● Name

● Age
● Relationship status and children (if any)
● Disability/welfare status
● Occupation/Education
● Living situation (where? with whom?)
● Family/siblings
● Health care providers: GP, psychiatrist, specialists, etc.

See also: Geriatric Psychiatry Interview and Child and Adolescent Psychiatry Interview

History of Presenting Illness

● Start with close ended questions, do not ask leading questions. Make them
direct!
● Who brought you here? Who sent you here?
● Allow your patients to tell you the story. Doctors have a bad habit of interrupting
patients within the first few minutes of meeting a patient. [1]
● You should focus on their symptoms for the past month (and up to 1 year if
necessary)
○ Anything further in the past should be considered as past psychiatric
history

Chronology of Events
Timing is everything. Use these questions to help you get a sense of the timeline:

● “How do you feel now?”, “How do you feel compared to your well self?”, “When did
you last feel 'normal/well'?”
● Always compare the patient's current symptoms to their baseline
● Are there any acute stressors presently?
● What are their coping strategies?

The Psychiatric Review of Systems

● Key questions on a psychiatric review of systems includes asking questions about

mood (both depression and mania), sleep, anxiety, psychosis, obsessions and
compulsions, dissociative symptoms, trauma history, body image disturbances,
eating disorders, and somatic/pain disorders.
● It will be difficult to get through all these areas in a one-time assessment, and the
clinician should use their clinical judgment to determine which questions will be the
most helpful and high yield.
● An example of a relatively comprehensive psychiatric review of systems is detailed
below, but is by no means exhaustive. Some individuals early on may find using a
checklist helpful to keep themselves organized.

Depression See also main articles: Major Depressive Disorder (MDD), Trauma and
Stressor Disorders, Body Dysmorphic Disorder (BDD), and Feeding and Eating Disorders
 ● Mood
○ “Tell me about your mood right now,” “How's your mood right now?”
○ On a scale of 0 to 10 (0 = worst you've ever felt, and 10 = best mood you ever
had)
○ When someone says they are “depressed,” it is important to clarify what they
mean by that, don't just take it at face value
○ If someone says they've “always been depressed,” try to get them to describe
what their earliest memory of being depressed was like
● Substance-induced mood/anxiety disorder? (if concomitant substances) ask
specifically: did the mood symptoms appear before, or after the substance
use started? Substance use can masquerade as a depression or anxiety
disorder (substance-induced mood disorder or substance-induced anxiety
disorder).

“Now I'm going to ask you about some other symptoms people might feel when they're
depressed.”:

See main article: Introduction to Sleep Medicine

● Sleep
○ Sleep is more than just good or bad, you need to ask specific questions about
the nature of the sleep:
■ “Tell me about your sleep”
■ Ask about sleep hygiene (screen time)
■ How long are you asleep?
■ What time do you fall asleep?
■ What time do you get up?
■ Are there night time awakenings?
■ Are you told you snore at night? (think about sleep apnea, which can
cause depressive symptoms)
■ Do you ever experience nightmares? (could be a sleep disorder or a
trauma disorder)
● Interest (Anhedonia)
● Guilt
● Energy
● Concentration
○ ADHD screen may be applicable here
● Appetite
○ Now may be a good time to ask about eating disorders (always ask, because
patients do not always volunteer eating disorder information!):
■ How much weight loss?
■ What is their ideal weight?
■ What specifically makes this ideal?
■ Are they pre-occupied with their weight
■ Current weight and highest weight
■ Compensatory behaviour: medications, purging, laxatives, diuretics
● Psychomotor Slowing
● Suicide (leave this for later, unless your patient brings it up)
Anxiety

See main article: Generalized Anxiety Disorder (GAD)

Always ask about anxiety and depression at the same time since these symptoms often
overlap and are “co-morbid.” Key questions to ask include:

● Find your worry is difficult to control?

● Do you easily blanking out or have difficulty concentrating?
● Easily fatigued?
● Sleep changes (difficulty falling or staying asleep, or restless, unsatisfying sleep)?
● Feel keyed up, on edge, or restless?
● Feel irritable, or others comment on it?
● Experience muscle tension when you are worried?
● Would you describe yourself as a worrier?

Mania

See main article: Bipolar I Disorder and Bipolar II Disorder

“Now I'm going to ask you about some symptoms when people feel the opposite of
depressed.”

