Assessment, Diagnosis, and Treatment Planning
Comprehensive Assessment
A thorough psychiatric assessment includes:
- History: presenting problem, psychiatric history, medical history, substance use, social and developmental history, family history.
- Mental status examination (MSE): appearance, behavior, speech, mood, affect, thought process, thought content, cognition, insight, judgment.
- Risk assessment: suicide, violence, self-harm, withdrawal, medical instability.
- Standardized tools: PHQ-9 for depression, GAD-7 for anxiety, C-SSRS for suicide risk, AUDIT for alcohol use.
Diagnosis
- Use DSM-5-TR criteria; diagnosis is based on pattern, duration, and functional impairment.
- Differential diagnosis: rule out medical conditions (e.g., hypothyroidism causing depression) and substance-induced symptoms.
- Cultural formulation: consider cultural norms and idioms of distress.
Treatment Planning
- Multidisciplinary approach: psychiatrist, nurse, therapist, social worker, occupational therapist.
- Goals: SMART (specific, measurable, achievable, relevant, time-bound); patient-centered; recovery-oriented.
- Levels of care: outpatient, intensive outpatient, partial hospitalization, inpatient, residential.
Traps in Questions
- Confusing mood (sustained emotional state) with affect (observable expression).
- Missing medical mimics: always consider organic causes for new psychiatric symptoms.
- Overlooking substance use as a contributor.
- Forgetting to assess risk at every encounter.
Worked Example
A 70-year-old with new-onset depression and memory problems. What is the priority? Answer: Medical evaluation to rule out dementia, thyroid disease, or medication side effects. Rule of thumb: new psychiatric symptoms in older adults or with physical signs demand medical workup first.