The medical psychological evaluation plays a central role in psychiatry, psychosomatics, and psychotherapy. An important component of the psychological evaluation is the medical history. This is a detailed conversation between the doctor and the patient. The medical history provides the most important information regarding the type of mental disorder present.
A comprehensive medical psychological evaluation includes:
- A review of the patient’s current medical history and past medical history. Both mental and physical illnesses are important
- A review of the patient’s life history and the occurrence of mental illnesses in the family
- A description of the patient’s current mental state (= psychopathological findings)
- A physical examination and, if necessary, the ordering of further tests. These may include: additional psychological testing or diagnostic imaging tests such as an EEG or CT scan to rule out physical causes of the mental symptoms
The most important psychopathological symptoms include:
- Disorientation: The patient is unable to orient themselves, e.g., regarding time, place, or situation. Occurs, for example, in cases of dementia or delirium
- Memory disturbances: These manifest as short-term memory impairment, for example, in cases of dementia or depression
- Concentration difficulties: Occur in many mental disorders
- Formal thought disorders: The flow of thought is disrupted. For example, disorganized thinking in schizophrenia: The train of thought is completely jumbled and no longer comprehensible
- Content-related thought disorders: The content of thoughts is disturbed; for example, delusional thoughts in schizophrenia involving pathologically false beliefs about reality. For example, the belief that one is being poisoned or persecuted, even when there is no objective evidence to support this
- Perceptual disturbances (hallucinations): The patient sees, hears, smells, or tastes things that are not there. These typically manifest as hearing voices in schizophrenia
- Thought disturbances: The belief that one’s own thoughts are being taken away, spreading, or being implanted by an external source. This also includes the feeling of being remotely controlled from the outside (experience of external influence). Typically occurs in schizophrenia
- Affective symptoms: Manifesting as a lack of joy, loss of interest, and increased fatigue in depression, or as an elevated (euphoric) or irritable mood in mania
- Anxiety: Manifesting as situational anxiety (panic disorder, phobias) or non-specific anxiety (generalized anxiety disorder)
- Motivational disturbances: Inhibition or increased drive to do certain things. Occurs in depression and mania
- Suicidal ideation: Thoughts of no longer wanting to live or plans to take one’s own life. Occurs in all mental disorders, most commonly in depression, substance use disorders, and schizophrenia. A patient’s suicidal statements must always be taken very seriously! Statements such as “People who talk about suicide don’t actually do it anyway” or similar remarks are false—patients with suicidal thoughts must always be referred as soon as possible to a specialist in psychiatry and psychotherapy or to a psychiatric hospital! Patients who are suicidal must never be left alone!
Individual symptoms are never pathological in and of themselves, nor do they ever occur exclusively with a specific illness. Only the overall picture of the symptoms, together with the other test results, can lead to a diagnosis. An accurate diagnosis is the foundation for successful treatment.
In psychiatry, psychosomatics, and psychotherapy, confidentiality is of particular importance. Mental health symptoms are often stigmatized (rejected) by the general public and are associated with feelings of shame for patients.
All medical and other staff members at a hospital or practice are bound by confidentiality. They may therefore only disclose information if the patient has expressly consented to it. This also applies to family members.
Mental disorders must always be considered on an individual basis; the focus is on the patient and their well-being. Nevertheless, standardized assessment and examination procedures also play a role in psychology. They serve to facilitate better classification and comparison. Under certain conditions, they can supplement the psychological examination conducted during a medical consultation. Specifically:
- To objectively assess the suspicion of a mental disorder. These include, for example, standardized interviews whose results can be evaluated according to predetermined criteria. For example, the “Statistical Clinical Interview Based on the American Diagnostic System DSM-IV” (SKID).
- To determine the severity of disorders. Such questionnaires exist for almost all mental health conditions. For example, the “Beck Depression Inventory (BDI),” which assesses the severity of depressive symptoms.
