History Taking & Mental State Examination

Warning

Psychiatric History

The history should be given, as much as possible, in the patient’s own words.  Do not use jargon unless the patient does!  You can show off your knowledge of how to label symptoms accurately when presenting the Mental State.  If the patient experiences auditory hallucinations, give a verbatim quote of what is heard.

Introduction: (name, age, marital status, occupation, known previous contact, reason for referral)


Presenting Problem(s)

History of presenting problem(s)

Onset, course, other help sought, response to treatment so far

Symptom details

Precipitating events a) for illness; b) for seeking help


Family history

Family details (parents, siblings, ages)

Relationship with family members

Family history of psychiatric illness


Personal history

Pregnancy & birth

Early life – developmental milestones, memory of difficulties within family

Schooling – educational achievement, ability to form friendships

Occupational history

Sexual/relationship history (ask details appropriate to interview)

Serious life events


Present circumstances – current relationship, children, work, finances, recent stresses


Past psychiatric & medical history  (including current medications)

Previous admissions

Admissions under the Mental Health Act

Previous treatment (medication or psychological)


Personality before illness (may require informant)


 

Current and past drug/alcohol use

if evidence of problem then detail:

-       a)  quantity, timing etc

-       b)  evidence of dependence

-       c)  harmful consequences of use


Forensic History

Mental State Examination

Remember – the mental state should take into account not just your observations during the course of the interview but also information obtained on symptoms and signs during the course of this episode of illness.  If there is evidence of disorder of thought form you should give examples of speech to demonstrate this.

 


Appearance and behaviour

General description

Self-care

Rapport and eye contact

Activity/retardation, pre-occupation/attentiveness, irritability etc


Mood

Euthymic, elated, depressed, labile, incongruous, blunted


Speech

Rate, rhythm, volume, tone


Disorders of thought form (continuity of thought as reflected in speech/writing)

-      acceleration/retardation

-       circumstantiality/loosening of association

-       perseveration

-       neologisms

-       word salad


Disorders of thought content

Pre-occupations (including suicidal ideation)

Overvalued ideas (including ideas of reference)

Obsessions/phobias

Delusions (including disorders of the possession of thought)

-       primary, secondary

-       disorders of the possession of thought (thought insertion, thought withdrawal, thought broadcasting


Disorders of perception

Derealisation/depersonalisation

Illusions

Hallucinations


Cognitive assessment

Orientation

Attention and concentration

Memory

Intelligence and general knowledge

Insight/judgement


Insight

What does the patient think is the explanation for their problems?What is their attitude to treatment/ supervision/ staying in hospital?

Editorial Information

Last reviewed: 29/04/2024

Next review date: 16/08/2028

Author(s): MyPsych Editorial Group.

Version: 1.0

Author email(s): mypsych@ggc.scot.nhs.uk.

Approved By: MyPsych Editorial Group

Reviewer name(s): MyPsych Editorial Group.