This document outlines the components and process of conducting a psychiatric history and mental status examination. It details the objectives, diagnoses, formulation, management, and categories of information to cover which include history, mental status examination, and psychosocial investigation. It provides examples of specific components to evaluate such as chief complaint, history of present illness, past psychiatric history, and family history. It also describes the expected signs and findings under each section of the mental status examination.

1. PSYCHIATRIC HISTORY
& MENTAL STATUS
EXAMINATION
PSYCHOLOGICAL MEDICINE
PHASE II, MD
Thursday, September 13, 2018

2. OBJECTIVES
•Formulation
•Investigation
Diagnosis
•Pharmacological
•psychosocial
Management

3. DIAGNOSIS –
SYMPTOM/SIGN
Present? Characteristic, typical, atypical features
Details
Frequency, intensity,
duration, sequence, personal
meaning
Pattern
Longitudinal,
evolution,
relation between
symptoms

4. DSM-IV
DIAGNOSTIC CRITERIA
Core /
Characteristic
features
• Delusions
• Hallucinations
• Disorganized
speech
• Grossly
disorganized or
catatonic behavior
• Negative symptoms
Threshold criteria
• Social/Occupational
dysfunction:
• Duration: 6 months
Exclusion
• Schizoaffective and
Mood Disorder
exclusion
• Substance/General
Medical Condition
exclusion
• Relationship to a
Pervasive
Developmental
Disorder

5. FORMULATION
Predisposing Genetic, personality
Precipitating Stress, drugs
Perpetuating Noncompliance,
ongoing stress

6. RELAPSE
RISK FACTORS
Diagnosis
Side effects
Social
support
Compliance
Insight
Inadequate
response

7. MANAGEMENT
Diagnosis
• General
guideline
Formulation
• Individualized
plan

8. CATEGORIES OF
INFORMATION
History
• Behavioral
description
• Phenomenology
• Causes
• Background
Mental Status
Examination
• Expected signs
Psychosocial
Investigation
• Confirming the
diagnosis
• Excluding specific
causes

9. COMPONENTS OF
PSYCHIATRIC HISTORY
Chief Complaint Symptoms that is characteristic or
problematic
History of Present
Illness
Further elaboration of
the current complaint
Past Psychiatric
History
Background
of the illness

10. THE FLOW
Time
• Onset –
admission –
progress in the
ward
Specific
• History – MSE –
Investigation
• Layman –
terminology
Complete
• Behavior –
phenomenology
• Core –
characteristic –
associated
features
Priority
• Present –
absent
• Important –
unimportant
• Establish – rule
out

11. CHRONOLOGICAL
ORDER
Attended PLKN 2 months ago. Noted to be quiet and
having poor sleep at night
1 week later, noted smiling to himself and wandering at
night.
A few days later, the condition worsen. Pt talked and
shouted for no reason. Threw stones at other trainees
tent at night. The relative came and brought pt home
On the day of admission, he punched his father

12. VERBATIM -
TERMINOLOGY
• “I heard other trainees were badmouthing me
at night”CC
• It occurred especially at night time when
everybody was asleep
• It angered him when the voices discussed
about him and commented on his behavior
HOPI
• Third person (auditory) hallucinations
MSE

13. COMPLETE
• Threshold criteria
•Duration
•Impairment
• Exclusion
•Bipolar
•Drugs, GMC
• Bio-psychosocial
• Predisposing/
precipitating/
perpetuating factors
• Auditory hallucinations
• Delusions?
• Disorganization?
• Subjective & Objective
• “I heard voices”
•Seen talking to himself
• Fulfill definition
• Further description of
form and content
Psycho-
pathology
Syndrome
Disorder
Mental
Illness

14. COMPONENTS OF
PSYCHIATRIC HISTORY
Family history Presence of mental illness
Personal history
Childhood, academic,
occupational,
relationship, drug use
Social history

15. COMPONENTS OF
MENTAL STATUS
EXAMINATION
General behavior
• Appearance, attitude, rapport, activities
• Neglect, abnormal movement
Mood & affect
• Quality, range, depth, appropriateness, lability
Speech
• Rate (rapid, slowed, pressured, hard to interrupt)
• Volume (loud, soft, monotone, highly inflected or dramatic)
• Quality (neologisms, fluent, idiosyncratic)

16. COMPONENTS OF
MENTAL STATUS
EXAMINATION
Thought
• PROCESS: Flow, form, content, possession
• CONTENT: Delusion, obsession, suicidal
Perception
• Hallucination, illusion
• Modality, content
Cognition
• Attention, concentration, orientation, memory,
intelligence
• Judgment, insight

17. Sign/symptoms
• Knows
something is
wrong
Mental illness
•That he/she is
ill, that illness is
psychiatric;
Treatment
•Understands
the need for
treatment
Test
• Response to
standard
questions
Personal
• His future plan
Social
• Evidence from
behavior prior
to and during
interview

18. SUMMARY
•Abu is an 18-year-old single, unemployed Malay boy from Kota Bharu.IDENTIFICATION
•He was admitted to psychiatric ward for punching his father on the of admission.CHIEF COMPLAINT
•While attending National Service program about 2 months ago, he was noted to
become quiet and had poor sleep. Later he was seen talking to himself, wandering
at night, shouting and throwing stones to the other trainees.
HISTORY OF
PRESENT ILLNESS
•One of his siblings has mental illness needing regular treatment.FAMILY HISTORY
•He scored grade 2 in SPM in 2011. He is a smoker. He denied use of other
substance.
PERSONAL
HISTORY
•It revealed a young man with poor personal hygiene, 3rd person hallucinations
discussing and commenting on him, persecutory delusions and disorganized
speech. Insight and judgment were poor.
MENTAL STATUS
EXAMINATION

19. FORMULATION
Biological Psychosocial
Predisposing Mental illness
among close
relatives
Premorbid
adjustment,
personality, early
childhood
experience
Precipitating Drug abuse, medical
illness, steroid
Stress e.g.,
National Service
program
Perpetuating Current drug abuse Ongoing stress

20. DIAGNOSIS &
INVESTIGATION
Biological & Psychosocial Investigations
• to get more information to established provisional
diagnosis
• A corroborative history from a friend, relative or other
professional may be helpful
• To rule out differential diagnosis
• Urine drug screening test
• Brain CT scan

21. MANAGEMENT
Objective Biological Psychosocial
Acute
(in-patient)
To reduce
symptoms
ECT,
pharmacologic
Psycho-
education,
occupational
therapy,
psychotherapy,
family therapy,
group therapy
Maintenance
(out-patient)
To regain
function
As above As above