《精神医学》课程教学资源（书籍文献）2006APA成人精神科评估（第二版）PRACTICE GUIDELINE FOR THE Psychiatric Evaluation of Adults Second Edition

staff. In many emergency settings, patients initially are examined by a nonpsychiatric physicianto exclude acutegeneral medical problems.Such examinations usually arelimited in scopeandrarely are definitive (18, 19, 2830). Furthermore, psychiatrists and emergency physicians some-times have different viewpoints on the utility of laboratory screeningfor substance use or med-ical disorders in psychiatric emergencydepartment patients (31,32).Therefore, on thebasis ofclinical judgment and the specific circumstances of the evaluation, the psychiatrist may needto request or initiate furthergeneral medical evaluation to address diagnostic concerns thatemerge from the psychiatric evaluation (12, 16, 1827, 3335).CLINICALCONSULTATION1CClinical consultations are evaluations requested by other physicians or health care professionals,patients, families, or others for the purpose of assisting in the diagnosis, treatment, or management of an individual with a suspected mental disorder or behavioral problem. These evalua-tions may be comprehensive or may be focused on a relatively narrow question, such as thepreferred medication for treatment of a known mental disorder in a patient with a particulargeneral medical condition. Psychiatric evaluations for consultative purposes use the same datasources as general evaluations. Consideration is given to information from the referring sourceon the specific problem leading to the consultation, the referring source's aims for the consul-tation, information that the psychiatrist may be able to obtain regarding the patient's relation-ship with the primary clinician, and the resources and constraints of those currently treatingthe patient. Also,in the case of a consultation regarding a mental or behavioral problem in apatient with a general medical llness, information about that illness, its treatment, and its prognosis is relevant.The patient should be informed that the purpose of the consultation is to ad-vise the party who requested it. Permission to report findings to others, including family, needsto be clarified with the patient and other concerned parties before the evaluation begins.Theaim ofthe consultative psychiatric evaluation is to provide clear and specific answers tothe questions posed by the party requesting the consultation (36, 37). For example, the psychi-atrist may be asked to determine the patient's capacity to give consentfor treatment decisions.On other occasions, the psychiatrist may be asked to assess a particular sign, symptom, or syn-drome;provideadiagnosis;and recommend evaluation,treatment,ordisposition at a level ofspec-ificity appropriate to the needs of the treating clinician.In the course of the evaluation, the consultant may also identify a diagnostic or therapeuticissue that was not raised in the request for consultation but that is of concern to the patient orof relevance to treatment outcome. For example, treatment adherence may be affected by per-sonality and countertransference issues that compromise the patient's therapeutic alliance withthe referring clinician. Ifany conflicts between the patient and the primary clinician do emergeas an issue, positive resolution of them should be encouraged in a manner that respects the pa-tient's relationship with theprimary clinician.If agreed to by the patient, discussion offindings and recommendations with the family orinvolved persons can assist with appropriate follow-up and adherence with recommendations.OTHER CONSULTATIONSD.Other psychiatric consultations are directed toward theresolution ofspecific legal,administra-tive, or other nonclinical questions. While the details ofthese evaluations, such as forensic eval-uations, child custody evaluations, and disability evaluations, are beyond the scope of thisguideline, several general principles apply. First, the evaluee usually is not the psychiatrist's pa-tient, and there are limits to confidentiality implicit in the aims of the evaluation; accordingly,the aims of the evaluation and the scope of disclosure should be addressed with the evaluee atthe start of the interview (38, 39). Second,questions about the evaluee's legal status and legal11Psychiatric 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 permissionfor reuse,visit APPIPermissions&Licensing Centerat http://www.appi.org/CustomerService/Pages/Permissions.aspx

Psychiatric Evaluation of Adults 11 staff. In many emergency settings, patients initially are examined by a nonpsychiatric physician to exclude acute general medical problems. Such examinations usually are limited in scope and rarely are definitive (18, 19, 28–30). Furthermore, psychiatrists and emergency physicians some￾times have different viewpoints on the utility of laboratory screening for substance use or med￾ical disorders in psychiatric emergency department patients (31, 32). Therefore, on the basis of clinical judgment and the specific circumstances of the evaluation, the psychiatrist may need to request or initiate further general medical evaluation to address diagnostic concerns that emerge from the psychiatric evaluation (12, 16, 18–27, 33–35).
