| The role of the Counselor aboard a ship or Starbase is two fold for one the CNS provides guidelines for the CO as they encounter new races or strange new worlds and to maintain the mental health of it's crews. One would think that in our time line that the existence of Mental Disorders have been wiped out. But as human continues to explore that which is of the unknown stresses and conflict with our thoughts can be affected and require treatment. The theories of Psychiatry is not a proven science and it takes years of education, patience, compassion along with a little bit of logic to provide and maintain the mental aspects of health for the crews and their families as one continues to live among the stars. With the following pages we will examine the different therapies of thought, Psychiatric Examination: History, Mental Status and Clinical Signs and Symptoms and Classification of mental disorders. A mental disorder is an illness with psychologic or behavioral manifestations associated with impairment in functioning due to biologic, social, psychologic, genetic, physical or chemical disturbance with each illness having it's own characteristic signs and symptoms. As we continue to explore space and encounter new species, The Federation Psychiatric Association have classified over 200 types of illnesses effecting one's psyche. Psychiatric Examination; History, Mental Status, and clinical signs and symptoms I. General introduction Patient interviewing is the core skill in medicine and psychiatry, and communication between doctor and patient is the basis of good medical practice. The purpose of the interview is 1 - Obtain historical perspective of patient's life 2 - Establish rapport and therapeutic alliance. 3 - Develope mutual trust and confidence 4 - Understanding present function 5 - Make a diagnosis 6 - Establish a treatment plan II. Clinical Interview Techniques Arrange a comfortable setting with privacy Introduce yourself, greet patient by name and explain the purpose of the interview Put patient at ease, establish rapport by showing personal qualities of empathy and sensitivity Don't make value judgments. Carefully observe patient's non verbal behavior, posture, mannerisms, and physical appearance Avoid excessive note taking Keep interview active. Don't argue or become angry. Keep language commensurate with patient's intelligence Length of interview ranging for 15 - 90 minutes. Use of open ended questions for cooperative patients and closed ended questions for less cooperative or delusional or depressed patients The psychiatric examination consists of two parts: The history and the mental status. This is to provide a systematic approach, all topics should be eventually be covered, although the order should not be followed rigidly. III. Psychiatric History The psychiatric history is the chronologic story of the patient's life from birth to present (also called anamnesis). Topics covered should include Identifying data: Name, Rank, Age, Location. Race, sex, belief structure, education. If patient unable to cooperate then name the source that provided the information. Chief Complaint (CC). Brief statement in the patients own words recording the data verbatim what brought the Patients in for a consultation. History of present Illness (HPI). Development of symptoms from time of onset. Relationship of life events, conflicts, stressors, use of chemicals and any changes in previous level of functioning. Previous Psychiatric / medical Illness List all pertaining information of any psychiatric disorders, psychosomatic, medical, neurologic conditions Past personal history Birth and infancy - To the extent known by the patient, ascertain mother's pregnancy, developmental landmarks Childhood - Feeding habits, toilet training, personality (shy, out going), general conduct and behavior. Relationships with parents, caregivers and peers. Separations, nightmares and fears. Adolescence - Peer and authority relationships, school history, grades, emotional problems, age of puberty. Adulthood - Work or Military history, choices in careers, martial history, and belief structure. Family History - Psychiatric/medical and genetic illness. List of all living and non living relatives and cause and date of the deceased. IV. Mental Status The mental status is a cross - section of the patient's psychologic life and represents the sum total of the psychiatrist's observations and impressions at the moment. It also serves for future comparison to follow the progress of the patient. Mental status should include these observations and documentation. General Appearance - Note appearance, gait, dress, grooming (neat or unkempt), posture, gestures, facial expressions, Does patient appear older or younger than stated. Motoric behavior - Level of activity-psychomotor agitation or psychomotor retardation - tics, tremors, automatism's, mannerisms, grimacing, stereotypes, negativism, apraxia, echopraxia, waxy flexibility; emotional appearance - anxious, tense, panicky, bewildered, sad, unhappy'; voice - faint, loud, hoarse, eye contact. Attitude during interview - How patient relates to examiner - irritable, aggressive, seductive, guarded, defensive, indifferent, pathetic, cooperative, sarcastic. Mood - Steady or sustained emotional state - gloomy, tense, hopeless, ecstatic, resentful, happy, bashful, sad, exultant, elated, euphoric, depressed, apathetic, anhedonic, fearful, suicidal, grandiose, nihilistic. Affect - Feeling tone associated with idea-Labile, blunt, appropriate to content. Inappropriate, flat, la belle indifference. Speech - Slow - fast, pressured, garrulous, spontaneous, taciturn, stammering, stuttering, slurring, staccato, Pitch, articulation, aphasia, coprolalia, echolalia, incoherent, logorrhea, mute, paucity, stilted. Perceptual disorders - Hallucinations - olfactory, auditory, haptic (tactile), gustatory, visual; hypnopompic or hypnagogic experiences; feelings of unreality, déjà vu, deju entendu, macroposia. Thought content - Delusions - persecutory (paranoid), grandiose, infidelity, somatic, sensory, thought broadcasting, thought insertion, ideas of reference, ideas of unreality, phobias, obsessions, compulsions, conflicts, nihilistic ideas, hypochondriasis, depersonalization, derealization, flight of ideas, idee fix magical thinking, neologisms. Thought process - Goal - directed ideas, loosened associations, illogical, tangential, relevant, circumstantial, rambling, ability to abstract, flight of ideas, clang associations, perseveration. Sensorium - Level of consciousness - Alert, clear, confused, clouded, comatose, stuporous; orientation to time, place, person; cognition. Memory: Remote memory (long term memory) Recent memory Immediate memory (short -term memory) Concentration and calculation - Ability to pay attention, distractibility, ability to do simple math. Information and intelligence - Use of vocabulary, level of education, fund of knowledge. Judgment - Ability to understand relationships between facts and to draw conclusions; response in social situations. Insight Level - Realizing that there is physical or mental problem; denial of illness, ascribing blame to outside factors; recognizing need for treatment. V. Medical and Neurologic Examination Some psychiatric disorders may have an organic cause. Neurologic and or medical examinations may be indicated in these conditions. VI. Recording of Data (By the end of the examination you must be able to judge) 1. Presence or absence of psychosis 2. Any organic defects 3. If patient has any suicidal or homicidal ideation that is additional to your diagnosis Axis I: Clinical syndromes Axis II: Psychical disorders or conditions Axis III: Physical disorders or conditions Axis IV: Severity of Psychosocial stressor Axis V: Gobal assessment of functioning A Sample of DSM-III-R diagnosis could look like this Axis I: Schizophrenia, catatonic type Axis II: Borderline personality disorder Axis III: Hypertension Axis IV: Psychosocial stressor : Death of mother Severity: 5 (extreme) Axis V: GAF 30 characterized by behavior influenced by delusions. After diagnosis there are four areas the must be covered for proper and adequate treatment 1. Psychodynamic formulation 2. Differential diagnosis 3. Prognosis 4. Treatment plan Types of Interviews Withdrawn patient - Be active structured interview, pay attention to nonverbal clues, body movements. Change the subject if patient begins to have difficulties in the subject. you can always come back at a later time. Depressive patient - Focus attention on identified patient's problem. Ascertain that the patient does not support any suicidal ideation and access the plan. Attempt to raise self esteem by commenting positively on accomplishments. Aggressive patient - Do not be close in closed room. Sit near door for quick exit. Have security guard nearby or in room. Set limits. If patient seems too agitated, terminate interview immediately. Psychosomatic patient - Do not discuss somatic symptoms as "in your head." Assume patient that complaint is real. Delusional patient - Do not challenge delusions directly; you may tell patients that you do not agree with their thinking but that you understand their belief system. Manic patient - Try to set limits. Tell patient you need specific information e.g. Who is in your family, and later you will talk about the other areas. Be firm but not belligerent. Amytal interview - 10 % IV at 1 ml / min. After 150 - 500 mg, patient gets drowsy and is willing to answer queries. Used in catatonia, mutism, amnesia. Patient confusion is suggestive of organic condition. Important Notice and disclaimer: The above information is provided for the Role-players experience while taking on the post as the CNS or Ship's Counselor. This information is in no means to replace or attempt to counselor anyone that may have any form of Mental Illness to do so may cause much more harm than good and the person should be advised to seek a Trained Professional in the field of Psychiatry. Any advice given in the art of role-playing by a CNS to his/her's Client is just role-play and are not held accountable along with any members of the SFEF. Ref: Pocket Handbook of Clinical Psychiatry Harold I. Kaplan M.D. Benjamin. J. Sadock M.D. Information compiled by: Captain Kate Sadira M.D. SFEF Medical Division Associate Clinical Professor of Psychiatry. Vulcan Science Academy Stardate: 212734.48.633 September 25, 2002 |
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