EVALUATION & DIAGNOSTIC

1. EVALUATION & DIAGNOSTIC CLASSIFICATION DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT

2. EVALUATION GREETING & INITIAL OBSERVATION BASELINE DEMOGRAPHIC DETAILS HISTORY MENTAL STATE EXAMINATION PHYSICAL EXAMINATION SPECIAL INVESTIGATIONS RISK ASSESSMENT SUMMARY DIAGNOSIS

3. 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?

4. 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

5. 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)

6. 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?)

7. 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

8. 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

9. 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?

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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

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