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Psychiatry History Taking

By Bikash Sharma, M.D


Howard University Hospital
2! "e#
$. Psychiatry History Taking
A) Introduction: To establish Rapport
Patients name (How patient wants to be addressed?)
Age
Living environment (Where do you live who do you live with sin!e when any !hanges
in "amily stru!ture and "un!tion)
Re"erral?
Who brought the patient to hospital?
B) Chief Complain/s: Reason "or the visit in #patients own words$
C) History of Presenting Illness: Revolve around the !hie" !omplain%s

Duration/ Progression of &
A""e!tive disorder&
Depression (SI!CAPS): Sad or depressed mood% Insomnia% uilt or
worthlessness or hopeless or helpless with no motivation % !nergy de!reased% Cognitive
problems li'e con!entration( attention( planning( memory% Anhedonia in!luding Appetite
disturban!e with or without weight !hange and libido % Psy!homotor retardation or
agitation% Sui!idal thoughts
"ania (DI#AS$): Distra!tibility% Irritability and Indis!retion (e)!essive
pleasurable but ris'y regrettable in the "uture a!tivities) % randiosity% #lights o" *deas%
A!tivity in!reased% Sleep de!reased need% $al'ativeness (pressured spee!h)
An)iety disorders& +A,% Pani! atta!' w% - w%o Agoraphobia% ./,
,elusional disorders 0AH (nature)% 1H% *.R% T*%T2%TW%,elusion3
4omati5ation disorders% 6alingering% "a!titious disorder
Post& traumati! stress disorder&
Precipitating/ predisposing/ perpetuating factors :
Any ongoing physi!al health symptoms or issues% medi!ine non&adheren!e new
medi!ations new dosing or s!heduling% so!io& e!onomi!al hardships% Legal problems%
reemergen!e o" old memories% substan!e abuse)

Ho% did the patient try to cope and get help in this situation&
1
Any treatments% .utpatient !are% P/P% Psy!hiatrist% /6
4ubstan!e Abuse (temporal relation to symptomatology) & i" yes( head trauma(
bla!'outs( sei5ures( into)i!ation and withdrawal et!7 Also in8uire about amount( duration(
"re8uen!y
Socio' occupational impairments due to !urrent episode and any /urrent legal
issues prior or a"ter the episode7
Now, I would like to know about what happened in the past.
(Mostly open ended questions)
D) Past "edical History:
Psychiatric%
& 4imilar episode in the past?
& Anyway di""erent to !urrent episode (mani!% hypomani! episodes in parti!ular in the
past an)iety "alse per!eptions and belie"s)
& /onte)t (pre!ipitating% predisposing% perpetuating "a!tors)
& 9irst episode (when and its nature)
& ,uration% Progression% Remission% Relapse
& 4ui!idal% Homi!idal ris' assessment (4everity o" past attempts Availability o" means at
present)
& Any treatments (6edi!ations in a !hronologi!al order with dose and duration whi!h
wor's and whi!h does not% adheren!e to medi!ation% overdosing on any medi!ations)
*npatient hospitali5ation highlights previous severity (:ame o" the
hospital%duration%out!ome%;/T& as' i" you may get in"ormation "rom there)%.utpatient
!are ("or how long How the patient "eel about the treatment o""ered? Any missed
appointments)
& Any allergies "rom any medi!ations? *" yes( nature and out!ome?
& Any psy!hiatri! diagnosis? Patients insight on own diagnosis and state o" mental
health?
Physical %
& Any medi!al diagnosis% surgery (hospitali5ations% medi!ations)? As' sel" !are and
management o" physi!al illness7 *n8uire !hroni! pain% :ar!oti!s?
& 4ubstan!e Abuse (temporal relation to symptomatology) & i" yes( head trauma(
bla!'outs( sei5ures( into)i!ation( withdrawal et!7
Also in8uire about *1 drugs (needle sharing?)( amount( duration( "re8uen!y( "irst use( last
use( longest sobriety( and any drug reha( programs7 As' about Legal issues
(!onvi!tion( incarceration)
& Any psy!hiatri! symptoms when sober (at the prison or during probation or at
rehab)
& 4o!io& o!!upational problems due to illness?
