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Psychosocial Assessment: A Nursing Perspective

2 Contact Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Thursday, November 24, 2022
Outcomes

≥92% of participants will be able to perform a psychosocial assessment.

Objectives

After completing this course, the learner will be able to:

  1. Describe five components to the psychosocial interview.
  2. Discuss five components to the mental status examination.
  3. Identify three specialized mental health screening tests.
  4. Compare and contrast assessment findings noted in patients with depression, bipolar disease, anxiety, and schizophrenia.
  5. List two major roles each that psychologist, primary care provider, and psychiatrist play in the management of a mental health patient.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Authors:    Raymond Lengel (MSN, FNP-BC, RN) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Introduction

A psychosocial assessment is an evaluation of an individual's mental health and social well-being. It assesses self-perception and the individual's ability to function in the community. The psychosocial assessment goal is to understand the patient to provide the best care possible and help the individual obtain optimal health.

The psychosocial assessment helps the nurse determine if the patient is in mental health or a mental illness state. Mental health is a state of well-being where there is the ability to deal with the typical stresses of life, works productively, and contribute to their community.

Mental illness is a pattern of behaviors that is troubling to the person or the community where the individual lives. Mental illness may modify reality, influence daily living, or harm judgment. Mentally ill individuals often have a reduced ability to cope with society, maladaptive behaviors, and a reduced ability to function.

Psychosocial Assessment

The major components of a psychosocial interview include:
  • Identifying the patient
  • Chief complaint
  • History of presenting illness
  • Psychiatric history
  • Medical or surgical history
  • Medication list
  • Alcohol and drug use
  • Cultural assessment
  • Financial assessment
  • Coping skills
  • Violence risk assessment
  • Family or social history
  • Occupational history
  • Educational history
  • Legal history
  • Developmental history
  • Spiritual assessment
  • Interests
  • Abilities
  • Mental status examination

The first step in any assessment is to identify the patient. A patient's identity includes the patient's name, gender, birth date or age, marital status, race, ethnicity, and languages spoken.

The chief complaint is the main reason the patient is presenting, in their own words. The history of the present illness is the chronological account of what led up to the chief complaint. This section may include the problem's location, duration, severity, timing, context, modifying factors, and associated signs or symptoms.

The psychiatric, psychological history is the history of all psychiatric or psychological concerns in the past. The medical or surgical history includes listing all medical illnesses and listing all surgeries and dates. All current and past medications should be listed, including the dose and frequency. For medications currently taken, a listing of who prescribed them and why they are prescribed should be documented. For past prescribed medications, a listing of why they were started and why they were stopped should be documented.

History of alcohol and drug use is an important part of the psychosocial assessment. The substances currently used should be documented, including the method of use (oral, inhalation, injection, intranasal), the amount, the frequency, and the time. Any substances used in the past should be documented. Common abuse substances include alcohol, heroin, opiates, marijuana, cocaine, crack, methamphetamines, inhalants, stimulants, hallucinogens, caffeine, and nicotine.

Violence risk includes an assessment of suicidal ideation, homicidal risk, and abuse. While it is difficult to predict who will commit suicide, risk factors for suicide include a previous suicide attempt, family history, feelings of hopelessness, drug and alcohol abuse, history of depression or bipolar disorder, feeling isolated, physical illness, history of aggressiveness or impulsivity, unwillingness to seek help or barriers to mental health treatment.1

Risk factors for homicidal behavior include male gender, gang affiliations, unemployment status, drug or alcohol use, active psychotic symptoms, and lower socioeconomic status.

Questions to ask in assessing suicidal or homicidal ideation and abuse are included in Table 1.

Table 1: Questions to ask to assess violence risk
  • Have you had thoughts of hurting yourself?
  • Has there been a previous suicide attempt? When?
  • Do you have a plan to commit suicide?
  • Is there a means to carry out the plan?
  • Is there intent to carry out the plan?
  • How lethal is the plan?
  • Do you have thoughts of harming others? If yes, who is the target?
  • Can these thoughts of harm be managed?
  • Do you have the means to carry out a plan to harm others?
  • Is there intent to carry out the plan?
  • What is the lethality of the plan?
  • Do you have any high-risk behaviors such as self-cutting, anorexia, bulimia, headbanging, or other self-injurious behaviors?

Abuse Assessment

  • In the past year, have you been hit, kicked, or physically hurt by another person?
  • Are you in a relationship with someone who threatens or physically harms you?
  • Have you ever been forced to have sexual contact that you were not comfortable with?
  • Have you ever been abused? If yes, describe by whom, when, and how.

