Psychology-MSE

• Differences between psychiatric diagnosis and medical

  diagnosis:

  → absence of etiological certainty in psychiatric disorders.

  → lack of external validating criteria
• Identifying data includes name, address, and contact information.
• The chief complaint is the symptom or condition that brings the patient to the doctor.
• The history of present illness includes the onset and precipitating factors.
• Past illnesses can include psychiatric, medical, alcohol and other substance history.
• Family history can include psychiatric and medical history.
• Personal history (anamnesis) involves having the patient recall what happened to them in the past that may have contributed to their present illness.
• Prenatal and perinatal history can include medical history.
• Early childhood history (birth through age 3) can include medical history.
• Middle childhood history (ages 3 - 11) can include medical history.
• Late childhood history (puberty through adolescence) can include medical history.
• Adulthood can include medical history.
• Occupational history can include medical history.
• Marital and relationship history can include medical history.
• Military history can include medical history.
• Educational history can include medical history.
• Religion can include medical history.
• Social activity can include medical history.
• Current living situation can include medical history.
• Legal history can include medical history.
• Sexual history can include medical history.
• Fantasies and dreams can include medical history.
• Values can include medical history.
• HISTORY OF PRESENT ILLNESS

  Comprehensive and chronological picture of the events leading up to the current moment in the patient's life.
• PAST ILLNESSES

  Transition between the story of the present illness and the patient's personal history;
• FAMILY HISTORY

  Any psychiatric illness, hospitalization, and treatment of the patient's immediate family members
• PERSONAL HISTORY

  ● Anamnesis

  ● Thorough understanding of the patient's past and its

  relation to the present emotional problem.
• Prenatal and perinatal

  1. Full-term pregnancy or premature
  2. Vaginal delivery or cesarean
  3. Drugs taken by mother during pregnancy (prescription and recreational)
  4. Birth complications
  5. Defects at birth
• Infancy and early childhood (0 – 3 years old)

  1. Infant and mother relationship
  2. Problems with feeding and sleep
  3. Significant milestones
  4. Other caregivers
  5. Unusual behaviors (e.g., head-banging)
• Middle childhood (3 – 11 years old)

  1. Preschool and school experiences
  2. Separations from caregivers
  3. Friendships/play
  4. Methods of discipline
  5. Illness, surgery, or trauma
• Adolescence

  1. Onset of puberty
  2. Academic achievement
  3. Organized activities (sports, clubs)
  4. Areas of special interest
  5. Romantic involvements and sexual experience
  6. Work experience
  7. Drug/alcohol use
  8. Symptoms (moodiness, irregularity of sleeping or

  eating, fights and arguments)
• Young adulthood

  1. Meaningful long-term relationship
  2. Academic and career decisions
  3. Military experience
  4. Work history
  5. Prison experience
  6. Intellectual pursuits and leisure activities
• Middle adulthood and old age

  1. Changing family constellation
  2. Social activities
  3. Work and career changes
  4. Aspirations
  5. Major losses
  6. Retirement and aging
• MENTAL STATUS EXAMINATION

  Describes the sum total of the examiner's observations

  and impressions of the psychiatric patient at the time of

  the interview
• OUTLINE OF THE MENTAL STATUS EXAMINATION

  1. Appearance

  2. Overt behavior

  3. Attitude

  4. Speech

  5. Mood and affect

  6. Thinking

  7. Perceptions

  8. Sensorium

  9. Insight

  10. Judgment
• Objective

  ● General Appearance

  ● Overt Behavior

  ● Attitude

  ● Speech

  ● Mood

  ● Affect
• Subjective

  ● Thinking

  ● Perceptions

  ● Sensorium

  ● Insight

  ● Judgment
• GENERAL APPEARANCE

  ● Describe the patient's appearance and overall physical

  impression, as reflected by posture, poise, clothing, and

  grooming.
• ii. OVERT BEHAVIOR

  ● Check for signs of anxiety such as moist hands, perspiring

  forehead, tense posture, and wide eyes.

  ● Observe for mannerisms, tics, gestures, twitches,

  stereotyped behavior, echopraxia, hyperactivity, agitation,

  combativeness, flexibility, rigidity, gait, and agility.
• Echopraxia is a meaningless imitation of

  movements just made by another person, occurring as a

  symptom of mental conditions.