TABLE 1. Domains of the Clinical Evaluation (confinued)DomainQuestions to ConsiderGeneral medical historyWhatgeneral medical llnesses are known, including hospitalizations,procedures, treatments, and medications?Are undiagnosed illnesses causing major distress or functionalimpairment?Does the patient engage in high-risk behaviors that would predisposehim or herto a medical illness?Is the patient taking any prescribed or over-the-counter medications,herbal products, supplements, and/or vitamins?Has the patient experienced allergic reactions to or severe adverseeffects of medications?Developmental, psychosocial,What have been the most important events in the patient's life, andand sociocultural historywhat were the patient's responses to them?What is the patient's history of formal education?What are the patient's cultural, religious, and spiritual beliefs, and howhave these developed or changed over time?Is there a history of parental loss or divorce; physical,emotional,orsexual abuse; or exposure to other traumatic experiences?What strategies for coping has the patient used successfully duringtimes of stress or adversity?During childhood or adolescence, did the patient have risk factors forany mental disorders?What has been the patient's capacity to maintain interpersonalrelationships, and what is the patient's history of marital and othersignificant relationships?What is the patient's sexual history, including sexual orientation,beliefs, and practices?Does the patient have children?Whatpast or current psychosocial stressors haveaffected thepatient(including primary supportgroup, social environment, education,occupation,housing,economic status,and access to health care)?What is the patient's capacity for self-care?What are the patient's sociocultural supports (e.g, family, friends,work, and religious and other community groups)?What are the patient's own interests, preferences, and values withrespect to health care?Occupational andWhat is the patient's occupation, and what jobs has themilitary historyPatient held?What is the quality of the patient's work relationshipsWhat work skills and strengths does the patient have?Is the patient unable to work due to disability?Regarding military service, what was the patient's status (volunteer,recruit, or draftee), did the patient experience combat, and did thepatient suffer injury or trauma?Is the patient preparing for or adjusting to retirement?16APA Practice GuidelinesCopyright 2010American Psychiatric Association.APAmakes 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
16 APA Practice Guidelines General medical history What general medical illnesses are known, including hospitalizations, procedures, treatments, and medications? Are undiagnosed illnesses causing major distress or functional impairment? Does the patient engage in high-risk behaviors that would predispose him or her to a medical illness? Is the patient taking any prescribed or over-the-counter medications, herbal products, supplements, and/or vitamins? Has the patient experienced allergic reactions to or severe adverse effects of medications? Developmental, psychosocial, and sociocultural history What have been the most important events in the patient’s life, and what were the patient’s responses to them? What is the patient’s history of formal education? What are the patient’s cultural, religious, and spiritual beliefs, and how have these developed or changed over time? Is there a history of parental loss or divorce; physical, emotional, or sexual abuse; or exposure to other traumatic experiences? What strategies for coping has the patient used successfully during times of stress or adversity? During childhood or adolescence, did the patient have risk factors for any mental disorders? What has been the patient’s capacity to maintain interpersonal relationships, and what is the patient’s history of marital and other significant relationships? What is the patient’s sexual history, including sexual orientation, beliefs, and practices? Does the patient have children? What past or current psychosocial stressors have affected the patient (including primary support group, social environment, education, occupation, housing, economic status, and access to health care)? What is the patient’s capacity for self-care? What are the patient’s sociocultural supports (e.g., family, friends, work, and religious and other community groups)? What are the patient’s own interests, preferences, and values with respect to health care? Occupational and military history What is the patient’s occupation, and what jobs has the patient held? What is the quality of the patient’s work relationships? What work skills and strengths does the patient have? Is the patient unable to work due to disability? Regarding military service, what was the patient’s status (volunteer, recruit, or draftee), did the patient experience combat, and