C. CLINICAL CONSULTATION Clinical consultations are evaluations requested by other physicians or health care professionals, patients, families, or others for the purpose of assisting in the diagnosis, treatment, or manage￾ment of an individual with a suspected mental disorder or behavioral problem. These evalua￾tions may be comprehensive or may be focused on a relatively narrow question, such as the preferred medication for treatment of a known mental disorder in a patient with a particular general medical condition. Psychiatric evaluations for consultative purposes use the same data sources as general evaluations. Consideration is given to information from the referring source on the specific problem leading to the consultation, the referring source’s aims for the consul￾tation, information that the psychiatrist may be able to obtain regarding the patient’s relation￾ship with the primary clinician, and the resources and constraints of those currently treating the patient. Also, in the case of a consultation regarding a mental or behavioral problem in a patient with a general medical illness, information about that illness, its treatment, and its prog￾nosis is relevant. The patient should be informed that the purpose of the consultation is to ad￾vise the party who requested it. Permission to report findings to others, including family, needs to be clarified with the patient and other concerned parties before the evaluation begins. The aim of the consultative psychiatric evaluation is to provide clear and specific answers to the questions posed by the party requesting the consultation (36, 37). For example, the psychi￾atrist may be asked to determine the patient’s capacity to give consent for treatment decisions. On other occasions, the psychiatrist may be asked to assess a particular sign, symptom, or syn￾drome; provide a diagnosis; and recommend evaluation, treatment, or disposition at a level of spec￾ificity appropriate to the needs of the treating clinician. In the course of the evaluation, the consultant may also identify a diagnostic or therapeutic issue that was not raised in the request for consultation but that is of concern to the patient or of relevance to treatment outcome. For example, treatment adherence may be affected by per￾sonality and countertransference issues that compromise the patient’s therapeutic alliance with the referring clinician. If any conflicts between the patient and the primary clinician do emerge as an issue, positive resolution of them should be encouraged in a manner that respects the pa￾tient’s relationship with the primary clinician. If agreed to by the patient, discussion of findings and recommendations with the family or involved persons can assist with appropriate follow-up and adherence with recommendations.
D. OTHER CONSULTATIONS Other psychiatric consultations are directed toward the resolution of specific legal, administra￾tive, or other nonclinical questions. While the details of these evaluations, such as forensic eval￾uations, child custody evaluations, and disability evaluations, are beyond the scope of this guideline, several general principles apply. First, the evaluee usually is not the psychiatrist’s pa￾tient, and there are limits to confidentiality implicit in the aims of the evaluation; accordingly, the aims of the evaluation and the scope of disclosure should be addressed with the evaluee at the start of the interview (38, 39). Second, questions about the evaluee’s legal status and legal 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

representation should be resolved before the assessment begins, if possible. Third, many suchconsultations rely heavily,or even entirely, on documentary evidence or data from collateralsources.The quality and potential biases of such data should be taken into account.The aims of these psychiatric consultations are 1)to answer the requester's question to theextent possible with the data obtainable and 2) to make a psychiatric diagnosis ifit is relevantto the question.ILSITEOFTHE CLINICALEVALUATIONA.INPATIENTSETTINGSThe scope, pace, and depth of inpatient evaluation depend on the patient population served bythe inpatient service, the goals of the hospitalization, and the role of the inpatient unit withinthe overall system of mental health services available to the patient (40, 41),In addition to providing a highly structured and contained setting in which patient safety canbe monitored and optimized, the inpatient setting permits intensive and continuous observationof signs and symptoms while the patient is being treated for psychiatric and general medicalconditions through the collaborative efforts of the multidisciplinary treatment team (see also Section IVA.5). Particularly for individuals with complex psychiatric presentations or multiple co-occurringdisorders, theenhanced level ofobservation in the inpatient environment mayfacilitateassessment of co-occurring general medical conditions or evaluation for procedures such as elec-troconvulsive therapy, may aid in resolving diagnostic dilemmas, and may help in determining