Assessment

Question 1

Diagnostic hierarchy

Answer 1

Organic
Substance use + Med SES
Psychotic Spectrum Disorder
Affective Spectrum
Anxiety/ Trauma/ Eating disorder
Personality Factors

Question 2

Developmental Hx

Answer 2

Migration hypothesis
Obstetric complications
Developmental delay
Attachment and unmet dependencies model
Core schema
Coping styles
Violence - male: identification with aggressor, female: parallels in later life -> psychodynamic model, self blame: cognitive model
Conduct disorder
Hyperactivity

Question 3

Physical Exam

Answer 3

AIMS
Brief neurological exam
Thyroid: intolerance to cold, difficulty shifting wt, hair loss, brittle nails, dry skin
Alcohol dependence: peripheral neuropathy, opthalmoplegia, ataxia

Question 4

AIMS test

Answer 4

• Ask about the current condition of the patient’s teeth. Ask if he or she wears dentures. Ask whether teeth or dentures bother the patient now.
• Ask whether the patient notices any movements in his or her mouth, face, hands, or feet. If yes, ask the patient to describe them and to indicate to what extent they currently bother the patient or interfere with activities.
• Have the patient sit in chair with hands on knees
• Ask the patient to sit with hands hanging unsupported – if male, between his legs, if female and wearing a dress, hanging over her knees
• Ask the patient to open his or her mouth.
• Ask the patient to protrude his or her tongue.
• Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15 seconds, first with right hand, then with left hand
• Flex and extend the patient’s left and right arms, one at a time.
• Ask the patient to stand up
• Ask the patient to extend both arms out in front, palms down
• Have the patient walk a few paces, turn, and walk back to the chair

Question 5

First step in assessment refugee

Answer 5

Awareness that the patient may be guarded and information obtained after establishing adequate therapeutic alliance
-collateral information is important as part of ax. Risk of disengagement, mistrust and associations of hospital or authority figures w trauma

Question 6

In interviewing CALD

Answer 6

Awareness of cultural issues and cultural sensitivity

Involvement of MH multicultural team with specialised expertise in ax of refugees, migrants or asylum seekers

Involvement of translator if language difficulties or patient wishes

Question 7

Next steps in ax of refugee

Answer 7

Risk assessment - may be guarded

Cultural assessment - language, ethnicity, pre migration role, employment, social status, reasons for migration, post migration losses - family, finances, identity, stereotyping, racism
Acculturation

Evaluation of psychiatric disorders
-psychiatric disorders may present atypically e.g. depression with somatic symptoms, substance use as coping

Psychosocial evaluation - finances, relationships, vocation, accommodation stability, visa status of self and others that may act as stressors

Medical evaluation to avoid diagnostic overshadowing - MRI (head injury), sleep study, TFTs

Question 8

Assessment of pt with possible ADHD

Answer 8

1. Adult ADHD presents differently, more inattention and organisational difficulties. Can present primarily with depression, reckless behaviour, agitation, anger, D&A, gambling, thrill seeking
2. Longitudinal assessment and diagnosis may take several appts and medication not prescribed lightly
3. Assess for onset of sx (childhood)
   Impact on psychosocial functioning - work, home, relationships
   MSE - fidgetiness, pressured speech, inattention, organisational difficulties
4. Complete physical examination (rule out head trauma, seizures, substance misuse, hormonal problems)
5. Personality ax - rule out ASPD and childhood conduct disorder
6. Collateral from school or family to corroborate onset of sx
   School reports
   Pervasive sx across settings (school, home, playground)
   Fhx of ADHD
7. Questionnaires such as CADDRA, ASRS. Neuropsych. Consider second opinion

Question 9

Ax of OCD

Answer 9

-context in which OCD has developed
-nature of obsessions: content, insight, frequency, triggers, feared consequence
-main emotion linked with obsession or intrusion
-compulsion and neutralising behaviour: what the person does in response to the obsession; a rating of predicted distress if the compulsion is resisted; their experience of trying to stop a compulsion;
-avoidance behaviour: situations, activities and thoughts
* The degree of family involvement
* The degree of handicap in the person’s occupational, social and
family life
* Goals and valued directions in life
* Readiness to change and expectations of therapy, including previous
experience of CBT for the disorder

Question 10

Ax of ATSI

Answer 10

o Rapport
 Be introduced to patient
 Loose handshake and brief eye contact
 Adequate personal space
 Explain your role
 Start interview with a genogram – helps to quickly establish family, living arrangements, etc. – also places patient in the position of expert
 Create a problem list with patient – focuses the interview on the patient priorities

o Communication
 Informed listening – listen to silences and what is said
 Open ended questions – ATSI may feel confronted with direct questioning
 Accept that not all information can be obtained in the one sitting – may need several sittings
 Talk slowly and wait patiently for response
 Cultural considerations
* Not referring to a dead person by name
* Taboos associated with the use of personal names
* Recognising that spiritual experiences are not always psychotic

 Non verbal
* Sit bedside rather than opposite to patient
* Brief eye contact
 Effect of gender
 Transference issues

o MSE
 Speech – speech may be slow and softly spoken
 Mood – may have own cultural descriptions such as ‘wild’ for anger
 Affect – crying is uncommon as ATSI can believe it may cause sickness
 Thoughts – aboriginal worker to help place experiences in context
 Perception – may have brief visual hallucinations such as spirits in context of emotional experiences
 Cognition – biases which can affect performance in western cognition tests
 Time – ATSI often place events in a circular rather than a linear pattern of time. Events are placed in time according to their relative importance to the individual.
 Insight and judgement – consider traditional explanations of illness