History Taking & Mental

State Examination
Oman Medical College
Psychiatry Department

Course Coordinator
Dr. Mohamed Mitwally
Associate Professor of Psychiatry
mohmits@yahoo.com
Acknowledgment: We are grateful to Dr. Ahmed Moubarak for his valuable contribution to this presentation.
Hierarchy
 Demonstrate professionalism
• Attend required event
• Be punctual.
• Complete patient notes in time.
• Maintain professional demeanor.
• Proper professional boundaries.
• Be trustful.
• Be enthusiastic for care.
• Be enthusiastic for learning.
• Complete required reading assignment
• Be Courteous to all.
 I. Creating rapport
1. Introduce yourself to everyone
in the room. welcome patient with his
name
2. Acknowledge any waiting for
you by the patient.
3. Convey your knowledge of the
appointment to the patient
Creating rapport (cont.)
5. Make some social comment to
put the patient at ease.
6. Elicit the patient’s concerns with
open-ended questions.
7. Plan the visit .
The sequences of the events in the visit ( change the
priorities when necessary).
 II. Elicit the Patient’s Perspective Understands the
patients perspective before explaining your own

1. Identifying the context.

– Listens attentively. without
interrupting or directing patients
response. Encourages patient to tell
the story in own words FACILITATE
2. Eliciting specific requests. THE
EFFECTIVE
– Identifies the reason(s) for the EXCHANGE OF
consultation INFORMATIONS

3. Considering cross-cultural
factors.
– Clarifies ambiguous information
– Make sure that you get exactly what
the patient wants to tell you
A. Preliminary requirements
“Format”
• Quiet room ……. No intervention.
• The patient seats directly opposite to the
doctor, the same level ( the patient should
not looks upwards
• In diagnostic • In therapeutic
interview interview

Don’t memorize then write the notes

Personal Data
1. Name of the patient

• the importance to start with asking the name of

your patient is
– To break the state of fear, tension and suspicion in
the patient that usually occurs at the beginning of
the interview.
– To make an accurate recording of your patient.
– The name of the patient may be a source of stress
on him if this name is unfamiliar to the culture e.g.
the names that denote animals or ugly places.
 2. Age
• The importance of the age is due to:
– Some psychiatric disorders are common in certain
age period, e.g. mental retardation is common
among children. Schizophrenia is common among
adolescents and young adults and dementia more
in senile period.
– Certain developmental period are stressful to some
individual e.g. adolescence, menopause, and
retirement,
– The extremes of age i.e. children and senile
persons should be dealt with carefully when
prescribing the drug.
3. Home address of the patient

• The residence is important to help

communication with the patient in the
future.
• The residence of the patient is an
indicator of his cultural background,
4. The marital status
• Single , married, separated, widow or
divorced.
• Some psychiatric disorders are common
among widows and singles e.g.
depression. The impact of divorce and
separation depends mainly on the
circumstances of every case.
 5. Religion
• Religion in oriental societies is the most
important source of cultural values,
attitude and traditions. From this aspect it
may affect the concept of psychiatric
disorders
 6. Place of care
• Either out-patient or in-patient care. This
will give idea about the degree and
severity of illness, usually the minor
psychiatric disorders treated as out patient
and the major disorders as in patient,
 7. The nature & cause of patient referral

