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