Chapter 32Approach to the Psychiatric Consultation

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour reflecting dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as death of a loved one, is not a mental disorder. Socially deviant behaviour (e.g., political, religious, or sexual) and conflicts primarily between individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual.

The diagnosis of a mental disorder should have clinical utility: to determine prognosis, treatment plans, and potential outcomes, etc. However, the diagnosis of a mental disorder is not equivalent to a need for treatment. Need for treatment is a complex clinical decision taking into consideration symptom severity, symptom salience (e.g., presence of suicidal ideation), distress associated with the symptom(s), disability related to the symptoms, risks and benefits of available treatments, and other factors (e.g., psychiatric symptoms complicating other illness). Clinicians may thus encounter individuals whose symptoms do not meet full criteria for a mental disorder but who demonstrate a clear need for treatment or care. The fact that some individuals do not show all symptoms indicative of a diagnosis should not be used to justify limiting their access to appropriate care.

• Standard nomenclature
• Suggests treatment
• Communication among professionals
• Administrative Functions (Insurance)
• Improved understanding for families

• Stigma, Labelling and Social Discrimination → use person-first language: Robert has schizophrenia, not Robert is a schizophrenic
• Self-Stigmatization and Demoralization

• Civil: Involuntary hospitalization and treatment
• Criminal: Fitness to stand trial and criminal responsibility

• Medportal eLearning Course Modules (requires Medportal Login): The Comprehensive Psychiatric Interview; Intro to Mental Status Exam; Glossary of Mental Status Exam Terms (optional)
• Archived Lecture: Psychiatry Clinical Skills: Assessment and Reporting (requires Medportal Login)
• MacHealth Social Determinants of Child Mental Health online course

• John Doe is a 25-year-old black cisgender male (he/him) who works as an auto mechanic and lives at home by himself.

• Is the patient a good historian? Did you collect any collateral history? Did you consult electronic health record information as part of this consult note? Did you refer to another clinician involved in the patient’s care?

• Mr./Ms. _________ was referred for a Hx of _________________.
• If not a referral, can directly quote the patient’s CC (e.g. “I wish I wasn’t here.”)

As Usual: Feelings (F); Ideas (I); Functioning (F); Expectations (E)

Different from the OPQRST Approach in general medical consults

• Purpose: Provide account of circumstances leading up to current presentation. If this is the first psychiatric consult, want a thorough history for first psychiatric evaluation. If this is the most recent consult (i.e. past psychiatry consults for similar issues on their electronic health record), you can focus more-so on interval history since that consult note.
  • Items to include: Relevant recent events in patient’s life and their responses to these events; Presenting symptoms/ behaviours; Health-seeking behaviour (recent treatments and interventions)
  • Why now: Why are they presenting for help now? → Informs precipitating, perpetuating, protective factors
  • Impact of illness on social/work/academic functioning: E.g. for anxiety disorders, what patterns of avoidance does the patient engage in? Do they depend on having friends or use of alcohol to endure/overcome anxious avoidance?

Informing predisposing factors in formulation

• Anchor this episode in relation to past episodes: Quantify number of episodes; worst; first; most recent; best recalled; and longest episodes
• Previous hospitalizations: Including admission circumstances, diagnoses

• How long did you take past medications? What was your response like to the medications? What side-effects did you have? Why were the medications discontinued?

• Non-Pharmacological: e.g. other clinicians; psychotherapy; self-help books; other resources accessed - document which treatments are ongoing, and their frequency.
• What was your response to these treatments? Why were these treatments stopped?

• Previous Suicide Attempts; history of self-harm; When was the most recent attempt?

• History of harm to others; When was the most recent attempt?

Purpose: ask high sensitivity questions and cast a wide net

Constitutional; Derm; Head; Eyes; Ears; Nose; Mouth; Resp; Cardiovascular; Breast; GI; GU; Obs/Gyn; Endocrine; MSK; Neuro

1. Acute or Chronic conditions; Past hospitalizations; Past investigations (MRI, CT, etc.); Obstetrical, Gynecological History
2. Screening for Medical Causes of Mood & Anxiety Disorders (e.g. Multiple Sclerosis, Pancreatic cancer, Post-Stroke, Post-Myocardial Infarction, Thyroid disease, B12 deficiency, Systemic Lupus Erythematosus, R-sided subcortical lesions, Head Trauma, Seizures, Episodes of Loss of Consciousness, Treatment with L-DOPA or Corticosteroids)
3. Screening for Substance Use Influencing Anxiety symptoms: e.g. caffeine, EtOH, Street drugs, OTC, herbal remedies.
4. Risk Factors for Vascular Dementia: Hypertension (also ↑ risk for Alzheimer dementia); Dyslipidemia; Coronary Artery Disease (CAD); Cerebrovascular Disease (e.g. stroke)

Usual: What it was, opened up, when, what hospital…

• Electroconvulsive Therapy (ECT): e.g. for treatment-resistant depression, 2nd line for acute mania/bipolar I or II depression, schizophrenia, schizoaffective disorder, catatonia, neuroleptic malignant syndrome.
  • Clarify number of treatments, treatment frequency, unilateral vs. bilateral (bilateral has ↑ risk of retrograde amnesia)
• Deep Brain Stimulation (DBS): Placement of electrodes into target area of brain
  • Neurologic Indications for Deep Brain Stimulation: Advanced Parkinson Disease; Epilepsy; Essential Tremor; Dystonia
  • Psychiatric Indications for Deep Brain Stimulation: Obsessive compulsive disorder; Refractory major depression

