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FOCUSED LEARNING for the
psychiatry clerkship
Completely UPDATED
FOR THE DSM-5
FIRST AID FOR
THE®
PSYCHIATRY
CLERKSHIP
FOURTH EDITION
MATTHEW S. KAUFMAN, MD
Associate Director
Department of Emergency Medicine
Richmond University Medical Center
New York, New York
New York / Chicago / San Francisco / Athens / Lisbon / London / Madrid / Mexico City
Milan / New Delhi / Singapore / Sydney / Toronto
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Notice
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CONTENTS
Contributing Authors v
Introduction vii
Index 217
iii
CONTRIBUTING AUTHORS
Sean M. Blitzstein, MD Kelley A. Volpe, MD
Director, Psychiatry Clerkship Chief Resident, Department of Psychiatry
Clinical Associate Professor of Psychiatry University of Illinois at Chicago College of Medicine
University of Illinois at Chicago Chicago, Illinois
Chicago, Illinois Eating Disorders
Examination and Diagnosis Sleep-Wake Disorders
Personality Disorders Psychotherapies
Substance-Related and Addictive Disorders Forensic Psychiatry
Geriatric Psychiatry
Somatic Symptom and Factitious Disorders
Sexual Dysfunctions and Paraphilic Disorders Alexander Yuen, MD
Resident, Department of Psychiatry
University of Illinois at Chicago
Amber C. May, MD Chicago, Illinois
Resident, Department of Psychiatry Psychotic Disorders
University of Illinois at Chicago Mood Disorders
Chicago, Illinois Impulse Control Disorders
Anxiety, Obsessive-Compulsive, Trauma and Stressor-Related Disorders Psychopharmacology
Neurocognitive Disorders
Psychiatric Disorders in Children
Dissociative Disorders
v
INTRODUCTION
This clinical study aid was designed in the tradition of the First Aid series of
books. It is formatted in the same way as the other books in this series; how-
ever, a stronger clinical emphasis was placed on its content in relation to psy-
chiatry. You will find that rather than simply preparing you for success on the
clerkship exam, this resource will help guide you in the clinical diagnosis and
treatment of many problems seen by psychiatrists.
Each of the chapters in this book contains the major topics central to the
practice of psychiatry and has been specifically designed for the medical stu-
dent learning level. It contains information that psychiatry clerks are expected
to learn and will ultimately be responsible for on their shelf exams.
The content of the text is organized in the format similar to other texts in the
First Aid series. Topics are listed by bold headings, and the “meat” of the top-
ics provides essential information. The outside margins contain mnemonics,
diagrams, exam and ward tips, summary or warning statements, and other
memory aids. Exam tips are marked by the icon, tips for the wards by the
icon, and clinical scenarios by the icon.
vii
Chapter 1
Respect the Patients 2 How to Prepare for the Clerkship (Shelf ) Exam 4
Respect the Field of Psychiatry 2 Study with Friends 4
Take Responsibility for Your Patients 3 Study in a Bright Room 4
Respect Patients’ Rights 3 Eat Light, Balanced Meals 4
Volunteer 3 Take Practice Exams 4
Be a Team Player 3 Pocket Cards 5
1
2 Chapter 1 HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP
The psychiatry clerkship will most likely be very interesting and exciting.
A key to doing well in this clerkship is finding the balance between drawing
a firm boundary of professionalism with your patients and creating a relation-
ship of trust and comfort.
While anxiety and depression can worsen the prognosis of patients’ other
medical conditions, medical illnesses can cause significant psychological
stress, often uncovering a previously subclinical psychiatric condition. The
stress of extended hospitalizations can strain normal mental and emotional
functioning beyond their adaptive reserve, resulting in transient psychiatric
symptoms.
R E S P E C T T H E PAT I E N T S
R E S P E C T T H E F I E L D O F P S Y C H I AT R Y
TA K E R E S P O N S I B I L I T Y F O R Y O U R PAT I E N T S
Know as much as possible about your patients: their history, psychiatric and
medical problems, test results, treatment plan, and prognosis. Keep your
intern or resident informed of new developments that they might not be
aware of, and ask them for any updates you might not be aware of. Assist the
team in developing a plan; speak to consultants and family members. Never
deliver bad news to patients or family members without the assistance of your
supervising resident or attending.
R E S P E C T PAT I E N T S ’ R I G H T S
1. All patients have the right to have their personal medical information kept
private. This means do not discuss the patient’s information with family
members without that patient’s consent, and do not discuss any patient in
public areas (e.g., hallways, elevators, cafeterias).