apatient's ability to function safely and independently in a less restrictive setting (41, 42)Inpatient settings provide enhanced opportunity to corroborate clinical judgment and deci-sion making, includingdischarge planning, through accessto information from multiple sources.These include the multidisciplinary treatment team, family, friends, and individuals involvedin the care of the patient outside the hospital, as well as prior hospitalization records.From the outset, the inpatient evaluation should include assessment of the patient's accessto appropriate treatment following hospitalization, The patient's living arrangements shouldalso be assessed to determine whether they will continue to be suitable after discharge. If theposthospitalization disposition is not apparent, the evaluation should identify both patient fac-tors and community resources that would be relevant to a viable disposition plan and shouldidentify the problems that could impede a suitable disposition. Family involvement, when ap-propriate, can also be initiated, and goals for inpatient family work can be identified.IB.OUTPATIENTSETTINGSOutpatient settings differ widely,from office-based practices to community mental health cen-ters to intensive outpatient or partial hospital programs, among others. Nevertheless, evalua-tion in the outpatient setting usually differs in intensity from inpatient evaluation because ofless frequent interviews and less immediate availability oflaboratory services and consultants fromother medical specialties. Also, the psychiatrist in the outpatient setting has substantially lessopportunity to directly observe the patient's behavior and to implement protective interventionswhen necessary. For this reason, during the period of evaluation it is important for the psychia-trist to reassess whether the patient requires hospitalization or more intensive outpatient care(eg-,greater visit frequency, intensive outpatient or partial hospital programs, programs of as-sertive community treatment).Unresolved questions about the patient's general medical status12APA Practice GuidelinesCopyright 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 maybe reproduced except as permitted under Sections 107 and 108 of U.S.Copyright Act.For permissionfor reuse,visit APPIPermissions&Licensing Centerat http://www.appi.org/CustomerService/Pages/Permissions.aspx

12 APA Practice Guidelines representation should be resolved before the assessment begins, if possible. Third, many such consultations rely heavily, or even entirely, on documentary evidence or data from collateral sources. The quality and potential biases of such data should be taken into account. The aims of these psychiatric consultations are 1) to answer the requester’s question to the extent possible with the data obtainable and 2) to make a psychiatric diagnosis if it is relevant to the question. II. SITE OF THE CLINICAL EVALUATION
A. INPATIENT SETTINGS The scope, pace, and depth of inpatient evaluation depend on the patient population served by the inpatient service, the goals of the hospitalization, and the role of the inpatient unit within the overall system of mental health services available to the patient (40, 41). In addition to providing a highly structured and contained setting in which patient safety can be monitored and optimized, the inpatient setting permits intensive and continuous observation of signs and symptoms while the patient is being treated for psychiatric and general medical conditions through the collaborative efforts of the multidisciplinary treatment team (see also Sec￾tion IV.A.5). Particularly for individuals with complex psychiatric presentations or multiple co￾occurring disorders, the enhanced level of observation in the inpatient environment may facilitate assessment of co-occurring general medical conditions or evaluation for procedures such as elec￾troconvulsive therapy, may aid in resolving diagnostic dilemmas, and may help in determining a patient’s ability to function safely and independently in a less restrictive setting (41, 42). Inpatient settings provide enhanced opportunity to corroborate clinical judgment and deci￾sion making, including discharge planning, through access to information from multiple sources. These include the multidisciplinary treatment team, family, friends, and individuals involved in the care of the patient outside the hospital, as well as prior hospitalization records. From the outset, the inpatient evaluation should include assessment of the patient’s access to appropriate treatment following hospitalization. The patient’s living arrangements should also be assessed to determine whether they will continue to be suitable after discharge. If the posthospitalization disposition is not apparent, the evaluation should identify both patient fac￾tors and community resources that would be relevant to a viable disposition plan and should identify the problems that could impede a suitable disposition. Family involvement, when ap￾propriate, can also be initiated, and goals for inpatient family work can be identified.
