ASSESSMENT OF

MENTALLY-ILL
PATIENTS.
OBJECTIVES

➢ Outline comprehensive psychiatric

assessment
▪ Describe the psychiatric history
▪ Carry out the physical assessment
▪ Demonstrate the Mental State
Examination
 DEFINITION

A comprehensive psychiatric evaluation is a full assessment that

may be performed to diagnose any number of emotional,
behavioural or developmental disorders.
 The evaluation involves gathering information about the
individual's present behaviours as well as information on their
physical, genetic, environmental, social, cognitive (thinking),
emotional and educational history.
 The goal of the evaluation is to identify a diagnosis (if
appropriate) and to provide treatment recommendations.
1. History taking

2. Physical examination

3. Mental state examination

COMPONENTS OF COMPREHENSIVE
ASSESSMENT
1. HISTORY TAKING
A. PSYCHIATRIC HISTORY

The psychiatric history is the record of the patient's life; it allows a

psychiatrist to understand:
➢ Who the patient is,
➢ Where the patient has come from, and
➢ Where the patient is likely to go in the future.
It is the patient's life story told to the psychiatrist in the patients own words from his or
her own point of view or from other sources, such as a parent or spouse.
PSYCHIATRIC HISTORY
CONT

Important technique for obtaining a psychiatric

history is to allow patients to tell their stories in their
own words in the order that they consider most
important.
Recognize the points at which they can introduce
relevant questions about the areas described in the
outline of the history and mental status examination
IDENTIFICATION
DATA

The identifying data provide a concise

demographic summary of the patient;
name, age, marital status, sex, occupation,
ethnic background, religion,
and the patient's current living circumstances.
The source(s)of the information, the liability of
the source(s),
IDENTIFICATION DATA
CONT

and whether the current disorder is the first

episode for the patient.
Whether the patient came in on his or her own
was referred by someone else, or was brought in
by someone else.
 PRESENTING/CHIEF
COMPLAINT
State in the patient's own words, states why he or she has come
or been brought in for help.
It should be recorded even if the patient is unable to speak, and
the patient‘s explanation, regardless of how bizarre or irrelevant it
is, should be recorded verbatim in the section on the presenting
complaint.
If the patient is comatose or mute that should be noted in the
chief complaint as such.
PRESENTING/CHIEF COMPLAINT
CONT

Specify the duration of Chief complaints

Examples of Chief Complaints follow:
➢ Iam having thoughts of wanting to harm myself.
➢ People are trying to drive me insane.
HISTORY OF PRESENTING
ILLNESS

Comprehensive and chronological picture of the

events leading up to the current moment in the
patient's life.
This part of the psychiatric history is probably the
most helpful in making a diagnosis
When was the onset of the current episode, and
what were the immediate precipitating events or
triggers?
History of the present illness helps answer the
questions:
HISTORY OF PRESENTING
ILLNESS

Why now?
Why did the patient come to the doctor at this
time?
What were the patient's life circumstances at the
onset of the symptoms or behavioural changes,
and how did they affect the patient so that the
presenting disorder became manifest?
PAST MEDICAL/PSYCHIATRY
ILLNESS
The patient's symptoms, extent of
incapacity, type of treatment received,
names of hospitals, length of each illness,
effects of previous treatments recorded
chronologically.
Obtain a medical review of symptoms and
note any major medical or surgical
illnesses
and major traumas, particularly those
requiring hospitalization e.g head injury
PAST MEDICAL/PSYCHIATRY
ILLNESS

Episodes of cranio-cerebral trauma, neurological

illness, tumors, seizure disorders or HIV-AIDS.
History of infection with syphilis is critical
Ask about alcohol and other substances used,
including details about the quantity and
frequency of use.
FAMILY
HISTORY

A brief statement about any psychiatric illness,

hospitalization,
and treatment of the patient's immediate family
members should be placed in the family history
part of the report.
Does the family have a history of alcohol and
other substance abuse or of antisocial behaviour?
FAMILY HISTORY
CONT

Determine the family's attitude toward, and

insight into, the patient's illness.
Does the patient feel that the family members
are supportive, indifferent, or destructive?
What is the role of illness in the family?
PERSONAL
HISTORY
Prenatal and Perinatal
➢ Full-term pregnancy or premature
➢ Vaginal delivery or caesarean
➢ Drugs taken by mother during pregnancy
(prescription and recreational)
➢ Birth complications
➢ Defects at birth
Infancy and early childhood
➢ Infant-mother relationship
➢ Problems with feeding and sleep
PERSONAL
HISTORY
Significant milestones
➢ Standing/walking
➢ First words/two-word sentence
➢ Other caregivers
➢ Unusual behaviours (e.g., head-banging)
Middle childhood
➢ Preschool and school experiences
➢ Separations from caregivers
➢ Friendships/play
➢ Methods of discipline
➢ Illness, surgery, or trauma
PERSONAL
HISTORY

