Psychiatric Assessment

Question 1

Describe presenting complaint for psychiatry

Answer 1

-Open questions
-Patient’s own words where possible
-Organise into group of symptoms that are related

=Duration
=Development (how)
=Mode of onset (sudden)
=Course (constant intermittent, has it happened before?)
=Severity (and functional impact, social and occupational)
=Associated symptoms (e.g. biological, cognitive, psychotic features, suicide ideation in depression)
=Precipitating factors (e.g. psychosocial stress)

Question 2

Common symptoms for presenting complaint

Answer 2

-Low mood (depression)
-Elevated mood and increased energy (hypomania and mania)
-Delusions and hallucinations (psychosis)
-Free-floating anxiety, panic attacks or phobias (anxiety disorders)
-Obsessions or compulsions (obsessive-compulsive disorder)
-Alcohol or substance abuse

Question 3

Past psychiatric history

Answer 3

-Psychiatric diagnoses
-Mental illness episodes (dates and duration)
-Treatments (medication, psychotherapy and electroconvulsive therapy)
-Response to treatment
-Contact with psychiatric services (e.g. referrals and admissions)
-Assessment or treatment under mental health legislation
-History of self-harm, suicidal ideas or acts, or harm to others

Question 4

Past medical history

Answer 4

-Medical illness
-Surgical procedures
-Past head injury or surgery, neurological conditions (e.g. epilepsy) and endocrine abnormalities (e.g. thyroid problems) are particularly relevant
-Also important to ask about diabetes or other cardiovascular risk factors

Question 5

Current medication

Answer 5

-All psychiatric, non-psychiatric, over-the-counter drugs, herbal remedies(including depot medication)
-Duration
-Effectiveness
-Concordance
-Adverse reaction and allergies

Question 6

Family history

Answer 6

-Psychiatric illness (including suicide and substance use)
-Significant physical illness
-If parents are still alive, if not, causes of death
-Siblings and birth order
-Quality of relationship within family

Question 7

Personal history

Answer 7

-Infancy and early childhood
=Pregnancy and birth complications, developmental milestones, illnesses
=Aggressive behaviour or impaired social interaction
=Was childhood happy?

-Later childhood and adolescence
=School record, level of educational attainment (academic performance, number and types of schools attended, age on leaving, final qualifications)
=Relationship with parents, teachers and peers. Victim or perpetrator of bullying
=Behavioural problems (antisocial behaviour, drug use, truancy)
=Physical, sexual or emotional abuse or neglect

-Occupational record (types, duration, reason for unemployment)

-Relationship, marital and sexual history
=Details of significant relationships, break-ups, marriage/divorce
=Children
=If a problem suspected: sexual relationships, sexual dysfunction, fetishes, gender identity

Question 8

Social circumstances

Answer 8

-Accommodation
-Social supports
-Relationships
-Employment
-Financial circumstances
-Hobbies / leisure activities
-Contact with children

Question 9

Alcohol and substance abuse

Answer 9

-Alcohol
=Daily intake
=Type
=Time of first drink of the day
=Assess dependence (CAGE questionnaire for alcohol, ICD-10 criteria)

-Recreational drugs
=Drug names
=Route
=Duration of use
=Frequency
=Dependence

Question 10

Forensic history

Answer 10

-Previous offences
-Antisocial behaviour
-Prosecutions, conviction, length of prison sentences
-Violent crime
-Pending charges

Question 11

Premorbid personality

Answer 11

-Personality and character before onset of mental illness
=‘How would people have described you before?’
=‘How about now?’
-Personal history may give clues
=Hold down job, long-term relationship, interests
-Collateral history from friend or relative

Question 12

What is an MSE and what are the stages?

Answer 12

-Objective impression of mental functioning at a certain point in time
-MSE may fluctuate from hour to hour
-Note the patient’s description of significant symptoms or experiences word for word

=Appearance
=Behaviour, psychomotor function, rapport
=Speech
=Mood and affect
=Thoughts (form and content)
=Perceptions
=Cognition
=Insight

Question 13

Describe appearance

Answer 13

-Physical state
=Apparent age
=Weight
=Stigmata of physical illness or mental disorder
=Evidence of injury or self-harm

-Self-care and hygiene
=Good standard
=Unshaven, dirty tangled hair, malodorous, dishevelled

