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Psychosocial Assessment: A Nursing Perspective

2.00 Contact Hours:
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Raymond M. Lengel (ARNP)

Purpose/Goals

This course is directed at practicing nurses to assist them when performing a psychosocial assessment. The course discusses psychosocial assessment including the components of a psychosocial interview, the mental status examination, selected psychosocial screening tests, common mental health illness and different mental health professionals.

Objectives

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

  1. Describe five components to the psychiatric 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 on clients with depression, bipolar disease, anxiety and schizophrenia
  5. List two major roles each that the social worker, psychologist, primary care provider and psychiatrist play in the management of a mental health patient

Introduction

A psychosocial assessment is an evaluation of an individuals mental health and social well being. It assesses the perception of self and the individuals ability to function in the community. It typically involves a number of questions asked by the health care provider to assess multiple domains to understand the individual. The goal of the psychosocial assessment is to understand the client to help provide the best care possible and help the individual to obtain optimal health.

The psychosocial assessment of a patient is an extremely important part of nursing care. The goal of this course is to provide a basic overview of the psychosocial assessment. While all nurses will have their own technique for performing a psychosocial assessment, this course will help the nurse understand key components to a complete psychosocial assessment.

The psychosocial assessment is used to help the nurse determine if the patient is in a state of mental health or mental illness. Mental health is a state of well being where there is the ability to deal with the typical stresses of life, works productively and is able to contribute to their community (World Health Organization, 2011). It is estimated that only about 17 percent of people have optimal mental health (Center for Disease Control, 2011).

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, and/or harm judgment. Mentally ill individuals often have a reduced ability to cope in society, maladaptive behaviors and a reduced ability to function.

Psychosocial Assessment

The major components of a psychosocial interview include: identifying the patient, the chief complaint, the history of presenting illness, psychiatric history, medical/surgical history, medication list, alcohol and drug use, violence risk assessment, family/social history, occupational history, educational history, legal history, developmental history, spiritual assessment, cultural assessment, financial assessment, coping skills, interests and abilities and the mental status examination.

The first step in any assessment is to adequately identify the patient. This should include the patients name, gender, birth date/age, marital status, race/ethnicity and languages spoken.

The chief complaint is the main reason the patient is being assessed 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 problems location, duration, severity, timing, context, modifying factors and associated signs/symptoms.

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

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

Violence risk should also be assessed. This 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 of suicide, those who feel hopeless, those who abuse drugs and alcohol, history of depression/bipolar disorder, feeling isolated, physical illness, history of aggressiveness/impulsivity, those who are unwilling to seek help or those with barriers to mental health treatment (Center for Disease Control, 2012).

Risk factors for homicidal behavior include: male gender, those with gang affiliations, unemployment status, drug/alcohol use, active psychotic symptoms, and lower socioeconomic status (Drucker, 2011 & Shaw, Hunt, Flynn, Meehan, Robinson, Bickley, et al., 2006).

Key questions to ask in the assessment of suicidal/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 a means to carry out a plan to harm others?   
  • Is there intent to carry out the plan?   
  • What is the lethality of plan?   
  • Do you have any high risk behaviors such as cutting, anorexia/bulimia, head banging 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 one interacts with others. It is important to have an understanding of all social relationships as those who have a large social network are more likely to have less severe mental illness and recover better from mental illness. The nurse should have the patient describe their social relationships including number of siblings, who raised the patient, spouse/significant other, number of children, current living situation, military history including type of discharge and any other support or social networks should be reported. Any significant life event, such as a 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 patients family. Commonly hereditary mental illnesses include: depression, bipolar disease, schizophrenia and attention deficit disorder.

Employment history is important. Record the patients current employment status and what they do. 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 it the last five years? Patients who have held multiple jobs in the recent past are more likely to have avoidant personality disorder.

Determining the 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? Assessing how the patient functions at work and school can provide helpful clues to the mental health picture.

A quick screen of the patients legal history is important. Determine if the patient has had no legal trouble, on probation, on parole, has pending charges or has been previously incarcerated. A strong link is noted between legal trouble and mental illness. Sixty-four percent of jail inmates, 45 percent of federal inmates and 56 percent of state prisoners are afflicted with serious mental illness (Fitzpatrick, 2006).

