Download Psychiatric History for Junior Residents

Psychiatric Evaluation
Introduction:
Name, Role
Limits of confidentiality – harm to self, others (child, elderly person), records subpoenaed by the court, circle of
care
Identifying Data:
Name, age, sex, gender, living situation, marital status, children, ethnicity, income
Chief Complaint: In the patient’s own words, use open-ended questions
What brings you here today?
Is there anything else you would like to talk about?
History of Presenting Illness:
- How did the patient get here? Voluntarily, with family, Form 1, Form 10, Form 8
- Circumstances surrounding the admission
- Acute/chronic stressors? Current supports?
- Always elicit:
o Timeline of symptoms- onset, duration, getting worse/better
o Impact of symptoms on patient’s functioning in various domains (work, school, home,
relationships, etc…)
Schizophrenia: General screen
- Do you ever have experiences that other people don’t share, or that others consider unusual?
- Do you have strong ideas about things that you hold very strongly? Ideas that other people don’t
understand/disagree with/ tell you are impossible?
- Are you worried that others are out to harm you?
Delusions:
- Of Reference:
o Do you notice special message intended only for you when watching the TV, listening to the radio,
or reading the paper?
- Of Persecution:
o Are you concerned that others are out to harm you, or are following you/monitoring you?
- Somatic Delusions:
o Are you worried that something is wrong with your body that can’t be explained by medical
science?
- Of Thought Broadcasting:
o Do you worry that other people could hear your thoughts, even when you aren’t talking?
- Of Mind Reading:
o Are people able to read your mind and know what you are thinking? Are you able to read the
thoughts of others?
- Of Thought Withdrawal:
o Have thoughts ever been taken out of your head? Are your thoughts stolen or removed by force?
Who does this?
- Of Thought Insertion:
o Have thoughts ever been put into your head from the outside? How does this happen? Who does
this?
- Of Grandiosity:
o Are there periods where you felt more confident than usual? Have you acquired any have special
talents or abilities? Have you felt that you are going to become famous or do great things?
Hallucinations:
- Auditory Hallucinations:
-
o Have you every heard things (noises, sounds, voices) that other people didn’t hear?
Visual Hallucinations:
o Do you ever see things that other people didn’t see?
Mania: General Screen
- Have you ever felt full of energy or idea for at least four days?
- If yes: What was your sleep like? Did other people notice that you were acting differently (talking rapidly,
flight of ideas, distractible)? Were you doing things that were out of character for you (eg. spending
money excessively)? How long did this episode last? Have you had other periods like this? When were
they? Have you ever gotten treatment for an episode like this?
Major Depression: General Screen
- How has your mood been lately? (Sad, Irritable)
- Do you have any hobbies or interests? Have you lost interest in these hobbies or activities?
- Sleep:
o How have you been sleeping? How many hours per night? Do you have trouble falling asleep,
staying asleep or both? How does lack of sleep affect you during the day?
- Guilt:
o Have you been blaming yourself for things? Do you feel remorse/regret for things you have said
or done? Is it hard to get your mind off of these thoughts?
- Energy:
o How have your energy levels been?
o Do you feel tired/worn out?
- Concentration:
o Have you had problems concentrating or thinking?
o Is it harder to make decisions than before?
- Appetite:
o Have you noticed any changes in your appetite or interest in food? Have you lost or gained any
weight?
- Psychomotor sx: Observation
o Agitation: fidgety, pacing, pulling on hair/skin/clothing, handwringing, crossing/uncrossing legs
frequently
o Retardation: slowed speech, latency of response to questions, mute, slowed body movements
- SI:
o When a person feels depressed, they might think about dying. Have you been having thoughts
like that?
o Have you ever had thoughts about harming yourself? Have you ever had thoughts of ending your
life? Did you think of a way to do it? How close have you come to doing it?
o Do you wish you were dead? Do you ever go to sleep and wish you would not wake up?
- HI:
o Have you ever had thoughts of harming others? Have you had a plan to do so? Have you ever
carried through with this plan?
Anxiety: General Screen
o GAD: Do you worry? What kinds of things do you worry about? Do you find that your worry is
excessive or hard to control?
o Panic disorder: Have you ever had a panic attack? What did that feel like? Was it triggered or did
it come out of the blue?
o OCD: Do you have unwanted thoughts that repeatedly come into your mind? Do you have to
perform certain actions or rituals to decrease your worry? (eg. handwashing, counting)
o PTSD: Have you ever been exposed to or witnessed a traumatic event where your safety or the
safety of others was compromised? How does this event affect you now? (intrusion, avoidance,
negative affectivity, hyperarousal)
Other things to screen for:
- Substance use disorders
- Other safety questions: children in home, elderly dependents, domestic violence, driving
Past Psychiatric History:
- Have you ever had a mental health diagnosis before?
- Have you ever seen a psychiatrist?
- Have you ever been admitted to hospital for a psychiatric reason?
- Have you ever attempted suicide? (Number of attempts, method, severity, medical attention)
- Have you ever taken psychiatric medication? (Name, dose, reason for discontinuation, who manages your
medications?)
- Have you ever seen a therapist? (Type and duration of therapy, helpful or not)
Past Medical and Surgical History:
- Head injuries, seizures
- Cardiac problems: hypertension, arrhythmia, tachycardia
- Diabetes, Thyroid
- Pregnancy
Family Hx:
- Psychiatric illness: depression, anxiety, bipolar, schizophrenia, personality, substance use, dementia
- Medical illness: especially cardiovascular, metabolic, neurologic, endocrine
Social History:
- Developmental hx:
o Any complications with your pregnancy or delivery? Were you a healthy baby?
o Did you walk and talk at the same time as the other kids your age? (milestones)
- Academic/occupational:
o What is your highest level of education? Were you ever held back in school? Troubles focusing or
sitting still/waiting your turn?
o Are you currently employed outside the home? What were your reasons for leaving your current
job? How many jobs have you had in the past? What did they involve? Are you currently on
disability insurance/AISH? How are you doing financially?
- Abuse: physical, sexual, emotional
- Social and relationship:
o Are you currently in a relationship? How is that going?
o Have you had previous relationships? Marriages? Have you ever been divorced? When did the
marriage end? How are you feeling about the divorce now?
o Do you have any children? Custody arrangement
- Abuse: I usually ask questions about your safety…
o Do you feel safe at home?
o Has anyone tried to harm you physically?
o Emotional/verbal abuse?
o Have you ever been in an abusive relationship?
o In your past, have you ever experienced physical/sexual/emotional abuse
- Legal history, history of aggression
Mental Status Exam:
Appearance, Behaviour, Cooperation/Reliability, Cognition, Mood, Affect, Speech, Thought process, Thought
content, Insight, Judgment
Physical Exam: as necessary, assess for EPS, lithium tremor
Sources: Calgary Cambridge Guide, Interview Guide for Evaluating DSM-IV Psychiatric Disorders and Mental
Status Examination (Mark Aimmerman)