28th November 2023

Psychiatric History and Examination

Psychiatric History

Introduction

This chapter will explore the tools required to carry out a comprehensive psychiatric assessment. The psychiatric history builds upon the standard medical history taking framework that you will be familiar with from medical school. The psychiatric assessment should include a mental state exam (MSE), a full physical examination, and investigations to ensure organic causes are accounted for.

This section will focus principally on the framework and contents to enable you to carry out a thorough psychiatry history.

Structure of a psychiatric history 

This table provides an outline for areas to cover in a psychiatry history. The approach and technique can be tailored to suit your individual interviewing style, as well as tailoring your approach accordingly to each patient.

Initiating the consultation

This may well be your first time seeing this patient; therefore, first impressions are important. This initial interaction can set the tone for the remainder of the consultation, so it is imperative to ensure you get off on the right foot. Consider the set-up of the room where you are sitting, and limit distractions or interruptions where possible. Remember that flexibility is important, and although having a rough structure in mind is useful, fluidity and flexibility tailored to your patient is needed.

From the moment you first meet your patient, your assessment should begin in the form of a continued mental state exam (MSE); note this will be covered in detail later in the chapter.

• Start by introducing yourself.
• Ensure a comfortable and confidential environment.
• Ask the patient for their name, date of birth, what they prefer to be called and how they are today – The beginning of the consultation can take a relaxed tone to initiate the construction of rapport.

Presenting complaint 

After initiating the consultation, allow the patient to take the lead where possible and express their thoughts in their own words. Your role at this point should be to guide and steer the conversation when necessary whilst gaining as much information from the patient as possible. It may be useful to reassure the patient that this is a confidential environment and a safe space for them to speak openly and freely. You will begin to build a picture of what has been going on and, where possible, begin to establish a chronological order of events. Remember, structure is useful but not compulsory; patients will relay information in a way that is comfortable for them. Do not underestimate the power of listening and silence.

• The history is to be taken directly from the patient; if this is not possible, a collateral history can be useful.
• Initiate the consultation with open questions (questions that typically can’t be answered with a ‘yes’ or ‘no’):
  • ‘Can you tell me what’s brought you in today?’
  • ‘Can you tell me what’s been happening lately?’
  • ‘Can you tell me what you have been feeling lately?’
• Considerations at this point:
  • What are the symptoms that brought the patient in?
  • Who has initiated seeking help / seeing a doctor?
  • Has this patient been referred / voluntarily consulted or detained?
  • Probe symptoms further where necessary: ‘Tell me more about that.’
  • Use simple, non-technical language.
  • Use the same language the patient uses – e.g. if they state they are gay, use the same word rather than a term such as homosexual, which you may perceive to mean the same thing.

History of presenting complaint 

This section delves deeper into exploring the presenting complaint. Allow the patient to tell their story with minimal interruptions. You can make notes to refer back to, but try to let the patient voice their experience in their own words and at their own pace.

• This section should explore screening, likely to include but not exclusive to:
  • Depression.
  • Anxiety.
  • Mania.
  • Psychosis.
  • PTSD.
  • ADHD.
  • Obsessions and compulsions.
  • Body image disturbances.
  • Eating disorders.
• Consider the following for the above:
  • Explore the onset and course of symptoms.
  • Explore each symptom in depth whilst screening for other possible differential diagnoses.
  • ‘When did you first notice these feelings?’
  • ‘How long have you been feeling this way?’
  • ‘Have you ever had these feelings before?’
  • ‘Are these feelings always present, or do they come and go?’
• Are there any events that have now led to the patient seeking help?
  • Explore possible triggers/events that may have contributed.
  • Are these resolved or ongoing?
  • Why has the patient decided to seek help now?

The table below explores the presenting complaint and associated symptoms, as well as example questions you can use to elicit more information:

Past psychiatric history 

The next part of the consultation to consider is past psychiatric history. Most psychiatric conditions will never be truly ‘cured’ in the same way other medical presentations might. It is better to look at mental health conditions entering phases of ‘recovery and remission’. Hence, there is the need to establish whether patients have previously been treated and counselled for psychiatric conditions in the past.

• Past psychiatric diagnoses:
  • Treatment – Medications/counselling / talking therapies?
  • Previous admissions – MHA / voluntary?
  • Community involvement – GP / CMHT / home therapy/crisis team?
  • Number of depressive/manic/psychotic episodes.

Remember, the focus should primarily be on the presenting complaint. Try to get a snapshot of past psychiatric history to inform your ongoing assessment, but do not lose focus on the problem that brought the patient to see you.

If there are past admissions and diagnoses, how does this episode differ from previous admissions?

Family history 

Many psychiatric conditions have a genetic component to them. Taking a family history can be a useful tool in assessing this further.

