Psychiatry Assessment

❍ What are the three types of clinical psychiatric evaluations according to the American Psychiatric
Association (APA)?
The general psychiatric evaluation, the emergency psychiatric evaluation, and the clinical psychiatric consultation.

❍ What are the goals of a general psychiatric evaluation according to the APA?
To establish a diagnosis, generate a case formulation, develop a treatment plan, and ascertain if any symptoms (such
as suicidal ideation) need emergency treatment. Development of an empathic rapport is also essential to initiating
and maintaining treatment compliance.

❍ How do the goals of an emergency psychiatric evaluation differ from the goals of a general psychiatric
evaluation?
Not much, in reality. However, out of necessity, there is a greater emphasis on safety and willingness to participate
in treatment during the emergency psychiatric evaluation. In the event that a person is unable to maintain his or
her own safety (and/or others), and unwilling to participate in an appropriate level of care, involuntary
commitment processes are indicated.

❍ What is the essential component of the clinical psychiatric consultation?
The reason for the evaluation. If you do not answer the question the consulting physician, court, therapist, or
caseworker is asking, you will not be consulted again. When the reason for the psychiatric consultation is vague,
it is best to ascertain (from the person/institution requesting the evaluation) the exact reason for the evaluation
(i.e., psych 2C = call 2U).

❍ True/False: The patient is not to be informed of who requested a psychiatric consultation or the reason for
the evaluation.
False. The person/institution requesting the psychiatric evaluation should ideally ask the patient to participate in a
psychiatric evaluation and the reason why, while the consultant should clearly state who is requesting the evaluation
and the reason thereof. When psychiatric consultations are requested for nonclinical reasons, the limits of
confidentiality should be reviewed and agreed to by the patient and/or their guardian before the evaluation
begins.

❍ What are the components of a clinical psychiatric examination?
The components of a clinical psychiatric examination are the reason for evaluation, history of present illness; past
psychiatric history; review of collateral sources of information including previous psychiatric records, psychological
testing, and rating scales; past medical history; review of pertinent laboratory and radiology studies; review of
systems; developmental history; family history; social history; mental status examination; physical examination; risk
assessment; multiaxial diagnoses; and treatment recommendations.

❍ What sources of information are utilized during a clinical psychiatric examination?
The first and foremost source of information for a psychiatric evaluation is the clinical interview with the patient.
Additional information can be obtained from structured interview, various questionnaires, and results of
psychological testing. With written permission from the patient or their guardian, review of previous records and
interviews with appropriate persons involved the patient’s life can yield valuable perspectives as to the patient’s level
of functioning and risk for adverse events.

❍ What factors should be considered when determining the reason for a psychiatric evaluation?
Who, why, and what services the psychiatrist is expected to render. All these factors will influence the nature and
the course of the psychiatric evaluation.
It is important to determine who requested the evaluation, especially if not requested by the patient. Reliability
and willingness to be examined can be significantly compromised if the patient did not request the evaluation (such
as when the patient is in emergency protective custody or when an examination is requested by the courts), and
additional sources of information may need to be pursued more diligently if questions of safety or reliability are
present.
Ascertaining the reason for the evaluation is imperative in order to collect sufficient information and make
appropriate recommendations. Generally, when a patient requests an evaluation, the reason for assessment is to
determine appropriate interventions for distressing symptoms. However, when someone other than a patient
requests an evaluation, it is essential to determine the specific reason why the evaluation is needed, again, so that
specific and appropriate recommendations can be made.
Finally, determining what services are to be rendered by the psychiatrist will influence what recommendations
are made. For instance, if the evaluation is for purposes of disability determination, the psychiatric examination
and recommendations will be somewhat different than if the psychiatrist is expected to be the treating physician.

❍ What information should be included in the history of present illness?
The severity and duration of current symptoms, as well as identifiable stressors. Pertinent negatives as well as
statements regarding dangerousness to self and others should also be included.

❍ True/False: A substance abuse history is not a component of the psychiatric evaluation.
False. A substance abuse history is critical to every psychiatric evaluation, even if it is negative. The use of
substances during any psychiatric illness does tend to expand the differential diagnosis and is a major risk factor
in dangerousness to self or others.

❍ Past psychiatric history should include what information?
The past psychiatric history should include information about any inpatient psychiatric hospitalizations, the reason
for hospitalization, and diagnoses, if available. Information about index hospitalizations are often very helpful as to
the severity of illness and diagnosis, especially if the patient is presenting for treatment in a stable condition. In
addition, prior outpatient services by psychiatrists and other mental health providers should be included, as well as
a history of previous medication trials and the response thereof.

❍ Why is past medical history an essential component of the psychiatric evaluation?
Past medical history is essential in ruling out medical causes of psychiatric symptoms, as well as assessing for
medication interactions that may be present. In addition, a medical illness may be a major stressor, particularly
when that illness is disabling or disfiguring.

❍ What information should be included in a developmental history?
Information regarding birth history, developmental milestones, relationships, and level of functioning in those
relationships are the items that are generally included in a developmental history.

❍ What clinical implications does a family history of psychiatric disorders?
A positive psychiatric family history may help with establishing risk factors for particular diagnoses, predicting
response to various medications, and in developing a greater understanding of the patient’s past and current family
milieu.
❍ What is one of the best means for evaluating the distribution of mental illness in a family?
A genogram.

