02 - 24 - Psychiatric Assessment PDF [PDF]

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YL6: 02.24 09/03/2019 03:45-04:30



Psychiatric Assessment Family and Community Health Hannah Martella Maddatu-Pajarillo, MD, DSBPP PSYCHIATRY



IV. TECHNIQUES IN PSYCHIATRIC INTERVIEW



TABLE OF CONTENTS I. OBJECTIVES ...........................................................................................1 II. THE PSYCHIATRIC INTERVIEW ..........................................................1 III. GENERAL PRINCIPLES OF THE PSYCHIATRIC INTERVIEW ........1 IV. TECHNIQUES IN PSYCHIATRIC INTERVIEW...................................1 V. ELEMENTS OF THE INITIAL PSYCHIATRIC INTERVIEW ................2 A. THE HISTORY ...............................................................................2 B. OVERVIEW ....................................................................................2 C. PARTS OF THE PSYCHIATRIC INTERVIEW ............................2 VI. MENTAL STATUS EXAMINATION ......................................................3 VII. TOWARDS END OF THE PSYCHIATRIC INTERVIEW ....................5 QUICK REVIEW ..........................................................................................5 SUMMARY OF TERMS .....................................................................6 MNEMONICS .....................................................................................6 REVIEW QUESTIONS .......................................................................6 REFERENCES ............................................................................................7 REQUIRED .........................................................................................7 APPENDIX ...................................................................................................7



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The MOST important element in the evaluation and care of persons with mental illness Obtain information necessary to establish a criteria-based diagnosis A well-conducted interview must result in an understanding of the BIOPSYCHOSOCIAL elements of the disorder The interview is an essential part of the treatment process Medical history vs Psychiatric history Medical History → Subjective findings can be directly observed ▪ Complain about shortness of breath → Check chest and lungs ▪ Complain about abdominal pain → Check abdomen Psychiatric History → Subjectively revealed but CANNOT be directly observed ▪ Hallucinations ▪ Phobias ▪ Obsessions



III. GENERAL PRINCIPLES OF THE PSYCHIATRIC INTERVIEW •



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I. OBJECTIVES To give an overview about the psychiatric interview To differentiate a medical history and a psychiatric history To give an overview of the general principles of the psychiatric interview To review different interview techniques To review the parts of a psychiatric history To learn how to conduct a proper mental status examination



II. THE PSYCHIATRIC INTERVIEW •



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It is the job of the psychiatrist to make the patient comfortable How to make the patient comfortable Privacy and Confidentiality → Break only if there is a threat to themselves ▪ A lot of patients express they want to kill themselves but psychiatrists use suicide risk assessment Agree to the process → Make sure the patient comes voluntarily. Otherwise, they will not talk Establish rapport and empathy → Rapport – harmonious relationship between the physician and the patient → Empathy – Putting yourself in the shoes of the patient Safety and comfort → The Physician’s safety is priority → There should be 2 mode of exits in the psychiatrist’s office ▪ 1st door close to the psychiatrist, 2 nd door close to the patient → If only 1 door is available, physician should be closest to the door



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Facilitating Interventions Reinforcement – convey your interest in the patient continuing → Leaning forward to make the patient continue talking  Brief phrases such as: “I see”, “Go on” Reflection – using the patient’s words; statement of a fact → Nod, no judgmental tone Summarizing – opportunity for patient to clarify or modify the physician’s understanding → Summarize what has been identified about the certain topic Reassurance – to strengthen resolve to continue in treatment → Emphasize confidentiality → Example: Sa ngayon, ang mga itatanong ko po ay sensitibo. Kung ‘di po kayo komportable, sabihan nyo lang po ako. Encouragement – providing positive feedback about patient’s efforts Acknowledgement of emotion – leads to the patient sharing more feelings → Example: kumunot ang noo ▪ State fact/observation: “Napansin ko po na kumunot yung noo mo” or “mukhang nagalit ka, pwede mo bang sabihin ang dahilan?” → Note: Avoid asking “why” questions Humor – laughing with the patient, not at the patient  Sharing of humor can decrease the anxiety and reinforce the interviewer’s genuineness Silence – careful use can facilitate the progression of the interview Non-verbal Communication In interviews, the most common facilitating interventions are nonverbal. These indicate that the psychiatrist is concerned, listening attentively, and engaged in the interview. → Nodding of head → Body positioning (open stance) ▪ Avoid crossing of arms → Moving chair closer → Putting down pen or folder → Facial expressions Expanding Interventions Clarifying  Clarifying what the patient has said can lead to unrecognized issues or psychopathology Associations  As the patient describes his or her symptoms, there are other areas that are related to a symptom that should be explored  Example: symptom of nausea leads to questions about appetite, bowel habits, weight loss Leading  The story can be facilitated by asking a “what”, “when”, “where”, “who” question Probing  The interviewer can gently encourage the patient to talk about the topic at hand Transitions  Example: the patient is talking about her education degree in college, and the interviewer can ask, “Did that lead to your work after college?” Redirecting  Can be used when the patient changes the topic or when the patient continues to focus on areas that have not been covered yet Obstructive Interventions Close-ended questions – questions answerable by yes or no Compound questions – difficult for patients to respond because more than one answer is being asked from the patient → Example: umiinom ka ba? Kung oo, anong iniinom mo? Ilang baso? “Why” questions → Example: “Bakit mo ginawa ‘yun?” → Avoid these types of questions because patients would be defensive. It would seem like you (physician) are accusing them of something



