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History Flashcards

1
Q

What are the 2 parts of the psychiatric assessment? What do they consist of?

A
  1. Gathering information
    - Psychiatric history
    - Mental state examination
  2. Formulation - assessing and acting upon that info
    - includes ddx, risk assessment, thinking about aetiology and management plan
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2
Q

Before taking a history, what are some factors to take note of?

A
  1. Demographics
    - Sex
    - Age
    - Occupation
    - Ethnicity
  2. Mode of referral and reason
    - Inpatient/outpatient/ED?
    - Who made the referral and what are their concerns?
  3. If the patient is an inpatient, are they detained under the Mental Health Act?
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3
Q

What are the 9 elements of a psychiatric history?

A
  1. PC and Hx of PC
  2. Past psychiatric Hx
  3. FHx
  4. Medical Hx
  5. Substance misuse and alcohol Hx
  6. Personal Hx
  7. Forensic Hx
  8. Premorbid personality
  9. Social circumstances
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4
Q

What questions should you ask regarding the PC (2) and Hx of PC? How should you record the answers (7)?

A

PC:

  1. Record patient’s main problem briefly in their own words
  2. Remember some patients may not have any “complaint” as they don’t think they are unwell. In this case, just mention they don’t have any complaint

Hx of PC: (For each problem, list:)

  1. When did problem start
  2. Any precipitating events
  3. How did it develop
  4. Any associated symptoms
  5. How the problem affects day to day functioning
  6. Has any help or treatment been sought for it and the response of these interventions
  7. Temporal relationships between symptoms and any physical disorder, psychological or social problems
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5
Q

What questions regarding past psychiatric history should you ask about?

A
  1. Details of past problems including psychiatric admissions (informal/ under the Mental Health Act) and treatments (drug and psychosocial)
  2. Any history of under the mental health service or psychiatric treatment in primary care
  3. Also need to include any past self-harm and suicide attempt

Consider:

  1. What interventions were helpful and which were not, benefits, side effects and doses of medication used, concordance to treatment plan
  2. If the diagnosis is in doubt, record symptoms of previous episodes and how they have changed over time. What led to episodes of illness?
  3. Predisposing, precipitating and perpetuating factors as well as protective factors and positive coping strategies
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6
Q

What questions should you ask about regarding family history?

A

This should include parents, siblings and other significant other relatives – ask about age, health, employment, psychiatric history and relationships with patient

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7
Q

What should you ask about regarding a medical history in a psychiatric Hx?

A
  1. This should include any major illness and any current treatments including current medications – also to consider concordance to medications
  2. Any known allergy
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8
Q

What topics should you consider asking about in regards to substance misuse and alcohol history (3)?

A

Consider tobacco, alcohol, illicit drugs

  1. Pattern of use, past and current use
  2. Effects (including withdrawal symptoms, dependence features
  3. How substance use relates to mental health difficulties
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9
Q

What topics should you consider asking about with regards to personal history and what specific questions related to that topic?

A
  1. Childhood
    -Birth
    -Developmental milestones
    -Family atmosphere
  2. School and education
    -primary and secondary schooling
    -relationship with teachers and peers
    problems at school (academic, behavioural e.g. truancy, school refusal)
    -age when left school
    -any further training or courses
  3. Occupations
    -job taken
    -for how long
    -why left
    -how long being unemployed
  4. Psychosexual and relationship history
    -past and current relationship
    -marital history
    -any children (ages and contact – remember children safeguarding)
    -sexual orientation and difficulties if relevant
  5. Past history of emotional, sexual and physical abuse if appropriate
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10
Q

What should you ask about with regards to forensic history?

A

Consider all offences whether convicted or not – especially any violence, sexual offences and persistent offending

  • Arrest or caution by police
  • Under probation
  • Prison sentence
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11
Q

What should you ask about with regards to premorbid personality?

A

Focus on patient’s personality BEFORE they became unwell, including:

  1. Attitudes to others in relationships
  2. Attitudes to oneself (self-esteem)
  3. Any predominant mood and stability
  4. Leisure activities and interests
  5. Reaction pattern to stress
  6. Religious and cultural issues
  7. Individual’s strengths and abilities
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12
Q

What specific questions may help you ascertain a patient’s premorbid personality?