Romantic involvements and sexual experience

Work experience
Drug/alcohol use
Symptoms (moodiness, irregularity of sleeping or
eating, fights and arguments)
Young adulthood
➢ Meaningful long-term relationship
➢ Academic and career decisions
➢ Military experience
PERSONAL HISTORY
CONT’

Work history
➢ Prison experience
➢ Intellectual pursuits and leisure activities
Middle adulthood and old age
➢ Changing family constellation
➢ Social activities
➢ Work and career changes
➢ Aspirations Major
PERSONAL
HISTORY
Marital and Relationship History
➢ History of each marriage, legal or
common law.
Education History
➢ How far did the patient go in school?
What was the highest grade or graduate
level attained?
➢ What was the level of academic
performance?
➢ What is the patient's attitude toward
academic achievement?
PERSONAL
HISTORY

Religion
➢ Was the family‘s attitude toward religion strict or
permissive, any conflicts between the parents
over the child's religious education?
➢ Any strong religious affiliation, how does this
affiliation affect the patient's life?
➢ What is the religious attitude toward suicide?
PERSONAL
HISTORY

Social Activity
➢ Social life and the nature of friendships and
quality of human relationships.
➢ Does patient prefer isolation because of anxieties
and fears about other people?
Then give a professional summary of the history
2. MENTAL STATE EXAMINATION
 MENTAL STATE EXAMINATION

Describes the sum total of the examiner's

observations and impressions of the psychiatric
patient at the time of the interview.
Where as the patient's history remains stable, the
patient's mental status can change from day to
day or hour to hour.
The mental status examination is the description
of the patient's appearance, speech, actions, and
thoughts during the interview.
GENERAL
DESCRIPTION

Appearance
➢ Describe the patient's appearance and overall physical impression, as
reflected by posture, poise, clothing, and grooming.
➢ Examples of appearance category include posture, poise, clothes, grooming,
hair, and nails.
➢ Common terms used to describe appearance are healthy, sickly, ill, at ease,
poised, old looking, young looking, childlike, and bizarre.
➢ Signs of anxiety noted: moist hands, perspiring forehead, tense posture, wide
eyes.
 Here describe both the quantitative and qualitative aspects of the patient's
motor behaviour.
➢ e.g.
mannerisms,gestures,twitches,hyperactivity,agitation,flexibility,rigidity,gait,a
nd agility.
➢ Describe restlessness, wringing of hands, pacing, and other physical
manifestations.
➢ Note psychomotor retardation or generalized slowing of body movements.
Describe any aimless, purposeless activity
OVERT BEHAVIOUR AND PSYCHOMOTOR ACTIVITY
➢
ATTITUDE TOWARD EXAMINER

➢ Cooperative, friendly, attentive, interested, frank, seductive, defensive,

perplexed,
➢ apathetic, hostile, or guarded;
➢ Record the level of rapport established.
➢ Was the patient easy to engage with?
MOOD AND AFFECT

Mood: Mood is defined as pervasive and sustained emotion that

colours the person's perception of the world.
➢ The psychiatrist is interested in whether the patient remarks
voluntarily about feelings or
➢ whether it is necessary to ask the patient how he or she feels.
➢ Common adjectives used to describe mood include; depressed,
➢ irritable, empty, guilty, hopeless, anxious, angry, expansive,
➢ elated, euphoric, irritable, futile, frightened, and perplexed.
MOOD AND AFFECT CONT
Mood can be labile, fluctuating or alternating
rapidly between extremes
e.g. laughing loudly and expansively one
moment, tearful and despairing the next.
Types of mood
Euthymia
➢ Normal range of mood, implying absence of
depressed or elevated mood
Elevated mood
➢ Air of confidence and enjoyment; a mood more
cheerful than normal but not necessarily
pathological.
TYPES OF MOOD

Expansive mood
➢ Expression of feelings without restraint,
frequently with an over-estimation of
their significance or importance. Seen in
mania.
Euphoria
➢ Exaggerated feeling of well-being that is
in appropriate to relevant.
➢ Can occur with drugs such as opiates,
amphetamines, and alcohol.
TYPES OF MOOD CONT

Elation
➢ Moodconsisting of feelings of joy, euphoria,
triumph,
➢ and intense self-satisfaction or optimism.
➢ Occurs in mania when not grounded in
reality
AFFECT

