Psychiatric

Assesment
The need for a comprehensive
information
 Your are seeing a human being, not a
disorder
 To view patients from biological, dynamic,
social, cognitive & behavioral perspective
e.g. A married woman who drink too much alcohol
 Her overbearing husband reminds alcoholic father
 Self-medicating her anxiety & distress
 Her friends drink, drinking is acceptable &
encouraged in her social milieu
 Genetic contribution from her alcoholic father
 “I am a loser, I can’t do things right, nobody cares!”

 A 45 yrs old successful business man who got

depressed
Important caveats
 Learn the skills early in your training
before ineffective habits became fixed
styles
 Don’t assume but ask every possible
question
 The best textbook - patient, to learning
interview skill as well as psychopathology
 Observe interview do by experienced
others
 Accept & incorporate feedbacks
General points
 Setting
 Concern for patient’s comfort & privacy
 Beginning the relationship
 Greeting, introducing yourself, address by name
 Indicate the seating arrangement,
 Inform about the interview process
 Taking notes
 Indicate that you will be taking notes & keep it to the
minimum
 Stop note taking when patient breaks in to emotions
 When patient indicated a certain information not to be
recorded
Cont….
 Developing rapport
 The feeling of harmony & confident that should exist between
patient & clinician
 Facilitate obtaining good information
 Keep the patient coming, help to develop trust so that patient tries any
suggestion & treatment
 How to develop it
 Appear relaxed, interested & empathic
 Monitor your facial expression, node & smile when appropriate
 Use praise, “I understand you” & other similar comments carefully
 Patients demeanor
 Drooping shoulder, a clenched fist, tears – draw a little closer to show concern, if
you sense hostility – withdraw physically even a few inches
 Humor – be careful not to laugh at your patient, but laugh with the
patient
 Adopt a none judgmental & an empathic attitude
 Keep the professional boundary clean & limit self disclosure
Cont…
 Empathy
 On some level you can feel as your patient
feels, that you can put yourself at your
patient’s place
 Express it appropriately
 Be in control of your emotion
 Sympathy ?
Managing the early patient
interview
 Much of the task is to keep patient talking
 Try to intrude as little as you can
 Nonverbal encouragement
 Differentiate a brief pause from a long gap
 Don’t break eye contact; a smile or nod will
say, “it is all right to proceed at your own
pace”
 Lean a little closer to show attentiveness &
interest
 Keep an arm distance when you sense some
paranoia
Cont…
 Verbal encouragement
 “yes”, “Ahaa” etc..
 “go on”, “I am listening”
 Repeat the patient’s last word or two
“I was so angry that for hours I was hearing voices”
pause = “voices”
 Elaborate on a word the patient used earlier
 = ”you said you felt desperate” pause
 Directly request more information
 =“Tell me more”
 =“How do you mean”
 Offer brief summaries
 =“so you felt that …”, “Do you mean that…”
Interview format
 ID
 Chief compliant
 History of the present illness
 Past psychiatric history
 Past medical/ surgical history
 Family history
 Personal history
 Mental state examination
 Physical examination
 Multiaxial diagnosis ????
 Formulation (Biopsychosocial)
Identification data
 Name  Helps to know the person
 Sex well
 Age
 Marital status
 Occupational status  Sometimes the crucial
 Educational level issue would sprung up
while taking ID
 Religion
 ??? Ethnicity  Shade light in to important
 Source of referral areas to explore further
 First vs. repeated visit/
admission  Ask in a casual manner,
 Came alone, accompanied don’t interrogate
with, escorted/ brought by,
Chief compliant
 Patient’s stated reason to seek help
 Use patient’s own words
 Patient may give a list of problems, select the most important & the
main reason for the visit
 Questioning =“Please tell me what problems made you come for
treatment”
 Open-ended & clear
 Try to learn the real reason for coming
 Some may not recognize it
 Others may feel ashamed or fearful
 An acute problem/ availability of money may triggered a visit in a
chronically sick but untreated patient
 “I have no problem it is them who have a problem”
=“why do you think they brought you?”
=“Is anything else bothering you?”
History of present illness
 Time of onset

 Mode of onset

 Chronological order of different symptoms

 Positive & negative statements

 Psychosocial stressors, substance of abuse &

any contributing medical condition
Cont…
 It may start to flow from ID or as an elaboration of the
C/C

 Free speech – it can direct to the areas of clinical

interest
 Difficulty thinking (cognitive disorders)
 Substance abuse
 Psychosis
 Mood disorder
 Anxiety, avoidance behavior, & arousal
 Physical complaints
 Social & personality problems

 A case of Carpopedal spasm

 A mother fixated on her late son, only child
Cont…
 Learn as much as you can about each
symptom
 What does nervous/ depressed me to the patient?
 Characterize symptoms as much as possible
 Continues/ episodic
 How intense & variation with time
 Context
 Why now? Psychosocial, environmental, life
event
 Vegetative symptoms – appetite, sleep,
weight, energy & sex
Cont…
 In the initial period, be nondirective & use open-ended
questions
 Don’t agree or collude with the patient’s belief system
 Positive-negative statement
 Consequences of illness
 Occupational function
 Social functioning
 Personal functioning
 Marital & legal problems
 Subjective distress
 Diagnostic implication
 Severity of the illness
 Management implication
Cont…
 Risk assessment
 Suicide
 Violence
 Explanatory model
 Patient & family expectation
Risk assessment
 A suicidal patient
 Asking about suicide ??
 Plan
 Intent/ gesture
 Understanding of the lethality of the means
used
 Reaction of patient for being rescued or
surviving
 Is she/ he planning to try again
 Past history of attempt & family history of
suicide
Cont…
 Aggression & violence
 Patients with sever mental illness are largely none
violent
 Past history of violence, use of weapon, under the
influence of substance
 Follow your gut feeling – it is the best indicator of
an imminent violence & aggression
 Interview patient in the presence of others
 Get out of the interview room if you sense an

imminent attack by the patient, arrange the room so

that both you & the patient has an easy access for
the door
Past psychiatric history
If we don’t know our history, we don’t know where we are going

