2.3.1 Psychiatric Assessment of Patients with Physical Illness

Psychiatric Assessment of Patients with Physical illness

Psychiatric assessment of patients with physical illness is a crucial part of providing comprehensive medical care. Patients with physical illnesses often experience psychiatric symptoms such as depression, anxiety, and adjustment disorders. These symptoms can significantly impact their quality of life and medical outcomes. A thorough psychiatric assessment can help identify these symptoms and lead to appropriate interventions.

The following table summarizes key components of psychiatric assessment for patients with physical illness:

Component	Description
Presenting problem	A brief statement of the patient’s primary psychiatric complaint
History of psychiatric illness	Past psychiatric diagnoses, treatment, hospitalizations, and response to treatment
Medical history	Current and past medical conditions, surgeries, medications, and allergies
Substance use	History of alcohol, tobacco, and illicit drug use
Family history	Psychiatric and medical history of first-degree relatives
Psychosocial history	Educational, occupational, and social history; current living situation; support network; and recent life events
Mental status examination	Assessment of the patient’s appearance, behaviour, speech, mood, affect, thought process, thought content, perception, cognition, and insight
Diagnostic formulation	Integration of the patient’s history, examination, and laboratory findings to arrive at a diagnostic formulation
Treatment plan	Recommendations for pharmacological and non-pharmacological interventions, including psychotherapy, psychopharmacology, and referral to other specialists

It is important to note that the above table provides a general overview of the psychiatric assessment of patients with physical illness, and the specific components of the assessment may vary depending on the patient’s individual needs and clinical context.

History Taking and Examination of the Mental State

One of the axioms of modern medical practice is that obtaining a clear and accurate history is key to making a correct diagnosis and developing a treatment plan. This is particularly true in psychiatry, in which laboratory or imaging investigations are not typically of great value. Any factor that compromises a history could compromise care.

Psychiatric history taking and mental state examination are core clinical skills. They are best learned by practice and repetition

Always consider your personal safety when interviewing: There is a risk of aggression or violence in only a small percentage of psychiatric patients. For most patients, the only risk of violence is directed toward themselves. Violence is rare and this can often result in doctors placing themselves in harm’s way due to thoughtlessness. Prior to an assessment/interview consider: who you are interviewing, where you are interviewing, and who will be accompanying you if needed. Always ensure the wider MDT are aware of the same risks you note. The ideal interview room has two doors, one for you and one for the patient. If this is not available, sit so that the patient is not between you and the door. Remove all potential weapons from the interview room.

Familiarize yourself with the ward’s panic alarm system before you first need to use it.

Psychiatric History

The first step in taking a psychiatric history is gathering information about the patient’s medical history, including any previous psychiatric treatment or diagnoses, as well as any other relevant medical conditions.

The history should be conveyed in the patient’s own words as much as is feasible.

Introduction: (name, age, marital status, occupation, known previous contact, the reason for referral) (name, age, marital status, occupation, known previous contact, the reason for referral)

Presenting complaint:

• History of presenting complaint(s)
• Onset, course, other help sought, response to treatment so far
• Symptom details
• Precipitating events a) for illness; b) for seeking help

Family history:

• Family details (parents, siblings, ages)
• Relationship with family members
• Family history of psychiatric illness
• Deceased family members (circumstances, patient’s response, effect)

Personal history:

• Pregnancy & birth
• Early life – developmental milestones, the memory of difficulties within the family
• Schooling – educational achievement, ability to form friendships
• Occupational history
• Sexual/relationship history (ask for details appropriate to the interview)
• Serious life events

Personal circumstances:

• Current relationship
• Children
• Occupation
• Finances
• Recent stresses

Past psychiatric and medical history:

• Current medications
• Previous admissions
• Admissions under the Mental Health Act
• Previous treatment (medication or psychological)

Personality before illness:

• Collateral history from a reliable source (or the patient may be able to recall)

Current and past drug/alcohol use:

• If evidence of a problem then details:
  • Substance(s) used, quantity, timing, tolerance, withdrawal symptoms, attempts to cut down, complications, impact on relationships/work
  • Evidence of dependence
  • Harmful consequences of use

Forensic history:

• Clear details of circumstances and involvement
• Consider how this is important to your risk assessment

Questioning Techniques

• Open vs closed questions – In general, begin the interview with open questions, turning to more closed questions to clarify details or factual points.
• Non-directive vs leading questions – try to avoid leading our patients to certain replies.

Useful Acronyms

Mental State Examination

The MSE is an organised summary of the clinician’s findings regarding the patient’s mental experiences and behaviour during the interview. Its objective is to offer evidence for and against a mental disorder diagnosis, as well as to record the current type and intensity of symptoms if a mental condition is present. The information gathered, coupled with the psychiatric history, should allow for a determination of the presence and severity of any mental condition, as well as the risk of harm to oneself or others.

Use jargon only if the patient does. When presenting the mental State, you can demonstrate your ability to appropriately label symptoms. If the patient has auditory hallucinations, provide a direct statement of what they hear.

References:

(1) Manjunatha N, Saddichha S, Sinha BN, Khess CR. Assessment of Mood and Affect by Mental State Examination in Different Cultural Contexts. Psychopathology. 2008; 41: 336-337.

(2) Semple, D. and Smyth, R. (2019). Psychiatric assessment. Oxford Handbook of Psychiatry, [online] pp.45–98. doi:10.1093/med/9780198795551.003.0002.

(3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association.