The social history provides clues as to how the person interacts with others. It is important to understand social relationships as those who have a large social network are more likely to have less severe mental illness and recover better from mental and medical illness. The nurse should have the patient describe their social relationships, including several siblings, who raised the patient, spouse, or significant other, several children, current living situation, military history including the type of discharge, and any additional support or social networks reported. Any significant life event, such as death, divorce, or birth, should be reported.

Family history is important because many mental illnesses are hereditary. Record any history of mental illnesses in the patient's family. Commonly genetic mental illnesses include depression, bipolar disease, schizophrenia, and attention deficit disorder.

Employment history is important. Record the patient's current employment status and occupation. If the patient is currently employed, determine if this is a long-term job prospect or a temporary job. Determine how they function at their job. Do they perform their job well? Do they get along with co-workers? Has the patient ever been fired? How many jobs has the patient held in the last five years? Patients who have held multiple jobs in the recent past are more likely to have an avoidant personality disorder.

Determining educational history will help the nurse understand the best way to interact with the patient. What is the highest grade that the patient completed? Where did the patient go to school? Were there any discipline problems at school? The assessment of how the patient functions at work and school can provide helpful clues to the patient's mental health status.

A quick screen of the patient's legal history is important. Determine if the patient has legal trouble, probation, parole, pending charges, or incarcerated. There is a strong link between legal problems and mental illness.

Developmental history will provide insight into the origins of behavior, help diagnose and manage some conditions. Any psychological trauma experienced as a child may lead to problems in adulthood. Determine how the patient functioned in their childhood concerning school, friends, personality, and hobbies. Also, determining the patient's sexual orientation will help the nurse provide better plan care for the patient.

The spiritual assessment should note the patient's religious background. Also, the degree of involvement within the religious community and any spiritual practices. Nurses who understand the patient's spiritual views will be better able to be empathetic. It can also help the nurse determine if the patient has unresolved spiritual needs or concerns. Unresolved spiritual issues will inhibit recovery. When spiritual concerns are identified, appropriate referrals may help assure holistic wellness.

The cultural assessment should list any critical issues regarding the patient's ethnic and cultural background. A nurse cannot fully understand every culture, but a good cultural assessment will help the nurse understand the patient's beliefs, values, and practices. These factors can be respected and considered when providing care. Different cultures express, report, and develop mental illnesses in different ways.

The financial assessment should describe the patient's financial situation. Understanding the patient's financial situation is important for multiple reasons. Patients in a lower socioeconomic class are at higher risk for many mental health conditions. Also, patients who have limited financial resources may need help with money and may benefit from a social worker's consultation.

Determining coping skills is an important part of the psychosocial assessment. If the nurse understands the patient's current coping techniques, they will provide better care by fostering adaptive coping skills. Determining the patient's abilities and interests helps get a full picture of the patient. Ask the patient: What are their hobbies? What are they good at doing? What gives the patient pleasure?

Mental Status Examination

The mental status examination assesses the function of the brain, mental functions, and behaviors. A good mental status examination helps assess many mental health or central nervous system disease states. A good mental status examination can be used over time to monitor a patient's severity of illness.

The first step in the mental status examination determines the patient's degree of arousal. Is the patient alert, sleepy, attentive, or unresponsive? Is the patient oriented to person, place, and time, or is the patient confused?

How does the patient look? Is the patient well groomed? Is eye contact appropriate? Note poor hygiene, inappropriate dress, and lack of concern for appearance. Poor grooming indicates a potential psychiatric problem. Stooped posture and poor eye contact suggest depression. Colorful clothes or unusual clothing suggest a manic state.

Assess behavior and motor activity. Is the patient calm and relaxed, or is there any indication of restlessness, agitation, or lethargy? Note any abnormal motor movements such as unusual facial expressions, tremors, or tics. Tremors or tics suggest a neurological disease, medication side effect, or anxiety. Excessive body movements suggest mania, anxiety, or stimulants. Repeated motor movements suggest obsessive-compulsive disorder. Minimal body movement may be depression, catatonic schizophrenia, or drug abuse.

Evaluate the mood and affect. Asking patients how they are feeling is a simple way to assess mood. Is the patient's emotional response to the situation appropriate? Observe the verbal or non-verbal behaviors to determine mood. Mood disturbances may be demonstrated by inappropriate feelings or behavior to the situation. Note euphoria, agitation, depressed mood, flat affect, anxiety, labiality (shifting from one affect to another rapidly), irritability, excessive rage, indifference, carelessness, inability to sense emotions, and lack of sympathy.

