INITIAL PSYCHIATRIC CASE HISTORY I. II. III.

Identifying Data: This is the __nth (VA Medical Center, UUMC Medical Center, UNI), psychiatric hospitalization for this ____ year old, (marital stat s), (race), (se!), (occ pation). Informants: Incl de all informants, their relationship to the patient, and estimated relia"ility. If pre#io s hospital charts are sed, say so. Chief Com laint: This sho ld al$ays "e a !"otation of the patient%s o$n complaint and not the relati#e%s statement or the doctor%s paraphrase. If desired, an additional chief complaint, that of an informant other than the patient, may "e added pro#ided the so rce is made clear. Present Illness: The f ndamental elements of a psychiatric &'I are( ). Cardinal sym toms incl din* ertinent ositi#es and negati#es, or*anized "y dia*nostic cate*ory, "e*innin* $ith the +A+ criteria ,. Onset and d"ration of sym toms and treatments $% E#iden&e of f"n&tional im airment '% E(&l"sion &riteria) sy&hiatri& and organi& -. In&l"de all the diagnosti& ossi*ilities and to a#oid pre. dice "y presentin* data refera"le to only one of the illnesses $hich re/ ires differential consideration The present illness is the most important part of the history. Most of the data $hich $ill aid directly or indirectly in the dia*nosis and treatment of the patient0s illness sho ld "e incl ded here. 1#en certain phases or manifestations of an illness $hich ha#e e!isted for years may "e reported in the present illness. 2or e!ample, in the case of a patient $ith affecti#e symptoms, a depression ,3 years a*o $o ld "e descri"ed in the present illness. It is also important, ho$e#er, not to cl tter p the present illness $ith tri#ia. 4hen the rele#ancy of certain aspects of the more remote history is indeterminate, s ch data sho ld "e incl ded in the past medical or social history, as is appropriate. The presentation of the present illness is a lo*ical, coherent story nfoldin* from the onset and smoothly carryin* the reader p to the day of the present admission. 5ccasionally, ho$e#er, the comple!ity of the present illness $ill re/ ire separate consideration of a part of the history or separate consideration of one informant0s report. The &on&l"ding senten&e of the resent illness sho"ld *e a statement of the e#ent re&i itating admission at this time) and of the means +here*y the atient +as *ro"ght to the hos ital% V. Past ,edi&al History: In chronolo*ical order incl de operations, other hospitalizations, si*nificant in. illness not res ltin* in hospitalization. 6pecific in. ry sho ld "e made concernin* head in. ry and ne illness. As7 each patient a"o t medicines and dr *s, "oth those prescri"ed and those o"tained $itho prescription. In/ ire as to the amo nt and 7ind of alcohol inta7e and the se of to"acco, if not pre#io ries or rolo*ical t sly reported.

IV.

VI.

System Re#ie+: The chief f nction of the system re#ie$ in a psychiatric case history is to pro#ide a systematic in#esti*ation of symptoms of nonpsychiatric illnesses. The system re#ie$ does not ser#e to fill *aps $hich ha#e "een left in the present illness. 4hen the patient0s psychiatric differential dia*nosis incl de hysteria, the special symptom re#ie$ for that illness "ecomes a part of the present illness. De#elo mental History: &ere yo m st doc ment three items( )) history of "irth tra ma, e.*., ano!ia, infection, or maternal illness8dr * a" se9 ,) ac/ isition of early de#elopmental milestones9 :) a re#ie$ of all criteria for antisocial personality disorder. So&ial History: Altho *h commonly dele*ated to the social $or7er, the psychiatrist sho ld ma7e e#ery effort to "ecome familiar $ith the patient%s social history. Not only $ill this *i#e a "etter o#erall nderstandin* of the patient, " t some psychiatric dia*noses, nota"ly antisocial personality, depend hea#ily on this history for their delineation. ;oc mentation of this information can "e #ery "rief. ;o not try to constr ct a literary "io*raphy of yo patient. 6ome areas that are important to in#esti*ate incl de( a) Up"rin*in*( 2amily constellation and position in si"ship, socioeconomic stat s, and reli*ion "oth as a child and at present9 ") 6chool and occ pational history( <ast *rade complete, a*e $hen stopped and for $hat reason9 a"ility, performance and "eha#ior in school9 tr ancy=ho$ often and at $hat a*e9 c) >o" history( Type of $or7, n m"er of .o"s, $hether e#er military ser#ice, $hy not? e) 6e! al and marital history( ;etails of se! al and datin* e!perience, a*e at $hich married, n m"er of marria*es, and reason for di#orces, if any. +2amily dynamics+, the interaction $ith one%s parents, si"s, spo se, children may "e descri"ed here9 f) 'remor"id personality( This refers to the personality of the patient "efore onset of an ac te illness. Altho *h often delineated only $ith diffic lty, the premor"id personality is $orth assessin* to appreciate the chan*es s "se/ ent to illness and is s ally "est o"tained from informants other than the patient. In/ ire a"o t the patient0s premor"id acti#ities, interests, *eneral mood and social patterns.

