psych history taking Flashcards
What should you do before starting the consultation?
Wash your hands and don PPE if appropriate.
What should you include when introducing yourself to the patient?
Include your name and role.
What should you confirm about the patient at the start of the consultation?
Confirm the patient’s name and date of birth.
How should you address the confidentiality of the consultation?
Explain that what they tell you will be kept confidential unless there is a risk to them or another person.
What should you say to the patient about difficult questions?
I appreciate that some questions may be difficult to answer – if there’s anything you don’t want to answer right now, we can come back to it another time. Does that all sound ok?
Why is it important to explain the areas you will cover in a psychiatric assessment?
Patients may not know that their life story, family background, etc., are important parts of the assessment.
What should you establish about the time available for the consultation?
Establish how much time you have and explain that you may need to interrupt to move on to another area if you have enough information.
What should you ask the patient at the start of the consultation?
Ask the patient if they’d be happy to talk with you about their current issues.
What are some general communication skills relevant to all patient encounters?
Demonstrating empathy, active listening, appropriate eye contact, open body language, establishing rapport, signposting, and summarising.
How can you demonstrate empathy in a consultation?
Respond to patient cues both verbal and non-verbal.
How can you practice active listening?
Through body language and verbal responses to what the patient has said.
What is important about eye contact during a consultation?
Maintain an appropriate level of eye contact throughout the consultation.
What kind of body language should you use during the consultation?
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward).
How can you establish rapport with the patient?
Ask the patient how they are and offer them a seat.
What is signposting in a consultation?
Explaining to the patient what you have discussed so far and what you plan to discuss next.
What is summarising and why is it important?
Summarising at regular intervals ensures the patient and you are on the same page.
Why should you establish the status of the patient’s admission in inpatient settings?
It gives you information regarding their current mental state and helps you consider any risk that may be present.
What is an example of an open question to explore the patient’s presenting complaint?
What’s brought you in to see me today?
Why should you provide the patient with enough time to answer?
To allow them to fully express their issues without interruption.
How can you facilitate the patient to expand on their presenting complaint?
Ok, can you tell me more about that?
What should you do after the patient has finished speaking about their presenting complaint?
Check if there are any other issues.
What is the purpose of establishing a shared agenda in the consultation?
To prioritize multiple presenting complaints with the patient.
When might a collateral history be necessary?
If the patient has been detained under the Mental Health Act.
What is the role of open questions in history taking?
Allow the patient to tell you what has happened in their own words.
What is the role of closed questions in history taking?
To explore symptoms in more detail and identify relevant risk factors.
What range of symptoms can patients present with?
“Patients can present with mania, low mood hallucinations anxiety delusions and memory loss.”
What are the key psychiatric symptoms/presentations?
“Low mood, self-harm/suicidal ideation elevated mood and energy anxiety delusions and hallucinations obsessions or compulsions alcohol or substance abuse issues around food or weight.”
What does the acronym NOTEPAD stand for when exploring symptoms?
“Nature, Onset Triggers Exacerbating/relieving factors Progression Associated symptoms Disability.”
What are the core symptoms of depression?
“Low mood, lack of pleasure (anhedonia) and low energy levels.”
How should you ask about a patient’s mood in depression?
“How has your mood been recently? Have you felt low in yourself?”
What questions can you ask to assess anhedonia?
“Have you felt little interest or pleasure in doing things?”
What questions can you ask to assess energy levels in depression?
“Have your energy levels been lower than normal? Have you been feeling more tired than normal?”
What associated symptoms should you ask about in depression?
“Disturbed sleep, change in appetite and/or weight agitation or slowing down poor concentration lack of hope feelings of worthlessness excessive guilt reduced libido thoughts of self-harm thoughts of death or suicide.”
What is essential to carry out in any patient presenting with low mood?
“A risk assessment.”
How can you introduce questions about suicidal thoughts?
“It is not uncommon that people who have been feeling and thinking in this way start thinking about suicide. Have you had any similar thoughts?”
What are some characteristic symptoms of hypomania and mania?
“Increased self-esteem, reduced social inhibitions over-familiarity reduced attention spending recklessly inappropriate sexual encounters extravagant plans persecutory delusions incomprehensible speech self-neglect loss of insight.”
What are some questions to ask a patient about mania/hypomania?
“Have you noticed any change in your mood or energy levels recently? Can you describe the change? Have you felt more irritable or impatient than usual?”
What are common physical symptoms associated with anxiety disorders?
“Palpitations, chest tightness breathlessness sweating dizziness dry mouth nausea vomiting insomnia paraesthesia.”
What should you screen for in patients presenting with anxiety?
“Co-existing depression.”
What are common symptoms of psychosis?
“Hallucinations, thought abnormalities delusions.”
What are some screening questions for hallucinations?
“Do you ever hear noises or voices when there is nobody else there? Do you ever feel that someone or something is touching you when there is nobody there?”
What are some screening questions for delusions?
“Do you sometimes have thoughts that others tell you are false? Do you have any beliefs that aren’t shared by others you know?”
What are obsessions and compulsions?
