NEW YORK MEDICAL COLLEGE DEPARTMENT OF PSYCHIATRY & BEHAVIORAL SCIENCES THE EVALUATIVE PSYCHIATRIC REPORT This should

be a concise yet a complete presentation of the total picture of the patient and his illness. During your initial interviews you have obtained much factual information in disconnected or incomplete fragments, sometimes repeated, sometimes modified, sometimes contradictory; you have observed the patient's characteristic ways of presenting facts; you have seen changes occurring in him during the course of your contacts; you have yourself experienced reactions to him; and you have probably spoken to members of his family. Writing a report whether for your personal use, for a hospital chart or staff discussion provides you with an opportunity to collate, to organi!e, and to evaluate all this material enabling you to arrive at a preliminary diagnosis and recommendations. "t the same time, your report should give evidence of some understanding of the dynamic factors and forces operating within your patient to produce his symptoms. #t is usually advisable to follow some orderly systematic formulation in your report such as is presented here, so that you will be more easily aware of the lacunae or contradictions. #t will seldom be possible to obtain all the details indicated here. They are simply indicated as a possible framework or guide. The organi!ation of the report may be altered if doing so will make for greater lucidity. $reliminary #dentification %ame; age; marital status; sex; occupation; language if other than &nglish. 'ace, nationality and religion should be stated in so far as they are pertinent. $revious admissions to this hospital, or to other hospitals for the same condition. ". (hief (omplaint )tate, if possible, exactly why the patient came to the hospital at the time he did. #f this information does not come from the patient, note who supplied it. )tate in the patient's own words what the presenting problem seems to be. *&xample+ $atient was brought to the hospital by his wife after he had destroyed the television set because it was talking about him. ,e stated that he had come for a rest because he was nervous.. $ersonal #dentification /ive a brief non technical description of the patient the kind of description of appearance and behavior a novelist might write. This little description often makes it much easier for the reader to see the history and examination as pertaining to an individual human being. *&xample+ )he is a thin young woman with flowing black hair, bloodshot eyes, but there is no facial expression as she describes, with dramatic gestures, her unhappy life.-

(. ,istory of $resent #llness Describe the background and development of the symptoms or behavioral changes which culminated in the patient's seeking assistance. 1ne's knowledge *or opinions- about human behavior or assistance. 1ne's knowledge *or opinions- about human behavior or diagnostic entities often has a profound effect on the choice and organi!ation of material in this section. )ometimes the patient's account, with little editing, is the best exposition. #ndicate the patient's life circumstances at the time of onset, and state what is known abot his personality when 2well.2 (onsider how the illness has affected his life activities and personal relations. )ome of the areas toward which in3uiry may be directed are+ changes in character, interests, mood, attitudes toward others, dress, habits, changes in level of tenseness, irritability, activity, attention, concentration, memory, speech. #f psychophysiologic symptoms are present, indicate the nature and details of the dysfunction such as location, intensity, fluctuation, relationship between physical and psychological symptoms. %ote to what extent the illness serves some additional purpose for the patient in his dealings with others *secondary gain-. D. $revious #llness 0. &motional or mental disturbances, including extent of incapacity, type of treatment, names of hospitals, length of illness and effect of treatment. 4. $sychophysiologic disorders, such as hay fever, arthritis, colitis, asthma, hyperthyroidism, gastrointestinal upsets, recurrent colds, skin conditions. 5. 6edical conditions, following the customary review of systems if necessary. 'emember lues, use of alcohol or drugs, ,#7. 8. %eurologic disorders, such as cranio cerebral trauma, convulsions, tumors. &. $ast $ersonal ,istory This consists of a history *anamnesis- of the patient's life from infancy to the present, to the extent it can be recalled. 9ou are not to accumulate details merely except in so far as these may help you to envisage him as a total personality in a specific environment, which, in turn, may contribute to your understanding of his present condition. /aps in the history as spontaneously related by the patient, may be filled in at a later date, as facts emerge during treatment *if you decide to continue therapy- or from collateral sources of information. #ndeed, attention should be paid to such gaps, since they indicate life periods and emotions associated therewith, which may have been painful, stressful or conflictual, and therefore had to be repressed. The purpose of the past personal history is therefore+ *0- To understand the early developmental pattern of the patient, and abnormalities in it; *4- To visuali!e his earlier attitudes and patterns of reaction toward others, and how these have changed with growth; *5To note any early unresolved problems, insecurities, inferiorities, conflicts and solutions of them, and symptoms thereof; *8- To define any early predisposition toward or early sign of the present illness.

