Psychiatric versus Physical Illness

 Diagnosis based on etiology is not likely  No external validating criteria  Addressed by DSM
y

Diagnostic criteria based on descriptive phenomenology

Psychiatric History
y 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 History
Identifying 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. Values
I.

Identifying Data
y 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 Complaint
y In patient s own words on why patient was brought in

for help y Record also version of other individuals present

History of Present Illness
y 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 Illnesses
y Medical history y Psychiatric history y Alcohol and Substance history

Family History
y 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 problem
y 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 History
y Home situation into which patient was born y Wanted or planned pregnancy? y Maternal health problems y Maternal substance abuse

Early Childhood
y 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 childhood
y Gender identification y Disciplinarian in the family and punishments used at

home y Separation anxiety on first school day y Relationship with friends

Late Childhood
y 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

Adulthood
y Occupational history y Marital and relationship history y Military history y Educatioin history y Religion y Social activity y Legal history

Sexual History
y 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 Dreams
y 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

Values
y Social and moral values y Values about money, work, play, children, parents, sex,

community concerns, cultural issues

Mental Status Examination
y 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 Description
y 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 activity
y

y Attitude toward examiner
y

Speech
y Describe in terms of quantity, rate of production and

quality
y Talkative, unspontaneous, normally responsive, y Rapid, slow, hesitant, monotonous, whispered, slurred y Unusual rhythms (dysprosody)

Mood and Affect
y Mood y patient s subjective emotional state y Depressed, despairing, irritable, anxious, euphoric, frightened, perplexed

Mood and Affect
y Affect - objective emotional expression; what examiner infers

from patient s facial expression/expressive behavior
y

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 Affect
y Appropriateness y Considered in context of what patient is discussing

Perceptual Disturbances
y 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 Process
y 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 Process
y 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 Content
y What a person is actually thinking about: ideas,

beliefs, preoccupations, obsessions y Delusions
y 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 Cognition
y 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

Remote
childhood data, important events before illness Last to be impaired

‡ ‡ ‡
y

Recent past past few months Recent past few days Immediate retention
Repeat 3 words immediately and 3-5 min later

‡
y

Confabulation
Unconsciously 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 answers
Giving 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

Impulsivity
y Ascertains patient s awareness of socially appropriate

behavior y Measure of patient s potential danger to self and others

Judgment
y

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

Reliability
y Estimate of psychiatrist s impression of patient s

truthfulness or veracity

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