History and Examination Flashcards
Key features of a psych history
History of presenting complaint Past psychiatric history Sociodemographic details Past medical history Medication history Family history Personal history Pre-morbid personality Mental state exam
Features of personal history
Infancy and early childhood - normal pregnancy - developmental milestones - who live with Adolescence and education - experience of school Occupational record Sexual development/relationships - first relationship Alcohol/drugs Forensic - police contact, prison, etc
Features of mental state exam
Appearance and behaviour Speech Mood - subjective - objective Thought - form - content Perceptions Cognition Insight ? Risk
Features of appearance and behaviour
Well kempt/unkempt
Eye contact - appropriate, sustained, intense
Level of rapport
Psychomotor retardation - significant slowing of speech and body movement
Psychomotor agitation - noticeable and marked increase in body movements
Distracted, responding to unseen stimuli
Features of speech
Comment on rate, rhythm and volume/tone - if normal state normal RRV
Evidence of formal thought disorder - can you follow flow
- circumstantiality - organised but over inclusive eventually gets to point in painstakingly slow manner
- tangential - occasional lapses, sudden change and never returns
- loosening of associates - frequent lapses between thoughts
- word salad - incomprehensible speech
- neologisms - words created by patient
- flight of ideas - flow extremely rapid but connections remain intact
Features of mood
Subjective
- how to they describe mood - mood scale
Objective
- low, expansive, euphoric, euthymic (normal)
- describe affect - emotional responsiveness
- blunted - decrease in amplitude of emotional expression
- flat - virtually complete absence of affective expression
- inappropriate - emotions expressed are not congruent with content of patients thoughts
- labile - unpredictable shifts in emotional state
Features of thought
Form - delusion - over-valued idea, paranoid ideation - obsessive rumination - obsessive intrusive thought - phobia Content - who thought relates to - spouse cheating (content) could be any form
Features of perception
Illusion - misinterpretation of sensory stimulus that can occur in any sensory modality
Hallucination - perceiving sound, sight, taste, smell or touch in absence of external sensory stimuli that seem indistinguishable from experience in reality
Depersonalisation - sense one is outside his/her self
Derealisation - vague sense of unreality in one’s perception of the external world
Features of cognition
Comment on orientation to time, place and person
- normal = oriented to time, place and person not formally tested
Features of insight
Persons understanding of their experience
- do they believe they are unwell
- do they believe they have a mental disorder
Features of risk
Risk to self harm - self-harm, suicide, self neglect
Risk to health - worsening mental illness, deteriorating physical health
Risk to others - paranoid delusions, command hallucinations
Define suicide
Fatal act of self injury, undertaken with more or less conscious self-destructive intent, however vague and ambiguous
Define para-suicide
Similar to suicide but victim survived the attempt
Define deliberate self harm
Act of self harm where action was not with the intention of death but to cause harm
Risk factors for suicide
Being male Living alone Unemployment Drug and alcohol misuse Mental illness Chronic physical illness Past self harm
Clinical variables for suicide for mood disorders
Greater severity of illness Self neglect Hopelessness Alcohol abuse Impaired concentration History of suicidal behaviour
Clinical variables for suicide for schizophrenia
Positive psychotic symptoms Post psychotic depression Young and male First decade of illness Relapsing pattern of illness Recent discharge from hospital Social isolation Good insight into illness
Clinical variables for suicide for alcohol abuse
Male sex Longer duration of problems Single/divorced/widowed Multiple substance abuse Co-morbid depressions
Clinical variables for suicide for chronic physical illness
Patients with chronic neurological, GI, CVS and cancer
Severe chronic pain leads to increased risk
Disfigurement
Chronic physical illness -> loss of job, role, family, money
Features of deliberate self-harm
Behaviour self-initiated - harm is intended - results in injury of harm Two main types - self-poisoning - self-injury
Associations with repeated self harm
Previous self-harm/psychiatric contact Alcohol/drug misuse Unemployment/social class Hx of trauma, sexual or physical abuse Criminal record/history of violence Single/divorced/separated Family hx
Motivations underlying DSH
Wish to die, cry for help, communication with others, unbearable symptoms
Psychological characteristics
- impulsivity, cognitive rigidity, problem-solving deficits, hopelessness
Coping mechanism
- temporary relief of anxiety, stress, emotional numbness, sense of failure
Features of a risk assessment
Psychiatric examination
- protective factors
- risk factors
- dynamic/static
- modifiable risk factors
- specific suicide inquiry
Risk level - low, med, highHx for overdose
Triggers Preparation - planning, final acts Circumstances - alone, precautions against discovery, alcohol, what did they think would happen After act - seek help, regret failure, intent Psych history Ideation, intent and plans
