0
1

General psychiatric evaluations involve a systematic consideration of the broad domains described in this guideline and vary in scope and intensity. Table 1 summarizes the domains. The intensity with which each domain is assessed depends on the purpose of the evaluation and the clinical situation. An evaluation of lesser scope may be appropriate when its purpose is to answer a circumscribed question. Such an evaluation may involve a particularly intense assessment of one or more domains especially relevant to the reason for the evaluation.

Across all domains, evaluations are generally based on three sources of information: 1) observation and interview of the patient; 2) information from others (e.g., family, significant others, case managers, other clinicians [including the patient's primary care physician]) that corroborates, refutes, or elaborates on the patient's report; and 3) medical records. An awareness of how people report current symptoms and events is important to the clinical assessment process. In considering the information obtained, the patient's current mental state is relevant. Mistakes in comprehension, recall, and expression may also lead to erroneous reporting of information (44).

+

A. Reason for the Evaluation

The purpose of the evaluation influences the focus of the examination and the form of documentation. The reason for the evaluation usually includes (but may not be limited to) the chief complaint of the patient. It should be elicited in sufficient detail, including the patient's words, to permit an understanding of the duration of the complaint and the patient's specific goals for the evaluation. If the symptoms are of long standing, the reason for seeking treatment at this specific time is relevant; if the evaluation was occasioned by a hospitalization, the reason for the hospitalization is also relevant. If the patient did not initiate the evaluation, the reason another individual or entity may have requested or required it should be noted. The opinions of other parties, including family, can also assist in establishing a reason for evaluation. Under some circumstances (e.g., with psychotic or uncommunicative patients), input from others may be crucial.

+

B. History of the Present Illness

+
Table Reference Number
Table 1. Domains of the Clinical Evaluation 

The history of the present problem or illness is a chronologically organized history of recent exacerbations or remissions and current symptoms or syndromes. These may involve descriptions of worries, changes in mood, suspicions, preoccupations, delusions, or hallucinatory experiences as well as recent changes in sleep, appetite, libido, concentration, memory, or behavior, including suicidal or aggressive behaviors. Information gathered on the pertinent positive and pertinent negative features of the history of present illness will vary with the patient's presenting symptoms or syndrome. Temporal features relating to the onset or exacerbation of symptoms may also be relevant (e.g., onset after use of exogenous hormones, herbal products, or licit or illicit substances; variation in symptoms with the menstrual cycle; postpartum onset). Also pertinent are factors that the patient and other informants believe to be precipitating, aggravating, or otherwise modifying the illness. Available details of previous treatments and the patient's response to those treatments will be delineated as part of the history of present illness. If the patient was or is in treatment with another clinician, the effects of that relationship on the current illness, including transference and countertransference issues, are considered. Input from members of a clinical team who care for the patient can be very helpful (Section IV.A.6). For patients seen on medical-surgical units, it is important to consider the history of both the present medical-surgical illness and the present psychiatric illness (45).

+

C. Past Psychiatric History

The past psychiatric history includes a chronological summary of all past episodes of mental illness, including substance use disorders, and treatment. The summary includes prior hospitalizations; suicide attempts, aborted suicide attempts, or other self-destructive behavior; psychiatric syndromes not formally diagnosed at the time; previously established diagnoses; treatments offered; and responses to and satisfaction with treatment. With respect to psychotherapy, it is important to ascertain the type (e.g., psychodynamic, cognitive, behavioral, supportive), format (e.g., group, individual, couple), frequency, duration, patient's perception of the alliance, and adherence. With respect to medications, the dose, efficacy, side effects, treatment duration, and adherence are important to ascertain while understanding that reporting errors are more likely to occur when treatment involved more than one medication (46). With respect to other somatic therapies such as electroconvulsive therapy, information on the number of treatment sessions, treatment course duration, technical parameters, efficacy, and side effects is similarly useful to obtain. When past medical records are available and readily accessible, it is important that they be consulted for ancillary information.

The chronological summary also delineates the most recent periods of stability as well as episodes when the patient was functionally impaired or seriously distressed by mental or behavioral symptoms, even if no formal treatment occurred. Such episodes frequently can be identified by asking the patient about the past use of psychotropic medications prescribed by other clinicians and otherwise unexplained episodes of social or occupational disability.

