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Appendix B The Novice’s Guide to Psychiatric Assessment Demonstration complements description in any teaching endeavor, and more so in psychiatry, where the phenomena of interest cannot readily be photographed, diagrammed , or dissected. One has to encounter mental illness in actual patients if one is to flesh out the concepts conveyed in books and lectures. To truly know a thing, one must work with it to see how it performs; to truly know a person, it is best to engage the person in an active, goal-directed discussion or activity. You have, I hope, found the portrait of mental life and illness described in this book an enlightening way to think about these most human of biological functions and dysfunctions. I hope also that you will have ample opportunity to test this way of thinking with actual patients. To derive something meaningful from interaction with patients, it is useful to approach the interaction with a method in hand. This provides a framework for guiding the conversation to productive areas, sorting out the many and various facts that emerge, and understanding their significance. Of equal importance, a method is needed to put a patient at ease so the patient will trust the interviewer with sensitive, intimate, often shameful and painful information. This appendix is intended as a guide for the student in his or her first encounters with psychiatric patients and as a supplement to the book’s discussion of mental life and psychopathology. The overall question to be answered in the psychiatric assessment is: Why is the patient there? What is the patient’s problem? The first clue may come from the circumstances of the encounter. Where, how, and with whom the patient shows up for treatment says much about the acuity and nature of the problem. From here, the aim of the interview is to help the patient tell the story. Some patients need little help with this, but often it will be necessary to encourage a timid patient to elaborate or an overly loquacious patient to rein it in. It will also likely be necessary at some point to steer the interview in the direction of a question-and-answer discussion to test hypotheses about the nature of the patient’s problem. All the while, try to attend not just to the content of patient’s words but to how they are delivered, along with the patient’s appearance and actions in the interview, simultaneously. The goal is to develop a diagnostic formulation for the patient. This is not the same as a formal DSM diagnosis; quite the contrary. One may or may not derive adequate information from a single interview to be able to assign a meaningful formal diagnosis. 228 Appendix B But even with sketchy information one can provide a summary description of the patient’s problem and dissect its components. Specifically, the formulation lays out what parts of the patient’s problem arise from a disruption of normal cerebral processes , what parts are the direct result of the patient’s behavior, what parts suggest enduring traits that cause trouble for the patient, and what the problem means for the patient (alternatively, how other meaningful events in the patient’s life contribute to the problem). Table B.1 summarizes the stages of a psychiatric assessment. B.1. Psychiatric Problems Patients see psychiatrists for one or a combination of three kinds of problem: dangerousness, dysfunction, and distress. Dangerousness encompasses suicide and nonlethal acts of self-destruction as well as violence and threatened harm against other people. Dysfunction refers to problems of performance, including cognitive impairment or confusion, erratic or unpredictable behavior, and failure to engage successfully in life roles. Distress comes in the form of pure suffering and also of chaotic emotional states that almost inevitably accompany chaotic lives. Assessment of the salience of each kind of problem for an individual patient, and of the specific nature of the problem, guides the rest of the interview. For each variety of presenting problem, a brief description is provided and some illustrative scenarios. Suggestions about the interviewer’s approach for each sort of problem are given later, under the heading “The Patient’s Problem.” Dangerousness Danger is both extremely significant and overrated in its importance in the psychiatric setting. On the one hand, the risk posed by a truly dangerous patient trumps all other concerns, including the patient’s autonomy; all states provide for the involuntary hospitalization of patients who present an unmanageable threat to...

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