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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.
master the recommended sections of the text to reinforce these introductory lectures.
3 Let’s begin with a basic overview of this medical specialty.
2 Please
Why is psychiatry important?
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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
1It’s
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After mastering the information
contained in this block, you will be
able to
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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.
perfectly okay to like some specialties better than others.
don’t let on. A medical student introduced himself and told me he hated psychiatry.
2Just
What are the scientific (brain) pillars
of psychiatry?
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Neuroscience
Neuroanatomy
Neurophysiology
Neurochemistry
Psychopharmacology
Neurology
Molecular biology
Genetics
And others
What are the scientific (mind) pillars
of psychiatry?
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1Let
me illustrate this with a couple of typical cases.
Psychoanalysis
Psychotherapy
The unconscious
Psychodynamics
The mind
Psychology
Psychometrics
And others
What does the typical psychiatrist
do?
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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
1Pick
2Deal
something you would do for nothing.
with the disparity in incomes right now.
• 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.
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
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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?
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They interview
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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.
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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.
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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
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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.
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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.
Acknowledge 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.
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What is included in the typical mental
status examination?
• Appearance and behavior
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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
1I
• Thought
– Process
– Content (distortions,
preoccupations)
• Perception
– Illusions
– Hallucinations
• Sensorium and intellectual
function
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once got too close to a withdrawn paranoid patient and paid the price.
Consciousness
Orientation
Concentration
Memory
Fund of knowledge
Abstraction
Judgment, insight
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
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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?
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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.
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Make flash cards for the major classes of psychiatric
medications.
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Diagnostic criteria
Common differential diagnoses
Treatment
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?
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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?
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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
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Sarah Ann Flaherty, DO
OUCOM 2003
Thomas Carter, DO
OUCOM 2004
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