1. Clinical Evaluation
of Psychiatric
Patient

2. INTRODUCTION
Psychiatric evaluations vary according to their
purpose.
The purpose depends on:
1- Who requests the evaluation.
2- Why it is requested.
3- The expected role of the psychiatrist in the
patient's care.
Three main types:
1) General psychiatric evaluation.
2) Emergency evaluation.
3) Clinical consultation.
Other types such as forensic evaluation.

3. Clinical Examination
Mental Status Examination.
Psychiatric History.
Laboratory Tests in Psychiatry.
Physical Examination in Psychiatry.
Psychological Factors.

4. Interview of A
Psychiatric Patient
Interviews explore the following
factors: Genetic, Temperamental, Biological,
Developmental, Social & Psychological.
Successful Interview creates:
* Empathy, Respect, Competence & Interest.
* An atmosphere of trust that encourages the
patient to talk honestly about his or her
innermost feelings & thoughts.

5. The Aims of Psychiatric Evaluation
To establish a provisional diagnosis.
To identify other diagnostic possibilities.
To identify social, environmental & cultural
factors relevant to immediate treatment
decisions.
What precautions are needed if there is a risk of
harm to self or others & whether involuntary
treatment is necessary.
To develop a plan for immediate treatment with
determination of whether the patient requires
treatment in a hospital or other supervised
setting.
What follow-up will be required.

6. 1. General Psychiatric Evaluation
A general psychiatric evaluation is a face-
to-face interview with the patient.
The interview-based data are integrated
with a review of medical records, a
physical examination & diagnostic tests.
Several meetings with the patient may be
necessary.

7. 2. Emergency Evaluation
The emergency psychiatric evaluation occurs
in response to the occurrence of:
1) Thoughts or feelings that are intolerable
to the patient.
2) Behavior that prompts urgent action by
others, such as violent or self-injurious
behavior, threats of harm to self or others,
failure to care for oneself, deterioration of
mental status, bizarre or confused
behavior, or intense expressions of distress.

8. A. Identification Data
Name.
Age.
Gender.
Marital Status.
Educational Level.
Occupation.
Religion.
Residence.

9. B. Referral, Informant & Complaint
Source of referral.
Cause of referral.
We have to choose the informant
particularly in psychotic & forensic
patients.
Complaint of the patient & that of the
informant.
(Can you tell me why you are here?)

10. C. History of The Present Illness
It is a chronologically organized history of
1) Current symptoms or syndromes.
2) Onset, Course & Duration.
3) Recent exacerbations or remissions.
4) Available details of previous treatments
& the patient's response to those treatment.
5) Factors that the patient believes to be
precipitating, aggravating, or otherwise
modifying the illness.
6) Sleep, Eating & Sexual activities.

11. D. Past Psychiatric History
A chronological summary of all past episodes of
mental illness & treatment:
1) Psychiatric syndromes not formally
diagnosed.
2) Previously established diagnoses, treatments
& responses to treatment (Psychiatric, Mental,
Psychosomatics & Medical Diseases.
3) The dose, duration of treatment, efficacy, side
effects & patient's adherence to previously

12. E. General Medical History
General medical illnesses (e.g., hospitalizations,
procedures, treatments & medications).
Undiagnosed health problems that have caused
the patient major distress or functional
impairment.
History of any episodes of important physical
injury or trauma; sexual & reproductive history
& any history of neurological disorders,
allergies & drug sensitivities.
High prevalence diseases, e.g., infectious
diseases in users of intravenous drugs or
pulmonary & cardiovascular disease in people
who smoke.
Information regarding all recent medications.

13. F. History of Substance Use
The psychoactive substance use history
includes past & present use including: alcohol,
caffeine, nicotine, marijuana, cocaine, opiates,
sedative-hypnotic agents, stimulants, solvents
& hallucinogens.
Relevant information includes the quantity and
frequency of use & route of administration: The
pattern of use (e.g., episodic versus continual;
solitary versus social); functional, interpersonal
or legal consequences of use; tolerance &
withdrawal phenomena.
Any temporal association between substance
use & present psychiatric illness.

14. G. Personal History:
Psycho-Social & Developmental.
Perinatal: Pre-natal, Natal & Post-natal.
Early Childhood: Through age 3 years.
Middle Childhood: Ages 3-11 years.
Late Childhood: Puberty & Adolescence.
Adulthood: Occupational History, Military
History, Educational History, Social
Activities, Legal History, Marital History,
Sexual History, Fantasies & Dreams.

15. H. Occupational History
The sequence of jobs held by the
patient.
Reasons for job changes.
The patient's current or most
recent employment, including
whether current or recent jobs
have involved unusual physical
or psychological stress, toxic
materials or shift work.

16. I. Military History
Relevant data about military experience
would include:
- Volunteer versus draftee status.
- Whether the patient experienced
combat.
- Discharge status, awards, disciplinary
actions.
- Whether the patient suffered injury or

17. K. Social History
The patient's living arrangements &
currently important relationships.
Relationships, both familial & non-
familial, that are relevant to the
present illness, act as stressors.
Any formal involvement with social
agencies or the courts, as well as,
details of any current litigation or
criminal proceedings.