Transcribed by TG 20: Aguinaldo, Burca, de los Santos, Galicia, Matinong, Pascual



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Judgmental questions or statements – inhibit the patient from sharing even more private or sensitive material → Example: Patient tells you that she had 5 sexual partners. Don’t react by saying “limaaa??” Minimizing patient’s concerns → Don’t belittle their worries/concerns → Patient may feel that the physician does not understand what he/she is trying to express Premature advice → Psychiatrists do not give advice. They make the patient realize what they’re supposed to do, NOT tell the patient what to do → Counselors tell patients what to do Premature interpretation  May be counterproductive because the patient may feel misunderstood Transitions  May interrupt important issues that the patient is discussing Non-verbal communication  The physician that repeatedly looks at a watch, yawns, or turns away from the patient conveys disinterest



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Transference Patient's unconscious feelings projected towards physician → Example: Patient is used to her mother having no time for her. Now she’s thinking twice about seeing her therapist because the therapist might think she’s too needy



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Countertransference Occurs when the physician transfers emotions to the patient → Example: During a psychiatric interview, Patient Jude shares how he had a bad childhood. The doctor would react by being emotional and saying he feels the same way.



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V. ELEMENTS OF THE INITIAL PSYCHIATRIC INTERVIEW A. THE HISTORY



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Usually more important than physical examination Must be familiar with the characteristic landmarks and milestones of each period of the past history → Include anamnesis: complete history from conception, prenatal care until present time Should convey a picture of a person and his individual characteristics



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B. OVERVIEW I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV.



Identifying data Source and reliability Chief complaint Present illness Past psychiatric history Substance use/abuse Past medical history Family history Developmental and social history Review of systems Mental status examination Physical examination Formulation DSM-5 diagnoses Treatment plan



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Mnemonic: I See Cool People Portray Some Pretty Faces During Reality Movies. Please Free Download the Torrent.



C. PARTS OF THE PSYCHIATRIC INTERVIEW • 



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Identifying data Must be clearly established during initial interview Typically includes patient’s name, age, gender, marital status, race or ethnicity, and occupation. Source and reliability Clarify where the information came from → Especially when people other than the patient has provided information (e.g. relative, yaya, boyfriend) Write the reliability whether it is good or poor



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Chief complaint Written using the patient’s own words E.g. Patient comes to you and says “Doc hindi po ako nakakatulog” → You do NOT write: Patient has insomnia → You write: “Hindi nakakatulog” YL6: 02.24



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Family and Community Health: Psychiatric Assessment