!) Personal/ #amily/ Social Histories:
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- 4iblings and parents (alive and dead)% single or both parents% Parents
o!!upations% Relationship with parents and siblings% 6other drug use % 2irth
history (mode o" delivery% preterm% LW2% !ongenital problems)
- How was li"e while growing up % Relationship with "riends( tea!hers and others %
:eighborhood% 9oster !are% Physi!al( se)ual abuse or emotional negle!t (i" yes(
age o" onset( !hara!ters o" perpetrator%s( duration( episodi! or !ontinual( help
see'ing (i" yes what was the result( i" not what stopped) % Witnessed any
violen!e7
- 4tatus o" siblings and !urrent relationship and support
- Highest edu!ational level attended% Any spe!ial !lasses % Reason "or not being
able to !ontinue s!hool% 9irst <ob % 9irst emotional relationship (se) o" the
partner( duration)%
- 6arried% single 0duration% times% separated or divor!ed% (reasons "or separation)3
- /hildren ( Planned or =nplanned Who they live with Any stressors ;)tra
responsibilities status o" "ather%s)
- 4e)ual a!tiveness% orientation% prote!tions% ;ver tested "or 4T,s
- ;mployment? ,o you en<oy the wor' that you do? Longest <ob( types o" <ob(
numbers o" <ob?
- *nterests% hobbies?
- Anyone in the "amily has any mental illness (*" yes what medi!ations they ta'e)
- Anyone in the "amily has any medi!al problems
- Anyone in the "amily !ommitted% attempted sui!ide% homi!ide (Witnessed or
unwitnessed)
- Anyone in the "amily with substan!e abuse
- What do you thin' what 'ind o" person you are? who you thin' 'nows and
understands you better (What does he% she says about you)
- Any sour!e o" motivation in li"e How do you !ope with stress 4pirituality
-
II) !*aluations:
A) "ental state !+amination',It is common that people in stress have problem with
memory and concentration. To test your memory, I am going to ask you ew questions,
some are very easy to answer and some may be a little diicult.!
I) Level o" Cons!iousness& normal" #lert, clouded,delirium,$btundation, %tupor,
coma
II) Appearan!e and general behavior: Age( se)( ethni!ity( build Appearan!e 0dress
(subdued%riotous)( grooming (imma!ulate%un'empt)( hygiene3 Attitude
0Postural orientation to e)aminer( ;ye /onta!t (dire!t%"urtive)( engage with
e)aminer( !ooperation( sedu!tive% de"ensive%hostile%paranoid% vague3
III) Spee!h> nature> ?uality& Rate ( rapid% pressured) rhythm ( "low or hesitan!y)
volume (hypo%hyperphonia) tone (6anner o" e)pression in spee!h pit!h(
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melody interval and duration in diatoni!) vo!abulary( word !hoi!e( dysprosody(
neologisms
I-) "otor a!tivity> gait( position( posture (ere!t%'yphoti!)( ti!s( gestures(
dys'inesia( a'athesia
-) A""e!t and mood> #ect is the patient@s immediate e)pression o" emotion mood
re"ers to the more sustained emotional ma'eup o" the patient@s personality7
Patients display a range o" a""e!t that may be des!ribed as broad( restri!ted(
labile( or "lat7 A""e!t is inappropriate when there is no !onsonan!e between what
the patient is e)perien!ing or des!ribing and the emotion he is showing at the
same time (e7g7( laughing when relating the re!ent death o" a loved one)7 2oth
a""e!t and mood !an be des!ribed as dysphori! (depression( an)iety( guilt)(
euthymi! (normal)( or euphori! (implying a pathologi!ally elevated sense o"
well&being)7 A""e!t must be <udged in the !onte)t o" the setting and those
observations that have gone be"ore. A""e!t A a7 ;)pression o" emotions>
range( "ull% !onstri!ted)( !hange o" pattern ( labile( monotonous( "luid(
appropriate) b7 *ntensity o" e)pression !7 !onne!tion with interviewerB
VI. $hought and per!eption> tenden!ies toward somati5ation or may be troubled
