Wednesday, February 04, 2009

Chapter Two, Section One: The Psych Eval

We've mentioned that the Shrink Rappers have a book proposal out there. It's gone through two review processes, with one more to go before we'll know if it's a go. Still no final name, our editor and Roy are both unhappy with Off the Couch...

Okay, so I thought I'd try to write a piece of a chapter here and see what our Shrink Rap readers think.... this is rough, I'm typing as I go, so the pre-draft, if such a thing exists. Here goes:

Tell Me About Yourself: The Psychiatric Evaluation

Josh Ford has never been so tired in all his life. He was the starting quarterback on his high school football team, and a pretty decent shortstop as well, even though he suffers from asthma. He was always a good student and he didn't have any trouble making friends in the dorm when he went to college. It's the Spring semester of his sophomore year, and Josh is just not feeling well. Josh has lost interest in hanging out with his friends, he's virtually stopped going to class, he sleeps long hours-- even for a college kid-- and when he went home for Spring Break, his parents were shocked to see he'd lost twenty pounds. His primary care doctor could find nothing wrong, and Josh admitted to him that he's feeling pretty down and hopeless, suicidal even. Josh was told he's suffering from depression and a psychiatric evaluation was recommended.

So Josh is not real, he's a figment of the Shrink Rap imagination. We'll borrow him to walk us through different aspects of this Chapter, called All in A Day's Work.

The purpose of a psychiatric evaluation depends, in part, on the setting in which it is conducted. In an outpatient setting where the patient will go for on-going treatment, the psychiatric evaluation is used to make a diagnosis and formulate a treatment plan. It offers the psychiatrist a chance to hear the patient's history and gather information necessary to do those things, and it gives the patient a chance to see if he's comfortable working with the psychiatrist. In an Emergency Department, the purpose is much different. The mental health professionals in the ED will not be offering on-going care and their goal is to determine if the patient requires hospitalization, and if not, then to provide an outpatient referral. The issues in an emergency setting are often focused around determining safety. In an outpatient setting, the psychiatrist may be interested in hearing many details about the patient's life, in other settings, the focus may be more on the acute symptoms that have brought the patient to care now.

So Josh goes to see a psychiatrist. This particular psychiatrist schedules the evaluation as a two hour session. Some psychiatrists allow one hour, some allow two, and some designate the first few sessions as a time to diagnose and make a plan. In clinics, the psychiatric evaluation is usually done in one hour, and the evaluating psychiatrist may or may not be the treating psychiatrist, depending on how the clinic is set up.

The questions the psychiatrist asks Josh may depend on the particular orientation of the psychiatrist. Some psychoanalysts leave the patient the space to tell their own story and ask very few questions. Most psychiatrists do a very structured interview to collect very specific information.

Like Josh's fictional psychiatrist, I usually allow two hours to see a patient on the first visit. I start by asking about what brings the patient to treatment: what doctors call the Chief Complaint. I then ask ask when the problem started and ask questions about what may have precipitated the problem-- did something upset Josh? How long has he been depressed? Did it come on suddenly or gradually? What symptoms is he having and how much are they interfering with his life? This is called the History of Present Illness. Psychiatrists have different styles of doing interviews, and I actually like to take a history backwards. Once I've heard about the current problem, I ask the patient if I can ask about their past and come back to the current problem later. I then ask questions about the family: Who is in it? What are their occupations? Are they healthy? What are the patient's relationships with other like? I then specifically ask about any history of psychiatric illness in family members, specifically blood relatives, and I ask the question in several different ways because genetics are so important in psychiatry. Josh's mother, we learn, has bipolar disorder, and a sister has been treated for panic attacks.

Once I've learned about the patient's family, I ask about their personal history from gestation forward. Were there problems in childhood with health, behavior, or development. I want to know details about education, occupation, encounters with the law, and romance. If there are children, I want to hear about them. I then ask about drug and alcohol use, medical and surgical issues, a list of current medications, drug allergies. At this point, I feel like I've gotten some lay of who my patient is as a person, who is important in their lives, and what has transpired. I then ask about their past psychiatric encounters, though most psychiatrists do this much sooner in the interview. What's important? Past diagnoses, hospitalizations, episodes of suicidality or violence towards others, and what treatments have been tried. I want to know the response to every treatment: were the outcomes good or bad. If medications have been used, then ideally I want to know each medication, the maximum dose that was taken, if the response was good or bad, and why the medication was stopped. In the course of taking the history, Josh's new psychiatrist learned that Josh had fairly severe asthma and he'd been to the Emergency Department a couple of time a year as a child for acute episodes of bronchospasm. He'd never seen a mental health professional before, but in high school he'd had a pretty rough period after a girlfriend broke up with him and he felt now a bit like he'd felt back then. He had not been as depressed during that episode, though his grades did drop during that marking period. Josh has never had any symptoms of mania, a condition which in which mood, energy, and activity are elevated, rather than depressed.