2. All patients have the right to refuse treatment. This means they can refuse
treatment by a specific individual (the medical student) or of a specific
type (no electroconvulsive therapy). Patients can even refuse lifesaving
treatment. The only exceptions to this rule are if the patient is deemed
to not have the capacity to make decisions or if the patient is suicidal or
homicidal.
3. All patients should be informed of the right to seek advance directives on
admission. Often, this is done by the admissions staff or by a social worker.
If your patient is chronically ill or has a life-threatening illness, address
the subject of advance directives with the assistance of your resident or
attending.
VOLUNTEER
BE A TEAM PLAYER
Help other medical students with their tasks; teach them information you
have learned. Support your supervising intern or resident whenever possible.
Never steal the spotlight or make a fellow medical student look bad.
K E E P PAT I E N T I N F O R M AT I O N H A N D Y
P R E S E N T PAT I E N T I N F O R M AT I O N I N A N O R G A N I Z E D M A N N E R
patient feels [state the patient’s words], and the mental status and physi-
cal exams are significant for [state major findings]. Plan is [state plan].”
Many patients have extensive histories. The complete history should be pres-
ent in the admission note, but during ward presentations, the entire history
is often too much to absorb. In these cases, it will be very important that you
generate a good summary that is concise but maintains an accurate picture of
the patient.
2–3 weeks before exam: Read this entire review book, taking notes.
10 days before exam: Read the notes you took during the rotation and the
corresponding review book sections.
5 days before exam: Read this entire review book, concentrating on lists and
mnemonics.
2 days before exam: Exercise, eat well, skim the book, and go to bed early.
1 day before exam: Exercise, eat well, review your notes and the mnemonics,
and go to bed on time. Do not have any caffeine after 2 pm.
Group studying can be very helpful. Other people may point out areas that
you have not studied enough and may help you focus more effectively. If you
tend to get distracted by other people in the room, limit this amount to less
than half of your study time.
Find the room in your home or library that has the brightest light. This will
help prevent you from falling asleep. If you don’t have a bright light, obtain a
halogen desk lamp or a light that simulates sunlight.
E AT L I G H T, B A L A N C E D M E A L S
Make sure your meals are balanced, with lean protein, fruits and vegetables,
and fiber. A high-sugar, high-carbohydrate meal will give you an initial burst
of energy for 1–2 hours, but then your blood sugar will quickly drop.
TA K E P R A C T I C E E X A M S
The purpose of practice exams is not just for the content that is contained in
the questions, but the process of sitting for several hours and attempting to
choose the best answer for each and every question.
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 5
POCKET CARDS
The “cards” on the following page contain information that is often helpful in
psychiatry practice. We advise that you make a photocopy of these cards, cut
them out, and carry them in your coat pocket.
Cognition:
Level of consciousness: alert, sleepy, lethargic
Orientation: person, place, date
Attention/concentration: serial 7s, spell “world” backwards
Memory:
Registration: immediate recall of three objects
Short term: recall of objects after 5 minutes
Long term: ask about verifiable personal information
Delirium
Investigations:
Routine: CBC, electrolytes, glucose, renal panel, LFTs, TFTs, UA,
urine toxicology, CXR, O2 sat, HIV
Medium-yield: ABG, ECG (silent MI), ionized Ca2+
If above inconclusive: Head CT/MRI, EEG, LP
Orientation (10):
Registration (3): Ask the patient to repeat three unrelated objects (1 pt.
each on first attempt). If incomplete on first attempt, repeat up to six
times (record # of trials).
Delayed recall (3): Ask patient to recall the three objects previously
named (1 pt. each).
Language (9):
■■ Name two common objects, e.g., watch, pen (1 pt. each).
■■ Repeat the following sentence: “No ifs, ands, or buts” (1 pt.).
■■ Give patient blank paper. “Take it in your right hand, use both hands
to fold it in half, and then put it on the floor” (1 pt. for each part
correctly executed).
■■ Have patient read and follow: “Close your eyes” (1 pt.).
■■ Ask patient to write a sentence. The sentence must contain a
subject and a verb; correct grammar and punctuation are not
necessary (1 pt.)
■■ Ask the patient to copy the design. Each figure must have five sides,
and two of the angles must intersect (1 pt.).
