Mental Status-WEEK 3

psychiatric diagnosis is universally recognized. The one that follows calls for including a tremendous amount of potential information about the patient, not all of which need be obtained, depending on the circumstances in the case. Beginning clinicians are advised to get as much information as possible; more experienced clinicians can pick and choose among the series of questions they might ask. In all cases, however, the person is best understood within the context of his or her life events.

Table 1-7 Psychiatric Report

I. Psychiatric History A. Identification: Name, age, marital status, sex, occupation,

language if other than English, race, nationality, and religion if pertinent; previous admissions to a hospital for the same or a different condition; with whom the patient lives

B. Chief complaint: Exactly why the patient came to the psychiatrist, preferably in the patient’s own words; if that information does not come from the patient, note who supplied it

C. History of present illness: Chronologic background and development of the symptoms or behavioral changes that culminated in the patient’s seeking assistance; patient’s life circumstances at the time of onset; personality when well; how illness has affected life activities and personal relations —changes in personality, interests, mood, attitudes toward others, dress, habits, level of tenseness, irritability, activity, attention, concentration, memory, speech; psychophysiological symptoms—nature and details of dysfunction; pain—location, intensity, fluctuation; level of anxiety—generalized and nonspecific (free floating) or specifically related to particular situations, activities, or objects; how anxieties are handled—avoidance, repetition of feared situation, use of drugs or other activities for alleviation

D. Past psychiatric and medical history: (1) Emotional or mental disturbances—extent of incapacity, type of treatment, names

of hospitals, length of illness, effect of treatment; (2) psychosomatic disorders: hay fever, arthritis, colitis, rheumatoid arthritis, recurrent colds, skin conditions; (3) medical conditions: follow customary review of systems— sexually transmitted diseases, alcohol or other substance abuse, at risk for acquired immunodeficiency syndrome (AIDS); (4) neurologic disorders: headache, craniocerebral trauma, loss of consciousness, seizures, or tumors

E. Family history: Elicited from patient and from someone else, because quite different descriptions may be given of the same persons and events; ethnic, national, and religious traditions; other persons in the home, descriptions of them— personality and intelligence—and what has become of them since patient’s childhood; descriptions of different households lived in; present relationships between patient and those who were in family; role of illness in the family; family history of mental illness; where does patient live—neighborhood and particular residence of the patient; is home crowded; privacy of family members from each other and from other families; sources of family income and difficulties in obtaining it; public assistance (if any) and attitude about it; will patient lose job or apartment by remaining in the hospital; who is caring for children

F. Personal history (anamnesis): History of the patient’s life from infancy to the present to the extent it can be recalled; gaps in history as spontaneously related by the patient; emotions associated with different life periods (painful, stressful, conflictual) or with phases of life cycle 1. Early childhood (Birth through age 3)

a. Prenatal history and mother’s pregnancy and delivery: Length of pregnancy, spontaneity and normality of delivery, birth trauma, whether patient was planned and wanted, birth defects

b. Feeding habits: Breast-fed or bottle-fed, eating problems

c. Early development: Maternal deprivation, language

development, motor development, signs of unmet needs, sleep pattern, object constancy, stranger anxiety, separation anxiety

d. Toilet training: Age, attitude of parents, feelings about it e. Symptoms of behavior problems: Thumb sucking,

temper tantrums, tics, head bumping, rocking, night terrors, fears, bed-wetting or bed soiling, nail biting, masturbation

f. Personality and temperament as a child: Shy, restless, overactive, withdrawn, studious, outgoing, timid, athletic, friendly patterns of play, reactions to siblings

2. Middle childhood (ages 3–11): Early school history— feelings about going to school, early adjustment, sex identification, conscience development, punishment; social relationships, attitudes toward siblings and playmates