History of Present Illness Chronological description of the evolution of symptoms of the current episode What to note: → Onset and duration → Other symptoms → Stressors → Factors that alleviate or exacerbate symptoms → Severity → Why seek help now? ▪ Note: this was emphasized by Doc ▪ E.g. Patient comes to you with a complaint that started 5 years ago o How to properly ask: “Bakit ngayon lang po? Ano pong nangyari para masabi niyo sa sarili niyo na kailangan ko na magpacheck-up kung 5 years niyo na po palang nararamdaman?” o Do not bluntly ask: “So why seek help only now?” Past Psychiatric History Obtain all information about all psychiatric illnesses and their course over the patient’s lifetime, including symptoms and treatment. Past symptoms/episodes: → When they occurred → How long they lasted → Frequency and severity of episodes Past Treatments → Medications and dosages → Side effects ▪ Important reference for future prescriptions Past Diagnosis Substance Use, Abuse, and Addiction Expect some reluctance to share Use CAGE questionnaire for alcohol abuse (Note: Doc emphasized this) → Have you ever felt the need to CUT down your drinking? → Has anybody been ANNOYED because of your drinking? → Have you ever felt GUILTY about your drinking? → Have you ever felt you need to drink this in the morning as an EYE-OPENER? Periods of sobriety History of treatment Past Medical History Important consideration when determining potential causes of mental illness Medical illness can: → Precipitate a psychiatric disorder ▪ E.g. A patient comes to the ER at nagwawala (flies into a rage) o Labs showed sodium levels= 112 mmol/L (normal range = 135-145 mmol/L) o The patient is in delirium because of the low sodium levels (medical condition) and not psychiatric concern → Mimic a psychiatric disorder ▪ E.g. A patient comes to the ER very happy, hyper, and greets everyone o Thyroid levels were checked. Hyperthyroidism can mimic manic episodes o Upon checking, patient was already tachycardic and is about to have a thyroid storm → Be precipitated by a psychiatric disorder or its treatment ▪ Some treatments can cause metabolic syndromes → Influence the choice of treatment for a psychiatric disorder Family History Many psychiatric illnesses are familial There is a familial response to medications → When a patient’s family member has depression and is taking medications for it, usually, the same medication would work for the patient Look at relationships → Clarify terms clearly Developmental and Social History Also known as ANAMNESIS Reviews the stages of the patient’s life 2 of 7



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Important tool in determining the context of psychiatric symptoms Parts emphasized by Doc (see Appendix A for full version) → Early childhood ▪ Was the patient breastfed? (feeding habits) ▪ During the mother’s pregnancy, how was the relationship of the mother and father? (prenatal history) o Was there a father figure? ▪ Who took care of the patient when he/she was a child? ▪ How was the child disciplined? → Middle childhood ▪ Related to school ▪ Was the patient sent to the principal’s office? ▪ How was the school performance? Average, above average? → Later childhood ▪ Peer relationships ▪ Check for depression (15-24 years old) → Adulthood



Review of Systems NOTE: This part was not discussed by Doc  Attempts to capture any current physical or psychological signs and symptoms not already identified in the present illness  Particular attention is paid to neurological and systemic symptoms • • • • • •



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VI. MENTAL STATUS EXAMINATION The psychiatric equivalent of the physical exam in the rest of medicine Explores all areas of mental functioning including the cognitive functioning Gives a clinical snapshot of the patient’s mental status at the time of examination Must not be confused with MMSE (mini-mental status examination) → MMSE: used to check for patient’s cognitive functioning → MMSE more neurological than psychiatric Has 16 parameters Appearance & Behavior Describing the patient’s distinguishing features → Keep in mind that after describing patient’s appearance, the doctor should be able to identify which one is the patient in a room full of people Appropriateness of attire and accessories Grooming and hygiene Appears of stated age? Behavior: patient’s approach to the interview Examples: → “A 60-year-old woman who is wearing excessive number of accessories” → “A 15-year-old dark-skinned boy with tattered clothing seating in a wheelchair” Motor Activity Normal, slowed, or agitated Gait, limitations in movement, posturing Examples: → Tics: Habitual spasmodic contraction of the muscles → Mannerisms: Habitual characteristic way of doing something (not discussed) → Stereotypes: Ritualistic movement in response to a certain stimulus like body rocking (not discussed) Speech How the patient says it (the physical quality of the speech) Fluency: has full command of native language Production → Hyperproductive: Talkative → Lag/Hypoproductive: Responds slowly → Normoproductive: normal rate Rate: Fast or Slow Tone and Volume  Decrescendo: From loud to soft volume  Crescendo: From soft to loud volume Quantity  Talkative? With poverty of speech? Mute? Quality  Pressure (rate/speed)? Monotonous (tone)? Loud/Mumbled (volume)? Comprehensible (fluency)?  Coherence can be noted here, but it is more appropriate to observe the thought process YL6: 02.24



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Impairments in the speech  Stuttering Spontaneous or not? Mood & Affect How do you feel today? Mood: Internal and sustained emotional state → How patient describes his state → Use patient’s own words Affect: External state; Inferred from the patient’s facial expression → What the clinician perceives Is the patient’s mood inappropriate to her affect? → The patient said he feels empty (mood) but he is inappropriately laughing (affect)



