13.04.15 Assessment

Psychiatric history

    • Presenting complaint

    • History of presenting complaint

      • Reason for referral

      • What is the main problem / Which problems are the worst?

      • How has it affected you?

      • Precipitants?

      • When did you last feel well?

    • Past psychiatric history

      • Hospitalisations?

      • Sections?

      • Current treatment / care

    • PMH

    • Medications

    • Social history

      • Accommodation

      • Finances

      • Employment

      • Support

    • Drugs + alcohol

    • Forensic history

    • Family history (incl. psychiatric)

      • Still alive / How did they die?

      • Well?

      • Occupations?

      • Relationship with brothers + sisters

    • Personal history

      • Delivery + early development

      • Schooling

      • Teenage years

      • Relationships with family

      • Psychosexual

      • Employments

    • Premorbid personality

      • Describe themselves before they got ill

Mental state assessment

    • Appearance and behaviour

      • Describe to someone who's never seen them before

        • Don't say "normal"

      • Mannerisms, EPSEs, Posturing, Eye contact, Preentation

  • Speech

      • Form

        • Quantity, Rate, Volume, Rhythm

      • Content (quote if possible)

        • Words, Meanings, Appropriateness

    • Mood and affect

      • Subjective vs Objective

      • Mood (climate) vs Affect (weather)

      • Sleep, Appetite, Libido, Psychomotor, Anxiety, Restlessness, Aggitation, Appropriateness, Congruence

  • Thoughts

      • Form

        • Abnormal flow

          • Flight, Crowding, Retardation, Circumstantiality

        • Interrupted flow

          • Derailment, Blocking

        • Passivity

          • Withdrawal, Insertion, Broadcasting

      • Content

        • Delusions (Fixed, Unshakeable)

          • Persecution, Grandeur, Religious, Control

        • Judgement

        • Paranoia

        • Ideas + beliefs

        • Reality

    • Perceptions

      • Sensory systems (all)

      • Distortions (Still identified correctly)

      • False perceptions

        • Illusions (Mis-interpreted stimuli)

        • Hallucinations (Absence of stimuli)

        • Pseudohallucinations (Perceive thoughts or memories as voices)

    • Cognition

      • Level of consciousness

        • Qualitative (vs Quantitative

        • Twilight state, Perseverence, Confabulation, Fugue, Deja vu

    • Insight

      • Not absolute

      • Treatment ideas

      • Cultural factors