)ome of the factors and areas to which attention should be paid are+ a. &arly (hildhood *through approximately age 0:-+ 0. %ature of mother's pregnancy and delivery+ length of pregnancy, spontaneity and circumstances of delivery; birth trauma; 4. (ircumstances of teething, walking, talking, etc.; note any delays or abnormalities associated with these activities; 5. ;eeding habits+ breast or bottle fed; eating problems; 8. Toilet training+ age, attitude of parents, feeling about it. <. )ymptoms of behavior problems+ e.g., thumbsucking, temper tantrums, tics, head bumping, night terrors, fears, bedwetting or soiling; nailbiting; =. $ersonality as a child+ e.g., shy, restless, overactive, withdrawn, studious, outgoing, timid, athletic, friendly; >. &arly or recurrent dreams or fantasies; ?. &arly school history+ e.g., feelings about going to school; early ad@ustment and anxiety about separation; A. "ny experience relating to abuse, e.g., emotional, physical or sexual. b. Bater (hildhood *pre puberty through adolescence-+ 0. )ocial relationship+ e.g., attitudes toward siblings and playmates; number and closeness of friends; leader or follower; social popularity; 4. )chool history+ e.g., how far did he go; ad@ustment to school; relationships to teachers; teacher's pet; rebellious, favorite studies or interests, particular abilities or assets; extracurricular activities+ sports, hobbies, etc. relationships of problems or symptoms to any school period.. 5. $articular adolescent emotional or physical problems+ e.g., running away+ delin3uency, smoking, drug taking, overweight, feelings of inferiority, fears or anxieties. 8. $sychosexual history+ *a- &arly curiosity, infantile masturbation, sex play; *b- "c3uiring of sexual knowledge, attitude of parents to sex; *c- 1nset of menses; feelings about it, prepared or not; subse3uent feeling about menstruation; *d- "dolescent sexual activity+ crushes, parties, petting, masturbation, wet dreams, and attitudes toward them; *e- "ttitudes toward oppositeCsame sex+ timid, shy, aggressive, need to impress, sexual con3uests, anxiety, seductive; *f- )exual practices+ sexual intercourse, sexual problems, homosexual experiences; other types of sexual experiences. <. 'eligious background+ strict, liberal, mixed *possible conflicts-. 'elationship between background and current religious practices. c. "dulthood 0. 1ccupational ,istory+ choice of occupation training, ambitions, conflicts, relation to bosses and co workers; how many @obs and for how long, change to @obs of lesser status; current @ob and feelings about it; 4. )ocial "ctivity+ Does he have friends, is he withdrawn or sociali!ing well; kind of social activities, intellectual or physical interests; relationship to oppositeCsame sex;
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5. "dult )exuality+ *a- $remarital sexual relationships *see 8 e, f above*b- ;eelings about marriage+ sexual ad@ustment and compatibility; *c- )exual symptoms+ frigidity, impotence, etc. *d- "ttitudes toward pregnancy and having children; contraceptive practices and feelings about them; feelings about abortion; *e- )exual orientation. 8. 6ilitary history+ general ad@ustment, combat, in@uries, referral to psychiatrist, veteran status. #f deferred from draft, whyD ;. ;amily ,istory The importance of eliciting a history from someone other than the patient is often seen most clearly in this area, where 3uite different descriptions may be given of the same people and events. &thnic national religious traditions should be described. "nyone who lived in the home should be mentioned, for the significant relationships might be with people other than parents. What were the different members of the household like as people *personality, intelligence, traitsD-. What has become of them since the patient's childhoodD #f patient lived in different households, describe each. What relationships now exist between patient and those who were in the familyD What was the role of illness in the familyD Was there any mental illnessD /. 