-Clothes and accessories
=Manner of dress, e.g. casual, formal, flamboyant, overly-sexual
=Appropriateness to weather and circumstances or bizarre
=Strange objects

Question 14

Describe behaviour

Answer 14

-Eye contact
-Abnormal movements
=Tremors, tics, twitches
=Extrapyramidal side-effects from antipsychotics: Parkinsonism, acute dystonia, akathisia, tardive dyskinesia
-Psychomotor retardation (slow, monotonous speech; slow, absent movements)
-Psychomotor agitation (fidgeting, pacing, hand-wringing, rubbing, scratching)
-Behaviour / attitude: cooperative, cordial, uninterested, aggressive, defensive, guarded, suspicious, fearful, perplexed, preoccupied, disinhibited, catatonic features, distractible
-Rapport

Question 15

Describe speech

Answer 15

-Rate
=Pressure of speech in mania
=Long pauses and poverty of speech in depression
-Quality and flow
=Volume, fluency
=Dysarthria (articulation difficulties)
=Dysprosody (unusual speech rhythm, melody, intonation, pitch)
=Stuttering
-Word play
=Punning, rhyming, alliteration (generally in mania)

Question 16

Describe mood and affect

Answer 16

-Mood – sustained emotional state over a period of time
=Subjective
=Objective
-Affect – emotional state at a given time during the interview
=Range, depth, communicability
==Within normal range (euthymic) or higher (elated)
==Reactive or flat
=Congruity to mood
==Patient reports feeling suicidal but looks happy – incongruous affect
=Stability of affect, e.g. lability

Question 17

Describe types of thought form

Answer 17

-Normal: relevant associations, goal directions, linear
-Circumstantial/ over inclusive thinking: less relevant associations, goal reached but by circuitous route
-Tangential thinking/ flight of ideas: less relevant associations, goal never reached. Normal speed= tangential, accelerated= flight of ideas
-Loosening of associations: poorly or unrelated concepts, unclear goal

Question 18

Describe thought content

Answer 18

-Delusions – A fixed belief arrived at illogically, not amenable to reason, and not accepted in the patient’s cultural background
=Primary or secondary
=Mood congruent or mood incongruent
=Bizarre or non-bizarre
=Content of delusion, e.g. persecutory, grandiose, religious
-Overvalued ideas – plausible belief that patient becomes preoccupied with to an unreasonable extent, causing distress to the patient or others around them. Feature in anorexia nervosa, hypochondriacal disorder, etc.
-Obsessions – recurrent, intrusive, unpleasant, resisted thoughts arising from within one’s own mind

Question 19

Describe perception

Answer 19

-Hallucination – perceived as normal sensory experience in absence of external physical stimulus, patients often have little insight.
=Auditory
==Elementary: simple sounds
==Complex: formed sensation* ‘voices’ may be heard as 1st (echo, audible thoughts)/2nd (critical, persecutory, complimentary, command)/3rd person
=Visual, somatic, olfactory, gustatory

-Illusions – misperceptions of real external stimuli

-Pseudohallucination – involuntarily rise in the subjective inner space of mind, not through external sensory organ

-Intrusive thoughts

-Assessment during interview. Distracted? Responding to unseen stimuli?

Question 20

Describe cognition

Answer 20

-Orientation to time and place and person, comprehension, attention and concentration
-Other domains: consciousness, attention, memory, language, executive function, praxis
-Standardised cognitive tests, depending on time and degree of concern
=4AT
=Montreal Cognitive Assessment (MoCA)
=Addrenbrooke’s Cognitive Examination (ACEIII)

Question 21

Describe insight

Answer 21

-Good, partial or poor
-Does the patient believe they
=Are unwell in any way
=Are mentally unwell
=Need treatment (pharmacological, psychological or both)
=Need to be admitted to hospital (if relevant)

Question 22

How are diagnoses classified?

