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INTRODUCTION &
ORGANIZATION OF EDUCATION
IN PSYCHIATRY
Psychiatry 1 – Practical # 1
Author: MUDr. Ľubomíra Izáková, PhD.
Supervisor: prof. MUDr. Ján Pečeňák, CSc.
Podporené grantom KEGA č. 099UK-4/2012
Psychiatrická klinika LFUK a UN Bratislava
Learning objectives
to review information about:
types of psychiatric/mental health services
structure and organization of Psychiatric Clinic
organization of education in psychiatry
to introduce:
terminology used in psychiatry
types of mental disorders
principles of classification of mental disorders
to explain:
law regulations in psychiatry
clinical documentation
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EDUCATION
AT THE DEPARTMENT OF PSYCHIATRY
MENTAL HEALTH SERVICES
MENTAL DISORDERS
(terminology & classification)
LAW REGULATIONS IN PSYCHIATRY
DOCUMENTATION IN PSYCHIATRY
4KEGA 099UK-4/2012
EDUCATION
AT THE DEPARTMENT OF PSYCHIATRY
MENTAL HEALTH SERVICES
MENTAL DISORDERS
(terminology & classification)
LAW REGULATIONS IN PSYCHIATRY
DOCUMENTATION IN PSYCHIATRY
Introduction Department of Psychiatry FMCU & UHB
1864 – Psychiatric Ward of Urban Hospital in Bratislava
60 beds, 6 cells
1900: new building (530 beds)
1915 – Neuropsychiatric Clinic, Elizabeth University,
from 1919 FM CU Bratislava
1950 – Psychiatric Clinic
Present – Department of Psychiatry FMCU & UHB
Head of the Department: prof. MUDr. Ján Pečeňák, CSc.
70 beds (+ 15 in DS)
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Organization of education in psychiatry
undergraduate study
2 semesters
postgraduate study
specialization study (5 years)
sub-specialization study gerontopsychiatry, children psychiatry, sexuology
continuing education
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Content of the Subject
General Psychiatry
etiology and mechanisms of
mental disorders
psychopathology
therapy in psychiatry
biological therapy
psychotherapy
rehabilitation and resocialization
investigations in psychiatry
first aid in psychiatry
prevention in psychiatry
social psychiatry
forensic psychiatry
Special Psychiatry
classification of mental disorders
description of mental disorders
etiology
clinical picture
course
therapy
forensic issues
special patients groups
children psychiatry
gerontopsychiatry
sexology
addictions
suicidology
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PSYCHIATRY
One of the basic medical
disciplines.
Deals with diagnostics,
treatment, prevention and
research of mental
disorders.
PSYCHOLOGY
• Originally philosophical
discipline, science of the
human mind („mental life“).
• Examines• individual psyche
• psychological functioning,
relations, characteristics
• development
• Clinical Psychology
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„NEUROSCIENCE“
connection
cognitive psychology
imaging methods
consciousness research
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Recommended literature
and internet sources for learning Kolibáš E et al: Introduction to Clinical Psychiatry. Asclepios: Bratislava, 1996
Semple D, Smyth R: Oxford Handbook of Psychiatry. 2nd Edition, 2009, 3th Edition,
2013
Kolibáš E et al: Všeobecná psychiatria. Bratislava: UK, 2011
Novotný V et al: Špeciálna psychiatria. Bratislava: UK, 2010
Jarema M (Ed) et al: Practical aspects of Psychiatry. Praha: Amepra, 2009
Stoudomire A: Clinical Psychiatry for Medical Students. 2nd Edition, 1998
http://www.fmed.uniba.sk/index.php?id=4244
http://eprints.utas.edu.au/287/
World Health Organization: The ICD-10 Classification of Mental and Behavioural
Disorders. Diagnostic criteria for research. Geneva: WHO, 1993
https://www.who.int/classifications/icd/revision/en/
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EDUCATION
AT THE DEPARTMENT OF PSYCHIATRY
MENTAL HEALTH SERVICES
MENTAL DISORDERS
(terminology & classification)
LAW REGULATIONS IN PSYCHIATRY
DOCUMENTATION IN PSYCHIATRY
Etiology of mental disorders
biological
factors•congenital
•acquired
psychological
factors
social
factors
genetics
gravidity risks
injuries
somatic diseases
endocrinology
epilepsy
poverty
wars
nature disasters
discrimination
religiosity
type of personality
resistance to stress
social relationships
„BIO-PSYCHO-SOCIAL MODEL“
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Mental disorder
???