did the patient suffer injury or trauma? Is the patient preparing for or adjusting to retirement? TABLE 1. Domains of the Clinical Evaluation (continued) Domain Questions to Consider 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 Evaluation (continued)DomainQuestions to ConsiderLegal historyDoes the patient have any past or current involvement with the legalsystem (e.g.,warrants,arrests,detentions, convictions,probation,parole)?Do past or current legal problems relate to aggressivebehaviors orsubstance intoxication?Has the patient had other significant interactions with the courtsystem (e.g., family court, workers’ compensation dispute, civillitigation,court-ordered psychiatric treatment)?Is past or current legal involvement a significant social stressor for thepatient?Family historyWhat information is available about general medical and psychiatricillnesses, including substance use disorders, in close relatives?Is there a family history of suicide or violent behavior?Are heritable illnesses present in familymembers that relateto thepatient's presenting symptoms?Review of systemsIs the patient having difficulty with sleep,appetite, eating patterns,orother vegetative symptoms, or with pain, neurological symptoms,orothersystemic symptoms?Does the patient have symptoms that suggest an undiagnosed medicalillness that may be causing or contributing to psychiatricsymptoms?Is the patient experiencing side effects from medications or othertreatments?What istheappropriatetiming, scope,and intensityoftheexamforPhysical examinationthis patient, and who is the most appropriate examiner?Upon examination, are there abnormalities in the patient's generalappearance,vital signs, neurological status, skin,or organ system?Is more detailed physical examination necessary to assess the patientfor specific diseases?Mental status examinationWhat symptoms and signs ofa mental disorder is the patient currentlyexhibiting?What are the patient's general appearance and behavior?What are the characteristics of the patient's speech?What are the patient's mood and affect, including the stability,range,congruence, and appropriateness of affect?Are the patient's thought processes coherent?Are there recurrent or persistent themes in the patient's thoughtprocesses?Are there any abnormalities of the patient's thought content(e.g., delusions, ideas of reference, overvalued ideas,ruminations, obsessions, compulsions, phobias)?Is the patienthaving thoughts,plans,or intentions ofharming selfor others?Is the patient experiencing perceptual disturbances (e.g,hallucinations, illusions, derealization, depersonalization)?17Psychiatric 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,visitAPPIPermissions&LicensingCenterathttp://www.appi.org/CustomerService/Pages/Permissions.aspx
Psychiatric Evaluation of Adults 17 Legal history Does the patient have any past or current involvement with the legal system (e.g., warrants, arrests, detentions, convictions, probation, parole)? Do past or current legal problems relate to aggressive behaviors or substance intoxication? Has the patient had other significant interactions with the court system (e.g., family court, workers’ compensation dispute, civil litigation, court-ordered psychiatric treatment)? Is past or current legal involvement a significant social stressor for the patient? Family history What information is available about general medical and psychiatric illnesses, including substance use disorders, in close relatives? Is there a family history of suicide or violent behavior? Are heritable illnesses present in family members that relate to the patient’s presenting symptoms? Review of systems Is the patient having difficulty with sleep, appetite, eating patterns, or other vegetative symptoms, or with pain, neurological symptoms, or other systemic symptoms? Does the patient have symptoms that suggest an undiagnosed medical illness that may be causing or contributing to psychiatric symptoms? Is the patient experiencing side effects from medications or other treatments? Physical examination What is the appropriate timing, scope, and intensity of the exam for this patient, and who is the most appropriate examiner? Upon examination, are there abnormalities in the patient’s general appearance, vital signs, neurological status, skin, or organ systems? Is more detailed physical examination necessary to assess the patient for specific diseases? Mental status examination What symptoms and signs of a mental disorder is the patient currently exhibiting? What are the patient’s general appearance and behavior? What are the characteristics of the patient’s speech? What are the patient’s mood and affect, including the stability, range, congruence, and appropriateness of affect? Are the patient’s thought processes coherent? Are there recurrent or persistent themes in the patient’s thought processes? Are there any abnormalities of the patient’s thought content (e.g., delusions, ideas of reference, overvalued ideas, ruminations, obsessions, compulsions, phobias)? Is the patient having thoughts, plans, or intentions of harming self or others? Is the patient experiencing perceptual disturbances (e.g., hallucinations, illusions, derealization, depersonalization)? TABLE 1. Domains of the Clinical Evaluation (continued) Domain Questions to Consider 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
