Psychiatric Assessment

Includes: history, MSE, physical exam/ investigations, risk assessment, differentials, management

Can be challenging to assess because patients may not have insight, they may have poor concentration and there is still a stigma around mental illness

History:

Before history taking, must take note of the following:

Some demographics (sex, age, occupation and ethnicity of the patient)
Mode of referral and the reason of referral:

Are you seeing the patient as inpatient, outpatient, at the ED etc?
Who made the referral and what are their concerns, what was the trigger?
If the patient is an inpatient, are they detained under the Mental Health Act?

Marksheet for History Taking

Include a presenting complaint (could be as simple as 'lack of insight')
History of presenting complaint with symptoms supporting the diagnosis
Past psychiatric history
Family history, past medical history, current mental health and current medications
Substance misuse history (including both alcohol and illicit drug use)
Include childhood, schooling and occupational history in the personal history
Include psychosexual and relationship history in the personal history. (Any past trauma?)
Include a forensic history
Established pre-morbid personality
Include current social circumstances (housing, carers...)
Demonstrated a logical progression in the history

1. Presenting complaint:

Patient may not offer one – lack of insight

2. History of present illness: - very important

For each problem (may need to first list all of the problems), clarify:

When and how did problem start/ develop, any precipitating life factors?
Any associated symptoms
Affecting day to day functioning- what symptom struggling with most?
Have you tried any treatment/ interventions, and did they work?
Temporal relationships between symptoms and any physical disorder, psychological or social problems.

3. Past psychiatric history

Previous diagnoses (including self-harm or suicide attempts), management and duration: including psychiatric admissions (informal/ under MHA) and primary care mental health services
Any symptoms they didn’t seek help for?
Consider:

what interventions were helpful and which were not, benefits, side effects and doses of medication used, concordance to treatment plan
If the diagnosis is in doubt, record symptoms of previous episodes and how they have changed over time. What led to episodes of illness?
predisposing, precipitating and perpetuating factors as well as protective factors and positive coping strategies

4. Family history

Parents, siblings, other significant relatives – ask about age, health, employment, psychiatric history and quality of relationships with patient- high expressed emotion?

A family tree may be helpful if it is complicated (perhaps more useful for real life, not in the 10 mins OSCE)

5. Medical history

Normal surgical and medical conditions – any current treatment? Concordance?
History of head trauma or endocrine abnormalities (organic differentials)
Could medication be causing presentation (e.g. steroids cause manic type)
Any known allergies and check interactions

6. Substance misuse and alcohol history

Consider tobacco, alcohol, illicit drugs:

Pattern of use, past and current use
Effects (including withdrawal symptoms, dependence features)
How substance use relates to mental health difficulties

Personal history

A brief biographical history including:

Childhood – birth, developmental milestones, family atmosphere, bullying
School & education – primary and secondary schooling, relationship with teachers and peers, problems at school (academic, behavioural e.g. truancy, school refusal), age when left school, any further training or courses
Occupations – job taken, for how long, why left, and how long unemployed
Psychosexual and relationship history – past and current relationship, marital history, any children (ages and contact – remember children safeguarding), sexual orientation and difficulties if relevant

Past history of emotional, sexual and physical abuse if appropriate

Forensic history

Consider all offences whether convicted or not – especially any violence, sexual offences and persistent offending (cautions, probation, prison)

Premorbid personality

How would you describe yourself before you became unwell? (May struggle to remember if been ages). Premorbid personality includes:

attitudes to others in relationships

"How would you describe your normal self?"
"How would other people describe you?"
"How do you cope when.... (e.g. stress)?"

attitudes to oneself (self-esteem)
predominant mood and stability
leisure activities and interests
reaction pattern to stress
religious and cultural issues
individual’s strengths and abilities

It may be necessary to get information from others and it needs to state that what information is from patient and what information is from other people

Social circumstances

Housing, any children in the house, social support, jobs, financial circumstances (debt and benefits), relationships and support network (personal and professional)
Any carer identified and support to the carer

Mental State Examination (MSE)

An assessment of how the patient is thinking right now – the information can be gathered as part of the psychiatric history or a proper assessment after

When presenting, don’t repeat the history (e.g. can say depressed mood but don’t give time scale or precipitants etc). Should be succinct and highlight the psychopathology present, specifically during the consultation/ assessment

Marksheet:

Reasonable description of appearance, behaviour and speech
Comprehensive description of mood (subjective and objective) as well as the affect
Covered any abnormality of thought form (including verbatim quote if disorder of thought form is elicited)
Covered any abnormality of thought content
Covered any abnormality of perception
Adequate description of cognitive examination
Comprehensive description of patient’s insight
Described the mental state with appropriate psychopathological terms and under appropriate heading
Demonstrated a logical progression in the mental state

Section 1: Appearance and Behaviour

Appearance

Behaviour

Clothes:

Colourful and loud clothes (mania)

Dirty and crumpled clothes (self-neglect)

Movements:

Mania - overactive, agitated or restless

Schizophrenia - catatonic features

Abnormal movement - e.g. dystonia, tremor (neuro disorder or medication SE)

Weight:

Rapid weight loss suggests self-neglect - consider ill-fitting or new belt holes

Low weight – anorexia?

Obesity - side effect of medication?

