Psychiatric Assessment and Interview

Psychiatric Interview - The Mind Meld Kickoff

• Purpose & Goals:
  • Diagnosis: Identifying the disorder.
  • Formulation: Understanding contributing factors.
  • Treatment Plan: Guiding interventions.
  • Rapport: Building a therapeutic alliance.
• Ethical Pillars:
  • Informed Consent: Patient autonomy.
  • Confidentiality: Protecting patient information.

    ⭐ Tarasoff duty: Clinician's duty to warn potential victims if a patient poses a serious threat.

• Building Rapport:
  • Empathy: Understanding patient's perspective.
  • Active Listening: Attentive engagement.
  • Non-judgmental Stance: Unconditional positive regard.
• Optimal Setting:
  • Privacy: Ensuring confidentiality.
  • Safety: For both patient and clinician.
  • Comfort: Facilitating open communication.

Psychiatric History - The Past Unpacked

• Identifying Data & Chief Complaint: Key demographics; patient's primary concern verbatim.
• History of Present Illness (HPI): Detail onset (acute/insidious), duration, course (episodic/continuous), severity, precipitants, and impact on functioning. Note associated mood, thought, perception, or behavioral changes.
• Past Psychiatric History: Previous episodes (nature, duration, outcome), treatments received (type, dose, duration, response, side effects, compliance), hospitalizations (voluntary/involuntary), history of suicide attempts or self-harm.
• Family History: Inquire about psychiatric illnesses, substance use, and suicides among first-degree relatives.
  • Consider Genogram structure.
• Personal History:
  • Developmental milestones, childhood, education, occupation, relationship history, psychosexual history.
  • For adolescents: HEADSSS 📌 (Home, Education/Employment, Activities, Drugs, Sexuality, Suicide/Safety).
• Substance Use History: Type, amount, frequency, duration, pattern of use, last use, features of dependence/withdrawal for alcohol, nicotine, cannabis, opioids, stimulants, etc.
  • CAGE questionnaire 📌 for alcohol: Cut down, Annoyed, Guilty, Eye-opener. Score > 2 is significant.
• Past Medical & Surgical History: Significant illnesses, surgeries, head injuries. Current medications & allergies.

⭐ Collateral history from reliable informants (family, friends) is invaluable, especially in cases of psychosis, severe depression, mania, or cognitive impairment, to obtain an objective and comprehensive account.

Mental Status Exam - The MSE Snapshot

Systematic evaluation of a patient's current mental state. 📌 Mnemonic: ASEPTIC (+J)

• Appearance & Behavior: Hygiene, grooming, eye contact, posture, psychomotor activity (agitation/retardation), rapport.
• Speech: Rate (e.g., pressured, slow), rhythm, volume, tone, articulation, quantity.
• Emotion:

  Feature	Mood	Affect
  Nature	Subjective (patient's words)	Objective (observed expression)
  Descriptors	e.g., "sad", "elated", "anxious"	Range (flat, blunted), appropriateness, intensity, lability

• Perception: Hallucinations (auditory, visual, tactile, olfactory, gustatory), illusions, depersonalization, derealization.
• Thought:
  • Process (Form): Coherence, flight of ideas, tangentiality, circumstantiality, thought block.
  • Content: Delusions, obsessions, phobias, suicidal/homicidal ideations.
• Insight: Awareness of illness (Grades 1-6).
• Cognition: Orientation (TPP), attention (serial 7s), memory (immediate, recent, remote), abstract thought. MMSE score < 24 suggests impairment.
• Judgment: Social and test judgment.

⭐ Auditory hallucinations are most common in schizophrenia; visual hallucinations are more common in organic mental disorders.

Risk & Formulation - The Danger Zone Check

• Risk Assessment:
  • Suicide: Assess ideation, plan, intent, means. Use SAD PERSONS scale 📌 (Scores: 0-4 low/med, 5-6 high, ≥7 very high risk).

-   Homicide/Violence: Assess ideation, intent, plan, past violence, impulsivity.

• Physical Exam & Investigations: When indicated (e.g., baseline bloods, TFTs, toxicology, neuroimaging).
• Case Formulation (Biopsychosocial): Integrate 4Ps: Predisposing (vulnerability), Precipitating (triggers), Perpetuating (maintains), Protective (strengths).
• Diagnosis: Provisional & Differential (DSM/ICD criteria).

⭐ Past suicide attempt is the strongest predictor of future suicide.

High‑Yield Points - ⚡ Biggest Takeaways

• Psychiatric history includes HPI, past illnesses, family, personal history (developmental, substance use), and premorbid personality.
• MSE evaluates appearance, behavior, speech, mood, affect, thought, perception, cognition, insight, and judgment.
• Rapport building through empathy and a non-judgmental attitude is vital.
• Key thought assessments: formal thought disorders (e.g., flight of ideas) and delusions/obsessions (content).
• Evaluate patient's insight into illness and their judgment (social/test).
• Risk assessment for suicide and violence is a priority.