PSYCHIATRIC EXAMINATION

PARTS OF THE PSYCHIATRIC RECORD

I. Personal data and demographic information (Identification):

a, name, address, phone number (especially that of next of kin)
b, age
c, gender
d, place of birth
e, marital status
f, ethnic group
g, occupation
h, highest level of education

II. Circumstances of admission :Why the patient (client) has been admitted to the ward
(outpatient unit), who admitted the patient, when, who accompanied the patient (relative,
ambulance, police). Has the patient ever been treated on a ward before, if yes, when, where, and
what diagnoses did they get. was it a first or repeated admission. Did the patient consent to the
admission or was it a voluntary or a forced admission.

III. Autoanamnesis (History of Present Illness): (It is worth paying attention to what
complaints the patient tells unasked, and what has to be explored by asking questions. If a drug
wasn’t effective, ask what dose the patient took it in.)

a, current complaint, or complaints, problems (why the patient turned to a psychiatrist)

b, how the symptoms started, how long they lasted, and what their course was
c, occurrences that happened around the time the symptoms started, got worse, or
improved which can be:
1, other medical problems
2, social and financial difficulties
3, problems occurring in interpersonal relationships
4, problems at school or at work
d, period of patient’s development in which the symptoms started
e, changes in the patient’s personality that preceded or followed the development of the illness
f, changes in the patient’s emotions towards people important for them
g, changes in important routines like eating, interests, daily routine, sleeping, attitude to work
etc…
h, problems at the workplace, changing in performance
i, Why in particular did the patient come now?
j, the patient’s premorbid personality: mood (anxious, worrying, happy, optimist, pessimist,
low self-esteem, too much self-esteem, stable, changing, controlled or spontaneous), character
(sensitive, shy, suspicious, jealous, quarrelsome, irritable, impulsive, confident, egocentric,
proud, rigid, perfectionist, dependent), attitudes and values.

(In case of poor communication the anamnesis and mental state could be not completed, this
fact has to be documented.)

IV. Medical history (Past psychiatric and medical history):

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1. Previous and current somatic diseases:
a, other somatic illnesses
b, previous illnesses (e.g. infections)
c, losing consciousness
d, surgical interventions, accidents (head injury!)

2. Previous psychiatric illnesses (diagnoses, treatments, outcome):

a, diagnoses
b, medication
c, outcome of previous treatments

V. Gynaecological anamnesis (in case of female patients):

First period at the age of…
Last period at the age of…, year, month, day.
Were the periods regular, irregular, did dysmenorrhea, menorrhagia, premenstrual tension
occur?
What did the patient learn about menstruation and how? (This is especially important in case of
younger patients, adolescents, or patients with sexual identity problems.)
Method of contraception.
Pregnancies, abortions (artificial and spontaneous).

VI. Medication:
- what medication does the patient take
- does the patient take the prescribed dose
- does the patient have an allergy to any drugs (cave)

VII. Consumer goods and environmental effects:

a, smoking
b, alcohol
c, coffee
d, drugs
e, behavioural addictions

VIII. Family history:

- father: age (if deceased, why) state of health
- mother: age (if deceased, why) state of health
- siblings: age (if deceased, why) state of health
- children: (were they born out of a desired pregnancy), gender, age (if deceased, why) state
of health
Illnesses in the family:
- neurological illnesses (stroke, epilepsy)
- cardiovascular ailments (hypertension)
- diabetes
- tumour
- tuberculosis
- psychiatric illnesses
- suicide
- addictions (alcohol, drugs)

IX. Biography (psychosocial anamnesis) (Personal History) : (important interpersonal

relationships, important events from birth till the day)

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- Personality, temperament of family members, patient’s relationship with them. Patient’s
social role, social relationships in the family.
- The parents’ relationship to each other, their divorce, remarriage, rivalry with siblings, a
serious illness of one of the siblings, favouritism, spoiling of one child.

a, infanthood (circumstances of pregnancy, was it a desired pregnancy, circumstances of birth,

relationship between the parents, social and financial status of the family, parents’ state of
health, who cared for the patient, who raised them, separation from parent(s) (carers) and its
impact.)

