Psychiatric Assessment Questions for a 25-Year-Old Female
Conduct a structured interview covering history of present illness, psychiatric and substance use history, medical and family history, psychosocial factors, and mental status examination, following the American Psychiatric Association's comprehensive framework for initial psychiatric evaluation. 1
History of Present Illness
Begin by establishing the chief complaint and current symptoms:
- Psychiatric review of systems including specific inquiry about anxiety symptoms, panic attacks, and sleep abnormalities (including sleep apnea) 1
- Assessment of impulsivity and any current behavioral concerns 1
- Duration, severity, and functional impact of presenting symptoms 1
Psychiatric History
Prior Symptoms and Behaviors
- Past and current psychiatric diagnoses with dates and treatment settings 1
- Suicidal ideation history: Ask specifically about past suicidal thoughts, plans, and attempts—including aborted or interrupted attempts, with details about context, method, damage, potential lethality, and intent 1
- Self-injury without suicidal intent (non-suicidal self-injury) 1
- Aggressive or violent thoughts: Prior or current thoughts of physical or sexual aggression toward others 1
- History of aggressive behaviors including any domestic violence, workplace violence, or other physically or sexually aggressive acts 1
Treatment History
- Prior psychiatric hospitalizations and emergency department visits for psychiatric issues 1
- All past psychiatric treatments with specific types, duration, and doses of medications 1
- Response to past treatments and reasons for discontinuation 1
- Adherence patterns to both pharmacological and non-pharmacological treatments 1
Substance Use History
- Tobacco, alcohol, and illicit substance use: Specifically ask about marijuana, cocaine, heroin, and hallucinogens 1
- Misuse of prescribed medications, over-the-counter medications, or supplements 1
- Current or recent substance use disorder or changes in substance use patterns 1
Medical History
- Allergies and drug sensitivities 1
- All current and recent medications (prescribed, over-the-counter, herbal supplements, vitamins) and their side effects 1
- Relationship with primary care provider 1
- Past or current medical illnesses and related hospitalizations 1
- Neurological or neurocognitive disorders or symptoms 1
- History of physical trauma, particularly head injuries 1
- Sexual and reproductive history 1
- Cardiopulmonary status 1
- Endocrinological disease 1
- Infectious disease history: HIV, sexually transmitted diseases, hepatitis C, tuberculosis 1
- Conditions associated with significant pain or discomfort 1
Family History
- Family history of psychiatric illness in biological relatives 1
- Family history of suicidal behaviors (particularly important if patient has current suicidal ideation) 1
- Family history of violent behaviors (if patient has aggressive ideation) 1
Personal and Social History
Psychosocial Stressors
- Current stressors: Financial problems, housing instability, legal issues, school or occupational difficulties, interpersonal or relationship problems 1
- Social support network and its adequacy 1
- Trauma history: Comprehensive review of past traumatic experiences 1
- Exposure to violence or aggressive behavior, including childhood abuse 1
Cultural and Contextual Factors
- Cultural factors related to social environment 1
- Personal and cultural beliefs about psychiatric illness 1
- Need for interpreter services 1
Mental Status and Physical Examination
Physical Parameters
- Height, weight, and body mass index (BMI) 1
- Vital signs 1
- Skin examination for stigmata of trauma, self-injury, or drug use 1
- General appearance and nutritional status 1
Neurological Assessment
- Coordination and gait 1
- Involuntary movements or abnormalities of motor tone 1
- Sight and hearing 1
- Speech, including fluency and articulation 1
Mental Status Proper
- Mood and level of anxiety 1
- Thought content and process 1
- Perception and cognition 1
- Hopelessness (critical suicide risk factor) 1
Current Safety Assessment
If suicidal ideation is present, assess:
- Current suicidal thoughts: Active versus passive thoughts of suicide or death 1
- Suicide plans and their specificity 1
- Patient's intended course of action if symptoms worsen 1
- Access to lethal means, particularly firearms 1
- Motivations for suicide (e.g., seeking attention, revenge, shame) 1
Critical Pitfalls to Avoid
The most dangerous error is failing to detect underlying medical causes for psychiatric symptoms, which can result in significant morbidity and mortality 2. Always maintain a high index of suspicion for medical etiologies, particularly in new-onset psychiatric symptoms in a young adult.