6arital ,istory The important information is similar to that sought in family history. #n3uire about nontraditional marriages as well as traditional. #f there were previous marriages, where are childrenD Euestion include+ length of courtship, age at marriage, family planning and contraception, names and ages of children, attitudes toward children, problems of any family members. #f housing difficulties have been important to the marriage, data should be obtained. ,. (urrent )ocial )ituation Where does patient liveD $ro@ect, furnished room, etc.D #n a high crime neighborhoodD " middle class neighborhoodD #s his home crowdedD Do family members have privacy from each other or from other familiesD What are sources of family incomeD ,ave there been difficulties in obtaining itD #f public assistance, attitude about it. #f patient has a @ob or an apartment, will he lose it by remaining in the hospitalD #f there are children, who is caring for them while mother is in hospitalD *While in3uiring about these and any related matters, one can sometimes inform patient about his eligibility for disability or 7" $ayments.#. 6ental )tatus This is the sum total of your observations and impressions of your patient derived from your initial interviews. The following order and organi!ation is indicated only for completeness. ;rom prior knowledge or the presenting complaint and history, you may already be considering a preliminary or differential diagnosis, therefore paying more attention to some areas and less to others in the examination, i.e. the organic series of symptoms might be of lesser importance in a suspected neurosis. ;urthermore, because of the patient's attitudes, you may not be able to elicit particular symptoms during your early interviews, but they may emerge only later during subse3uent visits or during treatment. Therefore, you should not feel disturbed if you cannot cover all the following areas, but keep them in mind as a possible outline for exploration+ The lists of descriptive terms are intended to be a guide for accurate description, not the end all of possible observations.
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*"- 1bservation+ 0. Bevel of alertness+ clouding of consciousness, alert, responsive to the environment. *Does the patient respond to you, recogni!e you, understand you, pay attention to what is going on around himD4. "ppearance+ observe posture, gait, bearing, clothes, grooming hair, nails. )ome ad@ectives , might be healthy, sickly, angry, frightened, apathetic, perplexed, contemptuous, ill at ease, poised, old looking, young looking, effeminate, masculine. 5. .ehavior and psychomotor activity+ mannerisms, compulsions, tics, gestures, twitches, stereotypes, picking, touching examiner, echopraxia, clumsy, agile, limp, rigid, retarded, combative, 2waxy2. 1bserve signs of anxiety such as moist hands, perspiring forehead, restlessness, tense posture, strained voice, wide eyes. 8. "ttitude toward examiner+ cooperative, attentive, interested, frank, defensive, hostile, playful, ingratiating, evasive, guarded, seductive. *.- $sychiatric $henomena+ 0. "ffective *or emotional- state+ a. 6ood a pervasive and sustained emotion that in the extreme markedly colors one's perception of the world. ,ow does the patient say he feelsD #n3uire about depth, intensity, duration and fluctuations of mood. )ome examples+ depressed, despairing, irritable, panicky, terrified, angry, enraged, elated, ecstatic, empty, guilty, unreal, awed, futile, self contemptuous. b. "ffect the outward manifestation of a person's feelings, tone or mood. "ffect and emotion are commonly used interchangeably. "ffect is also described according to the range. #n this regard it can be constricted, *only one or a few emotions are demonstrated in the course of an interview- flat, blunted, *either no emotions are demonstrated or they are of low intensity-. "ffect can be described according to its fluctuations, the term labile refers to affect which rapidly shifts from one emotion to another. ;inally affect is described according to its appropriateness given the social situation and the content of the patient's thinking. " patient who laughs while describing the death of a loved one is demonstrating inappropriate affect. *1b@ective evaluation-. 4. )peech+ descriptive+ )pontaneous, hesitant, free flowing, guarded rate+ slow, pressured, rapid articulation+ slurred, mumbled, stuttering tone+ monotone, high pitched volume+ loud, whispered relevance+ coherent, goal directed, incoherent 3uality+ repetitive, rambling, echolalia, neologisms, clang associations, word salad.
