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• Help them talk about painful or embarrassing subjects by
1.02
PSYCHIATRIC HISTORY AND MENTAL STATE EXAMINATION
DR. Rebucal/August 19, 2016
PRELIMS Quiz 1
RED emphasized; Blue Audio; Green –Book/OT
PSYCHIATRIC HISTORY
General Principles of History Taking
• Aim to understand problems/symptoms and effect on life
• To put presenting problems into context by enquiring about
background history and previous treatment
• Is followed by Mental Status Examination (MSE)
“It enables Formulation to be reached. When we say formulation
in psychiatry it is termed psychodynamics. Psychodynamics is
quite similar to the term pathophysiology.”
• Enables formulation to be reached – psychodynamic
occurrences, psychopathology
• Is therapeutic in itself – ventilating emotions and problems
Preparing The Setting
• Safety—“sit next to the door during interview for easy escape
in case the patient becomes violent. ”
• Privacy—“provides participation and increase the
participation of the patient”
• Try to avoid interruption
• Arrange seating so sitting at angle to patient--“the level of the
chair should always be equal: the therapist and the patient”
• Writing materials
• Box of tissues. --“some patient really cry during interview”
Starting the Interview
• Put patient at ease – establish rapport with the patient
• Introduce yourself and explain role
• Introduce to anyone who is accompanying patient
• Inform them about the length of interview
• Need to take notes.
• Confidentiality “reassure patient that the information given
will not be disclosed to others. Except in cases of SUICIDE and
HOMICIDE” Inform the object of the attack.
Interview Style
• Relaxed even if under time pressure
• Appropriate eye contact (convey/appear you are interested)
- Patient’s with schizophrenia and psychotic
disorder: has poor eye contact
• Begin with a general question eg “tell me about your problem”
• Have a systematic but flexible plan – at beginning can be
helpful to take a list of headings as prompt
• Keep in control. May need to interrupt “I’m sorry but I need to
move on to other things”; “We can come back to this if we have
time later”
Interview Techniques
• Use of open questions (open-ended) when possible,
especially at beginning eg “How is your appetite?”
• Closed questions are useful if time is short eg “is your appetite
good?”
• Avoid leading questions eg “You have a poor appetite, don’t
you?” -Patients are more likely in a regressed state kaya most
of them will just answer ‘Yes’
• Encourage patient by leaning forward, nodding, saying “go
on” “tell me more about…..” –This gesture convey that you want
to know more and you are in tune sa sinasabi ng pasyente
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Psychiatry
being non-judgmental, acknowledging distress and explaining
why you are asking, eg “I can see this is difficult to talk about…”
–Avoid being judgemental in both verbal and non verbal.
Expressions like:”hindi ako makapaniwala”; “grabe!”
• Summarise key points to check understanding
• As experience grows start to select questions according to
emerging diagnostic possibilities and management options.
This becomes more important when time is limited or patient
uncooperative (to prevent agigation of patient)
• Don’t take words at face value eg “paranoid”
• Pick up non-verbal cues
• Watch experienced clinicians and get them to watch you!
• Video yourself (to check for your expressions and reactions
during the interview session)
Interviewing Informants
• Always useful and more so if patient is cognitively impaired,
or if patient is concealing information
-Cognitively Impaired: You cannot tell if they are telling the
truth. e.g Dementia
• Gain patient consent “Ask if the patient would agree that you
interview other informants.
• Often best to see patient alone first and then informant
“Because, in cases of paranoid disorder talking to the informant
will make them think that you are conniving against him.”
• Establish confidentiality (and limits) “Ito lang po ang pag-
uusapan namin ng nanay niyo…”
• Ascertain informants concerns as well as gain information.
• May need to help informant if stressed carer (carer
assessment)
Care giver fatigue can lengthen the interview time with the
informant.
Question sa exam would be: Which one of the following would be
most likely a diagnosis that you should interview the informant:
a. Schizophrenia
b. Alzheimer’s Dementia (answer)
c. Depression
d. Bipolar Disorder
Schizophrenia patients can always be asked. Bipolar Disorder and
Depression patients, you can always ask them. In Alzheimer’s
Dementia, you will not be able the get the exact information that
you need.
Interviewing patients from other cultures (Cultural
competency)
• Interview patients in first language when possible. You may
need interpreter.
• Using an interpreter is skill. Discuss approach first. Manage
chunks of information. 2nd person, direct translation is most
useful.
• Distress is shown via different symptoms e.g physical rather
then psychological symptoms.