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 7
Distractibility
Irritable mood/insomnia
Grandiosity
Flight of ideas
Agitation/increase in goal-directed activity
Speedy thoughts/speech
Thoughtlessness: seek pleasure without regard to consequences
Drugs of Abuse
(continued)
8 Chapter 1 HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP
First Aid for the Psychiatry Clerkship, 4e; copyright © 2015 McGraw-Hill. All rights reserved.
HOW TO SUCCEED IN THE PSYCHIATRY CLERKSHIP Chapter 1 9
Psychiatric Emergencies
notes
Chapter 2
11
12 Chapter 2 EXAMINATION AND DIAGNOSIS
INTERVIEWING
Allergies:
First contact:
Developmental History:
Diagnosis:
Prior hospitalizations:
Relationships (children/marital status):
Suicide attempts:
Outpatient treatment:
Education:
Med trials:
Work History:
Housing:
Smoking: Income:
Legal History:
must establish a meaningful rapport with the patient in order to get accu-
rate and pertinent information. This requires that questions be asked in a WARDS TIP
quiet, comfortable setting so that the patient is at ease. The patient should
feel that the psychiatrist is interested, nonjudgmental, and compassionate. If you are seeing the patient in the ER,
In psychiatry, the history is the most important factor in formulating a diag- make sure to ask how they got to the
nosis and treatment plan. ER (police, bus, walk-in, family member)
and look to see what time they were
triaged. For all initial evaluations, ask
why the patient is seeking treatment
today as opposed to any other day.
TA K I N G T H E H I S T O R Y
The psychiatric history follows a similar format as the history for other types of
patients. It should include the following: WARDS TIP
■■ Identifying data: The patient’s name, gender, age, race, marital status,
place and type of residence, occupation. When taking a substance history,
■■ Chief complaint (use the patient’s own words). If called as a consultant, remember to ask about caffeine and
list reason for the consult. nicotine use. If a heavy smoker is
■■ Sources of information. hospitalized and does not have access
■■ History of present illness (HPI): to nicotine replacement therapy,
■■ The 4 Ps: The patient’s psychosocial and environmental conditions pre- nicotine withdrawal may cause anxiety
disposing to, precipitating, perpetuating, and protecting against the cur- and agitation.
rent episode.
■■ The patient’s support system (whom the patient lives with, distance and
■■ Past psychiatric history (include as applicable: history of suicide attempts, Psychomotor retardation, which
history of self-harm [e.g., cutting, burning oneself], information about pre- refers to the slowness of voluntary
vious episodes, other psychiatric disorders in remission, medication trials, and involuntary movements, may
past psychiatric hospitalizations, current psychiatrist). also be referred to as hypokinesia or
■■ Substance history (history of intravenous drug use, participation in outpa- bradykinesia. The term akinesia is used
tient or inpatient drug rehab programs). in extreme cases where absence of
■■ Medical history (ask specifically about head trauma, seizures, pregnancy status). movement is observed.
■■ Family psychiatric and medical history (include suicides and treatment
response as patient may respond similarly).
■■ Medications (ask about supplements and over-the-counter medications).
■■ Allergies: Clarify if it was a true allergy or an adverse drug event (e.g., KEY FACT
abdominal pain).
■■ Developmental history: Achieved developmental milestones on time, Automatisms are spontaneous,
friends in school, performance academically. involuntary movements that occur
■■ Social history: Include income source, employment, education, place of during an altered state of consciousness
residence, who they live with, number of children, support system, reli- and can range from purposeful to
gious affiliation and beliefs, legal history, amount of exercise, history of disorganized.
trauma or abuse.
14 Chapter 2 EXAMINATION AND DIAGNOSIS
M E N TA L S TAT U S E X A M I N AT I O N
WARDS TIP
This is analogous to performing a physical exam in other areas of medicine. It
A hallmark of pressured speech is
is the nuts and bolts of the psychiatric exam. It should describe the patient in
that it is usually uninterruptible and
as much detail as possible. The mental status exam assesses the following:
the patient is compelled to continue
speaking. ■■ Appearance
■■ Behavior
■■ Speech
■■ Mood/Affect
KEY FACT ■■ Thought Process
■■ Thought Content
An example of inappropriate affect is a ■■ Perceptual Disturbances
patient’s laughing when being told he ■■ Cognition
has a serious illness. ■■ Insight
■■ Judgment/Impulse Control
The mental status exam tells only about the mental status at that moment; it
can change every hour or every day, etc.
KEY FACT
able to define a particular vocabulary ■■ Bruises in hidden areas: ↑ suspicion for abuse.
it in a sentence reflects a person’s ■■ Eroding of tooth enamel: Eating disorders (from vomiting).
