Interview + MSE
Interview
Patient History : Basic information
Name, age, and marital status.; Current occupation.; Route of referral; Current legal status (primarily r/t
hospitalization)
Presenting complaints
Number & brief description of presenting complaints. Assess: ‘ Which is the most troublesome
symptom?’
History of presenting complaints
For each complaint, assess: nature of the complaint (in patient’s words if possible); chronology
( onset, frequency and duration); severity; life events at/around the time; precipitating, aggravating, &
relieving factors ; any associated symptoms,
assess: Have these or similar symptoms occurred before? To what do you(does the
patient) attribute the symptoms?
Past psychiatric & medical history
previous psychiatric diagnoses. ; Chronological list of psychiatric treatments--in hospital, in partial-
hospital programs and at out-patient centers; Current medical conditions; Chronological list of medical
/ surgical illness; Episodes of symptoms which were never treated
Drug history
names/doses of current medications, and whether the patient takes each as prescribed. Previous
psychiatric drug treatments. History of AEs or allergies. Any non-prescribed or alternative medications
taken
Personal history
Childhood:
Did they reach development milestones normally? Was their childhood happy? In what sort of family
were they raised? Where did they grow up?
Education
Do they recall any problems in primary or secondary school? What sort of student were they? Did they
enjoy school? If not, why? Did they have difficulties with peers or teachers? At what age did they leave
school, and with what qualifications?
Was any post-secondary education sought? What did they study? If they didn’t finish their program/
graduate university, why not? Do they have any qualifications or other training?
Employment_Chronological list of jobs. Which job did they hold for the longest period? Which job did
they enjoy most? If the patient has had a series of jobs?why did they leave each? Account for periods of
unemployment in the patient's history. Is the type of job undertaken consistent with the patient's level of
educational attainment?
Relationships_Sexual orientation. Chronological account of major relationships. Reasons for
relationship breakdown. Are they currently in a relationship? Do they have any children from the current
or previous relationships? Who do the children live with? What relationship does the patient have with
them?
Social background information
Current occupation. Are they working at the moment? If not, how long have they been off work and
why? Current family/relationship situation. Alcohol and illicit drug use (pp._510,_511, pp._548,549).
Main recreational activities.
Premorbid personality
How would they describe themselves before they became ill? How would others have described them?
Mental state examination
Appearance
Apparent age. Racial origin. Style of dress. Level of cleanliness. General physical
condition.
Behaviour
Appropriateness of behaviour. Level of motor activity. Apparent level of anxiety.
Eye contact. Rapport. Abnormal movement or posture. Episodes of aggression.
Distractibility.
Speech
Volume, rate, and tone. Quantity and fluency. Abnormal associations, clang and
punning. Flight of ideas.
Mood
Subjective and objective assessment of mood.
Risk
Thoughts of suicide or deliberate self-harm. Thoughts of harm to others.
Anxiety
Anxiety and panic symptoms. Obsessions and compulsions.
Perception
Hallucinations and pseudo-hallucinations. Depersonalisation and derealisation.
Thought
Form:_formal thought disorder._Content: delusions, over-valued ideas.
Cognition
Orientation. Level of comprehension. Short-term memory. Concentration.
Insight
Does the patient feel his experiences are as the result of illness? Will he accept
medical advice and treatment?
Case summary
Synopsis
This should be a short paragraph summarising the salient points of the preceding information. Mention
the basic personal information, previous psychiatric diagnosis, description of presentation, description of
current symptoms, positive features on MSE, suicide risk, and attitude to illness.
Differential diagnosis
This will usually be a short list of two or three possibilities. In an exam situation, mention other less likely
possibilities you would consider in order to exclude. Your presentation should have directed you towards
choosing one as your working diagnosis.
Formulation
For general psychiatric patients the formulation should include comment on why the person has become
ill and why now. You should identify the ?three P's??predisposing, precipitating, and perpetuating
factors for the current illness. This information will be important in guiding a suitable management plan.
