General assessment Flashcards
How should you begin the interview?
Arrange the room. Read information - referral, old notes, risk assessment, alerts. Introduce yourself to patient and explain what to expect.
What are the 9 elements to the history?
Presenting complaint History of presenting complaint Past psychiatric history Past medical history Family history Personal history Social history Forensic history Pre-morbid personality
What should you ask about in history of presenting complaint?
Nature of symptoms - onset, course and duration
Precipitants, exacerbating and alleviating factors
Interventions already tried
Risk factors for suicide, self-harm and harm to others
What should you ask about in past psychiatric history?
Previous episodes of illness
Previous contact with health services
Previous treatments and level of success
Previous episodes of self-harm or suicide attempts
What should you ask about in medical history?
Chronic illnesses
Medication and adherence
Allergies
What should you ask about in family history?
Genogram (adoptions and half relations)
History of physical and psychiatric illness
Relationships
What should you ask about in personal history?
Obstetric history Milestones and development Childhood experiences Education Employment history Psychosexual history
What should you ask about in social history?
Living arrangements
Social support and activities
Financial circumstances
Habits eg. smoking, alcohol, recreational drugs
What should you ask about in forensic history?
Arrests, charges and convictions
Undetected crimes
What is the pre-morbid personality?
How the patient sees themselves when well
How they think others see them
How others actually see them
What phrases should you avoid when taking a history?
Avoid starting with closed questions Avoid apologising for asking questions Avoid leading questions Avoid multiple strands Avoid questions starting with why
How could you ask about suicidal thoughts?
It is not uncommon for people who are very low to think of ending things. Have you had thoughts like that?
How could you ask about psychotic symptoms?
Sometimes when people are under stress, they might hear things that other people can’t. Do you?
How could you ask about childhood experiences?
What was your childhood like? Did you have any experiences that were frightening or upsetting?
How could you ask about forensic history?
Have you ever done anything that might have got you into trouble with the police?
How could you ask about pre-morbid personality?
How would you describe your normal self? How do you cope with difficult situations?
What are the 8 aspects to the mental state examination?
Appearance and behaviour Speech Mood Perceptions Thought form Thought content Cognition Insight
What is included in appearance and behaviour?
Gender, age, personal care, distinctive characteristics Psychomotor agitation or retardation Eye contact Distracted, perplexed or restless Responding to unseen stimuli
What is included in speech?
Rate
Volume
Tone
Coherence
What is included in mood?
Subjective - patient’s description of mood
Objective - observed external manifestation of mood eg. reactive, labile, flattened, blunted, congruent/incongruent
What is included in perceptions?
Sensory distortion - intensity or quality of perception eg. hyperacusis, visual hyperaesthesia
Illusion - misperception of a real object
Hallucination - perception without an object in all five sensory modalities
What are the different types of hallucinations and when do they occur?
Auditory - most common
Visual - delirium tremens
Olfactory and gustatory - organic eg. epilepsy
Tactile - drug intoxication
Sleep-related - hypnopompic and hyponogogic
What are hypnopompic and hynpogogic hallucinations?
Hypnogogic - occur when falling asleep
Hypnopompic - occur when waking up
What is included in thought form?
Structure of thought process
Loss of coherence or connectivity of speech
What is thought acceleration?
Flight of ideas with logical connection between each sequential idea
What is circumstantial thinking?
Inability to answer a question without giving excessive, unnecessary detail
What is loosening of associations?
Loss of logical connections between sequential ideas
What is thought blocking?
Sudden stop in thought flow as though removed
What is included in thought content?
Obsessions
Overvalued ideas
Delusions
What is an obsession?
Recurrent intrusive, usually unpleasant thoughts that the person recognises as their own and tries to resist
What is an overvalued idea?
Acceptable comprehensible idea pursued by the person beyond the bounds of reason and causes distress or disturbed functioning
What is tangential thinking?
Train of thought wanders, showing no clear focus and does not return to the original point
What is a delusion?
False unshakeable idea/belief which is out of keeping with the patient’s educational, cultural and social background, held with extraordinary conviction and subjective certainty
What is a primary delusion?
Delusion not occurring in response to another psychopathology
What is a secondary delusion?
Delusion is understandable in the present circumstances eg. severely depressed mood
What are some different types of delusion?
