Please summarize the lecture below
Leah Rigney
00:00:14
Hello, Hello! And welcome to Seminar. 5 guys. Can you hear and see me? I can see the chat box. So you guys just put it in the chat box if you can see and hear me.
Yeah, alright.
let me get this together.
No.
give me a second. You guys know I’m gonna fumble every time with this second.
Okay?
Alright guys, chat box back.
Okay?
Now, I’m situated.
No, yeah. We don’t want to spot the corner of my screen up there.
Alright, guys, so welcome. Welcome. Seminar 5. You guys are halfway through, and I would imagine that you are feeling it. Now you know the work, the clinical, the worry, all of that fun. Jazz. So with that, said,
you guys are doing a great job.
you know. Y’all are keeping up
y’all are about what most of my classes, you know, kind of where you guys are. You know you’re where you need to be with clinical encounters. Most of you.
So tonight is clearly seminar. 5 Wednesday, may fifteenth reminder. Next Wednesday we will not have a live seminar. I’m gonna say that again, because someone will text me and be like, Where are you? Where are you? And I’m gonna be like? No, I can’t do it. But there’s no live seminar. I will post a recording either the evening of May 22,
which is next
yeah, which is next Wednesday or before noon on on the following day.
so do not show up. Live. Do not adjust your schedules. Go, go! Do what you want this time next week.
let’s see. Yeah, that’s objectives. But I was going to do the course reminders. So
you know. Just make sure. You know, we’re
it seems like we blinked. And now we’re day one of week 5. That’s what today is. Day, one of week 5. So just make sure that you are keeping up with your clinical hours that you are keeping up with your encounters and logging them. Have not been in this. I try to go in once a week and approve and look at them, and you know I know to a certain extent you are on your presenters schedule.
but at the same time I promise you it’s not fun to have to go and log them all like the last week. So just, you know, set a goal and try to stick to it, and you won’t feel so rushed that last week of of term
midterm evaluations. Let’s see, I sent out
a calendar email last week
and
half of your preceptors scheduled and half of you have a midterm grade. So if you see a midterm grade.
you, that means I spoke with your preceptor, and I thought you all you guys all did very well. There were a few preceptors that that probably graded a little harder, and you know but I but they said, and
you know, if it’s not what you wanted. No fears.
you know.
I doubt any of you when you look at the other work that you turn in for me. You know. You probably notice I’m a little more flexible. I do try to give you a little cushion, because at the end of the day I don’t control the midterm, and I don’t control the final of the clinical evaluation. But I do try to give you a little cushion where I can with my assignments. So you know again, if the grade is not what you want, none of you are failing, first of all for midterm.
and second of all, you know, if it’s not where you won’t, don’t get discouraged. It doesn’t mean you’re a bad student. I think it just means like some preceptors just may grade a little
harder, and they’re usually going to be the psychiatrist, the psychiatrist, or the long time practicing psychic bees. Those are the ones I found that grade harder.
so yeah, let’s go back to objectives. That slide got out of order a little bit. Now I will tell you if any of you end up having me. You know I do teach M. In 6, 4. I don’t know if I’m teach it next next term or not, so some of this
may come about. So I I in M in 6, 6, 4. It’s not therapy. It’s like straight up. You know what you’re gonna be doing as a psych. And PI talk a lot about medicines which I love talking about medicines. I love talking about neuroscience.
