1. Clincial Hx MSE Flashcards
Question Styles?
- Non-leading open questions. ‘Tell me about your sleep’?
- Non-leading closed questions. ‘ Do you have any problems with your appetite’?
- Leading Questions. ‘you’re eating less aren’t you?’
Name some facilitating Techniques?
- Silence, can be helpful if used judiciously
- Verbal facilitation
- Non-verbal facilitation:
Nodding, smiling, leaning forward etc.
Not too much eye-contact as this can be threatening.
Try to avoid giving cues of disapproval.
‘The interview will last 45 minutes’.
Informative
I know this is difficult for you to discuss’
Empathic (do not overuse)
‘So you started to feel depressed after your mother died’
Summarising
‘So you’ve told me that you’re feeling anxious’
Clarifying
‘You seemed uncomfortable when you were speaking about your father’.
Commenting re non-verbal communication
‘I’ve been upset myself when I’ve failed at things’
Self-relevant. (Careful!)
What should the interviewer control in an interview?
Rate, flow, direction.
How is control achieved?
Encouraging (examples, guesses, motives)
Discouraging (Interruptions, Not Now)
What are the stages of a patient psychological pt interview
Setting the scene. Introduction & orientation. Psychiatric History. Mental State Examination (MSE). Cognition (e.g. MMSE). Physical examination. Finishing the interview.
What is involved in setting the scene?
Environment.
Safety.
Reason for referral.
What is involved in the introduction and orientation?
Purpose. Time. Notes. Confidentiality. Ask if patient happy to proceed.
What should be elicited as part of the standard history?
Presentation (who, what, when, where why)
History Presenting complaints (+screen for other problems)
What should be elicited as part of the past psychiatric history?
Episodes of illnesses (Treated or untreated, By whom GP, psychiatrist, counsellor etc).
Past diagnoses & treatments (biological, psychological, social).
Number of in patient admissions, first and last.
Functioning between episodes?
What should be elicited as part of the past medical history?
Medications: (Psychiatric, Non psychiatric)
Allergies
Medical/Surgical illnesses & Treatments.
Surgery
What should be elicited as part of the family history?
Genogram useful
1st degree
What should be elicited as part of the personal history?
Childhood School Occupational History Sexual/Marital/Relationship Hx Social History Forensic History
What should be elicited as part of the pre-morbid personality assessment?
Attitudes to self. Attitudes to others in social, family, sexual relationships. Predominant mood. Leisure activities & interests. Religious beliefs Reaction pattern to stress.
What is an MSE?
Mental State Exam ‘Here & Now’ observation of patient. Avoid the term ‘normal’ where possible. Use the conventional headings. Concentrate on positive findings unless the absence of a specific symptom is relevant
What are the headings for the MSE?
Appearance & Behaviour. Speech. Mood. Thought. Perception. Cognition (MMSE). Insight.
What is meant by cognition?
Orientation
Attention
Concentration
Memory.
If >65yo or you suspect cognitive impairment then a more comprehensive assessment of cognition may be needed
What are the limitations of the Mini MSE?
Does not test long-term memory
Also insensitive to Frontal Lobe pathology.
What is meant by insight?
Not all or nothing.
Subjective
Questions:
Is the patient aware that anything is wrong?
If there is something wrong, does the patient think it is due to an illness or an external agency?
If an illness, is it physical or psychological/psychiatric?
If psychological, can it be helped?
Is the patient willing to accept help?
What is involved in the review of the psychiatric history?
Summarise the patient’s account of problems briefly and seek clarification if necessary
Ask a final question: ‘Is there anything else you wish to tell me’?
Explore any issues raised.
What is the purpose of the physical examination?
Full physical including neurological assessment.
Looking for physical manifestations of psychiatric disorder, physical causes of psychiatric disorder, evidence of DSH/ substance abuse/side effects of treatment.
How should Ddx be presented?
Present in order of decreasing probability.
Don’t be tempted to give diagnoses for which there is no evidence.
Use standard diagnostic terms only-ICD 10 or DSM V, not “depression” but “moderate depressive episode” for example
Don’t forget to outrule organic & substance abuse as causes of symptomatology.
What is the Multi-Axial (DSM-V) System?
Axis 1-Mental disorders, Axis 2-Personality disorders, Axis 3-Physical illness, Axis 4-Psychosocial stressors, Axis 5-Level of functioning (GAF scale).
What should be considered as part of the risk assessment?
Especially if DSH is the presenting event.
Also consider if need to assess risk of violence
What are Predisposing Factors?
WHAT MAKES IT MORE LIKELY TO OCCUR?
Family hx mental disorder Birth complications Childhood adversity Social circumstances Past psychiatric illnesses etc.
What are precipitating factors?
WHAT MAKE IT COME ABOUT?
Recent life events Physical illness Medication with psychiatric adverse effects Alcohol & substance misuse Non-compliance with treatment etc.
What are perpetuating factors?
WHAT MAKE IT CONTINUE?
Poor insight
Lack of compliance
Ongoing social adversity/relationship problems etc.
What investigations should be performed?
History: (Patient+Collateral (family, GP, etc)).
MSE
Relevant blood tests
Urine drug screen if appropriate,
Alcometer if appropriate
Other: ECG, CXR, EEG, CT/MRI etc.
Psychological assessment: (Cognitive,Personality)
What form should Tx take?
Bio-Psycho-Social:
Biological (Medication+Physical: E.g. ECT)
Treat co-morbid disorders & substance abuse.
Some examples of PSYCH Tx?
PSYCHOLOGICAL
Psychoeducation Supportive Compliance monitoring Psychodynamic psychotherapy CBT (Cognitive Behavioural Therapy) IPT (Interpersonal Therapy) DBT (Dialectical Behavioural Therapy) Family Therapy Anxiety Management & Relaxation training, Marital/Couples counselling
Some examples of SOCIAL Tx?
Address family issues Education Support Accommodation, Social Welfare supports, Day Centre Social/support groups, Occupational support e.g. retraining ‘Fresh Start’ etc.
