History

Biodata

Mnemonic: NASRREMO

• Name
• Age
• Sex
• Religion
• Residence
• Education
• Marital Status
• Occupation
• Source of referral
• Cause of referral
  • One particular reason why the patient has been brought to the hospital at that moment and not earlier?
• Mode of admission
  • Voluntary admission
    • Form filled on admission: MOH 613
  • Involuntary admission
    • Forms filled on admission:
      • MOH 614: Filled by source of referral
      • MOH 615: Recommendation filled by medical practitioner
      • MOH 637: For individuals <16 years old, filled by parent or guardian
  • Emergency admission
    • Form filled on admission: MOH 638- Filled by officer
  • Admission of foreign nationals
  • Admission through the criminal justice system
  • Admission of members of the armed forces
• Date of admission
• Place of interview
• Date of interview
• Informant
• Language of Interview
• Role of the biodata in psychiatry?
  • Suggest diagnostic possibilities and etiological factors
  • Help the clinician understand something of the background, aspirations and resources of the patient, the tasks faced, and the social supports likely to be available.

Presenting Complaints/Allegations

Guides you on the questions to ask in the HPI. Ask the patient: Why do you think you are here?

History of the Presenting Complaint

Chronological Sequence of how the symptoms appeared

Description of symptoms: Triggers, Onset, Duration, Aggravating factors, severity, Chronology (any changes experienced over time)

Precipitating factors

How these problems have affected the patient’s life (self-care, school, family, work)

Prior consult for the current episode

Associated symptoms

Exacerbating factors

Patient’s understanding and expectations

Psychiatric ROS

Reveals symptoms that might not have showed up in the HPI. Some of these symptoms may be egosyntonic and the patient may regard them as being “normal”.

It is important to ask about any mood symptoms (of depression or mania), anxiety symptoms (from generalised anxiety symptoms, OCD, PTSD, phobias etc.), psychosis (hallucinations, delusions, paranoia), and other symptoms of psychiatric illnesses such as ADHD or eating disorders.

Some of the following questions should be asked of most (if not all) patients presenting for psychiatric assessment.

• Changes in sleep – difficulty getting off to sleep (initial insomnia); waking in the middle of the night then getting back to sleep (middle insomnia); waking more than two hours earlier than usual and being unable to get back to sleep (early morning waking); disturbed sleep; waking unrefreshed; and excessive sleep.
• Changes in appetite (for food, sex, risk, drugs etc.) – any changes need to be quantified if possible – loss of appetite for food may be reflected weight loss or gain (how many kgs), increase or decrease in alcohol intake (by how many standard drinks?), alteration in the frequency of sexual activity (what was the base and is the current frequency?).
• Changes in mood – depressed, sad, unhappy, fearful, worried, happy, elated, ‘tormented’ (by psychosis rather than mood disorder), heightened sense of spirituality (closer to God).
• Changes in energy – increased or decreased.
• Changes in interest in social contact – increased or decreased.
• Changes in thought content – new or unusual thoughts, new secrets which other people might not believe, suspicious behavior or persecution by others, repetitive thoughts which cannot be ignored (particularly clever thoughts which will solve problems or make a lot of money), repetitive “silly” thoughts that are your own, but you stop coming.
• Changes in the experience of thinking – sensation of thinking being more difficult, slower or mixed-up, sensation of thinking being faster, easier or more efficient
• New perceptions.- hearing, seeing, touching, smelling that you haven’t had before, or which other people might not be able to notice.
• New physical symptoms – pains, constipation, poor vision, fits, headache, muscular weakness, loss of consciousness

DIG FAST for Mania

• Distractibility
• Irritability
• Grandiosity
• Flight of ideas
• Activity increase
• Sleep (decreased need of)
• Talkativeness

SIG E CAPS for depression

• Sleep
• Interest
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor agitation/retardation
• Suicidal ideation

Medical ROS

• Ask the patient about any systemic symptoms.
• It is important to consider whether any symptoms are linked to psychiatric illness and vice versa.

