Welcome to 2016, and Welcome to Unit III
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Transcript of Welcome to 2016, and Welcome to Unit III
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