❍ What does the occupational and social history tell the examiner about a patient’s level of functioning?
An occupational and social history gathers information about a person’s ability to “work and love.” The ability to
hold a job for a period of time demonstrates an ability to structure daily activities, meet expectations, relate
adequately with peers and supervisors, and take on a certain minimum level of responsibility. The ability to have a
long-term relationship indicates an ability to attend to someone else’s needs, control impulses, and make a
commitment.

❍ List some questions pertaining to a patient’s religious background.
Questions to ask about the role of religion in a person’s life could include some of the following: Were there
conflicts between the patient’s and parent’s religious beliefs? How large a role does religion play in the patient’s life?
How do the parent’s religious beliefs impact on the patient’s attitude toward emotions, conflict, and psychiatric
treatment?

❍ An extensive legal history can lead one to consider which two diagnoses?
Antisocial personality disorder, and alcohol and/or substance dependence.
❍ Is physical examination included in a psychiatric evaluation?
Yes. Particularly because some physical findings may be directly related to the patient’s psychiatric condition or
psychotropic medication side effects.

❍ What conditions can cause increased psychomotor activity?
Anxiety, akathesia, hyperactivity associated with attention deficit hyperactivity disorder, elevated mood, agitation
during psychotic episodes, confusional states due to delirium or dementia, and iatrogenic causes.

❍ What are the components of a mental status examination?
The components of a mental status examination include general appearance, movements, speech, attitude, thought
process, mood, affect, thought content, orientation to time and place, immediate and short-term recall,
concentration, fund of knowledge, insight, judgment, and estimate of intelligence.

❍ What aspects of the patient’s speech should be assessed?
Rate and rhythm, quality, volume and tone, grammar and syntax, and vocabulary.

❍ List some possible causes of muteness.
Aphasia, acute depression, conversion disorder, psychosis, and secondary gain.
❍ What is motor aphasia?
Motor aphasia is a disturbance of speech in which understanding remains intact but the ability to speak is grossly
impaired. Speech is halting, laborious, and inaccurate. Motor aphasia is also known as expressive aphasia, Broca’s
aphasia, or nonfluent aphasia.

❍ What is echopraxia?
The pathological imitation of one person’s movements by another.

❍ What is alexithymia?
Alexithymia is the inability or difficulty a person has in describing or even being aware of their emotions or
moods.

❍ A patient states, “It’s one or my mother, I mean, one or another.” Of what psychological phenomenon is this
an example?
Parapraxis or Freudian slip.

❍ What is the difference between a neologism and a word salad?
Neologisms are new, nonsensical words created by the patient, while word salad is an incoherent mixture of words
and phrases.

❍ How is affect characterized?
Affect is described by its range, lability, appropriateness, intensity, relatedness, and congruence with mood.

❍ How is a patient’s mood described in a mental status examination?
In the patient’s own words, usually.

❍ What aspects of thought content are generally included in a psychiatric evaluation?
The patient’s thought content is examined for suicidal or homicidal ideation (and intent): perceptual disturbances such as auditory, visual, tactile, or gustatory hallucinations; delusions, ideas of reference, and ideas of influence.

❍ Name five risk factors for suicide.
Previous attempts, seriousness of attempts, a history of alcohol or drug usage, lack of social support, and presence
of an Axis I disorder.

❍ Does the risk of suicide increase with direct questioning about suicide?
There is no evidence that it increases risk, and it is likely to increase communication and trust with the
patient.

❍ While interviewing a potentially violent patient, what precautions should be taken?
Do not interview the patient alone. Leave the door to the interview room open, and sit between the patient and the
door to allow for unrestricted exit.

❍ What factors are involved in assessing acute dangerousness?
History of violent behavior, current violent ideation, a realistic and premeditated plan, and intent.

❍ Name three kinds of normal perceptual disturbances?
Illusions, hypnagogic hallucinations, and hypnopompic hallucinations.

❍ Should a patient’s delusions be directly confronted?
No, the patient will generally become more defensive and even more fixed in their beliefs.

❍ What exactly is a delusion?
A delusion is a false belief not based on reality.

❍ List five types of delusions?
Paranoid, somatic, delusions of infidelity, delusions of poverty, and delusions of grandeur are five types of
delusions. Other types of delusions include, but are not limited to those of control (thought withdrawal,
thought broadcasting, thought insertion, thought control), erotomania, nihilistic delusions, and bizarre
delusions. In general, delusions can form about anything or anyone, and may not fit into any particular type of
delusion.

❍ How is concentration assessed on a mental status examination?
By patient report, behavioral observation, serial 7’s (or 3’s if there are educational or developmental deficits noted),
or by spelling the word “world” backward.

❍ In a patient who is disoriented, which sphere is the last to be affected; which is the first?
Orientation to person; orientation to time.

❍ What is the best way to infer a patient’s level of intellectual functioning?
By considering the patient’s vocabulary and ability to interpret proverbs.

❍ What is considered to be a normal digit span?
The majority of people are able to recall seven digits forward and five to seven digits backward.

❍ What are the essential differences between delirium and dementia?
Delirium is characterized by an acute state of confusion, disorientation, and varying levels of consciousness, while
dementia is a gradual or step-wise decline in intellectual functioning.

❍ What are the characteristic features and course of delirium?
Delirium is characterized by an acute onset of impaired consciousness, with global impairment of cognitive
functions. The course is usually brief and fluctuating, and rapid improvement occurs when the underlying etiology
resolves.

❍ How can agitation be distinguished from anxiety in the geriatric population?
Agitated individuals do not generally complain of a sense of impending doom or dread.

❍ In distinguishing between schizophrenia and bipolar disorder, what single finding on mental status examination would most likely lead to a diagnosis of schizophrenia?
Flat affect.