The Psychiatric Evaluation

A psychiatric evaluation follows the same approach as any medical evaluation, with additional components designed to test for evidence of underlying psychiatric disorders. The format of a psychiatric evaluation contains the information listed in Table 1-1.

TABLE 1-1 Approach to the Evaluation of Psychiatric Patients

History

Sources of Information

Chief complaint

Identifying information

Age, gender, ethnicity, relevant psychiatric history, means of presenting, symptoms, context of symptoms
Example: This is a 46-year-old married white woman with a past psychiatric history of depression who presents to the ED in an ambulance with worsening depression and suicidal ideation in the context of recent economic and relationship stressors.

History of Present Illness

Nature of symptoms (in the patient’s own words when possible)
Onset, duration, qualities, what makes it better or worse
Recent stressors that may be contributing to symptoms
Detailed questions regarding feelings of safety

Psychiatric Review of Systems

Depression and suicidal ideation (see page 65 for more details)
Anxiety (see page 52 for more details)
Mania (see page 76 for more details)
Psychosis (see page 92 for more details)

Psychiatric History

Previous diagnoses and age(s) diagnosed
Previous hospitalizations (where, when, why)
Previous treaters
Previous medication trials
Current treaters (with contact numbers), including therapists, psychopharmacologists, primary care physician, other specialists
Current medications and allergies

Medical History

All medical diagnoses and past surgeries
Medications including dosages
Allergies

Family History

Type of relative (relation, maternal vs. paternal)
Conditions
Suicide attempts; completed suicides

Social History

Where born and raised and by whom
Siblings(s) information (level of functioning including education, employment and relationships)
Abuse (see page 72 for more details)
Highest level of education
Past and current employment
Current source of income
Current relationships (married, single, children?)
Substance abuse history: Substances used, amount, time since last use, treatment history (see page 102 for more details)
Legal issues

Medical Review of Systems

Focus on major organ systems as well as neurologic symptoms (see Appendix I)

Physical Examination

General medical and neurologic examination (see Appendix II)

Mental Status Examination

Psychiatric mental status (see below for details) Mini-mental status examination in all geriatric patients and when otherwis appropriate

Laboratory Studies, Imaging Studies, and Other Diagnostic Tests

First-line tests: Toxicology screens (blood and urine), chemistries, thyroid-stimulating hormone level, complete blood count, urinalysis Second-line tests, if indicated: Dependent on particular symptoms

Global Assessment of Functioning

91-100: Superior functioning in a wide range of activities; life’s problems never seem to get out of hand; is sought out by others because of his or her many qualities. No symptoms.

81-90: Absent or minimal symptoms; good functioning in all areas; interested and involved in a wide range of activities; socially effective; generally satisfied with life; no more than everyday problems or concerns.

71-80: If symptoms are present, they are transient and expectable reactions to psychosocial stresses; no more than slight impairment in social, occupational, or school functioning.

61-70: Some mild symptoms OR some difficulty in social, occupational, or school functioning but generally functioning pretty well and has some meaningful interpersonal relationships.

51-60: Moderate symptoms OR any moderate difficulty in social, occupational, or school functioning.

41-50: Serious symptoms OR any serious impairment in social, occupational, or school functioning.

31-40: Some impairment in reality testing or communication OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood.

21-30: Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communications or judgment OR inability to function in all areas.

11-20: Some danger of hurting self or others OR occasionally fails to maintain minimal personal hygiene OR gross impairment in communication.

1-10: Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death.

0: Not enough information available to provide global assessment of function.

Assessment and Plan

Items to Include

Identifying information (from HPI)
Symptoms present
Formulation
Diagnosis (or diagnoses) with discussion of differential

Plan

Level of acuity
Recommended behavioral interventions (if any)
Recommended pharmacologic or somatic interventions (if any)

Specific diagnostic components of the psychiatric evaluation include the mental status examination and (when appropriate) the mini-mental status examination. Mental Status Exam: