Psychiatric Assessment
by Dr.Perjan Hashim Taha M.B.Ch.B. Msc.C.A.P. F.I.C.M.S.(Psych)*
The psychiatric interview
Similarities between the psychiatric interview and the general medical interview The goal of all communication between doctor and patient is to diagnosis and treatment and further the aims of the working alliance between doctor and patient.*
The psychiatric interview
Differences between the psychiatric interview and the general medical interview It must communicate personal concerns about disturbed mental functioning through language In all cases, special tact and sensitivity are required of the psychiatric interviewer*
Psychiatric Assessment
Goals:1. Diagnosis2. understand context of diagnosis (patient’s life)3. Establish therapeutic relationship *Psychiatric Assessment
Stages: Preparation Collection of information: by h. and MSE Evaluation of information: for DD. Using of information: for R.*
Preparing for Interview
Put patient at ease Ensure privacy Ensure safety of interviewer Free from interruption Comfortable Arrange the chair at angle and should little at higher level than patient
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It takes some skill…. *
? Psychiatric Interview ?
Skill to encourage disclosure of personal information for a professional purposeEmpathy → rapport → therapeutic alliance *If there is possibility of violence:
Another person should know when and where is the interview Ensure that help can be called if needed (emergency call button) Ensure that neither the patient or any obstruction is between the interviewer and the exit Remove from sight any object that can be used as a weapon*
Starting of Interview
Welcome the patient and explain the reason for the assessment Greet the companion and explain how long is expected to wait Keep confidentiality Start by open question ( tell me about your problem?) Interviewer should be ( relaxed, unhurried, eye contact, alert to verbal and non verbal cues, control over talkative patient)*
Assessment
The interviewer should introduce and identify himself, clearly explain the purpose of the meeting with the patient. Invite the patient to begin in as open-ended a manner as possible Eg : what sort of trouble have you been having? Tell me about the problem that bring you here.
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Specific interviewing techniques
Learn to be quiet. Pay attention to body language. Start broadly and then focus in.*
Specific interviewing techniques
Remember that the patient is more scared than you are.Tell the patient what you think he or she is feeling.When an interview goes down, try repeating the patient’s last words.Go ahead and ask the “unaskable”. *Psychiatric Interviewing
*Psychiatric Assessment Parts
Psychiatric History MSE Physical Examination Neurological Examination Further Investigation*
Name: Age: Sex: Marital status: Occupation: Address: Date of admission: Name of the informant and his/her relationship to patient Reason and source of refferal
I- Present Complain and duration:
II- History of present Condition: Symptoms (onset, duration, flactuation, details) Expected symptoms Relationship between symptoms and physical dis., or social problem Functional impairment Previous R. effects and S.E. use simple terms and try to avoid technical scientific terms
Psychiatric History
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Chief Complaint
What brought the patient in? Patient’s own wordsWhy now and not 6 months ago?What happened in the past week?Past 24 hours? *
III- Family history:
1- Father and mother: including: name, age, occupation, health (mental and physical), education, personality, attitude, and emotional relation of each with the patient. Include divorce and separation from each. If dead time, place and cause of death and age of the parent and the patient then.2- Siblings: The rank of the patient. In Chronological order include name, age, sex, occupation, marital status, health (mental and physical), personality, social and economical status, relation with the patient and his feeling towards them.
3- Relatives: Relations and illness. Ask specifically about abnormal personality, mental disorders, epilepsy and alcoholism.
4- Home atmosphere:
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IV- Personal history:
1- Pregnancy and birth: include date and place of birth, mother’s condition during pregnancy, delivery (normal, prolonged, instrumentation and operation), (premature, low birth weight, convulsions) 2- Early childhood: Feeding breast or bottle. Development (milestones): attachment, talking, walking, bowel and bladder control Neurotic symptoms; bed wetting, temper tantrum, nail biting, thumb sucking, night terror, sleep walking, stammering, fears, mannerism, and tics. Behavior; playing, (alone), hostility, hyperactivity and relation with others specially the family.3- Adolescence and adulthood: Include social life (isolation and peer group), difficulties and crises, fantasies.
4- Education history: School; age to start and finish school, name of schools, reaction to school, regularity (school phobia, truancy with age), difficulties, attitude to teacher and peers, achievements and ambitions. University and higher education.
