Psychiatric History taking and mental status examination

Assessment of
mental health
status
🤔 Susmita Halder
Lecturer
Neotia Academy of Nursing
1

Assessment is
defined as a systematic
and continuous collection
of data on the health
status of a patient.
Subjective
data Objective
data
2

• To describe the patient’s condition, family, development and
environmental fators affecting the behaviour.
• To find out the predisposing and primary cause of his
behaviour.
• To make nursing diagnosis.
• To identify psychiatric emergencies.
• To plan nursing interventions.
3

History taking
Mental status examination
Medical investigations,
Neuroimaging techniques,
Psychological tests
Health education
4

Psychiatric History Taking
I. Identification Data:
Name:
Age:
Gender:
Marital Status:
Father’s name/Husband’s name:
Education:
Occupation:
5

Language:
Religion:
Provisional Diagnosis:
Consultant’s name:
Brought by:
Address:
Source of referral:
Identification marks of the patient:
6

II. Chief Complaint:
According to patient:
According to informant:
Informant’s name:
Relationship with patient:
Intimacy with the patient:
Does the informant live with the patient:
Duration of relationship with the patient:
Bias with the patient:
Interest of informant in the patient’s property/money:
Reason for consultation:
Reliability of information:
Adequacy of information:
7

III. History of Present Illness:
Predisposing factor:
Precipitating factor:
Perpetuating factor:
Mode of onset: Abrupt/Acute/Insidious
Course:Continuous/Episodic/Fluctuating/
deteriorating/unclear
Intensity: Same increasing/decreasing
Progression: Improving/Deteriorating/Static
Chronological development of symptoms/ behavior
Patient's life circumstances at the time of onset
8

Treatment history
• Drugs
• ECT:
• Psychotherapy:
• Family therapy:
• Rehabilitation:
Date Duration Mode of
treatment
Drugs Side
effects
Response Adherence Outcom
e
Remarks
IPD/OPD
9

IV. Past History of Illness:
Past Medical/Surgical history:
Past Psychiatric history:
V. Family History: (from patient and other member of the family)
Type of family
Decision maker in family:
Source Of Income:
Role of patient in the family:
Family history of mental illness:
Family Genogram:
Description of family members:
10

SL
No.
Name
Age
Sex
Relationship
with
patient
Education
Occupation
Mental
health
issues
if
any
If
dead,
Age
of
death,
mode
of
death
11

VI. Personal History:
• Perinatal History
Antenatal period: Maternal infections/exposure to
radiation/any other/Check-ups Any complications
Intra-natal period: Type of delivery-
normal/Instrumental/caesarian/ Any complications
Birth: Full-term / premature/post-mature
Birth cry: Immediate/delayed
Birth defects: Yes or no, if yes, specify
Postnatal complications:
Cyanosis/convulsions/jaundice/neonatal infections any other
12

• Childhood History
Primary caregiver:
Feeding: Breastfed/artificial mode of feeding
Age at weaning
Developmental milestones and Behavior and emotional
problems: Thumb sucking/excessive temper tantrums/stuttering/
head hanging/body rocking/nail biting/pica enuresis/morbid
fears/night terrors/somnambulism
Illness during childhood: Specifically for CNS
infections/epilepsy/neurotic disorders/malnutrition
13

• Educational history
• Play history
• Emotional problems during adolescence
• Puberty
• Adulthood
• Obstetrical History:
• Occupational history:
• Sexual history
• Addiction history (Onset/ Amount/Maximum intake/History of
withdrawal/Abstinence)
14

VII. Pre-morbid Personality
• Interpersonal relationships Family and social relationships:
Extrovert/introvert
• Family and social relationships
• Use of leisure time: Optimistic/pessimistic; stable/fluctuating
• Predominant mood: cheerful/despondent
• Usual reaction to stress:
• Attitude to self and others:
• Religious beliefs and moral attitudes
• Fantasy life: Daydreaming frequency and content
• Habits:
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• Eating pattern
• Addiction
• Elimination
• Sleep
Summary
16

Mental status examination
I. Identification Data:
II. Cheif complaints
III. History of present illness
17

IV. General Appearance and Behavior:
Appearance: Looking one’s age/looks older/younger than his
age/underweight/overweight/physical deformity
Facial expression: Anxious/blunted/pleasant/fearful
Level of grooming: Normal/shabbily dressed/overdressed/idiosyncratically
dressed Adequate/inadequate/overtly clean
Level of cleanliness:
Level of consciousness: Fully conscious and alert/confused/clouding of
conciousness/drowsy or somnolence/stuporous/comatosed/delirium/dream state
Mode of entry: Came willingly/persuaded/brought using physical force
Behavior: Normal/over friendly/preoccupied/aggressive
Co-operativeness: Normal/more than so/less than so
18