TABLE1. Domains of the Clinical Evaluafion (confinued)DomainQuestions to ConsiderMental status examinationWhat are the patient's sensorium and level of cognitive function(continued)(e.g.,orientation,attention, concentration,registration,short-and long-term memory,fund of knowledge, levelof intelligence, drawing, abstract reasoning, language, andexecutivefunctions)What are the patient's level of insight, judgment, and capacity forabstract reasoning?What is the patient's motivation to change his or her health riskbehaviors?What are the patient's functional strengths, and what is the diseaseFunctionalassessmentseverity?To what degree can the patient perform physical activities of dailyliving (eg,eating, toileting, transferring, bathing, dressing)?To what degreecan the patient perform instrumental activities of dailyliving (eg., driving, using public transportation, takingmedications as prescribed, shopping, managing finances, keepinghouse, communicating by mail or telephone, caring fordependents)?Would a formal assessment offunctioning be useful (e.g.,todocument deficits or aid continued monitoring)?What diagnostic tests are necessary to establish or exclude a diagnosis,Diagnostic testsaid in the choice oftreatment, or monitor treatmenteffects or sideeffects?Information derived fromAre symptoms minimized or exaggerated by the patient or others?theinterviewprocessDoes thepatientappearto provideaccurate information?Doparticularquestions evoke hesitation orsignsofdiscomfort?Is the patient able to communicate about emotional issues?How does the patient respond to the psychiatrist's comments andbehaviors?periences as well as recentchanges in sleep,appetite, libido,concentration,memory,or behavior,including suicidal or aggressive behaviors. Information gathered on the pertinent positive andpertinent negative features ofthe history of present illness will vary with the patient's presentingsymptoms or syndrome. Temporal features relating to the onset or exacerbation of symptomsmay also be relevant (e.g-, onset after use of exogenous hormones, herbal products, or licit orillicit substances; variation in symptoms with the menstrual cycle; postpartum onset).Also per-tinent are factors that the patient and other informants believe to be precipitating, aggravating,or otherwise modifying the illness.Available details of previous treatments and the patient's response to those treatments will be delineated as part ofthe history of present llness. If the pa-tient was or is in treatment with another clinician, the effects of that relationship on the currentillness, including transference and countertransference issues, are considered. Input from mem-bers of a clinical team who care for the patient can be very helpful (Section IV.A.6). For patientsseen on medical-surgical units, it is important to consider the history of both the present med-ical-surgical illness and the present psychiatric illness (45)18APA Practice GuidelinesCopyright 201o,American Psychiatric Association.APA makes this practice guideline freely available to promote its dissemination and use; however,copyrightprotections are enforced in full.No partof this guideline may be reproduced except as permited under Sections 107 and 108 ofU.S.Copyright Act. For permissionforreuse,visitAPPIPermissions&LicensingCenterathttp://www.appi.org/CustomerService/Pages/Permissions.aspx
18 APA Practice Guidelines periences as well as recent changes in sleep, appetite, libido, concentration, memory, or behavior, including suicidal or aggressive behaviors. Information gathered on the pertinent positive and pertinent negative features of the history of present illness will vary with the patient’s presenting symptoms or syndrome. Temporal features relating to the onset or exacerbation of symptoms may also be relevant (e.g., onset after use of exogenous hormones, herbal products, or licit or illicit substances; variation in symptoms with the menstrual cycle; postpartum onset). Also pertinent are factors that the patient and other informants believe to be precipitating, aggravating, or otherwise modifying the illness. Available details of previous treatments and the patient’s response to those treatments will be delineated as part of the history of present illness. If the patient was or is in treatment with another clinician, the effects of that relationship on the current illness, including transference and