What is case history taking in psychology?
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Overview
The history and Mental Status Examination (MSE) are the most important diagnostic tools a psychiatrist has to obtain information to make an accurate diagnosis. Although these important tools have been standardized in their own right, they remain primarily subjective measures that begin the moment the patient enters the office.
Pinel stated "to seize the true character of mental derangement in a given case, and to pronounce an infallible progrosis of the event is often a task particular delicacy and requires the unied exertion of great discernment of extensive knowlegde and of incorrupible integrety." This exemplifies the importance of the mental status examination to the practice of psychiatry. The clinician must pay close attention to the patient's presentation, including personal appearance, social interaction with office staff and others in the waiting area, and whether the patient is accompanied by someone (ie, to help determine if the patient has social support). These first few observations can provide important information about the patient that may not otherwise be revealed through interviewing or one-on-one conversation. [1]
When patients enter the office, pay close attention to their personal grooming. One should always note things as obvious as hygiene, but, on a deeper level, also note things such as whether the patient is dressed appropriately according to the season. For example, note whether the patient has come to the clinic in the summer, with 3 layers of clothing and a jacket. These types of observations are important and may offer insight into the patient's illness. Other behaviors to note may include patients talking to themselves in the waiting area or perhaps pacing outside the office door. Record all observations.
The next step for the interviewer is to establish adequate rapport with the patient by introducing himself or herself. Speak directly to the patient during this introduction, and pay attention to whether the patient is maintaining eye contact. Mental notes such as these may aid in guiding the interview later. If patients appear uneasy as they enter the office, attempt to ease the situation by offering small talk or even a cup of water. Many people feel more at ease if they can have something in their hands. This reflects an image of genuine concern to patients and may make the interview process much more relaxing for them.
Legally, a mental status if conducted against the patient's will is considered assault with battery. Therefore, it is important to secure the patient's permission or to document that a mental status is being done without the patient's approval if in an emergency situation.
The time it takes to complete the initial interview may vary; however, with experience, interviewers develop their own comfortable pace and should not feel rushed to complete the interview in any time that is less than comfortable for either the interviewer or the patient. All patients require their own time during this initial interview and should never be made to feel they are being timed.
Beginning with open-ended questions is desirable in order to put the patient further at ease and to observe the patient's stream of thought (content) and thought process. Begin with questions such as "What brings you here today?" or "Tell me about yourself." These types of questions elicit responses that provide the basis of the interview. Keep in mind throughout the interview to look for nonverbal cues from patients. As they speak, for example, note if they are avoiding eye contact, acting nervous, playing with their hair, or tapping their foot repeatedly. In addition to the patient's responses to questions, all of these observations should be noted during the interview process.
As the interview progresses, more specific or close-ended questions can be asked in order to obtain specific information needed to complete the interview. For example, if the patient is reporting feelings of depression, but only states "I'm just depressed," determining both the duration and frequency of these depressive episodes is important. Ask leading questions such as "How long have you had these feelings?" or "When did these feelings begin?" and "How often do you feel this way?" or "How many days in the past week have you felt this way?" These types of questions help patients understand what information is needed from them. For safety reasons, both the patient and the interviewer should have access to the door in case of an emergency during the interview process.
Overview
The history and Mental Status Examination (MSE) are the most important diagnostic tools a psychiatrist has to obtain information to make an accurate diagnosis. Although these important tools have been standardized in their own right, they remain primarily subjective measures that begin the moment the patient enters the office.
Pinel stated "to seize the true character of mental derangement in a given case, and to pronounce an infallible progrosis of the event is often a task particular delicacy and requires the unied exertion of great discernment of extensive knowlegde and of incorrupible integrety." This exemplifies the importance of the mental status examination to the practice of psychiatry. The clinician must pay close attention to the patient's presentation, including personal appearance, social interaction with office staff and others in the waiting area, and whether the patient is accompanied by someone (ie, to help determine if the patient has social support). These first few observations can provide important information about the patient that may not otherwise be revealed through interviewing or one-on-one conversation. [1]
When patients enter the office, pay close attention to their personal grooming. One should always note things as obvious as hygiene, but, on a deeper level, also note things such as whether the patient is dressed appropriately according to the season. For example, note whether the patient has come to the clinic in the summer, with 3 layers of clothing and a jacket. These types of observations are important and may offer insight into the patient's illness. Other behaviors to note may include patients talking to themselves in the waiting area or perhaps pacing outside the office door. Record all observations.
The next step for the interviewer is to establish adequate rapport with the patient by introducing himself or herself. Speak directly to the patient during this introduction, and pay attention to whether the patient is maintaining eye contact. Mental notes such as these may aid in guiding the interview later. If patients appear uneasy as they enter the office, attempt to ease the situation by offering small talk or even a cup of water. Many people feel more at ease if they can have something in their hands. This reflects an image of genuine concern to patients and may make the interview process much more relaxing for them.
Legally, a mental status if conducted against the patient's will is considered assault with battery. Therefore, it is important to secure the patient's permission or to document that a mental status is being done without the patient's approval if in an emergency situation.
The time it takes to complete the initial interview may vary; however, with experience, interviewers develop their own comfortable pace and should not feel rushed to complete the interview in any time that is less than comfortable for either the interviewer or the patient. All patients require their own time during this initial interview and should never be made to feel they are being timed.
Beginning with open-ended questions is desirable in order to put the patient further at ease and to observe the patient's stream of thought (content) and thought process. Begin with questions such as "What brings you here today?" or "Tell me about yourself." These types of questions elicit responses that provide the basis of the interview. Keep in mind throughout the interview to look for nonverbal cues from patients. As they speak, for example, note if they are avoiding eye contact, acting nervous, playing with their hair, or tapping their foot repeatedly. In addition to the patient's responses to questions, all of these observations should be noted during the interview process.
As the interview progresses, more specific or close-ended questions can be asked in order to obtain specific information needed to complete the interview. For example, if the patient is reporting feelings of depression, but only states "I'm just depressed," determining both the duration and frequency of these depressive episodes is important. Ask leading questions such as "How long have you had these feelings?" or "When did these feelings begin?" and "How often do you feel this way?" or "How many days in the past week have you felt this way?" These types of questions help patients understand what information is needed from them. For safety reasons, both the patient and the interviewer should have access to the door in case of an emergency during the interview process.
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