Transcript History and Examination in Psychiatry

Dr Donna Arya
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In Psychiatry history= medical history and
examination
Getting the environment right
The basic introduction for any patient
Open questions closed questions
 Its all information!
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Active listening
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Complains of..
 Pts own words
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History of present case
 How they came to your attention
 What did other people notice
 Effect on their life
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Past Psychiatric History
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Fist illness
Hospitalisations
Use of Mental Health Act
Use of previous medications
Medication and allergies
 Taking them?
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Personal History
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The pregnancy
Developmental milestones
Health and happiness in childhood
School & qualifications
Relationships
Bullying
Occupations
Sexual history
Current social situations
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Married
Accomodation
Children
Financial situation
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Substance misuse
 Smoking
 Alcohol
 Illicit drugs
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Premorbid personality
Past Medical history
Family history
Forensic history
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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
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Appearance and Behaviour
Speech (thought form/ structure)
Mood
Thoughts (content)
Perceptions
Cognition
Insight
Impression
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Age (range)
Ethnicity (in
general)
Appropriateness of
dress
 (kempt/unkempt)
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Anything striking,
unusual, out of
place
Rapport
Eye contact
Appropriateness of
interaction
 Movements/
posture
 Anything striking/
inappropriate?
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Rate
Volume
Rhythm
Tone
Spontaneity
Content (good/poor)
Coherence
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Any thought disorder?
 Thought block
 Flight of ideas
 Circumstantiality
 Tangentiality
 Loosening of
associations
 Word salad
 Neologisms
 Rhyming/punning
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Subjectively
 quote patient
 0-10 scale
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Other
 enjoyment/pleasure
Objectively
Somatic symptoms
 guilt/self blame
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 Motivation
sleep (EMW)
appetite/ weight
diurnal variation
Concentration
Energy
libido
 self esteem
 hopes/future plans
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Risk (or separately)
 Suicide
 DSH
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In general
 Open-ended questions
 Preoccupations
 Obsessions/ compulsions
 Worries/anxieties
 Panic attacks
 Intensity
▪ Delusions
▪ overvalued ideas
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Sub-types
 Paranoid
▪ Persecutory
▪ derogatory
 Grandiose
 Religious
 Hypochondriacal
 Nihilistic
 Passivity phenomena
 Ideas of reference
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Sensory modality
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auditory
visual
olfactory
gustatory
tactile/somatic
Timing, associations,
frequency, coping
strategies
 Auditory
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 2nd/ 3rd person
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Sub-types (content)
 Paranoid
 Persecutory
 Derogatory
 Grandiose
 Religious
 Hypochondriacal
 Nihilistic
 Command
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Orientation
 in time/ place/ person
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Attention/concentration/short term memory
 Deduce from taking history/general conversation
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Any concerns?
 MMSE, frontal and parietal lobe tests,
psychometry, MRI scan
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Why are you in hospital/clinic?
Do you have an illness?
 If so, is it physical, psychological, spiritual, social
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What has made you ill?
What will make you better?
 Medication, talking therapy, housing?
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Do you want to keep taking medication?
Do you want to keep taking drugs/alcohol?
Where do you see yourself in 5 years?
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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
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Further Practice
Observe people’s behaviour
 eg- night bus
 colleagues’ normal behaviour!
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Simulated Auditory Hallucination Experiment
Observe other people’s interviews and
write MSE
Read experienced Clinician’s MSEs
More practice makes it second nature