Psychiatric assessment
Encyclopedia
A psychiatric assessment, or psychological screening, is a process of way of gathering information about a person within a psychiatric (or mental health) service, with the purpose of making a diagnosis
. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist
, but it could be a multi-disciplinary process involving nurses, psychologist
s, occupational therapist
s and social workers.
of the individual's problems, and to plan the individual's care and treatment. This may be done in a hospital (or in-patient) setting, in an ambulatory (or out-patient) setting, or in a community setting (as a home-based assessment). Clinical assessment is the main focus of this article.
assessment may have a number of purposes. A forensic assessment may be required of an individual who has been charged with a crime (usually a violent crime), to establish whether the person has the capacity
(in legal terms) to stand trial. If a person with a mental illness is convicted of an offense, a forensic report may be required to inform the Court's sentencing decision, as a mental illness at the time of the offense may be a mitigating factor. A forensic assessment may also take the form of a risk assessment, to comment on the relationship between the person's mental illness and the risk of further violent offenses.
for work-related stress or after a traumatic event such as an accident. The psychiatric assessment may be requested in order to establish a link between the trauma and the victim's psychological condition, or to determine the extent of psychological harm and the amount of compensation to be awarded to the victim.
Medico-legal psychiatric assessments are also utilized in the context of child safety and child protection services. A child psychiatrist's assessment can provide information on the psychological impact of abuse
or neglect on a child. A child psychiatrist can carry out an assessment of parenting
capacity, taking into consideration the mental state of both the child and the parents, and this may be used by child protective services to decide whether a child should be placed in an alternative care arrangement such as foster care
.
. The standard psychiatric history consists of biographical data (name, age, marital and family contact details, occupation, and first language), the presenting complaint (an account of the onset, nature and development of the individual's current difficulties) and personal history (including birth complications, childhood development, parental care in childhood, educational and employment history, relationship and marital history, and criminal background). The history also includes an enquiry about the individual's current social circumstances, family relationships, current and past use of alcohol and illicit drugs, and the individual's past treatment history (current and past diagnoses, and use of prescribed medication).
The psychiatric history includes an exploration of the individual's culture and ethnicity, as cultural values can influence the way a person (and their family) communicates psychological distress and responds to a diagnosis of mental illness. Certain behaviors and beliefs may be misinterpreted as features of mental illness by a clinician who is from a different cultural background than the individual being assessed.
The assessment often includes gathering collateral information from other sources such as family members or (with children) teachers at school.
..
's current state of mind, under the domains of appearance, attitude, behavior, speech, mood and affect, thought process, thought content, perception, cognition (including for example orientation, memory and concentration), insight and judgement. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state. The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptom
s, and formalized psychological tests. As with the psychiatric history, the MSE is prone to errors if cultural differences between the examiner and the patient are not taken into account, as different cultural backgrounds may be associated with different norms of interpersonal behavior and emotional expression. The MSE is not to be confused with the mini-mental state examination
(MMSE) which is a brief neuro-psychological screening test for dementia.
, vital signs
such as pulse, blood pressure, temperature and respiratory rate, observation for pallor
and nutritional deficiencies, palpation for lymph nodes
, palpation of the abdomen
for organ enlargement, and examination of the cardiovascular, respiratory
and neurological
systems.
to exclude hypo-
or hyperthyroidism
, basic electrolytes, serum calcium
and liver enzymes to rule out a metabolic disturbance, and a full blood count
to rule out a systemic infection or chronic disease. The investigation of dementia
could include measurement of serum vitamin B-12 levels, serology
to exclude syphilis
or HIV
infection, EEG
, and a CT scan or MRI scan. People receiving antipsychotic
medication require measurement of plasma glucose and lipid levels
to detect a medication-induced metabolic syndrome
, and an electrocardiogram
to detect iatrogenic cardiac arrhythmias.
for depression or the Brief Psychiatric Rating Scale
(BPRS) or Positive and Negative Syndrome Scale (PANSS) for psychotic disorders. Scales such as HoNOS or the Global Assessment of Functioning
are used to measure global level of functioning and to monitor response to treatment.
