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- Title: Hubio 563 Readings and Objectives
- Type: Notes
- School: Washington
- Course: HUBIO 563
- Term: Fall
563 Hubio Readings and Objectives Lectures: Mental Status Exam and Interviewing Reading: Chapter 2, The Psychiatric Evaluation Chapter Review 1. Review Table 2-1 Elements of the Psychiatric History Table 2-1 Elements of the psychiatric history Idenification and Chief Complaint Informants Present illness Psychiatric History Premorbid Personality Medical history, medications, drug allergies Social History Birth Early Development Education Occupational history Sexual Marital History Children Current living situation Legal history Alcohol/substance history Family History 2. Review Table 2-2 Elements of the Mental Status Exam Table 2-2 Elements of the Mental Status Examination Appearance Obsessions and Compulsions Speech Phobias Mood and affect Cognition Hallucinations Insight and Judgement Delusions 3. List the subheadings that should be included under Social History -Birth -Early Development -Education -Occupational History -Sexual Marital History -Children -Current Living Situation -Legal History -Alcohol/substance history 4. Define formal thought disorder Form of though, reflected in speech, is abnormal 5. Differentiate circumstantiality, tangentiality, looseness of associations, clanging, thought blocking. Circumstantiality-associations can be followed, but speech is overinclusive and circumlocutious Tangentiality-reponse is irrelevant or makes no sense Looseness of Associations-goal-0directed quality of speech is lost, most commonly seen in schizophrenia Clanging-association between words relies on words having similar first syllables Thought Blocking-severe example of impoverished thought with abrupt cessation of speech in mid sentence 6. Differentiate mood and affect. Mood-patient s subjective feeling state (subjective) Affect: observable behavioral expression of emotional state (objective) 7. Define hallucinations. True perception in the absence of an external stimulus 8. List the different types of hallucinations. Auditory Visual Tactile (or haptic) Olfactory Gustatory Hypnagogic (just falling asleep) Hypnopompic (just waking up) 9. Define illusion. Sensory misperceptions of real external stimuli 10. Define delusions. Fixed, false idiosyncratic beliefs (patient isn t swayed from belief by any amount of rational argument) 11. List common types of delusions Grandiose Persecutory Erotomanic Jealousy (infidelity) Referance (incidental events have special significance for the patient) Passivity (patient s body controlled by outside forces) Somatic 12. Define obsessions and compulsions. Obsessions-persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and the cause of marked anxiety or distress, not delusions so patient acknowledges the irrationality Compulsions-repetitive behaviors or mental acts that patient does in order to reduce anxiety of obsessions 13. Define phobias. Marked and persistent fears of specific objects or situations Specific Phobias:situational, natural environment, blood-injection-injury, animal type Agoraphobia Social Phobia 14. How does educational level affect the MMSE? Advancing age and lower levels of education can negatively influence scores Ranges of scores are based on average patient with at least a fifth grade education 15. What is the difference between insight and judgment? Insight: multidimensional concept relating to the patients awareness of their symptoms/illness 16. Review Table 2-11 and 2-12. Table 2-11 Common Psychiatric Screening Tests Serum Electrolytes, glucose, BUN, creatinine Serum chemistry panel (including hepatic enzymes) Complete blood count (CBC) Thyroid-stimulating hormone (TSH) assay, or full thyroid panel Serum vitamin B12 level Urine toxicology screen Articles: The Listening Healer Lecture: Somatization Reading: Chapter 13, Somatoform Disorders Chapter Review 1. Distinguish from each other: somatization disorder, conversion disorder, Pain Disorder, Hypochondriasis. Somatization Disorder-multiple, unexplained physical complaints spanning multiple organ systems (chronic) Conversion Disorder-unexplained symptoms affecting voluntary motor or sensory function that suggest a neurological or other general medical condition, but with psychological factors judged to be associated with the symptoms. Pain Disorder-Pain is the focus of clinical attention with psychological factors judged to have important role in its onset, severity, exacerbation or maintenance. Hypochondriasis-peroccupation with the fear of having, or the idea tha tone has, a serious disease based upon misinterpretation of bodily symptoms or functions 2. Be aware of comorbid depression and anxiety disorders in somatoform disorders. Depressive disorders are a commonly observed comorbidity among patients with somatoform disorders, occurring in about half of patients. In an alexithymic individual one might consider a trial of an antidepressant empirically Anxiety disorders are associated with significant visceral and somatic symptoms and secondary hypochondriacal concerns commonly arise in these patients. Patients with anxiety disorders may become sensitized to their body sensations, further encouraging somatic amplification. GAD and Panic disorder are common. When the distinction between somatoform disorder and anxiety disorder is in doubt, an empirical trial of medication may be useful. 3. Differentiate primary and secondary gain. Primary gain-unconscious, intrapsychic benefit Secondary gain-external benefit 4. Discuss the treatment of somatoform disorders. -address the behavior -once diagnosis is agreed upon by all concerned, patient should be informed of diagnosis and its nature -goal of discussion is for patient to achieve the desire to modify belief system and behavior -clinic visit itself is more important than treatments, so brief visits should be scheduled at regular intervals -gradually increase the intervals unless patient begins to call between visits complaining of worsening symptoms -if a new symptom occurs, take a basic history and do a routine workup -if the workup is negative, the symptom should be added to the list already attributed to the somatization disorder -address any comorbid medial and psychiatric conditions with conservative interventions -during visits convey tha the patient is more important than any particular symptom 5. Distinguish factitious disorders and malingering. Disorder Behavior Motivation Somatoform Disorder Unconscious Unconscious Malingering Conscious Conscious Factitious Disorder Conscious Unconscious Articles: Somatization Lecture: Affective Disorders Reading: Chapter 7, Mood Disorders Chapter Review 1. Why is it important for PCP to diagnose and treat mood disorders? At least 50% of patients who present for treatment in PCP setting have no diagnosable medical illnees, of these 86% Have lifetime histories of a psychiatric disorder with the most common diagnosis of Major Depressive Disorder 2. Define and distinguish: Major Depression (MDD), Dysthymic Disorder, Adjustment