B. OUTPATIENT SETTINGS Outpatient settings differ widely, from office-based practices to community mental health cen￾ters to intensive outpatient or partial hospital programs, among others. Nevertheless, evalua￾tion in the outpatient setting usually differs in intensity from inpatient evaluation because of less frequent interviews and less immediate availability of laboratory services and consultants from other medical specialties. Also, the psychiatrist in the outpatient setting has substantially less opportunity to directly observe the patient’s behavior and to implement protective interventions when necessary. For this reason, during the period of evaluation it is important for the psychia￾trist to reassess whether the patient requires hospitalization or more intensive outpatient care (e.g., greater visit frequency, intensive outpatient or partial hospital programs, programs of as￾sertive community treatment). Unresolved questions about the patient’s general medical status 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

may also require more rapid assessment in a more structured setting.Ifthe patient's presentationis atypical (e.g-,with respecttosymptoms,symptom severity,orageat onset),a morethoroughmedical workup may be required or coordinated with the patient's primary care physician. Pa-tients who do not have a primary care physician may need assistance in obtaining appropriatereferrals. A decision to change the setting for evaluation will depend on the patient's currentmental status and behavior as well as the patient's history of psychiatric symptoms and treat-ment,the status ofco-occurringgeneral medical conditions or substance use,and the availabilityof diagnostic resources, therapeutic resources, and sociocultural supports.Advantages of the outpatient setting include greater patient autonomy and the potential fora more longitudinal perspective on the patient's symptoms.However, the lack of continuousdirect observation of behavior limits the obtainable data on how the patient's behavior appearsto others. Consequently, extended evaluation of the patient in the context of psychoeducationalor time-limited groups can complement and augment observations from one-to-one interviews.With thepatient'spermission,involvement offamilyor significantothers as collateral sourcesin the evaluation process also deserves consideration. It is also useful to be aware that familyand significant others may not be supportive of the patient or of psychiatric treatment. If thepatient states thatfamily systems issues,especially marital or partner issues,area problem,anevaluation session with the partner can provide valuable information and clarify the systemsissues.When substance use is suspected, obtaining data from other involved persons (e.g.,fam-ily, close friends, staff), determining blood alcohol levels, or screening for substances of abusemay be especially important.Ac.GENERAL MEDICAL SETTINGSEvaluations are also conducted in hospital emergency departments (see Section I.B) and gen-eral medical (i.e., nonpsychiatric) settings, such as inpatient units.The latter allow for somedirect behavioral observation by staffand for some safeguards against self-injurious or other vi-olentbehaviorbypatients.However,the level ofbehavioral observation andpotential interven-tion against risky behavior in these settings tends to be less than on psychiatric inpatient units.In addition,psychiatric interviews on general medical-surgical units are often compromised byinterruptionsand lack of privacy.These problemssometimes can bemitigatedby usinga spaceon the unit where the patient and the psychiatrist can meet privately.Developing an ongoing relationship with staffon medical inpatient units willincrease thelike-lihood ofobtaining accurate behavioral data as well as of ensuring that staffimplement recom-mendations. If there is prominent hostility or anxiety in interactions berween the patient andhospital staff, theevaluating physician must consider interfacing with others in the hospital sys-tem to determine its contributors.If the patient has an unclear sensorium or other cognitive impairments, it is critical to in-terview people in the patient's relational network to see if these symptoms were present beforehospitalization or have developed since treatment was begun. In interviewing family members,it is very useful to discuss their beliefs about the patient's illness and prior treatment, the pa-tient's record of adherence to medication treatment, and concerns about discharge planning. Iffamily members do not perceive themselves as allies in treatment,the patient's treatment is like-ly to be compromised once he or she leaves the hospital (43).Documentation of psychiatric evaluations in general medical charts should be sensitive tothe standards of confidentiality of the nonpsychiatric medical sector and the possibility thatcharts may be read by persons who are not well informed about psychiatric issues. Informationwritten in general medical charts should be confined to that necessary for the general medicalteam and should be conveyed with a level of detail and specificity that will be most helpful tothe overall management of the patient. It is also important that documentation be of sufficientdetail to establish a diagnosis and treatment plan13Psychiatric 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 maybe reproduced except as permitted under Sections 107 and 108 of U.S.Copyright Act.For permissionfor reuse,visit APPIPermissions&Licensing Centerat http://www.appi.org/CustomerService/Pages/Permissions.aspx

Psychiatric Evaluation of Adults 13 may also require more rapid assessment in a more structured setting. If the patient’s presentation is atypical (e.g., with respect to symptoms, symptom severity, or age at onset), a more thorough medical workup may be required or coordinated with the patient’s primary care physician. Pa￾tients who do not have a primary care physician may need assistance in obtaining appropriate referrals. A decision to change the setting for evaluation will depend on the patient’s current mental status and behavior as well as the patient’s history of psychiatric symptoms and treat￾ment, the status of co-occurring general medical conditions or substance use, and the availability of diagnostic resources, therapeutic resources, and sociocultural supports. Advantages of the outpatient setting include greater patient autonomy and the potential for a more longitudinal perspective on the patient’s symptoms. However, the lack of continuous direct observation of behavior limits the obtainable data on how the patient’s behavior appears to others. Consequently, extended evaluation of the patient in the context of psychoeducational or time-limited groups can complement and augment observations from one-to-one interviews. With the patient’s permission, involvement of family or significant others as collateral sources in the evaluation process also deserves consideration. It is also useful to be aware that family and significant others may not be supportive of the patient or of psychiatric treatment. If the patient states that family systems issues, especially marital or partner issues, are a problem, an evaluation session with the partner can provide valuable information and clarify the systems issues. When substance use is suspected, obtaining data from other involved persons (e.g., fam￾ily, close friends, staff), determining blood alcohol levels, or screening for substances of abuse may be especially important.
