THE PSYCHIATRIC MEDICAL HISTORY. Prof. Paz García-Portilla
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1 THE PSYCHIATRIC MEDICAL HISTORY Prof. Paz García-Portilla
2 MEDICAL HISTORY (HX) Clinical data set gained by a physician by asking specific questions to the patient (or proxy), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient
3 MEDICAL HISTORY The information obtained in this way, together with the physical examination and additional evaluations, if needed, enables the physician to form a diagnosis, prognosis, and treatment plan Clinical reasoning based on facts elicited from symptoms and signs in the history-taking and examination has to be tested against basic scientific background and knowledge acquired during medical training
4 PSYCHIATRIC MEDICAL HISTORY A psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness. Mainly symptoms-based
5 HISTORY-TAKING IN PSYCHIATRY Based in the clinical interview 1. Initiation of a therapeutic alliance 2. Diagnostic data collection 3. Understand the views of the patients 4. Share the information 5. Reach agreements 6. Close the interview
6 HISTORY-TAKING PROCESS: 2. DIAGNOSTIC DATA COLLECTION Identification and demographics of the patient Chief complaint (CC) History of the present complaint (HPC) Somatic history Substance use history Previous psychiatric history Family psychiatric history
7 HISTORY-TAKING PROCESS: 2. DIAGNOSTIC DATA COLLECTION Psychopathological examination Systematic questioning about the symptoms of the psychiatric conditions Observed behavior Cognitive abilities Inner experiences
8 COMPONENTS OF THE PSYCHOPATHOLOGICAL EXAMINATION ABC STAMP LICKER Appearance Behavior Cooperation Speech Thought Form & Content Anxiety Mood Perception Modified from: Robinson DJ. Brain Calipers ABC STAMP LICKER Level of consciousness Insight Cognitive functioning Orientation Memory Attention & Concentration Abstract thinking PsyKophisiology Endings suicidal or homicidal ideation Reliability of information
9 ABC Appearance Behavior Psychomotor Restlesness Agitation Inhibition Repetitive behaviors Extrapiramidal Sx (EPS) Social. Cooperation with the interview
10 STAMP Speech Amount Increased: loquacious, talkative, logorrhea, pressure of speech, Decreased: paucity of speech, impoverished, laconic, minimally responsive, mutism, Mutism Pressure of speech Prosody (nonverbal communication) Intonation, spontaneity/latency, rhythm, inflection
11 STAMP Thought Form: circumstantiality 1, tangentiality 2, flight of ideas 3, loose associations 4, thought derailment 5 / blocking 6, word salad 7, incoherence,
12 STAMP Thought Content: overvalued ideas, delusions, obsessions, homicidal / suicidal ideas
13 STAMP Anxiety Psychic: anticipatory worry Physical Mood Depressed Disphoric Irritable Manic / hipomanic
14 STAMP Perception Hallucinations Ilusions Disturbances of self and environment Depersonalization Desrealization
15 LICKER Level of consciousness Insight Cognitive functioning Orientation Memory Attention & Concentration Abstract thinking??
16 LICKER PsyKophysiology Sleep-Wake Feeding and eating Sexual functioning Gender identity
17 LICKER Endings suicidal or homicidal ideation Reliability of information?
18 Demographics Medical Hx Psychiatric Hx Family psychiatric Hx Psychopathological examination Psysical examination Additional investigations (if needed) Additional investigations Vital signs and Anthropometry Lab analysis EEG, EKG Neuroimaging: CT scan, MRI, PET, SPECT Psychometric evaluation Diagnosis Provisional + Differential dx Prognosis Treatment plan
19 HISTORY-TAKING PROCESS: 3. UNDERSTAND THE VIEWS OF THE PATIENTS Determine, acknowledge and appropriately explore the patient s Ideas and concerns Expectations How each problem affects the patient s life Encourage expression of the patient s feelings
20 CLINICAL INTERVIEW: BASIC SKILLS It is not a conversation, but an active period of questioning and observation Be alert! Pursue suggestions and insinuations Display a neutral, calm, and objective/nonjudgmental manner Understand patients and empathize with them. Show an attitude of acceptance Be flexible, adjust your tone, vocabulary and type of questions to suit the patient At regular intervals, check your understanding of patient s problems with them
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