Psych Pt Eval

Taking a Comprehensive Psychiatric History & Mental Status Exam Patient Evaluation I

Framework for Psychiatric Encounter

  1. What is the patient experiencing? (Symptoms)

  2. Who is this patient? (Context: history + Social Determinants of Health - SDOH)

  3. What do I observe right now? (Mental Status Examination - MSE)

  4. Is the patient safe? (Risk assessment)

  5. What diagnosis fits best? (Clinical reasoning)

Distinctiveness of Psychiatric History

  • Unlike other medical evaluations, psychiatric diagnoses depend solely on history and observation; no lab test can confirm a diagnosis.

  • A small detail can lead to significant diagnostic shifts.

  • Safety decisions often require immediate action.

Objectives for Conducting a Comprehensive Psychiatric History

  1. Elicit a complete psychiatric history covering:
       - History of Present Illness (HPI)
       - Past psychiatric history
       - Medical history
       - Substance use
       - Family history
       - Social history

  2. Conduct targeted psychiatric review of systems using focused questions across various domains (mood, anxiety, psychosis, cognition, and sleep).

  3. Perform and systematically document all components of the MSE.

  4. Differentiate between normal and abnormal findings in psychiatric evaluations.

  5. Apply clinical reasoning to develop a prioritized differential diagnosis based on gathered data.

  6. Assess for safety risks including suicide and homicide.

  7. Demonstrate patient-centered communication techniques to foster rapport and accurate information gathering.

Communication Strategies

Building the Interview

  • Adopt a nonjudgmental stance.

  • Use open-ended questions leading to focused queries.

  • Normalize discussion of sensitive topics.

  • Practice empathy and active listening.

  • Utilize silence as a tool during the interview.

  • Employ motivational interview techniques, e.g. “Many people feel overwhelmed at times… can you tell me more about that?”

3-Step Communication Rule

  1. Ask

  2. Validate

  3. Clarify

Structure of Psychiatric History

  • The psychiatric history is a standard history and physical (H&P) but modified to address psychiatric elements:
      - HPI (focused on psychiatric)
      - Past psychiatric history
      - Medical history
      - Substance use history
      - Family history
      - Social history

Modification of Traditional OLDCARTS for Psychiatry

  • Adaptations must be made to fit psychiatric evaluations:
      - Onset
      - Location
      - Duration
      - Character
      - Aggravating factors (triggers/stressors)
      - Alleviating factors
      - Treatments tried
      - Timing
      - Setting
      - Severity (functional impact)

Examples of OLDCARTS in Psychiatric Context

  • Onset Questions:
      - “When did you start feeling this way?”

  • Duration Questions:
      - “Do you feel anxious all the time, or only at specific times?”

  • Character Questions:
      - “Can you describe your feelings in more detail?”

  • Aggravating Factors:
      - “Are there any circumstances that worsen your symptoms?”

  • Alleviating Factors:
      - “What helps improve your mood or decrease your anxiety?”

  • Treatment Tried:
      - “Have you attempted specific remedies for your mood?”

  • Timing Questions:
      - “Is there a specific time of day/year that worsens your condition?”

  • Setting Questions:
      - “What were you doing when you first noticed changes in your mood?”

  • Severity and Functional Impact:
      - “How do your symptoms affect your daily life?”

Assessment of Functional Impact

  • Domains:
      1. Work/School:
      - “How has this affected your ability to work?”
      2. Daily Activities:
      - “How do you manage day-to-day tasks?”
      3. Relationships/Social Life:
      - “How have your symptoms affected your relationships?”

Safety and Risk Assessment

Mandatory Inquiry into Self-Harm and Ideation

  • Assess for:

  • Suicidal ideation, plan, intent, and means, Prior attempts

Important Clarification

  • Discussing suicide does NOT increase risk!

How to Inquire regarding Suicidal Ideation

  • Ask patients about any thoughts of self-harm or suicide directly:
      - “Are you having, or have you had any thoughts about hurting yourself?”

  • Assess specifics:
      - “How do you intend to carry out your plan?”
      - “Have you prepared in any way?”
      - “What past attempts exist?”

Spectrum of Suicidality

  • Passive suicidal ideation

  • Active suicidal ideation

  • Suicidal intent

  • Suicidal plan

  • Suicide attempt

Examples of Suicidal Ideation on the Spectrum

  • “I wish I could just go to sleep and not wake up.”

  • “I can’t get these thoughts out of my head.”

  • “Killing myself seems like the only answer.”

