The clinical assessment Flashcards
What are the steps of a standard psychiatric assessment?
- Individual’s history
- Mental state
- Collateral information
- Physical investigations
- Diagnosis or formulation
- Risk assessment (to self/others, indirect vulnerability)
- Create a plan
What are the elements we want to have in the individual’s history?
- History of presenting complaint
- Past psychiatric history
- Past medical history
- Medications
- Family history
- Psychosocial history
What constitutes the individual’s history of the presenting complaint?
- Why here and now?
- Predisposing, precipitating, perpetuating factors
- Risk to self, others
- Acute precipitants of substance misuse
What constitutes the individual’s past psychiatric history?
- Number of episodes of ill-health
- Precipitants
- Typical duration
- Relieving/treating factors
- Location, type of treatment
- Past risk history (self/others)
- Past substance misuse
What are the categories to assess in the individual’s mental state?
- Appearance and behaviour
- Speech
- Mood
- Cognition
- Insight
- Thoughts
- Perceptions
- Risk
What is an important elements to keep in mind about the individual’s mental state?
Mental state is dynamic: here and now
- if you know your patient (their history) well, you might just assess their current mental state
How do the individual’s history and their mental state differ?
- Personal history is static
- Mental state is dynamic
- They differ in length and language
e. g. History: “I’m recorded by FBI and MI5”
- > mental state: patient had a paranoid delusion
Why do clinicians use the ‘history’ and ‘mental state’ systems?
- To be systematic
- Communication with other professionals (more rigorous and structured)
- Allows us to make a provisional diagnosis and/or formulation
- Allows us to monitor change
In what do the systems of assessing the patient’s history and mental state make clinicians systematic?
- More rigorous in defining psychopathology
- Reduces risk of missing areas of assessment (psychotic depression, bipolar past, OCD comorbidity, risk)
- > always ask even if no signs presented
How do we classify delusions?
- Delusions must be fixed (odd ideas are not enough)
- Delusions should be culturally inappropriate
What are the common delusional types?
- Paranoid:
feelings of being persecuted, followed or spied on - Nihilistic:
sense of things not being real or dying - Grandiose:
sense of having special powers or abilities
(positive component)
What is the most common delusional type in psychosis?
Paranoid
What is the delusional type most commonly linked with depression?
Nihilistic
What is the passivity phenomena observed in psychotic symptomatology?
- Made actions or thoughts
- Feeling of actions and thoughts being controlled by other people
What are ideas of reference in psychotic symptomatology?
Taking a personal message from a general medium
e.g. “FBI is sending me a message through the news”
What is the symptom of thought insertion?
Sense of thoughts being implanted into one’s brain
What is the symptom of thought withdrawal?
Sense of thoughts being taken out from one’s brain
What is the symptom of thought broadcasting?
Feeling that one’s thoughts can be heard by other people
What is the symptom of thought echo?
Feeling of thoughts echoing around one’s head
What characterises a formal thought disorder?
Difficulty in conveying thoughts (content) in a logical linear manner
- the problem is the form, not the content
- disjointed way of expressing one’s thoughts in the speech or writing
- > it’s still possible to get a sense of content
What are hallucinations?
Perception without stimulus
- can occur in any sensory modality
- taste, smell, sight, hearing, touch
- classical auditory
What is insight?
Ability to recognise one’s difficulties or limits
- it’s not necessarily present or absent
What are the areas a clinician can enquire about one’s insight?
Do they recognise:
- presence of mental illness
- nature of mental illness
- utility or need for medication
- utility or need for engaging with services/professionals
- risk to self and/or others
- vulnerabilities
Why can recovering insight be a major problem for patients?
As individuals recover, their improved insight on their illness and the negative impact it had in their lives can lead them to self-harm or feel depressed
What characterises the risk assessment?
- Static factors (e.g. risk ratio male-female)
- Dynamic factors (e.g. drug consumption)
- Risk to self or others
- Vulnerabilities
- Neglect or absconding (escape)
Why is detail required in a risk assessment?
To reduce ambiguity
What are common worries in a clinical assessment, especially amongst junior clinicians?
- Aggressive, agitated individual
- Someone without insight
- Who won’t engage
- Someone with ‘unusual’ symptoms
What are key ideas on the attitude to adopt during a clinical assessment?
- Treat people with respect and courtesy
- Don’t push areas people don’t wish to talk about
- Get senior support if you feel unsafe, uncomfortable or unprepared
- Try to empathise with your patient
