Psychiatric Sheet

Sources: Dr. Tarek Desoky Sheet, Assuit Sheet, Ain Shams Sheet

Dr Mohamed Moslem Al-Hefny

Psychiatric History
 Psychiatric History
History
Preliminary identification, personal data, personal history
Chief complaint
1- from paent 2-from informant
History of present illness
1. Psychiatric
a) positive data
b) negative data
2. Substance history
3. Medical (neurological, surgical)
Past history (previous illness):
1. Psychiatric
2. Medical (neurological, surgical)
3. Substance history
Past personal history (Past personal data)
Premorbid personality
Family history
1. Family history as a social history
2. Family history of psychiatric illness
Family history of medical illness
Family history of substance abuse
 Psychiatric History

Preliminary data
• Name
• Age
• Sex (gender)
• Marital state (single, married, divorced, separated widow)

• Occupation
• Residence (address)
• Educaon (illiterate, read and write, 1ry, preparatory, 2ry school ''grade'', dropped out of, graduated from
faculty of ……)
• Religion
• Special habits

• With whom the patient lives (the patient's current living circumstances)

• Handedness

• Previous admission to a mental hospital (and its date)

• Source and reason of referral: 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.
Ex. He was brought by his father voluntarily

Example; An example of the written report of the identifying data follows:

Mrs. Mona Ahmed Ali 22yrs old, Moslem, illiterate, from Girga, housewife, married and has no children, lives
in her father's house, no history of admission to a mental hospital. She was referred by his internist for
psychiatric evaluation.

Value
1- To be familiar with the patient.
2- The identifying data provide a succinct demographic summary of the patient. They are meant to provide
information of potentially important patient characteristics that may affect diagnosis, prognosis, treatment,
and compliance.
Median age at onset of major psychiatric disorders
Disorder Age (yr)
Schizophrenia 21 (men), 27 (women)
Major depression 40
Bipolar disorder I 30
Bipolar disorder II
Panic disorder 24
Obsessive-compulsive disorder 23
Drug abuse/dependence 18
Alcohol abuse/dependence 21
Kaplan

− More in females: Rett's disorder (exclusively in females), BPD, panic disorder, specific and social phobias
− More in males: ADHD, conduct disorder, antisocial PD
Chief complaint
1- From patient (in patient own wards, in Arabic) (including duration)
2- From informant (in his own words, in Arabic) (but can be slightly modified) (including duration)
− (who lives with the patient, reliable) [reliable = has no secondary gain]

Personal identification:
Ex. Adult male, average bodybuilt, clean groomed with good/poor eye to eye contact)
History of present illness
1- Analysis of positive data (complaint + other symptoms)
2- Mention negative data

Onset/Course/Duration
− School 1:
(a) If episodic, with interepisodal recovery and long history: Begin from the last episode and mention other
episodes in past psychiatric history, in this case it is better to say ''history of current/most recent episode'',
Their rational is that the most recent episode is the best remembered one.
(b) Exception are: if the whole history is short, the course of illness is non-episodic (continuous), or if remission of
episodes is incomplete (relapse rather than recurrence: then the history can be mentioned as a whole in
chronological manner beginning from the onset of psychiatric illness.
− School 2: the history should be mentioned as a whole in chronological manner beginning from the onset of
psychiatric illness (in any case).

Precipitating factors
You should define
Type of stressor Subordinary:
Ordinary (within the range of normal human experience):
− As loss, death, work troubles, divorce, joining school or army, …..
− May be related to adjustment disorders, dissociative disorders, conversion
disorder, or any other psychiatric disorder
Extraordinary (beyond the range of normal human experience):
− As disaster or traumatic event; experienced or confronted with actual or
threatened death or a threat to physical integrity of self or others
− May be related to ASD or PTSD
Significance of Significant: good prognostic factor
stressor Non-significant: poor prognostic factor .. why? This means high vulnerability
Time interval for ASD: within 4 weeks
emerging symptoms PTSD: anyme aCer stressor (if more than 6 month = with delayed onset)
Adjustment disorder: within 3 months
Persistent to the Adjustment disorder: should be relieved within 6 months of terminaon of the
moment or not? stressor

Absence of stressor:
− Absence of stressor doesn't always mean ''no stressor'', so you should say ''with no apparent stressor''
− Stressor may not be easily disclosable (as in dissociative disorders). Some stressors are secretive and
shameful (as rape or incest), and dissociative defenses can cause amnesia to the stressor. In the latter cae;
stressor can only be explored under drug-assisted interview.

Template: ''Symptoms of the current episode started 6 months ago,

− with no apparent stressor
− immediately, few days, 3 months, aCer being divorced, joining army failure in exam, being
disengaged from her fiance, a physical fight with his brother, death of his father, loss of his money,
marriage, being fired from work, being retired from work, joining school. ………..''
Onset/Course/Duration
Onset Dramatic: at the moment
Sudden/abrupt: hours
Acute: days to weeks
Insidious/gradual: months to years
∗ You can mention these terms in case summary or formulation
∗ In HPI, you should say: ''symptoms developed over days, weeks, months ….''
Course Progressive
Regressive
Intermittent
Relapsing and remitting
∗ You can mention these terms in case summary or formulation
∗ In HPI, you should describe the pattern of presence of symptoms in the following way:
''symptoms had been present all over the day, every day, fluctuating (wax and wan)
Come/occur in brief episodes,
Have a diurnal/seasonal pattern (increase in the morning, show night time exacerbation,
only in winter) ….''
Duration Duration of the first disturbance or change of functioning may be earlier than that mentioned in
complaint.
Severity VIP
'' …. To the extent that he couldn’t be controlled, killed his wife, reported them to the police,
stopped eating completely, starved himself since that time, left home, attempted suicide, ……''

Chronological order of symptoms

∗ It is better, for each symptom, to be dated or ordered in time in relation to other symptoms

Template: ''On 19/4 he started to report voices telling him abusive remarks about his wife, one week later he
started to accuse her vigorously. On 1/6 he killed her while she was sleeping in her bed''.
Psychiatric 1- Psychotic symptoms 1- Mood and mood
review of Delusion symptoms
systems Hallucination 2- Behavior
Incomprehensible speech 3- Thinking
Psychiatric Disorganized behaviors 4- Perception
symptoms 2- Depressive symptoms 5- Cognition
of all Depressed mode Loss of interest 6- Psychomotor activity
domains Guilt feeling Feelings of worthlessness 7- Vegetative symptoms
Lack of concentration Lack of energy 8- Somatic symptoms
Psychomotor agitation/retardation 9- Autonomic symptoms
3- Manic symptoms
Elevated mood
Inflated esteem / Grandiosity
Distractibility
4- Vegetative symptoms:
Sleep
Sex
Self hygiene
Appetite & Weight
5- Catatonic features
6- Anxiety symptoms
GAD: OCD
Panic: OCD, somatic, agoraphobia
OCD
PTSD
Social anxiety symptoms
Simple phobias
7- ADHD symptoms
8- Eating disorders symptoms: purging, excessive exercise
Drug and 9-
alcohol
history
Functioning 10- Dysfunction and premorbid baseline function
Risk 11- Suicide / Homicide
assessment Death wishes
Suicidal ideation
Suicidal plan
Suicidal attempt
History of
psychiatric
treatment
(current and
past)
History of
current
medical
illness & TTT
Mood // Mood symptoms (depressive and manic)
Ask for • Mood in certain period (month, year, ….)
Comment on • Quality
• Quantity (severity)
• Stability
• Reactivity: to pleasure provoking activities, good or bad news
• Affect control: episodes of anger, rage outbursts, uncontrolled violence
Pathological • Unpleasant: sad, depressed, dysphoric, guilt, worthlessness, inadequacy, shame, disgust,
mood states self-reproach/remorse/regret/derogation, anxious, irritable, restless, anger, hepervigilant,
foreboding, fear, apprehension, perplexed, discomfort, lack of empathy, …
• Pleasant: elevated mood, extremely happy, sesnse of wellbeing sense of internal peace,
sense of inflated worth, feeling a high, feeling harmony with the universe, feeling at union
with God and saints,.…
• Schizophrenia: suspicious, frightened, perplexed, irritable, agitated, indifferent, etc.
• Dementia: apathetic, agitated, excited, anxious, depressed, etc.
• Anxiety disorders: tense, irritable, excited, need to be outdoors to relieve his sense of
discomfort etc.
• Panic disorder: frightened, terrified, apprehended, etc.

Template:
Depressed
''He felt extremely sad, constantly low, spontaneously crying, isolated himself inside his room''
mood
Anhedonia ''He no longer enjoyed what he used to enjoy before, his hobbies and loved things. He showed
and lack of lack of concern about everything, had no interest in his household duties, or his social
interest activities, he is no longer participating in social occasions. He stopped going to the café,
meeting his old friends and playing domino with them as he formerly used to do''.
Guilt ''He has severe guilt about being responsible, neglecting his work and his family demands. He
told his family that he was sorry for all the pain and suffering he caused them, and that it
would be better if he wasn't around anymore. He reports that he had perpetrated an
unforgivable sin, and that he deserves punishment for it, and God will never forgive him''
Death wishes ''He feels that life is no longer worth living, he attempted suicide with an overdose of the pills.
and suicide He attempted to strangle himself with a piece of wire. He cut his wrist with a blade. He tried to
kill himself. He occasionally experienced infrequent suicidal thought without a specific plan or
intent. He denies that he would act on them because suicide is religiously prohibited''
Worthlessness ''He always feel unlucky, inadequate, irresponsible, unable to gain success, or to take a decision
and that it would be better if he wasn't around anymore''
MANIC ''Since that time, he felt extremely happy, self-confident, overly ambitious, overly energetic,
talkative, hyperactive, staying all the night cleaning the house, with decreased need for sleep,
being refreshed with few hours of it, intrusive, with tendency for high jocularity, flirting girls in
the street, telling sexual jokes and expressing sexual gestures, signing dud cheques, dancing,
and enjoying loud music and songs, etc.''

Anxiety symptoms ME
Thinking
Form Unintelligible speech, odd, vague, metaphoric speech
Content Erroneous ideas (delusions, overvalued ideas, ideas), obsessions, compulsions, phobias,
preoccupations ($, illness, threat, sin, etc.), depressive ruminations, foreboding, suicidal
ideations
Control Thought insertion, reading, withdrawal, or broadcasting
Flow
Rapid, slow interrupted
(stream/speed)

Delusions
Definition of − The word itself arise from the Latin word delirare
to deviate from a straight line-
delusion:
de (from)&lira (furrow or track)
− A false fixed belief based not shared by the others and not accepted by the
community. (It is a false fixed belief which is out of keeping with the patient social
cultural background.)
− It is characterized by:
Unusual conviction
Not amenable to reasoning
Absurd content
− Ranges from fragmented to systematized
− Ranges from situation who are possible (non bizarre) to those that are
impossible(Bizarre)
Types of Primary delusions
delusions : − Start de novo, one of the first rank symptoms of schizophrenia (Schneider) = These
are diagnostic of schizophrenia
a- Delusional mood: the patient has the knowledge that there is something going on
around him that concerns him, but he doesn’t know what it is.
b- Delusional perception: it refers to the abnormal significance ( new meaning) ascribed
to a real stimulus
• The new meaning cannot be understood as arising from the patient's affective
state or previous attitude.
c- Sudden delusional ideas: delusions appear fully formed in the patient's mind (sudden
arousal of an idea which automatically becomes a belief)
d- Delusional memory or retrospective delusions; refers to faulty recollection of
memories in a way that adds proof to current beliefs.
Secondary delusions
• It is arising from the morbid expense .the projection may have a role in its formation.
• (Primary delusions
delusional work
symptoms)
a- Systematized delusions
a- Non systematized delusions: incompletely systematized delusion: there is one basic
delusion & the reminder of the system is logically built on this error.
Content of 1. Erotomanic delusions (delusion of love or erotomania): delusions that another
delusion person, usually of higher status, is in love with the individual.
2. Grandiose delusions : delusions of inflated worth, power, knowledge, identity, or
special relationship to or famous person
3. Jealous delusions (delusions of infidelity): delusions that the individual's sexual
partner is unfaithful
4. Persecutory type: delusions that one (or someone to whom one is close) is being
attacked, cheated or persecuted.
 Robbed
 Poisoning
5. Somatic delusions: delusions that the person has some physical defect or general
medical condition
6. Delusions of reference: events, objects as TV, or other persons in one's immediate
environment have a particular and unusual significance. (may be based on somatic
hallucination) (Idea of reference: the false belief is not as firmly held nor as fully
organized into a true belief).
7. Delusions of misidentifications :
 +ve --->the patient recognizes strangers as his friends & relatives.
 -ve---->the patient denies that his friends & relatives are the people that he
know& they are stranger to him
8. Delusions of guilt
In mild cases of depression the patient may be somewhat self-reproachful and self-
critical. In severe depressive illness self-reproach may take the form of delusions of
guilt, when the patient believes that they are a bad or evil person and have
destructed their family.
9. Nihilistic delusions
Nihilistic delusions or delusions of negation occur when the patient denies the
existence of their body, their mind, their loved ones and the world around them.
They may assert that they have no mind, no intelligence, or that their body or parts
of their body do not exist; they may deny their existence as a person, or believe that
they are dead, the world has stopped, or everyone else is dead.
10. Delusion of ill health
11. Delusions of poverty

The patient with delusions of poverty is convinced that they are impoverished
and believe that destitution is facing them and their family.
12. Bizarre : a delusion that involves a phenomenon that the person's culture would
regard as totally implausible

13. Delusion of passivity or control: a delusion in which feelings, impulses, thoughts, or

actions are experienced as being under the control of some external force rather
than being under one's own control.(made affect---->insertion of feeling, made act---
->insertion of action, made volition--->inserti ion of an outside will.)

Made phenomena (passivity)?

 Made affect (someone controlling the mood/affect).
 Made volition (someone controlling the action).
 Made impulse (someone controlling the desire to act).
 Made thoughts = (Thought phenomena?)
− Thought withdrawal.
− Thought insertion.

(Other Thought phenomena?)

− Thought broadcasting “people act as if they know what I'm thinking”.
How to ask
What has been in your mind recently?
about delusions?
Do you spend a lot of time thinking about one or two things?

What are things that most important to you?

When you are not busy with something, what do you think about?

Do others frequently disagree with your views on things?

Do you have some idea that you hold very strongly?
Comment on Theme (content)
Evidence
Reaction
Conviction (intensity)
Extension (the degree to which the delusional belief involves various areas of the patient's life)
Pressure or Relations mood:
− Distress (affective response)
− Preoccupations (time spent thinking about it)
N.B. Don't say ''He has delusions of persecution'' Say ''He is convinced that, certain that,
believes that …………….''

Template
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….
………………………………………………………………….

Obsessions
How to ask about ………………………………………………………………….
obsession?
Perception
External • Deceptions: illusions, hallucinations (hallucinatory behaviour), autoscopy, phantom limb
• Distortions: macropsia, micropsia
• déjà vu, jamais vu, agnosia, etc.
Internal Disturbed self-image:
(self Negative self image (worthlessness) Inflated self image
perception) − Depression − Mania
− Social phobia − Narcissistic PD
− Borderline PD // Avoidant PD − Histrionic PD
− ADHD
Body dislike
− Eating disorders (DBI ME)
− BDD (DBI ME)
− Transsexualism
.

Hallucination
Def: Perception without actual stimulus present
They care from <within> although the subject reacts if they were true preceptors coming
from < without>
DD from illusions
Hallucination: no actual stimulus
Illusions: with actual stimulus
-
True versus
True Pseudo
pseudo
hallucinations: Occur in all sensory modules
In objective space ‫
ة ودا‬ In subjective space
Clearly delineated (seem as vivid as real experience) Not clearly delineated
Occurs spontaneously (out of control of patient)
Intrusive as obsessions
Occurs simultaneously with stimuli
Insight lost Insight preserved
-

Modality Auditory hallucination:

1- Elementary: noises
2- Partly organized: music
3- Completely organized: hallucinatory voice
• May be: Known or unknown, single or multiple, male or female
• Types:
(a) 2nd person (You): commanding (ordering), threatening, praising, criticizing,
mocking, teasing, abusive, saying obsene words, jocular saying (jokes)
(b) 3rd person (He, She): two or more voices arguing or discussing vigorously the
patient among them
(c) audible thought (thought echo)
Visual hallucination:
1- Elementary: flashes of light
2- Partly organized
3- Completely organized: vision of people, animals
Olfactory hallucinations: smell
Gustatory hallucinations: taste
Tactile hallucinations: sexual hallucinations
Hallucination of pain, deep sensation
 Somatic hallucination
Cenesthetic hallucination: pushing sensation in blood vessels

SPECIAL KINDS OF SENSATIONS

Functional hallucinations and Reflex hallucinations
Extra campine hallucinations
Autoscopy, Negative autoscopy, and Internal autoscopy (internal organs)
Reaction Reaction (attitude) to the hallucination
Behavioural − Searching behavior
response − Staring in the space
(hallucinatory - Self laugh
behavior) - Self talk (whispering): vocalization of the voices
- Looks as if talking or shouting to someone
− Ear blocking
- Resistance to nursing care
Emotional − Terrifies: organic, early schizophrenia
response − Accepting: mood
− Amused (enjoy it): Lilliputian hallucinations (DT)
− Suspicious: schizophrenia
− Not very troubled by voice: may treat them as old friends
Rational- Rationalization by the patient for origin of the hallucination:
ization May not be concerned
Witchcraft
Telepathy
Gen
Part of the body
= Cognitive interpretation of hallucinations
(2ry delusions: control, persecution)
How t o ask
Have you heard a voice from someone not in the room?
about?
Have you ever heard something and not been sure where it was coming from?

Did you ever hear something that sounded like a voice and not know who was talking?

Did you recognize whose voice it was?

Did the voices /voice tell you to do something?

Did a voice come seem to come from inside or outside your head?

Did you comply? & why & why not?

Have you seen something that others couldn’t see?
Comment on  Type:
− Pseudo, true (insight, voluntary control)
− Modality
 Content, circumstances (consciousness)
 Reaction // Response // Rationalization
 Relation to mood or mental state
Don’t say ''auditory hallucinations'' but say ''he hears voices telling him that …."

