Chapter 2: Psychiatric patient assessment

Learning objectives
 Upon finishing this unit, students will be able
to:
Explain the interview technique in psychiatry.

Describe the components of psychiatric

assessment.

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 Introduction
 Psychiatric History
Not very different from history in general medical
practice.
More emphasis given to this part as there are few
special investigations to reach at the diagnosis.
It may sometimes be difficult to obtain adequate
history from the patient.
 Collateral history (Corroboration).

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  Interview technique
 Interview room …..provides privacy & no
interruption.
 Seats ….arranged diagonally and of equal level.
 Both the health professional and the patient
should have access to exit.
 Length of the interview is usually 30min to one
hour (average 50min).

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 Con’d…
 Welcome the pt. in a calmly and politely
 Introduce yourselves by name and call patient by
name.
 Explain in a simple language: the purpose of the
interview & level of confidentiality s/he can expect.
 Begin with open ended questions.
 Let the pt. speak about the problems for the first
few minutes without interrupting.
 Observe the patient’s behavior.

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 Con’d…
 Ask specific close-ended questions later.
 Don’t impose your own moral values, beliefs etc.
regarding substance, suicide, sex.
 Ask the pt. if s/he has something to say before
wrapping up the interview.
 Explain in plain language the clinical problem &
treatment plan.

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 Important interview skills
 Maintaining good eye
contact with the patient.
 Adopting a relaxed posture.
 Using facilitator utterances
and gestures.
 Detecting verbal and non
verbal cues
AVOID:
 Premature false reassurance
of the patient.
 Normalizing the patient’s
experience.
 Impatience during the
interview.
 Appearing inattentive to
your patient during the
interview
 Components of Psychiatric patient
Assessment
A. Psychiatric history taking.

B. Mental state Examination

C. Physical Examination

D. Case Summary

E. DSM-V Diagnosis

F. Investigations

G. Management( including formulation)

H. Prognosis/suicide risk assessment

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 A. Psychiatric history taking
1) IDENTIFICATION
 Previous psychiatric
 Name, age, sex
admissions
 Address, ethinicty,  Living circumstance
 Religion,  Who brought the patient

 Status(education,occupa  Source of history

tion,marital),language,  Source of referral and

reasons for referral
 Reliability
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 2) Chief Complaints:- the main reason for visiting.
 Should be noted in the patient’s own words
 Examples: “I am thinking to kill myself”
“I am not sick”
 Write the duration of the Chief Complaint.

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 3) HPI:- elaborate the C/C in terms of;
 time of onset, mode of onset(course), aggravating
and alleviating factors.
 effect of illness(impact) on work, relationship,
academic life, etc.
 Mood(low or high) condition.
 Excessive worry/history of trauma

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  Psychosis(delusions or hallucinations)
 Use of psychoactive substances(Alcohol, khat,..)
 Look for any Suicidal or Homicidal ideas!!!
 Any treatments sought and the effect of such
treatment on the symptoms.

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 4) Past Psychiatric History
Psychiatric admissions, treatments, suicidal
attempts, aggression, substance abuse.
5) Past medical/surgical History
Major medical and surgical illnesses,
Medications allergies

6) Family History
Mental illness, Substance use, suicide, epilepsy,
aggression etc.
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 7) Personal History
 Helps to understand the patient as a person.
 It is usually divided into:
7.1) Peri-natal.
7.2) Infancy & Early childhood.
7.3) Middle childhood.
7.4) Puberty & Adolescence.
7.5) Adulthood.

