Psychiatric Assessment

A psychiatric assessment is the process of gathering information about a person with the purpose of making a psychiatric diagnosis (if warranted). This in-depth evaluation – which includes a full psychiatric history, mental status examination and physical examination – is the first stage in beginning to create an individual’s treatment plan. Dr. Askins will take into consideration the patient’s social and biographical information, his own direct observations and data gathered from specific psychological and medical tests. Lasting approximately 60-90 minutes, a psychiatric assessment may be done in a hospital (inpatient) setting, an outpatient setting or a community or “home-based” setting.

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Psychiatric History

Social, demographic and biographical data are all part of the patient’s psychiatric history:

Social history:  Current social circumstances, family relationships, current and past use of alcohol and illicit drugs, past diagnoses and treatment history, current and past use of prescription drugs

Demographic history:  Culture/ethnicity, cultural values, cultural behaviors and beliefs

Biographical history:  Name, age, marital and family connections, occupation and first language

Mental Status Examination

(MSE)The mental status examination (MSE), also referred to as the mental state examination, is an integral part of the psychiatric assessment. A structured method for determining a patient’s current state of mind, the MSE captures and evaluates the following information about the patient: appearance, attitude, behavior, speech, mood and affect, thought process, thought content, perception, cognition (including orientation, memory and concentration), insight and judgment.

Data is collected by both direct and indirect means, including: observations while obtaining social and biographical information, focused questions about current symptoms and structured psychological tests.

Physical Examination

The final component of the psychiatric assessment is a physical examination.  Mental disorders often go hand-in-hand with physical illnesses.   By determining the physical state of the patient, the mental state may become clearer.

A physical examination typically includes:  measuring body mass index (BMI), taking vital signs, checking for nutritional deficiencies, palpation of the lymph nodes, palpation of the abdomen (to look for organ enlargement) and an examination of the cardiovascular, respiratory and neurological systems.  Dr. Askins may also conduct other medical tests in order to rule out certain medical conditions.

Potential blood tests may include:  thyroid-stimulating hormone or TSH (to exclude hypothyroidism), basic electrolytes, serum calcium and liver enzymes (to exclude the possibility of a metabolic disturbance) and a full blood count (to rule out a systemic infection or chronic disease).  Other lab work may be advised in combination with the above.  Dr. Askins will determine the appropriate tests for each specific case.