Affect - Patient's present emotional

responsiveness, inferred from the patient's facial
expression,
including the amount and the range of expressive
behaviour.
➢ Shows variation in facial expression, tone of
voice, use of hands, and body movements.
➢ Affect can be classified as blunted, flattened,
appropriate, or inappropriate.
AFFECT CONT
Blunted affect
➢ Disturbance of affect manifested by a severe reduction in the
intensity of externalized feeling tone;
➢ one of the fundamental symptoms of schizophrenia
Flat affect
➢ Absence or near absence of any signs of affective expression.
➢ The patient's voice is monotonous and the face should be
immobile and expression less.
➢ The patient has difficulty in initiating, sustaining, or terminating
an emotional response.
AFFECT CONT’

Appropriateness of Affect
➢ The appropriateness of the patient's emotional
responses in the context of the subject the patient is
discussing.
➢ Delusional patients who are describing a delusion of
persecution should be angry or frightened about the
experiences they believe are happening to them.
➢ Anger or fear in this context is an appropriate
expression.
AFFECT

Inappropriate affect is used for a quality of

response found in some schizophrenia patients,
➢ in whom the patient's affect is incongruent with
what the patient is saying
➢ (e.g. flattened affect when speaking about
grandiose ideas)
SPEECH CHARACTERISTICS
Speech: Spontaneous or non-spontaneous
Rate: Rapid, slow, pressured, hesitant,
slurred
Volume: loud, whispered, slurred
Tone: emotional, monotonous, dramatic
The patient may be described as
talkative, voluble
Pressure of speech: Increased
production of speech where in a person
can’t be stopped once he starts speaking
SPEECH CHARACTERISTICS

Poverty of speech:
➢ Where in the patient is not speaking much or
there is restriction in the amount of speech or
➢ is speaking in monosyllables
Poverty of content of speech:
➢ The patient speaks adequately but it contains
little information because of its vagueness,
emptiness
PERCEPTION

Perceptual disturbances, such as hallucinations,

illusions (misinterpretation of normal stimuli),
➢ depersonalisation (sense of unreality in relation to
self) and derealisation (sense of unreality in
relation to surroundings).
➢ The hallucinations occur in five sensory modalities
(e.g. auditory, visual, taste, olfactory, or tactile).
THOUGHT
Thought can be divided into PROCESS OR FORM and CONTENT.
Process refers to the way in which a person puts together ideas
and associations,
Form way in which a person thinks.
Process or form of thought can be logical and coherent or
completely illogical and even incomprehensible.
Content refers to what a person is actually thinking about:
overvalued ideas, delusions, preoccupations, obsessions.
THOUGHT CONT

THOUGHT PROCESS(FORM OF THINKING)

➢ The patient may have either an over abundance
or a poverty of ideas.
➢ There may be rapid thinking, which, if carried to
the extreme, is called a flight of ideas.
FORMAL THOUGHT DISORDERS

Flight of ideas - A succession of multiple

associations so that thoughts seem to
move abruptly from idea to idea;
often (but not invariably) expressed
through rapid, pressured speech.
Neologism -The invention of new words
or phrases.
Perseveration - Repetition of out of
context of words, phrases, or ideas.
FORMAL THOUGHT DISORDERS

Tangentiality. In response to a question, the patient

gives a reply that is appropriate to the general topic
without actually answering the question.
➢ Example: Doctor: Have you had any trouble sleeping
lately?
➢ Patient: I usually sleep in my bed, but now I'm
sleeping on the sofa.
Thought blocking. A sudden a break in the flow of
ideas.
SENSORIUM AND RECOGNITION

Consciousness
Disturbances of consciousness usually indicate
organic brain impairment.
A patient may be unable to sustain attention to
environmental stimuli or to maintain goal-
directed thinking or behavior
1. Alertness
➢ (Observation)
SENSORIUM AND RECOGNITION

2. Orientation
➢ What is your name? Who am I? What place is this?
What city are we in?
3. Concentration
➢ Starting at 15, count backward by 3. or Say the
letters of the alphabet backward starting with Z.
➢ Name the months of the year backward starting
with December?
4. Memory
Immediate
➢ Repeat these numbers after me: 1, 4, 9, 2, 5.
Recent
➢ What did you have for breakfast? How did you come
here?
Long term
➢ Where did u do your primary school?
 5. Calculations
➢ If you buy something costing k45 and you pay K10, how much
change should you get?
6. Fund of knowledge
➢ What is the distance between Mansa and Samfya?
7. Abstract reasoning
➢ Which one does not belong in this group: a pair of scissors, a
knife, and a spider? Why?
➢ Is an apple and an orange alike
JUDGEMENT AND
INSIGHT

