Essentials of Psychiatric Assessment

Mohamed Ahmed Abd El-Hay

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351374408
• Edition: 1
• Topic: Psychology
• Subtopic: Forensic Psychology
• Index: Psychology

A psychiatric assessment is a structured clinical conversation, complemented by observation and mental state examination, and supplemented by a physical examination and the interview of family members when appropriate. After the initial interview, the clinician should be able to establish whether the individual has a mental health problem or not, the nature of the problem, and a plan for the most suitable treatment. Essentials of Psychiatric Assessment provides the resident or beginning psychiatrist with a complete road map to a thorough clinical evaluation.

1 Introduction

At the beginning of work with psychiatric patients, students and residents have already learned much about the process of medical evaluation. They know how to detect signs and symptoms of illness by taking history and performing a physical examination. They have also learned how to use a laboratory test and to appreciate the relevance of these findings to diagnosis and treatment. These skills are all necessary, though insufficient, in evaluating psychiatric patients.

Psychiatric assessment includes a structured clinical conversation, complemented by observation and mental state examination and supplemented by a physical examination and the interview of other informants when appropriate. After the initial interview, the clinician should be able to establish whether the individual has a mental health problem or not, the nature of the problem, and a plan for the most suitable treatment.

Many of the difficulties of learning to be a psychiatrist reside in the differences between mental and physical illnesses. The traditional educational approach in psychiatry encourages students to ignore or minimize these differences and to emphasize similarities between all illnesses. Though that approach is assuring to students, it can retard or inhibit their capacity to grasp issues that are critical for psychiatric evaluation and management. This requires the psychiatrist both to become more thorough and skillful in using traditional medical methods of evaluation and to develop new skills that are unlikely to be learned in the process of traditional medical evaluation. The psychiatrist must have the following skills:

1. Helping the patients to communicate their inner experience. Thoughts, feelings, and perceptions are private phenomena, and many patients are unwilling or unable to discuss them with the physician. One of the first skills that psychiatrists must master is how to ask questions about inner experiences that the patients can understand and answer.

2. How to obtain accurate descriptions of abnormal behavior from the patient and other observers.

3. How to make direct observations of the patient’s current behavior. Skills in detecting current behavioral aberrations are essential; in particular, patterns that appear during the process of evaluation.

4. Taking an extensive history that focuses on past behavior and experience.

5. Testing for disorders of perception, thought, and feelings.

6. Determining how behavioral and experiential difficulties may be related. Sometimes inner experience can be inferred by observing deviant patterns of behavior; e.g., patients who are withdrawn and tearful are likely to feel sad. The reverse is also true: behavior may be predicted by learning about inner experiences; e.g., patients with uncontrollable feelings of anger are at greater risk of behaving violently than those who do not experience these feelings.

7. Detecting inaccurate history: the accuracy with which a patient reports or reveals experience. It is usually difficult to understand why some patients would voluntarily or involuntarily seek to create or exaggerate symptoms.

8. Stress tolerance: working as a psychiatrist can at times be stressful. Sometimes the stresses are intense, such as a patient who unexpectedly becomes extremely agitated.

INFORMATION NECESSARY TO BE OBTAINED

The psychiatric interview should always have some structure or form; however, it may differ in the degree of structuring, running on a continuum from a poorly structured to a completely structured. The interviewer should always have a scenario for how the interview ideally will proceed, including the ration ale for when to speak and when to keep silent and a sense of what the goals of interaction are. The aims of data collection in general psychiatric evaluation are as follows:

1. To collect data sufficient to permit a case formulation, and to establish a psychiatric diagnosis.

2. To understand how the patient experiences his/her difficulties and inner world.

3. To understand what events in the patient’s life might have contributed to the current difficulties.

4. To build up an initial treatment plan, with special attention to immediate interventions that may be necessary to ensure the patient’s safety.

5. To revise the treatment plan considering follow-up findings if the evaluation is a reassessment of a patient in long-term treatment.

The information obtained from the patient varies according to the availability of time, purpose of assessment, seriousness or urgency of the problem presented by the patient, and site of evaluation. These factors should be considered when ascertaining that certain settings meet the patient’s needs to get a satisfactory evaluation of acceptable speed, safety, accuracy, and confidentiality. In ordinary situations, the following information is usually obtained:

1. Why the patient has requested or has been sent for evaluation at this particular time. Some outpatients are in urgent need for care and may come or are brought involuntarily to emergency rooms; others come to regular clinics, either voluntarily or involuntarily. Inpatients may be admitted voluntarily or involuntarily, or seen in medical or surgical wards. Patients may also be brought for forensic evaluation.

