Psychiatric Assessment

• by

Dr.Perjan Hashim Taha

M.B.Ch.B. Msc.C.A.P. F.I.C.M.S.(Psych)

2013

The psychiatric interview

• Similarities between the psychiatric interview and the general medical interview

• The goal of all communication between doctor and patient is to diagnosis and treatment and further the aims of the working alliance between doctor and patient.

The psychiatric interview

• Differences between the psychiatric interview and the general medical interview

• It must communicate personal concerns about disturbed mental functioning through language

• In all cases, special tact and sensitivity are required of the psychiatric interviewer

Psychiatric AssessmentGoals:

1. Diagnosis

2. understand context of diagnosis (patient’s life)

3. Establish therapeutic relationship

Psychiatric AssessmentStages:

Preparation

Collection of information: by h. and MSE

Evaluation of information: for DD.

Using of information: for R.

Preparing for InterviewPut patient at ease

Ensure privacy

Ensure safety of interviewer

Free from interruption

Comfortable

Arrange the chair at angle and should little at higher level than patient

=It takes some

skill.…

?Psychiatric Interview?

Skill to encourage disclosure of personal information for a

professional purpose

Empathy → rapport → therapeutic alliance

If there is possibility of violence:

• Another person should know when and where is the interview

• Ensure that help can be called if needed

(emergency call button)• Ensure that neither the patient or any

obstruction is between the interviewer and the exit

• Remove from sight any object that can be used as a weapon

Starting of Interview • Welcome the patient and explain the reason for

the assessment• Greet the companion and explain how long is

expected to wait• Keep confidentiality• Start by open question ( tell me about your

problem?)• Interviewer should be ( relaxed, unhurried, eye

contact, alert to verbal and non verbal cues, control over talkative patient)

Assessment

• The interviewer should introduce and identify himself, clearly explain the purpose of the meeting with the patient.

• Invite the patient to begin in as open-ended a manner as possible

Eg : what sort of trouble have you been having? Tell me about the problem that bring you here.

Specific interviewing techniques

• Learn to be quiet.

• Pay attention to body language.

• Start broadly and then focus in.

Specific interviewing techniques

• Remember that the patient is more scared than you are.

• Tell the patient what you think he or she is feeling.

• When an interview goes down, try repeating the patient’s last words.

• Go ahead and ask the “unaskable”.

Psychiatric InterviewingPsychiatric Interviewing

Psychiatric Assessment Parts• Psychiatric History• MSE• Physical Examination• Neurological Examination• Further Investigation

• Name: Age: Sex: Marital status:

• Occupation: Address: Date of admission:

• Name of the informant and his/her relationship to patient

• Reason and source of refferal

I- Present Complain and duration:

II- History of present Condition:

Symptoms (onset, duration, flactuation, details)

Expected symptoms

Relationship between symptoms and physical dis., or social problem

Functional impairment

Previous R. effects and S.E.use simple terms and try to avoid technical scientific terms

Psychiatric History

Chief Complaint

• What brought the patient in? Patient’s own words

• Why now and not 6 months ago?• What happened in the past week?• Past 24 hours?

III- Family history:

1- Father and mother: including: name, age, occupation, health (mental and physical), education, personality, attitude, and emotional relation of each with the patient. Include divorce and separation from each. If dead time, place and cause of death and age of the parent and the patient then.

2- Siblings: The rank of the patient. In Chronological order include name, age, sex, occupation, marital status, health (mental and physical), personality, social and economical status, relation with the patient and his feeling towards them.

3- Relatives: Relations and illness. Ask specifically about abnormal personality, mental disorders, epilepsy and alcoholism.

4- Home atmosphere:

IV- Personal history:

1- Pregnancy and birth: include date and place of birth, mother’s condition during pregnancy, delivery (normal, prolonged, instrumentation and operation),

(premature, low birth weight, convulsions)

2- Early childhood: • Feeding breast or bottle.

• Development (milestones): attachment, talking, walking, bowel and bladder control

• Neurotic symptoms; bed wetting, temper tantrum, nail biting, thumb sucking, night terror, sleep walking, stammering, fears, mannerism, and tics.

• Behavior; playing, (alone), hostility, hyperactivity and relation with others specially the family.

3- Adolescence and adulthood: Include social life (isolation and peer group), difficulties and crises, fantasies.

4- Education history: School; age to start and finish school, name of schools, reaction to school, regularity (school phobia, truancy with age), difficulties, attitude to teacher and peers, achievements and ambitions. University and higher education.