- To describe the impairments in even greater detail. These include, for example, questionnaires that survey a wide range of different symptoms to form a comprehensive picture. For example, the “Symptom Checklist-90” (SCL-90).
All assessment methods are categorized as
- third-party assessment methods (which are completed by the examiner) and
- self-report measures (which the patient completes themselves).
In almost all clinics, patients complete such questionnaires at the beginning and end of treatment. This is important for better tracking the course of therapy and for implementing measures to improve outcomes.
Psychological testing is typically used to analyze specific aspects of mental functioning, such as
- perception,
- concentration,
- memory, or
- motor skills.
Psychological testing is most commonly used in psychiatry to
- measuring intelligence (usually with the Hamburg-Wechsler Intelligence Test for Adults, HAWIE) and
- assessing concentration and attention (e.g., using the Concentration Performance Test or the d2 Attention Load Test)
.
However, psychological testing can also be expanded to address certain other psychological symptoms. On average, the additional testing takes about one hour.
Psychological assessment is conducted within the framework of forensic psychiatry. It deals specifically with offenders. The term “forensics” is derived from the Latin forum, meaning “market” or “courtroom.”
Forensic psychiatry assesses, in particular, criminal responsibility in cases involving mentally ill individuals who have committed crimes. This is important when a mentally ill person commits a crime while in a state of acute mental disorder. In such cases, criminal responsibility may be waived or diminished. This is regulated in Sections 20 and 21 of the Criminal Code (StGB).
The Criminal Code also governs the commitment of mentally ill offenders. They are generally placed in specialized forensic psychiatric hospitals.
The following types of offenses are most common in assessment practice:
- alcohol-related offenses,
- crimes of passion,
- Sexual offenses, and
- theft.
If a mental disorder is of a prolonged duration and significant severity, the individual may be deemed legally incompetent. This is governed by §104 of the German Civil Code (BGB).
Patients with severe mental illness are often no longer able to live independently. This includes, for example, patients with schizophrenia or Alzheimer’s disease. In such cases, guardianship must be established for them.
The Guardianship Act (§§ 1896–1908 BGB), in effect since January 1, 1992, supersedes the provisions of
- § 6 BGB (incapacitation),
- § 114 BGB (limited legal capacity of persons under guardianship),
- § 1906 (provisional guardianship), and
- § 1910 (guardianship for care)
. By using the term “guardianship,” this legislation emphasizes that the patient is not completely deprived of legal capacity or placed under guardianship. Rather, through a guardian, the patient is given the opportunity to shape their life according to their own wishes within the limits of their abilities.
To establish guardianship, the court must hear from the person concerned. In addition, a medical report is required that provides information on
- the necessity of guardianship,
- the expected duration of the need for guardianship, and
- the scope of the guardian’s responsibilities
. Typical areas of responsibility covered by guardianship include
- financial management,
- health care, and
- determination of place of residence.
In special cases, other areas of responsibility may also be defined. The person concerned may also file an application for guardianship themselves. More often, however, the applicants are
- spouses,
- relatives,
- doctors, or
- public prosecutors.
These individuals then usually assume the role of guardian. Guardianship may only be maintained for as long as it is necessary. The conditions for guardianship must be reviewed no later than five years after its establishment, or one year in the case of involuntary commitment.
Committal of Mentally Ill Patients to a Psychiatric Hospital
In cases of acute danger to themselves or others, people with mental illness must be placed under guardianship. Under certain circumstances, this may involve involuntary admission to a psychiatric hospital and treatment against their will. This measure serves to protect them and others.
Such measures are regulated on a state-by-state basis under the state hospitalization laws (UBG).
The consultation with the psychologist is an important aspect of psychological assessment © VadimGuzhva | AdobeStock
As a result of mental illness, patients may become unable to work or earn a living. The requirements for this are regulated by social security law.
An insured person is considered unable to work if “their earning capacity, as a result of illness or other infirmity or weakness of their physical or mental faculties, has declined to less than half that of a physically and mentally healthy insured person with similar training and equivalent knowledge and skills.” (Section 43(2) of Book VI of the Social Code).
