《精神医学》课程教学资源（书籍文献）2006APA成人精神科评估（第二版）PRACTICE GUIDELINE FOR THE Psychiatric Evaluation of Adults Second Edition

PRACTICEGUIDELINEFOR THEPsychiatric Evaluationof AdultsSecond EditionWORKGROUPONPSYCHIATRICEVALUATIONMichael J. Vergare, M.D., ChairRenee L. Binder, M.DIan A. Cook, M.D.Marc Galanter, M.D.Francis G. Lu, M.D.This practice guideline was approved in December 2005 and published inJune2006.Aguidelinewatch,summarizingsignificantdevelopmentsinthescientificliteraturesincepublicationofthis guideline,maybeavailable inthePsychiatric Practicesection of the APAweb siteatwww.psych.orgCopyright 2010,American Psychiatric Association.APA makes this practice guideline freely available to promote its dissemination and use; however,copyrightprotections are enforced in full.Nopartof this guideline may be reproduced except as permitted under Sections 107 and 108of U.S.Copyright Act.Forpermissionforreuse,visitAPPIPermissions&LicensingCenterathttp://www.appi.org/CustomerService/Pages/Permissions.aspx

1 PRACTICE GUIDELINE FOR THE Psychiatric Evaluation of Adults Second Edition WORK GROUP ON PSYCHIATRIC EVALUATION Michael J. Vergare, M.D., Chair Renée L. Binder, M.D. Ian A. Cook, M.D. Marc Galanter, M.D. Francis G. Lu, M.D. This practice guideline was approved in December 2005 and published in June 2006. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at www.psych.org. 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

AMERICANPSYCHIATRICASSOCIATIONSTEERINGCOMMITTEEONPRACTICEGUIDELINESJohn S. Mclntyre, M.D.,ChairSara C. Charles, M.D.,Vice-ChairDaniel J.Anzia,M.DIan A. Cook, M.D.Molly T. Finnerty, M.D.Bradley R. Johnson, M.D.James E. Nininger, M.D.Paul Summergrad, M.D.Sherwyn M. Woods, M.D., Ph.D.Joel Yager, M.D.AREAANDCOMPONENTLIAISONSRobert Pyles, M.D. (Area I)C. Deborah Cross, M.D. (Area II)Roger Peele, M.D. (Area III)Daniel J. Anzia, M.D. (Area IV)John P. D.Shemo, M.D. (Area V)Lawrence Lurie, M.D. (Area VI)R. Dale Walker, M.D. (Area VII)MaryAnn Barnovitz,M.DSheila Hafter Gray, M.D.Sunil Saxena, M.D.Tina Tonnu, M.D.STAFFRobert Kunkle, M.A., Senior Program ManagerAmyB.Albert,B.A.,AssistantProjectManagerLaura J.Fochtmann, M.D., Medical EditorClaudiaHart,Director,DepartmentofQualityImprovementandPsychiatric ServicesDarrelA.Regier,M.D.,M.PH.,Director,DivisionofResearchCopyright 2010,American Psychiatric Association.APA makes this practice guideline freely available to promote its dissemination and use; however,copyrightprotections are enforced in full.No part of this guideline maybe 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

AMERICAN PSYCHIATRIC ASSOCIATION STEERING COMMITTEE ON PRACTICE GUIDELINES John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Paul Summergrad, M.D. Sherwyn M. Woods, M.D., Ph.D. Joel Yager, M.D. AREA AND COMPONENT LIAISONS Robert Pyles, M.D. (Area I) C. Deborah Cross, M.D. (Area II) Roger Peele, M.D. (Area III) Daniel J. Anzia, M.D. (Area IV) John P. D. Shemo, M.D. (Area V) Lawrence Lurie, M.D. (Area VI) R. Dale Walker, M.D. (Area VII) Mary Ann Barnovitz, M.D. Sheila Hafter Gray, M.D. Sunil Saxena, M.D. Tina Tonnu, M.D. STAFF Robert Kunkle, M.A., Senior Program Manager Amy B. Albert, B.A., Assistant Project Manager Laura J. Fochtmann, M.D., Medical Editor Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services Darrel A. Regier, M.D., M.P.H., Director, Division of Research 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

