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