• Family history of mental illness:
  • Previous or ongoing psychiatric diagnoses in the family?
  • Previous or ongoing psychiatric admissions in the family?
  • Previous suicide attempts/suicide in the family/self-harm?
  • Any family member displaying unusual/unexplainable symptoms? (possible undiagnosed psychiatric conditions)
  • Consider problematic alcohol or drug abuse in family members as well as neurodegenerative disorders and dementia.

Past medical history

• Comorbidities.
• Past surgical history.
• Past hospital admissions.

Systems to consider as possible contributors to mental illness (Haq and Ezeani, 2022):

• Neurological – Epilepsy, encephalitis, Parkinsonian, Huntington’s.
• Infections.
• Endocrine – Thyroid, Cushing’s, Addison’s.
• Systemic – SLE.
• Haematological – B12 / folate deficiency

Medication history

• History of allergies.
• Current medications:
  • Compliance?
  • Length of course?
  • Indication and understanding of medication (avoid polypharmacy).
• History of any previous psychiatric medications.
• Supplements:
  • Herbal, vitamins, steroids.
  • Anything else over the counter (e.g., consider St John’s wort and interactions).
• Recreational drugs.

Social, lifestyle and personal history 

This is an opportunity to learn more about your patient’s life and get to know who they are.

• Developmental:
  • Birth and any difficulties.
  • Experiences of childhood and growing up.
  • School experience.
  • Patient’s perception of themselves in childhood.
  • History of bullying.
  • Where did they grow up, and where have they lived?
  • Relationships with family and friends.
  • Traumatic experiences.
• Protective factors:
  • Children – How many, age, health, relationship with them.
  • Religion affiliations.
  • Relationship status.
• Lifestyle:
  • Recreational drugs, alcohol, and smoking.
  • Exercise, nutrition, and diet.
  • Stress management.
  • Sleep – Number of hours and quality.
• Personal history:
  • Education – Qualifications, perception, relationships with educators and peers.
  • Job – Types of job, employment timeline, employment status.

Forensic history

• ‘Have you ever had any interactions with the police?’
• Explore convictions/arrests/sentences/court hearings/prosecutions / pending investigations / any trouble with the law.

Premorbid personality 

This final section explores what the patient was like before their current presentation

• Assess the patient’s views, reactions, and attitudes to various aspects of their life.
• Explore how family, friends and peers describe the patient prior to their illness.

Closing the consultation 

Thank your patients and ask them if they have any concerns or questions.

References

• Waldinger, R., & Jacobson, A.M.,: The Initial Psychiatric Interview, Available online at: https://www.brown.edu/Courses/BI_278/Other/Clerkship/Didactics/Readings/THE%20INITIAL%20PSYCHIATRIC%20INTERVIEW.pdf [Accessed Feb 2023]
• Haq, M.Z., & Ezean, P. (2022). How To Take a Psychiatric History, Available online at: https://mindthebleep.com/psychiatric-history/ [Accessed March 2023]
• El-Sayegh, S., Bea, S., & Agelopoulos, A. (2003). Obsessive-compulsive disorder: unearthing a hidden problem. Cleveland Clinic Journal of medicine, 70(10), https://doi.org/10.3949/ccjm.70.10.824
• National Institute for Health and Care Excellence. (2019). Eating Disorders: How should I assess a person with a suspected eating disorder? Available online at: https://cks.nice.org.uk/topics/eating-disorders/diagnosis/assessment/ [Accessed Feb 2023]
• Phelan, M. and Blair, G. (2008) ‘Medical history-taking in psychiatry,’ Advances in Psychiatric Treatment. Cambridge University Press, 14(3), pp. 229–234. doi: 10.1192/apt.bp.105.001099.
• Carlat, D. J. (2005). The Psychiatric Interview: A Practical Guide. Lippincott Williams & Wilkins.
• Goldbloom, D. S., & Davine, J. (2011). Psychiatry in Primary Care: A Concise Canadian Pocket Guide. Centre for Addiction & Mental Health.
• Stubbe, D. (2007). Child and Adolescent Psychiatry: A Practical Guide. Lippincott Williams & Wilkins.

Mental State Examination (MSE)

A mental state examination (MSE) is an integral part of a full psychiatric examination. The MSE allows you to observe and assess the patient’s current frame of mind; it aids in giving a snapshot of the manifestation of the underlying state of mind of the patient. The MSE is a structured tool to assess your patient’s cognitive and behavioural functioning under the following domains:

• Appearance.
• Behaviour.
• Speech.
• Mood and affect.
• Thought.
• Perception.
• Cognition.
• Insight and judgement.

Initiating the consultation 

Introduce yourself to the patient and confirm the patient’s name and date of birth. Ensure the environment is comfortable for yourself and the patient. Remember that your MSE begins as soon as you see the patient; the MSE will be done simultaneously when you are carrying out your psychiatric history.

