PRACTICEGUIDELINEFOR THEPsychiatric Evaluationof AdultsSecond EditionWORKGROUPONPSYCHIATRICEVALUATIONMichael J. Vergare, M.D., ChairRenee L. Binder, M.DIan A. Cook, M.D.Marc Galanter, M.D.Francis G. Lu, M.D.This practice guideline was approved in December 2005 and published inJune2006.Aguidelinewatch,summarizingsignificantdevelopmentsinthescientificliteraturesincepublicationofthis guideline,maybeavailable inthePsychiatric Practicesection of the APAweb siteatwww.psych.orgCopyright 2010,American Psychiatric Association.APA makes this practice guideline freely available to promote its dissemination and use; however,copyrightprotections are enforced in full.Nopartof this guideline may be reproduced except as permitted under Sections 107 and 108of U.S.Copyright Act.Forpermissionforreuse,visitAPPIPermissions&LicensingCenterathttp://www.appi.org/CustomerService/Pages/Permissions.aspx
1 PRACTICE GUIDELINE FOR THE Psychiatric Evaluation of Adults Second Edition WORK GROUP ON PSYCHIATRIC EVALUATION Michael J. Vergare, M.D., Chair Renée L. Binder, M.D. Ian A. Cook, M.D. Marc Galanter, M.D. Francis G. Lu, M.D. This practice guideline was approved in December 2005 and published in June 2006. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at www.psych.org. Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx
AMERICANPSYCHIATRICASSOCIATIONSTEERINGCOMMITTEEONPRACTICEGUIDELINESJohn S. Mclntyre, M.D.,ChairSara C. Charles, M.D.,Vice-ChairDaniel J.Anzia,M.DIan A. Cook, M.D.Molly T. Finnerty, M.D.Bradley R. Johnson, M.D.James E. Nininger, M.D.Paul Summergrad, M.D.Sherwyn M. Woods, M.D., Ph.D.Joel Yager, M.D.AREAANDCOMPONENTLIAISONSRobert Pyles, M.D. (Area I)C. Deborah Cross, M.D. (Area II)Roger Peele, M.D. (Area III)Daniel J. Anzia, M.D. (Area IV)John P. D.Shemo, M.D. (Area V)Lawrence Lurie, M.D. (Area VI)R. Dale Walker, M.D. (Area VII)MaryAnn Barnovitz,M.DSheila Hafter Gray, M.D.Sunil Saxena, M.D.Tina Tonnu, M.D.STAFFRobert Kunkle, M.A., Senior Program ManagerAmyB.Albert,B.A.,AssistantProjectManagerLaura J.Fochtmann, M.D., Medical EditorClaudiaHart,Director,DepartmentofQualityImprovementandPsychiatric ServicesDarrelA.Regier,M.D.,M.PH.,Director,DivisionofResearchCopyright 2010,American Psychiatric Association.APA makes this practice guideline freely available to promote its dissemination and use; however,copyrightprotections are enforced in full.No part of this guideline maybe reproduced except as permitted under Sections 107 and 108 of U.S.Copyright Act.For permissionforreuse,visitAPPIPermissions&LicensingCenterathttp://www.appi.org/CustomerService/Pages/Permissions.aspx
AMERICAN PSYCHIATRIC ASSOCIATION STEERING COMMITTEE ON PRACTICE GUIDELINES John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Paul Summergrad, M.D. Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D. AREA AND COMPONENT LIAISONS Robert Pyles, M.D. (Area I) C. Deborah Cross, M.D. (Area II) Roger Peele, M.D. (Area III) Daniel J. Anzia, M.D. (Area IV) John P. D. Shemo, M.D. (Area V) Lawrence Lurie, M.D. (Area VI) R. Dale Walker, M.D. (Area VII) Mary Ann Barnovitz, M.D. Sheila Hafter Gray, M.D. Sunil Saxena, M.D. Tina Tonnu, M.D. STAFF Robert Kunkle, M.A., Senior Program Manager Amy B. Albert, B.A., Assistant Project Manager Laura J. Fochtmann, M.D., Medical Editor Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services Darrel A. Regier, M.D., M.P.H., Director, Division of Research Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx
CONTENTSStatement of Intent.-Development Process6IntroductionPurpose of Evaluation...9General Psychiatric Evaluation..9A.B.10Emergency Evaluation.c.Clinical Consultafion.11D.Other Consultations.1112Il. Site of the Clinical Evaluation12A.Inpatient SettingsB.12Outpatient SettingsS13General Medical SettingsD.Other Settings.14儿Domains of the Clinical Evaluation14.14A.Reason forthe EvaluationB.History of the Present llness .14CPast Psychiatric History .1919D.History of Substance Use ..19General Medical History..E.20Developmental, Psychosocial, and Sociocultural History.E.21Occupational and Military History .....G21H.Leqal History....22Family History. .22J.Review of Systems..22KPhysical Examination.23LMental Status Examination. 25IV.福Evaluafion Process25A.Methods of Obtaining Information.. 37B. The Process of Assessment.40Special ConsiderationsV40APrivacy and Confidentiolity .AB.Interactions With Third-Party Payers and Their Agents..42Legal and Administrative Issues in InstitutionsC.42D.Special Populations..3PsychiatricEvaluofionof AdulsCopyright 201o,American Psychiatric Association.APA makes this practice guideline freely available to promote its dissemination and use; however,copyrightprotections are enforced in full.No part of this guideline may be reproduced except as permitted under Sections 107 and 108 ofU.S.Copyright Act.For permissionforreuse,visitAPPIPermissions&LicensingCenterathttp://www.appi.org/CustomerService/Pages/Permissions.aspx
Psychiatric Evaluation of Adults 3 CONTENTS Statement of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 I. Purpose of Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A. General Psychiatric Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 B. Emergency Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 C. Clinical Consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 D. Other Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 II. Site of the Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 A. Inpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 B. Outpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 C. General Medical Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 D. Other Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 III. Domains of the Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 A. Reason for the Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 B. History of the Present Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 C. Past Psychiatric History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 D. History of Substance Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 E. General Medical History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 F. Developmental, Psychosocial, and Sociocultural History. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 G. Occupational and Military History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 H. Legal History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 I. Family History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 J. Review of Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 K. Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 L. Mental Status Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 IV. Evaluation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 A. Methods of Obtaining Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 B. The Process of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 V. Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 A. Privacy and Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 B. Interactions With Third-Party Payers and Their Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 C. Legal and Administrative Issues in Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 D. Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx
...44VI.Future Research Needs......44A.Interviewing Approaches...45B.Rating Scales .....45C.Diagnosis and FormulationD......45Diagnostic Testing....46Individuals and Organizations That Submited Comments5...47References4APA Practice GuidelinesCopyright 2010,American Psychiatric Association.APA makes this practice guidelinefreely available to promote its dissemination and use;however,copyrightprotections areenforced infull.Nopartof this guidelinemaybereproduced exceptas permited underSections107and 108ofU.S.Copyright Act.Forpermissionforreuse,visit APPIPermissions&Licensing Centerat http://www.appi.org/CustomerService/Pages/Permissions.aspx
4 APA Practice Guidelines VI. Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 A. Interviewing Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 B. Rating Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 C. Diagnosis and Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 D. Diagnostic Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Individuals and Organizations That Submitted Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx
STATEMENT OF INTENTThe American Psychiatric Association (APA) Practice Guidelines are not intended to be con-strued or to serve as a standard of medical care. Standards of medical care are determined onthe basis of all clinical data available for an individual patient and are subject to change as sci-entific knowledge and technology advance and practice patterns evolve. These parameters ofpractice should be considered guidelines only. Adherence to them will not ensure a successfuloutcome for every individual, nor should they be interpreted as including all proper methodsof care or excluding other acceptable methods of care aimed at the same results. The ultimatejudgment regarding a particular clinical procedure or treatment plan must be made by the psy-chiatrist in light of the clinical data presented by the patient and the diagnostic and treatmentoptionsavailableThis practice guideline has been developed by psychiatrists who are in active clinical prac-tice. In addition, some contributors are primarily involved in research or other academicendeavors. It is possible that through such activities some contributors, including work groupmembers and reviewers, have received income related to treatments discussed in this guide-line.A number of mechanisms are inplaceto minimize the potential for producing biasedrecommendations due to conflicts of interest. Work group members are selected on the basisof their expertise and integrity.Any work groupmember or reviewer who has a potential con-flict of interest that may bias (or appear to bias) his or her work is asked to disclose this to theSteering Committee on Practice Guidelines and the work group. Iterative guideline drafts arereviewed by the Steering Committee, other experts, allied organizations, APA members, andthe APA Assembly and Board of Trustees; substantial revisions address or integrate the com-ments of these multiple reviewers. The development of the APA practice guidelines is notfinancially supported by any commercial organization.More detail about mechanisms in place to minimize bias is provided in a document avail-able from the APA Department of Quality Improvement and Psychiatric Services, “APAGuideline Development Process."This practice guideline was approved in December 2005 and published in June20065Psychiatric Evaluafion of AdultsCopyright 2010,American Psychiatric Association.APAmakes this practice guideline freely available to promote its dissemination and use;however,copyrightprotections are enforced in full.No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S.Copyright Act.For permissionforreuse,visit APPIPermissions&LicensingCenterathttp:/www.appi.org/CustomerService/Pages/Permissions.aspx
Psychiatric Evaluation of Adults 5 STATEMENT OF INTENT The American Psychiatric Association (APA) Practice Guidelines are not intended to be construed or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some contributors are primarily involved in research or other academic endeavors. It is possible that through such activities some contributors, including work group members and reviewers, have received income related to treatments discussed in this guideline. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. Work group members are selected on the basis of their expertise and integrity. Any work group member or reviewer who has a potential conflict of interest that may bias (or appear to bias) his or her work is asked to disclose this to the Steering Committee on Practice Guidelines and the work group. Iterative guideline drafts are reviewed by the Steering Committee, other experts, allied organizations, APA members, and the APA Assembly and Board of Trustees; substantial revisions address or integrate the comments of these multiple reviewers. The development of the APA practice guidelines is not financially supported by any commercial organization. More detail about mechanisms in place to minimize bias is provided in a document available from the APA Department of Quality Improvement and Psychiatric Services, “APA Guideline Development Process.” This practice guideline was approved in December 2005 and published in June 2006. Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx