Psychiatric assessment

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7 Psychiatric assessment

Introduction

Psychiatry is the medical specialty that concerns itself with the diagnosis and management of mental illness. Medical students as well as lay people often feel confused about the distinction between psychiatry and other disciplines in which the prefix ‘psych’ appears, for example psychology and psychotherapy. The distinction is quite clear. Psychiatry is practised by medically qualified practitioners and concerns itself with diseases of the mind, just as gastroenterology is concerned with disease of the gut and cardiology with disease of the heart. The proper practice of psychiatry involves an understanding of the normal workings of the mind and human behaviour (the study of psychology) and a thorough knowledge of pathological manifestations of the mind and behaviours when there is disease of the mind or mental illness.

As in any medical specialty, the cornerstone of becoming a successful practitioner is mastery of how to take a detailed history and perform an examination of the mind, referred to as a mental state examination. It is also essential to perform a general physical examination. History taking follows a similar structure to that adopted in any branch of medicine with some additions and adaptations. The mental state examination is unique to psychiatry and involves learning a systematic way of observing and recording all aspects of how the patient behaves and appears in the consultation. The mental state records the clinical symptoms, signs and pieces of abnormal experience referred to as phenomena on which the diagnosis will rest. It is, therefore, crucial to properly understand how to perform a mental state examination and to be rigorous and systematic in recording abnormal phenomena which lead to a particular diagnosis. The process of history taking and examination should be seen as an exploration or piece of detective work during which pieces of evidence for the diagnosis are unearthed. Sometimes the evidence will be in the form of the patient’s narrative (i.e. a particular constellation of symptoms) or particular themes in his thinking. Sometimes it is the way the patient talks – for example, a patient’s speech can reveal thought disorder of the mind (a symptom of schizophrenia) – whereas at other times it may be the patient’s experience – for example, third-person auditory hallucinations are a hallmark of schizophrenia, whereas visual hallucinations are suggestive of an organic brain disorder.

Psychiatric diagnoses are syndromal diagnoses (i.e. they are based on clusters of symptoms). There are very few clinical signs in psychiatry. There are also no confirmatory investigations such as blood tests or X-rays for most functional mental illness. If, after taking a history and performing a mental state examination, the clinician suspects the patient has schizophrenia, he cannot confirm this in any way with a blood test or piece of imaging. His diagnosis rests solely on eliciting the typical cluster of symptoms of schizophrenia and observing abnormalities of behaviour, speech, thought and experience which are typically seen in the syndrome of schizophrenia. It is therefore clear that in psychiatry, the importance of meticulous history taking and mental state examination is paramount as he has nothing else upon which to base his diagnosis and therefore his management of the patient. It is also vital that the symptoms and phenomena are recorded accurately as, when reviewing a patient who has been ill for some while and whose illness may have evolved, it can be very important to the diagnosis to know which symptoms and abnormal mental experiences were present initially.

The main purpose of this chapter is to teach the skill of taking a psychiatric history and performing a mental state examination.

History taking

In addition to providing the cornerstone on which to make a diagnosis, the initial history taking is an important beginning of the development of a therapeutic rapport with the patient upon which effective management rests.

Possibly more than in other specialties, there are steps to be taken even before commencing the conversation with the patient. The first step is to consider the context of the interview and where it will take place. The second is to think about what background information is accessible.

Context of the interview

There are important factors which will tend to be different in different settings, for example outpatients, the emergency department, medical or psychiatric ward.

Patient factors

Is the patient aware of the referral? Is he expecting to see a psychiatrist? What does he think of seeing a psychiatrist? The assessment may be of a patient following an overdose, or who has been brought in by the police on a Mental Health Act section who has no wish to engage in a psychiatric assessment. A patient may have presented with what he thinks is a medical problem, and a psychiatic referral may not have been discussed with the patient. Clearly the approach to the interview in these situations will be very different compared to a patient voluntarily attending a psychiatric outpatient clinic. It will require skilful engagement of the patient in the assessment, and how successful this is will determine the depth of the history taking which is possible.

Factors in the physical environment

There must be a suitable interview room in terms of both safety and privacy and confidentiality issues.

Safety

The doctor should sit nearest the door and neither the patient nor any obstacles should block the doctor’s ability to exit. There should be an alarm buzzer and someone available to respond to the alarm. In the emergency department where patients have been brought to hospital in a disturbed state, other safety measures may also be needed, for example checking for weapons and having a security presence.

