Lecture Tripoli, Libya

Sunday 23rd January 20100

Mental health history taking

Dr Henk Parmentier

General Practitioner

- South West London, United Kingdom

- Wonca Working Party on Mental Health

Mental health history taking

objectives

Learn about mental health history

taking

Learn about psychiatric assessment

assessment

Questions to answer:

Does the patient has a mental health

problem?

What is the problem?

What is the treatment?

Can I give the treatment?

Is the patient happy to have the

treatment?

Assessment

A full assessment can take many

sessions and take hours

But it can be done in a few minutes by

a Family Doctor

Psychiatric assessment

A complete psychiatric requires:

Detailed personal history

Clear account of current problems

Risk assessment

Mental state examination

Physical examination

Psychiatric history

Administration:

Name

Age and sex

Address, telephone number

Languages

Marital status

Education

occupation

Presenting problem

What is the current problem?

How long has it been going on?

What events led up to this

presentation?

History of present illness

What are the specific symptoms and

for how long?

Is there a relationship with social

stressors / physical illness?

Disturbances in mood?, appetite?,

sleep?, sexual drive?

Has any treatment been given yet?

Personal history

Covers as much information about the

individual’s life from childhood to

present time

Pregnancy, birth, child behaviour,

development, education, relationships

Work history: how many jobs

Marital status: children

Criminal activities

Previous medical history

Next presentation

Drug history

Previous drugs: self medication,

prescribed drugs, illegal drugs

Allergic reactions?

Premorbid personality

how does the patient describe his

personality before getting unwel?

Mood, temperament, character traits,

confedence, religious believes, ambition

Social relationships with family, friends

and at work

Family history

Ask about individual’s close family and

their health status

Age, health, occupation, how's the

relationship with that person

Mental state examination

Obtain information about specific

aspects of the patient’s mental

experiences and behaviour at the time

of the interview

Appearance and behavious

Appearance

Attitude

Motor behaviour

speech

Rate

Volume

Quantity of information

Mood and affect

Mood: depressed, euphoric,

suspicious

Affect: restricted, flattened,

inapropriate

Form of thought

Amount of thought and rate of

production

Continuity

Disturbance in language or meaning

Content of thought

Delusions

Suicidal thoughts

other

perception

Hallucinations

Other: derealisation, depersonalisation

Sensorium ans cognition

Level of consiousness

Memory: immediate, recent, remote

Orientation in place, time and person

Concentration

insight

Awareness of problems