Answer 22

-Ideally medical disorders are classified by aetiology or by pathology.
-Currently these are unknown for many psychiatric disorders, so in psychiatry operational diagnostic classification is used.
-This defines disorders by means of an agreed and defined list of clinical features

Question 23

Main categorial classification systems in psychiatry

Answer 23

-ICD-10
=10th revision of the International Statistical Classification of Diseases, published by World Health Organisation,1992, 11th 2022
=Covers all disorders, chapter V covers ‘mental and behavioural disorders’
=Descriptive statements and diagnostic guidelines

-DSM-5
=5th edition of Diagnostic and Statistical Manual of Mental Disorders
=Covers only mental disorders
=Published by American Psychiatric Association, 2013
=By operational definitions (precise inclusion and exclusion criteria)

-Hierarchical diagnostic system
=Symptoms related to another medical condition of substance use, schizophrenia and mood disorders, anxiety
=Consider medical or substance related cause of mental disorders symptoms first
=Certain conditions have symptoms in common; schizophrenia may present with depression and anxiety

Question 24

Physical examination

Answer 24

-Neurological and endocrine systems
-Signs of liver disease in alcohol misuse
-Ophthalmoplegia or ataxia in someone withdrawing from alcohol
-Signs of self-harm in personality disorder
-Signs of IV drug use
-Side effects of psychiatric medication (parkinsonism, tardive dyskinesia, dystonia, hypotension, obesity, cardiometabolic sequelae, lithium toxicity)

Question 25

Approach to risk assessment and what areas to assess

Answer 25

-Risk assessment is a vital part of any psychiatric assessment and should always be performed
=No patient questionnaire or suicide risk-scoring system alone has been shown to be superior to thorough clinical assessment

-Key areas to assess are:
=Risk to self e.g. self-harm, suicide, self-neglect or exploitation by others
=Risk to others e.g. violent or sexual crime, stalking and harassment
=Risk to children e.g. physical, sexual or emotional abuse, neglect or deprivation
=Other risk (e.g. to property)

Question 26

Assessing risk to self (self-harm/ suicide)

Answer 26

1. Presence of suicide risk factors
   =Epidemiological factors, Psychiatric disorder, Debilitating physical illness, Recent adverse life-events
2. Is there suicidal intent? How intensely did they wish to end their life?
   =Advanced planning of attempt, writing a note or will
   =Dangerous method (hanging, firearm, jump from height)
   =Plans to avoid discovery/rescue or avoiding help after an attempt
   =Route of presentation (how were they discovered? Who called for help?)
3. Mental state examination
   =Current suicidality, Current mood, Other psychiatric illness, Evidence of future planning
4. Current social supports / protective factors
   =Family, children/other dependents, friends, enjoyable job

Question 27

Assessing other risks to self

Answer 27

-Welfare
=Untreated psychiatric illness is of itself a source of distress and functional impairment

-Self-neglect
=May arise in many psychiatric disorders
=Consider weight loss, personal hygiene, treatment of physical illnesses
=Specialised guidelines for assessment of physical risk in anorexia nervosa

-Exploitation
=Most likely to arise in impaired cognition (e.g. intellectual disability, dementia)Consider sexual exploitation, financial exploitation

Question 28

Assessing risk to others (violence)

Answer 28

-Ask the patient whether they feel or are worried they might harm someone else
=Why do they feel this way? (What “evidence” do they have?)

-Structured clinical judgement is the most effective way of assessing risk of violence and involves using the HCR-20 risk scale and clinical judgement

-The HCR-20 assesses
=History of problems with violence, antisocial behaviour, relationships, employment
=Recent problems clinically with insight, psychiatric symptoms, violent ideation, instability
=Future problems with risk management such as housing, support systems, health services/crisis planning and stress

-A history of violent behaviour is the best predictor of future violent behaviour

Question 29

Managing risk to others

Answer 29

-Patients posing serious risk of violence should be discussed with a multidisciplinary team including social workers and forensic mental health specialists

-Compulsory hospitalisation may be required in some cases
=This may require use of the mental health act if the patient refuses admission

-Important to note: clinicians have a duty to break confidentiality to warn potential victims of serious threats that have been made (in consultation with the police)

Question 30

Assessing risk to children

Answer 30

-Does the patient express or admit any thoughts/wishes to harm their own or other children?

-Have they placed a child in their care at risk? For example, by taking an overdose or substances while caring for child?

-Consider physical, sexual, emotional mistreatment or neglect/ deprivation

-Risk factors:
=Parent: abused, substance abuse, mental illness, step-parent, young, immaturity, criminality, low socioeconomic status, overcrowding
=Child: low birth weight/ prematurity, early maternal separation, unwanted child, intellectual or physical disability, challenging behaviour, excessive crying

Question 31

Managing risk to children

Answer 31

-If suspected
=Refer child protection guidelines
=Ask for child’s full name and DOB
=Tell senior. Involve police, social workers, duty paediatrician as per protocol
=Keep comprehensive notes

-Important to determine if the child may be in imminent danger
=Immediate steps should be taken to remove them from harm (contacting the police)

Question 32

What is in formulation?

