Psychiatric assessment & History taking Dr. Mohammad Hussein

1. Psychiatric Assessment
Bird View
‫د‬
.
‫حسين‬ ‫محمد‬

2. Why Psychiatric sheet?
The main
tool for
assessment
Start
treatment
Professional
communication
exam

3. Steps to case presentaion

4. vs

5. ‫استمارات‬ ‫بنملى‬ ‫مش‬ ‫احنا‬

6. History
Personal Data
Source & Reasons
Of Referral
Complain
History Of Present
Illness
Past History
Family History
Personal History
Premorbid
Personality
Examination
Physical
Examination
Neurological
Examination
Mental State
Examination
Formulation
&management
Descriptive
formulation
Dynamic
“etiological”
formulation
Prognosis
Psychiatric sheet
Differential
diagnosis
Investigation
Provisional
diagnosis
Management
‫د‬
.
‫خطاب‬
‫أحمد‬
‫د‬
.
‫حسين‬
‫محمد‬
‫د‬
.
‫البسيوني‬
‫محمد‬
‫د‬
.
‫الشعشاعي‬
‫أحمد‬

7. • Name; ‫األقل‬ ‫على‬ ‫ثالثي‬ ‫اإلسم‬
• Age;
• Sex:
• Address;
• Education
• Occupation;
• Marital Status
History
Personal Data
Rapport
Sociocultural level
Religion
Family atmosphere
Disorders
Prognosis
Drugs and doses

8. Source Of
Referral
By himself By Family
From
doctor
History
Source Of Referral
voluntary involuntary

9. Patient complaint:
 His own words
 ‫بالعربي‬
 Most distressing to him
Informant complaint:
 Reliable
 If unavailable >>>>> comment
History
Complain

10. History Of Present Illness
History
History Of Present
Illness
‫قصة‬

11. History Of Present Illness
History
History Of Present
Illness
‫قصة‬

12.  Previous Psychiatric history:
 Previous or ongoing psychiatric diagnoses.
 Dates and duration of previous mental illness episodes.
 Details of previous treatments, including medication,
psychotherapy, electroconvulsive therapy and hospitalization.
 Details of previous contact with psychiatric services.
 Details of previous assessment or treatment under mental health
legislation.
 Previous neurological or medical illness history:
 Epilepsy, thyroid
 Surgical operations, accidents
 Medication taking regular
History
Past History

13. History
Family History
Family history
Personal
history
parents
sibling
atmosphere
Natal &childhood
education
adolescence
Sexual history &marriage
Military history
Occupational history
Legal history

14. Premorbid Personality
 Traits
 Relations
 Habits
 Religiosity
 Reaction to stress
 Hobbies (interest)
History
Premorbid
Personality

15. Examination
Physical
Examination
Neurological
Examination
Mental State
Examination
Pulse
BP
RR
General examination
 Appearance & behavior
 Speech
 Affect &mood
 Thinking
 Form
 Content
 abstraction
 Perception
 Illusion
 Pseudohallucination
 hallucination
 Cognitive function
 Level of consciousness
 Orination to TPP
 Attention & concentration
 memory
 Insight
 judgment

16. Formulation
&management
Descriptive
formulation
Dynamic
“etiological”
formulation
Prognosis
Differential
diagnosis
Investigation
Provisional
diagnosis
Management

17. History
Personal Data
Source & Reasons
Of Referral
Complain
History Of Present
Illness
Past History
Family History
Personal History
Premorbid
Personality
Examination
Physical
Examination
Neurological
Examination
Mental State
Examination
Formulation
&management
Descriptive
formulation
Dynamic
“etiological”
formulation
Prognosis
Psychiatric sheet
Differential
diagnosis
Investigation
Provisional
diagnosis
Management
‫د‬
.
‫حسين‬
‫محمد‬
Formulation
&management
‫د‬
.
‫حسين‬‫محمد‬

18. • integrated summary and understanding of a particular
patient’s problems.
Formulatio
n
&managemen
t
Descriptive
formulation
Dynamic
“etiological”
formulation
Prognosis
Differential
diagnosis
Investigation
Provisional
diagnosis
Management

19. Descriptive formulation
• Personal Data
• Main features of the presenting complaint.
• Relevant background details
(e.g. past psychiatric history, positive family history).
• Positive findings in the mental state examination and
physical examination.
Formulatio
n
&managemen
t
Descriptive
formulation

20. Dynamic “etiological” formulation
Why has this patient
developed this disorder
at this point in their life?
Formulatio
n
&managemen
t
Dynamic
“etiological”
formulation

21. Dynamic “etiological” formulation
Commonly identified etiological factors:
 Recent stressful life events
 Non-compliance with medications
 Non-engagement with services
 Lack of insight
 Substance misuse
 Co-morbid physical illnesses
 Social isolation
 Poor financial support, lack of employment, housing
 Poor premorbid adjustments
 Previous history of mental illness
 Family history of mental illness
 Recent bereavement (elderly)
 Sensory deprivation (elderly).
Formulatio
n
&managemen
t
Dynamic
“etiological”
formulation

22. Dynamic “etiological” formulation
Predisposing factors
Precipitating factors
Perpetuating factors
Formulatio
n
&managemen
t
Dynamic
“etiological”
formulation
biological psychological
social

23. Dynamic “etiological” formulation
Formulatio
n
&managemen
t
Dynamic
“etiological”
formulation
social
psychological
biological
Predisposing
Precipitating
Perpetuating