Template:
− She was frequently seen as if talking to someone.
− She was seen talking to herself but nothing of what she said being understood.
− She reported hearing voices talking about her behavior and telling her what to do.
 − Voices kept commenting on her behaviors.
− Voices described what she was doing here and now.
− She said that she heard the voice of a man talking to her although she couldn’t see him.
− Voices told her that she is no longer worth living and that she has to kill herself.
− She had smelled a foul odour like burnt meat and she was afraid that it came from herself.
− No one else could hear the voice.
− She kept starring in the space and on the walls.
− He pointed aimlessly.

Cognition
Attention Difficulty focusing, shifting or sustaining attention, excessively distractible by external stimuli.
Concentration Difficulty concentrating during conversations or during activities "he has trouble concentrating"
Orientation Difficulty knowing where he is? Who he is? And who are near subjects around him?
Difficulty remembering days, dates, addresses, appointments, names, subjects or
Memory conversations, remembering where subjects are usually kept, lose or misplace things, repeat
the same question over and over again, tell the same story over and over again.
Visuospatial Difficulty in self direction, remembering places, difficulty transferring between the house
orientation rooms, getting way back home, getting way to the bathroom.
Executive
Difficulty making shopping, management of money, making decisions in day life matters.
function
− Basic activities (self dressing, feeding, toileting, shaving, or bathing)
Adaptive − Instrumental or home living activities (using utensils, lighting matches, cooking, working
behavior familiar machines around the house; working with the stove, working with the laundry,
using the iron)
Behavioral and − Behavioral symptoms: aimless wandering, screaming, repeating vocalizations, speaking
psychological loudly, destroying.
symptoms of − Psychological symptoms: hostility, losing temper, emotional outbursts, mood symptoms,
dementia psychotic symptoms (making accusations, hallucinatory behavior).
Safety Falling, wandering, driving
How t o ask  ‫
ار دار‬، ‫ ا ص‬، ‫ ا ء‬، ‫ ا ا‬، ‫ ا ا‬، ‫ ا ار‬، ‫  ا م‬،‫  آ‬، ‫  "! ا‬#‫اآ‬$‫• ا‬
about? .%& #' " 
‫و‬
(in Arabic) . +‫ و* ن  واآ‬+‫ اآ‬,  ‫ ل‬. ، ‫ ا‬/0‫ ا‬، ‫ ا‬1"*2 •
‫ '؟‬-" ‫ ' "* ن‬134 ‫ ا " د‬5
6
 •
.‫ ط‬%9‫ ا‬1: *" ' ;" 5 4‫ ا‬64 •
‫= ا*>م ا &  "   ؟‬2: ‫ و‬....   "   ‫= ا<ال ا‬2: ‫• *ر‬
. 1! ?:‫ " ا‬5
' ‫ " ك او‬A!* 
B" ‫  اء‬,‫  ' اآ‬C &> •
...........، ‫ ا م‬F‫ او‬، ‫ م‬4‫ ا‬DG ‫؟ ف‬#
 B5 ;' " B!G  ‫؟‬#  *" ‫ آ = و‬D3‫• ف ا‬
............، B" H‫ ا‬، !I ‫ "* ن‬، ‫ ل‬.%‫ ا‬: = ‫* ا" آ آ‬2 •
...........، ‫  رف ا
ا‬، 2: ‫•  رف‬
.#
 JC 5> K  ، #‫ ر‬0 ' ! L 4 ، ‫  ق‬، ‫ي‬/ ‫• ف‬
.#
 #‫ آ‬+ ‫ر‬. ‫ ا>ج و‬$K‫ ا‬، ;‫ ا‬، ‫ م‬4‫ ا‬، !‫ اآ‬، =% ' # " ‫ ج‬4 •
.#‫ م ا* ا‬،  I‫ ا‬+I/ ، ‫ ز‬H0 %‫ ا‬B ..... ?%‫ ا‬#,15‫• ف م ا‬
.........، ‫ ب‬%‫ ! ا‬J0 2‫  ا‬، ‫ ح‬2" ‫ ب‬%‫ ا‬L ، B‫ ز وا‬H0 %‫• "*  ا‬
.2: S ، %T .3 +‫  آ‬. ، +‫ ' اآ‬S •
.‫ ! ا ر‬+‫ اآ‬0 ، 3‫ ظ ا‬%0 ، %30 '‫? ";  ر‬. •
.L0" ;"‫ و‬6%!" . ">‫ آ‬، ‫ &ار‬K  ‫ "; & در‬. •
# ‫ ش د‬1 " ، *" ، ?‫ ل  آ‬G ! . ، +& ">‫ آ‬، ‫  ه ج‬+X4 : 
‫ ا‬، LYI‫ ا‬B ،  ':‫ ا‬. •
.5 4
Behaviour

Comment on A= Antecedents (before)

B= Behaviour (during)
C= Consequences (after)
Examples of Ask about the according to the context of symptomatology:
pathological − Manic and impulse control disorder
pleasure seeking behavior
behavior − Histrionic
attention seeking behavior
− SUD
drug seeking behavior
− Psychotic
disorganized or bizarre behavior (collecting things from the floor)
− Catatonia
catatonic behavior
− Unexplained behavior
− Disinhibited behavior [socially, sexually]
 Autism
Ritualistic behaviour
 Autism
Stereotyped behaviour
 Stereotyped behavior (due to any cause)
− Impulsive behavior
− Manipulative behavior
− Compulsive/ ritualistic behavior
 Aggressive/violent behavior
 Antisocial/conduct behavior
 Oppositional/defiant behavior
− Psychotic with hallucinations
hallucinatory behavior
− Maladaptive behavior
− Suicidal/homicidal behavior
− BPD
self mutilating behavior
− Sexually abused child
oversexualized/sexual promiscuity behavior
− GID
Cross gender identification behavior [cross dressing, play, games & activities]
Also ask about − Automatism
− Abnormal movement [motor disorders]

Template: ''He frequently while waking in the street:

− Gets into fights with the passerby accusing them that they laugh at and talk about him
− He aggressively assaults them, may hurt them, etc.''

In children: obstinacy, disobedience, aggressiveness, defiant, destructiveness, stealing, lying, delinquent behaviour, attention
problems, poor impulse control, hyperactivity, odd, repetitive behaviour, ununderstandable, disinhibited Behaviour,
suspiciousness, talking/smiling to self, irrevalent talking, apathetic, social withdrawal

Disruptive Oppositional
behavior
(antisocial  ‫ م ا"!؟ وح  
ا  ل  هت س ؟‬$%& ‫"ب آ)"؟ "(ق‬
behavior) $, ‫ح أو‬./ 0(1 ‫"؟‬2‫ذي ا"ات وا‬5 ‫"ت؟‬6‫ح ا‬7 ‫ ر؟‬9 ‫ &؟‬$%& ‫ ظ‬
Conduct

 $%& ;6 ‫=(" < &؟‬% ‫)ى‬6 ‫؟‬$%& = ? ‫"ل؟ @! & و‬6‫د " ا‬A ‫&دة؟‬
‫رات؟‬B ?" ‫؟‬$/‫ر‬1‫ب 
ا‬A ‫ م؟‬C !"‫" <
ا‬D ‫ ا"!؟‬E ‫؟ ت‬F
Self-injurious behavior ‫؟‬1(% ‫ّط‬I ‫؟‬E ‫ إ‬K6 ‫؟‬L‫ب < و‬M ‫(؟‬N OB ‫؟‬/‫ رأ‬PB"
Motor disorders ‫؟‬$="6 $‫"
؟ ")ك &آ‬6 9R‫"? و‬
− Stereotypic movements ‫(؟‬N ‫ و وخ‬T" ‫؟‬1(% UA" ‫؟‬6‫ا‬V‫ و‬E W ‫ "ف‬−
Psychomotor Activity:

Increase activity level: agitation

Decreased activity level: retardation

Within normal range.
How to Agitation [1" ، Z! + ، %X ، ‫ ي‬5 J‫ را‬، Y !  & ;" ،0 " ،‫
آ آ‬:
ask? Retardation 4 ‫ م‬. ‫ او‬+‫ اآ‬L!3 +3 .........، +!& ">‫ وآ‬، *"‫ و‬,
‫ &  دا‬،  ‫ء‬6% ‫ك‬4 ، !!& ‫
آ‬
(in Arabic) . " 0 2: +‫ اه‬............،

Template: ''He stays all the day in bed, he feels unable to move or to speak,. He no longer wants to get out of bed, to
do any or to go out. According to him, there is nothing worth getting out of bed. He stopped eating, bathing or
showering.''
Vegetative symptoms (sex, sleep, appetite)
A- Sex
Sexual functioning (desire, arousal, orgasm, resolution)
Fantasies and activities
Gender identity and role
Sexual orientation (homo-, hetero, bisexual)
Puberty and menarche (age at menarche, regularity of menses, P/C, absence of periods, date of last
period, etc.)

B- Sleep (sleep history)

The primary CO 1- Characterize the CO: falling asleep, s

2- Analyze the CO:
 Onset: abrupt in association with negative life events, gradual
 Course: progressive, intermittent.
 Duration: weeks, months, years.
 Frequency: night/week, times/night
 Severity: nighttime distress, daytime symptomatology
 Increasing and decreasing factors
Pre-sleep 1- Pre-bedtime activities: watching TV, reading in bed, having a snack, smoking,
conditions exercise, work, computer use.
2- Bedroom environment: bed/couch, light/dark, quiet/noisy, room temperature,
alone/bed partner, TV on/off, change of sleeping environment
3- Evening physical and medical status: relaxed/ anxious, tired
Sleep-wake 1- Sleep onset: ……………………………….
schedule 2- Nighttime awakenings: …………….
3- Morning awakenings: ……………….
4- Sleep duration: ……………..………….
5- Sleep wake rhythm: ………………….
Nocturnal 1- Respiratory: ……………..……………..………….
symptoms 2- Motor: ……………..………….……………..………
3- Medical/neurological: ……………..………….
4- Behavioral (parasomnias): ……………..……
Daytime 1- Sleepiness/ fatigue: napping (No, duration, times), work, lifestyle, travel
activities and 2- Daytime consequences:
functioning  QOL: ……………..………….……………..………….……………..………
 Mood disturbances: ……………..………….……………..………….
 Cognitive dysfunction: ……………..………….……………..……….
 Exacerbation of comorbid conditions: ……………..………….

How to ‫ ري‬4X ‫؟‬+!  #" ‫ا‬$‫ آ‬D!. ‫  ؟‬X ‫ ؟   م‬6%9  !*/‫ ' ا م ؟ ا ا‬+‫ آ‬/" ‫ك‬ •
ask (in ‫ " ا م ؟ د   ت‬S 2‫; آ‬0K‫ " ا‬S:‫ ن و
= ا‬%0 .% ‫? " د ! ؟‬:‫ " دك ا ا‬+%&
Arabic) ‫ &!? آ  اول ؟‬S" :
‫*! ا م ا‬/" B" "‫ا‬,0 " Z& " ' ،     ,0 ?. ‫ و‬، #]H' ‫*! ا م دي ]ت‬/" •
‫ك؟‬
‫  م ؟‬+‫ وأ م ^؟ و آ‬#` ‫ أ م‬+X4  ‫*! ا م دي "ة و ^؟‬/" •
‫ & إ " ك ؟‬1 •
‫ آ م "ة ' ا!! ا ا
ة ؟‬D!. ‫*! ا م دي؟‬/" ‫ " ك‬+X4 ‫ ع‬%‫آ م "ة ' ا‬ •
'  C  ، ‫اع‬C ‫ ك‬، ,‫ "; "آ‬، ‫ ن‬%0 S:‫= ا‬4‫ ر و‬1‫ ء ا‬d‫ ك ا‬%0 ‫*! دي‬/‫& إ ا‬ •
.........، ‫آ ا ء‬$0
!   ‫  ك‬1! " 5
' ‫ او‬، ‫*! ا م دي‬/" ‫ود‬, " 5
' +‫ي ه‬0  •
‫ا م؟‬
 ‫&‪ +  +‬ا &‪ +%‬ا م "‪ # %‬؟ ‪.‬أ‪2 ،‬ج ! ا!‪ ,2‬ن ‪ +%& / ، +I/ ،‬ا م‬ ‫•‬
‫"‪....# %‬‬
‫ا‪ H‬ا  م '   ! ا م و  ؟ ا ‪ ،‬ا‪ ، e%0‬ا‪ F‬ء‪ ، #‬ا‪1‬وء ‪ ،‬ا‪
' ....، H‬‬ ‫•‬
‫ م ‪ S%5‬؟ ‪ +"  " :‬ازاي ‪4 ،/‬ك آ ‪  L4 ،‬م ! ا ر ‪ D!. ،‬آ ‪.....،‬‬
‫او‪ S
 ZC‬ا‪,‬ا‪ 5‬وا‪ +%& H‬ا م ‪ S5 ، 1H" ، 0 " .%  :‬وا‪ ' ، S5‬ا‪A‬‬ ‫•‬
‫' اي
 ' ‪ S5‬؟‬
‫" ‪ 640 " 94‬د" ‪ ! ST‬ا‪ #‬وح ' ا م  & ا ؟‬ ‫•‬
‫‪ +‬ا  ‪ & ;" S2: &>0‬در ‪ 0‬م ؟ ‪ .0‬م ‪ J20‬ا!‪ ,2‬ن ؟‪ ' L!.0 +Y20 ،‬ا ‪+Y20 ،‬‬ ‫•‬
‫‪ B" ' 0‬ا م وا ا
 ‪ * S‬ن و&‪ " =f  .% 1‬ا م ‪ =
،‬ا‪ 0 * S:‬م ‪ " $K 0 ،‬م‬
‫‪............،‬‬
‫آ م "‪ ، +!  D!. #‬آ‪ 
C +Y2 #" +‬آ م   ‪ ،‬و‪ ' +K0‬ا م  & ا ؟ و‪ 4X‬و
ك‬ ‫•‬
‫و '
‪S4X " 5‬؟‬
‫‪ J%X0‬ا‪ J%X‬ازاي ‪
 :‬ك ‪ ! ،‬ا‪ S4X 
، %‬؟ و‪  1 4X‬و ‪  X‬؟ ' " دك‬ ‫•‬
‫و "]‪K‬؟ ' ‪ D‬و ف ؟ آ‪  +‬م ' ‪ =2:‬ا د و آ‪  +‬م ‪9‬و' ؟ ' ا م ا‪ 5‬زات ‪4X‬‬
‫‪ =2: ' F‬ا د؟‬
‫ا‪    5‬ت ‪ S" :‬آ م؟‬ ‫•‬
‫  ' ‪ I0 B" ،‬ا رد ت ‪ ' ،‬ا م ا‪ 5‬زات ‪ 6%! S" :‬و ؟‬ ‫•‬
‫‪ /‬ا‪ d‬ء ا م ؟ *‪ J‬؟ ‪ Z. S2:‬؟‬ ‫•‬
‫‪
+X4‬آ  اراد ا‪ d‬ء ا م ؟‬ ‫•‬
‫‪ S +X4‬ار‪ H0‬ج ‪ F ' ، 3% ،‬ت ا‪ H/0 ، L!.‬ت ‪C ،‬اع ‪ ،‬ا‪ ، A‬از" ‪ ،‬آ ‪ =2:‬ا‪ d‬ء‬ ‫•‬
‫ا م؟‬
‫‪ /‬وا‪ S ، S:  ! g&. ، A!* ، A : ?:‬وا‪,2" 4X ، A : ?:‬وع ‪......،‬‬ ‫•‬
‫ م ) ‪ ( +.‬ا‪ d‬ء ا‪ 1‬ر؟ آ م   ؟ آ م "‪ #‬؟ ' اي و&? " ا م ؟‬ ‫•‬
‫‪ S
، S!I‬ا‪ %X‬وا‪ H‬وا‪$‬ه ا‪ d‬ء ا‪ 1‬ر  "! ا ؟‬ ‫•‬
‫ه‪ !& +‬ا م  ‪ ! d‬اي ‪ 5 " L: 5‬ا‪ S0 
L:‬؟‬ ‫•‬

‫‪Template:‬‬
‫‪………………………………………………………………….‬‬
 C- Appetite / weight
Change of appetite
Change of weight (gain or loss) or failure to reach expected weight and premorbid weight
Specific patterns of eating: meal-time description, binge-eating episodes, skipping mals, extreme dieting,
disordered dieting habits, frequent bathroom visits especially after meals
Concerns about body image and weight
Concerns about gaining weight (weight phobia)
Concerns about caloric value of foods
Weight controlling behaviors: dieting, vomiting, over exercise, use of laxatives, diuretics, other substance
misuses

Template: ''He experienced marked decrease in appetite with no significant change of weight, he had
difficulty sleeping, no desire for sex, feeling fatigue with ease, he always feels very tired.''

Autonomic symptoms
Panic symptoms

N.B.

Template: ………………………………………………………………….

Somatic symptoms
− aches and pains, numbness, breathing difficulty, weakness, paralysis, tremors, palpitation
Drug and alcohol history
Symptoms of
Symptoms of dependence
dependence
1. Substance is often taken in larger amounts or over a longer period than was intended.
2. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of substance to achieve intoxication or
desired effect.
b. A markedly diminished effect with continued use of the same amount of
substance.

