Gero Psych Exam 1

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How much time is allotted for Psychiatric evaluation (new patient)?

45-60 minutes

How much time is allotted for medication management (follow-up)?

15-30 minutes

These key elements of the interview consist of personal perspectives, feelings, opinions, along with collateral information from friends/family and previous providers.

Subjective Data

These key elements of the interview consist of a snapshot of the patient's mental status at that time that the provider continues to assess throughout the interview, and also performs a Mental Status Exam.

Objective Data

Comprised of: name, age, gender, martial status, ethnicity, and if the patient is a reliable historian?

Identifying Data

Confidentiality must remain intact except for?

If the patient is under 18 and parents may be asked to leave, or if the patient plans to harm self or others

HPI: When did they start noticing this change? Has this happened before? Last time at baseline function

Timing

HPI: Patient description, what is depression like? Crying, unable to get out of bed, weak…

Quality

HPI: “Rate on a scale of 1-10, 10 being the worst” How's this impacting school, work, relationship?

Quality or Severity

HPI: What was going on? Stressors? Major life changes?

Context/Setting

HPI: Did PCP prescribed antidepressant? What makes better or worse ?

Modifying factor (alleviating or aggravating)

HPI: Maybe only anxious in a social setting Can go right into how neurovegetative areas impacted

Associated Symptoms

MSE: Appears stated age Position Body build Posture Eye contact Dress Grooming Manner/attitude Attentiveness Distinguishing Features Physical abnormalities Facial expressions

Appearance

MSE: Retardation Agitation-unable to sit still, wringing hands… Abnormal movements- tics, tremor, lip smacking Gait-shuffle, limping, stumbling Catatonia-stupor, excitement

Motor

MSE: Rate- slow, long pauses, rapid, pressured Rhythm-stuttering, monotonous Volume- loud, soft, whisper Amount- mute, hyper talkative Articulation-clear, mumbled, slurred

Speech

MSE: Patients self-reported mood- angry, empty etc.

Mood

MSE: External, How the patient appears to feel Appropriateness -does the person look the way they say they feels? Intensity- is their too much, -heightened or dramatic, or blunted or flat

Affect

Reduced Affect

Constricted

Further Reduced Affect

Blunted

Nothing elicits a reaction, no signs of expression voice is monotonus, no use of hands or body movements

Flat

Conversation drifts, provides unnecessary details

Circumstantial

Minor relation to topic, does not answer the question

Tangential

A sudden stop in the middle of a sentence, may/may not continue idea (seen in schizophrenia)

Thought blocking

Jumping from one topic to another with no apparent connection between the topics

Loose associations

A breakdown in both the logical connection between ideas and the overall sense of goal-directedness. Other unable to follow conversation

Derailment

Incoherent or incomprehensible connections of thoughts

Word Salad

Use of words associated by the sound rather than by their meaning (rhyming)

Clang associations

Inventing words or phrases

Neologism

Repeatedly come back to same topic, even when provider is trying to move on

Perseveration

False beliefs that something unrelated pertains to them. Radio speaking to them

Ideas of reference

Bizarre, erotomanic, persecution, reference, somatic, grandiose, thought broadcasting, thought insertion

Delusions false fixed beliefs

Hearing a name being called when the wind is blowing differs from having a conversation with someone not really there

Illusions

Disconnected from self, separate from feelings or body. Like watching self outside self

Depersonalization

Disconnected from the environment, world around you. Unfamiliar with surroundings, living in a dream, disconnected from people around you

Derealization

In a Cognitive Assessment, how do you assess for Attention/Concentration?

Spell world backwards; reverse digital span, count backwards from 100 by 7’s

In a Cognitive Assessment, how do you assess Fund of Knowledge?

Name three large states or current world events, level of highest education

In a Cognitive Assessment, how do you assess Abstract Reasoning?

How are apples and oranges are alike, ask proverb

-Repeat “No if, and, and buts” -Identify two objects- point at two objects (pen, watch) -3 stage command- “place R hand index finger on nose, then L ear”

Cognitive Assessment (Language)

-Close eyes -Capacity to read and write: (say & write any sentence) -Copy design (intersecting pentagons/three dimensional)

Cognitive Assessment (Executive Function)

A pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. Manifests in two areas: -Cognition (ways of perceiving and interpreting self, others, and events) -Affectivity (range, intensity, lability, and emotional response) -Interpersonal functioning -Impulse control -The pattern is inflexible and pervasive across a broad range of personal and social situations -The pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning -The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood -The enduring pattern is not better explained as a manifestation or consequence of another mental disorder -The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma)

Personality Disorders

What persoanlity Cluster(s) can decline with age?

Cluster B

What personality Cluster(s) can increase with age?

