DIAGNOSIS AND PSYCHIATRY:

EXAMINATION AND DIAGNOSIS OF

THE PSYCHIATRIC PATIENT

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 Learning Objectives
After completing this lesson the students will be able to:

1. Describe the general characteristics of psychiatry

interview
2. Conduct psychiatric interview for psychiatric patient

3. Perform Mental State Examination for psychiatric patient

4. Plan diagnosis and differential Diagnosis

5. Plan the general management

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 General Characteristics

Detailed Hx.

Thorough MSE

 The single most important method of

arriving to Dx.in psychiatry is a very good
psychiatric interview.

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 Developing good rapport with patients is key to

effective interviewing and thorough data gathering.

 Both the content (what the patient says and does not

say) and the manner in which it is expressed (body

language, topic shifting) are important

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 Usually takes about 45 minutes to 1 hours

For complex/uncooperative patients, it can take even

longer
For severely ill patients, information will needed to be

gathered from others (relatives/ friends)

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 A major purpose of the initial psychiatric interview

is
 To obtain information that will establish a criteria-
based diagnosis
 Helpful in the prediction of the course of the illness
 The prognosis of the patient
 Leads to treatment decisions.

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 Psychiatric History
The psychiatric history is the record of the patient's

life;
It allows a psychiatrist/M.professionals to understand

who the patient is,

where the patient has come from, and

where the patient is likely to go in the future.

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 Includes information about the patient obtained from

other sources
Parent

Spouse

Colleagues

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Components of History Taking
1. Identification data 7. Personal history
2. Chief complaints
8. Sexual history
3. History of presenting illness
9. Forensic history
4. Past psychiatric history
10. Premorbid personality
5. Past medical history

6. Family history

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1.Identifying Data
The identifying data provide a brief/ concise

demographic summary of the patient by

- name, age, marital status, sex, occupation, language
-ethnic background, and religion, and the patient's
current living circumstances.

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The information can also include

-the source(s) of the information,

-the reliability of the source(s), and
-whether the current disorder is the first episode for the
patient.
The psychiatrist should indicate whether the patient came in

-on his or her own,

-was referred by someone else, or
-was brought in by someone else.
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The identifying data are meant to provide

important patient characteristics

 that may affect diagnosis, prognosis,
treatment, and compliance

E.g. Ato Asmelash is a 25-year-old single,Amhara, Protestant male

who works as a department store clerk. He is a college graduate living
with his parents from Kolfe subcity. He was referred by his internist for
psychiatric evaluation.

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 2.Chief Complaint
States why he or she has come or been brought in for help

It should be recorded even if the patient is unable to speak,

and
-the patient's explanation, regardless of how bizarre or
irrelevant it is,
Examples:
If the patient“Iisam
comatose
havingorthoughts
mute thatof
should be noted
wanting in
to harm
myself”
the chief complaint as such.
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“People are trying to drive me insane” 13
3.History of Present Illness
 Provides a comprehensive and chronological picture of the events

 The last time the patient was well (helps to establish the whole

course of the illness)

 Mode of onset

 Chronological description of how symptoms in the current

episode have unfolded over time

 Initial and subsequent new symptoms must be elaborated

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Determine the nature of symptoms

How the symptoms have progressed

Pay attention should be paid to pertinent negatives as well as

pertinent positives.
Example:
 A patient complaining of depression,
 The absence of vegetative symptoms is significant and should
be mentioned
 Whether the patient has been in treatment,
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 The characteristics of symptoms should be described in

detail;
Small distinctions may be diagnostically useful

E.g., Stating that a patient suffers from insomnia is less

useful than describing the insomnia.
 Difficulty in falling asleep
 Difficulty in maintaining sleep
 A decreased need for sleep are each associated with different
disorders.
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 Whether the patient has been taking any psychotropic

medication
Whether he/she has (or has not) been compliant are

essential elements of the history of the present illness

If a patient has stopped taking a prescribed medication

the reasons should be determined

Noncompliance is a symptom that needs to be

investigated and not simply dismissed as poor judgment

or character weakness
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 Noncompliance has many possible causes:

1. Unpleasant adverse effects,

2. Failure to understand the necessity for chronic medication

despite symptomatic improvement,

3. Insufficiently treated symptoms such as the fear of being

poisoned by medication,

4. A reluctance to see oneself as psychiatrically impaired, or

5. Simply lacking the transportation and money to get a

prescription refilled.
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 Whether help is sought and if yes where and when and for

how long he or she has been there

The impact of the current patient’s psychiatric illness on

 Occupational area
 Interpersonal relationships
 The self
 caregivers
The immediate or remote precipitating factors
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Any current alcohol or other substance use should be
described, including
 Amounts,

 Frequency, and
 Last use
It is also useful to ask why the person came for

treatment at this time, and

 what the patient believes to be causing the present

symptoms
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Substance use history
 Type,

 Amount,

 Frequency,

 Duration,

 The time spent in searching and using the substance,

giving priority to substance or alcohol use
 Pattern of substance use compared to premorbid
substance
 Impact of use psychoactive substances on the patient’s
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 Suicide

