Psychiatric Evaluation and Evidence-Based Rating Scales

Week 2: Main Post:

Psychiatric Evaluation and Evidenced-based Rating Scales

Three important components of the Psychiatric Interview are the patient history, mental status exam, and psychosocial history.

Presenting Problem and History of Present Illness (HPI)
The presenting problem and HPI describe the patient’s reason for seeking care, outlining the characteristics of their symptoms, including when they began, how long they’ve lasted, and their impact on daily life. Collecting a comprehensive and accurate HPI is essential for understanding the patient’s current mental health concerns, aiding in the development of a differential diagnosis, and establishing a baseline for monitoring changes over time. According to the DSM-5-TR, the severity, frequency, and duration of symptoms are critical for diagnosing many psychiatric conditions, and tracking the illness’s progression can help confirm or rule out certain diagnoses.

Mental Status Examination (MSE)
The MSE assesses the patient’s mental state at the time of the evaluation, focusing on aspects such as appearance, behavior, mood, speech, thought processes, cognition, and insight. This examination is important because it allows the healthcare provider to directly observe symptoms and functioning, offering key insights into possible diagnoses like depression, psychosis, anxiety disorders, and cognitive impairments. Additionally, the MSE helps assess risk factors (e.g., suicidality or homicidally) and informs decisions regarding the need for urgent interventions or further diagnostic tests.

Psychosocial History
The psychosocial history includes details about the patient’s background, including their family dynamics, social relationships, work situation, and any history of trauma, substance use, or major life events. This information is crucial for understanding how external factors (e.g., family relationships, job stress, or social support) might contribute to or worsen the patient’s mental health symptoms. It also helps identify co-occurring conditions, such as substance use disorders or personality disorders. The psychosocial context provides valuable insights for creating a comprehensive treatment plan that incorporates medical and psychosocial strategies, in line with the DSM-5-TR’s emphasis on considering an individual’s life circumstances when assessing mental health.

Psychometric Properties of the Adult ADHD Self-Report Scale (ASRS)

The Adult ADHD Self-Report Scale (ASRS) is a widely used tool to screen for adult ADHD. The ASRS consists of 18 items assessing symptoms of inattention and hyperactivity/impulsivity, consistent with the diagnostic criteria for ADHD as outlined in the DSM-5-TR.

ADHD has been widely discussed for years. Most children are misdiagnosed or will continue to meet the criteria for continued treatment in adulthood. Adults who experience ADHD often have feelings of poor self-worth, increased self-criticism, and sensitivity toward higher levels of criticism throughout life ( Beaton et al., 2022) The treatment may include monotherapy or combination therapy consisting of medications and psychotherapy. This is where the adult rating scales or checklists are beneficial, and the psychometric properties need to be consistent.

These psychometric properties support the use of the ASRS as an effective, reliable screening tool for adult ADHD in clinical settings.

• Reliability: The ASRS has demonstrated strong reliability in consistently measuring the constructs of inattention and hyperactivity/impulsivity.
  • Validity: Research supports the ASRS’s strong construct validity, showing significant correlations with other well-established ADHD diagnostic tools, such as the Conners’ Adult ADHD Rating Scale (CAARS). It also exhibits good convergent validity, aligning well with clinical ADHD diagnoses.
  • Sensitivity and Specificity: The ASRS shows high sensitivity and specificity when compared to structured clinical interviews and diagnostic criteria

How the ASRS Helps the Nurse Practitioner’s Psychiatric Assessment

The ASRS is also a valuable tool in the psychiatric assessment because it allows for quick and efficient screening of ADHD symptoms. It aids in distinguishing between symptoms related to other psychiatric conditions (e.g., anxiety, depression) and those specific to ADHD, which can overlap. Given the nurse practitioner’s role in both diagnosis and treatment planning, the ASRS helps ensure that ADHD is not missed and facilitates an evidence-based approach to managing this often-underdiagnosed disorder.

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Furthermore, the ASRS tool (used in all stages of therapy screening, evaluation, and monitoring) promotes patient engagement in the diagnostic process, as it is a self-report tool that involves the patient in evaluating their symptoms. This participatory aspect enhances the therapeutic relationship and allows the NP to gather valuable insights into the patient’s symptomatology.

