Behavioral Health

Components of Psychiatric History

and Evaluation
 In any one year, a mental disorder or
substance abuse disorder affects 28.1% of
the American population older than 18
years of age (>52 million people)

 Severe mental illness affects 2.8% of the

American adult population, or
approximately 5 million people.
Prevalence of Psychiatric
Disorders
 Men have higher rates of substance abuse
and antisocial personality disorder.

 Women have higher rates of depression,

phobia, and dysthymic disorder.
 Classification of Disorders

DSM-V: 365 disorders in 17 sections

 American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders
 Fifth edition published in 2013
 Contains the official nomenclature used by psychiatrists and other mental health
professions
 It is the “Law of the Land.”

ICD-10
 Developed by WHO
 Textual difference between ICD 10 and DSM-V
 Accepted by Medicaid, Medicare and private insurances
 Causes of mental illness:
o Biological
o Psychological
o Sociocultural – environmental

 Normal reactions to stressful events

such as death of a loved one are not Classification of Mental Disorders
considered mental disorders.

 Socially unacceptable behavior such

as crime is not necessarily indicative
of a mental disorder.
 The multiaxial system was first introduced by
DSM-III in order to encourage the clinician to
focus his or her attention during the DSM-V Multiaxial
evaluation process on issues above and
beyond the psychiatric diagnosis. System
 Axis I – Clinical disorders and other conditions

 Axis II – Personality disorders and mental

retardation, defense mechanisms

 Axis III – any physical disorder or general

medical condition that is present in additional to
the mental disorder
DSM-V Multiaxial
 Axis IV – Psychosocial and Environmental
factors System
 Axis V – GAF; standard scoring 1-100; 1-severe
impairment and 100 being no impairment of
function

 Multiple diagnoses on each axis are to be listed

in order of importance. or principal diagnosis.
 Major mental health disorders, developmental
disorders, and learning disorders.

 This is the top-level of the DSM multiaxial system of

diagnosis.
Axis I
 Represents acute symptoms that need treatment Clinical Disorders
 Axis I diagnoses are the most familiar and widely
recognized (e.g., major depressive episode,
schizophrenic episode, panic attack).
 Axis II is designated for coding personality
disorders and mental retardation and the habitual
use of a particular defense mechanism

 Disorders on Axis II tend to be lifelong and first

arise in childhood
 Pervasive, a number of disorders on Axis I (e.g.,
schizophrenia, autistic disorder, dysthymic disorder) fit this
description as well. Axis II
 Distinct from the clinical disorders of Axis I which
Personality disorders
are often symptomatic of Axis II
 For example, a adult patient might have depression (an Axis I
and Intellectual
disorder) that is largely a result of a paranoid personality
disorder (an Axis II disorder). Disabilities
 Axis II disorders are accompanied by considerable
social stigma because they are suffered by people
who often fail to adapt well to society

 Axis II disorders can seem untreatable and be

difficult to pinpoint
 Axis III describes physical problems that may be relevant to
diagnosing and treating mental disorders
• Example: Hypothyroidism influencing depressive symptoms

 An Axis I disorder may be a psychological reaction to a general

medical condition on Axis III
• Example: Adjustment Disorder with Depressed Mood in response to an
Axis III:
amputation General Medical
 General medical conditions can be regarded in three ways: Conditions
• Directly related to mental disorders
• Important to the overall diagnostic picture
• Not having a sufficient relationship to the mental health condition
 Axis IV is for reporting psychosocial and environmental
stressors that may affect the diagnosis, treatment, and
prognosis of mental disorders
• Marriage, new job, death of a loved one

• For example, someone with an Axis I diagnosis of

depression who had recently lost their job would have
"job loss" or "unemployment" recorded on Axis IV.
Axis IV:
 Generally, only those stressors from the past 12 months
Psychosocial and
are recorded on Axis IV Environmental
 In Axis IV only list those problems which are relevant to
Problems
the patient's current situation.
 For example severe psychosocial and environmental problems such as
sexual abuse may be part of an Axis I diagnosis but not part of Axis IV
because this is not a current event.

 Stressors can be positive or negative.

