Psychiatric History Notes PDF

Psychiatric History ➔ Cultural Formation Interview (CFI)- Exploring pt’s way of life via religion, culture & preferences (RESPECTFULL) ◆ Religious/spiritual identity ◆ Economic Class ◆ Sexual Identity/Safety ◆ Psychological M...

Psychiatric History ➔ Cultural Formation Interview (CFI)- Exploring pt’s way of life via religion, culture & preferences (RESPECTFULL) ◆ Religious/spiritual identity ◆ Economic Class ◆ Sexual Identity/Safety ◆ Psychological Maturity ◆ Ethnic/Cultural/Racial ID ◆ Chronological/Developmental Challenges ◆ Trauma & Threats to well being ◆ Family Hx ◆ Unique Physical Characteristics ◆ Location of Residence ◆ Language Differences ➔ Social Hx includes legal history (ie-Incarcerations) ➔ Mental Status Exam- psych equivalent of a physical exam ◆ Describes mental state & behaviors of person ◆ Includes objective & subjective info ◆ ABC STAMPLICKER (LICK is MMSE) Appearance: Attire, Eye Contact, Facial Expressions, Posture Behavior ○ Fidgeting- hair pulling, nail biting, table rapping ○ Voluntary Movement- lip smacking, tongue chewing, pulling clothes ○ Involuntary Movement- tics, tremors, dyskinesias ○ Pacing Cooperation: Attitude/pt’s approach to interview & interaction w/ examiner Speech ○ Quantity- Hyperverbal ◆ Poverty of Speech- Alogia ◆ Poverty of Content- many words, little info ◆ Intonation- varying pitch/speech ◆ Tone- expressive attitude/emotion ◆ Rhythm- pausing, spacing ○ Rate- normal, slow, rapid ○ Pressured speech- can’t get words out fast enough ○ Echolalia- repetition (How’s your day x3) ◆ Aphasia, Schizophrenia, Dementia, Catatonia, Epilepsy, CVA, TBI ○ Word Salad- the combination of words don’t make sense (Don’t worry I have Jesus leather) ○ Blocking- stops talking ○ Confabulations- memory disturbances ◆ Confuses imagination w/ real memories w/o trying to deceive ○ Neologisms- made up words ◆ In adults- sign of brain damage/schizophrenia ○ Circumstantial- irrelevant details & frequent diversions but stays focused on broad topic ◆ ‘What’s your name’ followed with a bunch nothing… my name is John ○ Tangential- connection from 1 thought to the next ◆ ‘How do you feel’- I was waiting in line at the store, I hate lines, waiting, I waited to get my driver’s license, driving these days is crazy  ○ Flight of ideas- rapid movement from 1 subject to another; loose connections ◆ ‘What do you like to eat?’- Peaches, beach, beaches, sandcastles fall in the waves, fee fi fo fum, golden egg ○ Preservation- continues talking about a topic when it’s moved on to other things ◆ ‘How have you been’- I think people are following me ◆ ‘Where do you live’- At my house & people have been following me ○ Clanging- grouping rhyming words (usually) that sound similar w/o a logical connection ◆ Imagine the worst ◆ Systematic; Sympathetic ◆ Quite Pathetic; Apologetic; Paramedic ◆ Your heart is prosthetic Thought Process ○ Linear/Goal oriented ○ Obsessions- distressing, obtrusive thoughts (Fearing germs, Getting sick & dying) ○ Ruminations- over contemplating to solve a problem ○ Compulsions- actions (Hand washing, checking stove) ○ Phobias/Anxieties ○ Hallucinations & Delusions (Perceptions) Affect ○ Appropriate- emotional tone in harmony w/ accompanying idea, thought or speech (broad full affect) ○ Inappropriate- disharmony b/t emotional feeling tone & idea, thought or speech accompanying it ○ Blunted- disturbance in affect manifested by severe reduction in intensity of externalized feeling tone ○ Restricted/Constricted- reduction in intensity of feeling tone less severe than blunted but clearly reduced ○ Flat- absence or signs of affective expression, monotone, immobile face ○ Labile- rapid abrupt changes in emotional feeling tone unrelated to external stimuli Mood- how they are @ baseline ○ Depressed, Euthymic, Elevated, Irritable, Optimistic/Pessimistic, Emotionless (Alexithymia) Perceptions ○ Healthy- based in reality & experience ○ Abnormal ◆ Hallucinations: Visual, Auditory, Olfactory, Tactile, Olfactory (do u see the monster) ◆ Illusions: misinterpreting stimuli (finger on the eiffel tower) ◆ Delusions- rigid belief despite absurdity & lack of supporting evidence ◆ Derealization- Not feeling in control  ◆ Depersonalization- detached from surroundings, feeling trapped, wall/glass is separating them from the world ➔ Mini Mental Status Exam (LICK)- screens for cognitive impairment, includes dementia ◆ Max score- 30 ◆ Part of psych/mental status & neurologic exam ◆ Level of Consciousness Alert, Lethargic, Obtunded, Stupor, Coma ◆ Insight & Judgement Insight- ability to be self aware & understand ones condition ○ Depression vs psychosis Judgment- considering & forming decision/action & intended outcome ○ What would you do if… ◆ Cognition- Biased & dependent on intelligence, culture & education Orientation- your name, what year is it, where are you rn Conceptual languages- idioms, naming, sentence, repetition, perform an action, read this word Focus/Attention- WORLD backwards Registration & Short term memory- Repeat the 3 words I tell you Visual/spatial- draw a clock ◆ Knowledge- amount of general info an individual stores in long term memory; prone to bias, ask about something they know Name last 5 presidents/State capital ◆ Endings (Suicidal/Homicidal) ◆ Reliability- ability to state accurate medical/psychosocial history Psychiatric History Pacing the Interview o Convey collaboration, free expression, trust, and self-exploration o Interviewer should be relaxed, receptive, NOT preoccupied, rushed, abrupt, or irritable Normalizing o Introduce topic by first making a statement that the behavior is a normal, or understandable, response to a mood or situation o Decreases pts shame about certain thoughts + behaviors o Use scripts to normalize: suicidal ideation, substance abuse (overestimate amount of drug use), depression, hallucinations Emotive o Create space (container) for emotions and be with them and the pt o Allow time for pt to cry, be angry, sad o NOT time for you to express emotions Safety o Always keep a path open à you should be between the door and the pt o Watch for escalation + know when to leave RESPECTFULL Model o Religious/spiritual identity o Economic class/background o Sexual Identity / Safety (must always include abuse in SOAP) o Psychological maturity o Ethnic/ Cultural/ Racial ID o Chronological / developmental Challenges o Trauma and threats to well being o Family history o Unique physical characteristics (tattoos, scars) o Location of residence  o Language differences HPI (use OLDCARTS) Past Psychiatric History o Anything not described in HPI o Tx interventions (hospitalizations, Baker Acts, suicide attempts) Family History o Psychiatric + substance abuse in relative o Abuse/domestic violence hx (present and past) o Pertinent medical conditions (CAD can cause depression) History of Substance Use or Abuse o Use = experimental, low frequency use o Abuse = regular / compulsive use (includes caffeine and nicotine) o Current substance use can be in HPI Social History o Occupation, military (very important), legal history/incarcerations, relationships, religion, pets, libido, appetite, activity (ADLs, socializing, exercise), sleep Mental Status Exam (MSE) aka Psychiatric Exam vs Mini Mental Status Exam (MMSE) o MSE is psychological equivalent of a PE (describes mental state + behaviors) o MMSE screens pt for cognitive impairment, including dementia MSE à ABC STAMPLICKER o Appearance ▪ physical characteristics of the patient: attire + grooming, eye contact, physical characteristics, facial expression (Sad, happy, flat) ▪ attentiveness ▪ position + posture o Behavior ▪ Level and quality of pts physical/motor movement ▪ Fidgeting, voluntary movements, involuntary movements, pacing o Cooperation ▪ Attitude, pts approach to interview + interaction w/ examiner + staff ▪ Friendly, uncooperative, hostile, arrogant, guarded, etc. o Speech ▪ Quantity (hyperverbal vs poverty of speech (Alogia- not talking