Psychiatric History Taking & Mental Status Examination (MSE)
Put patient at ease & establish rapport (use open ended questions & leave about 5 mins for this)
- introduce yourself & explain the purpose of your interview to the patient
- let the patient run the first few minutes & try not to interrupt
- Demographics & social circumstances 🡪 type of accommodation? Who do they live with? What kind of support? Employment or if unemployed 🡪 do they have any financial problems/support?
- “can you tell me about yourself?”
- “what are some of the things that have led up to you coming here today?”
- “I was wondering if you could tell me a little about any concerns that you have had”
Assess the 4 P’s:
- Predisposing – why is this patient vulnerable to developing this disorder?
- baby (genetic, prenatal insults, birth trauma)
- child (delayed development, behavioural problems, poor peer relationships, parental neglect, physical or sexual abuse)
- Precipitating – what has caused them to develop it now?
- stressful life events or non-compliance with medication
- Perpetuating – what is stopping them from getting better?
- ongoing substance abuse, ψ-social stressors (stopping them from recovering)
- Protective – what factors are supporting their recovery & preventing relapse?
- resilience or +ve prognostic factors such as family/ψ-social supports, stable accommodation, employment, absence of drug/alcohol abuse, children to care for
- Presenting Complaint (eg auditory hallucinations, bizarre delusions)
- (include duration & intensity of complaint, circumstances of presentation, stressors, etc)
- “what first made you first see a doctor?”
- “Can you tell me why you’re in hospital” or “tell me how you were referred here”
- ? recent suicide attempt
- ? recent self harm
- ? recent aggression/ violence
- History of Presenting complaint
- Make sure you get the chronology!
- “when did you last feel well?” (may get information about specific life events that trigger the symptoms)
- Look at landmarks if vague (eg “how were you feeling last Christmas holidays?”)
- Do SYSTEMS REVIEW FOR PARTICULAR SYMPTOM SYNDROMES
- depression system review
- psychosis system review
- anxiety system review
- personality system review
- Recent life events or stressors
- most stressful ψ-social stressors are: (in order)
- loss of child
- loss of spouse
- separation from spouse
Nb: must look at the subjective perception of life events as we all react differently
- Systematic Review of Biological Symptoms (affect on neurovegetative state)
Consequences of symptoms
- Impact of symptoms of daily life generally: family, relationships, study & work (ie are they still working?)
- Impact on neurovegetative symptoms: “SAME-L”
- Sleep – initial (can’t get to sleep), middle (waking up after going to bed), terminal (early morning waking)
- Appetite & Weight
- Memory & Concentration
- Energy levels
- Libido
- Previous Psychiatric History
- date, duration & nature of all previous episodes of illness
- what treatments were given & the effect & side effects
- don’t forget to ask about depots & ECT (a lot of pts forget)
- “have you ever been given regular injections?”
- “Have you ever needed to have blood tests to check on the tablets you were taking?”
- “Have you ever had ECT?”
- Quality of past therapeutic alliances (did they get along with their last psychiatrist?)
- Past Medical History
- never underestimate the value 🡪 organic disease (esp. if it causes disability or pain) may precipitate or maintain psychiatric illness
- some physical illnesses cause ψ as well as physical Sx (eg hypothyroidism can present with depression & hyperthyroidism can give manic Sx)
- medical treatments can affect mood (eg steroids)
- also important for implications of drug choice (eg don’t choose TCAs for man with BPH or else anti-cholinergic SE will worsen urinary retention)
- also need to check for diabetes as atypical antipsychotics can ↑ risk of metabolic syndrome
- in particular, ask about:
- head injuries (longer duration of post-traumatic amnesia = ↑ risk of cognitive impairment)
- fits/ faints/ funny turns
- Current Medications
- list type & doses of ALL medications (including complementary medications)
- find out how long they have been taking (most ψ medication takes at least 2-3 wks to start working)
- important to get ALL medications (even non-ψ because of drug interactions – either CYP or protein binding or renal clearance, etc)
- Compliance
- “some people tend to forget to take their medication when they have a few to take – have you ever forgotten to take your medication?”
- “Have there ever been times when you didn’t take your medication? What were your reasons for that?”
- Allergies & Side Effects
- helps with future drug choices
- Forensic History
- “ever had any trouble with the law or police in the past?”
- “any criminal charges or convictions?”
- Past history of aggression (what were the circumstances for the aggression? Context – alone or in a group?)
- Family History
- family history of ψ disorder or of suicide
- if members deceased – what were circumstances? Pt response to it? Subsequent effect on them?
- many ψ illnesses have genetic basis so FHx should be determined in as much detail as possible
- early relationships within the family are important esp. in depressive illness with strong associations between parental neglect or abuse (physical/sexual) 🡪 childhood attachments
- “did you feel loved by your parents as a child?”
- “did you feel that you got enough attention?”
- “were you ever abused as a child?”
- Personal History (big difference between other medical specialties & ψ)
- trace the pt’s development & achievements from conception to present
- gestation & delivery
- childhood milestones
- family relationships & upbringing
- peer relationships
- schooling & academic achievements
- occupational history
- marital & sexual history (why did relationships end? Any recurring patterns?)