Noch ist der Schleier, der über die erste Entstehung des Lebens
auf unserer Erde gezogen ist, nicht gelüftet. Seit der Mensch
angefangen hat, über seine Umgebung nachzudenken, sind
mythische und mystische Vorstellungen, sind wissenschaftliche
Spekulationen und Theorien entstanden und vergangen und auch
heute haben wir für die Frage, wie die lebende organische Substanz
entstanden sei, keine Antwort zu geben. Wohl aber sind wir durch
die Fortschritte der Wissenschaft der Lösung einer sich daran
schliessenden zweiten Frage nahegetreten, nämlich der, wie die
ersten lebenden Organismen ausgesehen haben mögen.
Die erste Anwendung des Mikroskops im 17. Jahrhundert lehrte
den Menschen in den Gewässern der Erde Wesen von ungeahnter
Kleinheit erkennen, die Begründung der Zellenlehre im Anfange
unseres Jahrhunderts verschaffte denselben ihre richtige Bedeutung
als Elementarorganismen und die ungeahnte Vervollkommnung der
optischen Hilfsmittel in unseren Tagen gestattet uns einen tiefen
Einblick in den einfachen und doch so komplizierten Bau ihres
Körpers und lässt uns an ihnen die Lebensäusserungen der Materie
auf ihrer niedersten Stufe erkennen.
In diesem Reiche der Urorganismen oder Protisten stehen wohl
zu unterst die Schleimtiere, die Wurzelfüsser oder wie ihr Name
lauten mag, kurz diejenigen Organismen, deren Protoplasmaleib,
einer einzigen Zelle an Wert entsprechend, keine feste Gestalt
besitzt, sondern regellos nach allen Richtungen des Raumes
auszufliessen vermag. Ich will die Streitfrage nicht weiter berühren,
ob wirklich noch heute in den Abgründen des Oceans ausgedehnte
Mengen organischen Schleimes leben oder nicht, ob der seinerzeit
auch in der populären Litteratur viel besprochene Bathybius,
beziehungsweise ob ein ihm nahestehender Organismus wirklich
existiert, es mag uns die sichere Thatsache genügen, dass wir viele
und ganz unzweifelhafte Lebewesen kennen, die eben jener
Vorstellung von der niedersten Lebensstufe vollkommen
entsprechen. Im Meere sind die Wurzelfüsser schon lange bekannt,
weil dort auch dem blossen Auge sichtbare, von fester Schale
umgebene Formen leben. Die Reste solcher Schalen haben sich aus
den ältesten Zeiten unserer Erdgeschichte in grossen Massen
erhalten und schon im Altertum sind z. B. die Nummuliten bekannt,
wenn auch nicht erkannt gewesen.
Aber auch das süsse Wasser, mit dessen Bewohnern dieses
Buch sich beschäftigt, beherbergt Wurzelfüsser in grosser Zahl und
mannigfacher Gestaltung. Schon im Jahre 1755 hat der wackere
R ö s e l v o n R o s e n h o f [64] die ersten Amöben aufgefunden und in
seiner „Insektenbelustigung“ beschrieben und abgebildet.
Die Beschreibung ist, obgleich sie sich natürlich nur auf die
äussere Gestalt und Formveränderung bezieht, trefflich und, wie
alles im R ö s e l schen Buch, anmutend und auch für uns
Fortgeschrittenere noch belehrend.
Die Amöbe ist nichts weiter als ein kleiner Protoplasmatropfen,
von keiner festeren Haut umgeben und aller denkbaren
Formveränderung fähig, bald in gleichmässigem schneckenartigen
Kriechen oder, besser gesagt, wie der Regentropfen an der
Fensterscheibe gleitend, bald sich zusammenkugelnd oder hie und
da Fortsätze aussendend und wieder einziehend. Es giebt kaum
etwas Wunderbareres, als die mannigfaltigen Bewegungen dieses
Tröpfchens lebender Materie unter dem Mikroskope zu verfolgen.
Von hohem Interesse ist es, dass man in der jüngsten Zeit dahin
gekommen ist, dieselbe amöboide Bewegung an leblosen Objekten
zu beobachten[65]. Man stellte verschiedenartig gemischte
Schmierseifen- oder Olivenölschäume dar und sah Tropfen
derselben gerade wie Amöben bis sechs Tage lang ununterbrochen
strömen. Ist es also gelungen, künstliche Amöben im Laboratorium
darzustellen? Das natürlich nicht, denn all die komplizierten
Lebenserscheinungen, von welchen wir weiterhin zu sprechen
haben werden, fehlen diesen Schaumtropfen, sie lehren uns aber,
wie die so rätselhaften Bewegungserscheinungen der niedersten
Lebewesen auf bekannte mechanische Vorgänge zurückgeführt
werden können.