disorder with depressed mood, Bereavement, Bipolar I Disorder (BAD), Bipolar II Disorder, Cyclothymic Disorder, Mood disorder due to a general medical condition, Substance-induced Mood Disorder. Major Depression (MDD)-presence of fone or more major depressive episodes (at least 2 weeks of depressed mood Or anhedonia plus at least four associated depressive symptoms Dysthymic Disorder-insidious onset of more chronic symptoms, at least 2 years of depressed mood for more days than not plus at least two additional depressive symptoms Adjustment Disorder with Depressed Mood-difficulty adjusting to inevitable changes in life mild depression Bereavement-normal grief response following a death, generally DON T display pathological change in self attitude. Bipolar I Disorder (BAD)-presence of one or more manic or mixed episodes Bipolar II Disorder-one or more major depressive episodes accompanied by at least one hypomaniac episode but no full blown manic or mixed episodes Cyclothymic Disorder-numerous periods of hypomanic symptoms and of dysthymia-level depressive symptoms over at least a 2 year period but no full-blown depressive or manic episodes Mood Disorder due to general medical condition-direct physiological effect of a medical condition Substance-induced Mood Disorder-self explanatory 3. Is MDD more prevalent in women or men? Prevalence in women is about twice as high (25%) as in men (12%) 4. What is the course of illness in Major Depression? -onset in late 20 s -vulnerability to recurrent or chornic illness -social and physical morbidity -high risk of mortaility 5. What are mood-congruent psychotic symptoms? Psychotic symptoms which are typically altered in the same direction as the mood, self attitude is elevated in Manic sates, sometimes to the point where the patient believes he is a prophet or angel of God 6. What is the age of onset of MDD? Mean age of onset is the late 20 s and 50% of cases first appear after age 40 7. What is the morbidity, mortality (suicide, cardiovascular, post-stroke) in MDD? Depression is associated with greater degree of social and physical disability than many other medical conditions MDD conveys high risk of mortality, largely due to suicide. Risk of suicide higher than the general population Depression associated with greater morbidity and mortality from co-occuring medial illness Much higher rates of ischemic heart disease causing increased cardiac mortality in depressed patients Individuals who have astroke to appear to be predisposed to develop major depression 8. Discuss MDD in the elderly (morbidity and suicide rates). Rate of MDD in elderly is LOWER than seen in the general population, however there is a very high prevalence in hospital and nursing home setting Impact of depression is greater in elderly both in terms of morbidity (comorbid conditions) and mortality (completed suicide) More likely to present with new somatic complaints rather than complaints of sadness and self esteem 9. What are the recurrence rates in MDD? In absence of treatment: 50% who have experienced one major depressive episode with have a recurrence later in life After 2 episodes, recurrence rate is 70%, after three episodes recurrence rate is 90% After several recurrences, episodes recur more frequently and last longer, over 20 years average is 5-6 episodes 10. What is the course of illness in Bipolar Disorders? 11. What is the age of onset of BAD? Peak onset of symptoms between 15-19 but first diagnosed in early 20 s 12. Define rapid cycling. Four or more episodes of depressive or manic episodes within a single year 13. Define a mixed episode . Meeting diagnostic criteria for both a manic episode as well as MDD nearly every day for a week 14. What is the prognosis of BAD? Less favorable prognosis than MDD, following first manic or depressive episode 90% experience subsequent episodes Only 15% will ultimately achieve stable euthymic state, 45% have relapses, 30% achieve partial remission 15. What is the difference between mania and hypomania? Mania: persistently elevated, irritable mood for 1 week with 3 or more of the following -inflated self esteem or grandiosity -decreased need for sleep -more talkative, pressured -racing thoughts -distractibility -increased goal directed activity/agitation -excessive involvement in pleasurable activities Hypomania: Persistently elevated, irritable mood for 4-7 days with three or more of the following -inflated self esteem or grandiosity -decreased need for sleep -more talkative, pressured -racing thoughts -distractibility -increased goal directed activity/agitation -excessive involvement in pleasurable activities 16. What is the difference between baby blues and post-partum depression ? Baby Blues: crying, irritability, mood swings, onset about 3-10 days postpartum usually resolving in about a week Postpartum Depression: meets fulldiafnostic criteria for major depressive episode, related to MDD 17. Approximately how long post-partum are women risk for post-partum blues? When are they most at risk? Women are at higher risk for becoming depressed for up to several months postpartum, but greatest risk is at 2 weeks Articles: Bipolar Disorder Mood Patterns in Bipolar Disorder Medication Management of Depression Depression in Medical School Lecture: Anxiety Disorders Reading: Chapter 9, Anxiety Disorders Chapter Review 1. Review Table 9-1 Medical and Substance Abuse Disorders that can be associated with anxiety. Table 9-1. Some medical and Substance Use Disorders Potentially associated with Anxiety Neurological Disorders Systemic Diseases Cardiopulmonay Disease Substance Use Brain tumor/trauma Cerebrovascular disease Subarachnoid hemorrhage Migraine Encephalitis Neurosyphilis Multiple sclerosis Wilson s disease Huntington s disease Epilepsy Pituitary disease Tthyroid disease Parathyroid disease Pheochromocytoma Hypoglycemia Paraneoplastic syndrome Premenstrual hormonal changes Pophyria Uremia SLE Cardiac ischemia Cardiac arrhythmia Hypoxia Reactive airway disease Anemia Alcohol and drug withdrawl Amphetamine intoxication Sympathomimetic agents Vasopressors Caffeine and caffeine withdrawl antibiotics 2. Review the fear circuit , Figure 4-2 -fear circuit centers on the amygdala 3. Review DSM-IV criteria for GAD. -excessive anxiety and worry, occurring more days than not for at least 6 months about a number of events or activities -person finds it difficult to control the worry -anxiety and worry are associated with at least three of the following -restlessness or feeling keyed up or on edge -being easily fatigued -difficulty concentrating or mind going blank -irritability -muscle tension -sleep disturbance -focus of anxiety and worry is not confined to the features of an Axis I disorder 4. What are the common presenting complaints for GAD? Motor symptoms: shakiness, restlessness, sore muscles, headache Autonomic symptoms: shortness of breath, sweats, shakes, palpitations, GI symptoms Vigilance (cognitive) symptoms: irritability, fatigue, difficulty sleeping, difficulty concentrating 5. GAD commonly overlaps with what specific GI disorder? Irritable