February 2009

Dear YSM2 Students:
We look forward to your participation in the 5 workshops that are part of your psychiatry module. These sessions are meant to be interactive and to help you apply your knowledge to real-life, clinical scenarios. Questions have been crafted with practical applicability in mind, and whenever getting into finer points, the purpose is always didactic, not the pursuit of esoteric tangents.

It goes without saying that the more that you come prepared for these workshops, the more that you (and your small group) will come away with. To this end, we include with this package copies of materials that are both recent and synthetic. All of these materials are available online through the Cushing Library website: apart from the memoir by Leon Rosenberg, former dean of the medical school, and the developmental disorders summary from UpToDate, the other chapters are from the American Psychiatric Publishing Textbook of Psychiatry, 5th Edition. Full references are provided below.

We are aware that there are different learning styles (and budgets), and so provide you with an additional recommended book as an option (Lange). Should you decide to purchase it, it certainly will come in handy as you move forward in your clinical rotations.

  • APPT V: The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition.
    Edited by Robert E Hales, Stuart C Yudofsky, and Glen O Gabbard.
    Washington, DC: American Psychiatric Publishing, Inc., 2008.
    Available as an e-book form the Cushing Library.
  • Lange: Current Diagnosis & Treatment: Psychiatry, 2d Edition. A Lange Book.
    Edited by Michael H Ebert, Peter T Loosen, Barry Nurcombe, and James F Leckman. New York: McGraw-Hill, 2008.
    Available for purchase (suggested retail price, $52.25)
  • Rosenberg, L. Brainsick: A Physician’s Journey to the Brink. Cerebrum 4(4), Fall 2002.

We look forward to seeing you in the workshop series, and your feedback is always welcome.

Andrés Martin, MD, MPH
Esperanza Díaz, MD

Robert King, MD
WORKSHOP I: DEVELOPMENTAL DISORDERS

Learning Objectives

1.To appreciate common forms of mental retardation (MR), including clinical characteristics, etiology, diagnosis, prevention, and treatment approaches.

2.To understand basic concepts of psychological testing as relevant to the diagnosis of MR, learning disabilities, and related conditions.

3. To be able to clinically differentiate intellectual from social disabilities.

1. As the primary care physician for a community hospital, you see a 3-year old toddler in a well-child visit. During the past four visits colleagues have recommended a ‘wait and see’ approach, and not conveyed much urgency. His parents report the following history:

  • Pregnancy and delivery were unremarkable, but APGAR scores were low (5 and 4), and as a newborn their baby did not cry much and appeared listless at times.
  • Muscle tone was weak, at times ‘like a rag doll’.
  • It was only a few weeks ago that their child made utterances longer than 1 or 2 words: even those were not apparent until the age of ~18 months.
  • The child is not potty trained, and can walk only for short distances, and then usually requiring assistance.
  • They describe their child as their ‘easiest’ among 3.
  • What are you thinking about?
  • Do you concur with the ‘watch and wait’ approach? If so, why? If not, what would your alternative approach be?

2. On gathering further history, reviewing past records and talking to the family you make the findings described in each of the vignettes below. Describe how your diagnostic thinking would change in each of these alternative situations.

  • A. Hypotonia, flat facies, slanted palpebral features, small ears, short stature.
  • Mom was 43 at the time of conception. Is this commonly seen or unusual for this condition? (Note: trick question)
  • What diagnostic test would you order to confirm your suspicion?
  • Would a normal result necessarily rule out your impression?
  • Is this a genetic or an inherited disorder, and do these semantics make a difference?
  • What short- and long-term health outcomes would you be concerned about?
  • B. Growth deficiency, mild microcephaly, hypertelorism, short palpebral features, short and upturned nose, smooth upper lip, smooth filtrum, small jaw,
  • What prenatal risk factors would you be concerned about?
  • In addition to the likely main culprit, what outcomes could related exposures lead to?
  • C. Mild macrocephaly, large ears, poor eye contact, macroorchidism, poor attention and social skills.
  • Can this condition be seen in girls?
  • What laboratory test would you order to confirm the diagnosis?
  • How is the disorder transmitted?

