what do you think needs to happen to

make you better?’

Risk assessment

Risk assessment is a crucial part of every psychiatric assessment.

Consider:

• Who is at risk?

• What is the nature of the risk?

• What is the likelihood of the risk?

The person usually at risk, if anyone, is the patient themselves.

The risk posed to others by people with mental disorder must

Putting it all together: clinical vignettes • 325

16

Psychiatric rating scales

The use of psychiatric rating scales as clinical tools in psychiatric

assessment is increasing. Most were developed in research

studies to make a confident diagnosis or to measure change in

severity of illness. Some require special training; all must be used

sensibly. In general, scales are too inflexible and limited in scope

to replace a well-conducted standard psychiatric interview but

they can be useful adjuncts for screening, measuring response

to treatment or focusing on particular areas.

In routine practice, scales are most widely used to assess

cognitive function when an organic brain disorder is suspected.

They include:

• Abbreviated Mental Test (AMT): takes less than 5 minutes

(Box 16.11)

• Mini-Mental State Examination (MMSE) or Montreal

Cognitive Assessment (MoCA): takes 5–15 minutes.

Well-known instruments assessing areas other than cognition

include:

• general morbidity:

• General Health Questionnaire (GHQ)

• mood disorder:

• Hospital Anxiety and Depression Scale (HADS)

• Beck Depression Inventory (BDI)

• alcohol:

• CAGE questionnaire (Box 16.12)

• FAST questionnaire (Box 16.13).

Putting it all together: clinical vignettes

Examples in practice are provided in Boxes 16.14–16.17.

as far as possible by visual corrections, hearing aids and

interpreters.

The central matters to be assessed are essentially cognitive:

can the patient make, understand, remember and communicate

decisions about medical treatment or other options before them?

Determining that a patient lacks capacity for a particular

decision leads to the next stage: making that decision on their

behalf. The key principles here are to ensure that any treatment

proposed must benefit the patient and be the least restrictive

option available; it should take account of any wishes the patient

has previously expressed, as well as the views of family members

and any other relevant others (such as nursing home staff).

The physical examination

Physical and mental disorders are associated, so always consider

the physical dimension in any patient presenting with a psychiatric

disorder, and vice versa. The setting and the patient’s age, health

and mode of presentation will determine the extent of physical

assessment required.

In psychiatric settings, general physical observation, coupled

with basic cardiovascular and neurological examination, will usually

suffice. Bear in mind that some physical disorders can present

with psychiatric symptoms (such as thyrotoxicosis manifesting

as anxiety – look for exophthalmos, lid lag, goitre, tachycardia

and so on). For older patients with multiple medical problems, or

those with alcohol dependence and associated physical harm,

a more detailed examination is clearly needed.

In primary care and acute hospital settings, patients will

usually undergo physical examination tailored to the presenting

problem, but it is important to be aware that some psychiatric

disorders can present with physical symptoms, such as chest

pain and transient neurological symptoms as manifestations of

panic attacks.

Collateral history

Collateral history is important whenever assessment is limited by:

• physical illness, acute confusional state or dementia

• severe learning disability or other mental disorder impairing

communication

• disturbed, aggressive or otherwise uncooperative

behaviour.