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CMN 548 Module 1 study guide
1. GUIDE SADOCK Chapter 7.1 - 7.2, 7.6: Complete the following table which outlines the elements of the initial
psychiatric interview:
2. Identifying data Topic: Name, age, sex, marital status, religion, education, address, phone number, occupation, source
of referral
3. Identifying data Questions: Be direct in obtaining identifying data. Request specific answers.
4. Identifying data Comments and helpful hints: If patient cannot cooperate, get information from family member
or friend; if referred by a physician, obtain medical record.
5. Chief complaint (CC) topic: Brief statement in patient's own words of why patient is in the hospital or is being seen in
consultation
6. Chief complaint (CC) questions: Why are you going to see a psychiatrist? What brought you to the hospital? What
seems to be the problem?
7. Chief complaint (CC) comments and helpful hints: Record answers verbatim; a bizarré complaint
points to psychotic process.
8. History of present illness (HPI):: Development of symptoms from time of onset to present; relation of life events,
conflicts, stressors: drugs; change from previous level of functioning
9. History of present illness (HPI): questions: When did you first notice something happening to you? Were you
upset about anything when symptoms began? Did they begin suddenly or gradually?
10. History of present illness (HPI): comments and helpful hints: Record in patient's own words as
much as possible. Get history of previous hospitalizations and treatment. Sudden onset of symptoms may indicate drug-induced
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11. Previous psychiatric and medical disorders:: Psychiatric disorders; psychosomatic; medical,
neurologic illnesses (e.g., craniocerebral trauma, convulsions).
12. Previous psychiatric and medical disorders: QUESTIONS: Did you ever lose conscious- ness?
Have a seizure?
13. Previous psychiatric and medical disorders: comments and helpful hints: As- certain extent
of illness, treatment, medications, outcomes, hospitals, doctors. Determine whether illness serves some additional purpose (secondary gain).
14. substance use/abuse: Substance use disorders can mimic or induce psychiatric syndromes, elevate risk
of suicide and violence, and have important impact on safe medication prescribing. Various tools can be used to aid in gathering the substance use history. Examples include the commonly used CAGE questionnaire which has been modified to include other drugs (and now called CAGE-AID)
15. Past medical history: The interviewer is interested in obtaining an accounting of major medical disorders
both to develop a complete history and to identify illness that could mimic a psychiatric disorder, contribute to the context of the presentation or factor into treatment planning.
16. Family History (FH): topic: Psychiatric, medical, and genetic illness in mother, father, siblings; age of
parents and occupations; if deceased, date and cause; feelings about each family member, finances. Because many psychiatric illnesses have a genetic predisposition, if not cause, a careful review of family history is important to the assessment and can aid in diagnosis and establishing expected prognosis.
17. Family History (FH): question: Have any members in your family been depressed? Alcoholic? In a
mental hospital? In jail? Describe your living conditions. Did you have your own room?
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25. review of systems: psychosis: Experience of hallucinations, delusions, disorganized behavior, speech or
thought, negative symptoms
26. review of systems: obsessive-compulsive: Repetitive intrusive and unwanted thoughts, com- pulsive
behaviors to neutralize anxiety, hoarding behaviors
27. review of systems: trauma: Traumatic exposure; intrusive and avoidance symptoms, negative alter- ations in
cognitions and mood, excessive arousal and reactivity
28. review of systems: behavior: Substance use, gambling, impulse control problems, disordered eating,
repetitive self-harm
29. mental status exam: The MSE is the functional equivalent of the physical examination in other areas of medicine.
It is a systematic collection of the observations (e.g., signs such as blunt attect or rapid speech) and reported mental experiences (e.g., symptoms such as depressed mood or hallucinations) that produce a picture of the patient's current mental state. The interviewer makes these observations throughout an encounter and ultimately documents the findings together in the MSE section of the evaluation document.
30. physical exam: Psychiatrists do not usually personally conduct comprehensive physical examinations but
may conduct focused examinations such as neurological or thyroid examinations. In the outpatient setting, the psychiatrist generally relies on the PCP to conduct the physical examination and it is useful in the initial evaluation to record the date of the most recent physical examination and review of recent laboratories if results are available.
31. plan formulation: The formulation should include a brief summary of the relevant findings from the history
and examination including the psychosocial contexts in which the problem has developed and comments on the relevant contributions to the presentation of personality function, medical problems, social stress, and other social and cultural factors. Finally, the formulation should include a summary of the risk assessment with estimates of acute and long-term risk of suicidal or violent behavior and opinion about the appropriate level of care that will lead to a safe and successful outcome.