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 7.1) Perinatal
 Was the child wanted?
 Pregnancy and delivery
 Maternal emotional and physical state at the time of
the patient's birth.
 Maternal alcohol or substance abuse during her
pregnancy.
 Maternal trauma during pregnancy

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 7.2) Early Childhood
– Infant and mother relationship
– Problems with feeding and sleep
– Significant milestones
Standing/walking
First words/two-word sentences
Bowel and bladder control
– Unusual behaviors (e.g., head-banging)

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 7.3) Middle Childhood:
 Discipline & punishments
 Early school experiences
Tolerance to separation
Earliest friendships
Aggression, phobias, bed-wetting, etc.
 Major illnesses

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 7.4) Puberty & Adolescence:
– Age of menarche, the circumstance of its onset,
and preparations (females),
– Growth of pubic and axillary hair (males)
– Early experiences in dating, first sexual
experiences, and any confusion or discomfort
about sexual orientation.
– Experimentation with drugs (alcohol, illicit
drugs…)

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 7.5) Adulthood:
 Interference of psychiatric illness with the
capacity for sustained productive work.

 What patients do with their free time.

 Financial status and living arrangements.

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 8) Pre-morbid personality (traits)
How do you describe yourselves as a person?
How do you think others describe you as a
person?
 Military History: behavior problems, premature
discharge, etc.
 Forensic History: legal difficulties, imprisonment

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 B. Mental state examination
 Analogous to physical examination in physical
medicine.
General Description
 Appearance: the pt’s appearance & overall physical
impression as reflected by posture, gait, clothing, eye
contact,etc
 Behavior & Psychomotor Activity: quantitative &
qualitative aspects of pt’s motor behavior. Agitation,
rigidity, echopraxia, hyperactivity, hypoactivity…etc.
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  Attitude: pt’s attitude towards the examiner can
be described as cooperative, hostile, indifferent,
evasive, suspicious, friendly, over familiar,etc.

 Mood:- pervasive and sustained emotional state as

described by the patient (Subjective)
 Mood is recorded in verbatim “I feel cheerful”, “I
am feeling anxious”, “I feel good/ normal”

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 Affect:- the pt’s present emotional state as inferred
from the pt’s facial expression.
 Intensity & range: normal, constricted, blunted, or
flat.
 Quality: smiling, anxious, tearful, apathetic, angry,
etc.
 Stability: stable, labile
 Appropriateness:- assessed in the context of the
subject the patient is discussing

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  Speech: describes the physical production of
speech, not the ideas being conveyed.
 Quantity: scanty, talkative, copious, mute
 Rate: rapid, slow, pressured, hesitant, normal rate
 Spontaneity: spontaneous Vs. non-spontaneous
 Volume: low, high/ loud.
 Quality: prosodic, monotonous, slurred, stuttering
etc.

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 Thought
 Thought form(process) refers to the way in
which ideas are linked, not the ideas themselves.
 Normally thoughts are logically associated and
goal directed.
 Examples: flight of ideas, clang association,
tangentiality, circumstantiality, neologisms.

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  Thought Content refers to what a person is actually
thinking about: ideas, beliefs, preoccupations,
obsessions , suicidality , homicidality
 Perception:-

abnormalities in the various modalities of sensations

through sense organs.
E.g. hallucinations, illusions, etc.

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  Cognitive Functions
 Alertness: describes the degree of wakefulness.
 Alert, somnolence, lethargy, stupor, coma.

 Orientation: is conventionally described in three

spheres: time, place, and person.

 Concentration: describes the ability to sustain

attention over time.
 Formal assessment: serial 7s; reciting months of the
year backwards; spell “WORLD” backwards

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  Memory:
 the ability to register, store and retrieve
information.
 Immediate/ registration: repeat random
numbers after the examiner e.g. 5, 3, 7, 1, 4 (also
called digit span)
 Recent: the ability to remember information
registered after five minutes.
 Remote: Asking place of birth, date of birth…

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  Fund of knowledge: Questions about current
events, key geographical facts (Do you know any
lake/mountain in Ethiopia?) can be used.

 Abstract reasoning: describes the ability to

mentally shift back and forth between general
concepts and specific examples.
E.g. Proverbs, similarities (Orange and Mango), etc.

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  Insight: Patient’s degree of awareness
/understanding about being mentally ill.

 Judgment: ability to make rational decisions,

understand consequences of one’s behavior.
C. Physical examination
 Vital signs
 Complete physical examination for inpatients and
patients with medical complaints.

