JIT K A HÜ T T LOVÁ
DE PARTME NT OF PS YCH IATRY ,
U NIV E RS ITY H O S PITAL B RNO AND FACU LTY O F
ME DICINE OF MAS ARYK U NIV E RS ITY.
Psychiatric Assessment
Psychiatric Assessment
Primary aims
 to make a differential diagnosis
 to formulate a treatment plan
Main method
 an interview with the patient
 how the patient thinks and feels
Three sources of information
 Subjective feelings
 think, feel, perseive…
 what the patient says
 Behaviour and nonverbal communication
 express themselves, speak, gesticulation…
 how the patient says it
 Objective information
 family, friends…
Settings and techniques I
 Place
 choose a quiet, private place
 free from outside distractions
 Duration
 it takes approximately one hour
 Language
 try to use natural, commonly understood language
 avoid jargon and technical terms
Settings and techniques II
 Interviewing style
 provide a pleasant atmosphere
 help the patient to tell you what is wrong
 Empathy
 very important quality in psychiatric interviewing
 putting oneself in another´s place and experiencing
his/her state of mind, so as to understand how she/he
feels, thinks and behaves
Settings and techniques III
 Helpful interventions
 Repetition
 Restatement
 Summarization
 Clarification
 Asking for example
 Support
 NOT
 moralize, judge, advice
Settings and techniques IV
 Open-ended questions - as often as possible especially
at the beginning
X
 Closed-ended questions - targeted questions for
psychopatology
 Good questions often begin: who, what, when, how
much, how many
 Less useful questions: why
 they tend to provoke defensiveness
Phases of the Interview I
 1. Opening
 2. Middle
 3. Closing
 1. Opening phase
 the interviewer and patient are introduced (shake hand, introduce
yourself, invite patient to sit down)
 purposes and procedures of the interview are set
 Typical opening questions:
 “What brings you to see me/to the hospital today?“
 “How did you come to be in the hospital right now?”
 “What sort of trouble have you been having?“
 “Tell me about the problem that bring you here.“
Phases of the Interview II
 2. Middle phase
 the main part of the interview, we gain all the information we
need to determine a diagnosis
 3. Closing phase
 summarize the most important problem
 interviewer shares his/her conclusion with the patient and
makes treatment recommendations
 allow the patient to correct or add to the salient facts as
understood by the interviewer
Step by step
1.
Identifying
data
3.
Psychiatric
history
4.
Mental status
examination
2.
Chief
complaint
Step by step
1.
Identifying
data
3.
Psychiatric
history
4.
Mental status
examination
2.
Chief
complaint
1. Identifying data
 Name
 Age/date of birth
 Birth certificate number
 Marital status
 Occupation
 Place of residence
Step by step
1.
Identifying
data
3.
Psychiatric
history
4.
Mental status
examination
2.
Chief
complaint
2. Chief Complaint
 „What brings you to see me today?“
 use quotation marks
 use the language of the patient
Step by step
1.
Identifying
data
3.
Psychiatric
history
4.
Mental status
examination
2.
Chief
complaint
3.Psychiatric History
 I. PAST MEDICAL HISTORY
 II. FAMILY HISTORY
 III. PAST PSYCHIATRIC HISTORY
 IV. PERSONAL HISTORY
 V. HISTORY OF THE PRESENT ILLNESS
3.Psychiatric History
 I. PAST MEDICAL HISTORY
 patient’s general health status
 current medical illnesses and treatment
 major past ilnessess and treatment
 medical hospitalizations
 surgical history
3.Psychiatric History
 II. FAMILY HISTORY
 family history of mental illness
 dates and causes of death and other important
chronic illnesses of family members
 III. PAST PSYCHIATRIC HISTORY
 all previous episodes and symptoms
 previous treatment and response
 previous hospitalization
3.Psychiatric History
 IV. PERSONAL HISTORY
 Infancy
 birth history, developmental milestones
 Childhood
 pre-school years, school, academic performance
 Adolescence
 onset of puberty, early sexual experiance, peer
relationship
 Adulthood
 education, employement, social life, sexual history,
marriage, children
3.Psychiatric History
 V. HISTORY OF THE PRESENT ILLNESS
 onset of the problem (the approximate time since the
patient was last at his/her baseline level of
functioning)
 duration and course
 psychiatric symptoms
 severity of problem
 possible precipitants
Step by step
1.
Identifying
data
3.
Psychiatric
history
4.
Mental status
examination
2.
Chief
complaint
4.Mental status examination (MSE)
 the task is to explore and describe all areas of
psyche
 explicit description (no jargon)
4.Mental status examination (MSE)
 I. Appearance (observed)
 II. Behavior (observed)
 III. Attitude (observed)
 IV. Level of Consciousness (observed)
 V. Orientation (inquired)
 VI. Speech and Language (observed)
 VII. Mood (inquired)
 VIII. Affect (observed)
 IX. Thought Process/Form (observed/inquired)
 X. Thought Content (observed/inquired)
 XII. Perception (observed/inquired)
 XII. Suicidality and Homicidality (inquired)
 XIII. Insight and Judgment (observed/inquired)
 XIV. Attention Span (observed/inquired)
 XV. Memory (observed/inquired)
 XVI. Intellectual Functioning (observed/inquired)
4.Mental status examination (MSE)
 I. Appearance
 e.g. gait, posture, clothes, grooming…
 II. Behavior
 e.g. mannerisms, gestures, psychomotor activity, eye
contact…
 III. Attitude
 e.g. cooperative, hostile, open, suspicious, apathetic,
easily distracted, defensive…
 IV. Level of Consciousness
 e.g. igilant, alert, drowsy, lethargic, comatose, confused…
4.Mental status examination (MSE)
 V. Orientation
 to person -place -time -situation
 VI. Speech and Language
 quantity -rate -volume -fluency and rhythm
 VII. Mood
 a sustained state of inner feeling
 VIII. Affect
 an observed expression of inner feeling
4.Mental status examination (MSE)
 IX. Thought Process/Form
 the way ideas are linked
 X. Thought Content
 f.e. delusions, thought insertion/withdrawal, obsessions…
 XI. Perception
 illusions and hallucinations
 XII. Suicidality and Homicidality
 XIII. Insight and Judgment
 knows something is wrong, that he/she is ill, that illness is
psychiatric
4.Mental status examination (MSE)
 XIV. Attention Span
 attend –concentration -distractibility
 XV. Memory
 recent -remote -immediate memory
 XVI. Intellectual Functioning
 information –vocabulary -abstraction
Step by step
1.
Identifying
data
3.
Psychiatric
history
4.
Mental status
examination
2.
Chief
complaint
Specific situations
 Suicidal patient
 Agressive patient
Suicidal patient
 common cause of emergent psychiatric consultations
 the psychiatrist needs to ask about suicidality
directly
 Don´t be afraid to ask!
 Example of questions:
 “Do you ever feel that life isn’t worth living? Or that you would
just as soon be dead?”
 “Have you ever thought of doing away with yourself? If so,
how?”
 “What would happen after you were dead?”
Suicidal patient
 Suicidal course
 Suicidal Ideation – How frequent are the thoughts of killing
themselves? How long have they been present? Are they
changing in intensity or frequency?
 Suicidal Plan – Do they have a specific plan to end their life?
Is it realistic? Is it lethal? Are they likely to be rescued in the
attempt?
 Suicidal Intent – Do they want to die? Do they feel it is
inevitable that they will die?
 Preparation and Rehearsal for Suicide – Have they
obtained lethal means? Have they practiced the suicide attempt?
 Suicide Attempts – Have they ever tried to kill themselves in
the past? Do they have family or friends who have committed
suicide?
Suicidal patient
 Static risk factors for suicide
 Male Sex
 Age – young adults, older people
 Race – higher in White and Native Americans than in Black
and Hispanic Americans
 Family history of suicide
 Prior Suicide Attempts
 Being Single
 Dynamic risk factors for suicide
 Untreated mental illness.
 Emotional turmoil
 Expressed suicidality
 Access to weapons and other lethal means.
Suicidal patient
 Warning signs
 hopelessness, rage, anger, acting recklessly, feeling
trapped, increasing alcohol or drug use, withdrawal from
friends, anxiety, agitation, altered sleep, dramatic
changes in mood, and seeing no reason for living, direct
threats to harm themselves, searching for, means to kill
themselves, and writing or talking about death and dying.
Suicidal patient
 High–risk person
 Male, white, age greater than 65 years
 Widowed or divorced
 Living alone; no children under the age of 18 in the
household
 Presence of stressful life events
 Access to firearms
Suicidal patient
 Protective factors
 Effective clinical care for mental, physical, and substance
abuse disorders
 Easy access to a variety of clinical interventions and
support for help seeking
 Family and community support (connectedness)
 Support from ongoing medical and mental health care
relationships
 Skills in problem solving, conflict resolution, and
nonviolent ways of handling disputes
 Cultural and religious beliefs that discourage suicide and
support instincts for self-preservation
Aggressive patient
 Don´t stay alone with your patient in the room without
chance to call for help
 Always sit close to the door with the possibility to escape
 Remove dangerous objects from examination room/from
patien´t access
 Don´t turn your back to the patient
 Keep the safe distance (more then 1 meter)
 End up the interview if needed
 In case of danger – try to get a time, move to safer place,
call for help, inform the Police if needed
References
 Tasman A. et.al.: The Psychiatric Interview, Evaluation
and Diagnosis, 2013
 Waldinger R.J.: Psychiatry for Medical Students, 1997
 Tomb D.A.: Psychiatry for the House Offices, 1995
 Diagnostika a terapie duševních poruch, Dušek et al.,
2010
 Psychiatrie, Höschl et al., 2004
 Psychiatrická propedeutika, prof. Kašpárek
(hypertextová učebnice)
http://portal.med.muni.cz/clanek-509-psychiatricka-
propedeutika.html
Thank you very much for your
attention