Table of Contents
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.
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.
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.
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
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 :
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.
There is a definite hereditary vulnerbaility to mental illness in severe conditions
Not only alcohol abuse run in families but also alcoholic fathers may be abusers or violent with patient or mother
History of criminal behaviour in the family may predispose the patient to similar behaviour or reflect a disturbed family life in childhood.
What did he do after school? What jobs? Why did he change jobs and how many times?
How old is s/he? What does s/he do (employment)? How is her/his health? How is the relationship going?
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.
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 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 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).
Abnormality of thought form is evident in speech (See Above). Abnormal thought content includes abnormal ideas like delusions or obsessions.
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.
Passivity phenomena take the form of :
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.
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.
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.
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.
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.
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.
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.
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.
in order of probability, with reasons
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.
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.
Comment of the possible outcome of the current illness in the immediate future and long-term.
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:
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
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
DIFFERENTIAL DIAGNOSIS The pros and cons of each possible diagnosis with reasons for each.
AETIOLOGY - Precipitating Events: Remote, Intermediate and Recent.
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
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:-
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.