Judgment
During the course of history taking, the psychiatrist
should be able to assess many aspects of the patient's
capability for social judgment.
Does the patient understand the likely outcome of his
or her behavior?
Insight
Insight is a patient's degree of awareness and
understanding about being ill.
INSIGHT

A summary of six levels of insight are:

Complete denial of illness
Slight awareness of being sick and needing help,
but denying it at the same time
Awareness of being sick but blaming it on others,
on external factors, or on organic factors
Awareness that illness is caused by something
unknown in the patient
INSIGHT CONT’

Intellectual insight: admission that the patient is ill

and that symptoms or failures in social adjustment
are caused by the patient's own particular irrational
feelings
True emotional insight: emotional awareness of the
motives and
feelings within the patient and the important persons
in life, which can lead to basic changes in behavior
FURTHER DIAGNOSTIC STUDIES

Physical examination
Neurological examination
Additional psychiatric diagnostic
Interviews with family members, friends, or
neighbours by a social worker
Psychological, neurological, or laboratory tests as
indicated:
Electroencephalogram, computed tomography scan,
magnetic resonance imaging,
tests of other medical conditions, reading comprehension and
writing tests, test for aphasia,
24-hour urine test for heavy metal intoxication,
urine screen for drugs of abuse
3. PHYSICAL ASSESSMENT
INTRODUCTI
ON
Physical assessment is an examination that is conducted the first
time a patient comes to the health facility with a complaint.
It may also be conducted upon admission. Psychiatric patients
may not tell you what physical problems they are having,
Hence you need to be very observant and skilful in the way that
you conduct the examination.
INTRODUCTION
CONT’

A variety of techniques and medical equipment is used when performing a

physical assessment.
Can either be head to toe or system by system
Laboratory, x-ray and other investigations may be carried out depending on
the findings of the physical examination and any complaints from the patient.
INTRODUCTION
CONT
Ideally it is carried out as part of the admission procedure.
If there is a delay in examining due to an unstable mental state
reasons the delay should be recorded clearly.
A physical assessment contains 2 kinds of information: Subjective
and objective.
A patients’ feedback is subjective information.

While information elicited from a nurse’s observation is considered

objective information.
INTRODUCTION
CONT
It is advisable to have a chaperone in attendance, to guard against
accusations of sexual harassment when examining a member of the
opposite sex.
And guards against the risk of violence by patients who may be
aggressive
Note; when examining a patient with mental illness you should not be alone
with the patient in the room for safety reasons
Additionally be very observant and skilful in when conducting your
examination
Because psychiatric patients may not tell you what physical problems they are
having
But you need to elicit them
PURPOSE OF PHYSICAL EXAMINATION
To identify physical illnesses that may have been overlooked and
then refer the patient to appropriate specialists.
To assess impact of mental illness on the physical wellbeing of the
patient e.g. nutritional status and symptoms of dehydration in
conditions like major depression, anorexia nervosa and mania.
PURPOSE OF PHYSICAL EXAMINATION
To identify side effects of neuroleptic (drugs used to treat mental
illness) drugs.
To assess for signs of neglect and ill treatment such as messy hair,
unkempt appearance; injuries due to un-recommended methods of
restraint that lead to skin abrasions on the wrists
and ankles and swellings on the body due to being beaten.
BENEFITS OF PHYSICAL EXAMINATION
1.Physical disease is more prevalent in people with mental disorder
than in the general population.
Annual death rates from all causes among psychiatric patients are
2-4 times higher than in the general population with higher rates of
physical disorder across the entire range of mental disorder.
There physical examination should upto date to ensure that
physical illnesses are diagnosed and treated appropriately.
BENEFITS
CONT
Patients who are mentally disturbed may be unable to give a clear
account of their symptoms, even in the presence of a life
threatening disorder.
Studies have also shown that in many cases, physical diseases will
not be diagnosed and treated when a patient is admitted to a
psychiatric unit
Physical assessment addresses this anomaly
3.An important aspect of psychiatric evaluation is differentiating
organic disease from ‘functional’ psychiatric disorders.
BENEFITS OF PHYSICAL
ASSESSMENT
A competent assessment of patient’s physical health also helps to
tailor drug use and reduce the risk of side effects.
Physical assessment gives a clear baseline for comparison, should a
patient’s physical state change,
consequently informing the clinician of the severity of the effect of
a drug and of the need for action.
COMPONENTS OF PHYSICAL
ASSESSMENT

Physical assessment starts with vital signs,

and then a physical examination