Psych History Taking and MMSE Flashcards
What is the framework for taking a psych history?
History of presenting complaint
Insight
Risk Assessment
Past Psych History
Family History
Past Medical History
Drug Hx
Personal History and Premorbid Personality
Forensic History
Social History
How can you explore history of presenting complaint within a psych history?
What brings you in today? Can you tell me more about that?
Onset: ‘When did you realize things have changed?’
Severity: ‘How has this affected your life?’
Duration: ‘How long has this been going on for?’
Progression: ‘Have you had any fluctuations in the way you have been feeling?’
Precipitating events/Aggravating and relieving factors: ‘Has anything occurred in your life recently which could explain how you are feeling?’
How can you assess someone’s insight?
‘Do you think these symptoms could be due to a mental illness?’
‘If so, would you take medication for it, or let us help you in alternative ways?
‘If we were to give you some medication to help you, would you take it?’
How can you explore someone’s past psych history?
Have there been any similar problems to the presenting complaint in the past? Dates and duration of previous episodes?
do they have any diagnosed mental illness? have they had any contact with psychiatric services?
Previous treatments? MHA ever implemented?
How can you explore someone’s personal history?
problems with mum’s pregnancy with them / birth, did they hit developmental milestones ( e.g., crawled, walked)
how was home life, did they have emotional support, neglect / abuse, relationship between parents?
did they have friends in school, academic performance, bullying?
what have they done after school, work, long term relationships
support from family and friends?
What should you remember to ask in the medication history in a psychiatric patient?
Are they taking prescribed medications as intended?
What should you ask in an MMSE in an OSCE?
Mood
Thought- thought insertion, withdrawal and broadcast
Perception - any hallucinations or delusions? Do you think there’s anyone out to get you? Do you have any special powers or abilities?
Cognition - orientated to place and time? Can you tell me what my role is?
Insight - do you believe that your symptoms could be due to a mental illness? Do you think medication might help? Do you think being in hospital might help?
What questions should you ask in the history of presenting complaint for depression?
SIGECAPS
Sleep: insomnia or hypersomnia
Interest: reduced, with loss of pleasure
Guilt: often unrealistic
Energy: mental and physical fatigue
Concentration: distractibility, memory disturbance, indecisiveness
Appetite: decreased or increased
Psychomotor: retardation or agitation
Suicide: thoughts, plans, intention to follow through?
Ask about periods of elated mood to rule out bipolar disorder
What depressive delusions should you screen for?
any worries about your finances (delusions of poverty)?
Any worries about the way your body is working (hypochondriasis)?
Any feelings that nothing matters/ nothing is real (nihilism)?
Do you feel guilty about anything that has happened in the past?
What should you ask in a history of overdose?
What did they take and how much?
What did they take it with e.g., water or alcohol?
What did they think would happen when they took it ? (i.e. was their intention to end their life?)
Did they plan it in advance? How far in advance? Did they leave a note?
Methods to prevent being found?
Have they attempted before? Hx of self harm?
How do they feel about it now? How do they feel about being found?
Would they attempt again?
What are the core symptoms of depression?
low mood (at least 2 weeks)
anhedonia
anergia (low energy)
Give some biological sxs of depression
Diurnal Variation in Mood (DVM) : The patient’s low mood is more pronounced during certain times of the day, usually in the morning.
Early Morning Wakening (EMW) : waking up 2 hours earlier than they would premorbidly
Loss of libido
Psychomotor retardation
Changes in weight and appetite
What is Beck’s cognitive triad (depression)?
three types of negative though
The triad involves negative thoughts about: the self (i.e. the patient feels worthless), the world/environment (i.e. the world is unfair), and the future (i.e. the future is hopeless).
How would you investigate for depression?
Diagnostic questionnaires: e.g. PHQ-9, HADS and Beck’s depression inventory
Blood tests: FBC (e.g. to check for anaemia), TFTs (hypothyroidism), U&Es, LFTs, calcium levels (biochemical abnormalities may cause physical symptoms which can mimic some depressive symptoms), glucose (diabetes can cause anergia).
Imaging: MRI or CT scan may be required where presentation or examination is atypical or where there are features suspicious of an intracranial lesion e.g. unexplained headache or personality change.
