Patients with mental complaints or concerns or disordered behavior present in a variety of clinical settings, including primary care and emergency treatment centers. Complaints or concerns may be new or a continuation of a history of mental problems. Complaints may be related to coping with a physical condition or be the direct effects of a physical condition on the central nervous system. The method of assessment depends on whether the complaints constitute an emergency or are reported in a scheduled visit. In an emergency, a physician may have to focus on more immediate history, symptoms, and behavior to be able to make a management decision. In a scheduled visit, a more thorough assessment is appropriate.
Routine psychiatric assessment includes a general medical and psychiatric history and a mental status examination. (See also the American Psychiatric Association’s Psychiatric Evaluation of Adults Quick Reference Guide and American Psychiatric Association: Practice guideline for the psychiatric evaluation of adults.)
The physician must determine whether the patient can provide a history, ie, whether the patient readily and coherently responds to initial questions. If not, information is sought from family, caregivers, or other collateral sources (eg, police). Even when a patient is communicative, close family members, friends, or caseworkers may provide information that the patient has omitted. Receiving information that is not solicited by the physician does not violate patient confidentiality. Previous psychiatric assessments, treatments, and degree of adherence to past treatments are reviewed, and records from such care are obtained as soon as possible.
Conducting an interview hastily and indifferently with closed-ended queries (following a rigid system review) often prevents patients from revealing relevant information. Tracing the history of the presenting illness with open-ended questions, so that patients can tell their story in their own words, takes a similar amount of time and enables patients to describe associated social circumstances and reveal emotional reactions.
The interview should first explore what prompted the need (or desire) for psychiatric assessment (eg, unwanted or unpleasant thoughts, undesirable behavior), including how much 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 personality by reviewing significant life events—current and past—and the patient’s responses to them (see table Areas to Cover in the Initial Psychiatric Assessment). Psychiatric, medical, social, and developmental history is also reviewed.
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 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).
Areas to Cover in the Initial Psychiatric Assessment
The personality profile that emerges may suggest traits that are adaptive (eg, resilience, conscientiousness) or maladaptive (eg, self-centeredness, dependency, poor tolerance of frustration) and may show the coping mechanisms used. The interview may reveal obsessions (unwanted and distressing 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), mental symptoms (eg, phobic behavior, depression), or social behavior (eg, withdrawal, rebelliousness). The patient should also be asked about attitudes regarding psychiatric treatments, including drugs and psychotherapy, so that this information can be incorporated into the treatment plan.
The interviewer should establish whether a physical condition or its treatment is causing or worsening a mental condition (see Medical Assessment of the Patient With Mental Symptoms). In addition to having direct effects (eg, symptoms, including mental ones), many physical conditions cause enormous stress and require coping mechanisms to withstand the pressures related to the condition. Many patients with severe physical conditions experience some kind of adjustment disorder, and those with underlying mental disorders may become unstable.
Observation during an interview may provide evidence of mental or physical 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, is the patient clean and well-kept? Is a tremor or facial droop present?
A mental status examination uses observation and questions to evaluate several domains of mental function, including
Brief standardized screening questionnaires are available for assessing certain components of the mental status examination, including those specifically designed to assess orientation and memory. Such standardized assessments can be used during a routine office visit to help screen patients; such screening can help identify the most important symptoms and 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 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 abuse or attempted self-harm (eg, they have an odor of alcohol, scars suggesting IV drug abuse 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 physical 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:
The physician can assess whether ideas seem to be linked and goal-directed and whether transitions from one thought to the next are logical. Psychotic or manic patients 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