Chapter 8

Psychiatry

Ink Blot, 1964.

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

Whats 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
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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 patients 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.

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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 sectionsee above.)

Physical Exam
Mental status examination: (no need to memorize. You will be given a MMS cheat sheet by St. Josephs resident)
Objective assessment of the patients mental functioning at the particular point in time at which its 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 patients expression of emotion. Normal descriptor = full range Abnormal = constricted, blunted, flat, inappropriate, labile
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Thoughts and Perceptions: Thought processes = thought form; how well thoughts are strung together.

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 x4 Attention/concentration Spell a 5 letter word (world) backwards If patient cant spell world backwards, ask patient to say the days of the week backwards, starting with (todays 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 = patients 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 patients history of decision making, rather than by asking hypothetical questions. Normal = intact Abnormal = impaired, suspect
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Physical exam:
Standard physical exam with special emphasis on the neuro exam.

Labs:

Assessment:
Presumed diagnosis and differential. DSM Diagnosis: Axis I Axis II Axis III Axis IV Axis V
psychiatric disorders & substance abuse personality disorders & mental retardation medical conditions psychosocial (social, family, environmental, financial) 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) (80-71) (70-61) (60-51) (50-41) (40-31) (30-21) (20-11) (10-1) (0)
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good functioning in social, family, and work situations transient symptoms, expected reactions to stressors; mild impairment in social, family, and work situations mild symptoms; mild impairment in social and occupational functions moderate symptoms; moderate degree of social and occupational impairment suicidal ideation, no friends, and/or unable to keep job impairment in reality testing and communication disorders of thought content influence behavior; inability to function potential or actual harm to self or others; unable to maintain basic hygiene; impaired communication recurrent danger to self or others; unable to maintain minimal hygiene unable to assess

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 patients 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 patients 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 patients 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 patients own, are inserted into their mind Thought withdrawal = the belief that thoughts are removed from a patients 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 ones environment is unreal Depersonalization = feeling that ones 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 ones 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. Josephs 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. Josephs. 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&Ps (do not be terse).
updated by Rabeea Khan, 2013

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