How to diagnose and evaluate

1. Examination and diagnosis of
the psychiatric patients

2. 2
Mental health assessment outline

3. 3
• Identifying data - name, age, marital status, sex, address,
educational status, occupation, ethnicity, religion, current living
circumstances, the source(s), reliability of the source(s), and
episode of current disorder, the condition at which patient came
to hospital.
• Chief complaint - in the pt's own words, states why he/she has
come or been brought in for help. It should be recorded even if
the patient is unable to speak, and the patient’s explanation,
regardless of how bizarre or irrelevant it is.

4. 4
• History of Present Illness - provides a comprehensive and
chronological picture of the events leading up to the current
moment in the pt's life. This part of the psychiatric history is
probably the most helpful in making diagnosis. Onset,
precipitating and triggering events. What were the pt’s life
circumstances at the onset of the symptoms or behavioral changes
and how did they affect the patient.
• Assess by using MAPSS model or (mood, anxiety and psychotic
symptoms, substance and suicide ideation/attempt history) should
be assessed.

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• Past psychiatric history – previous similar different episodes, any
treatment any treatment response and side effect.
• Past Medical history - obtains a medical review of symptoms,
allergic reaction & note any major medical or surgical illnesses and
major traumas, particularly those requiring hospitalization.
• Family history - any psychiatric illness, substance use history,
hospitalization, and treatment of the patient's immediate family
members, suicidal history and history epilepsy, family tree.
• Does the family have a history of alcohol and other substance
abuse or of antisocial behavior?
• Does the pt feel that the family members are supportive,
indifferent, or destructive? What is the role of illness in the
family?

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• Personal history (anamnesis)
• Prenatal and peri-natal circumstances
• Full-term pregnancy or premature
• Vaginal delivery or caesarian, at home or hospital, situation of
labor
• Drugs taken by mother during pregnancy
• Pregnancy wanted or planed
• Birth complications and defects at birth
• Maternal starvation, viral infection or falling injuries during
pregnancy

7. 7
• Infancy and early childhood ( up to 3 years)
• Infant mother relationship
• Problems with feeding and sleep
• Significant milestones
• Standing/walking
• First words/two-word sentences
• Bowel and bladder control
• Unusual behaviors (e.g. head-banging)

8. 8
• Middle childhood
• Preschool and school experiences
• Separations from caregivers
• Friendships/play or hobby
• Methods of discipline
• Illness, surgery, or trauma

9. 9
• Late childhood (puberty through adolescence)
• Adolescence
• Onset of puberty and any reaction
• Academic achievement
• Organized activities (sports, clubs)
• Areas of special interest
• Romantic involvements and sexual experience
• Work experience
• Drug /alcohol use/
• Symptoms (moodiness, irregularity of sleeping or eating, fights
and arguments)

10. 10
• Adulthood
• Occupational history
• Marital and relationship history
• Military history
• Educational history
• Religion and Social activity
• Current living situation
• Legal history/forensic history
• Sexual history
• Fantasies and dreams
• Pre-morbid personality – social relations, activities and
interests, mood, character, standards, religious and reaction to
stress.

11. Mental Status Examination

12. Appearance and Behavior
• Does the patient appear to be his or her stated age, younger or older?
• Items to be noted include what the patient is wearing
• Distinguishing features, including disfigurations, scars, and tattoos
• Grooming and hygiene also are included in the overall appearance
• The description of a patient’s behavior includes a general statement about
whether he or she is exhibiting acute distress and then a more specific statement
about the patient’s approach to the interview
• The patient may be described as cooperative, agitated, disinhibited,
disinterested, and so forth

13. Motor Activity
• Motor activity may be described as normal, slowed (bradykinesia), or agitated
(hyperkinesia)
• This can give clues to diagnoses (e.g., depression vs. mania) as well as
confounding neurological or medical issues.
• Gait, freedom of movement, any unusual or sustained postures, pacing, and hand
wringing are described.
• The presence or absence of any tics should be noted, as should be jitteriness,
tremor, apparent restlessness, lip-smacking, and tongue protrusions.

14. Speech
• Elements considered include fluency, amount, rate, tone, and volume
• The evaluation of the amount of speech refers to whether it is normal, increased, or
decreased
• Decreased amounts of speech may suggest several different things ranging from anxiety
or disinterest to thought blocking or psychosis
• Increased amounts of speech often (but not always) are suggestive of mania or
hypomania
• A related element is the speed or rate of speech
• Speech can be evaluated for its tone and volume, descriptive terms for these elements
include irritable, anxious, dysphoric, loud, quiet, timid, angry, or childlike

15. Mood
• Mood is defined as the patient’s internal and sustained emotional state.
• Its experience is subjective, and hence it is best to use the patient’s own words in
describing his or her mood.
• Terms such as “sad,” “angry,” “guilty,” or “anxious” are common descriptions of
mood.