3. Craving, or a strong desire or urge to use substance.

4. There is a persistent desire or unsuccessful efforts to cut down or control substance use.
5. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for substance
b. Substance (or a closely related substance) is taken to relieve or avoid withdrawal
symptoms.
6. A great deal of time is spent in activities necessary to obtain substance, use it, or recover
from its effects.
7. Recurrent substance use resulting in a failure to fulfill major role obligations at work,
school, or home.
8. Important social, occupational, or recreational activities are given up or reduced
because of substance use.
9. Continued substance use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of substance.
10. Substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by
substance.
11. Recurrent substance use in situations in which it is physically hazardous.
First
• First experience: peer pressure, novelty seeking, iatrogenic, etc.
experiences
Pattern of use • Substances taken during the course of illness
ME • Substance of major problem
• Route of administration
• Maximum dose
• Last dose
• Overdose
Withdrawal • Abstinence
• Withdrawal symptoms
TTT • Previous admission
• O.P.T program
Problems • Legal problems related to drugs
• Medical problems related to drugs

Template:
 He denies any alcohol/illicit drug abuse
 ………………………………………………………………….
Functioning
Self-care • He is no longer taking care of himself, his personal hygiene, had to be observed by the
family. He would quickly be dirty and untidy. He didn’t wash or shave for weeks.
Family • He no longer shares in household duties, showing lack of concern about his family needs,
indifferent to good and bad events, making no effort at all even his self hygiene had to be
supervised by family.
• Assaultive against his family, provoked with ease with minor trivials, making frequent
accusations, getting into arguments, fights and conflicts, using foul language and
eventually being physically abusive.
Marital • Frequent marital conflicts, disturbed sexual relationship, violence toward spouse, etc.
Interpersonal • Frequently gets into conflicts with friends spouse, family members, coworkers, terminate
relationships, lose friends, children or husband, etc.
• Frequent getting into physical fight with neighbors, associates, frequent reporting to the
police, planned threatening behavior toward certain individual.
Educational • A significant decline in academic performance was reported since that time, irregular
attendance and repeated truancy from school, frequent conflicts, repeated getting into
fights with peers and teachers.
Work • He showed irregular attendance at work, neglecting his work, became hostile and
aggressive toward his coworkers, excessively argumentative, intrusive, disobedient,
masking excessive reckless mistakes at work, making frequent accusations, getting into
fights, etc.
Areas of functioning/impairment in children
(A global assessment of the child’s functioning in the areas of interpersonal relations with parents, other adults,
peers; household work; leisure activities. If impaired- mention moderately or severely.)
Relation with parents 9 )  ‫؟‬$1‫ آ‬F‫ 
أ‬.... ; M) ‫ آ)"؟‬T‫؟ "=آ‬C [‫م و‬.‫ ا‬91(" Z=6 ‫ ازاي؟‬F< ‫ وأ‬E‫ أ‬9 ‫آ‬/
and other adults ‫؟‬P] ...  ‫ & ل‬O  [‫ و‬$"\=‫ ا‬F) ‫؟‬0 E‫ أو أ‬C ‫؟ ل‬A" ;6) ‫ه؟‬6 6N ‫ وأ؟‬E‫أ‬
‫"ان؟ اا ؟‬7‫؟ ?ا؟ ا‬1< ‫ أآ =؟‬Z‫ أآ =؟ إ?ا_ ا‬Z‫ ا=س ا‬Z ).<
Relation to peers ‫)؟‬I" ‫ب؟‬M" ‫ه؟‬6 Z‫؟ <وا‬Z<1)%‫ب؟ ا‬V‫ل؟ " أ‬N`C‫ ا‬9 6 " ‫ ازاي؟‬$< Va ).<
‫(؟ أو‬Z<?a_) 6‫ ا‬A PB" ‫ن‬I< E=7)" ‫ل‬N`C‫؟ وا‬A)"&
 ‫ده؟ ب‬A" ‫ &دة؟‬$, ‫م‬B)(
1
‫اب ا(ك = آاآ!(؟‬2R‫ذي )ا‬5‫ و‬T"=< ‫ن‬I< ‫(؟ أو‬$‫ هدي )ط &آ‬6 6 O6 
Household work ‫ أآ =؟‬Z‫م ا‬B ‫ ا"!؟‬Z $\ ZM ‫؟‬B()"
Leisure ‫؟‬MN" Z‫ ا‬6‫ ا‬$"<  ‫ "
؟ ا‬9‫ و! ا] "
و‬ZM" ‫؟‬Z<17‫ ا‬6‫ ا‬FMN" [‫ و‬E& 6 "
= DV‫؟ أ‬C [‫ آ ("
و‬،‫ه‬6 6 " Z‫"ل ا‬6‫ ا‬$"<  ‫ أو[د و[ =ت؟ وإ‬6 ‫؟‬T"=< [‫ هدي و‬6
‫=؟‬/ cN Z [‫و[ أآ = و‬
Academic ‫"
؟‬/‫ر‬1 ).< ‫ ؟‬U ).< ‫؟‬F\N‫ ا‬Z ‫آ‬/ ‫؟‬$/‫ر‬1‫ ا‬Z E‫()ا‬
،$)‫ ا‬.‫اد )ااءة‬1‫ ا‬Z )‫ إ  أآ‬9 )I ‫)ا =؟‬I"
"/‫ر‬1‫؟ ا‬6")/‫_؟ ا‬%‫؟ در‬$/‫ر‬1‫ ا‬Z  ‫ إ‬F<
‫ار؟‬1)/ "D" ‫؟‬/‫؟ ات ر‬%‫ ا‬1< ‫"
؟‬/‫ر‬1‫ ا‬9 ‫و‬7_ ‫؟‬eN& $%‫؟ در‬F\N‫ ا‬Z EU"‫ا(ب(؟ _آ‬
‫؟‬FV‫ )ا‬FI ‫ < ا)ب‬6" </ ‫؟ آم‬$/‫ر‬1‫وغ 
ا‬U"
‫ي وهدي ز دة‬2= [‫ و‬،$I&‫ و‬gN‫ أ‬،F‫آ‬I F16" 1 ‫ دا‬،‫ ب‬،Z<‫ ا‬،Z‫؟ <وا‬F\N‫ ا‬Z  U ).<
‫وم؟‬U‫< ا‬
‫ض‬6)" 1 ‫ش < &"؟ دا‬6"  ‫م؟‬.‫ ا‬O61("  ‫ل؟‬2 < ‫ل‬1< T‫دل و =آ‬7" ‫"
؟‬/‫ر‬1 ).<
P=2=)" 1 ‫؟ دا‬M6 < ‫ش‬6" ‫؟‬$‫؟ آ@" اآ‬..... F\N‫ ا‬Z ‫آ‬/
 =I" 1 ‫"=؟ دا‬/‫ ر‬E" ‫ب؟‬6
‫ل؟‬1L‫"
و‬1 j ‫ إ  ؟‬Z ‫ك‬N ‫"؟ و‬%‫ ف ر‬UA $ L F‫؟ آ‬6 ‫ م و‬$ L F‫؟ آ‬... ‫؟‬0"I‫< ا (ت وا‬
‫ن آ؟‬1‫ب ا‬A
\.
Risk assessment
On Suicide Ideation Frequency
self Intensity
Duration
Intent
Plan Describe in details
Attempts Number of attempts
Theme (circumstances)
Rescue unlikely or inevitable // Discovery
Method lethality: high or low
Plan: planned or impulsive // Preparation
Intent: wish to die or wish to change
Regret for survival or relief of distress
Self mutilating
Type, object, sites, frequency, motives
behavior
Risk taking
Unsafe sex, substance abuse, reckless driving
behaviors
On Violence Spouse, children, others.
others Plan Lethal homicidal plan toward an individual
From Violence Exposure to violence from others
others Practices Exploitation in illegal practices: signaling dud cheques, gambling.
Abuse Physical/sexual abuse

Suicide
How you ask
Are there times when your difficulties are too much for you?
about Suicide?
Do you have feel life is too much for you to bear?

Have you thought that things would be easier if you were not around?

Have you worked out a plan for taking your life? What did you have planned?

Do you find your life devoid of happiness or things that interest to you? Is this so bad that
you wish you could die?

Do you have thoughts right at moment about wanting to take your life ? Do you feel suicidal
right now?

What happened the last time you felt this way?

Have you had thoughts about wanting to get revenge on some one? Did you ever develop a
plan?

Are you currently having any ideas about wanting to hurt someone? do you have a
particular person in your mind?

What would you do if you met a person you did not like?

Do you access to guns, knives , or other weapons?
How you ask

about Suicide?
(in Arabic)
History of psychiatric treatment
Hospitalization • Timing, frequency, length of stay
• Post discharge state
• Post discharge treatment plan
Received • Brand names
psychotropics • Doses, duration
• Responses, Side effects
• Compliance, Cost affordability, Drug availability
Received ECT • Inpatient (I.P.) or outpatient (O.P.), No of sessions
• Response, Side effects
Received • What kind?
psychotherapy • For how long? No of sessions?
• Response?
• Alone or in combination with drugs?

History of current medical illness [GMC] & TTT

Medical, neurological, surgical illnesses and Medical review of symptoms
 If he has any medical problems like DM, HTN, Heart disease.
 Neurological (loss of consciousness, seizures, headache)

Medications
 If he took treatment for long time for any reason.

History of past illness:

Past psychiatric history and past history of substance abuse
Past psychiatric
− Psychiatric illness, symptoms, hospitalization
symptoms
Past psychiatric − Type of treatment received (medication, ECT, psychotherapy, effect of
treatment previous treatment, degree of compliance)
History of
− Nature, quantity, frequency, withdrawal, tolerance, complications, distress.
substance abuse

Past medical history // Past medication // Past surgical history // Past major trauma
Past personal history
1- Prenatal and perinatal history
2- Feeding habits
3- Developmental milestones
4- Habits
5- Scholastic history (Educational history in adults)
6- Occupational history (work record)
7- Marital history & sexual history (adult sex)
8- Social history: friendships and interests
9- Military history (military service)

Prenatal and Prenatal history (pregnancy)

perinatal Parental attitudes
history a- Planned pregnancy or not
b- Wanted pregnancy or not
c- Wanted sex or not
Maternal health
d- Generally good, preeclampsia, exanthematous fever in 1st trimester, serious illness
e- X-ray during pregnancy
f- Drug intake during pregnancy
g- Attempted abortion
Perinatal history (delivery)
h- Full term pregnancy (FT) or premature (PT)
i- Normal vaginal delivery, instrumental or CS
j- Birth complication (defect at birth): LBW, obstructed labour, head injury, delayed cry,
cyanosis, neonatal jaundice, RH incompatibility, postnatal seizures.
Feeding habits Feeding habits (and problem with feeding) (e.g. breast, bottle feeding, both, weaning age)
in early childhood (0-3)
Developmental In early childhood (0-3)
milestones: Teething
Neck support
Sitting 6M
Motor
Standing 9M
Walking 12 M
1st word 9-12 M
Speech
3-words sentence 2-3 Y
Bowel control 2.5Y up to 4Y
Sphincter
Bladder control 3Y up to 5Y (e.g. delayed toilet training )
Self-direction
Self-care
Safety and health (protect himself against danger by learning or repeat errors)
Cognitive
Use of community resources
Home living
Leisure
Social relatedness (impaired in autism not in MR)
Social
Social smile (xxx)
Sexual (for GID)
Psychological (Emotional)
(a) See Temperament and Personality as a child
(b) See Neurotic traits
Mention any developmental problems: in speech, language, and motor function
Habits Sleep: normal, problems with sleep (fearful, bruxism)
Feeding: normal ,overeating
Personal care: adequate, unkempt
Neurotic traits/symptoms
− nail biting, thumb sucking, temper tantrums, head bumping, tics,
− enuresis or encopresis aCer 3y age(NE), nightmares and terrors, morbid fear of persons,
animals, and darkness
− excessive masturbation, fire setting, cruelty to animals
Behavioral (and emotional) problems in childhood and adolescence
− stealing, lying, truancy, fights, disobedience, etc.
− irregularity of sleeping or eating, depression, suicidal ideas
− smoking, substance abuse, sexual malpractice
Scholastic Type of school and age of joining it
history Preschool (KG)?
School performance (academic)
− School records
− Drop out ‫اب‬
− Attendance at school: regular/ repeated truancy.
− Classroom tasks: delayed completion, need for close continuous monitoring, careless
mistakes, … (ADHD)
− Home assignments: properly done, / not done
− Sharing in classroom: sharing/ withdrawn
Relations to peers and teachers (social):
− Sharing in activities and play
− No. of friends
− Type of relations: Harmonious, disharmonious, gets into fights, rejected from peers.
Psychosexual Middle childhood (3-11 years):-
history a- Gender identity (age)
b- Early curiosity (prime sine)
Later childhood (puberty through adolescence):-
a- Source of sexual knowledge (from whom?)
b- Age of onset of puberty (e.g. he reached puberty at age of … ) and reaction
c- Masturbation (age, frequency)
d- Attitude towards opposite sex (e.g. shy, romantic, sexual experience)
e- Adolescent sexual activity
f- Sexual problems (homosexuality, paraphilia)
Adult sexuality:-
• Premarital sexual relations
• Marital history (including marital sexual history)
 Number of marriage, age of marriage
 Wanted or not , age difference, how purposely
 Name, age, occupation, education level, consanguinity
 Relation between spouse
 Pregnancies, contraception measure, partner (personality & character)
 Children (number & relation )
 Sexual practice
 Sex symptoms
 Attitude towards raising children
 Attitude towards family planning
Social history Early childhood (0-3)
a- Infant mother relationship (e.g. good relation to mother)
b- Reaction to sibling
Middle childhood (3-11 years):-
a- Punishment at home
− Who?
− Physical, verbal both
− Excessive, average
b- Separation from caregivers
c- Friendship (play, peer relations)
Later childhood (puberty through adolescence):-
a- Social relationship (added by ME here)

Play: individual/group, companions (few, many; older, younger, same age; good, bad, both)
PLAY: Comment in children
Z<1%/‫دي‬ −
ZI)/‫ ا‬6 −
Z"B_ 6 −
(‫؟‬F" - ")‫"
؟ آ‬I&‫ و‬-
"( ‫ =ت؟ آ‬- ‫ )و[د‬6‫ء ا‬V‫أ‬ −
(‫؟‬ZM< – Z=‫؟ ذه‬T"=< - ‫ أو[دي؟ هدي‬- Z_= 6) 6‫ ا‬$"< −

Religious
background
Occupational jobs held, why taken on ,how long held ,pay received & reason for change ,frequent change of job
(work) history means mental instability
Military
history
Legal (forensic)
history

Template
If the patient is a child
mention in details
Scholastic history:
• He joined a public school at the age of 6y, aCer 2 years at preschool, with below average performance, regular
attendance, no history of truancy, with harmonious relation with peers and teachers.
Her school records had always been good,
She dropped out in the 6th grade
She ended her education and graduated from the college of literature.
• His relation with peers was limited, had few friends, used not to share them their activities and play, he always
gets into fights with them, rejected by his peers,
• She stopped going to school …… months ago because of illness.
If the patient is a adult
mention briefly
• Prenatal, natal and postnatal history: passed uneventful.
• Developmental history: normal motor and mental milestones, no neurotic traits (nail biting, NE, temper tantrums)
• Educational history
• Military history
• Occupational history
• Marital history and sexual history
• Social history: friendships and interests

Prenatal, natal and postnatal: passed uneventfully.

Had normal mental and motor milestones of development.

Scholastic History
The paent joined a public school at age of 6 with average performance & harmonious relaon with her
teachers and peers.
She joined ‫ ت و "! " ت‬%
e!‫ آ‬with average performance

Sexual history:

She reached menarche at age of 12 yr regular menstrual cycles till now, with female gender role and identity with
heterosexual orientation.

Marital history: never been married
she received 2 marriage proposal but she refused as she want to connue her study

Work history: never worked

Past psychiatric & medical History: irrelevant

Prenatal, natal and postnatal passed uneventful.

Normal motor and mental milestones of development.

Paent joined public school at age of 6 average performance and harmonious relaon with peers and teachers he
joined faculty of engineering didn't aYend exams for 2 years for the sake of changing career.

Paent reached puberty at age of 14 with male gender identy and role and with heterosexual orientaon.

Not called yet for military service.

Used to work for 8 months in ‫ ر ا م‬%K‫ ا‬and for a while in 
‫ ا‬e!H"

With –ve past medical history of neuropsychiatry importance

Patient joined a private school at age of 6 yrs with harmonious relaon with peers & teachers.

He had average achievement till ‫ ي‬: d h‫ او‬when he started to fail " 5 : 0 ‫ و‬h‫ ى واو‬: d  0 ‫ و‬: 0 ‫ و‬h‫(  د او‬pt
claimed that his father is responsible for his failure.)

