Biopsychosocial History & Collateral Data Flashcards
The Biopsychosocial-spiritual-cultural assessment is a tool that does what?
provides info on the current/presenting issue(s), a client’s past and present health, emotional functioning, educational/vocational background, cultural issues, spiritual and religious beliefs, environmental issues, and social functioning
- Each can be reviewed for its relationship/impact with the presenting issue – gives context
What does the biological component of assessment do and look at?
Biological: assesses client’s medical history, developmental history, current medications, substance abuse history, and family history of medical illnesses
○ Issues related to medical problems should be explored because MH symptoms can exacerbate them
○ Referrals should be made to address untreated medical concerns
- Those on medications should have care coordinated with their provider and side effects should be known as they can mask or exacerbate psychiatric symptoms/illnesses
What does the psychological component of assessment do and look at?
Psychological: assesses present psychiatric illness or symptoms, history of current psych illness/symptoms, past or present psychosocial stressors, and mental status
- Exploration of how the problem has been treated in the past, past or present medications, and family history of psych/SU issues included
What does the social component of assessment do and look at?
Social: focuses on client systems & context, may identify strengths/resources available for treatment planning.
- Includes sexual identity issues/concerns, personal history, family of origin, support system, abuse history (?), education, legal history, relationship status/concerns, work history and risks
What is the function of a Mental Status Exam?
> Structured way of observing & describing a client’s current state of mind
Necessary part of any client assessment no matter what the presenting problem
What is included in a mental status exam? (MOST I JAM)
- Appearance: Facial expression, grooming, dress, gait, etc.
- Orientation: awareness of time and place, events etc. (time, place, date - oriented x3)
- Speech Pattern: Slurred, pressured, slow, flat tone, calm etc.
- Affect/Mood: Mood as evidenced in both behaviour and client’s statements (sad, jittery, manic, placid, etc.)
- Impulsive/Potential for harm: Impulse control with special attention to potential suicidality and/or harm to others
- Judgement/Insight: ability to predict the consequences of behaviour, make “sensible” decisions, recognize contribution to problem
- Thought process/Reality testing: thinking style & ability to know reality, including difference between stimuli coming from inside/outside themselves (delusions, hallucinations, conclusions about whether or not client is psychotic) – thought content
- Intellectual functioning/memory: level of intelligence (cognition) and of recent and remote memory functions
What influences the ways in which clients experience chronic illness/disability
○ Personal characteristics (gender, race, age, coping style, past experience)
○ Social & family supports
○ Socioeconomic status
○ Culture
○ Environment (physical, social, political)
○ Activities (restrictions on those related to ADL’s, work, school, social)
Personal goals
- Limitations may not be due to illness but to environment - Societal attitudes may influence their responses with norms focused more on limitations than actual functioning - Also variance in terms of personal resources, functional capabilities, coping strategies, social supports
What are the biopsychosocial factors related to Mental Health
> Biological Factors
○ Genes play a factor
○ Brain structure/functioning - growth in utero
Psychological Factors
○ Personality
○ Relating to others & reacting to the world
Social Factors
- SES, age, gender, social networks, level of support, life events, migration, culture
When does psychosocial stress occur?
when there is a perceived threat (real or imagined)
> Threats to social status, social esteem, respect, and/or acceptance within a group, threats to self worth, uncontrollable threats
What causes psychosocial stress?
- Can be caused by upsetting events (natural disasters, sudden health problems/death, divorce)
○ Can also be past events
○ Should assess impacts of childhood abuse, bullying, discrimination, violence, trauma- Often not cause by single events, but ongoing problems (caring for a parent/child with disabilities)
- Can manifest in different ways (high BP, sweating, rapid heart rate, dizziness, feelings of irritability/sadness)
- Triggers a stress response - release of stress hormones that lead to a burst of energy. Can be helpful short term but not long term
What should ALWAYS be done before making a psychiatric diagnosis?
- Medical etiology should always be ruled out before making psychiatric diagnoses
Define differential diagnosis
Differential diagnosis: systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible
What are the 11 major Body Systems?
- Circulatory
- Digestive
- Endocrine
- Immune
- Lymphatic
- Muscular
- Nervous
- Reproductive
- Respiratory
- Skeletal
- Urinary
What does diagnosis refer to?
the process of identifying problems, with their underlying causes and practical solutions
When are diagnoses given?
- Generally obtained after using info gathered in assessment – should not diagnose if adequate info is not available
- Diagnostic info should always be shared with clients & used to facilitate the establishment of intervention plans
- Assessment & diagnosis MUST be a continual part of the problem-solving process