+

D. History of Substance Use

The psychoactive substance use history includes past and present use of both licit and illicit psychoactive substances, including but not limited to alcohol, caffeine, nicotine, marijuana, cocaine, opiates, sedative-hypnotic agents, stimulants, solvents, MDMA (methylenedioxymethamphetamine), androgenic steroids, and hallucinogens (47). Relevant information includes the quantity and frequency of use and route of administration; the pattern of use (e.g., episodic versus continual, solitary versus social); functional, interpersonal, or legal consequences of use; tolerance and withdrawal phenomena; any temporal association between substance use and other present psychiatric illnesses; and any self-perceived benefits of use. It is also important to inquire about prior treatments for substance use disorders as well as about periods of abstinence, including their duration, recentness, and factors that aided in sobriety or contributed to relapse. Obtaining an accurate substance use history often involves a gradual, nonconfrontational approach to inquiry that involves asking multiple questions to seek the same information in different ways and using slang terms for drugs, patterns of use, and drug effects. Patients are particularly likely to underestimate their level of substance abuse and their related functional impairments; corroboration by other family members is useful when possible. It is also helpful to inquire about patterns of substance use by others within the family or living constellation. For more extensive discussion of the assessment of substance use, abuse, and dependence, the reader is referred to the Center for Substance Abuse Treatment's Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (48) and APA's Practice Guideline for the Treatment of Patients With Substance Use Disorders (49).

+

E. General Medical History

The general medical history includes available information on known general medical illnesses (e.g., hospitalizations, procedures, treatments, and medications), allergies or drug sensitivities, and undiagnosed health problems that have caused the patient major distress or functional impairment. This includes history of any episodes of important physical injury or trauma; sexual and reproductive history; and any history of endocrinological, infectious (including but not limited to HIV, tuberculosis, and hepatitis C) (50), neurological disorders, sleep disorders (including sleep apnea), and conditions causing pain and discomfort. Of particular importance is a specific history regarding diseases and symptoms of diseases that have a high prevalence among individuals with the patient's demographic characteristics and background—for example, infectious diseases in users of intravenous drugs or pulmonary and cardiovascular disease in people who smoke. Information regarding all current and recent medications, including hormones (e.g., birth control pills, androgens), over-the-counter medications, herbal supplements, vitamins, complementary and alternative medical treatments, and medication side effects, is part of the general medical history. With all aspects of the general medical history, obtaining corroborating information (e.g., from medical records, treating clinicians, family) can be helpful, since ordinary errors in comprehension, recall, and expression can lead to errors in patient reports (51).

+

F. Developmental, Psychosocial, and Sociocultural History

The personal history reviews the stages of the patient's life, with special attention to perinatal events, delays in physical or psychological development, formal educational history, academic performance, and patterns of response to normal life transitions and major life events, including parental loss or divorce; physical, emotional, or sexual abuse; and other trauma such as exposure to political repression, war, or a natural disaster (52–55). The childhood and adolescent history of risk factors for later psychiatric disorders (Table 2) may also be relevant. History of adaptive skills and strengths to overcome challenges is also relevant.

The patient's capacity to maintain stable and gratifying interpersonal relationships should be noted, including the patient's capacities for attachment, trust, and intimacy. A sexual history is obtained and includes consideration of sexual orientation and practices, past sexual experiences (including unwanted experiences), and cultural beliefs about sex (54). The psychosocial history also determines the patient's past and present levels of interpersonal functioning in family and social roles (e.g., marriage, parenting) (56–58). This includes a delineation of the patient's history of marital and other significant relationships. For patients with children (including biological, foster, adopted, or stepchildren), the psychosocial history will include information about these individuals and their relationship to the patient.

As part of the psychosocial history, past or current stressors are assessed and include the categories on axis IV of DSM-IV-TR: primary support group, social environment (e.g., discrimination and acculturation), education, occupation, housing, economic status, and access to health care. Specific information obtained in evaluating psychosocial stressors may include details about patients' living arrangements, access to transportation, sources of income, insurance or prescription coverage, and past or current involvement with social agencies. Assessment of the patient's self-care functioning may also include consideration of exercise behavior and money management skills, including gambling behavior.