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 D. Case summary
• State all important findings in short.(one paragraph).
• Summery of important points mainly from ID, HPI
and MSE.
• Help the audience to remember all important findings.
• Facilitate diagnosis and treatment.
E. DSM-V Diagnosis
 Clinical diagnoses
 Differential diagnoses
 Biopsychosocial formulation.

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 F. Investigations –
E.g. baseline investigations like TFT,CBC,LFT,RFT
etc…
G. Management-
E.g. admission, psychotherapy, drugs
H. Prognosis/Suicide risk assessment

 Suicide is the act of self destruction

 Most mental illness result in suicide.
 Assessment of suicide risk can be carried out
through an acronym SAD PERSONS Scale.

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 The score is calculated from ten yes/no questions, with
one point for each affirmative answer:

S: Male sex R: Rational thinking loss

A: Older age S: Social supports lacking
D: Depression O: Organized plan
P: Previous attempt N: No spouse
E: Ethanol abuse S: Sickness
  This score is then mapped onto a risk assessment
scale as follows:
 ≥ 7- Hospitalize (forced)
 5-6 - Strongly consider hospitalization
 3-4 - Close follow up, consider hospitalization
 0-2 - Consider sending him / her home with family.

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  Homicide
 It is killing of others
 The patient intention of homicide should be
assessed.
 Patients at high risk of homicide includes those
who have;
 Delusion of persecution
 Antisocial personality disorder
 Substance related disorder

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 Chapter 3: Psychopathology
Learning objectives
After completing this session, students will be able
to:
 Describe general symptoms of mental disorders.

 Describe signs and symptoms in speech, mood,

thinking, perception, memory and motor disorders.

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 Common Signs/Symptoms of Psychiatric
illness(psychopathology)

 Psychopathology:- is defined as the study of the

abnormal state of mind.
 Phenomenological psychopathology:- is concerned
with an objective description of abnormal states of
mind.

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  Disorders of perception
 Perception is the process of becoming aware of
one’s environment through the sense organs.

 Extra sensory perception are forms of perception

that are not dependent on the five primary senses
e.g. telepathy

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  Hallucination and illusions are the commonest
disorders of perception.

 Hallucination is Perceptions experienced in the

absence of an external stimulus to the
corresponding sense organ.

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  Types of hallucination
 According to sensory modalities;
A. Auditory hallucination hearing voices in the
absence of external stimuli.
B. Visual hallucination seeing things in the absence
of external stimuli.
C. Olfactory hallucination sense of smell in the
absence of external stimuli.

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 D. Gustatory hallucination perceive unusual taste
in the absence of external stimuli.
E.Tactile(somatic , haptic) hallucination may be
experienced as sensations of being pricked , touched,
or strangled
 According to complexity
1. Complex music , song , speeches
2. Simple whistle , noises

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  Auditory hallucination can be;
 Commanding
 Commenting
 Praising
 Derogatory
 Threatening
 Second person &/third person

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  Types of Visual hallucination;
1) Autoscopic Visual hallucination
 Seeing one’s own image projected infront
3) Extracampain Visual hallucination
 Seeing out of the field of vision
3) Liliputhian Visual hallucination(Micropsia)
 Seeing images of persons , animals or objects in
their dwarf form

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 4) Macropsia
 Seeing images of persons , animals or objects in their
huge form
 Macropsia & Micropsia are more common in a patient
with substance abuse.
 Hallucinations are not restricted to the mentally ill.
 A few of normal persons experience them, especially
 When they are tired and
 In transition from sleeping to waking state

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 – Hypnogogic hallucinations
» When going to sleep
– Hypnopompic hallucinations
» On awakening
 Both are normal and non-harmful
 Illusion is misinterpretation of the external stimuli
 It is most common in a patient with delusion.

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  Thought disorders include:

I. Stream of thought

II. Content of thought

III. Form of thought

 Thinking is the capacity to understand, process and
interpret information and understanding of a person
to himself or others

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 I. Disorders of stream of thought
 Pressure of thought:
 Ideas arise in an unusual variety and abundance and
 Pass through the mind rapidly.
 Poverty of thought:
 Few thoughts in the person’s mind that lack variety
and
 Move through the mind very slowly

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  Thought blocking:

 Abrupt and complete emptying of the mind.

