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The actual assessment process during a psychiatric evaluation usually involves the development of initial impressions and hypotheses during the interview and their continual testing and refinement on the basis of information obtained throughout the interview and from mental status examination, diagnostic testing, and other sources (167).

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1. Clinical formulation

The integrative formulation aids in understanding the patient as a unique human being and allows the psychiatrist to appreciate the patient's environment, strengths, challenges, and coping skills. The formulation includes information specific to the patient that goes beyond what is conveyed in the diagnosis; it will vary in scope and depth with the purpose of the evaluation. Components of the formulation include phenomenological, neurobiological, psychological, and sociocultural issues involved in diagnosis and management (60, 168–179). As relevant to each domain, the formulation will typically include a concise synthesis of what is known about the patient (e.g., individual characteristics, genetic predispositions, general medical conditions or laboratory abnormalities, past life experiences and developmental history, extent and quality of interpersonal relationships, central conflicts and defense mechanisms) and the patient's past and current symptomatology (including childhood or subsyndromal illness and predisposing, precipitating, perpetuating, or protecting factors) as well as the responses of symptoms to treatment. Variations in phenomenology with factors such as a patient's age or gender can be relevant in determining whether or not a behavior is indicative of psychopathology (180). Thus, the formulation may also include a discussion of the diagnostic, therapeutic, and prognostic implications of the evaluation findings.

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a) Cultural formulation

The DSM-IV-TR Outline for Cultural Formulation (Table 5) provides a systematic method of considering and incorporating sociocultural issues into the clinical formulation (181–185). Depending on the focus and extent of the evaluation, it may not be possible to do a complete cultural formulation based on the findings of the initial interview. However, when cultural issues emerge, they may be explored further during subsequent meetings with the patient. In addition, the information contained within the cultural formulation may be integrated with the other aspects of the clinical formulation or recorded as a separate element.

The cultural formulation begins with a review of the individual's cultural identity and includes the patient's self-construal of identity over time (186). Cultural identity involves not only ethnicity, acculturation/biculturality, and language but also age, gender, socioeconomic status, sexual orientation, religious and spiritual beliefs, disabilities, political orientation, and health literacy, among other factors.

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Table Reference Number
Table 5. Components of a Cultural Formulation

Next, the formulation explores the role of the cultural context in the expression and evaluation of symptoms and dysfunction, including the patient's explanatory models or idioms of distress through which symptoms or needs may be communicated. These are assessed against the norms of the cultural reference group. Treatment experiences and preferences (including complementary and alternative medicine and indigenous approaches) are also identified. Cultural factors related to psychosocial stressors, available social supports, and levels of function or disability are also assessed; during this process, the roles of family/kin systems and religion and spirituality in providing emotional, instrumental, and informational support are highlighted.

The cultural formulation also includes specific consideration of cultural elements influencing the relationship between the individual and the clinician. In this regard, it is important for clinicians to cultivate an attitude of "cultural humility" (187) in knowing their limits of knowledge and skills rather than reinforcing potentially damaging stereotypes and overgeneralizations. Differences in language, culture, or social status, as well as difficulties in identifying and understanding the cultural significance of behaviors or symptoms, may add to the complexities of the clinical encounter. Transference and countertransference may also be influenced by cultural considerations and may either aid or interfere with the treatment relationship. Further, the potential effect of the psychiatrist's sociocultural identity on the attitude and behavior of the patient should be taken into account in the subsequent formulation of a diagnostic opinion.

The cultural formulation concludes with an overall assessment of the ways in which these varied cultural considerations will specifically apply to differential diagnosis and treatment planning.

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b) Risk assessment

An additional component of the formulation involves an assessment of the patient's risk of harm to self or others. This may include consideration of suicide or homicide risk as well as other forms of self-injury (e.g., cutting behaviors, accidents), aggressive behaviors, neglect of self-care, or neglect of the care of dependents. The risk assessment is intended to identify specific factors that may increase or decrease a patient's degree of risk, thereby suggesting specific interventions that may modify particular risk factors or address the safety of the patient or others. Specific risk factors may include demographic parameters (e.g., age, gender), past behavior (e.g., suicide attempts, self-injury, aggression), psychiatric diagnoses, psychiatric symptoms (e.g., anxiety, hopelessness), co-occurring general medical conditions, sociocultural factors, psychosocial stressors, or individual strengths and vulnerabilities. For patients with suicidal behaviors, this risk assessment process is described in detail in APA's Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (11). Although standardized rating scales of suicidal or aggressive behaviors are often used in research and may suggest helpful lines of clinical inquiry, their utility in clinical risk assessment is limited by their low predictive value (11).

For individuals with dependent children, the risk assessment also includes an evaluation of the patient's capacity to parent. In addition to considering the number and ages of any children, the assessment reviews the patient's capacity to meet the needs of dependent children, both in general and during psychiatric crises if these are likely to occur. The overall health, including mental health, of the children is also relevant, especially when the patient's psychiatric condition is likely to affect the children through genetic or psychosocial mechanisms or to impede the patient's ability to recognize and attend to the needs of a child.

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2. Diagnosis

On the basis of information obtained in the evaluation, a differential diagnosis is developed. The differential diagnosis comprises conditions (including personality disorders or personality traits) described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (188), APA's current edition of DSM. A multiaxial system of diagnosis provides a convenient format for organizing and communicating the patient's current clinical status, other factors affecting the clinical situation, the patient's highest level of past functioning, and the patient's quality of life (188, pp. 27–33). General medical conditions are established through history, examination, diagnostic tests, medical records, and consultation.

