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Psychiatry > History taking in Psychiatry > Flashcards

History taking in Psychiatry Flashcards

1
Q

What components make up a psych assessment?

A

Psych Hx (detailed history) + MSE (snapshot of patient today) + risk assessment (summising key ppints from Hx and MSE/like a systems review related to psych risk) –> formulate/summary Px

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2
Q

What are the parts of a psych history that are different to a normal history?

A
  • circumstances of referral (sectioned etc) - what did the patient say happened
  • Past Psychiatric history - understanding previous hospital admissions, what helped / what didn’t
  • Development history
  • Personal history (Inc. early life, education, occupation and sexual history & pre-morbid personality)
  • Forensic history
  • Collateral Hx
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3
Q

What are the components of the MSE?

A 
ABS MAT PCI and sleeping and appetite
- Appearance
- Behaviour
- Speech
- Mood
- Affect
- Thoughts 
- Perceptions
- Cognition
- Insight
\+ Sleep and Appetite
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4
Q

What does a risk assessment entail?

A

Looking at summarising the key points of the Psych history and MSE –> relating them to psychiatric risk including:
- To self
- From others
- Too others
- Accidents (e.g. neglecting personal safety)
and any other risk behaviours

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5
Q

What is the total psychiatric history?

A

1) Presenting complaint
2) History from others
3) Past psychiatric history
4) Premorbid personality
5) Past medical history
6) Family history
7) Personal history
8) Social History
9) Current medication
10) Tobacco, alcohol and drugs
11) Forensic history

+ MSE
+ RISK ASSESSMENT
+ SUMMARY & MANAGEMENT PLAN

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6
Q

What is a useful way to explore a patients presenting complaint?

A

N.O.T. S.A.D

Nature
Onset
Treatment [+ outcomes]
Severity [+ functional impact]
Alleviating / Aggravating
Duration [+ progression]

The PC may be regarding details of an episode indicative of risk

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7
Q

If someone has a PC of self harm/suicide - what are useful questions to ask?

A

Intentions/feelings:
How did you come to be here/get to A&E?
Did you want to die?
Do you know why you did it?
How dangerous did you think this may have been?
Did you want to die or escape your current situation?
Were you ordered to do it by voices / ideas put in your head / other persons or agencies? - are the voices saying you should kill yourself expressing what YOU actually think of yourself?
Are you sorry to survived?

Act Circumstances:
Did anybody see you take the overdose? - Did you tell anyone about it?
(were you expecting a visitor when you did it?)
Did you try to make sure you weren’t found?
Why do you think your suicide attempt failed?

Background to the act:
Did you plan this? For how long?
Do you feel you deserve punishment as you hate yourself?
Does harming yourself give you some relief?
What response were you hoping for from other people to your self harm?

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8
Q

What questions for PC could you ask someone about their current episode of depression?

A
  • Appetite?
  • energy?
  • enthusiasm?
  • Enjoyment?
  • Concentration?
  • Sleep?
  • Confidence?
  • hope?
  • Self esteem
  • Tears (how often in last week)
  • Guilt
  • Dinural variation in mood (gets better throughout day compared to in morning)
  • Social: withdrawal & avoidance
  • Rumination
  • Anxiety / panics
  • Self-care
  • Suicidal thoughts and intent
  • Ask patient to rate depression on a scale of 1:10 - 1 = immediate suicidal intent and 10 = completely fine
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9
Q

What questions could you ask about the PC of a current episode of psychosis?

A

Insight -
do other people think you have a mental illness?
Concentration - do you have trouble keeping to the subject?

Paranoia
- do you feel comfortable walking in a crowd? - do people seem to be looking at you in the street? any difficulties with the neighbours? - do you think you might be being oversensitive?–> that sounds unusual to me, what do you think?

Voices:
Thought block / insertion / echo?
What do the voices say? Talking to you/each other/ how many?
an they control or influence you in any way?

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10
Q

What PC questions can you ask someone in a current hypomanic episode?

A

How much sleep are you getting?
Thoughts:
Can you get what you want to say out?
Are your thoughts going at a good place?
Got plenty of good ideas?
Are people a bit slow for you?
Temperament:
Have you lost your temper with people?
been overfriendly, over familiar, said things you may regret later? Told your boss what you really think of him?
Have you been very witty, creative, realised your own very high potential,
/driving your car better, did you crash, could you be hurt?

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11
Q

What particularly is useful to ask regarding a history from others/collateral?