Bowel Syndrome (Chron s) 6. What is the most common comorbid condition in patients with GAD? The most common comorbid condition is major depressive disorder which occurs in 80% of those with GAD 7. What is the focus of worry in patients with GAD? Unrealistic or excessive worry about particular life circumstances (work, finances, health) There is generalized worry about everyday or real life problems 8. How do you distinguish GAD from normal anxiety? GAD differs from normal anxiety in form. In GAD the severity and duration of the patient s anxiety along with the associated social morbidity are all greater than might be expected under similar circumstances for the average person. The anxiety in GAD is more pervasive and more detached form current life circumstances 9. How are cognitive distortions in depression different from those seen in anxiety disorders? The typical cognitive distortions seen in anxiety disorders overlap to an extent with those seen in depressive disorders But there are differences: Depressive cognitions tend to overstate past failures (hopelessness, low self esteem, failure ) Anxious cognitions tent to overstate the risk of future failure or overstate the severity of the consequences that would result from a future failure, also these individuals express characteristic automatic thoughts 10. What are the most common distortions in GAD? Four most common cognitive distortions in GAD -overestimates of the likelihood of a feared event taking place -overestimates of the severity of the event -underestimates of one s personal coping abilities -underestimates of the help that others can offer 11. Review DSM-IV criteria for Panic Attacks. A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached peak within 10 minutes -palpitations, punding heart, or tachycardia -sweating -trembling or shaking -sensations of shortness of breath or smothering -feeling of choking -chest pain or discomfort -nausea or abdominal distress -feeling dizzy, unsteady, lightheaded or faint -derealization or depersonalization -fear of losing control or going crazy -fear of dying -parasthesias -chills or hot flushes 12. What medical problems need to be ruled out when a patient presents with symptoms of panic attack? Acute MI, asthma attack, temporal lobe seizure, hypoglycemia, pheochromocytoma, acute hyperthyroidism Drug/alcohol intoxication or withdrawal 13. What is the difference between PA and PD? A panic disorder is repeated spontaneous or unexpected panic attacks 14. Review DSM-IV criteria for PD. -Both 1 and 2 1)recurrent unexpected panic attacks 2)At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following: -persistent concern about having additional attacks -worry about the implications of the attack or its consequences -a significant change in behavior related to the attacks -presence (or absence of agoraphobia) 15. Do some attacks have to be unexpected to meet criteria for PD? -requires at least some of the attacks to have been unexpected and that significant worry of attacks has developed 16. Discuss issues regarding the comorbidity of MDD and PD. MDD co-occurs in 50-65% of individuals with panic disorder These patients demonstrate a more limited response to treatment and are more likely to remain chronically ill They also have twice the risk of suicide as patients with either disorder alone 17. Is PD more prevalent in men or women? Prevalence is about 1.5-3.5% and two to three times more prevalent in women than men 18. At what age does the first PA commonly occur? The first panic attack most often occurs in the mid-20 s though illness can onset at any age. 19. What is the relationship between PD and agoraphobia? One third to one half of individuals with PD also have agoraphobia, rate is even higher in those presenting for care 20. What is the usual course of PD? May be self limited but more often is chronic 30-40% are symptom free, 50% have mild symptoms and 10-20% continue to experience significant symptoms increased risk of suicide with rates similar to MDD 21. Define phobia, specific phobia, agoraphobia and social phobia. Phobia: marked and persistent fears cued by the presence or anticipation of specific objects or situations Response occurs despite recogniztion that the fear is unreasonable or excessive Specific Phobia:situational type, natural environment type, blood-injection-injury, animal type Agoraphobia: fear/avoidance of places or situations either where help is not available or escape difficult Social Phobia: marked and persistent fears of social or performance situations where they might be embarassed 22. How are phobias usually treated? Behavioral modification with other modes of therapy often playing ancillary roles Ex: graded exposure, relaxation training, breathing exercises and cognitive therapy Goal is to have patient recognize the irrationality of their fears and break the association of circumstance/response B-adrenergic blockers, antidepressant or benzodiazepine agents 23. Review DSM-IV criteria for PTSD. A.The person has been exposed to a traumatic event in which both of the following were present -experienced, witness or confronted with event that involved actual or threatened death or serious injury -persons response involved intense fear, helplessness or horror B.The traumatic event is persistently re-experienced in one (or more) of the following ways: -recurrent and intrusive distressing recollections of the event -recurrent distressing dreams of the event -acting or feeling as if the traumatic event were recurring -intense psychological distress at exposure to cues that sympbolize or resemble aspects of the event -physiological reactivity on exposure to internal or external cues that symbolize or resemble event C.Persistent avoidance of stimuli associated with trauma and numbing of general responsiveness (3 of the following) -efforts to avoid thoughts, feelings, or conversations associated with the trauma -efforts to avoid activities, places, or people that arouse recollections of the trauma -inability to recall an important aspect of the trauma -markedly diminished interest or participation in significant activities -feeling of detachement or estrangement from others -restricted range of affect -sense of a foreshortened future D.Persistent symptoms of increased arousal (not present before), as indicated by two or more of the following -difficulty falling or staying asleep -irritability or outbursts of anger -difficulty concentrating -hypervigilance -exaggerated startle response E. Duration of the disturbance (B,C and D) is more than 1 month F. Clinically significant distress or impairment in functioning 24. Distinguish Acute Stress Disorder from PTSD. Acute Stress Disorder is the noting of symptoms within a month of the trauma PTSD is if symptoms persist beyond this acute period 25. Review DSM-IV criteria for PTSD. 26. OCD has been linked to what other neuropsychiatric disorder? OCD has been linked to Tourette s disorder- vocal and complex vocal and complex motor tics -2/3 of patients with Tourette s meet the criteria for OCD (Recurrent major depressive