PSYCHIATRY INTERVIEW-history and mse

-Interview is the most important tool in psychiatry

-It is used to understand the patients problem, elicit signs and symptoms, make appropriate
diagnosis, initiate treatment and predict outcome

-It offers patients an opportunity to express themselves and others in a non judgmental and non
critical atmosphere

-Clinicians should know what, how , when to ask and how to interpret responses of the patient.

-History is obtained from patient, family, relatives or friends (coz in some cases the patient may
not be responsive or may be confused or may give inaccurate history e.g. in alcoholics, scz)

-In very sick, agitated or confused patients, the observation and a brief history may be all needed
to begin treatment. A more detailed history and MSE can be obtained later from relatives or
patient when s/he improves

GENERAL PRINCIPLES IN INTERVIEW

1. Active observation and awareness of behavior

- it begins from the moment patient walks into consultation room=gait, physical appearance,
greetings, general attitude

-focus on verbal and non verbal communication eg facial expression, hesitancy during interview,
absence of eye contact, constant checking around the room

2. Assessment and evaluation is two way process

-clinician is assessing patient while patient is also evaluating your sensitivity and genuine desire
to help

-good rapport and shared feelings of mutual respect and understanding

3. Acceptance of the behavior of patient- all behavior even if odd has a meaning to the patient.
Accept but don’t approve

4. Avoid arguments with patient

5. Don’t assume you understand the patient- e.g. clarify your thoughts of what the patient says
and feels by summarizing a number of times during interview, by repeating what the patient has
said and the feeling the patient has expressed.

6. Stress on feelings- feelings of patient may be difficult for clinician to understand e.g. crying,
suicidal. **how and when to ask questions
-focus on feelings and emotionally charged areas should be explored

-sensitive topics should be handled carefully and tactfully e.g. sexual life (introduce them
gradually). In case of resistance these areas should be kept in mind for further discussion (later in
interview or another day)

7. Focus on interpersonal relationships

-noted in family history

- Interpersonal sense of love, acceptance, security and discipline (helps reveal psychodynamic
factors responsible in shaping the personality of the patient)

8. Avoid being moralistic and judgmental- a patient may come feeling guilty, anxious and
expecting the worst

9. Show empathy i.e. direct identification with, understanding of experience of another person’s
situation, feeling and motives.//sensing the client’s inner world of private personal meaning as if
it were your own but without losing the “as if” quality NOT sympathy

10. Try to tolerate silence of patient- e.g. it could be thought problem or just doesn’t wish to
respond to your questions due to the illness or feeling aroused.

COMPONENTS OF PSYCHIATRIC HISTORY

1. IDENTIFICATION DATA

Name, age, sex, marital status, residence, religion, occupation of the patient

2. THE REFERRAL SYSTEM

Note the source- health worker, brought by family members or friends, self

-indicate main reason for referral

3. CHIEF COMPLAIN/ALLEGATIONS

-A brief statement of why the patient seeks help. It should contain the description of the problem
and should be stated in patient’s/relatives own words. Duration of complains and hierarchy

4. HISTORY OF PRESENT ILLNESS

-Patients problems are explored in details and in a chronological order. It should start from the
time when patient started feeling discomfort which may predate on his social interactions with
others both at work, home and its consequences on his family life, occupation
- should contain the psychosocial stress factors in the life of patient as well as physical illness
and time relationship with the present symptoms - review of systems/ros

5. PAST PSYCHIATRIC ILLNESSES/HX- plus investigations done, results, diagnosis,

treatment and outcomes

6. PAST MEDICAL ILLNESSES/MEDICAL HISTORY-

7. FAMILY HISTORY

*Nuclear vs extended-grandparents and other family members may play an important role

-For each member note-name, age, sex, ms, occupation, relationship(past and present) with the
patient, current health condition

- If dead indicate age at time of death and cause

-Partial/total economic dependency of the patient, siblings, parents and how the s/he feels about
it

-FHX of mental illness in nuclear and extended family

-Fhx of chronic general medical conditions

8. PERSONAL HISTORY

**The past life of the patient is reviewed with aim to get comprehensive picture of patient and to
find out factors in his/her past which may explain his psychological make up, personality and
present problem

a) Pregnancy, birth and early development upto 6 years

*tries to understand the early childhood development stages of patient and whether needs were
met or frustrated

- was pregnancy unwanted or outside wedlock and what were the consequences on the
relationship of mother and child and other family members

-problems during pregnancy and delivery and neonatal period

-Developmental milestones

-extended or nuclear family; who was closely attending to the patient’s needs?