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5. Thought $rocesses+ a. ;orm of thought Booseness of "ssociational links between different ideas *B1"- ;ragmented ideation. #s there a lack of cause and effect relationships in patient's explanationsD "re statements illogicalD #ncomprehensible utteringsD 2;ormal thought disorder2 b. )tream of thought+ *analogy of water flowing in a stream+productivity+ over abundance of ideas; paucity of ideas speed+ flight of ideas, slow, rapid thinking blocking+ i.e., a sudden interruption in the spontaneous flow of thinking perceived as an absence or deprivation of thought tangential+ replying to a 3uestion in an obli3ue or irrelevant way circumstantial+ thinking proceeds in a roundabout prolonged manner and then returns to original topic c. (ontent of thought+ Delusions+ if persecutory, establish whether it is systemati!ed, isolated, or diffuse, with pervasive suspiciousness. )omatic delusions must be distinguished from mere erroneous information. 1bsessive thoughts+ which are intrusive, distressing and against the individual's conscious desire. "bout suicide, homicide, antisocial urges, hypochondriacal symptoms. 1vervalued ideas, e.g., about body weight in an anorexic patient. ;ears and phobias. $reoccupations, e.g., religious or sexual not against the individual's conscious desire. Dreams+ prominent ones, if patient will tell them. %ightmares. ;antasies+ recurrent, favorite, or unshakable daydreams may be recounted. d. "lienation of thought+ This is also known as 2passivity phenomena2 first described by )chneider and is grouped together as )chneiderian ;irst 'ank )ymptoms. The patient experiences his thoughts as being controlled by others and thoughts that are alien to him are inserted into his mind. &xamples of this are+ thought insertion, thought withdrawal, thought control, and thought broadcasting, i.e., as he thinks of something he believes his thoughts are broadcasted and others can hear what he is thinking. 8. $erception+ Disorders of perception include illusions, i.e. distortions of a stimulus and hallucinations of all the senses, i.e., a sensory perception without a stimulus. 1ther perceptual disorders include depersonali!ation and dereali!ation, i.e., 'dF@G vu' i.e., an experience that one is seeing a situation that one has seen before and '@amais vu' i.e., inability to recogni!e a very familiar situation.
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<. #deas of reference *to self- or 2$erceptual delusion2+ an incorrect interpretation of casual incidents and external events as having direct reference to oneself. When this belief reaches sufficient intensity, it constitutes a delusion, e.g., television or radio sending messages to oneself. =. #mpulse control+ The individual's capacity to control compulsive habits, assaultive impulses or suicidal or homicidal impulses *(- (ognitive ;unctioningC)ensorium 0. 1rientation+ 1rientation as to time, place, person and significance of surroundings. *Does the patient know where he is and the dateD4. "ttention+ The person's capacity to attend in a focused manner to an immediate stimulus is evaluated. Three ob@ects are named and the individual is re3uested to repeat the three stimulus words. The ability to repeat digits *up to =- forwards and backwards also tests the level of attention. 5. (oncentration+ #f the traditional serial subtraction of >'s from 0:: cannot be done, it may be replaced by an easier task. )erial 5's with subtracting 5 from 4: serially may be used, a simple arithmetic problem, e.g., 2how many nickels are in H0.5<D2 or spelling a word backwards, e.g., 2world.2 8. #nformation and #ntelligence+ 1ften the patient's understanding of your 3uestions and his vocabulary and manner of speaking make possible an ade3uate evaluation without further testing. )ample 3uestions+ 2%ame the last four presidents of the I)"; give the capitals of the Inited )tates, &ngland and ;rance; give the dates of World War # and ##.2 #f the patient has interests and education different from the examiner, useful 3uestions must be invented. Thus geography, current politics and 3uestions which re3uire numerical answers may not be sufficient, since some with normal intelligence have narrow hori!ons. *)ome who do not know the mayor may know the private lives of T7 stars; a person who uses the subway should know where the station is and what the fare is.<. 6emory+ #f impairment exists, describe attitude towards it and efforts made to cope with the impairment, such as denial, confabulation, catastrophic reaction, circumstantiality. a. #mmediate recall+ "fter a few minutes interrupted by other discussion, ask patient to repeat three ob@ects used for testing attention. 1ther test 3uestions may be used. #ndicate instances where the same 3uestions, if repeated, call forth different answers at different times. b. 'ecent recall+ 'ecall events of the last few days and months. c. 'emote memory+ (hildhood data, important events known to have occurred when patient was younger or free of illness. *)ome people with good memory blot out personal matters, remember neutral material.-

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"bstract thinking+ &ven if the interviews have made clear that abstract thinking is impaired, it is worthwhile attempting the customary tests, in order to evaluate their utility. "mong the useful tests are+ similarities, e.g., between an apple and an orange, and proverbs. ;or example, you can ask meanings of simple proverbs+ 2" rolling stone gathers no moss.2 "nswers may be concrete, i.e., giving specific examples to illustrate the meaning, or abstract, i.e., giving generali!ed explanations. *(oncrete thinking is often seen in children, low intelligence, organic conditions; inappropriately concrete, metaphorical and bi!arre statements are sometimes seen in schi!ophrenics; abstract thinking is sometimes seen in others.

