Psychiatric History

Taking a Medical Psychiatric History the Proper Way

Identifying Data

What is your name ? What is your age? What is your occupation? What is your marital status? What is your living situation?

Chief Complaint

What is the reason that you are here today?

History of Present Illness OPPQRS...

Assess Perception, Mood and Anxiety

Perception (HDDDT):

Hallucinations - Do you ever hear or see things that others don't ? (noises, images, smells, tastes, touch)

Delusions - Do you feel that the TV or radio is speaking to you ?

Derealizations - Do you ever feel that the world is not real ?

Depersonalization - Do you ever feel you are someone else ?

Thought Blocking - thoughts just disappear - Do you ever feel as though someone is stealing your thoughts?

Mood:

Depression SIGMECAPS

S - increased or decreased sleep

I - decreased interest

G - guilt

M - depressed mood

E - decreased energy

C - decreased concentration

A - increased or decreased appetite

P - psychomotor slowing or agitation

S - suicidal ideation

Mania

Grandiosity, decreased sleep, talkative, pleasurable activities with painful consequences, increased activity, flight of ideas, distractable

Anxiety:

Anxiety, nervousness, past anxiety or panic attacks experienced

Phobias - what are your fears?

Obsessions - any persistent thoughts in your mind?

Compulsions - any persistent actions that you feel you must do?

General Anxiety Disorder (SKIM BE)

Sleep disturbances, Keyed up, Irritability, Muscle tension, Blank mind, Easily fatigued

Panic Disorder

STUDENTS FEAR the 3C's

Sweating, Trembling, Unsteadiness/dizzy, Depersonalization and derealization, Excessive heart rate and palpitations, Nausea, Tingling, Shortness of Breath, Fear of going crazy, dying and losing control, 3C's - chest pain, chills, choking sensation

Past Medical History, Allergies, Medications, Social History, Family History

Social History - What is the impact of the illness on Yourself? Family? Lifestyle? Occupation? Do you have any Coping strategies? Support systems?

Psychiatric History

Previous hospitalizations, Treatments, Psychiatrists

Age of first contact

Suicide attempts

Legal history - any violence, trouble with police

Family Psychiatric History

Psychiatric and mental illnessess, diagnosed personality disorders

Suicide attempts and completions

Legal history