Psychiatric Assessment and Diagnosis 1

Psychiatric assessment and diagnosis 1 The psychiatric assessment is different from a medical • Chairs should be at the same level and arranged at an or surgical assessment in that: (1) the history taking is of- angle, so that you are not sitting directly opposite the ten longer and requires understanding each patient’s unique patient. background and environment; (2) a mental state examina- • Establishing rapport is an immediate priority and tion (MSE) is performed; and (3) the assessment can in itself requires the display of empathy and sensitivity by the be therapeutic. Fig. 1.1 provides an outline of the psychiat- interviewer. ric assessment, which includes a psychiatric history, MSE, • Notes may be taken during the interview; however, risk assessment, physical examination and formulation. explain to patients that you will be doing so. Make sure that you still maintain good eye contact. • Ensure that both you and the patient have an unobstructed exit should it be required. INTERVIEW TECHNIQUE • Carry a personal alarm and/or know where the alarm in the consulting room is, and check you know how to • Whenever possible, patients should be interviewed in work the alarms. settings where privacy can be ensured – a patient who • Introduce yourself to the patient and ask them how is distressed will be more at ease in a quiet office than they would like to be addressed. Explain how long the in an accident and emergency cubicle. interview will last. In examination situations, it may Psychiatric history • Identifying information • Presenting complaint • History of presenting complaint • Past psychiatric history • Past medical history • Current medication • Family history • Personal history • Social circumstances Psychiatric history • Alcohol and substance use Mental state examination • Forensic history • Premorbid personality Physical examination Risk assessment Mental state examination • Appearance Formulation • Behaviour and psychomotor function • Rapport • Speech • Mood and affect • Thought form and content • Perception • Cognition • Insight Risk assessment Formulation • Self: self-harm, self-neglect, exploitation • Description of the patient • Others: aggression, sexual assault, children • Differential diagnosis • Aetiology • Management • Prognosis Fig. 1.1 Outline of the psychiatric assessment procedure 3 Psychiatric assessment and diagnosis prove helpful to explain to patients that you may need Identifying information to interrupt them due to time constraints. • Keep track of and ration your time appropriately. • Name • Flexibility is essential (e.g. it may be helpful to put • Age a very anxious patient at ease by talking about their • Marital status and children background before focusing in on the presenting • Occupation complaint). • Reason for the patient’s presence in a psychiatric setting (e.g. referral to out-patient clinic by family doctor, admitted to ward informally having presented at casualty) HINTS AND TIPS • Legal status (i.e. if detained under mental health legislation) Arrange the seating comfortably, and in a way that allows everyone a clear exit, before inviting the For example: Mrs LM is a 32-year-old married housewife with two chil- patient into the room dren aged 4 and 6 years. She was referred by her family doctor to a psychiatric out-patient clinic. Make use of both open and closed questions when Presenting complaint appropriate: Closed questions limit the scope of the response to one- or Open questions are used to elicit the presenting complaint. two-word answers. They are used to gain specific informa- Whenever possible, record the main problems in the pa- tion and can be used to control the length of the interview tient’s own words, in one or two sentences, instead of using when patients are being over-inclusive. For example: technical psychiatric terms. For example: Mrs LM complains of ‘feeling as though I don’t know who • Do you feel low in mood? (Yes or no answer) I am, like I’m living in an empty shell’. • What time do you wake up in the morning? (Specific Patients frequently have more than one complaint, some of answer) which may be related. It is helpful to organize multiple pre- Note that closed questions can be used at the very begin- senting complaints into groups of symptoms that are related; ning of the interview, as they are easier to answer and help for instance, ‘low mood’, ‘poor concentration’ and ‘lack of en- to put patients at ease (e.g. ‘Do you live locally?’; ‘Are you ergy’ are common features of depression. For example: married?’; see Identifying information later). Mrs LM complains firstly of ‘low mood’, ‘difficulty sleeping’ Open questions encourage the patient to answer freely and ‘poor self-esteem’, and secondly of ‘taking to the bottle’ with a wide