psychiatric disorders
Routine Psychiatric Assessment
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, caregivers, or other collateral sources (eg, police). Even when a patient is communicative, close family members, friends, or caseworkers may provide information that the patient has omitted. Receiving information that is not solicited by the physician does not violate patient confidentiality. Previous psychiatric assessments, treatments, and degree of adherence to past treatments are reviewed, and records from such care are obtained as soon as possible. Conducting an interview hastily and indifferently with closed-ended queries (following a rigid system review) often prevents patients from revealing relevant information. Tracing the history of the presenting illness with open-ended questions, so that patients can tell their story in their own words, takes a similar amount of time and enables patients to describe associated social circumstances and reveal emotional reactions. The interview should first explore what prompted the need (or desire) for psychiatric assessment (eg, unwanted or unpleasant thoughts, undesirable behavior), including how much the presenting symptoms affect the patient or interfere with the patient's social, occupational, and interpersonal functioning. The interviewer then attempts to gain a broader perspective on the patient’s personality by reviewing significant life events—current and past—and the patient’s responses to them (see table ). Psychiatric, medical, social, and developmental histories are also reviewed. A review of systems to check for other symptoms not described in the psychiatric history is important. Focusing only on the presenting symptoms to the exclusion of past history and other symptoms may result in making an incorrect primary diagnosis (and thus recommending the wrong treatment) and missing other psychiatric or medical comorbidities. For example, not asking about past manic episodes in a patient presenting with depression could result in making an incorrect diagnosis of major depressive disorder instead of bipolar disorder. Review of systems and past medical history should include questions about new or recent physical symptoms, diagnoses, and current drugs and treatments to identify potential Selected Mental Symptoms Due to Physical Disorders (eg, COVID-19 as a possible cause of anxiety or depression). The personality profile that emerges may suggest traits that are adaptive (eg, openness to experience, conscientiousness) or maladaptive (eg, self-centeredness, dependency, poor tolerance of frustration) and may show the coping mechanisms used. The interview may reveal obsessions (unwanted and distressing thoughts or impulses), compulsions (excessive, repetitive, purposeful behaviors that a person feels driven to do), and delusions (fixed false beliefs that are firmly held despite evidence to the contrary) 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 or its treatment is causing or worsening a mental condition (see Medical Assessment of the Patient With Mental Symptoms ). In addition to having direct effects (eg, symptoms, including mental ones), many physical conditions cause enormous stress and require coping mechanisms to withstand the pressures related to the condition. Many patients 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-kept? Is a tremor or facial droop present? 