실기 3일 - CPX 1독 3일차 - 정신/신경 1)

참고문헌: Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. 5th Edition. 2013.

 

흠...

 

Edvard Munch - The Scream

(출처: 위키피디아)

 

아직도 정리하려면 한참 멀었다니...

 

관련된 주제를 크게 1) 따로 외울 것이 있는 것, 2) 한 큐로 정리할 때 꽤 잘 묶이는 것으로 나눌 수 있겠습니다.

 

1)에 해당하는 주제는

 

기분변화

불안

수면장애

기억력 저하

 

2)에 해당하는 주제는

 

의식장애

어지럼

두통

경련

손떨림증

팔다리 근력 약화 및 감각 이상

 

이 되겠다.

 

이제 정신과 필기에도 나오는 기분변화, 불안, 수면장애 등 진단기준 먼저 살펴보겠습니다. 자세한 specifier 등은 일단 나중을 위해 남겨두고, 딱 한 번만 읽어보면 느낌 받는 데에 좋습니다.

 

<Major depressive episode> - DSM-5

 

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning: at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another medical condition.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
Note: Criteria A-C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.

 

정신과 CPX는 DSM-5 기준에 맞게 다 물어보는 것이 중요해보이네요. 모든 정신과 진단 기준이 다 똑같지만, 항상 기본 테마는

 

a) 약물이나 전신 질환에 의한 것이 아니며

b) 다른 정신 질환으로 더 잘 설명되지 않으며

c) 사회적/직업적/기타 분야에서의 기능 장애

 

가 반드시 있어야 하니 물어보도록 합시다. 아, 그리고 DSM-5부터는 Bereavement(정상 애도반응)가 MDD의 배제기준이 아니게 되었음을 알아두면 좋겠습니다. 뭐 이건 필기에 도움되는 말이긴 하지만, bereavement가 MDD의 주요한 risk factor가 될 수 있기 때문이라던가 하는 식이었습니다.

 

이제 주요우울삽화(DSM-5에서는 그냥 주요우울장애의 기준이라고 나오긴 하지만!) A 기준에 있는 증상 9가지를 외워야되는데, 구글링을 해보니 좋은 mnemonic이 있었다. (역시 ..)

Sleep – increased or decreased (if decreased, often early morning awakening) Interest – decreased Guilt/worthlessness Energy – decreased or fatigued Concentration/difficulty making decisions Appetite and/or weight increase or decrease Psychomotor activity – increased or decreased Suicidal ideation

 

의 SIG E CAPS로 외운다고 하네요. 기분 증상은 너무나 이 질환에서 basic하니깐 따로 mnemonic에 넣어두지 않은 듯합니다.

 

참고) 저는 이게 뭔데 대체? 라고 생각이 들었는데, 구글링을 조금 더 해보니 정말 묘하게 그럴 듯한 암기법임을 알 수 있었습니다...

 

Originally when a physician would write a prescription, the abbreviation SIG would be written which was to mean directions. The "E" CAPS was to remind the prescriber to write "E nergy capsules" for depression (antidepressants).

 Hence:  SIG:  E.   CAPS 

(출처: 정체모를 네브라스카 의대 서버 내 사이트 <- 구글링)

그렇네요. 이런 증상이 뜬다면 E caps를 주는 거다 이 말이네요. 이 증상에 대한 치료방향(SIG)은 E caps!

 

자 이번엔 variation(?)들을 보면, 이미 얘기했던 bereavement 이외에 persistent depressive disorder가 있습니다. 이건 DSM-IV-TR까지 있던 dysthymia(기분부전장애)랑 거의 같은 개념이라고 보면 됩니다. 2년 이상 증상 지속되고, 무증상 기간이 2달 이상이 안 되는 경우 진단합니다. 이외에 PMS(Premenstrual syndrome)가 정식 진단명을 얻어 Premenstrual dysphoric disorder가 되었으니, 월경력을 묻는 것도 잊지 않으면 좋을 거 같습니다.