Inquiry on Homicidal Ideation

  • Ask about thoughts or intentions to harm others:
      - “Are you considering hurting anyone else?”
      - “Do you have a plan in place for this?”

Legal Obligation

  • In Arizona, mental health providers must inform relevant authorities if there is an actionable threat to safely manage potential harm to others (Duty to Warn).

Psychiatric Review of Systems (ROS)

Components

  • Assess various states such as:
      - Sadness
      - Worry & Anxiety
      - Panic
      - Mood Swings
      - Suicidal & Homicidal Ideation
      - Hallucinations
      - Behavioral Changes
      - Impulsivity

Past Medical History Assessment

  • Review of diagnoses, chronic conditions, hospitalizations, and therapy history related to psychological conditions.

Family History Considerations

  • Identify any psychiatric conditions within first and second-degree relatives.

Social History: SDOH

  • Assessment of living situation, support systems, need for socio-economic assistance.

Substance Use Assessment

  • Evaluate any history of substance use, including alcohol, nicotine, illicit drugs, and behaviors associated with usage.

Additional Considerations in Psychiatric History

  • Explore the patient's spirituality/religious beliefs.

  • Evaluate how these aspects affect their mental health.

Mental Status Examination (MSE)

  • MSE serves as a snapshot of the patient at a particular moment, assessing various domains:
      - Appearance
      - Behavior/Motor Activity
      - Speech
      - Mood and Affect
      - Thought Process & Content
      - Perception
      - Cognition
      - Insight
      - Judgment

  • Utilize mnemonic ASEPTIC to guide the assessment.

Appearance Evaluation

  • Assess grooming, hygiene, and attire.

  • Observations leading to insights about mood disorders or cognitive impairments.

Behavioral Insights

  • Monitor emotional states through cooperation, agitation, and overall demeanor.

Motor Activity Evaluation

  • Observe physical restlessness or slowed movements as indications of anxiety or depressive symptoms.

Speech Patterns Analysis

  • Evaluate the rate, fluency, and tone of speech as indicators of mental disorders.

Mood and Affect Assessment

  • Differences between patient-reported emotions (mood) and provider-observed emotional expressions (affect).

Thought Process Evaluation

  • Inquire into disorganized thoughts which may signify psychosis or cognitive disorders.

Thought Content Evaluation

  • Recognizing harmful thoughts such as paranoia or obsessive thinking to ensure timely management.

Cognitive Testing

  • Memory and orientation checks, determining early signs of possible dementia.

Insight & Judgment Assessment

  • Evaluate the patient's decision-making and awareness of their condition to promote treatment adherence.

Normal vs Abnormal Findings in Mental Status Examination

Key Comparisons

  • Disheveled appearance indicating possible neglect due to depression vs well-groomed appearance.

  • Agitation vs calm behavior during the assessment.

Addressing Normal vs Abnormal Findings

  • Documentation should include all observable findings to support the clinical reasoning process.

Documentation Pearls

Content Structure

  1. Subjective: Patient history and symptoms.

  2. Objective: MSE findings plus evaluations from specific systems examined.

  3. Assessment: Clinical reasoning and differential diagnosis.

  4. Plan: Safety assessments and management recommendations.

Example Documentation: Subjective

  • Patient Name: Ryann M.

  • CC: “I am so stressed out; I don’t know what to do”

  • HPI: Anxiety and stress symptom evolution over 6 months, non-triggered.

Example Documentation: Objective

  • MSE Findings:
      - Appearance: Stated age, well-groomed, appropriate hygiene.
      - Behavior: Cooperative, no distress.
      - Mood: “nervous”
      - Affect: Anxious, congruent with reported feelings.

Assessment Synthesis

  • Evaluation highlights the synthesis of history with MSE to produce prioritized diagnoses and actionable insights.

  • Example: “Major Depressive Disorder (MDD) likely indicated by ongoing symptoms and psychosocial impact.”

Summary of Potential Symptoms and Signs for Disorders

Anxiety Disorders

  • Symptoms: Worry, panic, nervousness.

  • Signs: Fidgety, restlessness, increased distress.

Depressive Disorders

  • Symptoms: Anhedonia, feelings of guilt.

  • Signs: Poor self-care, withdrawn behavior.

Mania

  • Symptoms: Elated mood, impulsive behavior.

  • Signs: Hyperactivity, distractibility, poor judgment.

Psychosis Assessment

  • Evaluate full triad of delusions, hallucinations, and disorganized thinking.

Plan Elements

  • Safety: Assess suicide risk.

  • Management: Plan should be outlined and contain necessary components to ensure patient safety.