Psychiatric Assessment 2 Flashcards
What is ta mental state examination?
DETAILED and STRUCTURED description of your observations of your patient
* Careful description of the abnormalities in the mental state of the patient/ some are observable, some are inferred through empathic
understanding
* STARTS from the moment you start interviewing the patient
Components of the mental state examination?
- Appearance
- Behavior
- Speech
- Mood
- Thought form/Thought content
- Perception
- Cognition
- Insight
Appearance in MSE?
General appearance
self-care
facial expression
Behavior in MSE?
Posture
activity
abnormal movements
interaction
eye contact
rapport
Speech in MSE?
rate
rhythm
volume
quantity/ Content
Thought flow or form in MSE?
BY OBSERVING THEIR SPEECH.
- derailment
- tangentiality
- circumstantiality
- word salad (thought disorder)
- Poverty of thought
- pressure of thought
- flight of ideas
Thought of content in MSE?
- DELUSIONS
- Persecutory
- paranoid
- grandiose
- religiose
- of control/passivity phenomena - Neologisms/ Affective disorders
- cognitions
e.g. worthlessness, hopelessness, guilt, suicidal ideation - OCD – obsessions
- PTSD - intrusions
Perception in MSE?
HALLUCINATION vs Illusion?
- Visual hallucinations strongly associated with Organic illness
- Special types of AH
- 2nd person vs 3rd person
- Running commentary
- thought echo
- Command
Cognition in MSE?
OTPP
Attention and Concentration
short term and long term memory
Insight in MSE?
- continuum or spectrum: full, partial or absent.
- Examiner’s judgement based on consideration of entire case:
- Patient’s understanding that their experiences are abnormal,
they have a MI, reasonable understanding of aetiology,
understanding that they will benefit from treatment.
Describe risk assessment and its importance?
- Inability to recognise risks and appropriately manage them = adverse consequences for patient, family or community
- Not just arbitrary: ‘risk to self’;’ ’risk to others’
- Continuum from high to low
- Holistic overview of the unique risks in this particular patient: risks are elaborated
e.g., risk of self-neglect because, risk of deliberate self-harm, risk of assaulting someone, risk of exploitation, risk from others because
Physical examination?
Always consider a physical examination to complete your
assessment
How to make a summary of a case?
- May be useful to read through patient’s history and MSE (and physical exam/risk assessment) and create problem list of key symptoms,
signs and other features - Group symptoms and signs that are of the same cluster
Ideal summary?
= 3 sentences
1) Introductory sentence about relevant patient demographic details, background information and reason for presentation
2) Key findings in history
3) Key findings in MSE and examination
Making an aetiological table in case formulation?
- Theoretical framework: which biological, psychological or social factors have caused a patient’s psychiatric illness and may affect the prognosis?
- These aetiological factors are identified during history taking but may also be inferred from clinician’s knowledge of disease epidemiology
- Most psychiatric disorders result from an interplay between biological,
psychological and social factors
Aetiological risk factors?
1) Predisposing - Happened a long time ago, or have been there in the
background
2) Precipitating – Have happened recently and may have triggered current episode
3) Perpetuating – Are present, are likely to be there in the future and will adversely affect the patient’s prognosis
4) Protective factors – things unique to the patient that may help their prognosis
Making differential diagnoses?
1) Consider and exclude organic conditions first. Can the
Can the patient’s presentation be explained by organic disease?
Possible infections or metabolic conditions? We ensure that
treatable or life-threatening conditions are not missed
2) Consider and exclude possible drug and substance abuse,
Could the condition be caused by drugs and substances?
3) Only after excluding the organic and drugs do we consider
primary psychiatric illnesses
4) In making a diagnosis we see if someone’s presentation
meets the criteria
- Always suggest 2 or 3 differential diagnoses for a presentation
and put your preferred diagnosis first
- Don’t pull diagnosis from the air, you need to justify the diagnosis by saying which criteria (DSM5) they meet
Investigations in psychiatric assessment?
- Aim of investigation
1) help confirm diagnosis and
2) plan management - No test can diagnose psychiatric conditions; however can help
exclude organic illness and identify possible things that can be managed to improve patient’s prognosis
Type of investigations in psychiatric assessment?
- Biological investigations: Various relevant blood tests, neuroimaging
- Psychosocial investigations: Collateral interviews with family,
psychometric assessments (e.g. IQ tests), Home or school visits
Management in psychiatry?
- Biological
* Give her antidepressants for an adequate trial (2 years) - Psychological
* Psychoeducation on condition/adherence to medication
* Cognitive Behavioral Therapy - Social
* Family/ Couples counselling
* Referral to Victim support unit
* Occupational Therapy or Skills training so she can find a job and be self-reliant