Elements of Affect NOTE: This part was not discussed by Doc but part of her powerpoint  Quality: dysphoric, happy, euthymic, irritable, angry, agitated, tearful, sobbing, flat, labile (seesaw shift of emotions)  Quantity: measure of intensity (compared to others with same condition)  Range: normal, restricted, labile or flat  Normal range, constricted (parang pinipilit), blunted (nagpapatawa ka but then ayaw tumawa; example: grimacing instead of a laugh), or flat (same emotion all throughout)  Arranged from “highest” to “lowest”  Flat: monotonous voice, immobile face, no sign of expression  Appropriateness: Is the affect appropriate with the mood or the situation?  Congruence  Is the affect congruent with the mood?  If mood is happy, the external expression may be to smile  Does it correlate to the setting? • • •



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Family and Community Health: Psychiatric Assessment



Thought Content What thoughts are occurring to the patient Questions asked: What is the patient thinking about? Inferred by what the patient spontaneously expresses, as well as responses to specific questions aimed at eliciting particular pathology Problems with thought content Obsessions: Unwelcome and repetitive thoughts that intrude into the patient’s consciousness. Delusion: Fixed false beliefs that are not shared with other people → “Galit siya sa akin” pero wala namang galit sa kanya Suicidality and homicidality: Thoughts about suicide, death and of hurting other people. Don't be afraid to ask because it opens the door for discussion → They realise “may nakakapansin pala” so nagdadalawang isip sila Paranoia  Can be closely related to delusional material  Soft paranoia: general suspiciousness  Severe paranoia: negative effect on day-to-day functioning  Questions that elicit paranoia include asking about the patient worrying about cameras, microphones, or the government. Preoccupations Compulsions  Repetitive, ritualized behaviors that patients feel compelled to perform to avoid an increase in anxiety or some dreaded outcome Phobias Ideas of reference  The feeling that a patient has something negative being remarked about him/her  “Do you feel that the TV or radio has a special message for you?” Poverty of content  Reduction in the quantity of thought Thought Process Describes how the patient’s thoughts are formulated, organized, and expressed Normal thought process is described as linear, organized, and goal-directed



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Ex. When asked “Ano mga ginawa mo para maka-get over sa kanya?” → Linear thought process: answers questions directly ▪ I unfollowed him sa Twitter at Instagram, binenta ko yung bags na bigay nya and I just focused sa studies ko → Problems with thought process Problems with thought process Circumstantial: Answers questions but gives a lot of unnecessary information → It was hard though. We’ve been together tor 3 weeks, gabigabi kami magka-chat. She even watched me compete sa jiujitsu. She has this unique cheer for me so I would know sya yung sumisigaw. Minsan kita sa mall, she cheers me, papacute. But I just have to move-on. Play video games, watch movies, among others. Clang association: Did not answer the question. Association by sound (rhyming) of words rather than meaning → “Siya si Mr. Bean, manhinhin, walang pinapansin. Hiwalay? Eh di waley! Babay!!” Flight of ideas: Patient moves rapidly from one thought to another at a fast pace. Challenges the listener to keep up with ideas that are logically connected → “Nagpunta sa ano... Sa MOA! Emote emote. Nakakita pa nga ako ng puting bulaklak, sign yun na kailangan ko mag moveon. Dati binibigyan nya ako ng bulaklak, violet tulips. For me, tulips are the best flowers. When I was in Seattle sa US, I saw tulips during spring....” Thought blocking: Patient is unable to complete a thought. May stop mid-thought or mid-sentence → “I called up my parents, tapos sabi nila sa akin that I should...” Neologism: Answers questions using words that are made-up, not understandable, or undefined in the dictionary → Neo = New (words) → “Hagardo Versoza lang. I accept that we are like waterola. You know like water and minola. We just don’t mix. Iniisip ko lang, na-Duterte ako.” Perseveration: Patient will go back to the topic despite examiner’s attempts to change the subject. Focuses on a specific idea or content → “ I just sleep it off when I’m sad” “Some may say I am just escaping but, I just feel better when I get to sleep” Tangentiality: Reply is appropriate but did not directly answer questions → “Ang hirap, but I know God will not forsake me.” Loosening of association: No logical flow of thinking. Do not answer the question and makes no sense → Unlike word salad, loosening of association still has subject and predicate but together, makes no sense → “I wanted to go away. Far way, near the seashore. Where fire and water and the bed with all its wonders. Sometimes you win, but you better watch out. The rabbits will eat you alive.” Word salad: Just tossing words out without making any sense, babbling → “Step cellphone in the hair. The cellphone! Rainbows and curtains, smell baby cellphone rocking!” Perceptual Disturbances Perception of the 5 basic senses Hallucinations: False sensory perceptions in the absence of a stimuli → Wala namang bumubulong pero sinasabi niyang meron → Wala namang lason pero nalalasahan niyang may lason Illusions: there is a perception but you misperceive a real external sensory stimulus → Mukhang palaka pero tao pala Depersonalization: The feeling that the person is unreal, strange, unfamiliar → “Am I real? Am I really here?” Derealization: The feeling that the environment is unreal, feeling like one is in a dream Cognition Seeks to assess organic brain function