Privacy

The patient should be interviewed in a quiet private space where he is not likely to be overheard by other patients and staff.

Clearly there is a balance to be struck, and the need for police or security presence nearby will sometimes outweigh the privacy and confidentiality requirement.

Background information gathering

Previous medical and primary care notes, or information on the mental health record system, can provide valuable information. For example, in a patient with unexplained physical symptoms, a history of previous presentations with unexplained symptoms can point to a diagnosis of somatoform disorder. It is important to look out for a history of previous violent behaviour, as the best predictor of future violence is previous violence. It is vital that any violent behaviour is recorded accurately and prominently in the notes and electronic record systems. The other valuable source of information is talking to informants who know the patient well, for example family members. This requires the patient’s permission and so may take place after the interview. In the inpatient setting, however, it is appropriate to talk to other health professionals working with the patient prior to seeing him, for example his key nurse, physiotherapist or occupational therapist.

The psychiatric history

Introduction

Introduce yourself, shake hands and tell the patient clearly who you are, who has referred the patient to you, the purpose of the interview and how long it is likely to take. Obviously physical contact should be avoided with a patient who seems very fearful or likely to strike out. Sensitivity to the patient’s body language helps to judge the most appropriate way in which to greet him. It is worth asking patients if they were expecting to be seen and how they feel about this.

Confidentiality and note keeping

Inform patients that the conversation is confidential, but that information will be shared with other healthcare professionals as appropriate, for example a letter to the referrer and to the primary care physician.

Where patients object to information-sharing, be clear that some note keeping and communication are essential, but details of very sensitive issues can be avoided in the letters. However, the patient has to know that information cannot be withheld from others if it is likely to place him or others at risk.

Notes can be brief, but memorable and not intrusive to the flow of the interview. It is important sometimes to write some of the patient’s statements verbatim as this can provide evidence of the presence of certain phenomena when it comes to the mental state examination.

Interviewing a patient who does not speak English

A patient should always be offered an interpreter as he may feel more able and willing to discuss his feelings in their own language. Never use family members as an interpreter (except in emergencies where no alternative is available) as it raises confidentiality issues. Conducting an interview via an interpreter requires more time, and there are pitfalls. Sometimes the patient may feel suspicious of someone from his own community and may fear that the information will not remain confidential. It can occur that interpreters impose their own views and advice and the interviewer should be alert for this.

Interviewing technique

As with any patient, aim for an open, empathic and non-judgemental approach and maintain non-threatening eye contact as much as possible. Start with open questions, avoid loaded questions, encourage the patient to tell his story in his own words and follow the approaches for general history taking detailed in Chapter 1. Another way of questioning is to use a normalizing statement. This is employed when you are asking about symptoms or behaviours which the patient may find embarrassing or difficult to acknowledge. For example, you might say something like ‘Sometimes when people have been feeling very depressed or have been under great stress, they may have odd experiences which they cannot explain, for example they may hear or see things which are unusual – has anything like this happened to you?’ Further examples of these are provided in the appropriate sections. Finish with a summary of what you have understood and check with the patient if you have missed anything that he feels is important.

Structure of the psychiatric history

This section details all the areas of history taking which need to be covered in a full psychiatric history. There may be situations where, in the initial assessment, they cannot all be covered, usually because the patient is too disturbed to engage with the interview process or too disorganized in his thoughts to produce comprehensible information. In these situations, the omitted information can be gathered when the patient is somewhat better. Sometimes patients do not feel comfortable sharing all aspects of their personal background at a first meeting. The interviewer needs to be sensitive to this and check with the patient if he feels comfortable discussing a topic and negotiate this.

Order of sections

The order in which the sections of the history are covered is suggested in Box 7.1 and followed in the text. Conventionally, past medical and psychiatric history goes at the end. However, if it is impossible to complete the interview on a single occasion, it is more useful to have found out about previous psychiatric illness, current contact with mental health services, medication and important medical conditions than it is to know the patient’s father’s occupation or what jobs he has done.

It can be useful to present the information obtained as a life chart which illustrates, in adjacent columns, years, patient’s age, social history, family history, relationship/psychosexual history, medical history and psychiatric history as a way of illustrating possible predisposing factors, precipitating factors and maintaining factors in a patient’s illness.

Presenting complaint

Start by establishing the main problem for which the patient is seeking help. In psychiatry, there will be situations where the patient does not have any complaints and denies problems. In this situation, the details of the presentation and behaviour reported by others, and concerns of others, should be recorded in this section. If the patient is being formally held on any section of the Mental Health Act, this should be recorded. Sometimes a patient with somatoform disorder will deny any psychiatric illness, believing that his illness is physical. In this situation, record all physical symptoms and the patient’s current main health concerns.