The final part of the psychiatric evaluation is called the mental status exam. This is the psychiatrist's version of a physical exam, only it's not physical! The patient is assessed and described, much as a novelist might write a character analysis, but in a formulaic way. The psychiatrist will observe and record anything notable about the patient's appearance. In Josh's case, he presents as a neatly groomed, casually dressed young man who appears his stated age. The doctor will note any abnormal movements (meaning neurologic problems, such as tics). The patient's speech will me noted if something is unusual. In Josh's case, he moves rather slowly, and it takes him a long time to get his thoughts organized. He talks quietly and slowly, but his thoughts are expressed logically. Mood is assessed in several ways: the patient is often simply asked about his mood, his energy, his participation in his usual activities. Is his libido the same, and are there changes in his sleep and appetite. He may be asked specifically about feelings of hopelessness or suicidal thoughts. Josh reports that he is sad all the time, that he often cries, and that he is feeling guilty and hopeless. He has had thoughts about suicide and has entertained ideas about how he might do it, but he feels these are just thoughts and is certain he won't act on them. The patient is then asked if he's having any usual perceptions: is he hearing voices or seeing things that are not there? False perceptions are called hallucinations. Does the patient have an accurate assessment of reality, or is he suffering from delusions? Sometimes it's difficult to tell what is a delusion and what is real, and this is where it helps to have an outside informant. The patient is asked about obsessive and compulsive phenomena. Josh is not having any hallucinations or delusions, and he's not suffering from any obsessive or compulsive phenomena. Finally, the patient's cognitive state is assessed. If it's not obvious that the patient is fully aware of his surroundings, then he may be asked questions about where he is, the date, current events, and a brief test called a Mini-mental status exam may be administered. Finally, the psychiatrist makes an estimate as to the patient's intelligence, insight, and judgment, based on what he has heard.

After the mental status exam, any relevant laboratory or radiologic tests are listed. The data collection is now complete, and the psychiatrist writes an impression, where he lists the important findings and may discuss his thoughts about what might be going on. A formal diagnosis is given which may include provisional diagnoses, as well as diagnoses to be ruled out. It is here, in the five axis diagnosis, that the psychiatrist lists Josh's diagnosis: he believes Josh has Major Depression, moderate to severe in intensity, possibly recurrent, without any psychotic phenomena. He notes that Josh has asthma, he lists any major current stressors, and he makes an assessment as to Josh's overall level of functioning. A course of treatment is outlined, and in Josh's case, it includes starting a medication and psychotherapy. If you stick with us through the rest of the chapter, you'll find there are some surprises, and Josh does not have either a simple or uneventful recovery.


Anonymous said...

Your normal sense of humor and lightness about psych topics has been replaced by rather dry recitation. If I skimmed that in a bookstore I wouldn't buy the book.

If you want to have a section that tells everything about conducting a psych eval, I wonder if it might be more interesting to track 3,4,5 patient responses? So far Josh is not a very interesting patient even if he's typical.

On the whole though, you have lost, in your effort at being thorough, what makes your blog effective. Your blog is opinionated, to the point, light-hearted, funny, full of feeling. You also express your personality in the blog. I do not see any of that here, and I would not present this to the publisher as is.
You know how to write in a way that will sell. Write that way for the book.

Anonymous said...

Hey, I found it interesting.

Return Of Saturn said...

Dinah, this is somewhat off topic, but I'm curious:
When you write up your notes or come to a decision about the patient's diagnosis, how much do you share?
Have you ever had a patient ask for their records? Do you share them the same way a family practice doc would share with a patient?

I'm curious to read what's written in my chart. I'd never ask, of course. It's just kind of weird to think about, even though I'd imagine it's all written fairly objectively...

I think the idea for this book is great. For so many people, psychiatry is such a mystery. I get what Therapy Patient is saying about writing with your personality, but in this instance, it seems somewhat difficult. A structured interview is...well, structured. A little dry. Maybe it's the behaviorist in me, but I still enjoyed reading it.