• Psychiatric diagnoses; hospitalizations; substance use disorders; suicide history
• Strong genetic component to mood & anxiety disorders: 1st degree relative have mood or anxiety disorder? Did a particular medication help? (may also be helpful to patient)

• Usual: Diseases – age of onset, complications

• Early-Onset Alzheimer Disease (Age <65 years old): Clearer genetic risk with autosomal dominant inheritance re. genetic mutations altering amyloid beta protein production, aggregation, or clearance.
• Late-Onset Alzheimer Disease (Age ≥65 years old): 1st degree relative or multiple affected siblings ↑ risk; Apolipoprotein E4 allele also ↑ risk
• Frontotemporal Dementia: Highly heritable disease

• Motor, verbal and social milestones
• How was your childhood? Who did you grow up with? What was the birth order?
• Screen for anxiety at early age: Did they have separation anxiety? Were they afraid of the dark? Difficulty attending school or giving presentations?
• How did you deal with conflicts as a child? Who did you turn to when you were upset? What coping strategies did you make use of?
• Screen for history of abuse – physical, sexual, verbal, emotional

• Any bullying at school (as a perpetrator or as a victim/survivor)?
• How were you as a student? Did you enjoy school?
• Any drug or alcohol use while in school?

• Studies: highest level of education attained? Are you still in school/plan to return?
• Occupation: First paid employment; pattern of jobs; longest job held; current job

• Focus for Psychiatric Consult: Age of onset/attitude to puberty; sexuality; sexual abuse, intimate-partner violence; first intimate relationship; pattern of relationships; first enduring relationship; longest relationship; marital status; children; current relationship
• Sexual Hx: Sexual activity; contraception/STI protection and Hx; Abuse Hx; Past pregnancies

• Living arrangements; Support system; Finances; Smoking; Alcohol; Recreational drugs; diet & exercise; travel history

Name, Dose, Route, When Taken, How Long On…

5. Be sure to list all medications, not only psychiatric-related medications
6. Common Medication Classes in Brain and Behaviour:
   • Selective Serotonin Reuptake Inhibitors (SSRIs): e.g. Escitalopram; Sertraline; Citalopram; Fluoxetine; Fluvoxamine; Paroxetine
   • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs): e.g. Venlafaxine, Duloxetine, Desvenlafaxine; Milnacipran
   • Noradrenaline/Specific Serotonergic Antidepressants (NASSAs): e.g. Mirtazapine, Mianserin
   • Norepinephrine-Dopamine Reuptake Inhibitor (NDRIs): e.g. Bupropion
   • SSRI/ 5-HT1A receptor agonist and 5-HT3 receptor antagonist: e.g. Vortioxetine
   • Melatonin Receptor Agonist: Agomelatine
   • Tricyclic Antidepressant (TCAs): Amitriptyline; Nortriptyline; Clomipramine; Imipramine; Desipramine
   • Monoamine Oxidase (MAO) inhibitors (caution – risk of serotonin syndrome, hypertensive crisis, drug-food interaction, overdose – not commonly prescribed): e.g. Moclobemide (reversible inhibitor); Selegiline (irreversible inhibitor)
   • Antiseizure Drugs (ASDs): e.g. Divalproex; Pregabalin; Lamotrigine
   • Typical Antipsychotics: e.g. Haloperidol; Chlorpromazine; Methotrimeprazine; Loxapine
   • Atypical Antipsychotics: e.g. Aripiprazole; Quetiapine; Risperidone; Olanzapine; Ziprasidone; Brexpiprazole; Asenapine; Paliperidone; Cariprazine; Lurasidone; Clozapine
   • Mood Stabilizers: e.g. Lithium
   • Benzodiazepines: Alprazolam; Clonazepam; Lorazepam; Diazepam

Take any supplements…

What happens when rxn happens…?

Note: Recommendations listed are for general adult population; unique considerations and recommendations for pediatric populations, patients who are pregnant, and elderly populations