CONTENTSStatement of Intent.-Development Process6IntroductionPurpose of Evaluation...9General Psychiatric Evaluation..9A.B.10Emergency Evaluation.c.Clinical Consultafion.11D.Other Consultations.1112Il. Site of the Clinical Evaluation12A.Inpatient SettingsB.12Outpatient SettingsS13General Medical SettingsD.Other Settings.14儿Domains of the Clinical Evaluation14.14A.Reason forthe EvaluationB.History of the Present llness .14CPast Psychiatric History .1919D.History of Substance Use ..19General Medical History..E.20Developmental, Psychosocial, and Sociocultural History.E.21Occupational and Military History .....G21H.Leqal History....22Family History. .22J.Review of Systems..22KPhysical Examination.23LMental Status Examination. 25IV.福Evaluafion Process25A.Methods of Obtaining Information.. 37B. The Process of Assessment.40Special ConsiderationsV40APrivacy and Confidentiolity .AB.Interactions With Third-Party Payers and Their Agents..42Legal and Administrative Issues in InstitutionsC.42D.Special Populations..3PsychiatricEvaluofionof AdulsCopyright 201o,American Psychiatric Association.APA makes 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 ofU.S.Copyright Act.For permissionforreuse,visitAPPIPermissions&LicensingCenterathttp://www.appi.org/CustomerService/Pages/Permissions.aspx

Psychiatric Evaluation of Adults 3 CONTENTS Statement of Intent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 I. Purpose of Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A. General Psychiatric Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 B. Emergency Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 C. Clinical Consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 D. Other Consultations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 II. Site of the Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 A. Inpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 B. Outpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 C. General Medical Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 D. Other Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 III. Domains of the Clinical Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 A. Reason for the Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 B. History of the Present Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 C. Past Psychiatric History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 D. History of Substance Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 E. General Medical History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 F. Developmental, Psychosocial, and Sociocultural History. . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 G. Occupational and Military History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 H. Legal History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 I. Family History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 J. Review of Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 K. Physical Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 L. Mental Status Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 IV. Evaluation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 A. Methods of Obtaining Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 B. The Process of Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 V. Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 A. Privacy and Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 B. Interactions With Third-Party Payers and Their Agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 C. Legal and Administrative Issues in Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 D. Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 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

...44VI.Future Research Needs......44A.Interviewing Approaches...45B.Rating Scales .....45C.Diagnosis and FormulationD......45Diagnostic Testing....46Individuals and Organizations That Submited Comments5...47References4APA Practice GuidelinesCopyright 2010,American Psychiatric Association.APA makes 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

4 APA Practice Guidelines VI. Future Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 A. Interviewing Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 B. Rating Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 C. Diagnosis and Formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 D. Diagnostic Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Individuals and Organizations That Submitted Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 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

STATEMENT OF INTENTThe American Psychiatric Association (APA) Practice Guidelines are not intended to be con-strued or to serve as a standard of medical care. Standards of medical care are determined onthe basis of all clinical data available for an individual patient and are subject to change as sci-entific knowledge and technology advance and practice patterns evolve. These parameters ofpractice should be considered guidelines only. Adherence to them will not ensure a successfuloutcome for every individual, nor should they be interpreted as including all proper methodsof care or excluding other acceptable methods of care aimed at the same results. The ultimatejudgment regarding a particular clinical procedure or treatment plan must be made by the psy-chiatrist in light of the clinical data presented by the patient and the diagnostic and treatmentoptionsavailableThis practice guideline has been developed by psychiatrists who are in active clinical prac-tice. In addition, some contributors are primarily involved in research or other academicendeavors. It is possible that through such activities some contributors, including work groupmembers and reviewers, have received income related to treatments discussed in this guide-line.A number of mechanisms are inplaceto minimize the potential for producing biasedrecommendations due to conflicts of interest. Work group members are selected on the basisof their expertise and integrity.Any work groupmember or reviewer who has a potential con-flict of interest that may bias (or appear to bias) his or her work is asked to disclose this to theSteering Committee on Practice Guidelines and the work group. Iterative guideline drafts arereviewed by the Steering Committee, other experts, allied organizations, APA members, andthe APA Assembly and Board of Trustees; substantial revisions address or integrate the com-ments of these multiple reviewers. The development of the APA practice guidelines is notfinancially supported by any commercial organization.More detail about mechanisms in place to minimize bias is provided in a document avail-able from the APA Department of Quality Improvement and Psychiatric Services, “APAGuideline Development Process."This practice guideline was approved in December 2005 and published in June20065Psychiatric 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,visit APPIPermissions&LicensingCenterathttp:/www.appi.org/CustomerService/Pages/Permissions.aspx

