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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