Psychiatric assessment
• This chapter describes the skills of history taking in patients with mental illness. • It describes how to perform a Mental State Examination and the Mini Mental State Examination. • It provides you with a template for how to make sense of psychiatric histories and describes how to perform a risk assessment. • It includes guidance about personal safety, which should be read carefully. • Finally, it covers important issues about stigma and prejudice in relation to mental illness. Overview
2.1 Core history-taking skills • As with other branches of medicine, the student doctor should begin taking a history by formally introducing himself/herself to the patient, showing some formal identification and seeking permission from the patient to take a history. The student doctor should explain that he/she would like to take notes, and again seek permission from the patient to do this
2.1 Core history-taking skills • Some students are nervous about taking histories from patients with psychiatric problems. A common fear is that the patient may be aggressive or threatening. This, however, is extremely unlikely, as most patients who suffer from mental ill health are not violent. Some patients, however, may be tired or very depressed, and they may be unable to concentrate for long periods of time. The history may have to be taken in instalments over a few days. Patients who are treated in the community or in an inpatient setting may have a fixed programme of daily activities, which should not be interrupted. In such cases, it is best to make an appointment with the patient and negotiate a mutually convenient time to meet
The main history-taking skills • 1. Formal introduction • 2. Explanation of nature and purpose of interview • 3. Elicit consent • 4. Use of open questions moving to closed for specific details • 5. Use of facilitatory statements • 6. Pick up cues (either verbal or non-verbal) when appropriate • 7. Maintain control of Interview using empathic statements and refocusing techniques
2.1 Core history-taking skills • As with a general medical history, it is important to start with open questions and then move to more closed questions to elicit specific details. Open questions are non-specific, for example 'can you tell me how you've been feeling recently? ’, or 'can you tell me about some of the problems you’ve been experiencing recently?’. They encourage the patient to describe problems or difficulties in his/her own words. They enable a great deal of information to be obtained by the use of relatively few questions, which can make the interview procedure more efficient and less time consuming. Closed questions usually give the patient a fixed choice with two or three alternatives, (e.g. would you say that your mood is about the same as last week, better than last week or worse than last week?). They should be used sparingly, as they are time consuming and, if used a lot, can make the interviewer appear pedantic and unempathic
2.1 Core history-taking skills • If the patient is finding it difficult to describe his/her experiences, It can be helpful to respond by making encouraging noises, or nods, or making understanding statements (e.g. that sounds difficult , that must have been hard for you ). This is called facilitation, and it is an extremely useful technique to learn as it encourages patients to talk in depth about difficulties. It helps the psychiatrist to assess the severity of mood state or abnormal psychological experiences
2.1 Core history-taking skills • Cue-based responses are also helpful in eliciting information about mood. The interviewer can pick up on the patient's non-verbal or verbal cues. Non-verbal cues relate to the patient's body language, which may be indicative of a particular mood state (e.g. anxiety, depression or anger). Verbal cues relate to the language or tone of voice that the patient uses in conversation, which may be suggestive of some underlying mood state. If the interviewer chooses to make a cue- based response, it is best to couch it in a tentative manner, so that the patient can choose either to accept or reject it, without this damaging the overall interviewer -patient relationship (e.g. although you say you’re coping,. when you were talking about your son, just now, I noticed your eyes fill with tears . and I’m not sure . but I wondered whether you still feel very upset)
2.1 Core history-taking skills • As well as being able to elicit information from the patient, and encourage the patient to talk freely, it is also important to be able to control the interview. The purpose of history-taking is to collect specific information in a logical and systematized way to enable the doctor to make a diagnosis and formulate the problem. On some occasions, particularly if the interviewee is very garrulous or circumstantial, the doctor may have to interrupt and be more directive, without appearing rude or insensitive. This is best done in the following manner: acknowledge what the patient has been talking about, explain that this has been helpful, explain that you need to ask about other parts of his/her life and ask the patient's permission to do this
2.1 Core history-taking skills • It can also be helpful to summarize information, to check with the patient that the details are correct. For example, let me just check if I may, that I've understood you correctly. you’ve been feeling worse this last week, your mood has been low all the time, you've not , been sleeping well, waking at 4.00 a.m. most nights, you've lost interest in eating and you’ve not seen anyone all week’. This kind of summary helps the doctor to check that he/she has understood things correctly, and , it is usually perceived by the patient as being very empathic. It can also provide the basis for moving on to enquire about more sensitive issues, such as, in the above example ,the doctor could move on to asking about suicidal ideation