“Obsessions are recurrent intrusive thoughts images or impulses. Compulsions are repetitive mental processes or physical acts performed in response to an obsession.”
What are some questions to ask about obsessions?
“Do you get repeated unpleasant thoughts or images coming into your mind? Do you get these thoughts despite trying to keep them out?”
What are some questions to ask about compulsions?
“Do you feel that you need to repeatedly check things you have already done? Do you need to arrange touch or count things repeatedly?”
What are the CAGE screening questions for alcohol use?
“Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about drinking? Have you ever felt you needed a drink first thing in the morning to steady your nerves or get rid of a hangover?”
What are some key questions to screen for substance dependence?
“Do you feel a strong desire or compulsion to take __? Do you often take more than intended? Have you ever experienced withdrawal symptoms? Do you need more to achieve the same effect? Has your use caused any physical or mental health problems?”
What are some questions to explore eating disorders?
“Can you describe a typical day’s food intake? Are you on a diet? What has your weight been like? How often do you weigh yourself? How do you feel about your body?”
What should you ask about adaptive behaviours in eating disorders?
“What sort of exercise do you do and how much? Do you engage in purging behaviours like vomiting or medication use? What do you eat in a binge and are there any triggers?”
What are some physical signs and symptoms to explore in eating disorders?
“Amenorrhoea, fatigue constipation dizziness haematemesis seizures.”
What does ICE stand for in patient history taking?
“Ideas, Concerns Expectations.”
What are some questions to explore a patient’s ideas about their issue?
“What do you think the problem is? What are your thoughts about what is happening?”
What are some questions to explore a patient’s concerns?
“Is there anything, in particular that’s worrying you? What’s your number one concern?”
What are some questions to explore a patient’s expectations?
“What were you hoping I’d be able to do for you today? What would make today’s consultation a success?”
Why is summarising important in a patient consultation?
“It allows you to check your understanding and provides an opportunity for the patient to correct any inaccuracies.”
What should you explore after the patient’s presenting complaint?
Other areas of the history, including past psychiatric history.
Why is a past psychiatric history important?
It may help with reaching a diagnosis.
What questions should you ask about past psychiatric history?
Have you ever experienced symptoms like this before? Have you ever had any problems with your mental health before? Have you ever been diagnosed with a mental health problem? Have you ever had any treatment for your mental health before? Have you ever had any contact with mental health services before? Have you ever been admitted to hospital due to your mental health before?
What should you do if the patient has a relevant past psychiatric history?
Explore it in more detail.
What should you find out if a patient has an existing psychiatric diagnosis?
When it was diagnosed and any significant details.
Why is it important to know about an existing psychiatric diagnosis?
The current presentation could be a relapse of an existing condition or lead to a change in diagnosis.
What should you explore about previous treatments?
Any previous treatments the patient may have received, particularly in those with complex histories.
Why should you clarify the effectiveness of previous treatments?
It may change the medication given depending on their experiences.
Why should you ask if the patient has received electroconvulsive therapy (ECT) in the past?
It may signify that they are relatively resistant to treatment.
What should you explore about past contact with mental health services?
Whether it has been through primary care, the community mental health team, or the crisis team/home treatment team.
What should you determine about specific community teams?
If the patient is under the care of a mental health team and who they see.
What should you clarify if the patient has been admitted to the hospital due to their mental health?
The number of admissions, the dates or rough length of stay, if they were informal admissions or under a section of the mental health act, and if they have ever been admitted to a psychiatric intensive care unit (PICU).
Why is a forensic history important?
It helps to formulate a risk assessment and may give clues to help with diagnosis.
What questions should you ask about contact with the police?
Have you ever had any contact with the police? If yes, what happened? Were you charged?
What should you ask if the patient has had contact with the police?
What happened? Were you charged?
What should you document about charges?
Document all past and pending charges.
Why is it important to know about episodes of violent or aggressive behaviour?
They may be associated with previous episodes of mental illness and impact your risk assessment and management.
What should you find out about aggression or violence without police contact?
It is useful to know if there is a history of aggression or violence without contact with the police, which may be easier to find out from a collateral history.
What should you ask about time spent in prison?
Have you spent any time in prison?
What should you ask about medical conditions?
Do you have any medical conditions?
What should you ask about regular medical care?
Are you currently seeing a doctor or specialist regularly?
What should you ask about surgical history?
Have you ever had any operations?
Why is it important to know the patient’s past medical history?
There can be significant overlap between mental and physical health, and it is important to exclude physical causes for the patient’s symptoms.
Give an example of a physical condition that can present with psychiatric symptoms.
Hypothyroidism may present as low mood, or encephalitis can present as psychosis.
What medical conditions are risk factors for mental health disorders?
Chronic illness (e.g. chronic pain or cancer) is a major risk factor for depression.
Why is it important to know about medical conditions when considering psychiatric medication?
Some medical conditions, such as cardiovascular, renal, or hepatic disorders, are often contraindications for psychiatric medication.
How might a new psychiatric diagnosis affect a patient’s physical health management?
A patient with bipolar disorder who has co-existing asthma or inflammatory bowel disease may need their treatment plans altered to avoid or reduce the use of steroids.
