Psychiatric Assessment

The psychiatric assessment is the equivalent of a physical exam, tailored to evaluate a patient for psychiatric pathologies. While the psychiatric assessment has a mostly standardized approach, the interviewer can tailor it based on the presenting symptoms of the patient. The psychiatric assessment is designed to systematically assess for various features of psychiatric illnesses and involves both direct questioning and passive observation.

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Overview of a Psychiatric Encounter

While there may be variability between how different physicians conduct the encounter, and a physician may tailor the encounter to suit the needs of a patient’s diagnosis, the general structure should be reproducible and follow a logical course.

  1. Review available records and secure a safe, private place for the psychiatric interview.
  2. Observe the patient’s nonverbal communication cues and assess their level of agitation.
  3. Introduce yourself to the patient.
  4. Inquire about the patient’s chief reason for presentation.
  5. Obtain the patient’s recent history of presenting illness and conduct the psychiatric interview.
  6. Obtain the patient’s past personal history (i.e., past medical/psychiatric history, family history, social history).
  7. Conduct a mental state exam.
  8. List the differential diagnosis.
  9. Develop an appropriate plan of care with the treatment team:
    • Level of care required (hospitalization, intensive outpatient, outpatient)
    • Pharmacotherapy
  10. Determine an appropriate follow-up interval.

Initial Part of Psychiatric Assessment

  • Before speaking with the patient:
    • Secure a safe, private place for the interview:
      • Especially important for patients with potential for violence in the psychiatric hospital or emergency room setting 
      • Providers must have access to easy escape, and the room should be clear of objects that pose potential harm to themselves or others.
    • A review of past medical records and laboratory studies are also helpful but may also bias the interview.
  • Initial contact with the patient:
    • Observe nonverbal communication and assess their level of agitation.
    • Introduce yourself to the patient and establish the doctor-patient relationship.
    • Use open-ended questions.
    • May require contacting collateral informants for patients who are poor historians.

History of the Present Illness

  • Determine the onset and characteristic of symptoms: Be mindful of any prior stressful events, medical illness, or substance use.
  • Course of symptoms:
    • History of similar symptoms in the past
    • Waxing vs. waning or both intermittently
    • Progression of symptoms 
  • Triggers for symptoms: ameliorating and worsening triggers
  • Screen for 5 key diagnostic criteria:
    • Mood symptoms: depression vs. mania
    • Psychotic symptoms
    • Anxiety-related symptoms
    • Substance use
    • Suicidality/homicidality

Obtaining Past History

  • Past medical/surgical history:
    • Many medical illnesses have symptoms that can induce psychiatric conditions (e.g., hypothyroidism and depression).
    • Current medications, including dietary supplements, are also important to note.
  • Family history:
    • Psychiatric family history is important, as some mental illnesses are seen more predominantly in the children and family members of affected patients.
    • Medical family history is also important.
  • Social history:
    • Much more extensive than other history taking
    • Developmental/early childhood history
    • Education level
    • Occupation history and financial resources
    • Religious/spiritual beliefs 
    • Relationships, dating, sexual orientation, and sexual history 
    • Hobbies and interests

Mental Status Examination (MSE)

