general Flashcards
what things help to build a rapport when taking a psych history
eye contact
relaxed, non- threatening posture
appear unhurried
what is important about the safety of the interviewer in a psych history
easy exit - be near door
tell someone where you are
what are benefits of open questions
o Allows patients to start talking about themselves and puts them at ease as they have the floor
o Allows you time to think and plan areas of questioning as you assess their style and content of their response
o Allows a period of non-verbal response from interviewer; listening and facilitating.
what would you want to know about the circumstances of a psychiatry referral
who by
why
informal (voluntary) or not
what format should you record a persons presenting complaint
in their own words
what information do you want to obtain in the psychiatry history of presenting complaint
Onset, precipitants, course, severity
Associated symptoms, effects on daily living, effect on family/ relationships
Is it getting worse or better?
Has it responded to any treatment?
what questions may you ask about symptoms of depression
Are you low/ depressed? Is life worth living? Can anything give you pleasure? Energy levels? Sleep /appetite? Can you concentrate? Are ypu feeling guilty? Is your confidence low? Have you lost your libido? Are you preoccupied with guilt, regret/ hopelessness? Suicidal thought?
what questions may you ask about symptoms of mania
Have you felt more energy than normal (despite not sleeping)?
Can you focus on things?
Are you having difficulty settling?
Are you spending more than usual?
Are you interested in sex with different/ inappropriate people?
what questions may you ask about symptoms of psychosis
Has anything odd or unusual been happening recently?
If they have odd ideas ask how did these occur?
What actions do you feel the need to take?
Might your thoughts be being interfered with?
Do you feel anyone is controlling you?
Is anyone putting thoughts in your head?
do other people access or hear your thoughts?
Is anyone harming you?
Any plots against you?
Do you hear voices when thers no one nearby?
What do they say?
Do you see things other can’t?
what questions may you ask about symptoms of dug and alcohol abuse
What do you take? How much, how often and for how long? How much do you spend on all of this? Is it impacting you the next day? Has your use recently changed? Withdrawal signs?
what questions may you ask about symptoms of OCD
Any odd thoughts? Recurring, intrusive worries? Note any compulsive behavior
what questions may you ask about symptoms of anxiety
Any worries? Are you always worried or does it happen in discrete episodes (attacks)? What causes this? What physical symptoms do you get? How do you manage your anxiety?
what questions may you ask about history of eating disorders
What are you currently eating? How do you feel about your weight? Are you dieting?
what questions may you ask about suicide risk
Have you ever felt so low that you have considered harming yourself?
Have you ever actually harmed yourself?
What stopped you harming yourself more than this?
Have you made any detailed suicide plans?
Are you wanting to harm anyone?
Have you stopped looking after yourself (dressing, washing, eating, drinking)?
what do you want to know about someone’s past psychiatric history
Past episodes/ diagnoses / contacts
Previous treatments (psychological, drug and physical)
Inter-episode functioning
Previous admissions to hospital
Attempted suicide/ repeated DSH
Previous detentions under Mental Health Legislation
what things may be relevant to psychiatry about someone s past medical history
Developmental problems
Head injuries
Endocrine abnormalities – thyroid can mimic psych
Liver damage, oesophageal varices, peptic ulcers – alcohol intake
Vascular risks factors – memory problems, amnesia
what would you ask in a persons drug history
about tablets, injections medication recently – if they are taking them or not
Any drugs discontinued (within past 6 months)
how long medication has been taken for and at what dose
Ask about adverse reactions and allergies
what social history is relevant in a psychiatric history
Social circumstances including occupation Current financial situation/stressors smoking/ alcohol/ illicit drug use Screening questionnaires eg CAGE Current relationship/stressors Children – contact, relationship
what things are asked in the personal psychiatric history
Developmental milestones - Schooling/Education
Occupational history
Significant relationships – sexual and marital history
Financial
Friendships, hobbies and interests
Pre-morbid Personality-
what should be included in the forensic history
“Have you ever been in contact with the police? Charged with any crime?”
