PSYCHIATRIE

1
PSYCHIATRIE

• Dr Marc Gleis
• Dr Maryse Flammang

2
Généralités

• Trouble mental est une maladie accompagnée de
  manifestations psychologiques ou comportementales
  liées à des altérations dorigines diverses
• ( biologique, sociale, psychologique, génétique,
  physique, chimique)

3
suite

• Chaque maladie présente des signes et des
  symptômes caractéristiques.

4
Classification

• publiée par lAssociation américaine de
  psychiatrie
• 4e édition révisée du Manuel Diagnostique et
  Statistique ( DSM IV TR )

5

• Le système diagnostique proposé se veut fiable
  (identité des résultats par des observations
  différentes)
• et valide (permettant de vérifier des hypothèses)
• Approche descriptive

6
DSM IV TR moyen mnémotechnique

• Depressed Patients Sound Anxious , So Claim
  Psychiatrists
• DEPRESSION and other mood disorders
• PSYCHOTIC Disorders
• SUBSTANCE abuse disorders
• ANXIETY disorders
• SOMATIFORM disorders
• COGNITIVE disorders
• PERSONALITY disorders

7
EXAMEN PSYCHIATRIQUE

• INTERROGATOIRE
• COMMUNICATION ENTRE MEDECIN ET PATIENT

8
But de linterrogatoire

• Historique
• Etablir une relation et alliance thérapeutique
• Confiance mutuelle et fiabilité
• Comprendre le fonctionnement
• Faire le diagnostic
• Plan thérapeutique

9
Technique de linterrogatoire

• Lieu
• Présentation
• But ?
• Etablir une relation
• Observer le non-verbal
• Eviter la prise de notes excessives
• Ne pas discuter
• Adapter le language à lintelligence du patient
• Durée
• Questions ouvertes ou structurées et fermées

10
Questions ouvertes /fermées

• Authenticité (formulations spontannées/guide le
  patient)
• Véracité (réponse non reproductible/peut induire
  la réponse)
• Précision (intention contenue dans la question
  est vague/claire)
• Efficacité en terme de durée
• Couverture du champ diagnostic
• Acceptation par le patient

11
Histoire psychiatrique

• Identification
• Motif de la consultation
• HDM
• Antécédents
• Histoire personnelle
• Naissance / Premiere enfance
• Adolescence / Adulte
• Histoire familiale
• Histoire sexuelle
• Médicaments

12
Etat mental

• Observation transversale de la vie psychologique
  du patient
• ( somme des observations et des impression du
  psychiatre à ce moment donné )

13
MENTAL STATUS EXAMINATION

• All Borderline Subjects Are Tough, Troubled
  Characters
• APPEARANCE
• BEHAVIOR
• SPEECH
• AFFECT
• THOUGHT process
• THOUGHT content
• COGNITIVE EXAMINATION

14
cognition

• Level of awareness or wakefullness
• Attention and concentration
• Memory
• Jugement
• Insight

15

• MSE
• MMSE (specific screen for dementia)
• High sensitivity, low specificity
• MINI-COG

16
MINI-COG

• Combination of 2 tests
• Three-item recall (MMSE)
• Clock-drawing task (CDT)

17
MOOD DISORDERS

• Major depression
• Dysthymia
• Manic episode

18

• Cas cliniques
• Mme AN
• Mme JO
• M JA

19
MOOD DISORDERS

• Major depression
• SIGECAPS
• 4/8 with depressed mood or anhedonia gt2 weeks

• Sleep disorders
• Interest deficit(anhedonia)
• Guilt
• Energy deficit
• Concentration deficit
• Appetite disorder
• Psychomotor retardation or agitation
• Suicidality

20
Suite 1

• Dysthimia
• ACHEWS
• 2/6 with depressed mood gt 2 years

• Appetite disorder
• Concentration deficit
• Hopelessness
• Energy deficit
• Worthlessness
• Sleep disorder

21
Suite 2

• Manic Episode
• DIGFAST
• 3/7 with elevated mood or
• 4/7 with irritable mood gt1 week

• Distractibility
• Indiscretion
• Grandiosity
• Flight of ideas
• Activity increase
• Sleep deficit
• Talkativeness

22
PSYCHOTIC DISORDERS

• Schizophrenia
• Delusions Herald Schizophrenics Bad News
• 2/5 1 month with 5 months prodromal or residual
  symptoms

• Delusions
• Hallucinations
• Speech disorganisation
• Behavior disorganisation
• Negative symptoms

23
General screening questions

• Have you had any experiences like dreaming when
  youre awake?
• Have you had any strange or odd experience lately
  that you cant explain?
• Do you ever hear or see things that other people
  cant hear or see?