• Cultural beliefs may include ideas that appear delusional but
are culturally acceptable eg witchcraft. Need collateral
information.
• Treatment expectations may differ (e.g Albularyo)
The History: OUTLINE
• Presenting Complaint
• History of presenting complaint
• Family History
• Personal History
• Past Psychiatric History
• Past Medical History
• Substance Use
________________________________________________ Psychiatry
• Drug History Past Psychiatric History
• Forensic History • History of similar or other symptoms in past
• Personality • Previous diagnosis
• Current Social Situation • History of treatment – include from primary care,
counselling, complementary therapy (e.g. Acupuncture) as
General Data: name, age, marital status, educational attainment, well as mental health services
current address, birthday, birthplace, religion, race
• Previous hospitalisation, medications, ECT
Presentation/Referral and Presenting Complaint(s) (Electroconvulsant Treatment)
• Who referred patient and what is their concern/request • Recovery between episodes
because there is implication that the patient came on his own • Previous suicide attempts
or thought of having a consultation.
Past Medical History
• Where is patient being seen. E.g. clinic, hospital or ER
• Chronology of illness and treatment
• What is their problem, in their own words – Recommendation
in Medicine, chief complaints should be written in medical term. Substance Use
In Psychiatry, we still use the words of the patients to know the • Alcohol, other substances, tobacco.
background of what the he is feeling inside. How to ask this question: “Gaano kadalas ka umiinom ng alak?”
this surpass the question of “umiinom ka ba o hindi” (non
History of presenting complaint
judgemental)
• Nature of problem (e.g “nagwawala”)
• Pattern of use –How often?
• Precipitant (e.g life stresses the patient underwent before the
• Age at onset –to establish the pattern of use
emergence of the behavioral symptoms)
• Relationship to symptoms
• Onset, time span, development of symptoms, fluctuations,
• Harmful use
factors worsening or improving
• Psychological dependency (e.g smoking: they think that if they
• Degree of functional impairment
smoke it increases retention)
• Level of distress
• Physical dependency (e.g withdrawal symptoms: tremors,
• Treatments trialled (eg. Traditional healers)
palpitation; the next time gumamit sila ng alcohol, feeling nila
We still use OPQRST in Psychiatric Facility: na-“cure” sila)
o Onset • Previous detox
o Provocation or Palliation • Patient view
o Quality
Drug History
o Region and Radiation • Current medications
o Severity • Allergies
o Time (History)
Forensic History
‘What is unique in psychiatry is that we follow a flow of • Record all offences – convicted or not.
questioning: • Violence/Anger, sexual offences particularly important
1. Thoughts-what particular stress
• Persistent offending
2. Feelings-during that time
• Probation
3. Reaction-what happened and what did the patient do?
• Relationship to symptoms to the commission of the crime
Family History
• Parent: age (now or at death), occupation, relationship with Personality (not a part of formal Psychiatric report, except in
cases for example of annulment)
patient
• Hard to assess at one-off interview and collateral information
• Siblings: as above
should be sought.
• Psychiatric history in family members (genetic and effect on
• Ask patient how others see them/would describe them
home life). Substance use, suicide.
• Prevailing mood; how they get on with people; deal with
• Genogram (Male-Square; Female-Circle)
stress; hobbies; standards. (not a part of formal Psychiatric
report, except in cases of annulment)
• Impulsive “Pag may impulse kayong magreview, review agad”
• Prone to worry “hala! wala pa yung notes ko! Hala!”
• Strict, fussy
• Seek attention ex. Kris Aquino
Personal History • Untrusting, resentful
• Mother’s pregnancy, birth • Irritable
• Early development (start at age 2-6), illness • Sensitive
-You can ask: ‘What is your earliest memory’
• Suspicious
• Childhood separation, emotional problems
• Argumentative
• Relationships with family members, atmosphere at home
• Lack concern for others
• Schooling – academic performance and peer relationships.
(Bullying, school refusal, shyness, conduct disorders) Current social circumstances
• Qualifications. Further education • Who they live with
• Occupation(s), work performance • Current employment
• Sexual relationships, marriage, children • Stressors
• History of abuse (physical, sexual, emotional) in childhood or • Social supports
adulthood • Typical day
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Past, Personal, Social, Environmental (PPSE) state where the
patient is still normal. The end of PPSE is the start of History of
Present Illness (HPI).
