Download Psychiatric History Taking

Essential guide to the
psychiatric history
and
Mental state examination
for CT1s
Dr David Middleton
ST6, Cambridge
23rd August 2011
General Principles of History Taking
• Aim to understand problems/symptoms and effect
on life
• To put presenting problems into context by
enquiring about background history and previous
treatment
• Is followed by MSE
• Enables formulation to be reached
• Is therapeutic in itself
• Will vary according to setting (MHAA, A&E or OPD)
Preparing The Setting
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Safety
Privacy
Try to avoid interruptions
Arrange seating so sitting at angle to patient
Writing materials
Box of tissues.
Starting the Interview
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Put patient at ease
Introduce yourself and explain role
Introduce to anyone who is accompanying patient
Inform them about the length of interview
Need to take notes
Confidentiality
Interview Style
• Relaxed even if under time pressure
• Appropriate eye contact, appear interested
• Begin with a general question (e.g. “tell me about
your problem”)
• Have a systematic but flexible plan – at beginning
can be helpful to take a list of headings as prompt
• Keep in control.
• May need to interrupt:
 “I’m sorry but I need to move on to other things”
 “We can come back to this if we have time later”
Interview Techniques (1)
• Use of open questions where possible, especially
at beginning (e.g. “ how is your sleep?”)
• Closed questions are useful if time is short (e.g. “is
your sleep good?”)
• Avoid leading questions (e.g. “You have poor
sleep, don’t you?”
Interview Techniques (2)
• Encourage patient by mirroring their posture,
nodding and using phrases such as:
 “go on…”
 “tell me more about…..”
• Help them talk about painful or embarrassing
subjects by being non-judgmental, acknowledging
distress and explaining why you are asking:
 “I can see this is difficult to talk about…”
Interview Techniques (3)
• Summarise key points to check understanding
• As experience grows start to select questions
according to emerging diagnostic possibilities and
management options. This is becomes more
important when time is limited or patient
uncooperative
• Don’t take words at face value (e.g. “paranoid”)
• Pick up non-verbal cues
• Watch experienced clinicians and get them to
watch you!
• Video yourself
Interviewing Informants
• Always useful and more so if patient is cognitively
impaired, patient is concealing information
• Gain patient consent
• Often best to see patient alone first and then
informant
• Establish confidentiality (and limits)
• Ascertain informants concerns as well as gain
information.
• May need to help informant if stressed carer (carer
assessment)
Interviewing patients from other
cultures (cultural competency)
• Interview patients in first language where possible.
May need interpreter.
• Using interpreter’s skill. Discuss approach first.
Manageable chunks of information. 2nd person,
direct translation is most useful.
• Distress is shown via different symptoms (e.g.
physical rather then psychological symptoms)
• Cultural beliefs may include ideas that appear
delusional but are culturally acceptable
(e.g. witchcraft). Need collateral information.
• Treatment expectations may differ
Records
• Good notes are vital
• Record for you, aids formulation
• Record for others so history taking does not have
to be repeated, as a record of presentation for
future clinicians
• Patients may request access to them
• Life charts may be therapeutic way of recording
information together
The History (my preferred order!)
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Presenting complaint
History of presenting complaint
Past psychiatric history
Past medical history
Drug history
Family history
Personal history
Forensic history
Social history including drug/alcohol use
Premorbid personality
Presenting Complaint
• Who referred patient and what is their
concern/request
• Where is patient being seen.
• Are they voluntarily present or detained under MHA
(which section)
• What is their problem, in their own words
History of presenting complaint
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For each problem describe:
Nature
Precipitant/stressors
Onset, time span, development of symptoms,
fluctuations, factors worsening or improving
 Degree of functional impairment
 Level of distress
 Treatments attempted
Past Psychiatric History
• History of similar or other symptoms in past
• Previous diagnosis
• History of treatment – include from primary care,
counselling, CAMHS, complementary therapy as
well as mental health services
• Previous hospitalisation, MHA, medications, ECT.
• Recovery between episodes
• Previous DSH and suicide attempts
Past Medical History
• Chronology of illness and treatment
Drug History
• Current medications (including alternative
therapies)
• Allergies
• Check with GP
• Ask to bring list to appointment
Family History
• Parent: age (now or at death), occupation,
relationship with patient
• Siblings: as above
• Psychiatric history in family members (genetic and
effect on home life). Substance use, suicide.
• Genogram
Personal history
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Mother’s pregnancy, birth
Early development, illness
Childhood separation, emotional problems
Relationships with family members, atmosphere at
home
Schooling – academic performance and peer
relationships. (Bullying, school refusal, shyness,
conduct disorders)
Qualifications. Further education
Occupation(s), work performance
Sexual relationships, marriage, children
History of abuse (physical, sexual, emotional) in
childhood or adulthood
Forensic History
• Record all offences – convicted or not
• Violence/Anger, sexual offences particularly
important
• Persistent offending
• Probation
• Relationship to symptoms
Social history including
drug/alcohol use
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Current occupation
Working/off work – why?
Relationship status, support networks
Pastimes
• Alcohol, other substances, tobacco
 Pattern of use
 Age at onset
 Relationship to symptoms
 Harmful use
 Psychological dependency
 Physical dependency
 Previous detox
 Patient’s view
Premorbid Personality (1)
• Hard to assess at one-off interview and collateral
information should be sought.
• GP may have useful information
• Ask patient how others see them/would describe
them
• Prevailing mood; how they get on with people; deal
with stress; hobbies; standards.
