8. Psychiatric History, Clinical Interview & Mental Status Exam – Vocabulary Review

A comprehensive set of vocabulary flashcards covering key terms, concepts, and techniques from the lecture on psychiatric history taking, the clinical interview, and the mental status examination.

Psychiatric Interview

A multidimensional, biopsychosocial assessment that gathers information needed to create a person-centered treatment plan.

Biopsychosocial Model

Framework considering biological, psychological, and social factors in understanding mental disorders.

HIPAA

U.S. law that mandates protection of patient privacy and confidentiality in health care settings.

Consent to Interview

Patient’s agreement—voluntary or involuntary—to proceed with the psychiatric assessment after being informed of purpose and duration.

Confidentiality

Ethical and legal obligation to keep patient information private except under specific circumstances (e.g., duty to warn).

Duty to Warn

Legal requirement in many states (e.g., Illinois) for clinicians to notify potential victims and authorities if a patient poses a serious threat.

Transference

Patient unconsciously projects feelings and behaviors from past relationships onto the clinician.

Countertransference

Clinician unconsciously projects feelings from past relationships onto the patient, potentially affecting objectivity.

Rapport

Harmonious responsiveness between clinician and patient that fosters trust and openness.

Empathy

Clinician’s objective understanding of the patient’s feelings and thoughts while remaining detached enough to help.

Identification (Psychodynamic)

Over-involvement with the patient’s emotions, causing loss of objectivity—distinct from empathy.

Person-Centered Interview

Approach that prioritizes understanding the patient’s unique story over merely diagnosing disorders.

Open-Ended Question

Inquiry that invites a broad, narrative response (e.g., “Tell me what brings you in today”).

Closed-Ended Question

Inquiry that elicits a brief, often yes/no answer and may restrict patient narrative.

Chief Complaint

Patient’s main reason for seeking help, recorded in their own words.

History of Present Illness (HPI)

Chronological narrative describing onset, duration, severity, and context of current symptoms.

Psychiatric Review of Symptoms (PROS)

Systematic screen for mood, anxiety, psychotic and other psychiatric symptom clusters.

SIGECAPS

Mnemonic for major depressive symptoms: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidality.

Mania Symptoms

Impulsivity, grandiosity, decreased need for sleep, pressured speech, excessive energy, risky behavior.

Panic Attack

Sudden episode of intense fear peaking within minutes, with somatic symptoms like palpitations and shortness of breath.

Obsessive-Compulsive Symptoms

Unwanted intrusive thoughts (obsessions) and repetitive behaviors (compulsions) performed to reduce anxiety.

Post-Traumatic Stress Disorder (PTSD)

Condition with nightmares, flashbacks, hyperarousal, and avoidance after a traumatic event.

Psychosis

Loss of contact with reality, often featuring hallucinations, delusions, or severe thought disorganization.

Hallucination

Perception without external stimulus; auditory types most common in psychiatry.

Delusion

Fixed, false belief not shared by others and resistant to contrary evidence.

Paranoia

Persistent suspiciousness or belief of being persecuted or watched.

Past Psychiatric History

Record of prior psychiatric diagnoses, episodes, treatments, hospitalizations, and outcomes.

Lethality History

Assessment of past suicidal ideation, plans, attempts, and their medical seriousness.

CAGE Questionnaire

Four-item alcohol screen: Cut down, Annoyed, Guilty, Eye-opener.

Readiness for Change

Patient’s motivational stage—pre-contemplation, contemplation, or action—in addressing substance use.

Medication History

Detailed list of current and past psychiatric and medical drugs, doses, compliance, effects, and side effects.

Mental Status Examination (MSE)

Structured assessment of current cognitive and emotional functioning—the psychiatric counterpart of a physical exam.

Appearance and Behavior

Observations of grooming, posture, cooperativeness, and visible distress during the interview.

Motor Activity

Level and quality of movement—normal, bradykinetic, hyperkinetic, or abnormal (e.g., tics, tremors).

Speech

Assessment of fluency, amount, rate, tone, and volume (e.g., pressured, slowed, loud).

Mood

Patient’s sustained internal emotional state, ideally described in their own words.

Affect

Clinician’s observation of the patient’s emotional expression—range, intensity, and appropriateness.

Flat Affect

Severely limited emotional expression, often seen in schizophrenia.

Thought Content

Specific ideas, beliefs, and themes occupying the patient’s mind (e.g., obsessions, delusions, suicidality).

Thought Process

Organization and flow of thought—how ideas are connected (e.g., logical, tangential, circumstantial).

Circumstantiality

Over-inclusive speech with unnecessary detail that eventually reaches the point.

Tangentiality

Speech that departs from the topic and never returns to answer the original question.

Flight of Ideas

Rapidly shifting conversation with logically connected but fast, hard-to-follow topics—typical in mania.

Illusion

Misinterpretation of a real external stimulus (e.g., wind sounding like a name).

Depersonalization

Feeling detached from one’s body or mental processes, as if observing oneself externally.

Derealization

Sense that the external world is unreal, dreamlike, or distorted.

Cognition

Mental functions including alertness, orientation, concentration, memory, calculation, and knowledge.

Abstract Reasoning

Ability to shift between specific examples and general concepts (e.g., explaining similarities between objects).

Insight

Patient’s awareness of their illness, symptoms, and need for treatment.

Judgment

Capacity to make sound decisions and act appropriately in real-life situations.

Bradykinesia

Notably slowed motor activity, often observed in depression or medication side-effects.

Hyperkinesia

Excess motor activity as seen in anxiety, mania, or stimulant use.

Pressured Speech

Rapid, intense speech difficult to interrupt, characteristic of mania.

Akathisia

Subjective restlessness with observable movements, often a side-effect of antipsychotics.

Tardive Dyskinesia

Late-onset, involuntary movements (e.g., lip-smacking) due to long-term antipsychotic use.

Reinforcement (Interview)

Simple encouragers like “I see” or “Go on” that invite the patient to continue talking.

Reflection

Repeating the patient’s words to show understanding and prompt elaboration.

Summarizing

Periodic recap of key points to ensure shared understanding and transition topics.

Reassurance

Providing accurate information or commitment to help, aimed at reducing patient anxiety.

Acknowledgement of Emotion

Clinician explicitly recognizes patient feelings (e.g., moving tissues closer when patient cries).

Nonverbal Communication

Facilitating cues such as nodding, leaning forward, and attentive facial expressions.

Compound Question

Inquiry containing multiple parts, making it hard for patients to respond clearly.

Why Question

Often non-productive query that can feel accusatory and hamper patient openness.

Minimizing Patient Concerns

Obstructive intervention where clinician downplays patient distress, hindering rapport.

Premature Advice

Giving recommendations before gathering adequate information; can feel dismissive.

Premature Interpretation

Early analytical statement that may provoke defensiveness and miscommunication.

Obstructive Intervention

Any clinician behavior (verbal or nonverbal) that impedes the patient’s narrative flow.

Safety and Comfort

Strategies ensuring both patient and clinician feel secure, such as clear exits and staff presence if needed.

Initial Interview Timeframe

Typical duration of 45–90 minutes; shorter (20–30 min) if patient is distressed or confused.

Mini-Mental Status Examination (MMSE)

Brief cognitive screening tool often incorporated within the broader MSE but not equivalent to it.