As I have discussed in previous blogs on this website, the practice of Psychiatry is challenging. Unlike other medical specialties there are a paucity of laboratory testing or radiologic imaging that will reveal the true nature of the problems being presented at the time of our appointment. Instead of relying on objective data I must process a wealth of subjective information; that is, the words that you use in describing your current emotional state. I view this challenge much like a good detective would tackle a mystery. To help you better understand the complexities of the evaluation I will try to outline the key components.
Firstly, I certainly recognize that a new patient coming into my office will be uneasy and not sure of what to expect. So it is important to reassure the individual that he evaluation process is straightforward and geared to better understanding what brings the individual to my office.
This brings us to what I call the “Chief Complaint”, best expressed by asking “How can I help you?” Quite commonly people present with concerns about being depressed or suffering from anxiety. The problem with the chief complaint is that what people mean by words like depression or anxiety differ tremendously among individuals. So the chief complaint must be clarified with more specific descriptions of what the person means by the words they are using. Often a perceived problem with anxiety represents a symptom of a depressive disorder. I commonly hear individuals come in concerned about “mood swings” with a fear that they could have bipolar disorder (manic depressive illness). However, after clarifying their concerns by getting a more comprehensive description, I often discover that what they are describing I a swing between feeling fine and feeling depressed, a symptom complex that can be part of a core depressive disorder.
Once the chief complaint is determined, the next step is to obtain a “History of Present Illness”. Specifically, this entails finding out how long the difficulties have been present, what does the development of emotional symptoms look like and what was the context in which the difficulties presented themselves. Since a major goal of assessment is to discover if there are underlying biological (that is, brain related) factors causing symptoms, it is just as important to determine if there are situational factors present during symptom development. Then the challenge is to try to better understand whether there are psychological factors (coping style, attitude and belief systems) influencing or even responsible for producing the current problems bringing the person to my office.
Current problems and symptoms must be understood in the context of any “Past Psychiatric History”. Have these problems and/or symptoms been present in the past? If so, has there been a pattern of episodes? Has there been previous psychiatric treatment and what was the outcome of such treatment? It is always helpful to know if an individual had previous depressive episodes and responded to a particular antidepressant. If there is a history of prior courses of psychotherapy, what type of therapy was it and what was the outcome?
The presence of “Substance Abuse” (another section of the comprehensive evaluation) must be discovered because of the complicating role it may play in the presentation of the individual’s symptoms and concerns. The drugs, amount used and duration of use must be clarified. When substance abuse has been extensive and long term, all bets are off in determining a non-substance abuse primary psychiatric disorder. It is only after months of a brain free of the substance(s) abused can one adequately determine the presence or absence of a core mood or anxiety disorder.
A most important section of this initial assessment consists of the “Family Psychiatric History”. Knowing what the individual’s genetic pedigree is can be very telling. If mood and/or anxiety disorders are prevalent in nuclear and extended family members the possibility of an underlying biological problem must be considered when treatment planning occurs. This does not mean that biological dysfunction is the sole problem. It is quite common to discover that there has been a stress-diathesis interaction; that is, the external situational stressors are interacting with an underlying biological predisposition.
A “Childhood History” is another critical component. To discover that there is a past history of traumatic life experiences raises questions about both the nature of the present problem and aspects of treatment planning. Bullying has unfortunately become recognized as a major factor in the development of future suffering and trauma syndromes. Determining if there was any birth injury, delay in developmental milestones or school related anxiety and avoidance or academic learning difficulties is part of this section. Although a very sensitive area of investigation, learning about a history of abuse, whether it be emotional, physical or sexual, represents important albeit painful information to gather.
The person’s “Past Medical History” cannot be ignored. This section includes the presence or absence of medical system problems (involving heart/vascular, lungs, kidney. Liver, thyroid, gastrointestinal, other hormonal, and brain) that may be impacting on the individual’s current complaints. An accurate and detailed list of current medications and dosages taken is essential for treatment planning due to the varied effects of medication on mental state as well as the risk of drug to drug interactions when psychiatric medications need to be prescribed. Obtaining a history of medication-related or other allergies, surgeries, head injuries or concussions rounds out this section.
The “Psychosocial History” explores childhood specifics, religious background, educational level, job history, marital status and special interests or hobbies. It helps to fill in the context of the present illness.
The “Mental Status Examination” is the psychiatrist’s equivalent of the internist’s physical examination. This examination evaluates the behavior and demeanor of the individual. Emotional experience and expression is assessed. Thinking content and process along with speech characteristics are components as well. A formal assessment of memory, attention/concentration, abstract language use, fund of knowledge and perceptual/sensory disturbances are an integral part of mental status.
Because severe mental disorders can lead to self or other destructive thoughts and urges, an evaluation of dangerousness risks is an important aspect of a comprehensive evaluation.
After all this information is obtained, a preliminary psychiatric assessment is provided. This diagnostic section utilizes the American Psychiatric Association Diagnostic and Statistical Manual, Edition V to aid in evidence-based diagnostic consistency.
The initial plan of treatment may include medication, lifestyle recommendations and psychotherapy. It is important to recognize that both diagnostic impressions and treatment recommendations need to be flexible because as the therapeutic relationship unfolds additional information becomes available which may alter treatment planning.