with intrusive thoughts and obsessive ideas7 #Have you ever seen or heard
things that other people !ould not see or hear? Have you ever seen or heard
things that later turned out not to be there?C Pro!ess (8uantity( speed(
!onne!tion( abstra!tion) !ontent ( an)iety( psy!hosis( sa"ety) per!eptions
( hallu!ination( illusion( depersonali5ation( dereali5ation) *ntelligen!e
-II) Insight / .udgment The patient@s attitude is the emotional tone displayed
toward the e)aminer( other individuals( or his illness7 *t may !onvey a sense o"
hostility( anger( helplessness( pessimism( overdramati5ation( sel"&!enteredness(
or passivity7 Li'ewise( the patient@s attitude toward the illness is an important
variable7 *s the patient a help&re<e!ting !omplainer? ,oes the patient view the
illness as psy!hiatri! or nonpsy!hiatri!? ,oes the patient loo' "or improvement
or is he or she resigned to su""er in silen!e?
-III) !)aminer@s rea!tion to the patient> The "eelings aroused in the e)aminer by the
patient are o"ten a sour!e o" very use"ul in"ormation7 These data are sometimes
subtle and easily overloo'ed as the e)aminer( in an attempt to remain ob<e!tive(
"ails to note how he or she is responding to the patient7A developing sense o"
dysphoria in the e)aminer may be the "irst !lue that the physi!ian is dealing
with a depressed patient7 9rustration may be the response to the help&re<e!ting
!omplainer while a "eeling o" being o""&balan!e and slightly out o" tou!h with
the !onversation may be an early indi!ation that one is dealing with a
s!hi5ophreni! patient7
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I/) Cogniti*e a(ilities (""S!)> Attention (!on!entration on simple tas'( pla!ing
minimal demand on language "un!tion( motor response( or spatial !on!eption7 *t
is a state o" wa'e"ulness> let patient tap ea!h time most "re8uently o!!urring
letter !omes) 0anguage 2asi! e)amination o" language "un!tion should in!lude
an assessment o" spontaneous spee!h (Loo' "or disorders o" arti!ulation(
abnormalities o" !ontent( disorders o" output( and paraphasi! errors7 &honemic
errors are mista'es in pronun!iation semantic errors are errors in the meaning
o" words neologisms are meaningless nonwords that have a spe!i"i! meaning
"or the patient)( !omprehension o" spo'en !ommands (tested with several levels
o" responses7 9irst the patient is as'ed !omple) yes and no 8uestions su!h as(
C,o you ta'e o"" your !lothes be"ore ta'ing a shower?C thereby minimi5ing the
need "or motori! and spee!h a!ts7 4e!ond( 8uestions where gesture alone !an be
an ade8uate response are as'ed( "or e)ample( CPoint to where people may sit
down in this room7C "inally( the patient is as'ed to "ollow a !ommand with a
motor response> C48uee5e my "ingers7C( Word&"inding disability may be
suspe!ted when spontaneous spee!h is halting in nature as the patient sear!hes
"or the proper word7 To test this ability( the patient is as'ed to name a number o"
ob<e!ts o" several !ategories ranging "rom the everyday to the more unusual7 To
stress this ability "urther the naming o" parts o" ob<e!ts( "or e)ample( the !rystal
o" a wat!h( the lead o" a pen!il( is also tested7 Word "luen!y is more spe!i"i!ally
tested by having the patient generate as many words in a given !ategory as he or
she is able in a "i)ed time period7 4tandard tests as' "or su!h things as Citems
"ound in a supermar'etC or Cwords beginning with the letters 9( then A( then
47C) reading ability and reading !omprehension (#/lose your eyes$)( writing(
and repetition (CThat@s what she said to them yesterday(C and C:o i"s( ands( or
buts7C)1 "emory and 2rientation> Three subunits> immediate re!all ( Tell me
what D things * say to you)( short&term memory ( A"ter E minutes)( and long&