History of presenting complaint

Obtain a detailed description of how symptoms began, enquiring about the relationship to any life events that might have precipitated their onset. Establishing if the symptoms are recent or longer-lasting helps to clarify if the current presentation is part of longstanding personality traits or due to the acute onset of psychiatric disorder. The severity and persistence of symptoms and their impact on function should be sought. In order to fulfil diagnostic criteria for a psychiatric disorder, symptoms will be persistent across different circumstances, and severe enough to have an impact on a patient’s function in his daily life. For example, with low mood, establish whether the low mood is a brief fluctuation or whether it has persisted for a period of time (The ICD 10 specifies 2 weeks of low mood for a diagnosis of depression), how reactive it is to circumstances (unreactive mood being generally indicative of greater severity of depression) and how much it affects the patient’s function (a big impact being an indicator of severity). The evolution of symptoms over time, any help sought or given and any treatment received should all be documented.

Patients may volunteer symptoms which may be associated with the presentation. If none are volunteered, a systematic enquiry is essential. For example, in a patient presenting with depression, enquire about other symptoms in the depressive syndrome (Box 7.2) such as concentration, memory, enjoyment and social withdrawal. Anxiety and depression frequently coexist and so either presentation should lead to systematic enquiry about symptoms of the other. Somatic and psychic symptoms of anxiety are outlined in Boxes 7.3 and 7.4.

Box 7.4 Psychic symptoms of anxiety

Feelings of anxiety

Inability to relax

Inability to concentrate

Worry/anxious rumination

Feeling of impending doom

Depersonalization

Biological symptoms are important in all mental disorders so enquiry should always be made about sleep and appetite. Particular note should be taken of any abrupt change to sleep pattern as this is more significant in diagnosis than a chronic sleep problem. Enquire about sleep onset. Delay in getting to sleep is described as initial insomnia, and initial insomnia of 1 or 2 hours or more is pathological. Enquire about wakening. Waking through the night and going back to sleep is a pattern sometimes seen in anxiety. Waking regularly in the early hours and being unable to get back to sleep is a pattern described as early morning wakening and indicative of depressive disorder. Sometimes patients have a shifted sleep phase so, although they do not sleep until late in the night, they will sleep until late in the morning, which is sometimes seen in schizophrenia. In acute confusional states, there may be excess daytime sleep and wakefulness at night. If there is a sleep problem, you should ask about sleep-related behaviours (e.g. bedtime routines, if children share the bed). Establish if sleep is refreshing. Chronic fatigue patients describe unrefreshing sleep and waking still tired, which is also seen in anxiety patients.

Ask if the patient’s appetite has changed. In typical depression, appetite is lost, but in atypical depression, there may be an increase in appetite and craving of carbohydrate-rich foods. Some patients without depression will describe eating to cope with brief episodes of low mood or upsetting events. Ask if the patient’s weight has changed. Significant weight loss (more than 5%) in a depressed patient indicates moderate to severe depression. Weight increase can indicate a major problem of mood-related eating or bulimia. Very low weight may indicate anorexia. Cycling of weight gain and loss can occur in eating disorders. It is also very important to enquire into changes in weight in relation to starting psychotropic medication. Many psychotropic medications (e.g. antidepressants, antipsychotics and anticonvulsants) tend to cause weight gain which should not be ignored, and consideration should be given to stopping the relevant drugs.

History of psychiatric disorder

Enquiry should be made about the lifelong history of mental health problems. The questions need to be asked in terms the patient will understand. For example, you could ask ‘Have you ever had any problems with your nerves or mental health in the past?’ or ‘Have you ever suffered with depression, anxiety or had any kind of mental breakdown?’ Ask about previous contact with mental health, counselling or psychology services. In women who have had children, enquire as to whether they experienced any mental health problems during or after pregnancy. Ask about previous use of psychotropic medication: ‘Have you ever been prescribed any medication for your nerves or mental health, for example taken an antidepressant, sedative or sleeping tablet?’ Establish what previous medication has been effective in similar episodes or any medication to which they have reacted adversely. Establish whether the patient is currently in contact with any mental health professionals.

