Assessment the Condition and Symptomatic State of a Psychiatric Patient - Coursework Example

Schizophrenic Assessment: Focus on the Brief Psychiatric Rating Scale Introduction There are a great number of tools that can be used to assess the condition and symptomatic state of a psychiatric patient. A simple, yet effective tool that can be used is the Brief Psychiatric Rating Scale which was developed in 1962 (see Appendix 1). There are a number of research papers that have been conducted in relationship to this test. The test is used by a number of different medical professionals in the assessment of patients who are encountering difficulties with mental illness. The validity of this test has been verified through a number of research studies and the tool has been expanded and improved over time. The test has been found to have been used in studies across time since it was created, thus supporting it as a valuable addition to the study of schizophrenia during the last half of the 20th century and into the millennia. The BPRS tool has been evaluated over sixty years of use, expanding upon its structure with developments that can be used in modern practice. Tools There are different, but common tools that can be used to assess someone suffering from schizophrenia or to do research on diagnostic experiences of the disorder. One of the most common tools used in research is the Research Diagnosis Criteria (RDC) which was created in 1975. Structured interview instruments include the Present State Examination (PSE) from 1970, the Schedule for Affective Disorders and Schizophrenia (SADS), and the Structured Clinical Interview for DSM-IV are all valued instruments for the diagnosis of schizophrenia (Lieberman, 2006). The DSM-IV-TR is the most common diagnostic tool that is used for coming to the conclusion that someone is afflicted with the disorder of schizophrenia (see Appendix 3). One of the longest existing and still used assessments from the 20th century, however, is that of the Brief Psychiatric Rating Scale from 1962. The Brief Psychiatric Rating Scale was developed in 1962 by John E Overall and Donald R, Gorham in order to support a rapid assessment for psychiatric patients. The original assessment had sixteen criteria questions that all can be answered through a seven point ordered ratings scale. The purpose of the assessment is to efficiently determine changes that occur through an economic means so that the assessment supplies the most information possible within a short time. The developers of the tool recommend that two interviewers be present during the interview to independently assess the patient so that the best possible observations can accompany the assessment (Overall & Gorham, 1962). Throughout the fifty years since the creation of the test it has evolved into both an eighteen and a twenty-four question tool through experimentation and evaluation with the instrument. The use of the BPRS tool was originally confined to the use of the psychiatrist as he or she evaluated the progress of their patient. In the last couple of decades, however, nurses have been given the responsibility on a more frequent basis to administer the tool for later evaluation by the doctor involved in the case. Barker (2004) discusses how the tool as it is used to monitor “the experience of psychosis, or the differential effects of treatment” has been more often handed to nurses in recent years with a recognition and stipulation for validity based upon the understanding and clinical skills of the interviewer, in this case the nurse, who must be thoroughly trained on its use (p. 251). Nurses have been using the tool for the past couple of decades through a modified version used for evaluation that can be translated and interpreted across several providers of medical care. The tool evaluates the symptoms so that they can be tracked by the medical team and the immediate position of the mental state of the patient can inform them on how to proceed with treatment. Through the 24 question instrument that is used by most nurses a more comprehensive set of information can be gathered that allows for greater interpretation by a secondary party to the interview (Tusaie, & Fitzpatrick, 2013). Research Studies According to Kopelowicz, Ventura, Liberman, and Mintz (2008) the validity of the test to track the progress of patients with schizophrenia is substantial. Through tracking a total 565 patients over a 15 year period, the study showed that through evaluating four factors the on the 24 part BPRS that successful evaluation was provided by the tool. The BPRS provided enough evaluation so that interpreting the progress of patients with schizophrenia through the use of the tool was a valid effort. The capacity to track patients through the use of a tool like this through a long period of time provide for the development of an understanding of both the tool’s validity and the understanding of the psychiatric community about the disorder. In understanding the changes that occur over time, a greater understanding of the progression and regression of the illness can be developed. In a study that used a sample of 193 individuals with non-acute schizophrenia, Long and Brekke (1999) studied the effects of the illness every six months over a three year period of time. Using both the sixteen and eighteen versions of the assessment, the effects of thought disturbance, anergia, affect, and disorganization are endured and fairly constant over the course of time, but the way in which they are