To begin the process of assessment you would establish:
Therapeutic relationship/ working diagnosis/need for further evaluation and testing/initial plan
... [Show More] of care.
Prior to the interview review:
referral information/ patient questionnaires/ health assessments
You would set the stage and make the client comfortable by:
introducing yourself ( consider cultural norms)/ ensure that you won't be interrupted/ consider clinician safety, with exit strategies if patient should escalate.
Chief complaint:
Document the problem in the patient's words/
are symptoms: affective/ cognitive/ physical
seek permission to consult with family member
History of presenting problems:
duration of problem (s)
What other things were going on in their life when they started to have problems.
Precipitating factors:
1. exacerbating factors
2. triggers
3. connecting events
4. causality
Social History:
1. changes in role or social function
2. history of abuse and victimization
Social and developmental history:
1. identify who played roles in person's life.
2. Who are presently involved.
3. Social support
Family genogram:
biological: eval autosomal dominant genetic inheritance which is rare: present in more than one generation
~autosomal recessive- expressed in one generation
process: examine family patterns of communication and relating.
Social history continued:
1. friendships/ relationships with service providers
2. religious groups and/or clergy
3. history re: intimate relationships
4. status of interpersonal relationships
5. are important people in client's life- loving vs angry
6. involvement of family or other's in client's care
7. client's living situation
8. occupational status
9. educational/training status
10. financial situation
11. difficulties of activities of daily living
Family history:
1. family members with mental illness
2. unusual symptoms and behaviors
3. substance abuse/use
Personal Evaluation
evaluate strengths, hobbies, and area of pride/expertise/ competence- coping stratagies
Spirituality:
1. named religion or beliefs
2. source of strength and hope
3. source of comfort?
Past psychiatric history:
1. previous psychiatric care
2. experiences with hospitalization
3. past treatment
4. medications
5. names of previous therapist (written consent needed to consult with previous therapist and get records)
medical history:
1. some chronic medical illnesses have a high prevalence of psychiatric disorders
2. stressors that may have added strain to resources
3. history of:
a. autoimmune illness e.g. lupus
b. fibromyalgia
c. parkinson's disease
d. thyroid problems
e. cardiac disease
f. diabetes
4. any medications with a history of causing psychiatric problems e. g. acutane
5. new onset of physical illness that alters social life or image e.g. burns/ amputations
Substance use and abuse:
1. normal coping
2. how patient handles stress
3. use of substances to deal with difficulties
4. frequency/amount of drinking/ intake of substances
5. document first use, including circumstances
6. consequences of use- social, economic, interpersonal
7. inquire about each drug separately
8. ask about use in social history -keep in context
9. CAGE questionnaire
CAGE questionnaire
1. have you ever tried to CUT down on your drinking?
2. have you ever been ANNOYED about criticism of your drinking?
3. Have you ever felt GUILTY about your drinking?
4. Have you ever had a morning EYE opener?
Suicidal risk (SLAP)
1. Does the patient have any SOCIAL SUPPORT?
2. Is the plan LETHAL?
3. Does the patient have ACCESS to the means to end his/her life?
4. Can the patient describe the PLAN and PREVIOUS attempts?
5. Family history of suicide?
Suicidal Risk (IS PATH WARM?) endorced by the American Association of Suicidology
I. ideation
S. Substance Abuse: usually increased
P. Purpose for living seems lost
A. Anxiety with agitation and inability to sleep, or sleeping too much.
T. Trapped feeling, no way out.
H. Hopelessness
W. Withdrawing from friends and loved ones
A. Anger and rage, revengeful
R. Reckless behaviors, almost without thought.
M. Mood changes, usually dramatic shifts.
Depression
1. complaints of depression
2. duration
DSM IV tr definition of depression:
must have either:
a. depressed mood most of the day nearly every day for at least 2 weeks.
b. markedly diminished interest or pleasure in all, or most activities.
c. in addition, the patient may have other symptoms
Mnemonic for depression symptoms: SIGECAPS
S. Sleep disorder ( either increased or decreased)
I. Interest deficit ( anhedonia) change in sexual interest
G. Guilt ( worthlessness, hopelessness, regret)
E. Energy deficit
C. Concentration deficit
A. Appetite disorder ( either increased or decreased)
P. Psychomotor retardation or agitation
S. Suicidality
Bipolar disorder screening questions:
a. have you ever had a period of the week or so when you felt so happy and energetic that your friends told you that you were talking too fast or that you were behaving differently or strangely?
b. has there been a period where you were so hyper or irritable that you got into arguments with people?
Bipolar disorder screening question:
is there a family history of mania or "bipolarism"?
Bipolar disorder DSM IV TR criteria:
a. a distinct period of abnormality and persistently elevated , expansive or irritable mood, lasting at least a week, or such a mood of any duration if hospitalization is necessary.
b. persistence of three or more of the following symptoms ( four if mood is only irritable) during the period of mood disturbance and have been present to a significant degree: ( see DIGFAST)
Bipolar symptoms mnemonic:
D. distractibility
I. Indiscretion ( excessive involvement in pleasurable activities that have a high potential for painful outcome)
G. Grandiosity or inflated self-esteem
F. Flight of ideas or racing thoughts
A. Activities increase ( increase in goal directed activity or psychomotor agitation)
S. Sleep deficit
T. Talkativeness ( pressured speech)
Bipolar facts:
1. most bipolar patients will not present when manic or hypomanic.
2. may present with depression that may not respond to treatment.
Anxiety/possible questions:
1. would you describe yourself as a worrier?
2. Have you ever had a panic or anxiety attack?
3. Are you uncomfortable in social situations?
4. Have you any special fears, such as fear of insects?
5. what does the client do to try to relieve the anxiety
6. does the client self medicate with drugs/ alcohol
Symptoms of obsessive compulsive disorder:
1. constantly washing hands
2. constantly checking things
3. annoying, repetitive thoughts
Symptoms of post-traumatic stress disorder:
1. painful memories or dreams of terrible experience
Mental Status exam mnemonic for documenting
All Borderline Subjects Are Tough Troubled Characters
A. Appearance
B. Behavior
S. Speech
A. Affect
T. Thought process
T. Thought content
C. Cognitive exam
Cognitive Exam includes mini mental status
a. Ask memory questions
- recall short sentences asked to memorize 5 to 10 minutes before
- name the last three presidents
- name 10 common kitchen objects in 10 seconds
b. interpret 2 - 3 proverbs: abstract or concrete?
c. demonstrate and ask for return demonstration of simple repetitive motor tasks such as palm up/palm down or touching thumb to each finger of one hand in rapid succession.
Cognitive exam- can observe the patient during process of taking history and note:
a. mannerisms
b. gestures
c. speech patterns, rate, tone and volume
d. affect
e. how they think
f. what they think about
g. content and process during interview
Assessment Tools Mental status/ Clock drawing:
a. score 3 points for numeral 12 in the correct position
b. all 12 numerals 1 point
c. two distinct hands on the clock 1 point
d. correct time listed is 1 point
e. score of less than 4 is + for impairment needing further evaluation [Show Less]