Premorbid Personality (2)
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Impulsive
Prone to worry
Strict, fussy
Seek attention
Untrusting, resentful
Irritable
Sensitive
Suspicious
Argumentative
Lack concern for others
Mental State Examination
What is the MSE
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“Here and now” record of presentation
History will give clues as to likely symptoms
Systematic
Until more experienced carry out full mental state
Be observant but also learn the terminology to
describe symptoms/signs
• Use conventional headings to structure
examination – other colleagues and examiners will
expect it
MSE
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Appearance and Behaviour
Speech
Mood
Affect
Thought
Perception
Cognition
Insight
Appearance and Behaviour
Describe what you see:
• General appearance and behaviour. Striking
physical features. Posture.
• Physique, clothing, cleanliness, self-care, posture
• Eye contact, rapport
• Motor activity: agitation, retardation, stuperose
(akinesic and mute), abnormal movements (tic,
tardive dyskinesia, chorea, stereotypy, catatonic
features), mannerism, restlessness
• Tearfulness
• Distractibility
• Disinhibition
• “Appears to hear voices…”
• Preoccupied
Speech
• Rate: slow in depression; pressure of speech in
mania.
• Quantity: reduced (poverty) in depression and
chronic schizophrenia; flight of ideas in mania
• Volume
• Tone/rhythm: should have natural rhythm and
intonation
• Abnormal language: neologisms, word-finding
difficulties
Mood
Patient description: Sad, happy, on top of the world,
worried
Accompanying symptoms
• Depression: early morning wakening, diurnal
variation, anhedonia, loss of appetite, loss of
weight, fatigue, loss of concentration.
Hopelessness,
• Suicidal thoughts, plans, intent
• Anxiety: palpitations, dry mouth, sweating,
tremor
• Elation: Overactivity, excessive self-confidence,
reduced sleep, distractibility, increased libido
Affect
• Your objective description of emotion
• Depressed, anxious, fearful, irritable, suspicious,
perplexed, elated, angry
• Fluctuations: reactivity, lability (mania), blunting
(chronic schizophrenia)
• Consistent with thoughts/behaviour? Incongruity
seen in schizophrenia
Thought Content (1)
• Preoccupations: thoughts that recur frequently but
can be put out of mind
• Obsessional thoughts are ideas, images, impulses
that repeatedly enter mind in stereotyped form,
seen as senseless, distressing, recognised as own
thought even if repugnant.
• Compulsions are obsessional motor acts, often
resulting from obsession, may be attempt to
“neutralise” obsession.
• “Do you have to keep on repeating the same action
which most people would only do once?”
Thought Content (2)
Delusion is a false, unshakeable, belief that is out of
keeping with the patient’s social and cultural
background.
Primary Delusion: used to be thought diagnostic of
schizophrenia.
• delusional mood: something going on but not sure
what it is
• delusional perception: attribution of new meaning to
normally perceived object (e.g. traffic light change
means chosen to be Messiah)
• sudden delusional idea (autochthonous delusion):
sudden arrival of fully formed delusion, like a
“brain-wave”
Thought Content (3)
Secondary Delusion: explains another experience
such as auditory hallucinations
• Mood Congruent
• Content: persecution, infidelity, grandiose,
hypochondriacal, love, guilt, nihilistic, poverty,
reference, infestation.
Thought Content (4)
• Thought Interference - “loss of boundary with
outside world”, usually found in schizophrenia
Thought withdrawal: thoughts taken away (link with thought block)
Thought insertion: another agency’s thoughts implanted
Thought broadcasting: thought’s leaking, escaping, other people know
what thinking in unison (not thought echo)
• Passivity – humans usually experience actions,
thoughts, feelings as under their control but may
(usually in schizophrenia) experience them as
being under control of another agency
Derealisation and Depersonalisation
• Depersonalisation - feeling unreal
and unable to feel emotion; “as if cut off from world”
“watching self”
• Derealisation – feeling world is unreal
• Can occur in healthy people if tired
• Occurs in anxiety, depression, schizophrenia, TLE
• Unpleasant and very distressing
Perception (1)
• Illusion - Misperception of stimulus
• Hallucination – Perception experienced in the
absence of an external stimulus to the
corresponding sense organ.
• Can occur in any sensory modality: auditory, visual,
olfactory, gustatory, tactile, deep sensation
Perception (2)
• Hallucinations:
 Visual: more likely in organic conditions
 Gustatory: unpleasant taste. In schizophrenia,
TLE…may lead to delusion of being poisoned
 Olfactory: Schizophrenia, organic, TLE…may
believe result of gas being pumped into dwelling
 Tactile: touched, pricked, insects crawling on skin
(formication, drug withdrawal/cocaine addiction)
 Deep Sensation: often in schizophrenia…may be
sexual.
Auditory Hallucinations
• May be noises, whispers, partially organised
• 2nd person voices often in psychotic depression
Characteristic, but not diagnostic of schizophrenia:
• 3rd person discussing
• Running commentary
• Thought echo (echo de pensee,
gedankenlautwerden)
Cognition
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Orientation – time, place and person
Attention – digit span
Concentration – serial 7’s, WORLD
STM – name and address recall after 3 mins
LTM – history
Frontal Lobe – verbal fluency,
similarities/differences, Luria’s three stage task.
• General knowledge and intelligence – from
interview and PM, events
• Can use screening instruments: MMSE or ACE
Insight
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Awareness of abnormal state of mind
Understanding of cause
Understanding of benefits of treatment
Awareness of effects of not having treatment
Useful Reading
• Shorter Oxford Textbook of Psychiatry, Gelder,
Harrison & Cowen
• Cognitive Assessment for Clinicians, 2nd edition,
Hodges
• Fish’s Clinical Psychopathology, 3rd Edition, Casey
& Kelly
• Sims’ Symptoms in the Mind, Femi Oyebode