related to each other does vary. As would be expected, the expanded version of the tool was a bit better than the lesser version and the model of the instrument was invariant, with the sixteen question version being more so. Mueser, Curran, and McHugo (1997) reported that the five factor assessment was less successful than the four factor assessment (thought disturbance, anergia, affect, and disorganization) in evaluating with the BPRS. More recently, Hsiao, Hsieh, Tseng, Chien, and Chang (2012) used the BPRS tool along with several instruments in order to define the quality of life that is experienced by schizophrenia patients as they work towards existing within society. Finding that a number of factors contribute to the quality of life that an individual struggling with schizophrenia experiences, the tool helped to determine that the patient and family members should participate in treatment programs in order to sufficiently contribute within the social sphere so that integration and satisfaction can be achieved. Hsiao et al (2012) write that “Particularly, programs that enhance health status and mutuality should be identified and developed for both individuals with schizophrenia and their families” (p. 15). Conclusion The use of the BPRS has been a part of the study of psychiatric patients with schizophrenia for the last sixty years. Developed in 1962, the tool is used to evaluate the present condition of the patient so that progress or regression can be observed over the course of time. In recent decades the use of the tool has been handed over to nursing staff through an expanded version that can allow a secondary look at the patient and their state of symptoms. Changes can be seen through the changes that are given as answers to the questions on the tool about symptoms. Research studies have discovered that the aspects of thought disturbance, anergia, affect, and disorganization are the best assessed through the tool, providing for a dimensional evaluation of time and differentiation in the experience of the disorder. Working in teams with nurses and doctors, the tools of assessing psychiatric patients with schizophrenia allow for diagnosis and tracking. The BPRS allows for tracking of symptoms towards valued treatment. Resources Barker, Philip J. (2004). Assessment in Psychiatric and Mental Health Nursing: In Search of the Whole Person. Cheltenham: Nelson Thornes. Counseling Resource Research Staff. (2 April 2011). Schizophrenic symptoms. Counseling Resource. Retrieved from http://counsellingresource.com/lib/distress/schizophrenic/schiz ophrenia-dsm/schizophrenia-symptoms/ Hsiao, C., Hsieh, M., Tseng, C., Chien, S., & Chang, C. (2012). Quality of life of individuals with schizophrenia living in the community: Relationship to socio‐demographic, clinical and psychosocial characteristics. Journal Of Clinical Nursing, 21(15-16), 2367-2376. Infotech Soft (2012). BPRS. Retrieved from http://infotechsoft.com/products/downloads/Psy chiatryand_Menta l_Health_Forms/BPRS18_BriefPsychiatricRatingScale.pdf Kopelowicz, A., Ventura, J., Liberman, R., & Mintz, J. (2008). Consistency of Brief Psychiatric Rating Scale factor structure across a broad spectrum of schizophrenia patients. Psychopathology, 41(2), 77-84 Lieberman, J. A. (2006). Textbook of schizophrenia. Washington, DC: American Psychiatric Publishing. Long, J. D., & Brekke, J. S. (1999). Longitudinal factor structure of the Brief Psychiatric Rating Scale in schizophrenia. Psychological Assessment, 11(4), 498-506. Mueser, K. T., Curran, P. J., & McHugo, G. J. (1997). Factor structure of the Brief Psychiatric Rating Scale in schizophrenia. Psychological Assessment, 9(3), 196-204. Overall, J. E. & Gorham, D. R. (1962). The brief psychiatric rating scale. Psychological Reports. 10, 799-812. Tusaie, K. R., & Fitzpatrick, J. J. (2012). Advanced practice psychiatric nursing: Integrating psychotherapy, psychopharmacology, and complementary and alternative approaches. New York, NY: Springer Publishing Co. Appendix 1 The Brief Psychiatric Rating Scale (BPRS) Please enter the score for the term which best describes the patient's condition 0 = not assessed, 1 = not present, 2 = very mild, 3 = mild, 4 = moderate, 5 = moderately severe, 6 = severe, 7 = extremely severe 1. SOMATIC CONCERN 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Degree of concern over present bodily health. Rate the degree to which physical health is perceived as a problem by the patient, whether complaints have a realistic basis or not. 2. ANXIETY 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Worry, fear, or over-concern for present or future. Rate solely on the basis of verbal report of patient's own subjective experiences. Do not infer anxiety from physical signs or from neurotic defense mechanisms. 3. EMOTIONAL WITHDRAWL 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Deficiency in relating to the interviewer and to the interview situation. Rate only the degree to which the patient gives the impression of failing to be in emotional contact with other people in the interview situation. 4. CONCEPTUAL DISORGANIZATION 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Degree to which the thought processes are confused, disconnected, or disorganized. Rate on the basis of integration of the verbal products of the patient; do not rate on the basis of patient's subjective impression of his own level of functioning. 