Assessment
A psychiatric evaluation helps to (a) make a diagnosis, (b) estimate the severity of the patient’s condition, (c) decide on an initial course of action, (d) develop a relationship with the patient (therapeutic alliance), (e) assemble a dynamic understanding of the patient, and (f) engage the patient in psychotherapy. Some (primarily analytically oriented) psychiatrists argue that the most reliable understanding of a patient results from an open-ended interview in which the course of the interview is directed by the patient’s conscious and unconscious concerns. An alternate form of interview, and one encouraged by the requirements of Diagnostic and Statistical Manual of Mental Disorders (DSM), uses a structured format that demands precise historic and descriptive information and the answers to specific questions (1,2,3,4). Which technique produces a more accurate and useful understanding of the patient remains unresolved, yet modern diagnosis requires the structured form described later.
A thorough evaluation of a psychiatric patient consists of a psychiatric history, mental status examination, complete physical examination, laboratory screening evaluation, and, when indicated, specific psychological and biologic tests. The history and mental status are usually obtained during the initial interview.
More is required than merely collecting facts. The interviewer seeks useful information not only from the history and mental status examination but also from the patient’s interpersonal style and nonverbal communications and from the sequence and choice of issues raised by the patient. Because so much information is available from the patient outside the formal part of the interview, it is essential to avoid structuring the interview too early. Initially, allow the patient to express concerns and find out the reason for coming for help (Why now?). Be supportive, attentive, nonjudg-mental, and encouraging—develop a rapport with the patient and try to get an empathic understanding of his or her distress. Develop a qualitative sense for the patient’s impairment. Help allay anxiety, if present. Be patient, friendly, and receptive if the patient is quiet. If the patient rambles, you may have to impose a structure early. If the patient is paranoid, progress slowly. Decide
early if he or she is likely to be aggressive, suicidal, or in need of hospitalization.
early if he or she is likely to be aggressive, suicidal, or in need of hospitalization.
If the interview is skillfully conducted, much of the information required by the history and mental status examination may be obtained unobtrusively. As the interview proceeds, you usually can identify and narrow missing data so that more formal questions are minimal. However, certain information is almost always required (e.g., data to satisfy DSM diagnostic criteria, family psychiatric history, or mental status responses to rule out organicity or loss of abstracting ability). At times during the interview, mentally review what is missing, and save time toward the end to pursue it by direct questioning. The transition to a more formal style of interviewing can be smooth if rapport has been developed beforehand (“Now I need to ask you some very specific questions”).
PSYCHIATRIC HISTORY
Identification of the Patient
Name, age, birth date, marital status and children, ethnic status, religion, occupation, education, social class, handicaps, and so on;
Identification of informants (if not the patient), as well as mood and apparent biases of informants;
Estimate of the reliability of the information.
Chief Complaint
Usually a verbatim statement of “the problem.” Does it differ significantly from the reports of those who accompany the patient?
Present Illness
Usually the focus of the interview. Get the patient’s description of and feelings about the illness (problem) and need for care (“why now,” if ever). Establish the chronologic order of recent symptoms and treatments from an appropriate historic reference point (varies but often weeks). Has the patient noticed any other changes in him or herself? Have there been major life changes during this time or particular stresses and conflicts? Is any secondary gain
identifiable? What is the patient’s legal status? Is the patient suicidal or homicidal?
identifiable? What is the patient’s legal status? Is the patient suicidal or homicidal?
Past Psychiatric Illness
Backtrack any current psychiatric problems to their inception. Ask about the other most common psychiatric disorders; their diagnoses, and severity of illnesses. Get a chronologic history of symptoms, associated life problems, past psychopharmacology and its usefulness, psychotherapy, and hospitalizations. Get a detailed history of alcohol and drug use/abuse and history of past suicidal or homicidal behavior. Determine reliability of this history (attempt to obtain past records).
Personal History
Birth and early development: Mother’s pregnancy and delivery: Prematurity? Planned pregnancy? Get estimate of temperament and behavior problems. Are there any psychophysiologic problems? (Relatives may be a source of information.)
