Psychiatric History

Presenting problem(s)
Succinct statement, use patient’s own words

History of presenting problem

• Onset, duration, effects on life and relationships
• Events linked or coincident with onset
• Solutions tried, any reasons why they failed
• Mood and beliefs during last few weeks

Direct questions to elicit specific symptoms that support/refute particular diagnoses

• Anxiety
• Obsessions
• Depression (anhedonia, hopelessness, helplessness, guilt)
• Self-harm, harm others, suicidal thoughts, plans and ideas
• Psychosis
• Mania
• Eating disorders
• Drug and alcohol use

Past Psychiatric and Medical History

• Psychiatric outpatient treatment and/or admissions (voluntary or under section)
• Any previous deliberate self harm or suicidal attempts 
• Relevant medical history

Drug History

• Prescribed
• Illicit drugs and dependency
• Alcohol and dependency
• Smoking

Family History
Construct genograms with occupations and any associated mental health problems

Personal and Social History

• Early childhood:
• Education
• Occupational History (and any reasons for changing)
• Psychosexual development
• Present social circumstances: housing, finance, work, relationships, stressors and any changes from baseline

Forensic History
Police arrest and/or convictions for criminal activity, particularly violence against people

Premorbid Personality
Prior to period of ill health, when patient reports being well elicit self-description of their personality, mood, social and cognitive functionality

Mental State Examination

Appearance & Behaviour
Physical appearance, general attitude, motor behaviour

Speech
Volume, construction (flight of ideas), enunciation

Mood and affect

•  Mood is the sustained emotional state, however, affect is the instantaneous emotional state
•  Congruity of mood and affect with speech content
•  Stability
•  Emotional reactivity
•  Subjective (patient’s version)
•  Objective assessment
•  ELICIT deliberate self-harm OR harm to others or suicidal thoughts (ideation, intent and lethality of plan)

Thought

•  Depressive rumination
•  Over-valued ideas
•  Ideas of reference, self-referential ideation, grandiose ideas

Delusions

• Thought withdrawal, thought insertion, thought broadcasting
• Obsessional thoughts, preoccupations, compulsive traits (e.g. checking things repeatedly)
• Subjective experience of thought disorder
• Objective signs of thought disorder

Perception

• Altered perception of real environmental object or stimuli
• False perception, in absence of external object or stimuli: hallucination.
• Auditory hallucinations: loud thoughts, thought echo, familiar or unfamiliar voices, 2nd or 3rd person, or voices giving commands
• Depersonalisation

Cognitive and intellectual function

• Level of consciousness (fully alert, fluctuates, clouded)
• Orientation in time, place and identity
• Attention and concentration: serial sevens, months in reverse
• Memory: immediate (recall digit span); recent (recall an address), remote (recall personal history)
• General Knowledge and intelligence

Formulation

• Main presenting symptom(s) and why patient has become ill at that particular point in time:
• Predisposing factors
• Precipitating factors
• Perpetuating factors

Insight
Subjective attitude towards illness and treatment

Differential diagnosis (most relevant equates to working diagnosis)