Mental state exam SCP2 and NSB Flashcards
What are the key structures for psychiatric assessments
psychiatric history and mental state examination
Key differences between psychiatric hx and medical hx?
Time - psych is much longer
no definitive tests
multiple meetings before diagnosis
What sort of relationship is formed between HCP and patient in psychiatric interviewing?
Therapeutic relationship, based on strong comms and interpersonal skills.
What key communication/interpersonal attributes are needed for effective interview
-Open, friendly, non-judgemental
-respect autonomy
-sensitive (verbal and non-verbal cues)
-Expressing confidence/calmness
Preparing for interview - SSS?
Space (privacy)
Setting (seats, layout, tissues)
Safety (alarm, seat near door)
How to start the interview?
Introductions
Establish mode of address etc.
ID (think paranoia)
Explain purpose and duration
What are the components of the psychiatric interview? (flexible)
P
H
P
P
M
F
P
S
P
D
F
Presenting problem
History of presenting problem
Past psychiatric history
Past medical history
Medication
Family history
Personal history
Social circumstances
Premorbid personality
Drug and alcohol history
Forensic history
Hx of presenting problem
What are they here?
What happened
How did they arrive
What are they expecting
What needs screening?
Psychosis
Depression
Anxiety
Mania
Suicide risk (don’t be falsely reassured)
Hx presenting problem
Nature
Time of onset
Precipitating factors
Development over time
Ameliorating/excacerbating/perpetuating factors
What have they already tried/who have they seen?
Past psychiatric hx
Dates and symptoms
Treatments and effectiveness
Admissions and duration (mental health section?) Hx of self-harm or suicide?
Is it new or a recurrence of previous issue and does pt agree?
What legal framework for detention can pt be held under? how long
up to 28 days under Section 2 of the Mental Health Act (for diagnosis)
up to 6 months under Section 3 of the Mental Health Act, with further renewals
Past medical hx
Operations and admissions to hospital
Chronic Disease
Head Injury
Current or recent illness
Medications
Allergies and sensitivities
Current regular medications (Adherence &Duration)
Current ‘as required’ PRN medications (e.g. st johns)
How often used?
Over-the-counter medications
Family Hx
-Who makes up the family (parents, siblings)
-Relationships with all family members
-Social circumstances during development
-Are they alive – if deceased, reaction to death?
-Family Medical History
-Family Psychiatric History
Especially: Depression Anxiety Psychosis Suicide Dementia
Personal hx
Early life/development
Education
Occupation
Adult relationships
Early life and development:
Pregnancy, birth and early development
Serious illnesses, developmental delays, bereavements, separations
Describe childhood environment (Deprivation, neglect?)
Educational history:
Schools.
Academic achievements.
Friendships?
Problems? (Bullying, problematic conduct?)
Occupation history:
Jobs types
Duration, reasons for change
Job satisfaction
Relationships with colleagues
Adult relationship history:
Psychosexual history, including sexual orientation and any difficulties
Partner(s)
Any children
Social circumstances
Current description of:
Accommodation
Work
Finances
Social support and contact
Spiritual or religious beliefs
Driving
Daily activities
What does Premorbid personality mean?
“How would your friends and family describe you before this happened”
Temperament
Abilities to form relationships + friendships
Attitudes
Character
Interests
Spiritual beliefs
What can you ask regarding drug an alcohol hx?
Alcohol and tobacco
Illicit or misused substances
What?
When?
Why?
Amount?
How?
Pattern of use?
Dependence?
What is included in a forensic hx?
Arrests
Charges
Convictions
Imprisonments – Duration and index offence.
Violence, weapons?
Probation
Current or pending issues with the Criminal Justice System?
How long are a risk assessment and a MSE valid for?
They are just snap shots of the “here and now” and liable to change -
Also tracking to see how the pt is improving or deteriorating
Risk assessment could cover:
Risks to Self/others (Suicide/violence/abuse/exploitation)
Substances
Fire
Falls
What is MSE?
Mental state examination is a framework and structure for our natural observations
what topics should be covered within MSE?
Appearance and behaviour
Speech
Mood and Affect
Thoughts – Form + Content
Perception
Cognition
Insight
How do you assess appearance and behaviour?
Describe the patient so that someone else could recognise them.
