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Psychiatric Assessment

The psychiatric assessment is the equivalent of a physical exam, tailored to evaluate a patient for psychiatric pathologies. While the psychiatric assessment has a mostly standardized approach, the interviewer can tailor it based on the presenting symptoms of the patient. The psychiatric assessment is designed to systematically assess for various features of psychiatric illnesses and involves both direct questioning and passive observation.

Last updated: Sep 6, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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:

History of the Present Illness

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:
  • 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
Table: Major components of the MSE
Category Components
Appearance General description of patient’s appearance and behavior:
  • Age
  • Sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria
  • Race
  • Body build
  • Posture
  • Excessive or reduced eye contact
  • Appropriateness of dress
  • Grooming
  • Manner
  • Attentiveness to the examiner
  • Distinguishing features
  • Prominent physical abnormalities
  • Emotional facial expression
  • Alertness
Orientation Awareness of time, place, and person
Attention and
concentration
  • Ability to spell a word backward and forward
  • Serial 7s (counting down from 100 in 7s)
Spatial orientation Ability to draw a house, or a clock face with hands indicating a specific time
Motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology
  • Retardation
  • 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
  • Abnormal movements
  • Gait Gait Manner or style of walking. Neurological Examination
  • Catatonia Catatonia A neuropsychiatric disorder characterized by one or more of the following essential features: immobility, mutism, negativism (active or passive refusal to follow commands), mannerisms, stereotypies, posturing, grimacing, excitement, echolalia, echopraxia, muscular rigidity, and stupor; sometimes punctuated by sudden violent outbursts, panic, or hallucinations. This condition may be associated with psychiatric illnesses (e.g., schizophrenia; mood disorders) or organic disorders (neuroleptic malignant syndrome; encephalitis, etc.). Major Depressive Disorder
Speech
Mood Patient’s internal and self-described emotional state
Affect Expression of patient’s mood or how the mood appears to be to the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship
  • Appropriateness of affect: how affect correlates to the setting. For example, a patient who is describing depression while laughing would have an affect incongruent with or inappropriate to their mood.
  • A commonly used term for affect is “flat” for a severely restricted range of affect that is found in some patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia.
Thought
content
What thoughts are on the patient’s mind:
Thought
process
Describes how certain thoughts are made, organized, and expressed:
Memory
  • Ability to recall 3 simple objects after 2 and 5 minutes
  • Ability to recall distant events from the past
Abstract
reasoning Reasoning Decision-making Capacity and Legal Competence
Ability to shift between general concepts and specific examples (e.g.: “How are oranges and apples alike?”)
Perception
Intellect
  • Average, above average, below average
  • Determined during an interview by thought content and by educational and professional achievement
Insight Awareness of one’s illness, mood, and functioning level and its implications
Judgment
  • Ability to make and act on good decisions
  • Does not always correlate with insight

Related videos

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: 
  • 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?

References

  1. American Psychiatric Association. (2006). Practice guidelines for the psychiatric evaluation of adults, second edition. Am J Psychiatry. 163(6Suppl), 1–36. https://pubmed.ncbi.nlm.nih.gov/16866240/ 
  2. Black, D. (2017). The psychiatric interview and mental status examination. DeckerMed Medicine. Retrieved October 15th, 2021, from  https://doi.org/10.2310/7800.13001 
  3. Sadock, BJ, Sadock, VA, & Ruiz, P. (2014). Chapter 5: Examination and diagnosis of the psychiatric patient. In Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed., pp. 192–289. Philadelphia, PA: Lippincott Williams and Wilkins.

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