Psychiatry

Chapter 8

Psychiatry

Ink Blot, 1964.

Courtesy of the Blocker History of Medicine Collection, Moody Medical Library, UTMB, Galveston

What’s Inside:

Psychiatric History & Physical

Global Assessment of Functioning (GAF)

Progress Note (SOAP Format)

Disorders of Thought Process (or Form)

Disorders of Thought Content

Disorders of Perception

Defense Mechanisms

Psychiatry

Psychiatric History and Physical

History

Identifying data:

• Name, age, sex, race, marital and occupational status, residence, mode and

time of entry (er, office visit, direct admit), alone or accompanied, voluntary

or involuntary, source of referral.

Sources of information:

• Names, addresses, telephone numbers of informants other than the patient.

Chief complaint:

• Presenting problem. Try to use the patient’s own words.

History of present illness:

• The nature, duration, course, and severity of symptoms should be

described.

• Previous psychiatric symptoms and treatment.

• Stressors should be identified that may be related the onset of symptoms or

relapse.

• The reason the patient is presenting now.

• Should include all pertinent positives and negatives to assess for a

psychiatric diagnosis.

Past psychiatric history:

• Previous and current diagnoses (include age at onset of illness),

treatments, hospitalizations, outpatient treatments, medication trials (time,

dose duration, compliance), history of suicidal or assaultive behavior.

Substance use history:

• Drug, alcohol, and tobacco use including age of first use, amount, treatment (rehabilitation) history, time since last used.

Family psych and medical history:

• This should include history of known psychiatric illness, psychiatric

hospitalizations, psychiatric treatment, suicide attempts, drug or alcohol

abuse, major medical illnesses, or legal history.

Psychiatry

Past medical history:

• Major illnesses and hospitalizations.

• Current medications and allergies (with reaction).

• Any history of head injuries with loss of consciousness (LOC) or history of

seizure disorders.

• Testing and risk factors for HIV.

• History of TB.

• Last menstrual period for female patients.

Review of systems (ROS):

Social History:

• Obtain a “life story” including developmental history (family structure,

relationship with family members, developmental milestones, peer

relationships, school performance), childhood/adolescent history, sexual

and relationship history, vocational history and economic status, military

history, legal history, religious/spiritual history, current living status,

leisure activities, social supports. (Substance abuse can either be mentioned

here or given its own section—see above.)

Physical Exam

Mental status examination: (no need to memorize. You will be given a MMS cheat sheet by St. Joseph’s resident)

Objective assessment of the patient’s mental functioning at the particular point in

time at which it’s performed

• Appearance and behavior = dress, grooming, personal hygiene, body

language including posture, facial expression and motor behavior, attitude

towards behavior (interaction, level of cooperativity)

• Speech and language = quantity, rate (slow, rapid), rhythm (stammer),

volume (loud, soft), articulation of words (slurred, dysarthric), fluency

• Mood and Affect:

Mood = predominant emotion that a patient experiences Normal descriptor = euthymic Abnormal = dysthymic, sad, irritable, expansive, euphoric, nervous, angry.

Affect = objective description of the patient’s expression of emotion. Normal descriptor = full range Abnormal = constricted, blunted, flat, inappropriate, labile

• Thoughts and Perceptions:

Thought processes = thought form; how well thoughts are strung together.

Psychiatry

Normal descriptor = coherent and goal directed Abnormal = (refer to later section for details/definitions)

Thought content (include suicidal or homicidal ideation) Normal descriptor = no evidence of delusions. Denies obsessional thought, SI/HI. Abnormal = (refer to later section for details/definitions)

Perceptions (hallucination, illusions, derealization,

depersonalization) Normal descriptor = absent

Abnormal = (refer to later section for details/definitions)

• Cognitive functions:

Orientation (person, place, time,

situation) Normal descriptor = A&O

x 4

Attention/concentration Spell a 5‐ letter word (“world”) backwards If patient can’t spell “world” backwards, ask patient to say the days of the week backwards, starting with (today’s day for example).

Memory (immediate, recent,

remote) Immediate recall of 3

objects

Recent memory = recall of same three objects after 5 minutes Remote memory = recall of birthdays, anniversaries, etc.

• Higher level intellectual functions:

Fund of knowledge (past presidents starting with most

recent) Vocabulary

Calculations 5 x 3, 5 x 5, 5 x 13, 5 x 23

Abstractions

Similarities: table and desk, coat and sweater, cup and pitcher, statue and

poem

Proverbs: count chickens, glass houses, spilled milk, change horses

Constructional ability: copy a cube, draw a clock

• Insight = patient’s awareness of his/her problem and its meaning

Normal descriptor = intact Abnormal = absent, superficial

• Judgement = ability to make sound decisions regarding everyday activities. Judgement is best made by assessing a patient’s history of decision making, rather than by asking hypothetical questions.

Normal = intact Abnormal = impaired, suspect

Psychiatry

Physical exam:

• Standard physical exam with special emphasis on the neuro exam.

Labs:

Assessment:

• Presumed diagnosis and differential.

• DSM Diagnosis:

Axis I psychiatric disorders & substance abuse

Axis II personality disorders & mental retardation

Axis III medical conditions

Axis IV psychosocial (social, family, environmental, financial)

Axis V global assessment of functioning (GAF)

Treatment plan:

• Special comments or precautions (suicide, assault, elopement)

• Estimated length of stay/treatment

• Signatures

Global Assessment of Functioning

(GAF) (0 to 100 scale)

(90-81) good functioning in social, family, and work situations

(80-71) transient symptoms, expected reactions to stressors; mild

impairment in social, family, and work situations

(70-61) mild symptoms; mild impairment in social and occupational

functions

(60-51) moderate symptoms; moderate degree of social and

occupational impairment

(50-41) suicidal ideation, no friends, and/or unable to keep job

(40-31) impairment in reality testing and communication

(30-21) disorders of thought content influence behavior; inability to

function

(20-11) potential or actual harm to self or others; unable to maintain basic hygiene; impaired communication

(10-1) recurrent danger to self or others; unable to maintain minimal

hygiene

(0) unable to assess

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Progress Note (SOAP format)

Always put the date, title (eg: Psychiatry MSIII Note), and a signature at

the end of every page. If your signature is not legible, then print your name under your signature. Try to use every line without leaving spaces if possible. This is a legal document.