Offences including sentences
Recidivism
Particular attention to violent or sexual crimes
what is a good way to find someone’s pre-morbid personality
How would your best friend describe you as a person?
what things would you comment about appearance in the mental state examination
o Height/Build – literally what they look like, way to remember them
o Clothing - appropriate/inappropriate to occasion/ weather, bizarre
o Personal hygiene - clean/unshaven/malodorous
o Make up, jewellery, accessories
what things would you comment about behaviour in the mental state examination
o Greeting – shaking hand, hug etc. Idea of disinhibited/ wary
o Gesturing - normal, expansive, bizarre
o Eye contact
o Abnormal movements - tremor, choreioathetoid movements, posturing, akathisia
o Build a rapport / be Cooperative
what are some clinical signs of odd behaviour that may be picked up on MSE
- Responding to unseen stimuli (what you can’t see but real to the person)
- Evidence of side effects of medication – orofasial dyskinesia, rotunded
- Evidence of intoxication – can present as unwell
- Movement disorder etc catatonia, forced grasping, waxy flexibility, opposition
what is the difference between mood and affect
mood - patient’s subjective report on their current mood state
affect - objective manifestation of mood at interview (emotions conveyed)
what things would you comment on someones speech in the mental state examination
Content of speech (what the patient says) and form of speech (how they say it)
Spontaneity – offer information voluntarily
Volume - loud, quiet, poverty
Rate - pressured, slowed
Rhythm - rhyming and punning
Tone - monotonous, lilting
Dysarthria/ Dysphasia - expressive/receptive
if someone speaks about a mood disturbance, what should you probe them for
severity, duration, and ubiquity and any other associating features.
what 3 questions would you ask to check if someone has insight into their condition
Are symptoms due to illness?
Is this a mental illness?
Do they agree with treatment/ management plan?
what would you assess someones cognition in a mental state examination
Orientation - time, place, person
Attention/concentration - throughout interview,
standard test is reversed months DNOSAJJMAMFJ
Short term memory - 3 objects; name & address
Long term memory - personal history
If any concerns - perform objective tests eg MSQ, MMSE, MOCA, FAS, Clock drawing, executive function tests
what is the difference between pseudo and true hallucinations
pseudo - inside head
true - absence of stimuli
what is the difference between an illusion and a hallucination
illusions- misinterpret a stimulus
hallucination - true perception located in external space with no external stimulus
what different domains can a hallucination hold
auditory visual somatic/tactile - touch olfactory - smelll gustatory - taste
give some questions to ask about hallucinations
Have you seen or heard anything that other people have not been aware of?”
“Have you heard any people talking when there was nobody around?”
“What do they think is causing them?”
Does it seem possible?
“Has anything particular been playing on your mind?”
“Do you know why is this happening?”
“Have you noticed any change in your thoughts?”
“Has anyone interfered with your thoughts?”
“Does anyone else have access to your thoughts/ read your mind?”
“Is anyone deliberately trying to harm you, e.g. trying to poison you or kill you?”
how would you differentiate between a partial and full hallucination
Even when you seem to be most convinced, do you really feel in the back of your mind that it might not be true, it might be your imagination?
what 4 thins would you consider about someone’s thoughts
Speed and tempo of thoughts (slow)
Types of thoughts demonstrated (negative)
Linkage and thought form
Possession of thoughts (schizophrenia) – blocking/ insertion/ boradcasting
what is a formal thought disorder
A pattern of interruption or disorganisation of thought process
- broadcast, echo, insertion, thought block, withdrawal
what is a delusional belief
fixed, false belief out of normal cultural context, extraordinary conviction
“ a delusion is an unshakeable idea or belief which is out of keeping with the person’s social and normal cultural background; it is held with extraordinary conviction.”
