History and Examination in Psychiatry

Dr Donna Arya

History

History Taking

In Psychiatry history= medical history and examination

Getting the environment rightThe basic introduction for any

patientOpen questions closed questions

Its all information! Active listening

What to include 1 Complains of..

Pts own words History of present case

How they came to your attention What did other people notice Effect on their life

Past Psychiatric History Fist illness Hospitalisations Use of Mental Health Act Use of previous medications

Medication and allergies Taking them?

What to include 2 Personal History

The pregnancy Developmental milestones Health and happiness in childhood School & qualifications Relationships Bullying Occupations Sexual history Current social situations▪ Married▪ Accomodation▪ Children▪ Financial situation

What to include 3

Substance misuse Smoking Alcohol Illicit drugs

Premorbid personalityPast Medical historyFamily historyForensic history

Mental State Examination

Introduction Equivalent of Physical Examination in

otherSpecialtiesHere and now- a snapshotSerial MSEs highlight progressDon’t assess mechanically, like a

checklistBest results- informal, conversational

styleObserve as well as listenQuote ‘verbatim’Conjure a mental image in listener

Main components

Appearance and BehaviourSpeech (thought form/ structure)MoodThoughts (content)PerceptionsCognition Insight Impression

Appearance & Behaviour

Age (range)Ethnicity (in

general)Appropriateness

of dress (kempt/

unkempt)Anything

striking,unusual, out of

place

RapportEye contactAppropriateness

of interactionMovements/

postureAnything

striking/ inappropriate?

Speech

Rate Volume Rhythm Tone Spontaneity Content

(good/poor) Coherence

Any thought disorder? Thought block Flight of ideas Circumstantiality Tangentiality Loosening of

associations Word salad Neologisms Rhyming/punning

Mood Subjectively

quote patient 0-10 scale

Objectively Somatic symptoms

sleep (EMW) appetite/ weight diurnal variation Concentration Energy libido

Other enjoyment/pleasure guilt/self blame self esteem Motivation hopes/future plans

Risk (or separately) Suicide DSH

Thought content

In general Open-ended

questions Preoccupations Obsessions/

compulsions Worries/anxieties Panic attacks Intensity▪ Delusions▪ overvalued ideas

Sub-types Paranoid▪ Persecutory▪ derogatory

Grandiose Religious Hypochondriacal Nihilistic Passivity

phenomena Ideas of reference

Perceptions Sensory modality

auditory visual olfactory gustatory tactile/somatic

Timing, associations,

frequency, coping strategies

Auditory 2nd/ 3rd person

Sub-types (content) Paranoid Persecutory Derogatory Grandiose Religious Hypochondriacal Nihilistic Command

CognitionOrientation

in time/ place/ personAttention/concentration/short term

memory Deduce from taking history/general

conversationAny concerns?

MMSE, frontal and parietal lobe tests, psychometry, MRI scan

Insight Why are you in hospital/clinic? Do you have an illness?

If so, is it physical, psychological, spiritual, social

What has made you ill? What will make you better?

Medication, talking therapy, housing? Do you want to keep taking

medication? Do you want to keep taking

drugs/alcohol? Where do you see yourself in 5 years?

Impression

Summarise main features in the MSE

Should help to make a diagnosisShould be taken in context of the fullPsychiatric History and Collateral

History

Practice Practice PracticeFurther PracticeObserve people’s behaviour

eg- night bus colleagues’ normal behaviour!

Simulated Auditory Hallucination Experiment

Observe other people’s interviews and

write MSERead experienced Clinician’s MSEsMore practice makes it second

nature