Psychiatric History and Mental

Status Examination
 Psychiatric History
• The psychiatric history is the record of the
patient's life;
• it allows a psychiatrist to understand who the
patient is,
• where the patient has come from, and
• where the patient is likely to go in the future.
 1.Identifying Data
• The identifying data provide a concise
demographic summary of the patient by
- name, age, marital status, sex, occupation,
language
-ethnic background, and religion, and the
patient's current living circumstances.
 Identifying Data con..
• The information can also include
-the source(s) of the information,
-the reliability of the source(s), and
-whether the current disorder is the first episode
for the patient.
• The psychiatrist should indicate whether the
patient came in
-on his or her own,
-was referred by someone else, or
-was brought in by someone else.
 Identifying Data con..
• The identifying data are meant to provide
important patient characteristics
-that may affect diagnosis, prognosis,
treatment, and compliance
 2.Chief Complaint
• states why he or she has come or been
brought in for help
• It should be recorded even if the patient is
unable to speak, and
-the patient's explanation, regardless of how
bizarre or irrelevant it is,
• If the patient is comatose or mute that should
be noted in the chief complaint as such.
 3.History of Present Illness
• provides a comprehensive and chronological
picture of the events
-leading up to the current moment in the
patient's life.
• This part of the psychiatric history is probably the
most helpful in making a diagnosis:
-When was the onset of the current episode, and
and
-what were the immediate precipitating events or
triggers?
 3.History of Present Illness con…
• An understanding of the history of the present
illness helps answer the question,
- Why now? Why did the patient come to the
doctor at this time?
-What were the patient's life circumstances at
the onset of the symptoms or behavioral
changes, and
- how did they affect the patient so that the
presenting disorder became manifest
 3.History of Present Illness con…
• patient's symptoms should be determined and
summarized in an organized and systematic way.
• Symptoms not present should also be delineated.
• The more detailed the history of the present
illness, the more likely the clinician is to make an
accurate diagnosis.
• What past precipitating events were part of the
chain leading up to the immediate events?
 3.History of Present Illness con…
• In what ways has the patient's illness affected his
or her life activities
- e.g., work, important relationships
• Are there psychophysiological symptoms? If so,
they should be described in terms of location,
intensity, and fluctuation.
• Any relation between physical and psychological
symptoms should be noted.
• Current substance history
• Suicidal/homicidal ideation or attempt
 Past Psychiatric history
• The patient's symptoms, extent of incapacity,
type of treatment received,
-names of hospitals, length of each illness,
- effects of previous treatments, and
-degree of compliance should all be explored
and recorded chronologically.
• Inter-episodic Function
• Past suicidal/homicidal history
• Substance history
 Past Medical history
• obtain a medical review of symptoms and
- note any major medical or surgical illnesses and
-major traumas particularly those requiring
hospitalization.
• Episodes of craniocerebral trauma, neurological
illness, tumors, and seizure disorders
• history of testing positive for the human
immunodeficiency virus (HIV) or having acquired
immune deficiency syndrome (AIDS).
 Past Medical history con…
• Specific questions need to be asked about the
presence of a seizure disorder,
- episodes of loss of consciousness,
-changes in usual headache patterns, -
-changes in vision, and
-episodes of confusion and disorientation.
- A history of infection with syphilis is critical
and relevant.
• Many medical conditions and their
treatments cause psychiatric symptoms
that without an attentive medical history
may be mistaken for a primary psychiatric
disorder.
 Family History
• family history should provide a description of the
personalities and intelligence of the various
family members
• History of mental illness in the family
• family have a history of alcohol and other
substance abuse or of antisocial behavior?
• Family history of seizure disorder
• Family history of suicide.
• Family interaction with patient and each other.
 Family History cont…
• role each person played in the patient's
upbringing and
-this person's current relationship with the
patient.
• family's attitude toward, and insight into, the
patient's illness.
• Does the patient feel that the family members
are supportive, indifferent, or destructive?
• What is the role of illness in the family?
 Personal History
• the mental professional needs a thorough
understanding of the patient's past and its
relation to the present emotional problem.
• The anamnesis, or personal history, is usually
divided into perinatal, early childhood, late
childhood, and adulthood
• The predominant emotions associated with
the different life periods (e.g., painful,
stressful, conflictual) should be noted.
 Perinatal History
• whether the patient/pregnancy/ was planned
and wanted.
• Were there any problems with the mother's
pregnancy and delivery?
• What was the mother's emotional and physical
state at the time of the patient's birth?
• Were there any maternal health problems during
pregnancy?
• Was the mother abusing alcohol or other
substances during her pregnancy?
 Perinatal History con…
– Full-term pregnancy or premature
– Vaginal delivery or caesarian
– Drugs taken by mother during pregnancy
(prescription and recreational)
– Birth complications
– Defects at birth
 Early Childhood (Birth through Age 3
Years)
• The quality of the mother child interaction.
• Early disturbances in sleep patterns, including
episodes of head banging and body rocking(
provide clues about possible maternal deprivation or developmental disability.)

