Toronto, 58th AACAP/CACAP meeting, October 18-23, 2011

I've enjoyed a week of fascinating seminars/workshops at this year's meeting.
Toronto is an amazing city (see later posts)

Highlights:
- Implications of the Prenatal Hormonal Milieu for Psychosexual Development - Amy Wisniewski, Ph.D., Urology/Pediatric Urology, University of Oklahoma Health Sciences Center
- Dr. Susan Bradley's talk on gender identity disorder and its relationship to autistic spectrum disorder, and then her amazing talk : Moral Development Compete with Concern about Social-Emotional and Cognitive Development in Our Efforts to Prevent Mental Health Problems? followed by Hayley Wood's, PhD presentation of her research with GID kids and underlying ASD.
- Lenorre Terr, MD gave an impressive overview of her work with the children/families of the Chowchilla incident and her encouraging us 'younger ones' to consider undertaking clinical research work
- Peter Fonagy and colleagues presentation on the use of mentalisation in the treatment of borderline personality disorder from a neuroscience perspective
- other talks on transition to adult health services for both chronic medical problems and psychiatric was particularly useful. including strategies of how one could make this smoother - it included the need for infrastructure in order to support it. 


Although i would have loved to have attended all the available seminars - this was unnecessary. As i listened, i noticed that there was an underlying theme to all of them. In terms of what constituted an ideal environment for rearing well adjusted and healthy children/teens regardless of their physical/psychiatric concerns. The importance of connections is something that we probably don't pay much attention to, perhaps we take it for granted, perhaps we don't appreciate its essentialness? There is something so crucial about connection (and the degree + quality of connectedness throughout the lifespan) with your community, your primary care givers, your friends your family, your doctor/nurse etc...
More and more i realise that psychiatry is really about human relationship. If we were to forget about everything else and just remember to attend and preserve the sacredness of human relationships i think we might be okay. 
I suppose that this is not going to be news to a lot of you - and it doesn't surprise me either. But throughout the year i've began to really get a grip on what it all means. Is this the 'bigger picture' that i've been looking to see? 

how to talk?

There is surprisingly little published to guide therapeutic conversations with psychotic patients.
There is of course increasing data related to CBT principles which could be modified to fit in with the day-to-day work of treating patients on an inpatient unit with acute illness. It is difficult for various reasons including their lack of insight and intensity of their symptoms. In particular paranoia.

I have had the fortune of working with my supervisor who has like-minded concerns in this area. We have had a number of conversations within the context of supervision that has generated an enthusiastic drive to seek and learn of ways of working in a meaningful way with psychotic patients (+ the silent patient, the belligerent patient etc). Of course most of us would say that experience has much to contribute to the effectiveness of how a clinician communicates - its not true that experienced clinicians are always effective. There is always something to learn. Our counterparts in medicine, general practice and surgery have studied situations where communication between patient - doctor could mean the avoidance of a law suit or death. The use of acronyms such as A.S.S.I.S.T in the context of patient/family complaints has been particular useful and effective. The use of a structured way to communicate subverts clinician anxiety / fumbling for words and maybe minimises the risk of worsening the situation by saying something daft. One wonders if there are similar tools to use when talking to patients in psychiatric settings?

As with everything in psychiatry - more research is needed.

Learning goals part 1

Some bits and bobs re: learning goals

So it turns out you can co-administer zuclopenthixol decanoate with acuphase in the same syringe - both oil based vehicle. First dose of depot can be conveniently given together with more acute treatment.
Prof Castle and his team in OZ have developed a set of guidelines around the use of acuphase. A course of injections is recommended in preference to unsystematic use of crash Acuphase for patients its indicated for - recommend not exceeding >4 injections consecutively or stopping injections if total dose = 400mg.
Review articles say that most depots are much of a muchness but in general depot seem to improve compliance vs orals for various reasons - some more obvious.

Lithium - not much evidence supporting its use in teenagers with bipolar d/o.
Also not great for depressive phase of bipolar disorder.

Gender identity disorder (social/cultural)

Cases aged 13-17

Fairly easy to get cases to fill up my log book.

So far got these from inpatient experience.
Will need to get some more for Children treated with medications - this won't be difficult i suspect.
I haven't posted up summaries here.

Kubuntu 10.10

I've installed Kubuntu 10.10 on my Dell XPS M1210 - standard specs - after toying around with Ubuntu.

It appears to have a lot more geek factor to it compared to Gnome. I don't know but KDE just seems to fit with me. I didn't need to tweak it too much before i got it to work the way i wanted it to. THere were a few bugs e.g.: weird trackpad issues but this was solved with help from kubuntu forum.

Really dig the feel and the look.
So far so good. Its fast and it works.

http://www.scribd.com/doc/48413023/Davin-s-OCI-Notes-with-formulation-bits

I've added a formulation section to my OCI notes.
I must re-iterate that i am in no way a guru. I am not too sharp or "quick" so needed a simple template i could have in my head when trying to formulate during the interview process i.e.:

1. What is the what?
2. Why this patient?
3. Why now?
4. So what now?

Credit goes to one of my supervisors Dr. B Hock who passed this on to me

OCI notes

 i've put my OCI notes online for posterity. hopefully it'll be of some help to someone. i sat the RANZCP clinical exam in October 2010 in Melbourne.

preparation time 6 - 9 months. use of video camera was invaluable. study group with like minded candidates helped a great deal.

i am in no way an expert but i found that there were some things which helped me more than other things. when i get around to it - i'll add something about formulating cases.

http://www.scribd.com/doc/45715003/Davin-s-OCI-Notes