 

기분 장애의 양대 산맥, manic episode는 어떤가 볼까요? 그리고 hypomanic episode는 어떤 차이가 있을까요? 이는 Bipolar disorder I과 II의 진단으로 이어지게 됩니다.

 

<Manic episode> - DSM-5

 

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization
is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.

Note: A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and,
therefore, a bipolar I diagnosis.
Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required for the diagnosis of bipolar I disorder.

 

<Hypomanic Episode> - DSM-5

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant
degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment).
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar
diathesis.
Note: Criteria A-'F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.

 

그렇습니다. 역시 정신과 공부에서 제일 중요한 것은 '기능 장애' 여부입니다.

 

Mania든 hypomania든 증상속성(?)은 같은데 증상을 외우는 mnemonic이 역시 있고 이건 조금 유명합니다.

 

D = Distractibility and easy frustration I = Irresponsibility and erratic uninhibited behavior G = Grandiosity F = Flight of ideas A = Activity increased with weight loss and increased libido S = Sleep is decreased T = Talkativeness

 

으로, DIG FAST라고 외웁니다.

 

이제 남은 것은 불안, 수면장애, 기억력 저하인데, 불안 먼저 보겠습니다.

 

 

 

불안이라는 증상은 정말 많은 질환들과 연결되어있고, 일차적인 경우도 있고, 이차적인 경우도 있으니 자주 다뤄지는 질환 먼저 보면,

 

Anxiety disorder: Panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder

Trauma- and Stress-related disorders: PTSD, ASD

 

정말 많네요. 감별점은 결국 불안해지는 원인 혹은 상황, 증상이 있던 기간, 그리고 동반증상이 있느냐가 될 것입니다. 결국은 ROS였던 것입니다.

 

먼저 Panic disorder를 보면,

 

<Panic disorder> - DSM-5

 

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur;
Note: The abrupt surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).
12. Fear of losing control or “going crazy.”
13. Fear of dying.
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences

(e.g., losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder:
in response to circumscribed phobic objects or situations, as in specific phobia:
in response to obsessions, as in obsessive-compulsive disorder: in response to reminders
of traumatic events, as in posttraumatic stress disorder: or in response to separation
from attachment figures, as in separation anxiety disorder).

 

위에 기분장애보다 더 답답합니다.. 대체 panic attack이 의심되면 저걸 다 어떻게 외워서 물어보지? 싶을 때 역시 mnemonic이 있습니다.

 

sweating trembling unsteadiness,dizziness depersonalization,derealization excessive heartrate,palpitations nausea tingling shortness of breath FEAR of dying,losing control,going crazy 3 C'S CHEST PAIN CHILLS CHOKING

(출처: Best Medical Mnemonics)

이렇게 STUDENTS FEAR the 3 C's라고 외웁니다....

묘하게도 기준은 다 들어가 있네요.. Panic disorder 의심 환자에게 물어보면 딱입니다! 치료를 쓰라고 하면? 약물치료, 행동치료, 인지치료입니다

간단하게 질환을 설명하자면? Panic attack이 나타나고, 예기불안/회피행동이 나타남! (anticipatory anxiety/avoidance behaviour)

 

 

이번엔 Agoraphobia를 봅시다. 광장공포증이라 번역하는데, 광장에 대한 인식에 문화적 차이가 있는 건지, 제일 오해가 많은 개념이었어요..

 

<Agoraphobia> - DSM-5

 

A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
3. Being in enclosed places (e.g., shops, theaters, cinemas).
4. Standing in line or being in a crowd.
5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder): and are not related
exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmoφhic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety
disorder).
Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

 

일단 Agora의 뜻이 광장인 것은 맞습니다. 하지만 저기 굵은 글씨로 해놓은 것을 보면 광장인 것도 있고, 흔히 광장이라 부르지 않을 것 같은 곳도 있습니다. 그래서 제가 밑줄 친 포인트가 이 질환의 이해에 매우매우 중요한데,

 

