The psychiatric history and mental state examination

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Chapter 12 The psychiatric history and mental state examination

Law number four: the patient is the one with the disease.

House of God: Samuel Shem

This chapter deals with the psychiatric history and the mental state examination. The practising clinician must have an understanding of psychiatric illness and know how to perform a psychiatric interview and a mental state examination. This is because there is considerable overlap between psychiatric and physical illness.

Psychiatric disorders (especially anxiety and depression) are common, and people suffering from these conditions often have medical problems. Appropriate management of these patients will require an understanding of the intercurrent psychiatric disorder and the effect of that disorder on the primary medical problem. A medical illness may, in some instances, present as a psychiatric illness. For example, some endocrine disorders, such as myxoedema, may present with depression. On the other hand, some psychiatric disorders may present medically. Panic disorder (or acute anxiety) may be mistaken for an acute myocardial infarction. Furthermore, a patient’s psychological state may interfere with the course of a medical illness; it may lead in some cases to exaggeration of the symptoms and in others to denial of the severity of physical symptoms.

The psychiatric history generally follows the same format as the standard medical history, and the principles described in Chapters 1 and 2 apply just as much here as in any history taking.¹ One should inquire about the history of the present illness, the past psychiatric and medical history, and the social and family history. However, the psychiatric history aims to elicit more detail about the patient’s illness from a broad perspective, focusing not only on symptoms but also on the patient’s social background, psychological functioning and life circumstances (a biopsychosocial approach). There is, therefore, more attention paid to the developmental, personal and social history than is normal for a standard medical history.

The method of psychiatric history taking is somewhat different from the standard medical interview. The psychiatric interview aims to be therapeutic as well as diagnostic. In the course of the interview it is hoped that the patient will be able to talk about his or her problems and their context. In doing so, patients will gain some relief from their distress by airing their problems. For this to take place, the clinician’s attitude needs to be unhurried, patient and understanding. The psychiatric history also aims to gain an understanding of how the patient’s problem arose from a biological, interpersonal, social and psychological perspective, so that the best management plan can be worked out.

Obtaining the history

The clinician taking a psychiatric history wants the patient to tell his or her story in his or her own words. In this way the patient will be more likely to report the most important aspects of the illness. This is best achieved using a non-directive approach with open-ended questions. Open-ended questions are those to which the patient will respond with narrative (or a description about what has been happening) rather than a simple factual response. They give the patient an opportunity to talk about his or her problems. Closed questions are more likely to elicit ‘yes’ or ‘no’ responses. For example, in the assessment of a patient with depression, a closed question would be: ‘Have you been depressed?’ An open-ended question would be: ‘Tell me about how you have been feeling.’ At first glance it might appear that the open-ended question is less efficient, as it could take a longer time to find out about a range of symptoms. However, with a careful and judicious approach, open-ended questioning—by permitting the patient to tell the story—will enable the clinician to get a comprehensive history efficiently. This is not to say that targeted, more-closed questions must not be used—they are necessary to elicit certain symptoms.

While the patient is telling his or her story, the clinician should begin to formulate hypotheses about the problem or diagnosis. These hypotheses are tested by asking more-focused questions later in the interview, at which point a diagnostic hypothesis can be rejected or pursued further. For example, a patient may describe tiredness and lethargy, an inability to concentrate and loss of appetite. These symptoms will suggest a diagnosis of depression. Follow-up questions should focus on this possibility. The clinician should ask questions about other symptoms of depression such as: ‘How have you been feeling in yourself?’, ‘What has your mood been like?’ and ‘How have you been sleeping?’

Introductory questions

The psychiatric interview should start off with non-threatening questions. After introducing yourself, it can be useful to begin by asking about basic demographic information (age, marital state, occupation, whom the patient lives with) and then making the patient feel at ease by discussing some neutral topic.

History of the presenting illness

In assessing the history of the presenting illness, one needs to cover a number of areas.

1. The problem

Find out the nature of the patient’s problem, and the patient’s perception of his or her difficulties. This can, of course, be difficult if the patient is psychotic and does not believe a problem exists at all. In these cases a corroborative history must be taken. For example, a manic patient may consider that there is nothing wrong and that his or her behaviour is reasonable, whereas his or her partner is able to recognise that ordering an expensive new sports car when the family is impoverished is a problem.

A range of symptoms commonly found in psychiatric disorders needs to be reviewed in the course of assessing the history of the present illness. These include mood change, anxiety, worry, sleep pattern, appetite, hallucinations and delusions. A set of simple screening questions for each of the major diagnoses is listed within Table 12.1. It is especially useful to ask about symptoms of anxiety and depression (the most common psychiatric disorders). The definitions of other symptoms are given in Table 12.2. It is important to ask about drug usage (legal and illegal) as well as alcohol and caffeine (which may be associated with anxiety disorders).

TABLE 12.1 The common psychiatric disorders ^* and their screening questions

MOOD (AFFECTIVE) DISORDERS
Mood disorders have a pathological disturbance in mood (depression or mania) as the predominant feature. They are distinguished from ‘normal’ mood changes by their persistence, duration and severity, together with the presence of other symptoms and impairment of functioning.
1. Manic-depressive illness—bipolar disorder
Bipolar disorder is a broad term to describe a recurrent illness characterised by episodes of either mania or depression, with a return to normal functioning between episodes of illness.
a. Mania A disorder demonstrated by change in mood (elation), thought form (grandiosity) and behaviour disturbance (increased energy and disinhibition). Frequently associated symptoms: increased talkativeness, distractibility, decreased need for sleep, loss of inhibition (e.g. engaging in reckless behaviour such as spending sprees, sexual indiscretion or social overfamiliarity).