● Distractibility
○ “Found if easy to jump from one idea to another?” (more of a physical
observation in the patient)
● Irritability
○ Have your friends or family recently commented on this?
● Grandiosity
○ Ever get the feeling you have superpowers, or invincible?
● Flight of Ideas
○ “Racing thoughts in your head?” (more of the patient's subjective
experience)
● Activity
 ○ “Have you been doing a lot more at work? Sexual indiscretion when you
normally wouldn't? Having sexual relations with strangers?”
● Sleep
○ “Decreased to the point where you don't have to sleep for days?”, more
specifically, are not sleeping because you have so much energy?
● Talkative
○ “Talking more rapidly?”

Key questions to ask about bipolar symptoms and course of illness:

● Do you spend most of your time feeling depressed or manic?

● Do you tend to get psychotic symptoms when you have depressive or manic
symptoms? (think: either depression with psychotic features, or mania with psychotic
features)
● Was there a period of time (>2 weeks) where you did not feel depressed/manic, but
still had psychotic symptoms? (think schizoaffective disorder)
● When was your first manic/depressive episode? (The index event is important, this
informs you: what is the natural history of the illness in the person? Do they tend to
have a depressive or manic presentation?)

In patients with a history of multiple manic and depressive episodes, it can often be
overwhelming and not practical to ask about the course of each specific episode. It is
useful to obtain in broad strokes the following details instead:

Key Features of a Good Bipolar Disorder History

Mania Depression

# of lifetime manic # of lifetime

episodes depressive episodes

Index episode Index episode

Last episode Last episode

Triggers/precipitants Triggers/precipitants

Psychosis

See main article: Schizophrenia

● “Do you ever feel things are not real?

● “Do you worry that people might be against you or after you?”
● “Do you ever hear things other people don't hear?”
○ “Do the voices ever command you do to things?”
● “Do you ever things other people don't see?”
● “Are the voices outside or inside your head?” (auditory hallucinations are more
likely to be heard “outside,” and often patients will look for the voice)
● “Do you ever feel that thoughts are being put into your head?” (thought insertion)
● “Do you ever feel that thoughts are being taken out of your head?” (thought
withdrawal)
 ● “Do you ever feel that your thoughts are being broadcasting so that other people
know what you are thinking?” (thought broadcasting)
● “Do you feel like there are special messages for you?”
● Ask about hallucinations types, are they: auditory, visual, tactile, or olfactory? -
this may indicate brain pathology or lesions!

Substance-induced psychosis?

When there is concomitant substance use in the context of psychosis, ask specifically: did the
psychotic symptoms appear before, or after the substance use started?

Obsessions and Compulsions

See main article: Obsessive-Compulsive Disorder (OCD)

Most individuals with OCD will have both obsessions and compulsions. High
sensitivity screening questions and a good OCD history includes the following:

1. Obsessions: Do you ever get intrusive or unwanted thoughts, images, or

impulses that repeatedly enter your mind, despite you trying to get rid of
them?
○ e.g. - worries about dirt/germs, or thoughts of bad things happening
2. Compulsions: Do you ever feel driven to do certain things over and over
again?
○ e.g. - repeatedly washing hands, cleaning, checking doors or work
over and over, rearranging things to get it just right, or repeating
thoughts in your mind to feel better?
3. Does this waste significant time or cause problems in your life (Criterion B
of DSM-5 criteria)?
○ e.g. - interfering with school, work, or seeing friends?

The Relationship Between Obsessions and Compulsions

● Compulsions are usually performed in response to an obsession (e.g. -

obsession about contamination → compulsion of hand washing rituals;
obsession about a situation being incorrect → compulsion of repeating
rituals until it feels “just right”)
● For individuals with OCD, compulsions reduce the distress triggered by the obsession, or
prevent a feared event from occurring (e.g. - getting sick, hurting someone)
 ● It is important to note that compulsions are not connected in a realistic way to the feared
event (e.g. - arranging items in a certain colour to prevent harm to a loved one) or are
significantly excessive (e.g. - washing hands for 30 minutes at a time due to fears of
contamination)
● Compulsions that are performed are not pleasurable! Rather, they allow the individual to
experience relief from their anxiety or distress

Safety

Suicide

See main article: Suicide Risk Assessment (SRA)

Asking the question

● You can normalize the question, and ask directly:

○ “Some people might think of suicide when their mood is low, has this ever
crossed your mind?”
● Or turn the question around and ask it another way:
○ “You're going through the loss of a loved one, has your own death or suicide
ever crossed your mind?