Psychiatric Evaluation of Adults 5 STATEMENT OF INTENT The American Psychiatric Association (APA) Practice Guidelines are not intended to be con￾strued or to serve as a standard of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as sci￾entific knowledge and technology advance and practice patterns evolve. These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psy￾chiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. This practice guideline has been developed by psychiatrists who are in active clinical prac￾tice. In addition, some contributors are primarily involved in research or other academic endeavors. It is possible that through such activities some contributors, including work group members and reviewers, have received income related to treatments discussed in this guide￾line. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. Work group members are selected on the basis of their expertise and integrity. Any work group member or reviewer who has a potential con￾flict of interest that may bias (or appear to bias) his or her work is asked to disclose this to the Steering Committee on Practice Guidelines and the work group. Iterative guideline drafts are reviewed by the Steering Committee, other experts, allied organizations, APA members, and the APA Assembly and Board of Trustees; substantial revisions address or integrate the com￾ments of these multiple reviewers. The development of the APA practice guidelines is not financially supported by any commercial organization. More detail about mechanisms in place to minimize bias is provided in a document avail￾able from the APA Department of Quality Improvement and Psychiatric Services, “APA Guideline Development Process.” This practice guideline was approved in December 2005 and published in June 2006. 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

DEVELOPMENTPROCESSThis practice guideline was developed under the auspices of the Steering Committee on Prac-tice Guidelines.The development process is detailed in a document availablefrom theAPADepartment of Quality Improvement and Psychiatric Services, the“APA Guideline Develop-ment Process." Key features of this process include the following::A comprehensive literature review.Development of evidence tablesInitial drafting of the guideline by a work group that included psychiatrists with clinicaland research expertise in psychiatric evaluationProduction of multiple revised drafts with widespread review (14 organizations and64individuals submitted significantcomments)·Approvalby theAPAAssemblyand Board of TrusteesPlannedrevisionsatregularintervalsRelevant literature was identified through a computerized search of MEDLINE, usingPubMed, for the period from 1994 to 2005. The search strategy (psychiatric assessment ORpsychiatric assessmentsORpsychiatric emergencies OR psychiatricemergency ORpsychiatricevaluation OR psychiatric evaluations OR psychiatric histories OR psychiatric history ORpsychiatric interview OR psychiatric interviewing OR psychiatric interviews OR psychologicalassessment OR psychological assessments OR psychological evaluation OR psychological in-terviewORmental status examinationORmental status examinations ORpsychiatric rating)OR(mentaldisorders/diagnosisAND[laboratoryfindingsORlaboratorytechniquesORlab-oratorytest ORlaboratorytestsORradiographORradiographicORradiographyORxrayORimagingORMRIORtomographyORphysicalexamORphysical examinationORin-terview OR interviewing OR history taking OR evaluation OR assessmentl) yielded 19,429references, of which 7,894 were published between 1994 and 2005 in English and had associ-ated abstracts.An additional searchon historytakingAND(psychiatricOR sexual OR occu-pational OR social OR psychosocial) yielded 1,927 references, with 731 of these publishedwith abstracts in English between the years 1994 and 2005.Additional, more limited searches were conducted by APA staff and individual members ofthe Work Group on Psychiatric Evaluation to address discrete issues outside of the primaryguideline topic.This document represents a synthesis of current scientific knowledge and rational clinicalpractice on the psychiatric evaluation of adults.It strives to be as free as possible ofbias towardanytheoretical approach6APA Practice GuidelinesCopyright 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

