Table of Contents

Assessment of Psychiatric Patients

The first step in assessing a psychiatric patient is taking the history from patient and/or a companion corroborated with information from others or documents.

HISTORY:

Initial information about the patient’s name, date of birth, sex, address, contact numbers, occupation, social situation (married, single, living alone) are important identifying data for the record and also gives an idea about the person we will be talking to.

REFERRAL:

It is important to document in the notes who has referred the patient and why. It is usual in UK to see patients referred by their General Practitioners. Asking about the main problem may show a different focus of attention than the referral letter, the patient himself may see their problem differently from others. Ask about each complaint in detail and enquire about for how long such symptoms has been affecting the patient.

History of the Present Illness

The onset of symptoms may be gradual, insidious or sudden and their development may be related to certain precipitating life situation or life stressors. Ask about the effects of these symptoms on the patients life in the three spheres of a person’s life: the biological, the psychological and the sociological.

BIOLOGICAL PSYCHOLOGICAL SOCIOLOGICAL

  • Sleep: The patient may have insomnia, Interrupted sleep, early waking.
  • Poor concentration
  • Marital Relationship and problems with partner or spouse
  • Eating :
  • Are there more or less ability to take decision
  • Work relationship and ability to work
  • Bowels: Constipation or diarrhoea
  • Self Esteem
  • Friends: source of support or source of stress
  • Weight: Loss or gain
  • Suicidal Ideas or death wishes
  • Interests: what sort of interest are pursued if any
  • Sex Life: Decreased or increased libido(desire)
  • Despair
  • Drink Alcohol: more
  • Coping with Responsibility and duties
  • Smoking more
  • Early Morning Waking
  • Drugs : prescribed or over the counter or illicit drugs
  • Diurnal Variations of Mood
  • Energy: less or increased

Family History:-

Age, Health, Occupation, Personality, Relation with Patient of the Parents, Siblings and Children.

Family History of the following should also be asked about to investigate the hereditary factors in illness :

Medical illness :

Such as diabetes, Multiple Sclerosis, Huntington Chorea, Thyroid problems, Epilepsy History may indicate predisposing factors or history of head injury or brain pathology running in family.

Mental illness

There is a definite hereditary vulnerbaility to mental illness in severe conditions

Drug And Alcohol Abuse ##

Not only alcohol abuse run in families but also alcoholic fathers may be abusers or violent with patient or mother

Offences

History of criminal behaviour in the family may predispose the patient to similar behaviour or reflect a disturbed family life in childhood.

Home Atmosphere During Childhood

Past Personal History

Early Childhood from age 0 to Five:

  • Was the pregnancy normal or complicated?
  • Was the delivery full term or premature, easy or complicated with foetal distress, prenatal complications?
  • Was the child wanted? Was s/he in good health as a baby?
  • How were the milestones of development such as talking, walking, teething and toilet training?
  • Did s/he show developmental difficulties such as fears, enuresis, somnambulism, tics, school refusal ..etc.

School

  • What type of school attended?
  • Did s/he play truant, bully others or was bullies, picked upon by other children or teased? Expelled from school or suspended?
  • Trouble with teachers?
  • Did s/he sit exams? What grades?
  • What qualifications?
  • How was the relationship with teachers, mates and groups?

Occupation

What did he do after school? What jobs? Why did he change jobs and how many times?

Adolescence

  • Did s/he suffer any emotional difficulty during the teens?
  • Any problem with parents or family at that time? Did s/he experiment with drugs?

SEX

  • First experience, dating, relationships, how many partners and for how long each relationship?
  • How was the relationship with each partner?
  • Why and what happened when they separated?
  • Any current relationship now and how is it working?

Partner

How old is s/he? What does s/he do (employment)? How is her/his health? How is the relationship going?

Children

  • How many? How old is each? Any health problem?
  • How are they doing at school or at work?
  • Do they have a partner if grown up?
  • How is the relationship of the patient with each of them?

Past Medical History

History of medical illnesses of significance. History of Road Traffic Accidents, Head Injury, fits, operations, or gynaecological problems in women such as irregular menstruation or gynaecological operations.

Past Psychiatric History

  • History of previous psychiatric problem:
  • When and what happened?
  • Whom did s/he see for help?
  • Any medication prescribed or counselling therapy arranged?
  • Was s/he admitted at any stage and why?
  • History of overdoses or self-harm? Did s/he need to continue with medication or to see a psychiatrist?

Forensic History

  • Any trouble with the law?
  • What offences?
  • Was he charged or sentenced?
  • What sentence and for how long?
  • Any imprisonment and for how long?
  • Is s/he on probation?