DDx for depression?
Other mood disorders: Bipolar affective disorder, recurrent depressive disorder, SAD, PMDD, dysthymia , postnatal depression
Secondary to physical condition e.g. hypothyroidism
Secondary to psychoactive substance abuse
Secondary to other psychiatric disorders: Psychotic disorders, anxiety disorders, adjustment disorder, personality disorder, eating disorders, dementia.
Normal bereavement
Outline the mx of moderate- severe depression
Psychiatry referral: Indicated if: (1) suicide risk is high; (2) depression is severe; (3) recurrent depression; (4) or unresponsive to initial treatment
Mental Health Act may become necessary in some cases
Antidepressants: First-line antidepressants are SSRIs e.g. citalopram. Other antidepressants include TCAs, SNRIs and MAOIs
Adjuvants: Antidepressants may be augmented with lithium, or antipsychotics
Psychotherapy: Refer for CBT and interpersonal therapy (IPT)
Social support
ECT
How long should antidepressants be continued for after remission?
Should be continued for 6 months after resolution of symptoms for first depressive episode, 2 years after resolution of second episode, and long term in individuals who have had multiple severe episodes
Indications for ECT tx in depression?
(1) acute treatment of severe depression which is life-threatening; (2) rapid response required; (3) depression with psychotic features; (4) severe psychomotor retardation or stupor; (5) or failure of other treatments.
What should you ask in the history of presenting complaint for suspected mania?
“Have you noticed any change in your mood or energy levels recently? Can you describe the change?”
Do you feel like you have too much energy compared to the people around you?
“Have you felt more irritable or impatient than usual?”
Are you able to concentrate on day-to-day tasks?
“How are you sleeping at the moment? Is it more or less than normal? How is your appetite?”
Has your interest in sex changed?
“What is on your mind at the moment?”
Have you had any new interests or exciting ideas recently?
“Do you have any special abilities that are unique to you? Can you do things that other people might find difficult or impossible?”
“Are you having any problems in your job/relationships?”
ICD-10 diagnostic criteria for bipolar affective disorder?
at least two episodes in which a person’s mood and activity levels are significantly disturbed – one of which MUST be mania or hypomania
How may you investigate bipolar affective disorder?
Self-rating scales: e.g. Mood Disorder Questionnaire.
Blood tests: FBC (routine), TFTs (both hyper/hypothyroidism are differentials), U&Es (baseline renal function with view to starting lithium), LFTs (baseline hepatic function with view to starting mood stabilizers), glucose, calcium (biochemical disturbances can cause mood symptoms)
Urine drug test: Illicit drugs can cause manic symptoms
CT head: to rule out space-occupying lesions (can cause symptoms such as disinhibition).
DDx for bipolar affective disorder?
Mood disorders: hypomania, mania, mixed episode, cyclothymia
Psychotic disorders: schizophrenia, schizoaffective disorder
Secondary to medical condition: hyper/hypothyroidism, Cushing’s disease, cerebral tumour (e.g. frontal lobe lesion with disinhibition), stroke
Drug related: illicit drug ingestion (e.g. amphetamines, cocaine), acute drug withdrawal, side effect of corticosteroid use
Personality disorders: histrionic, EUPD
Mx of bipolar affective disorder?
CALMER
Consider hospitalization/CBT
Antipsychotics (Atypical)
Lorazepam
Mood stabilizers (e.g. lithium)
Electroconvulsive therapy
Risk assessment
Lithium is the standard long-term therapy in bipolar affective disorder. It minimizes the risk of relapse and improves quality of life. What are the key side effects?
polydipsia, polyuria, fine tremor, weight gain, oedema, hypothyroidism, impaired renal function, memory problems and teratogenicity (in 1st trimester)
How should lithium tx be monitored?
Lithium levels – 12 hours following first dose, then weekly until therapeutic level (0.5–1.0mmol/L) has been stable for 4 weeks. Once stable check every 3 months.
U&Es – every 6 months; TFTs – every 12 months.
What mood stabilisers may be used in an acute manic episode?
lithium or sodium valproate
When would hospitalisation be required for a manic patient?
(1) reckless behaviour causing risk to patient or others
(2) significant psychotic symptoms
(3) impaired judgement
(4) psychomotor agitation.