32. treatment plan: When evaluation produces treatment recommendations, these are typically shared with the
5 / 48 patient at the conclusion of the encounter in a manner consistent with the patient's capacity to receive and process the information and with explicit discussion of matters relevant to informed consent for recommended treatment. Treatment discussions typically involve a good deal of psychoeducation about diagnosis, the nature, risks, and benefits of recommended treatments and information that addresses stigma and adherence. It is wise to involve significant others in these conversations especially if there are concerns that the patient may need assistance in processing information and making decisions to ensure that decisions are consistent with the patient's best interest. Recommendations may include referral to other professionals or peer supports such as the National Alliance for Mental Illness (NAMI), the Mental Health Association (MHA), or Alcoholics Anonymous (AA). Plans for crisis contacts and supports are typically addressed. All of these counseling and coordination of care ettorts should be documented in the medical record.
33. Carlat, Chapter 14: ch 14
34. 1. How is the history of present illness different from the past psychiatric
history?:
35. Why is it important to have an understanding of the history of present illness if I'm
going to obtain the psychiatric history anyway?:
36. What time period should be covered in the history of present illness?: Often, psychiatric
crises occur over a 1- to 4-week period.
37. What are some common mistakes made by beginners in obtaining the history of
present illness?: The most common pitfall for beginners is spending too much time on the HPI
38. What are some examples of questions that can be asked to obtain a history of
present illness when the patient is in a crisis?: What has been happening over the past week or two that has brought you into the clinic? Have there been any events that you think have caused your problem or made it worse? Have you sought
7 / 48 the discussion of the smooth transition in Chapter 6). If the interviewer had not actively structured the interview this way, the patient might have discussed details of his work environment that would be less relevant to the diagnosis of major depression. Later, when ascertaining the social history, the interviewer can refer to what the patient said about work.
44. Why is it important to have an understanding of how the patient was func- tioning
prior to this exacerbation of their mental illness?: Asking about current versus baseline functioning is important diagnostically. The classic example is the ditterence between schizophrenia and bipolar disorder. In schizophrenia, the patient's level of functioning gradually decreases over months or years, whereas in bipolar disorder, the patient may have been functioning dramatically better within the past few weeks. Determining baseline functioning is also important in setting treatment goals. You might aim to help the patient achieve his best level of functioning over the past year.
45. Carlat Chapter 15: Chapter 15
46. What is the purpose of obtaining the past psychiatric history?: goals of establishing a
diagnosis and formulating a treatment plan.
47. Why is it important to obtain a chronological view of the patient's past
psychiatric history?: Specific psychiatric disorders have specific natural histories, with characteristic risk factors, prodromal signs, ages at onset, and prognoses. Obtaining a detailed PPH for a particular patient allows you to compare the course of her illness with the textbook's version of the course of illness, increasing the likelihood that you will make a correct diagnosis.
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48. What are some important points to cover in the past psychiatric history?: -
Include questions about the severity of episodes and exacerbations, as well as the duration of episodes. Often, this information comes out when you are obtaining the treatment history. For example, episodes of mania or exacerbation of schizophrenia often correspond with hospitalizations. As with hospitalizations, a time-eflcient method of asking about episodes is to ask about the first one, the latest one, and the total number of episodes.
49. About how long should the psychiatric history take to complete?: one or two
50-minute sessions for PPH. HPI between 5-10 minutes
50. Complete the following table which summarizes the components of the
psychiatric history:
51. Age of onset of symptoms: Knowing the age at onset may help you to decide between potential
diagnoses, with anxiety disorders having a much earlier onset than either mood disorders or schizophrenia
52. Premorbid functioning: p. 94, 90- 91
To assess overall functioning, ask about the three basic aspects of life: love, work, and fun. Love includes all-important relationships: family, spouse, and close friends. In addition to paid employment, work includes school, volunteer activities, and the structured day activities in which many chronically mentally ill patients participate. Fun refers to hobbies and recreational pursuits.
