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.
