Introduction
Substance-related and addictive behaviors are complex psychiatric conditions that involve the misuse of drugs, alcohol, or compulsive engagement in rewarding behaviors despite harmful consequences. A comprehensive psychiatric evaluation is essential for identifying the nature and severity of these disorders, understanding contributing factors, and developing an effective treatment plan.
This guide outlines the key components of a psychiatric evaluation focused on substance-related and addictive behaviors, including diagnostic criteria, assessment tools, and treatment strategies.
Purpose of the Evaluation
To determine the presence and severity of substance use or addictive behavior
To identify co-occurring psychiatric conditions
To assess risk factors such as overdose, withdrawal, or self-harm
To guide individualized treatment planning
To facilitate referrals and continuity of care
Key Components of the Evaluation
1. Identifying Information
Patient’s name, age, gender, occupation
Date of evaluation
Referral source (e.g., emergency department, family, court)
2. Chief Complaint
Patient’s own words describing the issue
Example: “I can’t stop drinking even though I’ve lost my job and my family is worried.”
3. History of Present Illness (HPI)
Onset and progression of substance use
Frequency, quantity, and type of substance
Triggers and patterns of use
Impact on functioning (work, relationships, legal issues)
Previous treatment attempts
4. Past Psychiatric History
Prior diagnoses (e.g., depression, anxiety, bipolar disorder)
Hospitalizations
Suicide attempts or self-harm
History of trauma
5. Medical History
Chronic illnesses (e.g., liver disease, HIV)
Neurological conditions
Medications and allergies
History of overdose or withdrawal symptoms
6. Family History
Substance use disorders in family members
Psychiatric conditions
Genetic predispositions
7. Social History
Living situation
Employment and education
Relationships and support systems
Legal issues (e.g., DUI, arrests)
Cultural and spiritual background
Mental Status Examination (MSE)
Domain Description
Appearance May show signs of intoxication or neglect
Behavior Agitation, sedation, cooperation
Mood Depressed, anxious, euphoric
Affect Blunted, labile, congruent
Speech Slurred, pressured, coherent
Thought Process Disorganized, tangential
Thought Content Cravings, guilt, suicidal ideation
Perception Hallucinations (especially with withdrawal)
Cognition Impaired attention, memory
Insight Often poor regarding substance use
Judgment Impaired decision-making
Risk Assessment
Suicidal or homicidal ideation
Risk of overdose
Risk of withdrawal complications
Risk to others (e.g., driving under influence)
Access to substances or weapons
Diagnostic Impression
Based on DSM-5 criteria, the clinician provides a working diagnosis. Common diagnoses include:
Alcohol Use Disorder
Opioid Use Disorder
Stimulant Use Disorder
Cannabis Use Disorder
Gambling Disorder
Tobacco Use Disorder
Criteria include:
Loss of control over use
Cravings
Tolerance and withdrawal
Continued use despite harm
Neglect of responsibilities
Formulation
A biopsychosocial summary explaining how biological, psychological, and social factors contribute to the disorder.
Example: “Patient’s opioid use escalated following a work injury and is maintained by chronic pain, social isolation, and lack of coping skills.”
Treatment Plan
Pharmacological
Detoxification protocols
Medication-assisted treatment (MAT): methadone, buprenorphine, naltrexone
Antidepressants or antipsychotics for co-occurring conditions
Psychotherapy
Cognitive Behavioral Therapy (CBT)
Motivational Interviewing (MI)
Contingency Management
12-Step Facilitation Therapy
Behavioral Interventions
Relapse prevention planning
Coping skills training
Urine drug screening
Supportive Services
Case management
Peer support groups (e.g., AA, NA)
Family therapy
Referrals
Inpatient or outpatient rehab programs
Dual diagnosis treatment centers
Legal advocacy or social services
Documentation Tips
Use objective, nonjudgmental language
Document substance use patterns clearly
Include direct quotes when relevant
Ensure confidentiality and informed consent
Conclusion
A comprehensive psychiatric evaluation for substance-related and addictive behaviors provides a structured approach to understanding and treating these complex conditions. By integrating medical, psychological, and social data, clinicians can develop personalized care plans that promote recovery and reduce harm.