History Taking and Mental State Examination

History Taking
Basic Information
Name, sex, age.
Martial status and children. Who does he live with?
Occupation.
Religion.

Any psychiatric illnesses and admissions? (Only for brief answers, details should be asked in HPI/
PMH).

Chief Complaint and History of Present Illness

Mode of admission.
Chronological events leading to admission.
Identify triggers (stressful events, substance use, etc).
Any psychophysiological symptoms?
Assess functional impairment (emotional, work, social, legal, etc)
What is the personality of the patient before and after the onset of illness? How do other people
see him?

Depression Screening Questions

Low mood, anhedonia, lack of energy.

Mania/Hypomania Screening Questions

Elated mood, excess energy, needing little sleep, new interests/ideas, racing thoughts, special
abilities or powers?

Hallucination Screening Questions

Voices only patient can hear (is it thought echo, people speaking to him, or people commenting
about him).

Delusion Screening Questions

Anyone trying to harm patient? Any events with special meaning? Any special abilities or powers?
Controlled by external forces? Any thoughts not patients?

Anxiety Screening Questions

Wake up anxious and dreading about day ahead, excessive worries about minor things most days
of the week, heart pounding so hard feels like going to die, avoid leave house alone because afraid
of having panic attack or being in situations where escape will be difficult or embarrassing, anxious
in social situations, specific phobias

Past Medical History

Any previously diagnosed psychiatric illnesses and admissions? How is the drug compliance?
Any medical illnesses or surgery (head trauma, neurological conditions, endocrine conditions, etc)

Drug History
Any drug allergies?
What drugs are the patient using? How long? Are they effective? Any side effects?

Family History
Psychiatric illnesses, substance abuse, suicide?
Significant physical illnesses.
Cause of deaths in the family.
Family members and relationships.

Personal History
Infancy and Early Childhood (up to age 5):
Prenatal history of the mother, method of delivery, any congenital problems, preterm birth, or other
complications?
Significant childhood illnesses? Developmental milestones?

Later Childhood and Adolescence (until completion of higher education)

History of physical, sexual, or emotional abuse by family, peers, or others.
Relationship with parents.
School record including grades and final qualifications.
Bullying at school (perpetrator or victim).
Relationship with teachers and peers.
Any behaviour problems (e.g. antisocial behaviours, drug use, or truancy)?
Higher education and training.

Occupational Record
Types, duration, and reasons for changing jobs.

Relationship, Marital, and Sexual History.

History of relationships with duration and reason for break up.
Sexual orientation, history of sexual relationships, and sexual dysfunction/fetish issues.

Social Circumstances
What is the financial status of the patient? Is patient on any financial support?
What does the patient enjoy doing?
Does the patient have any friends?

Alcohol and Substance Use

CAGE questionnaire for alcohol dependence,
Illicit drug use, route of administration, frequency, and duration.

Forensic History
Any arrests, prison history, or lawsuits?
Mental State Examination
Appearance
Body shape.
Clothes.
Hygiene.

Behaviour
Posture.
Facial expression, eye contact, social smile.
Displays of aggression or suspicion.
Abnormal gestures, catatonic behaviour, tics.

Mood and Affect

What is the patient’s mood?
Is the affect congruous with the patient’s mood?
Is the range of affect normal, blunted, or labile?

Speech
Rate, amount, flow.
Content and relevance.

Thoughts
Any formal thought disorders?
Any delusions (primary/secondary, mood congruent/incongruent, bizarre/non-bizzare, content) or
overvalued ideas?

Perception
Any hallucinations?
If auditory, is it simple/complex, first/second/third person?
How does the patient respond to these hallucinations?

Cognition
Consciousness (lowered, normal, hyperaroused)
Orientation (time, place)
Concentration, short term memory, and calculation (100 subtract 7 until 0)
Long term memory (recent — what he ate for breakfast, remote — what school they attended
[episodic], when did Hong Kong return to china [semantic])

Insight
Does the patient believe he is unwell or mentally unwell?
Does the patient believe he needs treatment?
Does the patient believe he needs to be admitted to the hospital?