 Death wish,
 Suicidal ideation
 Degree of suicide intent,
 Contemplated methods of carrying out suicidal acts,
 Suicide plan,
 Plans and attempt during previous episodes,
impulsive suicide attempt, other self injurious acts)
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  Passive suicidal behavior
 Suicidal ideation
 Suicidal ideation is commonly expressed indirectly

Death wish or believing that life is not worth living

a wish not to wake up or to die from a malignant

disease
Some depressed persons are tormented with suicidal

obsessions and are constantly resisting unwanted

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 careless driving

walking into high-speed traffic

Suicide intent
1. Passive (at the level of suicidal ideation)
2. Strong
 Contemplating
 Determining a means
 Preparing presumed lethal substances including guns,
pistols, chemicals, ropes etc.
 Writing a suicide later, arranging for children’s life
Homicide history related to current illness or to the past
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 SAD PERSONS SCALE
Sex Rational thinking loss

Age Social supports lacking

Depressive disorder Organized plan

Previous suicidal No spouse

attempt Sickness
Ethanol abuse

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 Interpretation
 > 7-10 Hospitalize (forced)

 5-6 strongly consider Hospitalization

 3-4 close follow up, consider Hospitalization

 0-2 consider sending him home with family

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 Summarized information of HPI

 The time of onset

 Mode of onset

 Development overtime

 Precipitating or relieving factors

 Help given

 Impact of the problem

 Negative and positive statement :

- Suicidal ideation, attempt, High mood, Low mood,

-symptoms of anxiety, History of substance abuse,

05/05/2025 -History of hallucination ,History of delusion 27

4. Past Psychiatric History
 Description previous episodes ( patient's symptoms )-Dx, Rx and

response
 Previous admission, names of hospitals and length of each illness,

 Extent of incapacity (status of functionality) and Inter-episodic

Functioning
 Previous medications: dose, duration, efficacy and side effects

 Effects of previous treatments (time patient felt completely well?)

 Degree of compliance /chronologically.

 Past suicidal/homicidal history, Substance history

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Substance Use, Abuse, and Addictions hx
 A careful review of substance use, abuse, and addictions is essential to

the psychiatric interview.

 a nonjudgmental style will elicit more accurate information.

specific questions for reluctant pts

 (e.g., “Have you ever used marijuana?” or “Do you typically

drink alcohol every day?”).

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Substance Use, Abuse, and Addictions…
 History of use should include which substances have been used, including
 Alcohol
 drugs
 medications (prescribed or not prescribed to the patient), and
 routes of use (oral, snorting, or intravenous).

 The frequency and amount /dose of use should be determined

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Substance

Use, Abuse, and Addictions…
Impact of use on
 social interactions
 work
 school
 legal consequences
 and driving while intoxicated (DWI) should be covered

 Some psychiatrists use a brief standardized questionnaire, the CAGE or

RAPS4, to identify alcohol abuse or dependence.

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Substance Use, Abuse, and Addictions…
 CAGE includes four questions:
 C- Have you ever Cut down on your drinking?

 A- Have people Annoyed you by criticizing your drinking?

 G- Have you ever felt bad or Guilty about your drinking?

 E- Have you ever had a drink the first thing in the morning, as an Eye-

opener, to steady your nerves or get rid of a hangover?

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Substance Use, Abuse, and Addictions…
 The Rapid Alcohol Problem Screen 4 (RAPS4) also consists of four

questions:
 Have you ever felt guilty after drinking (Remorse)?

 Could not remember things said or did after drinking (Amnesia)?

 Failed to do what was normally expected after drinking (Perform) ? or

 Had a morning drink (Starter)?

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 Substance Use, Abuse, and Addictions…
 The patient’s readiness for change should be determined by identifying whether they are

in the
 Precontemplative phase

 Contemplative phase , or

 Action phase.

 Referral to the appropriate treatment setting should be considered

 important substances and addictions that should be covered

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Substance Use, Abuse, and Addictions…
 Tobacco and caffeine use, gambling, eating behaviors, and Internet use.

 Gambling history should include casino visits, horse racing, lottery and

scratch cards, and sports betting.

 Addictive type eating may include binge eating disorder.

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5. Past medical history
 Obtain a medical review of symptoms
Major medical or surgical illnesses and
Major traumas particularly those requiring
hospitalization.
Medications (in the past/taken
regularly/allergic hx?)
Episodes of craniocerebral trauma,
neurological illness & tumors

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5. Past medical history …
Assessing past medical hx is important b/c
 Medical illnesses can precipitate a psychiatric disorder (e.g., anxiety

disorder in an individual recently diagnosed with cancer),

 Medical illness mimic a psychiatric disorder (hyperthyroidism
resembling an anxiety disorder),
 Medical illness can be precipitated by a psychiatric disorder or its treatment

(metabolic syndrome in a patient on a second-generation antipsychotic

medication), or influence the choice of treatment of a psychiatric disorder (renal
disorder and the use of lithium carbonate).
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Past medical history…
presence of a seizure disorder

History of testing positive for HIV

Episodes of loss of consciousness

Changes in usual headache patterns

Changes in vision, and

Episodes of confusion and disorientation

History of infection with syphilis

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6. Family history
Hx of psychiatric illness, hospitalization & treatment

of the patient's immediate family members.

