Nov 19, 2014
Psychiatric versus Physical Illness Diagnosis based on etiology is not likely No external validating criteria Addressed by DSMy
Diagnostic criteria based on descriptive phenomenology
Psychiatric Historyy Comprehensive record of patient s life y Derive personality characteristics y Insight into nature of patient s relationships with
others y Allow patients to tell their stories in their own words in the order that they consider most important
Psychiatric HistoryIdentifying data II. Chief complaint III. History of Present Illness IV. Past Illnesses V. Family History VI. Personal History (Anamnesis) VII. Sexual History VIII.Fantasies and dreams IX. ValuesI.
Identifying Datay Demographic summary of the patient y Provide thumbnail sketch of patient y Be direct in obtaining identifying data y If patient is uncooperative, get information from other sources
Chief Complainty In patient s own words on why patient was brought in
for help y Record also version of other individuals present
History of Present Illnessy Comprehensive and chronological picture of patient s
life y Development of symptoms from time of onset to present; precipitating events and triggering factors; changes from previous level of functioning y May ask relatives and other informants for difficult patients
Past Illnessesy Medical history y Psychiatric history y Alcohol and Substance history
Family Historyy Brief description of y any psychiatric illness, hospitalization, and treatment of immediate family members y role in patient s upbringing y Relationship with the patient y Attitude of patient towards family and siblings
Personal History (Anamnesis)y To understand patient s past and its relation to the
present emotional problemy Prenatal and perinatal y Infancy and Early childhood (up to age 3) y Middle childhood (age 3-11) y Adolescence (puberty through adoloscence) y Adulthood
Prenatal and Perinatal Historyy Home situation into which patient was born y Wanted or planned pregnancy? y Maternal health problems y Maternal substance abuse
Early Childhoody Mother-child relationship y Feeding habits y Developmental milestones y Symptoms of behavior problems y Thumb sucking, tantrums, tics, night terrors, etc y Child s personality
Middle childhoody Gender identification y Disciplinarian in the family and punishments used at
home y Separation anxiety on first school day y Relationship with friends
Late Childhoody To determine patient s emerging self-image: y Ascertain values of patient s peers y Idealized figures Social relationships School history Cognitive and motor development Emotional and physical problems
Adulthoody Occupational history y Marital and relationship history y Military history y Educatioin history y Religion y Social activity y Legal history
Sexual Historyy Onset of puberty and patient s attitude towards it y Attitude towards masturbation y Attitude towards sex y Shy, timid, aggressive y Explore any other sexual symptoms y Premature ejaculation, lack of sexual desire, impotence, etc
Fantasies and Dreamsy Dreams are the royal road to the unconscious
- Freud y Repetitive dreams are of particular value y Most common dreams:y Food, examination, sex, helplessness, feelings of
impotence
y Valuable sources of unconscious material
Valuesy Social and moral values y Values about money, work, play, children, parents, sex,
community concerns, cultural issues
Mental Status Examinationy Describes the examiner s observations and
impressions of the psychiatric patient at the time of interview y Ask open ended questions y Encourage patient to elaborate and explain
General Descriptiony Use descriptive terms for y Appearance (body type, posture, grooming, etc)y
Healthy, sickly poised, well kempt, well groomed, tense posture Mannerisms, tics, restlessness, pacing, slowing of body movements Cooperative, friendly, attentive, frank, defensive, apathetic, hostile
y Behavior and psychomotor activityy
y Attitude toward examinery
Speechy Describe in terms of quantity, rate of production and
qualityy Talkative, unspontaneous, normally responsive, y Rapid, slow, hesitant, monotonous, whispered, slurred y Unusual rhythms (dysprosody)
Mood and Affecty Mood y patient s subjective emotional state y Depressed, despairing, irritable, anxious, euphoric, frightened, perplexed
Mood and Affecty Affect - objective emotional expression; what examiner infers
from patient s facial expression/expressive behaviory
Normal range y Variation in facial expression, tone of voice, hand and body movements y Constricted y Reduced range and intensity of expression y Blunted y Further reduced emotional expression y Flat y No signs of affective expression, monotonous voice, immobile face
Mood and Affecty Appropriateness y Considered in context of what patient is discussing
Perceptual Disturbancesy Hallucination y false sensory perception not based on reality (auditory, visual, olfactory, tactile) y Delusion y false interpretation of external reality y Hypnogogic as person falls asleep y Hypnopompic as person awakens y Derealization extreme feelings of detachment from
self or environment
Thought Processy An assessment the process of the patient s thinking. y Involves the quantity of ideas (pressured thought,
poverty of ideas) and the way in which the ideas (thoughts) are produced.y Are they logical and relevant; are they fragmented and
irrelevant?; Do they flow logically, or are they disconnected and fragmented ?
Thought Processy Flight of ideas extreme rapid thinking y Loose associations
ideas not related y Blocking interruption of train of thought before completion y Circumstantiality irrelevant details but gets back to point y Tangentiality no flow of conversation, never gets back to point
Thought Contenty What a person is actually thinking about: ideas,
beliefs, preoccupations, obsessions y Delusionsy fixed, false beliefs in keeping with patients cultural
background; may be mood congruent or incongruent
y Compulsions y things done over and over or in a particular way
Sensorium and Cognitiony Assess brain function, including intelligence, capacity
for abstract thought and level of insight and judgement
Sensorium and Cognition Alertness and level of consciousness Disturbance of consciousness indicate organic brain impairment Patient unable to sustain attention to environmental stimuli Clouding, stupor, coma, lethargy, alert Orientation According to time, place and person Impairment appears in that order; clears in reverse
Sensorium and Cognition Memory
y y
Remotechildhood data, important events before illness Last to be impaired
y
Recent past past few months Recent past few days Immediate retentionRepeat 3 words immediately and 3-5 min later
y
ConfabulationUnconsciously making up false memory when memory is impaired
Sensorium and Cognition Concentration and attention Subtracting serial 7 s from 100, simple calculations, spelling backwards Capacity to read and write Patient asked to read a sentence and do as it says; write a complete sentence Visuospatial ability Patient asked to copy a figure (eg. Clock)
Sensorium and Cognition Abstract Thinking Ability to deal with concepts Eg. Similarity between apple and pear? Concrete answers
Giving specific examples to illustrate the meaning
Overly abstract answersGiving too generalized an explanation
Sensorium and Cognition Information and intelligence Ability to do mental tasks such as counting change Takes into account patient s educational level and socioeconomic status Psychiatrist estimates patient s intellectual capability and capacity to function
Impulsivityy Ascertains patient s awareness of socially appropriate
behavior y Measure of patient s potential danger to self and others
Judgmenty
y
Patient s understanding of the likely outcome of his behavior Can patient predict his/her actions in imaginary situations (eg. Smelling smoke in a movie theater)
Insight
Patient s degree of awareness that they are ill
y 6 levels: 1. Complete denial of illness 2. Slight awareness of illness and needing help but denies it at the same time 3. Awareness of being sick but blaming it on external factors 4. Awareness that illness is due to something unknown in the patient 5. Intellctual insight can admit they are ill and acknowledge their failure to adapt due to own irrational feelings 6. True emotional insight awareness of own motives and feelings leads to a change in personality/behavior
Reliabilityy Estimate of psychiatrist s impression of patient s
truthfulness or veracity