Psychiatric History and Mental Status

Examination
Dr Swapnil Sharma
MBBS, MD (Psychiatry), FRANZCP
Consultant Psychiatrist, Liaison Psychiatry & Pain Management, POWH
Conjoint Senior Lecturer, UNSW
“It is more important to know the patient with the
disease than to know the disease the patient has”
–William Osler
 The art and science of psychiatric examination

• Diagnosis based on symptoms rather than etiology

• Diagnosis has no external validation criteria
• Hence, diagnosis is only as good as the knowledge and skill of
the examiner
• Apart from factual data gathering and observation, diagnosis
requires empathic attunement and reflection by the examiner
 Outline of Psychiatric history
1. Identifying data
2. Presenting complaint
3. History of present illness
4. Past History
• Psychiatric
• Medical
• Drug and Alcohol history
5. Family history
6. Personal history
• Prenatal and perinatal
• Early childhood
• Adulthood
Educational history
Occupational history
Relationship history
Current living situation
Social activity
Sexual history
Religion
Forensic/legal history
 Identifying data

Name, age , sex, marital status, occupation, religion/ethnicity,

source of referral
 Presenting complaint

Brief statement in the patient’s own word stating the reason(s)

for hospitalization/consultation
 History of presenting complaint

‘ Why is the patient presenting with these problems at this stage

in their lives?’

Onset
Precipitant factors
Course
 Past history

• Longitudinal course of psychiatric disorders

• Acts of violence and self-harm
• Psychiatric hospitalizations
• Treatments
• Psychosomatic and neurological disorders
• Drug and alcohol history
 Family history

• Brief description of the family system and individuals

• Family history of mental illness
 Personal history

• Birth and infancy: age of parents, planned or unwanted

pregnancy, antenatal complications & developmental
milestones
• Childhood: childhood personality, relationships with parents,
separations & traumas
• Adolescence: peer and authority relationships, school history,
grades, emotional problems, drug use, puberty
• Educational, occupational, relationship, sexual, legal and
social history
 Mental Status Examination (MSE)

1. General appearance and behaviour

2. Speech
3. Mood and Affect
4. Thinking
Form
Content
5. Perception
6. Cognition
7. Insight and Judgement
 General appearance and behaviour

• Appearance: posture, clothing, grooming

• Overt behaviour and psychomotor activity
• Abnormal movements
• Attitude towards examiner
 Speech

Rate: pressured, poverty, mute

Tone
Volume
Slurring
Stuttering
Accents
 Mood and affect

Mood is defined as a pervasive and sustained emotional

state that colours the person’s perception of his
environment e.g. depressed, euphoric

Affect is defined as the patient’s present emotional

responsiveness
• Intensity of emotional expression
• Range: Normal or reactive, restricted, blunted, flat
• Appropriateness
 Thought form

Circumstantial thinking: indirect speech that is delayed in

reaching the point but eventually gets from original point to
the desired goal; characterised by over inclusions.

Tangentiality: inability to have goal-oriented association of

thoughts

Derailment and loosening of association: gradual or sudden

deviation in train of thoughts without blocking
 Thought form

Neologism: new words created by the patient for idiosyncratic

psychological reasons

Word salad: incoherent mixture of words and phrases

Verbigeration: meaningless repetition of words and phrases

Poverty of thought and poverty of thought content

 Thought form

Flight of ideas
• Rapid and continuous verbalization of words that produce constant
shifting from one idea to another
• Ideas are superficially connected by verbal and clang associations
• Easily diverted to external stimuli and internal superficial associations
• Usually occurs with pressure of speech
• Mania, hypomania and schizophrenia

Retardation of thinking
• Slowed thinking leading to poor attention span, loss of clarity and
difficulty in making decisions
• Depression, anxiety and manic stupor
 Thought form

Thought block
• Sudden arrest of train of thoughts before a thought is finished
• Person is unable to recall what was being said or going to be
said
• Schizophrenia, anxiety disorder and exhaustion
 Thought content

Delusions

Delusion is a false, unshakable idea or belief which is out of

keeping with patient’s educational, cultural and social
background; it is held with extraordinary conviction and
subjective certainty.
 Content of delusions

• Form and content of delusions and impact of socio-cultural

factors
• Delusions of persecution
• Morbid jealousy
• Delusion of love or Erotomania and de Clerambault
• Grandiose delusions
 Content of delusions

• Delusional misidentification
The Capgras syndrome
The syndrome of Fregoli
The syndrome of intermetamorphosis
Syndrome of subjective doubles
• Delusion of guilt and unworthiness
• Nihilistic delusions and Cotard’s syndrome
 Content of delusions

• Hypochondriacal delusions
Delusion of body odour and halitosis
Infestation delusions and Ekbom’s syndrome
Dysmorphic delusions
• Communicated or shared delusions
Folie a deux
Transferred with or without resistance or simultaneous
 Overvalued idea

• Solitary, abnormal belief that is neither delusional nor

obsessional in nature, but which is preoccupying to the extent
of dominating the sufferer's life
• Eg. Hypochondriasis, dysmorphophobia, anorexia nervosa,
morbid jealousy and paranoid personality
 Perception

• Perception is the process of attaining awareness or

understanding of sensory information
 Perceptual disturbance

New percept occurs which may or may not be in response to an

external stimuli i.e. Illusions or hallucinations

Illusions
Misinterpretation of a stimulus from an external object
 Hallucinations & psychiatric disorders

• 60-90 % patients with schizophrenia

• 20 % depressed and 10 % manic patients
• First rank symptoms as proposed by Schneider
 Hallucinations of individual senses
Auditory
• Elementary, partly or completely organized
• First, second and third person
• Command AH and risk of violence and suicide
• Content, explanations and emotions
• Schizophrenia, affective psychosis and organic states

Visual
• Lilliputian hallucinations
• Charles Bonnet syndrome
• 25-50% patients with schizophrenia may experience VH
• TLE, lesions of optic tract, LSD, mescaline
 Hallucinations of individual senses

• Smell-schizophrenia, depression, TLE

• Associated with strong emotional responses
• Taste-schizophrenia and organic states
• Touch or haptic ‘formication’-schizophrenia, parietal lobe
lesions, phantom limb (up to 65%), stimulants
• Deep sensation somatic/sexual hallucinations and delusional
zoopathy
 Sensorium and cognition

Level of consciousness
Attention and concentration: serial 7s
Orientation: time, place, person
Memory: immediate, recent, remote
 Insight and Judgement

Judgement: Ability to assess a situation correctly and to act

appropriately

Insight: Patient’s degree of awareness and understanding about

their state of being
Discussion