Assessment of Disorders Diagnosis & Prognosis

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  1. 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 
  2. 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
  3. History
    • Identifying Information 
    • Chief Complaint 
    • History of Presenting Illness
    • Past Psychiatric history & Developmental history 
    • Social History 
    • Family Psychiatric History 
    • Medical History
  4. Mental Status Exam
    • Appearance 
    • Behavior 
    • Speech
    • Emotion 
    • Thought Process
    • Perception 
    • Attention 
    • Orientation 
    • Memory
    • Judgment
    • Intelligence, Information, Capacity for Abstraction 
    • Insight
  5. 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)
  6. 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)
  7. 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"
    •  
  8. Hierarchy of Syndromes (from the most severe to least)
    • Medical or pharmacologic 
    • Psychotic
    • Mood
    • Anxiety
    • Somatic
    • Sexual
    • Personality
    • Adjustment
  9. 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?)
  10. 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

Card Set Information

Author:
suhland
ID:
173574
Filename:
Assessment of Disorders Diagnosis & Prognosis
Updated:
2012-09-26 17:04:08
Tags:
Psychopathology
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Description:
Class 2
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