C. GENERAL MEDICAL SETTINGS Evaluations are also conducted in hospital emergency departments (see Section I.B) and gen￾eral medical (i.e., nonpsychiatric) settings, such as inpatient units. The latter allow for some direct behavioral observation by staff and for some safeguards against self-injurious or other vi￾olent behavior by patients. However, the level of behavioral observation and potential interven￾tion against risky behavior in these settings tends to be less than on psychiatric inpatient units. In addition, psychiatric interviews on general medical-surgical units are often compromised by interruptions and lack of privacy. These problems sometimes can be mitigated by using a space on the unit where the patient and the psychiatrist can meet privately. Developing an ongoing relationship with staff on medical inpatient units will increase the like￾lihood of obtaining accurate behavioral data as well as of ensuring that staff implement recom￾mendations. If there is prominent hostility or anxiety in interactions between the patient and hospital staff, the evaluating physician must consider interfacing with others in the hospital sys￾tem to determine its contributors. If the patient has an unclear sensorium or other cognitive impairments, it is critical to in￾terview people in the patient’s relational network to see if these symptoms were present before hospitalization or have developed since treatment was begun. In interviewing family members, it is very useful to discuss their beliefs about the patient’s illness and prior treatment, the pa￾tient’s record of adherence to medication treatment, and concerns about discharge planning. If family members do not perceive themselves as allies in treatment, the patient’s treatment is like￾ly to be compromised once he or she leaves the hospital (43). Documentation of psychiatric evaluations in general medical charts should be sensitive to the standards of confidentiality of the nonpsychiatric medical sector and the possibility that charts may be read by persons who are not well informed about psychiatric issues. Information written in general medical charts should be confined to that necessary for the general medical team and should be conveyed with a level of detail and specificity that will be most helpful to the overall management of the patient. It is also important that documentation be of sufficient detail to establish a diagnosis and treatment plan. 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

D.OTHERSETTINGSLEvaluations conducted in other settings, such as residential treatment facilities, home care ser-vices, nursing homes, long-term care facilities, schools, and prisons, are affected by a number offactors: I) the level of behavioral observations available and the quality of those observations,2) the availability of privacyfor conducting interviews, 3) the availability ofgeneral medical eval-uations and diagnostic tests, 4) resources to conduct the evaluation safely, and 5) the degree oflikelihood that information written in facility records will be understood and kept confidential.In light of these factors,it is necessary to consider whether a particular settingpermitsanevaluation of adequate speed, safety, accuracy, and confidentiality to meet the needs of the pa-tient.Factors of the setting that compromise the evaluation merit documentation.III.DOMAINS OF THE CLINICAL EVALUATIONGeneral psychiatric evaluations involve a systematic consideration of the broad domains de-scribed in this guideline and vary in scope and intensity.Table I summarizes the domains.Theintensity with which each domain is assessed depends on the purpose of the evaluation and theclinical situation.An evaluation of lesser scope may be appropriate when its purpose is to answera circumscribed question. Such an evaluation may involvea particularly intense assessment ofoneor more domains especially relevant to the reason for the evaluation.Across all domains,evaluations are generally based on three sources of information: 1) obser-vation and interview of the patient; 2) information from others (e.g-, family, significant others,case managers, other clinicians [including the patient's primary care physician]) that corrobo-rates, refutes, or elaborates on the patient's report; and 3) medical records. An awareness of howpeople report current symptoms and events is important to the clinical assessment process. Inconsidering the information obtained, the patient's current mental state is relevant. Mistakesin comprehension, recall, and expression may also lead to erroneous reporting of information(44).A.REASONFORTHEEVALUATIONThe purpose of the evaluation influences the focus of the examination and the form of documen-tation. The reason