what things should you think about someone having in their thoughts
Phobias/ Obsessions / Flight of ideas/ Preoccupations/ Over valued ideas
what is the prevalence of mental health disorders
15%
what is the commonest cause of death in men under 35
suicide
what is meant by formulation of the case
Organic, social and psychological factors are assessed as either predisposing, precipitating or perpetuating factors.
what is phenomenology
refers to the observation and understanding of the psychological event or phenomenon so that the observer can as far as possible know what the patient’s experience feels like.
what are delusions
beliefs held unshakably, irrespective of counter argument, that are unexpected and out of keeping with the patients cultural background.
what is a nillhistic delusion
thinking you are rotting/ dying
what is a grandiose delusion
thinking you are bigger and more important
what kind of delusion are seen in schrizophrenia
Persecution delusion (theme of being followed, spied on, and conspired against with a belief that the persecutors intend to cause harms)
what is othello syndrome
firm belief that a sexual partner is unfaithful made without proof
(jealous delusion)
what are ideas of reference
Coincidental or innocuous events which are interpreted to have great personal significance. Associated with social phobia, psychosis and stress.
how are ideas of reference different form overvalued ideas
over valued ideas are understandable and reasonable beliefs which dominate a patient’s life to detriment of functioning.
what is the main characteristic of hallucinations
they are felt to occur in the external world along other objects, with the same quality as everything else, and can’t be consciously manipulated or stopped. They are real to the person experiencing them.
what diseases are visual hallucinations more common in
eye pathology, delirium, epilepsy , alcohol withdrawal
what are hypnagogic and hypnopompic hallucinations
Hypnagogic (going to sleep)
hypnopompic (waking up) auditory hallucinations are pseudohallucinations as the person knows it is in their mind.
what is the management of Patients with medically unexplained physical symptoms
focus groups, physiotherapists, occupational therapists
what % of hospital admission are directly related to ill effects of alcohol use
~ 20% of admissions
what will All patients admitted with self-harm will routinely receive
a psycho-social (psychiatric) assessment – check suicidal ideation
what is the biggest drug taken in overdose
paracetemol
what diseases is depression more common in
chronic illness, e.g. chronic renal failure, diabetes, rheumatoid arthritis
certain neurological diseases, e.g. MS, Parkinson’s disease, stroke
how may mental health disorders disguise themselves as physical disorders
pain, tiredness, lack of energy
reaction - anxious/ stress about physical condition
what are Somatoform/ functional disorders
symptoms with no physical explanation
why were mental health laws created
give the power to provide compulsory care and treatment for people with a mental disorder
what are the principles of the Mental Health (care and treatment) (Scotland) Act 2003
Non-discrimination Participation
Equality Respect for carers
Respect for diversity Least restrictive alternatice
Reciprocity (do to other what you would want)
Benefit (maximum)
Informal care Child welfare
what does the Mental Health (care and treatment) (Scotland) Act 2003 define a mental disorder as
any mental illness, personality disorder or learning disability
however caused or manifested.
