09 Mar The psychiatric examination is an essential aspect of patient care that a mental health nurse practitioner must know well to diagnose appropriately. According to Snyderman & Rovner (2009
The psychiatric examination is an essential aspect of patient care that a mental health nurse practitioner must know well to diagnose appropriately. According to Snyderman & Rovner (2009), "familiarity with the components of the psychiatric examination can help physicians evaluate for and differentiate psychiatric disorder." The psychiatric examination involves systematically gathering information, including many components such as the history of present illnesses, family history, personal history, medical history, psychiatric history, and suicide and violence risk assessment (Scher, 2018)). Among these components, the student found family history, medical history, and history of the present illness to be the most important when evaluating a patient for potential mental health concerns.
HISTORY OF THE PRESENT ILLNESS/CHIEF COMPLAINT
The history of the present illness is significant because it allows the patient to express the symptoms they are feeling and what is bothering them in their own words. Moreover, in return, if a patient or their loved ones is a good history, the clinician will have insights into what is going on with the patient at a differential diagnosis. During the interview, the clinician could have deduced other non-verbal clues from the patient which would aid their diagnosis. The student agrees that the history of the present illness is the most critical element of a psychiatric interview (Scher, 2018).
Family history is another vital component of the psychiatric interview because major psychiatric illnesses have a strong biological component, especially schizophrenia, bipolar, or depression. In the case of schizophrenia, family history is the strongest indicator and risk factor for developing schizophrenia (Mortensen et al., 2010). Genetics and hormonal plays a role in mental illness as it is in most medical condition. Moreover, a family history of a suicide attempt is a red flag. Therefore, a family history of mental illness is a key factor that a clinician should understand about a patient because it will help in profiling the patient and support diagnosis, especially in a patient who may present with comorbidity.
Medical history includes medical diagnosis, illness, medication profile, and recent laboratory results. In a psychiatric interview, it is essential for the clinician to no other conditions that could be interfering with the patient's mental health presentation. Also, there is some medical condition that the symptoms that could mimic mental health, like hyperthyroidism and hypothyroidism. Understanding the other medical condition that a patient has will guide medication choices. For instance, selective serotonin reuptake inhibitors may not be the medication of choice for a patient diagnosed with depression. In addition, medical history is critical in a psychiatric interview because of tolerance, side effects, and drug interaction.
Other factors like personal history, substance abuse, and past psychiatric history are equally important in a psychiatric interview.
Adult ADHD Self-Report Scale
As ADHD could persist into adulthood, the adult ADHD self-report scale for adults is a tool that can be used to screen for ADHD in adults to gain more knowledge in addition to doing a full psychiatric interview. It is a checklist with eighteen symptoms of DSM-5 criteria. The Adult ADHD self-report scale has two parts. First, some part of the response is shaded, and the further the patient is into the dark shaded area in response, the likelihood of them having ADHD is higher.
ADHD self-report for adults is a tool aligned with DSM-5 diagnostic criteria for ADHD in adults. In a study of 960 participants, it was found that the Adult ADHD self-report scale is easy to use and also has high diagnostic accuracy for ADHD in adults (Brevik et al., 2020). In addition, according to Brevik et al. (2020), “Retrospective childhood symptoms of aggressiveness and social problems are highly predictive of an adult diagnosis of attention-deficit hyperactivity disorder.”
In another study adult ADHD self-report scale was described as a sensitive screener for identifying possible ADHD cases, with very few missed cases among those screening negative in this population (Van de Glind et al., 2013). Therefore, based on the presented information about the adult ADHS self-report scale in the write-up, the student concluded that it is an excellent tool for diagnosing ADHD in adults.
Adult ADHD Self-Report Scale for Adults (n.d) retrieved: 10852_elto_question_fhp2.PDF (add.org)Links to an external site.
Brevik, E. J., Lundervold, A. J., Haavik, J., & Posserud, M. B. (2020). Validity and accuracy of the adult attention‐deficit/hyperactivity disorder (ADHD)
self‐report scale (ASRS) and the Wender Utah rating scale (WURS) symptom checklists in discriminating between adults with and without ADHD. Brain and behavior, 10(6), e01605.
Mortensen, P., Pedersen, M., & Pedersen, C. (2010). Psychiatric family history and schizophrenia risk in Denmark: Which mental disorders are
relevant? Psychological Medicine, 40(2), 201-210. doi:10.1017/S0033291709990419
Scher, L. M., (2018). Psychiatric Interview. Medscape.com
Psychiatric Interview: Overview, Identification and Chief Symptom, History of Present Illness (medscape.com)Links to an external site.
Snyderman, D. & Rovner, B. W. (2009). Mental Status Examination in Primary Care: A Review. American Family Physician, 80(8), 809–814.