The speech pattern is an important part of the psychosocial assessment. The patient's voice should be clear, strong, fluent, and articulate with a clear expression of thought. Note any of the following abnormalities in speech.

  • Slurred speech
  • Soft speech
  • Loud speech
  • Pressured speech
  • Limited interaction
  • Incoherent speech
  • Halting speech
  • Rapid speech

The slurring of words suggests intoxication. Pressured speech is seen in mania. Those with depression often have speech poverty. Note the patient's attitude. Is the patient cooperative, uncooperative, guarded, suspicious, or hostile?

The thought process is self-expressed by individuals and is observed through speech. It is not the content of the speech but the patterns of verbalization. It may range from normal to any of the terms in Table 2. A normal thought process is logical, relevant, sequential, and coherent.

Table 2: Terms to Describe Thought Process
TermDefinitionWhat it may suggest
Flight of ideasFrequently changing topicsMania
TangentialGoing away from a topic and not returningSchizophrenia, psychosis, anxiety, dementia
CircumstantialProvides unnecessary detail but eventually gets to the pointSchizophrenia, psychosis, obsessive-compulsive disorder
NeologismsMaking up new wordsSchizophrenia, psychosis
Looseness of associationIllogically shifting between topicsSchizophrenia, psychosis, dementia
Word saladNonsensical responsesSchizophrenia, psychosis, dementia
ClangingRhyming words, Speech makes no senseSchizophrenia, psychosis
Thought blockingSpeech is stoppedSchizophrenia, psychosis
Poverty of speechLimited content of speechDepression

Thought content is the theme that occupies the patient's thoughts and shows how coherent and logical the individual thinks. Disorders that suggest abnormalities include phobias, hypochondriasis, obsessive thought, hallucination, delusions, or other preoccupation.

Phobias are a morbid fear along with extreme anxiety. Hypochondriasis is the obsession with the idea of having a serious or life-threatening disease which is not diagnosed. Obsessive thoughts are unwelcome idea, impulse, or emotion that is continually forced into the conscious mind. Hallucinations are something that the patient perceives but is not real. Hallucinations are suggested in those who hear voices, see images, feel bugs crawling on the skin, or smell offensive odors without evidence of them being present. Inquire about any command-type hallucinations and what the patient is being commanded to do. Find out if the patient complies or is considering complying with the command.

Assess the patient for specific delusions and hallucinations. Table 3 gives questions to ask to determine if the patient is hallucinating or delusions. Delusions are classified in multiple ways (see Table 4).

Table 3: Questions to ask to elicit the presence of hallucinations or delusions
Hallucinations:
  • Can you see things that no one else can see?
  • Do you hear voices when no one else is around?
  • Do you have any mysterious sensations such as smells, sounds, or feelings?
Delusions:
  • Do you have any unusual powers or abilities?
  • Do you have any beliefs that others consider strange?
  • Does the television or radio give you special messages?
Table 4: Type of Delusions
Type of delusionDefinition
GrandioseA believe that the person is someone of extreme importance
PersecutoryA false belief that the person is being followed is under surveillance, being ridiculed or treated unfairly
JealousyBelief that the individual's sexual partner is unfaithful
ReligiousBelief in a special status with God
SomaticBelief that there is a physical defect or general medical condition when none exists
Ideas of referenceBelief that things in the environment refer to them when they do not
Thought insertionBelief that someone is putting ideas or thoughts into their mind
Thought broadcastingThinking that one's thoughts are being "broadcasted" to the outside world

Impulse control can be assessed by asking the patient if they do activities without planning or thinking about them. Those who have poor impulse control have limited ability to resist temptation or the urge to do something that may be harmful to themselves or others. Many disorders are linked to poor impulse control, such as substance abuse, antisocial personality disorder, bipolar disease, schizophrenia, and impulse control disorder. Behaviors noted in those with poor impulse control include pathological gambling, excessive substance use or abuse, aggression, binge eating, and excessive, unsafe sexual behavior.

Judgment can be assessed by asking a made-up scenario to determine if there is an appropriate response. For example, if there is a fire in a crowded theater, what should you do? Doing nothing would suggest poor judgment. Calling 911 or getting help suggests good responses. Other methods to assess judgment include looking at the patient's lifestyle. Poor judgment is likely to present in those involved in illegal activity or relationships with destructive ones. Judgment is impaired in schizophrenic, psychotic, intoxicated, manic, in some personality disorders or a low intelligence quotient.