Developmental history will provide insight into the origins of behavior and help in the diagnosis and management of some conditions. Any psychological trauma experienced as a child may lead to problems in adulthood. Determine how the patient functioned in their childhood in relation to school, friends, personality and hobbies. In addition, determining the patients sexual orientation will help the nurse provide better care for the patient.

The spiritual assessment should note the patients religious background. In addition, the degree of involvement within the religious community and any spiritual practices should be assessed. Nurses who have an understanding of the patients spiritual views will be better able to empathically identify with them. It can also help the nurse determine if the patient has unresolved spiritual needs/concerns. Unresolved spiritual issues will inhibit recovery. When spiritual concerns are identified appropriate referrals (such as to the Chaplin) may help assure holistic wellness.

The cultural assessment should list any important issues regarding the patients ethnic and cultural background. It is impossible for a nurse to have a full understanding of every culture, but a good cultural assessment will help the nurse understand the patients cultural 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 patients financial situation. Understanding the patients financial situation is important for multiple reasons. Clients with lower socioeconomic class are at higher risk for many mental health conditions (Hudson, 2005). In addition, clients who have limited financial resources may need help with money and would benefit from a consultation with a social worker.

Determining coping skills is an important part of the psychosocial assessment. If the nurse understands the patients current coping techniques, they will provide better care by helping patients foster adaptive coping skills.

Determining the patients abilities and interests helps get a full picture of the patient. Ask the patient: What are their hobbies? What are they good at? What gives the patient pleasure?

Mental Status Examination

The mental status examination assesses the function of the brain. The purpose is to evaluate mental functions and behaviors. A good mental status examination helps assess many mental health/central nervous system disease states. A good mental status examination can be used to monitor a patients severity of illness over time.

The first step in the mental status examination involves determining the patients 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 the eye contact appropriate? Things to note include poor hygiene, inappropriate dress, and lack of concern for appearance. Poor grooming indicates a potential psychiatric problem. Posture that is stooped and poor eye contact suggests depression. Colorful clothes/unusual clothing may be present in manic states.

Behavior and motor activity should than be assessed. Is the patient calm and relaxed or is there any indication of restless, agitation or lethargy? In addition, 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 abuse of stimulants. Repeated motor movements suggest obsessive-compulsive disorder. Little body movement may be seen in depression, catatonic schizophrenia or drug abuse.

The mood/affect should also be evaluated. Asking patients how they are feeling is a simple way to assess mood. Is the patients emotional response to the situation appropriate? The mood can be assessed by observing the verbal/non-verbal behaviors during the physical exam. Disturbances in the mood may be demonstrated by feelings inappropriate to the situation. 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 should all be noted.

The speech pattern is an important part of the psychosocial assessment. The patients voice should be clear, strong, fluent, and articulate with a clear expression of thought. Abnormalities in speech to be noted include: nonverbal, slurred speech, soft speech, loud speech, pressured speech, limited interaction, incoherent speech, halting speech or rapid speech. Slurring of words suggests intoxication. Pressured speech is seen in mania. Those with depression will often have poverty of speech.

The patients attitude should also be noted. Is the patient cooperative, uncooperative, guarded, suspicious or hostile?

The thought process is how individuals self-express and is observed through speech (Staurt, 2009). It is not the content of the speech but the patterns of verbalization. It may range from normal to any of the terms on Table 2. A normal thought process is logical, relevant, sequential and coherent?

Table 2: Terms to Describe Thought Process
Term Definition What it may suggest
Flight of ideas Frequently changing topics Mania
Tangential Going away from a topic and not returning Schizophrenia/psychosis/anxiety
Circumstantial Provides unnecessary detail, but eventually gets to the point Schizophrenia/psychosis/obsessive-compulsive disorder
Neologisms Making up new words Schizophrenia/psychosis
Looseness of association Illogically shifting between topics Schizophrenia/psychosis
Word salad Nonsensical responses Schizophrenia/psychosis
Clanging Rhyming words, speech makes no sense Schizophrenia/psychosis
Thought blocking Speech is stopped Schizophrenia/psychosis
Poverty of speech Limited content of speech Depression

Thought content is the themes that take up the patients thoughts and shows how coherent and logical the individual thinks. Things that suggest abnormalities include: phobias (a morbid fear along with extreme anxiety), hypochondriasis (obsessed with the idea of having a serious or life-threatening disease which is not diagnosed), obsessive thoughts (unwelcome idea, impulse or emotion that is continually forced into the conscious mind), hallucinations, delusions (fixed false believe) or other preoccupations (thoughts that are prominent in the mind of the patient such as thoughts of death, suspicion or fear).

