INTRODUCTIONPsychiatric evaluations vary according to theirpurpose.The purpose depends on:1- Who requests the evaluation.2- Why it is requested.3- The expected role of the psychiatrist in the patients care.Three main types:1) General psychiatric evaluation.2) Emergency evaluation.3) Clinical consultation.Other types such as forensic evaluation.
Clinical ExaminationMental Status Examination.Psychiatric History.Laboratory Tests in Psychiatry.Physical Examination in Psychiatry.Psychological Factors.
Interview of A Psychiatric Patient Interviews explore the following factors: Genetic, Temperamental, Biological, Developmental, Social & Psychological. Successful Interview creates:* Empathy, Respect, Competence & Interest.* An atmosphere of trust that encourages the patient to talk honestly about his or her innermost feelings & thoughts.
The Aims of Psychiatric EvaluationTo establish a provisional diagnosis.To identify other diagnostic possibilities.To identify social, environmental & culturalfactors relevant to immediate treatmentdecisions.What precautions are needed if there is a risk ofharm to self or others & whether involuntarytreatment is necessary.To develop a plan for immediate treatment withdetermination of whether the patient requirestreatment in a hospital or other supervisedsetting.What follow-up will be required.
1. General Psychiatric EvaluationA general psychiatric evaluation is a face-to-face interview with the patient.The interview-based data are integratedwith a review of medical records, aphysical examination & diagnostic tests.Several meetings with the patient may benecessary.
2. Emergency EvaluationThe emergency psychiatric evaluation occursin response to the occurrence of:1) Thoughts or feelings that are intolerable to the patient.2) Behavior that prompts urgent action by others, such as violent or self-injurious behavior, threats of harm to self or others, failure to care for oneself, deterioration of mental status, bizarre or confused behavior, or intense expressions of distress.
A. Identification DataName.Age.Gender.Marital Status.Educational Level.Occupation.Religion.Residence.
B. Referral, Informant & Complaint Source of referral. Cause of referral. We have to choose the informant particularly in psychotic & forensic patients. Complaint of the patient & that of the informant. (Can you tell me why you are here?)
C. History of The Present Illness It is a chronologically organized history of 1) Current symptoms or syndromes. 2) Onset, Course & Duration. 3) Recent exacerbations or remissions. 4) Available details of previous treatments & the patients response to those treatment. 5) Factors that the patient believes to be precipitating, aggravating, or otherwise modifying the illness. 6) Sleep, Eating & Sexual activities.
D. Past Psychiatric HistoryA chronological summary of all past episodes ofmental illness & treatment:1) Psychiatric syndromes not formally diagnosed.2) Previously established diagnoses, treatments & responses to treatment (Psychiatric, Mental, Psychosomatics & Medical Diseases.3) The dose, duration of treatment, efficacy, side effects & patients adherence to previously
E. General Medical HistoryGeneral medical illnesses (e.g., hospitalizations,procedures, treatments & medications).Undiagnosed health problems that have causedthe patient major distress or functionalimpairment.History of any episodes of important physicalinjury or trauma; sexual & reproductive history& any history of neurological disorders,allergies & drug sensitivities.High prevalence diseases, e.g., infectiousdiseases in users of intravenous drugs orpulmonary & cardiovascular disease in peoplewho smoke.Information regarding all recent medications.
F. History of Substance UseThe psychoactive substance use historyincludes past & present use including: alcohol,caffeine, nicotine, marijuana, cocaine, opiates,sedative-hypnotic agents, stimulants, solvents& hallucinogens.Relevant information includes the quantity andfrequency of use & route of administration: Thepattern of use (e.g., episodic versus continual;solitary versus social); functional, interpersonalor legal consequences of use; tolerance &withdrawal phenomena.Any temporal association between substanceuse & present psychiatric illness.
G. Personal History: Psycho-Social & Developmental.Perinatal: Pre-natal, Natal & Post-natal.Early Childhood: Through age 3 years.Middle Childhood: Ages 3-11 years.Late Childhood: Puberty & Adolescence.Adulthood: Occupational History, MilitaryHistory, Educational History, SocialActivities, Legal History, Marital History,Sexual History, Fantasies & Dreams.
H. Occupational HistoryThe sequence of jobs held by thepatient.Reasons for job changes.The patients current or mostrecent employment, includingwhether current or recent jobshave involved unusual physicalor psychological stress, toxicmaterials or shift work.
