PSYCHIATRIC

HISTORY TAKINGAND
MENTAL STATUS
EXAMINATION
Dr. Ali Anjum, NCHD to
Dr. Julieanne Dornan
 COMMON PSYCHIATRIC DISORDERS

 Schizophrenia
 Life time risk
 Seven and thirteen per thousand population

 Depressive illness
 Life time rates
 10 - 20%
 Sex ratio: M:F= 1:2

 Bipolar Affective Disorder

 Life time prevalence , 0.3 - 1.5%
 Mean age , 21yrs

 Anxiety Disorders
 Panic disorders, life time prevalence is 4.2%
 Phobias, life time prevalence is 11.3%
 GAD, 3 – 4%
 OCD, 0.5 – 2%

 Adjustment Disorders, 5%
 PTSD, 7.8%
 Eating Disorders

 Substance abuse disorders

Psychiatric history Components
Introduction
Demographics
Presenting Complaints
History of Presenting Illness
Past Psychiatric History
Past Medical History
Family History
Pre Morbid Personality
Personal History
Forensic History
Substance Abuse History
 MENTAL STATUS
Mental status is the total expression of a person’s emotional
responses, mood, cognitive function, and personality

COMPONENTS
 General appearance and behavior
 Speech
 Mood and affect
 Thought
 Perception
 Cognition (higher mental functions)
 Judgment
 Insight
 (A) GENERAL APPEARANCE AND
BEHAVIOUR
1. GENERAL APPEARANCE

 Body build and physical appearance (approx.-mate height,

weight, and appearance)
 Looks comfortable/uncomfortable
 Physical health
 Grooming
 Hygiene
 Self-care
 Dressing (adequate, appropriate)
 Facies (non-verbal expression of mood)
 2. ATTITUDE TOWARDS THE EXAMINER

 Cooperation/guardedness/evasiveness/ hostility
 Attentiveness
 Shows interest/appears disinterested

3. COMPREHENSION

 Intact/impaired (partially/fully)

4. GAIT AND POSTURE

 Normal or abnormal (way of sitting, standing, walking, lying)

 5. MOTOR ACTIVITY

 Increased/decreased

 Excitement/stupor

 Abnormal involuntary movements (AIMs) tics, tremors

 Restlessness/akathisia

 Catatonic signs (mannerisms, stereotypes, posturing, waxy

flexibility, negativism, ambitendency, automatic obedience, echo-

praxia, psychological-pillow)

 conversion and dissociative signs (pseudo seizures, possession

states).

 Social withdrawal, autism.

 6.SOCIAL MANNER

 Increased, decreased, or inappropriate.

7. RAPPORT

 Whether a working empathic relationship can be established

with the patient, should mentioned.

8. HALLUCINATORY BEHAVIOR

 Smiling or crying without reason

 Muttering/ talking to self (non-social speech)
 Odd gesturing in response to auditory or visual hallucinations.
 (B) SPEECH
1. RATE AND QUANTITY OF SPEECH

 Whether speech is present or absent (mutism)

 If present, whether it is spontaneous
 Productivity is increased or decreased
 Rate is rapid or slow
 Pressure of speech or poverty of speech

2. VOLUME AND TONE OF SPEECH

 Increased/decreased.
 3. FLOW AND RHYTHM OF SPEECH

 Smooth/hesitant
 Dysprosody
 Blocking (sudden)
 Circumstantiality
 Tangentially, loosening of associations
 Verbigeration, Perseveration
 stereotypies (verbal)
 Flight of ideas, clang associations
 Loosening of association
 (C) MOOD AND AFFECT
AFFECT

 It is an outward expression of person’s current feeling State

 Mood is sustained Emotional State; Overall General mood In
addition to non-verbal mood observed , the patient is asked
about present ‘mood.’
 This is recorded as subjective affect while the observed
emotional change is described as objective affect.

MOOD

 Mood is described as Relaxed, Happy, Anxious, Angry, –

Depressed, Hopeless, Hopeful, – Apathetic, Euphoric, Euthymic
 AFFECT AND MOOD

 Affect: How do they appear to you?