And you know this class, I? I have to pull myself back from the medicine because I have to keep in mind that it’s more therapy, more therapy, but I can’t help it. I slip a little medicine in every now and then, just because I think it’s helpful for the real world. And let’s just be honest. A lot of you really want to know that cause a lot of you are really concerned about prescribing medicine? So
But nonetheless, we are going to talk about anxiety, disorders, panic disorders, really panic, disorder, generalized anxiety, disorder, a little bit about major depressive disorder, the therapy recommendations for anxiety, disorder, major depressive disorder. You know, arriving at a diagnosis using screening assessment, this, this and that. And I know your book has all the stuff, and
I have that interview and book over there it’s it’s actually from when I was in school. And let me tell you, that thing’s a dry, dry. Read it. There are no pictures in that psychiatric interview book, and the chapters there were on the readings and the seminar schedule. I was like, Oh, my gosh! It’s like watching paint. So
I figured. And this is all science-based and research based. I figured I would just kind of take you through how I arrive at a diagnosis. Some of the things that I do the tips, the tricks, because at the end of the day
you are going to develop your own flow for assessment. You are going to develop. You know how you assess for things, and you know hopefully what I say. You can, you know, have some tools to kind of put in your arsenal. Alright, I’ll quit rambling
neuroscience of anxiety links, memorable psychiatry. All of that. Those are links there if you want to. If you’re interested in that
clinical pearls. So here’s the thing
with anxiety. And this is why probably the majority of this seminar is going to be about anxiety and depression. If I get to adult Adhd, I may. I may not, but you are going to see anxiety. It’s probably going to be one of the top 3
diagnoses in clinical practice, and you know there’s a whole bunch of diagnoses that fall under the umbrella of anxiety. But the the thing is is this is, I do not feel like as a clinician that I have an array of medicine. You know. I know some of you guys are family nurse practitioners, so I’ll just kind of put it into perspective.
Like you guys, you know, there’s so many and antibiotics you could use. There’s so many things for certain things as far as medicines that you could use for certain diagnoses. But in psychiatry I really don’t feel like overall. We have just like a huge ton of medicine to choose from.
and anxiety is one of those disorders it’s really hard to treat, because I don’t feel like there is a lot of medication
that really treats itly.
Okay, so medicine is only going to do so much for anxiety and don’t get me wrong. It helps a whole hell of a lot. Okay, I’m not downing medicine, but I also feel like therapy is going to help a lot of the patients who suffer from anxiety as well, because at the end of the day you could give someone appeal.
and hey, I may feel better with appeal. But if you don’t learn coping mechanisms and ways to kind of calm that anxiety and process.
you know, you’re only going to get so far with medicine. So the thing is, is, anxiety can be.
and pairing to real life, it can. And and when I’m interviewing patients or assessing patients or doing a Psyche, Val, you know there’s a couple of things I listen for with patients.
I listen for the symptoms.
you know. Don’t get ahead of yourself with a diagnosis. I know that, you guys.
you know, like diagnoses, and if you came from more the medical side you are hardwired in in objective data and diagnoses. But when you switch over to psychiatry.
you know a lot of times. You are not, you know, just talking to that patient for the first 30 min to an hour. You are not probably going.
You know, you have to put a diagnosis on that chart to Bill. That visit, I guess, is what I’m trying to say.
But the truth is is
that diagnosis can change with time. And as you come to know that patient, and as things kind of reveal themselves.
But yeah, we do have to stick a code on there to be a billable visit for insurance purposes.
So you know, I listen as they’re tell talking to me, and you know they come in the door.
What are the things that are problematic to their daily functioning? What are the things that are impairing them in their daily life. And I really look at 5 areas. You know, one of the first areas I look at is school or work is the anxiety so bad that it is affecting my functioning at work, my functioning at school. If you’re a child.
is it to a point to where I can’t do the things that I need to do in in work in school. Okay? Because you could have anxiety. But it may not be that impairing. And you may can manage it all natural.
Okay. Number 2.
I look at how the anxiety affects
affects relationships. So the relationships with your kid, your spouse, your partner, your family, and look at how the anxiety or depression and you could do this for any diagnos fill in the blank XYZ. Diagnosis. How does anxiety affect your sleep?
How does it affect your appetite? How does it affect your mood? You know common common thing, for anxiety is easily irritated and agitated over seemingly small things? That’s a very common common symptom of anxiety. I know we think jitters and inner shakes, and not never being to being able to be at peace. But you know.
you know you have someone with true blue anxiety. They can be pretty irritable, and a lot of times they don’t sleep.
you know, and the other thing just to kind of make it clear as mud is, you know. Anxiety can look a lot like Adhd can look a lot like bipolar mania.
So there’s all that, too.