The DSM classification and the specific diagnostic criteria are meant to serve as guidelines to be informed by clinical judgment in the categorization of the patient's condition(s) and are not meant to be applied in a rote fashion. (Other issues in the use of DSM and its application in developing a psychiatric diagnosis are discussed in DSM-IV-TR, pp. xxiii–xxxv and 1–12.) To augment the DSM multiaxial approach, some clinicians also find it helpful to identify the patient's level of defensive functioning or incorporate dimensional or other approaches into their diagnostic assessments (188, pp. 807–813; 189, 190).

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3. Initial treatment plan

The initial treatment plan addresses any specific diagnoses and psychiatric needs of the patient that have been identified during evaluation. If diagnostic or other questions have been posed or additional information is necessary, these issues should be addressed in the treatment plan.

The initial treatment plan begins with a determination of the appropriate treatment setting and includes an explicit statement of the diagnostic, therapeutic, and rehabilitative goals for treatment that includes short-term as well as longer-term goals. In the case of patients who initially will be treated in an inpatient or partial hospital setting, this implies apportioning the therapeutic task between a hospital phase and a posthospital phase. Within the acute care setting, some goals may be targeted for achievement within several days, whereas other goals will be targeted for completion by the time of discharge. On the basis of the goals, the plan specifies further diagnostic tests and procedures, further systematic observations or additional information to be obtained, and specific therapeutic modalities to be applied.

A comprehensive treatment plan addresses biological, psychological, and sociocultural domains. The psychiatrist can select from a range of individual, group, and family therapies to create an integrated multimodal treatment that includes biological and sociocultural interventions (60).

Quality care involves treatment plans that are safe, timely, effective, efficient, equitable (i.e., not influenced in quality by personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status), and person-centered (7). Such treatment plans encourage recovery from illness through community integration and empower patients to make choices that improve their quality of life (191). Thus, the treatment plan is ideally the result of collaboration between the patient, the psychiatrist, and other members of the treatment team as well as the primary care practitioner for patients who have an established source of primary care.

A range of potentially effective treatments is initially considered. More detailed consideration and documentation of the risks and benefits of treatment options may be needed in the following circumstances: when a relatively risky, costly, or unusual treatment is under consideration; when involved parties disagree about the optimal course of treatment; when the patient's motivation or capacity to benefit from potential treatment alternatives is in question; when the treatment would be involuntary or when other legal or administrative issues are involved; or when available treatment options are limited by external constraints (e.g., financial barriers, insurance restrictions, geographic barriers, service availability, the patient's capacity to participate in the proposed treatment). Such considerations are also relevant when considering the level of care needed to provide an individual patient with appropriate treatment. In addition, level-of-care determinations will vary with the diagnosis, the presence of co-occurring general medical or psychiatric disorders (including substance use disorders), the assessment of the patient's risk to self or others, the current severity of symptoms, the patient's prior illness course and complications, his or her psychosocial supports, his or her treatment adherence, and the strength of the therapeutic alliance, among other factors. In some circumstances, it is also important for the psychiatrist to be able to recognize the limitation of health care resources and demonstrate the ability to act as an advocate for patients within their sociocultural and financial constraints (60).

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4. Decisions regarding treatment-related legal and administrative issues

Although the consideration of forensic evaluations is outside the scope of this practice guideline, there are times when the general psychiatric evaluation may need to address legal or administrative concerns (Section V.C). Examples include deciding between voluntary and involuntary admission, determining whether legally mandated treatment should be pursued in objecting patients, determining whether there is a duty to protect (e.g., by modifying the patient's treatment, increasing outpatient visit frequency, initiating hospitalization, warning the victim) if the patient is deemed a potential risk to others, and deciding on the level of observation needed to address the patient's safety (11). In situations such as these, the psychiatrist's decision making will depend on the risk assessment (Section IV.B.1.b) as well as other relevant aspects of the history, examination, symptoms, diagnosis, and clinical formulation. Assessment of the patient's decision-making capacity may also be needed as part of the informed consent process. When a patient's capacity to consent to treatment is uncertain, questioning to determine mental status should be extended to include items that test the patient's decision-making capacity (192). As with other aspects of the evaluation, it is important to document the rationales for making a particular treatment decision, including a discussion of supporting evidence from the evaluation findings.

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5. Systems issues

An assessment of family, peer networks, and other support systems is an important part of the psychiatric evaluation because of the potential role of these systems in ameliorating or augmenting the patient's signs and symptoms of illness. This is particularly true when evaluating individuals with complex biopsychosocial challenges or serious psychiatric or general medical conditions. If the initial evaluation indicates that aspects of the care system have an important role in the patient's illness and treatment, goals are developed in response to these findings. Systems may be more open to considering change at times of crisis. Consequently, as well as generating goals for the patient's diagnosis and individual treatment, the evaluation may lead to goals for intervening with the family, other important people in the patient's life, other professionals (e.g., therapists), general medical providers, and governmental or social agencies (e.g., community mental health centers or family service agencies). Specific plans may be needed for addressing problems in the care system that are seen as important to the patient's illness, symptoms, function, or well-being and that appear amenable to modification. For example, a parent may be unable to attend follow-up appointments unless issues relating to care of dependents are addressed; financial issues or formulary restrictions may preclude patients from obtaining their medications; or geographic constraints may limit access to a full range of treatment options. Plans to address such systems issues should consider feasibility, the patient's wishes, and the willingness of other people to be involved.

Table Reference Number
Table 5. Components of a Cultural Formulation

References

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