Theory and Practice of Contemporary Psychotherapies

Psychiatric History Taking and the Mental Status Examination USMLE & COMLEX Video Transcript

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In this video, we're going to be taking a look at the psychiatric history and the mental status exam. I want to just take a step back, and we want to remember that whenever we're interviewing a patient, you want to consider the four aspects of the interview. Where S is subjective, O is objective, A is assessment, and P is plan. Now, when it comes to a psychiatry patient, subjective is obviously going to be the history. Now, objective, which is normally our physical exam, is actually going to be the mental status exam. The mental status exam is really the nuts and bolts of a psychiatric interview. And in this video, we're going to be going over both the history and the mental status exam.

Typically, when we think about a history, always have a chief complaint. You have a history of present illness. You have a past medical history. You ask also about a past surgical history. You ask about allergies. You ask about meds. You ask about a family history and a social history. Now, there's a couple small differences with a psychiatry patient. So not only do you want to ask about past medical history, but you also want to ask about past psychiatric history. When you're considering social history in a psychiatric patient, you also want to really make sure you ask about substance abuse. Now, you could probably be asking about substance abuse anyways, but it's something that's more emphasized in a psychiatry patient. Also, when you're thinking about the family history, you also want to ask about if the family has any psychiatric history as well.

Now, I would say the biggest difference is going to be the HPI. The way I like to think of it, an HPI can be divided for a psychiatric patient between symptoms and social. Now, of course, you always want to let the patient state in their own words what's going on because that's usually going to be the best information. So let this be kind of a guide to get more information from a patient.

Now, remember, we also do have a social history normally, so why are we asking it in the HPI? Well, instead of asking a lot of it in the social history, there is some of that information that can be gathered inside of the history of present illness if it's applicable or if it makes sense, it depends. So in this case, you want to think about the patient's support system. Do they have a family at home? Who do they live with? That kind of thing. You also want to really think about what kind of impact is this having on their work or family or social life. Usually, in order to make a diagnosis, you have to have some kind of impact in your life that's limiting you from doing things that you normally would do.

Another focus of the HPI can be the symptoms that the patient is experiencing. Things like quality of sleep, appetite, energy level, level of concentration. Kind of a good way to remember this, if you've heard of the pneumonic SIG-E-CAPS, kind of helps you remember the symptoms of depression. If you don't know this pneumonic, then just ignore this. But if you do, then it's kind of a good way to remember what symptoms you should be looking for overall with a psychiatric patient. Of course, you always want to ask about suicidal ideation or homicidal ideation. Another symptom that you want to ask about are any psychotic symptoms. For example, auditory or visual hallucinations.

Now that we've covered the subjective portion, we're going to be focused on the objective portion, and that's going to be the mental status exam. Now, when we're thinking about mental status exam, or basically the equivalent of a physical exam, there's a number of different areas that you want to focus on. First one is appearance and behavior. So first, you want to focus on their general appearance and any kind of distinguishing features. If there's anything that stands out, like let's say someone hasn't showered in several months and they smell, then that's something that you want to report and document because it's a significant finding. In order to break that down a little bit more, you can be focused on things like what they're wearing. If it's freezing outside but they're wearing shorts and a tee shirt, that's not an appropriately dressed patient. How's their hygiene? Are they well-groomed? You also want to pay attention to any kind of motor movements or motor ticks, for example. You can also observe their eye contact and whether or not they're cooperative.

Another part of the mental status exam is going to be speech. Some aspects of speech to focus on are going to be the rate of speech. Are they speaking really fast or speaking very slow? You can also comment on volume. Are they speaking really loud or not? Other things to comment on are how well they articulate. You can comment on how fluent they are, or the grammar. But overall, I would say the rate of their speech, and I guess maybe volume, I think these are really the big things in speech that I would be focused on.

Another part of the mental status exam is the patient's mood and affect. So, first of all, when we're talking about mood, we're asking the patient, in their own words, how they're feeling. As opposed to affect, which we're asking, how does the patient appear to be feeling? Another way to think of it is that mood is internal, so the patient's thoughts, versus affect, which is external. The first component of affect is the actual description of the affect itself. So they could be normal or euthymic. You could be irritable. If someone's irritable they would have an irritable affect, and that could be something that you document.