Psychopathological syndrome and other symptoms that
lead to clinically significant distress or disability of one or
more important mental abilities.
It is never a normal reaction to the common negative
psychological effects or cultural factors.
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Psychopathology
scientific background, basic language of psychiatry
involves recognition and definition of signs and
symptoms of mental disorders
psychopathological symptoms occur
in mentally ill
in healthy population
symptoms are rare, transient, isolated
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Psychopathological symptomatology
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Description of disturbances of mental functions
Cognitive ff.:
perception, fantasy/gnosia, thinking, memory/learning
Motivating ff.:
emotions, drives/instincts
Conative ff.:
will/acting, psychomotoric, praxia
Integrative and synthesising ff.:
consciousness, attention, intelligence, personality
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basic
psychopathological
unit for manifestation
and description of
mental disorders
subjective
objective
non-specific (general)
hallucinations
more-specific
microzooptic
hallucinations in
delirium tremens
structured
typical complex
of psychopathological
symptoms
main diagnostic indicator
complete/incomplete
manifestation
specific/non-specific
syndrome
combinations of
syndromes
reflects certain relations
(patogenesis)
known
etiology
pathogenesis
course
characteristics
symptom syndromenosological
unit
disorder
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according to current
diagnostic and
classification systems
basic approach
in psychiatry
is
DETERMINATION
OF SYNDROMES
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Relations between syndromes
non-specific (secondary) syndromemassive in clinical picture
specific (primary) syndromeborderline, subclinical, mild in clinical picture
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Symptoms in mental disorders
multiple etiologies may „generate“ similar / same clinical picture
biological
factors
psychological
factors
social
factors
depressive mood
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“Nosological” classification
etiology
pathogenesis
symptoms and signs
treatment
prognosis
„etiological“
treatment
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biological
factors
psychological
factors
social
factors
organic
mental
disorders(brain)
• dementia
• dellirium
somatogenic
(other system
as primary
problem)
“toxic disorders”acute intoxication
dependence
withdrawal syndrome
toxic“substance induced”
“psycho-reactive”reaction to acute or
chronic stress
“endogenous” • depression
• schizophrenia
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Classification of mental disorders
organic disorders
somatogenic disorders
„toxic“ disorders
psychoreactive
endogenous
mental retardation
personality disorders
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Types of psychiatric disorders
disease ↔ disorder
exogenous ↔ endogenous
psychotic ↔ non-psychotic
borderline
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PSYCHOTIC – NON-PSYCHOTIC – BORDERLINE
The classification of mental disorders according to disturbances
of mental and social functioning:
PSYCHOTIC STATE
Severe disturbances of:
• PERCEPTION of reality
• INTERPRETATION of reality
• ADAPTATION to reality
• CONTACT with reality
• PERSONALITY
NON-PSYCHOTIC STATES
• no severe disturbances, no personality
disintegration
• some disorders (neuroses, personality
disorders) have non-psychotic state as
basic characteristics.
• psychotic state is not defined by the
diagnosis, manifestations of disorder
should be examined (BAP)
• may have a more negative impact as
psychosis (OCD)
Severe impairment of
mental existence of
person in relation to
themselves and external
world.