– Nature: • Compulsory
– Compulsory or voluntary
referral occurs
– Cause:
– For treatment. in psychosis
– For medical report to use it in civil
purpose e.g. to take a leave from his
• The cause and
job. the motive of
– For assessment of his mental state.
Either to prove that he is ill or that he is referral can
sound.
affect the
– To assess his responsibility for a crime
or accident reliability of
– To assess the suitability for his job
data about the
patient
8. Source of patient referral
• The source of referral • Every source
could be could affect the
– The patient comes by reliability of
himself. informations
– Referred by the family about the patient
– Referred by the police.
– Referred by the court.
– Referred by his work.
– Referred by peoples
found him in the street.
 9. Informant
• The individual who give
information about the patient
and his illness during the
interview
– The informant could be:
Reliable
• The patient him self. Informant
• The family or not?
• The work mate.
• The treating doctor or the observing
nurse if the patient is in the hospital
Psychiatric History
• Illness related History
• Patient related History
• Family History
Complaints
• Should stress on the current complaints
specially the one which compels the patient to
ask for consultation.
• Should be taken by the language of the patient
• The doctor must clarify the meaning of
expressions.
• The doctor should translate the patient’s
expressions into clinical symptoms.
• The doctor should understand the significance
of these symptoms and how to use them in the
diagnosis
‫‪Symptoms‬‬ ‫شكوى المريض‬
History of Present illness
• Onset of illness.
• Precipitating factors.
• Course of the illness.
– i.e. the time line of exacerbations and
remissions of symptoms.
• Patient’s concept of his illness.
• Previous trials of treatment.
• Patient expectation about prognosis.
Past medical history
• Of psychiatric diseases.
– Similar to the current
– Other disease.
• Of Medical diseases.
Patient's related history
(Personal history)
1. Early development.
2. Educational history.
3. Occupational history.
4. Sexual history.
5. Menstrual history (females).
6. Military history.
7. Marital history.
8. Legal history.
9. Habits.
10. Pre-morbid personality.
Early development
• Situation of conception
– Wanted or not
• Mother during pregnancy
– Good health, drugs, infections…..etc.
• Labor (delivery).
– Normal or instrumental, hospital or home.
• Early childhood
– Diseases, Milestones of development, care
giver relationship.
 Educational history
• Age of joining school. • Deterioration of
• Scholastic relations. educational career
– With his/her mates can be an
– With his teachers. indication of
psychotic process
• School behavior and
e.g. schizophrenia
activities.
– Sports, social, truancy,
phobia,
• Achievements
– Below average, average
or above average.
Occupational history
• Employed or not • Deterioration of
• Type of the job. occupational
• Duration of joining. career can be
an indication of
– frequent changes….why?
psychotic
• Work relations and process e.g.
behaviors schizophrenia
– With his colleagues, seniors,
– Absences, leaves, compliance
to regulations.
– Satisfied with work,
salary,,,,,,,etc.
 Sexual history
• Age of puberty
• Sexual fantasies & orientation.
• Sexual relations and performance.
– Marital.
– Extramarital.
• Sexual abuse…..?

1-Don’t embarrass the patient by surprising him with

unexpected sexual questions specially the conservative
patients and those differ from the doctors gender.
2- If the patient is complaining of sexual problem this means
that he is suffering a lot specially the females
Marital history
• Age of marriage, Type of marriage,
Spouse, Children.
• Home atmosphere.
• Polygamy .
Menstrual history
• Age of menarche. and reaction towards it
• Nature of menstruation.
– irregular, painful, scanty……etc.
Military history
• History of service.
• Behavior in service.
• Reaction to service.
Legal history
• Involvement in legal case or not
• Criminal history and imprisonment.
Habits
Repetitive fixed pattern of behavior
• Biological habits
– Eating, sleeping.
• Other habits
– Smoking, drinking, …..etc
Assessment of the pre-morbid personality

• Social relations
– Dependent?
– Sociable?, leader?,
• Intellectual activities and interests.
– Reading, playing …..?
• Pre-morbid mood.
– Anxious, angry, cheerful, blunted….etc
• Character.
– Neat, perfectionist, shy, sensitive, bold, optimistic….etc
• Energy
– Energetic, day dreamer or not.
Family history
• Data of parents & Siblings, consanguinity and
polygamy.
• Parents- patient relationship.
• Home atmosphere
– Psychosocial aspect
• Troubles, broken home,
– Economic aspects.
• Poor, crowded, culturally impoverished
• Family diseases.
– Psychiatric.
– Medical.
General appearance &behavior
• Dressing, cooperation,
• Motor behavior
– Restless, agitated……. Excited.
– Retardation, ……….stupor.
• Bizarre behavior.
– Stereotypy, mannerism, perseveration,
automatism……..etc
• Aggression,
– Towards self or others……….ensure safety
Affect vs. Mood
• In examination of the mental state, the
term affect refers to the external
manifestation of an internal feeling state
during examination.
• It is said that affect is to mood as weather
is to climate, i.e. it the current mood state.
Affect vs. Mood
• Mood: Sustained and pervasive
emotion that colors the person’s
perception of the world.
• The patient may report his feelings or
the psychiatrist ask how he or she
feels.

