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dr. N.K. Sri Diniari, Sp.KJ
I. Interview tecnique
II. Psychiatric history
III. Mental status examination
IV. Multiaxial diagnosis
Interview Technique
• Privacy setting if possible
• Same level chairs, arranged at an angle
• Establishing raport, display empathy
• Note may be taken, explain to patient.
• Maintain good eye contact
• Seated closer the door
Interview Technique...
• Introduce yourself, ask them how they would
like to be addressed.
• Explain how long the interview
• Flexibility
• Use both open and closed question
Outline of Psychiatric History
I. Identifying data
II. Chief complaint
III. History of present illness
IV. Past illnesses
A. Psychiatric
B. Medical
C. Alcohol and other substance history
V. Current medication
VI. Family history
VII. Personal history
VIII.Premorbid personality
Identifying data
Name, age, sex, marital status, occupation,
race, religion, nationality, adress

Chief Complaint
In the patient's own words, states why he or
she has come
History of present illness
• Chronological background and development of
the symptoms or behavioral change that
culminated in the patient seeking assistance.
• Onset, duration, qualities, what make it better
or worse, Recent stressor that may contributing
• Detailed questions regarding the possibility of
the diagnosis
Consider the possibility of the diagnosis
Psychosis Mood Neurosis/anxietas

• Delusions, ideas of • Depressions • Fear, worry,

reference, Sad, anhedonia, low nervousness
incoherence, energi, hopeless, • Motoric tension:
hallusinations. suicide, etc Headache, inable to
Illusion, abnormal • Mania relaxs, trembling, etc
psychomotor grandiosity, decrease • Overactivity
behavior, etc sleep, talkactive, idea otonomic:
• Social withdrawal, of reference, etc palpitation, short of
affect blunted, apatis, • Bipolar breath, nausea,
etc (Mania + Depression) flushing, sweating, etc
• Impaired Reallity
Testing Ability (RTA)
• Impaired social
Mental Status Examination
1. General description
– Appearance
– Overt behavior
– Attitude
2. Speech
3. Mood and affect
4. Thinking Process
a. Form
b. Content
5. Perceptions
6. Sensorium & cognitions
7. Impulse instinct
8. Insight
9. Judgment
1. General description
1. Appearance:
1. Physical appearance: body type, posture, poise, clothes,
grooming, hair, and nails. healthy, sickly, ill at ease, old
looking, young looking, etc
2. Psychological appearance: disheveled, childlike, bizarre,
moist hands, perspiring forehead, tense posture, wide
eyes, suspicious look, blunted look, etc
2. Overt behavior
Friendly, attentive, interested, frank, seductive, defensive,
contemptuous, perplexed, apathetic, hostile, gigling, self
absorbed smiling, stupor, raptus, etc
3. Attitude toward examiner
Cooperative, uncooperative, Record the level of rapport
2. Speech

– Quantity, rate of production, and quality

– Fluent, nonfluent, mute/mutism, incoherent,
reticent, talkactive, stuterring, aphasia, etc
3.Mood and affect
– A pervasive and sustained emotion that colors
the person's perception of the world
– Depressed, despairing, irritable, anxious, angry,
expansive, euphoric, empty, guilty, hopeless,
futile, self-contemptuous, frightened, perplexed,
labile, fluctuating
– The patient's present emotional responsiveness,
inferred from the patient's facial expression
– Normal range, constricted, blunted, flat,
appropriate, inappropriate, etc
4. Thinking process
• Thought form
Non logic, logic, non realis, realis
• Thought flow
Mutism, blocking, incoherence, perseveration,
flight of idea, neologisme, etc
• Thought content
Preoccupations, obsessions, delusions,
compulsions, phobia, suicidal ideation, etc
5. Perceptions
• Hallucinations (e.g: auditory, visual, taste,
olfactory, or tactile)
• Illusions
• Depersonalization
• Derealization
6. Sensorium & cognition
• Consciousness
• Orientation (time, place, person)
• Concentration
• Memory
• Knowledge
• Abstrack thinking
7. Impulse instinct
• Sleep disorders (insomnia, hipersomnia, etc)
• Self-care (abulia, hipobulia, etc)
• Aggressiveness/impuls control
• Sexual problems
8. Insight
: Degree of personal awareness and
understanding of illness
Six levels of insight:
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, or on organic factors
4. Awareness that illness is caused by something
unknown in the patient
5. Intellectual insight
6. True emotional insight
9. Judgment
• Social judgment.
Does the patient understand the likely outcome of
his or her behavior?
• Test judgment.
Can the patient predict what he or she would do
in imaginary situations (e.g., smelling smoke in a
crowded movie theater)?
Multiaxial diagnosis

• Axis I: Psychiatric diagnoses; and other conditions

that may be the fokus of clinical attention
• Axis II: Personality disorders, mental
retardation, defence mechanism
• Axis III: Medical conditions
• Axis IV: Stressors
• Axis V: Global assessment of functioning
Example of multiaxial diagnosis
• Axis I : Schizophrenia Paranoid
• Axis II : Schizoid personality
• Axis III : Epilepsi, DM
• Axis IV : Problems breakup with boyfriend
• Axis V : GAF 70-61

I. (F00-F09) Gangguan Mental Organik &


(F10-F19) Gangguan Mental & Perilaku Akibat

Zat Psikoaktif

II. (F20-F29) Skizofrenia, Gangguan Skizotipal &

Gangguan Waham

III. (F30-F39) Gangguan Suasana Perasaan

IV. (F40-F48) Gangguan Neurotik, Gangguan

Somatoform & Gangguan Stress

V. (F50-F59) Sindrom Perilaku yang

dengan Gangguan
Fisiologis & Faktor Fisik

VI. (F60-F69) Gangguan Kepribadian & Perilaku

Masa Dewasa

VII. (F70-F79) Retardasi Mental

VIII. (F80-F89) Gangguan Perkembangan


IX. (F90-98) Gangguan Perilaku & Emosional

dengan Onset masa Anak & Remaja

X. (kode Z) Kondisi lain yang menjadi Fokus

Perhatian Klinik