A

~ Useful for issues where the patient may not be aware of them: weight loss, social withdrawal, thought disordered speech, inappropriate affect etc
Timeline: When did you first notice something wrong?
Was he like this months/years ago/ as a young man?
Condition (psychosis, depression, substance abuse): does he make you feel responsible for him?
Does he appear to hear voices / be perplexed / go off the point / smile or cry for no reason/appear suspicious/believe things which are not true/make odd movements?
Have they ever assaulted anyone? Self-harm?
Can you trust his reassurance that he wont attempt suicide?
Could he be using drugs without you knowing? ~that’s what he says but what’s your opinion?

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12
Q

What information should be gleaned from the past psychiatric history?

A

should give a chronic account of duration, nature & management of ALL past psychiatric illness
episodes which were not brought to the attention of doctors or treated should also be
included
[If episodes are the same illness then this can be abbreviated to the dates and which treatments tried with what effects]
inc. Dx, syx, date, treatments, hospital / dr and outomes for each episode is required + clarify: compliance, benefits, side effects

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13
Q

What are useful questions in the past psychiatric history?

A

Have you ever had any mental health problems before?
Have you ever seen anyone for mental health problems?
Have you ever suffered from ongoing or severe:
- Anxiety: nervousness, depression,
- Mania: extreme prolonged excitement/ elation, altered sense of reality,
- Psychosis: seeing /hearing things that others couldn’t/
- alcohol or drug abuse,
- Depression: deliberate self harm, suicide

Admission - or hospitalisation for any psychiatric illness?

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14
Q

What is a pre-morbid personality?

A

The patients personality and functioning before the onset of illness should be elicited. Could also be good that the history comes from others with long term knowledge
Personality = enduring characteristics of behaviour and includes:
- Cognitions (way of thinking)
How did you cope when something went wrong?
- Affectivity (emotions and feelings)
What was your temperament like?
- Behaviour (interpersonal, reaction, self-control)
How did you get along with other people?
- Talents (music, public speaking, wit, sporting ability)
- Interests (politics, reading, music, religion, TV, films)
What activities did you do, what interest did you have?

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15
Q

What questions are useful / should be asked in a past medical history?

A

*usually the same as any standard med or surg patient history, including: Diagnosis / syx / date / effect on patient / hospital / doctor / outcome. Inc. surgery and any non-medical treatment / interventions and their outcomes. NOTE: The psychological effects of medical illnesses and those which can cause psychiatric syx e.g. hypothyroidism and SLE
PMH - have you had any serious illnesses, hosp admissions, operations or health problems (that have affected you a lot?)
have you had any prescription medicines?
are you currently seeing a doctor or receiving any treatment?
have you ever been admitted to hospital or had any operations?

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16
Q

In psych what should you ask about family history?

A

Hx of illness particularly psychiatric

Has anyone in the family ever had any psychiatric illness? - dx, tx, admissions & outcomes

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17
Q

What is in a personal history?

A

upbringing: who brought them up?
and any changes to this / ages they took place
Were you separated from the family at any stage?
family structure with genogram
changes of residence and school
note the relationships between parents/guardians/carers themselves
How did they treat eachother? treat you?
& how the child was treated by each of them up till adulthood
e.g. hit, frightened, spoilt, disapproved of, loved, belonged, abused sexually/physically, ignored, punished, criticised,
How old when:
age of finishing school and academic achievements, age of leaving home.
Employment history - what was the longest job held?
Significant (romantic) relationships: What’s the longest relationship you’ve had?
How long (e.g. age 25-29), how did they treat each other, why did it end, children of the union (names and ages and who they live with)
other pregnancies

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18
Q

What should be asked in a social history for a psychiatric hx?

A 
"How would you spend a normal day?"
Accommodation
Activities of daily living
Finances 
Social support network - Fam, friends, colleagues and neighbours
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19
Q

How do you ask about current meds?

A

ALL current drug intake needs to be recorder including prescribed, alternative, OTC, psych and non psych. + allergies + drug rxns
any meds?
injections on a regular basis? (depo)
health supplements? herbal remedies? alternative medicine?
had any reaction to any medication or anything?

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20
Q

How to ask about tobacco, alcohol and drugs?

A

Record now - current use, amount, freq, periodicity/binging and triggers “what do you think makes you use substances in this way?”

record prev - age of first use, fluctuations in use, (“when was the last time you had a day/week/month without…?” periods of abstinence “why did you stop?” or lack of them, syx of physical dependence

How did you pay for them?

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21
Q

What needs including in a forensic history?

A

in chronological order record the details of all offences, charges, convictions and sentences passed

Do you have a criminal record? Spent any time in prison? any court cases pending?

& mention any impact this has had on the patients life and their attitude towards their past

22
Q

What is the MSE?

A

Systematic record of patients demeanour and functioning @timeof interview
ABS MAT PCI
Appearance and Behaviour, speech , mood, affect, thoughts, perceptions, cognitions, insight +sleep & appetite

23
Q

What should you look at for appearance and behaviour?