Past Medical and Surgical History

• *** RECORD ANY ILLNESS/ INJURY THAT MAY HAVE IMPAIRED THE PATIENT’S DEVELOPMENT, EITHER BY REDUCING OPPORTUNITIES, OR BY DIRECTLY AFFECTING BRAIN FUNCTION.
• History of admission
• History of Chronic Illness
  • Diabetes Mellitus
  • Kidney Failure
  • Liver Failure
  • Hypothyroidism/Hyperthyroidism
  • Hypertension
• History of Surgical procedures
• History of blood transfusion
• Food an drug allergies

Past Psychiatric History

• Chronological order of past episodes
• 1st time the patient developed symptoms (whether or not psychiatric help was sought)
• Past psychiatric services
• Past psychiatric admissions
  • Year, month, date
  • Institution
  • Presenting complaint/ allegation/ diagnosis for admission
  • Duration of admission
  • Drugs given (with compliance and response)
  • Procedures done (ECT)
• Compliance to treatment and follow-up

Family History

	Name	Age	Occupation	Personality	Relevant medical History	Relevant Psychiatric History	Relationship with Patient
Mother
Father
Brother
Sister
Uncle
Aunt

• Questions to ask in family history:
  1. Who raised the patient?
  2. Was there an adult of both sexes in the home?
  3. Were either of the parents away from the home for long periods?
  4. Were either, neither or both parents emotionally close to the patient?
  5. How many children were there in the family and what were their names?
  6. Where did the patient come in the sib-ship and what were the age differences?
  7. With which siblings did the patient have the closest emotional relationship?
  8. How would the patient describe each parent figure?
  9. How would the patient describe the family life of his or her early years – warm, frightening, etc.
  10. Were any other significant adults present during development?
  11. Any known family medical or psychiatric disorders? Time spent in a psychiatric hospital, suicide, substance use and convictions, etc.

Personal History

• An account of events in the life of the patient to present time.

Birth history

• Include events from the time before birth which may be relevant to personal history for example: unwanted pregnancy, father absent at time of birth, maternal substance use or illness during pregnancy, etc.
• Also include the manner of birth (vaginal or caesarean); any complications, the early development including age at which the patient first spoke and walked, comparisons with siblings and any evidence of delays or precocity

Childhood

• Early childhood (birth – 3 years)
• Middle childhood (3 – 11 years)
• Adolescence
• Education
  • How did you perform scholastically (“in lessons and tests”)? A history of having found these difficult may suggest intellectual disability, or a severely disorganized home life. Good performance in primary school followed by poor performance in secondary school suggests an inability to comply and delay gratification which may indicate an emerging personality disorder; alternatively, and less commonly, an prodromal psychosis.
  • How did you get along with the other students? A history of few friends or being very socially isolated suggests avoidant or schizoid traits or prodromal psychosis. A history of being ‘popular’ and frequent falling out (“fights”) suggests emerging Cluster B personality disorder. A history of few friends but above average school performance suggests obsessional traits.
  • How did you get along with the teachers? Shyness of primary school teachers may predict an anxiety disorder or Cluster C (anxious/fearful) personality traits. Teachers symbolize authority. Conflict with teachers often emerges in secondary school (although in pronounced cases it may be present in primary school) suggest the individual may not comply with the rules of society, in adult years.
  • Was the individual involved in other school activities? Some young people have as little to do with school as possible. Others engage in choirs, sporting and similar activities both in and outside school hours. Such engagement suggests ability to delay gratification and derive pleasure from social interaction; and in the case of sport, some confidence in physical ability.

Adulthood

• Occupational history:
  • If possible, obtain:
    • the type of work pursued
    • the dates of employment (starting and leaving): give the length of any periods of unemployment.
    • the name of each employer.
    • The reason for leaving each employer, and whether there was difficulty in finding the next position.
  • Inability to provide details with a relative ease suggests cognitive difficulties, secretiveness (may be paranoid or deceptive in origin), or that employment was only fleeting.
• Relationship/marriage history
  • Length of each relationship, as well as the reasons why they ended if they did.
  • Relationship between the patient and their partner
  • Children
• Military history
• Religion

Sexual History

• Sexual debut: age, with whom, consensual vs assault?
• Orientation – Heterosexual, MSM, WSW
• Number of sexual partners
• History of treatment for STIs
• Paraphilias
• Masturbation (worries, guilt, fantasies, deviation, dysfunction)

Menstrual History

• Menarche
• Cycle length, regularity, quantity
• Cycle abnormalities (dysmenorrhoea, amenorrhoea, AUB)
• Menopause (if relevant)

Drug/Substance History

• Name of drug
• When they first started using and why?
• Quantification
  • Rolls of cannabis
  • Pack years of cigarettes
  • Units of alcohol
  • Grams of cocaine
  • Kilograms of khat
• Frequency of use (daily, weekends, few days of the week)
• Craving
• Risky behavior from use of the substance
• Social impairment from use of the substance
• Withdrawal symptoms
• Herbal drugs
• Over the counter drugs
• ALWAYS RULE OUT THE POSSIBILITY OF SUBSTANCE USE DISORDER USING THE CRITERIA FOR EACH SUBSTANCE MENTIONED!