History

● Always ask about the index suicide attempt (when, how, why?)
● Are there any self-harm behaviours that might put their safety at risk? Could this lead
to an “inadvertent suicide”?
● Did they carry out their suicide attempt(s) with the expressed intent to die?
(Sometimes a “suicide attempt” is not actually an attempt, but an accidental
overdose - it is important to clarify this with your patient)

Current safety

● Is there any plan?

● Is there access to the means of death? (firearms, medications, poisons, etc.)
● Do they plan on doing this immediately?
● What are the chronic, acute, and imminent risk factors that might lead to suicide?

Homicide

See main article: Violence and Mental Illness

● Are there any threats to others due to psychotic symptoms?

 ● Are there any threats to specific individuals?
● “If you were to leave the hospital now, would you want to hurt anyone?”
● “If you saw [person they wanted to hurt] on the street, what would you do? Would you
defend yourself? Would you want to hurt/kill them?”

Driving

● Are there any symptoms that cause dangerous driving? If patients have suicidal idea,
homicidal ideation, mania, or psychosis, this is a critical safety question to ask
● Has their license ever been revoked?

Medications

See main section: Psychopharmacology

● What medications are they on now?

● Have they been on any psychiatric medications? Now? In the past? What doses?
● Are they using any supplements? (e.g. - anabolic steroids, vitamins, herbals)
○ Patients often forget about this, and it is important to prompt them. Certain
supplements (e.g. - St. John's wort) can have significant drug-drug
interactions.

Allergies

● Do they have any allergies to medications? Any specific reactions to psychiatric

medications?

Substance Use History

See main section: Substance Use and Addictive Disorders

● Tobacco/Nicotine
○ What age? How many packs per day? Ever use nicotine replacement therapy?
● Opioids
○ What age? What kind? IV/PO? Naloxone?
● Alcohol
○ What age? How much? History of blackouts? Have you ever been a binge
drinker? Alcohol withdrawal? Seizures?
○ This may be a good time to screen for alcohol use disorder (CAGE):
■ “Ever feel you need to cut down your drinking?”
■ “Have people annoyed you by criticizing your drinking?”
■ “Have you ever felt bad or guilty about your drinking?”
■ “Have you ever had a drink first thing in the morning to steady your
nerves or to get rid of a hangover (eye-opener)?”
● Cannabis
○ What age? How much? What specific effects from the cannabis do they like
or not like? Do they get paranoia?
 ● Stimulants
○ What age? How much? What effects?
● Benzodiazepines/Anxiolytics /Others
○ What age? How much? What effects?
● Caffeine (this is important if your patient complains of anxiety!)
○ How much caffeine do they use? What time of day? How many cups?

Substance-induced Psychiatric Symptoms?

When there is substance use, there can be a substance-induced mood (depression or mania),
anxiety, or psychosis.

Past Medical History

See main section: Medical Psychiatry

Various medical conditions can relate to psychiatric symptoms, and can also have
medication interactions. In brief, you should always ask:

● Any history of concussions or head injuries?

● Any history of seizures?
● Thyroid disease or disorders?
● History of surgeries

Past Psychiatric History

● If someone has a very long psychiatric history, it is best to ask:

○ How many life-time hospital admissions?
○ How many total depressive episodes?
○ How many total manic episodes?
○ How many total psychotic episodes?
● By staying general, but detailed enough to get broad strokes of a person's history,
you can avoid getting bogged down in too much detail.
● Have they ever had ECT or neurostimulation?

Family History

● Any family history of mental illness?