An insured person is considered unable to work “if, as a result of illness or other infirmities or weakness of their physical or mental faculties, they can no longer engage in gainful employment with a certain degree of regularity for an indefinite period of time, or can no longer earn more than only minimal income through gainful employment.” (§ 44(2) Social Code Book VI).
If incapacity for work is determined, the insured person is entitled to a disability pension. A determination of occupational disability as part of a psychological evaluation entitles the insured person to an occupational disability pension. This amounts to two-thirds of the disability pension.
Since 2001, in new cases, the reduced earning capacity pension has replaced the disability pension and the occupational disability pension. A full reduced earning capacity pension is granted to those who can work less than 3 hours per day. A half reduced earning capacity pension is granted to those who can work 3 to 6 hours per day.
The determination of a person’s incapacity for work, occupational disability, or inability to perform official duties is made by a court or administrative authority. The psychiatric expert only provides an opinion
- whether a patient can work regularly and
- what activities they can perform and to what extent without harming their health.
Rehabilitation measures are funded
- by the pension insurance carriers,
- the Employment Promotion Act, and
- the Federal Social Welfare Act.
The goal is to restore the ability to work and to promote the reintegration of people with mental illness. The same principle applies to patients with mental illness: rehabilitation takes precedence over retirement.
An expert assessor determines the degree of incapacity for work. The assessor evaluates not only the reduction in work capacity but also the prospects for rehabilitation.
Mental disorders and the use of psychotropic medications can impair a person’s fitness to drive motor vehicles. This is also determined as part of a psychological assessment.
The Federal Ministry of Transport and the Ministry of Health have issued guidelines for assessing fitness to drive. Among other things, these guidelines stipulate the following:
Individuals experiencing “acute psychosis” are not permitted to drive motor vehicles (of any class). This includes
After an “acute psychosis” has subsided, fitness to drive may be presumed again under certain conditions. The conditions are:
- There is no longer any evidence of disorders that significantly impair the person’s sense of reality, e.g.,
- delusions,
- hallucinations,
- severe thought disorders
- There must be no remaining symptoms of severe depression or mania. It is not expected that they will recur (e.g., due to appropriate medication).
In cases of acute or long-term treatment with psychotropic medications, these must not cause any side effects affecting the brain. However, long-term treatment does not preclude a positive assessment of fitness to drive. It may even be a prerequisite for such an assessment.
In cases of recurrent affective disorders or schizophrenia with repeated episodes: The disease activity must have decreased. A severe course of the illness, as previously described, must no longer be expected. This must be verifiable through regular psychiatric follow-ups.
In cases of substance use disorders, proof of abstinence must be provided. This is typically achieved through
- detoxification treatment and
- one year of abstinence with appropriate laboratory tests following detoxification during the rehabilitation period.
Psychosomatic and psychotherapeutic diagnostic methods focus on explaining problem constellations. Therapeutic treatment recommendations are derived from this.
Psychodynamic diagnosis focuses primarily on identifying
- personality structures,
- conflicts, and
- interpersonal relationship patterns in the present and past, particularly unconscious processes,
.
Behavioral therapy assessment involves behavioral observation and behavioral analysis. Here, the focus is on
- observable behavior,
- subjective experience (emotions and cognitions), and
- psychophysiological reactions
are central.
Methods of psychodynamic assessment
There are various methods of psychodynamic assessment:
- The psychoanalytic initial interview
- The Balint-style interactive interview
- The psychoanalytic initial interview according to Argelander
- The depth-psychological biographical anamnesis according to Dührssen and Rudolf
- The structural interview according to Kernberg
- The Relationship Episode Interview According to Luborsky
- Semi-structured psychodynamic interviews according to Janssen: Recently, an operationalized psychodynamic diagnosis (OPD) has been developed, for which a special interview protocol is provided.
