History Taking And
Mental State Examination
Maxim Obaisat , MD
RMS
Department of Psychiatry
Introduce yourself
Explain the purpose and approximately how long it
will take.
Start with open questions
Never hurry a patient – try to be empathic and listen
You might need an informant ( ask patients
permission )
Profile
Name
Age
DOB
Address
Occupation
Marital status
Cheif Complaints
Should always be in the patient’s own words
Hx Of Presented Illness
Reason for referral:
-Referred by..
-What are the main problems?
-Which of these are the worst?
-How has that affected you?
-Any precipitating factors
-When did you last feel well?
Obtain a clear chronological account of
symptoms ( e.g. depression, psychosis)
and the effects of these symptoms on
behavior
PAST PSYCHIATRIC HISTORY 1
In the past have you ever had problems
with your mental health / ‘nerves’/
depression.
Have you ever seen a psychiatrist before?
PAST PSYCHIATRIC HISTORY 2
Have you ever been admitted to a
psychiatric hospital?
What treatments have you had?
Has there ever been a time that you felt
completely well?
Have you ever thought of taking your own
life in the past?
PAST MEDICAL HISTORY
Do you have or had any problems with
your physical health?
Have you ever had any operations or been
in hospital?
CURRENT MEDICATIONS
What medications do you take regularly
and since when?
What medications have you had in the
past?
ALCOHOL AND DRUG HISTORY
Do you smoke? How many? Since when?
Do you take a drink?
How much do you drink?
Have you been drinking any more or less
than normal recently?
Have you ever taken drugs? Tell me more
about that.
FAMILY HISTORY
Are your parents still living? Are they
well?
Do you mind me asking how they died?
What did your parents do?
Do you have any brothers or sisters? Are
you close to them?
As far as you know, has anyone in your
family ever had problems with their
mental health?
PERSONAL HISTORY 1
Infancy and early childhood
Where were you born?
Where did you grow up?
As far as you know, was your mother’s
pregnancy and delivery normal?
PERSONAL HISTORY 2
If not, were there any problems around
the time of your birth?
Did you have any serious illnesses as a
young child?
Were you walking and talking at the
correct times?
PERSONAL HISTORY 3
Adolescence and education
Which school/s did you go to?
Did you enjoy school?
Any lasting memories of school?
PERSONAL HISTORY 3
Did you have many friends at school? Still
in contact?
When did you finish school ?
Qualifications?
Were you ever in trouble at school? ever
expelled or suspended? Bullied?
PERSONAL HISTORY 4
What did you do after finishing school?
Occupational record
Sexual development,
Relationships and marriage
Do you have any children? How old are
they?
PERSONAL HISTORY 5
Present social circumstances
Who lives at home with you now?
Do you have any worries about debt or
money in general?
Do you have friends or family who live
nearby?
PREMORBID PERSONALITY 1
Before all this happened, how would you
describe yourself?
How would other people describe you?
When you find yourself in difficult situations,
how do you cope?
What sort of things do you like to do to
relax?
PREMORBID PERSONALITY 2
Do you have any hobbies?
Do you like to be around other people or do
you prefer your own company?
Are you religious?
Do you have any ambitions or plans?
FORENSIC HISTORY
Have you ever been in trouble with the
police, or been convicted of anything?
***
MENTAL STATE
EXAMINATION
Mental Status Examination
This is analogous to performing a physical exam in other areas of medicine.
It is the nuts and bolts of the psychiatric exam. It should describe the patient
in as much detail as possible. The mental status exam assesses the following:
■ Appearance/Behavior
■ Speech
■ Mood/Affect
■ Thought process
■ Thought content
■ Perceptual disturbances
■ Cognition
■ Insight & Judgment/Impulse control
The mental status exam tells only about the mental status at that moment; it
can change every hour or every day, etc.
APPEARANCE, ATTITUDE AND
BEHAVIOUR 1
■ Appearance: Gender, age (looks older/younger than stated age), type of
clothing, hygiene (including smelling of alcohol, urine, feces), posture,
grooming, physical abnormalities, tattoos, body piercings.
Take specific notice of the following, which may be clues for possible
diagnoses:
■ Pupil size: Drug intoxication/withdrawal.
■ Bruises in hidden areas: ↑ suspicion for abuse.
■ Needle marks/tracks: Drug use.
■ Eroding of tooth enamel: Eating disorders (from vomiting).
■ Superficial cuts on arms: Self-harm.
■ Behavior: Attitude (cooperative, seductive, flattering, charming, eager to please, entitled,
controlling, uncooperative, hostile, guarded, critical, antagonistic, childish ), mannerisms,
tics, eye contact, activity level, psychomotor retardation/agitation,
akathisia, automatisms, catatonia, choreoathetoid movements,
compulsions, dystonias, tremor.
SPEECH AND LANGUAGE
Assess for:
Rate (pressured, slowed, regular), rhythm
, articulation (dysarthria,
stuttering),accent/dialect,volume/modulati
on (loudness or softness),tone, long or
short latency of speech.
MOOD AND AFFECT
Mood
Mood is the emotion that the patient tells you he/she feels, often in quotations.
Affect
Affect is an assessment of how the patient’s mood appears to the examiner, including
the amount and range of emotional expression. It is described with the following
dimensions:
■ Type of affect: Euthymic, euphoric, neutral, dysphoric.
■ Range describes the depth and range of the feelings shown.
Parameters:
flat (none)—blunted (shallow)—constricted (limited)—full (average)—
intense (more than normal).