Evidence-Based Literature Support       

Many studies support the use of ASRS validity and utility in clinical practice. For instance, a systematic review by Lichtenstein et al. (2021) affirmed the ASRS’s high sensitivity and specificity for identifying ADHD in adult populations, which makes it an effective tool for initial screening and diagnosis. A study by Lavoie and Pelham (2022) also showed that the  ASRS effectively monitors symptom severity in patients receiving treatment for ADHD, emphasizing its importance in long-term management. These results highlight the scale’s value in psychiatric evaluations, especially for adult ADHD, where diagnosis and treatment can be challenging.

References

• Beaton, D. M., Sirois, F., & Milne, E. (2022). Experiences of criticism in adults with ADHD: A qualitative studyLinks to an external site.. PloS one, e0263366.
• Lichtenstein, P., et al. (2021). The Adult ADHD Self-Report Scale (ASRS) and its psychometric properties in adult populations. Journal of Attention Disorders, 25(5), 540-549.
• Lavoie, S. L., & Pelham, W. E. (2022). The role of the ASRS in diagnosing and managing adult ADHD: A clinical overview. Psychiatric Clinics of North America, 45(3), 459-472.
• DSM-5-TR (2022). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association.

Important Components of the Psychiatric Interview

The psychiatric interview is a crucial part of assessing a patient’s mental health, and there are several key components that contribute to a comprehensive understanding of the patient’s condition. Three of the most important components are rapport building, mental status examination, and history-taking.

1. Rapport Building: Establishing trust between the clinician and the patient is foundational for a successful psychiatric interview. This component allows the patient to feel comfortable, which encourages open communication and facilitates accurate disclosure of symptoms and concerns. According to Thompson et al. (2019), creating a therapeutic alliance through rapport is essential for obtaining reliable information, as patients are more likely to share sensitive details about their mental health when they feel understood and respected.
2. Mental Status Examination (MSE): The MSE involves a systematic assessment of the patient’s cognitive function, mood, thought processes, and perception. It provides a snapshot of the patient’s current mental state and is essential for identifying potential psychiatric disorders. Wong et al. (2019) emphasize that a comprehensive MSE can reveal underlying conditions such as depression, psychosis, or cognitive disorders that may not be readily apparent through other aspects of the interview. It also guides the clinician in deciding on the appropriate course of treatment.
3. History-Taking: A thorough history-taking includes an exploration of the patient’s psychiatric, medical, family, and social histories. This component is vital because it helps the clinician understand the context in which mental health issues have developed, contributing to a more accurate diagnosis and treatment plan. Hutchins et al. (2021) highlight that understanding a patient’s background can uncover factors such as trauma or family history of mental illness, which may significantly influence the patient’s mental health.

Psychometric Properties of the Social Interaction Anxiety Scale (SIAS)

The Social Interaction Anxiety Scale (SIAS), developed by Mattick and Clarke in 1998, is a self-report tool used to assess the severity of anxiety related to social interactions. Psychometrically, the SIAS has demonstrated strong reliability, with a high internal consistency (Cronbach’s alpha) ranging from 0.86 to 0.95 (Thompson et al., 2019). This means that the scale consistently measures what it intends to measure—social anxiety related to interactions. It also has good validity, with strong correlations to other established measures of social anxiety, such as the Social Phobia Scale (SPS), indicating that it accurately assesses the construct of social anxiety (Wong et al., 2019). Furthermore, the SIAS has been found to be sensitive to changes in anxiety levels, making it useful for monitoring the effectiveness of treatment.

Appropriate Use of SIAS in the Psychiatric Interview

The SIAS is most appropriate in clinical settings when assessing patients for social anxiety disorder (SAD), especially when social interaction-related anxiety is a prominent symptom. Given its focus on social interactions, the SIAS is particularly useful in helping to identify and measure the severity of anxiety in patients who experience difficulty in social situations, which is a key feature of social anxiety disorder. Hutchins et al. (2021) note that tools like the SIAS are invaluable for differentiating between general anxiety and social-specific anxiety, which can guide tailored interventions. For a nurse practitioner, utilizing the SIAS during the psychiatric interview provides a structured method to quantify the patient’s anxiety symptoms, facilitating accurate diagnosis and treatment planning.

How the SIAS Helps in Psychiatric Assessment

The SIAS is helpful in psychiatric assessments as it provides an objective measure of social anxiety that complements the subjective experience reported by patients. This helps nurse practitioners not only assess the presence and severity of social anxiety symptoms but also track changes over time, which is crucial for evaluating treatment effectiveness (Thompson et al., 2019). For instance, in patients undergoing therapy for social anxiety disorder, repeated use of the SIAS can help determine whether the treatment is effective in reducing anxiety symptoms related to social interactions, guiding clinical decisions on whether adjustments are necessary (Wong et al., 2019).

