Taking a Psych History

Question 1

Before you even start a Psychiatric Interview how should you arrange the setting?

Note* - A psych interview covers all the same areas as any medical history, i will only be referring to the extra bits here

Answer 1

1) In a private space
2) Ensure no interruptions
3) Keep it informal by arranging the seats informally etc
4) Make sure you have an easy exit

Question 2

What should you do at the start of the interview before you start asking questions?

Answer 2

Patient’s in a psych interview may be confused, suspicious or nervous etc so make sure to:

• Explain the reason for the interview
• Explain why you’re taking notes
• Reassure about confidentiality

Question 3

How might you open a psych history

Answer 3

A nice open question e.g. Can you tell me in your own words why you’re here?

It’s helpful to know if the patient is an informal (voluntary) patient or has been referred under order

Question 4

When doing HoPC you want to cover it just like any other. An important extra to remember

Answer 4

Ask about the complaint’s response to any other treatments

Question 5

In term’s of exploring psychoses in the systemic enquiry, how might you ask about hallucinations?

Answer 5

Avoid the phrase “Do you hear voices”
Try something clear but diplomatic like:
- Have you ever seen or heard something others weren’t aware of?
- Have you ever heard someone speaking with no one around?

Be concerned about anyone hearing commands

Question 6

Also exploring Psychoses, what else might you ask

Answer 6

You want to know if they feel anyone is controlling their mind in some way e.g.:

• Is there anything particular playing on your mind?
• Does anyone else ever have access to your thoughts?

Question 7

What areas would you want to cover when asking a the psych part of the PMH?

Answer 7

• When/duration of episodes
• Treatments they received
• Any admissions or detentions
• Inter-episode functioning
• any suicide or self harm

Question 8

What none-psych PMH is particularly important?

Answer 8

• Developmental problems
• Head Injuries
• Endocrine abnormalities (particularly thyroid)
• Vascular Risk factors
• Liver damage, peptic ulcers or oesophageal varices

Question 9

What’s different about a psych FH?

Answer 9

with relative with a psych problem you want to know about their:

• Circumstances
• Relationships
• Age
• employment
• Health etc

Question 10

What’s different about a psych med history?

Answer 10

Make sure to see if any drugs have been started or discontinued in the last 6 months as this may cause symptoms

Question 11

what areas are particularly important in a psych social history?

Answer 11

Think about anything that could trigger or worsen mental illness:

• Employment/finance
• Relationships
• Substance abuse
• Parent or carer
• Other stressors

Question 12

What do we want to know about any substance abuse?

Answer 12

Amount
Reg vs Intermittent and Pattenr
Any dependance or symptoms on withdrawal

Impact on work, relationships etc
Police involvement

Can use screening questions e.g. CAGE

Question 13

During a psych social history we would also ask a personal history, what does this include?

Answer 13

• Developmental milestones (mainly in younger patients)
• Relationships/friendships
• Education & Occupation
• Financial history

Question 14

In a psych history we also ask a forensic history, how do we do this?

Answer 14

Be sensitive, open with:

- “Have you ever had any contact with the police?” And go from there

Question 15

Why is it particularly helpful to ask about sentences during a forensic history?

Answer 15

Gives you a more objective measure of any crime the patient was convicted of

Question 16

What is pre-morbid personality and how do we ask about it?

Answer 16

the person’s behaviour, mood and interactions prior to the illness (i.e. “normally”)

We need corroboration so if possible get it 3rd party. Otherwise ask “How would your best friend or partner describe you?”

Question 17

A major part of a psych history is assessing the patient’s mental state.
what are the different domains of this?

REMEMBER. this is not so much a section of the history but something you start doing the second you clap eyes or ears on them

Answer 17

• Appearance
• Behaviour
• Mood
• Speech
• Abnormal Thoughts
• Abnormal Percepts
• Suicide/Homicide
• Cognitive Function
• Insight

Question 18

What parts of the patient’s appearance can contribute to a Mental State exam?

Answer 18

Clothing
Hygiene
Make up, jewellery, accessories etc

Question 19

What parts of their behaviour are you observing for the mental state?

Answer 19

• How they greet you i.e. are they disinhibited, fearful, apathetic etc
• Their gesturing i.e. very still, expansive or bizarre
• Abnormal movements e.g. akathisia or tremors
• How well they cooperate/build rapport

Question 20

How do you assess their mood for the mental state exam?

Answer 20

Do they make/seek eye contact?
Obvious manifestations e.g. smiling, crying, shouting etc
Get them to tell you! Both just how they’re feeling and on a scale

Question 21

What parts of their speech can tell you about their mental state?

Answer 21

• Do they speak spontaneously or need prodding?
• How fast?
• Rhythm
• Tone and volume (e.g. monotonous and quiet)

also look for problems like dysphasia and dysarthria

Question 22

What kind of abnormal thoughts can tell you about their mental state?

Answer 22

Phobias or obsessions
Flight of ideas
Knight's move or derailment
Formal thought disorder e.g. a thought block
Delusions

Question 23

What are the stages of a delusion?

Answer 23

A pre-occupation e.g. keep thinking about their neighbour saying hi this morning

Then an over valued idea e.g. That was suspicious they’re hiding something

then a full on delusion e.g. It must mean they are a spy (the delusion is fixed, 100% certain and abnormal)

Question 24

What are abnormal percepts/

Answer 24

Illusions and hallucinations of any domain

Question 25

What’s the difference between an illusion and a hallucination?

Answer 25

An illusion is essentially mistaking one thing for another. e.g. seeing a glass of water as a vase of flowers

A hallucination is completely observing something that isn’t there e.g. seeing the vase of flowers where there’s nothing

Question 26

It is essential that you ask about suicidal/homicidal thoughts. What do you want to know?

Answer 26

Do they have any?
do they have intent to commit?
Have they made a plan?
Have they taken any steps e.g. writing a will etc.

Question 27

How do we assess cognitive function?

Answer 27

Observe their orientation, attention and short/long memory

If you’re concerned do a MOCA

Question 28

What questions do we want to ask to assess their insight?

Answer 28

Are the symptoms down to an illness?
Is it a mental illness?
Do you agree with our treatment plan?

Question 29

It’s especially important during a psych history to signpost and summarize

Answer 29

Not only will this help keep the patient calm and aware of what’s going on but it allows you to pick up anything you missed or misconstrued

Question 30

Quick summary of history:

• Do everything to make the patient comfortable
• Social & Personal history (& during the FH) is essential
• A forensic history is important
• Cover potential organic cause in the PMH, meds & substances
• Do not forget to ask about suicide

Answer 30

Quick summary of Mental State Exam:
Ensure you observe everything about he patient and ask specific questions to assess their mental state, covering the following domains:
- Appearance
- Behaviour
- Mood
- Speech
- Abnormal thoughts
- Abnormal percepts
- Delusions
- Suicide
- Cognitive function
- Insight