disorder occurs in up to 80% of individuals with OCD) 27. What is the mean age of onset of OCD? Mean age of onset is in early 20 s, over half present by age 25 and 75% by age 30 In younger patients there is greater preponderance of males with an eventual equalization 28. What medical condition has been associated with PTSD in children? (I think they meant OCD) Group A B-hemolytic streptococcal upper respiratory infection -OCD symptoms may be caused either by a toxin or an autoimmune reaction (PANDAS) Articles: Generalized Anxiety Disorder Lecture: Personality Disorders Reading: Chapter 10, Personality Disorders Chapter Review 1. Define personality. A consistent and enduring manner of thinking, feeling and behaving over time and across situations 2. What are personality traits? An individuals abiding, consistent tendiencies to react to particular circumstances in particular ways 3. Define the trait of neuroticism. Describes a person s degree of emotional reactivity 4. What is the difference between personality trait and personality disorder? Personality disorder is a mixture of characteristic attitudes and specific behaviors in a person who ALSO demonstrates the following: -characteristic pattern of difficulties in multiple areas of functioning including cognition, affectivity interpersonal functioning and impulse control that deviates from the expectations of culture -pattern of difficulties should be inflexible and pervasive across broad range of personal social situations -pattern of difficulties should lead to clinically significant distress or to impairment in social, occupational or other important areas of functioning -the pattern should be enduring (follows a stable pattern and should be of long duration) -pattern should not be better accounted for as a consequence of another mental disorder or substance/medical condition 5. Distinguish cluster A, B and C. Cluster A: Odd or Eccentric -paranoid personality disorder: distrust and suspiciousness of others -schizoid personality disorder: detachment from social relationships, restricted range of emotional expression -schizotypal personality disorder:acute discomfort in close relationships, cognitive or perceptual distortions (although not so sever that they would be considered hallucinations), and eccentricities of behavior Cluster B: Dramatic, Emotional or Erratic -antisocial personality disorder: disregard for and violation of rights of others occurring since age 15 -borderline personality disorder: instability in interpersonal relationships, self image and affects; impulsivity -histrionic personality disorder: excessive emotionality and attention seeking -narcissistic personality disorder: grandiosity, need for admiration, and lack of empathy Cluster C: Anxious or fearful -avoidant personality disorder: social inhibition, feelings of inadequacy, hypersensitivity to negative evals -dependent personality disorder: submissive and clinging to behavior, excessive need to be cared for -obsessive-compulsive personality disorder:preoccupation with orderliness, perfectionism and control 6. Classify personality disorders by clusters. See above 7. Distinguish each personality disorder. See above 8. What is the difference between mature, neurotic and immature defenses? Mature Defenses: appropriate, realistic ways of dealing with painful feeling brought on by emotional conflict or stress -Altruism -Anticipation -Humor -Sublimation -Suppression -Affiliation Neurotic Defenses: relied on particularly when more mature defenses are not sufficient; personality disorders rely much more frequently, evcen under lesser degrees of stress -Displacement -Externalization -Intellectualization -Dissociation -Repression -Reaction formation Immature Defenses: used by people with more severe personality disorders -Denial -Autistic (schizoid) fantasy -Passive-aggressive behavior -Acting out -Splitting -Projection -Projective identification Articles: Borderline Oscillations Lecture: Psychotic Disorders Reading: Chapter 8, Schizophrenia and Psychotic Disorders Chapter Review 1. Define and distinguish: Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, Delusional Disorder, Psychotic Disorder due to a General Medical Condition. Schizophrenia: presence of psychotic symptoms in absence of change in consciousness, disturbance of cognition or mood. Symptoms persist for at least 6 months, including at least 1 month of active-phase symptoms including hallucinations, delusions, thought disorder, disorganized or catatonic behavior or negative symptoms along with evidence of decline in social or occupational functioning Schizophreniform Disorder:same criteria as schizophrenia except duration is 1-6 months and no requirement that there be evidence of a decline in functioning Schizoaffective Disorder: patient meets criteria for both schizophrenia and mood disorder. Acute episodes of both mood disorder and active phase symptoms of schizophrenia but these are preceded or followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms Delusional Disorder: nonbizarre delusions in absence of other active-phase symptoms of schizophrenia, lasting at at least 1 month Psychotic Disorder due to a General Medical Condition: direct physiological consequence of a medical condition 2. Describe Kurt Schneider s first rank symptoms. Specific types of hallucinations and delusions. They can occur in other psychotic conditions but are more common in schizophrenia. They include the following: -Thought echo: auditory hallucinations that echo person s own thoughts -Voices commenting: running commentary on patient s behavior -Voices arguing: usually argue about patient in third person -Thought insertion: belief that thoughts are not patient s own and are literally inserted into their head -Thought withdrawal: belief that thoughts are literally being taken out of their head -Thought broadcasting: belief that thoughts are being broadcast widely - made implusive, made affect, made volition, somatic passivity: belief of being controlled like a puppet -Delusional perception: actual perception of innocuous event in environment triggers full blown delusion -may be accompanied by sense of relief of finally figured out what is going on 3. What is the difference between positive and negative symptoms.? Positive Symptoms: symptoms PRESENT in schizophrenic patients that are not in the general population Ex: hallucinations and delusions Negative Symptoms: DEFICITS that occur in schizophrenic patients but not in the general population Ex: lack of motivatin, affective blunting, poverty of speech, social withdrawal, poor grooming -usually persist after positive symptoms of an acute psychotic episode have resolved 4. What is the age of onset of Schizophrenia? Men have age of onset 15-25 Women have age of onset 25-35 5. What are the subtypes of Schizophrenia? Type I Schizophrenia Prominent symptoms Good premorbid functioning Acute onset Remissions and exacerbations Better response to traditional antipsychotics Good cognition between episodes Normal findings on routine neuroimaging Type II Schizophrenia Positive symptoms less prominent Poor (schizotypal) premorbid functioning Insidious decline Chronic deterioration Poor response to traditional antipsychotics Prominent cognitive impairment Atrophy and enlarged ventricles on neuroimaging 6. What is the course of illness of Schizophrenia? 