References

Hutchins, N., Allen, A., Curran, M., & Kannis-Dymand, L. (2021). Social anxiety and online social interaction. Australian Psychologist, 56(2), 142-153.
Thompson, T., Kaminska, M., Marshall, C., & Van Zalk, N. (2019). Evaluation of the social phobia scale and social interaction anxiety scale as assessments of performance and interaction anxiety. Psychiatry Research, 273, 725-731.
Wong, Q. J., Chen, J., Gregory, B., Baillie, A. J., Nagata, T., Furukawa, T. A., … & Rapee, R. M. (2019). Measurement equivalence of the Social Interaction Anxiety Scale (SIAS) and Social Phobia Scale (SPS) across individuals with social anxiety disorder from Japanese and Australian sociocultural contexts. Journal of Affective Disorders, 243, 165-174.

Mary Rucker, RN

Psychiatric Evaluation and Evidence-Based Rating Scales

December 4, 2024

Main Post

Psychiatric Interview

The psychiatric interview is a tool used is psychiatric/mental health settings to assist healthcare providers to develop professional therapeutic relationships with patients. The psychiatric interview allows providers to gather information by assessments and evaluations, make diagnoses, and implement interventions and treatment plans (Gibbs, 2021). The psychiatric interview has three components including the chief complaint/present illness, the Mental Status Examination (MSE), and the psychosocial and background history.

Components of the Psychiatric Interview

1. Chief Complaint/Present Illness: the chief complaint is vital because it highlights the reasoning for needing treatment, the patient’s current issues/symptoms, the onset of symptoms, the duration, and how the current symptoms affect the patient’s daily routine.
2. The Mental Status Examination (MSE): the MSE is utilized to identify the patient’s current mental state. It is divided into various sections including behavior, mood, speech, judgment, appearance, and cognition (Voss & Das, 2024, para. 6).
3. Psychosocial and Background History: The psychosocial and background history is essential to help identify past issues and patterns that have led and added to current issues. The psychosocial and background history consists of past psychiatric issues including substance abuse and treatments, past medical and surgery history, family history, and social history such as relationships, occupational, family, and military history (Gibbs, 2021).

The Psychometric Properties of the Positive and Negative Symptom Scale (PANSS)

The psychiatric rating scale assigned to me is the Positive and Negative Symptom Scale (PANSS) composed of 30 items is used to evaluate and determine the effectiveness of treatment options for psychiatric disorders such as schizophrenia and evaluates the “positive, negative, neuromotor, depressive” symptoms associated with schizophrenia (Opler et al, 2017, para. 3). PANSS is also used and efficient in research clinical trials for the severity of schizophrenia symptoms and medication treatment. The psychometric properties of the PANSS rating scale are in regard to the scale’s reliability, use of extractions from the scale, and validity of the PANSS score (Baandrup et al, 2022).

Use of the Positive and Negative Symptom Scale (PANSS) in Psychiatric Interview

Rating scales are vital in psychiatric and mental health settings to determine the severity of symptoms, history, and evaluation of treatment options. PANSS is an appropriate option for Nurse Practitioners to use during psychiatric interviews for patients diagnosed with schizophrenia to determine a total score based off data collected during the interview from all items from PANSS including baseline data such as history, current symptoms, and monitoring the progress of medication treatment and therapy. Opler et al (2017) highlights the importance of the PANSS in “clinical practice” due to its effectiveness in communicating with patients and families regardless of socioeconomic or cultural status especially while communicating the importance of continuing treatment and therapy (para. 14).

In conclusion, rating scales and psychiatric interviews are vital in psychiatric and research settings. While not only building therapeutic relationships with patients, interviews and rating scales help in determining a baseline for patient’s history and current concerns, interviews and rating scales also provide data to help determine current mental state of mind, necessary interventions and treatment options, and can also monitor and evaluate the effectiveness of treatment.