-interpersonal relationship of individual in the family unit, its cohesiveness and the socio
economic situation
-significant incidents eg separation, divorce, major illness and death of significant people

-neurotic traits eg thumb sucking, nail biting, temper tantrums

-school performance?

b) 6 years to puberty

-focusing on individual sense of identity , participation in structured activities, school(

performance, likes), discipline, attitudes towards authority at home and school, peer group
activities and influence on patient, coping mechanisms

c) Adolescent to 19 years

*period of heightened sexual awareness

- puberty and menarche in girls, early marriage

-boys- sexual matters and masturbation related anxiety and worry about physical and mental
illness

- school achievements, social relationships at home/school and other students

-professional interests and future goals

-involvement in extra curricula activities. **college

-daily activities and social contacts for those who didn’t go to school

d) Occupational history

-age and which work patient first engaged in

- any income generating activities or formal employment and job changes

-nature of work, social and occupational relationships, job satisfaction, growth/promotions and
improvement or deterioration in the job

-repeated absenteeism from work/ disciplinary issues or deterioration in work output eg in

alcoholism, depression,scz

e) Marital history

-age of marriage, personal decision or forced/arranged marriage

-individual feeling towards the marriage

- health and personality, religion, occupation, lifestyle of the partner (play a vital part in
relationship)

-children and ages, health, education achievements

**SUMMARY of history(optional)

**GENERAL physical exam

MENTAL STATE EXAMINATION/ASSESSMENT

A great deal of it is obtained during the interview about the present/current illness

1. General appearance

- grooming, posture, gait, physical characteristics, facial expression, eye contact, motor activity

- also note state of awareness or consciousness eg fully c, drowsy, coma, stupor

2. Speech- rate, pitch/tone, volume, clarity

3.Mood- describe it eg euthymic, low/depressed, expansive, euphoric, labile, irritable

4.Affect- eg appropriate, inappropriate, flat, blunted, labile

5. Perception- illusions, hallucinations, depersonalization, derealisation

6. Thoughts

a)process and form – flow of ideas and quality eg racing/speeded, slowed down. Circumstantial,
derailments, flight of ideas, neologisms,

b)alienation/control- eg thought broadcasting/echo/insertion/withdrawal

c)content- delusions, overvalued ideas, obsessions, suicidal/homicidal ideas

7.Orientation- in time,place and person

Time- time of day, day of week, date, month, year (determine with social cultural background of
the patient)

Place- ask of familiar place

Person- eg his name, age,children, parents, siblings or those with him if familiar (counter check)

8.Attention and concentration

A- if can follow interview and how they answer questions or name 3 objects to patient/telephone
number and repeat after interview

C- simple calculations eg serial 7 upto 65 (100-7) or serial 3 (20-3) or days of week/month

backwards or simple problems

9. Memory

Registration and recall/immediate- eg give items, telephone number of 5-6 digits

Recent- eg what ate for breakfast/supper, news,

Recent past- experiences in last few days/months

Remote- more than 1 year eg important dates/years, schooling, marriage, previous important
people

10. Intelligence/numeracy and abstraction- determine general level compared to education, social
and cultural background. I/N- eg calculations, differences and similarities, direction of wind,
reading and writing A- proverbs

11. Judgment- does patient understand harmful consequences of his/her behavior, can he/she
make wise decisions eg in life threatening situations like fire, drowning, road----

12. Insight – awareness of illness, cause its implications, need for treatment

FORMULATION- summary of history, physical exam and mental state examination findings

DIAGNOSIS(multiaxial or non multiaxial) AND DIFFERENTIALS

INVESTIGATIONS- physical, psychological, social

TREATMENT PLAN-physical, psychological, social

PROGNOSIS-good or bad
Out of syllabus

DEFENCE MECHANISMS
These are unconscious strategies that people use to deal with negative emotions. They limit
awareness so that life threatening and anxiety situations/acts can be excluded.

They are invoked automatically as psychological measures which allow stressful situations to be
coped with by distorting reality.

