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Assessment Process



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What the Assessment Includes

What the Assessment Includes

The purpose of a good assessment is to help the person clarify whether they have a medical condition, how it is affecting their functioning, and what type of treatment or support may be needed. With this information, the person and their loved ones are able to make informed decisions about their medical care and personal goals.
 
Typically, an assessment will include medical tests, interviews, observation and collection of history. There are usually multiple people involved in the assessment process, including a psychiatrist or psychiatric nurse practitioner, your primary care physician, a qualified mental health professional, and, in some circumstances, other specialists such as a neurologist or occupational therapist. In order to complete a thorough assessment, close friends or family members are usually asked for their input, as they are likely to detect changes in information processing and behavior which are difficult for the person to detect. Also, families and friends are a great resource for identifying the person's strengths. Also, psychosis interferes with the person’s ability to process information, and it may be difficult for them to report on their own medical situation. The following form was developed by EASA as a tool for families to provide input into the assessment process: Assessment Input Form (click to download PDF)

It is not uncommon for the diagnosis process to be ongoing over time. Some of the possible diagnoses require six months observation to confirm. You may be given a “rule-out” diagnosis, which means that additional observation or testing is needed to determine whether this diagnosis is correct.

Usually a preliminary diagnosis is made from the first interview, confirmed within approximately the first thirty days, and revisited periodically throughout treatment.

The following information will be important in any assessment:

Current situation:

How do you perceive what is going on- what do you observe? What changes or possible “symptoms” have you noticed:
  • Current illnesses and treatment you may be receiving
  • What medicines or supplements are you taking?
  • Physical changes with your body
  • Changes in your sleep and appetite
  • Changes in your moods
  • Changes in your thought process
History:
  • Illnesses that you or other family members have experienced
  • Injuries. Have you ever been knocked unconscious?
  • Allergies and adverse reactions to medicines
  • Drug use and reactions
  • Learning disabilities
  • progression
  • What do others around you observe (sometimes with neurochemical changes others notice changes when the individual doesn’t)
Current psychosocial situation:
  • How are these changes affecting your ability to focus at work/school and home?
  • How are they affecting relationships with others?
  • How are they affecting your ability to meet personal goals and priorities?
  • What information do you and your supporters have, and what do you need?
  • Do you have a strong support network?
  • Is your living situation stable and supportive of your healing process?
  • What are your personal goals and priorities, and are these changes interfering?
Medical tests:

Medical tests which EASA routinely recommends for people experiencing psychosis include:
  • CBC with differential
  • Chemistry panel (with liver enzymes, electrolytes, BUN, Cr, calcium)
  • Urine drug screen
  • Urinalysis, with microscopy
  • B-12 and folate
  • Thyroid screen (TSH, T4)
  • MRI or CT
  • Other tests indicated by additional medical conditions identified
The result of the assessment process is:
  • A clarification of preliminary diagnosis. In some cases, it may take a while to get a final diagnosis.
  • Identification of the type of treatment which is most likely to be helpful
  • Initial goals for treatment, based on your needs and priorities






  




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