learning Objectives - a) Psychiatry history taking b) Mental status examination c) Interview technique
Hours - 4
Teaching and Learning Activities - Lecture cum discussion Demonstration
Assessment Methods - Short answer Objective type Return Demonstration
Content of the chapter
a) Psychiatry history taking
b) Mental status examination
c) Interview technique
Mental health assessment is a structured process used to understand a patient’s psychological, emotional, behavioral, and social functioning. It forms the foundation for diagnosis, care planning, and evaluation in psychiatric nursing.
a) Psychiatric History Taking
Psychiatric history taking is the systematic collection of information about the patient’s mental illness, personality, and life situation.
Objectives
- Identify presenting problems
- Understand causes and precipitating factors
- Establish diagnosis
- Plan individualized care
Components of Psychiatric History
- Identification Data
- Name, age, sex, education, occupation
- Marital status, religion
- Informant and reliability
- Chief Complaints
- Presenting symptoms in patient’s own words
- Duration and severity
- History of Present Illness
- Onset, course, and progression
- Precipitating and relieving factors
- Associated symptoms
- Treatment taken so far
- Past Psychiatric History
- Previous mental illness
- Hospitalization
- Medications and response
- ECT or psychotherapy
- Past Medical and Surgical History
- Chronic illnesses
- Head injury
- Epilepsy
- Family History
- Mental illness in family
- Substance abuse
- Genogram if required
- Personal History
- Birth and childhood
- Education and occupation
- Sexual history
- Marital history
- Substance Use History
- Alcohol, tobacco, drugs
- Duration and amount
- Premorbid Personality
- Social relationships
- Work habits
- Emotional responses
- Coping skills
b) Mental Status Examination (MSE)
Mental Status Examination is a systematic observation and assessment of a patient’s current mental functioning at the time of interview.
Components of MSE
- General Appearance and Behavior
- Grooming, posture, eye contact
- Level of cooperation
- Psychomotor activity
- Speech
- Rate, volume, tone
- Coherence and relevance
- Mood and Affect
- Mood (subjective emotional state)
- Affect (objective expression)
- Thought
- Thought Process: Coherent, flight of ideas, circumstantiality
- Thought Content: Delusions, obsessions, suicidal ideas
- Perception
- Hallucinations (auditory, visual, etc.)
- Illusions
- Cognitive Functions
- Orientation (time, place, person)
- Attention and concentration
- Memory (immediate, recent, remote)
- Intelligence
- Insight
- Awareness of illness and need for treatment
- Judgment
- Social and test judgment
c) Interview Technique
Psychiatric interview is a therapeutic interaction aimed at gathering information while establishing a trusting relationship.
Principles of Psychiatric Interview
- Privacy and confidentiality
- Non-judgmental attitude
- Empathy and respect
- Clear communication
Types of Interview
- Initial interview
- Follow-up interview
- Crisis interview
Techniques Used in Psychiatric Interview
- Open-ended questions
- Encourage expression (e.g., “Tell me about your problem”)
- Active listening
- Full attention to verbal and non-verbal cues
- Clarification
- Making vague statements clear
- Reflection
- Repeating patient’s feelings
- Empathy
- Understanding emotions without judgment
- Silence
- Allows patient to think and express
- Summarization
- Organizing and validating information
- Confrontation
- Pointing out inconsistencies gently
- Validation
- Acknowledging patient’s feelings
Conclusion
Mental health assessment is a core skill in psychiatric nursing. Effective history taking, accurate mental status examination, and skilled interview techniques enable nurses to identify mental health problems early, ensure correct diagnosis, and provide holistic and patient-centered care.