Van de Glind, G., van den Brink, W., Koeter, M. W., Carpentier, P. J., van Emmerik-van Oortmerssen, K., Kaye, S., … & IASP Research Group. (2013).
Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. Drug and alcohol dependence, 132(3), 587-596.
Student respone 2
The psychiatric interview can be divided into three main components, which are all essential to a provider helping a patient. Establishing a relationship with the patient, collecting pertinent psychiatric data to formulate a diagnosis and treatment plan, and discussing the plan with the patient are all vital to the initial treatment process. The purpose of this discussion is to explain the three components of the psychiatric interview including their importance, and explain the psychometric properties of the Overt Aggression Scale—Modified (OAS-M).
The Components of the Psychiatric Interview
- Phase one – Alliance Building: During this phase of the interview, the provider can obtain a significant amount of information about the patient’s life (demographics) and what brings them to treatment (the chief complaint). Allowing your patient about 5 minutes of free speech accomplishes two things, (1) it gives the patient the sense that you are interested in listening and (2) it increased the likelihood that the provider will understand the issues troubling the patient, which contributes to the development of a correct diagnoses and treatment plan (Carlat, 2017). This is a crucial period for alliance building between the provider and the patient. During these first moments, the patient is already deciding on the providers’ trustworthiness as they are prompted to reveal their deepest and most shameful secrets to a stranger (Carlat, 2017). A psychiatric interview is anxiety-provoking, making this first phase of getting to know each other necessary. Furthermore, this initial phase of allowing free speech helps the clinician begin formulating a list of potential diagnoses (Carlat, 2017). Just from this short time you can discern if the patient appears depressed or manic, is talking fast, has organized thoughts, is cognitively impaired, smells of alcohol, or seems agitated or anxious (Carlat, 2017). This portion of the interview process will set the tone for the next two phases.
- Phase two – Data Collection: After the patient has shared their chief complaint and some details about their life, the provider may be able to determine some priorities to explore, such as substance abuse, depression, or trauma. The provider will start by obtaining historical information relevant to the current clinical presentation (Carlat, 2017). This information includes the psychiatric history (including the history of the present episode), medical history, family psychiatric history, and aspects of the social and developmental history. Also, in this phase is the psychiatric review of symptoms to formulate a correct diagnosis. During this phase, the provider will test their diagnostic hypotheses using probing questions to determine what symptoms match the DSM-5 diagnostic criteria (Carlat, 2017). It also guides the provider in determining the components of the treatment plan. An important piece of this portion of the interview is determining what psychiatric treatments the patient has trialed because this can help the provider determine which treatments have or have not worked including side effects and adherence (American Psychiatric Association, 2020).
- Phase three – Education: The closing phase of the interview is when the provider provides education to the patient while discussing the assessment findings and comes up with an agreement about treatment or follow-up plans (Carlat, 2017). This phase is essential because without the patient being onboard with the plan, it won’t be successful. When a patient feels like they have a say in their treatment, they are more likely to follow through and stick to the prescribed regimen.
Overt Aggression Scale—Modified (OAS-M)
The OAS-M is a four-part behavior rating scale conducted as an interview to evaluate the frequency and severity of impulsive aggressive episodes (Coccaro, 2020). The DSM-5 characterizes this type of aggression as recurrent, problematic, impulsive aggression called Intermittent Explosive Disorder (IED) (Coccaro, 2020). This tool helps practitioners assess patients’ aggression frequency and severity over a period of time in an outpatient setting plus their response to treatment. Though IED does not currently have any FDA-approved treatment interventions, some clinical trials have shown medications to be effective in decreasing aggressive episodes (Coccaro, 2020). This tool provides a starting point or a baseline for providers and a method of determining the effectiveness of an intervention. A nurse practitioner would first use this scale during the initial assessment portion of the interview as they collect other pertinent diagnostic information. They would then re-administer this scale periodically throughout treatment to assess intervention effectiveness. The psychometric properties of the OAS-M are adequate for the measurement of aggression over the course of one week of observation for cross-sectional research and clinical trials of interventions that attempt to reduce aggression (Coccaro, 2020). It demonstrates reliability, internal consistency, and convergent, divergent, and discriminant validity (Coccaro, 2020).
American Psychiatric Association. (2020). Practice guidelines for the psychiatric
evaluation of adults, third edition. Retrieved from
Carlat, D. J. (2017). The psychiatric interview (4th ed.). Wolters Kluwer.
Coccaro E. F. (2020). The Overt Aggression Scale Modified (OAS-M) for clinical trials targeting impulsive aggression and intermittent explosive disorder: Validity, reliability, and correlates. Journal of psychiatric research, 124, 50–57. https://doi.org/10.1016/j.jpsychires.2020.01.007
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