Basic Evaluation and Emergency Care
Peter Forster, MD, Clinical Professor of Psychiatry
Teaching Objectives: At the end of this class you should be able to ...
- Identify and properly define the key phrases used in the Mental Status Examination and be able to relate these phrases to the core diagnostic categories found in DSM-IV.
- Take a description of a patient, including language, thought, behavior, and come up with a "working diagnosis" that would be appropriate to guide initial treatment and further assessment of the patient.
- Have basic skills in how to create a preliminary therapeutic alliance with a patient in a crisis.
- Have basic skills in establishing appropriate limits or boundaries in an initial interview with a patient in a crisis.
- Have a beginning level understanding of transference, counter-transference, and projective identification as it relates to guiding an initial interview with a patient in a crisis.
Class Method: This class will consist of a combination of case presentation, lecture, and questions and answers designed to reinforce the key concepts so that they can be comfortably used in a clinical context.
Questions for Discussion: In preparation for this class consider the following questions...
- You are asked to see a patient in a crisis, because of the severity of the crisis, the patient cannot provide you with any reliable history, there are no past medical records, how would you establish enough of a relationship with the patient to begin an assessment.
- What information would you use to establish a working diagnosis.
- As you begin the interview you notice that you are experiencing strong emotions (anger, fear, disdain, confusion...), what could the significance of those emotions be and how would you use that information?
- The patient tells you that he is desperate to get some Valium for relief of his anxiety and insists on talking about that need before answering any more questions, what might you do?
Required Readings:
- Chapter Six of The Clinical Interview Using DSM-IV-TR, Volume 1: Fundamentals, Ohmer. 2002
- These four readings which are available online -
Additional Preparation for Class: None, read the required readings and review the questions above.
Recommended Readings:
- For this class: The Mental Status Exam Explained by David J. Robinson, MD. Rapid Psychler Press. 2000.
- For the overall section on Emergency Psychiatry my recommendation for a short book is: Handbook of Emergency Psychiatry by Jorge R. Petit. 2004. An alternative that is more of a review of the literature is: Emergency Psychiatry, edited by Michael H. Allen, M.D.; Washington, D.C., American Psychiatric Publishing, Inc., 2002, 216 pages, $31.95 softcover.
We will be following the following four cases throughout the classes in this cluster.
Carlos
- A 21 year old illegal immigrant from rural Mexico who has been homeless
for the last four weeks, since he hitchhiked to San Francisco from Los Angeles.
He was brought in by the police because he became involved in altercation with a
young mother dropping off her child at elementary school.
Frank
- A 26 year old man originally from Montana who has been living in San
Francisco for the past four years. He has, until recently, been working as a
bartender in the Tenderloin, but he was fired for missing work. He was brought
in by the police because he threatened to
kill himself when the manager
of his single room occupancy hotel told him he was going to be evicted.
Julie
-
A 24 year old woman who was brought in by the police after
she took an overdose of pills after an argument with her boyfriend. She is very
angry and says she needs to get some help or she doesn't know what she might do.
Ray
- A 35 year old man who was brought in by the police and paramedics for
"acting crazy" after they intervened in an altercation with his former
girlfriend. He was quite agitated when he was originally brought in but is now
fairly calm in the day room.
You are on your first day working in the psychiatric emergency service. After morning report you are assigned one of these patients. You will need to do a basic evaluation. What thoughts do you have in mind as you prepare to meet your patient?
How would you establish enough of a relationship with the patient to begin an assessment?
Some information that might be useful on creating a therapeutic alliance and limit setting.
What information would you use to establish a working diagnosis?
According to the DSM-IV TR Handbook of Differential Diagnosis, the process of establishing a diagnosis encompasses six steps -
Step 1: Is the Presenting Symptom for Real? Assess for factitious disorders, malingering, etcetera.
Step 2: Rule Out Substance Etiology (Including Drugs of Abuse, Medication, Toxin Exposure)
Step 3: Rule Out a Disorder Due to a General Medical Condition
Step 4: Determine the Specific Primary Disorder(s)
Step 5: Differentiate Adjustment Disorder From Not Otherwise Specified
Step 6: Establish the Boundary With No Mental Disorder
Carlos
is difficult to interview. He doesn't answer any questions in English
and you get a translator. Even with a translator he has very long pauses before
answers. The translator
suggests that he may be developmentally disabled because he seems to not
understand the questions... For instance, when you ask him why he is here he
answers (in Spanish) "The dogs." Early in the interview he seems suddenly
frightened and refuses to talk any more.
Frank
smells of alcohol and he is pretty disheveled. His speech is slightly slurred.
He tells you that he doesn't have a drinking problem but he is depressed because
of "those fucking assholes" at the hotel. You ask him how you can help and he
says, "You don't care what I say."
Julie
seems to have calmed down since she came into PES. When
you introduce yourself to her she smiles and tells you that you are the first
person today who seems to understand the situation. She is quite engaging and
animated. She uses puns alot and sometimes it is difficult to follow her train
of thought, but you are able to keep up with her.
Ray
is in the middle of a discussion with another man in the day room when you come
in. He quickly ends that conversation when you introduce yourself as a doctor.
He seems a little bit "on edge" as you take him into the interview room but he
tells you he is fine. Although he seems to understand your questions, the
answers he gives are a bit vague, and the details of his conversations with his
former girlfriend are quite different from what the paramedics reported. As you are
nearing the end of the interview he mentions that he has "insomnia" and that he
has not been sleeping more than a couple of hours a night. He asks you if you
can give him some "Valium" which is the only thing that seems to help.
Some information that might be useful on the differential diagnosis of psychosis.
Carlos
Frank
Julie
Ray
Based on what you know and what you surmise, write up a mental status examination for each patient and note those aspects of the examination that you have questions about.
Appearance:
Attitude:
Movement:
Speech:
Affect:
Mood:
Thought Content:
Thought Process:
Cognitive Function:
Perceptions:
Dissociative Symptoms:
Insight:
Judgment:
REFERENCES
Beauford JE, McNiel DE, Binder RL.Utility of the initial therapeutic alliance in evaluating psychiatric patients' risk of violence. Am J Psychiatry. 1997 Sep;154(9):1272-6.
Eisenberg GC, Barnes BM, Gutheil TG: Involuntary treatment and the treatment process: a clinical perspective. Bull Am Acad Psychiatry Law 1980; 8:44–55
Michael B. First, M.D., Allen Frances, M.D., and Harold Alan Pincus, M.D.
DSM-IV-TR® Handbook of Differential Diagnosis. APA Press. Washington, DC: 2006.
Monahan J, Hoge SK, Lidz CW, Eisenberg MM, Bennett NS, Gardner WP, Mulvey EP, Roth LH: Coercion to inpatient treatment: initial results and implications for assertive treatment in the community, in Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law. Edited by Dennis DL, Monahan J. New York, Plenum, 1996, pp 13–28
Neale, M, Rosenheck RA. Therapeutic Limit Setting in an Assertive Community Treatment Program. Psychiatr Serv 51:499-505, April 2000
Chen A: Noncompliance in community psychiatry: a review of clinical interventions. Hosp Community Psychiatry 1991; 42: 282–287