for the evaluation usually includes (but may not be limited to) the chief com-plaint of the patient. It should be elicited in sufficient detail, including the patient's words, topermit an understanding of the duration of the complaint and the patient's specific goals for theevaluation.If the symptoms are of long standing, the reason for seeking treatment at this specifictime is relevant; if the evaluation was occasioned by a hospitalization, the reason for the hospital-ization is also relevant.If the patient did not initiate the evaluation, the reason another individualor entity may have requested or required it should be noted. The opinions of other parties, in-cludingfamily,canalsoassistinestablishingareasonforevaluation.Undersomecircumstances(eg, with psychotic or uncommunicative patients), input from others may be crucial.B.HISTORYOFTHEPRESENTILLNESSDThe history of the present problem or illness is a chronologically organized history of recentexacerbations or remissions and current symptoms or syndromes.Thesemay involve descrip-tions of worries, changes in mood, suspicions, preoccupations, delusions, or hallucinatory ex-14APA Practice GuidelinesCopyright 2010,American Psychiatric Association.APA makes this practice guideline freely available to promote its dissemination and use; however,copyrightprotections areenforced infull.Nopartof thisguidelinemaybereproducedexceptas permittedunderSections107 and108ofU.S.CopyrightAct.Forpermissionforreuse,visit APPIPermissions&LicensingCenterathttp:/www.appi.org/CustomerService/Pages/Permissions.aspx

14 APA Practice Guidelines
D. OTHER SETTINGS Evaluations conducted in other settings, such as residential treatment facilities, home care ser￾vices, nursing homes, long-term care facilities, schools, and prisons, are affected by a number of factors: 1) the level of behavioral observations available and the quality of those observations, 2) the availability of privacy for conducting interviews, 3) the availability of general medical eval￾uations and diagnostic tests, 4) resources to conduct the evaluation safely, and 5) the degree of likelihood that information written in facility records will be understood and kept confidential. In light of these factors, it is necessary to consider whether a particular setting permits an evaluation of adequate speed, safety, accuracy, and confidentiality to meet the needs of the pa￾tient. Factors of the setting that compromise the evaluation merit documentation. III. DOMAINS OF THE CLINICAL EVALUATION General psychiatric evaluations involve a systematic consideration of the broad domains de￾scribed in this guideline and vary in scope and intensity. Table 1 summarizes the domains. The intensity with which each domain is assessed depends on the purpose of the evaluation and the clinical situation. An evaluation of lesser scope may be appropriate when its purpose is to answer a circumscribed question. Such an evaluation may involve a particularly intense assessment of one or more domains especially relevant to the reason for the evaluation. Across all domains, evaluations are generally based on three sources of information: 1) obser￾vation and interview of the patient; 2) information from others (e.g., family, significant others, case managers, other clinicians [including the patient’s primary care physician]) that corrobo￾rates, refutes, or elaborates on the patient’s report; and 3) medical records. An awareness of how people report current symptoms and events is important to the clinical assessment process. In considering the information obtained, the patient’s current mental state is relevant. Mistakes in comprehension, recall, and expression may also lead to erroneous reporting of information (44).
A. REASON FOR THE EVALUATION The purpose of the evaluation influences the focus of the examination and the form of documen￾tation. The reason for the evaluation usually includes (but may not be limited to) the chief com￾plaint of the patient. It should be elicited in sufficient detail, including the patient’s words, to permit an understanding of the duration of the complaint and the patient’s specific goals for the evaluation. If the symptoms are of long standing, the reason for seeking treatment at this specific time is relevant; if the evaluation was occasioned by a hospitalization, the reason for the hospital￾ization is also relevant. If the patient did not initiate the evaluation, the reason another individual or entity may have requested or required it should be noted. The opinions of other parties, in￾cluding family, can also assist in establishing a reason for evaluation. Under some circumstances (e.g., with psychotic or uncommunicative patients), input from others may be crucial.