24
suite

• Have people been harassing you or trying to harm
  you?
• Does it seem that strangers look at you a lot or
  make comments about you?

25
Assessing drinkingSuspicious signs and symptoms

• Elevated or uncontrolled BP
• Excess weight
• Recurent injuries / accidents
• Non specific GI complaints
• Back pain
• Poor sleep
• Tired all the time

26
suite

• Amount
• Time of day
• Socially or alone
• Dayly or in binges
• Blackouts
• Situations associated with heavy drinking

27
Abus/Dépendance

• Abus
• Qui entraine des conséquences
• Problèmes
• Sociaux
• Judiciaires
• Interpersonnels
• Professionnels

• Dépendance
• Qui entraine des problèmes pour lindividu

28
SUBSTANCE (ABUSE) dependance

• Tempted with cognac
• CAGE 2/4

• Tolerance
• Withdrawel syndrome
• Loss of Ccontrol

29
Loss of control / Tolerance / Withdrawel syndrome

• Alcohol ingested in larger amounts than the
  patient intended
• Patient has tried unsuccessessfully to cut down
• Great deal of time spent in activities related to
  obtain or recover from the effects of alcohol
• Social, occupational, or recreational activities
  are given up or reduced
• A use is continued despite patients knowledge
  of physical and psychological problems caused by
  its use
• 3/7

30
suite

• CAGE 2/4
• Have you felt you should Cut back on your
  drinking?
• Has anybody Annoyed you with comments on your
  drinking?
• Have you felt Guilty about your drinking?
• Have you ever had an Eye-opener in the morning to
  get rid of a hangover?

31
Health risks associated with levels of alcool
consumption

• Men
• Low lt21 u/wk
• Intermediate 21-50
• High gt50

• Women
• lt14
• 15-35
• gt35
• 1 bottle of 12 vine 9u

32
ANXIETY DISORDERS

• Panic Attac
• Heart cluster
• Breathlessness cluster
• Fear cluster
• 4/13

33
Suite 1

• Palpitations
• Chest pain
• Nausea
• Shortness of breath
• Chocking sensation
• Dizziness
• Paresthesias
• Chills or hot flashes

34
Suite 2

• Fear of dying
• Fear of going crazy
• Shaking
• Sweating
• Derealization or depersonalization

35

• Agoraphobia
• Fear of being in places where escape might be
  difficult
• Efforts to avoid such places

36

• Obsessive-Compulsive Disorder OCD
• Washing and Staightening Make Clean Houses
• Washing
• Straightening
• Mental rituals
• Checking
• Hoarding

37

• Posttraumatic Stress Disorder PTSD
• The patient Remembers Atrocious Nuclear Attack
• Reexperiencing the trauma via intrusive memories
• Avoidance of stimuli associated with trauma and
• Numbing of general responsivenes ( avoiding
  things associated with the trauma, amnesia for
  the trauma,restricted affect and activities,
  detachment and forshortened future) (1)
• Increased Arousal (insomnia, irritability,
  hypervigilance, startle response and pour
  concentration) (2)

38

• Generelised Anxiety Disorder GAD
• Macbeth Frets Constantly Regarding Illicit Sins
• Muscle tension
• Fatigue
• Concentration problems
• Restlessness, feeling on edge
• Irritability
• Sleep problems
• (3/6)

39

• We cannot tear out a single page from our life,
  but we can throw the whole book into the fire
  (George Sand)

40
Suicidal ideation

• SAD PERSONS risk factors for suicide
• Sex
• Age
• Depression
• Previous attempt
• Ethanol abuse
• Rational thinking loss
• Social supports lacking
• Organised plan
• No spouse
• Sickness

41
suite suicide

• CASE
• Chronological Assessment of Suicidal Events
• Start by assessing the presenting SI or event
• Elicit information about any SI over the past 2
  months
• Explore past SI
• Return to the present and explore any immediate
  suicidality

42
SOMATIFORM DISORDERS

• Somatization Disorders
• Recipe 4 pain convert 2 stomachs to 1 sex
• ( 8/8 lt 30 years )

43

• Number of medically unexplained symptoms with
  onset before age 30 years
• 4 pain symptoms
• 1 conversion symptom (pseudoneurologic)
• 2 gastrointestinal symptoms
• 1 sexual symptom

44
Suite 1

• Bulimia Nervosa
• Bulimics OverConsume Pastries (4)
• Bingeing
• Out-of-control feeling while eating
• Concern with body shape
• Purging

45
Suite 2

• Anorexia Nervosa
• Weight Fear Bothers Anorexics (4)
• Weight below 85 of ibw
• Fear of fat
• Body image distortion
• Amenorrhea