Ex. If the patient develop symptoms when he is 55, you would
expect that your PPSE would be until 54 years old but if the
patient develop symptoms which started at 14 years old
Mood
therefore your PPSE will stop until the time he develop a
symptom.
PPSE-Normality
HPI-Pathology
MENTAL STATE EXAMINATION
What is the MSE
• “Here and now” record of presentation
• History will give clues as to likely symptoms
• Systematic
• Until more experienced carry out full mental state
Affect
• Be observant but also learn the terminology to describe
symptoms/signs
• Use conventional headings to structure examination – other
colleagues and examiners will expect it
MSE: OUTLINE
• Appearance and Behaviour
• Speech
• Mood (subjective)
• Affect (objective presentation of the mood)
• Thought
• Perception
• Cognition
• Insight
Appearance and Behaviour
• Describe what you see.
Thought Content
• General appearance and behaviour. Striking physical
features. Posture.
• Physique, clothing, cleanliness, self-care, posture
Ex. “A patient was wearing black tshirt and white pants; was
seated comfortably; having a stup (or good) posture; with
(good/poor) eye contact. Rapport is established”
• Eye contact, rapport
• Motor activity: agitation, retardation, stuporous (akinesic and
mute), abnormal movements (tic (jerky movement), tardive
dyskinesia (long term side effect of anti psychotic drugs),
chorea, stereotypy, catatonic features), mannerism,
restlessness
• Tearfulness
• Distractibility
• Disinhibition –they want to voice out everything
• Appears to hear voices, preoccupied.
Speech
• Rate: slow in depression; pressure of speech in mania.
• Quantity: reduced (poverty) in depression and chronic
schizophrenia; flight of ideas in mania (ex. talkative, or in loud
voice)
• Volume
• Pattern: spontaneous, coherence, rationality, (circumstantial-
ang daming sinabi pero iisa lang ang idea vs tangential-you are
hitting the topic pero yung points lang. Ex. “gwapo ba sya? Ans.
“Mabait sya”, not direct ang answer) (trivial detail eg
obsessional traits), perseveration
• Neologisms, puns, clang associations (word that sounds the
same). “Burokotor”
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Psychiatry
• Formal thought disorder: loosening of associations; knight’s
move thinking, word salad (schizophrenia) .“Malaki Bato
tsinelas nagpunta kami duon, may buwaya mani?” Loosing the
train of thought.
• Thought blocking: arrest of train of thought leading to blank.
Different to losing train of thought
• Patient description: Sad, happy, top of the world, worried
• Accompanying symptoms
 Depression: early morning wakening, diurnal variation,
anhedonia, loss of appetite, loss of weight, fatigue, loss of
concentration. Hopelessness (Ask for plans in life) ,Suicidal
thoughts, plans, intent
 Anxiety: palpitations, dry mouth, sweating,
 tremor
 Elation: Overactivity, excessive self-confidence, reduced
sleep, distractibility, increased libido
• Your objective description of emotion (mood)
• Depressed, anxious, fearful, irritable, suspicious, perplexed,
elated, angry (feelings)
Range of affect:
 Full-Full range (ex. Use of expressions or hand
movement)
 Constricted-instead na ngumit sya ay parang pilit na
pilit
 Blunted-halos nawawala na ang reaction
 Flat-even monotony ng voice ay nawawala na
• Fluctuations: reactivity, lability (mania), blunting (chronic
schizophrenia)
• Consistent with thoughts/behaviour?
(ex. Incongruence: If they say they are happy but they think
someone is stalking them) Incongruity seen in schizophrenia
• Preoccupations: thoughts that recur frequently but can be put
out of mind
• Obsessional thoughts/compulsive rituals. Obsessional
thoughts are ideas, images, impulses that repeatedly enter
mind in stereotyped form, seen as senseless, distressing,
recognised as own thought even if repugnant. Compulsions are
obsessional motor acts, often resulting from obsession, may be
attempt to “neutralise” obsession.
• “Do you have to keep on repeating the same action which
most people would only do once?”
• Delusion is a false, unshakeable, belief that is out of keeping
with the patient’s social and cultural background.
• Mood Congruent
• Content: persecution (eg, “pakiramdam ko may papatay sakin
o pinagtutulungan nila ko”) infidelity (eg.”naniniwala ako yung
asaw ko may kabit”), grandiose (eg. “ako ang pinakamayaman,
pinakamaganda/gwapo, pinakamagaling” Parang sa kanila na
lahat) , hypochondriacal (fixated on having a non-existent
serious illness), love, guilt, nihilistic (things or everything,
including the self does not exist), poverty, reference,
infestation.