, occupational therapists, psychologists and social workers. A psychiatrist takes a history and carries out a mental state examination and physical examination as described above. A nursing assessment includes risk assessment (risk of suicide, aggression, absconding from hospital, self harm, sexual safety in hospital and medication compliance), physical health screening, and obtaining background personal and health information from the person being admitted and their carers. The immediate purpose of the nursing assessment is to determine the required level of care and supervision, and to have a plan to manage disturbed behavior. Assessment could include a visit to the person's home, for direct observation of the social and living environment. The role of a psychologist includes the use of psychological tests
: structured diagnostic instruments such as the Millon Clinical Multiaxial Inventory
or psychometric tests such as the WISC
or WAIS
, to assist with diagnosis and formulation of the person's problems. A psychologist might contribute to the team's assessment by providing a psychological formulation or behavioral analysis
, which is an analysis, through systematic observation, of the factors which trigger or perpetuate the presenting problems.
, with the collection of supposedly objective
data, identification of problems, formulation of a diagnosis leading to a specific treatment, but there are other approaches to the assessment of people with social and emotional difficulties. A family therapy
or systemic therapy
approach is not concerned with diagnoses but seeks to understand the problem in terms of relationships and communication patterns. The systemic tradition is suspicious of the objectivity of medical assessment, sees the individual's account as a subjective narrative
, and sees diagnosis as a socially constructed phenomenon. From a solution focused
perspective, the assessment deliberately avoids identification of problems, and seeks to elicit strengths and solutions.
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist
Psychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...
, but it could be a multi-disciplinary process involving nurses, psychologist
Psychologist
Psychologist is a professional or academic title used by individuals who are either:* Clinical professionals who work with patients in a variety of therapeutic contexts .* Scientists conducting psychological research or teaching psychology in a college...
s, occupational therapist
Occupational therapist
An occupational therapist is trained in the practice of occupational therapy. The role of an occupational therapist is to work with a client to help them achieve a fulfilled and satisfied state in life through the use of "purposeful activity or interventions designed to achieve functional...
s and social workers.
Clinical assessment
A psychiatric assessment is most commonly carried out for clinical and therapeutic purposes, to establish a diagnosis and formulationClinical formulation
A clinical formulation is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an alternative approach to the more categorical approach of...
of the individual's problems, and to plan the individual's care and treatment. This may be done in a hospital (or in-patient) setting, in an ambulatory (or out-patient) setting, or in a community setting (as a home-based assessment). Clinical assessment is the main focus of this article.
Forensic assessment
A forensic psychiatricForensic psychiatry
Forensic psychiatry is a sub-speciality of psychiatry and an auxiliar science of criminology. It encompasses the interface between law and psychiatry...
assessment may have a number of purposes. A forensic assessment may be required of an individual who has been charged with a crime (usually a violent crime), to establish whether the person has the capacity
Competence (law)
In American law, competence concerns the mental capacity of an individual to participate in legal proceedings. Defendants that do not possess sufficient "competence" are usually excluded from criminal prosecution, while witnesses found not to possess requisite competence cannot testify...
(in legal terms) to stand trial. If a person with a mental illness is convicted of an offense, a forensic report may be required to inform the Court's sentencing decision, as a mental illness at the time of the offense may be a mitigating factor. A forensic assessment may also take the form of a risk assessment, to comment on the relationship between the person's mental illness and the risk of further violent offenses.
Medico-legal assessment
A medico-legal psychiatric assessment is required when a psychiatric report is used as evidence in civil litigation, for example in relation to compensationDamages
In law, damages is an award, typically of money, to be paid to a person as compensation for loss or injury; grammatically, it is a singular noun, not plural.- Compensatory damages :...
for work-related stress or after a traumatic event such as an accident. The psychiatric assessment may be requested in order to establish a link between the trauma and the victim's psychological condition, or to determine the extent of psychological harm and the amount of compensation to be awarded to the victim.
