3
Assessment
Recommended Aspects of the Initial Psychiatric Evaluation
History of Present Illness
• Reason that the patient is presenting for evaluation, including current
symptoms, behaviors, and precipitating factors
• Current psychiatric diagnoses and psychiatric review of systems
Psychiatric History
• Hospitalization and emergency department visits for psychiatric issues,
including SUDs.
• Psychiatric treatments (type, duration, and, where applicable, doses)
• Response and adherence to psychiatric treatments, including psychosocial
treatments, pharmacotherapy, and other interventions such as
electroconvulsive therapy or transcranial magnetic stimulation
• Prior psychiatric diagnoses and symptoms, including:
▶ Hallucinations (including command hallucinations), delusions, and negative
symptoms
▶ Aggressive ideas or behaviors (e.g., homicide, domestic or workplace
violence, other physically or sexually aggressive threats or acts)
▶ Impulsivity
▶ Suicidal ideas, suicide plans, and suicide attempts, including details of each
attempt (e.g., context, method, damage, potential lethality, intent) and
attempts that were aborted or interrupted
▶ Intentional self-injury in which there was no suicide intent
Substance Use History
• Use of tobacco, alcohol, and other substances (e.g., vaping, marijuana,
cocaine, heroin, hallucinogens) and any misuse of prescribed or over-the-
counter medications or supplements
• Current or recent substance use disorder or change in use of alcohol or other
substances
Statement 3 - Treatment Planning
➤ APA recommends (1C) that a patient with BPD have a documented,
comprehensive, and person-centered treatment plan.
Statement 4 - Discussion of Diagnosis and Treatment
➤ APA recommends (1C) that a patient with BPD be engaged in a
collaborative discussion about their diagnosis and treatment, which
includes psychoeducation related to BPD.
