Unit 2

Mental Health Assessment

Nabina Paneru
Mental Health Assessment
Psychiatric mental health assessment is the gathering, organizing, and
documenting of data about the psychiatric and mental health needs of
the client and family.
Components
The components of Mental Health Assessment are:

 Psychiatric History Taking

Mental Status Examination

Psychological tests
Psychiatric History Taking
Objectives

- To build up good interpersonal relationship.

- To identify the redisposing factors and causes of mental illness.

- To formulate nursing diagnosis and plan and implement nursing

intervention.
Points to Remember
• Build good rapport

• A consistent scheme (though interview need not follow a fixed method)

• See pt. first

• Place pt. Comfortably and develop empathetic relationship.

• Be good listener (do not hurry)

• Observe patient’s interaction with his/her relatives

Contd.
• Avoid too much exploration in first interview (may increase anxiety
and pt. may not be cooperative)

• Confidentiality

• Observe and note non verbal communication and any abnormalities.

Psychiatric History Taking
Is carried out under the following headings:

• Personal bio data: Includes name, age, sex, address, I.P no, diagnosis,
date of admission, education, occupation, economic status, marital status,
religion, nationality, language spoken etc.

• Informant: Name, age, education, occupation, relationship with the

patient and duration of relationship

• Source of referral and reason for coming at this particular period

Contd.
• Presenting Complaints (with duration) Chronological order

 According to patients

According to the informants

Contd.
• History of Present Illness (HOPI)

 Mode of onset: sudden (within 48 hours), abrupt (more than 48 hours

but within 2 weeks)/ acute (1-2wks)/ subacute (more than 2 wks)/
insidious (more than 4 wks)

 Duration of illness: Total duration of the illness and total duration of

this episode
* Mode of onset and duration gives clues to the cause and its
implications on prognosis
HOPI contd.
• Course: (continuous/ episodic/ fluctuating/ deteriorating/ improving/
unclear associated with other symptoms

• Precipitating factors: Events that occur shortly before the onset of illness
or appear to induce illness.

• Description of present illness (chronological description of abnormal

behavior associated problems like suicide, homicide, disruptive behavior)
Contd.
• Biological functioning (sleep, appetite, bowel, bladder functions),

social functioning ( managing day activities, hobbies, leisure time

activities) occupational functioning, changes in ADLs)

• Mental functioning: Concentration, thought content, speech, mood

states, abnormal perception, interest, attitude etc.

• Interpersonal relations: quality of relationship with family members

• Loses beloved persons, property, financial matters

History Taking contd.
• Past Medical and Psychiatric History

Hospitalization

History of substance use

History of medical illness e.g. TB, DM, HTN, Neurological illness

Treatment history of mental illness (Name of drug, dose, route, side-

effects if any)

ECT, Psychotherapy, Family Therapy, Rehabilitation

Contd.
• Family History

 Family Tree

 Types of family (joint/ nuclear/ extended)

Consanguinity: Present/Absent

 Family Health History: History of mental illness/ Suicide/ Alcohol or drug

abuse/ personality problems etc.

Socio economic
Index of Family Tree
: Death
: Monozygotic twins

: Female : Sex unknown

: Present Patient : Dizygotic twins

: Male

: Psychiatric Disorder
: Child adopted out of family

: Indicates Consanguinity
: Child adopted in to the family

: Separation/Divorce
Contd.
• Personal History
(Brief and comprehensive information of the patient right from the
prenatal period onwards)
 Birth: Type of birth, any complications during pregnancy, birth
weight, any complications during birth
Developmental milestones: motor, psychosocial, immunization etc
Personal History contd.
Schooling

Psychosexual History

Menstrual History

Work Record/ Occupational History

Marital History
Contd.
• Premorbid Personality: (Collect from the informant)

- Inter personal relationship with family members, friends, coworkers etc.

• Mood: optimistic, pessimistic, cheerful, anxious, etc. Attitude towards

work and responsibility (acceptance of responsibility, decision making,
flexibility)

• Moral religious standards

• Use of alcohol/ tobacco

• If any other specify

Contd.
• Health Patterns

- Hygiene, eating habits, rest and sleep habits, elimination etc

• Physical Examination

- General/ Systematic examination

- Record of any significant abnormality after the examination so that it

would be helpful for the management of patient illness.
Mental Status Examination
• Definition: “Assessment of general motor behavior, thought,
emotional functioning along with evaluation of insight and judgement
of the patient’s present status.” : Bimala Kapoor, 2002

• Systematic evaluation of behavior, emotion, cognitive functions of the

individual. – K. Lalitha, 2007
Purpose of Mental Status Examination

• Provides an overview of the individuals functioning

• Monitor changes over time

• Helps with diagnosis

• Helps with treatment – where to start, evaluation

• Support Multidisciplinary collaboration

• Standardized recording
Aspects of Mental Status Examination
1. General appearance and behavior

2. Speech or Talk (attitude)

3. Mood or Affect

4. Thought

5. Perceptual changes
Contd.
Higher Mental Function

6. Consciousness

7. Orientation

8. Attention and Concentration

9. Memory

10. Fund of Knowledge

11. Abstraction

12. Judgement

13. Insight
1. General Appearance and Behavior
• Level of Consciousness: Conscious/ Cloudy/ Stupor/ Unconscious/
Comatose

• Body Built: (average/ underweight/ healthy/ thin/ petite/ stocky),

looking one’s age/ older/ younger

• Facial Expression: Anxiety, fear, apprehension ( a feeling of worry or

fear about what might happen), Depression, sadness, Anger, hostility
Contd.
• Hygiene/ grooming: Good, neglected, poor, satisfactory, adequate.
Dress: Casual, ok for work, ok for age, stylish, ok for weather, dirty

• Psychomotor Activity: Under activity/ over activity: Movement:

appropriate, awkward, purposeful, aimless, self injuries, destructive
mannerisms, tics (Spasm) , grimace (make a face) , echopraxia

• Posture Coordination and Gait: Relaxed, strange/ odd posture,

tensed, catalepsy
Contd.