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5- Occupational history: Include age of starting to work, list of job(s) and duration and causes (if any). Regularity, job satisfaction, economical status.
6- Menstrual history: Include; age of menarche, cycle, (regularity, duration, last period), dysmenorrhea, premenstrual tension, and menopause (time, reaction and symptoms)
7- Sexual history: Masturbation; worries, guilt, and fantasies, any deviations or dysfunction. Orientation; homosexual or heterosexual Experience; age and type.
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8- Marital history: Marriage; age, date, and number Partner; age, occupation, personality, and health Sex; mode of intercourse, orgasm, and impotence Satisfaction and relationship Abortion and contraception Extramarital relationship Children; list in chronological order, age, sex, health, personality, and relationship.
9- Alcohol, drugs and tobacco: Include; quantity and frequency of use
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11- Past psychiatric history: Include; date, duration, symptoms, and treatment of each.
10- Past Medical History: Illnesses, operations, accidents, drug treatments*
12- Forensic history: Illegal acts, courts and prison.
13- Present social circumstances: Include; living standard, interests and hobbies, and financial status*
V- Premorbid personality:
1- Mood: cheerful-sad, tense-calm, optimistic-pessimistic, stable-unstable, apathetic-inhibited.2- Character: hesitant, self confident-shy timid, tolerant-not, expressive, trusting-suspicious, irritable-not, sensitive-not, jealous-not.
3- Moral selfish, or altruistic, religious, rigid.
4- Energy; energetic, initiative, sluggish, or fluctuant.
5- Socially; Introvert or extrovert.
6- Fantasy life; Is he a day dreamer.
7- Habit and hobbies
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Developmental millstones
Back
3 y
8 m
1 year
Sit alone with good coordination
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Mental State Examination
Appearance, Attitude, Behavior, Speech Mood Thoughts Perceptions Cognitive functions Insight*
Appearance and Behavior
Observe from the first moment Ataxia Dressing: dirty? Wear bright color? Weight loss Facial and emotional expressions: - corners of mouth, Vertical furrow on brows, Omega sign? horizontal creases on forehead, wide palpebral fissures, and dilated pupils? Posture : Head and gaze downward? Social Behavior: Disinhibited behavior=mania withdrawal=schizophrania Aggression=antisocial PD as if they are elsewhere=dementia*
Speech
Rate Fast increased amount= mania Slaw and pauses= depression Difficulty speaking Neologisms Flow of speech Thought blocking= schiz. Flight of ideas= mania*
Mood
Depression and mania What is your mood like? Do you blame yourself? Fluctuation and incongruous mood Suicidal Ideation is very important anxiety Feelings and physical symptoms like palpitation, S.O.B.
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Thoughts
Thought Process: rapid, slow, goal directed, tangential, circumstantial, loose, incoherent (word salad), clang associations, neologisms Thought Content: preoccupations, obsessions, delusions, suicidal, homicidal Delusions: persecutory, grandiose, religious, somatic, jealousy, nihilistic*
Thoughts
ObsessionsDo thoughts repeated in coming to your mind? And you find difficulty in stopping them?Delusions: they cannot be asked directly because patient cannot recognize themSo by information from other people Thought insersionThought withdrawalThought broadcastingDelusion of control (passivity)PersectaryGealousGrandious ……………etc *Perceptions
Auditary Hallucinations Single voices or several Talk to patient or in third person examples Visual Hallucinations:*
Cognitive Functions
Orientation Time, place, person Attention and concentration Serial 7 test Memory Short term memory: name and address Memory for recent events: an event in last few days Remote memory: event in previous years Calculations: addition, subtraction, multiplication, and division Reasoning: practical judgment; abstraction: similarities and proverb interpretation*
Insight
Recognize that he is ill Illness is physical or mental Does he think that he need treatment*
Suicide Risk
Mood disorders: 15-20% Bipolar mixed highest risk Delusional depression Schizophrenia: 5-10% (young male, insight, high IQ, command hallucinations) 3 wks -3 mo from hospitalization Substance abuse: Young male, multiple substances, recent loss, co-morbid, previous OD WHAT WORKS TO DECREASE RISK: LI, CLOZAPINE, ECT, psychotherapy!!
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