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Assessment includes a general medical and psychiatric history and a mental status examination. (See also the American Psychiatric Association's Practice
Guideline for the Psychiatric Evaluation of Adults.)
History
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 and caregivers. Close family members may provide information that the patient has omitted. Receiving information that is not solicited by the physician does not violate patient confidentially. Previous psychiatric assessments and treatments are reviewed and records from such care obtained as soon as possible.
Conducting an interview hastily and indifferently with closed-ended queries (following a rigid system review) often prevents the patient from revealing relevant information. Tracing the history of the presenting illness with open-ended questions, so that the patient can tell his story in his own words, takes the same amount of time and enables the patient to describe associated social circumstances and reveal emotional reactions.
The interview should include psychiatric history, including previous treatment courses; medical history; social background, including educational level and marital, employment, and legal histories; family health history; and the patient's response to important life events and changes. Developmental history, including the family atmosphere during childhood, behavior during schooling, handling of different family and social roles, stability and effectiveness at work, sexual adaptation, pattern of social life, and quality and stability of marriage, helps in appraising personality. The physician should tactfully ask about use or abuse of alcohol, drugs, and tobacco; behavior while driving; and other aspects of everyday conduct. Responses to the usual vicissitudes of life—failures, setbacks, losses, previous illnesses—may help determine coping mechanisms (see Table 1: Personality Disorders: Coping Mechanisms ). When appropriate, the physician must ask about suicidal thoughts and plans.
The personality profile that emerges may suggest traits that are adaptive (eg, resilience, conscientiousness) or maladaptive (eg, self-centeredness, dependency, poor tolerance of frustration). The interview may reveal obsessions (unwanted and distressing thoughts or impulses), compulsions (urges to perform irrational or apparently useless acts), and delusions (fixed false beliefs) 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 is causing or worsening a mental condition. Many physical conditions cause enormous stress and require coping mechanisms to withstand the stress-related pressures. Most people 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-kempt? Is a tremor or facial droop present?
Mental
Status Examination
A mental status examination uses observation and questions to evaluate several domains of mental function, including speech, emotional expression, thinking and perception, and cognitive functions. Brief standardized screening questionnaires are available for assessing certain components of the mental status examination, including those specifically designed to assess orientation and memory. Screening questionnaires cannot take the place of a broader, more detailed mental status examination, however (see Sidebar 1: Approach to the Neurologic Patient: Examination of Mental Status ).
Speech can be assessed by noting spontaneity, syntax, and rate and volume. A patient with depression might speak slowly and softly, whereas a patient with mania might speak rapidly and loudly. Abnormalities such as dysarthrias and aphasias may indicate an underlying 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. If there is evidence of feelings of depression or anxiety, suicide risk should be assessed (see Suicidal Behavior: Prevention).
Thinking and perception can be assessed by noticing not only what is communicated but also how it is communicated. Abnormal content might take the form of delusions, ideas of reference (notions that everyday occurrences have special meaning or significance personally meant for or directed to the patient), or obsessions. 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; memory; abstract reasoning; insight; and judgment. Abnormalities of cognition most often occur with delirium or dementia and with substance abuse or withdrawal but can also occur with depression.
Last full review/revision November 2005
Content last modified November 2005
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