3. Later childhood (prepuberty through adolescence) a. Peer relationships: Number and closeness of friends,

leader or follower, social popularity, participation in group or gang activities, idealized figures; patterns of aggression, passivity, anxiety, antisocial behavior

b. School history: How far the patient went, adjustment to school, relationships with teachers—teacher’s pet or rebellious—favorite studies or interests, particular abilities or assets, extracurricular activities, sports, hobbies, relationships of problems or symptoms to any school period

c. Cognitive and motor development: Learning to read and other intellectual and motor skills, minimal cerebral dysfunction, learning disabilities—their management and effects on the child

d. Particular adolescent emotional or physical problems: Nightmares, phobias, masturbation, bed-wetting, running away, delinquency, smoking, drug or alcohol use, weight problems, feeling of inferiority

e. Psychosexual history

i. Early curiosity, infantile masturbation, sex play ii. Acquiring of sexual knowledge, attitude of parents

toward sex, sexual abuse iii. Onset of puberty, feelings about it, kind of

preparation, feelings about menstruation, development of secondary sexual characteristics

iv. Adolescent sexual activity: Crushes, parties, dating, petting, masturbation, wet dreams and attitudes toward them

v. Attitudes toward same and opposite sex: Timid, shy, aggressive, need to impress, seductive, sexual conquests, anxiety

vi. Sexual practices: Sexual problems, homosexual and heterosexual experiences, paraphilias, promiscuity

f. Religious background: Strict, liberal, mixed (possible conflicts), relation of background to current religious practices

4. Adulthood a. Occupational history: Choice of occupation, training,

ambitions, conflicts; relations with authority, peers, and subordinates; number of jobs and duration; changes in job status; current job and feelings about it

b. Social activity: Whether patient has friends or not; is patient withdrawn or socializing well; social, intellectual, and physical interests; relationships with same sex and opposite sex; depth, duration, and quality of human relations

c. Adult sexuality i. Premarital sexual relationships, age of first coitus,

sexual orientation ii. Marital history: Common-law marriages, legal

marriages, description of courtship and role played by each partner, age at marriage, family planning and contraception, names and ages of children, attitudes toward raising children, problems of any

family members, housing difficulties if important to the marriage, sexual adjustment, extramarital affairs, areas of agreement and disagreement, management of money, role of in-laws

iii. Sexual symptoms: Anorgasmia, impotence, premature ejaculation, lack of desire

iv. Attitudes toward pregnancy and having children; contraceptive practices and feelings about them

v. Sexual practices: Paraphilias such as sadism, fetishes, voyeurism; attitude toward fellation, cunnilingus; coital techniques, frequency

d. Military history: General adjustment, combat, injuries, referral to psychiatrists, type of discharge, veteran status

e. Value systems: Whether children are seen as a burden or a joy; whether work is seen as a necessary evil, an avoidable chore, or an opportunity; current attitude about religion; belief in heaven and hell

G. Summation of the examiner’s observations and impressions derived from the initial interview

II. Mental Status A. Appearance

1. Personal identification: May include a brief nontechnical description of the patient’s appearance and behavior as a novelist might write it; attitude toward examiner can be described here—cooperative, attentive, interested, frank, seductive, defensive, hostile, playful, ingratiating, evasive, guarded

2. Behavior and psychomotor activity: Gait, mannerisms, tics, gestures, twitches, stereotypes, picking, touching examiner, echopraxia, clumsy, agile, limp, rigid, retarded, hyperactive, agitated, combative, waxy

3. General description: Posture, bearing, clothes, grooming, hair, nails; healthy, sickly, angry, frightened, apathetic, perplexed, contemptuous, ill at ease, poised, old looking, young looking, effeminate, masculine; signs of anxiety—

moist hands, perspiring forehead, restlessness, tense posture, strained voice, wide eyes; shifts in level of anxiety during interview or with particular topic

B. Speech: Rapid, slow, pressured, hesitant, emotional, monotonous, loud, whispered, slurred, mumbled, stuttering, echolalia, intensity, pitch, ease, spontaneity, productivity, manner, reaction time, vocabulary, prosody

C. Mood and affect 1. Mood (a pervasive and sustained emotion that colors the

person’s perception of the world): How does patient say he or she feels; depth, intensity, duration, and fluctuations of mood—depressed, despairing, irritable, anxious, terrified, angry, expansive, euphoric, empty, guilty, awed, futile, self-contemptuous, anhedonic, alexithymic