So, for example, in a patient with depressed mood following the birth of a baby: predisposing factors
could be family history of depressive illness, female sex; precipitating factors could be the post-natal
period, job loss, change of role, and feelings of inadequacy; and prolonging factors could be disturbed
sleep, unsupportive partner.
Management plan
Following the presentation of history, MSE, physical examination, and formulation you would normally
go on to present or to document your initial management plan, including necessary investigations, initial
drug treatment, instructions to nursing staff, and comment on potential risks and whether or not, in your
opinion, the patient is currently detainable under the Mental Health Act.
What is the patient's appearance?
Describe the patient's physical appearance and racial origin. Compare what age
they appear with their actual age (i.e. biological vs. chronological age). What is
their manner of dress? Patients with manic illnesses may dress in an excessively
formal, flamboyant, or sexually inappropriate manner. Patients with cognitive
impairment may have mismatched or wrongly buttoned clothing.
What is the patient's behaviour during the interview?
Are there episodes of tearfulness? Do they attend to the interview or do they
appear distracted? Do they maintain an appropriate level of eye contact? Do you
feel that you have established rapport?
What is the patient's level of activity during the interview?
Does the patient appear restless or fidgety? Do they settle to a chair or pace
during interview? Is there a normal level of gesticulation during conversation?
Is there any evidence of self-neglect?
Does the patient have lower than normal standards of self-care and personal
hygiene? Are they malodorous, unshaven, or dishevelled? Are their clothes
clean? Are there cigarette burns or food stains on their clothes?
Is the patient's behaviour socially inappropriate?
Is there embarrassing, overly familiar, or sexually forward behaviour? All are seen
in manic illness or where there is cognitive impairment.
Is the patient's behaviour threatening, aggressive, or violent?
In manner or in speech does the patient appear hostile or threatening? Do you
feel at risk? Is there aggressive or violent behaviour on display during the
interview? What prompts it?
Are there any abnormal movements?
Does the patient have repetitive or rocking movements or bizarre posturing
(stereotypies)? Do they perform voluntary, goal-directed activities in a bizarre way
(mannerisms)? What is their explanation for this? For patients on neuroleptic
medication, is there evidence of side-effects (e.g. stiffness, rigidity, tremor,
akathisia)?
P.39
Is the patient distractible or appear to be responding to hallucinations?
Does the patient appear to be attending to a voice other than yours? Are they
looking around the room as if for the source of a voice? Are they murmuring or
mouthing soundlessly to themselves? Are there episodes of giggling, verbal
outbursts, or other unexplained actions?
Is there any speech at all?
A small number of patients are mute during interview. Here the doctor should aim
to comment on apparent level of comprehension
What is the quantity of speech?
Are answers unduly brief or monosyllabic? Conversely, are they inappropriately
prolonged? Does the speech appear pressured? (i.e. there is copious, rapid
speech, which is hard to interrupt).
What is the rate of speech?
There is a wide variation in normal rates of speech across even the regions of the
UK. Is the patient's speech unusually slow or unusually rapid, given the expected
rate? This may reflect acceleration or deceleration in the speed of thought in
affective illnesses.
What is the volume and quality of speech?
Does the patient whisper? Or speak inappropriately loudly? Is there stuttering or
slurring or speech
What is the tone and rhythm of speech?
Even in a non-tonal language like English, normal speech has a musical quality
with the intonation of the voice and rhythm of the sentences conveying meaning
(i.e. the rise in tone at the end of a question). Loss of this range of intonation and
rhythmic pattern is seen in chronic psychotic illnesses.
How appropriate is the speech?
Is the content of the speech appropriate to the situation? Does the patient answer
questions appropriately? Are there inappropriate or pointless digressions? Can
the meaning of the speech always be followed?
Is there abnormal use of language?
Are there word-finding difficulties, which may suggest an expressive dysphasia?
Are there neologisms (i.e. made up words, or normal words used in an
idiosyncratic manner)?
