history taking, mental state examination and diagnosis Flashcards
2 fundamental components of clinical method in psychiatric interviewing
collection of clinical data
intuitive understanding of the patient as an individual
- collection of clinical data
- descriptive psychopathology
psychiatry history taking; the setting
importance of privacy, avoid interruptions - phone, pagers
informal setting, avoid barriers, respect personal space
easy exit: if only one exit interviewer should have immediate access
psychiatry history taking: safety/risk assessment
treating team/primary nurse
violence is unusual
inform staff who you are going to interview and where
during IV - autonomic overactivity; posture, verbal aggression
-if uncomfortable end interview
overview of psychiatric history: main subheadings
Hx PC past psychiatric history PMH Drug history social history FHx forensic history personal history -developmental milestones -schooling/education -occupational history -relationships -pre-morbid personality
psychiatry history taking: introduction
greet verbally and introduce yourself non-verbal cues orientate and check; -purpose of interview -likely duration interview -not taking, confidentiality, part of team
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 responses
allows a period of non-verbal response from interviewer, listening and facilitating
objectives of psychiatric history
form rapport and gather info
establish and explore symptoms in context of personality and circumstances
explore possible biological and social factors related to symptoms
inform and motivate patient
examine mental state
begin formulation
asking about related symptoms
what other changes have your partner/family/friends noticed in you?
ask about specific symptoms - may be closed q
systematic enquiry to screen for other symptoms e.g. depression, obsessions, anxiety
exploring psychotic symptoms
have you seen or heard anything that other people have not been aware of?
have you heard people talking when there was nobody around?
what do they think is causing them?
past psychiatric history
past episodes/diagnoses/contacts
prev treatments (psychological, drug, physical)
inter-episode functioning
prev admissions to hosp
attempted suicide/repeated DSH (deliberate self harm)
prev detentions under mental health legislation
past medical history
developmental problems head injuries liver damage, oesophageal varices, peptic ulcers vascular risk factors
drug history
tablets, injections medication recently any drugs discontinued how long meds been taking for and what dose adverse reactions and allergies
family history
major mental illnesses
social history
social circumstances, incl occupation financial situ/stressors smoking, alcohol, ilicit drugs releationships children - contact
alcohol/ilicit drug history
regular or intermittent amount (know the units) pattern dependence/withdrawal symtpoms impact on work, relationships, money screening questionnaires
forensic history
contact with police, charged with any crime
offences incl sentences
recidivism
particular attention to violent or sexual crimes
personal history
developmental milestones early life schooling occupational relationships (sexual + marital history) financial friendships, hobbies, interests
pre-morbid personality
difficult to be comprehensive
emphasis on consistent patterns of behaviour, interaction, mood
‘how would your best friend describe you as a person’
mental state examination
appearance behaviour mood speech thoughts beliefs percepts suicide/homicide cognitive function insight
mental state exam: appearance
height/build
clothing: approp/inapprop, kemot, bizzare
personal hygiene: clean, unshaven
makeup, jewellery, accesosries
mental state exam: behaviour
greeting non-verbal cues gesturing: normal, abnormal abnormal movements: tremor, choreioathetoid movements cooperative, rapport
mental state exam: mood
eye contact
affect: objective manifestation of mood at i/v
mood rating: subjectively and objectively (out of 10)
psychomotor function - retarded, agitated
mental state exam: speech
spontaneity volume rate rythm tone
mental state exam: abnormal thoughts
phobias
obsessions
flight of ideas
formal though disorder - broadcoast, echo, insertion
mental state exam: abnormal beliefs
preoccupations
overvalued ideas
delusional beliefs - fixed, false belief out of cultural context
mental state exam: abnormal precepts
illusions
hallucunations
mental state exam: suicide/homicide
ideation
intent
plan
also homicidal risk
mental state exam: cognitive function
orientated
attention/concentration
short term memory
long term memory
mental state exam: insight
best seen as spectrum
very rarely 100% present/absent
are symptoms due to illness?
is this a mental illness?
do you need treatment/hosp?
psychopathology
concerned with abnormal experience, cognition + behaviour - what the patient is telling you
descriptie psychopathology
describes and categorises the abnormal experience as described by the patient
phenomenology
in psychiatry refers to the observation and understanding of the psychological event or phenomenon so that the observer can as far as possible know what the patien’t experience feels like
mood
patient’s subjective report on their current mood state
self raring scale 0-10 (10/10 best)
affect
emotions conveyed and observed objectively during interview
different types of thought displayed at MSE
preoccupations
phobias
obsessions
overvalued ideas e.g. body image distortion
delusions - primary (arise themself) or secondary (to something else)
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
formal thought disorfer
pattern of interruption or disorganisation of thought processes
- thought blocking
- fusion
- loosening of associations
- tangenital thinking
- derailment of thoughts
3 classes of perceptual disturbance
hallucinations
psuedohallucinations
illusions
hallucinations
full force and clarity of true perception
located in external space
no external stimulus, not willed or controlled
perception with no stimulus
formulation of case
consideration of diagnosis and in context of individuals particular personal and medical history
illusion
misperception of a real stimulus
psuedohallucination
like hallucination but not right character/fully realistic
blunted affect
don’t react in way would expect them to (facial reactivity)
wouldn’t be able to read person
congruity of affect
talking about something sad e.g. bereavment and appearing happy - smiling, laughing
