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Transcript of Ten Leading Causes of Disability in the World Note: DALYs=disability-adjusted life-years. Ten...
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Ten Leading Causes Ten Leading Causes of of Disability in the Disability in the WorldWorld
Note: DALYs=disability-adjusted life-years.Note: DALYs=disability-adjusted life-years.
Type of Disability Cost (in DALYs)
Cumulative %
of Cost
Unipolar major depression 42,972 10.3
Tuberculosis 19,673 14.9
Road traffic accidents 19,625 19.6
Alcohol use 14,848 23.2
Self-inflicted injuries 14,645 26.7
Manic-depressive (bipolar) illness 13,189 29.8
War 13,134 32.9
Violence 12,955 36.0
Schizophrenia 12,542 39.0
Iron deficiency anemia 12,511 42.0
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Two Major Two Major TraditionsTraditions
in Psychiatryin Psychiatry
Biomedical
Psychodynamic
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Purposes of Purposes of DiagnosisDiagnosis
in Psychiatryin PsychiatrySimplify our thinkingFacilitate communicationPredict outcomeDecide on treatmentAid search for etiology
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Overview Overview DSMDSM
Childhood Disorders
Delirium, Dementia
Substance Induced Disorders
Schizophrenia and Other Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Personality Disorders
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Overview Overview DSMDSM
Factitious Disorders
Dissociative Disorders
Sexual and Gender Identity Disorders
Eating Disorders Sleep Disorders Impulse-Control
Disorders Adjustment
Disorders
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MENTAL STATUS MENTAL STATUS EXAMEXAM
APPEARANCE provides many clues to patient’s mental state. Observe carefully. Look at type and condition of clothing, hygiene, apparent health, any mannerisms, unusual actions, signs of intoxication or withdrawal, signs of hallucinating.
PSYCHOMOTOR ACTIVITY: may be agitated, normal, slowed and provides clues to overall mental state.
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MENTAL STATUS MENTAL STATUS EXAMEXAM
ATTITUDE: How the patient relates to the examiner provides important clues. Attitude may be summarized in one or several words such as guarded, suspicious, hostile, friendly, ingratiating, manipulative, seductive, cooperative, threatening, flattering…reflecting much about the patient’s ability to function and relate.
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MENTAL STATUS MENTAL STATUS EXAM:EXAM:
SPEECH SPEECH
Evaluate tone, rate and volume of speech.
Look for the rapid, pressured speech of mania, the slowed speech of the profoundly depressed person. Other important variations from normal are seen in anxiety and in intoxicated states.
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MENTAL STATUS MENTAL STATUS EXAM:EXAM:MOOD AND AFFECTMOOD AND AFFECT
Mood is the prevailing subjective emotional state, primarily how the patient says he/she feels.
Affect is how the mood is expressed and refers primarily to the observable facial expression.
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MENTAL STATUS MENTAL STATUS EXAM:EXAM:DESCRIPTION OF DESCRIPTION OF MOODMOOD
EUTHYMIC HAPPY SAD EUPHORIC IRRITABLE ELATED ANXIOUS ANGRY
Often, the most clear and colorful means of describing mood is to use the patient’s own words
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MENTAL STATUS MENTAL STATUS EXAM:EXAM:ASSESSING AFFECTASSESSING AFFECT
Look for how appropriate the affect is and whether it corresponds to the topic under discussion. A full range of emotional expression is normal. Note any incongruent between affect and topic at hand. Look for lability of affect.
Blunted or flat affect is static regardless of topic at hand.
In mood disorders the affect is confined to either mania or depression and does not have full range.
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ASSESSMENT OF ASSESSMENT OF SUICIDE SUICIDE
The interviewer must develop an estimate of suicide risk with each patient by determining:
Extent of current suicidality Presence of risk factors for suicide Presence of psychiatric diagnosis
associated with risk for suicide
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SUICIDALITY AT SUICIDALITY AT TIME OF INTERVIEWTIME OF INTERVIEW
Passive wish to die versus wanting to kill self
Extent of specific plan Does the person have the means? How lethal is the plan? Suicide note Arrangements made?
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ASSESS FOR ASSESS FOR SUICIDE RISK SUICIDE RISK
FACTORSFACTORS
History of violence Family history of suicide History of prior attempts Male Single, divorced or separated History of certain types of
trauma
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IS PSYCHIATRIC DISORDER IS PSYCHIATRIC DISORDER PRESENT THAT IS PRESENT THAT IS
ASSOCIATED WITH SUICIDE?ASSOCIATED WITH SUICIDE?