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Family and Community Health: Psychiatric Assessment



Organic brain disorders can present as symptoms of some illnesses such as psychosis, depression, delirium, dementia



Levels of Alertness The skill needed here is observation Awake a. Patient is alert b. Responds fully and appropriately Drowsy/ Lethargic/ Somnolence a. Extreme decrease in activity b. The quality or state of being drowsy; state of obtrusion Obtunded Stuporous a. Arouses from sleep only after painful stimuli b. Lapses into an unresponsive state when stimuli ceases c. Minimal awareness of environment Coma → No evident response to inner need or external stimuli Orientation To time → Ask about time of the day, day of the week, month, season, date and year, duration of hospitalization → Usually the first to be affected in cases of delirium and dementia To place → Ask about patient’s residence and names of the hospital, city and state the patient is currently in To person → Ask about the patient’s own name and names of relatives and personal personnel → Not to be confused with delusion (fixed false belief that is not culture-bound) Concentration and Attention Test through serial subtraction by 7’s from 100s → Give the patient the instruction to test their concentration if they follow well enough. ▪ “Mula 100, magbabawas po tayo ng 7. Yung sagot po doon, babawasan niyo uli ng 7. Yung sagot po uli doon, babawas uli tayo ng 7. Bawas lang nang bawas ng 7 hanggang sabihin kong tama na.” → Also, if the patient is having a difficult time (or is illiterate), they may subtract in 3s or use 20 as a starting number. Patient can also be asked to spell “world” or “karne” normal or backward/reverse. Patient can also be asked to name 5 things starting with a certain letter Usually used to test patients suspected of having delirium Can also be important for patients suspected of depression, bipolarity, or ADHD → Patients with these conditions may have impaired attention span Calculation For common Filipino people, ask in the context of a day to day interaction: → “Binigyan ka ng 10 biscuits, kumuha ako ng 5 sa iyo. Ilan na ang natira sa iyo?” → “Sa palengke, pinabili kayo ng bigas; isang kilo, 45 pesos. Magkano ang 3 kilo ng bigas?” Memory Immediate memory: few seconds to minutes → Repeats 3 words after 3-5 minutes (ex. bola, mangga, puno) → Repeats 5 figures after examiner dictates them, forward and backward Recent memory: few hours to few days → e.g. “What did you eat for breakfast?” Recent past: the past few months Remote: years → Childhood data, important events, personal matters Reading and Writing Ask the patient to read a task and ask him to do what they just read → (e.g. “Close your eyes”) Ask the patient to write a simple but complete sentence with coherent thought



