for billing and insurance be sure to include two GAF scores, the most recent GAF and the highest that the patient has experienced in the past year.

the proper order of a presentation for morning rounds on psych

-ID 1-2 sentences

-reason for presentation, why on psych now?

-Axis dx

-meds + doses, organize the polypharmacy, don't care about prn

-clinical update on case, what's new

don't discharge anyone without a follow up appointment

getting a parallel history is crucial for establishing the history of present illness, but many patients don't want anyone talking to their families. in order to get consent try asking in this way, "who would you like us to contact?", in this way you kind of "assume" talking to family is part of the care, if patient still refuses, well then the trick didn't work

heard on the floor - "for now, she's going to marinate in zyprexa"

heard on the floor - "we once had a fireman try and crawl through the ceiling in an attempt to elope from the ward, patients can be inventive"

many personality defenses arise in psychotherapy, regarding anger vs. apathy - "it is easier to calm the wild than raise the dead"

in psychotherapy don't interrupt - goal is not to get the answers but to see how patient thinks, if you interrupt - sure you'll get the answers but you won't see how they think!

the act of worrying about having a panic attack strongly suggests panic disorder

SSRI first line treatment for panic disorder

buspirone - non benzo anxiolytic, takes time to work but no side f/x!

thinking about using tricyclic antidepressant? don't forget to get an ekg, these drugs can cause conduction blocks

end point of using meds for panic disorder? "1 year of feeling good"

not getting better on an SSRI?

1. increase the dose

2. switch to another class

3. augment - (buspirone, lithium, thyroid, atypical antipsychotic)

clomipramine is the only TCA that can be used for OCD

patient comes in with major depression, you treat with antidepressants, patient gets better with a very quick response - you should start to suspect bipolar disorder

sleep deprivation can trigger manic episode

patient on lithium sudden develops polyuria? check levels, they may have taken NSAIDS decrease renal clearance of lithium

"even if you don't go into psychiatry, you will be treating depression, in fact most provider's that treat depression are not pscyhiatrists. but if you see these 3 things you need to get a pscyh eval, 1. suicide/homicide 2. psychosis 3. mania

transference - displacement of emotions, thoughts, behaviors toward the therapist derived from earlier emotionally significant relationships

e.g. - patient comes in late, therapist asks "what's the deal?" patient says - "stop treating me like a child!"

countertransference (two types)

- true: thoughts feelings behavior directed toward patient from therapist that come from significant emotional relationships in past

- general: the ability of a patient to call out a similar response from all persons he/she interacts with,

how do you tell if its just you who has a problem w/patient? ask around about how others feel

are you a highly sensitive person? do you want to find out?

PTSD patients have different neurobiology -

hippocampus is decreased in size

emotion responsive areas (insula etc) are hyperactive

prefrontal executive dampening is decreased

PTSD - use of morphine good because lessens memory formation

beta blockers were a bust for treating autonomic hyperarousal in PTSD