Psychiatric History Taking, MSE, Formulation

Question 1

Why do we take a psychiatric history/mental state exam?

Answer 1

• Diagnosis & individual plan
• Risk
• Prognosis

Question 2

What are the important sections or differences in a psychiatric history?

Answer 2

• More individual impact
• Past psychiatric history/family history of psychiatric problems
• Forensic history
• Importance of drug/alcohol
• Importance of social history – true bio-psycho-social

Question 3

What are the steps in a history → on mental health?

Answer 3

1. Demographics
   
   • Who
   • What MHA (mental health act)
2. PC/HPC
   
   1. What happened?
   2. Why now?
   3. Symptom exploration
   4. Impact
3. Psychiatric history (past episodes)
   
   1. What (triggers, treatment, self-harm/suicide)
   2. When
   3. Who involved (GP, section)
   4. Outcome
4. Medication
   
   1. Now
   2. Past
   3. Opinion
   4. Allergies
5. Family history
   
   1. Medical
   2. Psychiatric (genetic component)
6. Drug/alcohol history
   
   1. Sensitive
      
      1. ‘This is a question I ask everyone’
   2. What
   3. When
   4. Dependence
   5. Behaviours
      
      1. Food? How pay for it?
7. Forensic history
   
   1. Offences
   2. Charges
   3. Prison
   4. Bail
8. Personal history
   
   1. Childhood (services, siblings, family)
   2. Development (milestones)
9. Social circumstances
   
   1. Life events
   2. Home
   3. Work
   4. Relationship
10. Pre-morbid personality
    
    1. Character
    2. Hobbies & Habits
    3. Aims & aspirations
    4. Relationships
    5. Mood
    6. Stressors
11. Collateral history
    
    1. Important in dementia, autism, severe psychosis, depression

Question 4

What is the mental state examination?

Answer 4

• Mental state is the psychiatric examination, used in conjunction with the history
• Its time specific
• It includes the lived experience (subjective) and the observed experience (objective)

Question 5

How is a mental state examination done?

Answer 5

• Observation
  
  • Appearance and behaviour
  • Speech
    
    • Rate
    • Tone
    • Volume
    • Quantity and quality of information
  • Mood and affect
    
    • Mood → depressed, euphoric, suspicious, labille
    • Affect → restricted, flattened, inappropriate
  • Thought
    
    • Form
      
      • Amount of thought and rate of production
      • Continuity of ideas
      • Disturbance in language or meaning
    • Content
      
      • Delusions
    • Perception
      
      • A change in reality as experienced by the individual
      • May include hallucinations
        
        • Olfactory
        • Gustatory
        • Tactile
        • Somatic
      • Derealisation, depersonalisation
    • Cognition/insight
      
      • Cognition
      • Insight (does patient think there is problem and will they accept treatment)
• Discussion
• Exploration

Question 6

What are some questions relating to psychotic phenomena?

Answer 6

• Do you ever:
  
  • Hear noises or voices when there is nobody else around? and no ordinary explanation seems possible?
• Have you had the feeling that:
  
  • People have been overly interested in you - or that things have been a special meaning for you?
  • Harm might come to you?
• Have there been any other:
• Odd or unpleasant experiences of any kind recently?
• Do you feel in control of you thoughts and actions?
• Do you ever feel compelled or ordered to act in a certain way?

Question 7

How to ask questions about suicidal thoughts?

Answer 7

Question 8

What are the risk factors to suicidal thoughts?

Answer 8

• Direct statements of suicide
• Male
• Divorced/widowed
• Psychiatric diagnosis
• Chronic physical illness
• Social isolation
• Recent loss
• Previous Deliberate Self Harm
• Hopelessness

Question 9

What is the management of risk factors of suicidal thoughts?

Answer 9

Risk Management

• Monitor mental state
• Treat underlying disorder
• Challenge hopelessness
• Maintain/promote support
• Home treatment vs hospital admission (formal vs informal)

Question 10

How to ask questions about homicidal thoughts?

Answer 10

• How have you been feeling towards others recently?
• Have you been less tolerant of others?
• Do you ever feel like hitting out?
• Are you preoccupied with thoughts of others?
• Have you felt life would be easier with someone not around?
• Have you had thoughts of killing this person?
• Have you ever made plans to carry them out?

Question 11

Questions to ask in alcohol and substance use (mental health)

Answer 11

Question 12

Topics and questions to cover in history of abuse

Answer 12

• Physical/Emotional/Neglect
  
  • Have you always felt cared for and looked after?
  • How would you describe your close relationships with people?
  • Do you feel your parents/partner/children could have behaved differently towards you?
• Sexual abuse
  
  • Can you tell me the age you were when you experienced sexual contact for the first time?
  • Have all your sexual relationships been consensual?
  • Have you ever felt others have touched you in a way that makes you feel uncomfortable?

Question 13

What is a formulation?

Answer 13

• MDT based
• Patient, carer and other agency involvement
• Considers all relevant factors for a patient and how these have affected them, in the past, now and in the future

Question 14

What is the purpose of a formulation?

Answer 14

• Helps with building differential diagnosis’ with going FOR and AGAINST
• Bring together all the evidence
• Consider the bio-psycho-social approach
• Come to an agreed:
  
  • Diagnosis
  • Management plan
  • Other agreements
    
    • Care package, placement etc.

Question 15

Draw out a formulation diagram

Answer 15