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Biopsychosocial Assessment
This type of assessment tries to look at the clinet & their current symptoms by taking into account:
- Biological Influences
- Psychological Influences
- Social Influences
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Guidelines for Conducting an Assessment
- I. History
- II. Mental Status Exam
- III. Auxiliary Data
- IV. Summary of Principal Findings
- V. Rendering a Diagnosis
- VI. Making a Prognosis
- VII. Biopsychosocial Formulation
- VIII. Treatment Plan
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History
- Identifying Information
- Chief Complaint
- History of Presenting Illness
- Past Psychiatric history & Developmental history
- Social History
- Family Psychiatric History
- Medical History
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Mental Status Exam
- Appearance
- Behavior
- Speech
- Emotion
- Thought Process
- Perception
- Attention
- Orientation
- Memory
- Judgment
- Intelligence, Information, Capacity for Abstraction
- Insight
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Auxiliary Data
- Interview w/ relative and/or friends
- Complete medical history (obtain records)
- Laboratory tests
- Standardized Interviews (DIS, SCID)
- Psychological Tests (MMPI-2, MCMI-III, SCL-90-R)
- Brain Imaging Studies (CAT, MRI, PET & other neurological exmas as indicated)
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Summary of Principal Findings
Once you've gathered the history, background information, mental status exam, & auxiliary information, your job is to synthesize & summarize the findings. You should address whether there is any immediate crisis, any major threat to life (e.g., suicide, homicide- specify if ideation, intent, or plan)
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Rendering a Diagnosis
Differential diagnosis: the process of choosing the correct diagnosis from conditions with simialr features
- Narrowing down the possibilities:
- Is there an organic medicial condition present?
- Neurotic vs. psychotic?
- Personality disorder?
- Did the symptoms come about in reaction to a major life
- stressor? Traumatic event?
- Rule of Parsimony: "when you hear hoof beats, think horses not zebras"
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Hierarchy of Syndromes (from the most severe to least)
- Medical or pharmacologic
- Psychotic
- Mood
- Anxiety
- Somatic
- Sexual
- Personality
- Adjustment
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Seven Steps for Psychiatric Diagnosis
- 1. collect data
- 2. identify psychopathology (symptoms)
- 3. evaluate reliability of information/data
- 4. determine overall distinctive features
- 5. arrive at a provisional diagnosis
- 6. check diagnostic criteria in DSM-IV-TR
- 8. resolve any diagnostic uncertainty (e.g., is there more than 1 diagnosis?)
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Prognosis
refers to a prediction of outcome based upon several patient factors & research:
- Natural course of the disorder
- Pre-morbid adjustment (the higher the GAF = better)
- Duration of the present illness (longer = poorer)
- Abruptness of onset (more acute = better)
- Age of onset (earlier onset = poorer)
- Availability of effective treatments
- Patient's compliance with treatment
- Supportive social & familial network
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