• Affect: The patient present emotional

responsiveness that is inferred from
his facial expression.
Affect / Mood
• Emotional expression
– Facial, ,,,,,,,looks depressed, anxious, angry, cheerful,
or apathetic.
– Hand movements and other body languages
• Emotional experiences.
– Inner feelings
• Stability of emotions
– Stable…….changeable.
• Control of emotions.
• Quantitative or qualitative changes.
Talk
• Stream
– Slow, rapid, blocks,
• Expression
– Vagueness, Flights of ideas, Incoherent,
neologism.
Thought
• Stream
• Expression
• Form.
– Degree of association
– Nature of disturbance of association
• Contents.
– Delusions
– Obsessions.
Perception
• Hallucinations
– Type…..visual, auditory, olfactory, tactile,
gustatory.
– Significance.
• Illusion.
• Types.
• Significance.
Consciousness & Orientation
Level of consciousness Disorientation for
time and place are
Conscious drowsy, usually due to
confused simi- delirium
comatosed but can occur with
comatosed severe dementia and
rare case of
dissociative state is
Orientation possible
– Time
– Place
– Person
– Situation
Attention and concentration
• Attention ( ability to • Disturbances of
focus) attention,
– Passive. concentration,
– Active . immediate and
• Concentration (ability short-term memory
to sustain attention) are usually due to
– Serial 7s, 3s, 2s, or simple delirium and can be
math characterized by
– Spell “WORLD” backwards or fluctuations
reverse 5 digits
Memory
1. Immediate recall Ask the patient to
(immediately) repeat 5-7 digits
or postal address
2. Short-term recall (at 5 min)
3. Recent: what patient did • Immediate
past several days memory is lost in
4. Recent past: what patient amnesic
did past few months syndrome
5. Remote: Childhood events,, • Short term and
historical events (years) recent memory
are affected in
dementia
 Intelligence / Information and Abstract
Thinking

1. Countries bordering Oman • Intelligence is

etc. affected in
2. What makes rust? What are mental
lungs for? retardation
3. Simple calculations • Abstract
4. Comparisons: orange/apple, thinking is
desk/chair, plane/truck affected in
psychosis
5. Proverbs: ‘don’t cry over particularly
spilled milk’, ‘a rolling stone
gathers no moss’ schizophrenia
and mental
retardation
 Methods of assessment of abstraction
1- Similarities
– Similarities require the patient to identify the class or category of
which two items are members (e.g., rose and tulip, bicycle and train,
watch and ruler).
2- Differences
– Differences require the patient to identify the salient distinguishing
feature between two similar items (e.g., child and midget, canal and
river, lie and mistake)
3- Idioms
– Idioms are metaphorical statements or aphorisms that require the
patient to generalize to a larger meaning (e.g., "seeing eye to eye,"
"level headed," and "eyes peeled")
4- Proverbs.
– Proverbs are usually double metaphors that require the patient to
ignore the immediate meaning and derive a lesson or maxim (e.g.,
"don't cry over spilled milk," "people who live in glass houses
shouldn't throw stones," "the tongue is the enemy of the neck").
 Insight & Judgment
Insight: Understanding /
appreciation of current situation
or illness. The patient knows that
s/he has a psychiatric illness. If
hallucinating, the patient knows
that his/her mind is playing tricks.
Judgment: Ability to make sound
decisions. An estimate of the
patient’s real-life problem solving
skills. (e.g., What will you do
when you leave the hospital?
What would you do if you found a
stamped, self-addressed
envelope?)
Insight is often lacking with
schizophrenia and other psychotic
conditions. Patients with organic
impairment such as delirium and
dementia will have absent or
diminished insight
Judgment is regularly impaired in
dementia, delirium and psychosis
including schizophrenia, as well
as at times with mental
retardation
 Glasgow Coma scale (Adults)
Spontaneous--open with blinking at baseline 4 points
Opens to verbal command, speech, or shout 3 points
Eye Opening Response
Opens to pain, not applied to face 2 points
None 1 point
Oriented 5 points
Confused conversation, but able to answer questions 4 points
Verbal Response Inappropriate responses, words discernible 3 points
Incomprehensible speech 2 points
None 1 point
Obeys commands for movement 6 points
Purposeful movement to painful stimulus 5 points
Withdraws from pain 4 points
Motor Response
Abnormal (spastic) flexion, decorticate posture 3 points
Extensor (rigid) response, decerebrate posture 2 points
None 1 point

Patients with scores of 3-8 are usually said to be in a coma.

The total score is the sum of the scores in three categories.
 Glasgow Coma scale
For children under 5, the verbal response criteria
are adjusted as follow

SCORE 2 to 5 YRS 0 TO 23 Mos.

Smiles or coos
5 Appropriate words or phrases
appropriately
4 Inappropriate words Cries and consolable
Persistent cries and/or Persistent inappropriate
3
screams crying &/or screaming
Grunts or is agitated or
2 Grunts
restless
1 No response No response
The Mini Mental State
Examination (MMSE)
 Areas Tested by MMSE
• Orientation (10 points)
• Memory (6 points)
– REGISTRATIN (3points)
– RECALL (3 points)
• Attention and Calculation (5 points)
• Language, Writing and Drawing (9 points)
Orientation
Ask (what &where): (10 points)

• What is the: • Where are we:

1. Year 1pnt 1. State 1pnt
2. Season 1pnt 2. Country 1pnt
3. Date 1pnt 3. Town 1pnt
4. Day 1pnt 4. Hospital 1pnt
5. Month 1pnt 5. Floor 1pnt

