Psychiatric History

and
Mental Status
Examination
LINUS PULE (5TH YR- CBU)
 What is a psychiatric History?
 The psychiatric history is the record of the patient’s life.
 it allows the psychiatrist to;
1. understand who the patient is
2. where the patient has come from, and
3. where the patient is likely to go in the future.
A thorough psychiatric history is essential to making a correct
diagnosis and formulating a specific and effective treatment plan.
 What is mental status examination?
 The mental status examination (MSE) is a description of the
patient’s appearance, speech, actions, and thoughts during the
interview. It is a systematic format for recording findings about
thinking, feeling, and behavior. A patient’s history remains stable,
whereas the mental status can change daily or hourly.
Psychiatric History

 Demographic Data
 Chief Complaint
 History of Present Illness
 Previous illness
 Personal History (Anamnesis)
Demographic 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
Past psychiatric and medical history

 Emotional or mental disturbances—extent of incapacity, type

of treatment, names of hospitals, length of illness, effect of
treatment.
 Medical conditions—customary review of systems, sexually
transmitted diseases, alcohol or other substance abuse,
acquired immune deficiency syndrome (AIDS).
 Neurologic disorders—headache, craniocerebral trauma, loss
of consciousness, seizures, or tumors.
Family history

 Elicited from patient and from someone else, because quite different
descriptions may be given of the same people and events.
 Ethnic, national, and religious traditions.
 List other people in the home and descriptions of them—personality
and intelligence—and their relationship to the patient
 Role of illness in the family and family history of mental illness.
 Where does the patient live—neighborhood and particular residence of
the patient; is the home crowded; privacy of family members from each
other and from other families.
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. Pre-natal and perinatal history
2. Early childhood (0-3 yo)
3. Middle childhood (3-11 yo)
4. Late childhood (puberty-adolescence)
5. Adulthood
6. Psychosexual history
7. Family history
8. 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. General Description
2. Mood and Affect
3. Speech
4. Perceptual Disturbances
5. Sensorium and Cognition
6. Judgment and Insight
General Description

 Appearance: posture, poise, clothing

grooming
 Body type, hair, nails
 Healthy, sickly, ill at ease, poised, old
looking, young-looking, childlike
 Behavior and psychomotor activity:
 Quantitative and qualitative aspects
of the patient’s motor behavior
 Mannerisms, gestures,twitches,
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 or angry,
 AFFECT: patient’s present emotional
responsiveness
Normal range, constricted,
blunted, flat
Speech

 Physical character of speech

 Quantity, rate of production, quality
 Talkative, garrulous, unspontaneous
 Rapid, slow, pressured, hesitant, dramatic,
monotonous, loud, whispered
Perceptual Disturbances

 Hallucinations and illusions: whether the

patient hears voices or sees visions; content,
sensory system involvement, circumstances of
the occurrence.
 Depersonalization and derealization:
extreme feelings of detachment from self or
from the environment.
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
Judgment and Insight

 JUDGMENT: patient’s capability for social

judgment

 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
THANK YOU