Eye-to-eye contact: Maintained/difficult/not maintained
Psychomotor activity: Normal/increased/decreased
Rapport: Spontaneous/difficult/not established
Gesturing: Normal/exaggerated/odd
Posturing: Normal posture/catatonic posture/stooped/stift/guarded
Other movements: Normal/stereotype/tremors/extrapyramidal
symptoms/abnormal movements
Other catatonic phenomena: Automatic obedience/negativism/excessive co-
operation/waxy flexibility/ echopraxia/echolalia
Conversion and dissociative signs: Pseudoseizures/possession states/any other
Compulsive acts or rituals or habits (for example nail biting):
Hallucinatory behavior: Smiling or crying without reason/muttering or talking to
self, odd gesturing
19

V: Talk and Speech:
Initiation: Spontaneous/speaks when spoken to/minimal/mute
Reaction time (time taken to answer the question): Normal/delayed/shortened/difficult to assess
Rate: Normal/slow/rapid
Productivity: Monosyllabic/elaborate replies/pressured Volume: Normal/increased (loud)/decreased
(soft)
Tone: Normal variation/high pitch/low pitch/monotonous
Relevance: Fully relevant/sometimes off target/irrelevant (answer the question appropriately)
Stream: Normal/circumstantial/tangential/blocking/verbigeration/stereotypies verbal/flight of
ideas/clang associations (flow and rhythm of speech)
Coherence: Fully coherent/loosening of associations (in coherent)
Others: Echolalia/perseveration/neologism
Sample of speech (in response to open-ended questions, verbatim in 2 or 3 sentences):
20

VI. Mood and Affect:
Subjective:
Objective:
Predominant mood state:
Irritable/labile/blunted/anxious/fearful/panic/aggre
ssive/cheerful/depressed Appropriate (relevance to
situation and thought congruent)/inappropriate
21

VII. Thought
• Formation level: Autistic/Derestic thinking
• progression level: Flight of ideas/Thought
retardation/Perseveration/Circumstantiality/Tangentiality/Incoherence/Blocking
• content level:
Delusions: Specify with examples-delusion of persecution/delusion of reference/delusion of
grandeur/delusion of influence and passivity/delusion of control/hypochondrial delusion/nihilistic
delusions/delusion of infidelity/bizzare delusions
Ideas: Worthlessness/helplessness/hopelessness/guilt/hypochondrial/death wishes
Thought alienation phenomena: Thought insertion/thought withdrawl/thought broadcasting
Obsessional/compusive phenomena: Thoughts/images/ruminations/doubts/impulsive rituals
Phobias (irrational fears):
Any preoccupations:
22

VIII. Perception:
• Illusion
• Hallucinations (specify type with example):
auditory/visual/olfactory/gustatory/ tactile
• Somatic passivity
• Deja vu/jamais vu
• Depersonalization/ derealization
23

IX. Cognitive function
Consciousness
Orientation: (Time, place, person)
Attention
• Normally aroused/ aroused with difficulty
• Digit forward
• Digit backward
Concentration
• Normally sustained/ sustained with difficulty/distractible
• 100-7
• 40-3
• 20-1
• Names of months
• Names of weeks
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Memory:
Immediate
Recent (recent happenings, last meal, visitors etc)
Verbal recall: 3 unrelated objects
Remote (personal events, impersonal events. Illness related events)
Intelligence:
General information:
Arithmatic ability:
Abstract thinking:
Normal/concrete
Interpretation of proverbs
Similarities between paired objects, dissimilarities between paired objects
X. Judgment: (personal, social, test judgment)
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XI. Insight:
Grade I Complete denial of illness
Grade II Slight awareness of being sick
Grade III Awareness of being sick attributed to external/physical factor
Grade IV Awareness of being sick but due to something unknown in himself
Grade V Intellectual insight : Awareness of being ill and knows the symptoms are
due to illness but is not able to use the knowledge to cope in future
Grade VI True emotional insight : Patient has awareness where the symptoms bring
changes in behaviour or personality

XII. Psychosocial Assessment: (Stressors, Coping Skills,
Relationship, Socio-cultural, Spiritual, Occupational)
Summary

Psychiatric History taking and mental status examination

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