Psychiatric Assessment
María Fernanda Gómez
Mary Alice O’Dowd
Athorough psychiatric evaluation is the cornerstone of diagnosis and treatment. Despite the popularity of “check list” evaluations that meet the requirements of third party payers, there is still much to be learned through an assessment based on both open- and closed-ended questions that enhance understanding of a patient and develop a life narrative. This is certainly true in the assessment of the patient with human immunodeficiency virus infection (HIV) or acquired immunodeficiency syndrome (AIDS), given the complex interaction of biopsychosocial factors at every stage of infection, including the risk behaviors underlying transmission, barriers to adherence, the stigma of diagnosis, cultural issues, and the impact of progressive illness and its treatment in an impaired population, more than 50% of whom may have psychiatric disorders antedating HIV infection.1
The form and completeness of the psychiatric assessment in a population with physical illness may be dictated in part by the stage of illness. The debilitated patient may be unable to participate in an extensive interview or may be unable to recall details of past history, giving collateral informants a more central role. Issues of discomfort, whether physical due to illness or its treatment, or emotional, due to the lack of privacy in a hospital or clinic setting may limit the assessment possible or may require changes in strategy. In such situations the assessment may need to be completed in a series of brief interviews or to be more problem focused, leaving more complete assessment for a time when the patient is better able to participate. In a multidisciplinary clinic setting, the interviewer may have the advantage of the data available in the medical chart, which can be mined for clues as to the patient’s past and present history and behaviors. Useful information can be found in the notes from social workers and other care providers, as well as in the medical progress notes, laboratory values, neuroimaging reports, and medication lists. This chapter reviews the wider range of topics that could be covered in the complete psychiatric assessment of an HIV-infected patient, but the actual assessment of a particular patient will be dictated by the circumstances.
Initial Assessment
The first step to the achievement of a successful psychiatric assessment is the formation of an alliance in which the patient experiences a level of trust and comfort with the interviewer that permits sharing of intimate information and feelings. Different interview settings may have an impact on the development of such an alliance. The individual who presents voluntarily to the psychiatrist’s office may have at least some level of insight into the need for mental health services and thus may be more open to participation in the assessment. A different situation may unfold when a patient in a multidisciplinary clinic is referred for psychiatric assessment. Here, the patient may not understand the reasons for referral and may even see the psychiatric assessment as an assault, as evidence that caregivers think him or her “crazy.” In addition to reluctance in being identified as a psychiatric patient, patients may be hesitant to participate in an in-depth interview due to experiences of stigmatization when HIV infection or risk behaviors have been divulged in other settings. It is also not unusual for a patient to feel uncomfortable initially discussing personal details with an interviewer perceived to differ in age, race, gender, sexual orientation, or socioeconomic status. The most effective way to build an alliance in this situation is by initially focusing not on psychiatric issues but on the patient’s experience of his or her illness. Discussing the patient’s illness, a story that patients usually never tire of telling, most often sets the patient at ease and offers an assurance of the examiner’s interest and understanding. While reviewing the patient’s experience with his or her illness, it is possible at the same time to gain considerable information about memory, insight, and judgment. At this point, it is almost always possible to move toward an examination of psychiatric issues, even in patients who are initially resistant or even hostile.
The psychiatric interviewer must be an acute observer on many levels. The interviewer must listen to what the patient is saying, as well as retain awareness of what is not being said. The patient’s behavior, appearance, and dress should be observed for appropriateness to the situation. Observed interactions with the examiner, clinic staff, and even other patients can provide insight into social skills. Motor skills and coordination can be examined directly or inferred from the ability to sign an insurance form or button a coat before leaving the office. The following sections do not include every topic that could be covered in the psychiatric assessment of a patient with HIV infection but do attempt to cover the topics of most concern.
Clinical Approach to the Psychiatric Assessment
The following guidelines detail areas that should be covered in the patient psychiatric assessment.
Determine from the patient or referring clinician the reason why the patient has been referred for assessment. Knowing what problem areas have been identified will help focus the assessment.
Gather a history from the patient or collateral sources, including the history of the psychiatric complaint; the past psychiatric history; the family psychiatric history; social history, including school and work history; history of trauma or abuse; and legal history. Identify social supports available to the patient, and explore the patient’s strengths in coping with this and prior stressors.
Pay special attention to a careful history of past and present substance abuse, including the age at which use of each substance began, quantities used, and the impact of substance use on all aspects of the patient’s life. It is important for the examiner to be familiar with evolving patterns of substance use in the community and direct the examination accordingly. In eliciting an accurate history of substance abuse, it may be useful to remember that users may underestimate use, deceiving both themselves and examiners. Questions assuming use and phrased in terms of quantities and even exaggerated quantities may elicit a more
honest response. Thus, rather than asking, “Do you drink beer?” the questioner might ask, “How many quarts of beer do you drink daily?” and so on.
Take a careful medical history, including medications used to treat HIV-related disorders and other illnesses. Understanding of and adherence to treatment regimens should be reviewed. Height, weight, body mass index, and vital signs should be recorded. Further elements of the physical and neurologic examination should be included when suggested by the history.
Take a sexual history, emphasizing behaviors that may put the patient or others at risk. Here, again, questions phrased so as to assume that behaviors are part of a patient’s expression of sexuality may lead to a more honest dialog than questions that encourage a simple “yes” or “no” response.
