Psychiatric Assessment 1

Question 1

Key points in assesment?

Answer 1

• Consider SAFETY before assessing patients
• A detailed history is essential to establishing diagnosis
• History taking is not only listing symptoms but understanding the patient and the illness’ impact on the patient

Question 2

What is the purpose of assessment?

Answer 2

1. develop a biopsychosocial database
2. establish rapport

Question 3

Importance of a biopsychosocial database?

Answer 3

• Establish diagnosis
• Understand aetiology
• Assess functional impairment
• Determine risks
• Plan patient-centered treatment

Question 4

What you need to set up for assessment?

Answer 4

1. safety
2. confidentiality and privacy

Question 5

Safety in assessment?

Answer 5

1. ALWAYS position yourself closer to the door
2. Avoid interviewing patients in isolated spaces
3. Agitated or threatening patient: terminate the interview and call for help
4. De-escalate the situation and offer oral sedation for the agitated patient before giving parenteral tranquilizers

Question 6

Confidentiality and privacy in assessment?

Answer 6

1. Mental health = highly stigmatized/ environment needs to be conducive for disclosure
2. Define boundaries of confidentiality with pt

Question 7

Basic identifying information to ask for?

Answer 7

• Name of patient
• D.O.B
• Address
• Highest level of education
• Occupation
• Next of kin (contact details)
• Source of information for history

Question 8

Presenting complaint questions to ask?

Answer 8

• Why has the patient come to the hospital today?
• Why did the Guardian bring the patient to the hospital?
• Best expressed in the patient’s own words
• Duration of symptoms
• Potential challenges
• ‘I don’t know’
• Uncommunicative, aggressive or hostile patient

Question 9

History of presenting complaint?

Answer 9

1. Chronological description of symptom evolution
   - How the problem/symptoms began
   - Progression: frequency, severity
   - Why is the patient presenting now?
2. Associated cluster of symptoms
3. Impact on functionality (work, relationships etc)
4. Medications used during current episode
   - Duration, dose
   - Adherence and attitudes towards treatment
   - Previous contact with alternative/traditional healers

Question 10

What could potentially hinder assessment and should be looked out for?

Answer 10

1. abnormalities of perception
2. abnormalities of thought process
3. abnormal thought content
4. abnormal behavior
5. abnormalities in mood
6. abnormalities in cognition

Question 11

What are abnormalities of perception?

Answer 11

hallucinations
- visual vs auditory

Question 12

Sensation vs perception?

Answer 12

sensation is the physical process of detecting stimuli, while perception is the mental process of interpreting those stimuli

Question 13

What are hallucinations?

Answer 13

False perceptions occurring in the absence of external stimuli
* Experienced as real by patient
* Experienced in external space`
* May occur in any sensory modality: visual, auditory, olfactory, gustatory,
tactile

Question 14

Describe visual hallucinations?

Answer 14

a perception of having seen something that wasn’t actually there
- strongly associated with organic conditions

Question 15

Auditory hallucinations?

Answer 15

a perception of having heard something that wasn’t actually there
- hallmark of psychosis
- Elementary vs complex
- Second person vs third person
- Schneider’s first rank symptoms: Thought echo, running commentary

Question 16

Name other false perceptions?

Answer 16

1. Pseudo hallucinations - an involuntary sensory experience that is vivid enough to be perceived as a hallucination but is recognized by the individual as subjective and lacking objective reality
2. Illusions - a perceptual disturbance characterized by inaccurate perception (distortion) of real sensory input; probably occur as a result of excessive stimulation
   e.g. perceiving a stationary object as being in motion

Question 17

What is abnormality of thought process?

Answer 17

a disturbance in the logical connection between thoughts or the flow of thoughts
- Normal thought process is linear and goal-directed
- Abnormalities of thought process is inferred through speech patterns

Question 18

What are the abnormalities of thought process?

Answer 18

1. Rate of thought process can be abnormal
   * Accelerated = flight of ideas
   * Reduced = psychomotor retardation
2. Changes in the number of associations
   * Increased number = pressure of thought
   * Reduced number = poverty of thought
3. Abnormalities in progression of thought (flow)
   * Circumstantiality
   * Tangentiality
   * Derailment
   * Thought blocking

Question 19

What is the abnormality of thought content?

Answer 19

a disturbance in the content of one’s thoughts or ideas
e.g.
1. delusions
2. obsessions
3. over-valued ideas

Question 20

What are delusions?

Answer 20

• Fixed, false beliefs that are held with great conviction and aren’t in keeping
  with individual’s social/cultural background
• Primary vs Secondary
• Content theme: persecutory, ‘of being controlled’, grandiose, religiose,
  nihilistic, guilt, bizarre, infidelity, love, misidentification

Question 21

What are primary delusions?

Answer 21

Primary delusions – appearing out of the blue/ not in response to anything:
1. Delusional intuition (autochthonous delusion)
2. Delusional perception
3. Delusional mood
4. Delusional memories

Question 22

What are obsessions?