24. Dynamic “etiological” formulation
Formulatio
n
&managemen
t
Dynamic
“etiological”
formulation
social
psychological
biological
Predisposing
Precipitating
Perpetuating
Schizophrenia example
Genetic risk
Schizotypal
personality
Urban
Birth
Cannabis misuse
High Expressed
Emotion
Life event
Non Compliance
with medications
Poor insight homelessness

25. Differential diagnosis
organic
substance
Psychotic disorders
Mood disorders
Neurotic disorders
Personality disorders
Formulatio
n
&managemen
t
Differential
diagnosis

26. Investigation
Physical / medical
psychological
social
Formulatio
n
&managemen
t
Investigation

27. blood
• • Full blood count (FBC)
• • B 12 and folate levels
• • Liver function tests (LFTs)
• • Urea and electrolytes (U&Es)
• • Creatinine
• • Thyroid function tests (TFT)
• • Blood sugar.
Formulatio
n
&managemen
t
Investigation
Physical / medical
urine
Urine drug screen
Infection in elederly
imaging
 Chest x ray
elderly patients and only where examination and
history suggests morbid respiratory and cardiovascular
conditions .
 ECG for specific cases (elderly patients and for
pjlients on high-dose antipsychotics, special
populations with cardiac problems)
 (EEC) - requires justification on the grounds of
Agnostic need
 (CT) - requires justification on the grounds of
diagnostic need
 Magnetic resonance imaging (MR!) - only for
specific cases
 Other investigations as dictated by findings on
physical examination.

28. Investigation
Formulatio
n
&managemen
t
Investigation
psychological
 Psychometric testing/neuropsychological assessment if
you suspect dementia, cognitive impairment, organic
psychiatric illness or learning disability
 Rating scales to establish baselines (mood rating scales,
anxiety and depression rating scales)
 Personality assessment (only for specific cases)
 The following types of self-monitoring can be requested if
appropriate:
• Mood diary
• Eating or drinking diary
• Activities diary.

29. Investigation
Formulatio
n
&managemen
t
Investigation
Collateral history from:
• Partners
• Relatives
• Friends
• Carers
social

30. diagnosis
Formulatio
n
&managemen
t
Provisional
diagnosis

31. diagnosis
Formulatio
n
&managemen
t
Provisional
diagnosis
ICD 10 Diagnosis for Schizophrenia
A. Two (or more) of the following, each present for a significant portion of time during a one-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1) Delusions.
2) Hallucinations.
3) Disorganized speech (eg, frequent derailment or incoherence).
4) Grossly disorganized or catatonic behavior.
5) Negative symptoms (ie, diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when
the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This six-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (ie, active-phase symptoms) and may include
periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an
attenuated form (eg, odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood
episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms
of schizophrenia, are also present for at least one month (or less if successfully treated).
DSM-5 diagnostic criteria for schizophrenia

32. Formulatio
n
&managemen
t
Provisional
diagnosis
ICD 10 Diagnosis for Schizophrenia
G1. Either at least one of the syndromes, symptoms, and signs listed under (1) below, or at least two of the symptoms and signs
listed under (2) should be present for most of the time during an episode of psychotic illness lasting for at least 1 month (or at
some time during most of the days).
1.At least one of the following must be present:
1. thought echo, thought insertion or withdrawal, or thought broadcasting;
2. delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions,
or sensations; delusional perception;
3. hallucinatory voices giving a running commentary on the patient’s behavior, or discussing the patient among
themselves, or other types of hallucinatory voices coming from some part of the body;
4. persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g., being able to
control the weather, or being in communication with aliens from another world).
2.Or at least two of the following:
1. persistent hallucinations in any modality, when occurring every day for at least 1 month, when accompanied by
delusions (which may be fleeting or half-formed) without clear affective content, or when accompanied by persistent
overvalued ideas;
2. neologisms, breaks, or interpolations in the train of thought, resulting in incoherence or irrelevant speech;
3. catatonic behavior, such as excitement, posturing or waxy flexibility, negativism, mutism, and stupor;
4. “negative―
symptoms, such as marked apathy, paucity of speech, and blunting or incongruity of emotional
responses (it must be clear that these are not due to depression or to neuroleptic medication).
G2. Most commonly used exclusion clauses
1.If the patient also meets criteria for manic episode or depressive episode, the criteria listed under G1(1) and GI(2) above must
have been met before the disturbance of mood developed.
2.The disorder is not attributable to organic brain disease or to alcohol- or drug-related intoxication, dependence, or withdrawal.

33. diagnosis
Formulatio
n
&managemen
t
Provisional
diagnosis
DSM-5 diagnostic criteria for schizophrenia
A. Two (or more) of the following, each present for a significant portion of time during a one-month period (or less if successfully treated).
At least one of these must be (1), (2), or (3):
1) Delusions. 2) Hallucinations. 3) Disorganized speech (eg, frequent derailment or incoherence).
4) Grossly disorganized or catatonic behavior. 5) Negative symptoms (ie, diminished emotionalexpression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work,
interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or
adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This six-month period must include at least 1 month of symptoms (or
less if successfully treated) that meet Criterion A (ie, active-phase symptoms) and may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more
symptoms listed in Criterion A present in an attenuated form (eg, odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major
depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or another
medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of
schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also
present for at least one month (or less if successfully treated).

34. Management
Formulatio
n
&managemen
t
Management
 Short term
 Long term
 Home
 Hospital
 Psychopharmacology
 Psychotherapy
 Psychoeducation

35. Prognosis
At the end of each clinical assessment ,
review both good and poor prognostic factors
Formulatio
n
&managemen
t
Prognosis