Psychiatric Assessment

Overview of a Psychiatric Encounter

While there may be variability between how different physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship conduct the encounter, and a physician may tailor the encounter to suit the needs of a patient’s diagnosis, the general structure should be reproducible and follow a logical course.

1. Review available records and secure a safe, private place for the psychiatric interview.
2. Observe the patient’s nonverbal communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence cues and assess their level of agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus.
3. Introduce yourself to the patient.
4. Inquire about the patient’s chief reason for presentation.
5. Obtain the patient’s recent history of presenting illness and conduct the psychiatric interview.
6. Obtain the patient’s past personal history (i.e., past medical/psychiatric history, family history Family History Adult Health Maintenance, social history Social History Adult Health Maintenance).
7. Conduct a mental state exam.
8. List the differential diagnosis.
9. Develop an appropriate plan of care with the treatment team:
   • Level of care required ( hospitalization Hospitalization The confinement of a patient in a hospital. Delirium, intensive outpatient, outpatient)
   • Pharmacotherapy
10. Determine an appropriate follow-up interval.

Initial Part of Psychiatric Assessment

• Before speaking with the patient:
  • Secure a safe, private place for the interview:
    • Especially important for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with potential for violence in the psychiatric hospital or emergency room setting 
    • Providers must have access to easy escape Escape With constant immune mechanisms holding unstable tumor cells in equilibrium, tumor-cell variants may emerge. These cancer cells may express fewer antigens on their surfaces or lose their MHC class I expression.Variants may also protect themselves from T-cell attack via expression of IC molecules on their surfaces, like normal cells.Creation of an immunosuppressive state in the microenvironment is another way to grow without immunologic interference. Cancer Immunotherapy, and the room should be clear of objects that pose potential harm to themselves or others.
  • A review of past medical records and laboratory studies is also helpful but may also bias Bias Epidemiological studies are designed to evaluate a hypothesized relationship between an exposure and an outcome; however, the existence and/or magnitude of these relationships may be erroneously affected by the design and execution of the study itself or by conscious or unconscious errors perpetrated by the investigators or the subjects. These systematic errors are called biases. Types of Biases the interview.
• Initial contact with the patient:
  • Observe nonverbal communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence and assess their level of agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus.
  • Introduce yourself to the patient and establish the doctor-patient relationship.
  • Use open-ended questions.
  • May require contacting collateral informants for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who are poor historians.

History of the Present Illness

• Determine the onset and characteristic of symptoms: Be mindful of any prior stressful events, medical illness, or substance use.
• Course of symptoms:
  • History of similar symptoms in the past
  • Waxing vs. waning or both intermittently
  • Progression of symptoms 
• Triggers for symptoms: ameliorating and worsening triggers
• Screen for 5 key diagnostic criteria:
  • Mood symptoms: depression vs. mania Mania A state of elevated excitement with over-activity sometimes accompanied with psychotic symptoms (e.g., psychomotor agitation, inflated self esteem and flight of ideas). It is often associated with mental disorders (e.g., cyclothymic disorder; and bipolar diseases). Bipolar Disorder
  • Psychotic symptoms Psychotic symptoms Brief Psychotic Disorder
  • Anxiety-related symptoms
  • Substance use
  • Suicidality/homicidality

Obtaining Past History

• Past medical/surgical history:
  • Many medical illnesses have symptoms that can induce psychiatric conditions (e.g., hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism and depression).
  • Current medications, including dietary supplements, are also important to note.
• Family history Family History Adult Health Maintenance:
  • Psychiatric family history Family History Adult Health Maintenance is important, as some mental illnesses are seen more predominantly in the children and family members of affected patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.
  • Medical family history Family History Adult Health Maintenance is also important.
• Social history Social History Adult Health Maintenance:
  • Much more extensive than other history taking
  • Developmental/early childhood history
  • Education level
  • Occupation history and financial resources
  • Religious/spiritual beliefs 
  • Relationships, dating, sexual orientation Sexual orientation The sexual functions, activities, attitudes, and orientations of an individual. Sexuality, male or female, becomes evident at puberty under the influence of gonadal steroids (testosterone or estradiol), and social effects. Sexual Physiology, and sexual history 
  • Hobbies and interests

Mental Status Examination (MSE)

• Psychiatric equivalent of the physical exam 
• Some components of the MSE are obtained through observation, while others are through questions.
• Useful for identifying cognitive impairments, disturbances in mood, psychotic symptoms Psychotic symptoms Brief Psychotic Disorder, and suicidal thoughts

Evaluation of Suicide Risk

• One of the most critical components of psychiatric assessment
• Determines whether patient meets criteria for inpatient vs. outpatient treatment
• Definitions:
  • Passive death wishes: when one thinks about not waking up without actively taking actions to harm oneself
  • Self-harm: methods to cause pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways without intent to complete suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide (e.g., cutting) 
  • Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide: when thoughts have escalated to acts of self-harm 
  • Suicide attempt Suicide attempt The unsuccessful attempt to kill oneself. Suicide: an action committed (e.g., shooting, hanging, overdose) in an attempt to harm oneself
  • Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide and past attempts are independent risk factors for suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide. 
• Start with more-indirect questions, such as “Have you ever felt that life wasn’t worth living?”
• Psychiatrists can then be direct and ask:
  • “Have you had thoughts or plans to kill yourself?”
  • “Do you have access to a firearm?”
• Formulation of a specific suicidal plan is indicative of more serious and imminent intent than vague self-harm ideas without concrete plans.

Psychiatric Rating Scales

• Research-validated provider- or patient-reported scales Scales Dry or greasy masses of keratin that represent thickened stratum corneum. Secondary Skin Lesions that are used to assist in diagnosis and to assess mental status
• Often administered quickly with paper and pencil 
• Not sufficient to diagnose a psychiatric condition on their own
• For MSE:
  • Mini-mental state examination Mini-Mental State Examination Major Neurocognitive Disorders ( MMSE MMSE Major Neurocognitive Disorders)
  • Montreal Cognitive Assessment Montreal Cognitive Assessment Major Neurocognitive Disorders ( MoCA MoCA Major Neurocognitive Disorders)
• For depression:
  • Patient health questionnaire
  • Beck Depression inventory II
• For anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder:
  • Generalized anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder 7 (GAD-7)
  • Screen for child anxiety-related disorders (SCARED) 
• For obsessive compulsive disorder: Yale Brown Obsessive Compulsive Scale Scale Dermatologic Examination ( Y-BOCS Y-BOCS The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a clinician-rated scale for assessing the severity of obsessive and compulsive symptoms. Obsessive-compulsive Disorder (OCD)) 
• For ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder: Vanderbilt ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder diagnostic rating 
• For substance use disorders
  • Cut down, Annoyed, Guilty, Eye-opener (CAGE): specifically for brief screening Screening Preoperative Care for alcohol use disorder Alcohol use disorder Alcohol is one of the most commonly used addictive substances in the world. Alcohol use disorder (AUD) is defined as pathologic consumption of alcohol leading to impaired daily functioning. Acute alcohol intoxication presents with impairment in speech and motor functions and can be managed in most cases with supportive care. Alcohol Use Disorder
    • Have you ever felt you needed to Cut down on your drinking?
    • Have people Annoyed you with your drinking?
    • Have you felt Guilty about your drinking?
    • Eye-opener: Have you ever had to drink 1st thing in the morning?