Perform a mental status examination, through a combination of questioning and observation. The spheres to be examined include the following:
Behavior and appearance: Does the patient sit quietly or move restlessly in the chair or about the room. Is his or her behavior appropriate for the interview? Are hygiene, clothing, grooming, and makeup appropriate? Are there abnormal movements?
Mood and affect: Does the patient acknowledge any disturbance in mood, whether sadness or elation? Is the affect displayed by the patient appropriate to the self-described mood? Does the patient exhibit lability or irritability during the examination? Does the patient endorse any symptoms of depression when asked specifically about anhedonia, helplessness, hopelessness, or worthlessness? Does the patient endorse any current or past symptoms of mania, including decreased need for sleep, overspending, or unusual sense of creativity? What was the duration of these episodes and how did they resolve? Was treatment ever sought and what was the outcome?
Speech and thoughts: Does the patient speak at a normal rate and rhythm or is speech slowed, rapid, or pressured? Is there any evidence of dysarthria or aphasia? Are the patient’s thoughts organized and logical or are the thinking processes concrete, vague, disjointed, loose, or disorganized? Does the patient ever think life is not worth living? Does the patient acknowledge any past or present suicidal, homicidal, or paranoid ideation? If suicidal or homicidal ideations are present, does the patient feel able to control these ideas?
Perceptions: Is there any evidence of acute or chronic perceptual disturbance, such as auditory, visual, gustatory, tactile, or olfactory hallucinations? If present, are these experiences culturally syntonic? Is the patient able to ignore or de-emphasize these experiences or are they central to or interfering with daily activity?
Insight, judgment, and impulse control: Does the patient demonstrate a good understanding of his or her illness and its treatment? Do the choices that the patient makes in this and other areas reflect his or her best long-term interests? What is the patient’s life-long pattern of decision making and do current decisions conform to that pattern?
Cognitive testing: Formal orientation to person, place, and time should be tested. Orientation to person seems the most obvious, but should include awareness of age, relationship to significant others, and other indicators of “personhood,” beyond the simple recognition of or response to a name.
Recent and remote memory: Memory is tested in the course of gathering a history, but should also be tested by giving specific memory tasks. Working memory can be tested by giving the patient a task (remembering three words) and then asking for the material to be recalled.
Attention: The ability to sustain attention is tested by nonautomatic, moderately demanding tests, such as spelling backward or serial subtraction. In assigning such tasks, information on a patient’s level of education is helpful, because this is not a test of knowledge. More simple tasks (serial 3s or even serial 1s) should be substituted if these are more reflective of the patient’s abilities.
Executive function: Executive function is the ability to plan, organize, and perform actions within a reasonable time frame, skills necessary for normal professional or social functioning. Dysfunctional behavior is marked by impulsivity, disorganization, or amotivation. Evidence of dysfunction can be elicited by examining a patient’s ability to function in real-life situations. More formal testing can include naming items in a category (animals, things that begin with letter D, etc.) within a minute or completion of a complex task. One such task is the “Marie Three Paper test,” in which the patient is given three pieces of paper and the instructions to return the largest to the examiner, throw the smallest on the ground, and place the middle one in his or her pocket or elsewhere. Abstractions also test executive function.
Instruments to aid in testing: Because deterioration can be expected in patients with HIV-associated dementia complex (HAD) and early signs of dysfunction can be subtle, it is useful to establish a baseline for each patient at the initial visit with more formal testing. The Internet offers literally millions of references to instruments that can be used as adjuncts to the psychiatric examination.*
The ideal instrument for neurocognitive testing in the clinical setting should be simple and within the purview of any examiner. Repeating such testing over time provides an invaluable monitor of cognitive change. An instrument that has proved useful in this population, although not specific to it, is clock drawing, which assesses planning and executive function. Advantages of this test are its simplicity, its lack of correlation with formal education, and the ease both of administration and of comparing repeated drawings over time. Difficulty in performing this test is linked to nonspecific cognitive dysfunction and slowing on electroencephalogram.2 Various strategies for scoring have been suggested.†
The Folstein-McHugh Mini-Mental Status Examination, which is commonly used in the assessment of mental state in medically ill patients, is insufficiently sensitive to HIV-related cognitive change. The HIV Dementia Scale was developed to focus specifically on the domains affected by HIV, including timed tasks that are more sensitive to executive dysfunction and cognitive slowing.3 However, one item, the antisaccadic eye movement task, which assesses attention, proved cumbersome to use and the test has been recalibrated without this item, with a score of 7.5 or less suggesting impairment.4 Trail Making A and B,‡ which are timed and structured versions of the “follow the dots” drawing enjoyed by children, have been used extensively with an HIV-infected population to quantify and track cognitive impairment. They are sensitive to the slowing and decline in executive function seen in the HIV-infected patient. Numerous instruments to assist in other diagnostic parameters have been developed, both those that can be filled out by the patient and those that require questioning by the examiner. Although originally designed for primary care,5 the General Health Questionnaire has stood the test of time, comes in versions ranging from 12 to 60 items, and examines the domains of somatization, anxiety, depression, and social function. It can be administered at baseline and repeated at intervals to monitor change in these domains. The Beck and Hamilton rating scales are well-known adjuncts to both diagnosis and follow-up. Instruments that have been developed to look more specifically at HIV-related distress and quality of life can be accessed through the previously cited websites.
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