a lot) vs poverty of content (many words, little info) ▪ Rate (normal vs slow vs rapid) ▪ Intonation, tone, stress, rhythm, audible ▪ Pressured speech = can’t get words out fast enough ▪ Echolalia = repeating, only able to repeat question and not able to answer ▪ Word salad = nonsensical combo of words ▪ Blocking = stops talking ▪ Neologisms = made up words, usually non-sensical and unrecognizable o Thought Processes/ content ▪ Relevant, organized, coherent ▪ Linear/goal directed ▪ Obsessions (Distressing, obtrusive thoughts)  ▪ Ruminations (over contemplating to solve a problem) ▪ Compulsions (Actions) ▪ Phobias/anxieties ▪ Can also include hallucinations and delusions ▪ Confabulations = memory disturbance, person confuses imagined scenarios w/ actual memories w/ NO intent to deceive ▪ Circumstantial = includes many irrelevant details and frequent diversions, but remains focused on broad topic ▪ Tangential = moves from thought to thought but never gets to main point. Connection from one thought to the next ▪ Flight of ideas = rapid movements from one subject to another. Loose connections ▪ Perseveration = continues talking about topic even when the conversation has moved on ▪ Clanging = groups of (usually rhyming) words that are based on similar-sounding sounds even though words don’t have logical connection o Affect ▪ The way the pt is at that moment, how the pt presents their emotional state, how they appear to feel ▪ Appropriate, inappropriate, Constricted, blunted, flat (nothing), labile (rapid change in emotion), incongruent o Mood ▪ How they usually are/baseline, how they feel ▪ Depressed, euthymic (everything’s fine), anger, anxious, dysphoria, elevate, irritable, impatient, cheerful, emotionless (alexithymia – I don’t feel anything) o Perceptions ▪ Healthy – based in reality ▪ Abnormal = hallucinations, illusions, delusions, derealization/depersonalization Delusions = rigid belief in something that is likely not true (grandiose, persecutory, jealous, somatic, erotomanic, mixed) Depersonalization = you don’t feel real Derealization – everything outside the person seems unreal o Level of Consciousness ▪ Alertness, Lethargy, Obtundation, Stupor, Coma o Insight and Judgement ▪ Insight = ability to be self-aware + understand one’s condition ▪ Judgement = process of considering and formulating a decision or action and intended/ expected consequences/outcomes o Cognitive Functions ▪ orientation, conception/language, attention and concentration (spell WORLD backwards), registration and short-term memory, long term memory, constructional and visuospatial ability, abstraction and conceptualization o Knowledge fund/base ▪ Amount of general info an individual stores in their long-term memory ▪ Ask about something they know o Endings (Suicidal/Homicidal)  ▪ “Are you thinking about hurting yourself or someone else?” ▪ Previous attempts, weapons in the home or other means o Reliability ▪ Ability to state accurate medical/psychosocial history Important Miscellaneous History o Coping mechanisms, values/ideal, aspirations Class Q o What part of cognition is tested by asking the pt to spell world backwards? (concentration) o Which of these describes an obsession? (Need for symmetry) o You ask a pt if they use an illicit drug and they say “Drugs are an interesting thing. There are so many drugs from A-Z, and I bet aardvarks and zebras don’t take any and neither do I”. This is an example of: (circumstantial) o A person who hears voices telling him to “go find fire under the house” is having: (hallucination) o What part of cognition is tested by asking pt to explain “a stitch in time saves nine”? (abstraction) o How would yfou assess a patients fund of knowledge? (ask the pt how to drive a car) o You ask a pt why they think they are having visual hallucinations and they answer it is bc the aliens are broadcasting into their brain. This is an example of: (poor insight) What is the greatest predictor of suicide? o Previous suicide attempt