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Clinical assessment of a psychiatric patient

The assessment of a patient usually is done via an interview.

In most cases, this interview can be done with the patient. Sometimes (in case of in
psychotic patients, uncooperative, suspicious, severely depressed patients) we need to
interview the family members.

Interviewing technique:
1) Settings
• privacy should be ensured
• Chairs should be at the same level, arranged at an angle. Not sitting directly opposite
the patient
• Ensure you are seated closer to the door
• Always 2 persons from the team or personal alarm

2) How to start:
• Introduce yourself
• Ask them how they would like to be addressed
• Notes may be taken. Explain to the patient that you take notes.
• Ask the patient about himself- work, school, family, maritial status
• Ask about Problem that brought him to the clinic or hospital
• Try to find out why a patient may have difficulties to communicate: paranoid
delusions, emotional or social withdrawal, apathy, etc).

3) The chief complaint:


Possible answers from the patient when you ask for the chief complaint:
“I have been feeling very depressed (anxious)“. “I don’t know.. The family brought
me”. “I have problems at school, work..”
-> You should ask for more details: “What kind of problems, what kind of troubles?”
-> Ask as many questions as it is necessary to elicit the problem.
-> People have more than one complaint, some of which may be related.
-> Organize multiple complaints into groups of related symptoms.

The chief complaint is an important base for diagnosis and ddx! Examples:
a) Patient sees: images, people, small animals -> alcoholic, anxious, disoriented –
delirium?
b) Hears voices -> schizophrenia, psychotic mania, substance abuse etc.?
c) Low mood -> depression, etc.
d) Memory problems -> Neurodegenerative disorder, Vascular disorder etc.?

4) How to build up a diagnosis:


• Use criteria –ICD-10, DSM-IV, DSM-5
• Rule diagnostic possibilities out
• Symptoms - syndrome - diagnosis - DDx
• Onset, course, precipitant factors -> drugs, alcohol, life events
• Be persistent to accurately determine the answer to the question.

5) Rules for the interview:


- Let the patient talk freely enough to observe how tightly his or her thoughts
are connected
- Listen to thinking disorder or coherent speech
- Use a mixture of open and closed questions -> Closed questions limit the scope of
response to 1 or 2 answers.
- Open vs closed questions:

a) Open- ended questions:


- require more thought and more than a simple one-word answer and thus permit the
patient to ramble and become disorganized
- The answers could come in the form of a list, a few sentences or something longer
such as a speech, paragraph or essay.
- One of the main reasons to use open-ended questions is to obtain deep, meaningful,
and thoughtful answers. Asking questions in this way invites people to open up,
because you are showing that you are interested in what they have to say.
- Ask open-ended questions when you want detailed explanations to build off .
- Use open-ended questions to expand the conversation after asking a closed-ended
question -> Take the fact or one word answer, and build an entire conversation of
open-ended questions from there.
- When someone has finished talking, ask them an open-ended question that refers to
what they just said, or is related to what they just said -> This keeps the conversation
flowing in an open and engaging way.
- Don't use "Is there anything else?" This is a closed-ended question, and can result in
a simple "no" answer.
- Make sure to listen. Asking the right questions is pointless if you don't listen.
Sometimes we are guilty of formulating the next question without paying attention to
the answer to the first.
You miss great opportunities for follow up questions if you do this. Make an effort to
listen to the answer you asked for.
- Examples: What brings you to (see me/the hospital) today? How have you been
feeling lately? What has caused you to feel this way? What are you planning to do
today? How did you and your best friend meet? Why is it that every time I talk with
you, you seem irritated? Tell me about your day at work

b) Closed questions
- They are often referred to as convergent questions.
- Closed questions- can be answered by a simple "yes" or "no"
- Closed ended questions may be asked as a starter before planning to gather more
information
- Closed ended questions are asked to verify and confirm, usually eliciting only simple
and specific answers.
- Don't use closed-ended questions when you want meaningful answers. These
questions can bring a conversation to a screeching halt. One word answers make it
hard to build any kind of conversation or relationship.
- Closed-ended questions also usually provide inadequate answers as well.
- If you wish to narrow down a lengthy conversation and get down to a decision or
conclusion, ask more of closed ended questions.
- Examples: Are you feeling better today? Can I help you with that? Are you sad? Do
you have a pet? Do you like animals? When is your birthday? Do you feel low in
mood? What time do you wake up in the morning?

Ask questions about topics that seem to be embarrassing:


- Sexual relationships
- Sexual experiences
- Use of alcohol and drugs

Ask about suicidal thoughts


• Give the patient the chance to ask questions at the end
• Conclude the initial interview by conveying a sense of confidence

6) Components of a psychiatric interview and assessment:


Anamnesis, Past history, General medical history, Current medications, Family
history, Social history, Personal history, Mental status examination

a) Anamnesis:
- The complete history of present illness recalled and recounted by a patient.
- Identifying information (Name, Age, marital status, Occupation, Reason for the
patient’s presence in a psychiatric setting
- presenting complain: onset (acute vs chronic), duration, development, course,
severity, associated symptoms, precipitating factors)

b) Past psychiatric history:


• Previous or ongoing psychiatric disorders
• Dates and duration of previous mental illness episodes
• Previous treatments- medications, ECT, psychotherapy, outpatient or hospitalization

c) Past medical history:


Medical illnesses, Surgical procedures, Past head injury, Neurological conditions like
epilepsy, Endocrine abnormalities
d) Current medications:
Psychiatric, non-psychiatric, etc

e) Family history:
Presence of psychiatric illness, Suicide, Substance abuse, Significant physical
illnesses in the family, Quality of relationships in the family

f) Personal history:
- Infancy and early childhood
• Pregnancy, birth complications
• Developmental milestones
• Childhood illnesses
• Aggressive behavior

- Later childhood and adolescence


- History of Abuse- physical, sexual, emotional
- School record
- Relationships with parents, teachers, peers
- Behavioral problems, drug use

- Occupation
• Types and duration of jobs
• Reasons for unemployment or dismissal
- Relationships, marital, sexual history
- Social circumstances
- Accommodation, social support, financial circumstances, hobbies, leisure
activities
- Alcohol and substance use
Names, routes of administrations, frequency

g) Mental status examination


- Begins the moment you meet the patient.
- Describes the interviewer’s objective impression of many aspects of a patient’s
mental functioning at the moment of assessment.
- May fluctuate in the day or day by day.
- Things to look for:
- Patient’s appearance. Clothes (clear, appropriate or bizarre, accessories). Self
care and hygiene. Evidence of injury or selfharm (cuts to wrists or forearms)
- Behavior. Body language. Communication. Posture, movements, facial
expression, tone of voice, spontaneity of speech, state of relaxation
- Thinking
- Mood (emotions)
- Volition
- Intelligence
- Memory
- Consciousness