But you know, anxiety disorders can be very impairing in multiple ways. They cause psychological distress and suffering. They can worse and occupational function. They can cause family marital problems
adversely impact morbid morbidity. Even mortality, physical functioning can deteriorate in the presence of anxiety, disorders all ages from very young to very old, and every age in them in between are susceptible to anxiety disorders, and it it can present in all ages, and it can be subtle and easily confused with other conditions, both physical and mental, because there are a lot of medical conditions, and if you get me
for the next clinical class. I’ll go into all of that. The medicals that mimic, but not for this presentation.
But you know.
remember that you know there’s no age that’s immune from having an anxiety disorder. So you know one of the things when you’re seeing patients and they walk in the door, and you have to assess them, and you have to talk to them. You know a lot of times you are going to have a therapist in the clinic that has already done an intake, assuming you’re not a psych. Mp. That is like doing therapy. You know, most of us are going to be doing medication management.
and you know, I always say, what brings you in? Or I might just. I’ll look at the intake from the therapist, cause they can diagnose, and I’ll look and see what they they wrote, what they they thought, what what diagnoses they thought. Now, a lot of times therapists are gonna put an an adjustment disorder on a lot of the charts.
That’s a therapist billing bread and butter, so to speak. But
Anyway, I look for core symptoms as they begin talking I start formulating. My problem list. And I listen for core symptoms.
And you know, when you’re looking at anxiety, you know, if they maybe they mentioned flashbacks or nightmares. I’m gonna maybe kind of go gear more towards Ptsd.
And again, let me just say this, you need to know what the Dsm 5 says about each diagnosis. What is the criteria
for? Ptsd. What is the criteria? What does the Dsm. Say? The criteria for anxiety, the criteria for depression, the criteria for panic, disorder, and all that the criteria for phobia. Because if you don’t know the criteria, you know, knowing what the Dsm. Says is going to kind of guide you
on kind of your questioning and your interview and your assessment. So if they come in and they mentioned flashbacks, nightmares, I might kind of hone in more on Ptsd
questions. If they come in and say, maybe they have obsessions, compulsions, you know, I might kind of gear my questioning towards you know, Ocd symptoms, and I might question them about those
they come in and say, you know, I have uncontrollable worry about several things, several areas. It’s just random, uncontrollable worry, those that’s typically going to be generalized anxiety, disorder.
And then, you know, when they come in and they say I have panic anxiety attacks, or they’re avoiding something, you know. I might hone in on, you know.
Social anxiety or social phobia, or a specific phobia from like. I don’t know an object, or flying or something.
and you know I also might kind of hone in on panic disorders. So you know. Listen to the symptoms.
Train your brain to kind of do a problem. List 1, 2, 3. What are the symptoms? These are the most problematic in their life and start there. Sometimes people come in and they will tell you I am so anxious, and then you’ll go through everything. But their main problem is is they are not sleeping. They’re getting 4 h of sleep or 3 h of sleep, because they’re turning things over and over and over and over in their head, and when they lay down at night they can’t stop their brain, and it’s like they don’t get sleep.
And then, you know, that makes things worse, because, you know if I don’t get sleep. I’m mean I’m very mean. I’m not a nice person, and you know you go with an extended period of time without sleep. It will make anybody psychiatric diagnosis or not mean. So you know. Always it says sleep. And if if they’re not sleeping, I recommend, you know.
helping with that. That’s a good place to start for a lot of people.
That’s just the same. This slide is the same thing as the other one. Okay, let’s let’s move on. So write questions to ask clinical technique to employee.
You know, this is this example is generalized anxiety disorder. So you know, you know. Start with exploratory set of questions.
you know a good
place to look for good questions like if you’re in clinical, and you’re like, Oh, my gosh, I’m nervous. I’m not used to doing this. You won’t need anything once you get years into this, or even a little experience under your belt.
But you know you probably do want to have something on hand. And so you can kind of, you know, in case you freeze up in case you get nervous in case you don’t know which way to move, you know. Maybe have a couple of screener screeners there in front of you. The Gad. 7 is a good one, so you know. I’ll go back. I I have. I have this right here.
