1. BASIC PSYCHIATRIC
HISTORY AND MENTAL
STATE EXAMINATION-1
Dr DAYANG ZURYIANI BT ABANG MOUHAMMAD
HASHIM
PSYCHIATRIST
HOSPITAL UMUM SARAWAK
2. INTRODUCTION
• To educate and prepare medical officers and staff:
o Basic knowledge of common PSYCHOLOGICAL ISSUES in general
setting
o Systemic review local studies in Malaysia prevalence of depression in
primary care range 6.7 to 14.4% *CPG MDD (2nd edition ) 2019
Ø Among elderly in community between 6.3% and 18%
Ø Woman higher rates than man
Ø Prevalence depression clinical setting post partum woman to be 20.7%
; post stroke 36%; breast ca 19.1%
o To encourage the primary health care services to DETECT EARLY
MENTAL HEALTH ISSUES/ MINOR PSYCHIATRY ILLNESSES ( generalized
anxiety disorder, schizophrenia, depression etc) and improve help
seeking behaviour among the public
o Reduce stigma among staff as well as public via psychoeducation.
3. Depression is often
under-recognised
and under-treated.
• It is estimated that
about 30-50% of cases
of depression in primary
care and medical
settings are not
detected*CPG MDD 1ST
EDITION 2007
8. Initiation of
the Interview
• Address patient warmly
• Put the patient at ease – smile
• Introduce yourself and anyone accompanying you
• Explain the role of the interview
• Length of the interview
• Appropriate eye contact, appear interested
• Begin with a general question e.g. “tell me about your
problem”
• Have a systematic but flexible approach
• May need to interrupt
9. HOW DO YOU APPROACH?
HISTORY TAKING
• Chief complaint
• Onset of the symptoms
• Duration
• Triggering factor
• Protective factor
• Psychosocial
• Family history
• Premorbid personality
• Substance use
• Suicidal risk
• Aggression risk
• * Collaborative history
MENTAL STATE
EXAMINATION/PHYSICAL
EXAMINATION
• General appearance (
abnormal movement/
behaviour)
• Cooperative
• Speech
• Mood/ Affect
• Perceptual/Thought
disturbance
• Orientation
• Judgement
• Insight
• Any signs of self-harm
• Vital signs
INVESTIGATION
• Baseline investigation (
FBC/ BUSE /CREAT/LFT)
• ECG
• UPT
• Thyroid function test
• Biohazard screening
• Dementia work-out ( Vit
B12/ folate/ VDRL/ Ct
brain)
• CT brain ( TRO organicity)
10. (History of) Present
Illness
• Nature of problem
• Chronology of each symptom
• Onset and duration
• Severity of symptoms and degree of
functional impairment
• Precipitating factors
• Perpetuating factors
• Protective factors
• Factors worsening or improving
12. Past Psychiatric History
• Similar or other symptoms in the past
• Psychiatric diagnosis, comorbids
• Onset, duration, frequency, severity
• Psychiatric admission
• Reason (voluntary vs involuntary)
• Any treatments
• Drugs (compliance, dosage, adequate trial, reason
stopped, complications, side effects e.g. EPS)
• Others (e.g. ECT, psychotherapy)
• Outcome of treatment, recovery, remission
• Suicidal or homicidal ideation, attempt, violence
13. Substance Use / Abuse / Addiction
Substances
• alcohol, drugs (e.g. syabu, ganja),
medications (prescribed or not) Routes of use (e.g. oral,
snorting, intravenous)
Frequency and amount,
tolerance, withdrawal
symptoms
• determine abuse vs dependence,
e.g. standardized questionnaire
CAGE
Impact of use on social
interactions
periods of sobriety
• length of time and setting such as
in jail
History of treatment (e.g.
