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
Define Contraindicated
not recommended or safe to use (medication that is contraindicated would not be prescribed because it could have serious consequences)
Define Dissociation
disturbance/change in the usually integrative functions of memory, identity, perception, or consciousness (common with history of trauma)
Endogenous Depression
depression caused by a biochemical imbalance rather than external factors
Exogenous Depression
depression caused by external events or psychosocial stressors
Define Folie a Deux
shared delusion
Hallucinations
hearing, seeing, smelling or feeling something that is not real (auditory most common)
Hypomanic
elevated, expansive, or irritable mood that is less severe than full blown manic symptoms (not severe enough to interfere with functioning and not accompanied by psychotic symptoms)
Postmorbid
Subsequent to onset of illness
Premorbid
Prior to onset of illness