3. You are the health advisor to the president of an impoverished and populous nation. You have a very small budget to allocate and have been charged with making recommendations for cost-effective preventive interventions to reduce the incidence of mental retardation. Name four (hints: food, drink, infections, environmental exposures)

  • ‘Cretinism’ (iodinization of table salt, neonatal testing for hypothyroidism)
  • Prenatal well-care visits, including vitamins, prenatal EToH, cigarette, and drug use.
  • Prenatal exposure to rubella, toxoplasmosis and other illnesses.
  • Pb and other heavy metal exposure

4. You are the pediatrician to an otherwise healthy 12-year-old boy whose parents report increasing school difficulties, notably dropping grades, failure to ‘keep up’ with reading and writing assignments despite clear efforts. Curiously, math is an area of strength, and he is clearly a bright and articulate child.

  • What are you thinking of?
  • After talking to his school principal you jointly refer him for testing with a school-based specialist. What testing would be likely done, and how would you interpret the following findings?:

Test / IQ (WISC) / Adaptive (Vineland) / Performance
(WIAT)
Results / FIQ 100
VIQ 105
PIQ 95 / Composite 100 / Reading 70
Writing 85
Math 95
  • What kind of intervention would you recommend?
  • What would you answer when parents replied that they could not possible pay for such services?
  • If school teachers had not mentioned your patient’s ‘focused and determined approach to all assignments’ would you be thinking differently? Would you be considering another intervention in addition to the one above?

5. You did such an amazing job with the previous case that your reputation now precedes you. A colleague refers you a patient with the diagnosis exemplified in vignette 2c above. By this time, the patient is 18 years old and intermittently quite aggressive and volatile. The family and the school are equally frustrated, worry about his short- and long-term future plans, and realize that more services are likely to be necessary – now and probably indefinitely.

  • How could these prohibitively expensive interventions be funded, and what kind of documentation might you need? What do you make of the patient’s testing results depicted below?

Test / IQ (WISC) / Adaptive (Vineland) / Performance
(WIAT)
Results / FIQ 60
VIQ 65
PIQ 55 / Composite 62 / Reading 60
Writing 65
Math 65
  • What institutional support might you enlist at the local, state, and federal levels?
  • Your battle has been successful and you get a blank check. Name some of the services and interventions that you would recommend instituting.
  • Parents note during several follow up visits that the aggressive outbursts seem to have increased in direct relation to your patient’s sexual maturation. Moreover, they describe that he has been sexually ‘forward’ with female teachers inappropriate at times (e.g. touching his crotch in public). What would you advise?

6. Can you help fill out this table and in so doing connect the dots and make sense of information that you have learned across a variety of classes?

Syndrome / Salient
characteristics / Behavioral Phenotype / Etiology:
chromosome or and /or gene involved / Heuristic value/
disease mechanism exemplified
Down syndrome / Most common type on non-idiopathic mental retardation / Docile, sweet and likeable, but often noncompliant and stubborn / 21 / Amyloid accumulation
Fragile X syndrome / Most common inherited from of MR / Gaze aversion, often misdiagnosed as autism / Xq27.3 / FMR-1 / Trinucleotide repeats, anticipation, expansion
Prader-Willi syndrome / Same location ‘hit’ can result in Angelman syndrome / Neonatal hypotonic and failure to thrive followed by hyperphagia; OCD-like symptoms / 15q11 / Imprinting, parent-of-origin gene
Williams syndrome / ‘Elfin’ facies / Language strengths, musically gifted, sociable / 7q11.23 / Vascular and facial anomalies related to elastin gene in affected region
Velocardiofacial syndrome / Palate, cardiac and facial abnormalities / Odd behaviors; often confused with autism / 22q11 / Very high rate of psychosis later in life
Rett syndrome / Head circumference deceleration, midline hand-wringing movements / Girls lose progressive ability to walk; often confused with autism / Xq28 / MeCP2 / Point mutation; single-gene ‘model’ for autism