Biographical Anamnesis
The biographical anamnesis (taking the patient’s history) aims to identify, symptomatically, the
- psychological,
- social, and
- medical
trajectories of a person’s development. This provides the therapist with a comprehensive overview of the patient’s personality development.
This enables the psychologist to develop an understanding of any characteristic conflicts and patterns in the patient’s personality development. Under certain circumstances, these may be relevant to the patient’s current or past illnesses.
Compared to the general clinical history, the biographical history takes a more person-centered perspective.
Contents of the biographical history
- Family history:
- Parents: parents’ background, age, and occupation;
- Sibling constellation (number, ages, and development of siblings);
- Family environment: emotional atmosphere within the family, parenting style, how parents interact with the child or children, the parents’ marriage, the role of other relatives (e.g., grandparents) in the family, and the relationships among siblings;
- Diseases, disease risks, and health behaviors within the family
- Individual medical history:
- Pregnancy and birth (specific risks, e.g., alcoholism; parents’ attitudes toward the pregnancy and the child’s birth);
- Social birth status (e.g., born out of wedlock);
- Early childhood development (specific illnesses, hospitalizations, learning to walk, language acquisition, and toilet training);
- Childhood behavioral problems: e.g., bedwetting, school anxiety, nail-biting, eating disorders
- Relationship history:
- Relationship with parents;
- to be assessed separately across different developmental phases; Relationship with siblings; Preschool years;
- School years
- Vocational training and/or college: Here, it is not only academic performance and behavior that are of interest. The nature and extent of social integration during different developmental phases are also significant
- Psychosexual development: puberty, first period, first sexual experiences, sexual orientation, romantic relationships
- Personal family structure: e.g.,
- marriage, divorce, children;
- Type of partner selection, how the relationship has developed within the marriage,
- Relationship with one’s own children, expectations and wishes for the children
- Professional situation:
- Professional development (e.g., career, professional disappointments),
- further career development opportunities, financial situation, areas of professional responsibility;
- Motivation to achieve
- Participation in areas of life outside the family: clubs, political parties, holding public office, etc., successes or failures in these contexts
- Attitudes, values, and emotional styles
- Attitudes toward illness and motivation for change
Psychodynamic Interview
The goal of a psychodynamic interview is to initiate a therapeutic relationship. This includes the diagnostic assessment of
- unconscious conflicts
- development of ego function (unconscious defense mechanisms)
- readiness for transference, and
- capacity for reflection.
During the one-hour session, the patient can
- describe their symptoms,
- describe their interpersonal relationship patterns in the present and past, and
- bring unconscious conflicts to light in the here and now.
In this respect, the development of transference and countertransference processes plays a central role even during the initial interview.
An assessment of psychodynamics emerges from the combination of the biographical history and the analytical interview. It is developed either in a free-form manner or according to Operationalized Psychodynamic Diagnostics (OPD).
OPD diagnostics encompasses the assessment
- of the experience of illness and the conditions for treatment,
- the relationship,
- conflicts, and
- structure.
These clinical examinations are supplemented by psychological testing. Standardized diagnostic procedures may also be used. These include, for example, structured or standardized interviews or checklists for specific disorder categories.
Essentially, the diagnosis of a mental disorder is made through the psychiatric-psychotherapeutic interview.
However, additional diagnostic procedures using medical equipment are employed for further evaluation and, in particular, to rule out physical causes. The specific procedures used in diagnostic testing include:
- the electrocardiogram (ECG)
- the electroencephalogram (EEG)
- polysomnography (PSG)
- neurochemical laboratory testing
- diagnostics using imaging techniques
Electrocardiography (ECG)
An electrocardiogram (ECG) measures the heart’s electrical activity and conduction. Among other things, it provides information on
- heart rate,
- the heart’s rhythm,
- the propagation of electrical signals in the heart (conduction), and
- the condition of the heart muscle.
An ECG should always be performed as part of the physical diagnostic workup before beginning treatment.