Assess the patient for specific delusions and hallucinations. A hallucination is something that the patient perceives, but is not there. 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 and if the patient complies or is considering complying with the command.

Assess the type of delusion that the patient is having. Table 3 gives questions to ask to determine if the patient is having hallucinations or delusions. Delusions are classified in multiple ways (see table 4).

Table 3: Questions to ask to elicit the presence of hallucinations/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 believes that others consider strange?   
  •   Does the television or radio give you special messages?
Table 4: Type of Delusions
Type of delusion Definition
Grandiose A believe that the person is someone of extreme importance
Persecutory A false belief that the person is being followed, is under surveillance, being ridiculed or treated unfairly
Jealousy Belief that the individual's sexual partner is unfaithful
Religious Belief of a special status with God
Somatic Belief that there is a physical defect or general medical condition when none exists
Ideas of reference Belief that things in the environment refers to them, when they do not
Thought insertion Belief that someone is putting ideas or thoughts into their mind
Thought broadcasting Thinking that ones 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 that may be noted in those with poor impulse control include: pathological gambling, excessive substance use/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 patients lifestyle. Poor judgment is likely present in those who are involved in illegal activity or in relationships with those that are destructive. Judgment is impaired in those who are schizophrenic, psychotic, intoxicated, manic, in some personality disorders or those who have 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 patients 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 to determine if the patient is oriented to person, place and time.

Attention is the ability to focus, direct thinking and not get distracted. Concentration is the ability to maintain attention over a time. A patient who is unable to maintain attention will have other problems in cognitive performance especially executive function and memory, making full assessment of mental status challenging.

Lack of attention will be demonstrated by patients who lose their train of thought, become easily distracted or those who ramble. Attention can be assessed by having the patient repeat a string a digits. An adult should be able to repeat 5-9 digits (Mendez & Cummings, 2003). Another way to assess attention includes having a patient spell a word backwards (W-O-R-L-D is often used) or repeat the months of the year 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 test of recent memory involves telling the patient three words and then having the patient repeat the three words to assure there is normal attention. Ask the patient to repeat the words five minutes later after they have been 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 historic events (such as the names of the presidents of the United States in reverse order).

The content of speech is assessed by noting the presence or absence of any language errors during 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 clients read a section of words and writing a sentence. Repetition is assessed by having a patient repeat a common phrase. One that is often used is no ifs, ads or buts.

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 a difficult time with 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. To assess praxis the patient is given a step-wise 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 (Gross & Grossman, 2008).

Assessing the patients ability to calculate is done by having the patient perform simple mathematical problems. This can be done by having the patient start at 100 and subtract 7 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 that are synchronized in the frontal lobe of the brain and helps people accomplish goals. It is hard to assess from exam alone. It may take getting a good history from the patient and family or neuropsychological testing to fully assess executive function. It includes the ability to organize, plan, remember details, switch focus, manage time, suppress inappropriate behavior/speech and merge 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. Clients 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 (child-midget)? .

Some clinicians will determine estimated intelligence and general fund of knowledge. In order to do this accurately more extensive testing is required. 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 health care providers with similar results.

Specialized Mental Health Tests

Many tests are available to assess cognition; this section will discuss a few tests often used.

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 to monitor for changes in cognition over time. It is not recommended as diagnostic tool. The score on the MMSE is affected by culture, age and education, but gender does not affect the score (Tombaugh, & McIntyre, 1992).

The Clock Drawing Test is another screening tool for cognitive problems, especially dementia. This test has a high sensitivity and specificity for dementia. The sensitivity and specificity is improved when it is combined with the MMSE (Aprahamian, Martinelli, Neri, Neri, & Yassuda, 2012). It should not be used for the screening of mild cognitive impairment (Ehreke, Luppa, Knig, & Riedel-Heller, 2010).

The patient is given a piece of paper with a pre-drawn circle. The patient is told to draw numbers in the circle to make the circle look like the face of a clock. The patient is given a time, 10 after 11 is often used, and then draws the hands of the clock 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.

The Becks 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 (McPherson & Martin, 2010). The questions focus around 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 sores 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 (Conradsson, Rosendahl, Littbrand, Gustafon, Olofsson, & Lvheim, 2013). 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).