 That leads to abrupt interruption of conversation

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 II. Disorder of Content of thought
 Delusion is a false belief which is firmly held
without adequate ground and contrary to
evidences
 Themes of delusion
1. Delusion of persecution
o False belief of being followed or persecuted by
other people
o Most common delusion

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 2. Delusion of grandeur
o A belief that one is great and has special gift of
power ,wealth , beauty ,brilliance , identity or love
3. Delusion of jealousy (infidelity)
o A belief that one’s sexual partner is unfaithful.
o Also called Othello’s syndrome

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 4. Delusion of reference
o A belief that one has been a topic of discussion
and everything happening in the environment
refers to him.
4. Delusion of sin , guilt or worthlessness
o A belief that one has committed unforgivable sin
and deserved death

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 6. Delusion of errotomania / sexual or amorous
delusion
o A belief that someone who is specially a
prominent public figure has fallen in love with the
subject
7. Religious delusion
o A belief that one is a prophet and has the mission
of preaching and saving the world

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 8. Delusion of hypochondriasis
o Are false beliefs about having an illness.
9. Delusion of nihilism /delusions of negation
o A belief that part of the person’s body is either non
existent or has stopped functioning
10. Delusion of poverty
o A belief that one is penniless(poor), stupid or ugly

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  Delusions about the possession of thought
 also called Kurt Schneider's first rank symptoms
1. Thought insertion
 A belief that ideas or thoughts from outside have
been put into the person’s mind forcefully

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 2. Thought withdrawal
 A belief that ideas or thoughts of a person have been
taken out of his/her mind.

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 3. Thought broadcasting
 A belief that thoughts of a person have been made
accessible to everyone through mass media.

4. Thought reading
 A belief that one’s mind is being read by others

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 5. Thought control
 Is a belief that personal actions, impulses, or
thoughts are controlled by an outside agency or
being a robot.
 The above 5 delusions are more common in
schizophrenia.

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 III. Disorders of form of thought
1. Flight of idea
 Thoughts and conversation move quickly from
one topic to another,
 One train of thought is not completed before the
next is taken up.
2. Clang association
 Speaking words that have similar sound

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 3. Loosening of association (Derailment):
 Lack of logical connection between train of
thoughts,
 Which is unexplainable by the process described
under flight of ideas,
 Person’s conversation becomes muddled and hard
to follow

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 4. Perseveration
 Repeating the same responses to consecutive
questions
5. Circumstantiality
 Over inclusion of unnecessary details in speech
 Goal of thinking is not completely lost

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6. Tangentiality:
 Patient always seems to get near to the matter in hand
but never reaches it.
 Goal of thinking is lost

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7. Word salad(Incoherence)
 Speaking a collection of words that do not make up a
statement. Example

“Birds are...trees green...then I said....now

the destroyer...this was a nice...almost....”

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 8. Verbigeration
 Meaningless and stereotyped repetition of words
or phrases.
 Common in schizophrenia

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  Disorders of speech
 Are seen in a broad range of psychiatric and
neurological disorders.
 They include stammering and stuttering, mutism,
talking past the point, neologisms and aphasia.
1. Stammering
 The normal flow of speech is interrupted by pauses
or by the repetition of fragments of the word.
 Grimacing and tic-like movements of the body are
often associated with stammer
 Occasionally occurs during the onset of acute
schizophrenia
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 2. Stuttering
 Talk with continued involuntary repetition of
sounds, especially initial consonants
 May only become noticeable when the person is
anxious for any reason.
3. Mutism
 Complete loss of speech
 May occur in hysteria , depression, schizophrenia
or organic brain disorders.

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 4. Talking past the point(Vorbeireden)
 The content of the patient’s replies to questions
shows that they understand what has been asked but
have responded by talking about an associated topic.

