Psychiatric diagnosis rests upon the established principles of a thorough history and examination. The forces contributing to the individual's life situation must be identified, and this can be done only if the examination includes the history, mental status, medical conditions (including medications), and pertinent social, cultural, and environmental factors impinging on the individual. The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-5) is the common language that clinicians use for psychiatric conditions. It utilizes specific criteria with which to objectively assess symptoms for use in clinical diagnosis and communication.
The examination of a psychiatric patient also should include a complete medical history and physical examination (with emphasis on the neurologic examination) as well as all necessary laboratory and other special studies. Physical illness may frequently present as psychiatric disease, and vice versa. In many instances, the physical examination is completed by the primary care clinician who is working with a psychiatrist.
Every psychiatric history should cover the following topics: (1) complaint, from the patient's viewpoint; (2) the present illness, or the evolution of the symptoms; (3) neurovegetative signs such as libido, appetite, and sleep; (4) previous disorders and the nature and extent of their treatment; (5) the family history—important for genetic aspects and family influences; (6) the personal history—childhood development, adolescent adjustment, level of education, and adult coping patterns; (7) current life functioning, with attention to vocational, social, educational, and avocational areas; and (8) present or past use of alcohol and other drugs.
It is often essential to obtain additional information from the family. Observing interactions of the patient with significant others in the context of a family interview may provide important diagnostic information and may even underscore the nature of the problem and suggest a therapeutic approach.
The mental status examination includes the items and clinical features shown in eTable 25–1 and should be assessed and documented for each patient visit.
eTable 25–1.Mental status examination. ||Download (.pdf) eTable 25–1. Mental status examination.
|Mental Status Item ||Clinical Features |
|Appearance ||Note unusual modes of dress, use of makeup, etc |
|Activity and behavior ||Gait, gestures, coordination of bodily movements, etc |
|Affect ||Outward manifestation of emotions such as depression, anger, elation, fear, resentment, or lack of emotional response |
|Mood ||The patient's report of feelings and observable emotional manifestations |
|Speech ||Coherence, spontaneity, articulation, hesitancy in answering, and duration of response |
|Content of thought ||Associations, preoccupations, obsessions, depersonalization, delusions, hallucinations, paranoid ideation, anger, fear, or unusual experiences; suicidal and homicidal ideation |
|Thought process ||Loose associations, flight of ideas, thought blocking, tangentiality, circumstantiality, perseveration, racing thought. For example, does the individual report being spied upon by outside agents? Does the individual have difficulty expressing a thought coherently? |
Orientation to person, place, time, and circumstances
Remote and recent memory and recall
Calculations, digit retention, serial sevens or threes...