Escolar Documentos
Profissional Documentos
Cultura Documentos
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m Addressed by DSM
Õ Diagnostic criteria based on g
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Õ ôomprehensive record of patientǯs life
Õ Derive personality characteristics
Õ Insight into nature of patientǯs relationships with
others
Õ Allow patients to tell their stories in their own words in
the order that they consider most important
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I. Identifying data
II. ôhief complaint
III. History of Present Illness
IV. Past Illnesses
V. Family History
VI. Personal History (Anamnesis)
VII. Sexual History
VIII.Fantasies and dreams
IX. Values
Õ Demographic summary of the patient
Õ Provide thumbnail sketch of patient
Õ Be direct in obtaining identifying data
Õ If patient is uncooperative, get information from other
sources
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Õ In patientǯs own words on why patient was brought in
for help
Õ Record also version of other individuals present
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Õ Medical history
Õ Psychiatric history
Õ Alcohol and Substance history
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Õ Brief description of
Õ any psychiatric illness, hospitalization, and treatment of
immediate family members
Õ role in patientǯs upbringing
Õ Relationship with the patient
Õ Attitude of patient towards family and siblings
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Õ xo understand patientǯs past and its relation to the
present emotional problem
Õ Prenatal and perinatal
Õ Infancy and Early childhood (up to age 3)
Õ Middle childhood (age 3-11)
Õ Adolescence (puberty through adoloscence)
Õ Adulthood
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Õ Home situation into which patient was born
Õ Wanted or planned pregnancy?
Õ Maternal health problems
Õ Maternal substance abuse
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Õ Mother-child relationship
Õ Feeding habits
Õ Developmental milestones
Õ Symptoms of behavior problems
Õ xhumb sucking, tantrums, tics, night terrors, etc
Õ ôhildǯs personality
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Õ ender identification
Õ Disciplinarian in the family and punishments used at
home
Õ Separation anxiety on first school day
Õ Relationship with friends
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Õ xo determine patientǯs emerging self-image:
Õ Ascertain values of patientǯs peers
Õ Idealized figures
u Social relationships
u School history
u ôognitive and motor development
u Emotional and physical problems
Õ ^ccupational history
Õ Marital and relationship history
Õ Military history
Õ Educatioin history
Õ Religion
Õ Social activity
Õ Legal history
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Õ ^nset of puberty and patientǯs attitude towards it
Õ Attitude towards masturbation
Õ Attitude towards sex
Õ Shy, timid, aggressive
Õ Explore any other sexual symptoms
Õ Premature ejaculation, lack of sexual desire, impotence,
etc
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Õ
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Freud
Õ Repetitive dreams are of particular value
Õ Most common dreams:
Õ Food, examination, sex, helplessness, feelings of
impotence
Õ Valuable sources of unconscious material
Õ Describe in terms of quantity, rate of production and
quality
Õ xalkative, unspontaneous, normally responsive,
Õ Rapid, slow, hesitant, monotonous, whispered, slurred
Õ ºnusual rhythms (dysprosody)
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Õ Mood
Õ patientǯs subjective emotional state
Õ Depressed, despairing, irritable, anxious, euphoric,
frightened, perplexed
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Õ Affect - objective emotional expression; what examiner infers
from patientǯs facial expression/expressive behavior
Õ Normal range
Õ Variation in facial expression, tone of voice, hand and body
movements
Õ ôonstricted
Õ Reduced range and intensity of expression
Õ Blunted
Õ Further reduced emotional expression
Õ Flat
Õ No signs of affective expression, monotonous voice, immobile
face
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Õ Appropriateness
Õ ôonsidered in context of what patient is discussing
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Õ Hallucination
Õ false sensory perception not based on reality (auditory,
visual, olfactory, tactile)
Õ Delusion
Õ Ȃ false interpretation of external reality
Õ V
Ȃ as person falls asleep
Õ V
Ȃ as person awakens
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Ȃ extreme feelings of detachment from
self or environment
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