Psychiatric history

Aims
• Diagnostic
• To gain a biopsychosocial
understanding of the patient’s
problem
• Therapeutic & psychoeducational
 Psychiatric history
• Identifying features
– Age, sex, marital state, family,occupation, housing arrangements
• History of the presenting illness
– Precipitating events
– Risk assessment
• Past history
– Psychiatric
– Medical
• Family history
– Genetic background
– Family environment
• Social and personal history
– Developmental history
– Occupational history
– Relationship history
• Premorbid personality
• Mental State examination
 Assessment of Suicide
• Suicide is the unfortunate outcome of psychiatric illness. Assessing the risk
for suicide is an essential part of the psychiatric interview.
• Asking about this does not increase the risk or put the idea into the
patients head. It may reduce the risk as the patient may feel relief in
talking about their fears.
• The risk for suicidality is assessed by asking directly as to whether the
person has contemplated suicide.
• Have you thought that life was not worth living?
Or
• Have you felt so bad that you have considered ending it all?
If yes…
• Have you thought of killing yourself?
• Have you though how you might do this?
• Have you made any plans for doing this?
 THE MENTAL STATE EXAMINATION
ITEM WHAT IS ASSESSED, DESCRIBED OR OBSERVED

GENERAL DESCRIPTION
Appearance This includes a general description of the patients appearance, including body
build,posture, clothing (appropriateness), grooming (such as make-up) and
hygiene. Any physical stigmata (such as tattoos) should be noted. Facial
expression (depression, apprehensive, worried, etc.) should also be noted.
Behaviour This includes description of all aspects of the patients behaviour. The
appropriateness of the patients behaviour within the interview context should
be noted. Abnormal motor behaviour: mannerisms, stereotype movement, tics.
Variants of normal motor behaviour: restlessness
Attitude towards examiner This includes the way the patient responds to the interviewer, their level of co-
operation, their willingness to disclosure information. A range of attitudes,
deviation from appropriateness may occur, ranging from hostility to
seductiveness.
MOOD AND AFFECT

Mood Mood refers to a relatively persistent emotional state – describe the depth,
intensity, duration and fluctuations of mood. Mood may be described as neutral,
euphoric, depressed, anxious or irritable.

Affect This refers to the way a patient conveys his or her motional state. Affect may
be described as full, blunted, restricted or inappropriate.

Appropriateness Determine whether the patients responses are appropriate to the matter being
discussed

Speech The tempo, modulation and quality of the patients speech should be described
here. Note should be made of dysphasia or dysarthria (see chapter 10)
 THE MENTAL STATE EXAMINATION
ITEM WHAT IS ASSESSED, DESCRIBED OR OBSERVED

MOOD AND AFFECT

Perceptual disturbances
THOUGHT
The presence of hallucinations (auditory, visual, gustatory or tactile) should be
noted. It is important to check as to whether they occurred with a clear
sensorium. Hypnagogic or hypnopompic hallucinations are normal experiences.
Other perceptual disturbances such as illusions, depersonalisation or
derealisation should be noted.

Thought form An assessment needs to be made of the process of the patient’s thinking. This
involves the quantity of ideas (pressured thought, poverty of ideas) and the way
in which the ideas (thoughts) are produced. Are they logical and relevant,or are
they fragmented and irrelevant? Finally, The link between ideas needs to be
assessed – do they flow logically, or are they disconnected and ‘fragmented’?
Are ideas connected by spurious concepts (rhyming, the way they sound – ‘clang’
associations).
Thought content The content of the patients thought needs to be assessed. Abnormalities range
from: preoccupation, obsessions, overvalued ideas and delusions. In addition
themes should be assessed, such as suicidal or homicidal thoughts, or paranoid
ideas. In the medical setting preoccupation with illness (hypochondriacal
thoughts) need to be assessed, as well as thoughts of omnipotence – denying
illness when it is present
 THE MENTAL STATE EXAMINATION
ITEM WHAT IS ASSESSED, DESCRIBED OR OBSERVED

SENSORIUM AND COGNITION Listed below are bedside tests for a basic assessment of cognitive function. If
abnormalities are detected a full Mini Mental State Examination (table 5) should
be carried out.
Alertness and level of An assessment of the patients level of consciousness should be made along with
consciousness his or her level of consciousness. Clouding or fluctuating levels of consciousness
should be noted
Orientation Orientation to time, place and person should be assessed. Patient should be
asked; day, date, month and year. Where he or she is; and if he or she knows
who he or she is.
Short term memory Short term memory refers to the ability of the patient to retain information
over a period of 3-5 minutes. Less than this refers to immediate recall. The
patient should be asked to recall a list of 3 objects after 3-5 minutes.
Long term memory This refers to memory over remote events. The patient is asked to recall
events of the previous few days as well as events of a year ago.

Concentration Subtract 7 from 100 and keep subtracting 7, or spell WORLD backwards

General knowledge and Ask about some recent events. Intelligence can be gauged by their language.
intelligence The patient can be asked to do some simple arithmetic tasks, literacy should be
assessed.
JUDEMENT AND INSIGHT

Judgement Assess the patient’s capacity to behave appropriately. They can be asked a
hypothetical situation and asked how they would behave. I.e. What would you do
if you smelt smoke while sitting in a cinema?
Insight Assess if the patient is sware he or she has a problem, and their level of
understanding of this.
 formulation
PREDISPOSING PRECITATING PERPETUATING

BIOLOGICAL

PSYCHOLOGICAL

PSYCHOSOCIAL