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Psychiatric Assessment

Psychiatric Assessment
The psychiatric assessment is the equivalent of a physical exam, tailored to evaluate a patient for psychiatric pathologies. While the
psychiatric assessment has a mostly standardized approach, the interviewer can tailor it based on the presenting symptoms of the
patient. The psychiatric assessment is designed to systematically assess for various features of psychiatric illnesses and involves
both direct questioning and passive observation.

Last updated: 4 Dec, 2021

Editorial responsibility: Stanley Oiseth (/author-stanley-oiseth/),

Lindsay Jones (/author-lindsay-jones/),
Evelin Maza (/author-evelin-
maza/)

CONTENTS

Overview of a Psychiatric Encounter

Initial Part of Psychiatric Assessment
History of the Present Illness
Obtaining Past History
Mental Status Examination (MSE)
Evaluation of Suicide Risk
Psychiatric Rating Scales
References

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Overview of a Psychiatric Encounter

While there may be variability between how different physicians (/concepts/clinician-patient-relationship/) conduct the encounter, and a
physician may tailor the encounter to suit the needs of a patient’s diagnosis, the general structure should be reproducible and follow a
logical course.

1. Review available records and secure a safe, private place for the psychiatric interview.
2. Observe the patient’s nonverbal communication (/concepts/decision-making-capacity-and-legal-competence/) cues and assess their
level of agitation (/concepts/st-louis-encephalitis-virus/).
3. Introduce yourself to the patient.
4. Inquire about the patient’s chief reason for presentation (/concepts/normal-and-abnormal-labor/).
5. Obtain the patient’s recent history of presenting illness and conduct the psychiatric interview.
Support
 6. Obtain the patient’s past personal history (i.e., past medical/psychiatric history, family history (/concepts/adult-health-maintenance/),
 social history (/concepts/adult-health-maintenance/)). (https://www.lecturio.com/)

7. Conduct a mental state exam.

8. List the differential diagnosis.
9. Develop an appropriate plan of care with the treatment team:
Level of care required (hospitalization (/concepts/delirium/), intensive outpatient, outpatient)
Pharmacotherapy
10. Determine an appropriate follow-up interval.

Initial Part of Psychiatric Assessment

Before speaking with the patient:
Secure a safe, private place for the interview:
Especially important for patients (/concepts/clinician-patient-relationship/) with potential for violence in the psychiatric
hospital or emergency room setting 
Providers must have access to easy escape (/concepts/cancer-immunotherapy/), and the room should be clear of objects
that pose potential harm to themselves or others.
A review of past medical records and laboratory studies is also helpful but may also bias (/concepts/types-of-biases/) the
interview.
Initial contact with the patient:
Observe nonverbal communication (/concepts/decision-making-capacity-and-legal-competence/) and assess their level of
agitation (/concepts/st-louis-encephalitis-virus/).
Introduce yourself to the patient and establish the doctor-patient relationship (/concepts/clinician-patient-relationship/).
Use open-ended questions.
May require contacting collateral informants for patients (/concepts/clinician-patient-relationship/) who are poor historians.

History of the Present Illness

Determine the onset and characteristic of symptoms: Be mindful of any prior stressful events, medical illness, or substance use.
Course of symptoms:
History of similar symptoms in the past
Waxing vs. waning or both intermittently
Progression of symptoms 
Triggers (/concepts/hereditary-angioedema-c1-esterase-inhibitor-deficiency/) for symptoms: ameliorating and worsening triggers
Screen for 5 key diagnostic criteria:
Mood symptoms: depression vs. mania (/concepts/bipolar-disorder/)
Psychotic symptoms (/concepts/brief-psychotic-disorder/)
Anxiety (/concepts/generalized-anxiety-disorder/)-related symptoms
Substance use
Suicidality/homicidality