2. Affect (the outward expression of the patient’s inner experiences): How examiner evaluates patient’s affects— broad, restricted, blunted or flat, shallow, amount and range of expression; difficulty in initiating, sustaining, or terminating an emotional response; is the emotional expression appropriate to the thought content, culture, and setting of the examination; give examples if emotional expression is not appropriate

D. Thinking and perception 1. Form of thinking

a. Productivity: Overabundance of ideas, paucity of ideas, flight of ideas, rapid thinking, slow thinking, hesitant thinking; does patient speak spontaneously or only when questions are asked, stream of thought, quotations from patient

b. Continuity of thought: Whether patient’s replies really answer questions and are goal directed, relevant, or irrelevant; loose associations; lack of causal relations in patient’s explanations; illogic, tangential, circumstantial, rambling, evasive, perseverative statements, blocking or distractibility

c. Language impairments: Impairments that reflect

disordered mentation, such as incoherent or incomprehensible speech (word salad), clang associations, neologisms

2. Content of thinking a. Preoccupations: About the illness, environmental

problems; obsessions, compulsions, phobias; obsessions or plans about suicide, homicide; hypochondriacal symptoms, specific antisocial urges or impulses

3. Thought disturbances a. Delusions: Content of any delusional system, its

organization, the patient’s convictions as to its validity, how it affects his or her life: persecutory delusions— isolated or associated with pervasive suspiciousness; mood congruent or mood incongruent

b. Ideas of reference and ideas of influence: How ideas began, their content, and the meaning the patient attributes to them

4. Perceptual disturbances a. Hallucinations and illusions: Whether patient hears

voices or sees visions; content, sensory system involvement, circumstances of the occurrence; hypnagogic or hypnopompic hallucinations; thought broadcasting

b. Depersonalization and derealization: Extreme feelings of detachment from self or from the environment

5. Dreams and fantasies a. Dreams: Prominent ones, if patient will tell them;

nightmares b. Fantasies: Recurrent, favorite, or unshakable

daydreams E. Sensorium

1. Alertness: Awareness of environment, attention span, clouding of consciousness, fluctuations in levels of awareness, somnolence, stupor, lethargy, fugue state, coma

2. Orientation a. Time: Whether patient identifies the day correctly; or

approximate date, time of day; if in a hospital, knows how long he or she has been there; behaves as though oriented to the present

b. Place: Whether patient knows where he or she is c. Person: Whether patient knows who the examiner is

and the roles or names of the persons with whom in contact

3. Concentration and calculation: Subtracting 7 from 100 and keep subtracting 7s; if patient cannot subtract 7s, can easier tasks be accomplished—4 × 9; 5 × 4; how many nickels are in $1.35; whether anxiety or some disturbance of mood or concentration seems to be responsible for difficulty

4. Memory: Impairment, efforts made to cope with impairment—denial, confabulation, catastrophic reaction, circumstantiality used to conceal deficit: whether the process of registration, retention, or recollection of material is involved a. Remote memory: Childhood data, important events

known to have occurred when the patient was younger or free of illness, personal matters, neutral material

b. Recent past memory: Past few months c. Recent memory: Past few days, what did patient do

yesterday, the day before, have for breakfast, lunch, dinner

d. Immediate retention and recall: Ability to repeat six figures after examiner dictates them—first forward, then backward, then after a few minutes’ interruption; other test questions; did same questions, if repeated, call forth different answers at different times

e. Effect of defect on patient: Mechanisms patient has developed to cope with defect

5. Fund of knowledge: Level of formal education and self- education; estimate of the patient’s intellectual capability

and whether capable of functioning at the level of his or her basic endowment; counting, calculation, general knowledge; questions should have relevance to the patient’s educational and cultural background