Anonymous said...

I agree with TP that the writing in the pre-draft is very different to that in the blog. However I disagree with the assessment of it being a dry recitation. What the chapter does is demystify the evaluation interview from the shrink's point of view. You get an insight into how the shrink conducts the interview, what he/she is looking for and how a diagnosis is reached. It takes the mystery out of psychiatry for the punters.

I found it fascinating and enjoyed reading it. And while the writing is a bit rough in parts, as you point out, it is only a pre-draft. I am sure that the next draft will be tighter after the literary spit and polish that we have come to expect from Shrink Rap is applied.

Anonymous said...

I have to agree with the comments about it being dry. Also I am confused about who the intended audience is? It seems mostly like info that the kind of person who would be drawn to the book would already know.

tracy said...

i would buy this book! More, please!

Anonymous said...

last para gives info re intended audiences.


Anonymous said...

There is nothing here that one cannot easily find on the internet--for free.
Agree with therapy patient on the writing.
You sound like you are writing a middle school textbook. It is geared to the intellectual level and sophistication of an average middle school kid.
People who buy psych type books go two ways, or both. They purchase the stuff they figure the shrink is reading so they can figure out what is going on or they buy a Yalom type book to be entertained.
Let's guess-- Josh is going to have a manic reaction to the antidepressant, the shrink has uncovered the bipolar that was waiting for the right trigger to express itself and this leads you into a discussion of how to choose meds, the trail and error process etc.
A few people might buy the book because they read the blog.


Anonymous said...

"Josh is not having any hallucinations or delusions, and he's not suffering from any obsessive or compulsive phenomena."

I know that this is a casual write-up. But when you, or any of us, decide that someone definitively is not suffering from something, we close the door to the possibility that we could be wrong.

I was trained to write more tentative, accurate, and honest conclusions, such as "Josh denied experiencing any auditory or visual hallucinations, and denied any unusual thoughts, such as thought insertion, thought deletion, or thought control. Josh denied any obsessions or compulsions." This style is even more boring, but puts me in the position of keeping my mind open, as well as keeping the mind of any reader open. There could very well be disordered thinking, such as the awakenings of paranoia or thought control - onset is in Josh's age range.

Also: I would put a bit more emphasis on his social context. You have the 'romance' part reported, but you do not include the nature of relationships with parents and friends. A great deal of teens these days are not actually raised by their parents, and suffer emotionally from it.

Teens need 'quality time' with their parents, and will suffer psychologically/emotionally if they don't receive it. Limited quality time that is often the case with a single parent, long work hours for the parent, or parental time investment in substance-related socialization (watching the professional sports home team while drinking, recreational use of mj with friends on the weekend, playing beer-league softball, etc.) altogether are extremely common. Extremely. Teens need monitoring, encouragement, and guidance. When they don't have this, they go off-track one way or another. Generally, they will eventually get depressed, get anxious, or 'act-out' with fighting, substance abuse, shoplifting, drag-racing, etc. If it seems like no one cares, or there is no one to help them figure out how to juggle team sports and school demands, etc., they perceive that they are not very high on the priority list of parent(s). "Time-out", being "grounded," and "allowance" are no longer parts of the parenting, but other things, such as a mentor-type role and quality time, are.

In psychiatry residency, and in other mental health training, no 'student' ever gets left on their own - they have their faculty and supervisors to keep track as they negotiate their new world. Same idea for teens.

So, adding social context, including relations with parent(s) would paint the picture and also lead to appropriate interventions, such as addressing the parent-teen relationship.

Some depression is largely biological/genetic. But a lot is only partly 'nature,' and some is very little or no 'nature,' versus 'nurture.'

This is worth noting. If the psychosocial setting is great, but the teen is depressed, this can be a clue to ask abt depression in other family members, then ask what meds work for the family members. Sometimes, with more genetic-influenced depression, the same med works for all that have dep.

It is easy to describe the family context in a couple statements: "josh reported decent relationships with his parents, who are divorced, although his mother lives a half hour away. There are no visitation-type issues reported by Josh." Or: Josh reported little contact with his father since his parents "ugly" divorce two years ago. He wants more contact with his father, but his mother reportedly interferes with this."

A long comment, I know, but just to make the case about including social context including, especially, parental involvement.

Anonymous said...