• Were any psychiatric or medical illnesses present in the

parents that may have interfered with parent child
interactions?
• Was the child shy, restless, overactive, withdrawn, out going,
friendly?
• Did the child prefer to play alone, with others, or not at all?
Early Childhood (Birth through Age 3
Years) con…
– Significant milestones
• Standing/walking
• First words/two-word sentences
• Bowel and bladder control
Middle Childhood (Ages 3 to 11 Years)
• patient's early school experiences,
• how the patient first tolerated being
separated from his or her mother.
• patient's earliest friendships and personal
relationships are valuable
• determine the number and the closeness of
the patient's friends,
• describe the patient's social popularity and
participation in group or gang activities.
• Was the child able to cooperate with peers, to be
fair, to understand and comply with rules, and to
develop an early conscience?
• Early patterns of assertion, impulsiveness,
aggression, passivity, anxiety,
-or antisocial behavior emerge in the context of
school relationships.
• A history of the patient's learning to read and
developing other intellectual and motor skills is
important.
• The presence of nightmares, phobias, bed-
wetting, fire-setting, cruelty to animals,
 Late Childhood (Puberty through
Adolescence)
• explore the patient's school history,
- relationships with teachers, and
- favorite studies and interests, both in school and
in extracurricular areas
• patient's participation in sports and hobbies
• inquire about any emotional or physical problems
that may have first appeared during this phase
• Was the patient interactive and involved with
school and peers, or
- was he or she isolated, withdrawn, and
perceived as odd by others?
 Social Relationships
• Attitudes toward sibling(s) and playmates,
• number and closeness of friends,
• leader or follower, social popularity,
• participation in group or gang activities,
• idealized figures, patterns of aggression,
passivity, anxiety, antisocial behavior
 School History

• How far the patient progressed,

• adjustment to school,
• relationships with teachers
• favorite studies or interests,
• particular abilities or assets,
• extracurricular activities, sports, hobbies.
• relations of problems or symptoms to any
social period
 Adulthood: Occupational History
• patient's choice of occupation,
• any work-related conflicts.
• explore the patient's feelings about his or her
current job and
• relationships at work (with authorities, peers,
and, if applicable, subordinates)
• describe the job history (e.g., number and
duration of jobs, reasons for job changes, and
changes in job status).
 Marital and Relationship History
• elicits a history of each marriage, legal or
common law.
• Describe the story of the marriage or long-term
relationship and the evolution of the relationship
• the age of the patient at the beginning of the
relationship.
• The areas of agreement and disagreement
including
-money management, housing difficulties, and
- attitudes toward raising children.
Marital and Relationship History con…
• Is the patient currently in a long-term
relationship?
-How long is the longest relationship that the
patient has had
• Can the patient initiate a relationship or
approach someone with whom he or she feels
attracted?
• How does the patient describe the current
relationship
 Education History
• Age first schooling
• How far did the patient go in school?
• What was the highest grade or graduate level
attained
• what was the level of academic performance?
• How far did the other members of the patient's
family go in school
• What is the patient's attitude toward academic
achievement?
 Social Activity

