History Taking, Mental State Exam and Making a Diagnosis Flashcards
What should be considered when choosing the setting for the history taking?
- Privacy, avoid interruptions
- Informal setting
- Avoid barriers and respect personal space
- Easy exit
What factors should be considered when considering safety when taking a psych history?
- Treating team
- Violence (unusual)
- Inform staff who you are interviewing and where
- Look out for autonomic overactivity, posture and verbal aggression
- If uncomfortable end the interview
What should be included in a psych history?
- PC/HPC
- Past psychiatric history and PMH
- Current and recent medication
- Social history
- Family history
- Personal history: developmental milestones, schooling/education, occupational history, relationships and pre-morbid personality
When asking about the presenting complaint what would you ask about?
- Why they are here (note each complaint and assess separately
- Oncet, precipitants, course and severity
- Associated symptoms
- Effect on daily living
- Getting worse or better
- Has it responded to treatment
- Has your partner/family/friends noticed any changes in you
- Systematic enquiry: depression, obsessions, anxiety and psychosis
Which questions might you use to explore perception (psychotic symptoms)?
- 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?
Which questions might you use to explore beliefs/thoughts (psychotic symptoms)?
- Has anything in particular been playing on your mind?
- Do you know why this is happening?
- Have you noticed any change in your thoughts?
- Has anyone interfered with your thoughts?
- Does anyone else have access to your thoughts
What do you need to ask the patient about their past psychiatric history?
- Past episodes/diagnoses/contacts
- Previous treatments
- Inter-episode functioning
- Previous admissions to hospital
- Attempted suicide/repeated DSH
- Previous detentions under Mental Health Legislation
What is important to ask about the patient’s family history?
- Parents, siblings, grandparents etc.
- Age, employment, circumstances, health problems and quality of relationship
- Major mental illness in more distant relatives
- Genogram
What is important to ask about in a patients PMH?
- Developmental problems
- Head injuries
- Endocrine abnormalities
- Liver damage, oesophageal varices and peptic ulcers
- Vascular risk factors
What is important to ask about a patients medication?
- Tablets and injections
- Recent medications
- Discontinued drugs (within the last 6 months)
- How long the medication has been taken for and at what dose
- Adverse reactions and allergies
What should be asked about a patient’s social history?
- Social circumstances incl. occupation
- Current financial situation/stressors
- Smoking/alcohol/illicit drug use
- Current relationship/stressors
- Children: contact
What needs to be asked in an alcohol/illicit drug history?
- Regular or intermittent
- Amount
- Pattern
- Dependence/withdrawal symptoms
- Impact on work, relationships, money and police
- Screening questionnaires e.g. CAGE
What needs to be asked as part of a personal history?
- Developmental milestones
- Early life
- Schooling
- Occupational
- Relationships
- Financial
- Friendships, hobbies and interests
What should be asked in a forensic history?
- Contact with the police, charges
- Offences including sentences
- Recidivism (reoffending)
- Particular attention to violent or sexual crimes
What is pre-morbid personality
- Patterns of behaviour, interaction and mood
- Important to corroborate
- How would their best friend describe them?
What is assessed in a mental state exam?
- Appearance
- Behaviour
- Mood
- Speech
- Thoughts
- Beliefs
- Percepts
- Suicide/homicide
- Cognitive function
- Insight
Which features of the patients appearance would you take note of?
- Height/build
- Clothing: appropriate/inappropriate, kempt and bizarre
- Personal hygiene: clean/unshaven/malodorous
- Make up, jewellery and accessories
- Evidence of side effects of medication or intoxication
Which features of a patient’s behaviour would you take note of?
- Greeting
- Non verbal cues
- Gesturing: normal/expansive/bizarre
- Abnormal movements: tremor, choreioathetoid movements, posturing and akathisia
- Cooperation and rapport
- Response to unseen stimuli
Which features of a patient’s mood would you take note of?
- Eye contact
- Affect: objective manifestation of mood
- Mood rating: subj and obj
- Psychomotor function: retardation and agitation
Which features of a patient’s speech would you take a note of?
- Spontaneity
- Volume: loud/quiet/poverty
- Rate: pressured or slow
- Rhythm: rhyming and punning
- Tone: monotonous/lilting
- Dysarthria
- Dysphasia: expressive/receptive
List the possible abnormal thoughts a patient might present with
- Phobias
- Obsessions
- Flights of ideas
- Formal thought disorder: broadcast, echo, insertion, block and withdrawal
- Knight’s move, derailment and loosening
List the possible abnormal beliefs a patient may have
- Preoccupations
- Over valued ideas
- Delusional beliefs: fixed, false belief out of cultural context and extraordinary conviction
List the abnormal percepts a patient may present with
- Illusions
- Hallucinations and pseudohallucinations
- Auditory/visual/somatic/tactile/olfactory and gustatory
What should be asked about suicidal/homicide in a mental state exam?
- Must ask about suicidal thoughts
- Ideation
- Intent
- Plans: vague, detailed, specific and already in motion
- Homicidal risk
How can cognitive function be assesed?
- Orientation: time, place and person
- Attention/concentration
- Short term memory
- Long term memory
- If any concerns then perform objective tests (MSQ, MMSE, MOCA, FAS, clock function and executive function tests etc.)
How can a patient’s insight be assesed?
- Are symptoms due to illness
- Is this a mental illness
- Do they agree with the treatment/Mx plan?
What is psychopathology?
Study of abnormal experience, cognition and behaviour
What does descriptive psychopathology do?
It describes and categorises the abnormal experience as described by the patient
What is phenomenology?
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 feels like
What is a delusion?
- An unshakeable idea or belief which is out of keeping with the person’s social and cultural background (it is held with extraordinary conviction)
- E.g. grandiose, paranoia, hypochondriacal and self referential
Which questions should you ask about delusional beliefs?
- Is anyone deliberately trying to harm you
- 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 is a though disorder?
- A pattern of interruption or disorganisation of thought processes that is broadly referred to as a formal thought disorder
- More specifically: thought blocking, fusion, loosening of associations, tangential thinking and derailment of though
Which questions can be asked for abnormal possession of thoughts/thought alienation?
- 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?
Describe the difference between the 3 classes of perceptual anomalies
- Hallucinations: perception of something in the absence of a stimulus (e.g you can see an object or hear a voice that isn’t there)
- Pseudohallucinations: an involuntary sensory experience that the patient can recognise is not real
- Illusion: there is a real perception but it is perceived to be something it is not
Which questions should you ask in a present state examination?
- Do they ever 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 with touch/taste/smell