7. Video clips and clinical vignette

Robert (age 16), diagnosis: ______, FSIQ: 136 (Gifted)

Robert is the older or two children; his father is a successful engineer and his mother is a secretary. He was born following a term, uncomplicated pregnancy, and his subsequent medical history is unremarkable. Developmental milestones were within normal limits. Robert talked before he walked. He started nursery school at age 2 years and already had unusual interests which were pursued to the exclusion of other activities. Over the years these interests have included stop signs, arrows, storm drains, and windmills, and, then changed to clocks, mathematics, and computers. Robert was a self-taught reader by age 3 and was reading adult-level books by age 4. In nursery school he had poor peer relations, talked incessantly about topics of interest only to himself, failed to listen to other children’s comments, and was often oppositional and impulsive. At the same time he was aware of his social isolation. A preschool psychological assessment recommended special education placement; various programs were tried with limited success. Robert moved to private schooling and finally homebound education. Despite precocious academic achievements he continued to have marked problems in social interaction and in the regulation of his behavior. A clumsy and poorly coordinated child. Robert often seemed markedly odd outside home or school settings. In his preoccupation with clocks he might approach a stranger and proceed to reset the person’s watch without asking permission and often reset public clocks, e.g., at school.

Things to look for in the video clips:

  • How reciprocal is his style of conversation (i.e., is he taking turns, building on what the other person says, providing background for what he is talking about, demarcating changes of topic in what he is telling the other person)?
  • How much does he know about people, their mental states such as intentions and motivations, about social conventions and what should and should be said in public, and about the impact of his own behavior on other people’s reactions to him?
  • How willful are his inappropriate behaviors (i.e., are his troubles due to being a “bad kid” vs. being a “socially disabled” kid)?

WORKSHOP II: EATING DISORDERS

Learning Objectives

  1. To identify the diagnostic criteria and clinical presentation of the major eating disorders (anorexia nervosa and bulimia nervosa).
  2. To understand the acute and chronic medical complications associated with AN and BN, their path physiology, and the optimal setting for their care.
  3. To articulate the key principles of treatment for AN and BN, including medical, psychotherapeutic, and pharmacological.

1. Videotape Interview

2.Clinical Vignette A. Diagnosis: As the physician in charge of the health services clinic for a small college, you are referred an 18-year-old freshman who has struggled in getting adapted to school. Her dean is concerned about the possibility of an eating disorder, as the student is seldom seen in the cafeteria and spends a lot of time in the gym, where she recently passed out after using the treadmill for over two hours. Your initial examination is significant for the following findings:

  • Weight=100lb (45kg) [3d percentile-for-age],or 80% of an ideal body weight (IBW) of 125lb (56kg) [50th percentile-for-age]; height = 64in (162cm)[50th percentile-for-age]; BMI =17 kg/m2 [<3d percentile-for-age]
  • Heart rate=50 bpm
  • Temperature=96ºF
  • Last menstrual period – 4 months ago
  • On interview, she is reticent and says to be here only because her dean gave her ‘an ultimatum’. She denies there being any problems.
  • When you ask about her weight and self-perception, she states that her weight is ‘about right’, but that her thighs are ‘chunky’ and wishes she could ‘thin them out’.
  • By now you have a pretty good sense of her main diagnosis, but are not sure just how concerned you should be:
    How would you decide whether she needs to be hospitalized?
  • You decide to ask a colleague, who seems unfazed, claiming that ‘these disorders are all media hype’. You are uneasy with this advice:
    Just how serious could this be? Could this be a potentially lethal condition, and if so, how?