○ If they aren't sure, you can specifically ask the patient if they observed any
unusual behaviours or symptoms in that family member
● Any family members die by suicide (or unexplained deaths)?
● Any family members with problematic alcohol or substance use?
● Any family members hospitalized for psychiatric reasons?
● Any family members with neurodegenerative disorders and dementias (for geriatric
patients)
Social History

● Place of birth
○ Location raised
● Developmental
○ Any issues with development/birth?
○ Were you raised by your parents?
○ Are your parents still together?
○ Parent's occupation and finances
○ Relationship with mother and father?
○ Relationship with your siblings?
○ Would you say you generally had a happy childhood? (individuals with a
generally unhappy childhood are more likely to be dysthymic)
○ What was school like for you?
○ How would you describe yourself as a child?
○ Bullying at school?
● Religion
○ Do you have any religious affiliation?
● Education
○ “How did you do academically?”, “What is your highest level of education?”
● Housing
○ “Do you live by yourself/with others?”, “House, condo, etc.?”
● Employment
○ “What kind of jobs did you have?”
● Who is your support?
○ Friends? Family? Co-workers?

Trauma

See main articles: Trauma-Informed Care and Adverse Childhood Experiences (ACEs)

While obtaining your social history, this is a good time to touch on any possible history
of trauma.

● It is good to have a non-threatening opener, such as: “Stressful life experiences can
affect your health, and it can be helpful for us as healthcare providers to understand
this. You can skip these questions if you don't want to answer them, and they are
non-mandatory.”
● “Have you ever experienced anything in your life that you would consider traumatic?,”
● Or more point-blank, “Have you ever experienced any physical, emotional, or sexual
abuse?”

Personality Traits/Disorders

See main section: Personality Disorders

This is a good time to screen for things like borderline personality disorder:
 ● Ask about self-esteem, sense of self, impulsivity
● “Are you by nature an impulsive person?”
● “Do you feel that you have a poor sense of self?”
● “Is it hard for you when people in your life leave you?”
● “Do you frequently feel empty inside?”
● “Do you ever harm yourself such as cutting or burning?”
● Remember, you cannot diagnose someone with a personality disorder while they are
having a primary mental disorder going on (e.g. - depression, psychosis, mania, etc.)
● Being able to tease out personality disorders can help you differentiate between
diagnoses (i.e. - cluster B traits vs. bipolar disorder)

Legal/Forensic History

● “Any issues with the law? Or being in jail?”

● Past arrests, incarceration, court dates, murder, assault, violence?

Closing the Interview

● Close with:
○ “Did you have any thoughts on how we might be able to help you today?”
○ “Did we go through the main concerns that you hoped to talk about today?”
○ Thank the patient for their time and sharing a “snippet” of their life with you
today

Mental Status Examination (MSE)

See main article: Mental Status Exam (MSE)

During the interview, you should pay attention to the mental status examination (MSE).
The MSE is a systematic way of describing a patient's mental state at the time you were
doing a psychiatric assessment.

Diagnosis and Biopsychosocial Formulation

See main articles: Diagnosing Psychiatric Disorders and Biopsychosocial Model and Case
Formulation

Now that you have finished gathering information, the next steps will be to establish a
diagnosis and to formulate the patient.

The Rule of Parsimony

See main article: History of the DSM

 Even though the DSM II was published in 1968 (!) the following excerpt is sage advice
even (and especially) today.

A Tip From the DSM-II...

The diagnostician, however, should not lose sight of the rule of parsimony and diagnose more
conditions than are necessary to account for the clinical picture. The opportunity to make multiple
diagnoses does not lessen the physician's responsibility to make a careful differential diagnosis.

Resources

Books

● Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The

Perspectives of Psychiatry
● Essentials of Psychiatric Diagnosis, Revised Edition: Responding to the
Challenge of DSM-5® Revised Edition

For Clinicians

● 14 Tips for the Diagnostic Interview of Mental Disorders - Dr. Allen Frances
● Maria Yang: The Social History
● R.S. Manley. Psychiatric Interview, History, and Mental Status Examination. Chapter
7.1
● The Hub (Psychiatry)
● Psychiatry: a Resource Guide for Residents and Researchers

Psychosis

See main article: Schizophrenia

● “Do you ever feel things are not real?

● “Do you worry that people might be against you or after you?”
● “Do you ever hear things other people don't hear?”
○ “Do the voices ever command you do to things?”
● “Do you ever things other people don't see?”
● “Are the voices outside or inside your head?” (auditory hallucinations are more
likely to be heard “outside,” and often patients will look for the voice)
● “Do you ever feel that thoughts are being put into your head?” (thought insertion)
● “Do you ever feel that thoughts are being taken out of your head?” (thought
withdrawal)
● “Do you ever feel that your thoughts are being broadcasting so that other people
know what you are thinking?” (thought broadcasting)
● “Do you feel like there are special messages for you?”
● Ask about hallucinations types, are they: auditory, visual, tactile, or olfactory? -
this may indicate brain pathology or lesions!
Substance-induced psychosis?