6 APA Practice Guidelines DEVELOPMENT PROCESS This practice guideline was developed under the auspices of the Steering Committee on Prac￾tice Guidelines. The development process is detailed in a document available from the APA Department of Quality Improvement and Psychiatric Services, the “APA Guideline Develop￾ment Process.” Key features of this process include the following: • A comprehensive literature review • Development of evidence tables • Initial drafting of the guideline by a work group that included psychiatrists with clinical and research expertise in psychiatric evaluation • Production of multiple revised drafts with widespread review (14 organizations and 64 individuals submitted significant comments) • Approval by the APA Assembly and Board of Trustees • Planned revisions at regular intervals Relevant literature was identified through a computerized search of MEDLINE, using PubMed, for the period from 1994 to 2005. The search strategy (psychiatric assessment OR psychiatric assessments OR psychiatric emergencies OR psychiatric emergency OR psychiatric evaluation OR psychiatric evaluations OR psychiatric histories OR psychiatric history OR psychiatric interview OR psychiatric interviewing OR psychiatric interviews OR psychological assessment OR psychological assessments OR psychological evaluation OR psychological in￾terview OR mental status examination OR mental status examinations OR psychiatric rating) OR (mental disorders/diagnosis AND [laboratory findings OR laboratory techniques OR lab￾oratory test OR laboratory tests OR radiograph OR radiographic OR radiography OR x ray OR imaging OR MRI OR tomography OR physical exam OR physical examination OR in￾terview OR interviewing OR history taking OR evaluation OR assessment]) yielded 19,429 references, of which 7,894 were published between 1994 and 2005 in English and had associ￾ated abstracts. An additional search on history taking AND (psychiatric OR sexual OR occu￾pational OR social OR psychosocial) yielded 1,927 references, with 731 of these published with abstracts in English between the years 1994 and 2005. Additional, more limited searches were conducted by APA staff and individual members of the Work Group on Psychiatric Evaluation to address discrete issues outside of the primary guideline topic. This document represents a synthesis of current scientific knowledge and rational clinical practice on the psychiatric evaluation of adults. It strives to be as free as possible of bias toward any theoretical approach. 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

INTRODUCTIONPsychiatric evaluationsvaryaccording to their purpose.This guideline is intended primarilyforgeneral,emergency,and consultation evaluationsfor clinical purposes.It is applicable to evaluations conducted by a psychiatrist with adult patients (age 18 or older),although sections maybe applicable to younger patients. Other types of psychiatric evaluations (including forensic,childcustody,and disability evaluations) are not thefocus ofthis guideline; however, the general rec-ommendations of this guideline may be applicable to other, more specialized evaluations.The guideline presumes familiarity with basic principles of psychiatric diagnosis and treat-ment planning as outlined in standard, contemporary psychiatric textbooks (1-6) and taughtin psychiatry residency training programs. It was developed following a review of contemporaryreferences, and it emphasizes areas of consensus in the field.Recommendations of this guideline are intended to be consistent with the care model en-dorsed in the Institute of Medicine report Crossing the Quality Chasm (7).This report notes thatwith advancements in medical science, the emphasis ofhealth care delivery must shift to ongo-ing management of chronic conditions. The initial psychiatric evaluation may set the stage forsuch ongoing care by establishing initial treatment goals, gathering relevant baseline data, estab-lishing a plan for systematic follow-up assessment using formal but practical and relevant mea-sures, and ensuring longitudinal follow-up.While there is broad agreement that each element of the extensive general evaluation de-scribed in this guideline may be relevant or even crucial in a particular patient, the specific em-phasis of an evaluation will vary according to its purpose and the patient's presenting problem.Consideration of the domains outlined in this guideline is part of a general psychiatric evalua-tion, but thecontent, process, and documentationmust bedetermined by applyingthepro-fessional skill and judgment of the psychiatrist. The performance of a particular set of clinicalprocedures does not ensure the adequacy of a psychiatric evaluation, nor does their omissionimply that the evaluation is deficient. The particular emphasis or modifications applied by thepsychiatrist to the generic evaluation offered in this guideline should be consonant with theaims of the evaluation, the setting of practice, the patient's presenting problem, and the ever-evolving knowledge base concerning clinical assessment and clinical inference. Although doc-umentation is an integral part ofan evaluation, it is important to emphasize that the scope anddetailof clinically appropriate documentation also will vary with the patient, setting, clinical sit-uation, and confidentiality issues. Because of the wide variation in these factors, this guidelinedoes not include recommendations regarding the content or frequency of documentation.Such determinations must be based on the specific circumstances of the evaluation.To share feedback on this or other published APA practice guidelines, a form is available athttp://www.psych.org/psych_pract/pg/reviewform.cfm.1Psychiatric 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,visit APPIPermissions&LicensingCenterathttp:/www.appi.org/CustomerService/Pages/Permissions.aspx