A wide variety of medications have adverse effects on the heart. Therefore, an ECG is always recommended before starting treatment with psychotropic medications.
Follow-up examinations must be conducted during the course of therapy. ECG changes are particularly likely with the following medications:
- Tricyclic antidepressants,
- certain newer antipsychotics, and
- lithium and
- carbamazepine.
Electroencephalography (EEG)
An electroencephalogram (EEG) records fluctuations in electrical potential. These fluctuations reflect the activity of groups of nerve cells in the brain. To do this, 32 to 128 electrodes are attached to the patient’s scalp.
The EEG first records brain activity at rest. However, epileptic potential fluctuations are also induced for comparison. This is achieved through:
- Hyperventilation: Forced rapid breathing for 3 to 5 minutes at a rate of approximately 25 deep breaths per minute
- Photostimulation: Application of high-frequency flickering stimuli
- Sleep-deprivation EEG: Recording an EEG after complete sleep deprivation
Since the development of imaging techniques, the importance of the EEG has declined compared to the past. In psychiatry, EEG recording still plays an important role in the following indications:
- to detect epilepsy (seizure disorders) associated with typical EEG changes
- for the diagnosis of certain other brain disorders associated with typical EEG changes. These include, for example, Creutzfeldt-Jakob disease and certain forms of encephalitis
- to detect EEG changes during medication treatment. This allows for the identification of an increased risk of side effects or seizures.
Polysomnography (PSG)
Polysomnography (PSG) is used in specialized centers to diagnose sleep disorders. During the procedure, the following are recorded simultaneously while the patient sleeps
- the EEG,
- the electrooculogram (EOG, which records eye movements), and
- the electromyogram (EMG, which records muscle activity, particularly in the legs and jaw region)
are recorded simultaneously. In addition, periodic nocturnal leg movements can be recorded using special electrodes. This is used to diagnose restless legs syndrome.
Other specialized diagnostic procedures include
- the measurement of nocturnal erections in men and
- the recording of certain respiratory physiological parameters.
Science distinguishes between different sleep stages. They are characterized by various changes in the EEG, EOG, and EMG. The sleep stages can be roughly divided into
- light sleep (sleep stages S 1–2),
- deep sleep (sleep stages S 3–4), and
- rapid eye movement (REM) sleep.
With regard to the diagnosis of sleep disorders, the following can be recorded using PSG:
- the objective extent of the sleep disorder (which often differs from the patient’s subjective perception)
- physical causes of sleep disorders, such as
Neurochemical laboratory diagnostics
In addition to the diagnostic methods mentioned above, laboratory diagnostics are also used. These include blood, urine, and, if necessary, cerebrospinal fluid tests. Laboratory diagnostics are a central component of psychiatric differential and supplementary diagnostics.
The following values should be measured for every patient:
- Erythrocyte sedimentation rate (ESR)
- Complete blood count (CBC) including differential count
- Electrolytes: primarily sodium, potassium, and calcium
- Renal function: creatinine
- Liver function: GOT, GPT, and gamma-GT
- Blood sugar
- Thyroid function (TSH)
- Urinalysis
Depending on the suspected diagnosis or the results of the physical examination, further tests may be performed as needed.
These parameters also serve as baseline values for monitoring progress during drug therapy. Various medications can affect lab values, e.g.,
- a decrease in white blood cell count,
- an increase in liver enzyme levels, or
- changes in blood electrolyte levels (especially sodium).
This must be taken into account when interpreting the results.
Some medications can have harmful effects on a pregnancy. The unborn child is particularly vulnerable during the first trimester. Therefore, if there is any doubt, women should take a pregnancy test before starting medication.
Many mental disorders can be caused by drug use. It is therefore important to rule out a drug-induced disorder. Standard drug screening methods can usually detect the following substances in the blood or urine:
- Alcohol,
- amphetamines,
- barbiturates,
- Benzodiazepines,
- cannabis,
- Hallucinogens,
- cocaine,
- LSD, and
- Opiates.
