Psychiatric history and mental state examination

Psychiatric History

Presenting problem(s)
Succinct statement, use patient’s own words

History of presenting problem

  • Onset, duration, effects on life and relationships
  • Events linked or coincident with onset
  • Solutions tried, any reasons why they failed
  • Mood and beliefs during last few weeks

Direct questions to elicit specific symptoms that support/refute particular diagnoses

  • Anxiety
  • Obsessions
  • Depression (anhedonia, hopelessness, helplessness, guilt)
  • Self-harm, harm others, suicidal thoughts, plans and ideas
  • Psychosis
  • Mania
  • Eating disorders
  • Drug and alcohol use

Past Psychiatric and Medical History

  • Psychiatric outpatient treatment and/or admissions (voluntary or under section)
  • Any previous deliberate self harm or suicidal attempts 
  • Relevant medical history

Drug History

  • Prescribed
  • Illicit drugs and dependency
  • Alcohol and dependency
  • Smoking

Family History
Construct genograms with occupations and any associated mental health problems

Personal and Social History

  • Early childhood:
  • Education
  • Occupational History (and any reasons for changing)
  • Psychosexual development
  • Present social circumstances: housing, finance, work, relationships, stressors and any changes from baseline

Forensic History
Police arrest and/or convictions for criminal activity, particularly violence against people

Premorbid Personality
Prior to period of ill health, when patient reports being well elicit self-description of their personality, mood, social and cognitive functionality

Mental State Examination

Appearance & Behaviour
Physical appearance, general attitude, motor behaviour

Speech
Volume, construction (flight of ideas), enunciation

Mood and affect

  •  Mood is the sustained emotional state, however, affect is the instantaneous emotional state
  •  Congruity of mood and affect with speech content
  •  Stability
  •  Emotional reactivity
  •  Subjective (patient’s version)
  •  Objective assessment
  •  ELICIT deliberate self-harm OR harm to others or suicidal thoughts (ideation, intent and lethality of plan)

Thought

  •  Depressive rumination
  •  Over-valued ideas
  •  Ideas of reference, self-referential ideation, grandiose ideas

Delusions

  • Thought withdrawal, thought insertion, thought broadcasting
  • Obsessional thoughts, preoccupations, compulsive traits (e.g. checking things repeatedly)
  • Subjective experience of thought disorder
  • Objective signs of thought disorder

Perception

  • Altered perception of real environmental object or stimuli
  • False perception, in absence of external object or stimuli: hallucination.
  • Auditory hallucinations: loud thoughts, thought echo, familiar or unfamiliar voices, 2nd or 3rd person, or voices giving commands
  • Depersonalisation

Cognitive and intellectual function

  • Level of consciousness (fully alert, fluctuates, clouded)
  • Orientation in time, place and identity
  • Attention and concentration: serial sevens, months in reverse
  • Memory: immediate (recall digit span); recent (recall an address), remote (recall personal history)
  • General Knowledge and intelligence

Formulation

  • Main presenting symptom(s) and why patient has become ill at that particular point in time:
  • Predisposing factors
  • Precipitating factors
  • Perpetuating factors

Insight
Subjective attitude towards illness and treatment

Differential diagnosis (most relevant equates to working diagnosis)

 

Dr Rajesh Varmamental state examination, psychiatric history