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Fund of knowledge and intelligence Patient can be asked to enumerate the last 5 presidents of the Philippines Ask for a list of presidents, cities in Metro Manila, national heroes, etc. Remember to tailor your test based on your patient’s educational level and socioeconomic background Abstract thinking/reasoning Ability to reason and to shift back and forth between general concepts and specific examples Tests understanding of concepts Can be examined by asking for similarities and differences between two things → E.g. Apples vs. oranges Patient can also be asked to interpret a proverb → Sometimes better because it also tests morality → Patients with psychiatric problems are often unable to interpret → Example given in class: “Better a diamond with a flaw than a pebble without one. -Chinese Proverb” Assessment: → There is no right or wrong answer; it only assesses if the thinking is abstract or not → If explanation is too concrete or literal, there is poor abstract thinking ▪ “Okay lang maging dyamanteng may gasgas kaysa sa makinis na bato, wala namang value” → If explanation is on the level of concept, good abstract thinking ▪ Ex. Concept applied to yourself – Career, education, etc. Cultural and educational factors and limitations must be kept in mind Judgement Refers to the person’s capacity to make good decisions and act on them 2 types: → Test judgement: uses traditional hypothetical examples ▪ “Kapag nakaamoy ka ng usok sa sinehan, anong gagawin mo?” o Good judgment: Look where the smoke is coming from. o Bad judgment: Run immediately. (No inspection done) → Social judgement: uses real situations from patient’s own experience Insight Degree of personal awareness and understanding of the disease Patient may NOT have good insight but has good judgment Levels: → 1 – Complete denial  Patient refuses to acknowledge the situation or circumstance he/she is in → 2 – Slight awareness but still denying  Patient partly acknowledges circumstances but insists that his/her condition will improve soon → 3 – Blames others  Patient refuses to acknowledge own mistake; blames other people for current condition → 4 – Intellectual insight  Patient acknowledges and accepts his condition but refuses to do anything about it → 5 – True emotional insight  Patient acknowledges and accepts his condition and tries to do something about it  Highest level of emotional awareness that initiates change in behavior



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Physical Exam In the OPD setting – little or no PE done → Usually get vital signs → If the patient presents difficulty in breathing, then we are expected to attend to them ▪ e.g. Auscultation and other procedures necessary for the situation. Focused neurological evaluation is an important part



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Closing the Interview The last 5-10 minutes is very important What happens: → Patient brings up something important → Issues that the patient wants to share ▪ Acknowledge the importance of the issue, but educate the patient by telling them that the issue may be discussed in the next session because the current session is about to end. → Give patient opportunity to ask questions



QUICK REVIEW • • •



Psychiatric Interview Most Important element in the evaluation of mental illness Medical history – subjective findings can be observed Psychiatric history – subjectively revealed but can not be directly observed



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How to Make patient comfortable Privacy and confidentiality Agree to the process Establish rapport and empathy Safety and comfort



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VII. TOWARDS END OF THE PSYCHIATRIC INTERVIEW •



Treatment Planning Discussed with the patient or family or companion



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Family and Community Health: Psychiatric Assessment



Interview Techniques Facilitating interventions → Reinforcement → Reflection → Summarizing → Reassurance → Encouragement → Acknowledgement of emotion → Humor → Silence Non-verbal communication → Nodding of head → Body positioning → Moving chair closer → Putting down pen and folder → Facial expressions Expanding interventions → Clarifying → Associations → Leading → Probing → Transitions → Redirecting Obstructive interventions → Close-ended questions → Compound questions → “Why” questions → Judgmental questions or statements → Minimizing patient’s concerns → Premature advice → Premature interpretation → Transitions → Non-verbal communication Elements of the Initial Psychiatric Interview Identifying data Source and reliability Chief complaint → Use the patient’s own words Present illness → Chronological description of the evolution of symptoms of the current episode → Why seek help now? Past psychiatric history → Past symptoms/episodes → Past treatments → Past diagnosis



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Substance use/abuse → CAGE questionnaire ▪ Have you ever felt the need to CUT down your drinking? ▪ Has anybody been ANNOYED because of your drinking? ▪ Have you ever felt GUILTY about your drinking? ▪ Have you ever felt you need to drink this in the morning as an EYE-OPENER? Past medical history → Medical illness can ▪ Precipitate a psychiatric disorder (e.g. low sodium levels) ▪ Mimic a psychiatric disorder (e.g. hyperthyroidism) ▪ Be precipitated by a psychiatric disorder or its treatment ▪ Influence the choice of treatment for a psychiatric disorder Family history → familial response to medications Developmental and social history → Anamnesis → Early childhood ▪ Pre-natal ▪ Discipline → Late childhood ▪ School-related concerns → Later childhood ▪ Peer relationships ▪ Depression → Adulthood Review of systems



SUMMARY OF TERMS



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Anamnesis: complete history from conception, pre-natal care until present time



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I See Cool People Portray Some Pretty Faces During Reality Movies. Please Free Download the Torrent. → Identifying data → Source and reliability → Chief complaint → Present illness → Past psychiatric history → Substance use/abuse → Past medical history → Family history → Developmental and social history → Review of systems → Mental status examination → Physical examination → Formulation → DSM-5 diagnoses → Treatment plan CAGE → Cutoff → Annoyed → Guilty → Eye-opener