The sociocultural history delineates the patient's migration history and past and current sociocultural context of supports and stressors as well as other important cultural and religious influences on the patient's life (59). Emphasis is given to relationships, both familial and nonfamilial, and to religion and spirituality that may give meaning and purpose to the patient's life and provide support, as described in the DSM-IV-TR Outline for Cultural Formulation (described in more detail in Section IV.B.1.a).

+
Table Reference Number
Table 2. Questions About Childhood Developmental History for Which Affirmative Answers May Indicate Increased Risk for Psychiatric Illness

Patients present for a psychiatric evaluation with their own interests, preferences, and value systems pertaining to health care practice, and these are another important part of the sociocultural history. They may involve cultural factors and explanatory models of illness that affect attitudes, expectations, and preferences for professional and popular treatments, as described in the DSM-IV-TR Outline for Cultural Formulation and the 2004 Core Competencies of the American Board of Psychiatry and Neurology (60). Also important to the assessment and treatment process are other domains such as existential, moral, and interpersonal values and social influences such as school, church, work, and community or other agencies. Attending to these factors plays a crucial role in developing a therapeutic alliance, negotiating a treatment plan, determining the outcome criteria for successful treatment, and enhancing treatment adherence. Belief systems may also influence the handling of privacy and confidentiality during the evaluation as well as influence the type and amount of information disclosed as part of any informed consent process. In addition, patients' value systems are relevant to clinical considerations at important life transitions (e.g., job and career transitions, marital transitions, genetic counseling before or during pregnancy, end-of-life planning).

+

G. Occupational and Military History

The occupational history describes the sequence and duration of jobs held by the patient, reasons for job changes, and the patient's current or most recent employment, including quality of work relationships and whether current or recent jobs have involved shift work, a noxious or perilous environment, exposure to hazardous materials, unusual physical or psychological stress, or injury or exposure to trauma while in the military or hazardous occupations (e.g., fire and rescue, law enforcement). Work skills and strengths are noted, as well as the quality of the patient's relationships with co-workers and work supervisors. Past or current experience with the workers' compensation system and patterns of recovery or disability following episodes of illness are also determined (61–64). When appropriate, a history of preparation for and adjustment to retirement is included.

Relevant data about military experience include volunteer, recruited, or draftee status; reasons for rejection at time of enlistment (if relevant); combat exposure (if any); awards; disciplinary actions; and discharge status.

+

H. Legal History

The legal history includes a description of past or current involvement with the legal system (65). This may include interactions with the police without formal arrest as well as involvement with the juvenile or criminal justice system (e.g., arrests, detentions including jail or prison confinement). Individuals may be on probation or parole or may have pending court appearances or active warrants for arrest that will influence treatment planning. A history of legal problems relating to aggressive behaviors or occurring in the context of substance intoxication is similarly relevant. Other past or current interactions with the court system (e.g., family court, workers' compensation, civil litigation, court-ordered psychiatric treatment) may serve as significant stressors for the patient and are also important to address (55, 66).

+

I. Family History

The family history includes available information about the patient's family constellation and the strength of relationships with family members. Information obtained about close family members, including parents and, if applicable, siblings, spouse, and children, will include general information (e.g., current age or age at time of death, position in sibship, occupation), quality of relationship to the patient, and health status. General medical and psychiatric illness in close relatives is noted, including disorders that may be familial or may strongly affect the family environment. A history of adoption or foster care or disruptions in the family environment because of divorce, remarriage, prolonged absences of family members (e.g., occupational absences, hospitalization, incarceration), or deaths may be useful to elicit. Family history information will also consist of any history of psychiatric hospitalizations, illness, or significant symptoms, including suicide and attempted suicide in first- and second-degree relatives. More specific questions are important to ask depending on the patient's clinical presentation, given the heritability of psychosis; mood disorders; anxiety disorders; cognitive disorders; learning disabilities; developmental disabilities, including autism, hyperactivity, or attention deficit disorder; substance use disorders; and antisocial behavior. For family members who have experienced psychiatric symptoms, it is helpful to learn the treatment received and their response to treatment. It is also important to determine first- and second-degree relatives' history of medical disorders (67), particularly those with relevance to psychiatric illness and treatment, such as cardiac, neurological, and endocrine disorders. If family health problems are current, this may contribute psychological or financial stresses for the patient.

