Assessment and Diagnosis
Assessment and Diagnosis
Psychological assessment is the process of gathering and evaluating data about a patient’s symptoms, mental state, behaviors, and background. Using these data, a diagnosis of the disease or disorder is made.
The purpose of psychological assessment is to reduce and organize the data concerning a patient so that a diagnosis and recommendation for a course of treatment can be made. The psychological assessment (also called the biopsychosocial or psychiatric assessment) gathers information to diagnose any mental disorder that the person may have; it is the first step in treating a diagnosed disorder. The process typically starts with a chief complaint or presenting problem—this is usually what prompts the person to seek help. A complete psychological assessment should include:
- biopsychosocial history
- neurological assessment
- psychological testing (if applicable)
- physical examination (if required by a psychiatrist)
- brain imaging (if necessary)
Once complete, the assessment will help establish either a tentative or definitive diagnosis. With this information, the clinician can inform the patient of the results, and treatment can begin.
Accurate information gathering and objective notes are essential for psychological assessment. However, these can be difficult to obtain if the person is not willing to disclose all necessary information, either out of embarrassment or through denial that symptoms of a mental problem even exist.
The American Psychological Association Code of Ethics states that a psychologist’s assessments must be based on evidence “sufficient to substantiate their findings,” usually including a direct examination of the patient. If an examination of the patient is not possible, the psychologist must note this explicitly in his or her conclusions or recommendations.
The psychological assessment, an extremely effective and accepted diagnostic tool, is a structured interview that has several parts:
- identifying information
- chief complaint (presenting problem)
- history of present illness
- past medical and psychological history
- personal history
- family history
- substance abuse history
- mental status examination (MSE)
Before beginning, the clinician should introduce himself or herself and attempt to make the person comfortable in a professional setting. A common fluency in language or competent translator is essential for information gathering and questioning.
These are general and emotionally neutral questions that usually include name, age, occupation, and marital status.
Chief complaint (presenting problem)
This consists of questions such as “Why are you seeking psychological help today?” that reveal past mental disorders and/or the symptoms that made the person seek psychotherapy. The patient’s responses can also help the clinician ask pertinent questions during other parts of the interview, and can help clarify the presence of symptoms.
History of present illness
The patient describes the onset of signs and symptoms that comprise the current mental problem.
Past medical and psychological history
Because medical problems—including thyroid disease, Parkinson’s disease, head trauma, and brain infections—can cause psychological symptoms, a thorough medical history must be taken. The interviewer also asks about previous psychological/psychiatric treatment, including hospitalization, outpatient or substance abuse treatment, and medication prescribed for mental disorders. The treatment’s duration, effectiveness, and outcome is also noted.
This portion of the assessment provides information on the patient’s entire life, beginning with prenatal development, including maternal abortions, nutrition, and drug use during pregnancy; birth trauma; and birth order. The patient’s life is then discussed in distinct phases:
EARLY CHILDHOOD (INFANCY-THREE YEARS)
Questions include information about temperament, walking, talking, toilet training, nutrition and feeding, family relationships, behavioral problems, hospitalization, and separation from early childhood caregivers.
MIDDLE CHILDHOOD (THREE-11 YEARS)
Pertinent information will be gathered concerning learning, relationship with peers and family, behavioral problems, and general personality development.
ADOLESCENCE (12-18 YEARS)
Information typically includes school history, behavioral problems, and sexual development.
This section details the patient’s education, sexual history, relationships and/or marriages, peer relationships, occupation, and current circumstances.
Family history is crucially important since many mental disorders can be inherited genetically. Additionally, family interactions may affect the patient’s symptoms and disorder.
Substance use history
This portion of the psychological assessment details information on the patient’s use of both illicit drugs (opiates, cocaine, alcohol, marijuana, hallucinogens, and depressants) and legally prescribed medications, as well as nicotine and caffeine. Questions usually focus on age of first use, age of last use, period of heaviest use, usage within the past 30 days, frequency, quantity, and route of usage. Tolerance and dependence, if present, are noted, as are the patient’s treatment history, any medical complications (e.g., AIDS), and legal problems associated with usage (e.g., driving or operating a vehicle or machine while impaired).
This assesses the patient’s mental state, and begins by evaluating:
- Appearance: hygiene, general appearance, grooming, and attire.
- Behavior: abnormal movements, hyperactivity and eye contact with the interviewer.