Paent is graduated from faculty of law at the age of 27yrs

How to ask for developmental history in Arabic

%G ‫  آ م؟‬h! ‫  ن‬B!G ‫  آ م؟‬h! /" ،Z&‫ و‬،h%
،& ‫؟‬1 ‫ آ م‬h! ‫  رأ‬:‫آ‬4‫ا ا‬
Motor
‫؟‬A1 K]0‫ " و ا‬%‫ ا! أآ‬0‫ ا‬K‫؟  زي ا‬K]0‫و ا‬
Speech ‫؟‬#,  !‫  ا‬% ‫  آ م؟ ف‬h! ( " " ،  ) e!‫ أول آ‬D3: ‫؟‬K]" ‫ و‬%G A!*0‫ ا‬:‫ ي‬I!‫ا ا‬
‫ وه‬F16" ‫ وه  ؟‬F16" ‫
آم؟‬/ < ‫  ال‬6_‫
آم؟ ا‬/ < ‫  ااز‬6_‫ ا‬:Z%‫ ا[?ا‬1=‫ا‬
Sphincter
‫؟‬F16" (
"=/ ٣ F1‫  آ‬6 ‫؟‬Z&V
‫؟‬A1 K]0‫ و ا‬0‫ ا‬K‫ ازاي؟ زي ا‬+"  1' :('‫ه )ا‬$‫ا ا‬
Self-direction B5 ‫ ف‬B!G  ،‫ رع‬/‫ف ي ا‬
،‫ زي ا ل‬+‫ " ';  آ‬،#‫ ا‬+I ،2: 4 ،2: +‫ ]آ‬،2: =%! ،‫ م‬4‫  ا‬2: Z3/ ‫ف‬
Self-care
+‫  آ‬A :‫! ط ا‬9
Safety and health
‫؟‬$=B/ ‫ ا* ة‬S ‫؟‬2: ‫ق‬4‫? و‬%*  L! ‫ ' ا ر؟‬+K ‫؟‬e/2‫ ا ر ' ا‬64 ‫_؟‬V‫ 
ا‬O16)" 
(protect himself against
e5
‫ أي‬+‫ دواء(؟ ]آ‬،Z90 +f ) $%& ‫ب أي‬I ‫ش و‬U"1  ‫؟‬$N"M O " ‫ب‬/ ‫ر؟‬6)
1‫ ("
و‬6
danger by learning or
Cognitive repeat errors)
‫ '؟‬+‫! ط ا* ن ا!  آ‬9 ‫؟‬e‫ و‬#‫ وإ‬+‫&ا"؟ ]آ‬
Use of community

"=/ ٣ .. ‫ <"؟‬92 ‫ و‬Z ‫" آ‬7 ،6) ‫ ن؟ اب؟  <وز‬U"N")‫؟ ا‬$%.@‫ ا‬l)N ‫ف‬6
resources
.. k:‫   و‬.. ‫ ا م‬eF‫ او‬O ‫م‬1‫ ل ' ا‬% ‫ وح‬.. ‫ م‬4‫ وا م وا‬%3‫ "* ن ا‬.. +23‫ آ‬+" 
Home living
e5>‫ " ا‬e5
LH .. %3‫ " ا‬e5
LH
 ‫؟‬6‫ ا‬A PB" ‫ن‬I< = ; M)) ‫"ل‬6‫ =؟ ا‬DV‫ أ‬Z‫"ل ا‬6‫ ا‬9 6 ّ‫ و‬،=( $/= ‫ب‬6‫ أ‬6
Leisure
‫؟‬E& ADI ‫ف‬6 $="6 F"DI_ $ ` A" $6 "
Social relatedness ‫ي‬/ ‫ & ] ؟ &ّب‬9 ‫  ا_(ب‬Z ‫ ؟ و‬D‫ف 
ا‬B ‫ وأ وأ?ا_؟‬Ea ;ّ6) :Z<1)%[‫ ا‬1=‫ا‬
(impaired in autism not
Social in MR)
‫؟‬I ّ1 E‫ي < أ‬7 ‫؟‬E&‫ و‬E"( ّ1 _‫ < ا?ا‬Z ‫؟‬$<( ‫ ع ا س‬K  ‫ل؟‬N`C‫  ا‬
Social smile (xxx)
Sexual [‫ ا[د و[ ا=ت؟ "ل أ و و‬6 F"1" ‫ ا[د و[ ا=ت؟‬c F"1" ‫( و وّ =!؟‬N ‫ ه <رف‬:Z(=7‫ ا‬1=‫ا‬
(for GID)
=/ 9 () [
"6 Z(=% ‫ك‬/ % F‫ أآ أ زي  و[ ؟ ه‬1 U < ‫=!؟ أ‬
Premorbid personality (premorbid adjustment):
1. Religious back ground: religious and practicing/ religious (believer) and not practicing / practitioner/
agnostic/ atheist
2. Social history (social activity): family and friendships
− social (introvert or extrovert)
− to family: dependent or independent
− to friend: good mixture (sociable)or not
follower or leader
3. Work
4. Hobbies (pleasurable)
5. Leisure activity (energy): Whether energy spent in reality (practice) or fantasy
6. Reaction to stress: (isolation, nervous , inflation with others)
7. Pervasive mood: Stability or fluctuation, cheerful or sad, optimistic or pessimistic, anxious, worrying & self
doubtful or self confidence
8. Character trait: Sensitivity, suspicious, timid, shy, jealous, selfish, aggressive, quarrelsome, irritable, religious
9. Impulsivity: Yes or No
How you ask ‫  ا
 ا‬
premorbid Religious ‫ ب "؟‬4C‫ ا‬S ‫؟‬H‫! ' ا‬X ‫>ة؟‬X‫ ! ا‬Lm‫ ا؟ " ا‬e!"   S&>
personality? Social ' ‫ رك‬/0 L4  ،D!3"  5‫ ا‬k S%3 ?:‫؟ ا‬+!& ‫ ب آ و‬4C‫ ا‬S ‫آ ن‬
(in Arabic) ‫>ت‬24‫وح ا'اح و ا‬0 ، ‫  ت‬5‫ و" *; ' ا‬S2: ! ‫ ي‬30 ‫ و‬،e 5‫ ا‬e3/:‫ا‬
.‫ات‬.‫ ا‬L40‫اء و‬,‫وا‬
Work +I/‫ ' ا‬+‫ آ‬/" ‫ آ ن ك‬،‫ ر‬Y4‫
 ا‬: " ،S!I ' A9" ?‫ آ‬L‫ ا‬+%&
Hobbies ‫ ه ا ت؟ زي ا؟‬S ‫آ ن‬
Habits ‫ ت؟‬2*‫ ب ا‬،f H‫؟ زي ا‬e" #‫  د‬S
(..... ،+‫ ا^آ‬،‫ ا م‬:‫ ل‬2G^‫)' ا‬
Leisure .e1'‫ ا‬e3/:‫ ازاي؟ ا‬ST‫آ? ! و&? 'ا‬
Reaction to stress ‫ود‬,0 ، ‫ ت‬f1" $K 0 ، g2Y20 L40 ‫ ا ؟‬+ ?‫ آ‬....n‫  &ر ا‬G‫*! او ور‬/" S'‫ د‬X0 ?‫ آ‬
.,0  S&>‫>ة و‬X! ]H!0 ، ,‫ ! م وا‬+0 ،  H‫ب ا‬
Prevailing mood ‫ن‬,4! ‫ ط و‬%:> + ‫ آ ن‬S5‫ا‬,"  ‫? ا ؟‬: ‫ او& ت آ‬A9" ' e5‫ا‬,‫ ا‬S
L‫ ا‬+%&
‫؟‬S2: ' ;*4" S! /‫ ا‬LYI‫
ت " ا‬S  ?: ‫ آ‬+‫؟ وه‬0 ! ‫و‬
Affective stability ‫؟‬e d ‫ و‬e%!." ‫? دا‬: ‫ آ‬e%5‫ا‬,‫ ا‬S

Impulsivity ‫م ! ا! &! أو !؟‬0 ‫ و‬،e5 4‫ ا‬+ ‫ ل أو‬. ‫? " ا ع ا‬:‫ أ‬+‫ه‬
Personality Paranoid 
‫ و ف اي‬S ‫
 ' ا&ب ا س‬/2.o "‫ ' ا س و‬.d ‫ وم‬S ‫? دا ك‬:‫ ا‬+‫ه‬
traits A1:‫= ا‬4‫ و‬، ‫ ا س‬6‫? و‬:‫= م ا" ن وا‬4 ، ‫ك‬F 1"  S e" !" ‫ف اي‬
(in Arabic) A10 'X0 ' A/‫ و‬A10‫ا‬9: ' ‫ ف‬/‫ و‬S0 'X0 ‫ ا‬%&‫ او ا‬S! ‫وا‬,I ‫ آ>م او‬S! ‫" ا‬
‫؟‬S
: " p :‫ر و‬T‫ و‬: K 4‫ر‬
Obsessive JC B!30 5 4‫ زم ا‬L40  q +‫! وا& ' آ‬4‫ ا‬L4 ‫? " ا ع ا  س ا‬:‫ ا‬+‫ه‬
+‫ دا ! ا ' آ‬S‫ " ا س ا
ا‬5
‫ و‬k!0 ‫ ";  رف‬S! #‫" ' ا ود‬
S X‫ دا ! ا‬S! :‫ ا‬#‫ م د‬9‫ ا‬L = " ‫ م‬9  " S:‫= دا ا‬4 ، 1! 5

' ‫ * ن‬S' K " k!0 ‫ر‬. ;" ;" ‫ ن‬/!   ‫ " ك‬K 0 ‫ك‬T B" D &‫ د‬K 0 ‫ ا‬5 4‫وا‬
;" ?:‫ ن ا‬/! ‫ ا س‬B" e!*/" S +"  ‫ * ن‬#‫ط د‬/ = %١٠٠ JC ;!3" ‫ او‬X& : 5

B" D: 0 ‫ ل ا م‬G +Y20‫ و‬1: *" ‫ه‬,  e5

+‫ ' ا   وآ‬B F !‫ آ‬S&‫ وو‬,H0 ‫ رف‬
.......( ‫ ا دي‬3
، ‫?  "! )   دي‬:‫ م ا ا‬9‫وا ا‬T ‫ ن‬/! ?%‫ا س ا ' ا‬
Borderline c_...6) 0%‫ا‬U / ‫ وون‬E7 c ‫ _ن آ‬Z=6 ....) 0%‫ا‬U 1 ‫ دا‬c) F‫• ه‬
‫؟‬0"‫ &ا‬Z‫ ا‬Z< m"A)_ ‫ او‬Z\< ‫=ق او‬B 0‫ا‬
c_ E‫ك و‬. 0(N c_ E Z=6 / ‫ وون‬Ea7 R "D)) 0(N= 0_e F‫• ه‬
0"  U<a 0).<‫ وا@" و‬e
" "D)) R ‫ =س‬0_e‫ و‬......‫ن‬2"L 0(N
.e Z ZA)=) )B
‫د [)ر؟‬A_ ، 0(N ‫ح‬7_ ، 01(% ‫ط‬I_ ، 0(N ‫ذي‬5_ U < 0‫ ا‬$ $]‫ ر‬0"7) •
."_ "]
 ‫ ))\ف‬، ‫ر‬A) ، 9= •
 ./ ‫ق ون‬2_ [ %‫ ا[? ر‬Z< ‫=ق‬B‫ ; و‬M 0‫ ا‬c_ ‫ )ات‬0"7) •
‫؟‬E&‫ا 
ا‬% ‫ف‬B) •
Histrionic ، S5 *"‫ و‬S!*‫ و‬S%! ‫ ا س‬# %:‫ي ا‬/0 %4 ، BH‫ ب ا‬H‫ ا‬64"‫ اه م و‬,‫ "آ‬: *0 %4
.S">‫ وآ‬S%‫ و‬S!*/ ‫ ب‬H‫ رات ا‬% S  . ;"‫ و‬S" 1  #K‫* ن "; وا‬0 ‫  ا س‬. Y0
Avoidant  ‫ س ا]اب او‬A" E6 Z <  Z=6 "<1)%[‫ ا‬T‫ا‬1‫ ا‬Z 9"e F7B c) F‫• ه‬
. 6) 0(‫ق و‬6_‫ و_)_ و‬0)6"` Z< O‫ب و‬A) 0‫ ا‬c) ‫ا او اح‬U< !?‫د‬
. ‫ ا=س‬9 Z]._‫ _) و‬O6) ،  L 1B ، Z<1)%‫ ا‬O 0‫ ا‬c) •
Narcissistic S">‫ آ‬.G ' ‫  ا س‬," ‫ا او‬5 S ‫ا او‬5 ‫ ذآ‬، ‫  دي‬T k S2: Z  ‫ دا‬+‫ه‬
L4 ، " .3 S!" 0 ‫ زم‬1!‫ ف ان ا س آ‬/ +‫ه‬، S% ‫ او‬S!* ‫ او‬S0 &> ‫ او‬Sf ‫او ذآ‬
.q A‫ اه‬S4!X" :‫ ا‬5‫ ر‬S2: L4 +‫ وه‬S‫ ' و‬S
0 ‫ا س‬
Dependent S:‫= ا‬4‫ و‬S0 
‫ ن‬p +‫ و' آ‬S0‫ را‬K‫ و' ا‬S0‫  ! ' &ارا‬S0 
' k ' +‫ه‬
.S%5 ‫ ش‬1&>0 " S‫
ا‬k%0 ‫ا " ا م ا‬5 ‫ و ف‬T " ZX0 ;'0 "
Antisocial ، S! g%.0‫ ا‬، ‫ زورت‬، ‫ ا>ح‬10 ?40 
" e5
‫ت‬K‫ ا‬، ?%XT‫ ا‬، ?& ، ‫*ب آ‬
.‫ "رات‬F 
Schizoid .A= T ? 0‫ ا‬c) [‫ ا=س و‬9 6_ ) ، 0V‫ ا‬، 0_.< ، 0_"<1)%‫• ا‬
..V‫دة ا‬% O A‫ ا‬c) [‫<ك   و‬I •
Schizotypal ،$N(N‫ ا‬،?n‫ ا‬6‫ ا‬،
7‫ ا‬،$/‫ ا(د‬$/‫ زي ا‬،$"] 0_%& Z N) 0‫ ا‬1 ‫ دا‬c) •
‫؟‬E‫ت 
ا=ع د‬% ‫ "ن‬0"? 1 ‫ودا‬
A(_ ‫ أو‬0‫ د‬A61(_ ‫ أو‬0="6 AI_ ، ‫(ه‬N_ ‫ <رف‬O Z) $ ] ‫ت‬/(&‫ ا‬c) •
.......... ‫"ة؟‬D)‫ < زي ا و‬0"‫ ا! او ان ا" &ا‬O !‫ ان ا‬c_ 1 ‫؟ ودا‬01(7
‫ او _"
؟‬E O 1 ‫دا‬
.............................. ‫ ان ا=س‬c_ 1 ‫ دا‬F‫• ه‬
•
Template:

Premorbidly, he was sociable, outgoing, and extravert with many friends, frequently involved in social activities.
He was interested in internet chatting and playing dominos where he used to spend his leisure time with friends.

Premorbidly, he was regularly practicing religious rituals with regular attendance at mosque.

He describes himself as being overtly anxious, easily provoked, impulsive, eventually hostile, emotionally unstable,
with prevailing depressed mood, feels easily frustrated in stress reacting to it with increased sleep hours/ use of
illicit drugs/ excessive smoking/ crying and ventilation/ paying and being overly religious.

Premorbidly, he had a regular attendance at work, with no reported work related stressors.

He finds it difficult to trust people even those who are very close. He feels it is necessary to be alert and
hypervigilant not to be exploited or cheated

He is overly concerned of being perfect 100% right. He does everything slowly mot to miss or skip any minor step.
He is overly attentive to minor details and trivials, a matter that always bring him into blaming and criticism.

Extrovert large no of friends
-spends his pleasurable times with his friends watching TV

React to stress by verbal & physical aggression

Believer does not practice.

Dependant trait: (indecisive, passive, interpersonal dependence)

Histrionic trait: (gestures, temper tantrums, constant need for assurance).
Dreams /Fantasies/ Values system
Dream: prominent dreams/ nightmares
Fantasies: day dreams/ hypnagogic phenomena
Value system:
• Children (seem as burden or joy)
• Work (seem as a necessary evil or as opportunity)
• Friends
• Concept of right
Early childhood recurrent dreams or fantasies
Childhood temperament, Childhood personality, and Neurotic traits

(a) Temperament = Psychological characters

Temperament Z(N=‫ ا‬1=‫ا‬
Mood (anxious irritable 1 ‫ ي(؟ دا‬F"< Z=6 ) =) 1 ‫ ; < `ل؟ دا‬M) ،_) ،Z\< 1 ‫ دا‬Z=6 ‫ إزاي؟‬L ‫م‬6‫ ا‬%‫ا‬U
nervous stubborn, hard) ‫ود؟‬A‫ و‬9"2 [‫؟ و‬$ ‫اد‬1‫ ا‬6V ،$NL /‫ رأ‬،‫ار؟ <=ي‬UA‫ وا‬0M‫(ط و  ا‬
Approach-
‫؟‬................... ‫ب؟‬7  ،‫ئ‬% ،‫در‬
withdrawal
e5
LH ‫ و‬،6%9  #‫ا‬,  ?:‫ ا! ا‬S LH ‫ إ؟    "* ن ف‬+"  ‫ ه‬%:‫ وا‬#,‫آ‬0
Attention span ' ,‫ آ‬+‫ و  رد؟ ه‬%" 4 !* : *0 ‫؟ و‬k K e2!" e5
S LH ‫ أو‬،& %‫ ا‬h‫و‬
‫اآة؟‬$‫ا‬
Activity ‫ودة؟‬4" ‫ وآ>ن و
آ‬eG‫ا(؟ و و‬5 .) ‫وم‬,!‫ ز دة  ا‬6/: ‫ ل؟ و‬." :‫آ ا م‬4‫ ا‬G /:
‫؟‬$<( ‫م‬e=‫ ع ا‬B) ( ‫م‬e ،‫م أآ‬e ، ‫م‬e) !"‫م ا‬e Z ""D_ ‫  " أي‬Z=6 ‫؟‬$<( 9ّ2
Adaptability
‫؟‬$6\ [‫و‬
،$"‫ب ا" و_م ا‬B :EU < ‫ ه‬$%& = ?‫ أو أ‬L!G !Y'‫ 
 ر‬.@ Z=6 ‫ إ ؟‬F< 6 ‫رد‬
Intensity of reaction
‫ (<ت؟‬Z 6 ‫ب و‬M ‫ و‬j
Rhythmicity ‫م؟‬e= ‫ م‬F‫ آ‬،PB [‫؟ و‬e)= ‫؟ أآ‬e)= 
Threshold of
‫؟‬O=2 [‫ و‬$<( ‫ د‬:"< Z) ‫  د‬Z=6 ‫؟‬$q"2 [‫ و‬$6 / )7)/‫ا‬
responsiveness
(b) Neurotic Nail biting ‫؟‬E‫ا‬R F‫آ‬a"
traits Thumb sucking ‫؟‬6‫ا‬V Z j1"
Nocturnal enuresis ‫(؟‬N < F16"
Temper tantrums ‫رض؟‬C‫ د] < ا‬PB ‫"؟‬% j FMN ‫رض و‬C‫ < ا‬Z)" F<U" 1

Personality as a child: (e.g. shy, restless, over active, withdrawn, persistent, athletic, friendly, pattern of play)

Special consideration in children:

If the symptoms are present since birth:
− Start history from conception through early and later development.
− Give chronological account of symptoms.
Family history
Order in birth
Consanguinity
• Consanguineous / non consanguineous marriage
• 1st , 2nd ,3rd degree/ cousin
Family history as a social history:
a- Family dynamics (family tree, family members):
− For each member: name, age, education, occupation, personality, relation to the patient
b- Crowding index: (persons/rooms)
c- Monthly income
− Adequate with ease // Barely adequate // Need for external support
d- Home atmosphere
− Warm, quiet, supportive/quarrelsome, conflictual, no emotional interaction between family members,
no empathy, caring or encouraging behavior, the patient reports that he didn’t use to ventilate or make
complaints.
e- Attitude of the family towards the patient
− Always criticizing, making critical comments, abusive remarks, rejecting, hostile, no emotional
interaction between family members, no empathy, caring or encouraging behavior, the patient reports
being frequently dismissed, beaten, bound and held at home, he didn’t use to ventilate or make
complaints.
f- Attitude of the family towards the illness
− Family attitude toward the illness is dissonant and ambivalent, spiritually outweigh medicine, they more
frequently seek help of traditional or spiritual healers, family is unconcerned about drugs, irregularly
observe the patient compliance, their willingness to work with the treating team is unreliable.
g- Burden on the family by the illness
− The family is significantly burdened by the patient illness, and economically loaded by the cost of
treatment, disturbed family routine, need for continuous supervision to protect against others or self
harm, suicide, or unexpected leaving home, frequent troubles outdoors and eventually legal problems,
physical threat for the family members, and the fear of being publicly stigmatized.
h- Religious traditions in the family

Family history of psychiatric illness/ other medical illnesses/ substance abuse

Family history of psychiatric illness: Psychic illness and symptoms // Hospitalization // Medication
Family history of transmissible: Medical//neurological: illness//symptoms
Family history of substance abuse

Template
• The paent is the 2nd in order of birth among 5 sibs of 1st cousin consanguineous marriage

The paent is 2nd in order of birth among 3 offsprings of non-consanguineous marriage

Father: ZU< ‫ه‬7 48 yrs, work as a teacher, owns a shop for selling fruits, described by the patient as being kind
and caring.

