PSYCHIATRY LEARNING MODULE Department of Psychiatry and Behavioral Medicine University of the Philippines — Philippine General Hospital For LEARNING UNIT 7 (CLINICAL INTERNSHIP) TABLE OF CONTENTS IA. Psychiatric History Taking 1 IB. History Taking in Consultation-Liaison Psychiatry 4 I. Objective Examination in Psychiatry 6 Ill, Diagnosis in Psychiatry 9 IV. Treatment in Psychiatry 14 V. Psychosis 16 VI. Major Depressive Disorder 18 VII. Bipolar Disorder 19 Vill. Suicide 20 References 24 Appendix |. Common Psychotropic Medications and Their Usual Doses 22 Appendix Il. Mini Mental Status Examination 23 Appendix Ill, Biopsychosocial Formulation 24 Prepared by: Constantine L. Yu Chua, MD; April 2016 For the exclusive use of UP-PGH medical interns.PSYCHIATRY LEARNING MODULE FOR MEDICAL INTERNS. University of the Philippines ~ Philippine General Hospital IA. Psychiatric History Taking Chief Complaint Chief complaint is written verbatim as much as possible, both “according to patient” and “according to companion (specify)”. Their reliability levels are also noted. History of Present Illness Elicit details regarding onset and quality of symptoms, as guided by the common diagnostic syndromes in the DSM. Common mistakes, and appropriate corrections. include: ‘Common Mistake Correction Focusing too much on external _ | As much as possible, try to explore the intemal experience of the patients events or acts For example: what did the patient think or feel that led him to become agitated? What belief led the patient to attempt suicide? Eliciting only non-specific ‘Although these are important to assess severity of the disorder, they do not symptoms such as “behavioral | contribute very much to diagnosis. Instead, try to run down characteristic change”, agitation, sleep symptoms seen in the DSM — hallucinations, delusions, specific mood disturbance, or withdrawal. disturbances, grandiosity, unfounded guit, suicidal thoughts, etc. Eliciting insufficient symptoms to | Make sure to run through symptoms comprehensively (e.g,, 5 for meet any diagnosis. psychosis, 9 for depression, and so forth) Taking interpretations by Patienis and families offen muse terms, The interview should describe informants as is (0.9, "na what the informants mean by the terms they use. They can be assisted depress kasi siya" of "nag- wth close-ended questions regarding symptoms nervous breakdown’). __ — Failing to note pertinent Part of DSW criteria fora paricular disorders the exclusion of other negatives conditions, so be sure to nclude negatives Failing to elicit and describe | A prior diagnosis must stil be described to confirm itis correct or f previous episodes OR just phenomeniogy of the condition has shied (eg. some patients who Deuce ccel Intally present at depressed may actualy have a prodrome of schizophrenia or are actualy bipolar ete) Taking a “storytelling” fone in | Although details are heipul, they shouldbe labaied with formal terminology documenting the HPI 4s with other specialties of medicine. Aside from the history of symptoms, the psychiatric history must include the F.A.C.T.S. Functionality ‘* Knowing the patient's level of function before and during the onset of symptoms will be useful for diagnosis (e g.. presence cognitive decline and subtle residual symptoms in chronic schizophrenia, history of hypomanic episodes in bipolar depression, etc.) and goal setting (i.e., what can be a realistic goal for treatment based on patient's baseline). ‘+ This would usually entail some back-tracking from the initial onset of symptoms identified by the informant, especially for prodromal symptoms. Abuse of substances / Another medical condition + These always have to be ruled out because these may be a significant comorbid of the patient or may even be the etiology of the psychiatric symptoms. Criteria for admission ‘* During the interview, the clinician must already have an idea if the patient needs to be admitted to the hospital or not. The absolute psychiatric indications for admission are 1. Harm to self 2. Harm to others 3. Non-compliance to medications 4, Social emergencies ~ having no watcher, victims of abuse with perpetrators living in ‘same house, etc.PSYCHIATRY LEARNING MODULE FOR MEDICAL INTERNS University of the Philippines Philippine General Hospital ‘© Other indications for admission are: - _ Need for medical work-up or uncertainty of diagnosis especially i entertaining a medical comorbid - Declining nutritional status (e.9., severe depression or negative symptoms) - Having medica/surgical comorbids ‘Trauma or triggers ‘+ Identifying a traumatic event or triggering situation for the episodes will aid in diagnosis (e.g.. adjustment disorder, post-traumatic stress disorder, specific phobia), prognosis, and treatment planning (ie., addressing the trigger and helping the patient to cope with it) ‘+ The discontinuation of a medication is a very common “trigger” for relapse, ‘Symptoms (Review of Systems) ‘This is the review of systems. In psychiatry, special attention must be given to neurologic, thyroid, and other endocrine-related symptoms. © Aside from physical symptoms, the clinician can run down common symptoms in four major criteria of psychiatric disorders if not yet mentioned in the HPI proper to ensure completeness: 1. Psychotic symptoms 2. Depressive symptoms 3. Manic symptoms 4. Anxiety symptoms Past medical history Aside from medical conditions, hospitalizations, surgeries, and allergies, include psychiatric consults, admissions, and history of psychiatric medication intake (identify the specific drugs, doses, effects, and reason for shifting if possible). Also include accidents, especially head trauma. Family medical history Aside from medical conditions, this should include psychiatric illnesses, substance abuse, and suicidal behavior in the family. These predispose the patient both neurogenetically and psychologically. Include all other components of history taking as applicable: OB-GYN history, developmental and immunization history, etc. Substance-use history Include age of initiation, frequency, quantity, response during intoxication, and the presence of withdrawal. Features of substance use disorder (see Part III) should also be elicited. Anamnesis ‘The usual personal-social history is already covered in the anamnesis, including the HEADSSS part in adolescents. In short, there is no need for a “personal-social history’ part. Anamnesis refers to the “life story’ of the patient. As a guide, the anamnesis gives us an idea of the patient's P.A.S.T. Personality ‘This includes the patient's way of perceiving the self and the world and how he reacts to this. Track the continuity from childhood to adulthood — if there are significant changes and how these changes came about. Some things to be watchful for include: © Borderline personality disorder for persons who have attempted suicide. © Antisocial personality disorder for drug abusers and perpetrators of violence. © Dependent or avoidant personality patterns in persons with depression.