(not alchohol/ drugs/ sexual )
how long is detention authorised in the Emergency detention certificate EDC (Mental Health (care and treatment) (Scotland) Act 2003)
up to 72 hours
how long is detention authorised in the Short-term detention certificate STDC (Mental Health (care and treatment) (Scotland) Act 2003)
up to 28 days
how long is detention authorised in the Compulsory Treatment Order CTO (Mental Health (care and treatment) (Scotland) Act 2003)
up to six months
how long is detention authorised by nurses power (Mental Health (care and treatment) (Scotland) Act 2003)
up to 3 hours for a medical assessment
what are the 5 criteria for detention in the Mental Health (care and treatment) (Scotland) Act 2003
- have a mental disorder
- impairment of decision making
- risk to health of them or another
- treatment available
- must be necessary
what is the criteria to be a named person under the Mental Health (care and treatment) (Scotland) Act 2003
must be nominated by the patient and witnessed and the named person must have witnessed acceptance
who can sign an Emergency detention certificate
registered medical practitioner
NOT FY1
can the emergency detention certificate be appealed
no - not enough time for a solicitor
who can sign a short term detention certificate
Approved Medical Practitioner – psychiatrist or working in psychology 4 years
how is a compulsory treatment order section arranged
Application to Mental Health Tribunal made by Mental Health Officer for the granting of a CTO
Tribunal considers evidence and makes decision
what does the Adults with Incapacity (Scotland) Act 2000
define an adult as
a person who has attained the age of 16 years
what does the Adults with Incapacity (Scotland) Act 2000 define incapable as
a) Acting
b) Making decisions
c) communicating decisions
d) understanding decisions
e) retaining the memory of decisions
what principles must be considered when applying the adults with incapacity act
- must benefit the adult
- least restrictive intervention possible
- take into account past and present wishes of adult
- take account of relative/ relevant other
does every old person have capacity
until proven otherwise
what is a guardianship order
Someone else is appointed to make decisions on behalf of the adult (financial or welfare or both)
what do you do if you need to treat someone that doesn’t have capacity but there is no welfare attorney/ guardianship
section 47 certificate - adult with incapacity act 2000
what is not allowed under the adults with incapacity act
- use of force/ detention
- action not consistent with competent court
- hospitalise against will
give 5 subsections of the Criminal justice and licensing (scotland) act 2010
- 51A - Criminal responsibility
- Unfitness for trial
- . 51B - Diminished responsibility
- restricted patients
- restricted pateitns
what things must the court be satisfied before a person is restricted
¥ Mental disorder ¥ Detention in hospital is necessary ¥ Civil risk criterion met ¥ Treatment ¥ Suitable bed available within 7 days ¥ Assessment could not be undertaken if not in hospital
what illnesses are higher in prison than the community
Psychotic illness, major depression, alcohol misuse and drug misuses
when is a patrons not criminally responsible for conducting an offence
if the person was at the time of the conduct unable by reason of mental disorder to appreciate the nature or wrongfulness of the conduct.
when is a person un fit for a trial
if it is established on the balance of probabilities that the person is incapable, by reason of a mental or physical condition, of participating effectively in a trial.
what should a person have the ability to do to have fitness for trial
(i) understand the nature of the charge,
(ii) understand the requirement to tender a plea to the charge and the effect of such a plea,
(iii) understand the purpose of, and follow the course of, the trial,
(iv) understand the evidence that may be given against the person,
(v) instruct and otherwise communicate with the person’s legal representative, and
(b) any other factor which the court considers relevant.
when is diminished responsbility used for culpable homicide over murder
if the person’s ability to determine or control conduct for which the person would otherwise be convicted of murder was, at the time of the conduct, substantially impaired by reason of abnormality of mind
what is needed for a restriction order (forensic) (1995 act)
ORAL evidence form at least 1 medical practitioner
- nature of charge
- antecedents of the person
- risk of offences he could commit
(no time limit - must be reviewed every 2 years)
what must the court be staisfied with for a treatment order
2 medical practitioners - mental disorders - treatable - civil risk no reasonable alternative
what is stigma
is a social construction that devalues people due to a distinguishing characteristic or mark
what is discrimination
is the actual behavior towards another group. It involves excluding or restricting members of one group from opportunities that are available to other groups
what is the prejudice
is a prejudgment: i.e. an assumption made about someone or something before having adequate knowledge to be able to do so with guaranteed accuracy
when is stigma developed
childhood
why are people reluctant to risk talking about mental illness or seeking help for it
worried about consequences
what are approaches to combat the stigma around mental illness
Good medication management
CBT approach to help overcome ‘felt’ stigma’ - lose ‘Us and Them’ attitude
Consider own attitudes and awareness eg disrespectful language/jokes
Influence of celebrities
give some controversies in modern psychiatry
- media stigma
- social control by state
- treatment without consent
- rising antidepressant prescriptions
- detention against will