What should you ask about in a history of psychosis?
Delusions
Hallucinations
Thought Disorders
Negative Symptoms
How can you ask about delusions?
‘Do you have any specific worries at the moment?’, ‘Do you feel safe at the moment? Are you afraid that anyone else is trying to harm you?’ (persecutory delusion)
‘Have you noticed that people are doing or saying things that have a special meaning to you?’ ‘When you watch television or read the newspaper do you ever worry that there are messages specifically for you?’ (delusions of reference)
‘Do you have any special powers or abilities?’ (grandiose delusions)
How can you ask about hallucinations?
‘Do you ever see (visual) or hear (auditory) things that other people seem unable to see or hear?’
‘Have you noticed any unusual smells that you cannot account for and there is nothing to explain them?’
Have you noticed any unusual sensations in your body?
What should you ask about auditory hallucinations?
Are the voices/people talking about you (third person) or directly to you (second person)
are they commenting on what you are doing? (third person – running commentary)
are they telling you to do certain things? If so, what are they telling you? How inclined are you to listen?
How could you ask about thought interference?
‘Have you ever felt that thoughts are being taken out of your mind?’ (thought withdrawal)
‘Have you ever experienced thoughts inside your head that are not yours and have been put there by someone else?’ (thought insertion)
‘Do you ever feel that your thoughts are being broadcast for everyone to hear? “
‘Have you ever felt under the control of an outside force?’ (passivity phenomenon)
Schneider’s first-rank symptoms of schizophrenia are symptoms which, if one or more are present, are strongly suggestive of schizophrenia. What are they?
Delusional perception: A new delusion that forms in response to a real perception without any logical sense, e.g. ‘the traffic light turned red so I am the chosen one.’
Third person auditory hallucinations: usually a running commentary
Thought interference: thought insertion, withdrawal or broadcast
Passivity phenomenon
What are the negative sxs of schizophrenia?
(the A factor)
Avolition (↓ motivation)
Asocial behaviour: Loss of drive for any social engagements
Anhedonia: Lack of pleasure in activities that were previously enjoyable to the patient
Alogia (poverty of speech): A quantitative and qualitative decrease in speech
Affect blunted: Diminished or absent capacity to express feelings.
Attention deficits: May experience problems with attention, language, memory, and executive function.
How could you investigate a patient with suspected schizophrenia?
Blood tests:
FBC: anaemia, infection
TFTs: thyroid dysfunction can present with psychosis
serum calcium: hypercalcaemia can present with psychosis
U&Es and LFTs : assess renal and liver function before giving antipsychotics
glucose or HbA1c, cholesterol: as atypical antipsychotics cause metabolic syndrome
vitamin B12 and folate : deficiencies can cause psychosis
Urine drug test
ECG: Antipsychotics cause prolonged QT interval
CT scan: To rule out organic causes such as space-occupying lesions
EEG: To rule out temporal lobe epilepsy as possible cause of psychosis
What are the options for biological mx of patient with schizophrenia?
Atypical antipsychotics are first-line, e.g. risperidone and olanzapine
Depot formulations should be considered if there is a problem with non-compliance
Clozapine is used for treatment-resistant schizophrenia (failure to respond to two other antipsychotics)
Adjuvants:
Benzodiazepines can provide short-term relief of behavioural disturbance, insomnia, aggression and agitation.
(Lorazepam doesn’t work as quickly as diazepam but has less risk of respiratory depression)
Antidepressants and lithium can be used to augment antipsychotics
ECT if tx resistant or catatonic
What are the options for psychological mx of schizophrenia?
CBT
Family intervention
Art therapy : good for negative sxs in young people
Social skills training
What are the options for social mx of schizophrenia?
Support groups - Rethink and SANE
Peer support
Supported employment programs
What can you ask in a history of presenting complaint of anxiety?
AND I CREST
Anxiety/ worry, control over it, duration
Irritability
Concentration
Restlessness
Energy
Sleep Impairement
Tension in Muscles
Ask about anticipatory anxiety – do they ever avoid situations because they are afraid they will feel anxious?
Ask about triggers for their anxiety – is it there all the time or is it situational?
Anything that they have tried to relieve it?
