Psychiatric History
Summary
·
Reasons for referral
·
Presenting symptoms and duration
· History of Current Illness, any medication and compliance with it
·
Systematic enquiry: anxiety,
mood, psychotic symptoms, suicidality, cognitive, neuro-physiological, alcohol
and drug, stressors, medications, impulse-control screen
·
Past psychiatric history
·
Medical History
·
Family History
·
Personal history
·
Premorbid personality
· Patient‟s attribution of illness
·
Mental State: appearance and
behaviour, speech, mood, affect, thought form, thought content, suicidal
ideation, perceptual phenomena, cognition, intelligence, insight and judgement,
rapport
·
Formulation
·
Diagnosis and Differential
Diagnosis
·
Management Plan
·
Suicide Assessment:
o Trying to assess nature of suicidal ideation and state of current plans
o Predisposing factors: family history of suicide, psych illness, or
alcohol & drug, personality, childhood and developmental difficulties,
suicide exposure, other illness, environment (eg living alone, isolated), age
and sex
o Precipitating factors (short-term risk factors): major/stressful life
event, current mood, thoughts about the future, mental state (eg psychosis,
judgement, impulsivity), alcohol and drug use, current plans, expectations of
outcome, availability and lethality of method
o Protective factors: cognitive flexibility, strong social supports,
hopefulness, treatment of disorders, responsibility for children
· For screening for psychiatric illness in teenagers
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