History Taking Flashcards
Talk through a complete psychiatric history
Patient details
Presenting Complaint
History of presenting complaint
Past psychiatric history
Past medical history
Medication history
Family history
Personal history o Birth and Development o Education o Occupation o Relationships o Social History
Substance Misuse History
Forensic History
Pre-morbid Personality
Mental State Examination
Physical Examination
Formulation
Management Plan
Talk through the mental state examination
Appearance and Behaviour
Speech and Language
Mood
Thoughts
Perception
Cognition
Insight and judgement
What do you look for in speech and language in the MSE?
- Fluency -> i.e. Rate, Rhythm and Volume
- Comprehension -> can you understand them?
- Relevant -> is what they say relevant?
- Spontaneous -> are their answers very direct or do they expand on the topic
- Unusual features
- –Repetition
- –Rhyming or punning
- –Verbal tics
- –Stutter
- –Excessive expletives
What do you look for in mood in the MSE?
Subjective mood
-how the patient feels in their own words
Objective affect
-how the patient objectively looks to you
Congruity
- does affect match what they are talking about
- e.g. smiling while talking about their kids -> congruous
- e.g. smiling while talking about death -> incongruous
Reactivity
- how does the affect change in conversation
- is it fixed? blunted? exaggerated? swinging (labile)?
What do you look for in appearance in the MSE?
APPEARANCE
What do you see? Start with the basic information and move to more descriptive terms, bearing in mind what may be relevant to a diagnosis.
Gender, height, apparent age (comment on whether it is different to chronological age), body habitus.
Comment on the level of self care, are they well groomed, in a state of neglect, unusual dress, extravagant make up etc.
Any distinguishing features such as scars, tattoos, needle sites
Comment on their level of consciousness, are they overly
sedated?
What do you look for in behaviour in the MSE?
BEHAVIOUR
Describe how you find the patient, their actions and interactions.
How engaging is the patient? Do they form a good rapport,
maintain good eye contact? Are they co-operative?
How is their non-verbal communication, such as facial expression
and body posture?
How is their manner? Are they overly familiar, aggressive, passive,
engaging, intimidating etc
Are they sedated or agitated? Are they distracted during the
interview?
Any characteristic movements like extra-pyramidal side effects,
involuntary movements and tics
What are the 5 thought forms?
Normal (linear)
Circumstantial
Tangential
Loosening of association
Flight of ideas
What are circumstantial thoughts?
the patient goes off topic, often making questionable links and being overly inclusive. However, eventually the patient comes to the relevant point.
What are tangential thoughts?
the patient goes off topic, but unlike circumstantial thoughts, loses sight of the purpose of the conversation, goes increasingly off topic, never coming to the relevant point.
What are loosening of association thoughts?
despite going off topic, tangential and circumstantial thoughts have links
that can be followed. However, in
loosening of association the
patient’s thoughts are so disordered that there is no link between statements or even words.
What are flights of thought?
This may present as similar to loosening of association, in that there is apparently no connection or link between thoughts. However, this is a feature of increased thought stream (such as in mania). The patient’s thoughts are racing so quickly that when the patient tries to talk they cannot keep up. As such, while you may hear unconnected words or statements, the actual thought
process is linear, and if you were to slow the thoughts down they would make sense.
What do you look for in thoughts during the MSE?
- Form - flow and connected nature of thoughts
- Stream - rate of thought
- Content
- Possession
What should you consider in thought content?
Predominant topic or issues
Preoccupations, ruminations, obsessions, anxieties, phobias
Hopeless or future orientated
Suicidal, self harm or homicidal ideation
Describe any delusions: o Grandiose o Persecutory o Delusions of reference o Nihilistic o Control/passivity
What are the 3 features to look for in thought posession”
Insertion
Withdrawal
Broadcasting
What do you need to ask about in perception during MSE?
Illusions
Hallucinations - ask about the various senses.
When asking about voices explore the nature, the content, the familiarity of the voice, whether it is second or third person,
whether it is commanding.
Depersonalisation, derealisation, déjà vu etc.
What do you need to ask about in cognition during MSE?
GOAL-CRAMP
General - Alertness and cooperation
Orientation - Time and Place
Attention - WORLD backwards, serial sevens
Language - Naming and repetition
Calculation - Division and subtraction
Right hemisphere - Intersecting pentagons/ clock face
Abstraction - Proverbs and similarities
Memory - Short and long term recall
Praxis - Physical instruction e.g. wave goodbye
What do you need to explore in insight and judgement during the MSE?
Awareness of disease:
Does the patient think they are unwell?
Does the patient know why they are seeing you?
Do they think they have a physical or mental illness?
Is the patient able to correctly label an abnormality?
How does the patient explain the symptoms they present with?
Willingness to take treatment:
Is the patient willing to take treatment?
Does the patient recognise any positive effect from medication,
currently or historically?
What does the patient think the medicine is doing?