Specific Mental Illnesses

The next section will review a few common mental illnesses. Understanding the basics of these illnesses will make it easier for the nurse to be able to perform a good psychosocial assessment.

Depression

It is estimated that 9.1% of people in the United States are currently depressed and 4.1% have major depression (Center for Disease Control, 2011). During a two week period at least five signs/symptoms on Table 6 must be present to make the diagnosis of major depression (American Psychiatric Association, 2000). Of the five, depressed mood and/or reduction of interest or pleasure in activities that were formerly enjoyed must be present. Medications, medical conditions, bereavement, general drug or alcohol abuse cannot be the cause of these symptoms. The symptoms must result in significant impairment of social, occupational or school functioning.

Table 6: SIG-E-CAPS pneumonic
S Sleep disorder (hypersomnia or insomnia)
*I Loss of interest in activities that formerly were enjoyed
G Guilt worthlessness/helplessness/hopelessness
A Reduced energy
C Lack of concentration
A Appetite disturbance increased or decreased with weight gain or loss
P Psychomotor agitation/retardation
S Suicidal thoughts, preoccupation of death
* Depressed mood
*Depressed mood and or loss of interest must be present

Bipolar disorder in adults

Bipolar disease is classified as bipolar I (sustained mania with depressive episodes) or bipolar II (at least one major depression 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 sub threshold bipolar disease (Merikangas, Akiskal & Angst, 2007)

Bipolar disorder is often misdiagnosed as unipolar depression. In one study, those being treated for depression were screened for bipolar disorder and it was found that 21.3 percent had bipolar disorder (Hirschfeld, Cass, Holt, & Carlson, 2005).

Bipolar II is more common in women and bipolar I is equally common in men and women (Benazzi, 2007). 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 (American Psychological Association, 2000).

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

Bipolar disease is associated with relapses and remissions. Manic and depressive episodes can be varied into the mix. Ninety percent of those with one manic episode will have another episode within five years (Hilty, Brady, & Hales, 1999). Nine out of ten people with bipolar disorder have at least one psychiatric hospitalization and two out of three will have more than one psychiatric hospitalization (Woods, 2000).

Those with bipolar disorder have a high prevalence of co-morbid addictive disorders and suicide risk. It is therefore 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 and the symptoms (fatigue, irritability, restlessness, sleep disturbance, on edge or keyed up, poor concentration and muscle tension) are present more than six months. The anxiety is distressful and impairs normal function.

Other signs/symptoms may include: high blood pressure, tachycardia, elevated respiratory rate, nausea, tremor, sweating, diarrhea, muscle tension, flushing, dry mouth, shaking, urinary frequency, dilated pupils and cold clammy hands.

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, sensation of choking, trembling, nausea, abdominal distress, chills, hot flashes, diaphoresis or 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; and social phobia is the constant fear in social situations that weaken the capability to function socially.

Post-traumatic stress disorder 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 clients do not think clearly, do not act normally in social situation, cannot differentiate between reality and fantasy and do not have normal emotional responses. Schizophrenics have a higher rate of divorce, incarceration or become homeless (Javitt & Coyle, 2007).

Schizophrenia is characterized by having two or more symptoms a significant portion of the time over a period of 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, use of nonsense words, slow movements, repetitive movements/gestures such as pacing or odd facial expressions, odd manner of dress, odd believes, 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.

Catatonic, disorganized, paranoid, residual and undifferentiated are the five different categories of schizophrenia. Catatonic schizophrenia presents with excessive or purposeless motor activity, extreme negativism, immobility, mutism and keeping a rigid posture or peculiar voluntary movements such as grimacing or prominent mannerisms. The disorganized type has disorganized speech or behavior and a flat or inappropriate affect. Hallucinations and delusions are common in paranoid schizophrenia. Residual schizophrenia has positive symptoms (hallucinations and delusions) that are reduced in severity but has continual negative symptoms. Undifferentiated schizophrenia is schizophrenia that does not reach diagnostic certainty for other types.

Case Study

A 32-year-old white female, who is the mother of three, presents to the primary care clinician with lack of energy, back pain, early morning wakening and irritability. She reports that she is so engrossed in her childrens' lives that she has no time to do anything herself. On the rare evening that she has an evening free she chooses to go to sleep instead of going out.

Her physical exam is unremarkable. Her past medical history is unremarkable except for three healthy vaginal births. She is on no medications and has no allergies to medications.