term storage (Who is the president? And who was be"ore him?) Constructional
A(ility and Pra+is: Ideomotor apre+ia Cuse an imaginary s!issors(C Ideatory
apre+ia #ta'e this paper in your le"t hand( "old into hal"( and give it ba!' to my
right hand$) Constructional ina(ility: #draw this pi!ture% draw a !lo!' at
F>DG$A(stract 3easoning (*nsight% Hudgment% problem solving): 2est assessed
by probing into how the patient "un!tions on the <ob( in !ommunity a""airs( and
so!ial situations by pro)y interview as well as by patient interview7 4ome
elements !an be "ormally tested by having the patient per"orm !al!ulations
(!omple) as well as rote tables)( interpret proverbs( and des!ribe similarities
between ordered pairs( "or e)ample( CHow is a tree li'e a banana?C CHow is
praise similar to !riti!ism?C
B) Appropriate 3ating scales
III) Closing& #ny important thing that I missed to ask to you and that you think I should
know about'
Thank you so much or your time and cooperation.
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I-) Summery( %alient eatures.
( )hat" why you would like to ask more' *ating scales (M#+*%, young
mania scale, &#N%% etc)
'. BioPsychoSocial (orm)lation with +%M I,(T* a-is diagnosis as ramework based on
gathered inormations.
( Diagnostic criteria pyramid& SymptomsI Syndrome (A)is *) I Pathology&
Psy!hologi!al (A)is **) or Physiologi!al (A)is ***) I !tiology
( *+is $% '
(*+is $$. It is too early or me to make a personality disorder diagnosis rom /0 minutes
interview. 1owever, the patient has ollowing personality traits, which demand
consideration because these traits impact the ormulation and treatment plan. (Talk
relationship" conlicts with people)
I also noticed the use o ollowing deense mechanisms which the patient used at the
conte-t o a conlict around2222222222..
Narcissistic. distortion, denial, delusion, pro3ection
*mmature. #cting out, undoing, splitting, pro3ection, intro3ections, blocking, regression,
hypochondriasis, somati4ation, passive( aggressive, schi4oid antasy
Neurotic. Intellectuali4ation, *ationali4ation, reaction ormation, isolation o aect,
displacement, repression
Mature. #ltruism, 1umor, %ublimation, suppression
-I) $reatment plans:
Target symptoms are2222222222

Pharmacological

5onsideration based on indications, compliance, cost, contraindication, *eview the best
medication and alternative" %6s" patient education

Psychological, psychosocial

a) %upportive therapy( ocused on most pressing issues" symptoms (immediate crisis
management to reduce symptoms to premorbid level in all disorders

b) Interpersonal psychotherapy, 57T, 7rie psychodynamic psychotherapy (long term)

Short and long term goal&
( I there is intolerability issues switch to another meds.
( I there is no %ide 6ects, or pt can tolerate meds and there is obvious symptomatic
improvements based on rating scales, continue primary pharmacology or 8(9 weeks.
( I complete resolution o symptoms lasting : months (*emission), continue primary
medication
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( I incomplete resolution and"or complete resolution o symptoms but lasting less than :
months (partial remission) based on rating scale, do augmentation" combination"
switching.
( I no signiicant symptomatic improvements (ineicient) irst do reevaluation o
diagnosis; ind possible psychiatric (&T%+, #n-iety, $5+, &ersonality disorder,
%ubstance abuse) and medical conditions; then evaluate the adequacy o dosing and
adherence to medications as well as drug( drug interactions and metabolism.
( Thereore short term goal is to produce complete remission and prevent relapse and
long term goal is to produce recovery (complete sustained remission) and prevent
reoccurrence.
