Psychiatry, as a specialty is unique in that diagnostic methods, rely very heavily on symptomatology, therefore assessment has to be thorough.

Components of psychiatric assessment

• Full history with mental state exam (MSE)
• Physical examination and investigations to rule out organic causes

1. Presenting complaint

• This should be from either the patient and a collateral
• Ask an open question – “Can you tell me what’s been happening with you lately?”
• Include all present signs and symptoms

2. History of presenting complaint

• Provide a detailed description of onset and time course of each symptom
• Ask probing questions to establish what the diagnosis could be, as well as screening for differential diagnoses
• Any life events – could be a precipitating factor
• Associated symptoms: sleep, appetite, psychotic
• Enquire how it has affected social and occupational functioning
• Ideas, Concerns and Expectations (ICE)
• Risk assessment

3. Past psychiatric history

• Previous psychiatric diagnoses and treatment
• Any previous admissions to mental health unit – sections or voluntary
• History of suicidal attempts or self-harm
• If in the community is this: primary care, CMHT or home treatment/crisis team

4. Past medical history

• Neuro: epilepsy (inter-ictal psychosis), encephalitis, Parkinsonian, Huntington’s
• Infectious: HIV
• Endocrine: thyroid, Cushing’s, Addison’s
• Systemic: SLE
• Haem: B12/folate deficiency
• History of allergies
• History of major operations
• Current and previous medications (important to assess adherence and compliance)
• Any OTC medications

5. Family history

• Family make up, quality of relationships/support, family dynamics
• Family history of mental disorders – particularly history of admissions or suicides

6. Drug history

• Alcohol use – frequency, quantity and duration of use. Any withdrawal symptoms?
• Illicit/Recreational drug use – what, how often and why
• Cigarettes – quantity and duration
• Caffeinated products (e.g. coffee or tea) – frequency, quantity and duration of use

7. Forensic history

• Prosecutions
• Convictions
• Sentences
• Pending court courses
• Arrests
• Any trouble with the police

8. Premorbid personality

• “How would your family or friends describe you when you were well?”
• Reactions and attitudes to various things in life
• Level of socialisation (introvert or extrovert) – “Do you have many or few friends? Are you a loner? What is your prevailing emotional tone?”

9. Personal history

• Birth: where, and prenatal/perinatal/neonatal issues
• Childhood: milestones, significant illnesses, traumatic experiences, abuse, bullying
• Education: mainstream/specialist, qualifications, relationship with teachers
• Occupation: types, length of stay, relationship with peers

10. Social history

• Current occupation – inquire about social and occupational difficulties including financial
• Accommodation – where, what type, who with, check if it is suitable
• Relationship status
  • Sexual orientation
  • Any relationship and its nature
  • Any previous relationships and difficulties
  • Any domestic violence or abuse
  • Is there are an emotional problem relating to sex?
• Children
  • Names
  • Age,
  • Health – are they fine?
  • Any social services
  • Where are they (important for risk assessment)

Formulation

After completing your psychiatric assessment it is time to formulate the case. This involves summarising the key features of the history, MSE and risk assessment, as well as (differential) diagnosis and management plan.

Case summary (5P’s)

• Presenting symptom(s)
• Predisposing factor(s) – e.g. family history, circumstances in upbringing
• Precipitating factors(s) – e.g. any recent triggers
• Perpetuating factor(s) – e.g. on-going stressors
• Protective factor(s) – e.g. children, supportive family/friends, spiritual beliefs

Differential diagnosis

Aim to give a broad range of possible conditions and settle for working diagnosis, with reasoning.

For example, a patient presenting with low mood and hearing voices could be considered as having an affective disorder, psychotic disorder, anxiety disorder or even organic disorder.

Management

Depending on risk, the first point to clarify is whether the patient can be managed as an inpatient or outpatient. The intensity of care can be broadly categorised below. In addition to this, the BioPsychoSocial model is used to ensure a holistic multi-disciplinary team approach to managing these patients.

Intensity of care: admission (formal or informal) → home treatment/crisis team → CMHT → primary care

• Bio: psychotropic medication, electroconvulsive therapy if indicated
• Psycho: psychoeducation, counselling, psychotherapies
• Social: social support, financial, housing, employment

Written by Dr Muhammad Zain Haq, Psychiatry Lead (F2)
Reviewed by Dr Patrick Ezeani (Consultant Psychiatrist)