• Major Depressive Disorder:
  • 1st Line Antidepressants with evidence of superior efficacy:
    • Escitalopram (SSRI); Sertraline (SSRI); Mirtazapine (NASSA); Venlafaxine (SNRI)
  • 1st Line Adjuncts for Non-response or Partial Response to Antidepressant:
    • Atypical Antipsychotics: Aripiprazole; Quetiapine; Risperidone
  • Note: Rx-Induced Mania: Antidepressants can induce a manic episode; if you encounter this history, look for evidence of true spontaneous manic or hypomanic episodes.
• Generalized Anxiety Disorder:
  • 1st Line – SSRIs: Escitalopram; Paroxetine; Sertraline
  • 1st Line – SNRIs: Duloxetine; Venlafaxine XR
  • 1st Line – Other: Pregabalin (ASD); Agomelatine (Melatonin Receptor Agonist)
• Panic Disorder:
  • 1st Line- SSRIs: Citalopram; Fluoxetine; Fluvoxamine; Paroxetine; Sertraline; Escitalopram; Paroxetine CR
  • 1st Line – SNRIs: Venlafaxine XR; Duloxetine; Milnacipran
• Social Anxiety Disorder:
  • 1st Line – SSRIs: Escitalopram; Fluvoxamine; Paroxetine; Sertraline
  • 1st Line – SNRI: Venlafaxine XR
  • 1st Line – ASD: Pregabalin
• Obsessive-Compulsive Disorder:
  • 1st Line – SSRIs: Escitalopram; Fluoxetine; Fluvoxamine; Paroxetine; Sertraline
• Posttraumatic Stress Disorder:
  • 1st Line – SSRIs: Fluoxetine; Paroxetine; Sertraline
  • 1st Line – SNRI: Venlafaxine XR
  • Note: Prazosin (α1-antagonist) in PSTD utility to ↓ trauma nightmares, ↑ sleep quality
• Bipolar Affective Disorder:
  • Acute Mania:
    • 1st Line – Mood Stabilizer: Lithium
    • 1st Line – Antiseizure Drug (ASD): Divalproex
    • Atypical Antipsychotics: Quetiapine; Aripiprazole; Asenapine; Risperidone; Paliperidone; Cariprazine
  • Acute Bipolar I Depression:
    • 1st Line – Atypical Antipsychotics: Quetiapine; Lurasidone ± Lithium/Divalproex
    • 1st Line – Mood Stabilizer: Lithium
    • 1st Line – Antiseizure Drug (ASD): Lamotrigine
  • Bipolar I Maintenance Treatment:
    • 1st Line – Mood Stabilizer: Lithium
    • 1st Line – Antiseizure Drug (ASD): Divalproex; Lamotrigine
    • 1st Line – Atypical Antipsychotics: Asenapine; Quetiapine ± Lithium/Divalproex; Aripiprazole ± Lithium/Divalproex
  • Acute Hypomania: Limited evidence – where hypomania frequent, severe or impairing enough to require treatment, consider similar treatments as acute mania (i.e. lithium, divalproex, or atypical antipsychotics)
  • Acute Bipolar II Depression → 1st Line – Atypical Antipsychotic: Quetiapine
  • Bipolar II Maintenance:
    • 1st Line – Mood Stabilizer: Lithium
    • 1st Line – Antiseizure Drug (ASD): Lamotrigine
    • 1st Line – Atypical Antipsychotic: Quetiapine
• Choosing Wisely Canada Recommendations – Psychiatry²:
  • “Don’t use SSRIs as the first line-intervention for mild-to-moderately depressed teens.”
  • “Don’t routinely use antidepressants as first-line treatment for mild or subsyndromal depressive symptoms in adults.”
  • “Don’t routinely continue benzodiazepines initiated during an acute care hospital admission without a careful review and plan of tapering and discontinuing, ideally prior to hospital discharge.”
  • Neurology: “Don’t treat women of childbearing potential with Valproic acid if other effective treatments are available.”

• First Episode Schizophrenia: Recommend treat with an antipsychotic for at least 2 weeks then reassess – following resolution of positive symptoms of first episode of schizophrenia, maintenance treatment recommended for at least 18 months. No specific antipsychotic recommendation, recommend shared-decision making – note that typical antipsychotics may have higher discontinuation rate vs. atypical antipsychotics
• Acute Exacerbation of Schizophrenia: Adjust antipsychotic medication, continue for 4 weeks then reassess.
• Relapse Prevention and Maintenance Treatment: Following resolution of positive symptoms, continue maintenance with antipsychotic treatment for 2-5+ years; may offer oral or depot antipsychotic formulation.
• Treatment-Resistant Schizophrenia (e.g. non-response to 2 antipsychotics): Recommend Clozapine (an atypical antipsychotic – monitor for severe neutropenia including pre-treatment absolute neutrophil account)
• Clozapine-Resistant Schizophrenia: No specific recommendation.
• Choosing Wisely Canada Recommendations²:
  • Psychiatry: “Don’t routinely prescribe high dose or combination antipsychotic treatment strategies in the treatment of schizophrenia.”

• General Principle: Agitation should be managed with nonpharmacologic strategies first, with restraints used as a last resort and regularly reassessed if used at all. Antipsychotic agents should be reserved for unremitting symptoms threatening patient safety.
• Typical Antipsychotics: e.g. Haloperidol (least sedating, ↑ risk extrapyramidal symptoms); Methotrimeprazine (used in Palliative Care contexts e.g. in terminal delirium)
• Atypical Antipsychotics: e.g. Risperidone; Olanzapine; Quetiapine; Ziprasidone
• Benzodiazepines: e.g. Lorazepam – may cause paradoxical excitation/agitation
• Choosing Wisely Canada Recommendations²:
  • Geriatrics: “Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for dementia, agitation or delirium.”
  • Physical Medicine and Rehabilitation: “Don’t use benzodiazepines for the treatment of agitation in the acute phase of traumatic brain injury after initial stabilization.”