When there is concomitant substance use in the context of psychosis, ask specifically: did the
psychotic symptoms appear before, or after the substance use started?

Obsessions and Compulsions

See main article: Obsessive-Compulsive Disorder (OCD)

Most individuals with OCD will have both obsessions and compulsions. High
sensitivity screening questions and a good OCD history includes the following:

1. Obsessions: Do you ever get intrusive or unwanted thoughts, images, or

impulses that repeatedly enter your mind, despite you trying to get rid of
them?
○ e.g. - worries about dirt/germs, or thoughts of bad things happening
2. Compulsions: Do you ever feel driven to do certain things over and over
again?
○ e.g. - repeatedly washing hands, cleaning, checking doors or work
over and over, rearranging things to get it just right, or repeating
thoughts in your mind to feel better?
3. Does this waste significant time or cause problems in your life (Criterion B
of DSM-5 criteria)?
○ e.g. - interfering with school, work, or seeing friends?

The Relationship Between Obsessions and Compulsions

● Compulsions are usually performed in response to an obsession (e.g. -

obsession about contamination → compulsion of hand washing rituals;
obsession about a situation being incorrect → compulsion of repeating
rituals until it feels “just right”)
● For individuals with OCD, compulsions reduce the distress triggered by the obsession, or
prevent a feared event from occurring (e.g. - getting sick, hurting someone)
● It is important to note that compulsions are not connected in a realistic way to the feared
event (e.g. - arranging items in a certain colour to prevent harm to a loved one) or are
significantly excessive (e.g. - washing hands for 30 minutes at a time due to fears of
contamination)
● Compulsions that are performed are not pleasurable! Rather, they allow the individual to
experience relief from their anxiety or distress

Safety

Suicide

See main article: Suicide Risk Assessment (SRA)

 Asking the question

● You can normalize the question, and ask directly:

○ “Some people might think of suicide when their mood is low, has this ever
crossed your mind?”
● Or turn the question around and ask it another way:
○ “You're going through the loss of a loved one, has your own death or suicide
ever crossed your mind?

History

● Always ask about the index suicide attempt (when, how, why?)
● Are there any self-harm behaviours that might put their safety at risk? Could this lead
to an “inadvertent suicide”?
● Did they carry out their suicide attempt(s) with the expressed intent to die?
(Sometimes a “suicide attempt” is not actually an attempt, but an accidental
overdose - it is important to clarify this with your patient)

Current safety

● Is there any plan?

● Is there access to the means of death? (firearms, medications, poisons, etc.)
● Do they plan on doing this immediately?
● What are the chronic, acute, and imminent risk factors that might lead to suicide?

Homicide

See main article: Violence and Mental Illness

● Are there any threats to others due to psychotic symptoms?

● Are there any threats to specific individuals?
● “If you were to leave the hospital now, would you want to hurt anyone?”
● “If you saw [person they wanted to hurt] on the street, what would you do? Would you
defend yourself? Would you want to hurt/kill them?”

Driving

● Are there any symptoms that cause dangerous driving? If patients have suicidal idea,
homicidal ideation, mania, or psychosis, this is a critical safety question to ask
● Has their license ever been revoked?

Medications

See main section: Psychopharmacology

 ● What medications are they on now?
● Have they been on any psychiatric medications? Now? In the past? What doses?
● Are they using any supplements? (e.g. - anabolic steroids, vitamins, herbals)
○ Patients often forget about this, and it is important to prompt them. Certain
supplements (e.g. - St. John's wort) can have significant drug-drug
interactions.

Allergies

● Do they have any allergies to medications? Any specific reactions to psychiatric

medications?