( <ltimately, pt should be able to start eeling better and unctioning (resume social"
occupational" personal such as hobbies and pleasure) at premorbid level


'$$. Prognosis& -./*PS0 compliance" chronicity, response to previous treatment,
accessibility (insurance, barrier to treatment) personality (deense), %ocial support.
'$$$. "ollow )ps. %ymptoms evaluation by appropriate screening tools" *isk assessment
(%uicide"homicide)" drug side eects" unhealthy behaviors and coping skills.
$1. .onstr)ction
A) Interests and Ho((ies (hedonia):
Reasons (less energy or less motivation or un'nown or !hange in interests or
Ale)ithymia)
B) #eelings of uilt>
(Appropriate vs7 inappropriate)( worthlessness% hopelessness% helplessness (reason and
severity assessment)
C) Sleep distur(ances:
,e!rease% :o need "or sleep with or without day time drowsiness ,yssomnias (.4A(
restless leg syndrome( periodi! limb movements( insomnia 0*nitial (R;6 laten!y)%
middle% terminal3( :ar!olepsy( Hypersomnia Parasomnia 4leep hygiene
D) 4uestions to e*aluate "ania:
Jou "elt so good or so Hyper that other people thought or said that you were not your
normal sel" or you were so hyper that you got into trouble?
.r anyone said to you that you were tal'ing too mu!h or too "ast and as'ed you to slow
down?
Jou were so irritable that you shouted at people or started "ights or arguments?
Jou "elt mu!h more sel" !on"ident than usual?
Jou got mu!h less sleep than usual and "ound you didnt really miss it?
Thoughts ra!ed through your head and% or you !ouldnt slow your mind down?
Jou were so easily distra!ted by things or people around you that you had trouble
!on!entrating or staying on tra!'?
Jou had mu!h more energy than usual?
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Jou were mu!h more a!tive and%or did many more things than usual?
Jou were mu!h more so!ial or outgoing than usual? 9or e)ample& you telephoned "riends
or "amily in the middle o" the night?
Jou were mu!h more interested in se) than usual?
Jou did things that were unusual "or you or that other people might have thought were
e)!essive( "oolish( or ris'y?
Jou spent money you got in things that later you regretted?
!) Suicide
4uestions $hat "ay Be Helpful in In5uiring A(out Specific Aspects of Suicidal
$houghts6 Plans6 and Beha*iors
2egin with 8uestions that address the patients "eelings about living
Have you ever "elt that li"e was not worth living?
,id you ever wish you !ould go to sleep and <ust not wa'e up?
9ollow up with spe!i"i! 8uestions that as' about thoughts o" death( sel"&harm( or
sui!ide
*s death something youve thought about re!ently?
Have things ever rea!hed the point that youve thought o" harming yoursel"?
9or individuals who have thoughts o" sel"&harm or sui!ide
When did you "irst noti!e su!h thoughts?
What led up to the thoughts (e7g7( interpersonal and psy!hoso!ial pre!ipitants(
in!luding real or imagined losses spe!i"i! symptoms su!h as mood !hanges(
anhedonia( hopelessness( an)iety( agitation( psy!hosis)?
How o"ten have those thoughts o!!urred (in!luding "re8uen!y( obsession 8uality( and
!ontrollability)?
How !lose have you !ome to a!ting on those thoughts?
How li'ely do you thin' it is that you will a!t on them in the "uture?
Have you ever started to harm (or 'ill) yoursel" but stopped be"ore doing something
(e7g7( holding 'ni"e or gun to your body but stopping be"ore a!ting( going to edge o"
bridge but not <umping)?
What do you envision happening i" you a!tually 'illed yoursel" (e7g7( es!ape( reunion
with signi"i!ant other( rebirth( and rea!tions o" others)?
Have you made a spe!i"i! plan to harm or 'ill yoursel"? (*" so( what does the plan
in!lude?)
,o you have guns or other weapons available to you?