b, childhood (periods of development e.g. walking, talking, potty training etc., important
occurrences in the family, younger siblings, first memories, major illnesses , especially if they
have affected the central nervous system, did the patient stutter, drawn-out enuresis, nightmares,
shyness, anxiety, specific fears)

c, school years (type of school, achievements, failures, relationship to teachers and classmates,
other performance connected to school, sports, community achievements)

d, adolescence (relationship to contemporaries, relationship to people of the opposite sex,

school, highschool, entrance exams, university studies, study groups, contests, relationship to
parents, aims, dreams, ambitions, first use of drug or alcohol)

e, adulthood
1, work, a chronological list of workplaces, reasons for changing jobs, satisfaction
with present job,
2, social relationships, friends (few or many, superficial or intimate, of same or of
opposite sex), relationship with colleagues, bosses, hobbies, interests, society or club
memberships,
3, sexual life, relationship to sexuality, hetero- and homosexual relationships, present
sexual relationship(s), contraception. If sexual life is satisfactory or not. (If the patient states
sexual problems as chief complaint you should explore this part thoroughly.)
4, marriage (family relationships), how long they had been engaged, how long they
have been married, previous marriages, engagements, divorces, reason for divorce, age,
occupation, personality of partner, patient’s relationship to partner. How decisions are made in
the family, what expectations the patient has of their marriage. Children and their relationship to
the parents.
5, financial circumstances
6, changes that come with age
7, alcohol and drug abuse
8, military service, conflicts, legal cases

f, plans for the future regarding family, work and interpersonal relationships.

X. Heteroanamnesis: (Can be obtained from relative, next-of-kin, guardian, neighbour, friend,

colleague etc. the help of which we can decide whether the information from the patient is
correct, and we are able to gain further important facts.)
Taking heteroanamnesis was not possible during the examination, as no important persons from
the patient’s social network were available.

XI. Physical and mental state

Internal medical state: internal state was not examined

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Neurological state: neurological state was not examined

Mental state examination:

1. Appearance
- general appearance: clothing, build
- facial expressions
- posture and movements

Negative state: Appearance is conventional / proper to the occasion, no sign of abnormal

movements.

2. Behaviour
- social behaviour: eg unduly friendly, bizarre, uncritical, aggressive, negativistic
- contact, eye-contact, co-operation
- disorders of motor behaviour (
Negative state: Behaviour is conventional, contact is easy to obtain, co-operation is good.

3. Speech
- rate, quantity, speed
- patient’s utterances

Negative state: Rate, volume of speech is average; tone is in accordance with the subject.

4. Awareness (consciousness)
Awareness is such an awakened state where we are adequately able to detect the stimuli from
the outside and inner world and understand their significance.

- watch out for possible fluctuations

Negative state: The patient is vigilant.

5. Orientation:

Examination:
a) autopsychic
- What’s your name?
- How old are you?
- When and where were you born?
- What’s your occupation?
- Are you married?
- Where do you live? (city)

a) allopsychic
- What’s my occupation? (doctor, student)
- Who are those people in the same room as you? (patients)
- Who takes care of you? (nurses)

a) in time
- What’s the date today? (day, month)
- What day of the week is it?
- What year are we in?

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b) in space
- Where are we now, what is this room? (examining room)
- What is this building, what is this institution?: (hospital, university, psychiatry)
- In which town, in which country are we in?: (Debrecen, Hungary)

Disorder: disorientation - partial

- total

Occurence of disorder:
- disorders of intelligence (total or partial)
- Korsakov’s syndrome (disorientation in time and space)
- schizophrenia (autopsychic)
- organic psychosyndromes: - delirium (in time and space)
- intoxications, fever, strokes,
after epileptiform convulsions

Negative state: The patient is well oriented both auto – and allopsychically, as well as in
time and space.

6. Apperception: Awareness of the meaning and significance of a particular sensory stimulus

as modified by one’s own experiences, knowledge, thoughts and emotions.

Examination:
Give an instruction which contains two or three parts (e.g. “Stand up, go to the door and open
it!”)

Disorders: disturbed apperception occurs in disorders of intelligence. Impeded/hampered

apperception.

Negative state: Apperception is intact, the patient’s answers are adequate; patient
performs two- and three-part commands faultlessly.

7. Attention: the ability to focus on the matter in hand. It selects among stimuli, might be
called the filter of the mind.

Characteristics:
- alertness
- capacity
- intensity
- tenacity (for how long the patient can focus it)
- vigilance (how easily the patient can change its object)

Examination:

a) Serial sevens test: ask the patient to subtract 7 from l00 and then take 7 from the
reminder repeatedly and observe the time and the number of errors)
b) Ask the patient to tell the days of the week or the months of the year in reverse order.

Disorders:
- reduction of each characteristic
- hypertenacity + hypovigilance (depression, epileptic, personality disorder)
- hypotenacity + hypervigilance (mania, schizophrenia)

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Negative state: Patient’s attention can be aroused, its capacity, intensity, tenacity and
vigility are intact.

8. Memory: the psychological function that forms, stores and recalls imagery.

Examination:
a) Short-term memory:
Ziehen’s test: Ask a multiplication (e.g. 9x7), then ask the patient to repeat 2 sequences
of numbers, then ask what the multiplication was.

b) Long-term memory: Ask for data the patient learnt at school and general knowledge.
Pay attention to the educational level!

Negative state: Short-term and long-term memory is intact.

9. Emotions: affect, mood: a complex feeling state with psychic, somatic, and behavioural
components that is related to affect and mood.