5. GUILT FEELINGS 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Over-concern or remorse for past behavior. Rate on the basis of the patient's subjective experiences of guilt as evidenced by verbal report with appropriate affect; do not infer guilt feelings from depression, anxiety, or neurotic defenses. 6. TENSION 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Physical and motor manifestations of tension "nervousness", and heightened activation level. Tension should be rated solely on the basis of physical signs and motor behavior and not on the basis of subjective experiences of tension reported by the patient. 7. MANNERISMS AND POSTURING 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Unusual and unnatural motor behavior, the type of motor behavior which causes certain mental patients to stand out in a crowd of normal people. Rate only abnormality of movements; do not rate simple heightened motor activity here. 8. GRANDIOSITY 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Exaggerated self-opinion, conviction of unusual ability or powers. Rate only on the basis of patient's statements about himself or self-in-relation-to-others, not on the basis of his demeanor in the interview situation. 9. DEPRESSIVE MOOD 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Despondency in mood, sadness. Rate only degree of despondency; do not rate on the basis of interferences concerning depression based upon general retardation and somatic complaints. 10. HOSTILITY 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Animosity, contempt, belligerence, disdain for other people outside the interview situation. Rate solely on the basis of the verbal report of feelings and actions of the patient toward others; do not infer hostility from neurotic defenses, anxiety, nor somatic complaints. (Rate attitude toward interviewer under "uncooperativeness"). 11. SUSPICIOUSNESS 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Belief (delusional or otherwise) that others have now, or have had in the past, malicious or discriminatory intent toward the patient. On the basis of verbal report, rate only those suspicions which are currently held whether they concern past or present circumstances. 12. HALLUCINATORY BEHAVIOR 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Perceptions without normal external stimulus correspondence. Rate only those experiences which are reported to have occurred within the last week and which are described as distinctly different from the thought and imagery processes of normal people. 13. MOTOR RETARDATION 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Reduction in energy level evidenced in slowed moments. Rate on the basis of observed behavior of the patient only; do not rate on the basis of patient's subjective impression of own energy level. 14. UNCOOPERATIVENESS 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Evidence of resistance, unfriendliness, resentment, and lack of readiness to cooperate with the interviewer. Rate only on the basis of the patient's attitude and responses to the interviewer and the interview situation; do not rate on basis of reported resentment or uncooperativeness outside the interview situation. 15. UNUSUAL THOUGHT CONTENT 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Unusual, odd, strange, or bizarre thought content. Rate here the degree of unusualness, not the degree of disorganization of thought processes. 16. BLUNTED AFFECT 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Reduced emotional tone, apparent lack of normal feeling or involvement. 17. EXCITEMENT 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Heightened emotional tone, agitation, increased, reactivity. 18. DISORIENTATION 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Confusion or lack of proper association for person, place, or time. BPRS-18: Brief Psychiatric Rating Scale Appendix 2 Mock Assessment of the BPRS Please enter the score for the term which best describes the patient's condition 0 = not assessed, 1 = not present, 2 = very mild, 3 = mild, 4 = moderate, 5 = moderately severe, 6 = severe, 7 = extremely severe 1. SOMATIC CONCERN 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Degree of concern over present bodily health. Rate the degree to which physical health is perceived as a problem by the patient, whether complaints have a realistic basis or not. (3) 2. ANXIETY 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 Worry, fear, or over-concern for present or future. Rate solely on the basis of verbal report of patient's own subjective experiences. Do not infer anxiety from physical signs or from neurotic defense mechanisms. 3. EMOTIONAL WITHDRAWL 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (5) Deficiency in relating to the interviewer and to the interview situation. Rate only the degree to which the patient gives the impression of failing to be in emotional contact with other people in the interview situation. 4. CONCEPTUAL DISORGANIZATION 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (5) Degree to which the thought processes are confused, disconnected, or disorganized. Rate on the basis of integration of the verbal products of the patient; do not rate on the basis of patient's subjective impression of his own level of functioning. 5. GUILT FEELINGS 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (6) Over-concern or remorse for past behavior. Rate on the basis of the patient's subjective experiences of guilt as evidenced by verbal report with appropriate affect; do not infer guilt feelings from depression, anxiety, or neurotic defenses. 