History Taking & Risk Assessment & Mental State Examination Resource Pack for use with videos Dr Sian Hughes Academic Unit of Psychiatry Oakfield House, Oakfield Grove, Bristol BS8 2BN Tel: (0117) 331410, Fax (0117) 3314026 Resource Pack Contents 1. Introduction 3 1.1 Main Menus of the videos 4 2. History Taking & Risk Assessment 6 2.1 Presenting Complaint & HPC 7 2.2 Past Psychiatric History 7 2.3 Medication 8 2.4 Family History 8 2.5 Personal History 10 2.6 Premorbid Personality 11 2.7 Difficult Questions, Difficult Patients 12 2.8 Risk Assessment 13 2.9 Further Study 14 3. Mental State Examination 15 3.1 Appearance & Behaviour 16 3.2 Speech 17 3.3 Mood 18 3.4 Thought 19 3.5 Perceptions 21 3.5 Delusions 22 3.6 Cognition 23 3.7 Insight 24 4. Appendices 4.1 Depression: criteria from DSM-IV and ICD-10 25 4.2 Mrs. Jackson: extracts from the old notes 26 4.3. Mrs. Down: transcript of notes 28 4.4 The Folstein MMSE 32 4.5 Cognitive State Examination 34 5. Bibliography 37 2 i.Introduction Introduction History taking, risk assessment and the mental state examination are core clinical skills. They are best learned by practice and repetition, and we recommend that you see as many patients as possible in order to enhance your skills. The purpose of the videos and this accompanying resource pack is to give you a starting point to work from as you learn to take a psychiatric history and do a mental state examination. The History Taking and Risk Assessment video and The Mental State Examination video feature extracts from patient interviews (conducted by Dr Jan Melichar), divided into sections to illustrate various stages of the interview process. There is also a submenu for further study and revision designed for use with the exercises suggested in this pack. They are suitable for varying levels of skill and can be used independently or in groups. A facilitator or clinical tutor should be able to offer further assistance with the tasks if necessary. 3 1. Menus Video 1: Psychiatric History Taking: Main Menu ◊ Introduction ◊ Presenting Complaint & History of Presenting Complaint ◊ Past Psychiatric History ◊ Past Medical History & Medication ◊ Family History ◊ Personal History ◊ Premorbid Personality ◊ Difficult Questions ◊ Risk Assessment Dr Jonathan Evans ◊ Further Study 4 1. Menus Video 2: Mental State Examination: Main Menu ◊ Introduction ◊ Appearance & Behaviour ◊ Speech ◊ Mood ◊ Thought ◊ Perceptions ◊ Delusions ◊ Cognition ◊ Insight ◊ Conclusion and Credits to both DVDs ◊ Further Study - submenu further subdivided into MSE categories 5 2.History Taking & Risk Assessment 2. Video 1: History Taking & Risk Assessment Taking a psychiatric history has things in common with any clinical history you take. The major difference is in the social and developmental history, which we cover in more depth. You may find it helpful to jot down notes as you go along, and this can help you to be methodical in your history taking. The areas you need to cover include: • presenting complaint/history of presenting complaint • past psychiatric history • past medical history • medication • family history • family psychiatric history • personal history - o birth & early life o school & qualifications o higher/further education o employment o psychosexual history o forensic history o substance use • premorbid personality It’s not always appropriate to ask all of the questions all of the time. Sometimes it can be better to leave gaps to fill in later, especially if your patient is particularly suspicious and paranoid, or acutely distressed. Some of the history can be gathered from old notes, and from speaking to an informant. Start off with open questions and focus in on areas with more specific, closed questions as necessary. This gives the patient a chance to talk about their experiences and concerns, whilst allowing you to get the information you need. Over time you will develop your own style of interviewing. You need to feel comfortable with the style you adopt, so that your questions don’t seem awkward or forced. 6 2.History Taking & Risk Assessment 2.1 Presenting Complaint & History of Presenting Complaint In the extracts shown, Jan encourages Mrs. Down to describe the problem in her own words. At first, she is not very specific, but with gentle prompting and some echoing of her own words back to her she soon elaborates the problem and talks more freely. Jan then picks up on the complaint of tiredness and asks about specific problems with sleep, aimed at eliciting symptoms of depression. He then goes on to ask about other associated symptoms. Appendix 1 sets out the symptoms of depression as classified in DSM-IV and ICD-10 Further Study: (1) Think about how you might use the symptoms of depression as a framework to structure your history taking. What sort of questions could you use to get the information you need? (2) Look up the ICD-10 diagnoses of other common disorders and make a similar list of questions for these. The presenting complaint and the history of presenting complaint may be difficult to separate, especially in more complicated cases. This doesn't matter: what is important is that you get a good account of what is troubling the patient and thoroughly investigate any associated symptoms. 