From history – incomprehensible,
inexplicable
Present:
pragmatic definition:presence of hallucinations
and / or delusions
(impairment of reality testing)
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Principles of classification
ICD-10
International Classification of
Diseases, 10th Revision
WHO, 1992
chapter V, blocks F00-99
mental and behavioural
disorders
DSM 5
Diagnostic and Statistical Manual of
Mental Disorders, 5th Revision
APA, 2013
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atheoretical – pragmatic – phenomenological
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ICD-11
International Classification of Diseases, 11th Revision
WHO, 2019
chapters 5, 7, 8 – Mental, Behavioural and Neurodevelopmental Disorders (7),
Sleep-wake Disorders (8) and Conditions Related to Sexual Health (5)
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EDUCATION
AT THE DEPARTMENT OF PSYCHIATRY
MENTAL HEALTH SERVICES
MENTAL DISORDERS
(terminology & classification)
LAW REGULATIONS IN PSYCHIATRY
DOCUMENTATION IN PSYCHIATRY
Mental Health Services
PRIMARY CARE
outpatient care
easily accessible
HOSPITALS
inpatient care
psychiatric departments/clinics
psychiatric hospitals
general, specialised
psychiatric sanatorium
daily sanatorium
Psychiatrists
Psychiatric nurses
Psychologists
Social workers
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crisis stabilization care
acute inpatient care
units for acutely mentally ill
partial (day/night) inpatient programmes
rehabilitation, resocialization
consultation services for general medical patients
specialized units for patients with specific mental disorders
eating disorders, children psychiatry, gerontopsychiatry, addictions
Types of Mental Health Services
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Consultantion-Liasion Psychiatric Services
liaison area between psychiatry and other medical disciplines
represent often the first patient's contact with psychiatry
requires knowledge of psychiatry and other medical fields
need personal contact between somatic doctor and consultant
psychiatrist
objective history is essential
(medical documentation, info from doctors and relatives, etc.)
the most common diagnoses:
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• delirium
• dementia
• affective disorders (depression, anxiety, mania)
• somatogenic disorders
• abuse of psychoactive substances
• sleep disorders
• eating disorders
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Intensive care
unit acute psychotic
states
severe somatic
comorbidity
self-harm
suicidal behaviour
Acute women's
unit• psychoses
• severe affective
disorders
• dementia
• somatic comorbidity
Acute men's
unit• psychoses
• severe affective
disorders
• dementia
• somatic comorbidity
Non-acute unit addictions
personality disorders
psychoreactive disorders, neuroses
affective disorders (mainly depressions)
sub-acute psychotic disorders
Outpatient care for
citizens from districts
BA I and IV
Consultation
services for
inpatients from
University Hospital
Daily sanatorium
(partial hospitalisation)
for patients with psychoses after
hospitalisation
sub-compensations of psychoses
predominance of negative symptomatology
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EDUCATION
AT THE DEPARTMENT OF PSYCHIATRY
MENTAL HEALTH SERVICES
MENTAL DISORDERS
(terminology & classification)
LAW REGULATIONS IN PSYCHIATRY
DOCUMENTATION IN PSYCHIATRY
Law Regulations in Psychiatry
Expert witness
Expert opinion Personal issues
informed consent
Civil issues
compulsory admission to hospital
restriction in legal competencies
(management of finances, guardianship..)
Criminal issues
criminal responsibility (degree of insanity)
competency to stand trial
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Informed Consent
should be obtained from the patient before any psychiatric treatment
form: formal written consent
Voluntary hospitalization
patient can withdraw consent at any time
doctor has to inform the patient about imminent risk of worsening
symptoms of his/her mental disorder
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Written Informed Consent
Signed:
patient
or
their legal representative
and
doctor
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If the patient is:
an imminent danger to himself/herself
an imminent danger to others
unable to take proper care
of himself/herself because of mental disorder
Involuntary hospitalization
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Involuntary – Procedures
in 24 hours information from hospital to district court
in 5 days civil commitment hearing at the hospital (legal assistent) and judge’s decision
court (judicial) approval for up to 3 months
court disagreement
patient signs written informed consent
discharge of patient
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Involuntary – Notification
within 24 hours after patient's
admission at clinic
sent by fax to the district court
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Involuntary – Beginning of the trial
starts according to
notification from the
psychiatric clinic to the
district court
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U Z N E S E N I E
Okresný súd Bratislava I z dôvodu ust. § 191b ods.l / Občianskeho súdneho poriadku
takto
r o z h o d o l:
Súd z a č í n a konanie o vyslovenie prípustnosti prevzatia do ústavu zdravotníckej
starostlivosti.