Sorry, Dinah, but I have to agree with what a few people said - this sounds a little too much like a med school lesson on how to take a psych history/mental status. I think that for a general audience, Josh would come alive a bit more with the actual details (even if fake) about occupation, life, family. I mean, I remember reading various versions of mental status/psych histories in files - and the things that stick with you are the details. (For example, "Pho was born in a refugee camp...married at age 15..." etc.)

It just sounds like a med school intro to psych rotation. Didactic.

tracy said...

....and why does "Josh" have my madien name...?
Hey s...

Bardiac said...

It's interesting that some folks have responded as if Josh is more a child than an adult. He's over 18, a sophomore in college. He's likely to be 20, and certainly over 18. Yes, he's apparently dependent on his parents (financially, probably for health insurance, emotionally), but this "teens need monitoring" business doesn't apply to an adult in Josh's position.

That said, young adulthood is a really fascinating and important time; I'm guessing you'll follow up on that aspect of his development when the time's right!

Return Of Saturn said...

@ Annon #4:
Dinah does describe her questions about the family:

>>I then ask questions about the family: Who is in it? What are their occupations? Are they healthy? What are the patient's relationships with other like?<<

Also, "Josh" is a sophomore in college, and since he is described as going home for spring break, I'm guessing he doesn't live at home. I hope he doesn't still need monitoring to prevent him from shoplifting and drag racing. ;)

Mike said...

It's an interesting post on an interesting blog.

Zoe Brain said...

Just a head's up on what is likely to be a particularly messy brouhaha regarding the DSM-V revision.

As you may know, Dr Zucker of CAMH is heading the section on sexual illnesses.

Allegations have recently been made of misconduct. Ones I do not believe to be true - it is routine at CAMH for gender-variant children's genitalia to be handled by the treating psychologist, and them to be ordered to "accept that they are just gay" as part of the reparative therapy. There is a specific exemption on the usual APA ban on all "reparative therapy" for gender-variant children, and this is regarded as quite usual practice. The treatment is sanctioned. Whether it should be or not is another matter, but the point is that there's no evidence of anything unusual that could be construed as misconduct.

Unfortunately, Dr Zucker's lawyers are now accusing any site that even links to any site that reports the fact that allegations have been made of libel, and demanding the newsfeeds be taken down. Letters have been sent to University administrators of academics who have such news feeds, threatening dire consequences.

Psychiatrists should be aware that their actions while evaluating patients can easily be misconstrued by those presenting with mental health issues, and to take appropriate precautions. They should also be aware of the unfortunate consequences of over-reaction by over-enthusiastic legal teams they may have retained.

I have issues with Dr Zucker's views on reparative therapy, but have no doubt that his standards of conduct are exemplary according to current practice.

Anyway, this is turning into a dirty mess. I thought you should know the facts before things get sensationalised, distorted and blown out of all proportion.

Zoe Brain said...

The newsfeed item:
01-17-09: Organisation Internationale des Intersexués (OII): "The self-proclaimed experts on intersex: Zucker and Lawrence", by Curtis Hinkle
"I am sure that many intersex people were aware that the APA had brought out a booklet on intersex. However, I am not sure that many understand how problematic it is to many intersex people to see some of the following names associated with this booklet: Margaret Schneider, Walter O. Bockting, Randall D. Ehrbar, Anne A. Lawrence, Katherine Louise Rachlin and Kenneth J. Zucker. At first glance, the booklet seems apparently harmless. However, that is what's so clever about it. It's a way for the Clarke/Northwestern clique to get their nose under the (intersex) tent and then later "come on in"."

According to Dr Zucker's attorney Peter Jacobsen, this segment contains "defamatory allegations of criminal conduct and sexual abuse".

Rach said...

This whole thing with Zucker is nothing new. It was reported on in the National Post in 1999, when his clinic for intersexed children (is that the correct term Zoe? Correct me if I'm wrong - I'm not up on the lingo - apologies) was just starting to become more publicized.

Anonymous said...

A lot to address here, keep going!

Therapy Patient: The book is being considered by an academic press, it will be a more serious endeavor. Our editor keeps telling us a book is different from a blog, and there has been concern that "opinionated...funny...light-hearted" (your kind words) come off as flippant. The book is designed to be more of a cognitive keyhole into how we think, but a lot of information about how the system works. So yes, drier. It may not appeal to readers of the blog. I'll work on making Josh a bit more interesting, thanks.