18. J. Sexual History
A sexual history: Premarital,
marital & extramarital.
Sexual orientation & practice.
Any history of physical,
emotional, sexual or other
abuse or trauma.

19. L. Other Personal History
Review of stages of patient's life, with special
attention to developmental milestones & to
patterns of response to normative life transitions
& major life events.
Important cultural & religious influences on
patient's life.
Any involvement with the juvenile or criminal
justice system.
Any experiences related to political repression,
war or a natural disaster.
Past & present levels of functioning in family &
social roles (e.g., marriage, parenting, work,
school).

20. M. Family History
Father & Mother: Mental & physical problems,
Death & cause of death, relationship to the
patient, attitude towards the patient illness.
Siblings & patient order.
Consanguinity.
Family history of NS disease, Tumors, MR,
Psychotic disorders, Psychiatric disorders,
Suicide & Substance abuse.
History of any treatment received & response to
treatment.
Current family health status that are of
emotional importance to the patient.
Attitude of the family members towards his or
her illness (Supportive, denial or criticizing).

21. N. Pre-Morbid Personality
Introversion-Extroversion.
Temperament.
Characters.
Religious Standard.
Hobbies & Interests.
Special Habits.

22. O. Review of Systems
Current symptoms not already identified in the
present illness.
Sleep, appetite, pain & discomfort, systemic
symptoms such as fever & fatigue &
neurological symptoms.
Common symptoms of diseases for which the
patient is known to be at particular risk because
of genetic, environmental, or demographic
factors.

23. P. Physical Examination
A physical examination is needed to evaluate
the patient's general medical condition (GMC),
(including neurological).
An understanding of patient's GMC is important
in order to:
1) Properly assess the patient's psychiatric
symptoms & their potential cause.
2) Determine the patient's need for general
medical care.
3) Choose among psychiatric treatments those
are suitable for the patient's GMC.

24. The Physical Examination Includes
Sections Concerning The Following:
General appearance & nutritional status.
Vital signs.
Head & neck, heart, lungs, abdomen &
extremities.
Neurological status, including cranial
nerves, motor & sensory function, gait,
coordination, muscle tone, reflexes &
involuntary movements.
Skin, with special attention to any
trauma, self-injury or drug use.
Any body area or organ system that is
sp., mentioned in the patient’s history.

25. Q. Mental Status Examination
(MSE)
A systematic collection of data based on
observation of the patient's behavior
during the interview & before & after the
interview.
Responses to specific questions are an
important part of the MSE, particularly in
the assessment of cognition.
The purpose of MSE is to obtain evidence
of current symptoms & signs of mental
disorders from which the patient might be
suffering.

26. Q. Mental State Assessment
Appearance:
Simply describe the patient's physical
presentation: Body built, Gait, Clothing & Make
up, hygiene & cultural appropriateness.
 Behavior:
Briefly describe the patient's behavioral style,
including agitation, retardation & any
inappropriate, unusual behavior, Involuntary
movement, Posture & Sitting.
 Conversation:
Describe both the content of conversation, as
well as the form, which includes the rate of
conversation.

27. Q. Mental State Assessment
Affect & Mood:
Mood level, variability, range, intensity &
appropriateness (Mood = Feeling; Affect = Non
verbal expressions of mood).
Characteristics of Speech:
Rate, rhythm, structure, flow of ideas &
pathologic features such as tangentially,
vagueness, incoherence, or neologisms), Also,
Aphonia & Aphasia (Receptive or expressive).
Language functions:
Naming, fluency, comprehension, repetition,
reading & writing.

28. Q. Mental State Assessment
Thinking Abnormalities:
Form, Stream, Control & Content (delusions,
obsessions, Compulsions, Phobia, Suicide,
Homicide, Self injurious thoughts.
Abstract Reasoning (e.g., explaining
similarities or interpreting proverbs).
Perceptual Abnormalities:
Illusions & hallucinations (Five Modalities).

29. Q. Mental State Assessment
Cognition:
1- Consciousness.
2- Orientation.
3- Attention.
4- Concentration.
5- Memory.
6- Intelligence.
7- General Knowledge.
8- Insight.
9- Judgment.

30. 1. Level of consciousness: (Fully conscious,
Semi conscious, Comatose or Deep coma), the
best evaluation is to use Glasgow coma scale
(eye opening, verbal & motor response).
2. Orientation: (To time, place and person).
3. Attention: (Ask the patient to mention days
of the week in reverse order or months of the
year), for illiterate, we use the digit test .
4. Concentration: (Subtraction test; 7s of 100 or
3s of 20 or others).
5. Memory: (Immediate, Recent & Remote).
6. Intelligence: (Clinical: Average or below).
7. General knowledge: (Ask the patient to name
5 governorates, newspapers).
8. Insight: Insight less, partial insight,
intellectual insight or insightful.
9. Judgment: Short term & long term plans.

