Makindo Medical Notes

Related Subjects: |Introduction to Psychiatry and Assessments |Psychiatric Emergencies |Depression |Mania |Schizophrenia |Suicide |Panic Disorder |Acute Psychosis |General Anxiety Disorder |Obsessive-Compulsive disorder |Wernicke Korsakoff Syndrome |Medically Unexplained symptoms |Post-Traumatic Stress Disorder (PTSD)

Introduction

• Psychiatry is a medical specialty focusing on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders.
• Unlike many other specialties, psychiatry often deals with conditions that may not have clear physical manifestations but can profoundly impact a patient's quality of life, daily functioning, and interpersonal relationships.
• Understanding psychiatric conditions requires a unique blend of medical knowledge, empathy, and communication skills.
• Psychiatry involves not only understanding symptoms but also appreciating the influence of biological, psychological, and social factors on a person’s mental health.
• For medical students, grasping foundational psychiatric concepts and familiarizing oneself with key disorders can pave the way for more advanced studies and clinical experiences.

Note: Each disorder has unique diagnostic criteria, associated symptoms, and management strategies that are essential for effective care.

Key Psychiatric Conditions

• Depression: Characterized by persistent low mood, loss of interest, and functional impairment. Includes major depressive disorder and dysthymia.
• Bipolar Disorder: Involves episodes of mania or hypomania and depression, impacting mood, energy, and activity levels.
• Schizophrenia: A severe mental illness with symptoms like hallucinations, delusions, and disorganized thinking.
• Generalized Anxiety Disorder (GAD): Marked by excessive, uncontrollable worry about various aspects of life.
• Panic Disorder: Sudden episodes of intense fear or discomfort, often accompanied by physical symptoms like palpitations and shortness of breath.
• Obsessive-Compulsive Disorder (OCD): Involves recurrent, intrusive thoughts (obsessions) and repetitive behaviors (compulsions).
• Post-Traumatic Stress Disorder (PTSD): Follows exposure to traumatic events, with symptoms like flashbacks, avoidance, and hyperarousal.
• Personality Disorders: Includes borderline, antisocial, and narcissistic personality disorders, affecting cognition, affectivity, and interpersonal functioning.
• Eating Disorders: Such as anorexia nervosa and bulimia nervosa, impacting physical health and self-perception.
• Substance Use Disorders: Encompasses alcohol, drug, and prescription medication misuse, leading to physical, psychological, and social consequences.
• Attention-Deficit/Hyperactivity Disorder (ADHD): A neurodevelopmental disorder with symptoms of inattention, hyperactivity, and impulsivity.

Studying these conditions provides insight into the diversity and complexity of mental health disorders and prepares medical students for effective patient care in various clinical settings.

Assessing the Patient's Mental Health: Identification and History

A comprehensive psychiatric assessment is essential for accurate diagnosis and management. This guide provides a structured approach to assessing a patient in psychiatry. Note: A respectful, empathetic approach helps the patient feel comfortable, promoting more open communication.

• Basic Information: Obtain age, gender, occupation, and presenting complaint.
• Reason for Referral: Determine if the patient is self-referred, or referred by family or healthcare providers, which can provide context to their presentation.

Presenting Complaint and History of Presenting Illness

• Presenting Complaint: Ask the patient to describe their main issue in their own words, allowing for open-ended responses.
• Symptom Duration: Identify when symptoms began, their frequency, and any changes over time.
• Triggering Events: Explore recent stressors, trauma, substance use, or other potential triggers that might have exacerbated symptoms.
• Impact on Functioning: Assess how symptoms affect daily life, including work, relationships, self-care, and leisure activities.

Past Psychiatric History

• Previous Diagnoses: Inquire about any prior psychiatric conditions, diagnoses, and treatments, including counseling or therapy.
• Hospitalizations: Document previous admissions, the reasons for hospitalization, treatment received, and duration.
• Medications: Review all current and past psychiatric medications, noting efficacy, compliance, and any experienced side effects.
• Therapy and Counseling: Record history of psychological treatments (e.g., CBT, DBT), frequency, and perceived benefit.

Family History

• Mental Health Disorders: Document any family history of mental health conditions such as depression, bipolar disorder, schizophrenia, or substance abuse.
• Genetic Risk: Note hereditary conditions that may influence the patient's mental health presentation.

Medical History

• Physical Health Conditions: Record significant medical issues or chronic illnesses that could impact mental health (e.g., hypothyroidism, epilepsy).
• Medication Review: Identify any medications that might affect mood or cognition, including steroids, pain medications, and antihypertensives.
• Substance Use: Document alcohol, drug, or prescription medication misuse, frequency, and any withdrawal or tolerance symptoms.

Social and Personal History

• Background: Explore childhood history, trauma, and early family life, which may contribute to current issues.
• Education and Employment: Document the highest level of education, employment history, job stressors, and any recent changes in job status.
• Living Situation: Assess current living arrangements, financial stability, and the presence of a support system.
• Relationships: Record marital status, quality of friendships, and family dynamics, as well as any recent changes in social support.
• Hobbies and Interests: Identify activities and interests, noting any recent loss of interest or enjoyment.

Mental State Examination (MSE)

• Appearance: Describe hygiene, attire, grooming, posture, and physical characteristics that may indicate mood (e.g., disheveled appearance).
• Behavior: Document activity level, eye contact, body language, and whether behavior is cooperative or guarded.
• Speech: Note tone, rate, volume, and coherence of speech (e.g., pressured, slow, loud, hesitant).
• Mood and Affect: Record subjective mood (e.g., sad, anxious) and objective affect (e.g., flat, reactive), noting any mood congruency.
• Thought Process: Assess organization, flow, and coherence of thoughts (e.g., tangential, flight of ideas, thought blocking).
• Thought Content: Explore any delusions, obsessions, or intrusive thoughts, and their impact on daily function.
• Perception: Check for hallucinations (e.g., auditory, visual), noting onset, frequency, and distress caused.
• Cognition: Test orientation (time, place, person), attention span, memory, and abstract thinking.
• Insight and Judgment: Evaluate the patient’s awareness of their illness, willingness to seek help, and decision-making abilities.

Risk Assessment

• Suicidal Ideation: Ask directly about self-harm thoughts, specific plans, and access to means, assessing intent and recent attempts.
• Homicidal Ideation: Explore any intent to harm others, especially in the context of paranoia or delusional thinking.
• Self-Harm: Inquire about history of self-injurious behavior (e.g., cutting, burning), triggers, and frequency.
• Substance Abuse: Document any alcohol or drug use, frequency, quantity, and any known triggers or impacts.
• Protective Factors: Identify factors such as family support, religious beliefs, or future goals that may reduce risk.

Formulation and Management Plan

• Diagnosis: Develop a working diagnosis based on assessment findings, considering differential diagnoses.
• Treatment Plan: Outline immediate interventions, including medication, therapy options, and lifestyle changes.
• Follow-Up: Arrange for regular follow-up appointments, case management, and any specialist referrals needed.
• Safety Plan: Collaborate with the patient to develop a safety plan that includes coping strategies, support contacts, and emergency resources.

Documentation

• Comprehensive Record: Document assessment findings, clinical observations, and risk evaluation thoroughly and accurately.
• Continuity of Care: Ensure clarity and detail for effective continuity of care, including treatment rationale and care decisions.
• Legal and Ethical Considerations: Maintain documentation as part of the legal medical record, ensuring compliance with confidentiality and ethical guidelines.