Lecture - Psychiatric history taking Flashcards by Kishan P

What are the aspects of the mental state examination?

Appearance and behaviour
Speech and thought form
Mood
Thought content
Cognition
Insight
Perception

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What are the components of the psychiatric history?

When presenting start with gender, age, single/married, occupation. Where seen, how they were admitted and whether admitted formally or informally.

PC + HPC
Past psychiatric history
PMH
DH
FH
Sx - substance misuse, forensic history, premorbid personality
Personal history
Collateral history - need consent but not to only listen

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What are the components of cognition? How can it be tested briefly?

Attention
Concentration
Orientation
Memory
Language

Can be tested quickly using a MMSE

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What is insight?

The patient’s awareness that something is wrong, that they are unwell in some way
That the problem is concerning their mental health.
That they require treatment.

Insight is often partial eg patient knows something is wrong but doesn’t think it is to do with mental health or is willing to take medication but doesn’t think they are unwell. Dellusions and hallucinations feel real and it is difficult to accept that they are not.

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What questions should you ask to explore insight?

What do you think it going on for you?
Do you think you are your usual self at the moment?
Are your family worried about you? Is that reasonable?
Could your mind be playing tricks on you?
Sometimes we can have strange experiences when we are under a lot of stress. Could this explain what’s been going on for you recently?
How would you feel about having some treatment?

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What is included in thought content when assessing a patient?

This describes the main themes of a patient’s thoughts

Depressive
Anxious
Obsessional thoughts
Overvalued ideas
Delusions

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What is important to note about a patient’s mood?

If what they say (mood) is congruent with what you see (affect)

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Give examples of formal thought disorder.

Poverty of thought
Racing thoughts
Too much info but still making sense e.g. circumstantial, tangential, over-inclusive
Abrupt stop in speech e.g. thought block or thought withdrawal
Flight of ideas with puns
Clang associations
Distraction
Derailment, knights move thinking, word salad
Neologisms

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What is labile affect?

When someone’s mood appears to change several times throughout the consultation

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How do you describe speech?

Rate - normal, fast, slow
Volume - normal, soft, loud
Tone - calm, hostile, sarcastic
Flow - spontaneous,hesitant, uninterruptible

Rate can be changed in anxiety, mania, psychosis

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What is knights move speech?

there is no link between the ideas or words

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What is derailment vs word salad vs neologisms?

Derailment aka knights move thinking e.g. “the traffic is rumbling along the main road. They are going to the north. Why do girls always play pantomime heores.”

Word salad e.g. “picture cake chocolate rambling UFO solar here fuse barking”

Neologisms - made-up words

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What are clang associations?

Words sound the same but do not mean the same things

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What is the word used to describe when someone’s thoughts and behaviours are in conflict with their needs and goals of the ego? What condition does this occur in?

Egodystonic (ego alien) occurs in OCD

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What should be included when describing appearance and behaviour?

age, gender, build
levels of self care, clothing
scars, pircings, tattoos
facial expression, posture
eye contact
level of activity
odd movements
engagement

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What is auditory verbal hallucination? Is it alway abnormal? What questions should you ask?

Internal monologue experienced as external/other

Experienced by ~5% of the healthy population

An antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficultues and poor coping, plus family history of psychosis etc

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What is the purpose of delusions thought to be?

Fixed, false, unshakeable belief, out of context with cultural background. Warning: can be tricky to define “false”

Often persecutory may be due to…

default to fear in the face of uncertainty?
related to experiences of being controlled/persecuted/to blame etc?

Result of efforts to make sense of perplexity?

“Doxastic shear-pin”: allow continued function in the face of paralysing uncertainty
It is importnat to think about what in their life may have caused them to feel as described as above and have that specific delusion.*

What are Schneider’s First Rank symptoms of schizophrenia?

Delusional perception
Thought interference
- Thought insertion
- Thought withdrawal
- Thought broadcasting
Auditory hallucinations -
- Third person
- Thought echo
Passivity phenomena (delusions of control)

What is thought interference? What types of thought interference occur in schizophrenia?

Thought interference - this is the delusional belief that someone or something is interfering with your thoughts (literally, not influencing, not persuading).

Thought insertion - an alien thought is placed in your mind, it is not your own (cf. obsessional thoughts). Patient will often say the thought feels odd, different to their own.
Thought withdrawal - your thoughts are being removed from your mind, suddenly gone. This can be very distressing.
Thought broadcasting - your thoughts are available for the public to hear/know eg being played on a loud speaker, written out on large signs, notices, etc.

What is an illusion? How does this differ with hallucination?