• patient's social life and the nature of friendships

• emphasis on the depth, duration, and quality of
human relationships
• What social, intellectual, and physical interests
does the patient share with friends?
• Is the patient essentially isolated and asocial?
• Does the patient prefer isolation, or is the patient
isolated because of anxieties and fears about
other people?
 Legal History
• Has the patient ever been arrested and, if so,
for what?
- How many times?
• Does the patient have a history of assault or
violence? Against whom? Were weapons
used?
• What is the patient's attitude toward the
arrests or prison terms?
 Sexual History
• The onset of puberty and the patient's feelings
about this milestone are important.
• Attitudes toward sex should be described in
detail.
• Is the patient shy, timid, aggressive? Does the
patient need to impress others and boast of
sexual conquests?
• Did the patient experience anxiety in the sexual
setting? Was there promiscuity? What is the
patient's sexual orientation?
 Premorbid History
 How was patients personality before he got sick
 When you are feeling well, how would you
describe yourself?
 How would other people describe you?
 When you find yourself in difficult situations,
what do you do to cope?
 What sort of things do you like to do to relax?
 Do you have any hobbies?
 Do you like to be around other people or do you
prefer your own company?
 Are you religious?
 Do you have any ambitions or plans?
 Mental Status Examination
• The mental status examination is the
description of the patient's
-appearance, speech, actions, and thoughts
during the interview.
• Even when a patient is mute, is incoherent, or
refuses to answer questions, the clinician can
obtain a wealth of information through careful
observation.
 General Description
• Appearance
- describes the patient's appearance and
overall physical impression
- posture, poise, clothing, and grooming, hair,
and nails.
• Common terms used to describe appearance
poised, old looking, young looking,
disheveled/uncombed, childlike, and bizarre.
 Attitude Toward Examiner
described as cooperative, friendly, attentive,
- interested, frank, seductive, defensive,
contemptuous,
-perplexed/confused, apathetic, hostile
/aggressive, playful, --
ingratiating /slimy, evasive, or guarded;
 Overt Behavior and Psychomotor Activity
• quantitative and qualitative aspects of the
patient's motor behavior
• Included are mannerisms, tics, gestures, twitches,
-stereotyped behavior, echopraxia, hyperactivity,
agitation,
- combativeness, flexibility, rigidity, gait, and
agility
• Describe restlessness, wringing of hands, pacing,
and other physical manifestations.
• Note psychomotor retardation or generalized
slowing of body movements.
• Describe any aimless, purposeless activity.
 2.Speech
• Speed: fast,slow ,and normal