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MNEMONICS



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Mental Status Examination Appearance & Behavior: features, appropriateness and hygiene Motor Activity: normal, slowed, agitated Speech: fluency, production, rate Mood & Affect: emotions feeling inside and showing outside Thought Content → Obsessions: unwelcome and repetitive thoughts → Delusion: fixed false beliefs → Homicidality: thoughts on hurting other people → Suicidality: thoughts on hurting yourself Thought Process → Circumstantial: answered but too much info → Clang association: rhyming → Flight of ideas: one topic to another → Thought blocking: sudden end → Neologism: made-up words → Perseveration: keeps going to the same topic → Tangentiality: not directly answered but appropriate → Loosening of association: no sense → Word salad: babbling Perceptual Disturbances → Hallucinations: absence of stimuli → Illusions: perception is misperceived → Depersonalization: feeling that a person is unreal → Derealization: feeling that the environment is unreal Cognition → Alertness: awake, drowsy/lethargic, obtunded, stuporous, coma → Orientation: time, place, person → Concentration and attention: serial 7 → Calculation → Fund of knowledge and intelligence: enumerate 5 names of PH presidents or 5 cities in Metro Manila → Abstract thinking/ reasoning: concrete thinking vs abstract thinking; general concepts and specific examples Judgment → Test judgment: traditional hypothetical examples → Social judgment: real life situation from patient’s experience Insight → Deepest level of personal awareness and understanding of disease → 5 levels: complete denial, slight awareness but still denying, blame others, intellectual insight, true emotional insight



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During the initial psychiatric review, the following must be done EXCEPT a) Clarify where the information came from b) Write the chief complaint in the patient’s own words c) Enumerate the evolution of symptoms of the current condition depending on magnitude d) Look at relationships of family members Which of the following is asked in the CAGE questionnaire? a) Have you ever felt guilty about your drinking? b) Have you ever felt the need to drink in the morning as an earopener? c) Have you ever felt the need to cool your drink? All of the statements are obstructive interventions in interviewing, EXCEPT: a) Bakit ka galit? b) Saan ka pumunta kagabi? Sinong kasama mo? Paano ka pumunta doon? c) Ahh, ganoon po ba. Ano pa pong nangyari? d) *silence for 5 seconds* True or False. Psychiatrists give advice. They tell the patients what they’re supposed to do. What is the most important element in evaluating a person’s mental illness? a) Psychiatric interview b) Family map c) Diet d) Family lifeline Which one is not a way to make the patient comfortable? a) Privacy and confidentiality b) Agree to process c) Safety and comfort d) Offering gifts These are all kinds of perceptual disturbances, except a) Hallucinations b) Delusion c) Illusions d) Depersonalization What is a kind of thought process that uses rhyming words in a sentence? a) Neologism b) Perseveration c) Clang association d) Tangentiality



Terminating the Interview Physical exam Treatment and planning Closing the interview



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Which response shows good judgment on what to do when there is sound of gunshot nearby? a) Cover your ear and hope that the sound would go away. b) Immediately dash towards the source of the sound to confirm if it’s gun which shot it. c) Drop down the floor to avoid the bullet. d) Staying vigilant of the surrounding while mobilizing to a safe place. 10. True or false. In doing serial 7 during OSCE, you have to give the full instruction to the patient on how to do it. Answers 1. C. History of present illness must be written in chronological order not depending on the magnitude. 2. B 3. C and D. Both are examples of facilitating interventions. C – reinforcement, D – silence 4. False. Psychiatrists make patients realize what they’re supposed to do, NOT tell them what to do. Counselors tell patients what to do 5. A 6. D 7. B 8. C 9. D. Because the person is heading to a safe place while staying low in case that the sound was really from a gun. 10. True. Because you are already testing for the concentration in giving the instructions.



REFERENCES REQUIRED (1) (2) (3)



ASMPH Batch 2022. 2017. Trans Format. Maddatu-Pajarillo, H. 2019. Psychiatric Assessment [Lecture slides]. Sadock, Benjamin, and Pedro Ruiz. Kaplan & Sadock's synopsis of psychiatry: behavioral sciences. Walters Kluwer, 2015. IMPORTANT LINKS



Trans evaluation link: https://tinyurl.com/AcadsTransFeedback Link to Word document: https://tinyurl.com/23YL6FCH[Lecture#]



APPENDIX Appendix A. Developmental and Social History



YL6: 02.24



Family and Community Health: Psychiatric Assessment



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