>. #nsight+ This refers to the degree of awareness and understanding the patient has that is ill. " sample 3uestion might be+ 2Do you think you have any problemsD2 *or anything wrong with you-; or 2Do you think you need helpD2 " yes or no is meaningless. )ome levels of insight are+ a. (omplete denial of illness b. )light awareness of being sick and needing help, but denying it at the same time. c. "wareness of being sick, but blaming it on others, on external factors or organic factors *2nervous breakdown2-. d. "wareness of illness being due to something unknown in himself. e. #ntellectual insight+ admission of illness, and that his symptoms or failures in social ad@ustment are due to his own particular irrational feelings or disturbances, without applying this to future experience. f. True emotional insight+ emotional awareness of the motives and feelings within himself, underlying symptoms, with change in personality and future behavior. ?. Judgment+ a. )ocial @udgment; evidence of poor @udgment in history, i.e., behavior which is harmful to the patient and contrary to accepted behavior in our culture. #f not gross *such as hitting a policeman or going nude in the street- it can become a matter of opinion. b. Test @udgment+ patient's prediction of what he would do in imaginary situations, such as, What would you do if you found a stamped, addressed letter in the streetD2

J. )ummary of $ositive ;indings+ #nclude here not only mental symptoms but also laboratory findings and psychological test results if available. "lso indicate any drugs the patient has been taking, including dosage and duration of intake. K. 6echanisms of Defense+ This reference to the dynamic psychological means, largely unconscious, used by the patient to deal with avoid experiencing and becoming aware of his inner conflicts, his anxieties, guilts and any emotional attitudes which may be threatening to his consciously predominating attitudes and self concept.
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#t is important to have some understanding of such processes in your patient, so that you can better visuali!e his total personality and his methods of functioning, and thereby to treat him more effectively. While various defense mechanisms have been described by different authors, some of the basic ones are+ 0. Denial+ The blocking from awareness of inner feelings, e.g., wishes, impulses, emotions, conflicts, etc., or of external reality, which may be replaced by fantasies. *;antasy formation has been described as a separate mechanism.4. #dentification+ The taking on of the attitudes of someone else in a mental picture, and then acting in thoughts, character traits and feelings as the other person is conceived to be. Differs from imitation which is said to be more of a conscious process; however, in practice how much is unconscious and how much is conscious is often difficult to determine. 5. 'ationali!ation+ Justifying an act or idea by making it appear reasonable when it is irrational or inconsistent. 8. $ro@ection+ 2The throwing out2 or attributing to another person of undesirable or unpleasant 3ualities of one's self. <. &xternali!ation, is a more general term, and includes not only negative 3ualities but positive ones as well, and not only other persons but all outside conditions. =. 'epression+ The active process of keeping from consciousness ideas or emotions that are unpleasant or unacceptable. Differs from suppression, which is said to be a conscious mechanism. ,owever, it may be difficult to distinguish conscious from unconscious process at times, so that it might be more advantageous to speak of degrees of awareness in describing these mechanisms. >. 'eaction formation+ The development of a trait or pattern that is directly opposed to an undesirable unconscious trend, e.g., aggressivity in opposition to fear, etc. ?. )ymboli!ation+ The expression of emotional impulses, traits, attitudes or ideas by means of disguised symbolic representations, e.g., in dreams, through symptoms, by other ideas, etc. " modified form of symbolic representation is described as displacement sometimes considered as a separate mechanism, in which the replacing symbol is less intolerable or indifferent as compared with the repressed one. A. Dissociation+ The functioning in consciousness of ideas, motives and attitudes which have escaped from repression into conscious life. The individual usually has no awareness of the contradiction between these two functional aspects of himself. B. Diagnosis The desire to make a precise diagnosis in every patient is understandable. "t times, however, as in incipient, borderline or some forms of functional or psychosomatic disease, it may be impossible and even in error to do so. #t is necessary to recogni!e your limitations, and accept the fact that with some patients a definite diagnosis may have to be deferred. "ll diagnoses are tentative and preliminary during the initial interviews, and it is necessary to be flexible and ready to modify your diagnosis if your subse3uent findings so demand. While you cannot disregard findings