Medico-legal psychiatric assessments are also utilized in the context of child safety and child protection services. A child psychiatrist's assessment can provide information on the psychological impact of abuse
Child abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...
or neglect on a child. A child psychiatrist can carry out an assessment of parenting
Parenting
Parenting is the process of promoting and supporting the physical, emotional, social, and intellectual development of a child from infancy to adulthood...
capacity, taking into consideration the mental state of both the child and the parents, and this may be used by child protective services to decide whether a child should be placed in an alternative care arrangement such as foster care
Foster care
Foster care is the term used for a system in which a minor who has been made a ward is placed in the private home of a state certified caregiver referred to as a "foster parent"....
.
History
A standard part of any psychiatric assessment is the obtaining of a body of social, demographic and biographical data known as the historyPsychiatric history
A psychiatric history is the result of a medical process where a clinician working in the field of mental health systematically records the content of an interview with a patient...
. The standard psychiatric history consists of biographical data (name, age, marital and family contact details, occupation, and first language), the presenting complaint (an account of the onset, nature and development of the individual's current difficulties) and personal history (including birth complications, childhood development, parental care in childhood, educational and employment history, relationship and marital history, and criminal background). The history also includes an enquiry about the individual's current social circumstances, family relationships, current and past use of alcohol and illicit drugs, and the individual's past treatment history (current and past diagnoses, and use of prescribed medication).
The psychiatric history includes an exploration of the individual's culture and ethnicity, as cultural values can influence the way a person (and their family) communicates psychological distress and responds to a diagnosis of mental illness. Certain behaviors and beliefs may be misinterpreted as features of mental illness by a clinician who is from a different cultural background than the individual being assessed.
The assessment often includes gathering collateral information from other sources such as family members or (with children) teachers at school.
..
Mental status examination
The mental status examination (or mental state examination in the UK and Australia) abbreviated MSE, is another core part of any psychiatric assessment. The MSE is a structured way of describing a patientPatient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
's current state of mind, under the domains of appearance, attitude, behavior, speech, mood and affect, thought process, thought content, perception, cognition (including for example orientation, memory and concentration), insight and judgement. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state. The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s, and formalized psychological tests. As with the psychiatric history, the MSE is prone to errors if cultural differences between the examiner and the patient are not taken into account, as different cultural backgrounds may be associated with different norms of interpersonal behavior and emotional expression. The MSE is not to be confused with the mini-mental state examination
Mini-mental state examination
The mini–mental state examination or Folstein test is a brief 30-point questionnaire test that is used to screen for cognitive impairment. It is commonly used in medicine to screen for dementia...
(MMSE) which is a brief neuro-psychological screening test for dementia.
Physical examination
A thorough physical examination is regarded as an integral part of a comprehensive psychiatric assessment. This is because physical illnesses are more common in people with mental disorders, because neurological and other medical conditions may be associated with psychiatric symptoms, and to identify side effects of psychiatric medication. The physical examination would include measurement of body mass indexBody mass index
The body mass index , or Quetelet index, is a heuristic proxy for human body fat based on an individual's weight and height. BMI does not actually measure the percentage of body fat. It was invented between 1830 and 1850 by the Belgian polymath Adolphe Quetelet during the course of developing...
, vital signs
Vital signs
Vital signs are measures of various physiological statistics, often taken by health professionals, in order to assess the most basic body functions. Vital signs are an essential part of a case presentation. The act of taking vital signs normally entails recording body temperature, pulse rate ,...
such as pulse, blood pressure, temperature and respiratory rate, observation for pallor
Pallor
Pallor is a reduced amount of oxyhaemoglobin in skin or mucous membrane, a pale color which can be caused by illness, emotional shock or stress, stimulant use, lack of exposure to sunlight, anaemia or genetics....
and nutritional deficiencies, palpation for lymph nodes
Lymphadenopathy
Lymphadenopathy is a term meaning "disease of the lymph nodes." It is, however, almost synonymously used with "swollen/enlarged lymph nodes". It could be due to infection, auto-immune disease, or malignancy....
, palpation of the abdomen
Abdominal examination
The abdominal exam, in medicine, is performed as part of a physical examination, or when a patient presents with abdominal pain or a history that suggests an abdominal pathology.The exam includes several parts:* Setting and preparation...
for organ enlargement, and examination of the cardiovascular, respiratory
Respiratory examination
In medicine, the respiratory examination is performed as part of a physical examination, or when a patient presents with a respiratory problem or a history that suggests a pathology of the lungs...
and neurological
Neurological examination
A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired...
systems.