A

Record how they look: Physical appearance (general appearance, nutritional state: avg build, over/underweight, slim, emaciated, frail, self-care: clean, groomed, unkempt, neglected, clothing: smart, casual, neat, shabby, appropriate, unconventional)
eye-contact (normal ~30%), facial expression, posture, gesture, movement & actions (e.g. relaxed, tense, rigid, abnormal movements, tremor, retarded levels of activity, agitated)
response to situation and rapport established: co-operative, overfamiliar, distant, distracted, reserved, guarded, suspicious, hostile

24
Q

What should be looked for with speech?

A

how the patient speaks & how much info they convey:
rate, volume and quality of speech e.g. quick, slow, loud, whispered, emphatic, monotonous, slurred, accented, incoherent
Do they speak spontaneously, freely or only reluctantly?
are their responses to qs relevant? informative? repetitive?
if they use neologisms (seemingly non existent words, write them down)

25
Q

What is poverty of speech?

A

marked lack of spontaneous speech
TF the replies to qs if given at all are very brief or even monosyllabic and often mumbled.
Often associated with severe depressive illness.

26
Q

What is pressure of speech?

A

A marked excess of spontaneous speech that is rapid, difficult to interrupt and often loud
frequently associated with flight of ideas.
(especially associated with mania)

27
Q

What is flight of ideas?

A

where speech runs from one subject to another on the basis of inconsequential links such as rhymes, puns & double meanings.
try to note verbatim example
pressure of speech and flight of ideas are especially associated with mania…

28
Q

How do you comment on mood in MSE?

A

Subjective mood - how patient reports their mood
&
Objective mood - how you observe it to be e.g. objective mood or affect

29
Q

What is euthymic affect?

A

“normal” mood
- is somewhere in the middle of usual range but variable in reaction to circumstances
Consider the pts emotional tone as a way of observing deviations from the norm, and also reactive variability. e.g. emotional tone can be abnormal and then the degree of reactive variability if exaggerated or diminished e.g. depressed affect will often be associated with loss of reactivity

30
Q

What is incongruity between the patients emotions and circumstances?

A

e.g. smiling broadly while describing persecution by neighbors is incongruity between patients emotions and circumstances

31
Q

What is a restricted or blunted affect vs flat affect?

A

a notable decrease in both intensity and variability of emotional expression

32
Q

What is labile?

A

Contrasts to flat affect - varying frequently and often quite abruptly between extremes

33
Q

What are the components of thought in the MSE?

A

How the patient thinks - thought form
Their sense of ownership of their thoughts (possession)
What they think about (content)

34
Q

What is thought form?

A

If the patients ideas follow a conventional logical progression
disorder of thought form - a formal thought disorder, denotes thinking disrupted by illogical shifts that proceeds from one idea to another without an discernible connections between the ideas
Formal thought disorder is especially associated with schizophrenia.
if mild the shifts are infrequent and overlooked, if = more frequent illogical shifts then there is a more severe thought disorder and easier to detect
NOTE: How these shifts occur as a measure of the severity of thought disorder. Their train of thought is more or less difficult to follow.

35
Q

What is thought block (part of thought)?

A

Patient suddenly stops talking for a few seconds and maybe unable to retrieve what they were talking about
if asked what just happened they may say their thoughts hit a block or just went
NB: not the same a losing concentration
Ask:
Do you ever have any difficulty thinking?
Do you ever completely lose your train of thought?

36
Q

What is thought withdrawal and thought insertion?

A

Disorders of thought possession (as opposed to content or form), where the individuals own thoughts are being taken from them or thoughts that are not their own being put into their head
Do you ever experience you thoughts being interfered with?
Do your thoughts ever get taken out / put into your head?
Are the thoughts in your head always your own?

37
Q

What is thought content?

A

What is on the patients mind…
What has been on your mind lately?
any preoccupations, “Is there anything you have been giving a lot of thought to?” worries, obsessions, overvalued ideas, delusions

38
Q

What are obsessions?

A

Recurring distressing thoughts that intrude into consciousness in spite of resistance
the patient recognise them as their own thoughts though and that they are irrational
Do you get stuck with the same thoughts over and over again?
Do they come into your head even if you don’t want them?
How do they make you feel when you get them?
What do you do when you get them?

39
Q

What are overvalued ideas vs delusions?

A

These are unreasonable and sustained preoccupations that are less intense than delusions.
Delusions = beliefs that are incorrect inferences about reality, firmly held in spite of evidence to the contrary and not explicable in terms of cultural, religious or social norms
Do you have any particular ideas that other people disagree with or say aren’t true?
To help in exploring the main types of delusions - how do you get on with people? can you take what they say at face value? do they say thinks that have another meaning? Drop hints about you? watch you? talk about you behind your back? feel things are set up? feel tested? coincidences? everyday things have a particular meaning?

