Wednesday, February 04, 2009

Chapter Two, Section One: The Psych Eval


We've mentioned that the Shrink Rappers have a book proposal out there. It's gone through two review processes, with one more to go before we'll know if it's a go. Still no final name, our editor and Roy are both unhappy with Off the Couch...

Okay, so I thought I'd try to write a piece of a chapter here and see what our Shrink Rap readers think.... this is rough, I'm typing as I go, so the pre-draft, if such a thing exists. Here goes:

Tell Me About Yourself: The Psychiatric Evaluation

Josh Ford has never been so tired in all his life. He was the starting quarterback on his high school football team, and a pretty decent shortstop as well, even though he suffers from asthma. He was always a good student and he didn't have any trouble making friends in the dorm when he went to college. It's the Spring semester of his sophomore year, and Josh is just not feeling well. Josh has lost interest in hanging out with his friends, he's virtually stopped going to class, he sleeps long hours-- even for a college kid-- and when he went home for Spring Break, his parents were shocked to see he'd lost twenty pounds. His primary care doctor could find nothing wrong, and Josh admitted to him that he's feeling pretty down and hopeless, suicidal even. Josh was told he's suffering from depression and a psychiatric evaluation was recommended.

So Josh is not real, he's a figment of the Shrink Rap imagination. We'll borrow him to walk us through different aspects of this Chapter, called All in A Day's Work.

The purpose of a psychiatric evaluation depends, in part, on the setting in which it is conducted. In an outpatient setting where the patient will go for on-going treatment, the psychiatric evaluation is used to make a diagnosis and formulate a treatment plan. It offers the psychiatrist a chance to hear the patient's history and gather information necessary to do those things, and it gives the patient a chance to see if he's comfortable working with the psychiatrist. In an Emergency Department, the purpose is much different. The mental health professionals in the ED will not be offering on-going care and their goal is to determine if the patient requires hospitalization, and if not, then to provide an outpatient referral. The issues in an emergency setting are often focused around determining safety. In an outpatient setting, the psychiatrist may be interested in hearing many details about the patient's life, in other settings, the focus may be more on the acute symptoms that have brought the patient to care now.

So Josh goes to see a psychiatrist. This particular psychiatrist schedules the evaluation as a two hour session. Some psychiatrists allow one hour, some allow two, and some designate the first few sessions as a time to diagnose and make a plan. In clinics, the psychiatric evaluation is usually done in one hour, and the evaluating psychiatrist may or may not be the treating psychiatrist, depending on how the clinic is set up.

The questions the psychiatrist asks Josh may depend on the particular orientation of the psychiatrist. Some psychoanalysts leave the patient the space to tell their own story and ask very few questions. Most psychiatrists do a very structured interview to collect very specific information.

Like Josh's fictional psychiatrist, I usually allow two hours to see a patient on the first visit. I start by asking about what brings the patient to treatment: what doctors call the Chief Complaint. I then ask ask when the problem started and ask questions about what may have precipitated the problem-- did something upset Josh? How long has he been depressed? Did it come on suddenly or gradually? What symptoms is he having and how much are they interfering with his life? This is called the History of Present Illness. Psychiatrists have different styles of doing interviews, and I actually like to take a history backwards. Once I've heard about the current problem, I ask the patient if I can ask about their past and come back to the current problem later. I then ask questions about the family: Who is in it? What are their occupations? Are they healthy? What are the patient's relationships with other like? I then specifically ask about any history of psychiatric illness in family members, specifically blood relatives, and I ask the question in several different ways because genetics are so important in psychiatry. Josh's mother, we learn, has bipolar disorder, and a sister has been treated for panic attacks.

Once I've learned about the patient's family, I ask about their personal history from gestation forward. Were there problems in childhood with health, behavior, or development. I want to know details about education, occupation, encounters with the law, and romance. If there are children, I want to hear about them. I then ask about drug and alcohol use, medical and surgical issues, a list of current medications, drug allergies. At this point, I feel like I've gotten some lay of who my patient is as a person, who is important in their lives, and what has transpired. I then ask about their past psychiatric encounters, though most psychiatrists do this much sooner in the interview. What's important? Past diagnoses, hospitalizations, episodes of suicidality or violence towards others, and what treatments have been tried. I want to know the response to every treatment: were the outcomes good or bad. If medications have been used, then ideally I want to know each medication, the maximum dose that was taken, if the response was good or bad, and why the medication was stopped. In the course of taking the history, Josh's new psychiatrist learned that Josh had fairly severe asthma and he'd been to the Emergency Department a couple of time a year as a child for acute episodes of bronchospasm. He'd never seen a mental health professional before, but in high school he'd had a pretty rough period after a girlfriend broke up with him and he felt now a bit like he'd felt back then. He had not been as depressed during that episode, though his grades did drop during that marking period. Josh has never had any symptoms of mania, a condition which in which mood, energy, and activity are elevated, rather than depressed.

The final part of the psychiatric evaluation is called the mental status exam. This is the psychiatrist's version of a physical exam, only it's not physical! The patient is assessed and described, much as a novelist might write a character analysis, but in a formulaic way. The psychiatrist will observe and record anything notable about the patient's appearance. In Josh's case, he presents as a neatly groomed, casually dressed young man who appears his stated age. The doctor will note any abnormal movements (meaning neurologic problems, such as tics). The patient's speech will me noted if something is unusual. In Josh's case, he moves rather slowly, and it takes him a long time to get his thoughts organized. He talks quietly and slowly, but his thoughts are expressed logically. Mood is assessed in several ways: the patient is often simply asked about his mood, his energy, his participation in his usual activities. Is his libido the same, and are there changes in his sleep and appetite. He may be asked specifically about feelings of hopelessness or suicidal thoughts. Josh reports that he is sad all the time, that he often cries, and that he is feeling guilty and hopeless. He has had thoughts about suicide and has entertained ideas about how he might do it, but he feels these are just thoughts and is certain he won't act on them. The patient is then asked if he's having any usual perceptions: is he hearing voices or seeing things that are not there? False perceptions are called hallucinations. Does the patient have an accurate assessment of reality, or is he suffering from delusions? Sometimes it's difficult to tell what is a delusion and what is real, and this is where it helps to have an outside informant. The patient is asked about obsessive and compulsive phenomena. Josh is not having any hallucinations or delusions, and he's not suffering from any obsessive or compulsive phenomena. Finally, the patient's cognitive state is assessed. If it's not obvious that the patient is fully aware of his surroundings, then he may be asked questions about where he is, the date, current events, and a brief test called a Mini-mental status exam may be administered. Finally, the psychiatrist makes an estimate as to the patient's intelligence, insight, and judgment, based on what he has heard.

After the mental status exam, any relevant laboratory or radiologic tests are listed. The data collection is now complete, and the psychiatrist writes an impression, where he lists the important findings and may discuss his thoughts about what might be going on. A formal diagnosis is given which may include provisional diagnoses, as well as diagnoses to be ruled out. It is here, in the five axis diagnosis, that the psychiatrist lists Josh's diagnosis: he believes Josh has Major Depression, moderate to severe in intensity, possibly recurrent, without any psychotic phenomena. He notes that Josh has asthma, he lists any major current stressors, and he makes an assessment as to Josh's overall level of functioning. A course of treatment is outlined, and in Josh's case, it includes starting a medication and psychotherapy. If you stick with us through the rest of the chapter, you'll find there are some surprises, and Josh does not have either a simple or uneventful recovery.