MOOD DISORDER SCHIZOPHRENIA PANIC DISORDER SUBSTANCE ABUSE OR
DEPENDENCE SOME TYPES OF PERSONALITY
DISORDERS
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MENTAL STATUS MENTAL STATUS EXAM:EXAM:
THOUGHT THOUGHT PRODUCTIONPRODUCTION
A patient’s thinking is mostly assessed by observing their verbal communication and judging their level of interest in the world around them.
Poverty of thought is seen in schizophrenia and depression.
Racing thoughts or “flights of ideas” are seen in mania.
Thought blocking is an abrupt cessation of conversation, after which the person is unable to recall the topic.
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MENTAL STATUS MENTAL STATUS EXAM:EXAM:
THOUGHT PROCESSTHOUGHT PROCESS
THE MANNER IN WHICH THOUGHTS ARE ASSOCIATED, THE TRAIN OF THOUGHT
Normal is goal-directed with coherence
Abnormal may manifest in different ways
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DISORDERS OF DISORDERS OF THOUGHT PROCESSTHOUGHT PROCESS
CIRCUMSTANTIALITY TANGENTIALITY LOOSE ASSOCIATIONS VERBIGERATION WORD SALAD NEOLOGISMS CLANG ASSOCIATIONS ECHOLALIA
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DISORDERS OF THOUGHT DISORDERS OF THOUGHT CONTENT: CONTENT:
PREOCCUPATIONPREOCCUPATION
PHOBIA: irrational fear or dread, results in avoidance behaviors and anxiety
OBSESSION: disturbing, intrusive thought
COMPULSION: irresistible urge to perform usually meaningless activity, often is ritualistic
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DISORDER OF DISORDER OF THOUGHT CONTENT: THOUGHT CONTENT:
DELUSIONSDELUSIONS
DELUSION = a fixed, false belief that does not have basis in reality, not a part of religion or culture. The patient holding a delusion cannot be talked out of it, even with evidence to the contrary.
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DELUSIONSDELUSIONS
Mood congruent delusions: themes are consistent with depression, such as centered around sin, nihilism, poverty, decay or consistent with mania, such as delusions about holding special powers
Contrast these with MOOD INCONGRUENT DELUSIONS….
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DELUSIONS THAT ARE DELUSIONS THAT ARE NOT MOOD NOT MOOD
CONGRUENTCONGRUENT
Delusions of reference: outside events refer to the self
Delusions of control: outside forces are controlling oneself in some way
Schneider’s first-rank symptoms of schizophrenia -- may also occur in psychotic mood disorders and delirium
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SCHNEIDERIAN SCHNEIDERIAN FIRST RANK FIRST RANK SYMPTOMSSYMPTOMS
Thought insertion Thought withdrawal Thought broadcasting Passivity feelings Delusional perception Auditory hallucinations
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PERCEPTUAL PERCEPTUAL DISTURBANCEDISTURBANCE
Illusions are misperceptions of existing stimuli
Hallucinations occur in the absence of sensory stimuli
Can involve any of the five senses but the type can provide clues as to diagnosis -- hallucinations are a symptom only
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HALLUCINATIONSHALLUCINATIONS
AUDITORY: seen in psychotic disorders such as schizophrenia, mania, psychotic depression
VISUAL: seen in medical, toxic disorders TACTILE: substance-withdrawal delirium OLEFACTORY AND GUSTATORY: seen as
prodrome of complex partial seizure
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COGNITIVE COGNITIVE FUNCTIONINGFUNCTIONING
Level of consciousness varies from lethargy to various levels of alertness
Orientation -- check for this to person, place, time, situation
Concentration/attention -- test by serial 7’s or serial 3’s
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MENTAL STATUS MENTAL STATUS EXAM:EXAM:
MEMORY ASSESSMENTMEMORY ASSESSMENT SIMPLE MEMORY TESTS CAN ASSESS
RETROGRADE AND ANTEROGRADE MEMORY FUNCTION
Remote memory is for events in the distant past, often the last memory system affected in dementia
Recent memory is for the last few months Immediate recall requires attention more than
memory Short-term memory is tested with remembering
three objects immediately and after 5 minutes
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MENTAL STATUS MENTAL STATUS EXAMEXAM
Make a estimate of the patient’s level of intelligence
Insight -- how aware is the person of their situation
Judgment -- how able is the person to stay out of harm, provide for self, handle finances
History and interview should provide ample opportunity to assess
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CONDUCT OF THE CONDUCT OF THE MENTAL STATUS MENTAL STATUS
EXAMINATIONEXAMINATION
In open-ended, unstructured interviewing, assess appearance, orientation, level of consciousness, behavior, attitude, speech, thought form and content, affect.
Direct, focused questioning and exploration will be required to assess mood, suicidal and homicidal ideation, perceptual disturbance, cognitive functioning.