What are the components of a comprehensive psychiatric workup?

Components of a Comprehensive Psychiatric Workup

A comprehensive psychiatric workup consists of five essential domains: psychiatric assessment (including detailed symptom evaluation and mental status examination), physical/medical assessment (to exclude organic causes), collateral information gathering, risk assessment, and psychological testing when clinically indicated. 1, 2

Psychiatric Assessment Components

Clinical Interview Structure

• Conduct interviews with both the patient and family members separately, balancing confidentiality needs against the requirement for a common information base for treatment decisions 1, 2
• Document identifying information including patient demographics, date/time of evaluation, and sources of information (patient, family, medical records) 2
• Record the chief complaint in the patient's own words and document circumstances leading to the current presentation 2

History of Present Illness

• Assess chronology of symptom development with specific attention to onset, duration, frequency, and progression 2
• Conduct a psychiatric review of systems including mood symptoms (depression, mania, irritability), anxiety and panic attacks, sleep patterns and abnormalities, psychotic symptoms (hallucinations, delusions), and assessment of impulsivity 2
• Evaluate symptom presentation with detailed characterization of the primary psychiatric complaints 1
• Document course of illness including any episodic patterns, triggers, and functional impairment 1

Past Psychiatric History

• Identify all past and current psychiatric diagnoses, including any prior diagnoses that may have been incorrect 3, 2
• Document history of psychiatric hospitalizations and emergency department visits for mood-related or behavioral issues 3, 2
• Assess prior suicidal ideas, plans, and attempts including context, method, damage, lethality, and intent 2
• Evaluate prior aggressive behaviors including homicidal ideation, domestic violence, and threats 2
• Review response to past psychiatric treatments, particularly noting any antidepressant-induced mood elevation or agitation 3

Substance Use History

• Obtain detailed substance use history including current and past use of tobacco, alcohol, marijuana, cocaine, hallucinogens, and other substances 1, 3, 2
• Assess misuse of prescribed or over-the-counter medications and complementary/alternative treatments 1, 2
• Consider toxicology screening to rule out substance-induced psychiatric symptoms and assess temporal relationship between substance use and symptom onset 3

Medical History

• Document allergies and drug sensitivities with specific attention to psychiatric medication reactions 1, 2
• List all current medications including prescribed, non-prescribed, and supplements 1, 2
• Assess past and current medical illnesses including cardiopulmonary status, endocrinological disease, infectious diseases (STDs, HIV, tuberculosis, hepatitis C), and neurological conditions 1, 2
• Evaluate for medication allergies or family history of medical problems associated with increased risk for side effects (e.g., structural cardiac abnormalities before starting stimulants, family history of malignant arrhythmias or sudden cardiac death before starting atypical antipsychotics) 1

Family Psychiatric History

• Focus on psychotic illnesses and mood disorders in biological relatives 1, 3
• Assess history of suicidal behaviors in relatives, especially for patients presenting with suicidal ideation 2

Personal and Social History

• Identify psychosocial stressors including financial problems, housing instability, legal issues, occupational difficulties, and relationship conflicts 2
• Assess trauma history including history of maltreatment and adverse childhood experiences 3, 2
• Evaluate developmental history when assessing children and adolescents, including any significant developmental problems 1

Mental Status Examination

The mental status examination provides observational data gathered throughout the patient encounter and includes both general observations and specific cognitive testing. 4, 5

Core MSE Components

• Appearance and behavior: Document general physical observations, grooming, hygiene, and appropriateness of dress 2, 5
• Speech characteristics: Assess fluency, articulation, rate, volume, and spontaneity 2, 5
• Mood and affect: Evaluate patient's subjective emotional state and objective emotional expression, including range, appropriateness, and stability 2, 5
• Thought process: Assess logical flow versus tangential, circumstantial, or disorganized thinking 2, 5
• Thought content: Evaluate for delusions, obsessions, preoccupations, suicidal or homicidal ideation 2, 5
• Perceptual disturbances: Screen for hallucinations (auditory, visual, tactile, olfactory) 2, 5
• Cognition and sensorium: Test orientation (person, place, time, situation), attention, memory (immediate, recent, remote), and executive functioning 2, 5
• Insight and judgment: Assess patient's understanding of their illness and ability to make appropriate decisions 5