Past medical history

Enquire about any current or previous physical health problems, including operations. Note childhood operations or chronic childhood illness which can be aetiological factors in somatoform disorders. Any chronic debilitating conditions or acute life-threatening events, such as a myocardial infarct, are important risk factors for depressive and anxiety disorders. Also some psychotropic medications are contraindicated in patients with certain medical diseases. A number of neurological illnesses have important psychiatric manifestations. Ask about all contacts with health services. Frequent consultations with many different specialists for a variety of symptoms in the absence of a definite medical diagnosis raises the possibility of somatoform disorder.

Current medication

Record all the medication a patient is currently taking (including over-the-counter medications and herbal products). Overuse of some over the counter medication can exacerbate a problem (e.g. analgesic overuse headache). Record any allergies clearly.

Family history

Ask about parents: their ages, whether they are alive and, if so, whether they have any physical or mental health problem, where they live and the nature of the patient’s current relationship with them. Enquire about the parents’ occupations and personalities and the patient’s relationship with them during childhood. Establish if the parents are separated or divorced and, if so, how old the patient was at the time. If the parents have died, enquire into when they died, their age at death, the circumstances of their death, how old the patient was at the time and how the patient has coped with the grieving process.

Establish how many siblings there are, whether full or half siblings, and the patient’s order in the family. As for the parents, enquire into any siblings’ mental and physical health, place of living, marital status, occupation, personality and the patient’s relationship with them.

Some family structures can be very complicated, with parental separations, remarriages or repartnerships, and half- or step-siblings from different parental relationships. In this situation, it can be helpful to draw a family tree and annotate it with the above information. Circles are used for women, squares for men; a line through the symbol denotes death. Marriage or permanent liaisons are indicated by a line connecting the symbols, and divorce or permanent separation by two oblique lines through the connecting line.

Considerable information can emerge about relationships with parents, siblings, etc. while taking the family history which can be explored further in the personal history. Specifically enquire whether there is any family history of mental health or psychological problems. When considering the heritable component of a condition, obviously you are only interested in first-degree relatives and not in relatives by marriage.

Personal history

Birth and early developmental milestones

This begins with enquiry about the patient’s birth. Was it a normal delivery or were there any medical interventions or birth complications requiring specialist care? This is relevant to assess the possibility of any early brain injury. It can also be relevant if there were problems in early maternal bonding. Were developmental milestones reached within the normal range (see Ch. 5)? Patients may not have any knowledge about their birth and milestones. If they tell you about some problem surrounding their birth and early milestones, this may be significant and is worth recording. If no problems are identified, it is possible that the patient just does not know. Clearly an informant, such as the patient’s mother, may have more accurate information.

Family milieu, childhood health and early relationships with caregivers

Start with an open question such as ‘How do you remember your childhood?’ ‘Was it a happy or unhappy time of life?’ Cover the family atmosphere during early upbringing, relationships between parents and relationships with parents or alternative caregivers such as grandparents or foster carers. It is important to note any periods of separation from parents and the quality of alternative caregivers. Enquire about and record any loss of parents or other caring figures through death or separation or divorce. These factors are important in understanding whether there has been any early disruption of attachment bonds for the individual. Childhood health is important. Ask about operations, hospitalization or chronic illness in childhood and about family attitudes to any illness. Asking how much time was missed off school due to illness is a good indicator of childhood health, whether organic or non-organic. A happy childhood can be covered quickly, with more time spent exploring causes of an unhappy childhood experience.

Specifically ask about physical or sexual abuse. This may seem difficult at first as these feel like taboo topics. Make sure the questions are in an appropriate context (i.e. when enquiring about the patient’s experience of childhood). Then you can ask, in a matter of fact though sensitive way, questions such as the following:

Did you ever have any experience of being badly treated as a child?

Were you ever neglected and not provided with adequate physical care?

Was anyone persistently mean or cruel to you in what they said?

Were you ever hit?

Were you ever physically abused in any way?

Were you ever sexually abused by anyone as a child?

If the rapport with a patient is poor for any reason, or if you are seeing a very psychotic disorganised patient, just asking a general question and deferring exploration may be better. Sometimes a patient will indicate that he did experience abuse, in which case it is important to sensitively test out how much to explore this in an initial interview. It is useful to ascertain if this is the first time he has disclosed the abuse. If he has disclosed it previously, ask who he disclosed it to and whether he has talked about it much. A patient who has undergone a period of therapy and discussed his abusive experience at length before may be comfortable recounting his experience at first interview. A patient who has never disclosed his abuse before may find it difficult to discuss it at all, and an agreement to talk further subsequently may be appropriate. Patients should never feel coerced, either overtly or covertly, by the whole context of the interview to talk about issues which cause pain or distress. If they do, the interview itself can feel like an abusive experience.