MadandWild, mindful, tracy: Thanks!

ReturnOfSaturn: I've never had a patient ask to read their charts. During the evaluation, I take notes which are what the patient says (so their own words onto the paper). Therapy notes are brief, with things like "patient discussed relationships with family, difficulties at work, events he's attended" being as exciting as I get. Mostly the notes are about what symptoms the patient is having and what medicines they are taking, and if I'm prescribing anything other than the obvious, why that is, and my thoughts about risks/benefits of the meds. It's even drier reading!

Anon: the intended audience is the intelligent lay public -- someone who might be interested in getting care (or has recently started care) for themselves or a family member. Many of the chapters (such as when to see a shrink versus another professional, or how a shrink picks different meds) may also appeal to primary care docs, or other mental health professionals. The target audience is not psychiatrists.

Anon: Yes! Josh will get manic from his antidepressant and then we'll use him to walk through the emergency room process, commitment issues, and inpatient settings. He will also get manic from the steroids he must have to treat an acute asthma attack, and thereby give us space to talk about the interplay of medical illnesses and psychiatric disorders.

Anon 4: I guess we need a little more about Josh's life here. I was leaving some room for my co-bloggers/authors to add to his personality in their sections, but I'll jazz him up a little. Clink wants all our characters to climb mountains.

Bardiac: Probably not going to get into developmental adolescents in this chapter--too ambitious a topic-- and Josh is just a vehicle to help us talk through the various psychiatric settings. Next book, maybe???

Zoe-- just Hi!

Thanks, everyone, the feedback is helpful and even if you thought it was dry, I like that everyone became engaged. Keep talking, I'm always interested.


Anonymous said...

Dinah--I am a member of the so called lay audience in that I am not a shrink. I would like to imagine that I am intelligent, and if various assessments have pointed to a positive answer to this, despite the fact that I am not a big believer in psychometrics, perhaps I am "intelligent". Perhaps the degrees I have hanging on the wall could convince a few people that I am intelligent.Perhaps not.
So let us say that I am an intelligent member of the lay audience at which this book is aimed. I still say my kid in middle school could pick it up and understand it and that the health teacher might be using it with the class but that it is not something an intelligent adult would be interested in. The dull issue is a non issue for middle school as most of their texts are dull and no teacher appears to have noticed. Of course you would have Josh become manic. I am thinking that if you did publish this as a book for intelligent kids that I would buy it after all so that my kids could finally learn the truth about all the pills their parent takes and where their parent disappears to and what the mystery illness is that renders parent incapable of parenting and takes them out of the picture for a time. The truth is that so many,many books have been written for the public. Do we need another one? This does one any service. Write a book for bright kids instead. That would be a great thing. Not a sappy book for little kids. A book for bright kids who can understand at a high level but who have not been exposed to the concepts yet. I think that is more what this chapter sounds like.

Anonymous said...

If you are trying to capture the intelligent lay public, take a look at books by Peter D. Kramer and Oliver Sacks. They are your "competition". This chapter isn't in the same league. I agree with "mysadalterego" that it sounds like a psych school lesson.

Midwife with a Knife said...

I'm not sure how helpful this is, but it might be interesting to switch out to Josh's perspective here and there. Sort of make him a character in your (admitedly non-fiction) book?


Midwife with a Knife said...

PS being a bacon fan, I love the new bacon tool! ;)

Anonymous said...

I am confused. Who is this aimed at? It is way too dry.No way this would make it, as is, onto my bed side table. Sorry guys. Love the blog....

tracy said...

Time for more of the story??? or a new post??? Not to be rude...just love the blog and want selfish!

Fordo said...

Like others, I am unsure who your intended is. However, that aside, I enjoyed what I read and found it extremely readable, although not at the middle school level one reader opined. The writing was clear and I felt sympathy for the patient, as well as curiosity for what caused the depression and what will happen to him next.

Anonymous said...

fordo--the middle schooler is only in middle school because of chronological age not mental age.this will probably lead to a breakdown at some point.

Dragonfly said...

OOoh, can't wait to read it (in about 2 years time though probably, I know these things don't happen overnight).

HP said...

Sorry, but I don't like it. As so many have already said, it reads like many undergrad. text books/case study books and I wouldn't buy it.

I thought the original idea was to capture the essence of Shrink the wall discussions about psychiatry etc. Infinitely more interesting and something I'd definitely buy.