Questions box 12.1 Questions to ask the patient with possible mania

1. Have you felt especially good about yourself?

2. Have you been needing less sleep than usual?

3. Do you feel that you are special or that you have special powers?

4. Have you been spending more than usual?

b. Depression

A disorder characterised by depressed mood (or loss of pleasure) and the presence of somatic (sleep disturbance, change in appetite, fatigue and weight), psychological (low self-esteem, worry- anxiety, guilt, suicidal ideation), affective (sadness, irritability, loss of pleasure and interest in activities) and psychomotor (retardation or agitation) symptoms.

Questions box 12.2 Questions to ask the patient with possible depression

1. How have you been feeling in yourself?

2. What has your mood been like?

3. Have you been feeling sad, blue, down or depressed?

4. Have you lost interest in things you usually enjoy?

5. How have you been sleeping?

ANXIETY DISORDERS Anxiety disorders are those in which the person experiences excessive levels of anxiety. Anxiety may be somatic (palpitations, difficulty breathing, dry mouth, nausea, frequency of micturition, dizziness, muscular tension, sweating, abdominal churning, tremor, cold skin) or psychological (feelings of dread and threat, irritability, panic, anxious anticipation, inner [psychic] tension, worrying over trivia, difficulty concentrating, initial insomnia, inability to relax). 1. Generalised anxiety disorder (GAD)

A chronic disorder characterised by a tendency to worry excessively about everyday things.

It is accompanied by: symptoms of anxiety or tension; mental tension (feeling tense or nervous, poor concentration, on edge); physical tension.

Questions box 12.3 Questions to ask the patient with possible anxiety

1. Have you been feeling nervy or tense?

2. Do you worry a lot about things?

3. Do you worry about things most other people would not worry about?

2. Panic disorder

A disorder characterised by episodes of panic occurring spontaneously in situations where most people would not be afraid.

A panic attack is characterised by the presence of physical symptoms (palpitations, chest pain, a choking feeling, a churning stomach, dizziness, feelings of unreality) or fear of some disaster (losing control or going mad, heart attack, sudden death). They begin suddenly, build up rapidly, and may last only a few minutes.

Questions box 12.4 Questions to ask the patient with possible panic disorder

1. Have you ever had an attack of acute anxiety or panic?

2. Did this occur in a situation in which most people would not feel afraid?

3. Can these attacks happen at any time?

3. Agoraphobia (phobic anxiety)

A disorder in which an individual avoids places (such as supermarkets or trains) in which they fear they may have a panic attack and cannot escape.

Questions box 12.5 Questions to ask the patient with possible phobic anxiety

1. Do you avoid going out?

2. Do you avoid going to places because you fear you may have an anxiety attack?

4. Obsessive–compulsive disorder

A disorder in which the person has either obsessions or compulsions which interfere with everyday life.

Questions box 12.6 Questions to ask the patient with possible obsessive–compulsive disorder

1. Are there any rituals or habits that you have to carry out every day?

2. Do they cause you problems?

3. Do you ever have a thought going round in your head that you can’t get rid of?

STRESS-RELATED DISORDERS 1. Acute stress disorders

Individuals may present shortly after a traumatic event with a range of symptoms, such as anxiety, depression, disturbed sleep, problems with memory or concentration. Images, dreams or flashbacks of the traumatic event may also occur.

Questions box 12.7 Questions to ask the patient with possible acute stress disorder

1. Have you been having any problems following … ?

2. Have you been feeling worried? Or depressed?

3. Have you had trouble sleeping?

4. Do you have bad memories?

2. Post-traumatic stress disorder (PTSD)

Onset of persistent problems within 6 months of a traumatic event of exceptional severity. The individual experiences repetitive and intrusive re-enactments of the trauma in images, dreams or flashbacks. Sleep, concentration, memory, mood and attention may be disturbed. Individuals may feel emotionally detached and avoid things that act as reminders of the traumatic event.

Questions box 12.8 Questions to ask the patient with possible PTSD

1. Since … happened, have you been troubled by bad memories of it?

2. Have you been having nightmares?

3. Have you had trouble with sleep?

4. Have you had trouble with your memory?

5. Are you jumpy?

SCHIZOPHRENIA AND DELUSIONAL DISORDERS A disorder characterised by disorders of content (presence of delusions), thought form (shown by difficulty understanding the connections between the patient’s thoughts), perception (hallucinations—predominantly auditory), behaviour (erratic or bizarre) and/or volition (apathy and withdrawal). Questions box 12.9 Questions to ask the patient with possible schizophrenia

1. Have you ever heard people speaking when there is no one around?

2. Do you ever hear voices?

3. Have you heard your thoughts out loud?

4. Do you have any thoughts or beliefs that others might find unusual or strange?

5. Have you felt people may be against you?

6. Have you felt that the TV or radio sends you messages?

7. Do you ever feel as if someone is spying on you or plotting to hurt you?

8. Do you have any ideas that you don’t like to talk about because you’re afraid other people will think you’re mad?

ORGANIC BRAIN DISORDERS These are disorders in which there is brain dysfunction manifested by cognitive disturbances such as memory loss or disorientation; there may be behavioural disturbance as well. 1. Delirium (acute brain syndrome)

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