• Volume: Loud,Low,Normal

• Quantity: Too little,too much or normal

• Tone : Low pitched,high pitched

• None-social speech: muttering ,neologism,ward

salad
 Mood
• pervasive and sustained emotion that colors the
person's perception of the world.
• ask the patient how he or she feels.
• Statements about the patient's mood should
include intensity, duration, and fluctuations.
• Common adjectives used to describe mood
include
- depressed, despairing, irritable, anxious, angry,
expansive,
-euphoric, empty, guilty, hopeless,
- self-contemptuous, frightened, and perplexed.
 Affect
• defined as the patient's present emotional
responsiveness,
• inferred from the patient's facial expression
• Affect may or may not be congruent with
mood.
• Affect can be described as within normal
range, constricted, blunted, or flat.
 Appropriateness of Affect
• consider the appropriateness of the patient's
emotional responses in the context of the
subject the patient is discussing
• inappropriate affect for a quality of response
found in some schizophrenia patients,
- in which the patient's affect is incongruent
with what the patient is saying
 Perception
• Perceptual disturbances, such as hallucinations and
illusions,
• The sensory system involved (e.g., auditory, visual,
taste, olfactory, or tactile) and the content of the
illusion or the hallucinatory experience should be
described.
• The circumstances of the occurrence of any
hallucinatory experience are important;
- hypnagogic hallucinations (occurring as a person falls
asleep) and
-hypnopompic hallucinations (occurring as a person
awakens)
• Feelings of depersonalization and derealization (extreme
feelings of detachment from the self or the environment)
• Formication, the feeling of bugs crawling on or under the skin,
is seen in cocainism.
 Thought Content
• Disturbances in content of thought include
- delusions, preoccupations (which may
involve the patient's illness),
-obsessions ,compulsions
-suicidal/Homicidal ideation
- ideas of reference and of influence
 Thought Process /Form
• The patient may have either an overabundance
or a poverty of ideas.
• There may be rapid thinking, which, if carried to
the extreme, is called a flight of ideas.
• does the patient have the capacity for goal-
directed thinking?
• Does the patient have loose associations
• Disturbances of thought continuity include
- statements that are tangential,
-circumstantial, rambling/incoherent,
evasive/shifty, or perseverative.
 Sensorium and Cognition
• Consciousness
- Disturbances of consciousness usually
indicate organic brain impairment
- Clouding of consciousness is an overall
reduced awareness of the environment.
• A patient may be unable to sustain attention
to environmental stimuli or to maintain goal-
directed thinking or behavior.
• Some terms used to describe the patient's level of consciousness are
clouding, somnolence, stupor, coma, lethargy, or alert.
 Orientation
• What is your name? Who am I?
What place is this? Where is it located?
What city are we in?
• Measuring PPT
• Disorders of orientation are traditionally
separated according to time, place, and person.
• Any impairment usually appears in this order (i.e.,
sense of time is impaired before sense of place);
 Concentration and attention
• Starting at 100, count backward by 7 (or 3).
• Say the days of the weeks for ward and backward.
Name the months of the year backward starting
with september
• A patient's concentration can be impaired for
many reasons.
- A cognitive disorder, anxiety, depression, and
-internal stimuli, such as auditory hallucinations,
can all contribute to impaired concentration.
 Memory
• Immediate:
-Repeat these numbers after me: 1, 4, 9, 2, 5.
• Recent:
-What did you have for breakfast?
-What were you doing before we started talking
this morning?
-I want you to remember these three things: a
yellow pencil, a cocker spaniel, and Cincinnati.
After a few minutes I'll ask you to repeat them.
 Memory con…
• Long term:
-What was your address when you were in the
third grade?
-Who was your teacher?
-What did you do during the summer between
high school and college?
 Fund of knowledge
• What is the distance between Addis Ababa
and your hometown?
• Who is the current PM of ethiopia?
 Abstract reasoning
• Abstract thinking is the ability to deal with
concepts.
• Patients can have disturbances in the manner
in which they conceptualize or handle ideas.
• Which one does not belong in this group: a
pair of scissors, a canary, and a spider? Why?
How are an apple and an orange alike?
 Judgment
• During the course of history taking, the
student should be able to assess many aspects
of the patient's capability for social judgment.
• Does the patient understand the likely
outcome of his or her behavior
• is he or she influenced by this understanding?
• Can the patient predict what he or she would
do in imaginary situations (e.g., smelling
smoke in a crowded movie theater)?
 Insight
• Insight is a patient's degree of awareness and
understanding about being ill.
• Patients may exhibit complete denial of their
illness or may show some awareness that they
are ill but place the blame on others,
 six levels of insight follows:
• 1.Complete denial of illness
• 2. Slight awareness of being sick and needing
help, but denying it at the same time
• 3. Awareness of being sick but blaming it on
others, on external factors, or on organic
factors
• 4. Awareness that illness is caused by
something unknown in the patient
 six levels of insight follows:
• 5. Intellectual insight: admission that the patient
is ill and that symptoms or failures in social
adjustment are caused by the patient's own
particular irrational feelings or disturbances
without applying this knowledge to future
experiences
• 6. True emotional insight: emotional awareness
of the motives and feelings within the patient and
the important persons in his or her life, which can
lead to basic changes in behavior.
 example how to write
• Alertness: Alert and awake throughout the interview
• Orientation: Intact to person, place, and time
• Concentration: Spelled word backward correctly; serial 7s
performed correctly and without hesitation
• Memory: Registration and recent memory (5 minutes)
intact for 3/3 phrases (blue rose, 37, happiness); long-
term memory appears intact as evidenced by his detailed
recall of past events in the history.
• Calculations: 6 × 12 = 72; $2.00 – 65 cents = $1.35
• Fund of knowledge: Good. He knew presidents back to
Carter. He said WWII started around 1940 and then
spontaneously added, “Hitler and Normandy.” He knew
that Einstein was responsible for the theory of relativity.

