History taking & mental state examination Dr: Shahid Hussain ST6 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 out 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 & 3rd 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