9/16/2019 Elements of the Psychiatric Assessment: Psychiatry and Behavioral Sciences: University of Nevada, Reno School of Medicine

Department of Psychiatry and Behavioral Sciences

University of Nevada, Reno School of Medicine

Elements of the Psychiatric

Assessment
Chief Complaint
Reason patient gives for presenting for treatment at this time; usually a direct quotation.

Example:
"I'm depressed."

Present Illness
Recent psychiatric symptoms (pertinent positives and negatives).

Timeframe of recent onset or exacerbation.

Triggers (stressful life events).
Recent treatment and treatment changes (new meds, dosage increases or decreases,
med compliance, therapy frequency, etc.)

Example:
If depressed, report all SIGECAPS.

If manic, report all DIGFAST, etc.

Always report presence or absence of suicidality.
One key trick is to stick to a description of "this episode." Begin by working to define the
current episode (often, why they came to the hospital). Often not easy with chronic
patients or patients with poor insight into their illness. You can assume that if they are
now hospitalized, something has changed.

Psychiatric Review of Systems

Screen for present and past:

Major depressive/dysthymic symptoms.

Manic or hypomanic symptoms.
Psychotic symptoms.
Generalized anxiety disorder.
Panic disorder.

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Obsessive-compulsive disorder.
Other areas suggested by HPI, for example:
Dementias
Eating disorders
Dissociative disorders
PTSD

Example:
MDD: SIGECAPS
Mania: DIGFAST
Psychotic symptoms, always screen for:
Hallucinations: do you hear things that others don't hear?
Paranoia: do you feel safe here? How about at home? Is anyone bothering you or
trying to harm you?
If indicated, also screen for:
Grandiosity: do you have any special powers or abilities?
Referential thinking: do you ever feel like the TV or radio or newspapers are
referring directly to you?
Thought broadcasting: do you ever feel that others can hear your thoughts or that
others are stealing your thoughts?
GAD: do you worry excessively? Often feel your worry is out of control? Muscle tension?
Irritability? Fatigue? Poor concentration? Restless?
Panic: attacks out of the blue? How long do they last?
OCD: anything you feel that you must do over and over again? What happens if you don't
do it? How much time do you spend? Does it interfere?

Psychiatric Treatment History

Inpatient: past psychiatric hospitalizations.
Number in life
Most recent: when, where, why, what meds?
Remote: year, where, why?
Outpatient: past outpatient treatment.
Most recent: where, who, how often seen?
Remote: years, where, who?
Medications: what has been tried in the past?
What, when, dose, how long, response, side affects?
Suicide history
Ever seriously considered in life? When? What was going on?
Ever tried to kill yourself? When? How?
How many times in life?
When most recently? How?
Have you been feeling suicidal lately? Now? Plan? Safe in hospital?

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9/16/2019 Elements of the Psychiatric Assessment: Psychiatry and Behavioral Sciences: University of Nevada, Reno School of Medicine

Violence history
What is the most violent thing you've ever done in your life?
Are you feeling at all violent now?
What if you happened to meet (potential victim) in a dark alley?
Psychotherapy: what type? How long? Response?

Substance Abuse History

Each drug (including alcohol).
First use
Heaviest use, when?
Consequences of use (legal, relationship, health, etc.)
Recent pattern of use, last use
Rehab, AA, NA

Family History
Any psychiatric illness in family?
Any substances abuse in family?
Any suicide in family?

Developmental and Social History

Where born?
Normal pregnancy and birth?
Describe childhood in a word or two.
Abuse of any type?
Parents — marital status, who raised patient, occupations.
Relationships, marriages, divorces, children.
Education: how much? Why left? Type of student? Trouble (suspensions)?
Occupation/economic
Military, job history
Disability (SSI/SSD)
Legal — arrests, for what, prison time
Spiritual

Example:
Be flexible. If patient needs to be drawn out more and if time allows, begin this section with an
open-ended question like, "Tell me what it was like for you growing up." If patient is hyperverbal
and/or tangential, begin with closed-ended questions.

Sexual History
Sexually active currently?

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9/16/2019 Elements of the Psychiatric Assessment: Psychiatry and Behavioral Sciences: University of Nevada, Reno School of Medicine

When last?
Any problems?
Contraception?
Any chance of pregnancy?

Medical/Surgical History
Significant medical illnesses, medical hospitalizations, surgeries, seizures, head injuries
with loss of consciousness

Mental Status Examination

Observational components:

Attitude (cooperative, easily engaged in conversation)

Appearance (normal)
Hygiene and grooming (good)
Affect (range of emotional expression)
Speech (rate, volume, articulation)
Thought process (logical and linear)
Insight (do they understand that they have a mental illness and need treatment?) If
unsure, ask.

Direct Inquiry components:

Mood (patient's description and rating 1–10; 10 = best)

Hallucinations
Delusions
Suicidal and violent ideation
Cognitive exam:
Orientation
Register and recall (three words)
Attention and concentration (WORLD backwards)
Abstraction (proverb)
Current events
Judgment (stamped envelope)

Example:
Ask these items of every patient during an initial assessment. Do the full Mini-Mental State
Examination if delirium, dementia, or other cognitive change is in the differential diagnosis.

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9/16/2019 Elements of the Psychiatric Assessment: Psychiatry and Behavioral Sciences: University of Nevada, Reno School of Medicine

University of Nevada, Reno School of Medicine

1664 North Virginia Street
Reno, NV 89557-0357

Clinics/Patients (775) 784-1223

Administrative (775) 784-6063

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