History, MSE and Diagnosis Flashcards
Give an overview of the structure of a psychiatric history
- Presenting Complaint(s)
- History of the Presenting Complaint(s)
- Past Psychiatric History
- Past Medical History
- Current and Recent Medication
- Social History - alcohol & drug use; smoking; social circumstances; occupation
- Family History
- Personal History
- Developmental milestones
- Schooling/Education
- Occupational history
- Relationships
- Pre-morbid Personality
What are the key things to ask about in the social history?
- Social circumstances including occupation
- Current financial situation/stressors
- Smoking/Alcohol/illicit drug use
- Current relationship/stressors
- Children - contact
What things should you ask about when completing the alcohol/ illicit drug history?
- Regular or intermittent
- Amount (know the units)
- Pattern
- Dependence/ withdrawal symptoms
- Impact on work, relationships, money, police
- Screening questionnaires eg CAGE
What should you ask about in the personal history?
- Developmental milestones
- Early life
- Schooling
- Occupational
- Relationships (sexual & marital history)
- Financial
- Friendships, hobbies and interests
What questions should you ask as part of the forensic history?
- “Have you ever been in contact with the police? Charged with any crime?”
- Offences including sentences
- Recidivism- the tendency of a convicted criminal to re-offend.
- Particular attention to violent or sexual crimes
How should you ask about pre-morbid personality?
- Difficult to be comprehensive
- Emphasis on consistent patterns of behaviour, interaction, mood
- Importance of corroboration
- “How would your best friend describe you as a person?”
What are the 10 aspects of the Mental State Examination?
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on appearance
- Height/Build
- Clothing - appropriate/inappropriate, kempt, bizarre
- Personal hygiene - clean/unshaven/malodorous
- Make up, jewellery, accessories
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on behaviour
- Greeting
- Non verbal cues
- Gesturing - normal, expansive, bizarre
- Abnormal movements - tremor, choreioathetoid movements, posturing, akathisia
- Cooperative, rapport
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on mood
- Eye contact
- Affect – objective manifestation of mood at i/v
- Mood rating – subj & obj; rate out of 10;
- Psychomotor function - retarded, agitated
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on speech
- Spontaneity
- Volume - loud, quiet, poverty
- Rate - pressured, slowed
- Rhythm - rhyming and punning
- Tone - monotonous, lilting
- Dysarthria
- Dysphasia - expressive/receptive
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on thoughts
- Close relationship to speech - external manifestation of thoughts
- Phobias
- Obsessions
- Flight of ideas
- Formal thought disorder – broadcast, echo, insertion, block, withdrawal
- Knight’s move, derailment, loosening
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on beliefs
- Preoccupations
- Over valued ideas
- Delusional beliefs - fixed, false belief out of cultural context; extraordinary conviction
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on percepts
- Illusions
- Hallucinations – pseudo, true
- Many domains - auditory, visual, somatic/tactile, olfactory & gustatory
- Specific types may be associated with certain conditions eg complex visual hallucinations in DLB
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on suicide/homicide
- Must always ask about suicidal thoughts
- Ideation
- Intent
- Plans - vague, detailed, specific, already in motion
- Also homicidal risk
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on cognitive function
- Orientation - time, place, person
- Attention/concentration - throughout i/v
- 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
The 10 aspects of the Mental State Examination are;
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/Homicide
- Cognitive function
- Insight
Expand on insight
- Best seen as spectrum
- Very rarely 100% present/absent
- Varies over time/illness
- 3 questions –
- Are symptoms due to illness?
- Is this a mental illness?
- Do they agree with treatment/Mx plan?
How should you ask a patient about whether they experience hallucinations?
- “I would now like to ask you a question which we ask to everybody. Do you ever seem to hear noises or voices when there is no one about and nothing else to explain it?”
- “Also is that true of visions or other unusual experience which some people have with touch or taste or smell?”
What does a mental state examination include?
- Appearance and Behaviour
- Affect
- Mood
- Speech
- Thinking
- Perceptual Anomaly
- Cognitive function
- Insight
- Risk assessment including suicide/homicide
- ALSO CONSIDER RESULTS OF PHYSICAL EXAM AND BLOOD and other TEST RESULTS
What is a delusion?