Assessment of cognition can be as simple as evaluating how the patient responds to questions asked during the assessment. More specific questions may be asked to provide a detailed analysis of the patient's cognitive ability. The use of the Mini-Mental State Examination is a common way to assess cognition.

The first part of a cognitive assessment is determining if the patient is oriented to person, place, and time. Attention is the ability to focus, direct thinking, and not getting distracted. Concentration is the ability to maintain attention over a while. A patient who cannot maintain attention will have other cognitive performance problems, especially executive function and memory, making a full mental status challenge assessment.

Lack of attention will be demonstrated by patients who lose their train of thought, become easily distracted, or ramble. Attention can be assessed by having the patient repeat a string of digits. An adult should be able to repeat 5-9 digits. Another way to assess attention includes having a patient spell a word backward (W-O-R-L-D is often used) or repeat the year's months in reverse order. Those who have a demonstrated deficit in attention may have a toxic metabolic encephalopathy or an acute psychiatric disorder.

The assessment of memory is the next step in the mental status examination. The immediate memory is tested by asking the patient to repeat a string of digits or asking the patient the time and place or asking about recent events.

Another recent memory test involves telling the patient three words and then having the patient repeat the three words. Ask the patient to repeat the words five minutes later, after being distracted by another task. A normal adult can remember all three words after five minutes. Offering the patient clues to help them remember can be done to assess the degree of memory impairment. Remote memory can be tested by asking about personal life events or important historical events, such as the states' names in reverse order.

The speech content is assessed by noting the presence or absence of any language errors during the speech. Naming is assessed by having the patient name objects shown to them. Show the patient three objects, such as a pencil, watch, and apple, and make sure they can name them. Reading and writing are assessed by having patients read a section of words and writing a sentence. Repetition is assessed by having a patient repeat a common phrase.

Visual spatial perception is assessed by having the patient copy an object (such as overlapping pentagons (Table 5), drawing an object, or building something. Having the patient draw a clock and telling them to make a certain time on the clock is another tool to assess visual-spatial perception. This test is often used as a screening test for dementia. Individuals with visual-spatial perception deficits may have difficulty navigation, get lost frequently, or often lose objects.

Table 5: Interlocking Pentagons

Praxis is learned motor movements and is demonstrated by the patient being able to perform learned, skilled motor movements such as feeding or dressing. Praxis is assessed by the patient being given a stepwise series of coordinated tasks. It can be demonstrated by asking a patient to take a piece of paper, fold it in half, put it in an envelope, and hand it to the examiner. Apraxia can be seen in corticobasal degeneration.

Assessing the patient's ability to calculate is done by having the patient perform simple mathematical problems. Calculation assessment can be done by having the patient start at 100 and subtract seven serially (100, 93, 86, 79, 72, 65). The ability to perform this test is affected by educational level and anxiety level.

Executive function is a set of mental abilities synchronized in the brain's frontal lobe and helps people accomplish goals. It is hard to assess from the exam alone. It may take a good history from the patient and family or neuropsychological testing to fully assess executive function. It includes organizing, planning, remembering details, switching focus, managing time, suppressing inappropriate behavior or speech, and merging past experiences with present action. Individuals who have impaired executive function may not be able to function independently. Executive dysfunction can be seen in dementia, head injuries, strokes, depression, attention deficit disorder, or learning disabilities.

The executive function is assessed in the history part of the exam when determining if a patient can function well in everyday life. Patients who demonstrate problems with judgment or insight may have executive dysfunction. Abstract reasoning can be used to assess executive function. Can the patient explain a proverb such as, "a rolling stone gathers no moss"? Can the patient describe an idiom, or can a patient interpret differences and similarities like child or dwarf?

Some clinicians will determine estimated intelligence and general fund of knowledge; more extensive testing is required to do this accurately. It is best left for more advanced assessment, such as neuropsychological testing.

Mental status examinations are often done with standardized assessment tools. Standardized tests are helpful because they can follow a patient over time and can be done by many healthcare providers with similar results.

Specialized Mental Health Tests

Many tests are available to assess cognition. The mini-mental state examination (MMSE) is a well-known test that assesses multiple domains, can be done in 5 to 10 minutes and is rated on a scale from 0 to 30. The mini-mental state examination is a useful test to screen for cognitive impairment and monitor cognition changes over time. It is not recommended as a diagnostic tool. The MMSE score is affected by culture, age, and education, but gender does not affect it.

The Clock Drawing Test is another screening tool for cognitive problems, especially dementia. This test has high sensitivity and specificity for dementia. The sensitivity and specificity are improved when it is combined with the MMSE. It should not be used for the screening of mild cognitive impairment. The patient is given a piece of paper with a pre-drawn circle. Tell the patient to draw numbers in the circle to make the circle look like a clock's face. The patient is given time, ten after 11 is often used, and then draws the clock's hands to read that time. A cognitively intact patient should make no errors or only minor visual-spatial errors such as slightly drawing outside the circle or mild spacing problems.

Beck's Depression Inventory asks 21 questions and rates them on a scale from 0 (minimal) to 3 (severe). It is recognized as a reliable and valid instrument to measure depression. The questions focus on sadness, hopelessness, guilt, self-dislike, loss of energy, insomnia, fatigue, anhedonia, irritability, crying, lack of interest in sex, agitation, self-blame, past failure, punishment, suicidal thoughts, loss of interest in activities, indecisiveness, worthlessness, decreased appetite and diminished concentration. The score is tallied, and scores over 30 are classified as severe depression. Less than 15 is mild to no depression, and 15-30 is moderate depression.

Two commonly used scales are available for older adults. The geriatric depression scale is useful to assess depression in older adults with an MMSE score above 10. The Cornell Depression Scale is useful to screen for depression in those with dementia. It asks 19 questions across five categories. It evaluates mood (sadness, affect, anxiety, irritability), behaviors (agitation, movement, slow speech), physical signs (weight loss, low energy), cyclic function (insomnia, mood fluctuations), and ideation disturbances (suicide, pessimism).

Suicidal Screens for Children and Adolescents

Four suicide screening instruments are recommended for children and adolescents.2

  1. Beck Scale for Suicide Ideation (BSI)
  2. Harkavy Asnis Suicide Scale (HASS)
  3. Suicide Ideation Questionnaire (SIQ)
  4. Suicidal Behaviors Questionnaire for Children (SBQ-C)

BSI is a 21-question self-report questionnaire that is used to detect and measure suicidal thoughts' severity. The authors of this screen emphasize that if a person endorses any item on the BSI, then a suicide assessment should immediately be initiated. The BSI is more thorough than other screens asking questions about the desire to live, suicidal ideation, duration and frequency of suicidal thoughts, and suicidal plan.

HASS is a 21-item questionnaire used to gather information about a child's current and past suicidal behavior. This screen collects demographic information, previous suicidal acts, the frequency of suicide-related behaviors over the last two weeks, and recent substance misuse. The HASS is used most commonly in high school students and includes questions like, "Have you ever thought about killing yourself but did not try?"

SIQ is used to determine the severity of suicidal ideation. There is a 30-item and 15-item version, both designed for younger adolescents. The SIQ asks individuals to rate the severity of their suicidal ideation on a 7-point Likert scale. This screen is based on a hierarchy of seriousness of suicidality ranging from thoughts to death to suicide. This screen does not assess previous or recent suicide attempts and should almost always be supplemented by a comprehensive suicide assessment.

SBQ-C is a 14-question screen designed to assess suicidal thoughts and behaviors in children and adolescents. It is a self-report tool designed to be easily understood by children and adolescents. Limited psychometric data is available about this questionnaire.

Suicidal Screens for Adults

There are various suicide risk screens available for adults; however, it is essential to remember that screens do not replace a professional's comprehensive suicide assessment. Commonly used suicide screens for adults include:

  1. Beck Scale for Suicidal Ideation (SSI)
  2. Columbia Suicide Severity Rating Scale (C-SSRS)
  3. Nurses' Global Assessment of Suicide Risk

SSI evaluates suicidal thoughts' intensity. It includes 19 questions. Each scored 0, 1, or 2 based on severity. It places individuals into three categories: active suicidal desire, preparation, and passive suicidal desire. This scale was later revised and named the Modified Scale for Suicide Ideation (MSSI). This screen used a scale of 0 to 3, increasing the ability to discriminate between those who are thinking about suicide and those who are likely to attempt.

C-SSRS is used in primary care settings, and it is available in over 100 different languages. The C-SSRS does not require mental health training to administer effectively, and it provides criteria for the next steps based on the score.

The Nurses' Global Assessment of Suicide Risk includes 15 items that help assess a person's risk of attempting suicide. It allows clinicians to evaluate high and low-risk characteristics quickly. Each item on the screen is supported by research; however, the screen has not been empirically tested.

