Hallucinations/ Delusions Flashcards
Sequence of events
Open question
Timeline
Auditory hallucinations
Tell me about the voices/ how many are there/ male or female/ same voices each time/ is it your voice (1st person)
Do you hear them inside or outside your head? Can you stop them?
Second (talk to you) or third person (talk about you), running commentary?
Commands- do they ask you to do things, like what?
Why do you think you can hear them?
What happens if you ignore them/ don’t do what they say?
Visual hallucinations
Do you see things others can’t ?
Describe them. How do you know they are/aren’t real?
Why do you think you can see them?
Other hallucinations
Strange tastes or smells
Strange sensations (tactile)
Why does you think you can taste/smell/feel these things?
Delusions
Persecutory- anyone out to get you
Reference- does news talk about you
Control- someone can put thoughts in/take out your head
Passivity- control your actions and feelings
Grandiose- special powers and abilities
Nihilistic- organs rotting
NB- to see whether the delusion is fixed gently challenge by asking “are you sure about that”
NB- ask why. Why does the news talk to you? Why can people hear your thoughts? Special powers?
Red flags
Loss of functioning
Risk to self or others
Command hallucinations
Grandiose delusions
Rule out other psychiatric diagnoses
Mania- energy levels/ have people said you are hyper/ spending habits/ libido
Depression- mood/anhedonia/ sleep/ future
Others- memory loss/ anxiety/ insight/ relationship with food
Risk
Consider a mini summary
Then tentatively discuss self harm, harm towards others
Previous self harm or suicide attempts?
Patients perspective
Feelings and affect on life
Ideas
Concerns
Expectations
PMH
Medical or psychiatric disorders
DH
Allergies
OTC or regulars
FH
Medical or psychiatric disorders
Insight
Do you accept you have a mental illness
Would you accept treatment
Important points
History may present with another complaint eg. Headache, in which you notice the patient is acting strangely, may have deluded thoughts, appear dishevelled or agitated, or respond to the hallucinations during the consultation
May present with patient being brought in by police or family and friends, due to behavioural concerns
Offer reassurance before offering lots of closed questions
If a headache, make sure to ask appropriate questions (red flags) as even psychiatric patients get I’ll
Schizophrenia (relapse or 1st presentation psychosis)
Schneiders first rank Sx
Positive and negative Sx
Rx- FH, cannabis use, social isolation
High risk of suicide
Drug induced psychosis
Alcohol, cannabis, LSD
Withdrawal states eg. DT (alcohol) can also mimic psychosis
Delirium
An acute confusion state common in the elderly
Can be due to infection eg. UTI pneumonia
Other causes inc. drugs eg. Morphine. Steroids (steroid induced psychosis), benzodiazapenes, alcohol abuse or withdrawal, metabolic disturbance (hypercalcaemia), stroke
Depression with psychosis
Core features of depression present (low mood, anhedonia, fatigue)
Delusions- mood congruent eg. Guilt, paranoia, persecution, nihilism
Hallucinations- same as above eg. Heavily critical
Mania
DIGFAST
Delusions of grandiosity often present
Patient talking very fast, switching between topics
May be previous depression history (BAD)
When mania always think- could it be hypomania
Investigations
Top to toe physical exam and observations
MSE
Urine dip and drug screen
Bloods- FBC UE LFT TFT B12 folate glucose
CXR
MRI head (first presentation of psychosis), HIV & syphyllis serology, lumbar puncture (meningitis)
NB- ECG before antipsychotic treatment
SH
Job- what does it involve. Impact on job
Home situation- occupants and difficulties
How is mood affecting home life
Support from family or friends
Smoke alcohol recreational drugs
Have you been looking after yourself and the home eg. showering and cleaning
Acute confusional state
Electrolyte imbalance
Hyper or hypoglycaemia
Acute illness eg. Stroke or PE
Head injury
Infection
