section name header

Information

Editors

TanjaLaukkala

Psychiatric Evaluation of an Adult

Essentials

  • The principal task is to form an impression of the patient's current
    • sense of reality (to differentiate between a psychotic and delirious patient)
    • mood (normal, mild/moderate/severe depression v. hypomania/mania) and emotional responses
    • self-destructive behaviour (in a depressed patient) in order to assess the need for treatment and its urgency
    • cognitive functioning, perception, concentration as well as the capacity for abstract reasoning.

Conduct of a psychiatric interview

  • A sufficient amount of time must be reserved for the interview as well as a quiet area, away from distractions. If the first meeting with the patient takes place in a busy emergency setting, a longer appointment time must be arranged at a later date so that the patient's overall situation can be evaluated.
  • Open questions can be used at the beginning of the interview, or the patient can be asked at the end of the interview whether any important, related matters have not yet been discussed. At the same time, it should be noted how the patient talks about himself/herself and his/her relationships with others, how he/she expresses emotions, observes causal relationships and what is left unsaid.
  • More questioning is used to establish
    • the reason for the evaluation
    • how the symptom/s started
    • the duration of symptoms
    • the effect of symptoms on functional capacity
    • factors that aggravate/relieve symptoms
    • factors that precipitate symptoms
    • previous symptomatic treatment and the benefit gained.
  • Relevant background data include
    • the age, sex, marital status and occupation of the patient
    • the source of information (patient/other source)
    • psychiatric family history
    • personal history
    • exposure to traumatic experiences
    • chronological order of the treatment-seeking process
    • cognitive capacity (schooling, studying, possible specific cognitive deficits)
  • The following should also be charted: past psychiatric and treatment history, past medical history, current medication or other treatment and the patient's functional capacity at work and everyday life.
  • History of substance abuse should be obtained from all patients
  • Psychiatric evaluation can be considered a therapeutic process.
    • A physical and neurological examination should always be carried out if a physical condition is suspected to be the cause of the psychiatric symptoms.
    • The history and current status are used to decide the need for laboratory tests and imaging studies.
  • Physical diseases in a person with psychiatric problems are often not adequately treated.

Psychiatric clinical assessment

  • As regards mental health disorders the important points to be noted in a clinical assessment are:
    • appearance and general behaviour
    • attitude towards the examination and treatment
    • motor activity and movements
    • mood and affect
    • thought processes and speech
    • sensory functions
    • orientation
    • memory
    • general knowledge
    • numeracy skills
    • reading and writing skills
    • visuospatial perception
    • concentration
    • abstract reasoning
    • judgement, insight to the current situation and motivation towards treatment.
  • The aim of the assessment, especially in an emergency situation, is to make a preliminary diagnostic judgement, to exclude disorders and diseases of differential diagnostic significance, to draw a treatment plan and to start treatment.

Charting of psychotic symptoms

  • The following should be observed: the patient's external appearance, motor activity and movements, thought processes and speech, sensory functions, orientation and memory. Is the patient calm, behaving appropriately and keen to cooperate or is he/she agitated and exhibits motor restlessness? The evaluation must take place in a setting that is safe for all concerned.
  • Are the patient's responses and actions, or other observations made during the interview, suggestive that the patient is experiencing hallucinations or delusions? With the patient's consent, significant collateral information may sometimes be obtained from close relatives. Do the patient's speech and its content correspond with his/her non-verbal communication? Mood and affect should also be noted.
  • More detailed analysis of psychotic symptoms is carried out in specialist medical care to where the patient must be referred. The patient's insight to the condition and motivation to treatment play a role in treatment planning.

What to note if a personality disorder is suspected

  • At first, the current complaint that led to the appointment should be addressed.
  • A personality disorder is suggested by repetitive and inflexible behavioural patterns that are injurious to the individual as well as to others and prove difficult to alter.
  • There is rarely any hurry to make a final diagnosis, but particular attention should be paid to building a successful therapeutic relationship in order to gain the patient's trust; many of these patients have repeatedly been disappointed in the past, including with healthcare providers.
  • See Borderline Personality Disorder Antisocial Personality Disorder.

Evaluating depressive symptoms

Evaluating symptoms of anxiety

  • When and how did the anxiety symptoms begin? Are there factors that alleviate or precipitate symptoms? Have similar anxiety symptoms occurred before in other situations?
  • Are the symptoms episodic or continuous? Are anxiety symptoms associated with avoidance behaviour? Are anxiety symptoms associated with other mental symptoms, and if so which symptoms were the first to emerge?
  • What impact do the symptoms have on functionality? Simple phobia, for example, rarely requires treatment, but the patient's occupation may significantly contribute towards the problem.
  • See Anxiety Disorder.

Evaluation of a patient with substance abuse

Evaluation of gambling problems

  • Gambling problems may be screened using the Lie/Bet questionnaire, which contains two questions: 1) Have you ever had to lie to people important to you about howmuch you gambled?; 2) Have you ever felt the need to bet more and more money? A positive answer to one or both questions warrants further assessment of gambling problems.

Evaluation of eating disorders

  • Eating disorders are more common in women than in men. In addition to anorexia nervosa and bulimia, nonspecific clinical pictures are recognised.
  • The patient should not only be asked about eating habits, but it should also be ascertained whether eating, body weight/size and its management has become a disproportionate, obsessive and dominating feature in the patient's life.
  • A physical examination including height and weight measurements is always warranted in a patient with an eating disorder. If the patient gives a history of vomiting, an examination by a dentist is also indicated.
  • See Eating Disorders Among Children and Adolescents.

Evaluation of non-organic sleep disorders

  • In insomnia, the patient should be asked to explain what he/she means by insomnia; does he/she have difficulties falling asleep or does the patient wake up in the middle of the night, how many hours does the patient sleep a night and does he/she need to sleep during the day. Does the patient feel refreshed upon awakening? Use of a sleep diary is recommended. The level of negative impact of insomnia can be assessed by Insomnia Severity Index (ISI) http://mapi-trust.org/questionnaires/isi/.
  • Does the patient snore, suffer from restless legs or is there anything else suggestive of an organic cause? Does the patient use any medication that may influence the quality of sleep? Has the patient tried to treat the sleep disorder with melatonin?
  • The use of stimulants (caffeine, alcohol) should be established . Does the patient smoke?
  • How have sleep disturbances been treated in the past and was the treatment effective?
  • See Insomnia.