1.Prodromal Phase-gradual development of negative symptoms 2.Active Phase- active phase symptoms such as hallucinations, delusions, gross disorganization or catatonia occur 3.Remission-may not display positive symptoms but active phase symptoms are present in attenuated form depressive symptoms commonly occur as part of acute phase or during residual phase 4.Relapse-often preceded by nonspecific prodromal symptoms; worsening dysphoria, tension, nervousness, insomnia, poor concentration, poor appetite or depression. May display increasingly bizarre behavior symptoms tend to plateau after about 5 years, 30% have good outcomes , 30% have bad outcomes, 40% have intermediate outcomes with occasional readmissions, some persistent symptoms and chronic interpersonal difficulty 10% ultimately commit suicide, often during episodes of depression that follow psychotic episodes (usually those with greater insight) Schizophrenia Longitudinal Course Specifiers 1. episodic, with interepisode residual symptoms 2. episodic, with no interepisode residual symptoms 3. continuous 4. single episode, in partial remission 5. single episode, in full remission 6. other or unspecified pattern. 7. What is the lifetime prevalence of Schizophrenia? Lifetime prevalence of schizophrenia is 0.5%-1.5% and is the same in women and men 8. Describe genetic factors in Schizophrenia. Between 5 and 30 genes have been implicated in conferring susceptibility to developing schizophrenia Environmental factors then help to convert vulnerability into active illness Elevated concordance rate in monozygotic versus dizygotic twins is consistent with an etiologic role of genetic factors Transmission is likely polygenic with two or more defective genes interacting synergistically to increase vulnerability Relationship to proband Risk of Schizophrenia No relationship (general population) 1% Parent One 5-6% One sibling 10% One Sibling and one parent 17% Two parents 46% Articles: Schizophrenia Lecture: Child Psychiatry I and II Reading: Chapter 19, Childhood Disorders Chapter Review 1. How do affective disorders present in preadolescent children? Major Depressive Disorder:prominent somatic complaints, irritability and social withdrawl Bipolar Disorder: extreme irritability, sever temper outbursts, mixed episodes and rapid cycling common 2. Name the most common anxiety disorders in children Obsessive-Compulsive Disorder:more difficulty with repetitive rituals than obsessional thoughts Panic Disorder with or without agoraphobia: less likely to report fears of dying, going crazy Post Traumatic Stress Disorder: most commonly presents with separation anxiety, fears of death , social withdrawl Generalized Anxiety Disorder: present in 3% of school-age children, appear shy and self-deprecating, somatic symps Social Phobia: extremely shy and withdrawn in unfamiliar situations, some display selective mutism -the most stable of the childhood anxiety disorders, interferes with academic performance and psychosocial development Separation Anxiety Disorder (see below) 3. Discuss the risk of schizophrenia in children. Occurs in only 0.014% of children-very rare 80% of children diagnosed with schizophrenia also experienced severe language deficits and motor development problems 4. Is Schizophrenia commonly diagnosed before age 15? No, very rare. 5. Is Schizophrenia more common in adolescent males or females? Adolescents with schizophrenia are primarily male 6. Review DSM-IV criteria for Separation Anxiety Disorder. A. Developmentally inappropriate and excessive anxiety concerning separation from home or individuals as evidenced by three or more of the following 1. Recurrent excessive distress when separation from home or major attachement figures occurs/anticipated 2. Persistent and excessive worry about losing, or possible harm befalling major attachment figures 3. Persistent and excessive worry that untoward event will lead to separation from attachment figure 4. Persistent reluctance or refusal to go to school or elsewhere because of fear of separation 5. Persistently/excessively fearful or reluctant to be along without attachment figure or significant adults 6. persistent reluctance or refusal to go to sleep without being near major attachment figure or sleep away from home 7. repeated nightmares involving the theme of separation 8. repeated complaints of physical symptoms when separation from attachment figure occurs or is anticipated B. Duration of disturbance is at least 4 weeks C. Onset before 18 years of age D. Disturbance causes clinically significant distress/impairment E. Does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia or other Psychotic disorder and is not better accounted for by panic disorder with agoraphobia 7. Selective mutism is often comorbid with what disorder? Definition: consistent failure to speak in specific social situations despite having the ability to speak in other situations Most commonly diagnosed between 5-8 and almost all meet the diagnostic criteria for Social Phobia 8. Review DSM-IV criteria for Reactive Attachment Disorder. A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2): (1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) (2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder. C. Pathogenic care as evidenced by at least one of the following: (1) persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection (2) persistent disregard of the child's basic physical needs (3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care) D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C). Specify Type: Inhibited Type: if Criterion A1 predominates in the clinical presentation Disinhibited Type: if Criterion A2 predominates in the clinical presentation 9. Review DSM-IV criteria for Autistic Disorder. A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one each from (2) and (3): (1) qualitative impairment in social interaction, as manifested by at least two of the following: (a) marked impairment in the use of multiple nonverbal behaviors, such as eye-to- eye gaze, facial expression, body postures, and gestures to regulate social interaction (b) failure to develop peer relationships appropriate to developmental level (c) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest) (d) lack of social or emotional reciprocity (2) qualitative impairments in communication, as manifested by at least one of the following: (a) delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime) (b) in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others (c) stereotyped and repetitive use of language or idiosyncratic language (d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level (3) restricted, repetitive, and stereotyped patterns of behavior, interests, and activities as manifested by at least one of the following: (a) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus (b) apparently inflexible adherence to specific, nonfunctional routines or rituals (c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting or complex wholebody movements) (d) persistent precoccupation with parts of objects B. Delays or abnormal functioning in at least one of the following areas, with onset prior to age 3 years: (1) social interaction, (2) language as used in social communication, or (3) symbolic or imaginative play. C. The disturbance is not better accounted for by Rett's disorder or childhood disintegrative disorder. 