How to Take an Excellent Psychiatric History

Love it or hate it, you have to admit there's something pretty cool about being able to evaluate a patient, just by having a conversation. Psych is different from other specialties in that you have to know what to ask the patient, when to ask it, and how to ask it appropriately to get the patient to open up instead of shutting down. Here's how I tried to frame my psych evals, and hopefully you can build off it to be a pro on your rotation.

Pertinent Psych Questions

It's a good idea to get a family and social history from the patient. For the family history, ask about relationships between the patient and family members, whether family is a support network or a main stressor. Patients may also have a history of psych conditions in their family. For social history, ask about employment, drug use, and stresses. Some more specific questions include birthplace and childhood, religious background, and military service. If the patient has been diagnosed with any psychiatric conditions, inquire as to previous treatment options and their efficacy.


Open with the PHQ-2: ask if the patient has felt sad/depressed, and whether they have lost interest in activities they used to enjoy. Depression cannot be diagnosed if the patient doesn't respond "yes" to both these questions. From there, complete the PHQ-9 with the acronym "SIG E CAPS": feeling Sad, loss of Interest, Guilty feelings, loss of Energy, unable to Concentrate, changes in Appetite (or sleep), Psychomotor retardation, and Suicidal thoughts. Diagnosis requires 5 of 9 positive answers, including positive answers to the first two.


Ask about previous episodes of increased energy or activity. If suspicion is high, go through "DIG FAST": Distractibility, Irritability, Grandiose thoughts, Flight of ideas, Agitation/increased Activity, decreased Sleep, and Talkativeness. Diagnosis requires 4 of 7 positive answers, or 3 of 7 with hospitalization.


There are no mnemonics for diagnosing anxiety conditions. Instead, assess if the patient has difficulty dealing with any specific stressors in life or feels anxious in general. Ask about symptoms of panic attacks, including palpitations, chest pain, diaphoresis, dyspnea, nausea, dizziness, paresthesias, and feelings of doom, death, or losing control. Ask about anxiety in social situations.


My favorite part of the psych exam! Ask the patient if they see or hear things that other people don't (hallucinations), or have certain thoughts or beliefs not shared with most other people (delusions). As a side note, patients are much more likely to admit to hallucinations (good insight) compared to delusions (poor insight). Ask if the patient has feelings of being watched or followed (paranoia). Even if not assessing for schizophrenia, always ask if a patient has thoughts about hurting themselves or others, how concrete and detailed these thoughts are, and whether they've ever acted on these thoughts. The severity of suicidal/homicidal ideations will determine whether a patient needs to be involuntarily admitted to the hospital.

Mental Status Exam

The Mental Status Exam (not to be confused with the MMSE) is the psychiatric equivalent of the physical exam. The goal is to get an overall picture of the patient's mental function and wellbeing. There are about 12-15 different sections, and different resources give different answers as to the appropriate number of sections. Some of the sections also appear (to the untrained student) to be redundant or overlapping. Below is a framework to use, which you can adjust as suggested by the circumstance or the team you're working with.

Appearance: Observe the patient and be able to describe what you see. Does the patient look "normal?" Do they seem appropriately dressed and groomed, and what about their posture? These are things you should be able to describe if you took a picture of the patient (don't do that, HIPAA violation).
Behavior: Related to appearance, how is the patient acting? Are they interactive and making appropriate eye contact, or are they slouched over and staring at the floor? Do they have psychomotor agitation or retardation? Do they have compulsions (need to act in a certain way, even if told not to)?
Attitude: How do you describe the patient's appearance/behavior as a whole? Is the patient cooperative with the interview, or are they evasive or confrontational? You have to take the appearance and behavior and interpret it to get these conclusions.
Level of Consciousness: This is the psych equivalent of the Glascow Coma Scale. Observe whether the patient is alert or if they appear somnolent, obtunded, or unresponsive. Is this a stable level, or does it wax and wane? Patient's can also be confused, or overly "conscious" (AKA vigilant).
Orientation: Same thing as the neuro exam. Does the patient know who, where, and when they are? In this case, understanding "why" they are will fit with insight/judgment.
Speech and Language: Observe a few different qualities to the patient's speech. First, describe the quantity; is there too much (talkative) or too little (paucity/poverty)? Then, describe the rate; is it too fast, too slow, or jusssssst right? Next, describe the volume; is it overly loud or barely a whisper, or just monotone? Last, describe the fluency/rhythm; are there pauses, is it slurred, or is the patient articulating with good inflection (I know I don't)?
Mood: Ask the patient, "how do you feel?" Mood is how the patient says they are feeling, so use whatever descriptors they give you.
Affect: This is how you describe the patient's emotional expression. Use the term "full" when the patient demonstrates a wide range of emotions at the appropriate times. You can describe affect by emotional fluctuations (use "labile" if abnormal), range (use "restricted" if abnormal), intensity (use "blunted" or "flat" if abnormal), or the specific quality if the affect appears fixed.
Thought Process/Form: This section describes your observations regarding the appropriateness of the patient's responses to your interview questions. Normal thought processes are linear and goal-directed. Some patients may demonstrate circumstantial (take time to answer the question) or tangential (get off track and never get back). Other patients demonstrate incoherent thoughts or perseveration (getting stuck on one thought).
Thought Content: This part is pretty similar to assessing for schizophrenia. You're trying to find out if the patient is having any thoughts that might be considered abnormal.
Insight/Judgement: These two aspects are connected but should be assessed differently. "Insight" is the ability of the patient to understand their illnesses or medical conditions, and can realize what is abnormal about their condition. "Judgment" is the ability of the patient to make decisions regarding their medical condition. They are usually defined as being "good," "fair," or "poor." A patient can be competent with one, both, or neither. A patient with good insight but poor judgment may understand they are depressed, but feel that they can handle it and don't need medications. Conversely, a patient with good judgment but poor insight may be able to make appropriate medical decisions, but doesn't recognize that they are hearing voices or are exhibiting paranoia. You might see this with patients who appear to be micromanaging their illness, but are not actually acknowledging the illness itself.