detox, rehab), patient keen
for treatment
Other substances and
addictions e.g. tobacco and
caffeine use, gambling,
eating behaviours (binge
eating disorder)
14. Past Medical History /
Medications
• Major medical illnesses and
conditions (e.g. CNS, endocrine,
systemic illness, head injury /
trauma)
• Past surgeries
• For women, reproductive
(pregnancy) and menstrual history
• Review of medications
• Allergies to medications
15. Family History
• Family tree
• Parents, siblings, relatives, biological vs
adopted, separation, divorce, steps
• Relationship with family, among family
members
• Known or suspected history of mental
illness
• Nature of death if anyone not alive, suicides
• Suicidal or homicidal behaviours, violence
in relatives
• Potential support vs stressor
• Availability and adequacy of potential
caregivers
16. Developmental and
Social History
• Premorbid history
• Prenatal or birth history
• Developmental milestones
• Childhood separation or emotional
problems
• Childhood physical and sexual abuse
• School history (e.g. learning disorders,
behavioural problems at school,
academic performance)
18. MENTAL STATE EXAMINATION/PHYSICAL
EXAMINATION
General appearance ( abnormal movement/ behaviour)
Cooperative
Speech
Mood/ Affect
Perceptual/Thought disturbance
Orientation
Judgement
Insight
Any signs of self-harm
Vital signs
19. Appearance and
Behaviour
• Body language (e.g., calm, cooperative)
• Rapport and eye contact
• Appropriateness of dress, grooming, evidence of
self-neglect
• Facial expression – dilated pupils, rigidity
• Abnormal movements, behaviour or posture –
EPS, catatonia
• Under or over psychomotor activity – excitation
or retardation
• Distractibility
• Any – tattoos, prominent scars, injection marks
20. Speech
Relevance,
coherence (e.g.,
relevant, coherent)
Fluency, amount,
rate, tone, and
volume
Amount: e.g.,
poverty of speech
in depression and
schizophrenia
Rate: e.g., slow in
depression,
pressured in mania
Tone and volume:
e.g., irritable, loud,
timid
21. Mood
• Definition: Patient’s internal and
sustained emotional state
• Subjective
• Best to use the patient’s own
words
• Sad
• Angry
• Anxious
22. Affect
• Definition: Expression of mood or what the mood
appears to be
• Objective
• Quality, quantity, range, appropriateness, and
congruence
• Quality: dysphoric, happy, euthymic, irritable,
angry, agitated, tearful, sobbing, and flat
• Quantity: mildly depressed
• Range: restricted (flat), normal, labile
• Congruence: congruent with thoughts /
behaviour
23. Thought
Process
• Formal thought disorder
• Disturbance in the form of thought
• Examples: Circumstantiality, Clang
associations, Derailment, Flight of
Ideas, Neologism, Perseveration,
Tangential, Thought Blocking,
Echolalia, Word Salad
25. Thought Content
• Delusion
• Definition: An abnormal belief which is held with
absolute subjective certainty, which requires no external
proof, which may be held in the face of contradictory
evidence, and which has personal significance and
importance to the individual concerned, and cannot be
understood as part of the subject’s cultural or religious
background
• Based on their content, 12 types of primary delusion are
commonly recognized: persecutory, grandiose, delusions
of control, of thought interference (insertion, broadcast,
withdrawal), of reference, of guilt, of love, delusional
misidentification, jealousy, hypochondriacal delusions,
nihilistic delusions, and delusions of infestation.
26. Thought Content
Over-valued ideas
A form of abnormal belief,
which are reasonable and
understandable in themselves
but which come to
unreasonably dominate the
patient’s life
E.g. concern over weight and
body shape in anorexia
nervosa
Obsessional thoughts
/ Obsessions
unwelcome and repetitive
thoughts that intrude into the
patient’s consciousness
Compulsions
repetitive, ritualized
behaviours that patients feel
compelled to perform to
avoid an increase in anxiety
or some dreaded outcome
Others: Paranoia, Magical thinking,
Phobias, Preoccupations
27. Perceptual Disturbance
• Hallucinations
• Perceptions in the absence of stimulus
• Auditory (e.g. running commentary, 2nd or 3rd person), visual, tactile,
olfactory, and gustatory (taste)
• Hypnagogic (occur on falling asleep) or hypnopompic (on waking)
• Lilliputian hallucination (visual hallucination in which the subject sees
miniature people or animals)
• Pseudo hallucination (false perception which is perceive as occurring
as part of one’s internal experience, not external world)
28. Perceptual
Disturbance
• Illusions
• Misperception of stimuli
• Depersonalization
• feeling that one is not oneself
or that something has changed
• Derealization
• feeling that one’s environment
has changed in some strange
way that is difficult to describe.
29. Cognition
• Alertness
• Orientation: time, place, person
• Concentration: Serial 7
• Memory: immediate – repeat, recent, long-
term
• Calculation
• Basic of knowledge
• Abstract reasoning: proverbs
30. Insight -3As
• Awareness of abnormal state of
mind
• Attribute the abnormal
symptoms due to mental illness
• Accept the benefit of treatment
and advice by doctor
31. Judgement
• person’s capacity to make good
decisions and act on them
• A patient may have no insight into his or
her illness but have good judgment
• Use hypothetical examples to test
judgment, for example, “What would
you do if you found a stamped envelope
on the sidewalk?”
32. Closing of
Interview
Alert
• Alert the patient to the remaining time
• “We have to stop in about 10 minutes.”
• patient to bring up important issues not yet discussed
Give
• Give the patient an opportunity to ask a question
• “I’ve asked you a lot of questions today. Are there any
other questions you’d like to ask me at this point?”
Discuss
• Discuss summary of the diagnosis and options for
treatment with the patient
Thank
• Thank the patient