53. Subsequent episodes of illness: 94- 95
Include questions about the severity of episodes and exacerbation, as well as the duration of episodes. Often, this information comes out when you are obtaining the treatment history. For example, episodes
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56. Current caregivers: 96
You will need to know who your patient is seeing currently. If he is a new patient, you may be the only caregiver. If you are interviewing a patient with a chronic mental illness, he will likely have both a therapist and a psychopharmacologist, and he may also have a case worker (usually a social worker), a group therapist, and a primary care doctor (a family practitioner or an internist) and may be involved in day treatment or residential treatment
57. Hospitalization history: 96- 97
For patients who have had multiple hospitalizations, do not spend your time ascertaining the names of the hospitals and dates of each admission; this could take the entire 50 minutes. Instead, find out when they were first and last hospitalized and about how many hospitalizations they've had over their lifetime. If a patient has had many hospitalizations, try to find out if they are clustered around a specific few years. Some patients will have had several hospitalizations earlier in the course of their disorder because they had little insight into their problem and were non compliant with their medications. Later in life, their hospitalizations may be spaced much farther apart. Alternatively, the opposite pattern may appear, in which an ettective disorder worsens with age. Think of hospitalizations as markers of disease severity.
58. hospitalization history 2: When were you first hospitalized?
How many hospitalizations have you had in your life? How many have you had in the past year? When was your last hospitalization? In addition to asking these questions, it is often useful to ask why your patient was hospitalized: In general, what
11 / 48 sorts of things have caused you to need to be in the hospital? Your assumptions about reason for hospitalization may be wrong, as illustrated by the following example CLINICAL VIGNETTE A patient with chronic schizophrenia stated that he'd been hospitalized several times over the past 2 years. The resident initially assumed that these hospitalizations were for psychotic de-compensations, but when asked, the patient said that most were alcohol detoxification admissions. This prompted the resident to obtain a much more thorough substance abuse history than he had planned.
59. Medication history: 97- 98
The most important limit on the bio-availability of medication has nothing to do with pharmacodynamics or pharma- cokinetics; rather, it is patient noncompliance. Have you been on medications for your depression? For how many weeks did you take your medications?
60. Medication History: To the extent possible, document all the medications the patient has tried. Many patients will
not remember generic names or may only remember what the pill looked like or the side ettect it caused. Obviously, the more you know about alternative names, shapes, and side ettects of medication, the more eflciently you will be able to obtain this history. I find smartphone apps such as Epocrates to be helpful, because they have photographs of medications, which help patients identify them. For psychologists and social workers, a number of books have been published that teach the basics of psychopharma- cology to non-MDs, and I recommend that you become familiar with this information. Many psychiatric medications take several weeks to have a therapeutic ettect. Antidepressants take 4 to 6 weeks. Antipsychotics may take 1 to 2 weeks or longer, depending on the clinical situation. Thus, merely documenting that a patient has tried a
13 / 48 Psychotherapy History In recent years, psychotherapies have become increasingly tailored to specific disorders, and evidence of ettectiveness has become irrefutable (Barlow 2014). In addition, it has become clear that therapy can have negative side ettects, as can medication. Thus, obtaining a history of psychotherapeutic treatments is important.
14 / 48 Have you ever had counseling or therapy for your problem? How often did you see your therapist? How long did you see him/her? These basic parameters of session frequency and length of treatment are usually nonthreatening and easy to elicit. What sort of therapy did you have? Did it have a name, like "cognitive therapy," "behavior therapy," or "psychodynamic therapy"? More often than not, your patient will not know the technical name of the therapy he received. You can compensate for this by describing the therapy. Did your therapist focus on "automatic thoughts" that make you more anxious or depressed? Did she give you homework assignments between sessions? Did she have you practice doing things that caused you anxiety? (For cognitive-behavioral therapy.) Did your therapist focus on your childhood experiences and how those attect your current life? (For psychodynamic therapy.) You can also ask a more open-ended question: Without going into too much detail, what sorts of things did you focus on in therapy? Was your therapist a psychologist, a psychiatrist, or a social worker?
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66. screen for general medical conditions: primary care provider: In the preceding
vignette, asking about illness elicited invalid information. One way to increase the validity of your medical history questions is to first ask if the patient is being seen by a doctor. Do you see a doctor regularly? What does he/she treat you for? By referring to a relationship with a caregiver, you will typically jog the patient's memory for past diagnoses and treatments. You can also learn information about the patient's character: Interviewer: Do you see a doctor regularly? Patient: Yeah, I see someone at the clinic. Not that he gives a damn about me. Such a statement could be explored further and might be a clue to character traits that may interfere with treatment, such as passive- aggressive or self-defeating traits. While you're at it, ask the patient if you may contact his doctor to share information. Discussing the patient with the primary care physician will help round out your evaluation, as well as provide useful information to the caregiver who referred the patient to you.