32. R. Psychometrics &
Neuropsychological Testing
Types of Tests
Personality:
Objective: MMPI 2 & EPQ.
Projective: Rorschach & TAT.
Neuropsychological Assessment:
Cognitive Evaluation.
Memory & Executive Functions.
Intelligence Testing:
– WAISIII.
– Stanford Binet.

33. Measurement of Cognitive Disorders:
* Delirium & Dementia:
Folstein Mini Mental Status Exam.
Traumatic Brain Injury:
Galveston Orientation & Amnesia Test
.
Mood scales:
– Beck Depression Scale.

34. S. Biological Tests
Computerized Tomography (CT).
Positron Emission Tomography (PET).
Magnetic Resonance Imaging (MRI).
Electroencephalogram (EEG).
Event-Related Potential (ERP).

35. T. Diagnostic Tests
Laboratory tests are included in a
psychiatric evaluation:
1) When they are necessary to establish
or
exclude a diagnosis.
2) To aid in the choice of treatment.
3) To monitor treatment effects or side
effects.

36. U. Functional Assessment
Functional assessment means assessing disease
severity & treatment outcome.
Functional assessment includes assessment of Physical
Activities of daily living (e.g., eating, using the toilet,
transferring, bathing & dressing) & Instrumental
Activities of daily living (e.g., driving or using public
transportation, taking medication as prescribed,
shopping, managing one's own money, keeping house,
communicating by mail or telephone & caring for a child
or other dependent).
Impairments in these activities can be due to physical or
cognitive impairment or to the disruption of purposeful
activity by the symptoms of mental illness.

37. V. Psychiatric Classifications
Illness, Disease, Syndrome or Disorder.
The most important classifications are the DSM-IV and
the ICD-10.
The DSM-IV:
Axis I: Clinical psychiatric diagnoses.
Axis II: Developmental and Personality.
Axis III: General medical condition.
Axis IV: Psycho-social stresses.
Axis V: Adaptation to role function.
The ICD-10:
Axis I: Psychiatric and physical diagnoses.
Axis II: Developmental, personality and stresses.
Axis III: Adaptation to role function.

38. W. Difficult Interview

39. 1. Depressed Patients
Depressed patients are often unable to
provide an adequate account of their
illness spontaneously because of such
factors as psychomotor retardation &
hopelessness.
Need to ask history & symptoms related
to depression including Suicidal Ideation.
Typical Symptoms Include: feelings of
hopelessness, sleep disturbance, appetite
change, concentration problems, lack of
energy or problem solving.

40. 2. Suicidal Patients
Evaluating Suicide Potential is
Imperative.
Inquire about suicidal thoughts… “Are
you suicidal now, or do you have plans
to take your own life?”
Other Risk Factors for Suicide: suicide
note, family history of suicide or
previous suicidal behavior, evidence of
impulsivity or of pervasive pessimism
about the future.

41. 3. Aggressive Patients
Assure the patient you can assist
them in managing their behavior
through the interview.
Must establish whether effective
verbal contact can be made with the
patient or whether the patient’s
sense of reality is so impaired that
effective interviewing is impossible.

42. 3. Aggressive Patients
Continued
May have to medicate the patient before
the interview begins.
Have to make the decision whether it is
safe to remove restraints.
With or without restraints a violent patient
should not be interviewed alone.
Other precautions include leaving the
door open & sitting between the patient &
the door.

43. 3. Aggressive Patients
Continued
Must make it clear that the patient may
say or feel anything but is NOT free to
act in a violent way.
Interviewer must remain calm & have
additional staff able to maintain control
by physical means if necessary.
Confrontation is to be avoided.

44. 3. Aggressive Patients
Continued
The interviewer should respect as
much as possible the patient’s need for
space.
Questions need to be asked regarding
previous acts of violence, violence
experienced as a child, under what
specific conditions the patient resorts
to violence, with corroboration from
friends & family members.

45. 4. Delusional Patients
The patients delusions should never be
directly challenged.
Challenging only increases a patient’s
anxiety & often leads the threatened
patient to defend the belief.
It is also inadvisable to believe the
patient’s delusion.
The interviewer can help by indicating that
he understands that the patient believes
the delusion to be true but that the
interviewer does not hold the same belief.

46. 4. Delusional Patients
Continued
Focus on the feelings, fears & hopes that
underlie the delusional belief to
understand the delusions particular
function.
Delusions may be excessively fixed &
chronic or they may be subject to
question & doubt by a patient & may last
only a relatively brief time.
A patient may or may not be influenced by
the delusional beliefs & may be able to
recognize their effects.

47. 5. Other Difficult Patients to Interview
(Behavioral Characteristics)
Histrionic.
Obsessive.
Dependent.
Malingering.
Sociopath or Psychopath.
Others.

48. X. Privacy & Confidentiality
Psychiatrists should follow WPA
standards for confidentiality in dealing
with the results of psychiatric
evaluations.
Evaluations should be conducted in the
most private setting compatible with the
safety of the patient & others.
Psychiatrists should not make audiotape
or videotape recordings of patient
interviews without the knowledge &
consent of the patient or the patient's
legal guardian.