How do you systematically evaluate a psychiatric symptom complaint?

Systematic Evaluation of Psychiatric Symptom Complaints

Begin with a structured diagnostic interview that includes psychiatric review of systems, comprehensive substance use history, suicide/violence risk assessment, and functional impairment evaluation, while using standardized screening tools to ensure no symptoms are missed. 1

Initial Assessment Framework

Chief Complaint and Symptom Characterization

• Document the presenting psychiatric complaint through spontaneous patient report, including onset, duration, frequency, and severity of symptoms 1
• Conduct a systematic psychiatric review of systems covering mood, anxiety, psychosis, sleep abnormalities (including sleep apnea), panic attacks, and impulsivity 1
• Assess the degree of associated distress and functional impairment in work, school, home, and social relationships 1
• Determine whether symptoms represent developmentally inappropriate manifestations (particularly in children/adolescents) versus normal psychological processes 1

Standardized Screening Implementation

• Deploy validated screening instruments systematically rather than relying on clinical interview alone, as nonsystematic methods have inherent variability 1
• Use the APA Level 1 Cross-Cutting Symptom Measures (freely available, parent- and self-rated versions) in intake packets to screen for multiple psychiatric disorders including anxiety, depression, and psychosis before the evaluation 1
• For depression screening, utilize PHQ-9 with cutpoint ≥10 (sensitivity 72%, specificity 72%) or PHQ-2 with cutpoint ≥3 for ultra-brief screening 2, 3
• For anxiety screening, deploy GAD-7 with cutpoint ≥10 (good sensitivity/specificity for generalized anxiety, panic, social anxiety, and PTSD) or GAD-2 with cutpoint ≥3 2
• In primary care or school settings, use general social-emotional screening instruments like the Pediatric Symptom Checklist or Strengths and Difficulties Questionnaire 1

Comprehensive Psychiatric History

Past Psychiatric History

• Document all past and current psychiatric diagnoses with treatment details (type, duration, doses, response, and adherence patterns) 1
• Obtain history of psychiatric hospitalizations and emergency department visits for psychiatric issues 1
• Assess prior psychotic or aggressive ideas, including thoughts of physical/sexual aggression or homicide 1
• Systematically evaluate prior suicidal ideas, suicide plans, and suicide attempts—including aborted or interrupted attempts—with details of context, method, damage, potential lethality, and intent 1
• Document prior intentional self-injury without suicidal intent 1

Substance Use Assessment

• Assess current and recent use of tobacco, alcohol, marijuana, cocaine, heroin, hallucinogens, and any misuse of prescribed or over-the-counter medications or supplements 1
• Evaluate for current or recent substance use disorder or changes in use patterns 1
• Document treatment adherence to past and current pharmacological and non-pharmacological psychiatric treatments 1

Medical Evaluation and Laboratory Testing

History-Directed Medical Workup

• In alert, cooperative patients with normal vital signs and noncontributory history/physical examination, diagnostic evaluation should be directed by the history and physical examination—routine laboratory testing of all patients is of very low yield and need not be performed 1
• Target laboratory testing based on specific clinical findings rather than obtaining routine batteries 1
• Recognize high-risk populations requiring lower thresholds for medical workup: elderly patients, those without prior psychiatric history, patients with substance abuse, those with new medical complaints, and patients of lower socioeconomic status 1

Urine Drug Screen Considerations

• Do not obtain routine urine toxicology screens in psychiatric evaluations, as they carry only 20% sensitivity for organic etiology and do not change management in most cases 1
• Consider targeted drug screening only when substance intoxication would alter psychiatric assessment validity or when required by receiving psychiatric facilities 1
• For alcohol intoxication, allow blood alcohol concentration to decrease before psychiatric evaluation, as intoxication impairs valid psychiatric examination and symptoms often clear as patient sobers 1

Differential Diagnosis Considerations

Distinguishing Psychiatric from Medical Causes

• Recognize that 9.1% of psychiatric outpatients have medical disorders producing psychiatric symptoms, most frequently infectious, pulmonary, thyroid, diabetic, hematopoietic, hepatic, and CNS diseases 4
• Visual hallucinations should indicate medical etiology until proven otherwise 4
• New-onset psychiatric symptoms (first presentation) require particularly careful medical evaluation, as most have medical illness as etiology 1
• Altered mental status, disorientation, confusion, or focal neurological deficits mandate comprehensive metabolic and neurological evaluation regardless of psychiatric presentation 1

Psychiatric Disorder-Specific Features

• For anxiety disorders: differentiate separation anxiety, selective mutism, specific phobia, social anxiety, panic disorder, agoraphobia, and generalized anxiety based on DSM-5 criteria focusing on the specific feared object/situation and associated avoidance patterns 1
• For mood disorders: assess for depressed/dysphoric mood interfering with daily functioning nearly every day for at least 2 weeks, plus at least 4 of 8 associated symptoms (appetite change, sleep change, psychomotor changes, anhedonia, fatigue, guilt/worthlessness, concentration problems, suicidal ideation) 5
• For psychotic disorders: establish duration, type, number, and combinations of symptoms, plus pattern of symptom development and course of illness using structured interviews or diagnostic decision trees 1

Collateral Information and Multidisciplinary Input

Information from Other Sources

• Obtain history from collateral sources including family members, prior treatment providers, and referral sources 1
• Review past medical records and historical information systematically 1
• In cases where primary psychiatric disorders versus neurocognitive disorders are on differential, ensure evaluation by clinicians with expertise in both neurocognitive disorders and psychiatry 1

Phenomenological Description

• Go beyond simple identification of psychiatric symptoms as general categories (e.g., "psychosis") and provide detailed phenomenological description that has diagnostic value 1
• Apply DSM-5 clinical criteria rigorously to identify specific psychiatric diagnoses and psychiatric comorbidities 1
• Use clinician-rated symptom scales (e.g., MADRS, HAM-D for mood symptoms) to systematically assess differentiating features and increase diagnostic consistency 1

Documentation and Follow-Up

Essential Documentation Elements

• Document who initiated the consultation process and whether the patient is over- or under-emphasizing severity of disability 1
• Assess and document the patient's degree of concern and insight into their symptoms 1
• Note fluctuating versus persistent symptom patterns 1
• Recognize that misdiagnosis is common, especially at illness onset, requiring longitudinal follow-up with periodic diagnostic reassessments to ensure accuracy 1