Childhood: Personality traits, behavior problems, social relationships, school adjustment, family relationships, and family stability. Any personal abuse (physical, sexual, neglect) or family violence?
Social history: What kind of interpersonal relationships can the patient make? Has he or she been a loner? Follower? Leader? What kind of group activities has he or she had in the past and in the present? Who are the people important to the patient now and in the past? What was the patient’s premorbid personality? Does the patient have any military history?
Marriage: At what age? How many times? Relationship patterns within the marriage? Number of children and attitude toward them?
Education: Highest grade attained? Specific academic difficulties? Behavior problems? Social problems?
Occupational history: Concentrate on job changes, length of time jobs have been held, best job obtained and when—get details. Social relations on job; with boss? With workers? How does job compare with ambition? With family expectations?
Sexual history: Sexual orientation? Psychosexual problems or deviant behavior? Feelings about sex?
Current social situation: Personal living situation, income? Social environment? Estimated current marital and family stability and happiness?
Family History
Who lives in the home? The patient should describe them and the relationship with them. Get description of patient’s family of origin and his or her role in it. Upwardly mobile family? Get a detailed description of psychiatric (and medical) illnesses in family members (family psychiatric history).
Medical History
Obtain current and past medical problems and treatments (medications, etc.). Ask about the most common or serious “likely suspects” (see Chapters 13,14,15), [e.g., HIV/AIDS (risk of?), thyroid, cardiac, steroid use, head injury].
MENTAL STATUS EXAMINATION
A mental status examination (5) is a systematic documentation of the quality of mental functioning at the time of interview. It helps both with current diagnosis and treatment planning, and it serves as a baseline for future reference. Although much of the information sought in a mental status examination is obtained informally during other parts of the interview, it is usually necessary for the patient to answer a few formal questions if the interviewer is to learn the patient’s abilities in each category of mental functioning listed below. After concluding the mental status examination, estimate its reliability. (Note: do not “over-read” mistakes on the MSE; we all make errors.)
General Presentation
Appearance: Overall impression of the patient: attractive, unattractive, posture, clothes, grooming, healthy versus sickly, old looking (vs.) young looking, angry, puzzled, frightened, ill
at ease, apathetic, contemptuous, effeminate, masculine, and so on.
General behavior: Mannerisms, gestures, combative, psychomotor retardation, rigid, twitches, picking, clumsy, hand wringing, and so forth.
Attitude toward the examiner: Cooperative, hostile, defensive, seductive, evasive, ingratiating, and so on.
The psychotic patient may appear disheveled and bizarre with odd posturing (particularly catatonics) and grimacing. Some schizophrenics may stare, and others look “blank.” Paranoid patients may be hostile and suspicious; borderline patients, hostile and angry; whereas histrionic patients often are seductive in manner and dress. Depressed patients may be nearly mute and display psychomotor retardation. Restlessness may suggest anxiety, withdrawal, mania, etc.
State of Consciousness
Is the patient alert (e.g., normally aware of both internal and external stimuli) or hyperalert? Is the patient lethargic (e.g., does he “drift off,” or do his thoughts wander)? The patient must be reasonably alert for the remainder of the examination to be reliable. The causes for decreased alertness are usually organic.
Attention
Can the patient pay attention for short periods (attend) without being distracted by minor stimuli? Can the patient attend for lengths of time (concentrate)? This ability is necessary if you are to assess higher-level functions (i.e., they may be intact, but the patient cannot demonstrate them because of lack of attention). Test attention level with digit recall (digit span) (e.g., speak a series of numbers in a monotone and ask the patient to repeat them; begin with three numbers and increase by one with each successful trial; a normal maximum is seven numbers repeated). Have them repeat numbers backward; the norm is five. Test concentration by the Random Letter Test [e.g., tell the patient to note (by raising a finger) each time a certain letter is mentioned, and then read a long string of letters; most people make very few errors]. Defects in attention usually are due to organic causes but may be caused by marked anxiety or psychotic interruption of thoughts. Ask patient to spell “watch” forward, then backward (also involves intelligence).
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