VII.

VIII.

I@.

-amily History: The psychiatric family history m st consist of a family tree, $ith all mem"ers of three *enerations (si"lin*s, parents, a nts, ncles, *randparents) $ith each mem"er specifically descri"ed for the presence or a"sence of any psychiatric or ne rolo*ic disorder, treatment and response, and the presence of any s icide. Physi&al E(amination: Incl des #ital si*ns and a complete ne rolo*ical e!amination, $ith frontal release si*ns assessed in any patient $ith a ne$ presentation of psychosis or dementia, or a treatment refractory psychosis or affecti#e disorder. ,ental Stat"s E(amination: The mental stat s e!amination is an amplification of the ne rolo*ical e!am. In the psychiatric e!amination it is rendered separately and placed after the physical e!am. It is ordinarily di#ided into si! parts, and sho ld "e caref lly follo$ed and metic lo sly recorded for each patient. Part .: Aeneral Appearance and Beha#ior ;oes the patient appear his stated a*e? ;escri"e his *eneral condition ($ellCno rished, nsha#en, to sled) and his dress. Is he responsi#e, alert, cooperati#e? ;escri"e the facial e!pression, $hich may "e sad, happy, smilin*, $eepin*, d ll or e!pressionless, stiff, ecstatic. If motor acti#ity is in any $ay n s al, descri"e it. It may "e o#erly acti#e, nderacti#e, may sho$ stereotypes or mannerisms, mit*ehen or forced *raspin*. 6t por, post rin*, $a!y fle!i"ility, restlessness, pic7in* motions, a7athisia sho ld "e mentioned. Part /: 2orm of Tho *ht This area of the mental stat s e!amination is the least precise. Beca se of conflictin* definitions of #ario s terms sed to descri"e a"normalities of tho *ht and speech prod ction, it is "est to descri"e $hat the patient says "y the se of a fe$ "rief / otations from his speech. 6peech (tho *ht) 'atterns( 2or descripti#e p rposes, there are t$o types of speech patterns( )) rate and rhythm patterns $hich refer to the rate and rhythm of the speech and ,) association patterns, i.e., the $ay in $hich a) sentences and phrases9 ") $ords9 or c) sylla"les are connected to*ether and related to each other or are related to / estions and statements "y another person. These t$o types of patterns may coC e!ist9 i.e., p sh of speech and fli*ht of ideas, or tan*ential speech and "loc7in*. Date and Dhythms of 6peech (tho *ht) 'atterns( Dapid and diffic lt to interr pt (p sh of speech), speech easily distracted "y s rro ndin*s, spontaneo s speech, e!cessi#e speech at s al rate, fe$ $ords at s al rate, slo$ speech, speech in ans$er to / estions only, monosylla"ic ans$ers, increased, decreased or #aria"le latency of response in ans$er to / estions, s dden stoppa*e of speech interr ptin* a tho *ht se/ ence ("loc7in*), and no speech (m te). Associated 'atterns of 6peech( Associated patterns may "e a) patterns of sentences and phrases, as seen in fli*ht of ideas, circ mstantiality and tan*entiality9 ") $ord patterns as seen in alliteration, clan* association and $ord salad9 c) sylla"le patterns as seen in neolo*isms. 2li*ht of ideas and circ mstantiality ha#e a de*ree of lo*ical str ct re or coherence. In tan*ential speech the connection "et$een t$o ideas is not nderstanda"le and is impossi"le to follo$ lo*ically. ). Terms sed to descri"e sentence and phrase patterns a. 1cholalia repeatin* $hat is said "y other people as if echoin* them. ". Circ mstantial speech a *oin* from one idea to another $ith the incl sion of many tri#ial details. The connection "et$een ideas can easily "e nderstood. The s ".ect may or may not reach the *oal. c. 2li*ht of ideas a rapid di*ression from one idea to another. The connection can "e follo$ed, " t $ith some$hat more diffic lty than in the case of circ mstantial speech. There is a certain coherence "et$een ideas, " t the direction is often chan*ed and the connections, tho *h present, may "e n s al. 2or e!ample, associations may "e made "y rhymin*, clan*in* or p nnin*. These latter types of associations are rarely, if e#er, seen in circ mstantial speech. d. Tan*ential, disconnected, incoherent, irrele#ant and loose associations are more or less e/ i#alent terms $hich descri"e ideas, sentences, phrases or $ords that follo$ one another $itho t any apparent lo*ical or nderstanda"le relationship. If the speech consists of a strin* of disconnected $ords, it is called $ord salad. e. 'erse#eration repeatin* the same $ord, phrase, sentence or idea o#er and o#er a*ain. ,. Terms sed to descri"e $ord patterns a. Clan* association connectin* to*ether $ords that ha#e the same so nd. 1!ample, +&o$ no$ "ro$n co$+. ". 4ord salad a series of disconnected or nrelated $ords. c. Alliteration $ords that follo$ one another that "e*in $ith the same so nd. 1!ample, +That "i* "ad "ear "o nced a"o t+. ,. Terms sed to descri"e sylla"le patterns a. Neolo*isms in#entin* ne$ $ords "y connectin* to*ether sylla"les.

