Taking psychiatric history

Presenting complaint

• Reason for presentation (i.e. symptoms etc)
• Onset and duration of symptoms
• Method of referral
• Circumstances of the presentation
• Significant events and stressors (triggers)
• Perception of need
• Specific questions to determine DSM-IV criteria

Current mental status

i.e. Mental status examination. Ask about:

• Mood
  * Hopelessness, helplessness, worthlessness
• Risk assessment
  * Previous history
  * Current ideation
  * Plan
  * Intent
• Thought possession (thought broadcast/insertion)
• Thought content (delusions)
• Perception (hallucinations)
• Cognition (MMSE)
• Judgment
• Insight

Past history

• Other psychiatric conditions (Background/Predisposing factors)
• Medical conditions

Medication history

• Medications
• Illicit drugs
• Alcohol, smoking
• Compliance and withdrawal

Family history

• Family psychiatric and medical history

Social history

• Social support
• Interaction between family members
• Functional impairment

Forensic history, Developmental history

Physical examination

• Consider neurological examination