ADDENDUM


Sample Psychiatric Screens

Introduction

Attitudes toward psychiatry and psychiatric patients are often enhanced when students develop competence in interviewing patients about sensitive issues. The following psychiatric "screens" are useful in general medical practice. The psychiatry clerkship would be an appropriate time for students to learn these (or other) sets of questions. Some screens may be more appropriate in different clinical sites, such as psychiatric emergency departments, consultation services, or outpatient departinents. However, the sites where they are practiced are less important than the fact that students achieve familiarity and comfort with using them.

The Psychiatric Workup

  1. Seven questions should be asked about any psychiatric patient:
  2. Why is the patient here now?
  3. What does the patient want/expect?
  4. Is a general medical illness contributing to the patient's difficulties?
  5. How lethal is the situation?
  6. In what ways are the patient's relationships helping or exacerbating the problem?
  7. What are the patient's cultural expectations/explanations/treatments for his/her illness?
  8. What is the psychiatric diagnosis?


Sample Psychiatric Screens

1. Mini-Mental State Examination

Note: this is a test of cognitive functioning, not a complete mental status examination.
Folstein MF Foistein SF, McHugh PR: Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. I Psychiatr Res 1975; 12:189-198


2. Alcohol and Drug Abuse Screen

Have you ever had a drinking or drug problem?
(Yes: 70% of alcoholics, 1% of nonalcoholics): Cyr M, Wortman S: The effectiveness of routine screening questions in the detection of alcoholism. JAMA 1988; 259:51
Has anyone else ever worried that you had a drinking or drug problem?
Did you ever use sleeping pills, weight loss medications, or painkillers?
CAGE questions: Ewing J: Detecting alcoholism: The CAGE questionnaire. JAMA 1984; 252:1905
(A positive answer on two or more will identify the majority of people with alcohol abuse or dependence.)
When is the last time you used any tobacco?
How much are you using now (were you using then)?
Have you used any other forms of tobacco (chew, cigarettes, cigars, pipes)?


3. Sexual Screen

A. General Screen

Are you sexually active at the present time? If NO, have you ever been?
Are (were) your partners men, women, or both? If BOTH, which do you prefer?
What means of birth control do you (have you) use(d)? Ask both males and females.
Do you have any concerns or problems with your sexual life?
Have there been any changes in your sexual activity? Changes in level and frequency of interest?
Changes in type of interest?
Do you or have you ever engaged in anal intercourse?
Are there any ways in which you would like your sexual life to be different?
Have any bad or frightening things ever happened to you sexually? For example: rape, sexual abuse, or molestation? (see Abuse Screen)
Have you had any sexually transmitted diseases such as herpes, chiamydia, gonorrhea, syphilis, or AIDS? (see HIV Screen)
Have you ever been treated for a sexually transmitted disease?

B. HIV Risk Factors

Do you worry about getting AIDS? Why? Why not?
Do you practice safer sex? (Explain)
Have you ever injected (or shot up) drugs into your veins? Have you smoked crack cocaine?
(If male) Have you ever had sexual contact with another man or with someone who used intravenous (iv) drugs?
(If female) Have you ever had sexual contact with someone who was bisexual or someone who used iv drugs?
How many sexual partners have you had in the last 10 years?
Have you ever needed a blood transfusion? What year? 1979-1985 is the risk period.)


4. Suicide and Violence Screen

Have you ever had thoughts that life is not worth living?
Have you ever had thoughts of killing yourself? (Now?)
How would you do it?
Have you taken steps to carry out your plan? (collected weapons, pills, etc.)
Patients who are suicidal may also be homicidal and vice versa, so ask:
Have you ever had thoughts of hurting anyone else? (Now?)
Have you ever hurt anyone else?
What plans do you now have to hurt anyone?


5. Screens for Family Violence

A. Child Abuse (modify for male perpetrators)

How did you feel during your pregnancy?
Has your child lived up to your expectations?
At what age do you think children know right from wrong? (Abusers often have unrealistically high expectations of children.)
How do you feel when your child behaves badly? What do you do?
Is there anyone you can turn to for help?
Have you ever been concerned that anyone would hurt your child?
Have you been frightened with thoughts of hurting your child?
Have you or anyone else hurt your child?