10. Is Autistic Disorder (a pervasive developmental disorder) more common in boys or girls? Autistic disorder is three to fiver times more common in males than in females Symptoms are often more severe in females and there is more likely to be a family history of cognitive impairment 11. Describe Rett s Disorder (a pervasive developmental disorder). Progressive neurodegenerative illness of unknown eitiology that occurs only in girls -normal development over first 5-48 months followed by development of autistic symptoms -deceleration of head growth, loss of motor skills in hands and disturbance of gait -characteristic hand sterotypies including hand wringing, wetting of hands with saliva 12. Describe Asperger s Disorder (a pervasive developmental disorder). Severe and sustained impairments in social interactions as in autistic disorder Also demonstrate restricted and repetitive patterns of behavior, interests and activites HOWEVER: Do not demonstrate significant language dysfunction or significant delays in cognitive development -normal curiosity about environment and are able to acquire age appropriate learning skills and adaptive behavior in all areas except for realm of interpersonal functioning (lack normal emotional reciprocity) -demonstrate eccentric and one sided social approach as opposed to complete social and emotional indifference seen in autism Five times more prevalent in males than females and occurs more frequently in setting of family history of autism 13. Review DSM-IV criteria for ADHD A. Either (1) or (2): A. six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: a. often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities b. often has difficulty sustaining attention in tasks or play activities c. often does not seem to listen when spoken to directly d. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) e. often has difficulty organizing tasks and activities f. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) g. often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) h. is often easily distracted by extraneous stimuli i. is often forgetful in daily activities B. six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity a. b. c. d. e. f. often fidgets with hands or feet or squirms in seat often leaves seat in classroom or in other situations in which remaining seated is expected often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness) often has difficulty playing or engaging in leisure activities quietly is often "on the go" or often acts as if "driven by a motor" often talks excessively Impulsivity g. often blurts out answers before questions have been completed h. often has difficulty awaiting turn i. often interrupts or intrudes on others (e.g., butts into conversations or games) Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home). There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). B. C. D. E. Specify Type: Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type: if Criterion A1 is met but Criterion A2 is not met for the past 6 months Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 is met but Criterion A1 is not met for the past 6 months 14. How do you diagnose ADHD? The diagnosis is assigned to an individual based upon clinical phenomenology. Clinicians must continually reassess for presumed ADHD at regular intervals since there is substantial diagnostic ambiguity with other psychiatric disorders such as depression and bipolar disorders 15. Review DSM-IV criteria for Conduct Disorder. A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past six months: Aggression to people and/or animals 1. Often bullies, threatens or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). 7. Has forced someone into sexual activity. Destruction of property 8. 9. Has deliberately engaged in fire setting with the intention of causing serious damage. Has deliberately destroyed others' property (other than by fire setting). Deceitfulness or theft 10. Has broken into someone else's house, building or car. 11. Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others). 12. Has stolen items of nontrivial value without confronting the victim (e.g., shoplifting, but without breaking and entering; forgery). Serious violations of rules 13. Often stays out at night despite parental prohibitions, beginning before age 13 years. 14. Has run away from home overnight at least twice while living in a parental or parental surrogate home (or once without returning for a lengthy period). 15. Is often truant from school, beginning before age 13 years. The disturbance in behavior causes clinically significant impairment in social, academic or occupational functioning. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. B. C. Specify severity: Mild: few if any conduct problems in excess of those required to make the diagnosis, and conduct problems cause only minor harm to others. Moderate: number of conduct problems and effect on others intermediate between "mild" and "severe." Severe: many conduct problems in excess of those required to make the diagnosis, or conduct problems cause considerable harm to others. 16. Discuss gender differences in Conduct Disorder. Conduct disorder is more common in boys (up to 16%) than girls (up to 9%) Males tend to engage in fighting, stealing and vandalism and have school disciplinary problems (confrontation) Females are more likely to engage in lying, truancy, running away, substance abuse, prostitution (nonconfrontational) 17. What adult personality disorder is related to Conduct Disorder? Almost half of those with conduct disorder go on to develop antisocial personality disorder 18. Review DSM-IV criteria for Oppositional Defiant Disorder (ODD). A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present: (1) often loses temper (2) often argues with adults (3) often actively defies or refuses to comply with adults' requests or rules (4) often deliberately annoys people (5) often blames others for his or her mistakes or misbehavior (6) is often touchy or easily annoyed by others (7) is often angry and resentful (8) is often spiteful or vindictive Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level. B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder. D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder. 19. In adolescences is ODD more common in boys or girls? ODD is more common in boys prior to puberty, but prevalence is equal in both sexes during adolescence There is a significant association with ADHD Articles: Adolescent