Abnormal mood
In describing disorders of mood we draw a distinction between affect (the
emotional state prevailing at a given moment) and mood (the emotional state over
a longer period). To use a meteorological analogy, affect represents the weather,
where mood is the climate. Variations in affect, from happiness to sadness,
irritability to enthusiasm are within everyone's normal experience. Assessment of
pathological abnormality of affect involves assessing the severity, longevity, and
ubiquity of the mood disturbance and its association with other pathological
features suggestive of mood disorder.
The two central clinical features of depressive illness are (1) pervasively
depressed and unreactive mood and (2) anhedonia?the loss of pleasure in
previously pleasurable activities. The clinical picture also includes the ?biological
features of depression?, thoughts of self-harm, and, in more severe cases, mood-
congruent psychotic features.
Interview
1. Initiation_
Introduce yourself and explain the nature and purpose of the interview. Describe how
long the interview will last and what you know about the patient already.
2 a. Patient led history
_Invite the patient to tell you about their presenting complaint. Use general opening
questions and prompt for further elaboration. Let the patient do most of the talking:
your role is to help them to tell the story in their own words. During this phase you
should note down the major observations in the MSE. Having completed the history of
the present complaint and the MSE you will be able to be more focused when taking
the other aspects of the history.
b. Doctor-led history _
Clarify the details in the history thus far with appropriate questions. Clarify the nature
of diagnostic symptoms (e.g. are these true hallucinations? Is there diurnal mood
variation?) Explore significant areas not mentioned spontaneously by the patient.
c. Background history _
Complete the history by direct enquiry. This is similar to standard medical history
taking, with the addition of a closer enquiry into the patient's personal history.
3. Summing-up _
Recount the history as you have understood it back to the patient. Ensure there are no
omissions or important areas uncovered. Indicate if you would like to obtain other
third-party information, emphasising that this would add to your understanding of the
patient's problems and help you in your diagnosis
other
Establish a therapeutic relationship
Aim to listen more than you speak (especially initially). Show respect for the patient--establish their
preferred address, ask permission for anyone else (ie clinical supervisor) to be present. Do not argue;
’agree to disagree’ if consensus cannot be reached. Accept that in some patients trust may take time to
develop.
Communicate effectively
Be specific- explain the diagnosis, and the treatment, you believe apply
Avoid jargon- use layman's language, or explain specialist terms
Connect the advice to the patient Explain why you think what you do and what it is
about the patient's symptoms that suggests the diagnosis to you.
Avoid ambiguity- say precisely what you mean, and what your plans are. Be explicit.
Use repetition and recapitulation- Use the ‘primacy/recency’ effect. State important
information first and repeat it at the end.
Break up/write down- Make information easier to remember by breaking it down to a
numbered list. Consider providing personalised written information, as well.
Encourage self-help
Explain clearly what they can do to help themselves. Explain that outcomes are
affected by the patient’s actions. Outcomes are improved by adherence to treatment,
and avoidance of exacerbating factors (drug or alcohol misuse.) It may also be
appropriate to consider lifestyle changes (house move, relationship counseling)
Where appropriate, encourage contact/attendance at voluntary treatment
organisations, self-help groups, or patient organisations.
Interview
Patient History : Basic information
Name, age, and marital status.; Current occupation.; Route of referral; Current legal status (primarily r/t
hospitalization)
Presenting complaints
Number & brief description of presenting complaints. Assess: ‘ Which is the most troublesome
symptom?’
History of presenting complaints
For each complaint, assess: nature of the complaint (in patient’s words if possible); chronology
( onset, frequency and duration); severity; life events at/around the time; precipitating, aggravating, &
relieving factors ; any associated symptoms,
assess: Have these or similar symptoms occurred before? To what do you(does the
patient) attribute the symptoms?