You also want to look at the intensity of the affect. Intensity is basically, how much emotion does the patient have the ability to show? Or, how much are they showing? A patient could have a flat affect, which they can't show or they're not showing any emotion at all. That would be something you would see in a patient with schizophrenia, for example. Or it could be described as blunted or constricted or full, basically average. So it gradually gets worse as you think of it from going from the bottom to the top in this chart.

Something to also be observing for is how appropriate their affect is. Is it appropriate for their thought content? If a patient is thinking something that's very upsetting, but is laughing while he has that kind of thought content, then that would be something to document. A lot of times we'll comment on whether the mood is congruent with the affect. For example, if the patient says they're feeling upset and they look like they're upset, then their mood would be congruent with their affect. Finally, you can also think about the mobility. Does their affect change? Or the level of change of their affect during the interview. If it's very, very different throughout the interview and it changes all the time, then they would have a labile affect.

Next we have thought process and thought content. This is basically, what is the patient thinking? And what is the association or what is their train of thought? What is their thought process? Things to look for or to ask in the patient would be something like hallucinations, delusions. These are examples of content. Flight of ideas, racing thoughts. Do they have loose associations? So someone could be thinking really quickly, has a lot of different ideas popping into their head, a lot of different thoughts that they're trying to communicate. They'd be having a flight of ideas, they'd be having racing thoughts. So, these are the kind of things that you want to look for. This category can also include other things like anything that stands out. For example, phobias, obsessions. So that's kind of a general overview of thought process and thought content.

Next category is called cognitive. Some things you want to focus on are orientation. So for orientation, you want to make sure the patient knows where they are and what time it is, or what month or what year. You also want to assess memory. For memory, you want to give the patient three words and have them repeat it to you right away, and then ask them to repeat those same words to you a few minutes later. That way you're assessing immediate memory and short-term memory. You also want to do a comprehensive assessment of language. So you can ask the patient to read something, to write something, to repeat something, or to point at something and name the object. So I can point at my watch and ask the patient, "What am I pointing at?"

Finally, we have the abstract and visual, spatial category. Do they have the ability to understand something that is typically abstract? If there's a proverb or a certain quotation that may need you to be a little bit more abstract than normal to understand, can they understand that? Visual, spatial can be assessed by having the patient repeat a symbol or a shape that you're drawing. So if I drew this symbol, could the patient repeat that drawing? That might be kind of hard, but you get the idea. If you've ever heard of the mini mental state exam, or the MMSE, it's kind of a short way to assess a patient's cognitive function. So it's kind of like a standard set of questions that you can ask to figure out a lot of this information that you generally look for under cognitive.

And finally, we have insight and judgment. Insight deals with whether or not the patient is aware of their own illness. You can describe it as no insight, someone has absolutely no idea, they could have partial insights, or they could have full insight, which is what you would consider as average. There's also judgment. Judgment is basically, does the patient understand the consequences of their actions? Whether the consequence is a good or a bad thing. Do they understand or are they able to judge what would happen if they took a certain action?

Let's do a quick recap. First we talked about how the history is part of the subjective part of the exam, and the mental status exam was part of the objective part of the exam. The history included all of these aspects. Some different things for a psychiatric patient were the HPI and a couple of other factors. HPI, a way that I think of it is between social and symptoms, and these are kind of things that can guide your history of present illness.

For the objective portion, we talked about all of these areas under the mental status exam, because that was the replacement for the physical exam in a psychiatric patient. We talked about appearance and behavior. Looking at dress, hygiene, if they're groomed or cooperative. We talked about speech. Mainly looking at rate and volume, but there are these other things. We talked about mood. What does the patient in their own words feel like? And we talk about affect. What do they look like they're feeling like? We talked about thought process and thought content. What's actually going on in their heads? What is the content and what is their train of thought? We talked about the cognitive exam. Orientation memory, language, abstract. You can assess it by the MMSE. And finally, we talked about insight and judgment.