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History

When undertaking any form of psychiatric assessment, always think about establishing the following information:

Background information
Presenting complaint, and its history

Past psychiatric history and pre-morbid personality
Past medical history
Medication history
Family history (including of mental illness)

Personal history
– Birth and early development
– Family background and early childhood
– Education
– Occupation
– Psychosexual/relationships
– Social history

Substance misuse history (see substance misuse for more information)
Forensic history

Collateral history

Risk history (including to self, to others, and from others)

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Mental State Examination

The mental state examination looks at the person’s current presentation as they are before you, and provides useful information about their state of mind. Just like a physical examination it is a snapshot of how they are at that moment and it can be highly revealing. In Extreme Psychiatry role-plays we do not ask you to comment on a person’s mental state, but you can use what you see to direct what you say.

Appearance and behaviour

Speech
– Rate, rhythm, volume, tone, pitch, flow
– Spontaneity, coherence, relevance (see also thoughts)

Mood
– Subjective (what they say) vs. objective (how they seem)
– Symptoms of mood changes (e.g. appetite, sleep, concentration, etc.)
– See mood for more

Thought
– Preoccupations and worries
– Delusions
– Overvalued ideas
– Obsessions
– Thoughts of harm

Perception
– Illusions and hallucinations
– Depersonalisation and derealisation

Cognition (e.g. MMSE or AMTS)
– See cognition for more

Insight (this is not ‘all or nothing’, and a person may have insight into some but not all aspects of their illness)

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Diagnosis and Management

The information gathered in the history and mental state examination can aid in reaching a differential diagnosis.

In psychiatry diagnoses are frequently made according to criteria set out in one of two main classification systems. The International Classification of Mental and Behavioural Disorders (ICD-10), currently in its tenth revision with an eleventh on the way, is published by the World Health Organisation and used around the world. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is at the point of publication of its fifth version and is particularly used in the USA.

The two systems have detailed descriptions of psychiatric diagnoses based on their symptom clusters. But whichever classification system is used, care planning should be more than just a generic treatment of the diagnosis. Instead remember to focus on the person’s own experiences and how to improve their life. One method is to consider interventions using the ‘bio-psycho-social’ model.

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