Appearance 

As mentioned within consultation initiation, your assessment and observations begin as soon as you meet the patient. The appearance of your patient can provide clues about their current lifestyle, which may be stemming from their underlying mental illness:

• Demographics – Age, gender, ethnicity, religion.
• Movement and gait – Observe how the patient walks into the room, is their gait uncoordinated/brisk/slow / shuffling / ataxic, and examine their body language, tremors, tics, and abnormal movements (side effects of medication).
• General appearance – Posture, cleanliness (ideas of how a patient is caring for themselves currently), assess for any signs of self-harm, signs of physical injury (violent environment / domestic abuse).
• Weight – Assess for extremes of weight, cachectic.
• Distinguishing features – Tattoos, bruising, scars, track marks, needle sites.
• Stigmata of disease – Jaundice, puffiness, cachectic.
• Clothing – What are they wearing? Are the clothes clean / ripped / dirty? Are these clothes appropriate for the current weather/consultation / general environment?
• Objects – Has the patient brought any objects? Are they holding anything? Observe jewellery.

Behaviour 

The patient’s non-verbal behaviour can be just as important as what they tell you in better understanding their mental state. Keep notes of behaviours you notice; these can be used to link to parts of your psychiatric history in order to build an overall picture.

• Eye contact and body language – Is eye contact maintained, point of fixation, wandering gaze, intense gaze, e.g., fixated with wandering gaze could suggest possible hallucinations in schizophrenia. Is the body language open or closed?
• Rapport and engagement – Do they follow the conversation? Are you able to establish rapport? Are they closed off, reserved, distractible, withdrawn, quiet, eccentric, or preoccupied?
• Attitude – Is the patient cooperative or hostile, open or secretive, evasive or eccentric, distracted or focussed, emotional or apathetic mannerisms, explore gestures, language used and tone of voice, pitch, and intonation.
• Facial expressions – Smiling/grimacing/laughing / anxious/happy/sad/angry/confused/blank.
• Mannerisms – Compulsions/repetitions/tics/tremors / involuntary movements.

Speech

Assessing speech is important in the MSE as it provides valuable information about an individual’s cognitive and psychological functioning. Speech can provide insights into a person’s mood, thought processes, communication abilities, and potential neurological or psychological disorders.

• Rate – Pressure of speech, rapid speech, slow speech, incoherent, fast or slow.
• Quantity – Minimal or absent, excessive, talkative, spontaneous, poverty of speech.
• Tone – Quiet, mild, soft, weak, monotone, tremulous, loud.
• Fluency and rhythm – Coherent, stammering, stuttering, slurring, hesitant, articulate.
• Volume – Quiet or loud.

Mood and affect 

Assessing mood and affect provides important information about a person’s emotional state and overall mental well-being.

Mood – Refers to a person’s predominant emotional state, such as sadness, happiness, or anxiety.

Affect – Refers to the observable expressions of mood, such as facial expressions, tone of voice, and body language.

Affect is momentary (like the weather), while mood is a prolonged emotion (like the climate). Hence, ‘mood is climate, and affect is the weather.’ (Manjunatha et al, 2009)

• Mood
  • ‘How are you / have you been feeling?’
  • ‘How do you feel at this moment in time?’
  • ‘Have you had any periods of feeling low/anxious/depressed?’
  • Consider the following for mood – Consistency/changes in mood / fluctuating mood/extremes of mood
  • Types of mood – Low, depressed (mild/moderate/severe), anxious, irritable, blunted, apathetic, flat, engaged, energetic, happy, content, optimistic, elated – consider these under the broader umbrella terms of positive/negative/neutral.
• Affect
  • Is the patient’s affect appropriate for the current scenario?
  • Assess – Posture, body movements, facial expression, tone of voice – assess patient’s apparent emotion via their affect.
  • Fluctuation – Labile, even, broad, expansive.
  • Range – Fixed, restricted, labile, expansive, normal.
  • Intensity – Blunted, flat, normal, heightened.
  • Congruency – Congruent or incongruent – e.g., patient speaking about distressing and violent events whilst laughing = incongruent.

Thought

Assessing thought allows us to understand how a person thinks and processes information. Thought refers to a person’s internal cognitive processes, such as perception, memory, attention, and reasoning. Additionally, thought content, such as delusions or hallucinations, can provide important information about a person’s perception of reality and potential risk to themselves or others.

When assessing thought, it is useful to consider it under the terms content, form and possessionThe following table provides an outline of questions and content relevant to each domain of thought:

Perception 

In the context of mental state examination, ‘perception’ refers to an individual’s subjective interpretation of their sensory experiences, including what they see, hear, smell, taste, and feel.