Family history of suicide, antisocial or aggressive

behavior
Family history of alcohol and other substance abuse

Who is available to support the patient

Who is exacerbating symptoms

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Family history …
Family's attitude toward, and insight into, the
patient's illness (supportive, indifferent, or
destructive?)
Patient's attitude toward each of his parents and

siblings
Family income & difficulties in obtaining it

Impact of illness on the family

Family history of seizure disorder

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 7.Personal History
The mental professional needs a thorough understanding of

the patient's past and its relation to the present emotional

problem.
The anamnesis, or personal history, is usually divided into

perinatal, early childhood, late childhood, and adulthood

The predominant emotions associated with the different life

periods (e.g., painful, stressful, conflictual) should be noted.

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Personal History …
1. Perinatal Hx
 Was pregnancy planned and wanted

 Full-term pregnancy or premature

 Vaginal delivery or caesarian

 Mother's emotional and physical state at the time of the pt's

birth?
 Maternal health problems during pregnancy?

 Drugs taken during pregnancy (prescription and recreational)

 Birth complications

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Personal History …

2. Infancy and early childhood (0-3yrs)

 Infant-mother relationship

 Problems with feeding and sleep

 Unusual behaviours (e.g., head-banging, rocking)

 Was the child shy, restless, overactive, withdrawn, out going,

friendly?
 Significant milestones

 Standing/walking
 First words/two-word sentences
 Bowel and bladder control
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Personal History …

3. Middle childhood (3-11yrs)

 Preschool and school experiences

 Tolerance to separation from caregivers

 Number & closeness of the patient's friends/play

 Methods of discipline & punishments

 Major Illness, surgery, or trauma

 Temperament, aggression, phobias, bed-wetting, etc.

 Learning disabilities

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Personal History …

4. Late childhood (puberty through adolescence) (15-17yrs)

 Onset of puberty & Academic achievement (r/ship with teachers )

 Organized activities (sports, clubs)

 Areas of special interest

 Romantic involvements and sexual experience

 Work experience

 Experimentation with drugs (alcohol, illicit drugs…)

 Symptoms (moodiness, irregularity of sleeping/eating,

fights/arguments)
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Personal History …
5. Young adulthood (18 to 22 or 18 to 25 yrs)
 Meaningful long-term relationships

 Academic and career decisions

 Military History, behaviour problems, premature discharge,

etc
 Work history (Summary of the jobs held, the length of time in

each, and the reasons for leaving)

 Interference of psychiatric illness with the capacity for
sustained productive work.
 Intellectual pursuits and leisure activities
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Personal History …
6. Middle adulthood and old ag (45
up to 65 yrs)
Changing family constellation

Social activities

Work and career changes

Major losses

Retirement and aging

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Forensic History:
Legal difficulties, imprisonment/prison history

List of offences/charges & legal outcomes

History of being in trouble with the police?

Ever been arrested and for what? How many

times?
Hx of assault/violent/sexual crimes and
persistent offending, weapons?
Attitude toward the arrests or prison terms?
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Sexual History
Developmental
 Onset of puberty/menarche

 Development of sexual identity and orientation

 First sexual experiences

 Attitudes toward sex (shy, timid, aggressive?)

 Have you noticed any changes or problems with sex

recently?
 patient needs to impress others and boast of sexual

conquests?
 patient experience anxiety in the sexual setting?

 Was there promiscuity? 49

Sexual dysfunctions
Desire phase

Excitement phase

Organic phase

Resolution phase

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 Desire phase

Presence of sexual thoughts or fantasies

When do they occur and what is their object?
Who initiates sex and how?
 Excitement phase

Difficulty in sexual arousal (achieving or

maintaining erections, lubrication), during
foreplay and preceding orgasm 51
Orgasm phase

 Does orgasm occur?

 Does it occur too soon or too late?

 How often and under what circumstances does orgasm occur?

If orgasm does not occur, is it because of not being excited or lack of

orgasm despite being aroused?

Resolution phase
What happens after sex is over (e.g., contentment, frustration,
continued arousal)?

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Premorbid personality (traits)
• What is personality?
• personality refers to individual differences in characteristic
pattern of thinking ,feeling and behaving
 An enduring pattern of inner experience and behavior that manifests in

two or more of the following:

– cognition (i.e., ways of perceiving and interpreting self and others);

– Affectivity (i.e., range, intensity, lability)

– Interpersonal functioning; Impulse control

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Premorbid personality (traits)…
 How was patients personality before he got
sick?
How would you describe yourself?
How would other people describe you?
When you find yourself in difficult situations,
what do you do to cope?
What sort of things do you like to do to relax?
Do you have any hobbies? (Fantasies &
dreams, Values)
Do you like to be around other people or do
you prefer your own company?
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THANK YOU

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