Mother: ‫د‬% ‫ل‬.% Z" 46 yrs, work as a teacher described by the patient as being kind and caring.

Siblings:
1 22yr, 4th yr medical school, single, with harmonious relation to the patient.
"‫ أ‬18yr, 9 =V ‫دم‬, work with his father in the shop .

Home atmosphere: harmonious

Crowding index 1/ room

Monthly income is adequate with ease

No FH suggestive of neuropsychiatric illness:

No FH suggestive of substance abuse // Uncle is a hash user

Family history of medical illness: Grandmother had DM, HTN
Patterns of parental functioning in children
(Follow the guidelines given below to elicit information)

"N ? [‫؟ وح ا=دي؟ و‬V‫ أ‬9 6 ‫رع؟‬I‫ ا‬92 ‫؟‬$ ‫ 
ا‬$&( 
 ‫  _ى‬
Permissiveness/Rigidity
‫؟‬A" Z‫ت ا‬%‫"= 
ا‬6‫<"؟ و‬
$1‫ ل آ‬E‫  أ‬.@ Z=6 ‫؟‬K6 c< [‫ و‬$")‫ ا‬Z &‫م وا‬e <
""L E‫ إ! وأ‬:
Consistency/Inconsistency Z _‫ا "= و"
ا?ا‬N) ‫  وا& ر ا[ن؟‬.‫ آ‬... [‫؟ و‬c6‫ وا‬A () !r
‫؟‬E‫ زي آ‬$%&  ‫
ل‬1‫؟ و‬E‫ آ‬c/& ‫ ه‬FC‫؟ أو < ا‬$")‫ا‬
Strictness of discipline/liberal (any
‫=ع؟‬1‫ <" و&ام و‬$%& F‫ آ‬Z=6 ‫؟‬$ L ‫د‬I) !"‫ ا‬Z ‫م‬e=‫ا‬
inappropriate supervision)
[‫؟ و‬E1)‫ اه‬R "." 1 ‫؟ _ى دا‬A" ‫ت ه‬%& Z=6 ‫؟‬$="6 ‫ت‬1)‫ "  اه‬FN` F‫آ‬
Approval of interests/disapproval :.@ Z=6 ‫؟‬%‫ا‬U < ‫ط _ن‬L O Z‫ وا‬2()‫ وه‬A" ‫ ه‬Z‫ ا‬$%‫)وا _و ا‬
....،/‫ ر‬،"/ ،$="6 $6
 [ ،O16_ [ :$ L F‫وم؟ آ‬U‫"
<" و`"
<" ز دة <
ا‬N ? : )"_ Z ‫  _ى‬
Protectiveness/Non-protectiveness
$ ‫ 
ا‬$( 
"  [‫؟ و‬EU < ‫ ه‬Z‫ ا‬F16 ‫ ح زي  ؟و‬1_ ="1A ّ‫؟ و‬O%B_
(any overprotection)
‫ <=" <"؟‬c $ L (N < 1)6 =""B‫و‬
Toleration of deviance/non-
toleration
Expectations from the child (any
pressures, deprivation)
Reactions towards the illness
F‫آ‬C‫ <= ا‬9=1" ‫؟ "(؟‬2" ‫"=؟‬A ‫ و‬1)I" 1 ‫؟ دا‬M" E‫ ؟ أ‬L ‫ب‬6 ‫ض‬6)" F‫ه‬
Punitive parenting
‫"؟‬1‫وا‬
$1")L 1 ‫ &ة؟ دا‬$1‫ وأ آ‬E‫ 
أ‬Z." O ‫؟‬$=(& $6 ‫
&="
أو‬M& Z." O ‫"=؟‬1A
Emotional neglect
‫ل(؟‬2 < ‫ل‬1<) ‫ وم‬$‫واه‬
Physical neglect ‫؟‬$e=‫ ا‬Z ‫؟‬c‫ ا‬Z ‫؟‬F‫آ‬C‫ ا‬Z " Z1)A)
!"‫ ا‬Z & ‫ ؟‬% ‫ ؟ د‬% !" ‫ا ا؟ )ا‬B)) ‫؟‬E‫ و"
أ‬0=" ‫ ا"!؟‬Z F‫آ‬I Z
Environmental stressors
‫ اا؟‬F?‫؟ د‬$"I"61‫وف ا‬e‫ وة؟ ا‬$& ‫؟‬K 
.
 Psychiatric
Mental State
Examination
Psychiatric Mental State Examination
General items of M.S.E. (ABC, SMAT, PS)
 Appearance.
 Behaviour.
 Cooperation & attitude towards the interviewer.
 Speach.
 Mood and affect.
 Thinking.
 Perception.
 Sensorium and Cognition.
 Insight.
Appearance ((A))
a) Apparent age (compared to the Causes of older looking appearance:
actual age):  Chronic severe psychiatric illness.
− The patient appears his/her  Chronic severe medical illness.
stated age? Or looks older or  Homelessness.
younger than his/her stated age?  Alcohol and substance abuse.
b) Facies:  Depression: depressed facies.
 Anxiety: sweaty forehead, dilated pupils.
c) Body built:  Overweight? Depression, hypothyroidism, poor impulse control with
food or alcohol, anabolic steroid abuse.
 Underweight? Depression, anorexia nervosa, substance abuse,
dementia, schizophrenia.
d) Self hygiene : Exaggerated self hygiene? OCD “skin callous”
 Body hygiene: skin, hair, Poor self hygiene?
nails & body odor.  Schizophrenia? Severe mental illness.
 Oral hygiene: teeth  Dementia? Severe mental illness.
“remnants of food”.  Severe depression? Psychomotor retardation.
 Dressing hygiene: soiled,  Substance abuse? Drug seeking behaviour.
food remnants, cig. spots. Comment: good, fair, poor.
e) Grooming (clothes &  Narcissistic PD? Fashionable.
cosmotics):  Obsessive personality? Time-consuming.
 Histrionic PD? Fashionable & excess cosmetics.
 Manic? Bright colors, excess cosmetics.
 Psychotic? Poor grooming, mismatched layers of clothes.
 Gender identity? Cross-dressing.
Make up: bizarre in manic, well done in histrionic.
Cooperation & attitude towards the interviewer ((C))
a) Eye contact: Poor eye to eye contact?
 Paranoid.
 Hallucinating.
 Social phobia (improve with development of rapport).
 Autism.
Exaggerated? Paranoid (suspicious or challenging).
Comment: Proper, poor, exaggerated.
b) attitude  Paranoid? Defensive, hostile, evasive, guarded, suspicious.
towards the  Manic? Playful, grandiose, seductive.
interviewer:  Neurosis? Cooperative.
Causes of uncooperative patient?
 Paranoid.
 Personality: borderline.
 Lack of insight.
 Chronic patient.
 Organic due to cognitive impairment.
 Malingering or factitious.

Behaviour ((B))
 Specific behaviors:
(a) Goal directed behaviors:
 Disorganized behaviour.
 Disinhibited behaviour (social or sexual).
 Catatonic behaviour**.
 Compulsive behaviour.
 Self mutilating behaviour.
 Attention seeking behavior
 Aggressive behaviour: gestures or threats.
 Promiscuous behavior
 Seductive behavior
(b) Non-goal directed behaviors:
 Catatonic stupor
 Catatonic excitement

Psychomotor activity level: psychomotor agitation* or retardation.

Psychomotor Causes - Depression
retardation - Dementia
Signs - Movement: ↓ adapve movements (expressive, reacve and goal-directed)
- Posture: stooped posture
- Speech: poverty of speech, telegraphic speech, alogia, etc.
- Thinking: poverty of thinking, thought block, indecisiveness, etc.
Psychomotor Signs Signs of agitation (marked anxiety):
agitation  ringing fingers, rubbing hands, fidgetting feet.
 finger and foot tapping .
 frequent change of posture.
 rhythmic leg movements.
 easy distractibility.
 frequent standing to walk around.
 unexpected leaving of the room.
 threatening behaviour : raising voice or shouting, raising hands, ....
.

DD Agitation Hyperactivity
With inner tension Without inner tension
Energy not used in a goal directed manner. Energy used in a goal directed manner.
.
 Causes * D.D of agitation or hyperactivity:
 Mania.
 Psychosis (paranoid).
 Anxiety.
 Agitated depression.
 Stimulant intoxication.
 ADHD.
 Delirium.
 Thyrotoxicosis.
 Akathisia.
 Motor disorders
Movement Adaptive • Expressive
• Reactive
• Goal directed: mannerisms
Non- • Spontaneous: motor stereotypy and neurological movement disorders: (chorea,
adaptive athetosis, dystonia, tremors, parkinsonism, akathisia, rigidity)
• Induced: echopraxia, motor perseveration, (automatic obedience, mitgehen,
mitmachen, forced grasping) *, (ambitendency, negativism, opposition) **
* Exaggerated cooperation ** Uncooperation

Posture  Anxiety: tense posture.

 Depression: stooped posture.
 Catatonic: catatonic posture (stereotypic "psychological pillow'', manneristic, waxy
flexibility)
Automatism • Motor or vocal

Catatonia
**Catatonic features:
 Catatonic stupor.
 Catatonic posturing.
 Rigidity.
 Catatonic excitement.
 Waxy flexibility.
 Stereotypy.
 Mannerism.
 Mutism.
 Automatic obedience.
 Negativism.
 Echopraxia.
D.D of catatonia:
 Organic.
 Psychotic depression.
 Catatonic schizophrenia.
 Dissociative.
Speech ((S))
What we assess?
 Language.
 Thinking.
(a) Articulation: dysarthria, paraphasia,  Autism? Delayed or lack of
stuttering/stammering language development
(b) Formulation: aphasias (motor/ transcortical motor, (without compensation with
Language sensory/transcortical sensory, mixed, nominal, alternative modes of
conduction, word blindness "alexia'', word deafness, communication as gestures or
agraphia) mimes).
(c) Grammatism: agrammatism, paragrammatism  Dementia? Dysphasia.
Comments?  Mania? Pressured speech.
a) Spontaneity:
Increased? Mania, anxiety.  Schizophrenia? Disorganized
Absent? Depression, autism, dementia, P.D. speech.
b) amount:  Schizotypal? Odd speech
Increased with? Mania (pressured speech), anxiety, OCPD, (vague, circumstantial,
cluster B P.D, early in dementia. metaphoric).
• Say “talkative or increased amount of speech”.  Histrionic? Hyperbolic,
Decreased with? Depression (poverty of speech), impressionistic.
schizophrenia (mutism or alogia), avoidant & schizoid P.D, 
late in dementia, delirium.
• Say ”telegraphic speech or pausity / decreased
amount of speech”
Thinking c) volume:
Increased with? Mania, psychosis, cluster B P.D, dementia,
delirium, substance intoxication or withdrawal, hearing
impairment.
Decreased with? Depression, hypothyroidism, hyperacusis,
avoidant PD, schizoid PD, paranoid, substance intoxication
or withdrawal.

d) stream (flow): see thought process disorders.

− Comment on stream of speech and later on stream of thinking

e) content: see thought process disorders.

f) form: see thought process disorders.
− Coherent and to the point?
Mood ((M))
Comment on:
 Quality (type): elevated, expansive, irritable, depressed, anxious, emotionally cold, feels emptiness
 Quantity (range): average, exaggerated, restricted.
 Stability: stable, fluctuating, with diurnal variation.
 Congruence with affect?
 Congruence with thinking? (delusions & hallucinations).

Affect ((A))
Comment on:
 Quality (type): depressed, euphoric, reactive, irreactive, inappropriate, ...
 Quantity (range): average, exaggerated, restricted, blunted, flat,..
 Stability: stable along the interview, unstable, labile, ...
 Congruence with mood: Mood congruent?
Thinking ((T))
General items of comment:
 Form? How thought are linked?
 Content? What thought contain?
 Control? Are thought, actions, feelings own or alien?
 Stream? How the line of thoughts runs?
 Abstraction.

Formal thought disorders (FTD or disorganized speech).

How to assess the thought process (form)?
 Goal directedness.
 Association between words, phrases, sentences & paragraphs.
 Rate, amount & rhythm of speech.
 Idiosyncrasy of word usage.
Normal thought process?
 Goal directed (direct).
 To the point.
 Good connection between elements of structure of the thought (words, sentences and paragraphs).
 No idiosyncratic use of words.
FTD can be elicited by open ended questions.

FTDs are:
Goal directedness − Circumstantiality:
 overinclusion of details not directly relevant to the question
 the sequential states are connected
 the patient eventually returns to address the subject or address the
question
− Tangentiality:
 The patient never returns to the original point of question
 The thought are irrelevant and related in a minor insginifiant manner
− Off-pointing
− Talking past the point (approximate answers).
Association − Incoherence (word salad, schizophasia): extreme loss of association
− Loosening of association: (difficult or impossible to see connections between
thoughts)
 Derailment: (gradual or sudden deviation in the train of thoughts
without blocking, sometimes synonymous with loss of association)
 Fusion
 Muddling = drivelling ME
 Rambling
− Clang associations (association based on alliteration rhyming or assonance)
"/
− Punning (association by double meaning) 97/
Idiosyncratic use − Neologism.
of language − Stock words and phrases
 (private − Cryptolalia = the use of obscure (or private) language
symbolism) − Cryptographia = the use of obscure (or private) written language ME
Repetition − Stereotypy (vocal and verbal) (repetitive or ritualistic utterance)
− Verbigeration (repetition of stereotyped phrases)
− Perseveration (repetition of word or phrase despite the absence or cessation of a stimulus)
− Echolalia (repetition of words spoken by others)
− Palilalia (auto-echolalia)
− Logoclonia (repetition of the last syllable of a word)
− Coprolalia (repetition of obscene language)

Thought control disorders

Made phenomena (passivity)?
 Made affect (someone controlling the mood/affect).
 Made volition (someone controlling the action).
 Made impulse (someone controlling the desire to act).
Thought phenomena?
 Thought withdrawal.
 Thought insertion.
 Thought broadcasting “people act as if they know what I'm thinking”.
Thought echo “audible thoughts”: is a type of auditory hallucinations.

Disorders of stream
 Flight of ideas: rapid rated speech, frequent shifts in topics, characterize manic patient.
 Thought block: a form of alogia, characterizes schizophrenic patient.
 Perseveration “? organic frontal”

Disorders of content
Delusions:
Comment on:
 Theme.
 Evidence.
 Reaction.
 Type (autochthonous, delusional perception / mood / memory).
 Congruence with mood.
Others: overvalued ideas, obsessions, compulsions, phobia, memory flashbacks, preoccupations, ...
Perception ((P))
Disorders of perception:
 Hallucinations (pseudo- or true ?).
 Illusions.
 Depersonalization & derealization.
 Déjà vu & jamais vu.
 Macropsia & micropsia (metamorphosia).
 Autoscopic hallucination (phantom mirror image) & negative autoscopy.

Hallucinations:
 Type (psudo- or true ?)
 Modality.
 Content.
nd rd
Content of Auditory hallucinations: running commentary, 2 / 3 person, command hallucinations, talking body part, audible
thoughts (thought echo).
 Circumstances.
 Reaction.
 Consciousness.
 Insight.
 Voluntary control.
 Relation to mood or mental state.
Sensorium and Cognition ((((S))))
General items: (((COAC-LM-V-GEJA)))
 Level of consciousness / Alertness.
 Orientation.
 Attention.
 Concentration.
 Memory.
 Language.
 Visuospatial orientation.
 General knowledge.
 Judgment.
 Abstraction.
 Executive function.
Consciousness Comment:
Alertness − Intact
(arousability) − Clouded, drowsiness, confusion, stupor, coma
− Fugue state
− Hyperarousable: highly distractible, agitated or hypervigilant “focus on minor stimuli”
Causes of hyperarousable patient?
 Mania.
 Anxiety? Panic attacks or flashbacks (PTSD) during the interview.
 Paranoid? Search for cameras or microphones.
 Substance? Cocaine, amphetamine.
 Medical? Hyperthyroid, pheochromocytoma.
Orientation General items:
 To time (time of day, day, date, month, season & year).
 To place (floor, hospital, clinic, city, governorate & country).
 To persons (family members, friends & medical team).
Orientation is lost in this sequence: time, place & persons.
Attention How to examine attention? Causes of inattentive
 Days of the week / months of the year reversely. patient?
 Backward spelling of a word.  Manic.
 From 1-20 reversely.  OCD? Engaged in his
 5 things that start with a parcular leYer. obsessions and
 Digit span test (forward & backward). compulsions.
AND How to examine? = Calculations  Schizophrenia?
Concentration  Serial 7s subtracQon test (Serial 7’s): “Starting with Hallucinations or
100, subtract 7 from 100, and then keep subtracng 7 develop delusions into
from that number as far as you can go.” the interview material.
 Serial 3s subtracQon test (Serial 3’s): “Starting with  Anxiety.
20, subtract 3 from 20, and then keep subtracng 3  ADHD.
from that number as far as you can go.”  Borderline & antisocial?
− [Monitor for speed, accuracy, effort required, and Get bored.
monitor patient reactions to the request]
Memory How to examine?
 Immediate recall: digit span test, short story, 3 different objects ,...
 Recent memory: today morning breakfast, last evening dinner, recall of the 3 objects.
 Remote memory: past life events.
Comment: impaired/ intact
Language General items of examination:
Screen for disability: hearing impairment, cranial nerve lesion, vision impairment, substance
intoxication, withdrawal.
Fluency. Assess degree of fluency: non
fluent speech is telegraphic (nouns .‫ت _أ ف اء‬1‫ آ‬Z F
& verbs), fluent speech contains .‫ء &"ات‬1/‫ أ‬Z F
jargons, paraphasias, neologisms.
Comprehension Assess degree of comprehension: $"‫ اآ‬$7)/[‫ ا‬
(motor & verbal • Motor response: use .0/‫ را‬U‫ه‬
response).
sequential motor tasks of . ‫ل‬1I‫ا‬ ‫ ك‬
"1"‫ا‬ 0‫ود‬ 0(‫ا‬
.‫رض‬C‫ ا‬Z< j T(‫ ا‬Z< j_  F
increasing complexity
.‫رض‬C‫ ا‬Z< A2&
6‫ و‬،A`‫ ا‬،‫ دي‬$‫? ار‬
• Verbal response: use a series
:$"eN‫ ا‬$7)/[‫ ا‬
of questions requiring yes or
:. ‫ او‬Es ‫وب‬%
no answer. ‫؟‬$/‫ ا&= " ر‬Z‫ن ا‬1‫ا‬
‫؟‬$= 1‫ أآ و[ ا‬$ ‫ا‬
Repetition. Assess ability to repeat: start with
+!K 6
! 
6K
complex sentences first.
Naming. Assess ability to name objects:
start with an object; if unable to
answer, give clues as if its use, if ْe  – A!&
still unable to answer, give the first ‫  أ ءه ؟‬.0‫ ر أ ء و‬C S‫
]ور‬
syllable of its name as a clue, if still ‫ ت؟‬:‫&  أ ء
 ا‬
unable to answer, offer a list
containing the item.
Definition. ‫آش؟‬I  ‫ ا‬F16= Z
‫ ="
؟‬$ ‫دو‬C‫)ي ا‬I=
‫(؟‬% Z=6  ‫ا‬
‫؟‬e $A%‫ و‬Z=6  ‫ا‬
Articulation
dysarthria, paraphasic
errors (semantic,
phonemic)
Reading. Assess ability to read: test reading
silently and aloud, ask questions to
.‫=ه‬6 Z F‫ و‬$"_n‫ت ا‬1‫اأ ا‬
evaluate degree of comprehension,
“0="< K1] ” ‫؟‬uN‫اأ و‬
there are often similar defects in
reading and speaking.
Writing. Test for writing ability: agraphia is
present to some degree in all forms
of aphasia, if intact, there is no
‫"ة‬N $1% )‫اآ‬
aphasia – continue only if an
abnormality is present.
Visuospatial Overlapping pentagons
orientation
− Copy this figure
− Pe E‫ د‬/‫ ا‬F‫ا‬

Drawing a clock face.