 The GAF is a scale used by clinicians to describe a
patient’s level of functioning in three areas:
 Social (i.e., marriage, friends)
 Occupational
 Psychological
Axis V:
 The GAF scale ranges from 0 to 100. Global Assessment of
 Designed to provide a comprehensive diagnosis that Functioning Scale
.
includes a complete picture of not just acute
symptoms

 From a diagnostic perspective, the GAF takes a

practical view of a patient's mental health
 A psychiatric diagnosis is ultimately
a complex clinical judgment that
occurs after you assess a patient’s
symptoms.

 Ask patients!
Psychiatric Diagnosis
 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.
 Important Role of the Psychiatric History

GOAL: Provides a multidimensional understanding of the biopsychosocial

elements of the disorder, and provides information about the disorder to
assist in developing a “person-centered” treatment plan.

1. Most important element in the evaluation and care of a person with mental illness
2. Interview establishes a criteria-based diagnosis
3. Often the essential part of the TREATMENT process.
a. Shapes the nature of the provider/patient relationship which can have a profound influence on
the treatment.
Important Aspects to successful interview
of patient:
1. Obtain an agreement with the patient to
discuss history of problem
a. Determine if patient is there voluntarily or
involuntarily

2. Assure patient of confidentiality

Components of
Psychiatric History
3. Consider including family members in
interview, but obtain consent from the
patient
a. During interview with family members do not bring up
history that patient has shared rather listen to the
family input.
 Components of Psychiatric History

Success of the interview with the patient will depend on your ability to allay
excessive anxiety
1.Show patient RESPECT

2.Patient must feel the evaluation is a joint effort and that the provider is truly interested in them
a.Be empathic-”That must have been difficult for you.” or “I’m beginning to understand how awful that
felt.”

Empathy: Understanding what the patient is thinking or feeling and occurs when the provider is able to put
themselves in the patient’s place while continuing to maintain objectivity.
• Objectivity is the most important ingredient in empathy.
Patient is coming to YOU seeking help!!!
 The patient believes you, the provider, has the expertise,
training and experience to be able to help
Patient – Physician
Patient’s desire for help motivates the patient to Relationship
share their story
• Information that is distressing, personal and often
private.
 As the provider you must be NON-JUDGEMENTAL!!!
• Patient’s past experiences are often very negative when they’ve
shared their stories with others who are not medical professionals.
• You must be a positive experience for the patient.

Patient – Physician
 As the provider you have two obligations to your
patient:
Relationship
• Empathy
• Recognition by the patient that the provider cares

**Both of these ingredients will increase trust with the patient.

The relationship is reinforced by the
genuineness of the provider

a. Be human with the patient-laugh, joke, apologize Patient – Physician

for mistakes Relationship
b. Be interested in the patient-for example if patient
brings in a photo, show interest.
 Focus of interview is on the patient
and allowing the patient to tell their
story

 Treatment goals should be based on

what the patient wants, not what Person-Centered and
the provider wants
• Example: Pt wants safe housing and the
Disorder Based Interviews
provider wants to decrease hallucinations

• Beware that the patient has been exposed to

numerous occasions to what the provider
“wants to hear” and therefore may attempt
to focus on acceptable and expected goals
 Look for immediate clues about your patient
upon first meeting
• Avoids eye contact
• How do they shake your hand? Do they shake your
hand?
• How are they sitting? Slouching? Upright? Arms and
legs crossed?
• Do not comment on these behaviors

Initiation of Interview
 Pt will form an initial impression of the
provider and determine how much
information they can share

 Primary goal of initial interview is to hear

the patient’s story of his/her health and
illness
 Signs and Symptoms in Psychiatry

 Signs – objective
 Clinician’s observations, such as noting patient’s agitation

 Symptoms – subjective
 Subjective experiences, such as a patient’s complaint of feeling depressed
In psychiatry, the presentation of signs
and symptoms is not always
straightforward.

 Ego-dystonic vs. Ego-syntonic

 Ego-dystonic: Aspects of a person’s personality that Signs & Symptoms
are viewed as repugnant, unacceptable, or
inconsistent with the rest of the personality.

 Ego-syntonic: Aspects of a personality that are

viewed as acceptable and consistent with that
person’s total personality.
 Signs & Symptoms
 Elicit the symptom – by asking the patient about the presenting complaint and
the history of the present complaint.

 Elicit the signs – by examining the mental state of the patient for
psychopathological features.

 Many people fail to understand that the origin of many symptoms is not always
obvious — even to a psychiatrist.