Think
Appearance, behaviour, movement
Behaviours that could be covered
Eye contact or gaze avoidance
Manner towards interviewer (Intimidating, over-familiar)
Rapport/Guarded
Facial expression
Excessive movements (Restless/distressed/agitated)
Decreased movements (psychomotor retardation/stupor)
define tremor
involuntary rhythmic shaking movement in one or more parts of your body.
what’s akathisia
internal restlessness
what is tardive dyskinesia
involuntary repetitive movements often peri-oral
what’s dystonia
muscular spasm of face or body movement/posture
what are tics
sudden, repetitive, non-rhythmic movement or vocalization
what is chorea
repetitive movements of whole limbs, sinusoidal
What mannerisms could a patient display
repetitive, voluntary, purposeful movements
What aspects of speech should be considered?
Rate
Volume
Pressure of Speech (Seen in mania-Fast, constant, hard to interrupt)
What is “euthymic”?
normal mood
what is mood vs affect?
Mood like “climate” - the general situation
Affect is like weather - storms blowing in and out
Give some examples of Affect
Brief emotional state
Reactive/unreactive
Labile
Flattened
Perplexed
Irritable
Incongruous
What is “dysthymic”?
also known as persistent depressive disorder (PDD)
as opposed to elated (ectstatic happiness)
How could you ask about mood? (depressed v elevated)
Have you been feeling low and tearful?
Do you still enjoy the things you used to?
1-10 can be useful
Do you feel hopeful for the future?
How are your spirits?
Have you felt very cheerful or confident?
Do you have more energy and less need for sleep?
Are your thoughts racing?
Have you done anything you wouldn’t usually do?
What biological considerations should be considered as possible links to altered mood?
Appetite
Weight Loss
Sleep
Libido
Concentration
What biological considerations should be considered as possible links to altered mood?
Appetite
Weight Loss
Sleep
Libido
Concentration
Thoughts:
What are stream/form/content?
Stream: How thoughts are flowing – a deluge or a trickle?
Form: The way that thoughts are expressed
Content: What the patient is thinking (saying)
what is a delusion
“Deeply held, unshakable beliefs, out of keeping with social, cultural, religious and educational norms”
Linked with psychosis
what is a delusion
“Deeply held, unshakable beliefs, out of keeping with social, cultural, religious and educational norms”
Linked with psychosis E.g. in schizophrenia, mania, depression, delirium, dementia
What could you ask about delusions?
Do you feel under threat?
How do you know this to be true?
Could there be an alternative explanation?
Do you have experiences that you find hard to explain?
Do you feel that others are out to harm you?
Do you feel under control by anything?
Do you have any special powers?
Does anything have a special meaning for you?
what is an overvalued idea?
type of delusion
Solitary abnormal belief preoccupies the person
Dominates experience and behaviour
what is an overvalued idea?
type of delusion
Solitary abnormal belief preoccupies the person
Dominates experience and behaviour
what is an Obsessional thought?
type of delusion
Repetitive thought, recognised as a product of their own mind
Recurs despite resistance, often distressing
what is suicidal ideation?
Passive suicidal thoughts (ideation)
may also have Intent & Plans
What is an illusion?
A “sensory deception” in response to a stimulus
A combination of the perception of an external object and a mental image to produce a false perception
Associated with anxiety, delirium, intoxication with drugs
How is a hallucination different to an illusion?
A perception in the absence of a stimulus (illusion requires a stimulus that is mis-precieved)
When do hallucinations happen?
Schizophrenia and psychotic disorders
Severe depression or mania
Organic brain conditions
Dementias, delirium, epilepsy, encephalitis
5 types of illusions are…
Sensory Modality
Auditory
Visual
Olfactory
Gustatory
Tactile
how could you ask about hallucinations in an open way?
Have you had any unusual experiences?
Things other people cannot see or hear?
What are 4 aspects of cognition?
Attention
Concentration
Orientation
Short and long term memory
what are three aspects of cognition- orientation
Time
Place
Person
how could you determine if someone is cognitively impaired?
Brief cognitive test if appropriate
What does “insight” mean when a patient is being assessed?
Whether they are self-aware about being unwell and needing treatment or do not accept..
can be partial
What are the 5 P’s?
Presenting problem
pre-disposing factors
protective factors
perpetuating factors
precipitating factors
