Psychiatric history

Aims • Diagnostic • To gain a biopsychosocial understanding of the patient’s problem • Therapeutic & psychoeducational

Psychiatric history
• • • • • Identifying features
– – – – – – – – – –

History of the presenting illness Past history
Precipitating events Risk assessment Psychiatric Medical

Age, sex, marital state, family,occupation, housing arrangements

Family history

Social and personal history
Developmental history Occupational history Relationship history

Genetic background Family environment

• •

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
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. 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 This includes the way the patient responds to the interviewer, their level of cooperation, their willingness to disclosure information. A range of attitudes, deviation from appropriateness may occur, ranging from hostility to seductiveness.

WHAT IS ASSESSED, DESCRIBED OR OBSERVED

Behaviour

Attitude towards examiner

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. This refers to the way a patient conveys his or her motional state. Affect may be described as full, blunted, restricted or inappropriate. Determine whether the patients responses are appropriate to the matter being discussed The tempo, modulation and quality of the patients speech should be described here. Note should be made of dysphasia or dysarthria (see chapter 10)

Affect

Appropriateness

Speech

THE MENTAL STATE EXAMINATION
ITEM
MOOD AND AFFECT Perceptual disturbances 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.

WHAT IS ASSESSED, DESCRIBED OR OBSERVED

THOUGHT 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). 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

Thought content

THE MENTAL STATE EXAMINATION
ITEM
SENSORIUM AND COGNITION

WHAT IS ASSESSED, DESCRIBED OR OBSERVED
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. An assessment of the patients level of consciousness should be made along with his or her level of consciousness. Clouding or fluctuating levels of consciousness should be noted 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 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. 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. Subtract 7 from 100 and keep subtracting 7, or spell WORLD backwards Ask about some recent events. Intelligence can be gauged by their language. The patient can be asked to do some simple arithmetic tasks, literacy should be assessed.

Alertness and level of consciousness Orientation

Short term memory

Long term memory

Concentration General knowledge and intelligence 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? Assess if the patient is sware he or she has a problem, and their level of understanding of this.

Insight

formulation
PREDISPOSING PRECITATING PERPETUATING

BIOLOGICAL

PSYCHOLOGICAL

PSYCHOSOCIAL

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