Post on 24-Sep-2015
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Psychiatric HistoryandMental Status Examination
Psychiatric HistoryIdentifying DataChief ComplaintHistory of Present IllnessPrevious illnessPersonal History (Anamnesis)
Identifying DataNameAgeMarital StatusOccupationEthnic BackgroundReligionCurrent Circumstances of LivingSource of information; Reliability
Chief ComplaintShould be written in the patients own words stating why he/she has come or been brought in for helpIt should be written in verbatim; no matter how absurd, illogical, irrelevant or bizarre it is.The accompanying person or relatives complaint should also be taken into account.
History of Present IllnessA comprehensive and chronological picture of the events leading up to the current moment in the patients life.Onset, precipitating factors/events, personality typeEvolution of the patients symptoms, how illness affects patients life, nature of dysfunction
Previous IllnessPast episodes of both psychiatric and medical illnessesCauses, complications, treatment, the effects of the illness on the patients lifeAlcohol and other substance abuse; quantity and frequency
Personal HistoryPatients past life and its relationship to the present emotional problemThe predominant emotions associated with the different life periods should be noted
Pre-natal and perinatal historyEarly childhood (0-3 yo)Middle childhood (3-11 yo)Late childhood (puberty-adolescence)AdulthoodPsychosexual historyFamily historyDreams, fantasies and values
Mental Status ExaminationDescribes the sum total of the examiners observations and impressions of the psychiatric patient at the time of interview
General DescriptionMood and AffectSpeechPerceptual DisturbancesThought DisturbancesSensorium and CognitionImpulse ControlJudgment and Insight
General DescriptionAppearance: posture, poise, clothing groomingBody type, hair, nailsHealthy, sickly, ill at ease, poised, odd looking, young-looking, disheveled, childlike, bizarreSigns of anxiety
Behavior and psychomotor activity:Quantitative and qualitative aspects of the patients motor behaviorMannerisms, tics, gestures, twitches, stereotyped behavior, echopraxia, hyperactivity, agitation, combativeness, flexibility, rigidity
Attitude toward examiner:Cooperative, friendly, attentive, interested, frank, seductive, defensive, hostile, playful, evasive, guardedLevel of rapport
Mood and AffectMOOD: pervasive and sustained emotion that colors the patients perception of the worldDepressed, despairing, irritable, anxious, angry, expansive, euphoricMaybe labile
AFFECT: patients present emotional responsivenessNormal range, constricted, blunted, flatAppropriateness of the patients response to the context of the subject matter the patient is discussing
Speech Physical character of speechQuantity, rate of production, qualityTalkative, garrulous, unspontaneousRapid, slow, pressured, hesitant, dramatic, monotonous, loud, whisperedImpairment of speech: stuttering
Perceptual DisturbancesHallucinationsIllusionsDepersonalization, derealizationFormication
Thought DisturbancesTHOUGHT PROCESS (Form of thinking): a way in which a person puts together ideas and associationsLoosening of association, derailment, flight of ideas, racing thoughts, tangentiality, circumstantiality, word salad, neologisms, clang association, blocking, relevant/irrelevant
CONTENT OF THOUGHTDelusions, preoccupations, obsessions, compulsions, phobias, suicidal or homicidal ideasDelusions: fixed false beliefsMood in/congruentPersecutory/paranoid, grandiose, jealous, somatic, erotic, nihilistic
Sensorium and CognitionAssesses organic brain functioning, intelligence, capacity for abstract thought, level of insight and judgment
Alertness and level of consciousnessOrientationMemory
4. Concentration and Attention5. Capacity to Read and Write6. Visuospatial ability7. Abstract Thinking8. Fund of Information and Intelligence
Impulse ControlCritical in ascertaining the patients awareness of socially appropriate behavior A measure of the patients potential danger to self and others
Judgment and InsightJUDGMENT: patients capability for social judgmentImaginary situationsINSIGHT: patients degree of awareness and understanding that they are ill
Levels of InsightComplete denial of illnessSlight awareness of being sick & needing help but denying it at the same timeAwareness of being sick but blaming it on others, on external factors, or on organic factors.Awareness that illness is due to something unknown in the patientIntellectual insightTrue emotional insight
Reliability Estimate of the psychiatrists impression of the patients truthfulness or veracity