What should you ask about allergies?
Do you have any allergies?
What should you clarify if a patient has allergies?
Clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
What should you ask about current medications?
Are you currently taking any prescribed medications or over-the-counter treatments?
What details should you document for prescribed or over-the-counter medications?
Document the medication name, dose, frequency, form and route.
Why should you ask specifically about injectable medications?
Patients may be on depot medications (e.g. depot antipsychotics).
Why is it important to ask about recent medication changes?
Dose changes may precipitate new issues, such as a relapse of symptoms or metabolism changes due to enzyme inhibitors and inducers.
What should you ask about side effects from medication?
Have you noticed any side effects from the medication you currently take?
Name some commonly prescribed SSRIs.
Sertraline, citalopram, escitalopram, fluoxetine.
Name some commonly prescribed SNRIs.
Venlafaxine, duloxetine.
Name a commonly prescribed tetracyclic antidepressant.
Mirtazapine.
Name some commonly prescribed TCAs.
Amitryptiline, nortriptyline.
Name some mood stabilisers.
Lithium, sodium valproate, carbamazepine.
Name some first-generation (typical) antipsychotics.
Chlorpromazine, flupentixol, haloperidol, levomepromazine, zuclopenthixol.
Name some second-generation (atypical) antipsychotics.
Amisulpride, aripiprazole, clozapine, olanzapine, quetiapine.
What should you ask about family history of psychiatric disease?
Have any of your parents or siblings had problems with their mental health in the past?
What should you ask to specify the type of mental health problems in the family?
Do you know what type of mental health problems they had?
What should you ask about family history of physical disease?
Do any medical problems run in the family?
What specific physical health problems should you ask about in the family history?
Diabetes, cardiovascular conditions, or any genetic conditions.
What is the aim of taking a personal history?
To get an understanding of the patient’s life experiences and their impact.
What structure is suggested for taking a personal history?
Chronologically, starting in childhood and moving on to education and employment.
What should you ask about childhood?
Do you know if there were any problems during your mother’s pregnancy with you? Are you aware of any problems around your birth? As far as you know, did you meet the normal milestones growing up? How would you describe your childhood?
Why is childhood environment important?
It significantly impacts personality and mental health as an adult.
What should you explore if the patient reports difficulties during childhood?
Try to find out more about the difficulties, acknowledging that it may be difficult for them to discuss.
What should you ask about schooling and education?
Did you enjoy school? Did you have a lot of friends at school? Did you have any problems with bullies at school? At what age did you leave school? What qualifications did you leave school with?
What aspects of school experience should be explored?
Whether they enjoyed primary and secondary school, difficulties with schoolwork, relationships with teachers, and bullying.
What should you ask if the patient attended college or university?
Ask about their experience, what they studied, and how they coped with responsibilities like finances and deadlines.
What should you ask about the patient’s occupation?
Are you employed at the moment? How long have you been at your current job? What jobs have you had in the past? Why did you leave your previous jobs? Have you ever been dismissed from a previous job?
What can an employment history indicate in psychiatric history?
How they cope at work gives a good indication of their current level of function and impact of mental health on employment.
What should you ask about relationships?
How do you get on with your family? Do you find it easy to make friends? Do you feel like you have a good social support system? Are you in a romantic relationship at the moment? What have your previous romantic relationships been like? Have your current problems affected your relationships?
What aspects of family relationships should be explored?
Immediate family, childhood circumstances, relationship with family both past and present, and any recent significant family events.
What can a patient’s relationship history indicate?
It can give clues to a diagnosis and relevance to ongoing management, such as patterns of turbulent relationships suggesting borderline personality disorder.
What sensitive topic should be screened for during a psychiatric assessment?
Experience of sexual abuse.
What should you ask about pre-morbid personality?
How would you describe yourself? How would others describe you? Do you think this would have changed at all recently? Do you have any hobbies or interests? Are you religious?
What emotional traits should be explored in pre-morbid personality?
Would they describe themselves as happy or sad? Do they experience mood swings? How do they manage anger?
What cognitive traits should be explored in pre-morbid personality?
How is their self-esteem? Are they a confident person? Do they see themselves as an optimist or pessimist? Are they naturally suspicious of others? How do they cope with decision-making?
What behavioural traits should be explored in pre-morbid personality?
Would they describe themselves as an introvert or extrovert? Would they say they are impulsive? Do they enjoy socialising?
Why is the social history important in a psychiatric history?
Social circumstances are often significant risk factors for developing psychiatric conditions.
What should you ask about living circumstances?
Where do you live currently? Do you live with anyone else? Are there any children at home?
What should you find out if a patient is homeless?
Why did they become homeless? How long have they been homeless? Do they have access to hostels, or are they sleeping on the streets?
Why is it important to ask about homelessness in a psychiatric assessment?
Homelessness can both be caused by and cause mental health problems, and it is essential to include accommodation in your assessment and management plan.
Why should you ask about children at home?
To ensure they are still being cared for and in case any safeguarding issues arise from the assessment.
What should you ask about activities of daily living?
How are you coping at home at the moment? Do you feel able to look after yourself? Do you have any worries at the moment?