 For example, if asked ‘What is the colour of grass?’,

the patient may reply ‘White’, and if then asked
‘What is the colour of snow?’, they may reply
‘Green’.

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 5. Neologisms
 Usage of words or phrases invented by the person
himself or herself
6. Aphasia
 Inability to comprehend language

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  Disorders of mood
 Mood is sustained or subjective or internal feeling
that covers the person’s life
 Affect is emotional expression or the reflection of
feeling or mood
1. Depression: feeling miserable ,unhappy , sad ,
gloomy , pessimism , losing hope
2. Elation: cheerfulness , happiness , optimism

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 3. Euphoria: elation with feeling of omnipotence ,
over activity, talkativeness , laughing loudly ,over
sociability disinhibited behavior
4. Anxiety: Feeling of apprehension due to
anticipation of danger which may be internal or
external.
5. Fear: anxiety due to consciously recognized and
realistic danger
6. Lability: frequent change of emotion/Excessively
rapid and abrupt emotional change
7. Apathy: lack of interest , unresponsiveness ,
withdrawal

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 8. Anhedonia: failure to experience pleasure
9. Agitation: feeling of restlessness , failure to sit or
stand still , pacing the ground and wringing hands
10. Constricted: When the total normal variation of
emotion is reduced.
11. Blunting:a severe reduction in the intensity of
feeling
12. Flattening: absence of emotion or feeling
13. Incongruity or inappropriateness: emotional
reaction contrary to the situation

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  Disorders of motor behavior
 Motor behavior is the aspect of the psyche includes
motivation , drive , instinct , movement , posture
1. Tics
 Is an irregular repeated movement that involves
several muscles e.g. touching one’s hair , pricking
one’s nose ,cleaning the throat

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 2. Mannerism
 Regular and repeated movement that appears to
have functional significance e.g. saluting
3. Stereotypy
 Irregular and repeated movement that appears to
have no functional significance e.g. rocking to and
fro.
4. Negativism
 Doing the opposite of what a person is told to do
5. Rigidity
 Assumption of a position and resistance of moving the part.

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 6. Posturing
 Assumption of a bizarre posture and maintaining it
for long duration e.g. raising the head above the
pillow , standing on one leg
7. Echolalia
 Repetition of words or parts of sentences that are
spoken by others.
8. Cataplexy
 Temporary sudden loss of muscle tone, causing weakness
and immobilization

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 9. Ambitendence
 Having contradicting/opposing movements at the
same time
10. Catalepsy
 A condition in which persons maintain the body
position into which they are placed. Also called
waxy flexibility
11. Echopraxia
 Imitating movement of another person

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 Disorders of memory
 Normal memory is the result of registering or recording
in the unconscious mind and recalling into the
conscious part when one want
A. Amnesia is loss of memory, it can be;
– Immediate/ registration memory loss:
» The inability to register/remember
information
• Repeat random numbers (digit span)
• Sunday, apple, ship, love, brown

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 – Recent memory loss :
» Inability to remember information
registered after 5 min.
– Remote memory loss :
» The inability to remember things that
happen before 2 wk.
• Asking place of birth …

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  Amnesia can be anterograde or retrograde
 Anterograde amnesia
 Inability to learn new information
 Retrograde amnesia
 Inability to recall previously learned material
B. Paramnesias
 Abnormal memories / a condition involving
distorted memory.
I. Confabulation
 Filling the gap with lossed memory with invented
events

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 II. Dejavu
 Sense of familiarity with events , persons or places
which are nobel
III. Jamaisvu
 Sense of unfamiliarity with events that he/she has
long and close relationship

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  Disorders of cognition
 Usually results from abnormalities of the cortex
 Cognition includes motivation , orientation ,
attention , concentration , language and memory
I. Apraxia: failure to perform motor skills which the
person had been doing in the past e.g. agraphia ,
acalculia

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 II. Agnosia: failure to identify persons or objects
 Attention is the ability to focus on matters at hand
 Concentration is the ability to maintain a focus or
attention
 Distractibility is failure to sustain attention

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