Clinical Evidence of Psychotic Symptoms

• Document specific psychotic symptoms including hallucinations, delusions, and formal thought disorder when evaluating for conditions like schizophrenia 1

Physical and Medical Assessment

General medical causes of psychiatric symptoms must be ruled out before attributing symptoms to primary psychiatric illness. 1

Physical Examination

• Perform thorough physical examination with particular attention to neurological findings 1
• Measure vital signs, height, weight, and BMI as baseline parameters 1, 2

Selective Medical Testing

• Order laboratory tests based on clinical indication from history and physical examination, not as routine screening 1
• Consider complete metabolic panel, thyroid function tests, B12, folate, liver function tests, and complete blood count when clinically indicated 1
• Obtain baseline laboratory testing when indicated for monitoring potential adverse effects of psychopharmacological agents (e.g., renal or hepatic function) 1

Neuroimaging and Specialized Testing

• Order neuroimaging (CT or MRI) only when indicated by focal neurological findings, new-onset psychosis in elderly patients, acute change in mental status, or history suggesting CNS pathology 1
• Consider EEG when seizure disorder is suspected based on clinical presentation 1
• Obtain toxicology screens when substance use is suspected or to establish baseline 1, 3

Medical Conditions to Exclude

Potential organic conditions requiring consideration include: acute intoxication, delirium, CNS lesions, tumors or infections, metabolic disorders, seizure disorders, thyroid dysfunction, and medication side effects 1

Collateral Information Gathering

Obtain information from family members or other collateral sources whenever possible, as patients often lack insight during acute psychiatric episodes and family members can describe behavioral changes and episodic patterns more objectively 3, 6

• Review past medical and psychiatric records to assess previous successful and unsuccessful treatments, which enhances the likelihood that proposed interventions will be the next logical treatment step 1
• Gather information from schools or other providers when assessing children and adolescents 6

Risk Assessment

Systematic evaluation of suicide risk with specific attention to actionable factors is essential, not just screening questions. 2, 6

Suicide Risk Evaluation

• Assess current suicidal ideation including both active and passive thoughts, specific plans, intent, and access to lethal means 2, 6
• Document prior suicide attempts including aborted or interrupted attempts, with attention to method, lethality, and circumstances 2
• Evaluate protective factors and risk factors including social support, access to mental health care, impulsivity, substance use, and psychiatric comorbidity 6
• Provide documented estimate of suicide risk with specific influencing factors rather than vague risk categorization 2

Violence Risk Assessment

• Assess current aggressive or homicidal ideation with specific inquiry about plans and intent 2
• Evaluate history of violent behavior including domestic violence, assault, and property destruction 2

Psychological Testing (When Indicated)

Psychological testing is not indicated as a method of diagnosing primary psychiatric disorders but has specific clinical applications. 1

Indications for Testing

• Intellectual assessment is indicated when there is clinical evidence of developmental delays, since these deficits may influence the presentation and interpretation of symptoms 1
• Cognitive testing may be useful for assessing the degree of impairment associated with illness and to help guide treatment planning 1
• Personality and projective tests are not indicated for diagnosing conditions like schizophrenia 1

Special Considerations and Common Pitfalls

High-Risk Populations Requiring Enhanced Evaluation

Four groups require particularly careful medical evaluation: the elderly, those with substance abuse, patients without prior psychiatric history, and those of lower socioeconomic level 1

Differential Diagnosis Considerations

• Differentiate psychiatric symptoms from normal developmental phenomena in children and adolescents, avoiding pathologizing developmentally appropriate behavior 6
• Consider cross-cultural issues that may influence the expression or interpretation of symptoms and treatment response 3
• Use longitudinal perspective (life chart) to characterize the course of illness, patterns of episodes, severity, and treatment response, which helps with diagnostic accuracy 3

Documentation Requirements

• All sections should be clearly documented with date, time, and authentication by the evaluating clinician 2
• Organize clinical information systematically to facilitate diagnostic formulation and treatment planning 3, 2