Specific Mental Illnesses

Depression

For two weeks, at least five signs or symptoms in Table 6 must be present to diagnose major depression.  Of the five, depressed mood or reduction of interest or pleasure in activities formerly enjoyed must be present. Medications, medical conditions, bereavement, general drug or alcohol abuse cannot cause these symptoms. The symptoms must result in significant impairment of social, occupational, or school functioning.   Depressed mood and or loss of interest must be present.

Table 6: SIG-E-CAPS pneumonic3
SSleep disorder (hypersomnia or insomnia)
ILoss of interest in activities that formerly were enjoyed
GGuilt – worthlessness, helplessness, hopelessness
EReduced energy
CLack of concentration
AAppetite disturbance (increased or decreased with weight gain or loss)
PPsychomotor agitation, retardation
SSuicidal thoughts, preoccupation with death

Bipolar Disorder in Adults

Bipolar disease is classified as bipolar I sustained mania with depressive episodes; or bipolar II at least one major depressive episode with at least one hypomanic episode. Approximately one percent of the population has bipolar I disorder, and one percent has bipolar II disorder, and 2.4 percent of the population has a sub-threshold bipolar disease.4 Bipolar disorder is often misdiagnosed as unipolar depression.

Bipolar II is more common in women, and bipolar I is equally common in men and women. A new diagnosis of bipolar disorder is uncommon in those over 65 and in children. There is a strong genetic component for bipolar disease.

Clinical manifestations of mania include:

  • At least one week of elevated, expansive, or irritable mood
  • During the mood disturbance, at least three of the following must be present or four if the mood is irritable
    • Reduced need for sleep
    • Excessive involvement in high-risk, pleasurable activities such as sexual promiscuity or excessive spending
    • Flight of ideas or racing thoughts
    • Inflated self-esteem or grandiosity
    • Excessive talking or pressured speech
    • Increased goal-directed activity or psychomotor agitation
    • Distractibility – attention drawn to irrelevant issues
  • It is not a mixed episode (major depressive episodes along with mania)
  • It impairs occupational or social functioning, requires hospitalization, or has psychotic features
  • Symptoms are not due to medication, a drug of abuse, medical treatment, or other medical conditions

Bipolar disease is associated with relapses and remissions. Manic and depressive episodes can be varied into the mix. Those with bipolar disorder have a high prevalence of co-morbid addictive disorders and suicide risk; therefore, it is important to assess all of those with diagnosed bipolar disorder for addictive disorders and suicide risk.

Anxiety

Anxiety is a diffuse discomfort that is non-specific and associated with feelings of uncertainty and vulnerability. Anxiety has different subtypes. Generalized anxiety disorder is extreme anxiety or worry without evidence or out of proportion to the present situation. The anxiety is not related to a single factor. The symptoms are fatigue, irritability, restlessness, sleep disturbance, on edge or keyed up, poor concentration, and muscle tension. The symptoms are present for more than six months. Anxiety symptoms are:

  • Distressful
  • Impairs normal function
  • High blood pressure
  • Tachycardia
  • Elevated respiratory rate
  • Nausea
  • Shaking
  • Urinary frequency
  • Tremor
  • Sweating
  • Diarrhea
  • Muscle tension
  • Flushing
  • Dry mouth
  • Dilated pupils
  • Cold, clammy hands

The panic disorder presents with repeated attacks of intense fear that characteristically appears quickly. At least four of the following must be present:

  • Fear of dying
  • Fear of impending doom
  • Chest pain
  • Palpitations
  • Tachycardia
  • Dizziness
  • Syncope
  • Shortness of breath
  • The sensation of choking
  • Trembling
  • Nausea
  • Abdominal distress
  • Chills
  • Hot flashes
  • Diaphoresis
  • Depersonalization

Obsessive-compulsive disorder (OCD) present with obsessions and compulsions that lead to distress. An obsession is a recurrent and persistent thought, image, or impulse that produces stress and anxiety. Compulsions are recurring behaviors performed to reduce anxiety caused by the obsession.

A phobia is a strong, irrational fear of something that is associated with limited or no actual danger. Three ordinary phobias are agoraphobia, claustrophobia, and social phobia. Agoraphobia is a fear of public places; claustrophobia is a fear of closed-in places. Social phobia is the constant fear in social situations that weaken the capability to function socially.

