History Taking Flashcards
What are the 2 fundamental components of psychiatric interviewing?
Collection of clinical data
- Taking a clinical history
- Examining the mental state
Intuitive understanding of the patient as an individual
- Empathy
- Descriptive psychopathology
What is important to ensure about the setting of the interview?
- Privacy
- Minimise chance of interruptions
- Informal setting, avoid barriers
- Easy exit for the physician
What safety/risk assessment can be done for the interview?
- Inform staff who you are going to interview and where
- Identify change in behaviour throughout interview
What sections should you cover when taking a history?
- Presenting complaint
- History of presenting complaint
- Past psychiatric history
- Past medical history
- Current and recent medications
- Social history
- Family history
- Personal history
What is important to cover in the introductions during a psychiatric interview?
- Greet verbally and introduce yourself
- Orientate and check the purpose and likely duration of the interview
- Let them know you wlll be taking notes but you will respect confidentiality
What general skills can be adopted for the interview?
-Eye contact
-Relaxed, non-threatening posture
-Use facilitative noises
-Pick up on non-verbal cues
-Control over talkativeness
-Do not offer advice or opinion too early
Clarify and summarise
What are the advantages of asking open questions?
- Allows patients to start talking about themselves and puts them at ease as they have the floor
- Allows you time to think and plan areas of questioning as you assess their style and content of their response
- Allows a period of non-verbal response from interviewer, listening and facilitating
What are the main objectives of the psychiatric interview?
- Form rapport and gather information
- Establish and explore symptoms in context of personality and circumstances
- Explore possible biological and social factors related to the symptoms
- Inform and motivate patient
- Examine mental state
- Begin formulation
How should you deal with a patient’s presenting complaint?
- Record each presenting complaint in their own words
- List the main ones and then deal with each individually
What should you enquire about with presenting complaint?
- Clarify each complaint in turn
- Onset, precipitants, course, severity
- Associated symptoms, effects on daily living
- Is it getting worse or better?
- Has it responded to any treatment?
How should you explore psychotic symptoms: percepts?
- “Have you seen or heard anything that other people have not been aware of?”
- “Have you heard any people talking when there was nobody around?”
- What do they think is causing them?
- Does it seem possible?
- Beware of commands
How should you explore psychotic symptoms: beliefs/thoughts?
- “Has anything particular been playing on your mind?”
- “Do you know why is this happening?”
- “Have you noticed any change in your thoughts?”
- “Has anyone interfered with your thoughts?”
- “Does anyone else have access to your thoughts?”
What should be explored in the past psychiatric history?
- Past episodes/ diagnoses / contacts
- Previous treatments (psychological, drug and physical)
- Inter-episode functioning
- Previous admissions to hospital
- Attempted suicide/ repeated DSH
- Previous detentions under Mental Health Legislation
What should be explored in the family history?
- 1st degree relatives mental health
- Age, employment, circumstances, health problems, quality of relationship
- Major mental illness in more distant relatives is important
What should you explore in past medical history?
- Developmental problems
- Head injuries
- Endocrine abnormalities
- Liver damage, oesophageal varices, peptic ulcers
- Vascular risk factors
What should you explore in current and recent medications?
- Tablet and injections
- Recent medications
- Any discontinued drugs (within past 6 months)
- Duration and dosage
- Adverse reactions and allergies
What should you explore in social history?
- Social circumstances including occupation
- Current financial situation
- Smoking/ alcohol/ illicit drug use
- Current relationship
- Children (contact)
What must you try to find out if there is alcohol or illicit drug misuse?
- Regular or intermittent
- Amount (know the units)
- Pattern
- Dependence/ withdrawal symptoms
- Impact on work, relationships, money, police
- Screening questionnaires eg CAGE
What should you explore in personal history?
- Developmental milestones
- Early life
- Schooling
- Occupational
- Relationships (sexual & marital history)
- Finances
- Friendships, hobbies and interests
What is important to explore if asking about a forensic history?
- “Have you ever been in contact with the police? Charged with any crime?”
- Offences including sentences
- Recidivism
- Particular attention to violent or sexual crimes
What is important to know about pre-morbid personality?
- Emphasis on consistent patterns of behaviour, interaction and mood
- Importance of corroboration
What are the components of a mental state examination?
- Appearance
- Behaviour
- Mood
- Speech
- (Abnormal) thoughts
- (Abnormal) beliefs
- (Abnormal) percepts
- Suicide/homicide
- Cognitive function
- Insight
What can be noted about a patient’s appearance?
- Height/Build
- Clothing - appropriate/inappropriate, kempt, bizarre
- Personal hygiene - clean/unshaven/malodorous
- Make up, jewellery, accessories
What can be noted about a patient’s behaviour?