• Abstract thinking: Somewhat concrete; similarities:

apple/orange—“both fruits”;poem/statue—“both have
form”; fly/tree—“both are nature, both are iridescent
green, flies fly around crap, which is brown, the same
color as tree bark”
• Insight: Poor. The patient does not recognize the
presence of any illness or that his behavior is
dangerous, stating, “Maybe I have a very mild case of
mania, but if I need to be here, then 90 percent of
everyone in the world needs to be locked up.” He
initially refused to take medication and repeatedly
says he doesn't need to be “locked up,” that he can
take care of his minor relationship problems as an
outpatient
• Judgment: Fair. He cooperates with staff even though
he doesn't think he needs hospitalization because he
fears that a history of involuntary commitment
would make it difficult for him to realize his goal of
becoming a teacher. He says that the next time he is
angry with his boyfriend, he will “work it out,” and
not try to kill himself.
• Physical examination
-vital signs
-HEENT
-Chest
-CVS
-Abdomen
-GUS
-integumentary
 Case summery
• Here all important findings stated in short in
one paragraph.
• This is the summery very important points
mainly from ID, HPI and MSE.
• Help the audience to remember all important
findings
• Facilitate diagnosis and treatment
 Multi-axial diagnosis
• Axis I: All diagnostic categories except mental
retardation and personality disorder
• Axis II: Personality disorders and mental
retardation (although developmental disorders,
such as Autism, were coded on Axis II in the
previous edition, these disorders are now
included on Axis I)
• Axis III: General medical condition; acute medical
conditions and physical disorders
• Axis IV: Psychosocial and environmental factors
contributing to the disorder
 Multi axial diagnosis cont.
 Problems with primary support group:

 Disruption of family by separation

 death of family member

 Discord with sibilings……

 Multi axial diagnosis cont
• Problems related with the social
enviornment: e.g

• Death of friend, living alone

• inadequate social support,

• problem with acculturation, ……..

 Multi axial diagnosis cont
• Educational problem: e.g

 Illiteracy, academic problems

 discord with teachers or classmates,

 inadequate school environment…..

 Multi axial diagnosis cont
• Occupational problems: e.g

 Unemployment,

 threat of job, stressful work schedule

 Job disatisfaction…..
 Multi axial diagnosis cont
• Housing problem: e.g

 homelessness, inadequate housing

 unsafe neighborhood,

 discord with neighborhood…..

 Multi axial diagnosis cont
• Economic problems: e.g extreme poverty,
inadequate finances ……

• Problems with access to health care services:

e.g
 inadequate health care services,
transportation to health care facilities……
 Multi axial diagnosis cont
• Problems related to interaction with the legal
system: e.g arrest, litigation …….

• Other psychosocial and environmental

problems: e.g exposure to disasters ,war
,discord with nonfamily caregivers…….
 Multi axial diagnosis cont
• Axis V: global assessment of functioning
• Reporting the clinician's judgment of the
individual’s overall level of functioning.

• The information is useful in planning

treatment and measuring its impact and in
predicting outcome.
 Multi axial diagnosis cont
• Functioning is related with respect only to
psychological, social and occupational
functioning.

• Has 10 point range. each 10 point range has

two components:
 Multi axial diagnosis cont
• the first part covers symptom severity and the
second part covers functioning.

• Do not include impairment in functioning due to

physical (or environmental) limitations.
 Formulation biopsychosocial
Biological psychological Social

Predis -family history, genetics, Hx of Punishment or Hx of social isolation

posing --prenatal/postnatal, reinforcement conflict
-developmental Traumatic life events
Over protection

precipit Trauma, toxins ,vascular Significant events

events
ating loss

perpet Chronic substance Lack of insight Marital discord, chronic illness

abuse, chronic Chronic occupational stress
uating illness,handicaps,disabilities
Financial problem,r/p problem

protect Absence of family history, Use of therapy, insight Increased intimacy, Job
good physical health,
ive satisfaction, Financial
medications Capacity to change
security, High academic
thinking pattern achivement,high IQ,good
Avoid destructive r/p family support