General The client’s basic knowledge (often called the fund of knowledge) and awareness of social
knowledge events are assessed.
QUESTIONS TO ASK
• Who is the president of the Egypt?
• Who is the prime minister?
• Who were the last three presidents, in order?
• What is the state capital?
Comment: within average
AND Test
Intelligence − Counting
− Calculation
− Kent Emergency Scale
Judgment  Social Judgment: ask about the social appropriateness of behaviour.
 Test Judgment:
• “What will you do when _____________ occurs?”
• “How will you manage if ____________ happens?”
• Stamped letter test: “If you found a stamped, addressed envelope on the street,
what would you do with it?”
• Fire test: “If you were in a movie theater and smelled smoke, what would you do?”
Abstraction  Proverb meaning. [0] [≤3] [5]
“How would you describe the meaning of the following sayings?”
• “People living in glass houses should not throw stones.”
• “A bird in the hand is worth two in the bush.”
• “You shouldn’t cry over spilt milk.”
• “Two heads are better than one.”
 Similarities.
“How are the following items similar?”
• “an apple and an orange” (round ~concrete, fruit ~abstract)
• “a chair and a table” (made of wood ~concrete, furniture ~abstract)
• “a watch and a ruler” (measurement instruments ~abstract)
 Differences.
Executive
 Wisconsin card sorting test
function It is a test of "set-shifting", i.e. the ability to display
flexibility in the face of changing schedules of
reinforcement. It tests the following "frontal" lobe
functions: strategic planning, organized searching, utilizing
environmental feedback to shift cognitive sets, directing
behavior toward achieving a goal, and modulating impulsive
responding.

Insight Ask the patient :

 Are you a patient?
 Do you need help?
 Are these psychological?
 Do you know where the disturbance is?
 Is that awareness affecting your behaviour?
Comment:
 Complete denial of illness
 Slight awareness of being ill and needing help, but denying it at the same time
 Awareness of being ill, but blaming it on [others], [external factors], [organic illness]
 Awareness that illness is due to something unknown to him or her
 Intellectual insight: admission that he is ill, and that symptoms and failure in social
adjustment are due to patient's own irrational feelings or disturbance, without applying
the knowledge to future experiences.
 Emotional insight: emotional awareness of the motives and feelings, leading to change in
future behavior.
Grades of insight? The table.
1 2 3 4 5 6
Are you a patient? N May be Y Y Y Y
Do you need help? N May be Y Y Y Y
Are these S N N N Y Y Y
psychological?
Do you know where N N Organic, N “some- Y “irrational feelings or Y
the disturbance is? others, thing thoughts”
external unknown”
factor
Does that affect ur N N N N N Y
behaviour?
Reliability
Template
Depressed • Appearance: the patient looks older than his stated age, with average body built, stooped
patient posture, with depressed facies with poor self hygiene and poor grooming.
• Cooperative with poor eye to eye contact.
• The patient shows psychomotor retardation with no motor disorder, abnormal behavior or
catatonia.
• Speech: the patient speaks only in answering to question with low volume, rate and scanty
amount of words (telegraphic speech).
• Mood: depressed, non reactive stable (with diurnal variation).
• Affect: depressed, stable, congruent with mood.
• Thinking:
 No FTD
 No TCD
 Depressive rumination about death, illness ,…
 Slow speech with repeated thought blocking.
• Perception:
 No illusions, hallucinations ,…
 No….
• Sensorium and cognation: the patient is alert, conscious, attentive, oriented TTPP, with
average concentration, average immediate recall, recant and remote memory, with
average visuospatial orientation with no language abnormality with fair abstraction and
average general knowledge.
• Intact social and test judgment.
• Insightful to symptoms, illness and need for treatment.
• Adequately reliable.
Manic patient • The patient looks his stated age, with average body built, no special facies or posture,
shows fair self hygiene, proper grooming.
• Cooperative with good eye or eye contact, playful grandiose attitude…. The examiner.
• The patient speaks spontaneously and answering to question, pressed speech, rapid rate
increase volume and amount
• Shows seductive behavior, no motor disorder or catatonia.
• Shows mild psychomotor agitation.
• Mood is markedly (elevated) irritable, stable.
• Affect: irritable euphoric, agitated, stable, congruent with mood.
• Thinking:
 FOI.
 Clang association.
 Delusion of grandiosity.
 Rapid stream of thinking….. Thought.
 No TCD.
• Perception: no abnormal perception expects delusion and hallucination telling him that he
is a prophet and hallucinatory behavior.
• Sensorium and cognation: the patient is alert, conscious, OTTPP, easily distractible with
poor concentration.
• Intact memory, average visuospatial orientation, with no language abnormality, with fair
abstraction and average general knowledge.
• Impaired social and test judgment.
• Insightful to symptoms, but insightless to illness and need for treatment.
Schizophrenic • The patient looks his stated age, with average body built, with poor self hygiene and poor
patient grooming.
• Hallucinatory behavior (whispering, self talk, self laugh), no catatonic features, no motor
disorder, silly smiling.
• Tear eye to eye contact, cooperative with frequent T.B
• Thinking:
 Marked FTD (incoherence, derailment, loosing of associate).
 Delusion of….
 No TCD
 Average stream of thinking.
• Perception: hallucinatory behavior….
• The patient is alert, conscious, OTP, with intact memory, distractible, difficult
concentration, intact visuospatial orientation, impaired abstraction, subaverage general
knowledge.
• Impaired social and test judgment.
• Insightless to …….
• No reliable.
Physical and Neurological examination
Schizophrenia
o Measure vital signs (pulse, blood pressure, temperature).
o Measure weight, height, and body mass index (BMI), which can be calculated with the
formula weight in kilograms/(height in meters)2 or the formula 703 × weight in
pounds/(height in inches)2 or with a BMI table
o Screen for diabetes risk factors
o Assess for extrapyramidal signs and abnormal involuntary movements.
o Screen for symptoms of hyperprolactinemia.
Case Formulation
 Case Formulation
• Case summary
• Diagnosis

• DD

• Non-dynamic etiological factors

• Psychodynamic formulation
− Ego psychological model
− Object relational model
− Self psychological model

• Investigation
− Lab. / Imaging
− Psychometry

• Prognosis (Good prognostic factors vs. bad prognostic factors)

• Plan of management (Treatment plan)
− Hospitalization or not
− Biopsychosocial model
1. Biological
2. Psychotherapy
 Case Summary
− Identification data
− Symptoms or signs
− Personal history
− Family history
1. Parents
• Parenting style
• Personality
• Relation with the patient
2. Home atmosphere
• Relation among father, mother & other family members
 Diagnosis (Most probable diagnosis)
According to DSM-5
Schizophrenia First Episode, currently in acute episode
First Episode, currently in partial remission
First Episode, currently in full remission
Multiple Episodes, currently in acute episode
Multiple Episodes, currently in partial remission
Multiple Episodes, currently in full remission
Continuous

Specify if:
− With catatonia
Specify current severity:
Substance/ Specify if
Medication- − With onset during intoxication
Induced − With onset during withdrawal
Psychotic Specify if
Disorder
 With delusions
 With hallucinations
MDD Specify:
Single episode, or recurrent episode
Severity/course specifier:
- Mild, Moderate, Severe, or With psychotic features (if in episode)
- In partial remission, or In full remission (if in remission)
Specify:
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern (only if recurrent episode)
Bipolar I Specify:
disorder Current or most recent episode (manic, hypomanic, depressed)
Severity/course specifier:
- Mild, Moderate, Severe, or With psychotic features (if in episode)
- In partial remission, or In full remission (if in remission)
Specify:
With anxious distress
With mixed features
With melancholic features (only if depressive episode)
With atypical features (only if depressive episode)
With mood-congruent psychotic features
 With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern (only if recurrent episode, applies only to the pattern of depressive episodes)
With rapid cycling (only if recurrent episode)
Depressive − With depressive features.
Disorder Due to
− With major depressive-like episode
Another
Medical − With mixed features:
Condition
Bipolar and − With manic features
Related
− With manic- or hypomanic-like episode
Disorder Due to
Another − With mixed features
Medical
Condition
Substance/ Specify if
Medication- − With onset during intoxication
Induced
Depressive − With onset during withdrawal
Disorder
Substance/ Specify if
Medication- − With onset during intoxication
Induced Bipolar
and Related − With onset during withdrawal
Disorder
Obsessive- Specify if:
Compulsive − With good or fair insight
Disorder − With poor insight
− With absent insight/delusional beliefs
Specify if:
− Tic-related
Conduct Specify whether:
− Childhood-onset type
− Adolescent-onset type
Specify if:
− With limited prosocial emotions
− Lack of remorse or guilt
− Callous—lack of empathy
− Unconcerned about performance
− Shallow or deficient affect
Specify current severity:
− Mild
− Moderate
− Severe
Autism SD Specify if:
− With or without accompanying intellectual impairment
− With or without accompanying language impairment
− Associated with a known medical or genetic condition or environmental factor
− Associated with another neurodevelopmental, mental, or behavioral disorder
− With catatonia
ADHD Specify whether:
− Combined presentation
− Predominantly inattentive presentation
− Predominantly hyperactive/impulsive presentation
Specify if:
− In partial remission
 Specify current severity:
− Mild
− Moderate
− Severe

According to DSM-IV
Axis I Current mental state diagnosis (definite or provisional)
Axis II Personality disorder and mental retardation
Axis III Any physical condition whether related or not to the psychiatric disorder
Axis IV Psychosocial or environmental factors contributing to the disorder
Axis V Global Assessment of Functioning (GAF) scale.

Global This is a measure of functioning at a specified time, (for example at me of evaluaon, highest level of funconing during past 6 months, at
me of discharge, etc). This 100-point scale provides a composite measure of psychological, social and occupational functioning. It excludes
Assessment of
impairment due to physical or environmental limitations.
Function)
• 91 – 100------ No symptoms. Superior functioning in a wide range of activities
(GAF)
• 81 – 90------- Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all
areas, i no more than everyday problems or concerns.
• 71 - 80 -------If symptoms are present, they are transient and expectable reactions to psychosocial
stressors , no more than slight impairment in social, occupational, or school functioning
• 61 – 70-------- Some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social,
occupational, but generally functioning pretty well, has some meaningful interpersonal relationships.
• 51 – 60--------- Moderate symptoms (e.g., flat affect and circumlocutory speech, occasional panic
attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts
with peers or co-workers).
• 41 – 50--------- Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent
shoplifting) or any serious impairment in social, occupational, or school functioning
• 31 – 40----- Some impairment in reality testing or communication (e.g., speech is at times illogical,
obscure, or irrelevant`t) or major impairment in several areas, such as work or school, family relations,
judgment, thinking, or mood
• 21 – 30------- Behavior is considerably influenced by delusions or hallucinations or serious impairment, in
communication or judgment
• 11 – 20------- Some danger of hurting self or others or occasionally fails to maintain minimal personal
hygiene.
• 1 - 10 --------Persistent danger of severely hurting self or persistent inability to maintain minimal personal
hygiene or serious suicidal act with clear expectation of death.
• 0----------- Inadequate information

According to ICD-10

Axis I Current mental state diagnosis including personality disorder

Axis II Disabilities
Axis III Contextual factors
Rational for diagnosis (HWP)
Against the rational for diagnosis (HWP)
DD
• For every diagnosis (what is with, what is against)
• Almost always:
1. Substance induced (no information in the history to denote the presence of substance abuse)
2. General medical condition (cerebral/systemic) (HWP)
3. Axis I (including child) ME
4. Axis II ME
5. Malingering ME
 Non-dynamic etiological factors
Non-dynamic etiological factors
− Genetics (family history)
− Associated organic or physical conditions
− Sociocultural factors
 Economic issues
 Socioeconomic level (status)
 Social support
 Religious factors
 Ethic and cultural factors

Genetics (Biological) Environmental (BioPsychosocial)

Predisposing − Genetics (family history) − Early life stress events
Precipitating − Recent trauma
− Recent change in role or responsibility
Maintaining − Genetics (family history) − Economic issues
− Socioeconomic level (status)
− Family atmosphere


 Psychodynamic Formulation (Interpretation)
A) Ego psychological model
1) Overall ego strength or resilience:
Two main indicators:
a. Work history: Job stability and progress.
b. Relationship pattern: Stable committed relationships.
2) Ego functions:
Key ego functions, e.g.
− reality testing,
− judgment,
− regulation and control of affects and impulses etc…
3) Defensive functioning:
• Predominant or commonly used defenses.
• Defensive style (ego syntonic) and resulting "character" pathology.
• Level of maturity of defenses (continuum: immature, neurotic, mature).

4) Relation between ego and super-ego:

• Optimum:
Flexible and harmonious relation.
• Pathogenic qualities
a. Rigid, ruthless and punitive superego.
b. Defective superego (immoral, over-permissive).
c. Over-demanding superego (unreasonable restrictions, goals and ideals).

5) Predominant type of anxiety

e.g loss of object or object love, paranoid anxiety, superego anxiety, separation, disintegration, castration

6) The nature of unconscious wishes, fantasies and fears (Drive derivatives).

7) Core unconscious conflicts repetitively reenacted by the patient:
e.g. conflicts related to the expression of aggressive or sexual drives.
8) Psychological mindedness
Ability to:
1. See problems as having internal origin (not externalized and blamed on others).
2. Think in metaphors and analogies.
3. Synthesize data to develop meaningful explanation.

• Conflict (wish, desire, impulse, defense, intrapsychic)

a) Intrapsychic factors. (Id drives or impulses in conflict with each other / Id drives in conflict with the
superego.)
b) External factors: (Interpersonal conflicts/ External threat or trauma to the ego. )
• Stage of fixation (classic Freud stages)
 B) Object relations model
Information relevant to this model includes:
1. Interpersonal relaƟonships in 3 contexts:
a. Childhood: Parents or caregivers, sibs etc..,
b. Current life: Spouse friends, etc....
c. Therapy: A mixture of real and transference elements.
2. Patterns of relationships in the patient's family:
• Between father and mother.
• Father and mother with sibs.
3. Persistent patterns of relationship: i.e. old object relationships repeated:
• Examples: Dependency, sadomasochistic, taking care of others etc.....
• The reenacted role in the repeated pattern may be "self' or "object".

• Persistence or internalized traumatic patterns of relatedness which become acted out in current
relationships.
• Persistence or internalized representations of self
• Identity diffusion (i.e. failure of identity formation

4. Memories of "Model Scenes":

• Represent a prototype of a key traumatic object relation.
• May be reenacted in real life or in therapy.

5. Level of maturity of object relations:

• Immature forms:
1. Idealization-devaluation (splitting). (introjection, projection)
2. Seeing others as need gratifying "part objects" rather than "whole objects".
3. Lack of object constancy: i.e. unable to tolerate being apart from significant others (Lack of
soothing internal object).
4. Failure of self-object differentiation
• Mature (HRP)
 C) Self-psychological model
1. State of self-esteem:
• Self representations as regards:
a. Worth and lovability.
b. Competence and power.
c. SeIf continuity and stable identity.
• On a continuum (low-optimum-exaggerated), with both extreme ends considered pathological.