Illusion - Misperception of a stimulus e.g. walking at night and you think there is a shadow of someone following you but when you look no one is there

Hallucination - Perception in the absence of a stimulus and can affect any of the 5 senses

What questions can you ask to screen for hallucinations?

E.g. if asking them to kill themselves you need to ask how they respond to this i.e. do they need to do it or can they ignore it?

What is the difference between a second and third person hallucination? Which is most common in schizophrenia?

Easy way to remember is 2nd person there are 2 people (you and another person) and 3rd person is at least 3 people (you and two other people talking about you)

Usually 2nd person in depression and 3rd person in schizophrenia.

How do you test the strength of the delusion?

Delusional system – where there are lots of associated delusions developed to support the main delusion i.e. that from another planet.

What is thought echo?

There is a voice repeating the person’s thoughts

What is a delusion? Is the patient aware that they are dilusional?

Fixed, false beliefs, held despite rational argument or evidence to the contrary. They are out of keeping with the person's cultural or social background. T**o the patient this is completely true** and usually very important.

What are the types of delusions?

Primary delusions - occur out of the blue Secondary delusions - develop after another symptom e.g. hearing a voice, smelling something Types of delusions: * Persecutory (most common) * Grandiose * Nihilistic * Hypochondriacal * Of guilt * Of reference * Erotomania * Of thought inference e,g, that someone is speaking to them from radio/TV

What is delusional perception? Give an example.

You see something normal and it triggers a delusional belief e.g. "the girl crossed the road and I knew I would be queen by the end of the day"

What types of auditory hallucinations are seen in schizophrenia?

**Third person** - running commentary on what the person is doing, or voices talking abourr the patient and judging them **Thought echo** - the patient hears a voice repeating exactly what they are thinking

What is passivity phenomena?

**Passivity phenomena** - delusions of control. This is the delusional belief that your movements, emotions or impulses are controlled by someone/something else i.e. not originating from you

How do you explore passivity phenomena with a patient?

* Do you ever feel that someone else is moving your body, without your involvement?* * Do you ever feel that someone or something else is controlling your emotions, making you laugh or cry randomly for no reason?*

What questions do you ask about delusions? Give examples.

If there is no obvious odd belief, you need to screen * *Is there anything unusual going on that’s been troubling you?* * *Have you had an odd experiences recently that you can’t explain?* * *Is anyone trying to harm you?* Once the patient has started telling you their story, listen carefully, be curious, ask logical questions, pick up on cues _‘My neighbour is poisoning me’_ * How do you know? * ‘She always smiles at me. I know what she’s up to’ * What’s that? * ‘She’s putting something in my food, she’s making me sick. She’s gassing me’ * Can you tell me how she is doing that? * How does she get to your food? Does it taste/smell different? Can you smell something unusual? * Why does she want to poison you? * Who else has noticed this? _'MI5 are monitoring me’._ * *How do you know?* * *'They’re watching me. Always hanging around, watching what I do’.* * *Tell me what you have seen?* * *These two women with their babies, they’re always outside my house, talking, laughing, on their phones.* * *Can you hear what they are saying?* * *How do you know they are talking about you?*

What questions should you ask to screen for delusions of reference?

* Does anything feel unusual when you watch TV?* * Do you ever think the programme is about you specifically?* * Do you ever feel that the presenters are talking directly to you?* * Does anything feel unusual when you’re out and about?* * Do you ever think that adverts are aimed at you? More so than others?*

What are the psychaitric symptoms of mania?

* Persistent elevation in mood, can be a mix of elation and irritability * Increased self confidence and wellbeing * Increased throughts reflected in speech, rapid speech, flight of ideas * Behaviour is overfamilia, increased risk taking with spending, substance use, speeding etc. * Psychosis usually in the form of grandiosity

What is an important thing to note in the assessment of mania?

Subjective mood described by the patient Objective observation of the affect

What types of questions should you ask in mania?

Mainly ask about how they are feeling and whether this is usual for them Do you feel better than other people? Do you have special powers? You sound busy, how much sleep are you getting?

What are the biological symptoms of depression?

* reduced need for sleep * increased energy * increased appetite but may be less actual eating * subjectively improved concentration * increased libido

What type of psychosis is seen in mania?

Grandiosity

How do you assess insight?

e.g. if you suggest that something is dangerous and the person dismisses this completely then they may have no insight.

What do you call it when a patient acts like they are your friend and say sometimes rude and honest things?

Overfamiliarity

What is the name for fidgeting?

Psychomotor agitation

What do you mean when you describe someone as reactive?

e.g.When nervous about something that sounds dangerous to most people (even if the thing sounds absurd)

What is meant by blunted?

e.g. when someone is saying less than you would expect them to say