Substance Use History

See main section: Substance Use and Addictive Disorders

● Tobacco/Nicotine
○ What age? How many packs per day? Ever use nicotine replacement therapy?
● Opioids
○ What age? What kind? IV/PO? Naloxone?
● Alcohol
○ What age? How much? History of blackouts? Have you ever been a binge
drinker? Alcohol withdrawal? Seizures?
○ This may be a good time to screen for alcohol use disorder (CAGE):
■ “Ever feel you need to cut down your drinking?”
■ “Have people annoyed you by criticizing your drinking?”
■ “Have you ever felt bad or guilty about your drinking?”
■ “Have you ever had a drink first thing in the morning to steady your
nerves or to get rid of a hangover (eye-opener)?”
● Cannabis
○ What age? How much? What specific effects from the cannabis do they like
or not like? Do they get paranoia?
● Stimulants
○ What age? How much? What effects?
● Benzodiazepines/Anxiolytics /Others
○ What age? How much? What effects?
● Caffeine (this is important if your patient complains of anxiety!)
○ How much caffeine do they use? What time of day? How many cups?

Substance-induced Psychiatric Symptoms?

When there is substance use, there can be a substance-induced mood (depression or mania),
anxiety, or psychosis.

Past Medical History

See main section: Medical Psychiatry

 Various medical conditions can relate to psychiatric symptoms, and can also have
medication interactions. In brief, you should always ask:

● Any history of concussions or head injuries?

● Any history of seizures?
● Thyroid disease or disorders?
● History of surgeries

Past Psychiatric History

● If someone has a very long psychiatric history, it is best to ask:

○ How many life-time hospital admissions?
○ How many total depressive episodes?
○ How many total manic episodes?
○ How many total psychotic episodes?
● By staying general, but detailed enough to get broad strokes of a person's history,
you can avoid getting bogged down in too much detail.
● Have they ever had ECT or neurostimulation?

Family History

● Any family history of mental illness?

○ If they aren't sure, you can specifically ask the patient if they observed any
unusual behaviours or symptoms in that family member
● Any family members die by suicide (or unexplained deaths)?
● Any family members with problematic alcohol or substance use?
● Any family members hospitalized for psychiatric reasons?
● Any family members with neurodegenerative disorders and dementias (for geriatric
patients)

Social History

● Place of birth
○ Location raised
● Developmental
○ Any issues with development/birth?
○ Were you raised by your parents?
○ Are your parents still together?
○ Parent's occupation and finances
○ Relationship with mother and father?
○ Relationship with your siblings?
○ Would you say you generally had a happy childhood? (individuals with a
generally unhappy childhood are more likely to be dysthymic)
○ What was school like for you?
○ How would you describe yourself as a child?
○ Bullying at school?
● Religion
○ Do you have any religious affiliation?
 ● Education
○ “How did you do academically?”, “What is your highest level of education?”
● Housing
○ “Do you live by yourself/with others?”, “House, condo, etc.?”
● Employment
○ “What kind of jobs did you have?”
● Who is your support?
○ Friends? Family? Co-workers?

Trauma

See main articles: Trauma-Informed Care and Adverse Childhood Experiences (ACEs)

While obtaining your social history, this is a good time to touch on any possible history
of trauma.

● It is good to have a non-threatening opener, such as: “Stressful life experiences can
affect your health, and it can be helpful for us as healthcare providers to understand
this. You can skip these questions if you don't want to answer them, and they are
non-mandatory.”
● “Have you ever experienced anything in your life that you would consider traumatic?,”
● Or more point-blank, “Have you ever experienced any physical, emotional, or sexual
abuse?”

Personality Traits/Disorders

See main section: Personality Disorders

This is a good time to screen for things like borderline personality disorder:

● Ask about self-esteem, sense of self, impulsivity

● “Are you by nature an impulsive person?”
● “Do you feel that you have a poor sense of self?”
● “Is it hard for you when people in your life leave you?”
● “Do you frequently feel empty inside?”
● “Do you ever harm yourself such as cutting or burning?”
● Remember, you cannot diagnose someone with a personality disorder while they are
having a primary mental disorder going on (e.g. - depression, psychosis, mania, etc.)
● Being able to tease out personality disorders can help you differentiate between
diagnoses (i.e. - cluster B traits vs. bipolar disorder)

Legal/Forensic History

● “Any issues with the law? Or being in jail?”

● Past arrests, incarceration, court dates, murder, assault, violence?

Closing the Interview

 ● Close with:
○ “Did you have any thoughts on how we might be able to help you today?”
○ “Did we go through the main concerns that you hoped to talk about today?”
○ Thank the patient for their time and sharing a “snippet” of their life with you
today

Mental Status Examination (MSE)

See main article: Mental Status Exam (MSE)

During the interview, you should pay attention to the mental status examination (MSE).
The MSE is a systematic way of describing a patient's mental state at the time you were
doing a psychiatric assessment.