- Speech: fluency, rate, clarity, and tone, all of which may indicate the patient’s mental state. A fast-talking person, for example, may be anxious. Speech can also reveal intoxication or impairment as well as problems in the mouth (e.g., dentures, cleft palate) or speech impairment.
Affect —The expression of emotion displayed to others through facial expressions, hand gestures, tone of voice, etc. Types of affect include flat (inanimate, no expression), blunted (minimally responsive), inappropriate (incongruous expressions of emotion relative to the content of a conversation), and labile (sudden and abrupt changes in type and intensity of emotion).
Assessment —In the context of psychological assessment (a structured interview), assessment is information-gathering to diagnose a mental disorder.
Biopsychosocial history —A history of significant past and current experiences that influence client behaviors, including medical, educational, employment, and interpersonal experiences. Alcohol or drug use and involvement with the legal system are also assessed in a biopsychosocial history.
Delusion —A false belief that is resistant to reason or contrary to actual fact. A patient may be convinced, for example, that someone is trying to poison him or her, or that he or she has a fatal illness despite evidence to the contrary.
Dependence —The adaptation of neurons and other physical processes to the use of a drug, followed by withdrawal symptoms when the drug is removed; physiological and/or psychological addiction.
Hallucinations —False sensory perceptions. A person experiencing a hallucination may “hear” sounds or “see” people or objects that are not really present. Hallucinations can also affect the senses of smell, touch, and taste.
Phobia —Irrational fear of places, things, or situations that lead to avoidance.
Psychotropic drug —Medication that has an effect on the mind, brain, behavior, perceptions, or emotions. Psychotropic medications are used to treat mental illnesses because they affect a patient’s moods and perceptions.
Tolerance —Progressive decrease in the effectiveness of a drug with long-term use.
The examiner then goes on to assess other aspects of the patient’s mental state, such as mood, thought process, and cognition, beginning with a question such as that suggested in the Merck Manual of Geriatrics: “I would like to ask you some questions about your feelings, your thinking, and your memory as a routine part of the examination. Is that all right with you?”
Mood and affect
These outward manifestations of the patient’s mental state are important indicators. The clinician can ask the patient to describe his or her current mood (“How do you feel? Are you happy? Sad? Angry?”). The patient’s affect, or emotional state, however, is observed and interpreted by the clinician throughout the interview, and described in standardized terms, such as excitable, flat, inappropriate, or labile (rapidly shifting).
Thought process and content
Thought process (or form) indicates whether or not the interviewee is properly oriented to time and place. Thought content reveals how connected, coherent, and logical the patient’s thoughts are. The interviewer may ask the patient to identify themselves and loved ones, to name the current date, and/or to describe the route taken to the examiner’s location. The patient’s responses to questions can indicate disturbances in thought, such as circumstantial thinking (circuitous, persistent storytelling), tangential thinking (response not pertinent to the question) black/white (extreme) thinking, and impoverished (minimally responsive) thinking. Disturbed thought content can also indicate delusions, hallucinations, phobias, and obsessions. In addition, the examiner may question the patient about suicidal and/or homicidal thoughts.
Cognition refers to the patient’s attention, awareness, memory (long-, intermediate-, and short-term), general knowledge, abstract thinking ability, insight, and judgment. The interviewer may ask the patient to spell a word forward and backward, identify the current president, read and/or write something, compare two objects, and explain the meaning of common sayings.
An evaluation session appointment is made with a qualified mental health practitioner. A specialist (someone specializing in anxiety/depressive disorders, pain management, hypnotherapy, or chemical dependency, for example) may be sought or recommended. A private, quiet, nonthreatening, environment is recommended to ensure comfort and confidentiality.
Aftercare depends on the results of the evaluation. Treatment may be initiated and/or further tests may be required to confirm the diagnosis.
There are no known risks involved. A person seeking a mental health evaluation does so for a reason and may learn of an existing or potential mental problem.
The patient does not require psychological therapy or psychotropic drug (medications beneficial to treat certain mental disorders) treatment.
The person has a mental disorder that may require psychotherapy or a combination of psychotherapy and medications.
Andreasen, Nancy C., and Donald W. Black. Introductory Textbook of Psychiatry. 3rd ed. Washington, D.C.: American Psychiatric Publishing, 2001.
VandenBos, Gary R., ed. APA Dictionary of Psychology. Washington, D.C.: American Psychological Association, 2007.
Laith Farid Gulli, MD
Bilal Nasser, MD