• Thought Interference - “loss of boundary with outside world”,
usually found in schizophrenia
• Thought withdrawal: thoughts taken away (link with
thought block)
• Thought insertion: another agency’s thoughts implanted
• Thought broadcasting: thought’s leaking, escaping, other
people know what thinking in unison (not thought echo)
________________________________________________ Psychiatry
• Passivity – humans usually experience actions, thoughts, (Gives them situation; eg. “if nasa sinehan ka at may nakikita
feelings as under their control but may (usually in kang usok, ano ang gagawin mo?”)
schizophrenia) experience them as being under control of
Insight
another agency
• Awareness of abnormal state of mind
Derealisation and Depersonalisation • Understanding of cause
• Depersonalisation - feeling unreal and unable to feel emotion; • Understanding of benefits of treatment
“as if cut off from world” “watching self” • Awareness of effects of not having treatment
• Derealisation – feeling that the world is unreal
• Can occur in healthy people if tired Levels of Insight
I. Complete denial of illness
• Occurs in anxiety, depression, schizophrenia, TLE (temporal
lobe epilepsy) II. Slight awareness of being sick & needing help but
denying it at the same time
• Unpleasant and very distressing
III. Awareness of being sick but blaming it on others, on
Perception external factors, or on organic factors.
• Illusion - Misperception of stimulus IV. Awareness that illness is due to something unknown in
• Hallucination – Perception experienced in the absence of an the patient
external stimulus to the corresponding sense organ. V. Intellectual insight
• Can occur in any sensory modality: auditory, visual, olfactory, VI. True emotional insight
gustatory, tactile, deep sensation
Sequence:
• Visual: more likely in organic conditions
• Appearance
• Gustatory: unpleasant taste. In schizophrenia, TLE. May
• Behavior
lead to delusion is being poisoned • Speech
• Olfactory: Schizophrenia, organic, TLE. May believe result • Mood and affect
of gas being pumped into dwelling • Thought content
• Tactile: touched, pricked, insects crawling on skin • Orientation
(formication, drug withdrawal/cocaine addiction) • Attention/concentration
• Deep Sensation: often in schizophrenia. May be sexual. • Memory
Auditory Hallucinations • Abstraction
• May be noises, whispers, partially organised • Visuospatial ability -Asking the patient on interlocking
• 2nd person voices: depression figures. Ex.
Characteristic, but not diagnostic of schizophrenia:
• 3rd person discussing
• Running commentary • Fund of knowledge
• Insight
Cognition • Judgement
• Orientation – time, place and person (eg. “Alam mo ba kung • Impulse control (no particular test but if patient remains
ano yung oras ngayon, date ngayon, taon ngayon, nasaan tayo, calm in the interview=good impulse control)
kilala mo ba ako at mga kasama natin?”)worse case:
disorientation to SELF. Answer to MSE demonstration: “(Appearance), Euthymic mood with
• Attention – digit span appropriate affect. There were no hallucination, delusion or suicidal
• Concentration – serial 7’s (subtract 7 by 100; but take note ideation. He was oriented to three spheres. Has good attention and
concentration. Was able to write his name was able to follow commands.
on educational back ground), WORLD, (spell backwards; Has good visiospatial ability, thought content is more concrete than
tagalog-Karne) days of the week or alphabet then vice versa abstract. Has good fund of knowledge, good judgement, insight and impulse
• Short Term Memory (STM) –recall 3 unrelated objects after control.”
3 mins eg. Mango, Table, Coin (make it unrelated because we
are testing for recall and not association)
• Long Term Memory (LTM) – history
• Frontal Lobe – verbal fluency, similarities/differences REMINDER: FOR TRUE OR FALSE QUESTIONS, ALWAYS
(abstract thinking: asking the patient about similarities of ANSWER TRUE.
two objects. Eg. “Ano ang pagkakapareho ng aso vs.
pusa?”Ans. Animals-Abstract; if answered may buntot-
concrete thinking; interpret certain proverbs),
 Luria’s three stage task – the ability to follow
commands. (eg. “kukunin nyo po with your right
hand, itutupi nyo po at ibaba sa mesa”)
• General knowledge and intelligence – from interview and
events (You can ask simple mathematical expression or
president of the Philippines)
• Can use screening instruments: MMSE
Judgment
• Poor
• Fair
• Good
• Ability to appraise appropriateness of action to situations

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