2. Cohesion versus fragmentation

• A sense of: Self continuity, stable identity and internal reliability.
Versus: Emptiness, shattered self and identity diffusion.
• Psychodynamics: Different self representations split off from one another and compete for domination over
the whole personality. (conflict)
Concept of anxiety: "Fragmentation (disintegration) anxiety"

3. Gratification of selfobject (esteem) needs:

a) Deficit state:
Early lack of "empathic responsiveness" from parents or significant objects leading to defective gratification of
mirroring, idealizing, twinship needs.
Ungratified selfobject (esteem) needs:
− "Mirroring deficits": disturbed self esteem, lack of ambition
− "Idealizing deficits": defective self-soothing or calming , deficiency or lack of
self-regulation, Inability to commit to ideals and values.
− "Twinship deficits": deficient learning, productivity and creative

b) Mature state:
Esteem needs satisfied by:
1. Internalized empathic objects.
2. Mutually gratifying (interdependent) relationship with others.

c) Self-boundaries
Sense of boundaries between self and objects (i.e. own mental content versus those of others)

IV) Predicting response to the therapeutic situation

• The formulation helps in predicting possible reactions during therapy.
• Generally, it helps in suggesting possible patterns of:
a. Transference.
b. Resistance.
• However, this is expressed differently in each psychodynamic model.
A) Ego psychological model:
• Possible defensive mechanisms.
• Possible manifestations of transference to be expected.
• Specific ego strengths and deficits to deal with
B) Object relations model:
Which inner representations of the self and others will be activated and enacted in the therapeutic situation?
C) Self-psychological model:
Which areas of empathic failure to be corrected by the therapist's empathic responses. e.g. needs for mirroring or
idealization?
 Case Example
I) Clinical and history data
• Mr. A is a 50 year old married man with two sons who works as a company executive.
• He presented with a depressive syndrome after being once passed over for promotion. This "rejection" was not understood by
the patient, but it is probably related to his lifelong tendencies to procrastinate (delay and postpone work) and to annoy his
superiors either by being too submissive or by challenging their authority (i.e. passive-aggressive traits)
• He has a history of 2 untreated depressive episodes:
1. One in his, 30s that also followed a professional failure (occupational failure).
2. One in his 40s that followed his son's marriage without his approval (personal failure).

Father:
• Was a sickly man (i.e. self-absorbed with some sickness or another most of the time).
• He was a perfectionist type A personality.
• However, he was professionally frustrated and died of heart attack when the patient was in his teens.
• He was generally unsupportive and over-controlling in his relation with the patient.

Mother:
• Suffered from chronic insomnia, gloomy mood, self doubt, social withdrawal and obsessive ruminations. Though these features suggest
a depressive disorder she never sought treatment.
• Her self absorption with her depression apparently interfered with her caring and nurturing role toward her son.
• During his childhood she was over-controlling and insisted that he behaves exactly the way she wanted.

Diagnosis:
• Axis I: Major depressive disorder, recurrent episodes.
• Axis II: Passive-aggressive personality traits.

II) Non-dynamic factors

• The patient is under treatment for hypertension.
• Mother's history suggests genetic predisposition to unipolar depression.

III) Psychodynamic interpretations

A) Ego psychological model:

• Central conflict related to aggression:
- Unconscious aggression (wish to kill) against his competitors and an unconscious fear that they will retaliate (kill him).
- As a compromise he resorts to expressing his aggression indirectly i.e. passive-aggressive behaviour.
- In response to fear of retaliation he becomes submissive and obedient.

• Depressive psychodynamics:
- His perfectionstic and controlling father was internalized as a demanding and punitive superego.
- Failures to fulfill his expectations (e.g. being passed over for promotion) generate his depressive episode.

• Predictions for therapy:

1. Transference to the therapist may lead to passive-aggressive behaviors (e.g. coming late or forgetting appointments etc...).
2. Feelings of guilt and self-destructive behavior may lead to trying to sabotage any improvement, e.g. by premature stopping
of treatment.

B) Object relations model

• Central problem:
The patient's central problem is the failure to integrate the good and bad representations of self and others generated from
traumatic negative experiences with both parents.

• As the good and bad representations are spilt:

- The bad angry self becomes repressed (fear of losing objects or retaliation from them).
- While a rather false good obedient self is presented externally.

• This splitting explains his behavior with his work superiors being at times too obedient and submissive (good obedient self) and at
others passively aggressive (bad angry self).
 • The dynamic process:
1. Failure of integration
Leads to a splitting of self and object representations into:
a) A bad angry self in response to:
• A bad self-absorbed and un-nurturing object image of mother
• A bad self-absorbed, unsupportive demanding and controlling object image of father.
b) A weaker good self, mostly acting as a good obedient son in order to gain approval.
2. The internalized representations of self and objects are projected on to repetitive patterns of relationship with others in which
others are viewed either as the un-nurturing mother or the unsupportive controlling father

• Depressive psychodynamics:
The patient's depression results from his demanding punitive conscience (superego) condemning him for:
a. His aggressive hostile wishes.
b. Failing to meet the perfectionistic ideals of the good self.

• Predictions for therapy:

1. Initially, the patient is likely to behave as a good obedient son depressively condemning himself for past and present failure
and feel worried that he will not meet the therapist's expectations.
2. With progress of therapy transference issues will emerge in which the object relation pattern with both parents will be
activated and the therapist may be perceived as being both emotionally uncaring and controlling.

C) Self-psychological model:
• Central problem: Low self-esteem and consequent need for continual recognition and approval from others.

• Origin:
1. Lack of empathic responsiveness to his age appropriate esteem needs (mirroring, idealizing and twinship needs) by his self
absorbed depressed mother and sickly father during childhood.
2. Demanding expectations:
- Both parents narcissistically invested in their son the hope that his achievements will make up for their failures.
- This has led to a lack of confidence, inappropriate solicitous (over-anxious and obsessive) behavior and procrastination
of challenging tasks.

• Depressive psychodynamics:
- Internalizing his parent's grand expectations led to a perfectionistic (ideal seeking) attitude with inability to accept his
limitations (e.g. his professional failures) or the limitations of others (e.g. his bosses).
- Being passed over for promotion was an injury to his self esteem which was already vulnerable.
- The rejection reawakened early empathic failures and frustrated ambitions.
- The resultant activation of his feelings of loss of self-esteem contributed to his current depression.

• Prediction for therapy

- Initially, the patient is likely to attempt to elicit therapist's admiration.
- He will have grand expectations about what can be done idealizing both himself and the therapist.
- When the therapist fails to respond with the right empathic quality he will feel hurt and enraged and may devaluate the
whole process.
Psychodynamic Formulation (Interpretation) From HWP
• Content of thinking
• Conflict (wish, desire, impulse, defense, intrapsychic)
• Deficit:
∗ Reality testing
 distorted perception of outside
 distorted perception of inside
∗ Judgment
 anticipate consequences of behaviour
? Behaviour itself
∗ Thought process
∗ Defense mechanisms: failure of defense mechanisms  symptoms
∗ Stimulus barrier
∗ Mastery competence (e.g. high subjectivity and lack of objectivity) P/ ‫ر وه‬AI ‫ ل ا‬

∗ Object relations (mature, immature)

∗ Synthetic integration functions
? Self representation ‫ة‬I& ‫ ل أ‬1
? Object representation Z=‫ ا=س )ه‬F‫ ل آ‬1

Do not forget
• Specific psychodynamics of each disease ME
 Investigation
• Rational for every investigation
• Further information (interview with patient and close relatives)
Consultation after…….
• Psychometric evaluation for personality and the diag. of the condition
• Tests for organicity
Urine screen for substances
Routine lab (diagnosis, drugs)
HWP

I. Psychometry
HWP
Mental MMPI (Minnesota Multiphasic Personality Inventory)
disorders and − Objective personality test to identify personality structure and pathology.
personality − MMPI: contains 10 scales
disorders MMPI 2: contains 567 items
MMPI 2 RF: contains 338 items
− The 10 scales: hypochondriasis, depression, hysteria, psychopathic deviate, masculinity-
femininity, paranoia, psychasthenia, schizophrenia, mania, and social introversion.
Suicide For assessment of suicide:
Columbia Suicide Severity Rating Scale
Childhood The Child Behavior Checklist (CBCL), now called the Achenbach System of Empirically Based
disorders in Assessment, is a parent report form to screen for emotional, behavioral, and social problems, as
general ADHD, ODD, conduct, depression, anxiety, phobia, and separation anxiety.
Intelligence Wechsler Intelligence Scale for Children (WISC) (6-12years)
scales a) Verbal: information, similarities, arithmetic, vocabulary, comprehension, digit span
b) Performance: picture completion, picture arrangement, block design test, object assembly,
mazes
Cattell infant intelligence scale: assessment of IQ in infants
Stanford-Binet Intelligence scale: assessment of IQ in children
Dementia Minimental state examination (MMSE)
− Screening for dementia
− Total score = 30
− <30  Dementia
Children motor Goodenough draw a person test: motor coordination in children
Children ADHD Abbreviated conners questionnaire (conners parent and teacher rating scales): ADHD
Children MR Benton visual retention test and bender gestalt test: detect brain damage in MR
OCD Yale brown obsessive compulsive scale: OCD
General Instruments to • Clinical global impression (CGI) - clinician
define and identify • Medical outcomes study short form health survey (SF-36) – self or clinician
psychiatric ‘cases’ • General health questionnaire (GHQ) – self
Instruments for • Brief Psychiatric Rating Scale (BPRS) - clinician
measuring It is a rating scale which a clinician or researcher may use to measure psychiatric
symptoms such as depression, anxiety, hallucinations and unusual behaviour.
psychiatric
• Symptom Rating Test (SRT)
symptoms
• Global Assessment/ Screening
 Clinical Global Impression (CGI)
global observation of severity of psychiatric illness
 Nurses Observation Scale for Impatient Evaluation (NOSIE)
mostly used for inpatients with psychosis
analysis produces three positive factors (personal neatness, social competence
and social interaction) and three negative factors (manifest psychosis,
retardation, and irritability)
 Global Assessment Scale (GAS)
evaluates social functioning and severity of symptoms
 Hopkins Symptom Checklist (SCL-90)
Global Scales • Clinical Global Impression (CGI) Scale
• Global Assessment of Functioning (GAF)
• Children's Global Assessment Scale
• The Sheehan Disability Scale
Psychosis • PANSS (Positive and negative syndrome scale - clinician)
• SANS (Scale for the assessment of negative symptoms – clinician)
• SAPS (Schedule for the assessment of positive symptoms – clinician)
• Manchester rating scale (Krawiecka)
Clinician-rated scale for assessment of symptoms of psychotic disorders. 14 items covering positive
and negative symptoms and medication side-effects
• Comprehensive Assessment of Symptoms and History (CASH)
It was developed for research studies of schizophrenia spectrum conditions and affective spectrum
conditions. It provides information concerning current and past signs and symptoms, premorbid
functioning, cognitive functioning, sociodemographic status, treatment, and course of illness.

Assessment of condition and comorbidity

• Structured Clinical Interview for DSM-IV Axis I Disorders [SCID]
• Brief Psychiatric Rating Scale [BPRS]
• Calgary Depression Scale for Schizophrenia (CDSS)

Others
• Camberwell assessment of needs (CAN)
It is an instrument which provides a comprehensive assessment of complex mixture of clinical and
social needs that people with severe mental illness often have.
• Camberwell Family Interview (CFI)
It assesses expressed emotion

Assessment of abnormal movement

• Abnormal Involuntary Movement Scale [AIMS]
Depression • Beck Depression Inventory (BDI)
• Beck Hopelessness Scale
• Geriatric depression scale (GDS)
• Hamilton rating scale for depression (HAM-D) – clinician, severe with somatic
 • Hospital Anxiety and Depression Scale (HADS)
• Impact of life events (ILE)
• Life events and difficulties schedule (LEDS) – clinician
• Montgomery-Asberg depression rating scale (MADRS) – clinician, changes
• Mood and feelings questionnaire in children (MFQ) – self
• Zung Self-Rating Depression Scale
Bipolar • Young mania rating scale (YMRS) - clinician
• Manic rating scale
• Modified manic rating scale
Anxiety • Beck's anxiety inventory (BAI) - self
disorders • Zung Self-Rating Anxiety Scale
PTSD • Clinician administered PTSD scale (CAPS)
OCD ∗ Yale–Brown Obsessive Compulsive Scale (YBOCS): Severity and OCD symptom types
• Maudsley Obsessional-Compulsive Inventory (MOCI)
• Leyton Obsessional Inventory (LOI)
• Obsessive Compulsive Inventory-Revised (OCI-R): self-report severity of symptoms
Assessing OCD, Comorbid Conditions
∗ Anxiety Disorders Interview Schedule-IV (ADIS-IV) / The Anxiety Disorder Interview Schedule – Revised
(ADIS-R) (2+ hrs): for detailed assessment of anxiety disorders
∗ Mini-International Neuropsychiatric Interview (MINI) (15 to 30 min): Brief screen for diagnosis
Eating Disorders • Eating Attitudes Test (EAT)
• Eating Disorder Inventory
• Anorectic Behavior Observation Scale
• Morgan Russell scale
It is used before and after treatment to measure these things:
 Whether people's attitudes towards food got better
 Whether people's eating habits got better (for example, whether they ate more
than before treatment)
 Whether people did better at school or work
 Whether people showed more interest in having a relationship
• Self report on eating behavior
Psychosomatic • McGill Pain Questionnaire
disorders • Psychosocial Adjustment to Illness Scale (PAIS)
.
Personality
Objective Projective
· Paper-and-pencil format · unstructured stimuli create
maximum freedom of response
· scoring is subjective
· quantitatively scored · designed to tap unconscious
· efficiency, standardization impulses
· reliability and validity lower than
· subject to deliberate distortion those of objective tests
• Minnesota Multiphasic Personality Inventory • Thematic Apperception Test
(MMPI-2) (TAT)
• Personality Assessment Schedule (PAS) • Rorschach Inkblot Test
• Structured Clinic Interview for DSM-III-R • Sentence Completion Test
Personality Disorders (SCID-II) • Draw-A-Person Test
 • The Million Clinical Multiaxial Inventory IV
(MCMI IV)
• Eysenck Personality Questionnaire
• California Psychological Inventory
• Hare Psychopathy Checklist
.

Child intellectual Assessment of cognitive function

disability - Used in children and adolescents who have acquired language
- Each instrument evaluate cognitive abilities across multiple domains including
verbal, performance, memory, and problem solving.
• Wechsler Intelligence Test for Children (for children 6-16 years)
• Wechsler Preschool and Primary Scale of Intelligence-Revised (for children 3 -6 years)
• The Stanford-Binet Intelligence Scale, Fourth Edition (starng at age 2 years)
• The Kaufman Assessment Battery for Children (for children 2½-12½)
• The Kaufman Adolescent and Adult Intelligence Test (from 11 to 85 years)
Assessment of adaptive function
• The Vineland Adaptive Behavior Scales (in infants through youth 18 years): includes
four basic domains including:
1. Communication (Receptive, Expressive, and Written);
2. Daily Living Skills (Personal, Domestic, and Community);
3. Socialization (Interpersonal Relations, Play and Leisure, and Coping Skills);
4. Motor Skills (Fine and Gross).

Behavioral rating scales: for the population with intellectual disability.

• Aberrant Behavior Checklist (ABC) General behavioral ratings scales
• Developmental Behavior Checklist (DBC)

• Behavior Problem Inventory (BPI) Screening for self-injurious, aggressive, stereotyped behaviors

Assessment of comorbid psychiatric symptoms and disorders

• Psychopathology Inventory for Mentally Retarded Adults (PIMRA)
Infant screening instruments for developmental and intellectual delay or disability
• Goodenough Draw-a-Person Test
Copying geometric figures may be used as quick
• Kohs Block Test screening tests of visual-motor coordination.
• Geometric puzzles

• Gesell and Bayley scales

• Cattell Infant Intelligence Scale
Childhood Questionnaires:
behaviour • The Eyberg Child Behavior Inventory
disorders (CD, • The Child Behavior Checklist
ODD, ADHD) • The Behavior Assessment for Children
• Conners Child Behavior Checklist
• Strengths and Difficulties Questionnaire
Observational instruments:
• The Disruptive Behavior Diagnostic Observation Schedule
Childhood Semistructured interviews:
Psychiatric • The Child and Adolescent Psychiatric Assessment
Structured interviews:
disorders (including • The Development and Well-Being Assessment (DAWBA)
behaviour disorders) • The Diagnostic Interview Schedule for Children (DISC)
Conduct • Conduct Disorder Scale (CDS)
• Adjustment Scales for Children and Adolescents (ASCA)
• Social Skills Rating System (SSRS)

• Reynolds Adolescent Adjustment Screening Inventory (RAASI)

Child ADHD • Conner's rating scale
Autism Questionnaires and scales
• Childhood Autism Rating Scale (CARS)
• The Checklist for Autism in Toddlers (CHAT)
• The Modified Checklist for Autism in Toddlers (M-CHAT)
• The Pervasive Developmental Disorders Screening Test (PDDST)
Standardized diagnostic instruments
• The Autism Diagnostic Interview-Revised (ADI-R)
• Autism Diagnostic Observation Schedule (ADOS)
Instruments for identifying broader dimensions of behavior associated with ASD in
children who had no evidence of autism
• The Social Responsiveness Scale (SRS)
• The Children’s Communication Checklist (CCC) covers pragmatic language difficulties
• The Social Communication Questionnaire or SCQ
Children specific Tests for reading disability
learning disorder • The reading subtests of the Woodcock-Johnson Psycho-Educational Battery-Revised,
• and The Peabody Individual Achievement Test-Revised
Tests for mathematics
• The Keymath Diagnostic Arithmetic Test
Tests for writing performance
• Test of Written Language (TOWL)
• Diagnostic Evaluation of Writing Skills (DEWS)
• Test of Early Written Language (TEWL)
Dementia and • Mini-mental state examination (MMSE)
cognitive − demena is suggested with scores less than 24-27
Impairment in • Montreal Cognitive Assessment (MoCA)
the Elderly (1) • Mini-Cog (Mini-Cognitive Assessment Instrument)
• Modified Mini-Mental State Exam (3MS)
• Short Test of Mental Status (STMS)
• Short Blessed Test (SBT)
• 7-minute Screen
• Self-Administered Gerocognitive Examination (SAGE)
• Abbreviated mental test score
• Cambridge Mental Disorders of the Elderly Examination (CAMDEX)
• Clifton Assessment Procedures for the Elderly (CAPE)
− can be used to predict survival, placement, level of disability, and decline in
elderly subjects
• Clinical Dementia Rating (CDR) Scale
• Crichton Behaviour Rating Scale
 • Geriatric Evaluation by Relative's Rating Instrument (GERRI)
• Geriatric Mental State Schedule
• General Practitioner Assessment Of Cognition
• Informant Questionnaire on Cognitive Decline in the Elderly
• Kendrick Battery
− distinguishes between normal, functionally impaired, and demented elderly
groups
• The Kew Cognitive Map
− assesses parietal lobe function and language functions in patients with dementia
• Mattis DemenQa RaQng Scale (1976)
• Mental Test Score
• Stockton Geriatric Rating Scale
− For use by “nonprofessional ward staff” to rate patients’ behaviour in such areas
as eating, toileting, self-direction, and sociability
Dementia (2) • Blessed Information-Memory Concentration (BIMC)
• Blessed Orientation-Memory Concentration (BOMC)
• Memory Impairment Screen (MIS)
• Clock Drawing Test
Dementia (3) • Instrumental Activities of daily living
Geriatric • Two question screener // Two – item scale (PHQ-2):
depression  in the past month felt down, depressed or hopeless
 in past month bothered by little interest or pleasure in doing things
• Geriatric Depression Scale (GDS): self-report
• Cornell Scale for Depression in Dementia
• Center for Epidemiologic Studies of Depression Scale (CES-D)
• Patient Health Questionnaire 9
Brain Injury • Clock Drawing Test
Organic Brain • Bender-Gestalt Test: can be used in the assessment of: MR, aphasia, psychoses,
Dysfunction neuroses, malingering.
Substance Abuse • Liverpool University Neuroleptic Side-Effect Rating Scale (LUNSER) - self
• Abnormal involuntary movement inventory (AIMS) – clinician
Drugs/side- • Barnes akathisia rating scale (BARS) - clinician
effects • Simpson Angus scale (SAS) – clinician (EPSE)
• Drug attitude inventory (DAI) – clinician in schizophrenia

• Drug abuse screening test (DAST)

• Michigan Alcohol Screening Test (MAST)
• CAGE questionnaire
Social Stress • Social Readjustment Rating Scale (Holmes and Rahe)
· self-report quesonnaire containing 43 classes of life event
· includes death of spouse (100) to minor legal violaon (11)
• Life Events and Difficulties Schedule (LEDS)
· semistructured interview schedule
 II. Laboratory Tests
1. No laboratory tests in psychiatry can confirm or rule out diagnoses as schizophrenia, bipolar I dis, & MDD.
2. Laboratory tests can help rule out potential underlying organic causes of psychiatric symptoms, as impaired
copper metabolism in Wilson's disease and a positive result on an antinuclear antibody (ANA) test in SLE.
3. Laboratory work is used to monitor treatment, such as
− measuring the blood levels of antidepressant medications and
− assessing the effects of lithium on electrolytes, thyroid metabolism, and renal function.