Paranoid
Grandiose
Nihilistic
What is included in cognition?
Orientation to time, place and person
Often not formally assessed but can use MMSE
What is included in insight?
Assessment of patient’s perception of their illness and the likelihood they will engage in treatment
What could you ask to determine a patient’s insight?
How do you explain your experiences? Some people who are ill have similar experiences to you, could that mean that you are ill too? Do you think you need treatment?
Should a physical examination be done?
Yes - all patients
Assess nutritional state
Secondary illnesses due to their mental illness or due to medication
What should be included in the risk assessment?
Past and present risks
Risks to self - suicide, self-harm, neglect
Risks from others - harm, abuse, exploitation
Risks to others - harm to adults or children
Protective factors
What is risk?
Likelihood of an event happening with potentially harmful or beneficial outcomes for self or others
What is the purpose of a risk assessment?
Anticipate and avoid adverse outcomes
Protect patients, others and ourselves
Optimise and guide management
What are the 5 main risks in psychiatry?
Risk to self Risk to others Risk from others Risk of absconding Risk of non-compliance
What is the definition of suicide?
Act of killing oneself deliberately initiated and performed by the person concerned in the full knowledge or expectation of its fatal outcome
What are the 2 points for legal suicide verdict from the Coroner?
- Deceased had intention to kill self
2. Death was self-inflicted
Which gender is more likely to take their own lives?
In the UK men are 3x more likely to take their own lives
Which demographic group has the highest suicide rate in the UK?
Men 45-49yrs
Which factors increase suicide risk?
Previous attempts or deliberate self-harm Past psychiatric history Current mental state: - Hopelessness - Persistently depressed mood - Psychosis - persecutory delusions, command hallucinations, schizophrenia - Mania and disinhibition Past medical history (chronic or debilitating illness) Substance misuse Financial difficulties Immigration Relationship problems Bereavement Family history Specific occupations
What is the SAD PERSONS scale?
Sex (male) Age (<20 or >40) Depression Previous suicide attempt Ethanol abuse Rational thinking loss (psychosis) Social support lacking Organised suicide plan No spouse Sickness
Each risk factor is given a score of 1 point
3-4 -> close monitoring
5-6 -> consider hospitalisation
7-10 -> hospitalisation for further assessment
What should you establish in the suicide risk assessment?
The patient’s intent
Seriousness and perceived seriousness of their attempt - triggers, method, final acts, discovery
Assess how they feel about the attempt - guilt, regret, no remorse
How should a suicide attempt be managed (generally)?
Psychosocial assessment
Diagnose mental illness and treat effectively
Address psychosocial and physical health issues
Increase support
Enhance coping skills
What factors increase a person’s risk of violence?
History of violence
Poor social network, recent major life events, unstable housing, unemployment
Substance misuse
Personality
Childhood trauma
Past psychiatric history with poor engagement and compliance
Current mental state:
- Fear, anger, humiliation, jealousy
- Command hallucinations
- Persecutory delusions, passivity phenomena
- Intoxication, confusion
How should risk of harm to others be managed (generally)?
Keep them safe
Use safe restraint
Least restriction approach
Diagnose mental illness and treat effectively
How can you keep yourself safe when seeing a patient?
Sit close to door. Go in pairs. Let people know where you are. Report any concerns.
Personal attack alarm. Clear exits. Observation panels in doors. No potential weapons.
Read available information on patient’s risk. Speak to nursing staff and medical team.
What are some types of abuse?
Physical abuse Domestic violence Sexual abuse Psychological/emotional abuse Financial abuse Modern slavery Discriminatory abuse Organisational abuse Neglect
Are people with mental health problems more vulnerable to abuse?
Yes, mentally ill people are 4x more likely to be victims of violence
What is derailment?
Loosening of logical associations between sequential ideas
What is clang association?
Speech is motivated by sound and words are chosen based upon their sounds rather than their meaning
What is an idea of reference?
Individual believing that irrelevant, unrelated or innocuous things in the world are referring to them directly or have special personal significance
What is delusional misidentification?
Umbrella term for a number of conditions including Capgras and Fregoli syndrome, seen in dementias and psychosis
What is a nihilistic delusion?
Belief that parts of the body do not exist or are dead, organs are malfunctioning or rotting, the patient is dead and there is no future for them
