Psychopathological findings
The results of a systematic psychological or psychiatric examination are summarized in a psychopathological finding . Together with other information, it is used to make a diagnosis and consists mainly of a list of disorder- relevant psychopathological symptoms (" items "), for example delusion , depression , memory disorders or state of consciousness .
The psychopathological finding is (like medical reports in other medical specialties as well) a standardized summary of significant individual facts and is used to provide quick information about "what the doctor or psychologist has found out". In this respect, it has a professionally objective character and the contents of the report are subject to medical confidentiality . There are numerous structured and semi-structured interviews that serve to standardize the psychopathological findings. The AMDP system is widespread in Germany.
Assessment
The psychopathological findings are collected by doctors or psychological psychotherapists , alternative practitioners for psychotherapy as well as child and adolescent psychotherapists . The investigation is usually divided into a more free and a more structured part and its level of detail depends heavily on the investigation situation (emergency, communication barriers, etc.). It usually begins with the freer part, in which the examiner mainly asks open questions in order to motivate the patient to report freely. This part serves to get an impression of the personality , the complaints and the general psychological state of the patient . Then you switch to the structured part, in which mainly closed, targeted questions are asked. Specific symptoms are queried, typical feature constellations are checked and the information from the free patient report is supplemented.
Findings report
The written findings report includes information from the person examined (patient), behavioral observation (by third parties such as relatives, but also by the examiner) and the examiner's assessment. A psychopathological finding in the narrower sense only lists deficits. In order to create a vivid picture of the patient, some examiners add a sentence or two in front of the finding in which they subjectively describe the first encounter or record significant interactional abnormalities and their own impressions. For an overall assessment of the patient, indications of his resources and skills are helpful, but these are not part of the finding in the narrower sense.
meaning
Since psychiatric diagnoses are subject to change over time, the psychopathological finding is of particular importance. So it is still possible after years to make a diagnosis according to the then valid guidelines. Changes in the psychopathological findings over time or over the duration of the illness can provide important information about diagnostic relationships and are the main means of assessing the clinical course (improvement, deterioration, etc.).
Components
The psychopathological finding has different components. It documents all changes and abnormalities that are significant for the psychological disorder of the respective patient: appearance (e.g. well-groomed, untidy, neglected), behavior, expression, inner-psychological experience disorders (which must be inquired about, e.g. hallucinations, abnormal Body feelings or inner restlessness.)
Expression disorders
Disturbances of expression include, above all, external appearance and social and situational behavior. The examiner can describe the psychomotor system and drive, facial expressions, linguistic expression and speaking behavior. Changes that can be observed in a broader sense also affect the patient's state of consciousness (quantitative and qualitative disorders).
Experience disturbances
An experience disorder is defined as all changes that are only or primarily revealed by the patient's report about his inner experience. This also includes changes in the emotional and emotional life , in particular sad or elated mood . The effects of mood changes can often be observed in behavior, such as the elevated mood in a mania. The disorders of formal thinking , such as slowed thinking as well as content- related thought disorders ( delusions and hallucinations ) only reveal themselves if patients report them to the examiner or are willing to confirm them through targeted questioning.
Cognitive disorders
Many mental disorders, especially dementias, are associated with impaired cognitive abilities. These are usually accessible to an objective examination. Orientation as well as attention , memory , memory , concentration and action planning are tested . The check of the orientation includes the temporal (can the patient give the date?), Local (does the patient know where he is?) And about himself (can the patient give correct information about himself?).
Other disorders
They include circadian abnormalities (arrhythmias). This refers to changes in the course of the day, such as the low mood in the morning in depressed patients. Patients with psychosomatic complaints often report organically unjustifiable physical disorders and pain . In the context of some diseases, suicidality or danger to others occurs. Some mental disorders are defined as having a reduced intelligence associated. Behavioral abnormalities , aggressiveness, self-harm tendency, feeling and insight into illness and addictive behavior are further items.
See also
literature
- Mathias Berger (Ed.): Mental illnesses. Clinic and Therapy. Urban & Fischer, Munich 2004, ISBN 3-437-22480-8 .
- Gerd Huber: Psychiatry. Textbook for study and further education. Stuttgart 1999, ISBN 3-7945-1857-8 .
- HJ Freyberger, A. Ermer, Rolf-Dieter Stieglitz : Psychological examination and assessment. In: HJ Freyberger, W. Schneider, R. Stieglitz (Eds.): Compendium Psychiatrie Psychotherapy Psychosomatic Medicine. 11th edition. Karger Verlag, 2002, ISBN 3-8055-7272-7 .
Individual evidence
- ↑ The AMDP system. Manual for the documentation of psychiatric findings. 9., revised. and exp. Edition. Hogrefe, 2016, ISBN 978-3-8017-2707-9 .