- separations, losses & consequences of these
- capacity to learn trust, patterns of coping, response to stress & adversity
- Substance Use History
- needs to be very detailed (many students fail in this area)
- don’t take things at face value – many will under-report usage
- with alcohol – are they dependent? Will they undergo withdrawal? If M = 6-8/day, F = 4-6/day for 1/12 then they will have withdrawal syndrome & thiamine deficiency too ∴give 100mg thiamine IM (not oral because will often have chronic gastritis too so poor absorption) 🡪 Wernicke’s encephalopathy
| Category | Ever Used | Used in 1st month | Date last used | Drug Name | Frequency of use | Duration of use | Other |
| Nicotine | |||||||
| Caffeine (tea, coffee, cola) | |||||||
| Alcohol | |||||||
| Cannabis | |||||||
| Stimulants (cocaine, speed) | |||||||
| Opiates (heroin, codeine, morphine) | |||||||
| Benzodiazepines | |||||||
| Hallucinogens (LSD, mushrooms) | |||||||
| Inhalants (glue, solvents, paint, petrol, amyl nitrate) | |||||||
| Others |
- Current Circumstances
- housing/residential
- financial/economic/employment
- relationships/supports
- self care/ life skills
- other contacts
- other comments
- Collateral interview with relatives or significant others
- no ψ interview is complete without collateral history!
- Are there features which the patient neglected to mention or denied? Eg depression may actually be mania if relatives report on episodes of grandiosity & ‘highs’
That concludes the ψ history 🡪 now move onto the MSE which is akin to the physical examination…
MENTAL STATUS EXAMINATION
- use FORMAL terms to document the Hx
- (eg don’t say that they heard voices – report on auditory persecutory hallucinations)
- Appearance & Behaviour
- Physical features
- Dress & grooming
- Motor activity
- Posture
- Rapport
- Speech
- Quantity of speech–> Talkative, spontaneous, expansive, paucity, poverty of speech (i.e. – very little is said)
- Rate of speech –> Fast, slow, normal, pressured
- Volume (tone) of speech –> Loud, soft, monotone, weak, strong
- Fluency and rhythm of speech –> Slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic
- Response latency –> How long does it take the patient to respond? Emotion
- Mood
- Internal feeling or emotion
- Depression, euphoric, distressed, angry, elevated, euthymic, expansive, irritable
- Internal feeling or emotion
- Affect
- Current observed emotional state
- descriptors for affect include:
- Fluctuations in affect: labile, even, expansive
- Range of affect: broad, restricted
- Intensity of affect: blunted, flat, normal, hyper-energized
- Quality of affect: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable
- Thought
- Stream (i.e. speed)
- Poverty of thought (thought blocking)
- poverty of content (perseveration)
- racing thoughts/flight of ideas.
- Form –> Logical & goal-directed or disordered
- Loose associations: moving rapidly from one topic to another with no apparent connection between the topics.
- Circumstantial thoughts: these are thoughts which include lots of irrelevant and unnecessary details but do eventually come back to the point.
- Tangential thoughts: digressions from the main conversation subject, introducing thoughts that seem unrelated, oblique, and irrelevant.
- Flight of ideas: seen with fast, pressured speech. Ideas run into one another, making it difficult for the observer to follow the flow of speech.
- Thought blocking: sudden cessation of thought, typically mid-sentence, with the patient unable to recover what was previously said.
- Perseveration: refers to the repetition of a particular response (such as a word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a patient is asked what their name is, and they then continue to repeat their name as the answer to all further questions).
- Neologisms: words a patient has made up which are unintelligible to another person.
- Word salad: speaking a random string of words without relation to one another.
- content – delusions, obsessions, passivity
- Content
- Delusions:
- a firm, fixed belief based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms.
- Delusions can be mood congruent, such as grandiose delusions (e.g. that they have special powers) in mania.
- Obsessions:
- thoughts, images or impulses that occur repeatedly and feel out of the person’s control.
- The patient is aware these obsessions are irrational, but the thoughts continue to enter their head.
- Compulsions:
- repetitive behaviours that the patient feels compelled to perform despite recognising the irrationality of the behaviour.
- Overvalued ideas:
- a solitary, abnormal belief that is neither delusional nor obsessional but preoccupying to the extent of dominating the person’s life (e.g. the perception of being overweight in a patient with anorexia nervosa)
- Suicidal thoughts
- Homicidal/violent thoughts
- Delusions:
- Stream (i.e. speed)
- Perception
- Altered bodily experiences (eg depersonalization, derealization)
- passivity phenomenon
- illusion
- Hallucinations (eg auditory, visual, olfactory, tactile)
- Cognitive function
- Level of consciousness –> Alert, drowsy, delirium, stupor.
- Orientation –>Awareness to confusion of self, current setting, date & familiar people.
- Attention –>Need for redirection/repeating, sustained activity, distractibility.
- Memory –>
- Immediate (eg repeat numbers, names back)
- short-term (eg recall three objects at 2 and 5 minutes)
- long-term (e.g. recall events of past week).
- Ability –>Impression of current abilities; concrete to abstract thinking.
- Insight & Judgement
- Insight –> Intact, partial or poor insight.
- Ability to identify potentially pathological events (eg hallucinations, suicidal impulses);
- acknowledgement of a possible mental health problem;
- locus of control (internal v external).
- Judgment –> Intact to impaired judgment.
- Problem solving ability in context of current psychological state (can be explored by recent decision making).
- Insight –> Intact, partial or poor insight.