Tag Archive: psychiatric history

What you see – descriptive psychopathology vs. what the patient tells you – phenomenology.

At first look you might say: objective vs. subjective. E.g.: appearance, behavior, speech, affect –  all accessible to an external (objective) observer vs. thought content and mood as (subjectively) reported by the subject. Now, these distinctions are not always as neatly clear-cut as one would like. As one can observe (as opposed to experience) his own process, i.e. one’s own thought content or process are the object of examination, an objective process. Or one can note someone’s else report of his internal experience, a report inherently filtered thorough the examiner’s preconceptions and predisposition, i.e. a subjective process. When it comes to a mental status examination the boundaries between objective:subjective are often times blurred.

The take home point: a comprehensive mental state exam necessarily includes an objective and a subjective examination of the external and internal attributes of one’s mental state.

For the objective component the examiner will aim to describe one’s mental state external manifestations (speech, behavior, affect) and ask the patient to describe his mental state internal manifestations (sensations, emotions, thoughts). Examples of questions aimed at internal experiences descriptions: “Please describe what you are feeling at this time.” “Describe your anxiety in terms of severity: mild, moderate, severe. Also frequency: you experience it once in a blue moon, weekly, a few times a week, daily, multiple times a day, all the time.” In other words the goal of the objective component of the examination is to quantitatively describe its objects regardless of their internal:external mental allegiance.

For the subjective component the examiner will aim to put himself in the patient shoes i.e. attempt to feel what the patient experiences. With regards to external manifestations of one’s mental state the examiner should carefully note his own feelings. E.g. an unaccounted for but palpable sadness in the room warrants a search for depressive symptoms even when the patient emphatically denies feeling depressed. With regards to internal manifestations the examiner should ask about the qualities of emotions, sensory experiences, or thoughts, “Describe your depression.” “What does hearing the voices feel like?” are good examples of how to inquire about the phenomenology of one’s internal experiences.

In summary:

A thorough mental status examination uses objective and subjective complementary approaches to assess external as well as internal attributes of one’s mental status exam.

The objective approach strives to produce quantitative data while the subjective approach aims to produce subjective data, regardless of the data’s provenance (external vs. internal).

Dual diagnosis technically means that the patient has two independent, i.e.  a primary psych and a substance misuse diagnoses. Which implies that a substance induced diagnosis has been ruled out. Easier said than done.

Case scenario: Patient reports a long history of polysubstance abuse and an equally long history of major symptoms (e.g., psychotic sxs, affective sxs, severe anxiety etc.)

How do you tease out what came first and what causes what? Ask:

1. Is there any history of sobriety?

‘No”. Then, you should assume that’s likely substance induced until proven otherwise (SIUPO).

“Yes”, then ask:

2. What’s the longest time that you’ve been sober?

If longest sobriety is less than a month, again likely SIUPO.

“More than a month”, ask:

3. During that time did you continue to have sxs?

“No”, SIUPO for sure.

“Yes”. Ask: What sort of sxs, etc.?

You see how the balance starts tilting towards dual diagnosis.

How does it affect you?

Most trainees do at least a fair job in gathering a long list of past and present symptoms and signs of psychiatric and other medical syndromes.

Most trainees also almost always forget to ask this ONE question:

“And how does this affect you?” Where “this” can be depression, anxiety, you fill in the blanks…

What do you get for this one question?

1. Improvement of rapport. As this question is not only a data gathering tool but also shows being concerned and caring about the patient’s experience.

2. A preliminary estimate of the patient’s insight.

“It affects me in a good way. I kind of like it actually.” A manic response.

 “Well, it affects me all right. I would like to have them stop following me.” A psychotic response.

“It drives me nuts. I would like to stop it.” An ego-dystonic response of an OCD patient.

3. When the level of insight is good: An estimate of the level of dysfunction.

“I can still work but I really feel like I am dragging my feet every day.” For a depressed patient this is probably more than mild but less than severe depression.

“It’s more of a nuisance. I am noticing it,  maybe my wife, but no one else”. For a patient complaining of short term memory loss this is probably more than just plain age related memory loss, but less than full blown Alzheimer’s Dementia. Mild cognitive impairment is likely.

Stages of Change

I find Prochaska and Di Clemente’s model of change a very useful guide for my first encounter with a new patient.

We see people who have issues.

The important question is: on the change continuum, where does your patient place himself regarding his ability to engage in change work? A practical question as the answer will inform your intervention as much as current Axis I symptoms and personality dimensions.

Case and point:

Approaching an already committed to change patient with an educational agenda is poorly timed at best, and, at worst, unproductive and even irritating to the patient. It is an equal waste of time to approach a precontemplator with a list of change promoting interventions (which would be much better suited for patients already are in a preparation or action stage).

There is a lot of discussion about the BPS model. Trouble is that in today’s climate this is more a point of discussion of academical interest than a reality informing our day-to-day assessments and treatment plans. Excuses of why this is are plenty: from the severely limited time allowed in most treatment settings for the regular intake and follow-up,  to the dis-interest of managed care in anything that is not clearly linked to medical/biological outcomes and interventions, viz medications.

It turns out that when one compares a patient-centered with a system-centered approach, the former is both more efficient (i.e. allows for more complete data collection) and more effective (i.e. captures more data per unit of time). Counterintuitive, yes – nevertheless, true.

One way to self-monitor one’s exam focus is to jot down the info in a 3 column format: 1st: biological data; 2nd: psychological data; 3rd: social data. Each piece of data would be placed on a line; the more data, the higher their column. An ideal interview/history should produce 3 columns of fairly comparable sizes, while a biologically/system-centered interview will necessarily result in a pretty sizable biological column and rather small psycho-social columns.

Of course this way of organizing the information is cross sectional in terms of the classical categories of anamnesis, i.e. history of present illness (HPI), past psychiatric, substance and medical history, family history etc.

Instead, each of the above categories will be constructed across the 3 BPS axes. For example, an HPI of recent neuro-vegetative symptoms (B), poor self-esteem (P), and recent break-up with the significant other (S), in context of work stress due to a difficult boss (S), which brings up memories of parental emotional abuse (P), will be divided along the 3 axes. By organizing the information accordingly, one can have a visual cue about the overall balance of the BPS contributors. An obvious unbalance can thus be easily noted and corrected.

Last but not least, by organizing the info visually along the 3 axes, dominant themes become more easily noticeable. Finally, a comprehensive BPS case formulation naturally emerges after this simple act of BPS organizing.

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