• Mild Cognitive Impairment: No evidence for medications used in dementia e.g. cholinesterase inhibitors (see below)
• Alzheimer’s Dementia (AD): Trial of medication for symptom management of cognition and global functioning.
  • Mild-Moderate AD: Cholinesterase inhibitors (e.g. Donepezil, Galantamine, Rivastigmine) - No evidence of medications slowing disease progression, trial for symptomatic improvement of cognition and global functioning.
  • Moderate-to-Severe AD: NMDA receptor antagonist (Memantine); may be used in combination with cholinesterase inhibitor (e.g. donepezil) – may be disease-modifying in severe dementia.
• Lewy Body Dementia (LBD): May trial Cholinesterase inhibitors, Memantine as above.
• Vascular Dementia (VaD): May trial Cholinesterase inhibitors, Memantine as above, where progressive cognitive decline not directly attributed to a clinical stroke – patients may have concomitant Alzheimer disease.
  • Primary focus on vascular risk modification (e.g. HTN, diabetes, dyslipidemia; antithrombotic therapy for patients with vascular dementia and history of TIA or ischemic stroke)
• Frontotemporal Dementia (FTD): No evidence for cholinesterase inhibitors or Memantine, unless diagnostic uncertainty (e.g. Alzheimer disease equally likely diagnosis)
• Neuro-behavioural Problems: Suggest low-dose atypical antipsychotics (e.g. olanzapine, aripiprazole; quetiapine preferred for Lewy Body Dementia with broad receptor profile) in severe refractory behavioural symptoms (caution due to adverse effect risk, ↑ mortality risk)
• Choosing Wisely Canada Recommendations²:
  • Psychiatry: “Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia.”

• Smoking Cessation⁸:
  • Nicotine Replacement Therapy (NRT): e.g. Long-acting (Transdermal patch), short-acting (gum, lozenge, inhaler, nasal spray, mouth spray, sublingual tablet)
  • Other 1st Line Agents: Varenicline (Partial nicotine agonist); Bupropion (NDRI)
• Alcohol Use Disorder⁹:
  • 1st Line for Treatment: Naltrexone (Opioid Antagonist); Acamprosate (GABA Agonist)
  • Alcohol Withdrawal Syndrome: Benzodiazepines (e.g. Diazepam, Lorazepam); Vitamins (e.g. Thiamine to prevent Wernicke’s Encephalopathy, Folic Acid)
• Opioid Use Disorder¹⁰:
  • 1st Line for Opioid Agonist Therapy: Buprenorphine (Opioid Partial Agonist) + Naloxone (Pure Opioid Antagonist – not absorbed PO – included in formulation to prevent misuse) – patient must be opioid-free 12-24 hrs pre-treatment to avoid precipitated withdrawal
  • 1st Line for Opioid Agonist Therapy: Methadone (Opioid Agonist, NMDA-R Antagonist)
  • Opioid Overdose: Naloxone IV/IM/Subcut (Pure Opioid Antagonist)
• Choosing Wisely Canada Recommendations²:
  • Psychiatry: “Don’t routinely prescribe antidepressants as first-line treatment for depression comorbid with an active alcohol use disorder without first considering the possibility of a period of sobriety and subsequent reassessment for the persistence of depressive symptoms.”

Categories to record: Dress, Grooming, and Idiosyncrasies - including congruence with stated age, piercings and markings, or other prominent symbols (jewelry, religious icons, etc.)

Why Check: The ABCs alone may suggest a certain diagnosis; allow you to get a feel for how well or ill a patient is; and allow you to judge how much the patient has changed vs previous assessments

How they are behaving here and now: record psychomotor agitation or retardation; abnormal movements; aggression; responding to hallucinations; and eye contact

Why Check: The ABCs alone may suggest a certain diagnosis; allow you to get a feel for how well or ill a patient is; and allow you to judge how much the patient has changed vs previous assessments

Cooperation is pt’s attitude towards interviewer: Are they easily engaged or difficult to engage? Are they guarded, hostile, dismissive, agitated, forthcoming or cooperative? Are they reliable? Are they malingering (purposeful production of false/exaggerated complaints with goal to receive a reward or avoid punishment)?

Why Check: The ABCs alone may suggest a certain diagnosis; allow you to get a feel for how well or ill a patient is; and allow you to judge how much the patient has changed vs previous assessments

Note: If patient was not reliable historian, include in ID of your write-up.

For a general assessment without concern for a mood disorder, you can ask – “how is your mood?” If concerned about a mood disorder, ask pertinent screening questions (refer to Ch 33 – Assessment of Mood and Anxiety)

Why Check: Mood is the patient’s internal subjective emotional state. It may be relatively long lasting. You must ask a person’s mood in order to know it - you can record a direct quote of their response into the MSE.

Comment on Quality of affect (what did you observe), its Congruency with stated mood, and describe course over interview including Range (broad or constricted?); Stability (labile/mobile or stable?); Intensity (intense, flat or blunted?); Appropriateness (to context and content of patient’s statements made during interview)

Why Check: Affect is the external manifestation of an emotional state observed by the interviewer. It is important to observe and record affect dynamics during the interview.

Fluency of Speech: Includes both Rate of Production (Fast or slow? Rapid or pressured, or a long latency of response? Poverty of speech?) and Volume (Loud vs soft-spoken)

Why Check: Speech is a window into thought process and may be a clue to drug intoxication or identify aphasia (See Ch 31 – Screening Neuro Exam). When describing speech, usually not every parameter is described, only pertinent positives and negatives.