A
  1. How would you describe your normal self?
  2. How would other people describe you?
  3. How do you cope when…. (e.g. stress)?
  4. You could get info from others
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13
Q

What would you ask about in regards to social circumstances?

A
  1. This describes briefly where the person is living, whom they are living with, whether there are any children in the house, the financial situation and the patient’s support network (personal and professional).
  2. Consider any debt and what benefits the person is receiving
  3. Any carer identified and support to the carer
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14
Q

What is the purpose of the mental state examination?

What does it look at?

A

It is a snapshot of patient’s behaviours and mental experiences at or around that point in time

It looks at symptoms (what patient subjectively reports) and signs (what you observe) of mental disorders

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15
Q

What are the 7 elements of the MSE?

A
  1. Appearance and behaviour
  2. Speech
  3. Mood and affect
  4. Thoughts
  5. Perceptions
  6. Cognitive examination
  7. Insight
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16
Q

With regards to a persons appearance, what are 4 elements of it and what could they indicate?

A
  1. Clothes
    - Colourful and loud clothes may suggest mania
    - Dirty and crumpled clothes may suggest self-neglect
  2. Weight
    - Evidence of rapid weight loss increases the possibility of self-neglect - consider ill-fitting or new belt holes
    - Low weight may be an indication of anorexia
    - Obesity could be a side effect of medication
  3. Facial appearance
    - Depression - turned down corners of mouth, furrowed brow
    - Anxiety - creases on forehead and dilated pupils
    - Anger and irritability - characteristics
  4. Posture
    - Depression - hunched posture
    - Anxiety - sitting on edge of seat, restless
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17
Q

With regards to a persons behaviour, what are 4 elements of it and what could they indicate?

A
  1. Movements
    - Mania - overactive, agitated or restless
    - Schizophrenia - catatonic features
    - Abnormal movement - e.g. dystonia, tremor (can be neurological disorder or side effect of medications)
  2. Social behaviour
    - Mania - over familiar
    - Schizophrenia - withdrawn or preoccupied
  3. Rapport
    - Schizophrenia/psychosis - suspicious and uncooperative
  4. Eye contact
    - Depression - poor eye contact
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18
Q

What are 5 elements that you can comment on regarding speech?

A
  1. Rate (fast/slow)
  2. Quantity (e.g. poverty of speech)
  3. Volume
  4. Flow of Speech (e.g. pressure of speech - if you cannot interrupt, consider this)
  5. Spontaneity
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19
Q

What is the definition of mood?

A

The pervasive and sustained emotional state of the individual (longer term)

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20
Q

What are the 2 elements of mood you need to describe?

A
  1. Subjective mood
    - how does the patient describe their mood?
  2. Objective mood
    - What is your impression of the mood? - elated/irritable, depressed, anxious, labile
21
Q

What is the definition of affect?

A

The observable behaviour associated with changing emotions such as fear, sadness, or joy (shorter term

22
Q

What are some common terms to describe affect that a patient may present with?

A
  1. blunted or flattened affect -
    dulling of normal emotional response
  2. labile affect - sudden rapid and often marked shifts of affect
  3. inappropriate or incongruent affect - can be inappropriate to the thought content (e.g. laughter upon recounting the death of loved one) or inappropriate to the magnitude of events (e.g. emotional outburst after a small and insignificant event)
23
Q

What is thought form?

How is it assessed?

A

Train of thought

Assessed through patient’s speech

24
Q

What might alert you to a formal thought disorder?

A

Not quite understanding what the patient is saying even when you pay extra concentration

25
Q

What are 3 aspects of perception abnormalities?

A
  1. sensory distortion (depersonalisation, derealisation)
  2. illusion
  3. hallucinations
26
Q

What are 4 general questions you could ask to screen for any abnormal perceptions?

A
  1. “I gather that you are quite stressed recently. When people are under stress, they can sometimes find that their imagination plays tricks on them. Have you had any similar experience?”
  2. “Have you heard/seen anything unusual?”
  3. “Have you noticed anything unusual about the way things look or sound, or smell, or taste?”
  4. “Have you heard voices when there was no one around?” (auditory hallucination)
27
Q

What is sensory distortion?

A

distortions of intensity, colour, form and proportions

28
Q

What is depersonalisation?