 For example, the cause of a psychiatric symptom may be either physiological or

psychological.
http://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptoms-medical-%E2%80%9Cmimics%E2%80%9D
http://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptoms-medical-%E2%80%9Cmimics%E2%80%9D
 Endocrine Disorders
 Infection
 Metabolic Disorders
 Autoimmune Disorders
 Narcolepsy
 Seizures
 Space Occupying Lesions
Secondary Causes of
 Strokes Psychosis
 Head Injuries
 Multiple Sclerosis
 Basal ganglia disorders
• Wilson disease,
• Huntington disease
• Fahr Disease
 Psychiatric Evaluation vs Medical Evaluation

 Psychiatric evaluation requires gathering information about patient’s illness

through their story

 Medical evaluation requires gathering information about the patient’s physical

ailments

 Two most important elements to the psychiatric evaluation

 Patient history
 Mental Status Exam (MSE) or (Mini Mental Status Exam)
Important information needed for psychiatric history:

• Description of past symptoms

• Length of time symptoms occurred
• Frequency and severity

Psychiatric Evaluation
Psychiatric Treatment History
• How long have you received treatment – counseling, medication?
• How long did patient receive treatment?
• Was the treatment on inpatient/outpatient basis?
• Voluntary or involuntary?
• Did patient participate in support groups?
Medication treatment
• What medications have worked? What didn’t?
• Why were medications stopped?
• Response to medications
• Side effects

Psychiatric Evaluation
Psychiatric Diagnosis
• What diagnoses have been made?
• Who made it?

**Do not always accept previous diagnosis by another

provider as valid
 Suicidal Ideation and Attempts
• Is there intent?
• Is there a plan?
• Review past attempts with patient

 History of non-suicidal self-injurious behavior

• Cutting Psychiatric Evaluation
• Burning
• Head banging
• Biting oneself
• How does the patient feel after inflicting wounds?
o Patients often feel great shame and guilt from self-injuring
behaviors
 Substance Use and Abuse

 Alcohol Assessment Tool

 Use the CAGE-Assessment tool for screening for ETOH
problems
1. Have you ever felt you should Cut down on use of
substance?

2. Have people Annoyed you by criticizing your

Psychiatric Evaluation
drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you ever had a drink first thing in the morning

to steady your nerves or to get rid of a hang-over
(Eye-opener)?
 Substance Use and Abuse

 Addiction Severity Index (ASI)

• Quantitative measure of symptoms and functional
impairment due to alcohol or drug disorders.
o Includes demographics
o Alcohol use Psychiatric Evaluation
o Drug use
o Psychiatric status
o Medical status
o Employment
o Legal status
o Family and social issues

Both assessment tools (CAGE or ASI) are designed to assess

patient’s readiness for change from substance abuse.
 Developmental and Social History

• Assists in determining context of psychiatric symptoms and

illnesses Psychiatric
• May help to identify evolution of disorder
Evaluation
o Did disorder start in childhood?
o Is there abuse in patient’s background?
o Did symptoms start in young adulthood?
o Did any family members have a psychiatric illness?
Remainder of psychiatric evaluation
mimics the medical exam except that a Psychiatric Evaluation
physical exam may or may not be taken.
 Mental Status Exam
 MSE is the equivalent of the physical exam in the rest of medicine

 Explores all the areas of mental functioning and denotes evidence of signs and
symptoms of mental illness.

 Most information of the MSE is observed.

 To properly assess the MSE information about the patients history is needed
including education, cultural and social factors.

 It is important to ascertain what is normal for the patient. For example some
people always speak fast!
Components of the Mental Status Exam
• Appearance
• Behavior
• Speech
• Mood
• Affect Mental Status Exam
• Thought process
• Thought content
• Cognition
• Insight/Judgment
 Mental Status Exam
Appearance and Behavior: What do you see?
 Appearance
o Build, posture, dress, grooming, prominent physical abnormalities
o Level of alertness: Somnolent, alert
o Emotional facial expression
o Attitude toward the examiner: Cooperative, uncooperative

 Behavior
o Eye contact: ex. poor, good, piercing
o Psychomotor activity: ex. retardation or agitation i.e.. hand wringing
o Movements: tremor, abnormal movements
Motor Activity

• How does the patient move?

oNormal Mental Status Exam
oSlow-bradykinesia
oAgitated-hyperkinesia
oCoordinated/uncoordinated
Speech
 Rate: increased/pressured,
decreased/monosyllabic, latency
 Rhythm:
• Articulation
• Prosody-the patterns of stress and
intonation in a language
• Dysarthria- difficulty saying words Mental Status Exam
because of problems with the muscles
that help with talking
• Monotone
• Slurred
 Volume: loud, soft, mute
 Content: fluent, loquacious (talkative),
paucity (sparse), impoverished
 Mood and Affect
Mood: Patient’s internal and sustained
emotional state.