Have you made any parti!ular preparations (e7g7( pur!hasing spe!i"i! items( writing a
note or a will( ma'ing "inan!ial arrangements( ta'ing steps to avoid dis!overy(
rehearsing the plan)?
Have you spo'en to anyone about your plans?
How does the "uture loo' to you?
What things would lead you to "eel more (or less) hope"ul about the "uture (e7g7(
treatment( re!on!iliation o" relationship( resolution o" stressors)?
What things would ma'e it more (or less) li'ely that you would try to 'ill yoursel"?
What things in your li"e would lead you to want to es!ape "rom li"e or be dead?
What things in your li"e ma'e you want to go on living?
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*" you began to have thoughts o" harming or 'illing yoursel" again( what would you
do?
#or indi*iduals %ho ha*e attempted suicide or engaged in self'damaging action(s)6
parallel 5uestions to those in the pre*ious section can address the prior attempt(s))
Additional 8uestions !an be as'ed in general terms or !an re"er to the spe!i"i! method
used and may in!lude>
/an you des!ribe what happened (e7g7( !ir!umstan!es( pre!ipitants( view o" "uture(
use o" al!ohol or other substan!es( method( intent( seriousness o" in<ury)?
What thoughts were you having be"orehand that led up to the attempt?
What did you thin' would happen (e7g7( going to sleep versus in<ury versus dying(
getting a rea!tion out o" a parti!ular person)?
Were other people present at the time?
,id you see' help a"terward yoursel"( or did someone get help "or you?
Had you planned to be dis!overed( or were you "ound a!!identally?
How did you "eel a"terward (e7g7( relie" versus regret at being alive)?
,id you re!eive treatment a"terward (e7g7( medi!al versus psy!hiatri!( emergen!y
department versus inpatient versus outpatient)?
Has your view o" things !hanged( or is anything di""erent "or you sin!e the attempt?
Are there other times in the past when youve tried to harm (or 'ill) yoursel"?
9or individuals with repeated sui!idal thoughts or attempts
About how o"ten have you tried to harm (or 'ill) yoursel"?
When was the most re!ent time?
/an you des!ribe your thoughts at the time that you were thin'ing most seriously
about sui!ide?
When was your most serious attempt at harming or 'illing yoursel"?
What led up to it( and what happened a"terward?
In short6 e*aluate follo%ings related to suicide attempt:
.irc)mstances
Isolation& somebody present% somebody nearby or in !onta!t (as by phone)% no
one nearby or in !onta!t7
$iming& timed so that intervention is probable% not li'ely% highly unli'ely
Pre!autions against dis!overy and%or intervention& no pre!autions% passive
pre!autions( e7g7 avoiding others but doing nothing to prevent their intervention
(alone in room( door unlo!'ed)% a!tive prevention( su!h as lo!'ing doors
A!ting to gain Help during or a"ter the attempt& noti"ied potential helper%
!onta!ted but did not spe!i"i!ally noti"y potential helper regarding% did not !onta!t
or noti"y potential helper
9inal a!ts in Anti!ipation o" death& none% partial preparation or ideations% de"inite
plans made (e7g7 !hanges in will( ta'ing out insuran!e)
4ui!ide 7ote& none% none written but torn up% present
Sel( report
Patient@s statement o" 0ethality& thought what he had done would not 'ill him%
unsure whether what he had done would 'ill him% very sure
9
4tated Intent& did not want to die% un!ertain or did not !are i" he lived or died%
did want to die
A!tion plan & impulsive( no premeditation% !onsidered "or KK L hour%
!onsidered "or KK L day% !onsidered "or II L day
3ea!tion to the a!t& patient is glad he has re!overed% patient is un!ertain
whether he is glad or sorry% patient sorry he has re!overed
*ct)al risk
Predi!table 2ut!ome in terms o" lethality o" patient@s a!t and !ir!umstan!es
'nown to him& survival !ertain% death unli'ely% death li'ely or !ertain
Would death have o!!urred without medi!al Intervention& no% un!ertain%yes
"nemonic' C33 (A7$IPH' 0IA3' 2I)
#) Auditory Hallucination>
True (doesnt have any !onstru!t or !omponent) vs7 Pseudo in nature> When "irst started?