Eine grosse Anzahl der Süsswasser-Amöben umgiebt ihren
weichen Körper mit einer schützenden Schale, die zwar nicht so
kompliziert ist, wie bei vielen der Meeres-„Foraminiferen“, aber
zierlich und in ihrer Entstehung interessant genug. Diese
Schalenträger sind es, welchen ich diesen kleinen Aufsatz widmen
möchte. Sie leben vorzugsweise in den stehenden Gewässern, teils
auf dem Grunde, teils an lebenden oder abgestorbenen
Pflanzenteilen hinkriechend. Umstehendes Gruppenbild (Fig. 16 S.
140) zeigt einen Tropfen irgend eines Weihers oder Sumpfes mit drei
Algenfäden, auf welchen verschiedene Vertreter der Wurzelfüsser
sich festgeheftet haben, alles bei starker Vergrösserung. Da sehen
wir rechts unten (Fig. 16, 2) das spitz zulaufende Gehäuse der
Difflugia acuminata, ganz aus Sandkörnern aufgebaut, zwischen
denen auch längliche Diatomeenschalen angeklebt sind, aus der
Mündung treten die Plasmafortsätze aus, mittels deren das Tier sich
fortbewegt. Noch zwei andere Difflugia-Arten zeigt unser Bild: Die
eigentümlich gewundene D. spiralis (Fig. 16, 3) und links oben (Fig.
16, 1) die D. urceolata, deren Gehäuse wie eine zierliche Urne
regelrecht gebaut ist. Ebenfalls eine Schale aus Fremdkörpern,
zugleich versehen mit stachelartigen Fortsätzen, besitzt die
Centropyxis aculeata (Fig. 16, 5). Im Gegensatz zu den genannten
Arten ist bei der Fig. 16, 6 abgebildeten Hyalosphenia papilio das
Gehäuse ein Ausscheidungsprodukt, ein feines Häutchen, so
durchsichtig, dass man den Plasmakörper deutlich darin liegen sieht,
mit feinen Fäden in der Schale aufgehängt. Nun giebt es aber auch
Formen, bei denen die Schale zwar auch vom Tier selbst erzeugt
wird, aber nicht im ganzen, sondern in einzelnen Stücken, die, wie
wir später sehen werden, kunstvoll an einander gefügt sind. Bei der
Arcella vulgaris (Fig. 16, 4), einer der häufigsten Arten in unseren
Gewässern, ist die linsenförmige Schale aus winzigen Prismen
zusammengesetzt, so dass dieselbe bei nicht ganz starker
Vergrösserung fein punktiert erscheint. Ebenso aus ganz kleinen
Bestandteilen besteht das Gehäuse der zierlichen Cyphoderia
ampulla (Fig. 16, 8), während bei Quadrula symmetrica (Fig. 16, 7)
und Euglypha alveolata (Fig. 16, 9) die einzelnen
Schalenbestandteile leichter zu erkennen sind; bei der erstern sind
es quadratische Plättchen, bei der andern annähernd kreisrunde
Scheiben, welche die zarte Hülle zusammensetzen. Ich könnte noch
eine grosse Reihe von Formen aufführen, die den auf der Tafel
dargestellten mehr oder weniger ähnlich sind und die, so weit unsere
Kenntnisse diesen Schluss erlauben, über die ganze Erde verbreitet
sind. Dieselben Arten nämlich, die wir in Europa kennen, sind
zumteil schon in Nord- und Südamerika, Asien, Afrika, Australien
und in den arktischen Ländern gefunden worden; auch vertikal
scheint für ihre Verbreitung kaum eine Grenze zu ziehen, denn in der
Schweiz fanden sie sich noch in 8000′, in Nordamerika sogar in
10000′ Höhe unverändert vor[66]. Es ist mir aber hier nicht um eine
Aufzählung aller bisher entdeckten Formen zu thun, ich möchte mich
begnügen eine einzige zu beschreiben, diese soll aber in ihren
feinsten Einzelheiten untersucht und in allen ihren Lebensvorgängen
verfolgt werden. Dass eine derartige Spezialisierung ihren hohen
Wert besitzt, hoffe ich dann am Schlusse nachweisen zu können.