67. screen for general medical conditions: allergies: The usual screening question is
Do you have allergies to any medications? This may work, but again there are potential pitfalls. Some patients have idiosyncratic understandings of what constitutes an allergy. They may think you're asking about serious allergic reactions, such as bronchospasm, and therefore may answer in the negative even if they've had milder allergic reactions. They also may not realize that you're interested in hearing about any negative reactions to medications, and not just allergies per se. Better to ask Have you ever had any allergies, reactions, or side ettects to any medication? A patient may say that he is allergic to a number of medications that only uncommonly produce true allergic reactions, such as neuroleptics
17 / 48 and antidepressants. If so, pursue the nature of the allergy. What kinds of reactions did you have to that medicine? If the patient's response is vague, make some suggestions based on your knowledge of drug ettects: Did the Haldol give you muscle spasms? Did it make your hands shake or your body move slowly? When you document allergies in your write-up, specify the nature of the reaction. For example, writing that a patient is "allergic to neuroleptics" is probably inaccurate and might mean that the patient will never again be ottered a neuroleptic, even if she could benefit from it. A more accurate statement would be, "Haldol causes dystonia." This leaves the door open to trials of other neuroleptics.
68. screen for general medical conditions: surgical history: It is important to ask specifically
about previous surgery; many patients do not volunteer this information when asked about "medical problems," either because it was too long ago or because they do not consider an operation to have indicated a medical problem per se. CLINICAL VIGNETTE A 54-year-old man with major depression had mentioned gastritis as his only medical problem. Midway through the interview, he mentioned in passing, "I divorced my wife back in '84 or so, just after they took out part of my pancreas." On further exploration, the patient considered that operation to be a turning point in his life, because he made the decision to stop drinking then and had been sober since.
69. screen for general medical conditions: review of systems: The purpose of the review
of symptoms is to note medical problems that the patient may have forgotten to describe in response to the MIDAS questions. Whether it's necessary to do a review of symptoms for every patient is a matter of controversy. The MIDAS questions may miss seemingly minor symptoms that may be the first clues to a big problem, such as the occasional cough that signals lung cancer. But the review of symptoms takes a lot of time, and most mental health clinicians refer their patients to an internist for physical examinations anyway. Here's a compromise.
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75. What is the benefit of obtaining a social and developmental history during the
psychiatric interview?: Allows us to get to know the patient as a person instead of as a diagnosis, and you can approach the diagnosis of a personality disorder through the social history p
76. How long should it take to obtain the social and developmental history?: 5 minutes
(essential) to 10-20 minutes (extended-across 2 sessions) p
77. What is the purpose of the social and developmental history in a brief
diagnostic interview? How extensive should it be? The social history is useful in two closely related ways:: (a) It allows you to get to know the patient as a person rather than as a diagnosis, and (b) you can approach the diagnosis of a personality disorder through the social history (see Chapter 31). The essential questions take 5 minutes to ask, whereas the extended version takes 10 to 20 minutes and should be reserved for occasions on which you can take two sessions to do the evaluation.
78. summarizes the components of the social and developmental history: Early
family life.: Begin with the following introductory question: Can you tell me a bit about your background, where you grew up, and how you grew up? Proceed to more specific questions, moving chronologically through the stages of life. How many siblings did you have, and where were you in the birth order? Each family configuration has a unique impact on psychological development. Typical scenarios include the loneliness of the only child, the
20 / 48 eldest child of a large family who was forced into the role of a parent, the ignored middle child, and the youngest child who grew up as the resented apple of his mother's eye. What did your parents do for a living? Parental employment may have affected the patient's relationship with her parents. For example, a father who worked as a traveling salesman may not have been home much. This question also gives you a sense of socioeconomic situation: Did the patient grow up amid poverty or affluence? How did you get along with your parents? Although there's not enough time to do this topic justice in the diagnostic interview, these questions will give you an idea of the general flavor of the home. Was it a peaceful, loving environment, or was it angry and chaotic? What did they do when you disobeyed? This question can gently introduce the topic of physical or sexual abuse. Depending on the answer, you can follow up with a more explicit question, such as Were you abused physically or sexually as you grew up? Were there any other important adults in the home? Often, another relative was a major factor in the patient's early life, with either a positive or a negative ettect. How did you get along with your siblings? A close relationship with siblings can often compensate for a terrible relationship with parents. Who were you closest to, growing up?
79. summarizes the components of the social and developmental history: edu-
cation: Did you enjoy school?
