Love

2. OBJECTIVE
Get to know how to do the interview with client
Recognize symptoms
Be able to diagnose patient

3. OUTLINE
➢Theory review:
oHistory taking in psychiatry
oMental Status Examination (MSE)
oDiagnostic criteria (ICD-10)
➢Students’ role play
➢Debriefing/ Questions and Answers

4. WHAT ISTHE HISTORYTAKING IN
PSYCHIATRY?
 ការស្រង់ស្រវត្តិជំងឺគឺជាការកត្់ស្ានូវស្រឹត្តិការណ៍រំខាន់ៗ នៅក
ន ុងជីវ ិត្រររ់
អ្នកជំងឺ ទាក់ទងនិងរញ្ហ
ា ផ្
ល ូវចិត្ត ចារ់រីនរលនកើត្មានរហូត្ដល់នរលរច
ច ុ
របនន។
 The history taking is the record of the important events in the
client’s life related to the mental problem since the birth until
now.

5. WHICH INFORMATION IS NEEDEDTO
ELICIT?

6. IDENTIFYING DATA
 Registration Number
 Name
 Age
 Gender
 Ethnicity
 Occupation
 Marital status
 Accompany

7. CHIEF COMPLAINT
 Client’s own words:
 Examples
“I got poor sleep at night…..”
“I got angry easily…..”
“I felt fearful….”
“I was difficult in breathing….”
“I got chest pain/tightness…”

8. HISTORY OF PRESENT ILLNESS
A. onset
B. Precipitating factor
C. Present symptoms
D. Symptoms progression
E. Any receiving treatment? If so what kind? effectiveness?
Side effects?

9. HISTORY OF PAST ILLNESS
A. Psychiatric (onset, treatment, change in symptoms,
length of episode)
B. Physical (current medical problem, prescription, drug
allergy, surgical problem…)

10. FAMILY HISTORY
A. Who is in family?
B. Who else has had psychiatric symptoms or treatment?
C.Genogram

11. Male
dead
Family relationship
Female
Dependent/living in the same house
Client male/female
Poor relation/conflict
Divorced/separated

12. ឧទាហរណ៍៖

13. PERSONAL HISTORY
A. Pre, peri and post natal
B. Childhood experience: early friendship,
academic record ….
C. Adulthood: job, romantic relationship, sexual,
D. Drug and alcohol use

14. MENTAL STATUS EXAMINATION (MSE)
A. Appearance:
1. Attitude toward examiner: cooperative, hostile
2. Behavior and psychomotor activity: agitated, normal
3. General description: moist hands, perspiring forehead, restlessness, tense
posture, voice trembling, eye contact is good/avoided
B. Mood and affect
1. Mood: angry, anxious
2. Affect: tension, worry, រសារ់ររល់, ត្ក់រ
ល ុ ត្, normal, appropriated
C. Speech:
1. Quantity: normal
2. Speed : normal
3. Quality: understandable

15. MENTAL STATUS EXAMINATION (MSE) CONT.
D. Perception: depersonalization/ derealization but no hallucination
E. Thinking:
1. Form: rapid / slow , paucity of ideas, patient speaks spontaneously or
only when questions are asked
2. Content: preoccupation about the illness and everyday life, suicidal
thought/ attempted(-)
3. Thought disturbance: no delusion

16. MENTAL STATUS EXAMINATION (MSE) CONT.
F. Consciousness
G. Orientation: oriented to time, place and person
H. Concentration: poor/normal
I. Memory: poor / normal
J. Impulse control : impair / lost
K. Insight: aware of being sick

17. DIAGNOSIS CRITERIA (ICD-10) OF GAD
A. At least 6 months with prominent tension, worry and feeling of
apprehension about everyday problems
B. At least 1 of the following symptoms (Autonomic arousal )must be
present:
1.Palpitation
2.Sweating
3.Trembling or shaking
4.Dry mouth (no due to medication or dehydration)

18. 1. Difficult in breathing
2. Feeling of choking
3. Chest pain or discomfort
4. Nausea or abdominal distress
5. Feeling dizzy, faint, unsteady, lightheaded
6. Derealization/ depersonalization
7. Fear of losing control, going crazy or
passing out
8. Fear of dying
9. Hot flashes or cold chills
10. Numbness or tingling sensations
11. Muscle tension
12. Restlessness and inability to relax
13. Feeling keyed up or mental tense
14. Sensation of difficulty in swallowing
15. Difficult in concentration or mind blank
16. Persistent irritability
17. Difficulty in getting to sleep
18. Exaggerated response to minor surprise/being
startled
C. At least 3 of following symptoms must be present:

19. D. In total at least 4 symptoms from B+C
E. The disorder does not meet the criteria for Panic disorder, phobic
disorder, OCD, Hypochondriacal disorder
F. The disorder is not due to physical disorders: hyperthyroidism, organic
mental disorder, psychoactive substances–related disorder.

20. INSTRUCTION FOR ROLE PLAY
1.A group of 4 people
2.1 for therapist, 1 for client, and 2 observers
3.Each person has 20mn to play one role
4.No criticism

21. ThankYou!