CHAPTER 1 The psychiatric interview and mental state examination
The key to psychiatric assessment is a comprehensive history and mental state examination. The history needs to cover the history of the presenting complaint, past psychiatric history and a longitudinal perspective of the patient, with important ‘milestones’ and events highlighted. A family history is also important.
The mental state is similar to the physical examination in general medicine, and provides a comprehensive cross-sectional assessment of signs and symptoms.
Any relevant physical examination and laboratory tests need to be performed to cover treatable ‘organic’ causes and contributors to the psychiatric presentation. This is covered in Chapter 2 of this book.
The framework presented here is taken largely from the so-called ‘Maudsley’ approach, named after the famous London psychiatric hospital. For a more detailed expostulation of the Maudsley approach, see the ‘References and further reading’ at the end of this chapter. This schema is for use in adults: adaptations for children and adolescents, and the elderly, are provided in Chapters 16 and 17, respectively. Special considerations pertinent to people with an intellectual disability are given in Chapter 19.
The history
The taking of a thorough history requires patience and skill. The initial phase of the interview is used to establish rapport with the patient, to put both you and the patient at ease, and to set the agenda for the interview. Always introduce yourself, say why you are there, the sort of areas you want to cover, and the approximate time frame. It is better to start with a general and non-threatening topic (e.g. one would not immediately ask about child sexual abuse). The sort of opening phrase could be:
I am Dr Jones, and I am a registrar here at the hospital. I want to spend 30 minutes or so with you to try to understand a bit more about why you have come to hospital, and try to work out a plan as how best we can help. Is that okay?
Reassuring the patient that your interview is confidential, but that you work as part of a team and do share information with them, sets the parameters nicely.
The main areas covered in the history are shown in Box 1.1. Of course, there is some flexibility about the sequence of questions, but ensure you cover the major areas. Generally, starting with non-directive, ‘open’ questions is recommended, later honing in on specific issues with more focused questioning. Certain issues such as suicidality must always be assessed thoroughly (see Ch 15 for a suggested approach).
History of presenting complaint
This is an account of the circumstances leading up to the current presentation. It should detail the relevant recent events in the person’s life, the sequence of their responses to these circumstances, and the main presenting symptoms. Some detail should be provided of the major symptoms and behaviours with which the patient presents, relevant to why and how they are presenting for help at this time in this way. Details of help-seeking behaviour, including recent interventions and treatments, should be assessed.
Other psychiatric symptoms
This is an opportunity to go through a quick checklist of psychiatric symptoms and behaviours other than those elicited under ‘presenting complaint’. Positives and salient negatives should be enumerated. For example, in a patient presenting with social anxiety disorder, other anxiety symptoms, the presence of panic attacks, mood state and use of drugs or alcohol are relevant. In the patient with an exacerbation of psychotic symptoms, comorbid depression is important to elicit, expressly if linked to suicidality.
Past psychiatric history
Full details are needed of past psychiatric illnesses, including first manifestation of psychiatric symptoms, first contact with a health professional for a mental health problem, and longitudinal course of psychiatric problems, including any hospitalisations; self-harm and suicide attempts should be asked about specifically. An overview is required of treatments received (psychological, medication and electroconvulsive therapy (ECT)); engagement with and adherence to such treatments; and treatment response and any adverse effects experienced. A list of current medications should be obtained.
Past medical history
An overview is required of any relevant medical conditions, injuries and times spent in hospital for medical conditions. Longstanding, expressly debilitating and painful medical conditions are especially important, given their impact on quality of life and on psychiatric symptoms. Treatments should be reviewed, with particular attention to those with psychiatric side effects, such as beta-blockers (depression) or dopaminergic agents (psychotic symptoms). Allergies, medication sensitivities and current medications should be documented.
Family history
The family history should encompass any history of psychiatric or physical health problems. This should include established or suspected diagnoses, and treatments received. It is useful to draw a genogram, which is often best done with the patient. Collateral history from another family member greatly enhances accuracy of the family history.
Personal history
The personal history is best mapped in a longitudinal manner.
Pregnancy and birth
Was the pregnancy planned/wanted? Were there any complications during the pregnancy or the birth?
Preschool
What sort of child were they? Did they adapt easily to change? Were they anxious and clingy? What was the family situation like? Gently broach issues of possible physical or sexual abuse.
School
Ask about primary and secondary schooling, covering: academic endeavours (including best and worst subjects, grades achieved); sporting prowess; engagement with peers; being teased or bullied; attitudes to authority (e.g. teachers); periods of non-attendance at school; and drug or alcohol use.
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