Forensic History

• Violence/aggression
• Trouble with police
• Theft
• Arrests
• Convictions
• Imprisonment

Premorbid Personality

• A description of themselves before the illness
• Hobbies
• What others would say about the patient personality wise?

Current Living Situation

• Who does the patient live with? Where do they live? What is their financial situation?

Mental State Exam

Appearance

Think of this as a written account of a still photograph, written for someone who cannot see it

• Estimated age by physical appearance
  • Difference in apparent vs. stated age
• Body habitus
  • Stature
  • Body weight/nutritional status
  • Physical abnormalities (buffalo hump, etc)
• Dressing
  • Type of clothing
  • Amount of clothing
  • Is the clothing appropriate?
• Hygiene
  • Level of grooming
  • Presence of body odor and/or halitosis
• Distinguishing features
  • Tattoos
  • Body piercings
  • Dental braces
  • Jewellery
  • Wounds (burns scratches, needle marks) and scars (previous self-harm)
• Evidence of substance misuse
  • Injection tracks: IV drug use
  • Spider naevi and jaundice: Alcoholic liver disease
• Stigmata of disease
  • Thyroid: exophthalmos
  • Cushing’s: buffalo hump
  • Liver: jaundice
• Objects the patient has or is carrying
• Posture

Behavior

Think of this as a written account of a video

• Eye contact
  • Level
    • None
    • Decreased
    • Normal
    • Increased
  • Type
    • Fleeting
    • Intrusive
• Attitude towards interviewer
  • Friendly
  • Cooperative
  • Indifferent
  • Seductive
  • Defensive
  • Playful
  • Guarded
  • Evasive
• Compulsions
  • Stereotyped action that the patient cannot resist performing repeatedly (usually follows an obsession)
• Disinhibition
  • Loss of control over normal social behavior
• Posturing
  • Maintenance of bizarre gait or limb position for no valid reason
• Distractibility
• Body language and Gestures

Psychomotor activity

• Psychomotor retardation
  • Reduced motor activity, usualy a combination of fewer and slower movement
  • Patient is aware of slowed thought
  • Common in depression, chronic schizophrenia with pronounced negative symptoms, intellectual disability disorders, hypothyroidism, and Parkinsonism.
• Psychomotor agitation
  • Agitation: restlessness and a measure of distress
    • Agitated depression: depression with signs of anxiety
    • Restlessness/over-activity takes the form of writhing while seated, highly distressed/tense facial expression, and classically, wringing of the hands.
    • These patients are unlikely to be threatening/intimidating toward others. They are, however, at risk of aggressive action directed toward the self (suicide).
  • Restlessness: inability to remain at rest/ still, AKA overactivity.
    • Marked by frequent, quick, large amplitude (often) movements of the hands, the demonstration of points with actions, standing to walk around, and unexpected leaving of the room (occasional). The voice may be loud and the speech rapid. The face is often smiling, and the behavior playful.
    • Common in ADHD, delirium, stimulant abuse, akathisia (Side effect of first generation antipsychotics)

Abnormal motor activities

• Mannerisms
  • Odd, idiosyncratic, and customary methods of performing a task (goal-oriented)
• Stereotypies
  • Intentional, repetitive, non-functional behavior (not goal-oriented)
  • Examples include: body-rocking or head-banging
  • Implicated in intellectual disability disorders.
• Tics
  • Sudden and non-rhythmic movements and/ or vocal productions
  • Involuntary but can be voluntarily suppressed
  • Implicated in: Tourette’s syndrome, obsessive compulsive disorder and attention deficit disorder. Rule out Huntington’s disease and Wilson’s disease
  • Transient tics may appear in healthy individuals at times of stress.
• Echopraxia
  • Involuntary repetition or imitation of another person’s actions
• Bradykinesia
  • Slow movement
• Hypokinesia
  • Decreased movement

Abnormal posture

• Mitmachen
  • A person’s body can be put into any position even if they have been instructed to resist movement
• Mitgehen
  • Extreme mitmachen (slight pressure exerted on the body will cause movement in any direction)

Amotivation

• Apathy
  • Lack of interest or enthusiasm or concern
• Abulia
  • Lack of will or initiative
• Akinetic Mutism
  • Patient neither moves nor speaks

Speech

• Spontaneous vs speech latency

Volume

• Loud
• Normal
• Soft
• Whispering
• Shouting

Rate

• Rapid
• Pressured
• Normal
• Slow
• Pressure of speech
  • Rapid, excessive continuous speech (due to pressure of thought) that is difficult to interpret/understand

