The Psychiatric Assessment

THE PSYCHIATRIC ASSESSMENT

INTRODUCTION

Psychiatric disorders are frequently encountered in patients with movement disorders and often mask or exacerbate neurological complaints.

Conducting a psychiatric interview can be a daunting task for many physicians, who are accustomed to a more “hands-on” approach to the patient examination.

It is critical for every physician working with these patients to have the basic skills required to assess psychiatric symptoms in order to screen for and measure the severity of emotional distress.

The longitudinal monitoring of psychiatric problems will assist in the treatment of the underlying neurological condition.

THE PSYCHIATRIC INTERVIEW

The first step in any interview is to establish rapport and develop therapeutic alliance with the patient. This is achieved by a number of fundamental interventions:

Establish a comfortable environment with minimal distractions.

Display a receptive posture and face the patient.

Maintain eye contact.

Remain calm and avoid reaction.

Acknowledge and normalize (if appropriate) the patient’s concerns.

In most cases, it is helpful to begin the visit by first discussing the “medical” or neurological concerns. These are typically easier for patients to discuss before more sensitive emotional or behavioral topics are approached.

The transition from gathering a “medical” history to obtaining a psychiatric history should be undertaken carefully and with empathy in order to allow the patient to experience the interviewer’s genuine interest. An abrupt or hasty “review of symptoms” of psychiatric disorders will yield only superficial data. Several ways to make this transition include the following:

“It seems as if you have been struggling for some time with (medical condition); how does that make you feel?”

“How did you cope when you discovered you had (medical condition)?”

“Your quality of life seems to have been affected by the diagnosis of (medical condition). Can you tell me more about that?”

“It is normal for people with (medical condition) to experience (psychological symptom). Have you experienced anything like this?”

External factors, such as a family history of psychosocial burden, play an influential role in the development of psychiatric conditions.

Table 11.1 lists sample questions that may be asked during a psychiatric assessment.

Table 11.1
Sample Questions to Ask in the Psychiatric Assessment of a Patient With Parkinson’s Disease

• When was the onset of Parkinson’s disease (PD) symptoms? How was PD diagnosed?

• What type of motor symptoms developed, and how quickly did they progress?

• Which PD medications have been tried to date?

• Have there been any adverse medication side effects, such as hallucinations, psychosis, and/or impulse control difficulties?

• Are there frequent on–off fluctuations that trigger distress?

• How did the patient initially cope with the diagnosis?

• What is the level of acceptance of the diagnosis?

• What functional limitations have occurred as result of the motor symptoms?

• What is the current level of socialization?

• Are there any cognitive changes or concerns?

• How have family/occupational demands been affected by the symptoms?

• Are there feelings of being a burden to the family?

• Has the patient had any thoughts of not wanting to live? Suicidal thoughts?

• Is there a history of psychiatric difficulties before the diagnosis of PD?

• Has the patient ever received formal psychiatric care or treatment?

• What are the patient’s goals regarding treatment?

• Is the patient optimistic about his or her future?

MENTAL STATUS EXAMINATION

The Mental Status Examination (MSE) is a comprehensive evaluation of the patient’s current state of psychiatric functioning, based on the examiner’s observations and responses directly elicited from the patient.

Documenting a thorough and descriptive MSE is important in accurately capturing a patient’s current mental state, which will assist not only in the diagnosis and management of the underlying psychiatric condition but also in the longitudinal monitoring of a patient’s stability.

The components of the MSE are listed in Table 11.2.

Table 11.2
Components of a Mental Status Examination

Domain	Description/Examples
Orientation	Intact, disoriented, confused
Attention	Alert, engaged, awake, drowsy, lethargic, sedated, sleepy
Appearance	Well nourished, well groomed, well dressed, unkempt, malodorous, obese, tired, cachectic, pale
Behavior	Gentle, confrontational, hostile, combative, passive, apathetic, restless, relaxed, casual
Attitude	Agreeable, pleasant, cooperative, difficult, threatening, suspicious, shy, resigned, assertive, stubborn
Speech	Appropriate rate and tone, underproductive, spontaneous, rapid, slow, overly inclusive, slurred, rambling, soft, incoherent
Mood	Usually taken directly from the patient’s report (“depressed,” “anxious,” “irritated,” “angry,” “good”)
Affect	Usually derived from the examiner’s observations (mood-congruent, mood-incongruent, restricted, blunted, flat, labile, intense, bright, serious, animated, aloof, worried)
Thought process/form	Linear, goal-directed, ruminative, circumstantial, loose, tangential, disorganized
Thought content	Paranoid, delusional, grandiose, nihilistic, somatically preoccupied, religiously preoccupied, magical thinking
Suicidality and homicidality	Presence of any suicidal/ homicidal thinking, intent, and/or plan
Insight and judgment	Intact, limited, good, fair, appropriate, impaired
Memory	Status of remote memory, recent memory, and immediate memory
Fund of knowledge	Appropriate, above average, below average, developmentally appropriate
Impulse control	Intact, poor, unpredictable