 Mood: asks the patient directly how he/she feels

EXAMPLES

 Mood is described as general warmth, euphoria, elation,

exaltation and ecstasy in mania
 Anxious and restless in anxiety and depression
 Sad, irritable, angry and despaired in depression
 Shallow, blunted, indifferent, restricted, inappropriate and labile
in schizophrenia.
 Anhedonia may occur in both schizophrenia and depression
 QUESTIONS TO ASK ABOUT MOOD

 How do you generally feel most of the time?

 What's your mood like?
 How would you say you feel generally - happy, sad, frightened,
angry?

DEPRESSED MOOD BLUNT AFFECT

IRRITABLE MOOD
FLAT AFFECT
 (D) THOUGHT
1. STREAM AND FORM OF THOUGHT

 Stream and form of thought’ overlaps with examination of ‘speech.’

 Spontaneity, productivity, flight of ideas, poverty of content of

speech, thought block

 Continuity of thought is assessed.

 Whether the thought processes are relevant to the questions asked.

 Any loosening of associations, tangentiality, circumstantiality,

illogical thinking, perseveration, verbigeration is noted.

 2. CONTENT OF THOUGHT

 Obsessions and contents of phobias; ideas and delusions of

persecution, reference, grandeur, love, jealousy (infidelity), guilt,
nihilism, poverty
 Hypochondriacal symptoms, hopelessness, helplessness,
worthlessness, and suicide should be explored.
 Delusions of control, thought insertion, thought withdrawal, thought
broadcasting, Neologisms
QUESTIONS ABOUT THOUGHT From PATIENT

 Do your thoughts seem faster than normal

 Do you find you have lots and lots of different thoughts?
 Does your mind seem to be slowed down?
 Do you ever have the experience when your thoughts suddenly stop?
 Do you ever feel that your mind is suddenly wiped blank and you have
 QUESTIONS ABOUT DELUSIONS

 Do you ever feel that people are following you?

 Do you ever feel that people are seeking to harm you in some way?
 Do people spy on you?  Has anything strange or unusual been going
on?
 Is there anything special about yourself which makes you different
from other people?
 Is there anything you can do which other people can't?
 Do you think that somebody has put a spell on you? Is a
spirit/djinn/demon causing problems for you?

QUESTIONS ABOUT THOUGHT INSERTION

 Do you ever have thoughts in your mind which are not your own?
 Does anything else use your mind to think with?
 Does anything put thoughts into your mind from outside?
 QUESTIONS ABOUT THOUGHT WITHDRAWAL

 Does anything ever take your thoughts away?

 Do you ever have your mind wiped blank?
 Does anything take thoughts out of your mind so that they're not
there any more?

QUESTIONS ABOUT THOUGHT BROADCAST

 Can other people tell what you are thinking?

 Do your thoughts ever go out of your own mind?
 Do your thoughts go out of your mind to other people?
 Are your thoughts ever put on the television or radio?
 Do your thoughts go out of your mind to somewhere else?
 (E) PERCEPTION
1. HALLUCINATIONS

 Auditory, visual, olfactory, gustatory or tactile Auditory hallucinations

should be further enquired -what was heard -how many voices were
heard -in which part of the day- -male or female voices -how
interpreted and whether second person or third person hallucinations
(i.e., whether the voices are addressing the patient or are discussing
him in third person).

2. ILLUSIONS AND MISINTERPRETATIONS

 Whether visual, auditory, or in other sensory fields; whether occur in

clear consciousness or not.

3. DEPERSONALIZATION AND DEREALIZATION.

4. SOMATIC PASSIVITY PHENOMENON

 (F) COGNITION OR NEUROPSYCHIATRIC
ASSESSMENT

1. CONSCIOUSNESS
CONSCIOUS/CONFUSION/CLOUDING/DELIRIUM/STUPOR/COMA.
 Any disturbance of consciousness should be rated on Glasgow Coma
Scale.