Was the patient alarmed when the voi!es "irst o!!urred? How voi!es started (suddenly%
gradually?) With or without drug use? ,o they !learly spea'( or are they mu""led and
indistin!t? ,id he hear voi!es during !hildhood? How many voi!es? 6ale or "emale?
1oi!es o" 'nown people or o" stranger or living% dead people or "rom nonhuman li'e
+od( 4atan or !omputer? 1oi!es !ome "orm inside or outside the head? Hear in le"t% right
or both sides? Are these voi!es patients own thoughts spo'en out loud? ,o the voi!es
spea' dire!tly to the patient in the "irst person or tal' about the patient in the third
person? *" two voi!es( do they !onverse about the patient? ,o they run a !ommentary
about the patients a!tions( "eelings or thoughts? ,oes the patient tal' ba!' to the voi!es
o!!asionally( regularly or not at all? ,o voi!es give order? ,o these orders in!lude
harming one or others? /an the patient resist these !ommands or worried that he might
!arry them out? ,o voi!es insult or praise? ,o they upset the patient or ma'e him laugh
by !ra!'ing <o'es? ,oes the patient laugh to himsel" be!ause o" what the voi!es say? ,o
they ma'e the patient !ry or s!ream in "rustration? ,o voi!es o!!ur !ontinuously or
sporadi!ally throughout the day? What ma'es them more intense( de!rease( or stop? Are
they worse at any time during the day? ,o they stop when patient is eating( wat!hing T1
or reading maga5ine( tal'ing to someone? ,o they ever wa'e the patient up at night? ,o
they ever prevent the patient "rom "alling asleep? Have the voi!es led the patient to
be!ome more paranoid% suspi!ious towards others? ,o they ma'e him depressed( an)ious
or agitated? ,o voi!es tell i" patient is guilty o" sins or that he will go to hell to be
punished? ,oes the patient want voi!es to stop( or he li'es hearing them( regards them as
"riend and would miss i" they are disappeared? Have voi!es stopped in the past in
response to medi!ations( and did the patient dis!ontinue medi!ation <ust to have voi!es
return? Any other hallu!ination asso!iated?
) #or indi*iduals %ith psychosis6 as8 specifically a(out hallucinations and
delusions
/an you des!ribe the voi!es (e7g7( single versus multiple( male versus "emale(
internal versus e)ternal( re!ogni5able versus non re!ogni5able)?
What do the voi!es say (e7g7( positive remar's versus negative remar's versus
threats)? (*" the remar's are !ommands( determine i" they are "or harmless versus
harm"ul a!ts as' "or e)amples7)
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How do you !ope with (or respond to) the voi!es?
Have you ever done what the voi!es as' you to do? (What led you to obey the
voi!es? *" you tried to resist them( what made it di""i!ult?)
Have there been times when the voi!es told you to hurt or 'ill yoursel"? (How
o"ten? What happened?)
Are you worried about having a serious illness or that your body is rotting?
Are you !on!erned about your "inan!ial situation even when others tell you
theres nothing to worry about?
Are there things that youve been "eeling guilty about or blaming yoursel" "or?
H) Consider assessing the patient9s potential to harm others in addition to him'
or herself
Are there others who you thin' may be responsible "or what youre e)perien!ing
(e7g7( perse!utory ideas( passivity e)perien!es)? Are you having any thoughts o"
harming them?
Are there other people you would want to die with you?
Are there others who you thin' would be unable to go on without you?