Psychiatric Evaluation of Adults 7 INTRODUCTION Psychiatric evaluations vary according to their purpose. This guideline is intended primarily for general, emergency, and consultation evaluations for clinical purposes. It is applicable to eval￾uations conducted by a psychiatrist with adult patients (age 18 or older), although sections may be applicable to younger patients. Other types of psychiatric evaluations (including forensic, child custody, and disability evaluations) are not the focus of this guideline; however, the general rec￾ommendations of this guideline may be applicable to other, more specialized evaluations. The guideline presumes familiarity with basic principles of psychiatric diagnosis and treat￾ment planning as outlined in standard, contemporary psychiatric textbooks (1–6) and taught in psychiatry residency training programs. It was developed following a review of contemporary references, and it emphasizes areas of consensus in the field. Recommendations of this guideline are intended to be consistent with the care model en￾dorsed in the Institute of Medicine report Crossing the Quality Chasm (7). This report notes that with advancements in medical science, the emphasis of health care delivery must shift to ongo￾ing management of chronic conditions. The initial psychiatric evaluation may set the stage for such ongoing care by establishing initial treatment goals, gathering relevant baseline data, estab￾lishing a plan for systematic follow-up assessment using formal but practical and relevant mea￾sures, and ensuring longitudinal follow-up. While there is broad agreement that each element of the extensive general evaluation de￾scribed in this guideline may be relevant or even crucial in a particular patient, the specific em￾phasis of an evaluation will vary according to its purpose and the patient’s presenting problem. Consideration of the domains outlined in this guideline is part of a general psychiatric evalua￾tion, but the content, process, and documentation must be determined by applying the pro￾fessional skill and judgment of the psychiatrist. The performance of a particular set of clinical procedures does not ensure the adequacy of a psychiatric evaluation, nor does their omission imply that the evaluation is deficient. The particular emphasis or modifications applied by the psychiatrist to the generic evaluation offered in this guideline should be consonant with the aims of the evaluation, the setting of practice, the patient’s presenting problem, and the ever￾evolving knowledge base concerning clinical assessment and clinical inference. Although doc￾umentation is an integral part of an evaluation, it is important to emphasize that the scope and detail of clinically appropriate documentation also will vary with the patient, setting, clinical sit￾uation, and confidentiality issues. Because of the wide variation in these factors, this guideline does not include recommendations regarding the content or frequency of documentation. Such determinations must be based on the specific circumstances of the evaluation. To share feedback on this or other published APA practice guidelines, a form is available at http://www.psych.org/psych_pract/pg/reviewform.cfm. 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

Copyright 2010,American Psychiatric Association.APA makes this practice guideline freely available to promote its dissemination and use; however, copyrightprotections are enforced in full.No part of this guideline maybe 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