 When, how many & how long

 Characterization
 Past suicidal or violence history
 Treatment Hx. – compliance, response, side
effect
 Inter episode symptomatic & functional status
 Pattern of relapse
 ?substance related
 ?Specific stressors
 ?Life event
 ? None compliance to medication
Past medical/ surgical
history
 Etiologic relationship - the disease itself or
medication used to treat it
 Drug-drug interaction
 Impact on psychological health & self-
esteem
 Integrated care
Family history
 Structure & interaction
 Parents, siblings, spouse & children
 Family dynamic
 Support system
 Family history of mental illness or suicide
 “Blood relatives!”
 Characterization of symptoms, course &
outcome
 Medication that worked best
Personal history
 Prenatal & postnatal period
 Growth & development
 Childhood illness
 Childhood period – life events, lose &
separation, traumatic experience etc…
 Schooling – age started, separation anxiety,
attendance & performance
 Peer relationship
 Frequent move between care givers &
residency
Cont…
 Oppositional & conduct problems
 Teenage - relationships, substance use,
sexual relationship
 Pre-morbid personality – pattern of
perceiving & interpreting the environment,
usual way of dealing with frustration, way
of relating with others (self description &
collateral informant)
 Adulthood – occupational, marital, sexual,
religious, living situation & legal
Mental state examination
 Appearance  Cognition
 Overt behavior  Alertness
 Attitude  Orientation (person,
place, time)
 Speech  Concentration
 Mood and affect  Memory (immediate,
 Thought recent, long term)
 Form  Calculations
 Content  Fund of knowledge
 Perceptions  Abstract reasoning
 Insight
 Judgment
 Appearance
 Posturing
 Dressing & grooming
 Hair & fingernails
 Walked in, forced in or carried in
 Behavior
 Attitude
 cooperative, friendly, attentive, interested, frank,
seductive, defensive, contemptuous, perplexed,
apathetic, hostile, playful, ingratiating, evasive, or
guarded
 Speech
 Quantity, rate of production, and quality
 Talkative, voluble, taciturn, none spontaneous,
 Rapid or slow, pressured, hesitant, emotional
 Dramatic, monotonous, loud, whispered, slurred, or
mumbled
 Speech impairments - stuttering, dysprosody

 Affect
 Patient's present emotional responsiveness,
inferred from the patient's facial expression
 Congruency with mood, appropriateness
 Normal range, constricted, blunted, or flat
 Mood
 Pervasive and sustained emotion that colors
the person's perception of the world
 Depressed, despairing, irritable, anxious, angry,
expansive, euphoric, empty, guilty, hopeless, futile,
self-contemptuous, frightened, perplexed & labile
 Perception
 Hallucination & illusion
 Derealization & depersonalization
 Thought
 Process/ form
 Circumstantiality
 Clang association

 Derailment

 Flight of ideas

 Neologism

 Perseveration

 Tangentiality

 Thought blocking
  Content
 Delusions, preoccupations, obsessions, compulsions
 Suicide & self harm

 Violence, aggression & homicidal

 Judgment
 Capability for social judgment
 Insight
 Degree of awareness and understanding about
being ill
Physical examination
Multiaxial diagnosis
Abolished by DSM -5, not sure what the clinical utility is.

 Axis I - clinical disorders and other

conditions that may be a focus of clinical
attention

 Axis II - personality disorders and mental

retardation. The habitual use of a
particular defense mechanism can be
indicated

 Axis III - any physical disorder or general

medical condition
Cont…
 Axis IV - psychosocial and environmental
problems that contribute significantly to the
development or exacerbation of the current
disorder

 Axis V - global assessment of functioning

(GAF) scale in which rate patients' overall
levels of functioning during a particular time
 Social functioning, occupational functioning and
psychological functioning
 A 100-point scale
General skills
 Have a listening attitude
 Open vs. closed ended question
 Don’t interrupt patient unless it is important
 Guide the rumbling patient
 Show respect to patients, their explanatory model
 Facilitate emotional expression
 Show a genuine empathy
 Use body gestures, praise, reassurance & advise wisely
 Summarization
 Confrontation
 Smooth shift from an area of inquire to another
Biopsychosocial factors
 Biological
 Genes, neurotransmitters, neuroanatomic &
neurophysiologic, endocrinology, general
medical conditions , brain pathology(tumor or
trauma), substance of abuse etc…
 Psychosocial –
 Problems with primary support group
Problems related to the social environment
Educational problems
Occupational problems
Housing problems
Economic problems
Problems with access to health care services
Problems related to interaction with the legal
system/crime
Other psychosocial and environmental problems
 Childhood trauma(abuse, neglect, separation, loss
etc..), life events(loss, conflict, transition, stressful
situation etc…)
 Predisposing factors
 Precipitating factors
 Perpetuating factors
 Protective factors
Barriers to effective
communication
Personal attitudes
Language
Time management
Working environment
Ignorance
Human failings (tiredness, stress)
Inconsistency in providing
information
Breaking bad news
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