2.2 Past Psychiatric History Remember that the patient's understanding of their illness may be different from the formal diagnosis. Corroborative evidence such as previous notes is often helpful. Don't get bogged down with rambling accounts of past admissions if these are frequent; rather, get the basic facts such as rough dates and length of admissions, treatment given and follow-up arrangements. Further Study: What would be your diagnosis and management plan for Mrs. Jackson before you saw the old notes? How are these altered by the notes? Further information about Mrs. Jackson is provided by her old notes. These are summarised in Appendix 2. 7 2.History Taking & Risk Assessment 2.3 Medication The patient’s beliefs about their medication can give useful insight into what they believe is wrong with them. Remember to ask about side effects and compliance and bear in mind possible drug interactions. Further Study: Look up psychiatric drugs in the BNF and learn the most common side effects and drug interactions for each group. It is particularly useful to do this for each patient you see, looking specifically at the medications they are taking. 2.4 Family History The family history should give you a good indication of a person's family relationships. Find out which members of the family they feel close to, and why. Equally, reasons for discord within the family should be explored. Bear in mind social, psychological and genetic risk factors for mental illness, and remember to ask about family psychiatric history. Further Study: 1. In pairs, take a family history and draw up a genogram for each other. 2. Think about your own family history and how your family has shaped your attitudes and attributes as an adult. See figure 1 for the symbols used in genograms. 8 2.History Taking & Risk Assessment Figure 1: a list of symbols used in genograms Male Parents / spouses Female Consanguineous parents Unknown sex Separated / divorced parents Deceased Siblings Spontaneous abortion Terminated pregnancy Monozygotic twins Current patient Dizygotic twins ? Various psychiatric diagnoses Twins of uncertain zygosity ? Uncertain psychiatric diagnosis Child adopted into family Child adopted out of family From Golderg & Murray The Maudsley Handbook of Practical Psychiatry, 4th ed. 2002. Oxford University Press 9 2.History Taking & Risk Assessment 2.5 Personal History Personal history is important, as it helps you to understand what has led to your patient becoming the person they are. It’s easiest to work through this in chronological order, remembering that some of the information may have been gathered earlier on. Things you need to ask about briefly include: • family of origin; • early experiences; • schooling; • friendships; • qualifications; • further or higher education. You can then move on to ask about the following areas: • employment history; • interests and current friendships • significant relationships, marriage and children • psychosexual history • forensic History • use of alcohol and illicit drugs If there are any problem areas you can go into these in more detail. Further Study: 1. What features of Alex’s personal history suggest a diagnosis of schizophrenia? 2. Using Jan's interview, write down Alex's personal history, and think about ways to take and record this information in a way that makes sense to you. 10 2.History Taking & Risk Assessment 2.6 Premorbid Personality Unless you know what the person is usually like, it’s difficult to fully understand how their illness has affected them. In asking about premorbid personality, the information from a third party or informant can be particularly helpful. Think about coping styles, interests and activities and how the person usually relates to other people. Further Study: Look up personality traits in a textbook and try to relate these to people you know. Make a list of characteristics you might recognise easily and another list of those which are less familiar. Try to look out for these less familiar traits over the next week. How many did you identify? 11 2.History Taking & Risk Assessment 2.7 Difficult Questions, Difficult Patients 2.7.1 Asking Difficult Questions You will need to ask some questions which might feel difficult. You might find that the patient doesn’t want to talk about a particular topic, or glosses over things. Some techniques you can use in these circumstances include: • normalizing statements (‘Often when people are that down, they feel like they can't carry on . have you ever felt like that?’) • symptom expectation/gentle assumptions (‘What drugs do you use?’ rather than ‘do you do drugs?’) • symptom exaggeration ('3 bottles of vodka.