■ Motility describes how quickly a person appears to shift emotional states.
Parameters: sluggish—supple—labile.
■ Appropriateness to content describes whether the affect is congruent with
the subject of conversation or stated mood.
Parameters: appropriate—not appropriate.
THOUGHT
DESCRIBE FORM OF THOUGHT:
The patient’s form of thinking—how he or she uses language and puts ideas
together. It describes whether the patient’s thoughts are logical, meaningful, and goal
directed. It does not comment on what the patient thinks, only how the patient
expresses his or her thoughts.
■ Logical/Linear/Goal-directed: Answers to questions and conversation
clear and follows a logical sequence.
■ Circumstantiality is when the point of the conversation is eventually
reached but with overinclusion of trivial or irrelevant details.
Examples of thought disorders include:
■ Tangentiality: Can follow conversation but point never reached or question
never answered.
■ Loosening of associations: No logical connection from one thought to
another.
■ Flight of ideas: Thoughts change abruptly from one idea to another, usually
accompanied by rapid/pressured speech.
■ Neologisms: Made-up words.
■ Word salad: Incoherent collection of words.
■ Clang associations: Word connections due to phonetics rather than
actual meaning. “My car is red. I’ve been in bed. It hurts my head.”
■ Thought blocking: Abrupt cessation of communication before the idea is
finished.
THOUGHT CONTENT 1
Describes the types of ideas expressed by the patient. Examples of
disorders:
■ Poverty of thought versus overabundance: Too few versus too many
ideas expressed.
■ Delusions: Fixed, false beliefs that are not shared by the person’s
culture and remain despite evidence to the contrary. Delusions are
classified as bizarre (impossible to be true) or non-bizarre (at least
possible).
■ Suicidal and homicidal ideation: Ask if the patient feels like harming
himself/herself or others. Identify if the plan is well formulated. Ask if
the patient has an intent (i.e., if released right now, would he/she go and
kill himself/herself or harm others?). Ask if the patient has means to kill
himself/herself (firearms in the house/multiple prescription bottles).
■ Phobias: Persistent, irrational fears.
■ Obsessions: Repetitive, intrusive thoughts.
PERCEPTUAL ABNORMALITIES
■ Hallucinations: Sensory perceptions that occur in the absence of an
actual stimulus.
■ Describe the sensory modality: Auditory (most common), visual,
gustatory, olfactory, or tactile.
■ Describe the details (e.g., auditory hallucinations may be ringing,
humming, whispers, or voices speaking clear words). Command auditory
hallucinations are voices that instruct the patient to do something.
■ Ask if the hallucination is experienced only while falling asleep
(hypnagogic hallucination) or upon awakening (hypnopompic
hallucination).
■ Illusions: Inaccurate perception of existing sensory stimuli (e.g., wall
appears as if it’s moving).
■ Derealization/Depersonalization: The experience of feeling detached from
one’s surroundings/mental processes.
COGNITION
USUALLY MMSE WOULD DO
■ Consciousness: Patient’s level of awareness; possible range includes:
alert—drowsy—lethargic—stuporous—comatose.
■ Orientation: To person, place, and time.
■ Calculation: Ability to add/subtract.
■ Memory:
■ Immediate (registration)—dependent on attention/concentration and can be tested by
asking a patient to repeat several digits or words.
■ Recent (short-term memory)—events within the past few minutes,hours, or days.
■ Remote memory (long-term memory).
■ Fund of knowledge: Level of knowledge in the context of the patient’s culture and
education (e.g., Who is the King? Who was the Prophet? What countries are next to
ours? ).
■ Attention/Concentration: Ability to subtract serial 7s from 100 or to count the days
of the week backwards.
■ Reading/Writing: Simple sentences (must make sure the patient is literate first).
■ Abstract concepts: Ability to explain similarities between objects and
understand the meaning of simple proverbs.
COGNITION
MMSE (Mini mental State examination)
1. Orientation to time (day, date, month, season, year) = 5 points
2. Orientation to place (floor, building, town, city, country) = 5 points
3. Registration (apple, penny, table) = 3 points
4. Attention & concentration (serial 7’s test, WORLD backwards) = 5 points
5. Delay recall (apple, penny, table) = 3 points
6. Naming (pen, watch) = 2 points
7. Expressive language = 1 point
8. Reading & comprehension ( Close your eyes ) = 1 point
9. Write a sentence = 1 point
10. Copy intersecting pentagons = 1 point
11. Three stage command (take this paper in your left hand, fold it in half & put
it on the floor) = 3 points
24-30 Within normal limits
18-23 Mild ~ Moderate cognitive impairment
0-17 Severe cognitive impairment
INSIGHT AND JUDGEMENT
Awareness of disease:
Do you consider that you are ill in any
way? Why have you come into hospital?
Do you have a physical or a mental
illness? If you have a mental illness, what
is it?
Correct labelling of abnormality:
You described several
symptoms…..namely….
What is your explanation of these
experiences?
Willingness to take treatment:
How do you feel about being in
hospital…..? Coming to the clinic….? How
do you feel about taking medication? Has
the medication been helpful? Have any
other treatments been helpful? Do you
think that medication helps you to remain
well?
Remember to always do a
PHYSICAL EXAMINATION
!!!!
General observations: Vital signs: HR, BP,
RR, Temp: Autonomic arousal, tremor,
sweating etc.
Important features: scars, tattoos, signs
of liver disease, signs of thyroid or
Cushing’s disease, etc., Specific CVS, RS,
GI, and CNS examination findings and
important negative findings