“ a delusion is an unshakeable idea or belief which is out of keeping with the person’s social and cultural background; it is held with extraordinary conviction.”
Examples
- grandiose
- paranoid (correctly persecutory)
- hypochondriacal
- self referential
How should you ask a patient whether they are experiencing a delusional belief?
- E.g. Persecutory delusion screening question:
- “Is anyone deliberately trying to harm you, e.g. trying to poison you or kill you?”
- Differentiation partial and full delusions
- “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 are the signs of thought disorder and linkage of thoughts?
- A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and can be described more specifically as
- thought blocking,
- fusion,
- loosening of associations,
- tangential thinking,
- derailment of thought, or knight’s move thinking.
Abnormal possession of thoughts; thought alienation.
Commonly reported in schizophrenia
- Thought insertion and withdrawal
- Thought blocking
- Thought broadcasting
How should you ask a patient whether they are experiencing this?
- “Can you think clearly or is there any interference with your thoughts?
- “Can anyone read your mind?”
- “Is anything like hypnotism or telepathy going on?”
What are the 3 types of perceptual anomalies?
- Hallucinations
- Pseudohallucinations
- Illusions
There are 3 types of perceptual anomalies;
- Hallucinations
- Pseudohallucinations
- Illusions
What are hallucinations?
- Have the full force and clarity of true perception
- located in external space
- no external stimulus
- not willed or controlled
May include any of the 5 special senses
- auditory or visual
- tactile
- olfactory and gustatory
How can you assess cognitive function?
- Orientation - time, place, person
- Attention/concentration - throughout i/v
- Standard concentration test is Reversed Months DNOSAJJMAMFJ
- Short term memory - 3 objects or name & address
- Long term memory - personal history
- If any concerns - perform objective tests eg MSQ, MOCA, MMSE, FAS, Clock drawing, executive function tests
What is insight?
- This should be conceptualised as a spectrum; rarely 100% absent or present.
- Three questions can indicate the place on this continuum:
- Do you think you are ill?
- If you are ill is it a mental illness?
- If you are ill and it is a mental illness do you agree broadly with the current treatment plan?
According to the ICD 10 diagnostic criteria, that are the key symptoms of a depressive episode?
Key symptoms:
- persistent sadness or low mood;and/or
- loss of interests or pleasure
- fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
if any of above present, ask about associated symptoms:
- disturbed sleep
- poor concentration or indecisiveness
- low self-confidence
- poor or increased appetite
- suicidal thoughts or acts
- agitation or slowing of movements
- guilt or self-blame
the 10 symptoms then define the degree of depression and management is based on the particular degree
- mild depression (four symptoms)
- moderate depression (five to six symptoms)
- severe depression (seven or more symptoms, with or without psychotic symptoms)
The Key symptoms of depression are:
- persistent sadness or low mood; and/or
- loss of interests or pleasure
- fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
if any of above present, ask about associated symptoms:
- disturbed sleep
- poor concentration or indecisiveness
- low self-confidence
- poor or increased appetite
- suicidal thoughts or acts
- agitation or slowing of movements
- guilt or self-blame
the 10 symptoms then define the degree of depression and management is based on the particular degree
How many symptoms would someone with mild depression display?
4
The Key symptoms of depression are:
- persistent sadness or low mood; and/or
- loss of interests or pleasure
- fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
if any of above present, ask about associated symptoms:
- disturbed sleep
- poor concentration or indecisiveness
- low self-confidence
- poor or increased appetite
- suicidal thoughts or acts
- agitation or slowing of movements
- guilt or self-blame
the 10 symptoms then define the degree of depression and management is based on the particular degree
How many symptoms would someone with moderate depression display?
5-6
The Key symptoms of depression are:
- persistent sadness or low mood; and/or
- loss of interests or pleasure
- fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
if any of above present, ask about associated symptoms:
- disturbed sleep
- poor concentration or indecisiveness
- low self-confidence
- poor or increased appetite
- suicidal thoughts or acts
- agitation or slowing of movements
- guilt or self-blame
the 10 symptoms then define the degree of depression and management is based on the particular degree
How many symptoms would someone with severe depression display?
7 or more, with or without psychotic symptoms
