(Chapter 5, Kaplan and Sadock’s 11th ed)

EXAMINATION AND
DIAGNOSIS OF THE
PSYCHIATRIC
PATIENT
Psychiatric Diagnosis
 Vs. Physical Diagnosis

 History:
physical symptoms vs. emotional, cognitive,
or behavioral symptoms
 Examination
P.E. vs. M.S.E.
PSYCHIATRIC DIAGNOSIS
 Interview: History and MSE
 Psychometric Testing
Intellectual assessment
Personality assessment
Neuropsychological assessment
 Medical and Laboratory Testing
 Physical Examination
PSYCHIATRIC DIAGNOSIS
 Interview: History and MSE
 Psychometric Testing
Intellectual assessment
Personality assessment
Neuropsychological assessment
 Medical and Laboratory Testing
 Physical Examination
HISTORY AND MENTAL STATUS EXAMINATION

The Psychiatric Interview

The Psychiatric Interview
 History
Subjective report of the patient
Report of collaterals (family, health profs)

 Mental Status Examination

Interviewer’s objective tool (similar to PE)
Initial interview
Aims:
 To obtain information that will establish
a criteria-based diagnosis

 To have a good understanding of the

biopsychosocial elements of the
disorder and come up with a
person-centered treatment plan
Parts of the INITIAL Psychiatric
Interview
 Identifying Data  Developmental and
 Source and social History
Reliability (Anamnesis)
 Chief complaint  Review of systems
 Present Illness  MSE
 Past Psychiatric  Other exams (PE)
History  Formulation
 Substance  DSM-5 Diagnosis
use/abuse  Treatment plan
 Past medical history
 Family history
Parts of the INITIAL Psychiatric
Interview
 Identifying Data  Developmental and
 Source and social History
Reliability  Review of systems
 Chief complaint
 Present Illness  MSE
 Past Psychiatric  PE
History
 Substance  Formulation
use/abuse  DSM-5 Diagnosis
 Past medical history  Treatment plan
 Family history
Psychiatric ROS
To obtain current physical or psychological
signs and symptoms not already identified
Neurological and systemic symptoms
○ weakness, fatigue
Illnesses that might contribute to presenting
complaints
○ Endocrine, hepatic, renal, musculoskeletal
Psychiatric ROS
 Mood symptoms
 Depression – sadness, loneliness, despair
 Mania – elation, agitation, hyperactivity
 Mixed – irritability
 Anxiety symptoms
 tremors, palpitations, diarrhea, worries
 Psychosis
 Hallucinations, paranoia, delusions
 Others
 ADHD, eating disorder symptoms
HISTORY and MENTAL STATUS EXAMINATION

The Psychiatric Case Report

I. Psychiatric History

A. Identifying Data
B. Chief Complaint
C. History of Present Illness (HPI)
D. Past Psychiatric and Medical History
E. Family History (social, psychological
background, family relations, issues)
F. Personal History (anamnesis)
II. Mental Status Examination (MSE)

A. Appearance
B. Speech
C. Mood and Affect
D. Thinking and Perception
E. Sensorium (A-O-C-M-C-F-A)
F. Insight
G. Judgment
E. Sensorium/Cognition
 Alertness
 Orientation
 Concentration
 Memory
 Calculation
 Fund of Knowledge
 Abstract Reasoning
 Insight
 Judgment
III. Further Diagnostic Studies
A. Physical examination
B. Neurological examination
C. Additional psychiatric diagnostic studies
D. Interviews with family members,
friends, or neighbors
E. Psychological, neurological, or
laboratory test (CT scan, EEG, MRI, IQ
tests, etc.)
Psychometric testing
 Neuropsychological assessment
 Personality Assessment
 Intellectual assessment

IQ tests
Weschler Adult Intelligence Scale (WAIS-R)
Weschler Intelligence Scale for Children (WISC-
R)
Personality Tests
 Objective Tests
Minnesota Multiphasic personality Inventory (MMPI)

 Projective Tests
Draw-A-Person (DAP) test
Rorschach’s (inkblot) Test
Thematic Apperception Test (TAT)
RORSHACH’S TEST
THEMATIC APPERCEPTION TEST
Neuropsychological Tests
 Halstead-Reitan Test
 Luria-Nebraska Battery
Other Examinations
 Physical Examination
 Medical and Laboratory Tests
Thyroid function test
Urine Tests for drugs
IV. Summary of Findings
 Mental symptoms
 Medical and laboratory findings
 Psychological and neurological test
results
 Current medications

 Clear and specific descriptions

V. Psychiatric diagnosis
 DSM-5 criteria and classification
 ICD-10 classification
Social (Pragmatic) Communication Disorder 315.39 (F80.89)
A. Persistent difficulties in the social use of verbal and nonverbal
communication as manifested by all of the following:

1. Deficits in using communication for social purposes, such as greeting and

sharing information, in a manner that is appropriate for the social context.

2. Impairment of the ability to change communication to match context or the

needs of the listener, such as speaking differently in a classroom than on the
playground, talking differently to a child than to an adult, and avoiding use of
overly formal language.

3. Difficulties following rules for conversation and storytelling, such as taking

turns in conversation, rephrasing when misunderstood, and knowing how to use
verbal and nonverbal signals to regulate interaction.

4. Difficulties understanding what is not explicitly stated (e.g., making

inferences) and nonliteral or ambiguous meanings of language (e.g., idioms,
humor, metaphors, multiple meanings that depend on the context for
interpretation).
B. The deficits result in functional limitations in effective
communication, social participation, social relationships, academic
achievement, or occupational performance, individually or in
combination.

C. The onset of the symptoms is in the early developmental

period (but deficits may not become fully manifest until social
communication demands exceed limited capacities).

D. The symptoms are not attributable to another medical or

neurological condition or to low abilities in the domains or word
structure and grammar, and are not better explained by autism
spectrum disorder, intellectual disability (intellectual developmental
disorder), global developmental delay, or another mental disorder.
VI. Prognosis
 Probable course, extent, outcome
 Good and bad prognostic factors
 Specific goals of therapy
VII. Psychodynamic formulation
 Causes of the breakdown; primary and
secondary gains; major defense
mechanisms used by the patient
VIII. Treatment Plan
 Should be comprehensive
 Requires a therapeutic team approach
Psychiatric Report
I. Psychiatric History
II. Mental Status
III. Further diagnostic studies
IV. Summary of findings
V. Diagnosis
VI. Prognosis
VII. Psychodynamic formulation
VIII. Comprehensive Treatment Plan
Psychiatric Report
I. Psychiatric History
II. Mental Status
III. Further diagnostic studies
IV. Summary of findings
V. Diagnosis
VI. Prognosis
VII. Psychodynamic formulation
VIII. Comprehensive Treatment Plan
 Thank you
 Thank you