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1. Methods of Obtaining Information

The psychiatrist'€™s primary assessment tool is the direct face-to-face interview of the patient.

  • Facilitate the patient'€™s telling of his or her story.

  • Consider time constraints. Attend to the patient'€™s most pressing concerns.

  • Use a combination of open-ended, empathic questioning and structured, systematic inquiry (e.g., about substance use, traumatic life events).

  • Give high priority to assessment of safety and identification of signs, symptoms, and disorders requiring urgent treatment.

  • Consider sociocultural issues.

  • Use professionally trained interpreters with mental health experience, when available, for evaluation of patients with limited English proficiency and those who are deaf or have severely limited hearing and who know a sign language.

Consider using collateral sources such as family members, other important people in the patient'€™s life, and records of prior general medical and psychiatric treatment.

  • These sources of information are frequently useful, especially for patients with impaired insight, impaired function, or unstable behavior.

  • Collateral sources may provide important information about the patient'€™s premorbid personality, illness course, and reasons for the evaluation.

  • Confidentiality should be respected. The psychiatrist may listen to input from collateral sources and ask questions without conveying confidential information to others.

Consider using structured interviews, psychological tests, forms, questionnaires, and rating scales.

  • These tools can be useful for establishing a diagnosis, measuring social or occupational function, and monitoring changes in symptom severity or side effects over time during treatment.

  • These tools vary as to their reliability and validity. Sociocultural and other issues may bias results and interpretation of results.

  • Many clinical rating scales are available in APA'€™s Handbook of Psychiatric Measures, published in 2000 by American Psychiatric Publishing, Inc.

Consider whether modifications in the evaluation are needed if the patient exhibits agitation or aggressive behavior.

  • Attend to safety considerations (e.g., office configuration and environment, availability of and mechanisms for summoning backup personnel).

  • Use a nonconfrontational approach that respects and addresses the patient'€™s stated concerns, feelings, and affect.

  • Remain alert for signs that agitation is escalating (e.g., increased body movements or pacing, clenched fists, verbal threats, or increasing verbal volume) and that the interview style or timing may require adjusting.

  • Consider whether administration of psychotropic medications or judicious use of one-to-one nursing care or seclusion or restraint may be needed to enhance the safety of the patient and others or to permit essential physical examination, laboratory studies, or other diagnostic assessment.

  • Guidelines for reducing the use of seclusion and restraint while at the same time maintaining the safety of patients and staff are available in a report developed by APA with the American Psychiatric Nurses Association and the National Association of Psychiatric Health Systems (http://www.psych.org/psych_pract/treatg/pg/learningfromeachother.cfm).

Use diagnostic tests to help establish or exclude a diagnosis, aid in choice of treatment, or monitor treatment effects or side effects.

  • Test utility will be determined by the prevalence of the condition in the population, the probability of error (i.e., a false positive or a false negative), and the treatment implications of the test results.

  • It is important to have a clear rationale for ordering tests, and each patient must be considered individually.

  • Table 3 lists tests that may be indicated in specific clinical situations.

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Table Reference Number
Table 3. Tests That May Be Indicated as Part of a Psychiatric Evaluation

Perform or request a physical examination as needed.

  • The patient'€™s general medical condition may 1) influence or cause psychiatric symptoms, 2) require general medical care, and 3) affect choice of psychiatric treatment.

  • When appropriate, the psychiatrist should ensure that indicated medical assessments are done and incorporate these findings into the evaluation.

  • The physical examination may be performed by the psychiatrist, another physician, or a medically trained clinician.

  • In most circumstances, the physical examination should be chaperoned.

Collaborate with members of multidisciplinary teams who are involved in caring for the patient and making observations about the patient'€™s behavior and symptoms.

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2. The Process of Assessment

Perform an integrative clinical formulation and risk assessment.

  • The formulation aids in understanding the patient as a unique human being and appreciating individual strengths and challenges.

  • Consider phenomenological, neurobiological, psychological, and sociocultural issues involved in diagnosis and management.

  • Consider using the DSM-IV-TR Outline for Cultural Formulation (Table 4) to address sociocultural issues.

  • In assessing the patient'€™s risk of harm to self or others, consider suicide or homicide risk, other forms of self-injury (e.g., cutting behaviors, accidents), aggressive behaviors, neglect of self-care, and neglect of the care of dependents. Identify specific risk factors that may be modifiable by intervention.

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Table Reference Number
Table 4. Components of a Cultural Formulation

Determine a diagnosis.

  • Develop a differential diagnosis based on the information obtained in the evaluation and summarized in the integrative clinical formulation.

  • Use the DSM multiaxial system of diagnosis as a method for organizing and communicating the patient'€™s current clinical status.

  • To augment the DSM multiaxial approach, consider identifying the patient'€™s level of defensive functioning or incorporate dimensional approaches into the diagnostic assessment.

Establish a comprehensive initial treatment plan that addresses biopsychosocial domains.

  • The plan is ideally the result of collaboration among the patient, the psychiatrist, and other members of the treatment team, including the primary care physician.

  • Establish both short- and long-term diagnostic, therapeutic, and rehabilitative goals.

  • Consider risks and benefits of potential treatment approaches.

  • If resources limit treatment options, consider advocating for the patient to obtain what is needed.

Address legal or administrative concerns as needed (e.g., involuntary admission, duty to protect, level of observation).

Assess family, peer networks, and other support systems.

Table Reference Number
Table 3. Tests That May Be Indicated as Part of a Psychiatric Evaluation
Table Reference Number
Table 4. Components of a Cultural Formulation

References

NOTE:
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