?

5- Occupational history: Include age of starting to work, list of job(s) and duration and causes (if any). Regularity, job satisfaction, economical status.

6- Menstrual history: Include; age of menarche, cycle, (regularity, duration, last period), dysmenorrhea, premenstrual tension, and menopause (time, reaction and symptoms)

7- Sexual history: Masturbation; worries, guilt, and fantasies, any deviations or dysfunction.

Orientation; homosexual or heterosexual

Experience; age and type.

8- Marital history: Marriage; age, date, and number

Partner; age, occupation, personality, and health

Sex; mode of intercourse, orgasm, and impotence

Satisfaction and relationship

Abortion and contraception

Extramarital relationship

Children; list in chronological order, age, sex, health, personality, and relationship.

9- Alcohol, drugs and tobacco: Include; quantity and frequency of use

11- Past psychiatric history: Include; date, duration, symptoms, and treatment of each.

10- Past Medical History: Illnesses, operations, accidents, drug treatments

12- Forensic history: Illegal acts, courts and prison.

13- Present social circumstances: Include; living standard, interests and hobbies, and financial status

V- Premorbid personality:

1- Mood: cheerful-sad, tense-calm, optimistic-pessimistic, stable-unstable, apathetic-inhibited.

2- Character: hesitant, self confident-shy timid, tolerant-not, expressive, trusting-suspicious, irritable-not, sensitive-not, jealous-not.

3- Moral selfish, or altruistic, religious, rigid.

4- Energy; energetic, initiative, sluggish, or fluctuant.

5- Socially; Introvert or extrovert.

6- Fantasy life; Is he a day dreamer.

7- Habit and hobbies

Developmental millstones

Back

3 y 8 m

1 year

Sit alone with good coordination

Mental State Examination• Appearance, Attitude, Behavior,• Speech• Mood• Thoughts• Perceptions• Cognitive functions• Insight

Appearance and Behavior• Observe from the first moment• Ataxia• Dressing: dirty? Wear bright color?• Weight loss

• Facial and emotional expressions: - corners of mouth, Vertical furrow on brows, Omega sign?

- horizontal creases on forehead, wide palpebral fissures, and dilated pupils?

• Posture :• Head and gaze downward?

• Social Behavior:• Disinhibited behavior=mania withdrawal=schizophrania• Aggression=antisocial PD as if they are elsewhere=dementia

Speech

• Rate• Fast increased amount= mania• Slaw and pauses= depression

• Difficulty speaking

• Neologisms

• Flow of speech• Thought blocking= schiz.• Flight of ideas= mania

Mood

• Depression and mania• What is your mood like?• Do you blame yourself?

• Fluctuation and incongruous mood• Suicidal Ideation is very important

• anxiety• Feelings and physical symptoms like palpitation, S.O.B.

Thoughts

• Thought Process: rapid, slow, goal directed, tangential, circumstantial, loose, incoherent (word salad), clang associations, neologisms

• Thought Content: preoccupations, obsessions, delusions, suicidal, homicidal

• Delusions: persecutory, grandiose, religious, somatic, jealousy, nihilistic

Thoughts• Obsessions• Do thoughts repeated in coming to your mind? And you find difficulty in

stopping them?

• Delusions: they cannot be asked directly because patient cannot recognize them

• So by information from other people • Thought insersion• Thought withdrawal• Thought broadcasting• Delusion of control (passivity)• Persectary• Gealous• Grandious ……………etc

Perceptions

• Auditary Hallucinations• Single voices or several• Talk to patient or in third person• examples

• Visual Hallucinations:

Cognitive Functions• Orientation• Time, place, person

• Attention and concentration• Serial 7 test

• Memory1. Short term memory: name and address

2. Memory for recent events: an event in last few days

3. Remote memory: event in previous years

• Calculations: addition, subtraction, multiplication, and division

• Reasoning: practical judgment;

• abstraction: similarities and proverb interpretation

Insight

• Recognize that he is ill

• Illness is physical or mental

• Does he think that he need treatment

Suicide RiskMood disorders: 15-20% – Bipolar mixed highest risk– Delusional depression

Schizophrenia: 5-10% (young male, insight, high IQ, command hallucinations)– 3 wks -3 mo from hospitalization

Substance abuse: – Young male, multiple substances, recent

loss, co-morbid, previous ODWHAT WORKS TO DECREASE RISK: LI,

CLOZAPINE, ECT, psychotherapy!!