B. Sexual Abuse Victims

Are there things going on in your home that you are uncoinfortable with or ashamed to talk about?
Has there been any sexual contact between family members in your home besides your parents?
Have you been involved sexually with any adult, including either of your parents?

C. Partner/Elder Abuse Victims

I know that you may be ashamed of what happened (or might have happened), but could it be that this injury did not happen by accident?
Is your family under a lot of stress?
What happens when you and your partner argue?
Do either of you have trouble with your temper?
Is there a weapon in the house?
Have you ever fought physically with your partner? How badly have you been hurt?
Are you afraid to go home?

D. Abuse History

Did you ever witness any violence in your home when you were growing up?
How were you disciplined as a child?
Were you ever physically hurt by a family member?
During your childhood or adolescence:
Did a relative, family friend, or stranger ever touch your body, or have you touch them, in a sexual way?
Did anyone attempt or succeed in having sexual intercourse with you?
Did you ever have an unwanted sexual experience of any kind?


6. Trauma Screen

Have you ever had anything happen to you where you thought you would be seriously injured or might die?
Have you ever been in a life threatening accident? Fire? Disaster?
Have you ever been attacked or raped?
Have you ever seen these things happen to someone else?


7. Screen for Sleep Disorders

Are you content with your sleep pattern?
Are you excessively tired during the day?
Does your bed partner complain about your sleep pattern?


8. Screen for Depression'Hypomania

A. Depression

How would you describe your mood?
1. In the past month, have you felt down, depressed, or hopeless most of the day nearly every day?
If yes: Describe what that is like for you.
Do you feel that way now?
How long have You felt depressed?
If no: When did you last feel down, depressed, or hopeless? How long did you feel depressed?
2. Have you lost interest or pleasure in doing things you used to enjoy?
If yes: What do you usually enjoy doing?
When was the last time you did one or more of those things?
Was it enjoyable?
How long have you had difficulty getting interested in or enjoying activities?
If no: What do you enjoy doing?
When was the last time you did one or more of those things?
If A or B is positive:
Sleep, increase or decrease
Interest (previously deterrhined)
Guilt, hopelessness, helplessness
Energy, decreased
Concentration, decreased
Appetite, increased or decreased
Psychomotor, retardation or agitation
Suicidality, active vs. passive

B. Hypomania

Have you had periods of needing very little sleep and not feeling tired?
Has anyone ever worried that you were excessively happy or so energetic that you were not your normal self?
Have your thoughts ever raced so that you could not control them?
Have you ever had periods of greatly increased energy when you felt you could accomplish alinost anything?
Have you had periods of thrill seeking when you took physical risks, such as speeding or doing other dangerous things?


9. Screen for Anxiety Disorders

Do you feel nervous or tense?
Have your ever felt extremely frightened, physically uncomfortable, or worried that something terrible was going to happen?
If yes: Tell me about that. Did you expect to feel that way?
Are there situations or activities that cause you a lot of anxiety or that you are more afraid of than most people would be?
If yes: What happens when you ? Do you avoid that (those) situations (activities)?
Do you worry a lot or have trouble gettihg things off your mind? If yes: What do you worry about?
What do you have trouble getting off your rhind?
Is there anything you have to do over and over again and cannot stop yourself from doing? If yes: Tell me about that.

10. Screen for Eating Disorders

Have you lost or gained weight in the last year? How much?
How many times have you started a diet in the last year?
Have you ever felt that your eating was out of control? Have you gone on eating binges?
Have you ever vomited or spit out food after eating to get rid of it?
Have you ever used diuretics or laxatives? How often?
Have people ever given you a hard time about being too thin?


11. Screen for Psychosis

Have you ever had trouble with your thinking?
Has your thinking ever been so confused that you lost track of your ideas?
Have any of your thoughts seemed frightening or disturbing to you?
Have you ever felt like people were watching or following you, or that they wanted to hurt you?
Have your eyes or ears ever played tricks on you?
Have you ever had the experience of hearing a voice when nobody else was around, or of seeing things that weren't there?


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