I. Military HistoryRelevant data about military experiencewould include:- Volunteer versus draftee status.- Whether the patient experienced combat.- Discharge status, awards, disciplinary actions.- Whether the patient suffered injury or
K. Social HistoryThe patients living arrangements ¤tly important relationships.Relationships, both familial & non-familial, that are relevant to thepresent illness, act as stressors.Any formal involvement with socialagencies or the courts, as well as,details of any current litigation orcriminal proceedings.
J. Sexual HistoryA sexual history: Premarital,marital & extramarital.Sexual orientation & practice.Any history of physical,emotional, sexual or otherabuse or trauma.
L. Other Personal HistoryReview of stages of patients life, with specialattention to developmental milestones & topatterns of response to normative life transitions& major life events.Important cultural & religious influences onpatients life.Any involvement with the juvenile or criminaljustice system.Any experiences related to political repression,war or a natural disaster.Past & present levels of functioning in family &social roles (e.g., marriage, parenting, work,school).
M. Family HistoryFather & Mother: Mental & physical problems,Death & cause of death, relationship to thepatient, attitude towards the patient illness.Siblings & patient order.Consanguinity.Family history of NS disease, Tumors, MR,Psychotic disorders, Psychiatric disorders,Suicide & Substance abuse.History of any treatment received & response totreatment.Current family health status that are ofemotional importance to the patient.Attitude of the family members towards his orher illness (Supportive, denial or criticizing).
N. Pre-Morbid Personality Introversion-Extroversion. Temperament. Characters. Religious Standard. Hobbies & Interests. Special Habits.
O. Review of SystemsCurrent symptoms not already identified in thepresent illness.Sleep, appetite, pain & discomfort, systemicsymptoms such as fever & fatigue &neurological symptoms.Common symptoms of diseases for which thepatient is known to be at particular risk becauseof genetic, environmental, or demographicfactors.
P. Physical ExaminationA physical examination is needed to evaluatethe patients general medical condition (GMC),(including neurological).An understanding of patients GMC is importantin order to:1) Properly assess the patients psychiatric symptoms & their potential cause.2) Determine the patients need for general medical care.3) Choose among psychiatric treatments those are suitable for the patients GMC.
The Physical Examination IncludesSections Concerning The Following: General appearance & nutritional status. Vital signs. Head & neck, heart, lungs, abdomen & extremities. Neurological status, including cranial nerves, motor & sensory function, gait, coordination, muscle tone, reflexes & involuntary movements. Skin, with special attention to any trauma, self-injury or drug use. Any body area or organ system that is sp., mentioned in the patient’s history.
Q. Mental Status Examination (MSE)A systematic collection of data based onobservation of the patients behaviorduring the interview & before & after theinterview.Responses to specific questions are animportant part of the MSE, particularly inthe assessment of cognition.The purpose of MSE is to obtain evidenceof current symptoms & signs of mentaldisorders from which the patient might besuffering.
Q. Mental State Assessment Appearance: Simply describe the patients physical presentation: Body built, Gait, Clothing & Make up, hygiene & cultural appropriateness. Behavior: Briefly describe the patients behavioral style, including agitation, retardation & any inappropriate, unusual behavior, Involuntary movement, Posture & Sitting. Conversation: Describe both the content of conversation, as well as the form, which includes the rate of conversation.
Q. Mental State AssessmentAffect & Mood:Mood level, variability, range, intensity &appropriateness (Mood = Feeling; Affect = Nonverbal expressions of mood).Characteristics of Speech:Rate, rhythm, structure, flow of ideas &pathologic features such as tangentially,vagueness, incoherence, or neologisms), Also,Aphonia & Aphasia (Receptive or expressive).Language functions:Naming, fluency, comprehension, repetition,reading & writing.
Q. Mental State AssessmentThinking Abnormalities: Form, Stream, Control & Content (delusions,obsessions, Compulsions, Phobia, Suicide,Homicide, Self injurious thoughts.Abstract Reasoning (e.g., explaining similarities or interpreting proverbs).Perceptual Abnormalities: Illusions & hallucinations (Five Modalities).
1. Level of consciousness: (Fully conscious,Semi conscious, Comatose or Deep coma), thebest evaluation is to use Glasgow coma scale(eye opening, verbal & motor response).2. Orientation: (To time, place and person).3. Attention: (Ask the patient to mention daysof the week in reverse order or months of theyear), for illiterate, we use the digit test .4. Concentration: (Subtraction test; 7s of 100 or3s of 20 or others).5. Memory: (Immediate, Recent & Remote).6. Intelligence: (Clinical: Average or below).7. General knowledge: (Ask the patient to name5 governorates, newspapers).8. Insight: Insight less, partial insight,intellectual insight or insightful.9. Judgment: Short term & long term plans.