• General Attitude: Co-operation/ guardedness/ hostility/

combativeness, argumentative/ haughtiness, attentiveness, interested/
disinterested/ apathetic, perplexity

• Eye contact: Normal eye contact/ hesitant eye contact/ staring at the
examiner, staring vacantly. (Maintained/ difficult/ not maintained).

• Rapport: Spontaneous/ difficult/ not established

2. Speech
• Initiation: Spontaneous/ speaks when spoken to/ minimal/ mute

• Reaction time: Normal/ delayed/ shortened/ difficult to assess

• Rate/ Speed: Normal/ slow/ rapid

• Productivity: Monosyllabic/ elaborate/ replies/ pressured

• Volume: Normal/ increased/ decreased

• Tone: Normal variation/ monotonous

• Relevance: fully relevant

3. Mood and Affect

• Mood: Subjective feeling of the patient. (How do you feel?), If the

client does not answer ask the leading question including all types of
mood state example, happy, sad, normal, excited, anxious etc.

• Affect: Objective data: assess depth or intensity of affect (normal,

increased, or blunted) and appropriateness of affect (in relation to
thought and surrounding environment).
4. Thought Process
i. Disorder in stream and form of thought

ii. Disorder in content

i. Disorder in stream and form of thought
• Normal/ racy thoughts (pressured thought)/ retarded thinking (poverty of
thought)/ thought block/ muddled or unclear thinking/ flight of ideas

• Associative looseness

• Circumstantialities

• Tangentialities

• Neologism

• Alogia
Contd.

• Stereotype • Echolalia

• Flight of ideas • Perseveration

• Word salad • Verbegeration

• Stuttering

• Clang association
ii. In content
a. Ideas or delusion of: Worthlessness/ hopelessness/ guilt/ hypocondriacal/
poverty/ nihilistic/ death wishes/ suicidal/ grandiose/ reference/ control
persecution/ bizarre

b. Thought alienation phenomena: Thought insertion/ thought withdrawal/

thought broadcasting

c. Obsessional/ compulsive phenomena: Thoughts/ images/ ruminations/

doubts/ impulsive rituals
5. Perceptual Changes
• Hallucinations: auditory/ visual/ olfactory/ gustatory/ tactile/ any other

• Somatic passivity

• Illusions

• Depersonalization

• Déjà vu/ Jamais vu

6. Consciousness
• Conscious/ cloudy/ comatose
7. Orientation
• Time: appropriate time/ day/ night/ date/ month/ year

• Place: kind of place/ area/ city

• Person: self/ close associates/ hospital staffs

8. Attention/ Concentration
Attention

• Normally aroused/ aroused with difficulty

• Digit forward: 1,2,3….100

Concentration

• Normally sustained/ sustained with difficulty/ distractible

• Digit backward: 100 – 7 or 40 – 3

• Name of months (backwards)

• Name of weekdays (backwards)

9. Memory
i. Immediate:

• Immediate registration: name three unrelated objects and ask to recall

immediately (example: tree, house and chair)

• Recall: Recall same name as in immediate registration after 3 – 5 minutes

ii. Recent: enquire recent events up to 24 hours, recent happening – last

meal, visitors etc. verbal recall
Contd.
iii. Remote:

• Personal events: birthdays, SLC passed year, graduation date, date and
place of marriage, children’s birthdays etc.

• Illness related events

Inferences: Intact or impaired

10. Fund of Knowledge/ Intelligence
Based on his/her educational background

• Simple arithmetic calculation (mathematical calculation – to find the

percentage of profit if buys something in Rs 100 and sells in Rs 120)

• General knowledge – current president of America, highest mountain,

neighboring country, president of Nepal

• Reading/ writing

Inferences: average, below average, above average

11. Abstraction
Assess patient’s concept formation:

• Proverb testing e.g. nachna najanne agan tedho, much ma ram ram
bagalima chhura, hune biruwako chillo pat.

• Similarities and difference between familiar objects e.g. table and chair,
banana and orange, dog and lion, eye and ear, bird and airplane etc

Inferences: normal in abstraction, poor in abstraction

12. Judgement
i. Personal Judgement: e.g. future plan

ii. Social Judgement

iii. Test Judgement

• House on fire

• Baby on busy road

• Snake on road

Inferences: good/ Poor/ Impaired

13. Insight
Insight absent if client says:

1. Complete denial of illness.

2. Slight awareness of being sick and needing help, but denying at the
same time

Insight partially present if client says:

3. Awareness of being sick, but it attributed to external or physical factors.

4. Awareness of being sick, due to something unknown in self.

Contd.
Insight present if client says:

5. Intellectual insight: Awareness of being ill and that the symptoms/

failures in social adjustment are due to own particular irrational
feelings/ thoughts; yet does not apply this knowledge to the current/
future experiences.

6. True emotional insight: It is different from intellectual insight in that

the awareness leads to significant basic changes in the future behavior.

Baseline data: Height, weight, vital signs