The patient was given a quick screening in the office using the SIG-E-CAPS criteria. While she denied depression she did test positive for sleep disturbance, loss of interest (key criteria), lack of energy, poor concentration, excessive appetite and psychomotor agitation. She was diagnosed with major depression.

When to Refer to a Mental Health Professional

Many reasons may be present to refer a patient to a mental health professional. In addition, 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. When a complete assessment is done many of these indicators may become evident.

Some general guidelines for when referral to a primary health care provider or psychiatrist include:

  • The patient is showing depressive symptoms (review SIG-E-CAPS) especially a decline in the ability to experience pleasure or prolonged sadness   
  • Any suicidal/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/risk taking behavior (e.g., an increase in promiscuous sex, excessive drug/alcohol use or spending sprees)   
  • Severe irritability/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)

Clients who may benefit from psychotherapy include those with:

  • Non-compliance with medical treatment   
  • Unresolved grief   
  • Parenting/family issues   
  • Struggles with adjustment to major life changes (e.g., death, move, divorce)   
  • Self-sabotaging behavior (e.g., drug/alcohol abuse, binge-eating)   
  • Anger issues/impulse control   
  • Significant relationship problems (e.g., dependency, manipulation, infidelity)   
  • Identity confusion (e.g., gender, race, sexual orientation)
Table 7: Selected Mental Health Professionals
Health Care Worker Role
Social Worker  Social workers have multiple roles. Some of their roles include:
  • Education of clients   
  • Helping clients find treatment facilities and in-patient mental health care centers   
  • Helping clients find a job or helping them find assistance to get finances such as disability or welfare benefits   
  • Assessing clients to evaluate mental health issues   
  • Counseling clients 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 health care members to coordinate a plan of care   
  • Increasing awareness of community resources and referring if appropriate   
  • Helping family members deal with and support the client   
  • Referring the client and family to community resources such as treatment programs or housing to assist in recovery   
  • Helping clients get to appointments by helping with transportation
Psychiatric/Mental Health Nurse Practitioner/Clinical Nurse Specialist This is an advanced practice nurse who manages clients at risk for and/or has a psychiatric disorder or mental health problem. These nurses assess psychiatric clients, diagnose psychiatric disorders, conduct psychotherapy, case manage, 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 Provider This is a medical doctor, doctor of osteopathy, nurse practitioner or physician assistant that medically manages (including prescribing medications) many common mental health conditions.
Psychologist A psychologist has an advanced degree in psychology and can help in the diagnosis of many mental health diseases as many are experts in advanced clinical assessment such as neuropsychiatric testing. Psychologists perform psychotherapy to help clients manage mental health conditions.
Psychiatrist This is a medical doctor or doctor of osteopathy who has specialized training in psychiatric issues who manages complex mental health issues that are out of the scope of the primary care provider.

Case Study Example of a Mental Health Assessment

Presenting Problem: Steve F. is an 82 year-old widowed white male. He presents to his primary health care provider because his family is concerned for Alzheimers disease. 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 past history of any medical, surgical or psychiatric problems. He currently takes no medications and has never been on any chronic prescription medications.

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

Family/Social History: Steve was married 51 years and has been a widow for 6 years. He currently lives alone. 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: Stan dropped out of high school in the 11th grade and reports he was an average student.

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

Developmental History: No significant abnormalities 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 is 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 is 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 patients functional ability was of slight concern. The patient is able to generally care for himself on his own, but there has been a 5 pound weight loss over the last 3 months without a known cause. There have been multiple problems with bills being 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/knowledge was tested with the Mini-Mental State Exam which the patient had a score of 24.

CLICK HERE TO DOWNLOAD AN EXAMPLE OF A PSYCHOSOCIAL ASSESSMENT

Conclusion

This course provided an overview of the psychosocial assessment. The psychosocial assessment starts with general psychosocial history and concludes with a mental status examination. The psychosocial assessment allows the nurse to pick up on many psychological and/or social issues that with proper intervention can lead to significant improvements in the quality of life for the patient. In order to provide optimal care for their clients, the nurse needs to know how to perform a good psychosocial assessment and know when to refer to another health care provider.

References

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C: American Psychiatric Association.

Aprahamian, I., Martinelli, J. E., Neri, A. L., & Yassuda, M. S. (2010). The accuracy of the Clock Drawing Test compared to that of standard screening tests for Alzheimer's disease: results from a study of Brazilian elderly with heterogeneous educational backgrounds. International Psychogeriatrics. 22(1), 64-71.