Physical investigations
Although there are no physiological tests that confirm any mental illness, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include blood tests measuring TSHThyroid-stimulating hormone
Thyrotrophin-stimulating hormone is a peptide hormone synthesized and secreted by thyrotrope cells in the anterior pituitary gland, which regulates the endocrine function of the thyroid gland.- Physiology :...
to exclude hypo-
Hypothyroidism
Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone.Iodine deficiency is the most common cause of hypothyroidism worldwide but it can be caused by other causes such as several conditions of the thyroid gland or, less commonly, the pituitary gland or...
or hyperthyroidism
Hyperthyroidism
Hyperthyroidism is the term for overactive tissue within the thyroid gland causing an overproduction of thyroid hormones . Hyperthyroidism is thus a cause of thyrotoxicosis, the clinical condition of increased thyroid hormones in the blood. Hyperthyroidism and thyrotoxicosis are not synonymous...
, basic electrolytes, serum calcium
Calcium
Calcium is the chemical element with the symbol Ca and atomic number 20. It has an atomic mass of 40.078 amu. Calcium is a soft gray alkaline earth metal, and is the fifth-most-abundant element by mass in the Earth's crust...
and liver enzymes to rule out a metabolic disturbance, and a full blood count
Complete blood count
A complete blood count , also known as full blood count or full blood exam or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood...
to rule out a systemic infection or chronic disease. The investigation of dementia
Dementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
could include measurement of serum vitamin B-12 levels, serology
Serology
Serology is the scientific study of blood serum and other bodily fluids. In practice, the term usually refers to the diagnostic identification of antibodies in the serum...
to exclude syphilis
Syphilis
Syphilis is a sexually transmitted infection caused by the spirochete bacterium Treponema pallidum subspecies pallidum. The primary route of transmission is through sexual contact; however, it may also be transmitted from mother to fetus during pregnancy or at birth, resulting in congenital syphilis...
or HIV
HIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...
infection, EEG
EEG
EEG commonly refers to electroencephalography, a measurement of the electrical activity of the brain.EEG may also refer to:* Emperor Entertainment Group, a Hong Kong-based entertainment company...
, and a CT scan or MRI scan. People receiving antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
medication require measurement of plasma glucose and lipid levels
Blood lipids
Blood lipids are lipids in the blood, either free or bound to other molecules. They are mostly transported in a protein capsule, and the density of the lipids and type of protein determines the fate of the particle and its influence on metabolism. The concentration of blood lipids depends on...
to detect a medication-induced metabolic syndrome
Metabolic syndrome
Metabolic syndrome is a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes. It affects one in five people in the United States and prevalence increases with age...
, and an electrocardiogram
Electrocardiogram
Electrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body...
to detect iatrogenic cardiac arrhythmias.
Assessment tools
Clinical assessment can be supplemented by the use of symptom scales for specific disorders, for example the Beck Depression InventoryBeck Depression Inventory
The Beck Depression Inventory , created by Dr. Aaron T. Beck, is a 21-question multiple-choice self-report inventory, one of the most widely used instruments for measuring the severity of depression...
for depression or the Brief Psychiatric Rating Scale
Brief Psychiatric Rating Scale
The Brief Psychiatric Rating Scale is rating scale which a clinician or researcher may use to measure psychiatric symptoms such as depression, anxiety, hallucinations and unusual behaviour...
(BPRS) or Positive and Negative Syndrome Scale (PANSS) for psychotic disorders. Scales such as HoNOS or the Global Assessment of Functioning
Global Assessment of Functioning
The Global Assessment of Functioning is a numeric scale used by mental health clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of adults, e.g., how well or adaptively one is meeting various problems-in-living. The scale is presented and...
are used to measure global level of functioning and to monitor response to treatment.
Multidisciplinary assessment
Psychiatric assessment in hospital settings is typically a multidisciplinary process, with contributions from psychiatric nursesPsychiatric and mental health nursing
Psychiatric nursing or mental health nursing is the specialty of nursing that cares for people of all ages with mental illness or mental distress, such as schizophrenia, bipolar disorder, psychosis, depression or dementia...