1) 공황발작 비슷한 증상이나 이외에 요실금 등 당황할 수 있는 상황에서

2) 이 상황을 벗어나는게 어려울 것 같고, 도움을 받을 수 없을 것 같은 느낌

3) 사회/직업 등의 분야에서 기능 장애 나타남

 

무슨 광장에서 두려워하는 게 아닙니다. 포인트를 이해하고나서 그 다음에 어떤 곳들에서 그런걸 느낄 수 있는가를 봐야 이해가 된다고 생각합니다. 말부터 보고 현혹되면 안 되구요. 광장공포증 진단하자고 저런 장소 하나하나 다 물어보는 것은 CPX 시험에 굉장히 어색하다고 판단이 되고, 문진을 통해 정보를 얻으려고 하다보면 S/P가 알아서 설명을 해주실 부분이 많기 때문에 어떤 mnemonic을 외우고 ROS처럼 긁을 필요는 없는 것이 됩니다. 그러니 생략하고 다음으로 넘어가죠.

 

 

이번엔 Specific phobia를 보죠.

 

<Specific phobia> - DSM-5

 

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
B. The phobic object or situation almost always provokes immediate fear or anxiety.
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety.
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.
E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia): objects or situations related to
obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

 

(+specifier)

 

시험에 나온다면 가장 난감할 수 있는 질환이라고 생각합니다. 특정 물체가 두렵지 않냐고 물었는데,

 

그게 무슨 소리죠?

 

이러면 눈물이 뚝 떨어질 것 같은 느낌이 듭니다. 뾰족한 물체, 비행, 높은 고도, .. 하아.. 눈물이 나네요.. 제발 ROS 긁을 때 어떤 특정 물체 때문에 두렵거나 하지 않으세요? 했을 때 네.. 뾰족한 물체를 유난히 두려워하고 그걸 피하려고 하느라 고생해요.. 등의 이야기로 화답해주면 정말정말 좋을 것 같아요....

 

 

이번엔 Social anxiety disorder(사회불안장애) 혹은 더 흔하게 쓰는 social phobia(사회공포증)이라는 것에 대해 살펴봅시다.

 

<Social anxiety disorder> - DSM-5

 

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from bums or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

 

이번엔 예시가 그리 많지 않으니 그냥 외워둡시다. 왜냐면,

 

사회적 상황에서 불안감을 느낀 적은 없으셨나요?

 

이라고 물어보면 거의 백타

  

그게 무슨 소리죠?

 

라고 답할 것이기 때문입니다. 사회적 상황에 해당하는데 물어보기 좋은 것은 1) 새로운 사람을 만나는 것, 2) 사람들 앞에서 발표하는 것 정도 된다고 외워놓으면 이후에 필기 때도 편할 것입니다. 역시 치료는 약물/행동/인지... 정도 물어보면 적어주자.. 굿굿

 

마지막으로 Generalized anxiety disorder(너무 기니 대강 GAD라고도 쓴다. 범불안장애)에 대해 알아보겠습니다.

 

<Generalized anxiety disorder> - DSM-5

 

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months);
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive
disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance
flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

 

복잡해보이는데, 사실 여기서는 저걸 다 외울 필요가 없을 것 같습니다. 어떤 것에 대해서 혹은 어떤 상황에서 불안감을 느끼는가를 물어봐서 그게 여러개면 일단 GAD를 의심하고, 그 때의 증상을 쭉 들어서 저런 비슷한 느낌이다 싶으면 GAD 진단을 내리면 되는 것입니다.. 물론 모의진료시험이니 그렇고, 실제 전문의 선생님들께서는 감을 잡고 더 깊게 파고들어가시지 않을까 싶습니다.... 난 비루한 학생이니 넘어가야지..

 

다음 글에서 PTSD, ASD, 그리고 다른 신경질환들을 살펴보고.. 총정리해서 면담용 질문 세트를 평소처럼 만들어야겠습니다..

 

참고서적: Real CPX 5판, 메딕메디슨 학술국. 10minutes CPX, 퍼시픽 학술국.