Obtaining Past History Support

 Past medical/surgical history:
 (https://www.lecturio.com/)
Many medical illnesses have symptoms that can induce psychiatric conditions (e.g.,
hypothyroidism (/concepts/hypothyroidism/) and depression).
Current medications, including dietary supplements, are also important to note.
Family history:
Psychiatric family history (/concepts/adult-health-maintenance/) is important, as some mental illnesses are seen more
predominantly in the children and family members of affected patients (/concepts/clinician-patient-relationship/).
Medical family history (/concepts/adult-health-maintenance/) is also important.
Social history:
Much more extensive than other history taking
Developmental/early childhood history
Education level
Occupation history and financial resources
Religious/spiritual beliefs 
Relationships, dating, sexual orientation (/concepts/sexual-physiology/), and sexual history 
Hobbies and interests

Mental Status Examination (MSE)

Psychiatric equivalent of the physical exam 
Some components of the MSE are obtained through observation, while others are through questions.
Useful for identifying cognitive impairments, disturbances in mood, psychotic symptoms, and suicidal thoughts

Table: Major components of the MSE

Category Components

Appearance General description of patient’s appearance and behavior:

Age
Sex (/concepts/gender-dysphoria/)
Race
Body build
Posture
Excessive or reduced eye contact
Appropriateness of dress
Grooming
Manner
Attentiveness to the examiner
Distinguishing features
Prominent physical abnormalities
Emotional facial expression
Alertness

Orientation Awareness of time, place, and person

Attention and
Ability to spell a word backward and forward
concentration Serial 7s (counting down from 100 in 7s)

Spatial orientation Ability to draw a house, or a clock face with hands indicating a specific time
Support
Category Components
 (https://www.lecturio.com/)

Motor (/concepts/histology-of-the- Retardation

nervous-system/) Agitation
Abnormal movements
Gait (/concepts/neurological-examination/)
Catatonia (/concepts/major-depressive-disorder/)

Speech Rate
Rhythm
Volume
Amount
Articulation
Spontaneity (/concepts/neurological-examination/)

Mood Patient’s internal and self-described emotional state

Affect Expression of patient’s mood or how the mood appears to be to the

clinician (/concepts/clinician-patient-relationship/)
Appropriateness of affect: how affect correlates to the setting. For example, a patient
who is describing
depression while laughing would have an affect incongruent with or
inappropriate to their mood.
A commonly used term for affect is “flat” for a severely restricted range of affect
that is found in some
patients (/concepts/clinician-patient-relationship/) with schizophrenia (/concepts/schizophrenia/).

Thought
What thoughts are on the patient’s mind:
content Suicidal ideation (/concepts/suicide/)
Death wishes
Homicidal ideation
Depressive cognitions
Obsessions (/concepts/obsessive-compulsive-disorder-ocd/)
Ruminations (/concepts/neurological-examination/)
Phobias (/concepts/neurological-examination/)
Ideas of reference
Paranoid ideation (/concepts/neurological-examination/)
Magical ideation
Delusions
Overvalued ideas

Thought
Describes how certain thoughts are made, organized, and expressed:
process Associations (circumstantial or tangential)
Flight of ideas
Clang associations
Perseveration (/concepts/neurological-examination/)
Neologism (/concepts/neurological-examination/)
Blocking

Memory Ability to recall 3 simple objects after 2 and 5 minutes

Ability to recall distant events from the past

Abstract
Ability to shift between general concepts and specific examples (e.g.: “How are oranges and
apples alike?”)
reasoning (/concepts/decision-
making-capacity-and-legal-
competence/)

Support
 Category Components
 (https://www.lecturio.com/)

Perception Hallucinations
Illusions (/concepts/schizophrenia/)
Depersonalization (/concepts/depersonalization-derealization-disorder/)
Derealization (/concepts/depersonalization-derealization-disorder/)
Déjà vu (/concepts/neurological-examination/)
Jamais vu (/concepts/neurological-examination/)