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

I.PURPOSEOFEVALUATIONThe purpose and conductofa psychiatric evaluation dependon who requests the evaluation, whyit is requested, and the expected future role of the psychiatrist in the patient's care. The outcomeof the evaluation may or may not lead to a specific psychiatric diagnosis.Three types of dlinicalpsychiatric evaluations are discussed: I) general psychiatric evaluation, 2) emergency evaluation,and 3) clinical consultation. In addition,general principles to guide the conduct ofevaluationsfor administrative or legal purposes are reviewed.At times there may be a conflict between theneed to establish an effective working relationship with the patient and the need to obtain com-prehensive information efficiently. If the psychiatrist expects to provide care directly to the patient,the establishment of an effective working relationship with the patient may take precedenceover the comprehensiveness of the initial interview or interviews (8). In such a case, emphasismay be placed on obtaining information needed for immediate clinical recommendations anddecisions (9).A.GENERALPSYCHIATRICEVALUATIONA general psychiatric evaluation has as its central component an interview with the patient. Theinterview-based data are integrated with information that may be obtained through other com-ponents of the evaluation, such as a review of medical records,a physical examination, diagnostic tests, and history from collateral sources.Ageneral evaluation usually is time intensiveThe amount of time necessary generally depends on the complexity of the problem and thepatient's ability and willingness to work cooperatively with the psychiatrist. Language compe-tence needs to be assessed early in the evaluation so that the need for an interpreter can be de-termined. Several meetings with the patient, and in many cases appropriate family or relationalnetwork members, may be necessary. More focused evaluations of lesser scope may be appro-priate when the psychiatrist is called on to address a specific, limited diagnostic or therapeuticissue.The aims ofa general psychiatric evaluation are 1) to establish whether a mental disorder orother condition requiring the attention ofa psychiatrist is present; 2) to collect data sufficientto support differential diagnosis and a comprehensive clinical formulation; 3) to collaboratewith the patient to develop an initial treatment plan that willfoster treatment adherence, withparticular consideration of any immediate interventions that may be needed to address the safetyof the patient and others—or, if the evaluation is a reassessment of a patient in long-termtreatment, to revise the plan of treatment in accordance with new perspectives gained from theevaluation; and 4) to identify longer-term issues (eg-, premorbid personality) that need to beconsidered infollow-upcareIn the course of any evaluation, it may be necessary to obtain history from other individuals(e-g-, family or others with whom the patient resides; individuals referring the patient forassessment,including other clinicians).Although the default position is to maintain confi-dentiality unless the patient gives consent to a specific intervention or communication, the psy-chiatrist is justified in attenuating confidentiality to the extent needed to address the safety ofthe patient and others (10, 11). In addition, the psychiatrist can elicit and listen to informationprovided by friends or family without disclosing information about the patient to the infor-mant.More detailed recommendations for performing ageneral psychiatric evaluation are providedinSection III.9Psychiatric 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 maybe 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 9 I. PURPOSE OF EVALUATION The purpose and conduct of a psychiatric evaluation depend on who requests the evaluation, why it is requested, and the expected future role of the psychiatrist in the patient’s care. The outcome of the evaluation may or may not lead to a specific psychiatric diagnosis. Three types of clinical psychiatric evaluations are discussed: 1) general psychiatric evaluation, 2) emergency evaluation, and 3) clinical consultation. In addition, general principles to guide the conduct of evaluations for administrative or legal purposes are reviewed. At times there may be a conflict between the need to establish an effective working relationship with the patient and the need to obtain com￾prehensive information efficiently. If the psychiatrist expects to provide care directly to the patient, the establishment of an effective working relationship with the patient may take precedence over the comprehensiveness of the initial interview or interviews (8). In such a case, emphasis may be placed on obtaining information needed for immediate clinical recommendations and decisions (9).
A. GENERAL PSYCHIATRIC EVALUATION A general psychiatric evaluation has as its central component an interview with the patient. The interview-based data are integrated with information that may be obtained through other com￾ponents of the evaluation, such as a review of medical records, a physical examination, diag￾nostic tests, and history from collateral sources. A general evaluation usually is time intensive. The amount of time necessary generally depends on the complexity of the problem and the patient’s ability and willingness to work cooperatively with the psychiatrist. Language compe￾tence needs to be assessed early in the evaluation so that the need for an interpreter can be de￾termined. Several meetings with the patient, and in many cases appropriate family or relational network members, may be necessary. More focused evaluations of lesser scope may be appro￾priate when the psychiatrist is called on to address a specific, limited diagnostic or therapeutic issue. The aims of a general psychiatric evaluation are 1) to establish whether a mental disorder or other condition requiring the attention of a psychiatrist is present; 2) to collect data sufficient to support differential diagnosis and a comprehensive clinical formulation; 3) to collaborate with the patient to develop an initial treatment plan that will foster treatment adherence, with particular consideration of any immediate interventions that may be needed to address the safety of the patient and others—or, if the evaluation is a reassessment of a patient in long-term treatment, to revise the plan of treatment in accordance with new perspectives gained from the evaluation; and 4) to identify longer-term issues (e.g., premorbid personality) that need to be considered in follow-up care. In the course of any evaluation, it may be necessary to obtain history from other individuals (e.g., family or others with whom the patient resides; individuals referring the patient for assessment, including other clinicians). Although the default position is to maintain confi￾dentiality unless the patient gives consent to a specific intervention or communication, the psy￾chiatrist is justified in attenuating confidentiality to the extent needed to address the safety of the patient and others (10, 11). In addition, the psychiatrist can elicit and listen to information provided by friends or family without disclosing information about the patient to the infor￾mant. More detailed recommendations for performing a general psychiatric evaluation are provided in Section III. 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