Answer 22

Recurrent, intrusive thoughts/imagery that are usually distressful

Question 23

What are over-valued ideas?

Answer 23

Culturally acceptable/understandable ideas that preoccupy individual and
lead to distress or functional impairment
- may be observed in pathological jealousy/ eating disorders/
hypochondriasis

Question 24

What is abnormal behavior?

Answer 24

an abnormal behavior characterized by the inability to perform goal-directed activities and inadequate emotional responses

Question 25

What are abnormal behaviours?

Answer 25

1- Psychomotor agitation and retardation - Observable restlessness or slowness 2. Disorganised behaviour - Mannerisms, Bizarre or stereotypical behaviour 3. Compulsions - Repetitive actions usually done in response to obsessions 4. Catatonia - Syndrome of variable aetiology - Features can incl: mutism, echolalia, stupor, agitation, echopraxia, waxy flexibility, negativism, automatic obedience 5. Negative symptoms - Syndrome in schizophrenia assoc with Alogia, Avolition, Anhedonia, Asociality

Question 26

What is abnormality in mood?

Answer 26

emotional disturbances and the inability to control them - associated with impaired social and occupational functioning e.g. emotions, mood, affect

Question 27

What are emotions?

Answer 27

Internal feelings – sudden in onset and relatively short lived * Triggered

Question 28

What is mood?

Answer 28

Prevailing emotional state * Relatively sustained, stable and enduring (hrs –wks) * Pervasive * Usually not associated with specific cause * Abnormalities in mood: persistently low (depressed); persistently high (hypomanic/manic); anxious

Question 29

What is affect?

Answer 29

Observable (visible and audible) aspect of emotion * Incl facial expression, posture, gesturing * Abnormalities (usually signs noted on MSE): flat; restricted; depressed; labile; fatuous; incongruent or bizarre; anxious

Question 30

What is collateral history?

Answer 30

- May be used to supplement history if pt is an inadequate informant - Source of history should be indicated * Relative * Hospital records * Etc.

Question 31

What to review in psychiatric symptomatology?

Answer 31

1. Comprehensive screen of clusters of psychiatric symptoms 2. Suicidal ideation 3. Violence/aggression

Question 32

Name psychiatric symptoms?

Answer 32

1. Psychotic symptoms– hallucinations, delusions, disorganised speech/thought, disorganised/catatonic behaviour, negative symptoms 2. Depressive symptoms– persistent sadness, loss of pleasure/interest etc 3. Manic symptoms – persistent elevated, elated or irritable mood etc 4. Anxiety symptoms – abnormal fears or worries, associated physical symptoms 5. (Cognitive symptoms - esp in Elderly)

Question 33

Physical review of symptoms?

Answer 33

A quick review of physical signs or symptoms is desirable as organic conditions can precipitate psychiatric illness

Question 34

Past psychiatric history?

Answer 34

1. Previous mental health symptoms or episodes 2. Previous contact with mental health care * Site of care * Diagnosis * Nature of prior treatment * Adherence and response to treatment 3. Previous acts of self harm, suicide, aggression and violence

Question 35

Drugs and substance history?

Answer 35

1. Past and current alcohol and drug use * Cannabis * (less common)– opioids * Duration/ Frequency/ Amounts of use * Impact of use 2. Initial screen for alcohol abuse – CAGE 3. Various others validated drug screening tools: AUDIT, ASSIST 4. Patients who screen positive with screening tool need a further detailed substance use history

Question 36

Past medical history?

Answer 36

1. Past and current physical illness 2. Physical illness can * Precipitate psychiatric illness * Mimic psychiatric illness * Affect choice of treatment 3. Previous major illnesses and admissions 4. Current chronic conditions: Diabetes (other endocrinopathies), Hypertension, HIV, Syphilis, neurological conditions (Epilepsy) 5. History and severity of head trauma 6. Current medications/prescriptions

Question 37

Family history?

Answer 37

1. Genograms 2. History of family members with suspected mental illness or confirmed diagnosis * Description of symptoms family member had is desirable * Nature of relationship with patient 3. Family history of suicide 4. Family history of substance use/addiction

Question 38

Developmental history?

Answer 38

Depth and scope of developmental history dependent on patient’s age at presentation * Pregnancy events * Birth events * Milestone achievement and early childhood development * Early life events (adversity/trauma, sexual abuse /neglect/ deprivation) * Schooling and educational attainment

Question 39

Social and occupational history?

Answer 39

1. Previous or current intimate relationships * Quality of relationships/intimate partner violence * Impact of psychiatric illness (substance use) on relationships 2. Children * Quality of relationships/ child neglect/abuse or endangerment * Impact of psychiatric illness on children 3. Work (school) * Occupational or scholastic problems * Impact of psychiatric illness on work 4. Activities of daily living (cognitive disorders)

Question 40

Forensic history?

Answer 40

- Previous arrests and convictions - Nature of offence - History of violence

Question 41

Premorbid personality?

Answer 41

* How would the patient have described themselves before the illness? * How would others have described the patient?