Construction of a formal pedigree or genogram is often helpful in delineating family relationships and identifying a family history of illness. The web sites of the American Medical Association (68), the American Society of Human Genetics (69), and the March of Dimes (70) provide additional details on the drawing of pedigrees.

+

J. Review of Systems

The review of systems includes current symptoms not already identified in the history of the present illness. If not already addressed in the history of present illness, sleep, appetite, eating patterns, vegetative symptoms of mood disorder, pain and discomfort, systemic symptoms such as fever and fatigue, and neurological symptoms are also relevant. In addition, common symptoms of diseases for which the patient is known to be at particular risk because of historical, genetic, environmental, or demographic factors are an important part of the review of systems. Special attention should be given to typical side effects observed with prescribed or over-the-counter medications and other treatments, including complementary or alternative therapies, that the patient is receiving.

+

K. Physical Examination

Evaluation of the patient's general medical status necessitates that a physical examination be performed. Although the process of the physical examination is described more fully in Section IV.A.5, specific elements assessed as part of the physical examination may include the following:

  1. General appearance, height, weight, body mass index (BMI), and nutritional status

  2. Vital signs

  3. Head and neck, heart, lungs, abdomen, and extremities

  4. Neurological status, including cranial nerves, motor and sensory function, gait, coordination, muscle tone, reflexes, and involuntary movements

  5. Skin, with special attention to any stigmata of trauma, self-injury, or drug use

  6. Any body area or organ system that is specifically mentioned in the history of the present illness or review of systems or that is relevant to determining the current status of problems mentioned in the past medical history

Additional items may be added to the examination to address specific diagnostic concerns or to screen a member of a clinical population at risk for a specific disease. For example, an individual with mental retardation might be assessed for the physical characteristics of a recognized syndrome.

+

L. Mental Status Examination

The purpose of the mental status examination is to obtain evidence of symptoms and signs of mental disorders, including dangerousness to self and others, that are present at the time of the interview. Further, evidence is obtained regarding the patient's insight, judgment, and capacity for abstract reasoning to inform decisions about treatment strategy and the choice of an appropriate treatment setting. Thus, the mental status examination is a systematic collection of data based on observation of the patient's behavior while the patient is in the psychiatrist's view during, before, and after the interview. During the mental status examination, the patient might also mention past symptoms and signs, but these should be recorded under the history of the present illness.

Responses to specific questions are an important part of the mental status examination (71, 72), particularly in the assessment of cognition. Consequently, in recording the findings of the mental status examination, it is useful to include examples that illustrate the clinical observations. For example, it would be preferable to note that the patient exhibited poor judgment in precipitously attempting to remove his intravenous line rather than simply describing the patient's judgment as impaired.

Although its precise organization may vary, the mental status examination typically contains the following elements:

  1. Appearance and general behavior. In describing the patient's appearance, factors such as approximate age, body habitus, dress, grooming, hygiene, and distinguishing features (e.g., scars, tattoos) may be noted. The patient's general behavior, level of distress, degree of eye contact, and attitude toward the interviewer are also considered.

  2. Motor activity. The patient's level of psychomotor activity is noted, as is the presence of any gait abnormalities or purposeless, repetitive, or unusual postures or movements (e.g., tremors, dyskinesias, akathisia, mannerisms, tics, stereotypies, catatonic posturing, echopraxia, apparent responses to hallucinations).

  3. Speech. Characteristics of the patient's speech are described and may include consideration of rate, rhythm, volume, amount, accent, inflection, fluency, and articulation.

  4. Mood and affect. The patient's expressions of mood and affect are noted. Although the use and definitions of the terms mood and affect vary, mood is typically viewed as referring to the patient's internal, subjective, and more sustained emotional state, whereas affect relates to the patient's externally observable and more changeable emotional state (71, 73). Affect is often described in terms of its range, intensity, stability, appropriateness, and congruence with the topic being discussed in the interview.

  5. Thought processes. Features of the patient's associations and flow of ideas are described, such as vagueness, incoherence, circumstantiality, tangentiality, neologisms, perseveration, flight of ideas, loose or idiosyncratic associations, and self-contradictory statements.