, occupational therapists, psychologists and social workers. A psychiatrist takes a history and carries out a mental state examination and physical examination as described above. A nursing assessment includes risk assessment (risk of suicide, aggression, absconding from hospital, self harm, sexual safety in hospital and medication compliance), physical health screening, and obtaining background personal and health information from the person being admitted and their carers. The immediate purpose of the nursing assessment is to determine the required level of care and supervision, and to have a plan to manage disturbed behavior. Assessment could include a visit to the person's home, for direct observation of the social and living environment. The role of a psychologist includes the use of psychological tests
Psychological testing
Psychological testing is a field characterized by the use of samples of behavior in order to assess psychological construct, such as cognitive and emotional functioning, about a given individual. The technical term for the science behind psychological testing is psychometrics...
: structured diagnostic instruments such as the Millon Clinical Multiaxial Inventory
Millon Clinical Multiaxial Inventory
The Millon Clinical Multiaxial Inventory-III is a psychological assessment tool intended to provide information on psychopathology, including specific disorders outlined in the DSM-IV. It is intended for adults with at least an 8th grade reading level. The MCMI was developed and standardized...
or psychometric tests such as the WISC
Wechsler Intelligence Scale for Children
The Wechsler Intelligence Scale for Children , developed by Dr. David Wechsler, is an individually administered intelligence test for children between the ages of 6 and 16 inclusive that can be completed without reading or writing...
or WAIS
Wechsler Adult Intelligence Scale
The Wechsler Adult Intelligence Scale intelligence quotient tests are the primary clinical instruments used to measure adult and adolescent intelligence. The original WAIS was published in February 1955 by David Wechsler, as a revision of the Wechsler-Bellevue Intelligence Scale...
, to assist with diagnosis and formulation of the person's problems. A psychologist might contribute to the team's assessment by providing a psychological formulation or behavioral analysis
Applied Behavior Analysis
Applied behavior analysis is a science that involves using modern behavioral learning theory to modify behaviors. Behavior analysts reject the use of hypothetical constructs and focus on the observable relationship of behavior to the environment...
, which is an analysis, through systematic observation, of the factors which trigger or perpetuate the presenting problems.
Other perspectives
This article describes the assessment process within a medical modelMedical model
Medical model is the term cited by psychiatrist Ronald D. Laing in his The Politics of the Family and Other Essays , for the "set of procedures in which all doctors are trained." This set includes complaint, history, physical examination, ancillary tests if needed, diagnosis, treatment, and...
, with the collection of supposedly objective
Objectivity (science)
Objectivity in science is a value that informs how science is practiced and how scientific truths are created. It is the idea that scientists, in attempting to uncover truths about the natural world, must aspire to eliminate personal biases, a priori commitments, emotional involvement, etc...
data, identification of problems, formulation of a diagnosis leading to a specific treatment, but there are other approaches to the assessment of people with social and emotional difficulties. A family therapy
Family therapy
Family therapy, also referred to as couple and family therapy, family systems therapy, and family counseling, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of...
or systemic therapy
Systemic Therapy
Systemic therapy is a form of psychotherapy which seeks to address people not on individual level, as had been the focus of earlier forms of therapy, but as people in relationship, dealing with the interactions of groups and their interactional patterns and dynamics.- History :Systemic therapy has...
approach is not concerned with diagnoses but seeks to understand the problem in terms of relationships and communication patterns. The systemic tradition is suspicious of the objectivity of medical assessment, sees the individual's account as a subjective narrative
Narrative therapy
Narrative Therapy is a form of psychotherapy using narrative. It was initially developed during the 1970s and 1980s, largely by Australian Michael White and his friend and colleague, David Epston, of New Zealand....
, and sees diagnosis as a socially constructed phenomenon. From a solution focused
Solution focused brief therapy
Solution focused brief therapy , often referred to as simply 'solution focused therapy' or 'brief therapy', is a type of talking therapy that is based upon social constructionist philosophy. It focuses on what clients want to achieve through therapy rather than on the problem that made them seek help...
perspective, the assessment deliberately avoids identification of problems, and seeks to elicit strengths and solutions.