Mental State Examination

APPEARANCE AND INTRODUCTORY SENTENCES:-

The first thing to notice is the appearance of the patient as he comes into the interview room, his grooming, his dress, his hair, cleanliness, self-care and his gait.

As s/he sits down; what sort of posture s/he takes, what gestures in his body as s/he talks. Does s/he keeps a good eye contact, or s/he avoiding gaze, looking downcast to the floor?

What facial expression? Is it depressive face with frowning, drooping angles of the mouth and tension in the face muscles? Is it a mask-like face?

Is the gait rigid, and the face as a mask (Possible parkinsonian symptoms)? Is s/he hunched down? Is s/he gazing or staring at the assessor with a facial expression of suspicion, challenge, alloofness or arrogance? Is s/he tearful, expansive, cheerful, elated?

How is the motility: * Is s/he restless, fidgety, on edge, wringing hands, shaking legs, tremulous? Is his activity decreased or increased? * Is s/he agitated? Does s/he move body involuntarily in tics or chorea movements? * Are lips and tongue moving continuously in a smacking movement or chewing or tongue protrusion (Tardive Dyskinesia)? * Are there repetitive movements which may have a certain peculiar significance? (Stereotypy or mannerism). * Is the patient repeating the question as an answer (echollalia) or refusing to answer or doing the opposite to requests like not sitting down (negativism). * Is s/he repeating the last part of his sentence (perseveration).

Manners: * Is the patient attentive, or distracted by inner thoughts or responding to real or imagined voices or noise? * Is s/he hostile, suspicious, irritable, tense? Is s/he cooperative, pleasant or friendly? * Is s/he over-familiar with the assessor for no proper reason, interrogative, seductive or disinhibited in behaviour ? * Is the patient slow in movement, takes time to respond with gaps of silence before answering?

SPEECH:

Speech abnormality can be assessed in its rate, volume, flow and pattern. The speech rate may be increased or decreased or the patient may be even mute. His talk may be scanty or monosyllabic. S/he may be talkative and voluble or talking very little (poverty of speech) with long pauses. The tempo may be fast or slow.

The Volume and the tone of voice may also show change: The tone or pitch may be low or high, loud or whispering, muttering or mumbling, monotonous or variable in pitch.

The Pattern may show thought abnormalities: like loose associations, flight of ideas, neologism, thought block, clang associations, rhyming, perseveration, circumstantiality.

Dysphasia should be also noticed as it indicates a brain pathology. It may be inability to comprehend simple instructions (receptive) or to express simple words (expressive) or to name objects (nominal)

MOOD

Mood is examined objectively by observing the patient’s emotional reactions to interview and also by his/her reports about their inner feelings. Thus, anxiety may be clear in movements, body and face but also mentioned by the patient. The same is true in states of depression, ecstasy, elation or euphoria. An apathy may not be reported by patient but observed by examiner. The patient may also look indifferent with no sign of anxiety or worry in contrast to the situation ( La Belle Indifference ) or thought content (Apathy). The emotional reaction may be blunted, flattened , or the patient may be perplexed or labile in emotions ( In organic conditions in particular).

THOUGHT CONTENT:

Abnormality of thought form is evident in speech (See Above). Abnormal thought content includes abnormal ideas like delusions or obsessions.

DELUSIONS:

are false fixed beliefs which can not be corrected by reason or discussion and not explainable by the patient’s culture or social background. They need to be differentiated from over-valued ideas which can be explained by the social and cultural background of the patient. Delusions represent misinterpretation of reality.

  • Delusions of reference are belief that people or TV or Radio refer to patient in their talk or broadcast.
  • Delusions of persecution takes various content but are mainly beliefs that the person is subjected to malevolence of others, e.g. Others are trying to harm, kill, poison, torture the patient, or destroy his status, property or steal his wealth.
  • In Delusions of control the patient believe s/he subjected to the control of other agencies which direct his actions or behaviour or Influence his/her body or mind.
  • Delusions of Grandeur or Grandiosity also takes different shapes and forms, but the main theme is special power, intelligence, ability, talent, possession or wealth.
  • Hypochondriacal Delusions are beliefs about malfunction, illness or disease of the body and internal organs.
  • Delusions of Guilt may take the extreme form of belief in committing a serious crime or sin for which a punishment is justifiable and there is a risk that the patient himself inflict the punishment on himself by mutilation or suicide.
  • Delusions of Nihilism are beliefs in the non-existence of self, organs, body, others or the whole world.
  • Delusions of Love (Erotic Delusions) are beliefs that one is in love with an attainable person of a higher social status who reciprocate love but for some reason is unable to express this love to the patient openly.
  • Delusion of The Double (Capgras) is a belief that a person well-known to the patient has been replaced by an imposter.