Post-traumatic stress disorder (PTSD) occurs after a trauma that involves a real or threatened death or injury. The condition leads to reliving the event, avoiding certain things, and excessive arousal. Specific things that may occur include flashbacks, repeated nightmares of the event, repeated upsetting memories of the event, emotional numbing, lack of interest, feeling detached, feeling irritable, startling easy, and sleep disturbances.

Schizophrenia

Schizophrenia is a mental disorder where patients do not:

  • Think clearly
  • Act normally in social situations
  • Differentiate between reality and fantasy
  • Have normal emotional responses

People with schizophrenia have a higher rate of divorce, incarceration, and homelessness.5

Schizophrenia is characterized by having two or more symptoms a significant portion of the time over one month. Symptoms include delusions, hallucinations, disorganized speech, disorganized behavior, and negative symptoms (loss of pleasure, catatonia, poverty of speech, flat affect, poor grooming, poor social skills, and social withdrawal). Relationships (work, interpersonal) or self-care are typically compromised.

Other features schizophrenics exhibit include repetitive and confusing speech, nonsense words, slow movements, repetitive movements, or gestures such as pacing or odd facial expressions, odd manner of dress, odd beliefs, thought blocking, and poor hygiene.

Conditions that may mimic schizophrenia include bipolar disease, seizure disorder, substance abuse, delirium, brain lesions, depression, psychotic disorders, schizoaffective disorder, schizotypal personality disorder, thyroid disorders, and infections.

When to Refer to a Mental Health Professional

Many reasons may be present to refer a patient to a mental health professional. Also, there are many different types of mental health professionals to refer to, depending on the situation. Different mental health professionals and who should be referred to them are included in Table 7. Many indicators become evident when a complete assessment is finished

Some general guidelines for when referral to a primary healthcare provider or psychiatrist includes:

  • The patient is showing depressive symptoms (review SIG-E-CAPS), especially a decline in the ability to experience pleasure or prolonged sadness
  • Any suicidal or homicidal gestures (immediate referral)
  • Any dangerous behaviors such as self-harming behavior (e.g., cutting)
  • Excessive anxiety (e.g., panic attacks, irrational fears, phobias)
  • Intrusive thoughts
  • Periods of euphoria associated with a reduced need for sleep or impulsive or risk-taking behavior (e.g., an increase in promiscuous sex, excessive drug or alcohol use, or spending sprees)
  • Severe irritability or outbursts of anger (e.g., argumentative, easily annoyed, easily upset)
  • Psychosis (e.g., hallucinations, delusions, paranoia)
  • Addictive behaviors (e.g., drug use, excessive alcohol use, excessive overeating)
  • Signs and symptoms of abuse (physical, emotional, or sexual)

Patients who may benefit from psychotherapy include those with:

  • Non-compliance with medical treatment
  • Unresolved grief
  • Parenting or family issues
  • Struggles with adjustment to major life changes (e.g., death, move, divorce)
  • Self-sabotaging behavior (e.g., drug or alcohol abuse, binge-eating)
  • Anger issues or impulse control
  • Significant relationship problems (e.g., dependency, manipulation, infidelity)
  • Identity confusion (e.g., gender, race, sexual orientation)
Table 7: Mental Health Professionals
Healthcare WorkerRole
Social WorkerSocial workers have multiple roles. Some of their roles include:
  • Education of patients
  • Helping patients find treatment facilities and in-patient mental healthcare centers
  • Helping find a job or helping them find assistance to get finances such as disability or welfare benefits
  • Assessing patients to evaluate mental health issues
  • Counseling patients on minor issues both in a group and individually to help them manage a variety of social issues such as mental or physical illness, substance abuse, financial issues, unemployment, or abuse
  • Collaborating with other healthcare members to coordinate a plan of care
  • Increasing awareness of community resources and referring if appropriate
  • Helping family members deal with and support the patient
  • Referring the patient and family to community resources such as treatment programs or housing to assist in recovery
  • Assisting patients to get to appointments by helping with transportation
Psychiatric or Mental Health Nurse Practitioner or Clinical Nurse SpecialistThis advanced practice nurse manages patients at risk for or has a psychiatric disorder or mental health problem. These nurses assess psychiatric patients, diagnose psychiatric disorders, conduct psychotherapy, manage cases, provide expert consultation to primary care providers, and prescribe mental health medications. They work in a variety of settings, including outpatient offices, hospitals, and community programs.
Primary Care ProviderThis is a medical doctor, doctor of osteopathy, nurse practitioner, or physician assistant who medically manages (including prescribing medications).
PsychologistA psychologist has an advanced degree in psychology and can help diagnose many mental health diseases as many are experts in advanced clinical assessment such as neuropsychiatric testing. Psychologists perform psychotherapy to help patients manage mental health conditions.
PsychiatristThis is a medical doctor or doctor of osteopathy who has specialized training in psychiatric issues who manage complex mental health issues outside of the primary care provider's scope.

