Initial Psychiatric Assessment

The clinician should first determine whether the patient can provide an accurate history (ie, whether the patient is relatively cognitively intact) and can readily and coherently respond to initial questions. If not, information is sought from family, caregivers, or other collateral sources (eg, caseworkers, police). Even when a patient is communicative, close family members, friends, or other people who are knowledgeable about the patient's medical and social situation may provide additional clinically useful information. Previous psychiatric assessments, treatments, and degree of adherence to past treatments are reviewed.

The psychiatric interview should be performed by an experienced clinician. Open-ended questions should be used and sufficient time should be allotted to allow patients to feel comfortable to and elicit relevant information. This allows patients to tell their story in their own words and to describe associated social circumstances and reveal emotional reactions.

The interview should first explore what prompted the need for psychiatric assessment (eg, unwanted or unpleasant thoughts, problematic behavior), including the degree to which the presenting symptoms affect the patient or interfere with the patient's social, occupational, and interpersonal functioning. The interviewer then attempts to gain a broader perspective on the patient’s physical symptoms by reviewing significant life events—current and past—and the patient’s responses to them (see table Initial Psychiatric Assessment).

Psychiatric, medical, social, and developmental histories are reviewed. Current medications, as well as relevant past medications, are noted. A review of systems to check for other symptoms not described in the psychiatric history is important. Focusing only on the presenting symptoms to the exclusion of past history and other symptoms may result in making an incorrect primary diagnosis (and thus recommending the wrong treatment) and missing other psychiatric or medical comorbidities. For example, not asking about past manic episodes in a patient presenting with depression could result in making an incorrect diagnosis of major depressive disorder instead of bipolar disorder. In addition, a thorough medical history and review of physical symptoms may identify potential general medical causes of psychiatric symptoms (eg, hyperthyroidism as a possible cause of anxiety).

The personality profile that emerges may suggest traits that are adaptive (eg, openness to experiences, conscientiousness) or maladaptive (eg, self-centeredness, dependency, poor tolerance of frustration) and may indicate the coping mechanisms used. The interview may reveal obsessions (unwanted and distressing repetitive thoughts or impulses), compulsions (excessive, repetitive, purposeful behaviors that a person feels driven to do), and delusions (fixed false beliefs that are firmly held despite evidence to the contrary) and may determine whether distress is expressed in physical symptoms (eg, headache, abdominal pain), psychological symptoms (eg, phobic behavior, depression), or social behavior (eg, withdrawal, rebelliousness). The patient should also be asked about attitudes regarding psychiatric treatments, including medications and psychotherapy, so that this information can be incorporated into the treatment plan.

The interviewer should establish whether a general medical condition or its treatment is causing or worsening a psychiatric condition (see Medical Assessment of the Patient With Psychiatric Symptoms). In addition to having direct effects (eg, symptoms, including psychiatric ones), many general medical conditions cause enormous stress and require coping mechanisms to withstand the pressures related to the condition. Many patients with severe medical conditions experience some kind of adjustment disorder, and those with underlying psychiatric disorders may experience a worsening of their symptoms.

Observation of the patient's demeanor and behavior during an interview may provide evidence of psychiatric or general medical disorders. Body language may reveal evidence of attitudes and feelings denied by the patient. For example, does the patient fidget or pace back and forth despite denying anxiety? Does the patient seem sad despite denying feelings of depression? General appearance may provide clues as well. For example, how is the patient's hygiene? Is a tremor or facial droop present?

A mental status examination uses observation and questions to evaluate several domains of mental function, including

• Speech

• Emotional expression

• Thinking and perception

• Cognitive functioning

Brief standardized screening questionnaires are available for assessing certain components of the mental status examination, including those specifically designed to assess orientation and memory, as well as symptoms of depression and anxiety. Such standardized assessments can be used during a routine office visit to help screen patients, can help identify the most important symptoms, and can provide a baseline for measuring response to treatment. However, screening questionnaires cannot take the place of a broader, more detailed mental status examination.

General appearance should be assessed for unspoken clues to underlying conditions. For example, patients’ appearance can help determine whether they

• Are unable to care for themselves (eg, they appear to be undernourished, disheveled, or dressed inappropriately for the weather or have significant body odor)

• Are unable or unwilling to comply with social norms (eg, they are garbed in socially inappropriate clothing)

• Have engaged in substance use or attempted self-harm (eg, they have an odor of alcohol, scars suggesting IV drug use or self-inflicted injury)

Speech can be assessed by noting spontaneity, syntax, rate, and volume. A patient with depression may speak slowly and softly, whereas a patient with mania may speak rapidly and loudly. Abnormalities such as dysarthrias and aphasias may indicate a general medical cause of mental status changes, such as head injury, stroke, brain tumor, or multiple sclerosis.

Emotional expression can be assessed by asking patients to describe their feelings. The patient’s tone of voice, posture, hand gestures, and facial expressions are all considered. Mood (emotional state reported by the patient) and affect (patient's expression of emotional state as observed by the interviewer) should be assessed. Affect and its range (ie, full vs constricted) should be noted as well as the appropriateness of affect to thought content (eg, patient smiling while discussing a tragic event).

Thinking and perception can be assessed by noticing not only what is communicated but also how it is communicated. Abnormal content may take the form of the following:

• Delusions (false, fixed beliefs)

• Ideas of reference (experiencing innocuous or coincidental events as having strong personal significance, eg, seeing people on the street laughing and assuming that the people are laughing at them)

• Obsessions (recurrent, persistent, unwanted, and intrusive thoughts, urges, or images)

The clinician can assess whether ideas seem to be linked and goal-directed and whether transitions from 1 thought to the next are logical. Patients experiencing mania or psychosis may have disorganized thoughts or an abrupt flight of ideas.

Cognitive functions include the patient’s

• Level of alertness

• Attentiveness or concentration

• Orientation to person, place, and time

• Immediate, short-term, and long-term memory

• Abstract reasoning

• Insight

• Judgment

Abnormalities of cognition most often occur with delirium or dementia or with substance intoxication or withdrawal but can also occur with depression.

The following English-language resource may be useful. Please note that The Manual is not responsible for the content of this resource.

1. American Psychiatric Association: Practice Guideline for the sychiatric Evaluation of Adults