A

an alteration in the perception or experience of the self, leading to a sense of detachment from one’s mental process or body.

29
Q

What is derealisation?

A

an alteration in the perception or experience of the environment, leading to a sense that it is strange or unreal.

30
Q

What are illusions?

A

misinterpretations of a real stimulus e.g. misinterpreting a branch of a tree as an arm of a person

31
Q

What are hallucinations?

A

perceptions in the absence of a stimulus

32
Q

What sensory modalities can hallucinations occur in?

A

Any - visual, auditory, tactile, olfactory and gustatory.

33
Q

How can auditory hallucinations be described as (3)?

A
  1. 2nd person (voice talking directly to the individual - usually say “you….”)
  2. 3rd Person (a number of voices talking among themselves and refer the individual as “he”/”she” or their name.
  3. Command hallucinations
34
Q

How can you quickly assess cognitive function?

A
  1. Orientation in time, place and person
  2. Attention and concentration (serial-7 test or backwards spelling)
  3. Memory - immediate recall, delayed recall, long-term memory/knowledge
35
Q

What are 2 tools for assessing cognitive function and who are they used for?

A
  1. MMSE - everyone

2. MOCA - for people who are illiterate or with low education

36
Q

What 5 questions should you ask yourself to ascertain a problem with insight?

A
  1. Is the patient aware that there is anything wrong?
  2. If there is anything wrong, does the patient think it is due to an illness?
  3. If an illness, is it physical or mental illness?
  4. If it is a mental illness, can it be helped?
  5. Is the patient willing to accept help or treatment?
    - This may include hospital admission - will the patient agree?
37
Q

Why should a psych history be followed up with a physical examination?

A
  1. Individuals with mental illness have a higher chance of various physical illness
  2. Some physical illness can also present with psychiatric symptoms (“organic causes”): physical examination will help to look for any
38
Q

What follows a physical examination?

A

Investigations

39
Q

What investigations should be done in a patient that presents with psych problems?

A
  1. Physical investigations: blood tests, ECG, urine tests, brain scan, EEG etc. (further guidance will be given in specific disorders)
    - Help exclude organic causes of psychiatric symptoms
    - Screen for psychical health difficulties
    - Act as a baseline, especially when initiating medication
  2. Psychosocial investigations: informant history with patient’s consent (which can be difficult at times), review medical records, social assessment, occupational therapy assessment for functioning, etc.
40
Q

What is vital in assessing while doing the history and mental state?

A

Risk assessment - very important

41
Q

After info has been gathered and investigations and risk have been evaluated, what is next?

A

DDx

  • organic differentials e.g. medical disorders, substance misuse
  • psychiatric ddx
42
Q

What are 4 important things to consider in the management plan of a psych patient?

A
  1. Capacity of patient to make decision on treatment
  2. The level of care that the patient needs?
    - Inpatient care
    - Community care
  3. Bio-psycho-social approach to treatment
  4. Follow-up plan in the community
43
Q

In the bio-psycho-social approach to treatment, what are considered in the biological part (2)?

A
  1. Medications

2. ECT

44
Q

In the bio-psycho-social approach to treatment, what are considered in the psychological part (6)?

A
  1. Psychoeducation
  2. Self-help materials
  3. Counselling
  4. Cognitive behavioural therapy (CBT)
  5. Psychodynamic psychotherapy
  6. Group therapy
45
Q

In the bio-psycho-social approach to treatment, what are considered in the social part (6)?

A
  1. Cultural needs
  2. Education and employment
  3. Finances
  4. Housing
  5. Relationships and carers
  6. Social inclusion activities (i.e. to enable patient to reintegrate back to society)
46
Q

If someone with psychosis asks you e.g. to do an x-ray because they have a tracker device in their head, should you comply?

A

No - do not go along with it because it will damage the trust. If they ask, you do believe me? - say “I believe that you really believe it”

47
Q

If someone asks you “Am i crazy/mental?” what should you say?

A

We don’t like to use that term - I don’t think you are.

Normalise it

48
Q

How to display empathy?

A

Reflect “I can see this is really upsetting you, but there are lots of things we can do to help…”

Give hope and normalise it “lots of people in a similar position feel this way…”

aaa (8 decks)

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