Risk management
Treat psychiatric disorder As an inpatient - closer supervision - adherence to treatment - staff numbers - staff training - safe environment
Risk to others
DPSD, alcohol/drug misuse, schizophrenia - cause small increased to others - but not affective disorders
Risk increased by
- specific persecutory delusions or hallucinations
- command auditory hallucinations
Define capacity
Ability to make a decision
- can involve personal welfare, healthcare and financial decisions
- empowers adults to make as many decisions as possible
Features of Mental Capacity Act 2005
Presumption of capacity at all times
- right to make unwise decisions
Single test of capacity
Legal right to support individuals in making own decision
Anything done for on behalf of people without capacity should be the least restrictive of their freedom and/or rights
- done in their best interests
Features of testing capacity
Is there an impairment of, or disturbance in the functioning of the persons mind
Has it made the person unable to make a particular decision
Must be able to understand relevant information for the decision
- information must be retained long enough to make the relevant decision
- should be able to use/weigh information
- information must be believed
- must be able to communicate decision
Time and issue specific
Key features of understanding capacity
Understand information
Retain information
Use/weight up information
Communicate decision
Features of acting in best interest
Patient should participate even if lacking consent
If patient will regain capacity it may be appropriate to wait
Decision maker must ascertain and consider patients past and present wishes and feelings
Features of advance decisions
Only relates to medical treatment
Only in the negative - to refuse medical treatment of a specific type
Cannot require a doctor to provide a treatment
Person must be over 18 and have capacity at the time
- may be withdrawn or altered orally if person still has capacity
Features of lasting powers of atterny
Must be made on prescribed form and registered with Public Guardian
Enables mentally capable person to plan for incapacity
Can appoint one for property, welfare and healthcare matters
Decisions taken by attorney are still subject to best interest requirements
Features of deprivation of liberty safeguards
For patients in hospital or care homes who lack capacity
MDT assessment lead by social workers
Prevent patients leaving but on set grounds - like visits x times a week
Features of Mental Health Act 1983
Can only be used to enforce treatment for mental health conditions
Guiding principles of MHA
Minimise undesirable effects of mental illness
Least restrictive
Participation of patient and NoK
Equity, effectiveness and efficiency
Criteria for implementing the MHA
Presence of mental disorder as defined by law
Disorder is of certain nature of degree
Significant risk to the persons health, safety or safety of others
No alternative to hospital admission as means of safeguarding that risk
Features of section 5(4) of MHA
Power granted to RMNs to detain an inpatient for up to 6 hours for medical assessment where medical illness is suspected
Form to be completed - pink paper
Forms submitted to hospital managers
Must be admitted to hospital - A&E does not count
Features of section 5(2) of MHA
RMO or nominated deputy can detain an inpatient for up to 72 hours under the mental health act
No appeal
Legal form for hospital managers
To allow formal mental health act to be completed
Must be admitted to hospital - A&E does not count
Features of section 2 of MHA
2 doctors - at least 1 of whom should be section 12(2) approved (reg/con psychiatrist)
1 AMHP - approved mental health practitioner
Community or inpatient - anywhere except prison
Section for maximum of 28 days for assessment and treatment of mental disorder
Appeal within first 14 days - heard within 7 days
Can be discharged at any point - con or NoK
Features of section 3 of MHA
2 doctors - at least 1 of whom should be section 12(2) approved (reg/con psychiatrist)
1 AMHP - approved mental health practitioner
Community or inpatient - anywhere except prison
Section for maximum of 6 months for treatment of a mental disorder - can be renewed for another 6 months
1 appeal to both hospital managers panel and tribunal
Features of section 136 of MHA
Police power to remove to a place of safety from a public place for an assessment by an AMHP and 1 doctor
Held up to 72 hours to allow assessment
Police stay with person
Must be public place - not own home
Features of section 17 of MHA
Whilst detained in hospital under S2,S3 a patient may leave under S17
Leave to walk outside, go home, for several hours or overnights or longer
Features of section 117 of MHA
Anyone who has been on section 3 is entitled to S117 aftercare from local authority for rest of life
Features of community treatment order
Patient on S3 can be considered for a CTO
Patient is well enough to leave hospital but may default from treatment/follow up
Treatment is necessary for the patients health, safety or protection of others
Patient can be recalled to hospital if they do not comply with treatment, attend appointments etc
Can still appeal to tribunal
Features of section 135 of mental health act
Used by police to assess and remove a person from their home if it is suspected they are suffering from a mental health disorder