Total 5pnts Total 5pnts

 Memory (6 points)
REGISTRATIN (3points)
a. name 3 objects to the
patient e.g.
1.Pen 2. Ball 3. Ring
b. Tell the patient to repeat
c. Give one point for each
repeated item.
Tell the patient to memorize the
Three items the wait for
minutes
RECALL (3 points)
Ask the patient to name the
previous 3 objects (give
1second to name it)
e.g. Name:
1.Pen 2. Ball 3. Ring
Give one point for each named
item.
Attention and Calculation
(5 points)

• Subtraction of serial 7s test

Ask the patient to start from number 100 then subtract 7 then subtract 7
from the result….etc then stop after 5 operations and give one
point for each correct answer:
The answers will be
93 1pnt
86 1pnt
79 1pnt
72 1pnt
65 1pnt
Language, Writing and Drawing (9 points)

Test (1): Ask the patient to identify and name

– Pencil 1pnt
– Watch 1pnt
Test ( 2 ): Ask the patient to repeat the phrase (no ifs, ands, or buts)
1pnt
Test (3) Ask the patient to:
take the paper in your right hand 1pnt
fold it in half 1pnt
put it on the floor 1pnt
Test (4) Ask the patient to read and obey the following (close your eyes)
1pnt
Test (5) Ask the patient to write a sentence 1pnt
Test (6) Ask the patient to copy complex interlocking pentagons
1pnt
Scores
Score Indication
27 or above Normal
23- 26 borderline
22 or below abnormal
20- 26 Mild dementia
10- 19 Moderate dementia
Below 10 Severe dementia
Limitations of MMSE
It is affected by educational level
 Investigations
• To assess mental functions
– Psychological tests.
• To exclude physical diseases
– Laboratory.
• Blood, csf, urine ……etc
– Imaging.
• X ray, CT, MRI……etc.
– Electrophysiological.
• EKG, EEG, EP…….etc
• Patient with Cognitive Disturbance
or concomitant organic findings
Case formulation
How…?
• 32 yo Omani married male teacher . 3
years of alternating depressed and irritable
mood, with irregular treatments. Repeated
absence from job and marital troubles.
Currently he is severely depressed with
suicidal thoughts. Lab test showed that he
is diabetic
Multi axial System
AXIS I: Clinical Disorders
Other Conditions That May Be a Focus of Clinical Attention
e.g. Diagnostic Code DSM-IV Name
300.21 Panic Disorder with Agoraphobia, Moderate
304.10 Diazepam Dependence, Mild
_________________________________________
AXIS II: Personality Disorders
Mental retardation.
e.g. Diagnostic Code DSM-IV Name
301.82 Avoidant Personality Disorder
__________________________________________
AXIS III: General Medical Conditions
e.g. ICD-9-CM code ICD-9-CM name
424.0 Mitral Valve Prolapse
Axis IV: Psychosocial and Environmental Problems

• Problems with primary support group Specify: Marital Discord

• Problems related to the social environment Specify:___________

• Educational problems Specify:_____________________________

• Occupational problems Specify: Excessive Work Absences

• Housing problems Specify:________________________________

• Economic problems Specify:_______________________________

• Problems with access to health care services Specify:__________

• Problems related to the legal system/crime Specify:___________

• Other psychosocial and environmental problems Specify:_______

Axis V: Global Assessment of Functioning Scale
score summery of functional disturbance
100 - 91 Superior functioning in a wide range of activities
90- 81 Absent or minimal symptoms (e.g. mild anxiety before exam.)
80-71 If symptoms are present they are transient and expectable reaction to
stressor.
70-61 Some mild symptoms are present (e.g. depressed mood & insomnia
60- 51 Moderate symptoms (e.g. flat affect and occasional panic attacks)
50-41 Serious symptoms (e.g. suicidal ideation severe obsessions0
40-31 Some impairment of reality testing (e.g. irrelevant speech)
30-21 Behavior is considerably affected by delusions or hallucinations
20-11 Some danger of hurting self or others
10-1 Persistent danger of severely hurting self or others.
0 Inadequate information.
Goals of treatment
• Symptomatic relief.
• Psychological and social
adjustment.
• Relapse prevention.
Tools of treatment
• 1- Psychotherapy
• 2- Somatic therapy
– a. Pharmacotherapy.
– b. Electroconvulsive therapy.
– c. Psycho surgery.
• 3- Environmental therapy
– a. Occupational therapy.
– b. Entertainment therapy.
– c. Cultural and religious therapies
Hierarchy
Follow up
• Clinical
– Medication, revaluation, psychotherapy
• Social and occupational (social worker)
– Family
– Work
Go on……
don’t hesitate to seek help or advice