Quantity of speech

• Talkative/loquacious
• Logorrheic
• Poverty of speech
• Mutism
• Garrulousness

Abnormal language

• Neologisms
• Dysphagia
• Clang association (clanging)

Tone and quality of speech

• Accent
• Emotionality
• Articulation and fluency
  • Incomprehensible
  • Stuttered lisping
  • Mumbled
  • Slurred
  • Clear
  • Stammering
  • Dysarthria
• Content:
  • Word salad: severely disorganized and virtually incomprehensible speech or writing, marked by severe loosening of associations strongly suggestive of schizophrenia. The person’s associations appear to have little or no logical connection.
  • Neologisms: An invented word, or a new meaning for an established word
  • Perseveration: the abnormal or inappropriate repetition of a sound, word, or phrase, as occurs in stuttering.
  • Echolalia: Senseless repetition of the interviewer’s words
  • Palilalia: a speech disorder or disturbance that involves the substitution of one speech sound for another (e.g., saying “wabbit” for rabbit or “lellow” for yellow).
  • Clang association: Thoughts connected by their similar sound rather than by meaning
  • Alexithymia: Patient is unable to describe their feelings

Mood and Affect

Mood is a pervasive and sustained emotion or feeling that influences a person’s behavior and colors his or her perception of the world. Usually described in the patient’s own words.

• Mood can be described as:
  • Euthymic
  • Depressed
  • Detached
  • Dysthymic
  • Dysphoric
  • Irritable
  • Expansive
  • Euphoric
  • Perplexed
  • Elated
  • Anxious
  • Labile

Affect is the pattern of observable behaviors that is the expression of a subjectively experienced feeling state (emotion) and is variable over time, in response to changing emotional states

• Quality
  • Irritable
  • Anxious
  • Sad
  • Euphoric
• Congruency
  • Mood congruent
  • Mood incongruent
• Range
  • Full
  • Flat
  • Blunted
  • Exaggerated
• Mobility
  • Fixed
  • Labile
  • Constricted
• Appropriateness
  • Appropriate
  • Inappropriate

Thought

Thought process

How the patient uses language and puts ideas together

• Circumstantiality
  • Indirect speech that delays reaching the point (patient gives too many trivial details) but eventually does
• Tangentiality
  • Going off on particularly relevant details and the point is never reached (patient gives ballpark responses)
• Thought block
  • Abrupt cessation of the patient’s train of thought before the thought or idea is reached

Thought form

Describes the way ideas are expressed by the patient

• Loosening of association
  • Patient jumps from topic to topic with no logical connection from one thought to another (vs flight of ideas which has some connection)
• Derailment
  • Marked impairment in maintaining a topic
• Flight of ideas
  • Thought changes rapidly from one idea to another (accompanied by pressured speech)
• Clang associations
  • Words are connected by phonetics **rather than actual meaning
• Perserveration
  • Persistent response to a previous stimulus even when a new stimulus is introduced
• Word salad
  • Incoherent collection of words
• Neologism
  • Patient uses common words in a new way

Contents

Describes the types of ideas expressed by the patient

• Delusions
  • Fixed false beliefs
  • Not shared by the patient’s culture
  • Not changed by reasoning
  • Can be bizarre (impossible) or non-bizarre (at least possible)
  • Can be mood congruent (MDD with Nihilistic delusions) or Mood incongruent (MDD with Grandiose delusions)
• Overvalued ideas
  • A strong persistent belief that is false or exaggerated
  • Neither delusional (not fixed, plausible)
  • Neither obsessive
  • Preoccupying to the extent of damaging pts life
• Obsessions
  • A repetitive, persistent, intrusive, and unpleasant thought or urge that causes severe distress and anxiety.
• Compulsions
  • Ritualistic, repetitive behaviors (e.g., touching, washing) or mental act (e.g., counting, repeating a word silently) carried out in an effort to relieve urges and decrease obsession-related distress.
• Ideas of reference
  • The belief that random events are uniquely related to the patient
• Suicidal/homicidal ideation
  • Does the patient have a plan?
  • Does the patient have intent?
  • Does the patient have a means?
• Phobias
  • Persistent irrational fears
• Poverty of thought
  • Too little ideas
• Overabundance of thought
  • Too many ideas

Perception

• Sensory distortions
  • A change in perception due to the change in stimulus intensity and quality or the spatial form