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which may have lead to an earlier diagnosis, it is wise not to accept this diagnosis but to make yours independently. ;or the record, it is essential that the diagnostic classification of the "merican $sychiatric "ssociation be followed. ,ere reference should be made to the Diagnostic 6anual *D)6 ### '- for nomenclature, classification number, severity and chronicity. )upplemental diagnosis may be made if the condition is not included in the 6anual. $rognosis #t is necessary to express some opinion as to the probable future course, extent and outcome of the illness in your particular patient. The evaluation must take into account the following factors+ 0. The particular illness and its natural history+ i.e., the progressive evolution of chronic undifferentiated schi!ophrenia; the fluctuating chronicity of senile psychoses; the recurrent nature of bipolar conditions; the spontaneous remissions of some forms of schi!ophrenic reactions; the gradual improvement of certain forms of anxiety disorders. 4. The distinction between improvement of the pathological process and social improvement. This corresponds to the degree of limitation of activity of a cardiac patient. " patient may be able to function ade3uately in his daily living, work, life with his family, even though he may continue to have some symptoms. 5. "ssessment of the positive *constructive- and negative *destructive- factors in the patient+ a. "ge of the patient at the time of onset of the illness. The younger the patient when he becomes ill, usually the less favorable the outlook. "ge of patient at the time of seeking treatment. The earlier he seeks treatment, usually the better. b. c. $revious duration *chronicity- and recurrences. " previous history of chronic illness makes for a less favorable outlook. $ast environmental factors+ " more stable early family surrounding is more positive than a shifting home environment, foster homes, orphanages, etc.; relatively healthy parents *warm, stable, consistent, accepting- are better than emotionally disturbed ones; two parents better than one; in the absence of parents or with disturbed ones, some other stable or warm figure *grandparent, teacher- may indicate a more constructive aspect. 6otivation for treatment+ is he coming on his own or to please someone else is he coming because of a positive desire to change his life, or is it out of fear or acute need does he simply want to get rid of one symptom or change some external situation "ccessibility for treatment+ is he genuinely interested and curious about himself, desirous of changing, and willing to work at his problems
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does he seem open for help, willing to accept it has he some feeling for psychological processes and can he present his thoughts does he seem essentially honest or evasive and duplicitous are his mental symptoms severe and rigid so that he is exclusively preoccupied with them; or can he endure them and overlook them temporarily while working at their basis is he close to and involved with his emotional inner self or is he distant and alienated from himself 8. $resent environmental factors+ a. present life situation; good possibilities of changing the external situation, of finding sources of warmth, understanding encouragement and support, make for a better outlook b. socioeconomic conditions+ a poor or difficult social environment may be less favorable to change 'ecommendations+ "mong the many possibilities, some are+ 0. ;urther diagnostic studies a. 6ore diagnostic interviews b. "dditional interviews with family members, friends or neighbors, to be done by yourself or social worker c. $sychological tests d. &&/, laboratory tests, consultations regarding medical conditions 4. Treatment here+ %o matter what other procedures are carried out, the therapeutic environment, which includes all staff and all patients, is having its effect on the patient. This is sometimes the most significant factor. "lso+ a. .rief psychotherapy *may wish to specify, i.e., insight oriented, cognitive, behavioral, group, etc.b. Drug therapy, shock treatment, medical or surgical treatment c. )ocial casework assistance for specific problem areas d. )pecific counseling such as vocational, marital 5. $rolonged Treatment a. 'eferral to our 1utpatient .ehavioral ,ealth (linic, other clinic, or private therapist. #n making such a referral, it is advisable to formulate whether you recommend brief psychotherapy, short term therapy, primarily supportive and counseling treatment, insight oriented therapy, specific cognitive behavioral therapy, etc.
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b. Day hospital attendance *partial hospitali!ationc. /roup therapy d. ".". or other specific program for substance abuse, eating disorders, etc.

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