Social Behaviour:

Mania - over familiar

Schizophrenia - withdrawn or preoccupied

Psychomotor agitation (mania, anxiety) or P retardation (catatonia etc)

Facial Appearance:

Depression – mouth down, furrowed brow

Anxiety – forehead creases, dilated pupils

Anger and irritability - characteristics

Rapport:

Schizophrenia/psychosis - suspicious and uncooperative

Posture:

Depression - hunched posture

Anxiety - sitting on edge of seat, restless

Eye contact:

Depression - poor eye contact

Could the police identify them from your comments?

Section 2: Speech

Include: rate (fast/ slow), quantity (e.g. poverty of speech), volume (quiet- depression, loud- mania), flow of speech (e.g. pressure of speech- you cannot interrupt), spontaneity, monot.

Comment on: rate, rhythm and volume. Can say normal rate, rhythm and volume

Section 3: Mood and affect

Mood is the pervasive and sustained emotional state (i.e. longer term) whereas affect is the observable behaviour associated with changing emotions (like fear, sadness or joy). Can describe mood as the climate (e.g. summer) and affect is the weather

Mood:

Subjective mood: how does the patient describe their mood? May have alexithymia and find it very hard to describe emotional state (in patients with ID). Suicide?
Objective mood: what is your impression of the mood? - elated/ depressed/ anxious/ labile (easily altered)

Affect:

Is the affect appropriate and reactive?
Blunted or flattened affect - dulling of normal emotional response
Labile affect - sudden rapid and often marked shifts of affect
Inappropriate or incongruent affect - can be inappropriate to the thought content (e.g. laughter upon recounting the death of loved one) or inappropriate to the magnitude of events (e.g. emotional outburst after a small and insignificant event)

Remember mood and affect can be congruent or incongruent

Section 4: Thoughts

Thought form: the train of thought, assessed through speech

If struggling to understand what the patient is saying, consider a formal thought disorder (can be subtle), e.g. disorder of thought form in schizophrenia – I don’t need to know details

Psychopathologies: flight of ideas, loosening of associations/ derailment, thought block (e.g. passivity phenomena- schiz), poverty of thought, a fixed false belief (could be a delusion), unusual perception in a specific modality (visual, auditory, tactile), internal or external

Thought Content:

Psychopathologies in this section: overvalued ideas, phobia (i.e. irrational fear), obsessions/ ruminations, delusions. Some questions to help screen for abnormal thought contents:

"I would like to ask you some questions that may seem a little strange but we ask all of our patients. Is that OK? Do you have any beliefs that your friends and family do not share?"
"Is anything bothering or weighing on you at the moment?"
The form is more important, but the content may be more worrying to the patient so ask

Is the content congruent? E.g. mood congruent in depression (delusions of guilt, crime etc), if the delusions are more bizarre or incongruent, lean more towards a psychotic illness

Section 5: Perception

General questions for screening any abnormal perceptions:

"I gather that you are quite stressed recently. When people are under stress, they can sometimes find that their imagination plays tricks on them. Have you experienced this?"
"Have you heard/seen anything unusual?"
"Have you noticed anything unusual about the way things look or sound, or smell, or taste?"
"Have you heard voices when there was no one around?" (auditory hallucination).
Sensory Distortion: distortions of intensity, colour, form and proportions

Depersonalization: an alteration in the perception or experience of oneself, leading to a sense of detachment from one's mental process or body
Derealisation - an alteration in the perception or experience of the environment, leading to a sense that it is strange or unreal

Illusions: misinterpretations of a real stimulus. It can happen in individuals without mental illness
Hallucinations: perceptions in the absence of a stimulus.

Auditory hallucinations can be described as:

2nd Person (voice talking directly to them - usually say "you....")
3rd Person (a number of voices talking among themselves and refer the individual as "he"/"she" or their name.
Command hallucinations

Section 6: Cognitive Examination

Can be related to dementia, mental illnesses like schizophrenia, or poor memory due to depression etc. You need to include the following items as minimum:

Alertness and orientation in time, place and person
Attention and concentration (spell WORLD backwards, count back from 100 in 7s)
Memory - immediate recall (3 words), delayed recall, long-term memory/knowledge

If you discover cognitive impairment, a more detailed cognitive examination is necessary:

Mini-mental state examination (MMSE):

by Folstein
Maximum score 30
does not test any frontal lobe abnormality
takes about 5-10 minutes depending on patient

Montreal Cognitive Assessment (MOCA):

A full version and a basic version (for illiterate or with low education/ <5y)
Maximum score 30
Covers most of cognitive domains including executive (e.g. frontal)

Section 7: Insight

You must address these 5 questions:

Is the patient aware that there is anything wrong?
If there is anything wrong, does the patient think it is due to an illness?
If an illness, is it physical or mental illness?
If it is a mental illness, can it be helped?
Is the patient willing to accept help or treatment? – including hospital treatment?

Physical Examination

Individuals with mental illness have a higher chance of various physical illnesses
Some physical illness can also present with psychiatric symptoms

Investigations

Physical investigations: blood tests, ECG, urine tests, brain scan, EEG etc

Help exclude organic causes of psychiatric symptoms
Screen for physical health difficulties
Act as a baseline, especially when initiating medication

Psychosocial investigations: informant history with patient's consent (which can be difficult at times), review medical records, social assessment, occupational therapy assessment for functioning, etc.

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