@.

@I.

Part $: Affect May "e descri"ed in three parts( ). Type Is the patient0s mood depressed, normal or ele#ated, an!io s, fearf l, irrita"le, e phoric, hostile? ,. <a"ility ;oes the patient0s mood remain sta"le or does it chan*e noticea"ly as yo spea7 $ith him? Note that some de*ree of affecti#e la"ility is normal. To "e noted are de#iations from the normal in affecti#e la"ility. In affecti#e incontinence there is complete loss of control of emotion. In "l ntin* or flattenin* of affect, there is loss of the normal #aria"ility in emotion so that the patient0s affecti#e response seems to "e all on one plane. :. Appropriateness This is a #a* e and s ".ecti#e term and may incl de la *hin* at sad happenin*s and cryin* at happy ones, or la Belle indifference, in $hich the patient is "landly indifferent to serio s physical symptoms. Part ': Content of Tho *ht A. 'ho"ias Intense nreasona"le fears associated $ith some sit ation or o".ect s ch as hei*hts, cro$ds, closed places, airplanes, etc. B. 5"sessions The ina"ility to rid oneself of an idea or tho *ht $hich is reco*nized as "ein* senseless or at least dominatin* and persistin* $itho t ca se. It sho ld "e noted that the sine / a non of o"sessions and comp lsions is the desire to resist. C. Comp lsions Dec rrent acts $hich are reco*nized as forei*n or alien to the indi#id al accompanied "y the desire to resist. ;. ;epersonalization The patient feels that he is no lon*er his normal or nat ral self. 1. ;erealization A feelin* of nreality in $hich the $orld is e!perienced as flat, d ll, nreal or chan*ed. 2. Ill sion A misinterpretation of a sensory stim l s. 1!ample, a crac7 on the $all is interpreted as a sna7e. A. &all cination A false sensory perception occ rrin* in the a"sence of any related e!ternal sensory stim l s. &all cinations may "e of any of the fi#e senses and may "e *raded in se#erity. 2or e!ample, a ditory #er"al hall cinations (phonemes) may consist of( a) indistinct m m"lin*9 ") distinct $ords and messa*es9 c) complete sentences or con#ersations. 'honemes may "e localized $ithin the head or "ody of the patient, o tside of the patient0s "ody, or from a specific so rce s ch as the nei*h"ors or the lampshade. A special form of phoneme is a di"le tho *hts or the e!perience of hearin* one0s tho *hts spo7en alo d. Vis al hall cinations may "e similarly *raded. 