2. The sequence of events that precede and follow the patient’s complaints, and their seeking help. This information is referred to as “history of the present illness.” It is essentially a chronology of what has happened (or more precisely, how the patient has interacted with the environment, usually in a maladaptive manner) from the time just preceding the symptoms until the present.

3. The patient’s current living environment (social, vocational, financial, academic), with an emphasis on how it contributes to the patient’s symptomatology.

4. The patient’s current and past psychiatric and medical history and treatment. It is also convenient to consider the family health history (i.e., mental and physical health of the extended family) under this heading.

5. The patient’s personal history including childhood development, educational experiences, work and military experiences, and patterns of relating to others. The family relationship and family history of physical and mental disorders are also included here.

6. The predominant personality traits. This information helps to clarify how the patient’s difficulties had developed, and how the patient is with them.

Again, the type and amount of information to be obtained from the patient can be modified according to the time available for the interview. When time is available, detailed information is obtained about the patient’s present and past psychiatric and medical history, personal history, personality and mental state assessment. When time is limited, as in emergency settings, the evaluation should focus on essential information that is critical to management (see later).

A general evaluation usually takes about 45–90 minutes to complete; it depends on the complexity of the problem and the patient’s ability and willingness to work cooperatively with the psychiatrist. Data collected from the interview should be integrated with that gathered from other parts of the evaluation, such as history from collateral sources, review of medical records, a physical examination, and diagnostic tests (American Psychiatric Association, 2006). Sometimes, several meetings with the patient may be necessary to reach a final conclusion about the patient’s symptoms and best management plan. Circumstances often dictate that the assessment is not completed in a single interview and the interview time needs to be shortened or extended.

SITE OF THE CLINICAL EVALUATION

The scene of psychiatric evaluation is variable, and is a critical factor in the process of evaluation; evaluation of inpatients may extend for several hours, a matter that is not feasible in an outpatient setting.

Inpatient Settings

The nature of inpatient population determines the extent, time, and depth of inpatient evaluation, while the goals of the hospitalization and the role of the inpatient unit should be considered within the system of mental health service. For example, a general hospital psychiatric unit specializing in patients with combined medical and psychiatric illness will necessarily do a relatively rapid general medical evaluation of all admitted patients. The evaluation of stable, chronic general medical conditions in a long-stay setting for the chronically mentally ill might proceed at a slower pace than in a psychiatric– medical specialty unit in a general hospital.

When a patient is admitted by someone other than the treating psychiatrist, the reason for hospitalization should be carefully assessed and alternative treatment settings should be considered.

From the outset, inpatient evaluations should include consideration of dis charge planning. The assessment must recognize both patient variables and community resources that are pertinent to a possible management plan and identify the problems that may hinder an appropriate disposition. If the patient was referred to the hospital by another clinician, the inpatient evaluation should be viewed in part as a consultation to the referring source. Special attention is given to unresolved diagnostic issues requiring data collection in an inpatient setting.

Outpatient Settings

The intensity of psychiatric evaluation of outpatients usually differs from inpatient evaluation; because of less frequent interviews, less involvement of other mental health professionals, and less availability of immediate laboratory services and consultants from other specialties. In outpatient settings, the psychiatrist has less opportunity to directly observe the patient’s behavior or to execute necessary protective interventions. Hence, it is critical to continually assess outpatients during interview about their need for hospitalization and whether unresolved questions about the patient’s general medical status entail more rapid assessment. The patient’s current mental status and behavior is definitive in deciding to change the setting for continued evaluation (American Psychiatric Association, 2006).

Advantages of the outpatient setting include less financial cost, greater patient autonomy, and the potential for a longer longitudinal perspective on the patient’s symptoms. However, the lack of continuous direct observation of behavior limits the obtainable data on how the patient’s behavior appears to others. The involvement of family or significant others as collateral sources in the evaluation process deserves consideration. When substance use is suspected, data from collateral observers, drug screens, and/or determination of blood alcohol levels may be especially important.

Other Settings

Evaluations conducted in other settings, such as partial hospital setti...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• 1 Introduction
• 2 Signs and Symptoms in Psychiatry
• 3 The Psychiatric Interview
• 4 Special Considerations
• Bibliography
• Index