countertransference issues, are considered. Input from members of a clinical team who care for the patient can be very helpful (Section IV.A.6). For patients seen on medical-surgical units, it is important to consider the history of both the present medical-surgical illness and the present psychiatric illness (45). Mental status examination (continued) What are the patient’s sensorium and level of cognitive function (e.g., orientation, attention, concentration, registration, short- and long-term memory, fund of knowledge, level of intelligence, drawing, abstract reasoning, language, and executive functions)? What are the patient’s level of insight, judgment, and capacity for abstract reasoning? What is the patient’s motivation to change his or her health risk behaviors? Functional assessment What are the patient’s functional strengths, and what is the disease severity? To what degree can the patient perform physical activities of daily living (e.g., eating, toileting, transferring, bathing, dressing)? To what degree can the patient perform instrumental activities of daily living (e.g., driving, using public transportation, taking medications as prescribed, shopping, managing finances, keeping house, communicating by mail or telephone, caring for dependents)? Would a formal assessment of functioning be useful (e.g., to document deficits or aid continued monitoring)? Diagnostic tests What diagnostic tests are necessary to establish or exclude a diagnosis, aid in the choice of treatment, or monitor treatment effects or side effects? Information derived from the interview process Are symptoms minimized or exaggerated by the patient or others? Does the patient appear to provide accurate information? Do particular questions evoke hesitation or signs of discomfort? Is the patient able to communicate about emotional issues? How does the patient respond to the psychiatrist’s comments and behaviors? TABLE 1. Domains of the Clinical Evaluation (continued) Domain Questions to Consider 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
CPASTPSYCHIATRICHISTORYThe past psychiatric history includes a chronological summary of all past episodes of mentalillness, including substance use disorders, and treatment.The summary includes prior hospitalizations; suicide attempts,aborted suicide attempts, or other self-destructive behavior psychiatricsyndromes notformally diagnosed at the time; previously established diagnoses; treatments of-fered; and responses to and satisfaction with treatment.With respect to psychotherapy, it is important to ascertain the type (e-g, psychodynamic, cognitive, behavioral, supportive), format(eg,group, individual, couple),frequency, duration, patient's perception of the alliance, andadherence. With respect to medications, the dose, efficacy, side effects, treatment duration, andadherence are important to ascertain while understanding that reporting errors are more likelyto occur when treatment involved more than one medication (46). With respect to other somatic therapies such as electroconvulsive therapy, information on the number of treatmentsessions, treatment course duration, technical parameters, efficacy, and side effects is similarlyuseful to obtain. When past medical records are available and readily accessible, it is importantthat they be consulted for ancillary information.The chronological summary also delineates the most recent periods of stability as well as episodes when the patient was functionally impaired or seriously distressed by mental or behavioralsymptoms, even if no formal treatment occurred. Such episodes frequently can be identified byasking the patient about the past use of psychotropic medications prescribed by other cliniciansand otherwise unexplained episodes of social or occupational disability.ID.HISTORYOFSUBSTANCEUSEThe psychoactive substance use history includes past and present use of both licit and illicitpsychoactive substances, including but not limited to alcohol, caffeine, nicotine, marijuana,cocaine, opiates, sedative-hypnotic agents, stimulants, solvents, MDMA (methylenedioxy-methamphetamine), androgenic steroids, and hallucinogens (47). Relevant information in-cludes the quantity and frequency of use and route of administration; the pattern of use (e.g.episodic versus continual, solitary versus social); functional, interpersonal, or legal consequencesof use; tolerance and withdrawal phenomena; any temporal association between substance useand other present psychiatric illnesses; and any self-perceived benefits of use, It is also impor-tant to inquire about prior treatments for substance use disorders as well as about periods ofabstinence, including their duration, recentness, and factors that aided in sobriety or contributedto relapse.Obtaining an accurate substance use history often involves a gradual, nonconfronta-tional approach to inquiry that involves asking