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 patient’s 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 relative’s
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 patient’s life.
 Onset, precipitating factors/events,
personality type
 Evolution of the patient’s symptoms, how
illness affects patient’s life, nature of
dysfunction
Previous Illness
 Past episodes of both psychiatric and
medical illnesses
 Causes, complications, treatment, the
effects of the illness on the patient’s life
 Alcohol and other substance abuse; quantity
and frequency
Personal History
 Patient’s past life and its relationship to the
present emotional problem
 The predominant emotions associated with
the different life periods should be noted
1.
2.
3.
4.
5.
6.
7.
8.
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 examiner’s
observations and impressions of the
psychiatric patient at the time of interview
1.
2.
3.
4.
5.
6.
7.
8.
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
patient’s 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 patient’s perception of the
world
– Depressed, despairing, irritable, anxious,
angry, expansive, euphoric
– Maybe labile
 AFFECT: patient’s present emotional
responsiveness
– Normal range, constricted, blunted, flat
 Appropriateness of the patient’s 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 patient’s
awareness of socially appropriate behavior
 A measure of the patient’s potential danger
to self and others
Judgment and Insight
 JUDGMENT: patient’s capability for social
judgment
– Imaginary situations
 INSIGHT: patient’s 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 psychiatrist’s impression of
the patient’s truthfulness or veracity