Examination: The patient’s mood can be judged more or less by their behaviour, facial
expressions and gestures. We have to be very careful in order to determine whether the patient
is dissimulating. The patient’s facial expressions and gestures have to be written down carefully.
It is also noteworthy if there is any discrepancy between the topic in question and the patient’s
behaviour.
What to do:
- write down our objective observations
- write down the patient’s subjective account (How do you feel now? How would you describe
your mood?)
- ask for how long the symptoms have been present
- ALWAYS ask whether the patient has had / has any suicidal thoughts or intentions or attempts
(This is a compulsory question which may indicate an endangering state that requires
institutional treatment.)

Disorders:

Negative state: Mood is appropriate/ patient is euthymic, affect is within the normal range.
Initiative is maintained. Patient denies having any suicidal thoughts or intent. No signs of
anxiety was detected.

9. Perception:

Definition: the uptake of stimuli through the sensory organs and their integration in the mind.

Examination
- If the patient doesn’t mention hallucinations then we have to ask direct questions. E.g.:
“Have you heard noises, voices or speech? Have you seen lights, figures, images which
others do not?”
- When writing down our findings we have to describe the type and content of the
hallucinations.

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Negative state: The patient denies having perceptional disorders. No sign of perceptional
disorders (illusion, hallucination) can be observed.

10. Thinking: The way in which a person puts together ideas and associations.

Examination: Observe the patient’s speech, ask him to tell a story or what he did the day
before. Observe whether the patient maintains the rules of grammar and logic. Ask indirectly
about unpleasant experiences, enemies, etc. All findings have to be written down meticulously.

Disorders:

I. Formal thought disorders:

1. disorders of speed
- slowing (depression, organic psychosyndromes, epileptic characteropathy)
- acceleration of speed (mania)

2. disorders of association
- incoherence: (loose associations) the patient’s train of thought is not respecting the rules
of logic. It can be primary, or secondary (e.g. when the speed of thinking is
accelerated).
- derailment: words form sentences but they do not respect the grammatical rules
- tangentiality: the thoughts only vaguely relate to the original topic
- circumstantiality
- neologism: inventing new words
- verbigeration: repeating words monotonously without meaning
- perseveration: repeating the same thought or action

Negative state: Rate of thinking is average, grammatical and logical rules are maintained,
patient keeps to original aim of thought. Delusions, overvalued ideas (preoccupations),
obsessional thoughts cannot be observed.

11. Insight: if the patient is aware of the illness, and how much they suffer under it.

Stages:
- total denial of illness
- feeble insight and need for help
- patient is aware of the illness, but blames others, circumstances, organic diseases
- the patient attributes the illness to an unknown internal cause
- the patient accepts the fact that they’re ill but doesn’t make any conclusions for the future
- the patient acts according to the conclusions they’ve made in order to get better

Negative state: Insight is appropriate.

12. Intelligence:

Definition: (according to Wechsler) a global ability of the person which enables them to think
rationally, act practically and manage their surroundings effectively.

Examination:
- in clinical practice (without the use of tests e.g. Wechsler’s Intelligence Scale) we assess the
ability to define, clarify and form certain conceptions (Kleist’s scheme)
- we have to ask questions according to the patient’s level of education

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 1. Definitions:
“What kind of furniture do you know?”
“What kind of vehicles?”
“What kind of tools?”
“What kind of illnesses?”
“What’s the common word for: pen, pencil, paper?”
“What’s the common word for: gold, silver, platinum?”
“How would you describe a table?”
“How would you describe sugar?”
“What is patriotism?”

2. Productive intelligence
“What is heavier: 1 pound of iron or 1 pound of feathers?”

3. Ask about the subtle differences between certain conceptions

“What is the difference between:
- a river and a lake
- a butterfly and a bird
- a staircase and a ladder
- the hand and the foot
- a loan and a gift
- cowardice and caution?”

4. Ask about symbolical thinking (meanings of proverbs)

e.g. “You can’t make an omelette without breaking eggs.” Sometimes it is advantageous to use
less well known proverbs.

Negative state: Patient’s intellectual capacity is in accordance with level of education.

13. Sleeping:

Examination: Ask if the patient has problems with going to sleep, how much they sleep, can
they sleep without drugs (sleeping pills).

Disorders: hypersomia, hyposomnia, insomnia

Negative state: Problems with sleep did not come to light.

14. Instinctive behaviour:

Appetite

Sexuality

Negative state: Patient’s appetite and sexual functions are sufficient.

XII. Summary:

1. Admission

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2. Anamnesis: previous illnesses, summary of treatment + autoanamnesis
3. Medication, allergies
4. Mental state
5. Diagnosis
6. Differential diagnosis
7. Suggestion of treatment
8. Course of illness (daily report) – if available