Past psychiatric & medical history
previous psychiatric diagnoses. ; Chronological list of psychiatric treatments--in hospital, in partial-
hospital programs and at out-patient centers; Current medical conditions; Chronological list of medical
/ surgical illness; Episodes of symptoms which were never treated
Drug history
names/doses of current medications, and whether the patient takes each as prescribed. Previous
psychiatric drug treatments. History of AEs or allergies. Any non-prescribed or alternative medications
taken
Personal history
Childhood:
Did they reach development milestones normally? Was their childhood happy? In what sort of family
were they raised? Where did they grow up?
Education
Do they recall any problems in primary or secondary school? What sort of student were they? Did they
enjoy school? If not, why? Did they have difficulties with peers or teachers? At what age did they leave
school, and with what qualifications?
Was any post-secondary education sought? What did they study? If they didn’t finish their program/
graduate university, why not? Do they have any qualifications or other training?
Employment_Chronological list of jobs. Which job did they hold for the longest period? Which job did
they enjoy most? If the patient has had a series of jobs?why did they leave each? Account for periods of
unemployment in the patient's history. Is the type of job undertaken consistent with the patient's level of
educational attainment?
Relationships_Sexual orientation. Chronological account of major relationships. Reasons for
relationship breakdown. Are they currently in a relationship? Do they have any children from the current
or previous relationships? Who do the children live with? What relationship does the patient have with
them?
Social background information
Current occupation. Are they working at the moment? If not, how long have they been off work and
why? Current family/relationship situation. Alcohol and illicit drug use (pp._510,_511, pp._548,549).
Main recreational activities.
Premorbid personality
How would they describe themselves before they became ill? How would others have described them?
Mental state examination
Interview styles
1. Initiation_
Introduce yourself and explain the nature and purpose of the interview. Describe how
long the interview will last and what you know about the patient already.
2 a. Patient led history
_Invite the patient to tell you about their presenting complaint. Use general opening
questions and prompt for further elaboration. Let the patient do most of the talking:
your role is to help them to tell the story in their own words. During this phase you
should note down the major observations in the MSE. Having completed the history of
the present complaint and the MSE you will be able to be more focused when taking
the other aspects of the history.
b. Doctor-led history _
Clarify the details in the history thus far with appropriate questions. Clarify the nature
of diagnostic symptoms (e.g. are these true hallucinations? Is there diurnal mood
variation?) Explore significant areas not mentioned spontaneously by the patient.
c. Background history _
Complete the history by direct enquiry. This is similar to standard medical history
taking, with the addition of a closer enquiry into the patient's personal history.
3. Summing-up_
Recount the history as you have understood it back to the patient. Ensure there are no
omissions or important areas uncovered. Indicate if you would like to obtain other
third-party information, emphasising that this would add to your understanding of the
patient's problems and help you in your diagnosis
other
Establish a therapeutic relationship
Aim to listen more than you speak (especially initially). Show respect for the patient--establish their
preferred address, ask permission for anyone else (ie clinical supervisor) to be present. Do not argue;
’agree to disagree’ if consensus cannot be reached. Accept that in some patients trust may take time to
develop.
Communicate effectively
Be specific- explain the diagnosis, and the treatment, you believe apply
Avoid jargon- use layman's language, or explain specialist terms
Connect the advice to the patient Explain why you think what you do and what it is
about the patient's symptoms that suggests the diagnosis to you.
Avoid ambiguity- say precisely what you mean, and what your plans are. Be explicit.
Use repetition and recapitulation- Use the ‘primacy/recency’ effect. State important
information first and repeat it at the end.
Break up/write down- Make information easier to remember by breaking it down to a
numbered list. Consider providing personalised written information, as well.
Encourage self-help
Explain clearly what they can do to help themselves. Explain that outcomes are
affected by the patient’s actions. Outcomes are improved by adherence to treatment,
and avoidance of exacerbating factors (drug or alcohol misuse.) It may also be
appropriate to consider lifestyle changes (house move, relationship counseling)
Where appropriate, encourage contact/attendance at voluntary treatment
organisations, self-help groups, or patient organisations.