2. ORIENTATION
 Whether the patient is well oriented to
 time (time, date, day, month, year, season, time spent in hospital)
 place (where is he, location, where does he stay) and
 person (his own name, can he identify people around him and their
role in setting).
3. ATTENTION
 It is easily aroused and sustained. Ask the patient to repeat digits
 4. CONCENTRATION

 Can the patient concentrate

 Ease of distractibility
 Ask to subtract serial sevens from hundred (100-7 test), or serial
threes from forty (40-3 test), or to count backwards from 20, or
 enumerate the names of the months (or days of the week) in the
reverse order.
 Note down the answers and the time take perform the tests.

5. MEMORY

 Immediate retention and recall (IR and R)

 Recent
 How did the patient come to the room/hospital
 what he ate for dinner the day before or for breakfast the same
morning.
 Remote
 Ask for the date of marriage
 name and birthdays of children
 any other relevant questions from the person’s past.
 Note any amnesia (anterograde/retrograde)
 confabulation, if present.
 QUESTIONS TO ASK FOR MEMORY

Long-term memory
 Where did you live when you were growing up?
 What was the name of the school you went to?

Short-term memory
 What did you have for breakfast?
 What did you do yesterday?

6. INTELLIGENCE

 Ask questions about general information, keeping in mind the patient’s

educational and social background, his experiences and interests e.g.,
ask about:
 the current and the past prime ministers and presidents of India
 the capital of India, and
 the name of the various states.
 Test for reading and writing.
 Give simple tests of calculation.
 7. ABSTRACT THINKING

 Abstract thinking testing assesses patient’s concept formation.

 The methods used are:

 Proverb testing: Asking the meaning of simple proverbs.

 Similarities (and also the differences) between familiar objects,
like: table and chair; banana and orange; dog and lion; eye and
ear.
 differences/Similarities: What do the following have in common?
Chair and desk? Apple and pear? Poem and statue? Proverbs:
What do people mean when they say…..? Don’t cry over spilled
milk A rolling stone gathers no moss When the cat’s away the
mice will play
 (G) JUDGEMENT
 Personal judgment
 Social judgment is observed during the hospital stay and during
the interview session.
 Test judgment is assessed by asking the patient what he would do
in certain test situations, like ‘a house on fire’, or ‘a man lying on
the road’, or ‘a sealed, stamped, addressed envelope lying on a
street’.
 Judgment is rated as Good/Intact/Normal

(H) INSIGHT
 patient’s degree of awareness and understanding that they are ill
 LEVELS OF INSIGHT

 Insight is rated on a 6-point scale from one to six

 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
 Intellectual insight
 True emotional insight
 RISK ASSESSMENT
RISK FACTORS FOR HARM TO OTHERS

1. PERSONAL FACTORS 2. ILLNESS RELATED FACTORS

 Previous violence to others  Psychotic symptoms
 Antisocial, impulsive  Substance abuse
personality traits  Treatment resistance
 Male and young  Poor compliance with treatment
 Recent life crisis  Stopped medication recently
 Poor social network
 Divorced or separated
 Unemployed
 Social instability
3. FACTORS IN THE MENTAL STATE
4. SITUATIONAL FACTORS

 Irritability, hostility, anger  Confrontation and

 Suspiciousness provocation by others

 Thoughts of violence towards
 Situations associated with
others
 Threats to people to whom patient previous violence

has access  Ready availability of weapons

 Planning of violence
 Persecutory delusions
 Delusions of jealousy
 Hallucination commanding violence
to others
 Suicidal ideas with severe
depression
 SUICIDE RISK ASSESSMENT

 The most obvious warning sign is a direct statement of threat

 Factors that point to greater risk are following:
 Marked hopelessness
 History of suicidal attempts (40-60%)
 Social isolation
 Older age
 Depressive disorders
 Alcohol dependency
 Schizophrenia especially young men
 Chronic painful illness
 Epilepsy
 Abnormal personality
Thank
You!