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EVALUATION & DIAGNOSTIC CLASSIFICATION DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT EVALUATION GREETING & INITIAL OBSERVATION BASELINE DEMOGRAPHIC DETAILS HISTORY MENTAL STATE EXAMINATION PHYSICAL EXAMINATION SPECIAL INVESTIGATIONS RISK ASSESSMENT SUMMARY DIAGNOSIS GREETING & INITIAL OBSERVATION INITIAL MEETING - STAND UP, INTRODUCE YOURSELF & GREET THE PATIENT WITH A HANDSHAKE SMILE, BE FRIENDLY, WELCOMING & COURTEOUS ATTEMPT TO PUT THE PATIENT AT EASE & ESTABLISH TRUST & RAPPORT ASK THE PATIENT TO BE SEATED INITIAL OBSERVATION & IMPRESSIONS - MAKE A MENTAL NOTE OF THE PATIENT’S INITIAL PRESENTATION & YOUR INITIAL IMPRESSION HOW DOES HE / SHE ENTER THE ROOM? HOW IS HE / SHE DRESSED? SCRUFFY AND DIRTY, NEAT & TIDY OR COLOURFUL & LOUD? HOW DOES HE / SHE MOVE? SWIFTLY, SLOWLY OR AWKWARDLY WITH A LIMP? WHAT IS THE DEMEANOR / BODY LANGUAGE LIKE? CONFIDENT OR HEAD DOWN & SLUMPED? WHAT IS THE GENERAL BEHAVIOUR LIKE? AGGRESSIVE, SUBDUED OR PURPOSELESS? IS THE EYE CONTACT GOOD OR POOR? WHAT IS THE FACIAL EXPRESSION LIKE? FRIENDLY SMILE? TEARFUL OR FRIGHTENED? WHAT IS THE SPEECH LIKE? LOUD & FAST, SOFT & INAUDIBLE OR INCOHERENT? DOES HE / SHE HAVE SWEATY PALMS OR A TREMOR OF THE HANDS? ARE THERE ANY OBVIOUS SIGNS OF PHYSICAL ILLNESS? BASELINE DEMOGRAPHIC DETAILS NAME AGE ETHNICITY GENDER MARITAL STATUS CHILDREN RESIDENCE & LIVING SITUATION OCCUPATION HIGHEST LEVEL OF EDUCATION RELIGION HOME LANGUAGE LANGUAGE OF INTERVIEW PLACE OF INTERVIEW - CONSULTING ROOM / WARD / HOSPITAL BED ETC LEGAL STATUS UNDER MENTAL HEALTH CARE ACT - VOLUNTARY / INVOLUNTARY / ASSISTED / OTHER HISTORY MAIN COMPLAINT - ACCORDING TO THE PATIENT ACCORDING TO COLLATERAL (PARENT, SPOUSE, REFERAL LETTER ETC) USE BIOGRAPHICAL STYLE OF RECORDING (PERSON’S OWN WORDS / DESCRIPTION OF SYMPTOMS) INTERVIEW PATIENT & FAMILY MEMBERS TOGETHER & SEPARATELY HISTORY OF PRESENTING COMPLAINT / PROBLEM / ILLNESS - ONSET (TIME & NATURE – WHEN? & HOW?) DURATION (HOW LONG?) SYMPTOMS (WHAT?) IMMEDIATE & PAST PRECIPITATING EVENTS / STRESSORS / TRAUMA (WHY?) COURSE RELATED PROBLEMS NATURE OF DYSFUNCTION IN PATIENT’S LIFE SYSTEMATIC ENQUIRY - STRUCTURED / FOCUSSED ENQUIRY ABOUT POSSIBLE SYMPTOMS IN THE PAST COGNITIVE SYMPTOMS MOOD SYMPTOMS ANXIETY SYMPTOMS VEGETATIVE SYMPTOMS PSYCHOTIC SYMPTOMS PSYCHOPHYSIOLOGICAL SYMPTOMS ADDICTIVE SYMPTOMS IMPULSIVITY SYMPTOMS BEHAVIOURAL SYMPTOMS (EG SUICIDAL BEHAVIOUR) HISTORY PAST PSYCHIATRIC HISTORY - EPISODES OF ILLNESS (WHEN?) - PROFFESIONALS CONSULTED (WHO?, WHEN?, WHY?, WHERE?) (GP, TRADITIONAL HEALER, PSYCHIATRIST, CLINICAL PSYCHOLOGIST, SCHOOL / EDUCATIONAL PSYCHOLOGIST, COUNCELLOR, PRIEST / MINISTER / RABI, SOCIAL WORKER) - HOSPITAL ADMISSIONS (WHEN?, WHY?, WHERE?) - DIAGNOSIS - COUNCELLING / PSYCHOTHERAPY (WHAT?, WHEN?, WHERE?, WHY?, EFFICACY?) - MEDICATION PRESCRIBED (WHAT?, WHY?, BY WHOM?, HOW LONG?, EFFICACY?, ADHERENCE?, SIDE-EFFECTS?) MEDICAL HISTORY - RECENT ACUTE ILLNESSES CHRONIC ILLNESSES (DIABETES, HYPERTENSION, ASTHMA, EPILEPSY, TB ETC) CURRENT & PREVIOUS MEDICATIONS (WHAT?, WHEN?, WHY?) PREVIOUS SURGERIES (WHAT?, WHEN?, WHY?) HEAD INJURIES ( WHEN?, WHERE?, HOSPITALISED?, LOSS OF CONSCIOUSNESS?) ALLERGIES FAMILY HISTORY - PARENTS (ALIVE / DEAD; CAUSE / AGE / DATE OF DEATH; MARRIED / DIVORCED; NATURE OF RELATIONSHIP WITH PARENTS) - SIBLINGS & CHILDREN (AMOUNT, GENDER, AGE, LOCATION, CAUSE / DATE OF DEATH, NATURE OF RELATIONSHIP) - FAMILY PSYCHIATRIC / MEDICAL ILLNESSES (WHO?, WHAT?, TREATMENT?) - FAMILY SUBSTANCE ABUSE (WHO?, WHAT?, TREATMENT?) HISTORY SUBSTANCE USE HISTORY - CURRENT / PREVIOUS WHAT?, WHEN?, HOW?, REGULARITY, QUANTITY ABUSE / DEPENDENCE ALCOHOL SMOKING (NICOTINE) ILLICIT DRUGS (CANNABIS, COCAINE, OPIOIDS, AMPHETAMINES, HALLUCINOGENS,INHALENTS ETC) PRESCRIPTION DRUGS (BENZODIAZEPINES, BARBITURATES ETC) FORENSIC HISTORY - ARRESTS, CHARGES & CONVICTIONS (WHEN?, WHAT FOR?, HOW MANY?) - PRISON SENTENCE / PSYCHIATRIC HOSPITAL STATE PATIENT TREATMENT (WHEN?, WHERE?) SOCIAL CIRCUMSTANCES - HOUSING (TYPE, LOCATION, WITH WHOM? ETC) - INCOME (FROM EMPLOYMENT / SOCIAL OR DISABILITY GRANT) PREMORBID PERSONALITY - WHAT TYPE OF PERSON WAS HE / SHE BEFORE THE PROBLEMS / SYMPTOMS / ILLNESS STARTED? HOBBIES & INTERESTS HISTORY PERSONAL HISTORY PRE- & PERINATAL - PLANNED PREGNANCY? COMPLICATIONS / MATERNAL SUBSTANCE USE DURING PREGNANCY? MATERNAL HEALTH? MODE OF DELIVERY (IF CAESARIAN SECTION, WHY?; IF NORMAL VAGINAL DELIVERY, WHERE?) COMPLICATIONS DURING LABOUR / DELIVERY? NEONATAL PROBLEMS / ILLNESSES? CHILDHOOD - HAPPY / TURBULANT? PRIMARY CAREGIVER? MILESTONES? ILLNESSES? DISCIPLINE? PHYSICAL / SEXUAL / EMOTIONAL ABUSE? SCHOOLING (AGE STARTED, WHERE?, SPECIFIC ACADEMIC PROBLEMS?, REPEATS?, HIGHEST GRADE COMPLETED, DISCIPLINARY PROBLEMS?, FRIENDS / LONER?) PROBLEMS WITH ATTENTION / HYPERACTIVITY? ENURESIS / ENKOPRESIS? PHOBIAS? DREAMS / FANTASIES HISTORY PERSONAL HISTORY ADOLESCENCE - RELATIONSHIPS WITH CARE GIVERS SEXUAL DEVELOPMENT, RELATIONSHIPS & ORIENTATION HOME ENVIRONMENT SCHOOL PROBLEMS? SOCIAL PROBLEMS? LEGAL PROBLEMS? ROLE MODELS? ADULTHOOD - FURTHER EDUCATION / TRAINING? (WHAT?, WHERE?) - OCCUPATIONS (SPECIFICS ABOUT DIFFERENT JOBS – WHAT?, WHEN?, WHERE?, HOW LONG?, REASON FOR LEAVING?) - RETRENCHMENTS - ROMANTIC RELATIONSHIPS & MARITAL HISTORY - MILITARY HISTORY - RELATIONSHIP / SOCIAL / FINANCIAL PROBLEMS? MENTAL STATE EXAMINATION GENERAL APPEARANCE & BEHAVIOUR - BUILD, POSTURE & FACIAL FEATURES CLOTHING, GROOMING & HYGIENE EYE CONTACT APPARENT LEVEL OF