History taking mental state examination Dr Shahid Hussain

History taking & mental state examination Dr: Shahid Hussain ST 6 Psychiatry of Acute Care

Lets revise • To assess the patient to identify any mental health difficulties. • Can be therapeutic. • Strongly variable on the basis of time, place & patient.

Set the scene • • Privacy & Confidentiality Try to avoid interruptions Safety- Seating arrangement Note taking

General principles • Put the patient at ease • Introduce yourself & anyone accompanying you & explain the role • Length of interview

Interview style • Keep relax & in control even in difficult situation • Appropriate eye contact, appear interested • Begin with a general question eg “tell me about your problem” • Have a systematic but flexible approach • May need to interrupt

Interview techniques • Open questions where possible • Closed questions can be helpful • Avoid leading questions eg “You have a poor appetite, don’t you? ”

Interview techniques • May need to explain the rationale of certain questions, eg abuse, criminal record etc. • Summarise to check understanding • Don’t take words at face value eg “paranoid” • Pick up non-verbal cues • Encourage patient by leaning forward, nodding, saying “go on” “tell me more about…. . ”

Collateral information • Always useful particularly if patient is cognitively impaired, patient is concealing information etc • Often best to see patient alone first and then with informant • Ascertain informants concerns as well as gather information. • Interview patients in first language where possible. May need interpreter • Symptomatology, cultural beliefs & treatment expectations may vary

History • Presenting Complaint • History of presenting complaint • Family History • Personal History • Past Psychiatric History • Past Medical History • Substance Use • Drug History • Forensic History • Personality • Current Social Situation

Presenting Complaint(s) • • Mode of referral Where is patient being seen. Presentation status eg informal etc What is their problem, in their own words

History of presenting complaint • Nature of problem • Chronology of each symptom • Onset & duration • Severity of symptoms & Degree of functional impairment Precipitating factors • Perpetuating factors Protective factors • Factors worsening or improving • Treatments trialled

Past psychiatric history • Similar or other symptoms in the past • Psychiatric diagnosis • Psychiatric admission • Any treatments (drugs, psychotherapy, psychosocial interventions, from primary care, counselling, CAMHS etc ) • ECT • Outcomes of treatment, any recovery, remission etc • Suicide, DSH attempts

Past medical history • Full medical history • Endocrine, CNS, systemic illness • Chronic medical conditions: diabetes, ischemic heart disease, epilepsy, asthma (use of steroids), CCF, stroke • Chronology of illnesses, hospitalizations • Recovery

Medications history • Current medications • All drugs taken for psychiatric or medical illness: dose, duration and outcome • Drugs that may precipitate psychiatric disorders • Side effects of psychiatric medication • Allergies • May need to check with the GP

Family history • Family tree to include patient’s siblings and parents eg adoptees, biological etc, separation, divorce, steps • Pt’s nature of relationship with the family & among family • Nature of death if any one not alive • Known or suspected Hx of mental illness • Suicides, suicidal behaviours or Hx of DSH in relatives • Hx of substance misuse

Personal history • Mother’s pregnancy • Neuro-developmental milestones – birth, walking, talking, sitting & socializing age • Childhood separation or emotional problems • Home & school environment (Bullying, school refusal, shyness, conduct disorders) • Schooling and academic achievements • Relationships with friends and family

Social history • Profession and employment record, Current employment • Financial situation in general • Current and past debt problems, spending etc • Marital status – single, married, divorced, widowed • Children – ages if dependent, parental responsibility • Housing situation, past and present-living alone • Stressors • Social supports • Typical day

Forensic history • Past and present charges, penalties, arrests and convictions (Violence/Anger, sexual offences etc) • Pending court cases • Unrecorded offences • Relationship to symptoms & substance misuse

Pre morbid personality • Life long persistent characteristics prior to illness • Moral and religious beliefs • Leisure activities and hobbies • How would others eg relatives/friends describe them

Mental state examination • Here and now • Hx- Symptoms • More reliant on observation & skilful exploration • History suggest relevant cluster of pathologies.

Appearance and behaviour • Body language & appropriateness of dress • Evidence of self neglect • Under or over psychomotor activity – excitation or retardation • Facial expression – dilated pupils, rigidity • Abnormal movements or posture • Rapport & eye contact • Distractibility • Disinhibition Preoccupation

Speech • Rate, tone & volume • Level of coherence • Rate: slow in depression; pressured in mania. • Quantity: poverty in depression & chronic schiz: • Pattern: spontaneous, coherence, circumstantial, trivial details eg obsessional traits, perseveration • Neologisms, word salad, FTD: loosening of associations

Mood • Subjective description-Sad, happy, top of the world, worried, up & down. • Objective • Range: depression – euthymic – euphoria • Inability to enjoy activities (anhedonia) • Inability to describe one’s emotion (alexithymia)

Affect • Your objective description of emotion • Depressed, anxious, fearful, irritable, suspicious, perplexed, elated, angry • Fluctuations: reactivity, lability (mania), blunting (chronic schizophrenia) • Congruent with thoughts/behaviour?

Thought • Pre-occupations: thoughts that recur frequently but can be put of mind eg obsessions, phobias & rituals • Form & content • Obsessions- ideas, images, doubts & images • Delusion. . out of keeping with the patient’s social & cultural background. • Primary & secondary delusions • Delusional perception: eg traffic light change means chosen to be Messiah.

• Content: persecution, infidelity, grandiose, hypochondriacal, love, guilt, nihilistic, poverty, reference, infestation. • Derealisation & depersonalization • First rank symptoms • Thought insertion, withdrawal, broadcast • Voices- echo, running commentary & 3 rd PAH • Passivity affect, action & impulse

Perceptions • Illusions • Hallucinations • Auditory (2 nd, 3 rd) visual gustatory, olfactory (organic, TLE), tactile (cocaine addiction, drug withdrawals) Pseudo-hallucinations Hypnopompic/hypnogogic hallucinations Functional/Reflex hallucinations Extracampine

Cognition • Orientation to time, place & person • Test short term and long term memory • Determine subjective and objective concentration levels • Carry out a MMSE • Separate poor concentration from memory problems

Insight • Awareness of abnormal state of mind • Insight rests on a continuum from being partially insightful to having insight • Ask the patient if they think they are ill • Mentally or physically • Ask the patient if they are willing to accept help • Ask the patient if they will take treatment

Multiaxial System • Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention • Axis II: Personality Disorders and Mental Retardation • Axis III: General Medical Conditions • Axis IV: Psychosocial and Environmental Problems • Axis V: Global Assessment of Functioning

Useful Reading • Lecture notes- Psychiatry • Shorter Oxford Textbook of Psychiatry (ed) Gelder, Harrison & Cowen • Fish’s Clinical Psychopathology, Casey & Kelly • Sims’ Symptoms in the Mind, Femi Oyebode • Psychiatric Inteviewing and Assessment, Poole & Higgo

This is to certify that: . . Has reviewed/completed. . . History Taking & Mental State Examination. . Date. . . . .