range of responses and should be used to elicit associated with withdrawal symptoms of ‘shaking, sweating the presenting complaint, as well as feelings and attitudes. and jitteriness’ in the morning. For example: It is not always easy to organize patients’ difficulties into • How have you been feeling lately? a simple presenting complaint in psychiatry. In this case, • What has caused you to feel this way? give the chief complaint(s) as the presenting complaint, and cover the rest of the symptoms or problems in the history of COMMUNICATION the presenting complaint. Rapport building is vital when working in History of presenting complaint mental health Always think why a patient may have difficulty establishing one with you (eg This section is concerned with eliciting the nature and devel- persecutory delusions, withdrawal, apathy) Failure opment of each of the presenting complaints. The following headings may be helpful in structuring your questioning: to establish rapport should never be due to the interviewer • Duration: when did the problems start? • Development: how did the problems develop? • Mode of onset: suddenly, or over a period of time? • Course: are symptoms constant, progressively worsening or intermittent? PSYCHIATRIC HISTORY • Severity: how much is the patient suffering? To what extent are symptoms affecting the patient’s social and The order in which you take the history is not as impor- occupational functioning? tant as being systematic, making sure you cover all the • Associated symptoms: certain complaints are associated essential subsections. A typical format for taking a psy- with clusters of other symptoms that should be chiatric history is outlined in Fig. 1.1 and is described in enquired about if patients do not mention them detail below. spontaneously. This is the same approach as in other 4 Psychiatric history 1 Table 1.1 Typical questions used to elicit specific • Delusions and hallucinations (psychosis) psychiatric symptoms • Free-floating anxiety, panic attacks or phobias Questions used to elicit… Chapter (anxiety disorders) Suicidal ideas 6 • Obsessions or compulsions (obsessive- Depressive symptoms 11 compulsive disorder) Mania/hypomania 10 • Alcohol or substance abuse Delusions 9 Hallucinations 9 Symptoms of anxiety 12 Dissociative symptoms 14 HINTS AND TIPS Obsessions and 13 Depression and obsessive-compulsive compulsions symptoms often coexist (>20%), with onset Somatoform disorders 15 of obsessive-compulsive symptoms occurring Memory and cognition 7 before, simultaneously with or after the onset of Problem drinking 8 depression You may find it useful to have a set of Symptoms of anorexia and 16 screening questions ready to use bulimia Symptoms of insomnia 25 Past psychiatric history specialties; for example, enquiring about nausea, diarrhoea and distension when someone reports This is an extremely important section, as it may provide abdominal pain. When ‘feeling low’ is a presenting clues to the patient’s current diagnosis. It should include: complaint, biological, cognitive and psychotic features • Previous or ongoing psychiatric diagnoses of depression, as well as suicidal ideation, should be • Dates and duration of previous mental illness episodes asked about. You can also ask about symptom clusters • Previous treatments, including medication, for psychosis, anxiety, eating problems, substance use psychotherapy and electroconvulsive therapy and cognitive problems, among others. Also, certain • Previous contact with psychiatric services (e.g. symptoms are common to many psychiatric conditions, referrals, admissions) and these should be screened for (e.g. a primary • Previous assessment or treatment under mental health complaint of insomnia may be a sign of depression, legislation mania, psychosis or a primary sleep disorder). • History of self-harm, suicidal ideas or acts • Precipitating factors: psychosocial stress frequently precipitates episodes of mental illness (e.g. bereavement, moving house and relationship Past medical history difficulties). Enquire about medical illnesses or surgical procedures. Past Table 1.1 directs you to the relevant chapters with ex- head injury or surgery, neurological conditions (e.g. epi- ample questions for different components of the history lepsy) and endocrine abnormalities (e.g. thyroid problems) and MSE. are especially relevant to psychiatry. Current medication HINTS AND TIPS Note all the medication patients are using, including psychiatric, nonpsychiatric and over-the-counter drugs. Also It is useful to learn how to screen patients for enquire how long patients have been on specific medication common symptoms This is especially so with and whether it has been effective. Nonconcordance, as well patients who are less forthcoming with their as reactions

Load more