Passivity phenomena take the form of :

  • Delusions of thought insertion (alien ideas are put into the patients mind by some external force or agency. This is different from the belief that others are suggesting ideas to the patient or that they influence his views or make him change his mind).
  • Delusions of Thought withdrawal are beliefs that ideas are taken away from his mind and sometimes Broadcast into Media like TV, Radio or waves, or may reach other peoples minds or broadcast directly into other people’s heads by some mysterious means.
  • The patient may also believes his acts are not his but made by control or influence of his persecutors or the voices he hears.

OBSSSESSIONS

Obsessional thoughts are abnormal recurring thoughts that intrude themselves into the patient’s consciousness against his will and in spite of their attempt to resist these ideas. These thoughts take the form of harm of self or others, sexually inappropriate acts, blasphemous thoughts or a belief in ugliness of body or organ (Dysmorphophobia).

The Obsessions may also take the form of images coming to the mind or visualisation of acts or unacceptable feelings like sexual arousal or an impulse to inflict injury on others.

PERCEPTIONS:

Illusions are misinterpretation of real stimuli, like seeing a ghost for a tree in a dark garden.

Hallucinations are perceptions without an external stimulus. The patient experiences a voice or a noise in his ears without any source to explain such perception.

Auditory Hallucinations

The voice may be a single voice or more than one, it may be heard inside the head (Pseudo-hallucination) or outside the head. The voice may be running commentary on the patients behaviour, commanding him to do certain acts, warning him, abuse him or calling him names, tormenting him with threats and asking him to do certain acts to avoid punishment, or argue with other voices about the patient’s behaviour. Sometimes, a couple of voices argue together, with one encouraging and supporting the patient while the other is derogatory and critical. In some patients the voices may be pleasing and saying good things about the patient, keeping his company and advicing him to protect himself from others.

Visual Hallucinations

are visions of objects in the absence of outside stimulus and in clear consciousness. They are rare in schizophrenia but common in organic brain conditions such as delirium.

Tactile hallucinations

are abnormal sensations in the body internally or on the skin. Some patients experience sexual sensation in their genital which they atrribute to persecutors penetrating them or if they feel pain they may believe it is inflicted on them at a distance by machines directed by their enemies.

Olfactory hallucination

may take the form of a strange smell which the patient associate with their delusions. It is commoner in temporal lobe epilepsy or organic brain conditions. Gustatory hallucinations are unusual tastes which the patient attributes to effect of persecution. Both Olfactory and Gustatory hallucinations may be associated with psychotic depressive delusions of nihilism or hypochondriacal beliefs.

Pseudo-hallucinations

are less vivid than real hallucinations and are usually experienced inside the body and not in the external reality.

Patients may feel that their outside environment has changed or that their body or self has changed DEREALIZATION/DEPERSONALIZATION

Déjà vu is the experience that the present perception of reality has been lived before in the same manner/ The opposite experience is JAMAIS VU.

COGNITIVE FUNCTIONS :

Observe the level of consciousness, if it is clouded, is the patient drowsy, in stupor or in coma?

Comment on patient's attention, concentration, and orientation to time, person and place. Test recent memory by simple questions or give name and address and ask to recall in 5 minutes. Test remote memory by asking about historical events known to everyone. Differentiate between anterograde and retrograde amnesia. Some may show retrospective falsification or delusional memory. Notice any evidence of confabulation or misidentification.

Premorbid intelligence can be inferred from educational history.

INSIGHT:

PHYSICAL EXAMINATION:

DIFFERENTIAL DIAGNOSIS

in order of probability, with reasons

AETIOLOGY:

Evaluate the events which has contributed to the causation of the current illness, either remote past events, intermediate and recent events.

Factors which are involved in causation include physical, psychological and social factors. Physical factors include things such as genetic and familial factors, constitutional and upbringing effects, history of illness and drug use. Psychological factors include personality structure and psychodynamic factors throughout the patient's life. Social factors and cultural factors are also important.

MANAGEMENT:

In organising a management plan first consider the needed investigations either physical, radiological, EEG or psychological. The immediate plan and the long term plan is then considered. In each we think of the biological, psychological and social aspects of the plan.

PROGNOSIS

Comment of the possible outcome of the current illness in the immediate future and long-term.