B. HISTORY OF THE PRESENT ILLNESS The history of the present problem or illness is a chronologically organized history of recent exacerbations or remissions and current symptoms or syndromes. These may involve descrip￾tions of worries, changes in mood, suspicions, preoccupations, delusions, or hallucinatory ex￾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

TABLE 1. Domains of the Clinical EvaluafionDomainQuestions to ConsiderReason for the evaluationWhat is the patient's chief complaint and its duration?Whatreason does the patientgive for seeking evaluation at thisspecific time?What reasons are given by other involved parties (e-g, family, otherhealthprofessionals)forseekingevaluationatthis specifictime?History of the presentillnessWhat symptoms isthepatient experiencing (eg.worries; preoccuations; changes in mood; suspicions; delusions or hallucinatory experi-ences; recent changes in sleep,appetite, libido, concentration,memory, or behavior, including suicidal or aggressive behaviors)?What is the severity of the patient's symptoms?Overwhattimecoursehavethesesymptomsdevelopedorfluctuated?Are associated features of specific psychiatric syndromes(i.e.,pertinentpositiveor negativefactors)presentorabsent during the present illness?Whatfactors does the patient believe are precipitating,aggravating,orotherwise modifying the illness or are temporally related to itscourse?Did the patient receive prior treatmentfor this episodeofillness?Are other clinicians who carefor the patient availableto comment?Past psychiatric historyWhat is the chronology of past episodes of mental llness, regardless ofwhether such episodes were diagnosed or treated?What are the patient's previous sources of treatment, and whatdiagnoses were given?Withrepect tosomatitherapies (eg,medications,electroconvulsivetherapy), what were the dose or treatment parameters, efficacy, sideeffects, treatment duration, and adherence?With respect to psychotherapy, what were the type, frequency,duration, adherence, and patient's perception of the therapeuticalliance and helpfulness of the psychotherapy?Is there a history of psychiatric hospitalization?Is there a history of suicide attempts or aggressive behaviors?Are past medical records available to consult?Historyofalcohol andWhat licitand illicit substances havebeenused, inwhatquantity,howother substance usefrequently, and with what pattern and route of use?Whatfunctional,social,occupational, orlegal consequences or selfperceived benefits of use have occurred?Has tolerance or withdrawal symptoms been noted?Hassubstanceusebeenassociatedwithpsychiatricsymptoms?Arefamily members available who could provide corroboratinginformation about the patient's substance use and itsconsequences?15Psychiatric Evaluafion of AdultsCopyright2010American Psychiatric Association.APAmakesthis practice guidelinefreely available to promote its dissemination anduse;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

Psychiatric Evaluation of Adults 15 TABLE 1. Domains of the Clinical Evaluation Domain Questions to Consider Reason for the evaluation What is the patient’s chief complaint and its duration? What reason does the patient give for seeking evaluation at this specific time? What reasons are given by other involved parties (e.g., family, other health professionals) for seeking evaluation at this specific time? History of the present illness What symptoms is the patient experiencing (e.g., worries; preoccupa￾tions; changes in mood; suspicions; delusions or hallucinatory experi￾ences; recent changes in sleep, appetite, libido, concentration, memory, or behavior, including suicidal or aggressive behaviors)? What is the severity of the patient’s symptoms? Over what time course have these symptoms developed or fluctuated? Are associated features of specific psychiatric syndromes (i.e., pertinent positive or negative factors) present or absent during the present illness? What factors does the patient believe are precipitating, aggravating, or otherwise modifying the illness or are temporally related to its course? Did the patient receive prior treatment for this episode of illness? Are other clinicians who care for the patient available to comment? Past psychiatric history What is the chronology of past episodes of mental illness, regardless of whether such episodes were diagnosed or treated? What are the patient’s previous sources of treatment, and what diagnoses were given? With respect to somatic therapies (e.g., medications, electroconvulsive therapy), what were the dose or treatment parameters, efficacy, side effects, treatment duration, and adherence? With respect to psychotherapy, what were the type, frequency, duration, adherence, and patient’s perception of the therapeutic alliance and helpfulness of the psychotherapy? Is there a history of psychiatric hospitalization? Is there a history of suicide attempts or aggressive behaviors? Are past medical records available to consult? History of alcohol and other substance use What licit and illicit substances have been used, in what quantity, how frequently, and with what pattern and route of use? What functional, social, occupational, or legal consequences or self￾perceived benefits of use have occurred? Has tolerance or withdrawal symptoms been noted? Has substance use been associated with psychiatric symptoms? Are family members available who could provide corroborating information about the patient’s substance use and its consequences? 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