46
COGNITIVE DISORDERS

• Dementia
• Memory BREW
• Memory impairment
• Behavior disorganisation (apraxia)
• Recognition impairment (agnosia)
• Executive functioning impairment
• Word problems (aphasia)
• Memory impairment 1/4 Brew

47
delirium

• Diminution de la capacité à maintenir lattention
  envers les stimulations externes et à
  sintéresser de façon appropriée à de nouvelles
  stimulations externes

48
Suite 1

• Delirium
• Medical FRAT (5)
• Medical cause of cognitive impairment
• Fluctuating course
• Recent onset
• Attention impairment
• Thinking (cognitive) disturbance

49
Suite 2

• Attention-Deficit Hyperactivity Disorder ADHD
• MOAT
• Mouvement excess (hyperactivity)
• Organisation problems (difficulty finishing
  tasks)
• Attention problems
• Talking impulsively

50
PERSONALITY DISORDERS
51
Assessing Personality Disorders

• Ground-up technique to assess for PDs from the
  social history
• Symptom-window technique to assess for PDs that
  might be linked to special symptoms
• Memorize self-statements, probing questions, and
  mnemonics for each disorder

52
Borderline PD

• I DESPAIRR
• Identity disturbance
• Disordered, unstable affect owing to a marked
  reactivity of mood
• Chronic feelings of Emptiness
• Recurent Suicidal behavior
• Transient stress-related Paranoid ideation
• Frantic efforts to avoid real or imagined
  Abondonment

53
Suite I DESPAIRR

• Impulsivity in at least two areas that is
  potentially self-damaging
• Inappropriate, intense Rage or difficulty
  controling anger
• A pattern of unstable and intense interpersonal
  Relationships characterized by alternating
  extremes of idealization and devaluation

54
Paranoid PD

• SUSPECT (4/7)
• Spousal infidelity suspected
• Unforgiving
• Suspicious of others
• Percieves attacks
• Views everyone as either an Enemy or a friend
• Confiding in others feared
• Threats percieved in benign events

55
Schizoid PD

• DISTANT(4/7)
• Detached affect
• Indifferent to criticism or praise
• Sexual experiences of little interest
• Tasks performed solitarily
• Absence of close friends
• Neither desires nor enjoys close relations
• Takes pleasure in few activities

56
Schizotypal PD

• ME PECULIAR (5/10)
• Magical thinking or odd beliefs
• Experiences unusual perceptions
• Paranoid ideation
• Eccentric behavior or appearance
• Constricted affect

57
Suite ME PECULIAR

• Unusual thinking and speech
• Lacks close friends
• Ideas of reference
• Anviety in social situations
• Rule out psychotic disorder and pervasive
  developmental disorder

58
Antisocial PD

• CORRUPT (3/7)
• 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

59
Histrionic PD

• PRAISE ME
• Provocative (or sexally seductive) behavior
• Relationships (considered more intimate than they
  are)
• Attention (unconfortable 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)

60
Narcissistic PD

• SPEEECIAL
• Special (beleaves he is special and unique)
• Preoccupied with fantasies (unlimited success,
  power)
• Envious
• Entitlement
• Excessive admiration required
• Conceited
• Interpersonnal exploitation
• Arrogant
• Lacks empathy

61
Avoidant PD

• CRINGES
• Certainty of being liked required before willing
  to risk involvement
• Rejection possibility preoccupies his thoughts
• Intimate relationship avoided
• New relationship avoided
• Gets around occupational activities that involve
  interpersonal contact
• Embarrassment potential prevents new activities
• Self viewed as unappealing, inept, inferior

62
Dependent PD

• RELIANCE
• Reassurance required for decisions
• Expressing disagreement difficult (because of
  fear of loss of support or approuval)
• Life responsabilities assumed by others
• Initiating projects difficult
• 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

63
Obsessive-Compulsive PD

• LAW FIRMS
• Loses point of activity
• Ability to complete tasks compromised by
  perfectionism
• Worthless objects
• Friendships (and leasure activities) excluded
  (owing to preoccupation with work)
• Inflexible, scrupulous, ovrtconscientious
• Reluctant to delegate
• Miserly
• Stubborn

64
What do you do if you dont like your
patient?.....
65

• Its often helpful to see them as expressions of
  psychopathology and awaken your compassion for
  the patient on that basis.

66
Références

• DSM IV Cas cliniques
• (Allen Frances / Ruth Ross)
• Manuel de Psychiatrie Clinique
• (Kaplan / Sadock)
• The Psychiatric Interview
• Danie J. Carlat
• Oxford Handbook of General Medecine