  • Psychiatric equivalent of the physical exam 
  • Some components of the MSE are obtained through observation, while others are through questions.
  • Useful for identifying cognitive impairments, disturbances in mood, psychotic symptoms, and suicidal thoughts
Table: Major components of the MSE
CategoryComponents
AppearanceGeneral description of patient’s appearance and behavior:
  • Age
  • Sex
  • Race
  • Body build
  • Posture
  • Excessive or reduced eye contact
  • Appropriateness of dress
  • Grooming
  • Manner
  • Attentiveness to the examiner
  • Distinguishing features
  • Prominent physical abnormalities
  • Emotional facial expression
  • Alertness
OrientationAwareness of time, place, and person
Attention and
concentration
  • Ability to spell a word backward and forward
  • Serial 7s (counting down from 100 in 7s)
Spatial orientationAbility to draw a house, or a clock face with hands indicating a specific time
Motor
  • Retardation
  • Agitation
  • Abnormal movements
  • Gait
  • Catatonia
Speech
  • Rate
  • Rhythm
  • Volume
  • Amount
  • Articulation
  • Spontaneity
MoodPatient’s internal and self-described emotional state
AffectExpression of patient’s mood or how the mood appears to be to the clinician
  • Appropriateness of affect: how affect correlates to the setting. For example, a patient who is describing depression while laughing would have an affect incongruent with or inappropriate to their mood.
  • A commonly used term for affect is flat for a severely restricted range of affect that is found in some patients with schizophrenia.
Thought
content
What thoughts are on the patient’s mind:
  • Suicidal ideation
  • Death wishes
  • Homicidal ideation
  • Depressive cognitions
  • Obsessions
  • Ruminations
  • Phobias
  • Ideas of reference
  • Paranoid ideation
  • Magical ideation
  • Delusions
  • Overvalued ideas
Thought
process
Describes how certain thoughts are made, organized, and expressed:
  • Associations (circumstantial or tangential)
  • Flight of ideas
  • Clang associations
  • Perseveration
  • Neologism
  • Blocking
Memory
  • Ability to recall 3 simple objects after 2 and 5 minutes
  • Ability to recall distant events from the past
Abstract
reasoning
Ability to shift between general concepts and specific examples (e.g.: “How are oranges and apples alike?”)
Perception
  • Hallucinations
  • Illusions
  • Depersonalization
  • Derealization
  • Déjà vu
  • Jamais vu
Intellect
  • Average, above average, below average
  • Determined during an interview by thought content and by educational and professional achievement
InsightAwareness of one’s illness, mood, and functioning level and its implications.
Judgment
  • Ability to make and act on good decisions
  • Does not always correlate with insight

Evaluation of Suicide Risk

  • One of the most critical components of psychiatric assessment
  • Determines whether patient meets criteria for inpatient vs. outpatient treatment
  • Definitions: 
    • Passive death wishes: when one thinks about not waking up without actively taking actions to harm oneself
    • Self-harm: methods to cause pain without intent to commit suicide (e.g., cutting) 
    • Suicidal ideation: when thoughts have escalated to acts of self-harm 
    • Suicide attempt: an action committed (e.g., shooting, hanging, overdose) in an attempt to harm oneself
    • Suicidal ideation and past attempts are independent risk factors for suicide. 
  • Start with more-indirect questions, such as “Have you ever felt that life wasn’t worth living?”
  • Psychiatrists can then be direct and ask:
    • “Have you had thoughts or plans to kill yourself?”
    • “Do you have access to a firearm?”
  • Formulation of a specific suicidal plan is indicative of more serious and imminent intent than vague self-harm ideas without concrete plans.

Psychiatric Rating Scales

  • Research-validated provider- or patient-reported scales that are used to assist in diagnosis and to assess mental status
  • Often administered quickly with paper and pencil 
  • Not sufficient to diagnose a psychiatric condition on their own
  • For MSE: 
    • Mini-mental state examination (MMSE)
    • Montreal Cognitive Assessment (MoCA)
  • For depression: 
    • Patient health questionnaire
    • Beck Depression inventory II
  • For anxiety:
    • Generalized anxiety disorder 7 (GAD-7)
    • Screen for child anxiety-related disorders (SCARED) 
  • For obsessive compulsive disorder: Yale Brown Obsessive Compulsive Scale (Y-BOCS) 
  • For ADHD: Vanderbilt ADHD diagnostic rating 
  • For substance use disorders
    • Cut down, Annoyed, Guilty, Eye-opener (CAGE): specifically for brief screening for alcohol use disorder
      • Have you ever felt you needed to Cut down on your drinking?
      • Have people Annoyed you with your drinking?
      • Have you felt Guilty about your drinking?
      • Eye-opener: Have you ever had to drink first thing in the morning?

References

  1. American Psychiatric Association. (2006). Practice guidelines for the psychiatric evaluation of adults, second edition. Am J Psychiatry. 163(6Suppl), 1–36. https://pubmed.ncbi.nlm.nih.gov/16866240/ 
  2. Black, D. (2017). The psychiatric interview and mental status examination. DeckerMed Medicine. Retrieved October 15th, 2021, from  https://doi.org/10.2310/7800.13001 
  3. Sadock, BJ, Sadock, VA, & Ruiz, P. (2014). Chapter 5: Examination and diagnosis of the psychiatric patient. In Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed., pp. 192–289. Philadelphia, PA: Lippincott Williams and Wilkins.

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