TRIPASS XR تري باس

 

 Is it a quick screening of a patient presenting

with other problems, a confirmation of a suspected diagnosis

or a comprehensive review for a second opinion?

The history

General approach

The distinction between symptoms and signs is less clear in

psychiatry than in the rest of medicine. The psychiatric interview,

which covers both, has several purposes: to obtain a history of

symptoms, to assess the present mental state for signs, and to

establish rapport that will facilitate further management.

A comprehensive history covers a range of areas (Box 16.1), but

the nature of the presenting problem and/or the referral question,

and the setting in which the history is being taken, will determine

the degree of detail needed for each. When seeing someone in

the accident and emergency department with a first episode of

psychosis, the focus is on symptoms, recent changes of function,

family history and drug use; when interviewing someone in an

outpatient clinic with a possible personality disorder, assessment

concentrates instead on their personal history, which is essentially

a systematised biography (Box 16.2).

Sensitive topics

Some subjects require particular skill. The common theme is

reluctance to disclose, which can arise because the information

is private, and disclosure is potentially embarrassing (such as

sexual dysfunction, gender identity), distressing (major traumatic

experiences, such as rape, childhood sexual abuse, witnessing a

16.1 Content of a psychiatric history

• Referral source

• Reason for referral

• History of presenting symptom(s)

• Systematic enquiry into other relevant problems and symptoms

• Past medical/psychiatric history

• Prescribed and non-prescribed medication

• Substance use: illegal drugs, alcohol, tobacco, caffeine

• Family history (including psychiatric disorders)

• Personal history

16.2 Personal history

• Childhood development

• Losses and experiences

• Education

• Occupation(s)

• Financial circumstances

• Relationships

• Partner(s) and children

• Housing

• Leisure activities

• Hobbies and interests

• Forensic history

The mental state examination • 321

16

any aspect of life, and at interview appear downcast, withdrawn

and tearful, with little brightening even when talking about their

much-loved children.

Pervasive disturbance of mood is the most important

feature of depression, mania and anxiety, but mood changes

commonly occur in other mental disorders such as schizophrenia

and dementia. You might ask patients ‘How has your mood

been lately?’, ‘Have you noticed any change in your emotions

recently?’ and ‘Do you still enjoy things that normally give you

pleasure?’ Abnormalities of mood include a problematic pervasive

mood, an abnormal range of affect, abnormal reactivity and

inappropriateness or incongruity. Some terms relating to mood

are defined in Box 16.5.

Some patients prompt affective responses in the interviewer,

via the process of countertransference. The elated gaiety of some

hypomanic patients can be infectious, as can the hopeless gloom

of some people with depression. Recognising these responses in

yourself can be helpful in understanding how the patient relates

to others and vice versa.

Thought form

As with speech, this is a not an assessment of what the patient

is thinking about, but how they think about it. Assess it by

observing how thoughts appear to be linked together, and the

speed and directness with which the train of thought moves,

considering rate, flow, sequencing and abstraction. Some terms

relating to thought form are defined in Box 16.6.

Thinking may appear speeded up, as in hypomania, or

slowed down, as in profound depression. The flow of subjects

• over-activity (agitation, pacing, compulsive hand washing)

• under-activity (stupor, motor retardation)

• abnormal activity (posturing, involuntary movements,

Box 16.3).

Speech

This is not a description of what the patient says (that is, content),

but of how they say it (form). Assess:

• articulation (such as stammering, dysarthria)

• quantity (mutism, garrulousness)

• rate (pressured, slowed)

• volume (whispering, shouting)

• tone and quality (accent, emotionality)

• fluency (staccato, monotonous)

• abnormal language (neologisms, dysphasia, clanging,

Box 16.4).

Mood

Mood is the patient’s pervasive emotional state, while affect is the

observable expression of their emotions, which is more variable

over time. Think of mood as the emotional climate and affect

as the weather. Both have elements of subjective experience

(that is, how the patient feels, according to their own report and

your specific questions) and how the patient appears to feel,

according to your own objective observation. So a depressed

patient might describe feeling sad, hopeless and unable to enjoy

16.3 Behaviour: definitions

Term Definition

Agitation A combination of psychic anxiety and excessive,

purposeless motor activity

Compulsion A stereotyped action that the patient cannot

resist performing repeatedly

Disinhibition Loss of control over normal social behaviour

Motor retardation Decreased motor activity, usually a combination

of fewer and slower movements

Posturing The maintenance of bizarre gait or limb positions

for no valid reason

16.4 Speech: definitions

Term Definition

Clang associations Thoughts connected by their similar sound

rather than by meaning

Echolalia Senseless repetition of the interviewer’s words

Mutism Absence of speech without impaired

consciousness

Neologism An invented word, or a new meaning for an

established word

Pressure of speech Rapid, excessive, continuous speech (due to

pressure of thought)

Word salad A meaningless string of words, often with loss

of grammatical construction

16.5 Mood: definitions

Term Definition

Blunting Loss of normal emotional sensitivity to experiences

Catastrophic

reaction

An extreme emotional and behavioural over-reaction

to a trivial stimulus

Flattening Loss of the range of normal emotional responses

Incongruity A mismatch between the emotional expression and

the associated thought

Lability Superficial, rapidly changing and poorly controlled

emotions

16.6 Thought form: definitions

Term Definition

Circumstantiality Trivia and digressions impairing the flow but

not direction of thought

Concrete thinking Inability to think abstractly

Flights of ideas Rapid shifts from one idea to another,

retaining sequencing

Loosening of

associations

Logical sequence of ideas impaired. Subtypes

include knight’s-move thinking, derailment,

thought blocking and, in its extreme form,