I have been performing comprehensive psychiatric evaluations, which are medical examinations, for more than thirty years, since beginning residency training in psychiatry in Dallas in 1994 (see online CV). Over the decades, I have documented tens of thousands of these evaluations, in all settings: public and private clinics, hospitals, nursing homes, rehabilitation centers, correctional and detention facilities, emergency rooms, and even private homes. Now, with telepsychiatry, every appointment is a virtual "house call."
The initial examination requires approximately one hour to complete, and consists of taking a thorough history, including reviewing any prior personal psychiatric history. While I am happy to review any documentation you may wish to provide, old records are not required for a proper assessment. The history-taking process includes noting the patient's complete past medical history, as well as documenting any relevant family history (the family psychiatric history can be very important to deriving the correct diagnosis, and elements of the family history can even sometimes direct treatment, if, for example, a primary degree relative did well on a particular medication for similar symptoms).
In addition to addressing any current or prior mood, behavioral, interpersonal, academic and/or occupational difficulties, the diagnostic interview will also always exhaustively address any history of substance abuse or chemical dependency, childhood and/or adult psychological trauma, baseline individual temperament, coping skills, suicidal thoughts and behaviors, other forms of self-harm, eating disorders, legal difficulties, problems with anger management, social and relational problems, and a host of other potential findings, directed by the answers provided to the basic screening questions for each category.
Rest assured that the evaluation will be comprehensive, and that I will ask about symptoms and symptom complexes that you may not be complaining about, or necessarily expect to have evaluated, in an effort to rule out any underlying, comorbid or erstwhile difficulties that may inform the current history of the present illness. All of this information will inform a proper diagnosis, and also help to formulate short- and long-term prognoses, and answer questions about the likely course of the illness, whether medication therapy is absolutely indicated, whether or not life-long treatment will likely prove necessary, how likely we are to achieve full remission with monotherapy, as opposed to resorting to combinations of psychotropic medications, and other details regarding medical treatment.
I will also always review any history of counseling services, and determine whether a given individual is a good candidate for psychotherapy, and whether such modalities have a place in treatment, which can vary depending on the severity of the illness, or what stage of recovery the patient finds himself or herself in at the time of the evaluation; sometimes depression is too severe to engage the patient constructively in therapy, and severe anxiety, by definition irrational, is often not amenable to supportive or insight-oriented psychotherapy, when the need for medication is absolute and paramount. The same can be said for patients experiencing acute psychosis, or chemically-dependent individuals who are as yet unwilling to work toward sobriety. In these instances, psychotherapy is relatively contraindicated, at least temporarily. Other individuals have permanent intellectual or communicative barriers to effective psychotherapy.
Every evaluation includes a detailed social history, beginning with birthplace and circumstance, and including information about family of origin, then and now, marital status, current nuclear family, social support system, educational level, current occupation and other cultural, socioeconomic and legal parameters, inasmuch as they characterize the patient and his or her situation, the demographic context in which the clinical disturbance complained of is occurring.
One of the most important aspects of the psychiatric evaluation is the Mental Status Examination (MSE), which is a visual exam that is nonetheless an active, objective process, and which does not rely on the patient's or family members' specific answers. An emergency room physician would not accept a diagnosis of, say, a broken arm, simply because a patient came in with that chief complaint; the physician would take a history, and examine the patient, including and especially the patient's arm. Although in psychiatry the clinician does not have the luxury of ordering an X-ray to make a definitive diagnosis (or MRI scan, or biopsy, or blood test, etc.), it is nonetheless incumbent upon the psychiatrist to perform an objective MSE, to observe and describe and rate a variety of parameters, gleaned during the interview process, but independent of the specific answers given by the patient to the interview questions themselves, items such as appearance, psychomotor activity, affect, thought process (as opposed to thought content), and objective, albeit indirect, assessments of mood, of the presence or absence of psychosis, or dementia, or suicidal or other violent and dangerous impulses, as well as gauging intellect, judgment, insight and reliability. Many of these determinations are derived by a combination of visual exam (observation), paired with the patient's answers, taking into consideration the patient's insight and reliability as a historian, both of which can be poor or impaired for a variety of reasons, often considering developmental, academic and occupational histories (for example, in estimating intelligence) and all of this information is also considered in the overriding context of patient demographics (age, developmental level, marital status, culture, lifestyle, general health status, etc.) and epidemiological principles specific to any given disease process. Special considerations must be taken when evaluating pediatric or geriatric populations and special needs individuals.
The evaluation is a complex process that evolves in real-time, and while certain items are always covered (e.g., expect me to ask if you have ever been arrested and taken to jail, and how much alcohol you drink, if any), other threads are followed and thoroughly examined only if screening questions indicate that further inquiry is warranted. Throughout the examination process, the clinician must be alert to inaccurate, unreliable data that may crop up, either consciously and intentionally, with certain patients who are unable or unwilling to be completely honest, or unintentionally, due to limitations the patient may be experiencing for a variety of reasons. It is also imperative that any jargon the patient uses be clarified and that common definitions are understood and agreed upon, to avoid semantic problems that might otherwise mislead the diagnostician; for example, when a patient talks about "racing thoughts," s/he is almost always referring to anxiety, as opposed to mania (which, strictly speaking, is the only condition that produces racing thoughts). Even after defining terms, it is still the clinician's responsibility to corroborate the likelihood that there are, or have been, racing thoughts, by comparing that report to the MSE, which should demonstrate pressured speech and other forms of psychomotor agitation, and thought processes ranging from tangentiality to flight of ideas.
The practitioner's ability to perform a thorough, comprehensive and accurate evaluation is honed through many years of practice, of evaluating and treating individuals with certain conditions and thereby being able to reference a collective memory and to intuit whether the new patient in question "fits" the familiar mold. I avoid the still-too-common trend of overdiagnosing bipolar disorder by comparing a patient's (verified) history and current presentation (MSE) against all of the truly manic-depressive individuals I have met, evaluated and treated over the decades, and it is only this way that the psychiatrist is not entirely at the mercy of what the patient claims.
The diagnosis is often refined at follow-up visits, and occasionally it takes me more than one or two visits to realize the truth concerning a given individual's condition and motive for treatment; some syndromes only become apparent when I embark upon a medication trial with a patient, and begin to receive feedback, especially those cases in which those reports are unexpected or seemingly paradoxical, but even unexpected reports nonetheless provide considerable, and important, diagnostic information to the astute, discerning mental healthcare practitioner.
By the end of our visit, I will share all of my initial diagnostic and prognostic impressions with the patient, supporting my assessment by highlighting the relevant facts, and educating, and sometimes debriefing, the patient about his or her symptoms and condition as much as possible. I will also provide treatment options, whenever feasible, and I will explain the rationale for selecting certain medication classes or specific agents in a target-symptom-based, evidence-based approach, and review the risks and benefits, so that the patient can provide his or her informed consent to treatment.