The Psychiatric Assessment

Overview – Psychiatric Assessment

The psychiatric assessment is a comprehensive clinical process used to evaluate a patient’s mental, emotional, behavioural, and cognitive health. It includes both a detailed history and a Mental Status Examination (MSE), aiming to identify psychiatric diagnoses, assess risk, and guide treatment planning.

1. History Taking in Psychiatry

Chief Complaint

  • Recorded in the patient’s own words
  • Includes:
    • Onset
    • Duration
    • Exacerbating or relieving factors

History of Present Illness

  • Reason for seeking help now
  • Detailed description of symptoms (onset, course, severity)
  • Recent stressors and support systems
  • Functional status: occupational, academic, social
  • Pertinent positives and negatives

Current Medications

  • Include names, dosages, and adherence

Safety Screen

Assess the patient’s immediate safety and ability to care for self or others:

  • Risk to self or others
  • Dependent care responsibilities (children, pets)
  • Fitness to drive
  • Capacity to maintain personal care

Psychiatric Functional Inquiry

Systematic review of major psychiatric domains:

  • Mood: depression, mania
  • Anxiety: generalised worry, phobias, panic, trauma
  • OCD symptoms
  • Psychosis: hallucinations, delusions
  • Risk: suicidal ideation, plans, past attempts
  • Organic concerns: drug use, withdrawal, medical illness, cognitive issues

Past Psychiatric History

  • Previous diagnoses and treating clinicians
  • Past therapies (medication, psychotherapy, hospitalisation)
  • Suicide attempts, substance misuse, legal history

Past Medical & Surgical History

  • Chronic illnesses, surgeries, psychosomatic conditions
  • Allergies and medication list

Family Psychiatric/Medical History

  • Psychiatric illnesses, suicide, or substance misuse in relatives
  • Quality of relationships with parents, siblings, and significant others

Developmental History

  • Prenatal/perinatal complications
  • Early attachments and stability
  • School and peer relationships
  • Trauma (abuse, domestic violence)
  • Substance use or legal issues during youth
  • Occupational history
  • Psychosexual development: puberty, relationships, dysfunction

2. Mental Status Examination (MSE)

The MSE is a clinician’s observational assessment of a patient’s current psychological functioning — a “snapshot in time”.

Appearance

  • Gait, grooming, hygiene, clothing, body habitus
  • Facial expression
  • Chronological vs apparent age
  • Degree of distress

Behaviour

  • Psychomotor activity (agitation, retardation)
  • Abnormal movements (tremors, akathisia, dyskinesia)
  • Eye contact, attentiveness
  • Cooperation and rapport

Mood (Subjective)

  • Patient’s self-reported emotional state (e.g., “I feel hopeless.”)

Affect (Objective)

  • Quality: euthymic, depressed, irritable, anxious
  • Range: full, flat, restricted, blunted
  • Stability: fixed or labile
  • Congruence with mood and content
  • Appropriateness to conversation/stimuli

Speech

  • Rate (pressured, slowed)
  • Volume, tone
  • Fluency, articulation, spontaneity

Thought Form (Process)

  • Coherence and logic
  • Stream of thought:
    • Goal-directed
    • Circumstantial
    • Tangential
    • Loose associations
    • Flight of ideas
    • Word salad
  • Other findings:
    • Perseveration, echolalia, thought blocking
    • Clang associations, neologisms

Thought Content

  • Suicidal or homicidal ideation
  • Obsessions and compulsions
  • Magical thinking
  • Ideas of reference, overvalued ideas
  • Delusions (including first-rank symptoms: thought insertion, broadcasting, etc.)

Perception

  • Hallucinations: auditory, visual, tactile, olfactory, gustatory
  • Illusions: misinterpretation of real stimuli
  • Depersonalisation: disconnection from self
  • Derealisation: perception of the world as unreal

Cognition

  • Level of consciousness (alert, drowsy, etc.)
  • Orientation to person, place, time
  • Memory: immediate, recent, remote
  • Intellectual function: attention, concentration, abstraction, language
  • Consider standardised tools: MMSE, MoCA

Insight

  • Awareness and understanding of one’s mental illness
  • Graded: none, limited, partial, full

Judgement

  • Capacity to make sound decisions
  • Ability to relate consequences and form appropriate conclusions

Summary – Psychiatric Assessment

The psychiatric assessment provides the essential framework for identifying mental illness, understanding a patient’s biopsychosocial background, and guiding management decisions. It includes a structured history, safety screening, psychiatric systems review, and the Mental Status Examination (MSE). For a broader context, see our Psychiatry & Mental Health Overview page.

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