6. Abstract thinking: Disturbances in concept formation; manner in which the patient conceptualizes or handles his or her ideas; similarities (e.g., between apples and pears), differences, absurdities; meanings of simple proverbs (e.g., “A rolling stone gathers no moss”) answers may be concrete (giving specific examples to illustrate the meaning) or overly abstract (giving generalized explanation); appropriateness of answers

F. Insight: Degree of personal awareness and understanding of illness 1. Complete denial of illness 2. Slight awareness of being sick and needing help but

denying it at the same time 3. Awareness of being sick but blaming it on others, on

external factors, on medical or unknown organic factors 4. Intellectual insight: Admission of illness and recognition

that symptoms or failures in social adjustment are due to irrational feelings or disturbances, without applying that knowledge to future experiences

5. True emotional insight: Emotional awareness of the motives and feelings within, of the underlying meaning of symptoms; does the awareness lead to changes in personality and future behavior; openness to new ideas and concepts about self and the important persons in his or her life

G. Judgment 1. Social judgment: Subtle manifestations of behavior that

are harmful to the patient and contrary to acceptable behavior in the culture; does the patient understand the likely outcome of personal behavior and is patient influenced by that understanding; examples of impairment

2. Test judgment: Patient’s prediction of what he or she

would do in imaginary situations (e.g., what patient would do with a stamped addressed letter found in the street)

III. Further Diagnostic Studies A. Physical examination B. Neurologic examination C. Additional psychiatric diagnostic studies D. Interviews with family members, friends, or neighbors by a

social worker E. Psychological, neurologic, or laboratory tests as indicated:

Electroencephalogram, computed tomography scan, magnetic resonance imaging, tests of other medical conditions, reading comprehension and writing tests, test for aphasia, projective or objective psychological tests, dexamethasone-suppression test, 24-hour urine test for heavy metal intoxication, urine screen for drugs of abuse

IV. Summary of Findings Summarize mental symptoms, medical and laboratory findings,

and psychological and neurologic test results, if available; include medications patient has been taking, dosage, duration. Clarity of thinking is reflected in clarity of writing. When summarizing the mental status (e.g., the phrase “Patient denies hallucinations and delusions” is not as precise as “Patient denies hearing voices or thinking that he is being followed.”). The latter indicates the specific question asked and the specific response given. Similarly, in the conclusion of the report one would write “Hallucinations and delusions were not elicited.”

V. Diagnosis Diagnostic classification is made according to DSM-5. The

diagnostic numerical code should be used from DSM-5 or ICD-10. It might be prudent to use both codes to cover current and future regulatory guidelines.

VI. Prognosis Opinion about the probable future course, extent, and outcome of

the disorder; good and bad prognostic factors; specific goals of therapy

VII. Psychodynamic Formulation Causes of the patient’s psychodynamic breakdown—influences

in the patient’s life that contributed to present disorder; environmental, genetic, and personality factors relevant to determining patient’s symptoms; primary and secondary gains; outline of the major defense mechanism used by the patient

VIII. Comprehensive Treatment Plan Modalities of treatment recommended, role of medication,

inpatient or outpatient treatment, frequency of sessions, probable duration of therapy; type of psychotherapy; individual, group, or family therapy; symptoms or problems to be treated. Initially, treatment must be directed toward any life-threatening situations such as suicidal risk or risk of danger to others that require psychiatric hospitalization. Danger to self or others is an acceptable reason (both legally and medically) for involuntary hospitalization. In the absence of the need for confinement, a variety of outpatient treatment alternatives are available: day hospitals, supervised residences, outpatient psychotherapy or pharmacotherapy, among others. In some cases, treatment planning must attend to vocational and psychosocial skills training and even legal or forensic issues.

Comprehensive treatment planning requires a therapeutic team approach using the skills of psychologists, social workers, nurses, activity and occupational therapists, and a variety of other mental health professionals, with referral to self-help groups (e.g., Alcoholics Anonymous [AA]) if needed. If either the patient or family members are unwilling to accept the recommendations of treatment and the clinician thinks that the refusal of the recommendations may have serious consequences, the patient, parent, or guardian should sign a statement to the effect that the recommended treatment was refused.