I) Clinical Significances of "ental state e*aluation:
/) Documentation
Competency Assessment
a) Initial Assessment
+eneral perspe!tive or spe!i"i! (Psy!hiatri! hospitali5ation( ;/T)
9ind out the best language o" !ommuni!ation
,etermine i" patient has ade8uate in"ormation on whi!h to base a de!ision
664;> attention( !on!entration( memory
*n"orm the patient about the nature o" the disorder( A:, the ris' and bene"it
o" the PR.P.4;, treatment( and o" ALT;R:AT*1; treatments or o" :.
treatment
Repeat in"ormation number o" times and in di""erent ways7
Let the patient paraphrase or restate the understanding7
;valuate nature o" 8uestions that patient as's regarding treatment plan
*" patient has #severe de"i!it$ in understanding in"ormation&
incompetentArrange a process for , a su(stitute decision ma8er:
Periodical 3!assessment of competency ( if any change in clinical
conditions6 mental status or any modifications in treatment plan)
To be competent to !onsent to #treatment$( M !riteria must be satis"ied in a
patient> (Appelbaum P4 et al :;H6( LNFF and Tan!redi L et al *nternational
<ournal o" law and Psy!hiatry LNFO)
L7 able to !ommuni!ate a !hoi!e
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O7 to understand relevant in"ormation about the PR.P.4;, treatment and treatment
.PT*.:4
D7 to appre!iate own !lini!al situation (insight) ( i" a patient is in denial o" illness(
s%he will not be !onsidered !ompetent)
M7 to rationally manipulate (reasonable sensible sound ;udgment)
(Periodical reassessment)
() Self disclosure: Psy!hiatri! pra!ti!e is dependent on the patients sel" report "or almost
every aspe!t o" pra!ti!e( "rom diagnosis to therapy
Ac8no%ledge the uncertainty of treatment
& ;)plain ,*R;/TLJ to the patient that the !lini!ian 6=4T rely on patients sel"
dis!loser in order to be o" most help7
& ;)plain and as' e)pli!itly to the patient the ris' in withholding and bene"it in
providing in"ormation
& 9or those who do not understand the importan!e o" reporting potentially
dangerous thoughts or emotions or unable to report "or whatever reason
(in!luding denial o" illness) will re8uire more !onservative management7
9or those who su""i!iently understand the signi"i!an!e o" reporting their dangerous
thoughts or emotions( ,./=6;:T it7( i" patient later ele!t not to report and
!onse8uently engage in sel"& in<ury( this ,./=6;:TAT*.: will reveal that the
patient understood the ris' o" withholding in"ormation and that the de!ision not to
see' help was a deliberate (1.L=:TARJ) and RAT*.:AL !hoi!e
*+is $ Diagnosis presentation
Psychotic disorder&
%chi4ophrenia. a) %ingle episode, in partial remission (with prominent negative
symptoms) , in ull remission b) episodic, with interepisodic residual symptoms
( with"without prominent negative symptoms), without interepisodic residual symptoms
c)continuous ( w" or w"out negative symptoms)
%chi4ophreniorm. w" or w"out good prognostic eatures
%chi4oaective. 7ipolar type" depressive type
%I&+. %ubstance with onset during into-ication or during withdrawal
Mood Disorder&
%everity (mild" moderate" severe) with (i severe) mood = congruent or incongruent
psychotic eatures in partial" ull remission. Type. chronic" recent onset with catatonic"
melancholic" atypical eatures or with postpartum onset. ()ith or without ull
interepisodic recovery" seasonal pattern" rapid cycling. I bipolar I disorder, speciy i.
single manic episode, M*6 hypo manic, M*6 manic, M*6 mi-ed, M*6 depressed, M*6
unspeciied.

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randiosity ma'es him poor insight% <udgment (*ndis!retion) esp7 with re"eren!e to
a!tions (Physi!al A!tivities su!h as pleasurable but ris'y regrettable in the "uture or
6ental li'e #lights o" ideas) or spee!h ($al'ative) to the e)tent that he "eels no need "or
Sleep ("eels well rested despite not sleeping) and when intera!ting to the environment he
gets easily Distra!ted and he responds with deregulated emotion li'e Irritable % Angry%
Hostile% ;mbarrassing to sel" (internal) or to others (e)ternal)7


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