Diagnosis and Biopsychosocial Formulation

See main articles: Diagnosing Psychiatric Disorders and Biopsychosocial Model and Case
Formulation

Now that you have finished gathering information, the next steps will be to establish a
diagnosis and to formulate the patient.

The Rule of Parsimony

See main article: History of the DSM

Even though the DSM II was published in 1968 (!) the following excerpt is sage advice
even (and especially) today.

A Tip From the DSM-II...

The diagnostician, however, should not lose sight of the rule of parsimony and diagnose more
conditions than are necessary to account for the clinical picture. The opportunity to make multiple
diagnoses does not lessen the physician's responsibility to make a careful differential diagnosis.

Resources

Books

● Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The

Perspectives of Psychiatry
● Essentials of Psychiatric Diagnosis, Revised Edition: Responding to the
Challenge of DSM-5® Revised Edition
For Clinicians

● 14 Tips for the Diagnostic Interview of Mental Disorders - Dr. Allen Frances
● Maria Yang: The Social History
● R.S. Manley. Psychiatric Interview, History, and Mental Status Examination. Chapter
7.1
● The Hub (Psychiatry)
● Psychiatry: a Resource Guide for Residents and Researchers

evaluating psychiatric reports

Item M Me Standard Item-scale

ax an deviation correlation

Chief complaint 4 3.2 1.03 0.119

7

Admission procedures 1 0.8 0.38 0.326

3

Current complaints 3 2.4 0.86 0.080

3
Substance abuse 3 2.5 0.96 0.322
0

Consumed substances 1 0.9 0.31 0.582

0

Consumed quantity 1 0.7 0.43 0.431

7

Duration of addiction 1 0.8 0.38 0.386

3

Biography 3 2.3 0.96 0.586

3

Family status 1 0.8 0.41 0.562

0

Profession 1 0.8 0.38 0.533

3
 Education 1 0.7 0.47 0.445
0

Past psychiatric 3 2.2 0.94 0.642

history 7

Frequency of episodes 1 0.7 0.47 0.121

0

Different diagnosis (if 1 0.7 0.47 0.218

necessary) 0

Duration of disease (since 1 0.8 0.35 0.178

when?) 7

Family history Family history 1 0.7 0.43 0.134

 7

Past medical Comorbidities 1 0.8 0.38 0.242

history 3

Mental State 25 19. 4.84 0.725

Examination 63

Orientation 2 1.7 0.43 0.165

7

Interaction 1 0.8 0.35 0.217

7

Attention/concentration 1 0.8 0.35 0.296

7

Sleep 1 0.7 0.45 0.037

 3

Appearance 1 0.5 0.51 0.243

0

Memory 1 0.7 0.45 0.411

3

Thought process 2 1.6 0.72 0.211

0

Fears 1 0.6 0.48 0.650

7

Compulsions 1 0.5 0.51 0.368

3

Delusion 2 1.8 0.46 0.130

 3

Perceptual disturbances 2 1.7 0.64 0.414

3

Self-disorders 2 1.5 0.82 0.321

3

Affect 2 1.6 0.61 0.578

7

Psychomotor activity 1 0.9 0.31 0.357

0

Suicidality 2 1.8 0.43 0.257

7

Endangerment to self 1 0.7 0.45 0.473

 3

Endangerment to others 1 0.6 0.49 0.348

3

Illness insight 1 0.7 0.47 0.346

0

Diagnosis 5 3.4 1.33 0.554

3

Correct diagnosis 3 2.6 0.81 0.641

0

Explained why making this 2 0.8 0.86 0.320

diagnosis 7

Impression 5 3.0 1.67 0.526

 3

Confirmability of 1 0.7 0.47 0.445

statements 0

Structure 2 1.3 0.92 0.548

0

Coherence (at rater’s 2 1.0 0.72 0.796

discretion) 3

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Nature.

Brief psychiatric interview: Screening

questions
One of the most important things primary care providers can do to elicit emotional information,
which may be somewhat hidden, is simply to "open the door" by asking screening questions. And
don't ask with your hand on the doorknob at the end of the assessment!
Two simple questions, for example, can help to detect depression:
 ● "Over the past month, have you felt down, depressed or helpless?"
● "Over the past month, have you felt little interest or pleasure in doing things?"