Subjective:

Information reported by the patient (c/o, symptoms, side effects of meds, feelings, etc.) Use quotations whenever writing the patient’s own

words.

Objective:

Note relevant observations and events noted by nursing staff or case workers. Describe affect, mood, thought processes, thought content, cognitive ability, insight, judgement, labs (new test results), and current meds.

Assessment:

Organized by problem. Write a separate assessment for each problem. Include reasons that support the patient’s continued need for hospitalization.

Plan:

Changes to current treatment, issues that require monitoring, future considerations.

Thought Process (or Form) Disorders

Blocking = abrupt cessation of speech, usually in mid-sentence

Circumstantiality = pattern of indirect speech that ultimately answers the question asked

Clanging = pattern of speech governed by sounds (rhyming)

Derailment = speech may appear linear initially, but with repeated shifts in focus

Echolalia = abnormal repetition of words, phrases, or sentences

Flight of ideas = subjective experience of racing thoughts

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Ideas of reference = interpretation of unrelated events as having

personal meaning or significance to the patient (ie: from the radio or television)

Loosening of associations = illogical transition between topics

Neologisms = a new word or phrase of the patient’s own invention; usually seen in schizophrenia.

Perseveration = repetition of ideas, phrases, or words

Poverty of speech = restriction in amount of spontaneous speech

Pressured speech = increased amount of spontaneous speech; difficult

to interrupt

Tangentiality = response that wanders from original question and does not answer the question

Thought insertion = the belief that thoughts, other than the patient’s own, are inserted into their mind

Thought withdrawal = the belief that thoughts are removed from a patient’s mind

Word salad = no apparent connection between thoughts, even within a sentence

Thought Content Disorders

Suicidal or homicidal ideation (be sure to ask these separately i.e do you

have any thoughts of hurting yourself or do you have any thoughts of

hurting others)

Delusions = fixed, false beliefs that can not be explained on the basis of

cultural background

• Paranoid • Grandiose • Somatic • Erotomatic • Bizarre

Phobias (specific, social)

Compulsion = can not refrain from performing an act

Obsession = can not get an unwanted thought out of his/her head

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Perceptual disturbances

Hallucination = false sensory perception

• Auditory • Visual • Tactile • Olfactory • Taste

Illusion = misinterpretation of a real stimulus

Derealization = feeling that one’s environment is unreal

Depersonalization = feeling that one’s self is unreal

Defense mechanisms

Mature defenses

Altruism = service to others without personal benefit

Anticipation = planning for future discomfort

Humor = using comedy to express personal feelings

Sublimation = impulse gratification via socially acceptable means

Suppression = postponing attention to a conscious impulse

Immature defenses

Acting out = avoiding unacceptable emotions by behaving in an attention‐ getting and socially inappropriate manner

Blocking = inhibiting thought

Displacement = moving emotions from a personally unacceptable situation (work) to one that is personally tolerable (home)

Introjection = internalizing the quality of a person/object

Passive-aggressive = indirectly expressing feelings through passivity

Projection = attributing one’s feelings to another person

Regression = return to an earlier phase of functioning

Somatization = psychic emotions into somatic symptoms

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Clerkship Advice

Rebecca Sealy Hospital (formerly our main psychiatric facility) has been

closed since and as a consequence of Hurricane Ike.

For Austin students, the entirety of the rotation is conducted in Austin.

For Galveston and Houston students, the inpatient portion of the rotation

is at St. Joseph’s hospital in Houston. The inpatient portion is half of the

rotation and lasts 3 weeks, during which time you are assigned to one of

two inpatient teams.

For Houston students, the remaining 3 weeks are spent at the either the

Jester IV prison hospital or a pediatric psychiatric facility in Houston.

For Galveston students, the remaining 3 weeks are spent in Consult and

Liaison, Geriatric psychiatry at Mainland Hospital, and various clinics for

outpatient.

They are no formal, PowerPoint lectures during the weekly didactic

exercise. Instead, there are small group collaborative learning exercises.

These are the AFE, an individual quiz (IRAT), and GRAT (a team quiz over

assigned reading materials from the class text, weighed more heavily than

the IRAT). The quizzes are straight from the text so it is in your best interest

(as well as your groups) to read. Do the assigned readings before class and

you will be well prepared for the shelf as well.

Recently the course has added one day of day call during inpatient at St.

Joseph’s. However the length of your stay depends on the faculty you will

be working with, and even so you will finish early.

There is a paper logbook that you are required to keep during the rotation.

The logbook lists a particular psychiatric diagnosis that you should see, such

as mania or psychosis, with an accompanying activity you should have

performed, such as an observed oral H&P or a written H&P. A portion of

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the logbook entries need to be signed by faculty, and residents can sign the

rest.

Faculty will grade your clinical performance in the wards. It is in your best

interest to prepare well for morning rounds as you will likely presents a few

patients. The students that do best are those that write out their H&P and

give a very thorough and detailed account of the patient.

For the graded written H&P, attempt to follow the examples provided on

Blackboard verbatim. And remember, provide an amply detailed H&P as

more is always better in both Psychiatry and Medicine H&P’s (do not be

terse).

updated by Rabeea Khan, 2013

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