Sensory deceptions

• Hallucinations
  • Sensory perceptions in the absence of external stimulus
  • Auditory hallucination
    • Commanding
    • 2nd person (address/command)
    • 3rd person (discussing about the patient)
    • echo de la pensee (repeats the patient’s thoughts)
  • Syndromes
    • Alcoholic hallucinosis
    • Organic hallucinosis
  • Special hallucinations]
    • Functional hallucination
    • Reflex hallucination (a morbid form of synesthesia)
    • Extra-campine hallucination
    • Hypnopompic (upon waking)
    • Hypnogogic (before sleeping)
• Illusions
  • Inaccurate perception of existing sensory stimulus
• Depersonalization
  • Loss of identity and feelings of unreality and strangeness about one’s personality
• Derealization
  • Feelings of altered reality i.e. the surroundings seem unreal or unfamiliar

Sensorium and Cognition (MMSE)

• Consciousness
  • Glasgow Coma Scale (3-15)

Orientation

• To time
  • Year → Month → day → time
  • +/- 2 hours is acceptable
• To place
  • Continent → country → country → hospital → ward/floor
• To person
  • Can the patient identify health workers and ward mates?

Attention and Concentration

• Attention
  • Ability to initiate focus
  • Tested the same as registration (Give the patient 3 unrelated objects)
• Concentration
  • Ability to Sustain focus
    • Serial 7s
    • Serial 3s
    • WORLD spelt backwards
    • Months of the year backwards
    • Days of the week backwards
  • Fail if the patient takes too long to answer (> 3 seconds)

Memory

• Registration
  • Register 3 unrelated objects: example; tree, chair, goat
• Immediate recall
  • Repeat 3 unrelated objects
• Recent memory
  • 48 hours prior
• Recent-past memory
  • 3-6 months
• Long-term memory
  • 6 months
• Remote memory
  • Memories in the distant part (in the order of years to decades)
• Abstract thinking
  • Proverb: “Mtaka cha mvunguni sharti ainame”
  • Similarity and differences: “What is the similarity and difference between a watch and a ruler?”
  • Grouping of objects
• Fund of knowledge
  • Last 4 presidents,
  • Year of independence
• Judgement
  • Do not present a dilemma. Give the patient a hypothetical situation relevant to their illness

Insight

• Level I
  • Complete denial of illness
• Level II
  • Slight awareness of illness; denies needing help
• Level III
  • The patient has awareness of illness; but blames it on external or organic factors
• Level IV
  • Awareness of illness; but the cause is unknown to the patient
• Level V
  • Intellectual insight
  • The patient has awareness of their illness; knows the cause of the illness; knows what should be done; but does not take the necessary steps to achieve recovery
• Level VI
  • True emotional insight
  • Emotional awareness of the motives and feelings within themselves; important persons in their life leads to basic changes in behaviour

Case Formulation

• 6 Ps of case formulation
  • Patient details
  • Presenting problems
  • Precipitating factors
  • Predisposing factors
  • Perpetuating factors
  • Protective factors
• Patient details
  • Name
  • Age
  • Sex
  • Residence
  • Education
  • Marital Status
  • Occupation
  • SOR
  • MOA
• Presenting complaint
  • Aggression/ physical fights
  • Increased talkativeness
  • Talking to themselves
  • Features of psychosis (hallucinations)
  • Sleep disturbances
  • Substance abuse
• Precipitating factors
  • Drug/substance related
  • Psychosocial stressors
  • Loss of job
  • Loss of family member
  • Loss of spouse/partner
  • Medical illness
  • Rape
  • Abuse
• Predisposing factors
  • Biological
  • Genetics (Family history)
  • Medical condition (Traumatic brain injury, hyperlipidemia, hypothyroidism, pregnancy)
  • Psychosocial factors
  • Early parental loss
  • Parental divorce
  • Unstable family life
  • Childhood trauma (abuse, rape, neglect)
• Perpetuating factors
  • Biological
  • Psychosocial
  • Ongoing drug/substance abuse
  • Financial difficulties
  • Ongoing poor interpersonal relationships
  • Poor coping mechanisms
• Protective factors
  • Social support
  • Insight
  • Previous treatment response
  • Age at presentation
  • Absence of comorbidities
  • Good premorbid personality

Multi-Axial Diagnosis

• Axis I
  • Psychiatric Disorder, with at least 3 differentials
  • What diagnostic criteria does the patient meet?
  • Mention the source of criteria used eg. DSM V or ICD-11
• Axis II
  • Personality Disorder
• Axis III
  • General Medical Condition
• Axis IV
  • Psychosocial stressors
• Axis V
  • Global assessement of functioning

Investigations

• List them in terms of biological, psychological and social investigations, justifying the reason for each.

Treatment plan

• This should also be divided into biological, psychological and social interventions with reasons as to why it would be beneficial to your patient.

Prognosis

• List the patient’s good and poor prognostic factors, with a final comment on whether it is overall good or poor.