multiple questions to seek the same information indifferent ways and using slang terms for drugs, patterns of use, and drug effects. Patients areparticularly likely to underestimate their level of substance abuse and their related functionalimpairments; corroboration by otherfamily members is useful when possible.It is also helpfulto inquire about patterns of substance use by others within the family or living constellation.For more extensive discussion of the assessment of substance use, abuse, and dependence, thereaderisreferredtotheCenterforSubstanceAbuseTreatment'sAssessmentandTreatmentofPatients WithCoexistingMental IlnessandAlcoholandOtherDrugAbuse (48)andAPA'sPracticeGuidelinefortheTreatmentofPatientsWithSubstanceUseDisorders(49)/E.GENERALMEDICALHISTORYThe general medical history includes available information on known general medical illnesses(e.g., hospitalizations,procedures, treatments, and medications),allergies or drug sensitivities,and undiagnosed health problems that have caused the patient major distress orfunctional im-pairment. This includes history of any episodes of important physical injury or trauma; sexualand reproductive history;and any history of endocrinological, infectious (including but not19Psychiatric 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,visitAPPIPermissions&LicensingCenterathttp://www.appi.org/CustomerService/Pages/Permissions.aspx
Psychiatric Evaluation of Adults 19 C. PAST PSYCHIATRIC HISTORY The past psychiatric history includes a chronological summary of all past episodes of mental illness, including substance use disorders, and treatment. The summary includes prior hospitalizations; suicide attempts, aborted suicide attempts, or other self-destructive behavior; psychiatric syndromes not formally diagnosed at the time; previously established diagnoses; treatments offered; and responses to and satisfaction with treatment. With respect to psychotherapy, it is important to ascertain the type (e.g., psychodynamic, cognitive, behavioral, supportive), format (e.g., group, individual, couple), frequency, duration, patient’s perception of the alliance, and adherence. With respect to medications, the dose, efficacy, side effects, treatment duration, and adherence are important to ascertain while understanding that reporting errors are more likely to occur when treatment involved more than one medication (46). With respect to other somatic therapies such as electroconvulsive therapy, information on the number of treatment sessions, treatment course duration, technical parameters, efficacy, and side effects is similarly useful to obtain. When past medical records are available and readily accessible, it is important that they be consulted for ancillary information. The chronological summary also delineates the most recent periods of stability as well as episodes when the patient was functionally impaired or seriously distressed by mental or behavioral symptoms, even if no formal treatment occurred. Such episodes frequently can be identified by asking the patient about the past use of psychotropic medications prescribed by other clinicians and otherwise unexplained episodes of social or occupational disability. D. HISTORY OF SUBSTANCE USE The psychoactive substance use history includes past and present use of both licit and illicit psychoactive substances, including but not limited to alcohol, caffeine, nicotine, marijuana, cocaine, opiates, sedative-hypnotic agents, stimulants, solvents, MDMA (methylenedioxymethamphetamine), androgenic steroids, and hallucinogens (47). Relevant information includes the quantity and frequency of use and route of administration; the pattern of use (e.g., episodic versus continual, solitary versus social); functional, interpersonal, or legal consequences of use; tolerance and withdrawal phenomena; any temporal association between substance use and other present psychiatric illnesses; and any self-perceived benefits of use. It is also important to inquire about prior treatments for substance use disorders as well as about periods of abstinence, including their duration, recentness, and factors that aided in sobriety or contributed to relapse. Obtaining an accurate substance use history often involves a gradual, nonconfrontational approach to inquiry that involves asking multiple questions to seek the same information in different ways and using slang terms for drugs, patterns of use, and drug effects. Patients are particularly likely to underestimate their level of substance abuse and their related functional impairments; corroboration by other family members is useful when possible. It is also helpful to inquire about patterns of substance use by others within the family or living constellation. For more extensive discussion of the assessment of substance use, abuse, and dependence, the reader is referred to the Center for Substance Abuse Treatment’s Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse (48) and APA’s Practice Guideline for the Treatment of Patients With Substance Use Disorders (49). E. GENERAL MEDICAL HISTORY The general medical history includes available information on known general medical illnesses (e.g., hospitalizations, procedures, treatments, and medications), allergies or drug sensitivities, and undiagnosed health problems that have caused the patient major distress or functional impairment. This includes history of any episodes of important physical injury or trauma; sexual and reproductive history; and any history of endocrinological, infectious (including but not 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