Clusters A and C

Personality Disorders with odd, eccentric features

Cluster A

Personality Disorders with dramatic, impulsive, erratic features

Cluster B

Personality Disorders with anxious and fearful behavior

Cluster C

Personality Disorder symptoms (total of 7): -Spousal infidelity suspected, questions friend’s loyalty -Unforgiving (bears grudges) -Suspicious of others -Perceives attacks on their character -Views everyone as either an Enemy or a friend -Confiding in others feared (fears info will be used against them) -Threats perceived from benign events or remarks

Paranoid Personality Disorder (need 4 of 7 symptoms)

Personality Disorder (4 of 7 symptoms): -Detached (or flattened) affect ( emotionless, cold) -Indifferent to criticism or praise of others -Sexual experiences of little interest -Tasks (activities) performed solitarily -Absence of close friends (other than relatives) -Neither desires nor enjoys close relations (including family) -Takes pleasure in few activities

Schizoid Personality Disorder

Personality Disorder (5 of first 9 + "rule out"): Magical thinking or odd beliefs Experiences unusual perceptions (bodily illusions) Paranoid ideation Eccentric behavior or appearance Constricted (or inappropriate) affect Unusual (odd) thinking and speech (circumstantial, metaphorical) Lacks close friends Ideas of reference Anxiety in social situations (paranoid fears) Rule out psychotic disorder and autistic disorder

Schizotypal Personality Disorder

Personality Disorder (3 of 7): Conformity to law lacking Obligations ignored Reckless disregard for safety of self or others Remorse lacking Underhanded (deceitful, lies, cons others) Planning insufficient (impulsive) Temper (irritability, aggressive) -Can not be diagnosed until age 18 yo, evidence of conduct disorder before 15yo

Antisocial Personality Disorder

Personality Disorder (5 of 9): Special (believes he is special and unique) Preoccupied with fantasies (e.g., of unlimited success, power) Envious Entitlement Excessive admiration required Conceited (exaggerates importance) Interpersonal exploitation (takes advantage of others) Arrogant Lacks empathy

Narcissistic Personality Disorder

Personality Disorder (5 of 8): Provocative (or sexually seductive) behavior Relationships (thinks more intimate than they are) Attention seeking (uncomfortable when not the center of attention) Influenced easily Style of speech (impressionistic, lacks detail) Emotions (rapidly shifting and shallow) Made up (physical appearance used to draw attention to self) Emotions exaggerated (theatrical)

Histornic Personality Disorder

Personality Disorder (5 of 9): Identity disturbance Disordered, unstable affect owing to a marked reactivity of mood Emptiness Suicidal behavior (recurrent), gestures, or threats, or self-mutilating behavior Paranoid ideation or severe dissociative symptoms Abandonment- efforts to avoid real or imagined, rejection sensitivity Impulsivity (in two areas that is potentially self-damaging; sex, spending) Rage or difficulty controlling anger- inappropriate with others Relationships- unstable, intense

Borderline Personality Disorder

Personality Disorder (4 of 7): Certainty of being liked required before willing to risk involvement Rejection possibility preoccupies his thoughts Intimate relationships avoided New relationships avoided Gets around occupational activities that involve interpersonal contact Embarrassment potential prevents new activities Self viewed as unappealing, inept, inferior

Avoidant Personality Disorder

Personality Disorder (5 of 8): Reassurance required for decisions Expressing disagreement difficult (because of fear of loss of support or approval) Life responsibilities assumed by others Initiating projects difficult (lacks self confidence) Alone (feels helpless and a sense of discomfort when alone) Nurturance (goes to excessive lengths to obtain nurturance and support) Companionship sought urgently when close relationship ends Exaggerated fears of being left to care for self

Dependant Personality Disorder

Personality Disorder (4 of 8): Loses point of activity- preoccupied with order, rules, list Ability to complete tasks compromised by perfectionism Worthless objects (unable to discard) Friendships and leisure activities excluded, devoted to preoccupation with work Inflexible, scrupulous, overconscientious (morals, ethics, values) Reluctant to delegate Miserly spending style Stubborn (rigid)

Obsessive-Compulsive Personality Disorder

PD Treatment for mood instability , depression, paranoia, fantasies, suspicion

Antipsychotics

PD Treatment for atypical depression, dysphoria (first line)

Antidepressants

PD Treatment for impulsivity, anger (OD danger)

TCAs

PD Treatment for emotional instability, depression, dysphoria

Mood Stabilizers

PD Treatment for anxiety

SSRIs, SNRI, and MAOI

When would you use a mood stabilizer over an antidepressant in treatment of PD?

Anger outbursts

When would you use an antidepressant over a mood stabilizer in PD?

Impulsive

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