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How are clinical evaluations performed?

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Alexandra’s Answer

If you are referring to clinical evaluations for mental health/psychologists, I can help to answer that. Clinical evaluations for MDs will be different.

Generally, evaluations include the following components: a general clinical interview, brief assessments/questionnaires, a structured/semi-structured diagnostic interview (sometimes), personality assessments (sometimes), and neuropsychological testing (sometimes). It varies based on the person's presenting problem. Typically a phone screen is conducted first to get basic information about the person and why they want the evaluation, and then we decide what components of the evaluation we will include based on their symptoms.

The clinical interview includes questions about the person's presenting problem (why they are coming in for the evaluation), any current cognitive difficulties, any current medical conditions, any current psychiatric diagnoses/treatments, their psychosocial history (information about their childhood and family structure, educational history, and history of psychological issues), occupational and/or military history, and their goals for treatment. Brief assessments may include questionnaires about depressive symptoms, anxiety symptoms, trauma history, ADHD symptoms, etc, based on the person's presenting problem. If they are coming in for psychological difficulties (rather than cognitive difficulties), we may give a structured interview that asks several yes/no questions about many different symptoms a person could be experiencing. Personality assessments such as the MMPI can tell us more about a person's psychological problems and general traits by giving us a profile for each person. Neuropsychological (or cognitive) testing can provide objective cognitive data for those who have cognitive complaints and further help us to differentially diagnose their difficulties (e.g., ADHD vs a learning disorder or Alzheimer's disease vs. Parkinson's disease). We then take all of this data into account to help determine where the person is having difficulty, what diagnoses may be relevant, and what we want to recommend to help them (therapy treatment, strategies for success [organizational skills for ADHD, using a pillbox to remember medications, etc], or further medical evaluation/treatment [eg, sleep study/treatment, neuroimaging]).