Assessment in Psychiatry Flashcards
What can be asked in history of presenting complaint of psychiatric symptoms?
Onset Severity Duration Aggravating and relieving factors Associated symptoms
What are important components of the psychiatric history?
Introduce self Identifying information Reason for referral Presenting complaint ICE Past psychiatric history PMH DH FH Social/personal history Premorbid personality
What is it important to consider before taking a psychiatric history?
4S’s
Site - comfortable and sound proof
Safety - sit close to door, chaperone, panic buttons and alarms
Setting - arrange chairs at 90 degrees, relaxed position, no interruptions
Study - read referrals, previous notes, take collateral history
What questions can be asked when enquiring about low mood?
How are you feeling
Can you tell me more about…
How long have you felt like this When did you last feel your normal self Anything worrying/troubling Do you feel you enjoy things How do you see the future Have you ever felt like this before Has anyone else commented
What questions can be asked when enquiring about risk?
Do you feel life is worth living
Has it ever gotten so bad you have thought about harming yourself/ending your life
What stops you from doing so
What can be asked about delusions in psychosis?
Open questions -
anything particular on your mind, anything out of the orindary going on, worried
Facilitating - tell me more
Clarifying - that must be frightening, how do you know this is happening
When did you first notice it, could there be any other explanation
Risks - have you ever taken any steps to protect yourself from e.g. these people
What can be asked about hallucinations in psychosis?
Ever heard things you cannot explain, hear voices, describe these voices, where do they come from inside or outside
Risk - do they ever tell you to do things, are you able to resist them
What are the aspects of the mental state examination?
Appearance and behaviour: describe the patient, eye contact, level of rapport, agitation, distracted
Speech: rate, rhythm, volume, tone, any evidence of formal thought disorder e.g. word salad, flight of ideas
Mood: subjective; how do they describe it, use of a mood scale or objective; blunted, flat, inappropriate, labile (shifts in emotional state)
Thought: form; delusion, over-valued idea, obsessive, phobia
Content; what the thought relates to - e.g. spouse cheating is obsessive or paranoid
Perception: illusion e.g. curtains are an intruder, hallucinations, depersonalisation, derealisation
Cognition - orientation to time, place, person.
Insight - understanding of their experience, do they believe they are unwell, do they believe they have a mental disorder, attitude to treatment
Risk - not part of MSE but key; risk to self e.g. self harm, suicide, self-neglect, risk to health and others.
What should be asked when enquiring about previous psychiatric history?
Similar problems to presenting complaint in the past
Ongoing psychiatric diagnoses
Dates and duration of previous episodes
Whether or not mental health act was implemented
Details of previous hospitalisation, treatment including medication, psychotherapy or ECT
Response to treatment and side effects
What should be enquired about in personal history?
Identifies predisposing factors to patient’s psychiatric illness
Early childhood:
pregnancy problems, walk and talk at right age, illness as child, were you planned, were parents married, any siblings or step-siblings, earliest memories, any abuse
Education: mainstream or specialist school did you enjoy school ever bullied at school anyone ever said you had any issues at school did you finish school higher education?
Employment: chronological order of jobs duration of work - how long in each job Why did you move on from a particular job Working environment like
Relationships:
Sexual orientation
Chronological account of major relationships
Current relationship
Any children from current or prev relationships, who do children live with, describe relationship with children
Forensic history:
charge or convicted of any offences
What sentence did you receive if convicted
Any outstanding charges or convictions
In women - ask about menstrual patterns, previous miscarriages, stillbirths or terminations
What is the mnemonic for the components of the mental state examination?
ASEPTIC
Appearance and behaviour Speech Emotion - mood Perception Thoughts Insight Cognition
How can delusions be classified?
Cause - primary unconnected to previous ideas or events, secondary arise from and are understandable in context
Mood - mood congruent vs mood incongruent - inappropriate to patient’s mood
Plausability - bizarre (impossible, not in keeping with reality) vs non-bizarre
Content - grandiose, persecutory, reference (random events special significance) guilt, hypochondrial, morbid jealousy, erotomania, infestation
What is a delusional memory/rare primary delusion?
Where a delusional belief is based upon the recall of memory or false memory for a past experience
e.g. saw a woman giggling at them in a restaurant a few weeks ago, now has realised that this person knew he was infested by small organisms
What are Schneider’s first rank symptoms?
Delusional perception - patient attributes false meaning e.g. sun beaming down means chosen by God
Third person auditory hallucinations
Thought interference:
Insertion - been put there
Withdrawal - taken away
Broadcast - being heard out loud
Passivity phenomenon - mood or actions being controlled by someone or something else
What are examples of risk to self?
Suicide
Para-suicide
Deliberate self harm