References

Baandrup, L., Allerup, P., Nielsen, M. Ø., Düring, S. W., Bojesen, K. B., Leucht, S., Galderisi, S., Mucci, A., Bucci, P., Arango, C., Díaz-Caneja, C. M., Dazzan, P., McGuire, P., Demjaha, A., Ebdrup, B. H., Fleischhacker, W. W., Kahn, R. S., & Glenthøj, B. Y. (2022). Scalability of the Positive and Negative Syndrome Scale in first-episode schizophrenia assessed by Rasch models. Acta psychiatrica Scandinavica, 146(1), 21–35. Retrieved from https://doi.org/10.1111/acps.13434

Gibbs, P. (2021). Psychiatric Interview. Retrieved from https://physicians.utah.edu/sites/g/files/zrelqx276/files/media/documents/2021/psychiatric-interview-module-1.pdfLinks to an external site.

Opler, M. G. A., Yavorsky, C., & Daniel, D. G. (2017). Positive and Negative Syndrome Scale (PANSS) Training: Challenges, Solutions, and Future Directions. Innovations in clinical neuroscience, 14(11-12), 77–81 Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC5788255/Links to an external site.

Voss, R., Das, J. (2024). Mental Status Examination. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK546682/Links to an external site.

Initial Post

Global Assessment of Functioning (GAF)  (APA, 2000: DSM-IV-TR)

Introduction

The psychiatric interview is essential in mental health assessment, allowing clinicians to gather comprehensive information about a patient’s psychological, social, and occupational functioning. Key elements such as rapport building, history-taking, and the mental status examination (MSE) help establish an accurate diagnosis and guide treatment planning (Lee et al., 2019). Tools like the Global Assessment of Functioning (GAF) scale, though less commonly used after the DSM-5 introduced the WHODAS 2.0, remain relevant in some clinical settings for evaluating overall functioning.

Three Important Components of the Psychiatric Interview

1. Establishing Rapport: Establishing rapport is fundamental in the psychiatric interview, as it fosters a therapeutic alliance that creates a trusting and open environment. Building strong rapport ensures that the patient feels comfortable sharing sensitive and personal information, which is essential for accurate assessment. Trust not only improves the quality and comprehensiveness of the information provided but also encourages collaboration between the patient and clinician (Moodley et al., 2020). This collaborative relationship enhances diagnostic accuracy and supports treatment adherence, ultimately leading to better clinical outcomes (Browne et al., 2019).
2. Comprehensive History Taking: Comprehensive history-taking is a vital component of the psychiatric interview, involving a detailed examination of the patient’s medical, psychiatric, social, and family history. This in-depth exploration provides valuable insights into the underlying causes and contributing factors of the patient’s condition. By identifying patterns, potential triggers, and risk factors, clinicians gain a thorough understanding of the patient’s overall functioning. Additionally, this process lays the foundation for individualized treatment planning, ensuring that interventions are tailored to the specific needs of the patient.
3. Mental Status Examination (MSE): The Mental Status Examination (MSE) is a structured and systematic assessment of a patient’s cognitive, emotional, and behavioral functioning. It involves observing key elements such as appearance, behavior, mood, thought processes, cognition, and insight. The MSE plays a crucial role in providing objective data that supports diagnostic decision-making, ensuring that assessments are both thorough and accurate. Additionally, it serves as a valuable tool for tracking changes in the patient’s mental state over time, enabling clinicians to monitor progress and adjust treatment plans as needed (Gilla et al., 2021).

Psychometric Properties of the GAF Scale (Global Assessment of Functioning, APA, 2000: DSM-IV-TR)

The Global Assessment of Functioning (GAF) scale evaluates overall psychological, social, and occupational functioning on a scale from 1 to 100.

Reliability: The GAF demonstrates moderate inter-rater reliability, with scores often varying based on the clinician’s training and experience. However, standardized training has been shown to improve consistency and reduce variability.

Validity: The GAF correlates moderately with other measures of functioning, such as the Social and Occupational Functioning Assessment Scale (SOFAS), making it a useful tool for capturing functional impairments. Nevertheless, its single composite score has been criticized for oversimplifying complex clinical presentations and failing to capture nuanced aspects of functioning.

Utility: The simplicity of the GAF scale makes it a practical choice for quick assessments, particularly in time-constrained clinical environments. However, its subjective nature, particularly in balancing symptom severity with functional impairment, can result in inconsistencies in scoring, limiting its precision in some cases. Despite its limitations, the GAF remains a valuable tool in specific clinical contexts where efficiency is prioritized.

Appropriate Applications of the GAF Scale

Initial Psychiatric Assessment: The GAF scale is particularly effective during initial psychiatric evaluations, as it provides a baseline measure of the patient’s overall functioning. This baseline helps clinicians identify areas most significantly impacted by mental health symptoms, offering valuable insights for diagnosis and care planning. By establishing the patient’s starting point, the GAF facilitates the prioritization of treatment goals and interventions, ensuring a structured approach to care (Salsabila et al., 2021).