Účastníkmi konania sú:
Umiestnený: LŠ
trvale bytom Bratislava
Ústav: Univerzitná nemocnica Bratislava, Pažítková 4, pracovisko Nemocnica
Staré mesto, Psychiatrická klinika LFUK a UNB, Mickiewiczova 13, Bratislava
O d ô v o d n e n i e
Na základe oznámenia ústavu zo dňa 27.12.2012 je súdu známe, že dňa 26.12.2012 bol do
ústavnej starostlivosti prijatý bez svojho súhlasu LŠ.
Podľa ust. § 191b ods.l/ Občianskeho súdneho poriadku (ďalej len O.s.p.) o každom, o ktorom
je ústav povinný urobiť oznámenie podľa § 191a O.s.p., začne súd, v obvode ktorého je ústav, konanie
o vyslovenie prípustnosti prevzatia do ústavu, ibaže prevzatie a držanie nariadil súd v inom konaní.
Podľa ust. § 81 ods. 3/ O.s.p. o začatí konania bez návrhu vydá predseda senátu uznesenie,
ktoré doručí účastníkom do vlastných rúk, ak zákon neustanovuje inak.
Podľa ust. § 94 ods.l/ O.s.p., veta prvá, v konaní, ktoré možno začať i bez návrhu, sú účastníkmi
aj tí, o právach alebo povinnostiach ktorých sa má konať.
Pretože z doposiaľ zisteného skutkového stavu je zrejmé, že umiestnený bol prijatý do ústavu
bez svojho súhlasu, rozhodol súd tak, ako je to uvedené vo výrokovej časti tohoto uznesenia.
P o u č e n i e : Proti tomuto uzneseniu odvolanie nie je prípustné.
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Involuntary – Appointment of guardian
to protect the patients
rights in the involuntary
admission procedures
(not in another legal
matter)
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U Z N E S E N I E
Okresný súd Bratislava I u s t a n o v u j e Mestskú časť Bratislava - Staré mesto,
Vajanského nábrežie 3, Bratislava
za opatrovníka
pre LŠ, nar. XX.XX,19XX, trvalé bytom Bratislava, na ochranu jeho práv v konaní o vyslovenie
prípustnosti prevzatia do ústavu zdravotníckej starostlivosti.
O d ô v o d n e n i e
Ustanovenie za opatrovníka na ochranu práv umiestneného je v tomto konaní potrebné z
dôvodu ust § 191b, ods.2/ Občianskeho súdneho poriadku, pretože umiestnený nemá iného zástupcu.
Podľa § 29 ods. 6 O.s.p. súd môže za opatrovníka ustanoviť aj obec.
P o u č e n i e : Proti tomuto uzneseniu možno podať odvolanie do 15 dní odo dňa jeho doručenia
na podpísanom súde, písomne.
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Involuntary – Court approval
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U Z N E S E NI E
Okresný súd Bratislava I v Bratislave vo veci o vyslovenie prípustnosti prevzatia umiestneného: LŠ, nar.
XX.XX.19XX, bytom Bratislava, zastúpený opatrovníkom Mestská časť Bratislava — Staré mesto, Vajanského
nábr. 3, Bratislava, do ústavu: Univerzitná nemocnica s poliklinikou Bratislava, Pažítková 4, Bratislava,
pracovisko: Nemocnica Staré Mesto, Mickiewiczova 13, Bratislava, Psychiatrická klinika I. FUK a UNB
r o z h o d o l :
Pre vzatie umiestneného: LŠ, nar. XX.XX.19XX, bytom Bratislava do ústavu: Univerzitná nemocnica
s poliklinikou Bratislava, Pažítková 4, Bratislava, pracovisko: Nemocnica Staré Mesto, Mickiewiczova 13,
Bratislava, Psychiatrická klinika L FUK a UNB, ku
ktorému došlo dňa 26.12.2012.
m á z á k o n n é d ô v o d y .
