Comprehensive Approach to Psychiatric History Taking and Mental Status Examination
A thorough psychiatric evaluation should include a structured mental status examination and targeted history components to ensure comprehensive assessment while identifying potential medical causes of psychiatric symptoms. 1
Patient History Components
Core Elements to Assess
- Current symptoms: severity, frequency, duration, and impact on functioning
- Previous similar episodes and pattern of symptoms
- Past psychiatric diagnoses and treatments
- Medication history: current medications, recent changes, adherence
- Substance use patterns (current and past)
- Suicidal/homicidal ideation and past attempts
- Treatment adherence history
- Collateral information from family/caregivers
Medical History Focus
- Medical conditions that may present with psychiatric symptoms
- Current medications that could affect mental status
- Recent changes in physical health
- History of head injury or neurological conditions
Mental Status Examination Framework
Appearance and General Behavior
- Physical appearance, grooming, hygiene
- Level of consciousness and alertness
- Psychomotor activity (agitation, retardation)
- Eye contact and interpersonal engagement
- Unusual mannerisms or posturing
Speech and Language
- Rate, volume, tone, prosody
- Fluency and articulation
- Quantity (poverty vs. pressure)
- Organization and coherence
Mood and Affect
- Self-reported mood
- Observed affect: range, appropriateness, intensity, stability
- Presence of anxiety symptoms
- Evidence of hopelessness or irritability
Thought Process
- Organization (logical, circumstantial, tangential, flight of ideas)
- Coherence and goal-directedness
- Thought blocking or insertion
- Racing thoughts
Thought Content
- Suicidal or homicidal ideation (requires detailed assessment)
- Delusions (type, fixity)
- Obsessions, phobias, preoccupations
- Paranoia or suspiciousness
Perceptual Disturbances
- Hallucinations (auditory, visual, tactile, olfactory, gustatory)
- Illusions
- Depersonalization/derealization
Cognition
- Orientation to person, place, time, and situation
- Attention and concentration (digit span, serial 7s)
- Memory (immediate, recent, remote)
- Abstract thinking and judgment
- Visuospatial ability
- Executive functioning
Insight and Judgment
- Awareness of illness
- Understanding of need for treatment
- Decision-making capacity
- Ability to anticipate consequences of actions
Physical Examination Components
Essential Elements
- Vital signs (temperature, pulse, blood pressure, respiratory rate)
- Neurological examination including:
- Cranial nerves
- Motor function (strength, tone)
- Sensory function
- Reflexes
- Coordination and gait
- Abnormal movements (tremor, dyskinesia, dystonia)
- Signs of substance intoxication or withdrawal
- Evidence of self-injury or trauma
Practical Implementation Tips
Establishing Rapport
- Begin with open-ended questions before specific inquiries
- Maintain a non-judgmental approach
- Explain the purpose of specific examination components
- Adjust approach based on patient's comfort and cooperation
When to Expand Assessment
- First-episode psychosis requires thorough medical workup
- Elderly patients with new psychiatric symptoms
- Patients with abnormal vital signs or physical findings
- History of substance use disorders
- Atypical presentation or treatment resistance
Common Pitfalls to Avoid
- Overlooking medical causes of psychiatric symptoms
- Relying solely on cognitive screening tools without clinical judgment
- Neglecting cultural factors in symptom presentation
- Failing to obtain collateral information when available
- Assuming lack of capacity based on diagnosis alone
- Ordering unnecessary laboratory and imaging studies 1
Special Considerations
Safety Assessment
- For patients with suicidal ideation, perform detailed risk assessment
- Place patient in safe setting without access to harmful objects
- Consider need for increased observation or supervision 2
Medical Clearance
- Focused medical assessments based on history and physical findings
- Routine diagnostic testing is generally low yield and unnecessary
- Target testing based on clinical presentation rather than routine panels 2
Documentation
- Document all components of the mental status examination
- Note specific observations rather than general impressions
- Include direct quotes from the patient when relevant to diagnosis
By following this structured approach to psychiatric history taking and mental status examination, clinicians can effectively assess patients with mental health concerns while ensuring appropriate identification of medical conditions that may present with psychiatric symptoms.