Answer 32

-Description of patient
=Case summary of identifying information, main features of presenting complaint, relevant background details, positive findings in MSE and physical examination
=Ascertain if conditions are independent or related

-Differential diagnosis (for and against, order of decreasing probability)

-Aetiology (9 grid: predisposing, precipitating, perpetuating/ biological, psychological, social)

-Management (immediate to short-term, medium to longer term/ biological, psychological, social)

-Prognosis (natural course of condition, individual patient factors)

Question 33

Asking about depressed mood

Answer 33

-How has your mood been lately? (depth, objective vs subjective)
-Does your mood vary throughout the day? (does anything account for this)
-What is your appetite like at the moment? (loss of interest in food/ loss of motivation to prepare food/ swallowing/ recent weight loss/ fitting clothes)
-How is your concentration? (ability to perform standard tasks read newspaper TV show, work performance)
-What is your memory like at the moment?
-How is the sexual side of your relationship? (loss of libido)
-Do you have any worries on your mind at the moment?(guilty?)

Question 34

Asking about thoughts of self-harm

Answer 34

-How do you fee about the future?
-Have you ever thought that life was not worth living?
-Have you ever wished that you could go to bed and not wake up in the morning?
-Have you had thoughts of ending your life? (frequency, fleeting, rapidly dismissed, prolonged)
-Have you had thoughts about how you would do it? (methods)
-Have you made any preparations? (how far plans have progressed from ideas to action, place, bought pills, suicide note)
-Have you tried to take your own life?
-Self-harm: in what circumstances do they harm themselves? What do they feel and think before harming themselves, how do they feel afterwards)

Question 35

Asking about elevated mood

Answer 35

-How has your mood been lately?
-Do you find your mood is changeable at the moment? (mania lability: tearful and irritable and elation)
-What is your thinking like at the moment (increase in speed and ease of thinking)
-Do you have any special gifts or talents?
-How are you sleeping (length and quality)
-What is your appetite like at the moment?
-How is your concentration?
-How is the sexual side of your relationship?

Question 36

Asking about anxiety symptoms

Answer 36

-Would you say you were an anxious person?
-Recently, have you been feeling particularly anxious or on edge?
-Do any particular situations make you more anxious than others?
-Have you ever had a panic attack?
-Do any thoughts or worries keep coming back to your mind even though you try to push them away?
-Do you ever fund yourself spending a lot of time doing the same thing over and over like checking things or cleaning- even though you’ve already done it well enough

Question 37

Asking about abnormal perceptions

Answer 37

-Now I want to ask you about some experiences which sometimes people have but find difficult to talk about. These are questions I ask everyone.
-Have you ever had the sensation that you were unreal or that the world had become unreal?
-Have you ever had the experience of hearing noises or voices when there was no one about to explain it? (when, awake, how often, where did the sound appear from, what did it say, recognise the voice, more than one, how did they refer to the patient, examples)
-Have you seen any visions (when, how often, circumstances, was the vision seen with the minds eye or perceived as being in external space, distinct from surroundings or seen as part of wallpaper or curtain pattern)
-Do you ever notice smells or tastes that other people aren’t bothered by?

Question 38

Asking about abnormal beliefs

Answer 38

-Do you have any particular worries preying on your mind at the moment?
-Do you ever feel that people are watching you or paying attention to what you are doing?
-When you watch television or read the newspapers do you ever feel that the stories refer to you directly or to things that you have been doing?
-Do you ever feel that people are trying to harm you in any way?
-Do you fee that you are to blame for anything, that you are responsible for anything going wrong?
-Do you worry that there is anything wrong with your body or that you have a serious illness?

Question 39

Asking about the first-rank symptoms of schizophrenia

Answer 39

-Do you ever hear voices commenting on what you are doing? Or discussing you between themselves? Or repeating your own thoughts back to you? (him her not you)
-Do you ever get the feeling that someone is interfering with you thoughts- that they are putting thoughts into your head or taking them away? Or that your thoughts can be transmitted to others in some way?
-Do you ever get the feeling that you are being controlled? That your thoughts or moods or actions are being forced on you by someone else?