  6. Thought content. The patient's current thought content is assessed by noting the patient's spontaneously expressed worries, concerns, thoughts, and impulses, as well as through specific questioning about commonly observed symptoms of specific mental disorders. These symptoms include delusions (e.g., erotomania or delusions of persecution, passivity, grandeur, infidelity, infestation, poverty, somatic illness, guilt, worthlessness, thought insertion, thought withdrawal, or thought broadcasting), ideas of reference, overvalued ideas, ruminations, obsessions, compulsions, and phobias. Assessment of suicidal, homicidal, aggressive, or self-injurious thoughts, feelings, or impulses is essential for determining the patient's level of risk to self or others as part of the clinical formulation. If such features are present, details are elicited regarding their intensity and specificity, when they occur, and what prevents the patient from acting on them (11, 74–79).

  7. Perceptual disturbances. Hallucinations (i.e., a perception in the absence of a stimulus) and illusions (i.e., an erroneous perception in the presence of a stimulus) may occur in any sensory modality (e.g., auditory, visual, tactile, olfactory, gustatory). Other perceptual disturbances that patients may experience include depersonalization and derealization.

  8. Sensorium and cognition. Systematic assessment of cognitive functions is an essential part of the general psychiatric evaluation, although the level of detail necessary and the appropriateness of particular formal tests will depend on the purpose of the evaluation and the psychiatrist's clinical judgment. Evaluation of the patient's sensorium includes a description of the level of consciousness and its stability. Elements of the patient's cognitive status that may be assessed include orientation (e.g., person, place, time, situation), attention and concentration, and memory (e.g., registration, short-term, long-term). Arithmetic calculations may be used to assess concentration or knowledge; other aspects of the patient's fund of knowledge may also be assessed as appropriate to sociocultural and educational background. Additional aspects of the cognitive examination may include assessment of level of intelligence, language functions (e.g., naming, comprehension, repetition, reading, writing), drawing (e.g., copying a figure or drawing a clock face), abstract reasoning (e.g., explaining similarities or interpreting proverbs), and executive functions (e.g., list making, inhibiting impulsive answers, resisting distraction, recognizing contradictions).

  9. Insight. The patient's insight into his or her current situation is typically assessed by inquiring about the patient's awareness of any problems and their implications. Patients may or may not recognize that psychosis or other symptoms may reflect an underlying illness or that their behavior affects their relationships with other individuals. They also may or may not recognize the potential benefits of treatment.

    Another element of insight involves the patient's motivation to change his or her health risk behaviors. Such motivation often fluctuates over time from denial and resistance to ambivalence to commitment, a sequence that has been referred to as "stages of change" (80–82). The stages, which are not necessarily discrete, have been labeled precontemplation (denial, minimization); contemplation (musing or thinking about doing something); preparation (actually getting ready to do something); action (implementing concrete actions to deal with the problem); and maintenance (acting to ensure that the changes are maintained) (83). Patients who are not quite ready to change may vacillate about modifying their behaviors before actually committing to change and acting on it. Assessing stages of change as part of the evaluative process leads to stage-appropriate educational and therapeutic interventions that attempt to help patients move to more adaptive stages in a patient-centered manner (84–86).

  10. Judgment. The quality of the patient's judgment has sometimes been assessed by asking for the patient's responses to hypothetical situations (e.g., smelling smoke in a theater). However, in assessing judgment, it is generally more helpful to learn about the patient's responses and decision making in terms of his or her own self-care, interactions, and other aspects of his or her recent or current situation and behavior. If poor judgment is present, a more detailed explication of the patient's decision-making processes may help differentiate the potential causes of this impairment.

Table Reference Number
Table 1. Domains of the Clinical Evaluation 
Table Reference Number
Table 2. Questions About Childhood Developmental History for Which Affirmative Answers May Indicate Increased Risk for Psychiatric Illness

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Related Content
Articles
Books
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 36.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 38.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 40.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 43.  >
The American Psychiatric Publishing Textbook of Psychiatry, 5th Edition > Chapter 44.  >
Psychiatric News
 
  • Print
  • PDF
  • E-mail
  • Chapter Alerts
  • Get Citation