Affect: Expression of mood-quality, Mental Status Exam

quantity, range, appropriateness,
congruence.
Mood
 The prevalent emotional state the patient tells
you they feel
 Often placed in quotes since it is what the
patient tells you
Mental Status Exam
 Examples “Fantastic, elated, depressed,
anxious, sad, angry, irritable, good”, flat
• Flat: term used most often with
schizophrenics-restricted range of affect.
Affect
 The emotional state we observe
• Type: euthymic (normal mood),
dysphoric (depressed, irritable, angry),
euphoric (elevated, elated) anxious

• Range: full (normal) vs. restricted,

blunted or flat, labile
Mental Status Exam

• Congruency: does it match the mood-

(mood congruent vs. mood incongruent)

• Stability: stable vs. labile

Thought Process
 Describes the rate of thoughts, how they flow and
are connected.

 How does the patient formulate, organize, and

express thought
• A patient can have a normal thought process

Mental Status Exam

with significant delusional content

 Normal: tight, logical and linear, coherent and goal

directed

 Abnormal: associations are not clear, organized,

coherent.
• Examples: circumstantial, tangential, loose,
flight of ideas, word salad, clanging, thought
blocking
 Mental Status Exam

Abnormal thought process examples:

 Circumstantial: Provide unnecessary detail but eventually get to the point
Tangential: Move from thought to thought that relate in some way but never
get to the point
 Loose: Illogical shifting between unrelated topics
 Flight of ideas: Quickly moving from one idea to another- see with mania
 Thought blocking: Thoughts are interrupted
 Perseveration: Repetition of words, phrases or ideas
 Word Salad: Randomly spoken words
Thought Content
 What patient spontaneously expresses and
responds to questions

 Refers to the themes that occupy the patients

thoughts and perceptual disturbances Mental Status Exam
 Examples: preoccupations, illusions, ideas of
reference, hallucinations, derealization,
depersonalization, delusions
Thought Content Examples

 Preoccupations:
Suicidal or homicidal ideation (SI or HI),
perseverations, obsessions or compulsions
Mental Status Exam
 Illusions: Misinterpretations of environment

 Ideas of Reference (IOR): Misinterpretation of

incidents and events in the outside world
having direct personal reference to the patient
Perseverations-some form of response
repetition or the inability to undertake set
shifting (changing of goals, tasks or activities)
as required.
Thought Process Examples
 Delusions: Fixed, false beliefs firmly held in
spite of contradictory evidence
• Control: outside forces are controlling
actions
• Erotomanic: a person, usually of higher
status, is in love with the patient Mental Status Exam
• Grandiose: inflated sense of self-worth,
power or wealth
• Somatic: patient has a physical defect
• Reference: unrelated events apply to them
• Persecutory: others are trying to cause
harm
 Perceptual Disturbances
 Hallucinations: False sensory perceptions.
Can be auditory (AH), visual (VH), tactile or
olfactory

 Derealization: Feeling that the outer Mental Status Exam

environment feels unreal

 Depersonalization: Sensation of unreality

concerning oneself or parts of oneself
Cognition
 Elements of cognitive functioning
• Alertness
• Orientation
• Concentration
• Memory Mental Status Exam
• Calculation
• Fund of Knowledge
• Abstract Reasoning

See Table 5.1-5 for examples of questions on pg 203.

Abstract Reasoning
 Able to shift back and forth between
general concepts and specific examples.
Mental Status Exam
 Example Question: How are an apple
and an orange alike?
Insight
 Patient’s understanding of how he/she is
feeling, presenting and functioning as well
as the potential causes of his/her psychiatric
presentation
Mental Status Exam
 Example Questions:
• Do you think you have a problem? Do
you need treatment?
• What are your plans for the future?
Judgment
 Person’s capacity to make good decisions and
act on them.