40
Q

What are good qs to ask for persecutory (delusions)?

A

How do you get on with people?
Do you ever feel that you are being targeted or tormented?
Do you worry that people want to harm you?

41
Q

What is somatic passivity?

A

Do you ever feel that you have no will of your own? Do you ever feel that your actions are being controlled? (NB: not by a higher power, will subversion by an external agency that only the individual may be able to specify)

42
Q

What are good questions to ask regarding guilt or grandiose delusions?

A

Guilt: how do you feel about yourself?
Do you feel that you may have caused anyone hurt or harm?
Do you feel as if you deserve to be punished?
Grandiose:
Are you a person of influence? do you feel that you have any special talents or powers?

43
Q

What is abnormal perception?

A

“Have you ever heard, seen or smelt anything others couldn’t?”
Have you ever heard voices?
Hallucinations or illusions and depersonalization/derealisation which is a distorted perception in which they and/or the world around them feels as if its unreal
Hallucinations = false perceptions in the absence of any real external stimulus e.g. seeing, hearing, feeling, smelling or tasting something that isn’t there
Illusions = false perceptions of real external stimulus i.e. misperceiving something that is there

44
Q

What are important questions to ask if a patient reports hearing voices?

A

Is it one voice or more?
Through your ears, like im talking to you now?
What kind of things does it / do they say?
Does it/ do they talk TO you?
Do they tell you to do things? - what kind of things? - what do you do if it tells you to do something?
Does it/do they talk about you as if you weren’t there?
Do you known whose voice it is/they are?

45
Q

What is cognition and useful questions to ask for it?

A

Cognition section = noting any impairments of orientation, concentration and memory
gleaned from Hx and responses to interview
Disorientation in person, place or time is important
- Where are we?
- What day/month/season is it?
- Who am i? (repeated shortly after telling the person and checking they got it right before moving on)

46
Q

What is insight and useful questions regarding it?

A
  • The patients understanding of their situation
  • It is not all or nothing and may fluctuate
    –> do they think their experiences are abnormal?
    What is their explanation for these experiences?
    Do they think that they are unwell?
    Do they think that they are in need of some kind of help?
    If so, what kind of help?
    Do they think that mental health services can help?
47
Q

What is a risk assessment?

A

To see whether the patient poses a risk to themselves or others or is at risk from others
the extent of RA needed will be largely determined by the circumstances of the assessment and nature of the presenting history and mental state.
Unless the assessment has already made it clear that they pose no risk of harm to themselves, all patients should as a minimum be screened for the risk of harm to themselves w/ a questions hierarchy
- to self
- from others
- to others
- Accidents / other risk behaviour

Common causes of the various risks are depression, schizophrenia, PD in crisis and hypomania which are all made worse in the presence of substance use or abuse

48
Q

What can provide risk to self and are useful questions to ask?

A

Common risks include DSH: have you ever intentionally caused yourself any harm? suicide: what are your hopes / plans for the future? do you ever feel as though there is nothing worth living for? have you ever had any ideas of ending it all? have you ever acted on these ideas/made any plans/taken any action?
neglect, dangerous driving, dangerous liasons, belief in indestructability, (do you think any harm might come to you being so confident?)unawareness of physical dangers, provocation of others, poor judgement in matters of finance, social life, work, study, housing, substance use
do you have to obey (dangerous) voices/thoughts? Do you think you will act on this (dangerous) belief?

49
Q

How can you assess harm from others?

A

This could be violence in response to the persons challenging or provocative behaviour or from exploitation of vulnerabilities.
Sexual disinhibition –> hypomania, schizophrenia and intoxication states for example
Do you get into fights?
Could you be pregnant?
have you been buying things for other people or lending them money?
are you letting someone else stay at your place?
is someone else taking your stuff, using your car, ipod etc?

50
Q

What questions can you ask about risk to others?

A

Direct violence:
Violence to others, objects, animals?
What made you violent? were alcohol or drugs involved?
Specific person or anyone?
Did you know the victim? Sorry for what you did? any choice in what you did? commanded by voices? under compulsion that you could not resist?
Did you intend to harm/kill/injure that person? did you feel justified in what you did?
Could this happen again?
Neglect: Were you worried about the possibility that… did it occur to you that…
did you take care to make sure…
–> inquire about accidents e.g. neglect of personal safety
Recklessness:
what do you feel was your duty or responsibility in that situation?

51
Q

What should be included in the summary and management plan?

A

Briefly describe (1) the salient features of the patients clinical presentation,

(2) significant risk issues,
(3) diagnosis and any actions recommended including advice, medication and any arrangements made for follow up

Psychiatry (6 decks)

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