limited to HIV, tuberculosis, and hepatitis C) (50), neurological disorders, sleep disorders (in-cluding sleep apnea),and conditions causing pain and discomfort.Of particular importance isaspecific history regarding diseases and symptoms of diseases that have a high prevalence amongindividuals with the patient's demographic characteristics and background-for example, in-fectious diseases in users of intravenous drugs or pulmonary and cardiovascular disease in peo-ple who smoke. Information regarding all current and recent medications, including hormones(eg,birth control pills,androgens),over-the-counter medications, herbal supplements, vitamins,complementary and alternative medical treatments, and medication side effects, is part of thegeneral medical history.With allaspects ofthegeneral medical history,obtainingcorroboratinginformation (e.g-,from medical records, treating clinicians,family)can be helpful, since ordi-nary errors in comprehension, recall, and expression can lead to errors in patient reports (51).F.DEVELOPMENTAL,PSYCHOSOCIAL,ANDSOCIOCULTURALHISTORY?The personal history reviews the stages of the patient's life, with special attention to perinatalevents, delays in physical or psychological development,formal educational history, academicperformance, and patterns of response to normal life transitions and major life events, includ-ingparental lossordivorce; physical,emotional,orsexual abuse; andothertrauma such as ex-posure to political repression, war, or a natural disaster (52-55). The childhood and adolescenthistoryof risk factors forlaterpsychiatric disorders (Table2)mayalso be relevant.History ofadaptive skills and strengths to overcome challenges is also relevant.The patient's capacity to maintain stable and gratifying interpersonal relationships shouldbe noted, including the patient's capacities for attachment, trust, and intimacy.A sexual historyisobtained and includes consideration of sexual orientationandpractices,past sexual experi-ences (including unwanted experiences), and cultural beliefs about sex (54). The psychosocialhistory also determines the patient's past and present levels of interpersonal functioning in fam-ily and social roles (eg-, marriage, parenting) (56-58). This includes a delineation of the patientshistory of marital and other significant relationships. For patients with children (including bi-ological, foster, adopted, or stepchildren),the psychosocial history will include informationabout these individuals and their relationship to the patient.Aspartofthepsychosocialhistory,pastor current stressors areassessed and includethecategories on axis IV of DSM-IV-TR: primary support group, social environment (e.g., discrim-ination and acculturation),education, occupation,housing, economic status, and access tohealth care. Specific information obtained in evaluating psychosocial stressors may include detailsaboutpatients living arrangements,access totransportation,sources of income,insurance orprescription coverage,and past or current involvement with social agencies.Assessment of thepatient's self-care functioning may also include consideration of exercise behavior and moneymanagement skills, including gambling behavior.The sociocultural history delineates the patient's migration history and past and current so-ciocultural context of supports and stressors as well as other important cultural and religiousinfluences on the patient's life (59).Emphasis is given to relationships, both familial and non-familial, and to religion and spirituality that may give meaning and purpose to the patient's lifeand provide support, as described in theDSM-IV-TROutline for Cultural Formulation (de-scribed in more detail in Section IV.B.1.a).Patients present for a psychiatric evaluation with their own interests, preferences, and valuesystems pertaining to health care practice,and these are another important part of the socio-culrural history. They may involve cultural factors and explanatory models of illness that affectattitudes, expectations, and preferences for professional and popular treatments,as describedin the DSM-IV-TR Outline for Cultural Formulation and the 2004 Core Competencies of theAmerican Board of Psychiatry and Neurology (60). Also important to the assessment and treat-ment process are other domains such as existential, moral, and interpersonal values and social20APA Practice GuidelinesCopyright 2010,American Psychiatric Association.APAmakes this practice guideline freely 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