B.EMERGENCYEVALUATIONTheemergency psychiatricevaluation generllyocurs in response tothoughs,feelings,orurgsto act that are intolerable to the patient, or to behavior that prompts urgent action by others, suchas violent or self-injurious behavior, threats of harm to self or others, failure to care for oneself,bizarreor confused behavior, or intense expressions ofdistress.The aims and specific approachesto the emergency evaluation have been reviewed elsewhere in detail (11-15) and include thefollowing:1. Assess and enhance the safety of the patient and others.2. Establish a provisional diagnosis (or diagnoses) of the mental disorder(s) most likely tobe responsiblefor the current emergency, including identification ofany general medicalcondition(s) or substance use that is causing or contributing to the patient's mentalcondition.3. Identify family or other involved persons who can give information that will help thepsychiatrist determine the accuracy of reported history, particularly if the patient is cogni-tively impaired, agitated,or psychotic and has difficulty communicatinga history ofevents.If the patient is to be discharged back to family members or other caretaking persons,their ability to care for the patient and their understanding of the patient's needs mustbeaddressed.4. Identify any current treatment providers who can give information relevant to the evaluation.5.Identify social, environmental, and cultural factors relevant to immediatetreatmentdecisions.6. Determine whether the patient is able and willing to form an alliance that will supportfurther assessment and treatment, what precautions are needed if there is a substantialrisk of harm to self or others, and whether involuntary treatment is necessary.7.Develop a specificplanforfollow-up,including immediate treatment and disposition;determine whether the patient requires treatment in a hospital or other supervised settingand what follow-up will be required if the patient is not placed in a supervised setting.The emergency evaluation varies greatly in length and may on occasion exceed severalhours. Patients who will be discharged to the community after an emergency evaluation mayrequire more extensive evaluation in the emergency setting than those who will be hospitalizedFor example, patients who have presented with intoxication or who have received medicationsin the emergency department mayrequire additional observation to verify their stabilityfordischarge.In other individuals with significant symptoms but without apparent acute risk toself or others,additional time maybe needed to obtain more detailed input from family, otherinvolved caretaking persons, and treatment providers; to verify that the proposed plan of fol-low-up is viable; and to communicate with follow-up caregivers about interventions or recom-mendations resulting from the emergency assessment.When patients are agitated, psychotic,or uncooperative with assessment,and when their clinicalpresentation appears to differ from the stated factors prompting assessment, it may be especially im-portant to obtain historyfrom other individuals (eg,family members, other professionals, police),keeping in mind principles of confidentiality, as described in Section I.A above and in Section VA.Patients presenting for emergency psychiatric evaluation have a high prevalence of com-bined general medical and psychiatric illness, recent trauma, substance use and substance-related conditions, and cognitive impairment (16-27). These diagnostic possibilities deservecareful consideration. General medical and psychiatric evaluations should be coordinated sothat additional medical evaluation can be requested or initiated by the psychiatrist on the basisof diagnostic or therapeutic considerations arising from the psychiatric history and interview.Although issues ofconfidentiality are sometimes raised, in an emergency situation necessary in-formation about the patient can be communicated with the emergency medicine department10APA PracticeGuidelinesCopyright 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 permissionfor reuse,visit APPIPermissions&Licensing Centerat http://www.appi.org/CustomerService/Pages/Permissions.aspx