6. TENSION 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (0) Physical and motor manifestations of tension "nervousness", and heightened activation level. Tension should be rated solely on the basis of physical signs and motor behavior and not on the basis of subjective experiences of tension reported by the patient. 7. MANNERISMS AND POSTURING 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (4) Unusual and unnatural motor behavior, the type of motor behavior which causes certain mental patients to stand out in a crowd of normal people. Rate only abnormality of movements; do not rate simple heightened motor activity here. 8. GRANDIOSITY 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (5) Exaggerated self-opinion, conviction of unusual ability or powers. Rate only on the basis of patient's statements about himself or self-in-relation-to-others, not on the basis of his demeanor in the interview situation. 9. DEPRESSIVE MOOD 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (2) Despondency in mood, sadness. Rate only degree of despondency; do not rate on the basis of interferences concerning depression based upon general retardation and somatic complaints. 10. HOSTILITY 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (0) Animosity, contempt, belligerence, disdain for other people outside the interview situation. Rate solely on the basis of the verbal report of feelings and actions of the patient toward others; do not infer hostility from neurotic defenses, anxiety, nor somatic complaints. (Rate attitude toward interviewer under "uncooperativeness"). 11. SUSPICIOUSNESS 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (6) Belief (delusional or otherwise) that others have now, or have had in the past, malicious or discriminatory intent toward the patient. On the basis of verbal report, rate only those suspicions which are currently held whether they concern past or present circumstances. 12. HALLUCINATORY BEHAVIOR 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (6) Perceptions without normal external stimulus correspondence. Rate only those experiences which are reported to have occurred within the last week and which are described as distinctly different from the thought and imagery processes of normal people. 13. MOTOR RETARDATION 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (6) Reduction in energy level evidenced in slowed moments. Rate on the basis of observed behavior of the patient only; do not rate on the basis of patient's subjective impression of own energy level. 14. UNCOOPERATIVENESS 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (1) Evidence of resistance, unfriendliness, resentment, and lack of readiness to cooperate with the interviewer. Rate only on the basis of the patient's attitude and responses to the interviewer and the interview situation; do not rate on basis of reported resentment or uncooperativeness outside the interview situation. 15. UNUSUAL THOUGHT CONTENT 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (6) Unusual, odd, strange, or bizarre thought content. Rate here the degree of unusualness, not the degree of disorganization of thought processes. 16. BLUNTED AFFECT 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (7) Reduced emotional tone, apparent lack of normal feeling or involvement. 17. EXCITEMENT 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (1) Heightened emotional tone, agitation, increased, reactivity. 18. DISORIENTATION 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (5) Confusion or lack of proper association for person, place, or time. 1. SOMATIC CONCERN 􀀄 0 􀀄 1 􀀄 2 􀀄 3 􀀄 4 􀀄 5 􀀄 6 􀀄 7 (3) (Observation: This is an example of a patient in a state of moderate agitation) Appendix 3 Diagnostic Criteria for Schizophrenia A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., affective flattening, alogia, or avolition Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement). C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive Episode, Manic Episode, or Mixed Episode have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). Subtypes 1. Paranoid Type A type of Schizophrenia in which the following criteria are met: Preoccupation with one or more delusions or frequent auditory hallucinations. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect. 2. Catatonic Type A type of Schizophrenia in which the clinical picture is dominated by at least two of the following: motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor excessive motor activity (that is apparently purposeless and not influenced by external stimuli) extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing echolalia or echopraxia 3. Disorganized Type A type of Schizophrenia in which the following criteria are met: All of the following are prominent: disorganized speech disorganized behavior flat or inappropriate affect The criteria are not met for Catatonic Type. 4. Undifferentiated Type A type of Schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type. 5. Residual Type A type of Schizophrenia in which the following criteria are met: Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for Schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). Associated features Learning Problem Hypoactivity Psychosis Euphoric Mood Depressed Mood Somatic or Sexual Dysfunction Hyperactivity Guilt or Obsession Sexually Deviant Behavior Odd/Eccentric or Suspicious Personality Anxious or Fearful or Dependent Personality Dramatic or Erratic or Antisocial Personality (Counseling Resource Research Staff, 2012) Read More