Intellect Average, above average, below average

Determined during an interview by thought content and by educational and professional
achievement

Insight Awareness of one’s illness, mood, and functioning level and its implications

Judgment Ability to make and act on good decisions

Does not always correlate with insight

Related videos

15:41

Mental Status Exam

Evaluation of Suicide Risk

One of the most critical components of psychiatric assessment
Determines whether patient meets criteria for inpatient vs. outpatient treatment
Definitions: 
Passive death wishes: when one thinks about not waking up without actively taking actions to harm oneself
Self-harm: methods to cause pain (/concepts/physiology-of-pain/) without intent to commit suicide (/concepts/suicide/) (e.g.,
cutting) 
Suicidal ideation (/concepts/suicide/): when thoughts have escalated to acts of self-harm 
Suicide attempt: an action committed (e.g., shooting, hanging, overdose) in an attempt to harm oneself
Suicidal ideation (/concepts/suicide/) and past attempts are independent risk factors for suicide (/concepts/suicide/). 
Start with more-indirect questions, such as “Have you ever felt that life wasn’t worth living?”
Psychiatrists can then be direct and ask:
“Have you had thoughts or plans to kill yourself?”
“Do you have access to a firearm?”
Formulation of a specific suicidal plan is indicative of more serious and imminent intent than vague self-harm ideas without concrete
plans.

Support
 
Psychiatric Rating Scales (https://www.lecturio.com/)

Research (/concepts/conflict-of-interest/)-validated provider- or patient-reported scales (/concepts/secondary-skin-lesions/) that are

used to assist in diagnosis and to assess mental status
Often administered quickly with paper and pencil 
Not sufficient to diagnose a psychiatric condition on their own

For MSE: 
Mini-mental state examination (/concepts/major-neurocognitive-disorders/) (MMSE (/concepts/major-neurocognitive-disorders/))
Montreal Cognitive Assessment (/concepts/major-neurocognitive-disorders/) (
MoCA (/concepts/major-neurocognitive-disorders/))
For depression: 
Patient health questionnaire
Beck Depression inventory II
For anxiety:
Generalized anxiety disorder (/concepts/generalized-anxiety-disorder/) 7 (GAD (/concepts/generalized-anxiety-disorder/)-7)
Screen for child anxiety-related disorders (SCARED) 
For obsessive compulsive disorder: Yale Brown Obsessive Compulsive Scale (/concepts/dermatologic-examination/) (
Y-BOCS (/concepts/obsessive-compulsive-disorder-ocd/)) 
For ADHD (/concepts/attention-deficit-hyperactivity-disorder/): Vanderbilt ADHD (/concepts/attention-deficit-hyperactivity-disorder/)
diagnostic rating 
For substance use disorders
Cut down, Annoyed, Guilty, Eye-opener (CAGE): specifically for brief screening (/concepts/preoperative-care/) for
alcohol use disorder (/concepts/alcohol-use-disorder/)
Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you with your drinking?
Have you felt Guilty about your drinking?
Eye-opener: Have you ever had to drink 1st thing in the morning?

References

1. American Psychiatric Association. (2006). Practice guidelines for the psychiatric evaluation of adults, second edition. Am J
Psychiatry. 163(6Suppl), 1–36. https://pubmed.ncbi.nlm.nih.gov/16866240/ (https://pubmed.ncbi.nlm.nih.gov/16866240/) 
2. Black, D. (2017). The psychiatric interview and mental status examination. DeckerMed Medicine. Retrieved October 15th, 2021, from 
https://doi.org/10.2310/7800.13001 (https://doi.org/10.2310/7800.13001) 
3. Sadock, BJ, Sadock, VA, & Ruiz, P. (2014). Chapter 5: Examination and diagnosis of the psychiatric patient. In Kaplan and Sadock’s
Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed., pp. 192–289. Philadelphia, PA: Lippincott Williams and
Wilkins.

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