This document outlines the key components of conducting a psychiatric interview, including history taking, mental state examination, and communication skills. It describes the structure of a psychiatric interview, including gathering demographic details, chief complaints, history of presenting illness, past medical/psychiatric history, and family history. It also details the process of a mental state examination and assessing appearance, behavior, mood, thought processes, cognition, insight and other areas. The goal is to describe the proper techniques for interviewing psychiatric patients and evaluating their mental condition.

1. DEPARTMENT OF PSYCHIATRY, UKMMC
History Taking,
MSE,
Communication
Skills
Dr Nuur Asyikin Mohd Shukor
Dr Tuti Iryani Mohd Daud
Creative Commons License
History taking, MSE and communication skills by Dr Nuur Asyikin Mohd Shukor & Dr Tuti Mohd Daud is licensed under a Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

2. At the end of
this session,
learners
will be able
to:
Describe the structure
of psychiatric history
and mental state
examination.
Demonstrate
therapeutic
communication skills in
conducting a
psychiatric interview.
Demonstrate gathering
information skills in
conducting a psychiatric
interview (including
eliciting sensitive
personal information).
Demonstrate the
cultural and ethical
sensitivity in
conducting a
psychiatric interview.
Conduct a proper
mental state
examination.
Elicit basic
psychopathology.

5. What is Psychiatric Interview?
Components in Psychiatric Interview
Mental State Examination
Outline
Process

9. What is a Psychiatric
Interview?
Elicit narrative while
guiding the
interview with
diagnostic reasoning
Facilitate with
compassionate
listening and
reflectionNature of the
psychiatric interview is
getting the patient’s
narrative
Purpose
Use mixtures of
open-ended and
close-ended

10. Components in a
Psychiatric
Interview

11. Components in a
Psychiatric Interview
History of Presenting
Illness (HOPI)
Demographic details
Past Psychiatric History
Chief complaints
Past Medical/Surgical
History
Family History
Personal History Premorbid Personality

12. Demographic
Details
WHAT TO ASK?
Important details that adds value in management
Name, age, status (e.g.: single/married), race,
employment

13. Chief
Complaint
WHAT IS THE MAIN REASON TO SEEK
TREATMENT?

14. History of
Presenting Illness
Comprehensive and events in chronological order
Major symptoms
Differences between baseline level of
functioning and now
Predisposing / precipitating factors
Description of symptoms in detail
(psychopathology)
Need to understand whether substance
contributes to current illness
Relationship with significant physical symptoms
and illness
Important to get corroborative history
whenever possible

15. Previous episode of the problem(s)
Symptoms, course, duration and
treatment
inpatient/outpatient
psychopharmocology/
psychotherapy
Psychiatric diagnosis
Suicidal attempt(s): Details
Self—harm behavior
ECT
Past Psychiatric
History

16. Past Medical/
Surgical History
Medical: past and current
Surgical: past and current
Accidents: Include TBI
Other treatments: Complimentary treatment
Allergies
Current medications: prescribed and OTC with dosages

17. Family tree
Family relationship
Family psychiatric history
Family medical history
Family History

18. Personal
History
PRENATAL/PERINATAL EVENTS
DEVELOPMENTAL HISTORY
Adverse life events/childhood trauma
Neurotic symptoms
CHILDHOOD HISTORY
Academic achievement
Behavioural problems
Social interaction
SCHOOL HISTORY

19. WORK HISTORY
Nature/type
Salary
Reason for changing jobs
SEXUAL HISTORY
Heterosexual/homosexual
relationships
Masturbation
Sexual practices
Contraception/safe sex
Promiscuity

20. MARITAL HISTORY
Age at marriage & spouse age
Love/arranged marriage
Any sexual problems
Spouse
Children
SUBSTANCE HISTORY
Drugs: Frequency/dependency
Alcohol: Frequency/dependency
Rehab
Sobriety

21. Premorbid
Personality
Personality trait or particular
personality types
Description of the characteristics

23. Mental State Examination
General Appearance
Grooming, posture, abnormal
movements, mannerism, tattoos,
scars
Behaviour
Normal, fidgety, restless,
hyperactive, hypoactive, tense,
agitated
Attitude
Cooperative, uncooperative, hostile,
indifferent, polite

24. Mental State Examination
Eye Contact
Normal, limited, poor, looking
away, looking down
Speech
Rate: Mute/talkative/pressure
or poverty of speech
Volume: Loud/low tone
Coherence
Relevance
Mood
What the patient reports
Normal, anxious, depressed,
sad, irritable, numb

25. Mental State Examination
Affect
What the psychiatrist observe
Depressed, irritable, labile
Thought Disorder
Form
Content
Perceptual Disorders
Hallucinations
Illusions

26. Mental State Examination
Cognitive Function
Memory:
Immediate (Immediate
recall)
Recent (5 min recall)
Remote
Orientation
Concentration and attention:
Serial seven
General
knowledge/intelligence
Judgment
Abstract thinking
Insight
3 components
Awareness of symptoms
Attributes symptoms to
illness
Recognize need for
treatment
Graded as good, partial, and
no insight

27. The process:
Calgary and Cambridge Model

28. Reference: Kurtz SM, Silverman JD, Benson J and Draper J (2003)
Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Medicine

30. Reference:
Kurtz SM, Silverman JD,
Benson J and Draper J (2003)
Marrying Content and
Process in Clinical Method
Teaching: Enhancing the
Calgary-Cambridge Guides.
Academic Medicine

31. Reference:
Kurtz SM, Silverman JD,
Benson J and Draper J (2003)
Marrying Content and
Process in Clinical Method
Teaching: Enhancing the
Calgary-Cambridge Guides.
Academic Medicine

32. Reference:
Kurtz SM, Silverman JD,
Benson J and Draper J (2003)
Marrying Content and
Process in Clinical Method
Teaching: Enhancing the
Calgary-Cambridge Guides.
Academic Medicine

33. Reference:
Kurtz SM, Silverman JD,
Benson J and Draper J (2003)
Marrying Content and
Process in Clinical Method
Teaching: Enhancing the
Calgary-Cambridge Guides.
Academic Medicine

34. Peer Role-Play

35. Doctor Patient Observer

37. Role Play Instructions
HERE ARE SOME THINGS YOU NEED TO KNOW ABOUT DOING A ROLE PLAY:
1. Pay attention to the instructions- you are playing a part. Concentrate on that part and
watch for details. The instructions have specific goals that will be apparent later.
2. Try to stay in the role and proceed; try to think like the person described in the part.
3. Do not take anything personally. The purpose is to learn education techniques from
recreating some of our common situations and their problems and by working with them.
4. When giving feedback, be positive:
a. Describe helpful behaviors you saw
b. Do not criticize
c. Make constructive suggestions