If the patient replies "yes" to either question, the clinician can ask further questions.

Screening for specific psychiatric

disorders
Primary care providers should ask specific screening questions for specific psychiatric disorders.
Due to time constraints, the screening questions should be:
● related to the specific problem(s) that the patient presents with on that day
● fairly stark, so that a positive answer would be quite significant, and should be
explored.

The following section provides examples of screening questions for different psychiatric
disorders.

Depression
● Have you ever had a period where you felt down? Not just for a week or two but for
many weeks or, perhaps, months?
● Did you find you had no energy, had no interest in things, and overall had great
difficulty functioning?
● Has this ever happened to you before?

Hypomania/mania
● In the past, have you ever had a period where you felt not just good, but better than
good?
● Did this feeling of unusually high energy and a decreased need for sleep go on not for
hours or an evening, but for days and days at a time?

Dysthymic disorder
● Have you felt down or low but able to function over the last number of years?

Generalized anxiety disorder

 ● Would you describe yourself as a chronic worrier? Would others say you are someone
who is always worrying about things?
● Do you worry about anything and everything as opposed to just one or two things?
●  If so, how long has this been going on?
● Some people tell me that they are worriers but they can usually handle it. Other people
tell me that they are such severe worriers that they find that worrying gets in the way of
their life or paralyzes them. Is this the case for you?

Obsessive-compulsive disorder
● Do you have any unusual or repetitive thoughts that you know are silly but you simply
cannot stop thinking about (for example, being contaminated by germs)?
●  Do you feel there are certain rituals you have to do, such as tap your hand a certain
way or do things in sets of threes, which takes up a lot of time in the day?

Delusions and hallucinations

● Do you have unusual experiences, such as hearing voices that other people cannot
hear? What about seeing things that other people cannot see?
● Do you have unusual ideas, such as feeling that the TV or radio has special messages
for you?
● Do you have unusual ideas that people you do not even know are plotting to harm or
kill you?
● Do you have unusual ideas, such as feeling that you have special powers that no one
else has?

Panic attacks
● Do you have panic attacks or anxiety attacks? By that I mean an attack of anxiety that
comes fairly suddenly and is rather uncomfortable and involves feeling a certain
number of physical sensations such as heart palpitations, shortness of breath or
dizziness.

Agoraphobia
● Do you avoid going certain places because you are fearful of having a panic attack?
Has this feeling restricted your activities?

Posttraumatic stress disorder

 ● Do you find it hard to stop thinking about a very difficult event that has happened to
you?
● Do you find that you have nightmares related to the event?
● Do you find that you have flashbacks? By that I mean very vivid daydreams or what we
may call a "daymare" about the event?
● When something happens that reminds you of the event, does that trigger a very large
response in you?
● Do you find that you avoid things that remind you of the event?
● Generally, do you feel anxious since the event and have trouble sleeping or startle
easily?
● Do you feel that this event, and the way it has left you feeling, still gets in the way of
your life?

Social phobia
● Are you able to go to social situations where you may have to interact with people you
don't know well, or is that very daunting for you?
● Can you eat in restaurants in front of others?
● Were you able to give presentations in front of others when you were in school, or can
you do it now?
● Do your social fears get in the way of your life?

Borderline personality disorder

● Do you feel you are still searching for your sense of who you are (self-identity)?
● By "sense of who you are," I mean do you have a set of values (what is important to
you) that stays constant over time?
● Do you have long-term feelings of sadness?
● Do you have long-term feelings of anger?
● Do you find that your relationships usually get very difficult and end abruptly?
● Have you had thoughts of killing yourself on and off over the years?
● Have you tried to kill yourself in the past?
● Have you had episodes in the past where you tried to hurt yourself, not to kill yourself
but simply to cause yourself pain or distract you from something?
● How do you feel after these episodes? (Patients often respond that they feel a sense
of release or relief.)
● Do you often feel empty inside?
● Do you find that you can be feeling okay then suddenly feel angry, or you can be
feeling okay and suddenly feel sad? Does this happen a lot during the course of a
day?
● Do you find that you do things on impulse and then regret it afterwards?