Welcome to 2016, and Welcome to Unit III

Unit III Co-leaders:Dr. Heather MacleanDr. Katherine Allen (replacing Dr. Elliott Lee)

Calculation of overall mark – Unit 3

SIM (10%) WRITTEN (75%)LAB (15%)

Calculation of overall mark – Unit 3

Essay (10%)topics and due date to be announced by SIM directors

SIM (10%) WRITTEN (75%)LAB (15%)

Calculation of overall mark – Unit 3

Final Practical Examination (13.5%)

SIM (10%) WRITTEN (75%)LAB (15%)

ABL (1.5%)

ABL = AnatomyBased Learning

Calculation of overall mark – Unit 3

Final (60 %)Midterm (15%)

SIM (10%) WRITTEN (75%)LAB (15%)

Calculation of overall mark – Unit 3

Midterm (15%)

Eye( 25% )

SIM (10%) WRITTEN (75%)LAB (15%)

Psychiatry( 75% )

Final (60 %)

Ratio of MCQ : CDMQ = 75% : 25%

Calculation of overall mark – Unit 3

Final (60 %)

SIM (10%) WRITTEN (75%)LAB (15%)

Ratio of MCQ : CDMQ = 75% : 25%

Eye( 7% )

Psychiatry( 25% )

Neurology ( 68% )

Midterm (15%)

Calculation of overall mark – Unit 3

Psychiatry

Eye

Neurology

1 week

3 weeks

5 weeks

Contribution to overall mark is proportional to # weeks / topic

MidtermWeeks 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 (adjusted to 75%)

21 (adjusted to 25%)

Final ExamWeeks 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 ~10078(adjusted to 75%)

20.5 (adjusted to 25%)

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%• Legal7%

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 alerts4) Failure to adjust (e.g. age, renal failure)5) Use of smart phones6) 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

Elliott Lee MD, FRCPC, D. ABPN Sleep Medicine, Addiction Psychiatry, D. ABSM, F. AASM, F. APAJanuary 4, 2016

(Not Psychology)

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 DisordersDepressed 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 examRelevant lab/diagnostic test resultsFormulation, Treatment and Management Plan

Mental Status ExaminationABC 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)

Knowledge Emptiness/Suicide/Homicide Reliability

- assess with others

Mental Status Examination (cont’d)

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 OlympicsBest ever medal for a Canadian woman figure skater to this dayMany thought she should have won goldWhat 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)

Pituitary Gland

HypothalamusMidbrain

Pons

Medulla

Ventricle (3rd ventricle)

Internal Capsule

Mamillary body

Thalamus (lateral nuclei) Thalamus (anterior nuclei)

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.

Ventricle (3rd ventricle)

Internal Capsule

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

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

Pituitary Gland

Hypothalamus

Mamillary body

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.

Pituitary Gland

Hypothalamus

Mamillary body

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

Midbrain

Pons

Medulla

Brain stem divisions – midbrain, pons, medulla.Within the brainstem are numerous nuclei/tracts. Important ones in psychiatry:

5-HT = serotonin

Midbrain

Pons

Medulla

- 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 brainmesolimbic pathwaymesocortical pathway

5-HT = serotonin

Midbrain

Pons

Medulla

- Locus Coeruleus (pons) – noradrenergic neurons originate from here; project to various parts of the brain, mediate arousal, anxiety, emotional context to memories

5-HT = serotonin

Basal Nuclei (globus pallidus)

Hippocampus

Cerebral Fornix

Cerebellum

Plays an important role in memory consolidation (converting short term to long term memories)

Globus pallidus - Regulates voluntary movements

Hippocampus

Cerebral Fornix

Amygdala

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

Thalamus (anterior nuclei)

Hypothalamus

Mamillary body

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

Basal Nuclei (putamen)

Basal Nuclei (caudate nucleus)

Amygdala

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 (putamen)

Basal Nuclei (caudate nucleus)

Amygdala

Basal Ganglia includes striatum (putamen, caudate, nucleus accumbens), lentiform nucleus (putamen, globus pallidus) and substantia nigra.Striatum - Dorsal = putamen, caudate

- Ventral = nucleus accumbens, olfactory tubercleLentiform nucleus = putamen and globus pallidus

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

Corpus Callosum (white matter)

Nucleus Accumbensimportant part of reward circuit; involved in feelings of pleasure(near where head of caudate and putamen meet)

cognitive analysis, executive functioning, planning, abstract thought. One of the last areas to mature (maybe why teens can make very poor judgements)

Prefrontal Cortex:

Cerebrum