Psychiatric History

and
Mental Status Examination

Psychiatric History

Identifying Data
Chief Complaint
History of Present Illness
Previous illness
Personal History (Anamnesis)

Identifying Data

Name
Age
Marital Status
Occupation
Ethnic Background
Religion
Current Circumstances of Living
Source of information; Reliability

Chief Complaint
Should be written in the patients own words
stating why he/she has come or been brought
in for help
It should be written in verbatim; no matter how
absurd, illogical, irrelevant or bizarre it is.
The accompanying person or relatives
complaint should also be taken into account.

History of Present Illness

A comprehensive and chronological picture
of the events leading up to the current
moment in the patients life.
Onset, precipitating factors/events,
personality type
Evolution of the patients symptoms, how
illness affects patients life, nature of
dysfunction

Previous Illness
Past episodes of both psychiatric and
medical illnesses
Causes, complications, treatment, the
effects of the illness on the patients life
Alcohol and other substance abuse;
quantity and frequency

Personal History
Patients past life and its relationship to the
present emotional problem
The predominant emotions associated with
the different life periods should be noted

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Pre-natal and perinatal history

Early childhood (0-3 yo)
Middle childhood (3-11 yo)
Late childhood (puberty-adolescence)
Adulthood
Psychosexual history
Family history
Dreams, fantasies and values

Mental Status Examination

Describes the sum total of the examiners
observations and impressions of the
psychiatric patient at the time of interview

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General Description
Mood and Affect
Speech
Perceptual Disturbances
Thought Disturbances
Sensorium and Cognition
Impulse Control
Judgment and Insight

General Description
Appearance: posture, poise, clothing
grooming
Body type, hair, nails
Healthy, sickly, ill at ease, poised, odd
looking, young-looking, disheveled,
childlike, bizarre
Signs of anxiety

 Behavior and psychomotor activity:

Quantitative and qualitative aspects of the
patients motor behavior
Mannerisms, tics, gestures, twitches,
stereotyped behavior, echopraxia,
hyperactivity, agitation, combativeness,
flexibility, rigidity

 Attitude toward examiner:

Cooperative, friendly, attentive, interested,
frank, seductive, defensive, hostile,
playful, evasive, guarded
Level of rapport

Mood and Affect

MOOD: pervasive and sustained emotion
that colors the patients perception of the
world
Depressed, despairing, irritable, anxious,
angry, expansive, euphoric
Maybe labile

 AFFECT: patients present emotional

responsiveness
Normal range, constricted, blunted, flat
Appropriateness of the patients response to
the context of the subject matter the patient
is discussing

Speech
Physical character of speech
Quantity, rate of production, quality
Talkative, garrulous, unspontaneous
Rapid, slow, pressured, hesitant, dramatic,
monotonous, loud, whispered
Impairment of speech: stuttering

Perceptual Disturbances

Hallucinations
Illusions
Depersonalization, derealization
Formication

Thought Disturbances
THOUGHT PROCESS (Form of thinking): a
way in which a person puts together ideas
and associations
Loosening of association, derailment, flight
of ideas, racing thoughts, tangentiality,
circumstantiality, word salad, neologisms,
clang association, blocking,
relevant/irrelevant

 CONTENT OF THOUGHT
Delusions, preoccupations, obsessions,
compulsions, phobias, suicidal or
homicidal ideas
Delusions: fixed false beliefs
Mood in/congruent
Persecutory/paranoid, grandiose, jealous,
somatic, erotic, nihilistic

Sensorium and Cognition

Assesses organic brain functioning,

intelligence, capacity for abstract thought,
level of insight and judgment

1. Alertness and level of consciousness

2. Orientation
3. Memory

4. Concentration and Attention

5. Capacity to Read and Write
6. Visuospatial ability
7. Abstract Thinking
8. Fund of Information and Intelligence

Impulse Control
Critical in ascertaining the patients
awareness of socially appropriate behavior
A measure of the patients potential danger
to self and others

Judgment and Insight

JUDGMENT: patients capability for social
judgment
Imaginary situations
INSIGHT: patients degree of awareness
and understanding that they are ill

Levels of Insight
Complete denial of illness
Slight awareness of being sick & needing help but
denying it at the same time
Awareness of being sick but blaming it on others,
on external factors, or on organic factors.
Awareness that illness is due to something
unknown in the patient
Intellectual insight
True emotional insight

Reliability
Estimate of the psychiatrists impression of
the patients truthfulness or veracity