes, COUPE 2015 Essay Winner, University of Ottawa Class of 2016
Medicolegal Issues
 Civil

Involuntary hospitalizations
 Presence
of a mental illness
 Dangerousness
 Disability


Treatment acceptance/refusal (capacity)
Community Treatment Orders (CTO)
 Private

Confidentiality
Ethical Issues
 Capacity
 Closure of psychiatric hospitals w/o
investment in community supports
 Stigma and discrimination
Stigma
1988 Olympics, Calgary
 Figure Skating – favorites to win gold:
Katarina Witt (East Germany)
Debi Thomas (United States)
“Battle of the Carmens”
video
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?
LET’S FIND OUT….
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
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
Questions?
Back to the brain…
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
Click the Region to see its Name
Korbinian Broadmann - Learn about the man who divided the Cerebral Cortex into 52 distinct regions:
http://en.wikipedia.org/wiki/Korbinian_Brodmann
Modified from: http://www.bioon.com/book/biology/whole/image/1/1-8.tif.jpg
x
Neuroanatomy 101
Thalamus (lateral nuclei)
Thalamus (anterior nuclei)
Ventricle (3rd ventricle)
Internal Capsule
Hypothalamus
Midbrain
Pons
Pituitary Gland
Mamillary body
Medulla
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 (lateral nuclei)
Thalamus (anterior nuclei)
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
Hypothalamus – part of
the neuroendocrine
system, with strong
connections to the
pituitary gland. Helps to
regulate various
metabolic processes
(thyroid, stress, glucose
Hypothalamus
control, sexual function,
fluid balance), as well as
Pituitary Gland sleep, appetite, body
temperature, circadian
Mamillary body
cycles.
Hypothalamus
Pituitary Gland
Mamillary body
Mamillary bodies – play an important role in memory.
Damaged with thiamine (vitamin B1) deficiency –
leading to Wernicke Korsakoff syndrome)
Brain stem divisions – midbrain, pons, medulla.
Within the brainstem are numerous nuclei/tracts. Important ones in psychiatry:
Midbrain
Pons
Medulla
5-HT = serotonin
- 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
Midbrain
Pons
Medulla
5-HT = serotonin
- Locus Coeruleus (pons) – noradrenergic
neurons originate from here; project to
various parts of the brain, mediate
arousal, anxiety, emotional context to
memories
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)
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
Lateral ventricles
Contains cerebrospinal
fluid (CSF)
Gives brain buoyancy,
physical support, and
chemical stability
(CSF transports
nutrients/carries waste
away)
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)
Amygdala
Basal Nuclei (putamen)
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)
Amygdala
Basal Nuclei (putamen)
Cerebellum
Coordination of movements
Corpus Callosum (white matter)
Corpus Callosum – connects two hemispheres;
important for interhemispheric communication
Cingulate gyrus
important in
emotion learning,
processing, memory,
motivation
The Reward Circuit – consists of
Ventral Tegmental Area, Nucleus
Accumbens and Prefrontal Cortex
(all bidirectionally connected;
important in mediating addictions
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)
Cerebrum