16. Affect
•Affect is often described with the following elements: quality, quantity,
range, appropriateness, and congruence
•Terms used to describe the quality (or tone) of a patient’s affect include
dysphoric, happy, euthymic, irritable, angry, agitated, tearful, sobbing, and
flat
•Range can be restricted, normal, or labile
•Flat is a term that has been used for severely restricted range of affect
•Appropriateness of affect refers to how the affect correlates to the setting
•Affect can also be congruent or incongruent with the patient’s described
mood or thought content

17. Thought content
• Thought content is essentially what thoughts are occurring to the
patient
• Some patients may perseverate or ruminate on specific content or
thoughts
• Obsessional thoughts are unwelcome and repetitive thoughts that
intrude into the patient’s consciousness
• They are generally ego alien and resisted by the patient
• Compulsions are repetitive, ritualized behaviors that patients feel
compelled to perform to avoid an increase in anxiety or some
dreaded outcome.
• Delusions are false, fixed ideas that are not shared by others
• Commo delusions
• Suicidality and homicidality
• Grandiose - are unfounded or inaccurate
beliefs that one has special powers,
wealth, mission or identity
• Erotomanic - is a psychiatric syndrome
characterized by the delusional belief
that one is loved by another person of,
generally of a higher social status,
• Jealous - a psychiatric phenomenon in
which an individual has a delusional
belief that their spouse (or sexual
partner) is being unfaithful
• Somatic - in which individual believes
something is wrong with part or all of
their body and
• Persecutory - are persistent, troubling,
false beliefs that one is about to be
harmed or mistreated by others in some
way

18. Thought process • With flight of ideas, the patient rapidly moves from one thought to
another, at a pace that is difficult for the listener to keep up with, but all of
the ideas are logically connected
• The circumstantial patient overincludes details and material that is not
directly relevant to the subject or an answer to the question but does
eventually return to address the subject or answer the question. Tangential
thought process may at first appear similar, but the patient never returns to
the original point or question
• Loose thoughts or associations differ from circumstantial and tangential
thoughts in that with loose thoughts it is difficult or impossible to see the
connections between the sequential content
• Perseveration is the tendency to focus on a specific idea or content
without the ability to move on to other topics
• Thought blocking refers to a disordered thought process in which the
patient appears to be unable to complete a thought
• Neologisms refer to a new word or condensed combination of several
words that is not a true word and is not readily understandable, although
sometimes the intended meaning or partial meaning may be apparent.
• Word salad is speech characterized by confused, and often repetitious,
language with no apparent meaning or relationship attached to it
it does not describe what the person is
thinking but rather how the thoughts are
formulated, organized, and expressed.
A patient can have normal thought process
with significantly delusional thought content.
Conversely, there may be generally normal
thought content but significantly impaired
thought process.
Normal thought process is typically described
as linear, organized, and goal directed.

19. Perceptual disturbances
• Hallucinations are perceptions in the absence of stimuli to account for them
• Auditory hallucinations are the hallucinations most frequently encountered in the psychiatric setting
• Other hallucinations can include visual, tactile, olfactory, and gustatory (taste)
• The interviewer should make a distinction between a true hallucination and a misperception of stimuli
(illusion)
• Hypnagogic hallucinations (at the interface of wakefulness and sleep) may be normal phenomena
• In describing hallucinations the interviewer should include what the patient is experiencing, when it occurs,
how often it occurs, and whether or not it is uncomfortable (ego dystonic)
• In the case of auditory hallucinations, it can be useful to learn if the patient hears words, commands, or
conversations and whether the voice is recognizable to the patient.
• Depersonalization is a feeling that one is not oneself or that something has changed.
• Derealization is a feeling that one’s environment has changed in some strange way that is difficult to
describe.

20. Cognition
Elements of cognitive
functioning
• alertness,
• orientation,
• concentration,
• memory
• calculation,
• fund of knowledge,
• abstract reasoning,
• insight, and
• judgment

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• Further Diagnostic Studies
• Physical and Neurological examination
• Additional psychiatric diagnostic Interviews with family
members, friends, or neighbors by a social worker.
• Psychological, neurological, or laboratory tests as indicated.

22. Formulation and diagnosis
22

23. Biopsychosocial model
• The Biopsychosocial Model
and Case Formulation (also
known as the Biopsychosocial
Formulation) in psychiatry is a
way of understanding a
patient as more than a
diagnostic label.
• Biopsychosocial formulation
combines biological,
psychological, and social
factors to understand a
patient, and uses this to guide
both treatment and prognosis.

25. Predisposing
Biological Psychological Social
• Family history of mental
disorders and substance use
• History of concussions
• Fearful/anxious temperament
at birth
• Fears of abandonment which
developed early in childhood
• History of invalidation and lack of
acknowledgment by parents
• Early parental divorce,
unstable home life, history of
trauma
Precipitating
• Increase in alcohol use in the
last 3 months
• Re-experienced these feelings of
invalidation and abandonment
after being fired from work
• Recently fired from job
Perpetuating
• Current dose of sertraline is
subtherapeutic
• Ongoing alcohol use
• Her lack of adaptive coping
mechanisms resulted in using
self-harm to cope
• Additionally, the lack of coping
mechanisms leading to intense
thoughts of suicide
• Ongoing discord in her
romantic relationship
• Ongoing financial difficulties
Protective • Medically healthy
• Previously responded well to DBT
• History of being psychologically-
minded and insightful
• University educated
• Good interpersonal support
from her best friend who
brought her to hospital
• Has a psychiatrist that she
sees every month

26. Formulation
• The formulation should include a brief summary of the patient’s
history, presentation, and current status.
• It should include discussion of biological factors (medical, family, and
medication history) as well as psychological factors such as childhood
circumstances, upbringing, and past interpersonal interactions and
social factors including stressors, and contextual circumstances such
as finances, school, work, home, and interpersonal relationships.

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Diagnosis
DSM-IV-TR - This uses a multi-axial classification of five axes.
Axis I: Clinical syndromes (e.g., Major Depressive disorders, schizophrenia,
generalized anxiety disorder) and other conditions that may be a focus of
clinical attention
Axis II: Personality disorders & mental retardation
Axis III: Any General Medical Condition (e.g., epilepsy, cardio vascular
disease, endocrine disorders)
Axis IV: Psychosocial and environmental problems (e.g., divorce, injury, death
of a loved one) relevant to the illness
Axis V: GAF exhibited by the patient during the interview

28. Further readings
• Kaplan & Saddocks’ Synopsis of Psychiatry