This is a ppt on History taking and Examination in psychiatry.

1. Psychiatry case taking &
Examination
Dept. of Psychiatry
KIMSRF

2. Roadmap
History taking
• Purpose
• General principles
• Interview room
• Questioning
• Basic details
• HOPI
• Past history
• Personal history
• Family history
• Pre morbid personality
MSE
• General appearance &
Behaviour
• Psychomotor activity
• Speech
• Mood
• Thought
• Perception
• Cognitive functions

3. History taking
• Most important in evaluation and care of
persons with mental illness.
• Purpose-
– Establish diagnosis.
– Prediction of course & prognosis.
– Treatment decisions.
– Shapes patient-physician relationship.

4. General principles
• Agreement to the process-
– Introducing
– Voluntary/ Involuntary patient
• Privacy & Confidentiality-
– Very essential
– Assure patient of confidentiality
– Legal obligation
• Respect & Consideration-
– Allaying anxiety

5. • Rapport/ Empathy-
– Harmonious responsiveness of physician to patient
and vice versa
– Understanding what the patient is thinking and feeling
by putting in patient’s place
– Verbal & Non verbal responses
– Not to get carried away
• Patient-Physician relationship-
– Increases trust & therapeutic alliance
• Safety & Comfort-

6. Interview room
• Relatively soundproof
• Décor- pleasant, non distracting
• Chair of patient
• Approx 4 to 6 feet apart
• Distractions should be kept minimum
• No telephone

7. Questioning
• Open ended vs Closed ended
• They identify an area, provide minimal structure
as to how to respond.
• Ex- tell me about your problem
• Provide structure and narrow the field of
responses. Mostly yes or no.
• Ex- is sleep your problem

8. • History- obtained from patient and collaterals,
like family members & other caregivers.
• MSE- Interviewer’s objective tool similar to
physical examination in other areas of
medicine.
• Physical examination- to rule out organic
conditions.

9. • Identifying data
• Source & reliability
• Chief complaints
• HOPI
• Past history
• Family history
• Personal history
• Pre Morbid Personality

10. Basic details
• Identifying data-
– Patient’s name, age, sex, marital status, education,
occupation & residence
• Source & reliability-
– From the information came & how reliable is the data
• Chief complaints-
– In patient’s own words.
– Noted chronologically.

11. HOPI
• Onset, duration of illness.
• Basic information of specific chief complaints-
duration, intensity etc..,
• Details of precipitating factors.
• Positives & negative history.
• Note down important life events.
• Different approaches may be needed-
– Emergency setting
– Out patient setting

12. Past history
• Includes- psychiatric & medical.
• Information about past psychiatric illnesses,
course including symptoms & treatment.
• Details like- when, how long, frequency,
severity etc..,
• Treatment details should be reviewed in detail
like- pharmacotherapy, psychotherapy, ECT.
• Making a life chart gives a clear picture.

13. Family history
• Genogram- 3 generations
• Family history of psychiatric illness- details
regarding the same.
• Many- familial & significant have genetic
predisposition.
• There appears to be familial response to
medications, suicide- important in
management of patient.
• Interpersonal issues.

14. Personal history
• Birth & early development
• Behavior during childhood
• Physical illness during childhood
• Schooling
• Occupation
• Menstrual history
• Sexual history
• Marital history

15. Pre morbid personality
• Prior to the beginning of mental illness
• Details like-
– Social Relation
– Mood
– Intellectual activities, hobbies & interests
– Fantasy life
– Habits

16. Mental status examination
• General behavior and appearance
• Psychomotor activity
• Speech
• Thought
• Mood
• Perception
• Cognitive functions

17. Definitions
• Hallucination-
– A false perception which is not a sensory distortion or a
misinterpretation, but which occurs at the same time as real
perception.
• Illusion-
– False perception of the stimulus.
• Obsession-
– A thought that persists & dominates an individual’s thinking.
• Compulsion-
– Obsessional motor acts.

18. • Delusion-
– False, unshakable belief that is out of keeping with the patient’s
social and cultural background.
• Amnesia-
– Partial or total inability to recall past experiences and events.
• Emotion-
– Stirred up state caused by physiological changes occurring as a
response to some event.
• Mood-
– Pervasive & sustained emotion that colors the person’s
perception of the world.

