Overview of a Psychiatric Encounter
While there may be variability between how different physicians 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.
- Review available records and secure a safe, private place for the psychiatric interview.
- Observe the patient’s nonverbal communication cues and assess their level of agitation.
- Introduce yourself to the patient.
- Inquire about the patient’s chief reason for presentation.
- Obtain the patient’s recent history of presenting illness and conduct the psychiatric interview.
- Obtain the patient’s past personal history (i.e., past medical/psychiatric history, family history, social history).
- Conduct a mental state exam.
- List the differential diagnosis.
- Develop an appropriate plan of care with the treatment team:
- Level of care required (hospitalization, intensive outpatient, outpatient)
- 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 with potential for violence in the psychiatric hospital or emergency room setting
- Providers must have access to easy escape, 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.
- Secure a safe, private place for the interview:
- Initial contact with the patient:
- Observe nonverbal communication and assess their level of agitation.
- Introduce yourself to the patient and establish the doctor-patient relationship.
- Use open-ended questions.
- May require contacting collateral informants for patients 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
- Psychotic symptoms
- Anxiety-related symptoms
- Substance use
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:
- Psychiatric family history is important, as some mental illnesses are seen more predominantly in the children and family members of affected patients.
- Medical family history is also important.
- Social history:
- 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, 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, and suicidal thoughts
|Appearance||General description of patient’s appearance and behavior:
|Orientation||Awareness of time, place, and person|
|Spatial orientation||Ability to draw a house, or a clock face with hands indicating a specific time|
|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
|What thoughts are on the patient’s mind:
|Describes how certain thoughts are made, organized, and expressed:
|Ability to shift between general concepts and specific examples (e.g.: “How are oranges and apples alike?”)|
|Insight||Awareness of one’s illness, mood, and functioning level and its implications|
Evaluation of Suicide Risk
- One of the most critical components of psychiatric assessment
- Determines whether patient meets criteria for inpatient vs. outpatient treatment
- Passive death wishes: when one thinks about not waking up without actively taking actions to harm oneself
- Self-harm: methods to cause pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain without intent to commit 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: when thoughts have escalated to acts of self-harm
- Suicide attempt: an action committed (e.g., shooting, hanging, overdose) in an attempt to harm oneself
- Suicidal ideation 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 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 (MMSE)
- Montreal Cognitive Assessment (MoCA)
- For depression:
- Patient health questionnaire
- Beck Depression inventory II
- For anxiety:
- Generalized anxiety disorder Generalized anxiety disorder Generalized anxiety disorder (GAD) is a common mental condition defined by excessive, uncontrollable worrying causing distress and occurring frequently for at least 6 months. Generalized anxiety disorder is more common in women. Clinical presentation includes fatigue, low concentration, restlessness, irritability, and sleep disturbance. Generalized Anxiety Disorder 7 (GAD-7)
- Screen for child anxiety-related disorders (SCARED)
- For obsessive compulsive disorder: Yale Brown Obsessive Compulsive Scale (Y-BOCS)
- For ADHD: Vanderbilt ADHD diagnostic rating
- For substance use disorders
- Cut down, Annoyed, Guilty, Eye-opener (CAGE): specifically for brief screening 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?
- Cut down, Annoyed, Guilty, Eye-opener (CAGE): specifically for brief screening 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
- 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/
- Black, D. (2017). The psychiatric interview and mental status examination. DeckerMed Medicine. Retrieved October 15th, 2021, from https://doi.org/10.2310/7800.13001
- 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.