EVALUATION & DIAGNOSTIC
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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.

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EVALUATION & DIAGNOSTIC

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Evaluation diagnostic

EVALUATION & DIAGNOSTIC

CLASSIFICATION

DR GIAN LIPPI

CONSULTANT PSYCHIATRIST

UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL

FORENSIC UNIT


Evaluation diagnostic

EVALUATION

GREETING & INITIAL OBSERVATION

BASELINE DEMOGRAPHIC DETAILS

HISTORY

MENTAL STATE EXAMINATION

PHYSICAL EXAMINATION

SPECIAL INVESTIGATIONS

RISK ASSESSMENT

SUMMARY

DIAGNOSIS


Evaluation diagnostic

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?


Evaluation diagnostic

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


Evaluation diagnostic

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)


Evaluation diagnostic

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?)


Evaluation diagnostic

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


Evaluation diagnostic

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


Evaluation diagnostic

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?


Evaluation diagnostic

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


Evaluation diagnostic

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


Evaluation diagnostic

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)


Evaluation diagnostic

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


Evaluation diagnostic

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


Evaluation diagnostic

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


Evaluation diagnostic

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


Evaluation diagnostic

THE END


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