Case Study

Presenting Problem: Steve F. is an 82-year-old widowed white male. He presents to his primary healthcare provider because his family is concerned about his memory loss. He has been becoming more forgetful and is having problems functioning independently. Specifically, he is getting lost when driving and having problems preparing his meals.

Past History: Steve has been an extremely healthy individual. He is not afflicted with a history of any medical, surgical, or psychiatric problems. He currently takes no medications and has never been on any chronic prescription medications.

Drug or Alcohol History: Steve has been a lifelong nonsmoker, has never used illegal drugs, and reports drinking a glass of red wine 3-4 times a week for most of his adult life.

Suicidal or Homicidal Ideation: He denies any suicidal or homicidal ideation. There is no history of abuse in his past.

Family or Social History: Steve was married 51 years and has been a widow for six years. He currently lives alone in his home. He has no close living friends. He has one grown daughter and two grandchildren, who all live over 100 miles away.

Employment history: He worked 44 years at a steel factory and has been retired for 18 years.

Education: Steve dropped out of high school in the 11th grade and reports he was an average student.

Crime or Legal Trouble: He has never had any legal trouble.

Developmental History: No significant abnormalities were reported.

Spiritual Assessment: He reports being a Catholic and regularly attending mass.

Cultural Assessment: He considers himself an American.

Financial Assessment: He reports no financial issues.

Coping Skills: He reports limited stress in his life and reports he copes with stress well.

Interests and Abilities: He reports that his favorite activities are spending time with family and reading.

Mental Status Exam:

Steve is an alert, calm appearing white male who appears to be his stated age and is accompanied by his daughter. He has dressed appropriately and is well-groomed. He is cooperative and polite during the interview and maintains good eye contact. His mood is normal and affect appropriate. His rate of speech is slow, and speech is soft. His thought process showed a limited ability to think abstractly and some loose associations. His thought content was normal and did not demonstrate any paranoia, aggressiveness, or obsessive thinking. No psychotic thinking was demonstrated. He was oriented to person and place but was unable to report the day of the week. He had normal impulse control and demonstrated normal judgment during the exam.

The patient's functional ability was of slight concern. The patient can generally care for himself independently, but there has been a 5-pound weight loss over the last three months without a known cause. There have been multiple problems with bills being paid late, and the patient has received many calls from creditors. He has had some problems preparing meals for himself. Of greatest concern to the daughter was that the patient got lost coming home from the mall last week that he has been going to for over 20 years.

His cognition or knowledge was tested with the Mini-Mental State Exam, in which the patient had a score of 24.

Based on the psychosocial assessment, it is determined that the patient has some dementing illness. The medical doctor diagnoses Alzheimer's disease. Given the problems with self-care, the patient will be moved to an assisted living facility with part-time nursing care. The assisted living facility will monitor the patient closely to ensure all self-care needs are being met. If self-care needs are not being met, moving to a long-term care nursing facility will be considered.

This complete and thorough psychosocial history helped the primary care physician diagnose and fully understand the patient's impairments. Based on the strength of the psychosocial history taken by the nurse, the patient will now receive safe and effective care. If a complete psychosocial assessment was not taken, it might have been determined that the patient functioned well in his own house. Allowing the patient to return to his home may have led to poor quality of life for him and his family.

Conclusion

The psychosocial assessment starts with a general psychosocial history and concludes with a mental status examination. The psychosocial assessment allows the nurse to pick up on many psychological or social issues that can significantly improve the patient's quality of life with proper intervention. To provide optimal care for their patients, the nurse needs to know how to perform a good psychosocial assessment and know when to refer to another healthcare provider.

Select one of the following methods to complete this course.

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References

  1. Suicide: Risk and Protective Factors. Center for Disease Control. Updated September 3, 2019. Visit Source.
  2. DeCapua, M. Suicide Screening and Referral [Continuing Education]. CEUFast.Com. September 9, 2020. Visit Source.
  3. Farlax. (n.d.). The Free Dictionary. The Free Dictionary. Visit Source.
  4. Soreff, S. Bipolar Affective Disorder. MedScape. Published May 30, 2019. Visit Source.
  5. Frankenburg, F. Schizophrenia. MedScape. Updated September 17, 2020. Visit Source.