What are the key areas to assess in a comprehensive psychiatric evaluation?

Key Areas to Assess in a Comprehensive Psychiatric Evaluation

A comprehensive psychiatric assessment must systematically evaluate history of present illness, psychiatric history, substance use, medical history, family history, personal/social history, mental status examination, physical examination, and risk assessment, as these domains form the foundation for accurate diagnosis and treatment planning. 1

History of Present Illness

• Psychiatric review of systems including specific inquiry about anxiety symptoms, panic attacks, and mood disturbances 1
• Sleep patterns and abnormalities, with particular attention to sleep apnea and other sleep disorders 1
• Assessment of impulsivity and its manifestations in the patient's current presentation 1
• Chronological development of symptoms from onset to current presentation 2
• Circumstances leading to the current evaluation or hospitalization 2

Psychiatric History

• Past and current psychiatric diagnoses with detailed documentation of each condition 1
• Prior psychotic symptoms or aggressive ideation, including thoughts of physical or sexual aggression or homicide 1
• History of aggressive behaviors such as homicide, domestic violence, workplace violence, or other physically/sexually aggressive threats or acts 1
• Complete suicidal history including prior suicidal ideas, plans, and attempts (both completed and aborted), with details of context, method, damage, potential lethality, and intent of each attempt 1
• Prior intentional self-injury without suicidal intent 1
• History of psychiatric hospitalizations and emergency department visits for psychiatric issues 1
• Past psychiatric treatments including type, duration, and doses where applicable 1
• Response to past psychiatric treatments and reasons for discontinuation 1
• Adherence patterns to past and current pharmacological and non-pharmacological treatments 1

Substance Use History

• Use of tobacco, alcohol, and other substances including marijuana, cocaine, heroin, and hallucinogens 1
• Misuse of prescribed or over-the-counter medications and supplements 1
• Current or recent substance use disorders or changes in substance use patterns 1

Medical History

• Allergies and drug sensitivities with specific reactions documented 1
• All current and recent medications including prescribed, non-prescribed, herbal supplements, and vitamins, along with their side effects 1
• Relationship with primary care provider and continuity of medical care 1
• Past and current medical illnesses and hospitalizations 1
• Neurological or neurocognitive disorders including history of head injuries or physical trauma 3
• Cardiopulmonary, endocrinological, and infectious disease status (STDs, HIV, tuberculosis, hepatitis C) 3
• Sexual and reproductive history as clinically relevant 3

Family History

• Psychiatric disorders in biological relatives with specific diagnoses when known 1, 3
• History of suicidal behaviors in relatives, particularly important when the patient presents with suicidal ideation 1, 3
• History of violent behaviors in biological relatives, especially relevant when assessing patients with aggressive ideation 3

Personal and Social History

• Psychosocial stressors including financial problems, housing instability, legal issues, occupational difficulties, and relationship problems 1, 3
• Trauma history with assessment of exposure to violence or aggressive behavior 1, 3
• Legal or disciplinary consequences of past behaviors 3
• Cultural factors related to the patient's social environment and need for interpreter services 1, 3
• Educational and occupational functioning across the lifespan 1

Mental Status Examination

• General appearance and nutritional status 1
• Coordination, gait, and involuntary movements or abnormalities of motor tone 1
• Sight and hearing assessment 1
• Speech including fluency and articulation 1, 2
• Mood, level of anxiety, thought content and process 1
• Perception and cognition including assessment of hallucinations, delusions, and cognitive impairment 1
• Hopelessness as a specific indicator of suicide risk 1

Risk Assessment

Current Suicidal Risk

• Current suicidal ideas, plans, and attempts including both active and passive thoughts of suicide or death 1
• Patient's intended course of action if current symptoms worsen 1
• Access to suicide methods including firearms 1
• Possible motivations for suicide such as attention-seeking, revenge, shame, humiliation, delusional guilt, or command hallucinations 1
• Reasons for living including sense of responsibility to children or others and religious beliefs 1
• Quality and strength of the therapeutic alliance 1

Current Aggressive Risk

• Current aggressive or psychotic ideas including thoughts of physical or sexual aggression or homicide 1
• Specific triggers for aggressive behavior and response to interventions 2

Physical Examination

• Height, weight, and BMI 2
• Vital signs including blood pressure, pulse, temperature, and respiratory rate 2
• General physical examination findings relevant to psychiatric presentation 1
• Laboratory testing and neuroimaging as indicated based on history and physical examination to rule out organic causes of psychiatric symptoms 1

Impression and Plan

• Documented estimate of suicide risk with specific factors influencing risk 1
• Documented estimate of aggressive behavior risk (including homicide) with influencing factors 1
• Diagnostic formulation integrating all assessment data 2
• Rationale for treatment selection with discussion of factors influencing treatment choice 1
• Patient's treatment-related preferences and collaboration in treatment decisions 1
• Explanation to patient of differential diagnosis, risks of untreated illness, treatment options, and benefits/risks of treatment 1

Special Considerations

For children and adolescents with intellectual disability, assessment must account for developmental level rather than chronological age, with symptoms evaluated in excess of what is typical for the child's developmental stage 1. Environmental factors such as changes in routine, educational placement appropriateness, and caregiver stress require specific attention 1.

For family assessment, evaluation should identify family functions that may precipitate, predispose, or maintain clinical problems, as well as protective factors that promote health 1. Cultural and religious worldviews of the family must be understood to ensure accurate assessment 1.

Common Pitfalls to Avoid

• Neglecting collateral information sources such as family members, prior treatment records, and other healthcare providers can result in incomplete assessment 1
• Failing to assess developmental appropriateness in children and adolescents with intellectual disabilities leads to "diagnostic overshadowing" where behaviors are incorrectly attributed to the disability rather than a treatable psychiatric condition 1
• Omitting systematic review of all domains compromises the comprehensiveness required for accurate diagnosis and treatment planning 1
• Using no-suicide contracts rather than evidence-based safety planning for patients with suicidal ideation 2