Schooling

A person’s experience of school can be very important in terms of understanding the development of his peer relationships and indicating whether there were any behaviour problems, as well as finding out what educational level he attained and what his academic and other abilities were. Enquire about both primary and secondary school, what sort of school he attended, whether he enjoyed school, what he was good at, any experience of bullying and the nature of it, peer relationships, ease of friendships, whether he has kept friends from school and if he had any problems at school. Truancy, school refusal, exclusions from school and referral to any children’s service are all important.

Truancy is where a child misses school deliberately, usually without parental knowledge, and does something else such as working or playing with other truants. School refusal is where a child stays at home refusing to go to school despite persuasion from parents, usually due to an anxiety disorder. Sometimes parents keep children at home due to the parent’s health or practical needs (the parent may need practical help due to physical illness or with looking after other children).

Establish the patient’s level of academic achievement (qualifications attained). Ask about further education or training on leaving school and his experience of this (college or university). Further education is an important point in a person’s developmental trajectory as it is often the point at which an individual starts to live independently. How successfully this major milestone is negotiated is an important indicator of psychological health and can reveal information about emotional attachments and functioning. Enquire specifically about the transition from home to living independently, even if not for further education, or whether the patient still lives in the parental home.

Time may not allow all aspects of schooling to be covered, but always record age at start and end of full-time education, any problems encountered and the highest level of qualifications attained. This information can be important in evaluation of cognitive state.

Occupational history

Take a history of the first job the patient had after education and what other jobs he has had, how long he remained in the jobs and the reasons he left. It is not necessary to go into exhaustive detail, but it is important to establish if the individual is able to sustain long-term periods of employment. Use a shortened approach by asking about total number of jobs, longest period of employment and highest level of employment, longest period of unemployment, difficulties at work and relationships at work. If a pattern emerges of frequent job switches after brief periods of employment, it is important to establish the reason for this pattern: is there a pattern of repeated behaviour (e.g. getting bored) or a particular problem (e.g. difficulty with authority figures or other problems in interpersonal relationships). This can give important information about ability and personality. Ask about his current job (if he has one) such as the hours worked, what it involves, if it is enjoyable and any particular current work stressors. If a patient is unemployed, establish when he last worked and the reason he is not working (e.g. illness).

Psychosexual history, including marital/relationship history and children

The psychosexual history can be a source of embarrassment for students and patients, but this is unnecessary if handled in a straightforward way. If there is a problem, the patient may be relieved to be asked about this, as he may have found it difficult to mention. Many psychotropic drugs have psychosexual side effects (e.g. erectile dysfunction with some antidepressants), but patients may not mention these side-effects unless asked. How much detail is needed will vary depending on the presenting complaint. Obviously, if the patient is complaining of marital or psychosexual difficulties, a full history of this area is relevant. The level of detail outlined in Box 7.5 is usually not necessary, but you should routinely gather basic details of the psychosexual history. In the relationship history, do not make an assumption about sexual orientation. Ask about sexual orientation in an open non-judgemental way. Look for patterns which may be indicative of relationship problems (lots of brief relationships, a repeated pattern in intimate relationships, repeatedly entering into abusive relationships). Be aware of domestic violence and the need to ask about this if there is a very difficult or aggressive relationship. Basic details about children (also in Box 7.5) can be important later if child-protection issues are raised.

Box 7.5 The psychosexual history

Women: age at menarche, menstrual history, sex education at home/school

Men: puberty, sex education at home/school

For both sexes, a full sexual history would also cover sexual fantasies, masturbation and deviant sexual behaviour (this level of detail is inappropriate unless the problem is specifically a psychosexual one)

Boyfriends/girlfriends in adolescence, age at first sexual relationship

Marital history: age at marriage, how they met, parental attitude to marriage and quality of marital relationship – confiding, conflict, separations. Establish age, occupation and health of spouse. How and why relationships ended

Current relationship: any conflict? What is the partner’s attitude to the patient’s illness? Are they supportive?

Children: how many, names, ages, who the biological parents are, who cares for them. Any worries about the children’s health, behaviour, schooling or relationships with the patient

Reproductive history in women: did they get pregnant easily? Fertility treatment? Were the pregnancies planned? History of miscarriages, terminations of pregnancy or stillbirths. Mental health problems during pregnancy or after childbirth or related to menstruation

Current social situation – see Box 7.6

Forensic history

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