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• The psychiatric evaluation of a patient may involve a variety of procedure, including a physical and neurological examination. By far, the most frequently used procedure is what is called the mental status examination (MSE). This chapter focuses on the MSE and the means of conducting the examination, the psychiatric interview.
PURPOSES OF THE INTERVIEW
• The psychiatric history attempts to answer the question, “How did this person happen to become the way he is now?” and thus gives a longitudinal view of the patient. The psychiatric history encompasses chief complaints and history of the present illness, as well as a personal and family history and other features included in the general medical history. It should focus on relationships between occurrence of symptoms and life events and feelings.
• The interview is a basic tool of the physician. It is a systematic attempt to gain knowledge of the patient and the nature of the illness. It is through the interview that a history of the patient’s present illness and past life is elicited, and the same principles apply in the interview of patients, whether they are seen in a psychiatric or medical setting. It is also through the interview that a mental examination, an essential part of the physical examination is performed.
– Psychological stressors (or precipitating events) – Predisposing factors – Area of conflict about instinctual drives – Defense mechanisms used
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OUTLINE FOR PSYCHIATRIC HISTORY PATIENT IDENTIFICATION
Name, age, sex, marital status, cultural background, occupation Source of referral History of hospitalizations Estimated reliability of information
CHIEF COMPLAINT/PRESENTING COMPLAINT
PRESENT ILLNESS This is chronological story of the difficulties which prompted the patient to see the psychiatrist (or the difficulties which prompted other to refer him to a psychiatrist). The report of the present illness should contain precise descriptions of symptoms of the first occurrence of symptoms. Attention should be given to possible relationships between symptoms and life events, especially feelings, fantasies, and thoughts associated with these life events.
PERSONAL HISTORY A longitudinal view of the patient’s personality development and origin of his psychopathology.
– Economic and social status of parents, personality of parents, quality of patient’s relationship with parents, compatibility of parents. – Personality of siblings, relationship of patient to siblings, birth order of patient. – Remarkable family history, medical history, particularly family history of psychiatric illness, suicide, eccentric relatives.
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INFANCY AND EARLY CHILDHOOD The patient can report only what he has been told. Sometimes an interview with the patient’s parents is indicated. CHILDHOOD School; Special likes and dislikes in school subjects; relationships with peers, teachers; sports and extracurricular activities, interference with schooling by illness, accidents trouble at home. Childhood personality: Passivity/aggressiveness, independence/dependence, rebelliousness/conformity, attitudes toward responsibility, competition, frustration, pleasure, reactions to family events such as births, deaths, illness, separations, etc.
– – – – – – – School, special relationships with teachers, issues of achievement, sports. Religious upbringing. Relationship to family, examples of rebelliousness. Special interests. Health and physical development, reactions to onset of puberty. Personality; changes in disposition and temperament. Psychosexual development: attitudes toward peers of same and opposite sexes, how information about sexuality was acquired; interest in sex literature, homosexual information, interests experiences, heterosexual contact (dating, intercourse, parties, dancing).
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ADULT ADJUSTMENT PRIOR TO ILLNESS a. Education:chronologic educational events b. Occupation:employment history & ambitions, gains. c. Psychosexual:marital history of current status, sexual adjustment; parenting history & attitudes toward child bearing relationship with children prior to onset of present illness. d. Family:nature of relationship to family of origin. e. Military record:date of service, type of discharge, combat experiences, hospitalizations, rank in service. f. Social adjustment: organizations, community activities, friends, political activities, antisocial activities, criminal record. g. Habits:smoking and a careful history of drug and alcohol abuse. h. Interests:hobbies, sports, recreation, etc.
FURTHER EXAMINATION OF PREMORBID PERSONALITY AND ONSET OF PRESENT ILLNESS