• Disorganized, incoherent or bizarre speech is usually regarded as evidence of a thought disorder; the thought disorder itself is recorded under Thought Process.
• Quality, flow, prosody: Speech defect – slurring, stuttering or aphasia; look for evidence of dysarthria, dysprosody or stuttering

Ask open ended questions (e.g. to open interview) so the patient can talk uninterrupted for a few minutes. Open-ended questions are helpful to observe thought process, because they enable patients to decide what is important to say, how to directly answer questions, how much detail to give, and how to move to new topics while being connected to previous topic.

Why Check: Thought process reflects how patients are communicating ideas. Also called train of thought – Normal: coherent, logical, goal-directed, with tightness of associations (pt stays on topic).

• Rate of Production: Poverty of Content; Poverty of Speech; Flight of Ideas
• Association of Ideas: Normal (Goal Directed, Logical, Relevant) → Circumstantiality → Tangentiality → Loose Associations or Derailment → Incoherence (Word Salad)
• Language Impairments: Neologisms, Clang Associations, Perseverations, Idiosyncrasy of word usage (R/O Wernicke’s aphasia).

Pertinent Positives to Screen for: Thoughts of harm to self or others, Suicidal Ideation (SI), Homicidal Ideation (HI), Delusions (don’t confront these as non-real, as you run the risk of fracturing rapport), Obsessions, Preoccupations, Ruminations, Phobias

Why Check: Thought content is what patients talk about – the predominant topics/themes or issues discussed by patient. You can then relate this info to themes of the psychiatric history in formulating your impression. For SI and HI, when reporting your risk assessment, important to state it is based only on one assessment.

Screening questions: Do you ever have the sense your mind is playing tricks on you? (Approach with this first, as patients could take offence if you asked specifically about one type) Do you hear voices when no one is around? Can you see things that others cannot see? Do you have any unexplained sensations such as smells, sounds, etc.?

Why Check: Hallucinations are profound distortions in person’s perception of reality, as a subjective sensory experience with no underlying external stimulus. The most common are auditory (hearing things - occur in psychotic disorders, mood disorders, psychosis, substance abuse disorders, and temporal lobe seizures) and visual (seeing things - more likely to be due to organic causes e.g. toxins, withdrawal or delirium). Other hallucinations include olfactory, gustatory, or tactile.

• Risk Assessment: Command Hallucinations – do you tend to do what voices say? Can you ignore them?
• Illusion: Abnormal perception caused by a sensory misinterpretation of external stimulus, sometimes precipitated by strong emotion (e.g. fear-provoking illusion of an intruder in the shadows) – Particularly important to distinguish visual hallucinations from illusions.
• Other pertinent positives: Depersonalization, Derealisation, Hyperacusis, Déjà vu, Jamais vu.

GOAL-CRAMP – I’d like to ask you a few questions to test your concentration & memory.

• General: Alertness and Cooperation
• Orientation: Can comment on hypervigilance, drowsiness, stupor, coma, fluctuations – implications for attention and concentration. Quick screen: A&O x 3 (person, time, place)
• Attention: Spell WORLD Backwards, Serial Sevens subtracted from 100
• Language: Name object, repeat phrases, respond to instructions, and through Speech in MSE.
• Calculation: Division and subtraction
• Right Hemisphere functions: Intersecting pentagons and clock face
• Abstraction: Interpretation of proverbs (e.g. a rolling stone gathers no moss → look for concreteness); Similarities/Differences (how is orange similar to apple? different?)
• Memory: Short Term & Long Term: Immediate retention and recall, delayed recall at 5 minutes, recent past (current events, what you ate yesterday), remote past (from Social Hx, FMHx, etc.)
• Praxis: Wave-goodbye and comb hair

Why Check: Cognition is essential component of the MSE, with a need to comment on baseline intellectual disabilities or cognitive impairment in your note which may vary during course of longitudinal assessments. Cognitive impairment is explored in Ch 36 – Assessment of Psychosis, Delirium and Dementia.

Why do you think you are having these difficulties? Do you think that you are ill? What do you think needs to happen for things to get better? Do you think you need a treatment of some kind?

Why Check: Insight refers to patient’s understanding of having an illness and factors contributing to illness, and appreciation of various signs/symptoms as part of the disease process, and how the illness impacts their life. Insight also includes a recognition of need for treatment – range from complete denial and refusal of accepting treatment, to genuine understanding and acceptance.

• Insight and Judgement and Assessment of Risk: Intertwined concepts – can lead to increased risk to either self or others or property, and non-adherence to medications → Note: for information on assessment of suicide and violence risk, see Chapter 35 – Risk Assessment.

How did you arrive for assessment? How will you manage at home? How will you look after yourself or your family?

Why Check: Judgment includes the ability to make sound decisions regarding everyday activities, including weighing pros/cons of decisions and actions. It is a process of consideration and formulation of situation leading to decision or action. It is often closely related to insight → if you have good insight, likely the judgment will be sound.