5lfactory, * statory and tactile hall cinations are less common. &. ;el sion A del sion is a fi!ed, false "elief. A del sion may "e #a* e, $ith the patient ncertain re*ardin* the del sions or $illin* to consider alternati#e e!planations. The patient may accept the del sions ncritically, " t realize that other people may not "elie#e it, or he may also e!pect others to accept the del sion ncritically. They may "e circ mscri"ed, in#ol#in* fe$ areas of the patient0s thin7in* and "eha#ior, or massi#e, in#ol#in* many areas of his "eha#ior. In a del sional system there is one "asic del sion and the remainder of the system is lo*ically " ilt pon this error. I. 'ersec tory ;el sions The patient "elie#es he is "ein* ridic led, deli"erately interfered $ith, discriminated a*ainst or threatened. &e may feel that these feelin*s are deser#ed or ndeser#ed, the former "ein* partic larly common $hen associated $ith del sions of * ilt or sin. In del sions of passi#ity or infl ence, the patient "elie#es that his actions or tho *hts are "ein* controlled or infl enced in an n s al $ay s ch as "y radio $a#es, tele#ision, $itchcraft, etc. In del sions of reference, the patient 7no$s that people are tal7in* a"o t him, spyin* pon him, slanderin* him. &e may "elie#e that the tele#ision, radio or ne$spapers ha#e messa*es directed especially to him. In del sions of *rande r, the patient "elie#es he is a person of some e!alted station. In del sions of ill health and "odily chan*e, the patient "elie#es he has syphilis or is "ecomin* insane, that his "o$els ha#e t rned to cement, his "rain is rottin*, his *enitals ha#e shr n7, etc. In del sions of .ealo sy, the patient is mor"idly .ealo s and "elie#es that his partner has "een nfaithf l. Part 0: 6ensori m and Intellect al Deso rces This m st "e assessed sin* the miniCmental state e!amination, $hich is incl ded on all $riteC p forms. Part 1: Insi*ht and > d*ment A. Insi*ht si*nifies that the patient realizes that he is ill (if he is), and that he nderstands somethin* of the nat re of his illness. It may "e assessed "y as7in* the follo$in* sorts of / estions( Are yo sic7 in any $ay? 4hat sort of sic7ness do yo ha#e? ;o yo need help? 4hat sort of sic7ness do people ha#e here? B. > d*ment is "est assessed "y history from the informants, " t may "e appro!imated "y as7in* the follo$in* / estions( 4hat $o ld yo li7e to do ne!t? 4hat do yo plan to do $hen yo lea#e? ;o yo need to "e in the hospital? @II. Im ression: (yo r dia*nostic choice sin* ;6MCIIICD M ltia!ial 6ystem)

@III.

Differential Diagnosis: incl din* yo r impression as first choice. Be incl si#e, not e!cl si#e. Use precise terminolo*y.

@IV. Dis&"ssion: (s pport yo r dia*nostic choice) @V. Re&ommendations: (o tline) for ). ;ia*nosis ,. Therapy