19. General behavior and appearance
• Appearance- grooming, hair and nails.
• Rapport- established or not
• Eye to eye contact- maintained or not
• Presence of any tics or mannerisms.
• Behaviour towards examiner.
• Anxiety signs-moist hands, perspiring
forehead, tense posture, wide eyes, wringing
of hands, fidgeting behaviour etc..,

20. Psychomotor activity
• Increased
• Decreased

21. Speech
• Form of utterance
• Spontaneously or not?
• Amount- little or excessive?
• Tone- high or low?
• Tempo- fast or slow?
• Reaction time- increased or decreased?
• Prosody of speech maintained?
• Relevant & Coherent?

22. Thought
• Formal thought disorder
• Stream-
– Flight of ideas,
– Thought block, circumstantiality, perseveration.
• Possession-
– Obsessions & compulsions,
– Thought alienation.
• Content-
– Overvalued ideas and Delusions.

23. Mood
• Assessed as-
– Subjective report
– Objective evaluation
• Quality of emotion
• Intensity or depth of emotional experience
• Range of affective responses, mobility, reactivity, and
appropriateness.
• Evidence of labiality.

24. Perception
• Illusions
• Hallucinations- visual, auditory, tactile, gustatory,
olfactory & kinesthetic.
• Special varieties- Functional hallucinations, Reflex
hallucinations, Extra-campine hallucinations,
Synaesthesia and Autoscopy.
• Other perceptual disturbances-
Depersonalisation/ derealisation experiences.

25. Cognitive functions
• Orientation
• Attention & Concentration
• Memory
• Intelligence
• Judgment
• Insight

26. Orientation
• Time-
– Appropriately what time of the day is it?
– Is it morning, afternoon, evening or night?
• Place-
– What place is this?
– Is this a school, office, hospital, restaurant etc.?
• Person
– Identifying of the patient’s relative or family
members.

27. Attention & Concentration
• Tests used-
– Digit span test
– Serial subtraction
– Days or months forward to backward
• Digit span test-
– Forward- numbers are given & asked to repeat in the same order
– Backward- numbers are given & asked to repeat in opposite order.
• Serial subtraction-
– increasingly difficult tests are presented.
– 20-1, from 20 to 0 reversed in 15 seconds, 40-3 & 100-7.
• Days or months may be asked for in backward or forward.

28. Memory
• Memory is tested as
– Immediate,
– Recent and
– Remote memory
• Immediate memory – tested by digit span test
• Recent memory –
– Address test-an address consisting of about 4-5 facts is given & patient to
repeat.
– 2. Asking the patient to recall events in the last 24 hours.
• Remote memory-
– Date of birth or age
– Names and number of family members
– Time since marriage or death of any family members

29. Intelligence
• Tested as-
– General information,
– Comprehension,
– Arithmetic and
– Abstraction
• General Information - Information relevant to the patient’s literacy age or
occupation may be asked
• Comprehension - ability to understand the questions asked, like-
– What will you do when you feel cold?
• Arithmetic - basic questions on calculation, like
– How much is four rupees and five rupees?

30. • Abstraction- tested by-
– Similarities, differences and proverbs.
• Similarities- two items are given & asked to point out the
similarities
– Orange - banana (fruits)
– Dog - lion (animal)
• Differences- two items are given & asked to point out the
differences
– Stone - potato (not edible-edible/ hard- soft)
– Fly - butterfly (small-large/ colourful-not colourful)
• Proverbs- a proverb is given & patient is asked to interpret it .

31. Judgment
• Assessed in the following areas:
– Personal
– Social
– Test
• Personal judgement- assessed by inquiries about the patient’s future
plans.
• Social judgement- assessed by observing behaviour in social situations.
• Test judgement – following problems are presented
– Fire Problem- if the house in which you live catches fire what is the first thing
that you will do?
– Letter problem- If when you are walking on the road, you see a stamped and
sealed envelope with an address on it, which someone had dropped. What
will you do?
– Baby near the pond- If a small baby is lying near the pond, what will you do?

32. Insight
• To know patient’s level of awareness of his illness.
• Absent insight- does not think that he/she is ill
• Partial insight- he/she recognises the presence of
the illness but gives explanation in physical terms.
• Complete insight- he/she fully recognise the
emotional nature of his illness and the cause of
his symptom.

33. Thank you