• Insight and Judgement and Assessment of Risk: Intertwined concepts – can lead to increased risk to either self or others or property, and non-adherence to medications → Note: for information on assessment of suicide and violence risk, see Chapter 35 – Risk Assessment.

• Scanning Physical Exam: Brief vital signs, scanning head to toe exam (skin warm/dry, listen to lungs, listen to heart, listen to bowel sounds/assess for tenderness, check pulses, etc.), with a complete screening neurological examination.
• Be sure include an exam of their eyes & head/neck exam:
  • Are the eyes PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation)?
  • Are the eye movements EOMI (Extra-Ocular Movements intact)?
  • Is the head on general inspection NCAT (Normocephalic and Atraumatic)?

• Include any lab tests performed - Common Tests Ordered in Psychiatric Consults Include:
  • General: CBC, lytes, BUN, Cr, gluc, PO-3/4, Mg, Ca++, Albumin
  • Mood Disorders: TSH, Vitamin B12
  • Substance Abuse: AST, ALT, GGT, Alkaline Phosphatase, Bilirubin (TBili and DBili)
  • Levels: Lithium, carbamazepine; can also do levels for drugs of abuse
  • Other Investigations: ECG, EEG, CT, MRI – where indicated

List both the medical and psychiatric problems – not formal diagnoses, as these are found under DSM-5 diagnoses.

Differentials in Psychiatry: Consult the DSM-5, which contains important differential diagnoses for a given mental disorder diagnosis, and how to differentiate, scenarios where one diagnosis takes precedence, where 2 diagnoses can co-exist, etc.

7. 4P’s Formulation Model: Systematic method of describing impression into 4 categories – Predisposing, Precipitating, Perpetuating, and Protective Factors. Further, within each category can be Biological, Psychological, or Social factors.
8. Predisposing: Why me? (Items in Past Psychiatric Hx or the Big 6) → Biological: FMHx, Pregnancy, health; Psychological: Upbringing, abuse, personality; Social: Culture, Poverty, Migration
9. Precipitating: Why now? (items in HPI) → Biological: Trauma, infection, substances; Psychological: Bereavement, loss, failure; Social: Retirement, Lost employment
10. Perpetuating: Why does it continue? → Biological: Ongoing drug abuse, poor response to Tx; Psychological: Domestic violence; Social: Isolation, finances
11. Protective: What can I rely on? (Strengths, resilience, supports) → Biological: FMHx of Tx response; Psychological: Insight, treatment-seeking; Social: Community, faith, marriage

12. DSM-IV vs DSM-5: DSM-IV used an Axis System, whereas the DSM-5 has done away with this system and recommends listing the diagnoses. That said, many psychiatrists still use the Axis system, so it is useful to be familiar with:
13. Axis I: Mental disorders → Combined with Axis II and III into Documentation of Diagnosis in DSM-5
14. Axis II: Developmental/Personality disorders → Combined with Axis I & III into Documentation of Diagnosis in DSM-5
15. Axis III: Other general medical conditions → Combined with Axis I and II into Documentation of Diagnosis in DSM-5
16. Axis IV: Psychosocial/contextual factors → A “separate notation” instead of an axis in DSM-5
17. Axis V: Global Assessment of Functioning → Replaced by WHO Disability Assessment Schedule (WHODAS) in DSM-5

18. Plan for management: Admit orders, investigations, psychotherapy recommendations, medication recommendations, etc.

The Mental Status Exam is an essential component of the psychiatric interview focused on structured observations and inquiries regarding signs and symptoms of conditions affecting the CNS. It is a record of behaviour, cognitive abilities, and inner experiences expressed in the interview. It is the psychiatry physical exam, where objective findings on the MSE helps inform psychiatric diagnosis. It is a sensitive, specific, inexpensive tool in your psychiatric assessment that can be completed with minimal interviewing as it is predominantly based on observation. The MSE emphasizes the interview process – how that interview went, how the patient presented at that time, which can fluctuate hour-to-hour. The MSE paints a picture of the patient and their thoughts without over-inclusion of detail. It is used to arrive at a provisional diagnosis, formulate a treatment plan and follow the clinical course.

• Equity-Deserving Populations and the Mental Status Exam: Structural vulnerabilities such as education level and cultural factors can impact the MSE. In addition, any disorders of the special senses can impact your capacity to do a full MSE.

• Video 1: Stethopedia Mental Status Examination (Link: https://videopress.com/v/nwZhzPC2)

• What are the skills to master for an MSE? Your powers of observation will help make developing an MSE become more efficient and well-defined. In addition, you should be able to think in terms of observations under the structured headings of the MSE during the interview, and then structuring each note the same way.
• You start observations of the patient before the interview: how do they first behave on meeting you? What is their body language, and how do they behave during attempts to establish rapport? What do they look like on presentation?
• You have to directly ask some components of the MSE: Some components of the MSE emerge spontaneously (and are captured due to your honed observation skills), whereas others you must ask specific questions to elicit. For example, you can observe affect, but can only come to know the patient’s mood by asking about it directly.
• Use Open Ended Questions: Open-ended questions, generally, should begin any interview. In a psychiatric interview, their clinical utility with respect to formulating an MSE is even higher. This is because a patient’s uninterrupted speech coupled with your empathic listening (and observational skills) yields great insight into their mental status, helps form a solid foundation for further history taking, and builds a therapeutic alliance.
  • What can you observe via Open Ended Questions and Attentiveness to detail? Level of Consciousness, Appearance, Behaviour, Cooperation, Reliability, Affect, Speech, and Thought Process
  • What do you need to directly question? Orientation, cognitive functioning, Suicidal/Homicidal ideation, Knowledge base, Perception, Mood, and Thought Content, Insight and Judgment
• What observations to include: Include only pertinent positives and negatives – this is especially critical in an MSE given the broad lexicon available to you.