Before initiating psychiatric treatment, a clinician should undertake a routine medical
evaluation for the purposes of (screening for concurrent disease, ruling out organicity,
and establishing baseline values of functions to be monitored). Such an evaluation
includes
Basic Screening 1. a medical history and
Tests 2. routine medical laboratory tests, such as a CBC; hematocrit and hemoglobin;
renal, liver, and thyroid function; electrolytes; and blood sugar.

Thyroid disease and other endocrinopathies can present as a mood disorder or a
psychotic disorder; cancer or infectious disease can present as depression; infection
and connective tissue diseases can present as short-term changes in mental status.

Thyroid Function Tests
Neuroendocrine
Dexamethasone-Suppression Test
Tests
Other Endocrine Tests

Prolactin

Catecholamines: serotonin metabolite: 5-hydroxyindoleacec acid (5-HIAA)
Kidney Function

Lithium
Tests

LFTs must be monitored routinely when using certain drugs, such as carbamazepine
Liver Function Tests
(Tegretol) and valproate (Depakene).
Lipids, Fasting Blood

Some atypical antipsychotic agents have been associated with abnormalities in lipid
Sugar and
and serum glucose levels, including the development of diabetes mellitus.
Glycosylated HgB

VDRL, FTA-ABS. A central nervous system (CNS) VDRL test is performed in patients with
Blood Test for
suspected neurosyphilis.
Sexually Transmitted

A positive HIV test result indicates that a person has been exposed to infection with
Diseases
the virus that causes AIDS.
1. Thyroid
2. Kidney
Lithium
3. CBC, Serum electrolytes, Fasting blood glucose, ECG
4. Pregnancy testing for women of childbearing age

No special tests are needed for patients taking benzodiazepines.
Benzodiazepines
Baseline LFTs are indicated for patients with suspected liver damage.

Urine is tested routinely for Bz in patients being treated for substance abuse.

No special tests are needed for patients taking antipsychotics, although it is a good
idea to obtain baseline values for liver function and a CBC.

CBC: Adverse effects include leukocytosis, leukopenia, impaired platelet function, mild
anemia (both aplastic and hemolytic), and agranulocytosis.
Antipsychotics
Liver functions: These agents can cause hepatocellular injury and intrahepatic biliary
stasis (indicated by elevated total and direct bilirubin and elevated transaminases).

They also can cause ECG changes

With the exception of clozapine, all antipsychotics cause a short-term elevation in
serum prolactin concentration.
Clozapine
Clozapine levels are determined in the morning before administration of the morning
 dose of medication.

Weekly CBCs are required during the first 6 months of treatment with clozapine
because of the risk of agranulocytosis.

ECG ME

An electrocardiogram (ECG) can be taken before starting a regimen of cyclic drugs to
assess for conduction delays, which may lead to heart block at therapeutic levels.
Tricyclic and

Blood levels should be determined routinely when using imipramine (Tofranil),
Tetracyclic Drugs
desipramine (Norpramin), or nortriptyline (Pamelor) in the treatment of depressive
disorders.

Patients taking MAOIs are instructed to avoid tyramine-containing foods because of
the danger of a hypertensive crisis. A baseline normal blood pressure (BP) must be
recorded, and the BP must be monitored during treatment.
− MAOIs can also cause orthostatic hypotension as a direct drug adverse effect
Monoamine Oxidase
unrelated to diet.
Inhibitors (MAOIs)
− Other than their potential for elevating BP when taken with certain foods,
MAOIs are relatively free of other adverse effects.

A test used both in a research setting and in current clinical practice involves
correlating the therapeutic response with the degree of platelet MAO inhibition.

CBC: Carbamazepine can cause aplastic anemia, agranulocytosis, thrombocytopenia,
and leukopenia.
− A pretreatment CBC, including a platelet count should be done.
− These tests should be repeated weekly during the first 3 months of treatment and
monthly thereafter.
− The medication should be discontinued if the patient shows any signs of bone
marrow suppression as measured with periodic CBC.

Because of the minor risk of hepatotoxicity, LFTs should be done every 3 to 6 months.
Carbamazepine

The therapeutic level of carbamazepine may be measured.
1. Complete blood count (CBC)
Platelet count and reticulocyte count
2. Serum electrolytes
3. Electrocardiogram
4. Aspartate aminotransferase (SGOT), alanine aminotransferase (SGPT), lactate
dehydrogenase (LDH) alkaline phosphatase (ALP)
5. Pregnancy test for women of childbearing age

Serum levels should be determined periodically.
Valproate
LFTs should be run every 6 to 12 months.

Pregnancy test for women of childbearing age ME
III. Neuroimaging
Uses of Neuroimaging
Indications for Ordering Neuroimaging in Clinical Practice
Neurological Deficits

In a neurological examination, any change that can be localized to the brain or spinal cord requires
neuroimaging. Neurological examination includes mental status, cranial nerves, motor system, coordination,
sensory system, and reflex components.

Consultant psychiatrists should consider a workup including neuroimaging for patients with new-onset
psychosis and acute changes in mental status.
Dementia

Alzheimer's disease, does not have a characteristic appearance on routine neuroimaging but, rather, is
associated with diffuse loss of brain volume.

One treatable cause of dementia that requires neuroimaging for diagnosis is normal pressure hydrocephalus.

Infarction of the cortical or subcortical areas, or stroke, can produce focal neurological deficits, including
cognitive and emotional changes. Strokes are easily seen on MRI scans.
− Depression is common among stroke patients, either because of direct damage to the emotional
centers of the brain or because of the patient's reaction to the disability. Depression, in turn, can
cause pseudodementia.

Vascular dementia: In addition to major strokes, extensive atherosclerosis in brain capillaries can cause
countless tiny infarctions of brain tissue; dementia may follow this phenomenon as fewer and fewer neural
pathways participate in cognition. This state is characterized on MRI by patches of increased signal in the white
matter.

Certain degenerative disorders of basal ganglia structures, associated with dementia, may have a characteristic
appearance on MRI. Huntington's disease typically produces atrophy of the caudate nucleus; thalamic
degeneration can interrupt the neural links to the cortex.

Space-occupying lesions can cause dementia.

Chronic subdural hematomas and cerebral contusions, caused by head trauma, can produce focal
neurological deficits or may only produce dementia.

Brain tumors can affect cognition in several ways.

Chronic infections, including neurosyphilis, cryptococcosis, tuberculosis, and Lyme disease, can cause
symptoms of dementia and may produce a characteristic enhancement of the meninges, especially at the base
of the brain.

HIV infection can cause dementia directly, in which case is seen a diffuse loss of brain volume, or it can
allow proliferation of the Creutzfeldt-Jakob virus to yield progressive multifocal leukoencephalopathy,
which affects white matter tracts and appears as increased white matter signal on MRI scans.

Chronic demyelinating diseases, such as multiple sclerosis, can affect cognition because of white matter
disruption (MS appears as plaques).
Any evaluation of dementia should consider medication effects, metabolic derangements, infections, and
nutritional causes that may not produce abnormalities on neuroimaging.

Specific Techniques
Computed Tomography (CT) Scans
Magnetic Resonance Imaging (MRI) Scans
Functional Magnetic Resonance Imaging (fMRI)
Magnetic Resonance Spectroscopy (MRS)
Single Photon Emission Computed Tomography (SPECT) Scanning
Positron Emission Tomography (PET) Scanning
Schizo • Conduct laboratory tests: including a complete blood count (CBC); measurements of
blood electrolytes and glucose; tests of liver, renal, and thyroid function; a syphilis test;
and, when indicated, a urine or serum toxicology screen, hepatitis C test, and
determination of HIV status.
• Consider use of a computed tomography (CT) or magnetic resonance imaging (MRI) scan
(MRI is preferred) for patients with a new onset of psychosis or with an atypical clinical
presentation, because findings (e.g., ventricular enlargement, diminished cortical volume)
may enhance confidence in the diagnosis and provide information relevant to treatment
planning and prognosis
• and measure fasting blood glucose.
• Obtain lipid panel.
• Obtain ECG and serum potassium measurement before treatment with thioridazine,
mesoridazine, or pimozide; obtain ECG before treatment with ziprasidone in the presence
of cardiac risk factors.
• Conduct ocular examination, including slit-lamp examination, when beginning
antipsychotics associated with increased risk of cataracts.
• Screen for changes in vision.
 Consider a pregnancy test for women with childbearing potential.
Lab and  Lab investigations
− Including: Antineuronal antibodies - Anticardiolipin antibodies - Erythrocyte
imaging In OCD
(From Ain Shams
Sedimentation Rate (ESR) - Antinuclear antibodies - Antistreptococcal DNase-B
seminar) assay - best test of previous streptococcal infection.
 Neuro-imaging for structural lesions
Intellectual Chromosome Studies
Urine and Blood Analysis
disability A. Assays of the appropriate enzyme or organic or amino acids for:
Lesch-Nyhan syndrome, galactosemia, PKU, Hurler’s syndrome, and Hunter’s syndrome
B. Enzymatic abnormalities in chromosomal disorders, particularly Down syndrome, promise to
become useful diagnostic tools.
Electroencephalography
− Electroencephalography is indicated whenever a seizure disorder is considered.
− “Nonspecific” EEG changes are found among populations with intellectual disability.
Neuroimaging
− Neuroimaging is indicated, if accompanying findings: seizures, microcephaly or
macrocephaly, loss of previously acquired skills, or neurologic signs such as dystonia,
spasticity, or altered reflexes.
− Neuroimaging studies are used to gather data that may eventually uncover biological
mechanisms contributing to intellectual disability. MRI is also useful to elucidate
myelination patterns. MRI studies can also provide a baseline for comparison of a later,
potentially degenerative process in the brain.
Hearing and Speech Evaluations
Geriatric − Careful history and physical …… Screening instruments
depression − Labs (CBC, urinalysis, thyroid screen, chemistry, electrocardiogram, B12)
* CMP (lipids,lytes, BUN, creat, Ca++, glucose)
* CBC
* Serum levels of anticonvulsant drugs, TCAs, digoxin, theophylline
* Thyroid function (T3, T4, TSH)
* ECG
* Folate level
* UA
* Vitamin B6&12
− Imaging (vascular depression)
 Prognosis
Good prognostic factors Bad prognostic factors
Married Single, divorced, or widowed
Social Good support systems Poor support systems
Stressful situations
Good premorbid family, social, sexual, and Poor premorbid family, social, sexual, and
Premorbid occupational functioning occupational functioning
Solid friendships during adolescence
Men are more likely than women to experience
Sex a chronically impaired course in schizophrenia,
MDD, and BD
Age of onset An advanced (late) age of onset An early age of onset (childhood onset in OCD)
Mild symptoms Severe symptoms
Previous remission in schizophrenia (short dur. in OCD) No remissions in 3 years or many relapses in schiz
Course of Severe, long and multiple episodes in mood
Mild, short and few episodes in mood
illness Continous nature of the symptoms in OCD ME
Episodic nature of the symptoms in OCD
Short hospital stay, few times of hospitalization Long hospital stay, multiple hospitalizations
No history of assaultiveness History of assaultiveness
Absent or few suicidal thoughts High risk of suicide
Cognitive impairment
In schizophrenia In schizophrenia
- Mood disorder symptoms (esp. depressive) - Withdrawn, autistic behavior
- Positive symptoms - Negative symptoms
- Neurological signs and symptoms
In MDD In MDD
- Absence of psychotic symptoms - Psychotic symptoms
Symptoms
In BD
- Psychotic features, depressive features,
interepisode depressive features
In OCD
- Delusional beliefs
- The presence of overvalued ideas (i.e.,
acceptance of obsessions & compulsions)
- Yielding to (rather than resisting) compulsions
- Bizarre compulsions – Soft neuro signs
Comorbidity for any disease
- Another mental disorder
- Abuse of alcohol and other substances
Absence or few comorbid disorders - Personality disorder
- another psychiatric disorder Comorbidity in MDD:
Comorbidity
- personality disorder - Dysthymic disorder
- medical disorder - Anxiety disorder symptoms
Comorbidity in OCD
- MDD
- Personality disorder ( esp. schizotypal)
In schizophrenia and OCD: In schizophrenia and OCD:
Stressor - Presence of a obvious precipitating factors or events - No precipitating factors
with onset
Acute onset (in schiz) Insidious onset (in schiz)
FH In schiz: Family history of mood disorders In schiz: Family history of schizophrenia
Perinatal History of perinatal trauma (in schiz)
[

Treatment plan
• According to the most probable diagnosis
• Treatment plan must be implemented in the context of therapeutic …… and with the patient and
therapeutic environment

I. Ultimate goal: achievement of adaptation, integration, reconstruction of object relationship

II. Intermediate goals:
a) Diagnosis clarification
b) Protection of the patient (safety)
c) Symptom reduction (mood, psychosis, …)
d) Dealing with psychosocial problems

• To achieve the intermediate goals:

− The patient is candidate for hospitalization because:
 …………………….
 ……………………. (i.e. indications for hospitalization in case)
− Also the patient is candidate for ECT or not (i.e. indications for ECT in case)
− Drug therapy
 Type
 Dose
 Timing
 Duration // For how long
− Other therapies
− Psychotherapy (start psychotherapy)
− Maintenance therapy: For how long
− What measures for follow up

− Don't forget management of patient personality

− Implementation of treatment plan

For goals 1,2,3: Short term treatment
Long term treatment
− Monitor …. response and side effects
− ECT
Stabilization of case

(HWP)

TTT Any
Select medication depending on the following factors:
• Prior degree of symptom response
• Past experience of side effects
• Side effect profile of prospective medications
• Patient’s preferences for a particular medication, including route of administration
• Available formulations of medications (e.g., tablet, rapidly dissolving tablet, oral concentrate, short- and long-acting injection)

Family
Vocational Therapy
 Developmental millstones

Age Gross motor Fine motor Language social

2 Ms Lift chest of table Follow object past Responsive smile Recognize parent
midline
4Ms Rolls over Move arms to grape Orients to voice Enjoy looking around
6Ms Sit unsupported Grape with either Babbles Recognize strangers
hand
9Ms Crawl, pulls to stand Gasp, hold bottle Dada, mama Explore
12Ms Walks alone Throw object uses two words Imitate comes when
beside dada, called
mama
18Ms Runs feeds self with spoon Knows body parts Copies tasks, plays
with other
24Ms Walks stairs alone Remove clothes, ..... Use two word Parallel play
sentence
3Yrs Pedals tricycle Draw a circle, …. Use three word Group play, share
sentence toys
4Yrs Hops and skips Catch ball, … Know color , ask
question
6Yrs Jump over low barrier Ties shoes Ask word meaning Competitive play

* Primitive reflexes:
 Childhood trauma and psychopathological implication
A) situation that can be traumatic: B) Psychological implication: * Management of child trauma:
1) Child abuse: 1) In child: 1) Muldiscipline system.
- Physical, a) Trauma related disorders:
- Sexual. - Acute stress disorder. 2) Deal with child:
- Emotional. - PTSD - Psychotherapy.
- Neglect. - Dissociative disorder. - Play therapy.
- Munchausen’s by proxy. - …………………….
b) Elimination disorder: - Behavioral ….
2) Chronic chaoc environment: Encopresis - verbalize……
- Unstable home. Enuresis
- Authoritarian parental style. 3) Deal with parents (family
c) Eating disorders: treatment).
3) Experience or witness trauma - Pica
that threaten or physical body - Rumination 4) Deal with problem and
integrity. - Failure to thrive anxiety.
- Anorexia nervosa
4) Pathogenic care: - Sensory aversion
- Unfulfilled physical need.
- Unfulfilled emotional need. d) Psychological dwarfism
- Frequent change of primary care e) Reactive attachment
givers as faster care. disorder
f) Separation anxiety disorder.

2) In adult:
- Sexual dysfunction.
- Personality disorder.
- PTSD/anxiety.
- Dissociative disorder.
- Depression.