Ask about effect on day-to-day life
Safety net and screen for suicide and self-harm
What questions should you ask to explore organic causes of anxiety?
Change in bowel habit/waterworks?
Heat intolerance? Tremor?
Headaches ?
How could you investigate a patient with anxiety?
Blood tests: FBC (for infection/anaemia), TFTs (hyperthyroidism), glucose (hypoglycaemia)
ECG: may show sinus tachycardia
Questionnaires: GAD-2, GAD-7, Beck’s Anxiety Inventory, Hospital Anxiety and Depression Scale.
What are the differentials for anxiety?
Other neurotic disorders: panic disorder, specific phobias, OCD, PTSD
Depression
Schizophrenia
Personality disorder (e.g. anxious PD, dependent PD)
Excessive caffeine or alcohol consumption
Withdrawal from drugs.
Organic: anaemia, hyperthyroidism, phaeochromocytoma, hypoglycaemia
How should GAD be managed?
Biological: SSRI (sertraline), then SNRI (venlafaxine or duloxetine), then pregabalin
Psychological: low intensity interventions e.g. psychoeducational groups, high intensity interventions e.g. CBT and applied relaxation
Social : self help methods (e.g. journalling) and support groups
What features distinguish phobic disorders from GAD?
SS, AA, AA
Specifc situtaions
Anticipatory Anxiety
Attempted Avoidance
Questionnaires for phobic disorders?
Social Phobia Inventory and Liebowitz Social Anxiety Scale
DDx for phobic disorders?
Psychiatric:
Panic disorder
PTSD
anxious personality disorder
somatoform disorders
adjustment disorder
depression
schizophrenia (may avoid socializing because of paranoid delusions)
Organic
Mx of specific phobia?
exposure using self help methods or CBT
Benzos can be used as an anxiolytic short term e.g. for claustrophobic patient having CT
Mx of social phobia?
CBT
SSRIs, SNRIs, or if no response then MAOI
Mx of panic disorder?
SSRIs are first-line but if they are not suitable, or there is no improvement after 12 weeks, then a TCA, e.g. imipramine or clomipramine may be considered
Benzodiazepines should not be prescribed
CBT is the psychological intervention of choice
What questions can you ask to screen for PTSD in someone who has gone through something traumatic?
reliving- any flashbacks, nightmares?
hyperarousal - startle more easily, jumpy?
avoidal- do you ever avoid certain situations that remind you of the event?
difficulty sleeping? concentration?
How could you investigate someone with suspected PTSD?
Questionnaires: Trauma Screening Questionnaire (TSQ), Post-traumatic diagnostic scale
CT head: if head injury suspected
How can you distinguish between PTSD and adjustment disorder?
adjustment disorder requires a non-catastrophic event, whereas PTSD involves an exceptionally traumatic event
The symptoms in adjustment disorder must occur within 1 month of the event whereas PTSD must occur within 6 months
DDx for PTSD?
Psychiatric: Adjustment disorder, acute stress reaction, bereavement, dissociative disorder, mood or anxiety disorders, personality disorder
Organic: Head injury (result of traumatic event), alcohol/substance misuse.
Mx of PTSD?
SSRI (most commonly paroxetine), mirtazipine, SNRI
CBT, EMDR
Obsessions and compulsions must share all of the following features:
FORD Car
Failure to resist: At least one obsession or compulsion is present which is unsuccessfully resisted.
Originate from patient’s mind
Repetitive and Distressing
Carrying out the obsessive thought (or compulsive act) is not in itself pleasurable, but reduces anxiety levels.
What is the ICD-10 criteria for diagnosis of OCD?
A. Either obsessions or compulsions (or both) present on most days for a period of at least 2 weeks.
B. Obsessions (thoughts, ideas or images) or compulsions have all of the clinical features (FORD Car)
C. The obsessions or compulsions cause distress or interfere with the subject’s social or individual functioning, usually by wasting time.
What are the DDx for OCD?
Anankastic personality disorder
Eating disorders - AN and BN
Body dysmorphic disorder (time consuming behaviours e.g. mirror gazing)
Anxiety disorders
Depressive disorder
Hypochondriacal disorder
Organic: dementia, epilepsy, head injury
How can you investigate OCD?