- Their greeting
- Non-verbal cues
- Gesturing- normal, expansive, bizarre?
- Abnormal movements- tremor, choreiathetoid movements, posturing, akathsia?
- Cooperative, rapport
What can be noted about a patient’s mood?
- Eye contact
- Affect: objective manifestation of mood
- Mood rating: out of 10
- Psychomotor function
What can be noted about a patient’s speech?
- Spontaneity
- Volume - loud, quiet, poverty
- Rate - pressured, slowed
- Rhythm - rhyming and punning
- Tone - monotonous, lilting
- Dysarthria
- Dysphasia - expressive/receptive
What can be noted about a patient’s thoughts?
- Close relationship to speech - external manifestation of thoughts
- Phobias
- Obsessions
- Flight of ideas
- Formal thought disorder – broadcast, echo, insertion, block, -Knight’s move, derailment, loosening
What can be noted about a patient’s beliefs?
- Preoccupations
- Over valued ideas
- Delusional beliefs - fixed, false belief out of cultural context; extraordinary conviction
What can be noted about a patient’s 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
What can be noted about a patient’s suicide/homicide risk?
- Must always ask about suicidal thoughts
- Ideation
- Intent
- Plans - vague, detailed, specific, already in motion
- Also homicidal risk
What can be noted about a patient’s 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
What can be noted about a patient’s insight?
- Does the patient think they are ill?
- If the patient thinks they are ill, do they think it is a mental illness?
- If the patient thinks they are ill and thinks it’s a mental illness, do they broadly agree with the treatment plan?
What skills does a good interviewer have?
- Focus on relevant facts
- Sensitive to patient’s needs
- Able to control the interview
Psychopathology
Concerned with abnormal experience, cognition and behaviour
Descriptive psychopathology
Describes and categorises the abnormal experience as described by the patient
Phenomenology
In psychiatry, it refers to the observation and understanding of the psychological event or phenomenon so that the observer can as far as possible know what the patient’s experience fells like
What does empathy as a psychiatric term mean?
Feeling oneself onto
What is empathy in descriptive psychopathological terms?
It is a clinical instrument that needs to be used with skill to measure a patient’s internal subjective state using your own emotional and cognitive experience as a yardstick
How is empathy achieved?
By precise, insightful questioning until the doctor is able to give an account of the patient’s subjective experience. This questioning continues until the patient recognises the account as accurate
What is mood?
Mood is generally held to be the patient’s subjective report on their current mood state in terms of how they rate themselves from depressed through euthymic (neutral) to elated
What is affect?
Affect is held to be the emotions conveyed and observed objectively during interviewed
What should be noted about effect?
- Types of affect observed
- Range and reactivity of affect
- Congruity of affect
What is blunt affect almost pathognomic for?
Schizophrenia
What 4 sections can thinking be organised into?
- Speed and tempo of thoughts
- Types of thoughts demonstrated
- Linkage and though form
- Possession of thoughts
What may decreased speed of thought suggest?
- Depression
- Schizophrenia
- Dementia
- Other organic brain disease
What may rapid, incoherent speech suggest?
Mania
What type of thoughts can be demonstrated?
- Preoccupations
- Phobias
- Obsessions
- Overvalued ideas
- Delusions
Delusion
An unshakable idea or belief which is out of keeping with the person’s social and cultural background; it is held with extraordinary conviction
What types of delusions are there?
- Primary vs secondary
- Partial vs full
- Grandiose
- Paranoid
- Hypochondrial
- Self referential
Formal thought disorder
A pattern of interruption or disorganisation of thought processes
How can formal thought disorders be specified?
- Thought blocking
- Fusion
- Loosening of associations
- Tangential thinking
- Derailment of though or knights move
In what condition is abnormal possession of thoughts commonly reported?
Schizophrenia
What forms of abnormal possession of thoughts are there?
- Thought insertion and withdrawal
- Thought blocking
- Thought broadcasting
What are the 3 classes of perceptual disturbances?
- Hallucinations
- Delusions
- Pseudo hallucinations
What senses can be involved in hallucinations?
- Auditory
- Visual
- Tactile
- Olfactory
- Gustatory
What is a hallucination?
A false perception of something that is not really there as it lacks an external stimulus
What is a pseudo hallucination?
An experience described by a patient but judged by the psychiatrist as not perceived as such by the patient
What is an illusion?
A false perception due to misinterpretation of the stimuli arising from an object
What does formulation of the case allow?
Allows consideration of the diagnosis in the context of the individual’s particular personal and medical history
