HX taking, MSE and making a diagnosis

Question 1

what would you ask about related symptoms? (questions below are how/what to ask for the categories of the psychiatric hx)

Answer 1

what other changes hhave your parents/partner/family/friends noticed in you? Ask about specific symptoms, systemic enquiry.

Question 2

what would you ask about psychotic symptoms?

Answer 2

“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 commands.

Question 3

how to ask about beliefs/thoughts

Answer 3

“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?”

Question 4

past psychiatric hx

Answer 4

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

Question 5

family hx

Answer 5

Parents, siblings, grandparents etc, Age, employment, circumstances, health problems, quality of relationship, Major mental illness in more distant relatives is important, Genogram can be helpful

Question 6

past medical hx

Answer 6

Developmental problems, Head injuries, Endocrine abnormalities, Liver damage, oesophageal varices, peptic ulcers , Vascular risks factors

Question 7

current and recent medicationn hx

Answer 7

Ask about tablets and injections, Ask about medication recently , Any drugs discontinued (within past 6 months) , Ask how long medication has been taken for and at what dose, Ask about adverse reactions and allergies

Question 8

social hx

Answer 8

Social circumstances including occupation, Current financial situation/stressors, Smoking/Alcohol/illicit drug use, Current relationship/stressors, Children - contact

Question 9

alcohol and illicit drug hx

Answer 9

Regular or intermittent, Amount (know the units), Pattern, Dependence/ withdrawal symptoms, Impact on work, relationships, money, police, Screening questionnaires eg CAGE

Question 10

personal hx

Answer 10

Developmental milestones, Early life, Schooling, Occupational, Relationships (sexual & marital history), Financial, Friendships, hobbies and interests

Question 11

forensic hx

Answer 11

“Have you ever been in contact with the police? Charged with any crime?”, Offences including sentences, Recidivism, Particular attention to violent or sexual crimes

Question 12

premorbid personality

Answer 12

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?”

Question 13

appearance

Answer 13

Height/Build , Clothing - appropriate/inappropriate, kempt, bizarre, Personal hygiene - clean/unshaven/malodorous, Make up, jewellery, accessories

Question 14

behaviour

Answer 14

Greeting , Non verbal cues, Gesturing - normal, expansive, bizarre, Abnormal movements - tremor, choreioathetoid movements, posturing, akathisia, Cooperative, rapport

Question 15

mood

Answer 15

Eye contact, Affect – objective manifestation of mood at i/v, Mood rating – subj & obj; rate out of 10; Psychomotor function - retarded, agitated

Question 16

speech

Answer 16

Spontaneity, Volume - loud, quiet, poverty, Rate - pressured, slowed, Rhythm - rhyming and punning, Tone - monotonous, lilting, Dysarthria, Dysphasia - expressive/receptive

Question 17

abnormal thoughts

Answer 17

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

Question 18

abnormal beliefs

Answer 18

Preoccupations, Over valued ideas, Delusional beliefs - fixed, false belief out of cultural context; extraordinary conviction

Question 19

abnormal percepts

Answer 19

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

Question 20

suicide and homicide

Answer 20

Must always ask about suicidal thoughts, Ideation, Intent, Plans - vague, detailed, specific, already in motion, Also homicidal risk

Question 21

cognitive function

Answer 21

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

Question 22

insight

Answer 22

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?

Question 23

What is Psychopathology, Descriptive Psychopathology and Phenomenology

Answer 23

Psychopathology is concerned with abnormal experience, cognition and behaviour.
Descriptive Psychopathology describes and categorizes 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 patient’s experience feels like.

Question 24

what does a MSE consist of?

Answer 24

appearance, behaviour (affect) mood, speech, thinking, perceptual anomaly, cognitive function, insight, risk assessment for homocide/suicide

Question 25

what are the 4 categories to consider when asking about thinking?

Answer 25

speed, types demonstrated, linkage, possession of thoughts

Question 26

types of thoughhts displayed at MSE

Answer 26

preoccupations, phobias, obsessions, overvalued ideas, delusions.

Question 27

what are the 3 classes of perceptual anomalies?

Answer 27

hallucinations, pseudohallucinations, illusions

Question 28

Case…

Answer 28

31 year old unmarried teacher complaining of “severe depression” and suicidal ideation in context of alcohol misuse.
Felt “down” when left home to go to teacher training college12 years ago but recovered within weeks without medical intervention.
In recent episode GP commenced oral treatment with Citalopram 20mg 2 months ago but she did not collect 2nd prescription as not helping.
Grandfather who died had depression all his adult life and some question of his death being suicide. Younger brother Eric attends this hospital as outpatient for treatment of depression. Elder brother and a niece have alcohol problems.
No childhood illnesses hospitalisations or developmental delay after normal delivery.
Lives with mother in a council house.
Working at local secondary school as guidance teacher, “used to love job”.
Heterosexual but no longterm relationships. Not currently in a relationship.
Non-smoker, denies any street drug experience, no debt, denies past or current forensic history.
One best friend is her confidante but not available in view of her “horrendous divorce”. No other close friends.
Parallel history from mother: “ Couldn’t ask for a better daughter. Not herself since father died …last 2 months have been awful.”
A 31 year old single teacher presenting as an emergency via her GP with depressive disorder, suicidal ideation and alcohol misuse.
There is no previous psychiatric history. She may have predisposition to depression through previous head injury and is being investigated for thyroid disease. She has a strong family history of depressive disorder. This episode may have been precipitated by a double bereavement and absence of her best friend as confidante.
Differential: Depressive episode, severe without psychotic symptoms, Adjustment disorder, prolonged depressive (bereavement reaction). Organic disorder hypothyroidism

Question 29

what factors are considered in thhe formulation table

Answer 29

biological/psychological/social, predisposers/ precipitants/ perpeturators

Question 30

what are ICD 10 diagnostic criteria for depressive episodes

Answer 30

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)