SUMMARY

HISTORY * Record : Name, age, Sex, marital state, Address, accommodation, occupation. * Referral by Who? , When? , Why? * Complaints and their duration. * History of Present Illness: * Onset, precipitating factors

Family History: * Age, health , occupation, personality, relation to the patient of parents, siblings. * Family history of Psychiatric illness * Family history of Medical illness (Epilepsy, Drug abuse or alcohol) * History of offences in the family.

Past Personal History:- * PRESCHOOL * SCHOOL * OCCUPATION * SEX * MARITAL. * Children * Past Medical History * HABITS: Drugs, Alcohol, Smoking * FORENSIC * Premorbid Personality

Mental State Examination:

APPEARANCE:

  • Groom: Hair, Face, eyes, dress, Clean
  • Gait, posture, Facial Expression, Eye contact, Motility
  • Manners
  • Slow/ energetic

SPEECH: - Fast/retarded, scanty , monosyllabic , mute - Continuous/pauses - Pressure of speech /poverty of speech - Loud / low-toned , whispering ,muttering - Variable /monotonous

MOOD: - Quality: Anxiety , depression , elation, anger - Quantity: Blunting(flattened affect) , apathy , indifference - Reactivity: Congruous/ incongruous (Inappropriate) - Variability: Lability, incontinence

THOUGHT

FORM: - Loosening of associations: derailment , incoherence , word salad ,verbigeration. - Circumstantiality , flight of ideas ( Punning, rhyming , clang associations ). - Neologism - Concrete thinking , over-inclusive thinking , Vorbeireden (Talking past the point) - Stereotypy , Echolalia , palilalia, logoclonia, perseveration. - Dysphasia : Nominal , fluent , non-fluent (expressive)

CONTENT: - DELUSIONS :persecution, reference , passivity , delusional perception. - DELUSIONS: of guilt , hypochondriacal , nihilistic - DELUSIONS : religious , grandiose, erotic (delusion of love) , jealousy. - OVER-VALUED IDEAS, preoccupations , suicidal ideas . - OBSESSIONAL : doubts, impulses , thoughts, ruminations

PERCEPTIONS - ILLUSIONS: deja vu, jamais vu, depersonalization , derealization. - AUDITORY HALLUCINATIONS: - Third person, running commentary , Gedanklautwerden (predict thoughts) - VISUAL HALLUCINATIONS:- - OLFACTORY and GUSTATORY HALLUCINATIONS - TACTILE and DEEP Somatic hallucinations - COGNITIVE FUNCTIONS - CONSCIOUSNESS: Alert ,drowsy , clouded consciousness. - ATTENTION: attentive /distractable - CONCENTRATION - ORIENTATION: Time , place and person - MEMORY:- - INTELLIGENCE

INSIGHT - For the illness - For the cause of illness - For the treatment

FORMULATION

DIFFERENTIAL DIAGNOSIS The pros and cons of each possible diagnosis with reasons for each.

AETIOLOGY - Precipitating Events: Remote, Intermediate and Recent.

  • Predisposing Factors:-
    I. BIOLOGICAL:
        A. Genetic (Hereditary , Constitutional)
        B. Illnesses
        C. Drugs (iatrogenic)
    
    II. PSYCHOLOGICAL**:
        A. Personality (PMP)
        B. Early family atmosphere
        C. Interpersonal dynamics
        D. Psychodynamics
    
    III. SOCIO-CULTURAL:**
        A. Marital aspect
        B. Social relationships
        C. Occupational aspect
        D. Financial aspect
        E. Supportive services
        F. Losses ,bereavement and disappointments
        G. Expressed emotions
    

MANAGEMENT

A) Further information - from an Informant : Next of kin, Nurse, Social Worker, GP , Records - Investigations: Invasive (FBC, U&E , LFT, TSH+T4, Others) and Non-invasive: Skull x-ray, EEG , CT Scan , NMR , EP - Psychometry - Social Casework

B) Management Plan

I. SHORT-TERM: Admission: Compulsory /Informal to hospital, Day-centre, Treatment at home, Medication, Support of the family and Crisis intervention

II. LONG-TERM: - PHYSICAL: Maintenance , depot injection, Lithium , carbamazepine - PSYCHOTHERAPY : Individual/ group, Supportive/depth, Psychodynamic/behavioral, cognitive , counselling , marital therapy, family therapy , sex therapy

C) SOCIAL INTERVENTION:-

  • Housing : Hostel ,group home
  • Occupational therapy
  • Sheltered workshop, Day - centre

PROGNOSIS: - SHORT-TERM: Improvement , recovery , residual defects in the short-term - LONG-TERM: * Improvement , recovery , residual defects * Relapse and recurrence * Deterioration of personality and social functioning.