Risk Assessment
To self: any previous or current self harm or suicidal ideations?
To others: any thoughts on hurting others?
Depression

Suicide Risk Assessment and Mental State
Examination

Risk Assessment
Steps for Risk Assessment
1. Look for epidemiological and clinical risk factors
2. Assess suicidal Intent

Risk Factors
Epidemiological Risk Factors Clinical Risk Factors

Identity: male gender, LGBT Psychiatric illnesses, in particular:

1. Unipolar depression (20x), highest with anxiety/
severe insomnia/previous inpatient.
2. Bipolar affective disorder (15x), more common
in depressive phase, 1/3 have at least attempted
suicide.
3. Schizophrenia (8.5x), highest risk in young,
intelligent, unemployed males with good insight and
recurrent illness.
4. Alcohol dependence (3-4% lifetime), highest
amongst elderly males, poor work record, social
isolation, previous self-harm.
5. Anorexia nervosa (30x) and bulimia nervosa
(7.5x), anorexia nervosa is the psychiatric illness
wth the strong association with suicide.
6. Personality disorder, highest in borderline
where 10% will die by suicide. Also high in
antisocial, narcissistic disorder, and often co-morbid
with depression or substance abuse.

Social life: unmarried, living alone, social isolation, Family history of depression, alcohol dependence
low socioeconomic status or suicide.

Work: unemployed or certain occupations (farmer), Physical illnesses, in particular chronic painful
vet, nurse, doctor, conditions, CNS diseases, cancer (particular
breast/genitals), endocrine and metabolic
conditions.

Recent adverse life events, including legal,

financial, and social (relationship, family) difficulties
in the last 6 months.

Previous self-harm (100x in the following year)

Basically you ask for:

1. Age, gender, sexual orientation
2. Who patient lives with, marital status, any friends
3. Occupation
4. Psychiatric illness, alcohol use, physical illness, family history
5. Previous self-harm
6. Recent adverse life events
Suicidal Intent
1. Was the suicide attempt (past or future) planned in advance? Was the patient sober (alcohol,
drug) at the time?
2. Were their any precautions taken to avoid discovery or rescue?
3. Was a more dangerous method used?
4. Did the patient regret or seek any help after the attempt?

Mental State Examination


Schizophrenia and Related Disorders

Schizophrenia
DSM Criteria
A. Two (or more) of the following, each present for a significant portion of time during a 1-month
period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behaviour.
5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in
one or more major areas, such as work, interpersonal relations, or self-care, is markedly below
the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is
failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e.,
active-phase symptoms) and may include periods of prodromal or residual symptoms. During
these prodromal or residual periods, the signs of the disturbance may be manifested by only
negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated
form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been
ruled out because either 1) no major depressive or manic episodes have occurred concurrently
with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase
symptoms, they have been present for a minority of the total duration of the active and residual
periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood
onset, the additional diagnosis of schizophrenia is made only if prominent delusions or
hallucinations, in addition to the other required symptoms of schizophrenia, are also present for
at least 1 month (or less if successfully treated).

In summary, the diagnosis requires a disease persisting over 6 months with at least one month of
active phase symptoms, with significant functional impairment, and exclusion of other causes
(schizoaffective, bipolar, depression, substance abuse, medical condition).

Schizoaffective Disorder
DSM Criteria
A. An uninterrupted period of illness during which there is a major mood episode (major
depressive or manic) concurrent with Criterion A of schizophrenia.
 *Note: The major depressive episode must include Criterion A1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode
(depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total
duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.

This is basically a disorder where there are major mood episodes with concurrent acute phase
features of schizophrenia, but also has psychotic episodes in the absence of mood episodes.

The major differential diagnoses here are depressive and bipolar disorder with psychotic features.
In these disorders, the psychotic features occur concurrently with the major mood episodes.
Schizoaffective disorder is distinguished from them by the fact that while the patient sometimes
displays both mood and psychotic features concurrently, there are periods of time where there are
only psychotic features and no mood features.

Substance Use
DSM Criteria

A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as

manifested by at least two of the following, occurring within a 12-month period:
1. Alcohol is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or
recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or
home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of
alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve intoxication or desired
effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the
criteria set for alcohol withdrawal, pp. 499–500).
b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or
avoid withdrawal symptoms.

Specify if:
In early remission: After full criteria for alcohol use disorder were previously met, none of
the criteria for alcohol use disorder have been met for at least 3 months but for less than 12
months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,”
may be met).
In sustained remission: After full criteria for alcohol use disorder were previously met,
none of the criteria for alcohol use disorder have been met at any time during a period of 12
months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use
alcohol,” may be met).

Specify if:
In a controlled environment: This additional specifier is used if the individual is in an
environment where access to alcohol is restricted.