ANXIETY / CALMNESS MANNERISMS, TICS, ECHOPRAXIA, STEREOTYPED BEHAVIOUR / OTHER SIGNS OF CATATONIA CHOREA, ATHETHOSIS, RESTING TREMOR PSYCHOMOTOR ACTIVITY ATTITUDE & COOPERATION INTERACTION & RAPPORT SPEECH - QUANTITY & RATE (EG PRESSURED) QUALITY (RHYTHM, TONE, FLOW, VOLUME, MELODY, PROSODY, EMOTIONAL COLOURING) REPITITION SPEECH IMPAIRMENTS VOCABULARY COHERENT / DISORGANISED (SIGN OF THOUGHT FORM DISORDER) AFFECT - DEPTH & RANGE QUALITY (EG RESTRICTED, BLUNTED, FLAT) APPROPRIATENESS STABILITY / LABILITY MENTAL STATE EXAMINATION MOOD & RELATED SYMPTOMS - SUBJECTIVE EXPERIENCE OBJECTIVE ASSESSMENT (EG IRRITABLE, LOW, ELEVATED) ENERGY LEVELS MOTIVATION & CONCENTRATION FEELINGS OF HOPELESSNESS / HELPLESSNESS / WORTHLESSNESS / GUILT / DOOM / GRANDIOSITY / INVINCIBILITY - APATHY & ANHEDONIA / EXCESSIVE ENGAGEMENT IN POTENTIALLY HARMFUL PLEASURABLE ACTIVITIES VEGETATIVE SYMPTOMS - SLEEP (QUANTITY & PATTERN) - APPETITE & EATING BEHAVIOUR (QUANTITY & PATTERN) - LIBIDO & SEXUAL ACTIVITY ANXIETY & RELATED SYMPTOMS - GENERAL ANXIETY LEVELS PANIC ATTACKS (WHAT?, WHEN?, WHERE?, HOW MANY?) PHOBIAS (WHAT?, WHEN?, WHERE?) OBSESSIONS & COMPULSIONS (WHAT?, WHEN?, WHERE?) POSTTRAUMATIC STRESS SYMPTOMS IMPULSIVITY & ADDICTION RELATED SYMPTOMS & SIGNS - AGGRESSION SEXUAL BEHAVIOUR HAIR PLUCKING, NAIL BITING, SKIN PICKING GAMBLING, STEALING, ARSON EXCESSIVE SHOPPING, INTERNET / CELL PHONE USE MENTAL STATE EXAMINATION THOUGHTS THOUGHT FORM - LOGICAL, COHERENT, GOAL DIRECTED, RELEVANT RESPONSES? - PRESSURE / POVERTY OF THOUGHT? - DISORGANISED WITH CIRCUMSTANTIALITY, TANGENTIALITY, LOOSENING OF ASSOCIATIONS, DERAILMENT, THOUGHT BLOCKING, WORD SALAD, NEOLOGISMS, PUNNING, RHYMING, FLIGHT OF IDEAS, PERSEVERATION, VERBIGARATION? THOUGHT CONTENT - THEME? INTRUSIVE THOUGHTS? OVERVALUED IDEAS? MAGICAL THINKING? DELUSIONS (TYPE?, SPECIFIC CONTENT?, MOOD CONGRUENT / INCONGRUENT?) SUICIDAL THOUGHTS? PERCEPTIONS HALLUCINATIONS - TYPE? - SPECIFIC DETAIL ILLUSIONS DEPERSONALIZATION / DEREALIZATION DISSOCIATIVE SYMPTOMS ICTAL PHENOMENA (EG DÉJÀ VU) MENTAL STATE & PHYSICAL EXAMINATION SENSORIUM & COGNITION - LEVEL OF CONSCIOUSNESS (FLUCTUATION?) PERCEIVED INTELLIGENCE & GENERAL KNOWLEDGE IMMEDIATE, RECENT & REMOTE MEMORY ABSTRACT THOUGHTS (DIFFERENCES, SIMILARITIES, IDIOMS) JUDGEMENT INSIGHT INTO ILLNESS SIFTING TESTS FOR COGNITIVE FUNCTIONING: 1) MONTREAL COGNITIVE ASSESSMENT (MOCA) 2) FOLSTEIN MINI – MENTAL STATE EXAMINATION 3) MAYO MINI – MENTAL STATE EXAMINATION - RELIABILITY ADDITIONALLY, IN CHILDREN: - ASK CHILD TO DRAW A PICTURE (EG OF THE FAMILY) ASSESS DEVELOPMENTAL LEVEL (IS THERE A DEVELOPMENTAL DELAY? IF SO IN WHICH AREAS?) ASSESS AGE – APPROPRIATE READING, WRITING, MATHEMATICS ASSESS COORDINATION ASSESS UNDERSTANDING & ABILITY TO FOLLOW INSTRUCTIONS