inside orange county cognitive therapy services

Psychiatric Evaluations

A psychiatric evaluation is a systematic assessment used by psychiatrists to identify the causes, symptoms, and course of a psychiatric illness. A psychiatric evaluation can be an initial assessment or a reevaluation of an ongoing problem. An initial psychiatric evaluation aims to formulate a diagnosis and devise a treatment plan based on the diagnosis.  If the evaluation is a reassessment of a patient, it will focus on revising the plan of treatment according to the new insights obtained from the evaluation. 

Diagnoses can include a wide range of mental health conditions, including but not limited to depression, anxiety, bipolar disorder, schizophrenia, and addiction. 

What is Included in a Psychiatric Evaluation?

In general, any psychiatric evaluation consists of an interview section and an examination part.

A. Psychiatry Interview

Psychiatric evaluation varies on a per patient basis. At Orange County, our trained specialists consider interviewing the patient as the core component of a psychiatric evaluation. 

The components typically covered during a psychiatric interview before making a clinical diagnosis and recommendation include:

1. Chief Complaint

You will be first inquired about the reason for the evaluation. For this, your psychiatrist will usually ask an open-ended question. For instance, “what brought you here today?”

The psychiatrist will also try to figure out the reason for evaluation from other involved parties (e.g., family, other healthcare providers) for seeking evaluation at this specific time.

2. History of Present Illness

This entails obtaining answers to the following questions:

For this section, you may also be given a patient health questionnaire to fill in prior to the start of the interview. Your psychiatrist will go through the questionnaire while interviewing you.

3. Past Psychiatric History 

If the evaluation is a reassessment, then your psychiatrist will need to know about:

  • The past outpatient visits
  • List of psychiatric medications tried in the past, including:
  • Past inpatient psychiatric hospitalizations
  • Suicidal history
  • History of violence
  • History of any Psychotherapy
  • 4. Substance Abuse (and Alcohol) History

    5. General Medical History

    6. Family History

    7. Psychiatric Review of Systems

    This section involves screening the patients for major psychiatric disorders. Your doctor will ask you a series of questions to rapidly screen you for:

    8. Developmental and Social History

    This section covers questions about your:

    9. Sexual History

    B. Mental Status Examination

    Mental Status Examination (MSE) is the psychological counterpart of a physical exam that evaluates a patient’s mental state and behaviors. During an MSE, we observe the patient (known as objective assessment) as well as ask questions (termed as subjective assessment).

    MSE can be regarded as a continuation of the interview and a part of the comprehensive physical examination.

    The MSE is composed of the following components: 

    Appearance and behavior

    This is the first step of an MSE. The doctor first observes: 

    Mood and Affect

    Thoughts

    Your thoughts will be assessed in terms of:

    Speech   

    Speech is assessed in terms of:

    Insight and judgment

    Insight: Do the patients understand that they are sick and need treatment?

    Sensorium and cognition

    This includes assessing:

    How Long Does It Take to Do a Psychiatric Evaluation?

    The duration of a psychiatric evaluation varies from one person to another. The degree of information needed can predict the duration of an assessment. Typically, a psychiatric evaluation lasts for 30 to 90 minutes. At Orange County, evaluations take approximately 2 hours to ensure a comprehensive and accurate evaluation.