Cerebrospinal Fluid Diagnostics
Cerebrospinal fluid, also known as CSF, is a fluid found in the brain and spinal canal.
During a cerebrospinal fluid test, approximately 10 to 20 ml of cerebrospinal fluid is withdrawn from the lumbar region of the spine. Since no spinal nerves are present in this area, there is generally no risk of nerve injury.
A cerebrospinal fluid test should be performed especially when encephalitis is suspected.
The procedure is usually associated with few side effects. Headaches may occasionally occur. However, this can be mitigated by ensuring adequate fluid intake and using very thin withdrawal needles.
Imaging Techniques
Imaging techniques are divided into structural and functional methods. The following structural procedures are performed as part of neuroradiological diagnostics. They are primarily used to rule out brain disorders as the cause of mental illnesses:
The following functional procedures are performed as part of nuclear medicine diagnostics:
- Single-photon emission computed tomography (SPECT)
- Positron Emission Tomography (PET)
These provide information on blood flow or glucose metabolism in the brain. This allows for conclusions to be drawn about brain function.
Structural imaging techniques (CT and MRI)
In the
- the first occurrence of a mental illness or
- if an organic mental disorder is suspected
, a structural imaging procedure must be performed.
Typically, a computed tomography (CT) scan of the skull is performed. CT scans can detect conditions such as
- tumors,
- hemorrhages,
- older cerebral infarcts,
- abscesses,
- malformations,
- brain atrophy, and
- bone changes
.
Magnetic resonance imaging (MRI) offers better resolution of various tissues. As a result, it can visualize brain structures more clearly than a CT scan. MRI is therefore increasingly replacing CT in the differential diagnosis of mental disorders.
MRI is particularly effective at detecting
. MRI does not produce bone-related artifacts. For this reason, MRI is superior to CT, particularly at the base of the skull and in the posterior fossa.
An MRI uses strong magnetic fields. Therefore, having a pacemaker is a contraindication. This means that people with pacemakers cannot undergo an MRI. Other metallic foreign bodies, such as implants or screws, may also be a contraindication, depending on their location.
Unlike CT, MRI does not involve radiation exposure.
Functional Imaging Techniques (SPECT and PET)
Functional imaging techniques are used to detect physiological and pathophysiological processes in the brain. In both cases, radioactively labeled substances are injected. Therefore, these procedures involve radiation exposure (roughly as high as that of a CT scan).
Single-photon emission computed tomography (SPECT) is a nuclear medicine or scintigraphic procedure. In this procedure, radioactively labeled substances are injected into the patient’s vein.
Substances such as technetium-99m or 123I are used. These gamma-emitting isotopes are then coupled to special carrier molecules. Their distribution in the tissue or binding to receptors can then be measured using a gamma camera. The examination takes 20 to 60 minutes.
Examples of radiopharmaceuticals used include:
- Technetium-99m-HMPAO for measuring blood flow in the brain
- 123I-IBZN for visualizing dopamine receptor sites in the brain
- 123I-Jomazenil for visualizing benzodiazepine binding sites
SPECT is now rarely used in routine diagnostics.
In positron emission tomography (PET), gamma rays emitted during the decay of positron emitters are detected. The following positron emitters are used:
- ¹⁵O-labeled water for measuring cerebral blood flow: ¹⁵O-H₂O-PET
- ¹⁸F-fluorodeoxyglucose for measuring energy metabolism (sugar metabolism): ¹⁸F-FDG-PET
- ¹⁸F-Fluorodopa for assessing dopamine function: ¹⁸F-Fluorodopa-PET
Positron emission tomography is most commonly used clinically for advanced diagnostics of Alzheimer’s disease. In such cases, F-18-FDG-PET often reveals reduced glucose consumption in the temporal lobe of the brain. It is also used in Parkinson’s disease. In this case, the binding of F-18-fluordopa to dopamine receptors in the brain is measured.