10 APA Practice Guidelines
B. EMERGENCY EVALUATION The emergency psychiatric evaluation generally occurs in response to thoughts, feelings, or urges to act that are intolerable to the patient, or to behavior that prompts urgent action by others, such as violent or self-injurious behavior, threats of harm to self or others, failure to care for oneself, bizarre or confused behavior, or intense expressions of distress. The aims and specific approaches to the emergency evaluation have been reviewed elsewhere in detail (11–15) and include the following: 1. Assess and enhance the safety of the patient and others. 2. Establish a provisional diagnosis (or diagnoses) of the mental disorder(s) most likely to be responsible for the current emergency, including identification of any general medical condition(s) or substance use that is causing or contributing to the patient’s mental condition. 3. Identify family or other involved persons who can give information that will help the psychiatrist determine the accuracy of reported history, particularly if the patient is cogni￾tively impaired, agitated, or psychotic and has difficulty communicating a history of events. If the patient is to be discharged back to family members or other caretaking persons, their ability to care for the patient and their understanding of the patient’s needs must be addressed. 4. Identify any current treatment providers who can give information relevant to the evaluation. 5. Identify social, environmental, and cultural factors relevant to immediate treatment decisions. 6. Determine whether the patient is able and willing to form an alliance that will support further assessment and treatment, what precautions are needed if there is a substantial risk of harm to self or others, and whether involuntary treatment is necessary. 7. Develop a specific plan for follow-up, including immediate treatment and disposition; determine whether the patient requires treatment in a hospital or other supervised setting and what follow-up will be required if the patient is not placed in a supervised setting. The emergency evaluation varies greatly in length and may on occasion exceed several hours. Patients who will be discharged to the community after an emergency evaluation may require more extensive evaluation in the emergency setting than those who will be hospitalized. For example, patients who have presented with intoxication or who have received medications in the emergency department may require additional observation to verify their stability for discharge. In other individuals with significant symptoms but without apparent acute risk to self or others, additional time may be needed to obtain more detailed input from family, other involved caretaking persons, and treatment providers; to verify that the proposed plan of fol￾low-up is viable; and to communicate with follow-up caregivers about interventions or recom￾mendations resulting from the emergency assessment. When patients are agitated, psychotic, or uncooperative with assessment, and when their clinical presentation appears to differ from the stated factors prompting assessment, it may be especially im￾portant to obtain history from other individuals (e.g., family members, other professionals, police), keeping in mind principles of confidentiality, as described in Section I.A above and in Section V.A. Patients presenting for emergency psychiatric evaluation have a high prevalence of com￾bined general medical and psychiatric illness, recent trauma, substance use and substance￾related conditions, and cognitive impairment (16–27). These diagnostic possibilities deserve careful consideration. General medical and psychiatric evaluations should be coordinated so that additional medical evaluation can be requested or initiated by the psychiatrist on the basis of diagnostic or therapeutic considerations arising from the psychiatric history and interview. Although issues of confidentiality are sometimes raised, in an emergency situation necessary in￾formation about the patient can be communicated with the emergency medicine department 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