ASSESS EMOTIONS THROUGH FANTASY, PLAY & MAKE – BELIEVE SCENARIOS ASSESS PARENT – CHILD INTERACTION PHYSICAL EXAMINATION - FULL PHYSICAL EXAMINATION - THOROUGH NEUROLOGICAL EXAMINATION (ALSO TEST FOR PRIMITIVE REFLEXES) - SIFTING FOR FRONTAL LOBE ABNORMALITIES IN MOTOR PROGRAMMING SEQUENCING, ATTENTION, PLANNING, CONSTRUCTION, SET SHIFTING, VISIO-SPATIAL PERCEPTION, RESPONSE INHIBITION & VERBAL FLUENCY SPECIAL INVESTIGATIONS, RISK ASSESSMENT & SUMMARY SPECIAL INVESTIGATIONS - CHOSEN ACCORDING TO FINDINGS FROM HISTORY & PHYSICAL EXAMINATION - FBC, UKE, LFT, CMP, TFT, GLUCOSE, LIPOGRAM, RPR, HIV, ESR, CRP, VITAMIN B12 & FOLATE (BLOOD TESTS REGULARLY REQUIRED) - IRON STUDIES, HEAVY METALS, COPPER, DRUG LEVELS, LACTATE & PYRUVATE, GENETIC TESTS, AMMONIA, CREATININE CLEARANCE, ANTINUCLEAR ANTIBODIES, PORPHIRINS, ß - HCG (BLOOD TESTS OCCASIONALLY REQUIRED) - URINE DIPSTIX, URINE DRUG SCREEN - LUMBAR PUNCTURE - ECG - EEG - CT SCAN, MRI SCAN, SPECT SCAN RISK ASSESSMENT - DETERMINES URGENCY & LEVEL OF INTERVENTION REQUIRED ARE RISKS HIGH, MEDIUM OR LOW? ARE RISKS IMMEDIATE OR OVER THE SHORT – TERM OR LONG – TERM? ASSESS RISKS FOR SUICIDE, HARM TO SELF, HARM TO OTHERS, HARM TO SELF BY OTHERS, SELF – NEGLECT, ABSCONDING, SUBSTANCE ABUSE & NON – ADHERENCE TO TREATMENT SUMMARY - SUMMARIZE THE MOST RELEVANT INFORMATION ATTAINED - USED TO POINT TO THE MOST LIKELY DIAGNOSIS AND COURSE OF TREATMENT REQUIRED DIAGNOSTIC CLASSIFICATION DIAGNOSES ARE MADE ACCORDING TO THE DIAGNOSTIC & STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV-TR) THE OTHER PSYCHIATRIC CLASSIFICATION IS ACCORDING TO THE INTERNATIONAL CLASSIFICATION OF DISEASES (ICD-10) DSM CONTAINS DIAGNOSTIC CRITERIA WHICH ARE USED AS A DIAGNOSTIC GUIDE DSM ALSO STANDARDISES PSYCHIATRIC TERMINOLOGY & DIAGNOSES, WHICH ARE GROUPED INTO THE FOLLOWING CATEGORIES: - DISORDERS OF INFANCY, CHILDHOOD, OR ADOLESCENCE MENTAL DISORDERS DUE TO A GENERAL MEDICAL CONDITION SUBSTANCE – RELATED DISORDERS COGNITIVE DISORDERS PSYCHOTIC DISORDERS MOOD DISORDERS ANXIETY DISORDERS SOMATOFORM DISORDERS FACTITIOUS DISORDERS DISSOCIATIVE DISORDERS SEXUAL & GENDER IDENTITY DISORDERS EATING DISORDERS SLEEP DISORDERS IMPULSE - CONTROL DISORDERS ADJUSTMENT DISORDERS PERSONALITY DISORDERS DIAGNOSTIC CLASSIFICATION DSM USES A HOLLISTIC, MULTIAXIAL SYSTEM OF DIAGNOSIS: AXIS I - CLINICAL DISORDERS - OTHER CONDITIONS (V – CODES) THAT MAY BE A FOCUS OF CLINICAL ATTENTION (EG SEXUAL ABUSE) AXIS II - PERSONALITY DISORDERS - MENTAL RETARDATION AXIS III - GENERAL MEDICAL CONDITIONS AXIS IV - ENVIRONMENTAL & PSYCHOSOCIAL PROBLEMS / STRESSORS AXIS V - GLOBAL ASSESSMENT OF FUNCTIONING ALWAYS USE THIS MULTIAXIAL SYSTEM OF DIAGNOSIS SO THAT ALL THE DIFFICULTIES OF THE PATIENT CAN BE TREATED OR ATTENDED TO THE END