Psychiatric History

and
Mental Status Examination

Christine Joyce A. Villero, MD

Medical Officer IV

Department of Psychiatry
Psychiatric History

Identifying Data - includes patients name,

age, sex, marital status, race and occupation.

Source and Reliability - source of information

and reliability.
Chief Complaint

Should be written in the patients own words

stating why he/she has come or been brought
for help.

It should be written verbatim.

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 and events.

Evolution of the patient's symptoms; how

illness affects a patients life.
Previous Illnesses

Past episodes of both psychiatric and medical

illnesses.

Obtain information about all psychiatric

illness and their course over the patient's
lifetime including symptoms and treatment.

Causes, complications , treatments, the effect

of the illness on the patient's life.
Family History

A careful review of family history is an

essential part of the psychiatric history.

Medical illnesses present in the family.

Family's attitude toward, and insight into the

patient's illness.

Relationship of the patient to family members.

Personal History (Anamnesis)

Patient's past life and it's relationship to the

present emotional problem.

The predominant emotions associated with

the different life periods should be noted.

Usually divided into perinatal, early

childhood, late childhood, and adulthood.
Perinatal History

Ask whether pregnancy was planned or not.

Problems with the mother's pregnancy or

delivery.

Maternal health problems during pregnancy.

Early Childhood (birth to age 3)

Infant-mother relationship

Problems with feeding and sleeping

Significant milestones

Unusual behaviors

Other caregivers
Middle Childhood (3-11 years)

Preschool and school experiences

Separation from caregivers

Friendship/play

Methods of discipline
Late Childhood

During late childhood, persons begin to

develop independence from their parents
through relationship with peers and group
activities.
Adulthood

Occupational History

Marital and relationship history

Military history

Education history

Social activity

Current living situation

Legal history
Mental Status Examination

Describes the sum total of the examiners

observations and impressions of the
psychiatric patient at the time of interview.

MSE can change from time to time.

It is the description of the patient's

appearance, speech, actions and thoughts
during the interview.
Appearance and Behavior

Posture, poise, clothing; Grooming and

hygiene; distinguishing features;

Behavior and psychomotor activity; Attitude

toward the examiner (cooperative, friendly,
attentive, seductive, defensive, hostile,
guarded)
Speech

Physical character of speech

Quantity, rate of production, quality

Speech can be rapid or slow, pressured,

hesitant, dramatic, monotonous, loud and
whispered.

Impairments of speech: stuttering.

Mood and Affect

Mood is defined as the patient's internal and sustained

emotion that colors the patient's perception of the
world. (Irritable, anxious, angry, depressed, angry,
expansive, euphoric, empty , guilty, hopeless.

Affect is the expression of mood. It is the patient's

present emotional responsiveness. Can be described as
within normal range, restricted, labile, blunted or flat.

Appropriateness of the patient's response to the context

of the subject matter the patient is discussing.
Perceptual Disturbances

Hallucinations

Illusions

Depersonalization,

Derealization
Thought Disturbances

Thought Process (Form of thinking): How

thoughts are formulated, organized or
expressed.

Flight of ideas, circumstantiality,

tangentiality, loose associations,
perseveration, thought blocking, neologism,
word salad.
Thought Disturbances

Thought Content: thoughts occurring in the

patient.

Delusions; obsessions, compulsions,

suicidality or homicidality.

Common delusion: grandiose, jealous,

erotomanic, somatic or persecutory.
Sensorium and Cognition

Alertness and level of consciousness

Orientation

Concentration

Memory (immediate, recent, long term)

Calculations

Fund of knowledge

Abstract Reasoning
Judgement and Insight

Judgement: Person's capacity to make good

decisions and act on them.

Insight: Patients degree of awareness and

understanding that they are ill.
Levels of Insight
Complete denial of illness

Slight awareness of being sick and 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.