Inadequate use of dm can lead to open/clear anxiety or depressive feelings. DMs

-don’t alter the stressful situation

-have an element of self deviation/deception

-help during rough times but delay the solution seeking behavior

-are unconscious processes as opposed to other methods of coping with problems

-if it is the dominant mode of responding, it may become personality maladjustment

1. Repression

-It is considered the central and basic psychological dm. Other dm come into play when
repression has failed.

-Thoughts or feelings which our consciousness find unacceptable are repressed—a way of
dealing with unbearable aspects of inner life; so that aggressive or sexual feelings, fantasies or
desires are thrust into unconsciousness.

-It is considered to be a mental process arising from the pleasurable principle (ID) and reality
principle(EGO) ie indicates that when impulses and desires are in conflict with enforced
standards of conduct(superego), painful emotions arise and the conflict is resolved by repression.
Hence normalcy is once again attained and sustained/maintained.

2. Denial

-Involuntary and automatic distortion of an obvious aspect of external reality.

-Eg after death of a spouse, failed exam and promotes self, when doctor informs patient that he
has a terminal illness, this fact may be denied at subsequent visits even though a clear concise
explanation was given which patient obviously understood.

3. Displacement

-Transfer of feelings/emotions usually of fear or anger from one person, situation or object to
another.

-Eg wife who is furious and irritated by her husband for always coming home late or giving her
no support with children, she vents her anger on the children but not the husband.

Employer, husband, wife, children,cat,. Husband/wife(boss), junior workmates

4. Rationalisation

-Process of justifying by reasoning after the event. This is act of providing logical and believable
explanations for behavior, to peruade self and others that the irrational behavior is justified and
therefore should not be criticised… **sour grapes

5. Projection

-Individual unconsciously disowns an attribute or attitude of his own and ascribes it to someone
else.

-Eg. I hate you becomes you hate me,, I am lazy becomes you are lazy,, am gay/lesbian becomes
they are gay, immoral
6. Reaction formation

-The repressed wish is warded off by its diametric/equal opposite.

Eg hate someone but eventually end up showing love/kindness towards them(but the repressed
hostility can still be detected underneath the loving exterior/mask)

7. Isolation

-Dangerous memories are allowed back into consciousness but the associated motives and
emotions are not recalled. The memories are isolated from their associated feelings

-Eg in people who suffered severe physical or psychological trauma like in concentration
camps/mau mau, kidnap victims, torture chambers/nyayo hse

8. Sublimation

-Occurs when potentially dangerous urges are given socially acceptable expression. Sexual or
aggressive impulses instead of being given free expression are sublimated to other activities
which are carried out with great vigour and often with great success

Eg some sports/wrestling,boxing,rugby.. butcherman.. model,stri?

9. Introjection

-Victim takes in and swallows/accepts the values of others

Eg in detention camps some prisoners deal with overwhelming anxiety by accepting the values
of the enemy thro identification with the aggressor.. Kidnap/car jacking..**Stockholm syndrome
1973, Ohio 2013 anel castro vs 3 kidnapped women

10. Compensation

-Consists of masking of perceived weaknesses or developing certain positive traits to make up

for limitations.

People who are intellectually inferior may develop the physical aspects of their bodies

People who are socially incompetent may develop their intellectual capacities and spend most of
their time in lonely academic pursuits

11. Identification

People who feel inferior may identify themselves with successful causes, organizations or
persons in the hope that they will be perceived as worthwhile (some get symbolic status and
famous, distinguished, workaholic).. Helps as a dm against anxiety of inferiority
12. Idealization

The negative/bad aspects of a person are not given attention thus the person is taken to be
“perfect”… love

13. Intellectualization

-Excessive use of intellectual processes to avoid emotional expression or experience, stress is

excessively placed on irrelevant details to avoid perceiving the whole.. Academics

-closely allied to rationalization

14. Regression

-Attempting to return to an earlier libidinal phase of functioning to avoid the tension and conflict evoked
at the present level of development. Eg bed wetting, thumb sucking,, speech/grooming/crying when
hungry

-It reflects the basic tendency to gain instinctual gratification at a less developed period

15. Somatizaton

-Converting psychic derivatives into bodily symptoms and tending to react with somatic manifestations
rather than psychic manifestations. Eg headaches, backaches, abd pains,