I’ll just do a little screen, you know the guide 7. There’s a lot of little questions there you can ask, and I know it says 2 weeks. I don’t know if I like the 2 week thing. But who am I to disagree with research? But one of the things you know that I do is, you know.
I might ask them, you know. And this is purely Leah technique. Okay, this is not my. But I find that patients. This is more as measurable as I can get psychiatry. Okay? So they come in, and they’re telling me all these anxious things. The thing is is what anxiety is to this person or that person, or the person next door may may be different. You know, we’re all different. We don’t experience all the same symptoms.
And so one of the things I like to do with patients, and and this is also to put a baseline measurement on it too, because when they follow up, I ask them the same question. But
I say, you know. Imagine a sheet of paper, you know, and at the top of this paper we have anxiety and everything that I’ve heard over the years patients say about anxiety. I’ve heard patients say, you know, I’m easily agitated, irritated over seemingly small things. I worry, I worry. I worry about this. I worry about random things. I only worry about this. I’m only anxious when I go here. You know there’s social anxiety.
I’m locking myself away from the world. There’s a goraphobia there’s, you know, Ocd is its own thing, but it definitely has some underlying anxiety. You know. Some people say jittery. Some people say on edge. Some people say you know what I can never relax and find peace, and I say, you know just whatever anxiety is to you, if 10 is the worst, and I will say 10 to me
is, is a panic attack 3 times a week. That’s the worst.
and 0 is, I’m completely at peace, and there is no anxiety at all in my life.
and I said, but to make it even more confusing for you.
you know.
in the last 3 to 6 months of your life. Because, see, I’m not trying to give somebody medicine.
In most situations there’s only had anxiety for 2 weeks. I’m not interested in 2 weeks now, I mean, if they have like a death or something, I might be like, Okay, here’s a little bit of clonapin, you know. But
you know I’m not interested in starting Pros act just because we’re having a bad 2 weeks. We all have bad 2 weeks, 3 weeks. Hell, we all have bad months.
I’m not interested in that. I’m interested in what is the last 3 to 6 months of your life. Look like, and what is your number for anxiety most days. Okay? And you know, the truth is, is, people who have true blue anxiety, you know, even with medicine, even with therapy. They’re never gonna be a 0, probably on that scale. There at best, we wanna go from an 8 to a 2.
So you know, I say, rate rate your anxiety, you know I know some days are 2, some days are 9, some days or 7, but what’s your number? Most days in the last 3 to 6 months for anxiety, and when I paint it to them like that, they give me a number
7, 7 out of 10. Well, okay. And then, you know, we go on. We go on. I write it down. I might get them to do the same thing for depression. Kind of a similar example. I might go through, you know the the questions on the Gad. 7. Because even though
that’s really more for generalized anxiety, disorder, there are a lot of really good questions on there. You can pull some of the questions from the Dsm criteria. And I might say, Okay, in the last 3 to 6 months. Do you feel this way? Mostly I’ll make a statement.
and I’ll say, Do you feel this way most of the time? Some of the time. Not at all.
And you know that really helps me to understand where they are, because they may think things are way way bad.
And you know maybe they are. Maybe they aren’t. Some people have personality disorders, and everything is always going to be bad for them. So you know, just
figure out some little way to really kind of nail down and get a measurement on it, you know.
and and you will find that, you know, if you start medicine. If you start therapy when they follow up with you. A month later, 6 weeks later, 3 months later. Whatever
than that again, you know. What’s your number now, since you’ve had, you know, 6 therapy sessions, and you’ve you’ve you’ve been on. I don’t know Prozac for
10 weeks. You know what is your number for anxiety. Now I had a couple of patients.
you know.
it just helps
put things into perspective, and it helps save you time as well.
So you’re all on the same page now, when you start with the exploratory set of questions.