T. Diagnostic TestsLaboratory tests are included in apsychiatric evaluation:1) When they are necessary to establish or exclude a diagnosis.2) To aid in the choice of treatment.3) To monitor treatment effects or side effects.
U. Functional AssessmentFunctional assessment means assessing diseaseseverity & treatment outcome.Functional assessment includes assessment of PhysicalActivities of daily living (e.g., eating, using the toilet,transferring, bathing & dressing) & InstrumentalActivities of daily living (e.g., driving or using publictransportation, taking medication as prescribed,shopping, managing ones own money, keeping house,communicating by mail or telephone & caring for a childor other dependent).Impairments in these activities can be due to physical orcognitive impairment or to the disruption of purposefulactivity by the symptoms of mental illness.
V. Psychiatric ClassificationsIllness, Disease, Syndrome or Disorder.The most important classifications are the DSM-IV andthe ICD-10.The DSM-IV:Axis I: Clinical psychiatric diagnoses.Axis II: Developmental and Personality.Axis III: General medical condition.Axis IV: Psycho-social stresses.Axis V: Adaptation to role function.The ICD-10:Axis I: Psychiatric and physical diagnoses.Axis II: Developmental, personality and stresses.Axis III: Adaptation to role function.
W. Difficult Interview
1. Depressed PatientsDepressed patients are often unable toprovide an adequate account of theirillness spontaneously because of suchfactors as psychomotor retardation &hopelessness.Need to ask history & symptoms relatedto depression including Suicidal Ideation.Typical Symptoms Include: feelings ofhopelessness, sleep disturbance, appetitechange, concentration problems, lack ofenergy or problem solving.
2. Suicidal PatientsEvaluating Suicide Potential isImperative.Inquire about suicidal thoughts… “Areyou suicidal now, or do you have plansto take your own life?”Other Risk Factors for Suicide: suicidenote, family history of suicide orprevious suicidal behavior, evidence ofimpulsivity or of pervasive pessimismabout the future.
3. Aggressive PatientsAssure the patient you can assistthem in managing their behaviorthrough the interview.Must establish whether effectiveverbal contact can be made with thepatient or whether the patient’ssense of reality is so impaired thateffective interviewing is impossible.
3. Aggressive Patients ContinuedMay have to medicate the patient beforethe interview begins.Have to make the decision whether it issafe to remove restraints.With or without restraints a violent patientshould not be interviewed alone.Other precautions include leaving thedoor open & sitting between the patient &the door.
3. Aggressive Patients ContinuedMust make it clear that the patient maysay or feel anything but is NOT free toact in a violent way.Interviewer must remain calm & haveadditional staff able to maintain controlby physical means if necessary.Confrontation is to be avoided.
3. Aggressive Patients ContinuedThe interviewer should respect asmuch as possible the patient’s need forspace.Questions need to be asked regardingprevious acts of violence, violenceexperienced as a child, under whatspecific conditions the patient resortsto violence, with corroboration fromfriends & family members.
4. Delusional PatientsThe patients delusions should never bedirectly challenged.Challenging only increases a patient’sanxiety & often leads the threatenedpatient to defend the belief.It is also inadvisable to believe thepatient’s delusion.The interviewer can help by indicating thathe understands that the patient believesthe delusion to be true but that theinterviewer does not hold the same belief.
4. Delusional Patients ContinuedFocus on the feelings, fears & hopes thatunderlie the delusional belief tounderstand the delusions particularfunction.Delusions may be excessively fixed &chronic or they may be subject toquestion & doubt by a patient & may lastonly a relatively brief time.A patient may or may not be influenced bythe delusional beliefs & may be able torecognize their effects.
5. Other Difficult Patients to Interview (Behavioral Characteristics) Histrionic. Obsessive. Dependent. Malingering. Sociopath or Psychopath. Others.
X. Privacy & ConfidentialityPsychiatrists should follow WPAstandards for confidentiality in dealingwith the results of psychiatricevaluations.Evaluations should be conducted in themost private setting compatible with thesafety of the patient & others.Psychiatrists should not make audiotapeor videotape recordings of patientinterviews without the knowledge &consent of the patient or the patientslegal guardian.