 Example Question: What would you do if

you found a stamped envelop on the ground?
Mental Status Exam

 Use real situations from the patient’s own

experience to test judgment to see if patient
is dangerous or at risk for getting into trouble
Normal Exam

 The patient is alert and oriented x 3.

 Correct registration of 3 objects was noted.

 Attention and calculation are appropriate with Mental Status Exam

serial 7 counting.

 Short term memory is intact.

 Language skills are demonstrated without

evidence of agnosia, aphasia or apraxia.”
• Agnosia is the inability to process sensory information.
Often there is a loss of ability to recognize objects, persons,
sounds, shapes, or smells while the specific sense is not
defective nor is there any significant memory loss

• Aphasia is a disturbance of the comprehension and

expression of language caused by dysfunction in the brain

• Apraxia is the inability to execute learned purposeful

movements, despite having the desire and the physical
capacity to perform the movements.
Example of abnormal exam
 The patient is alert and oriented to person and time,
but is unable to identify the location, believing she is
in her childhood home in Omaha.

 Correct registration of 3 objects is noted.

 The patient’s attention and calculation are deficient, Mental Status Exam
with the patient correctly counting backwards from
100 by 7s to 86.

 The patient correctly repeats the names of objects,

without evidence of agnosia or aphasia. The patient is
unable, however, to complete commands or
purposeful actions and demonstrates difficulty
completing written or verbal commands. Apraxia is
suspected.
 By the end of a standard psychiatric
interview most of the information for
the MSE has been gathered.

 The MSE provides information for

diagnosis and assessment of disorder
Summary of MSE
and response to treatment over
time.

 Remember to include both what

your hear and what you see!
A 30-point cognitive test developed
to provide bedside assessment of a
broad array of cognitive function,
including orientation, attention,
memory, construction and language.
Mini-Mental Status Exam

 Can be administered in 10 minutes

 Considered highly reliable
 Mini Mental Status Exam (Folstein Test)
 Brief 30-point questionnaire test that is used to screen for cognition

 It was introduced by Folstein et al. in 1975

 The most popular mental status examination.

 Quantitative assessment of the cognitive functioning and capacity of a patient.

• Commonly used to assess for dementia

 Estimates the severity of cognitive impairment and allows the clinician to follow the course
of cognitive changes in an individual over time thus making it an effective tool to assess
patient’s response to treatment
 11 questions, takes 5-10 minutes to administer

 Examines functions including arithmetic, Mini Mental Status Exam

memory and orientation

 This test is not a mental status examination.

 Mini Mental Status Exam

Category Possible points Description

From broadest to most narrow.

Orientation to time 5 Orientation to time has been correlated
with future decline.
From broadest to most narrow. This is
Orientation to place 5 sometimes narrowed down to streets,
and sometimes to floor.
Registration 3 Repeating named prompts

Attention and calculation 5 Serial sevens, or spelling "world"

backwards.

Recall 3 Registration recall

Language 2 Naming a pencil and a watch
Repetition 1 Speaking back a phrase
Complex commands 6 Varies. Can involve drawing figure shown.
 Mini Mental Status Exam
Interpretations
 Any score greater than or equal to 27 points (out of 30) indicates a
normal cognition

 Below this, scores can indicate severe (≤9 points)

 Moderate (10–18 points)

 Mild (19–24 points) cognitive impairment. The raw score may also
need to be corrected for educational attainment and age
 Low to very low scores correlate closely
with the presence of dementia

 The MMSE has been able to differentiate

different types of dementias
Mini Mental Status Exam
• Alzheimer's disease score significantly lower on
orientation to time and place, and recall
compared to patients with dementia with Lewy
bodies, vascular dementia and Parkinson's
disease dementia.
 Wechsler Adult Intelligence Scale (WAIS)
Most common test for ages 16 to 75
Assesses overall intellectual functioning
Two parts: Verbal and visual-spatial
Other Scales
 Stanford–Binet Test
Tests intellectual ability in patients ages 2 to 18
 Minnesota Multiphasic Personality Inventory
(MMPI)
• Tests personality for different pathologies and behavioral
patterns
• Most commonly used

 Thematic Apperception Test (TAT)

• Test-taker creates stories based on pictures of people in Other Scales
various situations.
• Used to evaluate motivations behind behaviors

 Rorschach Test
• Interpretation of ink blots
• Used to identify thought disorders and defense mechanisms