Module 2 Objectives
1. Describe the components of the mental status examination
2. Discuss the Psychiatric Assessment across the Lifespan
3. Demonstrate/practice proficiency in presenting a psychiatric case to your preceptor
🧭 Module 2 Learning Pathway
1. Review readings and learning materials posted in the module Learning Materials.
2. Listen to the Assessment and Diagnosis Exercise Recording under Learning Materials.
General Principles of Assessment and Diagnosis
Objectives
•Identify the goals of assessment
• Describe interview techniques
• Discuss case formulation
• Examine the diagnostic process
INTRODUCTION: ASSESSMENT OF PSYCHIATRIC DISORDERS
For better or for worse, an assessment is a relational process. It represents a verbal and
nonverbal dialogue between two therapeutic partners, whose behaviors reciprocally influence
each other’s style of communication and result in a specific pattern of interaction (Shea, 2017).
To the degree that this pattern of interaction transcends its question-and-answer format to
constitute an authentic encounter between the patient and the therapist, an assessment can
play a significant role in the change process (Safran & Muran, 2000).
,GOALS OF THE CLINICAL ASSESSMENT
?…
TAKING A HISTORY
Fundamentally, the comprehensive psychiatric history is a form of life story told to the
therapist by a patient in their own words and from their own point of view (Sadock,
Sadock, & Ruiz, 2015).
•Obtaining a comprehensive history from the patient and, if necessary, from informed
sources close to the patient is essential to making an accurate, culturally appropriate
diagnosis and developing a specific, culturally sensitive, and effective treatment plan.
•Taking a history allows the therapist and ultimately the patient to more completely
understand who the patient is, where the patient has come from, and how the patient
may develop in the future.
Fundamentally, the comprehensive psychiatric history is a form of life story told to the
therapist by a patient in their own words and from their own point of view (Sadock,
Sadock, & Ruiz, 2015).
ANATOMY OF A 60-MINUTE ASSESSMENT
During the first 5-7 min…
•Chief Complaint
•Free Speech – the time it takes for the pt to narrate his or her story
By the end of the first 30 minutes, the therapist should be nearing completion of the most
pertinent content regions for the HPI.
During the 3rd 15 min…
•Family Hx
•Medical Hx
, •Social Hx
•MSE
During the last 15 min..
•Complete major sections of psych hx
•Clarify final points
•Discuss findings
•Tx recommendations
•Follow-up plan
•Process pt’s experience
•Answer pt questions
•Termination occurs
Opening moves
Introduce yourself to the patient and orient them to how long you will be meeting.
In settings where a comprehensive history must be completed in one session, the therapist
must accomplish a number of important alliance-building tasks in the first minutes of the initial
assessment
ASSESSMENT QUESTIONS: CONTINUUM OF OPENNESS
● A nondirective interview style with open-ended questions yields control to the patient,
generally builds rapport, and garners facts that are more reliable. Closed—ended
questions elicit the specific details.
● Open ended types
○ Open-Ended Questions
■ •“What brings you in today?”
■ •“How can I help you?”
○ •Gentle Commands
■ •“Tell me about your family situation.”
, ■ •“Try to describe how you felt when…”
● Intermediate types
○ Swing Questions
■ •“Can you tell me more about that?”
○ •Qualitative Questions
■ •“How is school going?”
○ •Statements of Inquiry
■ •“You say you just want to stay in bed all of the time?”
○ •Empathic Statements
■ •“That is very frustrating.”
○ •Facilitating Statements
■ •“Go on.”
● Closed ended types
○ Closed-Ended Questions
■ •“How many drinks did you have?”
■ •“How often do you feel that way?”
○ •Closed-Ended Statements
■ •“You can sit down here.”
■ •“Medications can be very effective in these cases.”
