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The Psychiatric History and Mental State Examination

The Psychiatric History and Mental State Examination

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Published by Ema
History taking
History taking

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Published by: Ema on Aug 14, 2011
Copyright:Attribution Non-commercial

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06/10/2014

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8
The psychiatric history and mental state examination (MSE)
The psychiatric history and mental stateexamination (MSE)
In taking a psychiatric history and assessing the mental state, it iscrucial both to establish and maintain rapport and to be systematicin obtaining the necessary information. The outline below isintended as a schema for written documentation. Greater flexibilityis clearly required during the interview.
The psychiatric history
The history begins with an
introduction
noting the patient’s name,age, marital status, occupation, ethnic origin, religion and circum-stances of referral. Then follows the
complaint 
(in the patient’s ownwords) and the
history of the present illness
(duration, precipitatingfactors, effect on interpersonal relationships, working capacity and details of treatment to date). In the
 family history
, note parents’/sib-lings’ages, occupations, physical and mental health and relation-ships with the patient. If a relative is deceased, note the cause of death and the patient’s age at the time of death. Enquiry is made intofamily history of psychiatric illness (‘nervous breakdowns’),suicide, drug/alcohol abuse and forensic encounters.The
 personal history
 begins with the patient’s
early life and development 
including details of the pregnancy (? planned) and  birth (especially complications). Any serious illnesses, separationsin childhood or delays in development are noted. The childhood home environment is described (geographical situation, atmos- phere) as are details of school (academic achievements, relation-ships with peers, teachers). The occupational history should list jobs, reasons for change, work satisfaction, relationships with col-leagues. Document details of sexual practices (past/present abuse,sexual orientation, difficulties, satisfaction), relationships, marriage(duration, details of partner, children) and, in the case of women,menstrual pattern, contraception, miscarriages, stillbirths and ter-minations of pregnancy.
 Previous psychiatric history
(dates of illnesses, symptoms, diag-noses, treatments, hospitalizations) and 
 past medical and surgical history
are obtained. The patient’s alcohol, drug (prescribed and recreational) and tobacco
consumption
and any
 forensic
history arerecorded. The patient’s attitude to and practice of religion, politicsand hobbies are noted. The
 premorbid personality
(e.g. character,social relations) and finally, details of the present circumstances(accommodation, occupation, financial details), are described.
The MSE
The patient’s
appearance and behaviour 
are documented, includ-
1
Psychiatric history
IntroductionComplaintsHistory of present illnessFamily historyParentsSiblingsPersonal historyBirthDevelopmentSchoolOccupationsSexualAbuseOrientationMarriage/partnerHabitsAlcoholTobaccoDrugsPrescribedRecreationalReligionPast psychiatricMedicalForensicCurrent circumstancesPremorbid personality
Mental state examination
Appearance and behaviourThought (speech) formRateQuantityPatternFlight of ideasLoosening of associationsMood (subjective)Affect (observed)Thought contentPreoccupationsObsessionsOvervalued ideasIdeas of referenceDelusionsSuicidalityAbnormal experiencesHallucinationsPassivityThought interferenceCognitionConsciousnessAttention/concentrationMemoryOrientationIntelligenceExecutive functionInsightDifferential diagnosisPlan of investigationPlan of management
Informant historyPhysical examination
KRP01 7/11/05 5:27 PM Page 8

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