Dr Donna Arya History and Examination in Psychiatry
History Taking • In Psychiatry history= medical history and examination • Getting the environment right • The basic introduction for any patient • Open questions closed questions • Its all information! • Active listening
What to include 1 • Complains of.. • Pts own words • History of present case • How they came to your attention • What did other people notice • Effect on their life • Past Psychiatric History • Fist illness • Hospitalisations • Use of Mental Health Act • Use of previous medications • Medication and allergies • Taking them?
What to include 2 • Personal History • The pregnancy • Developmental milestones • Health and happiness in childhood • School & qualifications • Relationships • Bullying • Occupations • Sexual history • Current social situations • Married • Accomodation • Children • Financial situation
What to include 3 • Substance misuse • Smoking • Alcohol • Illicit drugs • Premorbid personality • Past Medical history • Family history • Forensic history
Introduction • Equivalent of Physical Examination in other • Specialties • Here and now- a snapshot • Serial MSEs highlight progress • Don’t assess mechanically, like a checklist • Best results- informal, conversational style • Observe as well as listen • Quote ‘verbatim’ • Conjure a mental image in listener
Main components • Appearance and Behaviour • Speech (thought form/ structure) • Mood • Thoughts (content) • Perceptions • Cognition • Insight • Impression
Age (range) Ethnicity (in general) Appropriateness of dress (kempt/unkempt) Anything striking, unusual, out of place Rapport Eye contact Appropriateness of interaction Movements/ posture Anything striking/ inappropriate? Appearance & Behaviour
Rate Volume Rhythm Tone Spontaneity Content (good/poor) Coherence Any thought disorder? Thought block Flight of ideas Circumstantiality Tangentiality Loosening of associations Word salad Neologisms Rhyming/punning Speech
Subjectively quote patient 0-10 scale Objectively Somatic symptoms sleep (EMW) appetite/ weight diurnal variation Concentration Energy libido Other enjoyment/pleasure guilt/self blame self esteem Motivation hopes/future plans Risk (or separately) Suicide DSH Mood
In general Open-ended questions Preoccupations Obsessions/ compulsions Worries/anxieties Panic attacks Intensity Delusions overvalued ideas Sub-types Paranoid Persecutory derogatory Grandiose Religious Hypochondriacal Nihilistic Passivity phenomena Ideas of reference Thought content
Sensory modality auditory visual olfactory gustatory tactile/somatic Timing, associations, frequency, coping strategies Auditory 2nd/ 3rd person Sub-types (content) Paranoid Persecutory Derogatory Grandiose Religious Hypochondriacal Nihilistic Command Perceptions
Cognition • Orientation • in time/ place/ person • Attention/concentration/short term memory • Deduce from taking history/general conversation • Any concerns? • MMSE, frontal and parietal lobe tests, psychometry, MRI scan
Insight • Why are you in hospital/clinic? • Do you have an illness? • If so, is it physical, psychological, spiritual, social • What has made you ill? • What will make you better? • Medication, talking therapy, housing? • Do you want to keep taking medication? • Do you want to keep taking drugs/alcohol? • Where do you see yourself in 5 years?
Impression • Summarise main features in the MSE • Should help to make a diagnosis • Should be taken in context of the full • Psychiatric History and Collateral History
Practice Practice Practice • Further Practice • Observe people’s behaviour • eg- night bus • colleagues’ normal behaviour! • Simulated Auditory Hallucination Experiment • Observe other people’s interviews and • write MSE • Read experienced Clinician’s MSEs • More practice makes it second nature