Depression Evidence-Based Approach to Emotional and Behavioral Dysregulation Lecture: Delirium Reading: Chapter 5, Delirium Chapter Review 1. How do you make the diagnosis of delirium? A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. The best way to assess for impaired attention, memory an dothe rcognitive function is by perfoming a min-mental status Exam, serial examinations often reveal waxing an dawning defecits 2. What is the etiology of delirium? Name 10 different causes (i.e. infection, drug withdrawal, drugs, toxins ) Infection Withdrawal Acute metabolic Trauma CNS pathology Hypoxia Deficiencies Endocrinopathies Acute vascular Toxins or drugs Heavy Metals HIV, sepsis, Pneumonia Alcohol, barbiturate, sedative-hypnotic Acidosis, alkalosis, electrolyte disturbance, hepatic failure, renal failure Closed-head injury, heat stroke, postoperative, severe burns Abscess, hemorrhage, hydrocephalus, subdural hematoma, Infection, seizures, stroke, tumors, metastases, vasculitis, Encephalitis, meningitis, syphilis Anemia, carbon monoxide poisoning, hypotension, Pulmonary or cardiac failure Vitamin B12, folate, niacin, thiamine Hyper/hypoadrenocorticism, hyper/hypoglycemia, Myxedema, hyperparathyroidism Hypertensive encephalopathy, stroke, arrhythmia, shock Prescription drugs, illicit drugs, pesticides, solvents Lead, manganese, mercury 3. What patient populations are at greater risk of developing dementia (I think they mean delirium)? Certain classes of hospitalized patients are at greater risk for developing delirium Elderly (30-40% of hospitalized, 60% of those in nursing homes) Post operative patients (40-50%) AIDS patients Burn patients Patients with brain injury or dementia Patients in drug withdrawl Those with terminal illness nearing death 4. What is the morbidity and mortality associated with dementia (I think they mean delirium)? Short term physical danger to both staff and patient Increased likelihood of longer term functional decline and need for institutionalization Prolonged hospitalization, particularly for postoperative patients, and worse-poor recovery After acute delirium resolves, residual neurologic signs or persisting symptoms of dementia may be noted Delirium is a clinical marker indicating much greater risk of dying 5. Why are elderly patients, post-operative patients and individuals suffering from HIV at increased risk? Elderly: more susceptible to experiencing adverse effects of medical problems as well as medications due to -pharmacodynamic factors: decreased neuronal mass -pharmacokinetic factors: differences in amount of drug available at a given dose (decreased lean muscle) -coexistence of other diseases Post-operative patients: use of anticonlinergics, decreased cardiac output, complement activation, embolism, nutritional status, all of these can contribute to increased risk in post-op patients HIV: 1)direct effects of the virus 2)secondary complications such as opportunistic infections and/or CNS or systemic tumors 3)medications -HIV both causes delirium and increases vulnerability to delirium 6. What is the treatment for delirium? Initial focus: diagnosing and treating those conditions that might lead to increased morbidity and mortality History and Physical Exam with ancillary tests to determine cause of delirium EEG can be useful in confirming diagnosis of delirium and distinguishing from other psychiatric conditions Symptomatic Management: keep delirious patient comfortable and keep patient and staff safe. -familiar objects in the room are helpful, use of clocks,calendars to help orientation Closely and frequently asses for signs of clinical deterioration If agitation is not due to substance abuse, use haloperidol -if no response to haloperidol, coadministration of lorazepam can give anxioilytic and sedating effect Once patient is calm, gradually taper the haloperidol over next several days 7. Figure 3-2 pg 56 of book 8. Tables 5-5, 5-6 and 5-7 pg 110 and 111 of book Articles: Delirium Lecture: Dementia Reading: Chapter 6, Dementia Chapter Review 1. Define dementia. Global decline in cognitive functioning in clear consciousness global =impaired memory along with several other cognitive domains 2. What is the prevalence of dementia in the US? 5% of Americans over age 65 have severe dementia prevalence doubles every 5 years through age 80 reaching 50% by age 85 3. Define Mild Cognitive Impairment (MCI). Distinct from dementia; patients presenta with difficultiy coming up wihth their right word, recalling a name, Absentmindedness, mislpalcing things more often and some increased difficulty concentrating Increased risk of progression to Alzheimer s disease 4. Define Amnestic Syndrome and look at table 6-2. Isolated deficit in memory without other cognitive impairment Do not demonstrate a decline in multiple aspects of cognition, as seen in dementia Do not demonstrate change in consciousness, as seen in delirium Always demonstrate anterograde amnesia and may also demonstrate retrograde amnesia Indicates a lesion affecting some element of the medial temporal lobe circuit Most common causes of amnestic difficulties Head trauma (most common) Wernicke-Korsakoff syndrome Stroke (posterior cerebral artery) Subarachnoid hemorrhage (anterior cerebral artery rupture) Anoxic brain injury (anoxia, hypoperfusion, CO poisoning) Herpes Simplex encephalitis Alzheimer s disease Brain tumors or metastasis Temproal lobectomy Transient global amnesia (acute anterograde AND retrograde) ECT Benzodiazepines 5. Define Wernicke-Korsakoff Syndrome. What is the treatment? Caused by thiamine deficiency due to malnutrition or chronic alcoholism Associated with bilateral lesions of the mammillary bodies and dorsomedial thalamus -Acute delirious state accompanied by ataxia and opthalmoplegia (Wernicke) -following delirium, patients are left with chronic amnestic disorder (Korsakoff) Treatment: thiamine supplementation 6. At what age does AD typically begin? AD most commonly begins at some point after age 55, most commonly in the 60 s,70 or 80 s) 7. How do you make the diagnosis? Diagnosis of AD is one of exclusion, made only after other causes of dementia have been excluded DSM IV clinical criteria are already very sensitive and specific in diagnosing AD, additional neuroimaging is of Limited benefit: Structural neuroimaging study may show cortical atrophy in AD though this is not specific Functional neuroimaging might deomnastrate fidning typical of AD even at early stages See hypometabolism in the temporal and prietyal lobes early on in AD See hypometabolism in the frontal lobes later in AD AD can only definitively be diagnosed when a microscopic examination displays characteristic histopathology 8. What is the initial symptom? Most common initial symptom is impaired short term memory Patients might also show impaired visual-spatial performance form early on and mild aphasic difficulties 9. How does the disease usually progress (Table 6-5)? Stage 1 Stage 2 Stage 3 Duration of illness 1-3 years 2-10 years 8-12 years Memory Visuospatial skills Language Other Personality changes