O d ô v o d n e n i e :
Dňa 27.12.2012 ústav súdu oznámil, že dňa 26.12.2012 bol bez svojho súhlasu prevzatý do ústavnej
starostlivosti ústavu LŠ, nar. XX.XX.19XX, bytom Bratislava.
Z dôvodu ust. § 191b ods. 1 Občianskeho súdneho poriadku (ďalej len O.s.p.), § 81 ods. 1 O.s.p. súd
uznesením č.k. IPu 285/2012-4 zo dňa 27.12.2012 začal konanie o vyslovenie prípustnosti prevzatia
umiestneného do ústavu zdravotníckej starostlivosti.
Súd v prejednávanej veci vykonal dokazovanie výsluchom ošetrujúceho lekára, MUDr. K a
umiestneného LŠ, a zistil tento skutkový stav veci:
Súd z výsluchu ošetrujúceho lekára zistil, že pacienta priviezla RZP z CP Ružinov, kde bol vyšetrený
psychiatrom a bola mu doporučená hospitalizácia na psychiatrickej klinike pre suspektnú toxickú psychózu.
Pacient bol v metadonovom programe, dňa 21.12.2012 metadon nedostal, pretože sa nedostavil na čas a pacient
bol vyradený z metadonového programu. V deň prijatia užil prervitín a benzodiazepíny, nakoľko bol v kríze. Na
CP Ružinov udával, že má pocit, že zabije otca, že spácha lúpežné prepadnutie, keď vystúpil z trolejbusu, mal
zrakové halucinácie. Pri vyšetrení nepokojný, zabiehavé myslenie s paranoidnými bludmi, poruchy vnímania,
agresívne prejavy, doma napadol otca, rozvinutý abstinenčný syndróm. Diagnóza: akútna psychotická porucha
— toxická, polymorfná toxicita, abstinenčný stav. Predpokladaná dĺžka hospitalizácie je 1 týždeň. Výsluch a
doručovanie uznesení ošetrujúci lekár odporučil.
Súd z výsluchu umiestneného LŠ, nar. XX.XX.19XX, bytom Bratislava zistil, že pacient v piatok
nedostal na Hraničnej metadon, pretože meškal. Mal abstinenčný stav a kúpil si lieky a drogy. Po užití drog
napadol v skratovom konaní otca, ktorému rozbil hlavu. Následne pacient išiel do Ružinovskej nemocnice, kde
ho vyšetril psychiater. Sanitka ho potom previezla na psychiatrickú kliniku I. FUK a UNB. KEGA 099UK-4/2012
Involuntary – Approval to hold
after 3 months
if there is still need for involuntary hospitalization, the judge asks the
expert witness (non-working in the hospital) for an expert opinion
(max. for 1 year).
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EDUCATION
AT THE DEPARTMENT OF PSYCHIATRY
MENTAL HEALTH SERVICES
MENTAL DISORDERS
(terminology & classification)
LAW REGULATIONS IN PSYCHIATRY
DOCUMENTATION IN PSYCHIATRY
Outpatient psychiatric documentation
Recommendation
physician
outpatient psychiatrist
doctor from rescue system
Psychiatric examination
subjective history from patient side
objective history from relatives
objective findings, clinical symptomatology, conclusion,
diagnosis (ICD-10) and recommendations
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Inpatient psychiatric documentation
Psychiatric examination
history of patient (subj., obj.)
presenting complaints
objective findings
assessment of cognitive functions
clinical symptomatology
general physical examination
psychopathological analysis and
discussion
conclusions - working clinical
diagnosis (ICD-10)
diagnostic and therapeutic plan
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Inpatient psychiatric documentation
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Statistical data
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Any questions?
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