3. Assessment: You decide to err on the side of safety and admit her for observation. As part of your more detailed examination, you pay particular attention to the following aspects:

  • On physical exam, you note these common findings.
  • Skin:
  • Breasts:
  • Vagina:
  • Extremities:

How do you explain their pathophysiology?

  • On laboratory exam, you are especially interested in her ECG.
    What are you looking for?
  • When she takes her clothes off, you notice just how fragile-appearing she is. This concerns you, and you want some corroboration.
    What test would you like to get, and how important would it be in her long-term management and care?

4. Treatment and Prognosis: Things don’t go well: your patient is reluctant to eat or drink, is found pacing the room and doing sit-ups and abdominal ‘crunches’ even as she denies doing so, and her weight goes down by 250grams after her first day in the hospital. You decide to start treatment aggressively.

  • You will weigh her every day, and guide your treatment accordingly (you hope to go on to weigh her weekly and eventually monthly).
    Are there special precautions or considerations you should have in getting routine weights?
  • Although you will elicit the help of a nutritionist in guiding your patient’s care, you set some overall targets for weight gain.
    What could be a reasonable target, and are there potential risks to ‘overshooting the mark’?
  • Apart from her fluid and calorie regimen, should you consider any medications or supplements?
  • Your patient is refusing to eat, and threatens to leave the hospital. She is at great risk.
    Can you make her stay? Can you force her to eat?
  • Should psychiatric medications be part of her treatment regimen?
    Would your answer differ if she had comorbid OCD or psychosis?
  • Using these interventions, as well as some of those discussed below, your patient recovers to the point of being discharged and resuming school.
    Based on your reading of the literature, what would you say about her long-term prognosis?

5. Clinical Vignette B. Diagnosis and Assessment: A 30-year-old woman presents with fatigue and depression. She is 163cm (64in) tall, weighs 54kg (119) and has a BMI of 20 kg/m2 [35th percentile-for-age]). Her vital signs are unremarkable, but routine laboratory tests reveal a potassium of 2.3 mEq/l (normal range, 3.5-5.2) and a bicarbonate of 36 (normal range, 18-23 mEq/L).

  • You suspect bulimia nervosa and ask the patient about her eating habits. She acknowledges binge-eating several times a week, but denies purging, claiming that her ‘fast metabolism’ explains why she doesn’t gain weight.
    You remain suspicious, especially given the subtle physical findings you note in her:
  • Hair:
  • Face:
  • Mouth:
  • Extremities:
  • Your hunch was right, and she admits to purging behavior.
    How else could she be compensating for her binge-eating and which lab tests might give you some clues?
  • She admits to past use of ipecac to induce emesis.
    Does this raise special concerns?
    What laboratory test(s) would you consider, and what would you look for?
    What is the mechanism involved?

6. Treatment and Prognosis:Your patient seems legitimately motivated to start treatment. She is bright and articulate, and agrees to begin regular care in your clinic. It so happens that you are one among a handful of physicians in this rural clinic, and no mental health provider is available. Lucky for you, you do have the support of a team of psychiatrists and psychologists via telemedicine consultation.

  • You learn about the role of Cognitive-Behavioral Treatment (CBT) in the treatment of bulimia nervosa.
    What are the premises of CBT, and how to they pertain to BN?
  • Your consultants tell you to encourage the patient to write a diary of her daily activities and eating habits.
    What could be useful templates for this diary, on which your CBT intervention could be based?
  • You jointly identify areas of stress and apprehension.
    How could you use such a hierarchy to help your patient get better?
  • Relaxation exercises and guided imagery prove to be helpful to your patient.
    How can you help her continue similar exercises on her own, once she leaves your office?
  • Assuming no comorbid psychiatric conditions, would you recommend using any psychotropic medication?
  • What would you say about her long-term prognosis?

WORKSHOP III: MOOD DISORDERS AND SUICIDE