History Taking

Question 1

What is the basic outline of a psychiatric history?

Answer 1

Patient Details
Presenting Complaint
History of Presenting Complaint
Previous medical and psychiatric history
Drug and allergies
Family medical and psychiatric history
Personal history
Social history
Drugs and Alcohol
Forensic History
Pre-morbid personality
Mental State Examination

Question 2

What aspects are considered in a mental state examination?

Answer 2

Appearance & Behaviour
Mood – Subjective, Objective & Affect
Speech
Thought-form
Thought-content (delusions)
Abnormal Perceptions
Thoughts of self harm
Suicidal and homicidal ideation
Insight
Cognition

Question 3

What things should be asked about in a past psychiatric history?

Answer 3

Past episodes/ diagnoses / contacts
Previous treatments (psychological, drug and physical)
Inter-episode functioning
Previous admissions to hospital
Attempted suicide/ repeated DSH
Previous detentions under Mental Health Legislation

Question 4

What things should be asked about in the family psychiatric history?

Answer 4

Parents, siblings, grandparents etc
Age, employment, circumstances, health problems, quality of relationship
Major mental illness in more distant relatives is important

Question 5

What psychiatry aspects are important in a past medical history?

Answer 5

Developmental problems
Head injuries
Endocrine abnormalities
Liver damage, oesophageal varices, peptic ulcers 
Vascular risks factors
Epilepsy

Question 6

What should be asked about in a drugs and alcohol history?

Answer 6

Regular or intermittent
Amount (know the units) 
Pattern
Dependence/ withdrawal symptoms
Impact on work, relationships, money, police
Screening questionnaires eg CAGE

Question 7

What questions are asked in the cage screening test for alcohol use?

Answer 7

Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Question 8

What should be asked about in the personal history?

Answer 8

Developmental milestones
Early life
Schooling
Occupational    
Relationships (sexual & marital history)
Financial
Friendships, hobbies and interests

Question 9

What is a good question to assess the pre-morbid personality of a patient?

Answer 9

How would your best friend describe you?

Question 10

What aspects are considered in the appearance section of the MSE?

Answer 10

Height/Build
Clothing - appropriate/inappropriate, kempt, bizarre
Personal hygiene - clean/unshaven/malodorous
Make up, jewellery, accessories

Question 11

What aspects are considered in the behaviour section of the MSE?

Answer 11

Greeting 
Non verbal cues
Gesturing - normal, expansive, bizarre
Abnormal movements - tremor, choreioathetoid movements, posturing, akathisia
Cooperative, rapport

Question 12

What aspects are considered in the mood section of the MSE?

Answer 12

Eye contact
Affect – objective manifestation of mood at i/v
Mood rating – subj & obj; rate out of 10;
Psychomotor function - retarded, agitated

Question 13

What aspects are considered in the speech section of the MSE?

Answer 13

Spontaneity
Volume - loud, quiet, poverty
Rate - pressured, slowed
Rhythm - rhyming and punning
Tone - monotonous, lilting
Dysarthria
Dysphasia - expressive/receptive

Question 14

What are some aspects of abnormal thought in the MSE?

Answer 14

Speed and tempo of thoughts
Types of thoughts demonstrated
Linkage and thought form
Possession of thoughts
Close relationship to speech - external manifestation of thoughts
Phobias
Obsessions 
Flight of ideas
Formal thought disorder – broadcast, echo, insertion, block, withdrawal
Knight’s move, derailment, loosening

Question 15

What are some aspects of abnormal beliefs in the MSE?

Answer 15

Preoccupations
Over valued ideas
Delusional beliefs - fixed, false belief out of cultural context; extraordinary conviction

Question 16

What are some aspects of abnormal perceptions in the MSE?

Answer 16

Illusions

Hallucinations

Question 17

What aspects are considered in the suicide section of the MSE?

Answer 17

Must always ask about suicidal thoughts
Ideation
Intent
Plans - vague, detailed, specific, already in motion
Also homicidal risk

Question 18

What aspects are considered in the cognitive function section of the MSE?

Answer 18

Orientation - time, place, person
Attention/concentration - throughout i/v
Short term memory - 3 objects; name & address
Long term memory - personal history
If any concerns - perform objective tests eg MSQ, MMSE, MOCA, FAS, Clock drawing, executive function tests

Question 19

What aspects are considered in the insight section of the MSE?

Answer 19

Best seen as spectrum that is very rarely 100% present/absent and varies over time/illness
3 questions – 
Are symptoms due to illness?
Is this a mental illness? 
Do they agree with treatment/Mx plan?

Question 20

What is psychopathology?

Answer 20

Psychopathology is concerned with abnormal experience, cognition and behaviour

Question 21

What is descriptive psychopathology?

Answer 21

Descriptive Psychopathology describes and categorizes the abnormal experience as described by the patient

Question 22

What is phenomenology?

Answer 22

Phenomenology in psychiatry refers to the observation and understanding of the psychological event or phenomenon so that the observer can as far as possible know what the patient’s experience feels like

Question 23

What is the difference between primary and secondary delusions?

Answer 23

Primary delusions are not understandable and are psychologically irreducible, while secondary delusions are understandable in the context of preceding affects or other experiences

Question 24

What are delusions?

Answer 24

A delusion is an unshakeable idea or belief which is out of keeping with the person’s social and cultural background; it is held with extraordinary conviction
grandiose
paranoid (correctly persecutory)-is anyone trying to kill you?
hypochondriacal
self referential

Question 25

What are the three classes of perceptual disturbances?

Answer 25

Hallucinations
Pseudohallucinations
Illusions

Question 26

What are hallucinations?

Answer 26

Have the full force and clarity of true perception
located in external space
no external stimulus
not willed or controlled
Can affect the 5 special senses-auditory, visual, tactile, olfactory and gustatory

Question 27

What are pseudohallucinations?

Answer 27

A pseudohallucination is an involuntary sensory experience vivid enough to be regarded as a hallucination, but considered by the person as subjective and unreal, unlike “true” hallucinations, which are considered real by patients

Question 28

What is an illusion?

Answer 28

An illusion has an external stimulus and is something that appears diffferent to what it actually is

Question 29

What is the ICD diagnostic criteria for depression?

Answer 29

Key symptoms:
persistent sadness or low mood;and/or
loss of interests or pleasure
fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
if any of above present, ask about associated symptoms:
disturbed sleep
poor concentration or indecisiveness
low self-confidence
poor or increased appetite
suicidal thoughts or acts
agitation or slowing of movements
guilt or self-blame
the 10 symptoms then define the degree of depression and management is based on the particular degree
mild depression (four symptoms)
moderate depression (five to six symptoms)
severe depression (seven or more symptoms, with or without psychotic symptoms)