And again, this is anxiety, disorder, you know. Move on to confirm, you know, maybe I start with these 2 little questions on the screen, feeling nervous, anxious, or on edge, not being able to stop or control worrying. And then, you know, if they they tell me, that’s a significant problem. You know. I mean, I’m gonna do my my rating skill. That’s what I like to do. But
you know, if you don’t want to do that, ask them a few little questions, and if they’re positive for those, maybe move on to what the Dsm criteria says for generalized anxiety disorder. If they’re negative, well, there’s no need for any further questioning.
We’ll click along.
And I’ve already looked at. We’re not fooling with this. Okay?
So let’s kind of backtrack a little bit. What are anxiety disorders, what falls under anxiety disorders? So panic disorder. Clearly
agoraphobia. I’ve had a I’ve had one. I don’t see that much in practice, but I’ve had one when I worked home. Health, you know. They don’t want to leave their home a lot of the time. So you know, that explains, I saw a good many when I worked home. Health generalized anxiety, disorder definitely the most common, probably in in outpatient practice. You every now and then I’ll get some specific phobias panic disorder every now and then. But you know anxiety is a normal reaction to stress. What I find in my patients is a lot of times.
and there’s neuroscience behind it. But they don’t have the coping skills in place to deal with
with stress. Also, there’s that, too. But it be, it becomes problematic. It requires treatment when the anxiety is so excessive that it interferes with functioning. So again, you know, you’re going to be sitting in clinical one day from now, and you’re going to have that patient, and they’re going to be talking to you, and you are going to be thinking
to start medicine or to not to start medicine or to not. And you’re going to be on the fence to start medicine or to not.
and I would say, if you ever feel that question in your mind, go back to how impaired is their functioning in life if they’re functioning in life is significantly impaired. Of course medicine
needs to be started now. Clearly they need to start therapy if they don’t even want to do medicine. But that’s just an extra tidbit. So you know you, you need to know the difference between stress, anxiety and fear.
because here’s the trees, and this is the cold, hard trees.
You know, life is not fun sometimes it’s just not fun, you know. We all fail.
We all have heartache. We all have days, hill, even months, that aren’t fun. We all feel stress. We all feel pressure. We all don’t get the job don’t make the great. I mean, those are like normal life things, and I mean it sucks. Sometimes it it sucks bad. But you know
some people can recognize that like, I’m having a bad day. I’m having a bad week. This is just a phase of my life. And I’m just, gonna you know. Put my bootstraps up, pull my bootstraps up and go. But you know a lot of people
don’t have that. A coping mechanism. They don’t. They don’t have that. They don’t have tools in place. So again, it can really affect their life. But anyway, I’m going to stop the ramble.
You know
you can give someone medicine and therapy all they want. But if they’re stressed out because they’re going home to an abusive relationship.
you know, that’s gonna be there. Pill and therapy is not gonna make an abusive relationship go away.
You know.
you know. So if it’s an external, the difference between anxiety and stress is this
stress? And yes, you know the Venn diagram where the the circles in our lap. They do play in the same arena, and and then one can be the cause of the other. But
you know, you can throw medicine at someone who’s works a stressful job or is in a stressful situation. And they’re never gonna feel like they’re better because the stressors are external. So sometimes I tell people, okay, if you could take everything you told me like this job, or you know the fact that I rate my car, whatever is stressing them out, and you and that never happened, or you could just take it in. Throw it away. How would you feel? They go? Oh, I don’t feel like a million bucks. I would have no problems at all. Well, that’s stress.
But again, you know, always go back to functioning and impairment in life, you know, because again, if they’re not sleeping and they’re not eating, and they’re locking themselves away from the world, and their marriage is on the fringe because their moods are up and down.
You know you have to consider those things as well, but also no fear. Fear is is one thing, too. It’s a rapid response to an actual stress, and stress is a response and external calls. And then, of course, anxiety.
anxiety is a preparatory emotion to ready for future possible threat. Anxiety is a person specific reaction to stress. So we’ll click along so on set of anxiety, disorder. So the average age of onset for an anxiety disorder is 11 years of age. And I do believe that to be true, because I do see a lot of 11 year old females in particular.
and you know, I noticed that
you know some some people have anxious personalities. That’s just. Some people just have anxious personals, and that just is what it is. But you know.