Questionnaires: Yale–Brown obsessive–compulsive scale (Y-BOCS) → 10-item questionnaire with each item graded from 0–4; e.g. Time occupied by obsessive thoughts (0 = none, 4 = extreme, >8 hours/day).
How can OCD be managed?
CBT : ERP - patients are repeatedly exposed to the situation which causes them anxiety (e.g. exposure to dirt) and are prevented from performing the repetitive actions which lessen that anxiety (e.g. washing their hands)
SSRIs : fluoxetine, paroxetine, sertraline, citalopram
How would you approach taking an eating disorder history?
Can you describe your food intake on a typical day to me? Are your eating habits similar to your friends’ and families’? Have they expressed any worries about your eating?
How do you feel about your weight? Are you concerned about gaining weight?
SLIM
The obvious methods people use to lose weight are to eat less and exercise more. Are these things that you personally do? (deliberate weight loss)
Do you restrict your calories? How many do you have a day?
What kind of exercise do they do? How much / how often?
Do you ever make yourself sick? Do you take any medications to help with weight loss? (e.g. laxatives, amphetamines, insulin)
Screen for binge eating:
Do you ever feel that your eating is ever out of control?
How do you feel after these episodes?
How can you use SLIM to explore someone’s change in weight?
S - stages- weight at different stages of life?
L – loss - periods of rapid weight loss? Triggers?
I – ideal weight – when were you most happy with your weight? What do you think would be a healthy weight for you?
M- minimum / maximum weight
What physical symptoms should you ask about in a history of an eating disorder?
Do you ever feel dizzy/ faint? More tired than usual? Headaches?
Changes to your skin or hair?
Short of breath? Chest pain? Palpitations? (anaemia)
Any muscle aches? (hypokalaemia)
Fever/night sweats? (screen for malignancy)
What should you cover in a social history of someone with an eating disorder?
Did you have a happy childhood? Attitudes towards food at home?
Did you enjoy school? Any bullying?
What do you do for work? Any occupational pressure to be slim?
DDx for AN?
Bulimia nervosa
Depression
Obsessive–compulsive disorder
Schizophrenia: Delusions about food
Organic causes of low weight: Diabetes, hyperthyroidism, malignancy
Alcohol or substance misuse.
How should you investigate a patient with suspected AN?
Blood tests:
FBC , U&Es, LFTs, TFTs
lipids (↑ cholesterol)
cortisol (↑)
sex hormones (↓ LH, FSH, oestrogens and progestogens)
glucose (↓)
amylase (pancreatitis is a complication)
VBG: Metabolic alkalosis (vomiting), metabolic acidosis (laxatives)
DEXA scan: To rule out osteoporosis
ECG: Arrhythmias such as sinus bradycardia and prolonged QT are associated with AN patients
Questionnaires: e.g. eating attitudes test (EAT)
Mx of AN?
biological:
tx of medical complications e..g electrolyte disturbance
SSRIs for co-morbid depression / OCD
psychological:
CBT
cognitive analytic therapy
family therapy
Social:
self help groups
voluntary organisations
DDx for BN?
Anorexia nervosa – with bulimic symptoms.
EDNOS (Eating Disorder Not Otherwise Specified)
Depression
Obsessive–compulsive disorder
Obsessive compulsive PD
Organic causes of vomiting, e.g. gastric outlet obstruction.
How could you investigate a patient with suspected BN?
Blood tests: FBC, U&Es, amylase, lipids, glucose, TFTs, magnesium, calcium, phosphate
Venous blood gas: May show metabolic alkalosis
ECG: Arrhythmias as a consequence of hypokalaemia (ventricular arrhythmias are life threatening), classic ECG changes (prolongation of the PR interval, flattened or inverted T waves, prominent U waves after T wave)
How can BN be managed?
Biological: A trial of antidepressant should be offered and can ↓ frequency of binge eating/purging. Fluoxetine (usually at high dose, 60 mg) is the SSRI of choice. Treat medical complications of repeated vomiting, e.g. potassium replacement.
Psychological: Psychoeducation about nutrition, CBT-BN
Social: Food diary to monitor eating/purging patterns, techniques to avoid bingeing (eating in company, distractions), small, regular meals, self-help programmes.