Monitoring Progress: The GAF scale is also useful in follow-up appointments to assess the effectiveness of treatment interventions. It allows clinicians to track changes in the patient’s functioning over time, providing measurable indicators of improvement or decline. This is particularly valuable in managing chronic conditions such as major depressive disorder and schizophrenia, where monitoring progress is crucial for adjusting treatment plans (Maramis et al., 2021).

Transition of Care: In addition to its role in assessments and progress monitoring, the GAF scale is instrumental in guiding transitions between levels of care. For instance, it can help determine whether a patient is ready to move from inpatient treatment to outpatient support by assessing their overall functioning and readiness for less intensive care. This ensures that transitions are made at the appropriate time, minimizing risks and optimizing continuity of care.

The Role of the GAF Scale in Nurse Practitioner Practice

Identifying Functional Impairments: The GAF scale is instrumental in highlighting specific areas where mental illness impacts a patient’s daily life, such as workplace performance, interpersonal relationships, and self-care abilities. By identifying these functional impairments, nurse practitioners can focus on targeted interventions that address the most pressing challenges, improving the patient’s quality of life and overall functioning.

Guiding Treatment Planning: The GAF facilitates effective treatment planning by quantifying the severity of functional impairments. This allows nurse practitioners to set realistic and achievable treatment goals while prioritizing care strategies based on the areas most affected. This structured approach ensures that interventions are both practical and tailored to the patient’s specific needs (Chen et al., 2019).

Enhancing Team Communication: The GAF provides a standardized measure of overall functioning that enhances communication and collaboration among interdisciplinary teams. By offering a common language for assessing and discussing a patient’s condition, the GAF helps ensure that all team members are aligned in their approach to care, fostering coordinated and comprehensive treatment.

Conclusion

The Global Assessment of Functioning (GAF) scale remains a practical tool for psychiatric assessments in settings where it is still in use, providing a quick and straightforward measure of a patient’s overall functioning. It is particularly helpful for guiding treatment planning, monitoring progress, and supporting transitions of care. While the WHODAS 2.0 has replaced it in DSM-5 due to its multidimensional approach, the GAF’s simplicity and effectiveness in chronic mental health conditions highlight its ongoing relevance in specific clinical contexts.

References

Chen, M., Fitzgerald, H. M., Madera, J. J., & Tohen, M. (2019). Functional outcome assessment in bipolar disorder: A systematic literature review. Bipolar Disorders, 21(3), 194–214. https://doi.org/10.1111/bdi.12775Links to an external site.

Gilla, D., Rana, D., & Kp, D. (2021). Application of mental status examination in homoeopathic prescribing. International Journal of Homoeopathic Sciences, 5(3), 224–230. https://doi.org/10.33545/26164485.2021.v5.i3d.427Links to an external site.

Lee, Y., Ngaiman, N., Poon, L., Abdul Jalil, H., Yap, M., Abdin, E., Subramaniam, M., Lee, H., & Verma, S. K. (2019). Evaluating singapore’s chat assessment service by the world mental health organisation (who) “youth-friendly” health services framework. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00422Links to an external site.

Maramis, M. M., Sofyan Almahdy, M., Atika, A., Bagus Jaya Lesmana, C., & Gerick Pantouw, J. (2021). The biopsychosocial-spiritual factors influencing relapse of patients with schizophrenia. International Journal of Social Psychiatry, 68(8), 1824–1833. https://doi.org/10.1177/00207640211065678Links to an external site.

Moodley, N., Saimen, A., Zakhura, N., Motau, D., Setswe, G., Charalambous, S., & Chetty-Makkan, C. M. (2020). ‘they are inconveniencing us’ – exploring how gaps in patient education and patient centred approaches interfere with tb treatment adherence: Perspectives from patients and clinicians in the free state province, south africa. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-08562-3Links to an external site.

Salsabila, K., Khairina, K., & Djuari, L. (2021). Profile of chronic mental disorder patients with or without suicide ideation in the psychiatric ward of dr. soetomo general hospital, surabaya. JUXTA: Jurnal Ilmiah Mahasiswa Kedokteran Universitas Airlangga, 12(2), 48. https://doi.org/10.20473/juxta.v12i22021.48-53Links to an external site.