• Important to include all main components of the MSE using a structured approach with typical/common order (an example order is given above). It is helpful to make use of headings to structure your note (e.g. Appearance, Behaviour, Cooperation…). Mental Status Exam write-ups should be professional with respect to spelling and syntax.
• Include every section of the MSE even if you don't have specific content for that area. For example, if in an interview you forgot to ask about mood, you should still include it and then add something like: "The patient's mood was not elicited during the interview” OR if you want to include both mood and affect together in the same sentence you can use something like: “Although mood was not elicited, the patient’s affect was predominantly sad, stable and somewhat restricted.”
• If there are no specific delusions, obsessions, or compulsions to put in the Thought Content section, then it is often useful to add the common themes of discussion that arise during the interview. For example, 'Thought Content was significant for themes of loss, sadness, and a preoccupation with death.'
• Clarification of the differences between poverty of thought, poverty of content and poverty of speech. While we don't always explicitly note poverty of thought within the MSE, it can be used within the description of thought form to denote when patients are very vague or there is a lack of production of thoughts.

Common Mistakes on MSE:

• Failed to identify and write-up psychotic content (delusions and hallucinations)
• Mixed in subjective observations or impressions within MSE – Say what you see and observe.
• Didn't use a quote for 'mood' or omitted it altogether
• Forgot elements of 'affect' (i.e., quality, range, stability, etc.)
• Over-inclusion of details from psychiatric history within Mental Status Exam.
• Serious errors of omission in a mental status exam:
  • Thought Content Omissions: It’s critical to always mention Suicidal Ideation (SI) or risk of self-harm; Homicidal Ideation (HI) or risk of harm to others; and presence or absence of delusions (with particular sub-type with example if present). These are always pertinent positives or negatives on the Mental Status Exam.
  • Perception Omission: Presence or absence of hallucinations. If present, particular sub-type(s) with example not mentioned. (If hallucinations are not currently present, but are described, this should be noted. You may include the patient’s statements about the hallucinations under Though Content).
  • Insight is not commented on. This is particularly important if Insight is impaired or lacking.
  • Judgement is not commented on. This is particularly important if Judgment is impaired or lacking, with an example of poor judgement from the history.

Common Question – Should I include SIGECAPS criteria within the MSE’s Thought Content? It would NOT be typical to cover all the symptoms of major depression within the MSE write-up. Typically you would mention depression (or other mood) under the Mood heading. Within Thought Content, you would comment on suicidal ideation. You would also comment on any prominent depressive cognitions (so this might lead you to describe the patient’s feelings of anhedonia, perhaps; or negative cognitions such as feelings of guilt or worthlessness). If they had any delusions - such as somatic or nihilistic delusions - then those would also be described under Thought Content. Poor concentration might impact on Thought Form/Process, and psychomotor agitation or retardation would be reported under Behaviour, but it would be unusual to include those in Thought Content unless the patient talked a lot about those symptoms for some reason. The more ‘constitutional’ symptoms of sleep, energy, concentration, appetite would not typically be described within the MSE, unless there were some major preoccupations with one of these domains that led the person to talk about it so much that you might include mention of it under ‘thought content’. Those would typically be reported in the HPI of the full psychiatric note and not in the MSE. So, in summary, one would not normally include the SIGECAPS criteria per se within the MSE; those would be described in detail in the HPI of the full psychiatric note.

Example 1 – Style 1(Headings separate):

• Appearance, Behaviour, Cooperation: 32 y.o. East Asian woman who appears younger than stated age; reasonably groomed, dressed in hospital gown; sitting up in bed. Some increased psychomotor activity (wringing hands, repeated scratching). Good eye contact. Pleasant and cooperative throughout the interview.
• Mood and Affect: Mood: “ok, but a bit anxious”. Affect generally euthymic, broad range, stable, congruent and appropriate.
• Speech and Thought Form: No gross abnormalities of speech or thought form. Logical and coherent.
• Thought Content: No SI, HI, or frank delusions. Some paranoid ideation (“I hear the nurses saying negative things about me”) and ideas of reference (“I feel like I’m in the Truman Show movie sometimes”), but redirectable and not fixed false beliefs. No obvious depressive or anxious cognitions, but endorses compulsions to use drugs/ cocaine, and endorses feeling anxious and agitated periodically.
• Perception: No obvious perceptual abnormalities.
• Cognition: Grossly intact, not formally tested.
• Insight and Judgement: Some insight into her issues, but poor judgement (putting her health and fetal health at risk through impulsive behaviours).