• Illusions
  • Misperception of external stimuli or real object, e.g., leaves blowing in the wind, misinterpreted as a goblin.
• Hallucinations
  • Perception that can be auditory or visual in the absence of sensory stimuli
• Auditory hallucinations
  • Who is speaking? – One or several voices?
  • Is the voice male or female?
  • Does the voice sound familiar?
  • Does the voice speak to them or about them?
  • Is the voice speaking in a positive or negative manner?
  • Is the voice telling the patient to do things?
  • Does the voice communicate in simple or complex sentences / laughing or crying/engaging in conversation, or commenting on a patient’s thoughts?
• Visual hallucinations
  • What are they seeing? > figure/shadow/person / is the person familiar?
  • When did this start / how often do they occur?
  • How do they make the patient feel?
  • Do they appear at any specific time of day or location?
• Pseudo-hallucination
  • Presents in the same way as a hallucination, but the patient will be aware that what they are experiencing is not real.
• Hallucination screening questions
  • ‘Do you ever see, hear, smell, taste, or feel things that others can’t?’
  • ‘Did you believe this was real?’ – Assess on a scale of 1-10.
  • ‘Do you ever think your surroundings are not real?’
  • Remember to not challenge the hallucination too intensely as this is what the patient believes to be real; explore it with them to build a broad picture of what they are experiencing before challenging and probing the experience.

– Note visual hallucinations can stem from either psychiatric, infective, or neurological pathology; it is important to consider the following:

• Delirium.
• Lewy body dementia.
• Charles-Bonnet syndrome.
• Migraines.
• Schizophrenia.

– Depersonalisation and derealisation

• Depersonalisation refers to a feeling of detachment or disconnection from one’s self or body. Individuals experiencing depersonalisation may feel as if they are watching themselves from outside their body or feel as if their body is not their own. They may also feel disconnected from their emotions or as if they are in a dream-like state.
• Derealisation refers to a feeling of detachment or disconnection from the external world. Individuals experiencing derealisation may feel as if the world around them is unreal, distorted, or unfamiliar. They may feel as if they are watching the world from behind a veil or as if they are in a movie.
• ‘Do you ever feel like you are not in your own body?’
• ‘Do you ever feel like you’re watching yourself from an outside perspective?’

Cognition 

Cognition refers to an individual’s mental processes involved in acquiring, processing, and using information. Cognition includes various aspects, such as attention, memory, language, perception, and executive functioning.

• Collateral history is of great importance in assessing cognition to understand what the baseline is for your patient.
• Assess the patient’s orientation to time, person and place, as well as their name, address and date of birth.
• Assess the patient’s immediate/recent/long-term memory.
• Note general knowledge will vary depending on education/ethnicity and culture, so questions such as ‘Who is the monarch?’ may not be useful depending on the context.
• Consider using the following formal cognitive assessment tools:
  • Mini-mental state exam (MMSE).
  • Addenbrooke’s cognitive examination III (ACE-III).
  • Abbreviated Mental Test Score (AMTS).
  • Montreal Cognitive Assessment (MoCA).

Insight and judgement 

Insight refers to an individual’s awareness and understanding of their own mental health symptoms and the impact they have on their life.

Judgement refers to an individual’s ability to make sound and appropriate decisions based on their understanding of a situation.

• Insight
  • Can the patient understand their illness?
  • Can the patient understand the environment around them?
  • Can they appreciate what the reality of the situation is?
  • ‘Do you think you have a problem?’
  • ‘Do you feel you need help?’
  • ‘What do you think is causing you to feel this way?’
  • Can be described as poor, fair or good
• Judgement
  • Judgement can be assessed continuously throughout the MSE.
  • ‘What would you do if you could smell smoke in your house?’
    • Poor – Patient would do nothing / stay in the house
    • Good – Patient is aware of the danger and would leave the house and call for help.
    • Impaired – Patient may otherwise have good judgement, but due to acute intoxication, judgement is impaired.

Closing the consultation 

Thank your patient and ask them if they have any concerns or questions

References

• Manjunatha, N., Khess, C. R., & Ram, D. (2009). The conceptualisation of terms: ‘Mood’ and ‘affect’ in academic trainees of mental health. Indian journal of psychiatry, 51(4), 285–288. https://doi.org/10.4103/0019-5545.58295
• Potter, L. (2023) Mental State Examination (MSE) – OSCE guide, Geeky Medics. Available online at: https://geekymedics.com/mental-state-examination/ [Accessed Feb 2023]
• Wilcha, R. and Beehuspoteea, N. (2022) Mental State Examination, Mind The Bleep. Available online at: https://mindthebleep.com/mental-state-examination/ [Accessed March 2023]
• Trzepacz, P.T. and Baker, R.W. (1993) The Psychiatric Mental Status Examination. New York: Oxford University Press.
• El-Hay , M.A.A. (2018) Essentials of Psychiatric Assessment. New York, NY: Routledge.
• Robinson, D.J. (2002) Mental status exam explained. London, ON: Rapid Psychler Press.