20 APA Practice Guidelines limited to HIV, tuberculosis, and hepatitis C) (50), neurological disorders, sleep disorders (including sleep apnea), and conditions causing pain and discomfort. Of particular importance is a specific history regarding diseases and symptoms of diseases that have a high prevalence among individuals with the patient’s demographic characteristics and background—for example, infectious diseases in users of intravenous drugs or pulmonary and cardiovascular disease in people who smoke. Information regarding all current and recent medications, including hormones (e.g., birth control pills, androgens), over-the-counter medications, herbal supplements, vitamins, complementary and alternative medical treatments, and medication side effects, is part of the general medical history. With all aspects of the general medical history, obtaining corroborating information (e.g., from medical records, treating clinicians, family) can be helpful, since ordinary errors in comprehension, recall, and expression can lead to errors in patient reports (51). F. DEVELOPMENTAL, PSYCHOSOCIAL, AND SOCIOCULTURAL HISTORY The personal history reviews the stages of the patient’s life, with special attention to perinatal events, delays in physical or psychological development, formal educational history, academic performance, and patterns of response to normal life transitions and major life events, including parental loss or divorce; physical, emotional, or sexual abuse; and other trauma such as exposure to political repression, war, or a natural disaster (52–55). The childhood and adolescent history of risk factors for later psychiatric disorders (Table 2) may also be relevant. History of adaptive skills and strengths to overcome challenges is also relevant. The patient’s capacity to maintain stable and gratifying interpersonal relationships should be noted, including the patient’s capacities for attachment, trust, and intimacy. A sexual history is obtained and includes consideration of sexual orientation and practices, past sexual experiences (including unwanted experiences), and cultural beliefs about sex (54). The psychosocial history also determines the patient’s past and present levels of interpersonal functioning in family and social roles (e.g., marriage, parenting) (56–58). This includes a delineation of the patient’s history of marital and other significant relationships. For patients with children (including biological, foster, adopted, or stepchildren), the psychosocial history will include information about these individuals and their relationship to the patient. As part of the psychosocial history, past or current stressors are assessed and include the categories on axis IV of DSM-IV-TR: primary support group, social environment (e.g., discrimination and acculturation), education, occupation, housing, economic status, and access to health care. Specific information obtained in evaluating psychosocial stressors may include details about patients’ living arrangements, access to transportation, sources of income, insurance or prescription coverage, and past or current involvement with social agencies. Assessment of the patient’s self-care functioning may also include consideration of exercise behavior and money management skills, including gambling behavior. The sociocultural history delineates the patient’s migration history and past and current sociocultural context of supports and stressors as well as other important cultural and religious influences on the patient’s life (59). Emphasis is given to relationships, both familial and nonfamilial, and to religion and spirituality that may give meaning and purpose to the patient’s life and provide support, as described in the DSM-IV-TR Outline for Cultural Formulation (described in more detail in Section IV.B.1.a). Patients present for a psychiatric evaluation with their own interests, preferences, and value systems pertaining to health care practice, and these are another important part of the sociocultural history. They may involve cultural factors and explanatory models of illness that affect attitudes, expectations, and preferences for professional and popular treatments, as described in the DSM-IV-TR Outline for Cultural Formulation and the 2004 Core Competencies of the American Board of Psychiatry and Neurology (60). Also important to the assessment and treatment process are other domains such as existential, moral, and interpersonal values and social 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