Example 1 – Style 2 (Narrative/Paragraph):

Appearance, behaviour, cooperation: 32 y.o. East Asian woman who appears younger than stated age; reasonably groomed, dressed in hospital gown; sitting up in bed. Some increased psychomotor activity (wringing hands, repeated scratching). Good eye contact. Pleasant and cooperative throughout the interview. Mood: “ok, but a bit anxious”. Affect: generally euthymic, broad range, stable, congruent, and appropriate. No abnormalities of speech or thought form. Thought content showed no SI, HI, or frank delusions. Some paranoid ideation (“I hear the nurses saying negative things about me”) and ideas of reference (“I feel like I’m in the Truman Show movie sometimes”), but re-directable and not fixed false beliefs. No obvious depressive or anxious cognitions, but endorses compulsions to use drugs/cocaine, and endorses feeling anxious and agitated periodically. No obvious perceptual abnormalities. Cognition intact, not formally tested. Some insight into her issues, but poor judgement (putting her health and fetal health at risk through impulsive behaviours).

Example 2 – Style 1 (Headings separate):

• Appearance, Behaviour, Cooperation: Appearance: Jordan is a 22-year-old male who looks his stated age. He was dressed in a hospital gown and was sitting in a wheelchair. He had a baseball cap on his head pulled forward over his forehead such that it was difficult to see his eyes. He was unshaven, but otherwise well groomed. His hand and arms were flexed in a fashion typical of spinal cord fracture patients. He had obvious muscle wasting of both upper and lower limbs.
• Behaviour: He had no abnormal movements, evidence of tardive dyskinesia or the presence of any tics. He kept his eyes averted throughout the interview.
• Cooperation: While he was cooperative with the majority of the interview his answers were often evasive.
• Mood and Affect: His mood was "non-existent" and his affect was flat, congruent to mood, appropriate and stable.
• Speech and Thought Form: His speech was soft spoken, slow and at times dysarthric. His thought form was normal with no evidence of a thought disorder.
• Thought Content: Content significant for both active and passive SI, no HI, and extensive delusions. He is clear that if he could get free of his wheelchair he would "get it right this time." He asked if I could help him to kill himself. He finds every day an unbearable torment and prays that they will just kill him. He has no desire to harm anyone else. Evidence of persecutory delusions (“they follow me, track my scent, and plan to force me to kill myself." "It is a game, I have to stay one step ahead of them so that they don't get me first."). He reports being afraid of all new staff, and convinced they are part of ‘them’ in disguise. The rest of his content was significant for themes of hopelessness, and torment.
• Perception: He endorsed extensive auditory hallucinations ("they talk to me constantly, haunting my every movement"; “they talk about everything I do and how inadequate I am."), visual hallucinations ("I can see the entity in your stomach taunting me; I see skeletons attached to crosses being tortured in the corner”); tactile hallucinations ("I feel them trying to crawl through my skin at night; they try to crawl under my toe nails and stab my soft flesh").
• Cognition: In terms of cognition, although no formal testing was completed, he was fully oriented, coherent and appeared cognitively intact. There was no evidence of a delirium.
• Insight and Judgement: He has no insight into his illness. His judgement is impaired as he is currently refusing pain medication because of his psychotic interpretation of his pain symptoms.

Example 2 – Style 2 (Narrative/Paragraph):

Appearance: Jordan is a 22-year-old male who looks his stated age. He was dressed in a hospital gown and was sitting in a wheelchair. He had a baseball cap on his head pulled forward over his forehead such that it was difficult to see his eyes. He was unshaven, but otherwise well-groomed. His hand and arms were flexed in a fashion typical of spinal cord fracture patients. He had obvious muscle wasting of both upper and lower limbs. Behaviour: He had no abnormal movements, evidence of tardive dyskinesia or the presence of any tics. He kept his eyes averted throughout the interview. Cooperation: While he was cooperative with the majority of the interview his answers were often evasive. His mood was "non-existent" and his affect was flat, congruent to mood, appropriate and stable. Speech: His speech was soft spoken, slow and at times dysarthric. His thought form was normal with no evidence of a thought disorder. His thought content was significant for both active and passive SI, no HI, and extensive delusions. He is clear that if he could get free of his wheelchair he would "get it right this time." He asked if I could help him to kill himself. He finds every day an unbearable torment and prays that they will just kill him. He has no desire to harm anyone else. Evidence of persecutory delusions (“they follow me, track my scent, and plan to force me to kill myself." "It is a game; I have to stay one step ahead of them so that they don't get me first."). He reports being afraid of all new staff, and convinced they are part of ‘them’ in disguise. The rest of his content was significant for themes of hopelessness, and torment. Perception: He endorsed extensive auditory hallucinations ("they talk to me constantly, haunting my every movement"; “they talk about everything I do and how inadequate I am."), visual hallucinations ("I can see the entity in your stomach taunting me; I see skeletons attached to crosses being tortured in the corner”); tactile hallucinations ("I feel them trying to crawl through my skin at night; they try to crawl under my toe nails and stab my soft flesh"). In terms of cognition, although no formal testing was completed, he was fully oriented, coherent and appeared cognitively intact. There was no evidence of a delirium. He has no insight into his illness. His judgement is impaired as he is currently refusing pain medication because of his psychotic interpretation of his pain symptoms.