Psychiatric assessment: History taking

1. Demographics
2. Chief complaint
3. Hx of present illness
4. Psychiatric functional inquiry
5. Anxiety: Worries, obsessions, compulsions, panic attacks, phobias
6. Psychosis: hallucinations, delusions, thought form disorders
7. Suicide/homicide: ideation, plan, hx of attempts
8. Organic: ethanol, drug use, illness, dementia

1. Appearance
   1. Friendly
   2. Cooperative
   3. Withdrawn
   4. Uncommunicative
   5. Hostile
   6. Guarded
   7. Does the patient appear his stated age?
   8. Describe facial expression as well as condition and dress.
   9. Evidence for tattoos, piercing, scar, …
   10. Is patient responsive? alert? cooperative? calm? Agitated?
2. Mood:
   1. Depressed
   2. Manic
   3. Anxious
   4. Angry
   5. Elated
   6. Fearful
3. Affect:
   1. Normal
   2. Flat
   3. Restricted
   4. Appropriate/Inappropriate for mood
   5. Stable vs. Labile (in response to changes in conversation)
4. Speech
   1. Rate? Is it monotone?
   2. What is the rhythm? Is there an increase in latency?
   3. What is the level of the vocabulary? Is there neologism (words invented by connecting syllables in a fashion to produce a new word)?
5. Perception:
   1. Hallucination:
      1. Getting messages from television
   2. Illusion
   3. Depersonalization
   4. Derealization
6. Thought:
   1. Thought Form:
      1. Flight of Ideas describes speech in which one idea is quickly followed by another.
      2. Logic: Loosening of Associations is the generic description of thought in which the logicality and sequentiality of the ideas breaks down
      3. Circumstantiality:
         1. involves inclusion of too many trivial details. It is logical and sequential thus the connection between ideas is easily understood.
      4. Tangentiality:
         1. also appears to be sequential but the patient goes off on a tangent and does not arrive at the goal.
      5. Perseveration
      6. Thought blocking
      7. Clang association
   2. Thought Content: GST PAID
      1. Grandiosity: self-esteem/confidence, special talents, going to be famous
      2. Sleep: decreased need
      3. Talkative: more and faster than usual, others’ noticed, get interrupted more
      4. Pleasurable activities: combine w/ e) for impulsivity/risky screen, sexual activities, cause problems for self/family (money, promiscuity, offending)
      5. Activity increased: work, chores, exercise, sex
      6. Ideas: flight of ideas (more ideas than N, can combine w/e)
      7. Distractibility: easily off track, so many things seem interesting etc…
7. Insight:
   1. Insight:
      1. Impaired
      2. No insight, partial: eg. recognizes problem but not attributing to illness
      3. Full: Egodystonic vs. egosyntonic re: behavior causing problem
   2. Judgment :
      1. Poor/impaired/limited/good
      2. Compliance with Tx, interview etc
8. Cognition:
   1. Consciousness
   2. Orientation: person (their name), place (city/province/country and hospital/floor/office), time (day, date, month, year, season, time)
   3. Memory
   4. Intellectual functions

Depression:

1. Sleep
2. Loss of interest
3. Guilt
4. Decreased Energy
5. Inability to concentrate
6. Loss of Appetite
7. Psychomotor retardation (felling slowed down)
8. Suicidal ideation

Mania:

1. Impulsivity
2. Pressured speech
3. Increased Activity (new project, problem with sitting still)
4. Insomnia
5. Racing thoughts
6. Esteem inflation
7. Distractible

Psychosis:

1. Hallucination
2. Delusions
3. Negative symptoms (flat affect, alogia,…)
4. Disorganized speech

Anxiety:

1. Panic attacks
2. Recent traumatic event
3. Obsessions and compulsions

Suicidal thoughts

1. Ideation
2. Plan
3. Tools
4. Attempts

Homicidal thoughts

1. Plan
2. Tools

• Hospitalization
• Surgery
• Allergies
• HEENT
• Endocrine disorders
• Cardiovascular
• pulmonary
• Gastrointestinal
• Urological
• Musculoskeletal
• Skin

1. Prenatal, perinatal
2. Early childhood to age 3
3. Middle childhood to age 11
4. Late childhood to adolescence
5. Adaptation or foster home experience

1. Alcohol
2. Tobacco
3. Opioids
4. Cocaine/crack
5. Amphetamines/Meth Amphetamines
6. Cannabis