MAJOR SECTIONS OF THE PSYCHIATRIC HISTORY
● Reason for the evaluation
○ Identifying data
○ Source and reliability of data
○ Chief complaint
● History of the present illness
○ Symptoms
○ Stressors
● Past psychiatric history
1. Describe the components of the mental status examination
2. Discuss the Psychiatric Assessment across the Lifespan
3. Demonstrate/practice proficiency in presenting a psychiatric case to your preceptor
🧭 Module 2 Learning Pathway
1. Review readings and learning materials posted in the module Learning Materials.
2. Listen to the Assessment and Diagnosis Exercise Recording under Learning Materials.
General Principles of Assessment and Diagnosis
Objectives
•Identify the goals of assessment
• Describe interview techniques
• Discuss case formulation
• Examine the diagnostic process
INTRODUCTION: ASSESSMENT OF PSYCHIATRIC DISORDERS
For better or for worse, an assessment is a relational process. It represents a verbal and
nonverbal dialogue between two therapeutic partners, whose behaviors reciprocally influence
each other’s style of communication and result in a specific pattern of interaction (Shea, 2017).
To the degree that this pattern of interaction transcends its question-and-answer format to
constitute an authentic encounter between the patient and the therapist, an assessment can
play a significant role in the change process (Safran & Muran, 2000).
,GOALS OF THE CLINICAL ASSESSMENT
?…
TAKING A HISTORY
Fundamentally, the comprehensive psychiatric history is a form of life story told to the
therapist by a patient in their own words and from their own point of view (Sadock,
Sadock, & Ruiz, 2015).
•Obtaining a comprehensive history from the patient and, if necessary, from informed
sources close to the patient is essential to making an accurate, culturally appropriate
diagnosis and developing a specific, culturally sensitive, and effective treatment plan.
•Taking a history allows the therapist and ultimately the patient to more completely
understand who the patient is, where the patient has come from, and how the patient
may develop in the future.
Fundamentally, the comprehensive psychiatric history is a form of life story told to the
therapist by a patient in their own words and from their own point of view (Sadock,
Sadock, & Ruiz, 2015).
ANATOMY OF A 60-MINUTE ASSESSMENT
During the first 5-7 min…
•Chief Complaint
•Free Speech – the time it takes for the pt to narrate his or her story
By the end of the first 30 minutes, the therapist should be nearing completion of the most
pertinent content regions for the HPI.
During the 3rd 15 min…
•Family Hx
•Medical Hx
, •Social Hx
•MSE
During the last 15 min..
•Complete major sections of psych hx
•Clarify final points
•Discuss findings
•Tx recommendations
•Follow-up plan
•Process pt’s experience
•Answer pt questions
•Termination occurs
Opening moves
Introduce yourself to the patient and orient them to how long you will be meeting.
In settings where a comprehensive history must be completed in one session, the therapist
must accomplish a number of important alliance-building tasks in the first minutes of the initial
assessment
ASSESSMENT QUESTIONS: CONTINUUM OF OPENNESS
● A nondirective interview style with open-ended questions yields control to the patient,
generally builds rapport, and garners facts that are more reliable. Closed—ended
questions elicit the specific details.
● Open ended types
○ Open-Ended Questions
■ •“What brings you in today?”
■ •“How can I help you?”
○ •Gentle Commands
■ •“Tell me about your family situation.”
, ■ •“Try to describe how you felt when…”
● Intermediate types
○ Swing Questions
■ •“Can you tell me more about that?”
○ •Qualitative Questions
■ •“How is school going?”
○ •Statements of Inquiry
■ •“You say you just want to stay in bed all of the time?”
○ •Empathic Statements
■ •“That is very frustrating.”
○ •Facilitating Statements
■ •“Go on.”
● Closed ended types
○ Closed-Ended Questions
■ •“How many drinks did you have?”
■ •“How often do you feel that way?”
○ •Closed-Ended Statements
■ •“You can sit down here.”
■ •“Medications can be very effective in these cases.”
MAJOR SECTIONS OF THE PSYCHIATRIC HISTORY
● Reason for the evaluation
○ Identifying data
○ Source and reliability of data
○ Chief complaint
● History of the present illness
○ Symptoms
○ Stressors
● Past psychiatric history