Psychiatric symptoms Neurologic exam EEG CT/MRI PET/SPECT indifference, irritability possible delusions normal normal normal bilateral posterior parietaltemporal hypometabolism, hypoperfusion impaired short term poor complex constructions and geographic orientation anomia; poor verbal fluency impaired short and long term poor simple constructions and spatial orientation fluent aphasia acalculia, ideomotor apraxia indifference, irritability possible delusions aberrant motor behavior (pacing wrestlessness) background slowing normal or mild atrophy/ ventricular enlargement biparietal and fronal hypometabolism/hypoperfusion severe impairment severe impairment severe impairment urinary/fecal incontinence severe impairment severe impairment limb rigidity; flexion posture diffuse slowing ventricular dilatation and sulcal enlargement biparietal and frontal hypometabolism/ hypoperfusion 10. What are the two major histological findings in AD? Describe them. Neuritic plaques: extracellular with a cor of B-amyloid surrounded by dystrophic neuritic processes Neurofibrillary tangles: intracellular made up of abnormally phosphorylated microtubules 11. What are the risk factors for developing AD? Age Genetics: 40% of AD cases are familial (chromosomes 1 and 14-presenilin, 21-APP, 19-ApoE4) Head Trauma 12. Distinguish dementia due to AD from Vascular Dementia and Frontotemporal dementia. Vascular Dementia:caused by one or more strokes -in contrast to AD, abrupt onset of cognitive disturbance followed by a stepwise decline accompanying following successive episodes of vascular insult -onset of vascular dementia may occur at any time but after age 75 incidence declines whereas AD increases Frontoetemporal Dementia (Pick s Disease) -in contrast to AD, the initial signs are more hypofrontal changes in personality and cognition (apathy, behavioral disinhibition, prominent language abnormalities) -memory problems and apraxia tend to develop LATER in the course of illness -typical oset is between age 50-60 Articles: Memory Dysfunction Dementia Update Alzheimer's Disease Lecture: Psychotherapy Reading: Chapter 18, Psychotherapy Chapter Review 1. Define psychotherapy. form of treatment in which an individual is suffering from some distress comes to a socially sanctioned healer who in turn attempts to relieve distress by using personal influence to mobilize change in the sufferer 2. Define therapeutic alliance. relationship between the patient and therapist, depends on characteristics of both and the fit of personalities equivalent of therapeutic alliance in group therapy is group cohesion 3. What is the difference between insight-oriented psychotherapy and supportive psychotherapy? 4. Define interpretation, confrontation, clarification and empathic validation. Interpretation: most expressive of these interventions; hinge on the suggestion of the therapist that a conscious behavior might reflect an unconscious motivation. Might involve comment about possible transference feelings or resistances that the pt might be developing -Most important thing is that it weaves events of the pt s life into a coherent story Confrontation: next most expressive intervention; gentle and involves helping pts address areas that they would like to minimize or avoid Clarification: pulling together several comments made by pts to help put into words something they have been trying to understand or convey -differs from confrontation b/c involves material that the pt isn t necessarily minimizing or denying Empathic validation: toward supportive end of the continuum; essential part of expressive psychotherapy therapist conveys that he has appreciation for the pt s subjective experience Articles: Cognitive Therapy for Depression Lecture: Suicide Reading: Chapter 16, Suicide Chapter Review 1. Why is it important to assess for suicidality in the primary care setting? People encountered in a primary care setting are at higher risk for committing suicide when compared to the general population About 80% of those who commit suicide visit their physician within 6 months of the suicide 2. Distinguish suicidal ideation, gesture, and attempt. Suicidal ideation common, occurring at some point or another in a third of the population, reflects a patient who had the thought of killing themselves Suicidal gestures deliberate nonlethal attempts designed more to elicit rescue by friends or family than to cause their own death Suicidal attempt individuals who strongly desire to end their lives at the time of the attempt and succeed or survive (some express relief at having survived) 3. Why can't we predict suicide? Even though risk factors for suicide have been identified, these factors are too numerous and too nonspecific to be useful when applied to an individual patient Suicide occurs so rarely in the general population that even excellent physicians cannot avoid overpredicting suicide in their clinical practice Patients often provide unreliable information, and patients can also run into certain circumstances outside the physicians office that pushes that patient over the edge 4. Discuss the assessment of risk and dangerousness. Dangerousness: A Social Rather Than Clinical Term - Clinicians trained to assess for particular clinical symptoms and to assign clinical diagnoses Some of these diagnoses are associated with a greater risk that the affected individual will engage in particular behaviors - Two aspects of a possibly suicidal patient s behavior o Magnitude of the behavior o Likelihood that the person will engage in the behavior - Whether or not to admit a patient to a hospital for suicide watch is not simply a clinical decision o Decision usually social rather than clinical - Doctors and lawyers think very differently on this issue Risk Assessment Rather Than Prediction - Clinicians are called upon in a variety of legal issues - Clinicians should attempt to restrict the scope of their opinions to the clinical issues and also should avoid making predictions of future dangerousness - Should perform a risk assessment, attempt to determine whether patients appear to be at a greater or lesser risk of engaging in specific behaviors such as suicide or severe violence - Should distinguish the determination of risk (clinical task) from the ultimate societal weighing of whether this level of risk justifies involuntary confinement (legal task) - Once level of risk is assessed, clinician should formulate a treatment plan with the goal of eliminating all risk of suicide or violence - Need to do a risk-benefit analysis for all treatment plans 5. Discuss static and dynamic risk factors in suicide. Static risk factors risk factors that are not subject to change with clinical intervention Ex:age, race, sex, presence of psychiatric diagnosis, history of previous suicide attempt, comorbidity Dynamic risk factors risk factors that are potentially amenable to clinical intervention Ex:clinical variables, situational variables(limited social support, unemployment, access to gun) - Links: NIH suicide prevention information
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