Benazzi, F. (2007). Bipolar disorder--focus on bipolar II disorder and mixed depression. Lancet. 369, 935.

Bossers, W.J,, van der Woude, L. H., Boersma, F., Scherder, E. J, & van Heuvelen, M. J. (2012). Recommended measures for the assessment of cognitive and physical performance in older clients with dementia: a systematic review. Dementia and Geriatric Cognitive Disorders Extra. 2(1), 589-609.

Center for Disease Control. (2012). Suicide: Risk and Protective Factors. Retrieved March 10, 2013 from the CDC.

Center for Disease Control. (2011). Mental Health Basics. Retrieved March 13, 2013 from the CDC.

Center for Disease Control. (2011). An Estimated 1 in 10 U.S. Adults Report Depression Retrieved March 9, 2013 from the CDC.

Conradsson, M., Rosendahl, E., Littbrand, H., Gustafon, Y., Olofsson, B, & Lvheim H. (2013). Usefulness of the Geriatric Depression Scale 15-item version among very old people with and without cognitive impairment. Aging and Mental Health. Retrieved March 19, 2013 from Taylor Francis Online.

Drucker, J. (2011). Risk Factors of Murder and Non-Negligent Manslaughter. RTM Insights. 15, 1-2.

Ehreke, L., Luppa, M., Knig, H. H., & Riedel-Heller, S. G. (2010). Is the Clock Drawing Test a screening tool for the diagnosis of mild cognitive impairment? A systematic review. International Psychogeriatrics. 22(1), 56-63.

Fitzpatrick, M. (2006). Mental illness of prison inmates worse than past estimates. Retrieved March 3, 2013 from The National Alliance of Mental Illness

Gross, R. G., & Grossman, M. (2008). Update on Apraxia. Current Neurology and Neuroscience Reports. 8(6), 490496.

Hilty, D. M., Brady, K. T., & Hales, R. E. (1999). A review of bipolar disorder among adults. Psychiatric Services. 50(2), 201-13.

Hirschfeld, R. M., Cass, A. R., Holt, D. C., & Carlson, C. A. (2005). Screening for bipolar disorder in patients treated for depression in a family medicine clinic. Journal of the American Board of Family Practice. 18(4), 233-239.

Hudson, C. G. (2005). Socioeconomic Status and Mental Illness: Tests of the Social Causation and Selection Hypotheses. American Journal of Orthopsychiatry. (75)1, 318.

Javitt, D. C., & Coyle, J. T. (2007). Decoding Schizophrenia. In Bloom Editor. Best of the Brain from Scientific American: Mind, Matter, and Tomorrows Brain. New York: Dana Press; p. 1158-1168.

Mendez, M. F., & Cummings, J. L. (2003). Mental status assessment. In: Dementia: A Clinical Approach. Philadelphia: Butterworth Heinemann.

Merikangas, K. R., Akiskal, H. S., & Angst, J. (2007). Lifetime and 12-month prevalence of bipolar spectrum disorder in the national co-morbidity survey replication. Archives of General Psychiatry, 64(5), 543-552.

McPherson, A., & Martin, C. R. (2010). A narrative review of the Beck Depression Inventory (BDI) and implications for its use in an alcohol-dependent population. Journal of Psychiatric and Mental Health Nursing. 17(1), 19-30.

Stuart, G. W. (2009). Principles and Practices of Psychiatric Nursing. St. Louis, Missouri: Mosby.

Shaw, J., Hunt, I. M., Flynn, S., Meehan, J., Robinson, J., Bickley, H., Parson, R., McCann, K., Burns, J., Amos, T., Kapur, N., & Appleby, L. (2006). Rates of mental disorder in people convicted of homicide. National clinical survey. British Journal of Psychiatry. 188, 143-7.

Tombaugh, T. N., & McIntyre, N. J. (1992). The mini-mental state examination: a comprehensive review. Journal of American Geriatric Society. 40(9), 922-35.

Woods, S. W. (2000). The economic burden of bipolar disease. Journal of Clinical Psychiatry. 61 Supp 13, 38-41.

World Health Organization. (2011). Mental Health: A State of Well Being. Retrieved March 3, 2013 from the The World Health Organization.


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)

Topics:

CPD: Practice Effectively, CPD: Prioritize People, Medical Surgical, Psychiatric


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