Psychiatric History and MSE Flashcards
1
Q
Basic structure of psychiatric history - where to do it
A
- HPC
- Psychiatric history
- PMH
- DH
- SH
- Drug and alcohol history
- FH
- Personal history
- Pre-morbid personality - what like before became unwell
2
Q
How do people access secondary care MH services
A
- Self refer - call central access point
- Referred by GP
- From police
- Concerns from friends and family
3
Q
Symptoms patients may present with
A
- Low mood
- Anxiety
- Paranoia
- Self harm/suicide attempt
- Memory loss
- Weight loss
- Personality change - aggressive, irritable
- Hallucinations
- Poor sleep
4
Q
HPC for psychiatric symptoms
A
- Onset and precipitants
- Duration
- Progression/severity
- Aggravating
- Relieving
- Associated symptoms
Explore each presenting complaints individually (eg overdose and low mood seperately)
5
Q
Open questions for overdose
A
- Whats brought you into hospital today?
- I understand that you took some extra medications - would you be able to tell me about that?
6
Q
Focused questions re overdose
A
- Key question - how did you get here, eg did someone find you (worrying more if found by chance, no self preservation)
7
Q
Open questions for patient alleges family are poisoning him
A
- What’s brought you in today?
- Is there anything in your mind? Anything troubling you?
- Then when get something ambigious - can I ask what you mean by that?
8
Q
Clarifying questions for patient alleges family are poisoning him
A
Then may want to ask questions re psychosis eg hallucinations etc
9
Q
Risk assessment for patient alleges family are poisoning him
A
This sounds very frightening, have you ever taken steps to protect yourself - eg knife etc need to check
10
Q
If talk about low mood, what to ask about?
A
- Sleep
- Appetite
- Thoughts about future
11
Q
A
12
Q
Specific PMH to ask about and DH
A
- Cardiac disease and DM - antipsychotics higher
- TFTs and renal function affected by lithium
- Epilepsy
- Vascular history for dementia
- Ask re drug compliance?
13
Q
SH
A
- Who’s at home with you?
- What type of property do they live in?
- Owned, rented or council
- Employed?
- Benefits?
- Any package of care?
14
Q
DH
A
- Smoking
- Alcohol
- Illicit drugs - what, when and how frequent
- History of dependence - alcohol and drugs
Know when to ask more detailed questions
15
Q
FH
A
- Medical and psychiatric
- Sometimes can draw family tree if needed
16
Q
Personal history elements
A
- Mum’s pregnancy and birth complications - infection, premature, labour problems (don’t ask if can’t remember)
- Early childhood development - did they meet milestones
- Childhood - how do they look back on their childhood? prolonged seperation from parents? how did they get on with their family?
- Education - age left full time, academic achievement, friendships or bullying
- Employment - chronological history of job types and length of time, reasons for leaving?
- Relationships - sexuality, current and previous (any divorce, widowed), children
- Forensic - previous charges or convictions, sentences?
- Abuse - any type of abuse - emotional, neglect, physical, sexual
Make it personal to them - do not always need to ask everything
17
Q
Pre-morbid personality
A
- Description by them or their family of personality before unwell
- Predominant mood/emotions eg worrier, laid back
- Can consider religious beliefs/attitudes
18
Q
MSE and history - how do they work together
A
- Different to normal systems
- While taking history can get a lot of MSE
- Then anything that is left can ask about
- MSE is way of painting picture to collegue of how patient is presenting now - more descriptive the better
19
Q
Domains of MSE
A
- Appearance and behaviour
- Speech
- Mood - subjective, objective, affect
- Thought - form and content
- Perception
- Cognition
- Insight
- Risk
ABS MAT PCI
20
Q
Appearance and behaviour
A
- Describe the patient
- Eg well kempt, unkempt, clothing
- Eye contact - appropriate, sustained, intense, reduce
- Level rapport - easy, quick develop, frosty, guarded
- Psychomotor retardation - significant slowing speech and body movements
- Psychomotor agitation - noticable and marked increase in body movements, pacing etc
- Notable change movement - shuffling, pill-rolling tremor
21
Q
Speech
A
Rate:
* Long delay to start?
* Slow
* Fast ….difficult to get a word in edgeways?
Tone:
* Monotonous?
* Varied
Volume
* Quiet
* Normal
* Loud
Any difficulty speaking?
* Dysarthria?
* Dysphasia?
22
Q
Mood
A
Subjectively
* How do they describe their mood?
* If struggling – can they rate it 0-10
Objectively
* Depressed
* Anxious
* Manic
* Irritable
* Euthymic (‘normal’).
23
Q
Affect = emotional responsiveness
A
- Blunted - decrease in variation of emotional expression.
- Flat - virtually complete absence of affective expression.
- Inappropriate /incongruous - emotions expressed are not congruent with content of patient’s thoughts eg having sad thoughts but laughing
- Labile – Rapid and sometimes extreme changes in emotional state.
- Reactive - i.e. normal – appropriately responsive/reactive
24
Q
Formal thought disorder
A
- Whether or not thoughts are ordered, coherently and logically - conveyed by patients speech
- eg are they forming their thoughts normally
- If not = formal thought disorder
25
Mood vs affect
* Mood = climate eg supposed to be cold and grey in winter
* Affect = weather - may get a sunny day in winter
26
Thought content
* Predominant themes pre-occupying the patient and their nature, what they are thinking about
Examples:
* Delusions - persecutory, reference, grandiose, nihillistic, control
* Overvalued ideas
* Obsessions
* Phobias
27
Form of thought vs same content
* Content stays the same but how the thought has formed can change
* eg could be as a result of a phobia, delusion, obsession, overvalued idea
28
Examples of formal thought disorders
* **Loosening of associations** – The loss of the normal structure of thinking. Loss of connection between thoughts. Patient changes topic with no obvious link from one thing to the next. Worst extreme = word salad.
* **Flight of ideas** – Thoughts (& therefore speech) move quickly from one topic to another – so that one train of thought is not carried on to the point of completion. There is usually a link that is identifiable for the change in topic e.g. distracting cue in the environment or distraction from a word used (may pun on a word of rhyme etc).
* **Circumstantiality** - Eventually answers the question – but includes excessive detail, over inclusive. Eventually gets to the point in a painstakingly slow manner
* **Tangentiality** - occasional lapses in organisation such that the patient suddenly changes the subject (goes off at a tangent) and never returns to it; if a question is asked, it isn't answered
* **Neologisms** - words that are created by the patient and have their own idiosyncratic meaning
* **Normal** = no evidence of formal thought disorder
29
What is a delusion?
A fixed false (usually) unshakeable belief that the patient holds despite evidence to the contrary (which is against their cultural/social/religious norms)
30
Types of delusions
* Delusion of persecution
* Delusion of reference - grafitti/newspaper about them
* Delusion of control (passivity phenomena) - under control of something else
* Delusions of thought possession (thought insertion, withdrawal & broadcasting) - schizophrenia
* Delusion of grandeur - think is the king
* Delusion of poverty - think they have no money
* Delusion of guilt - responsible for bad things happening
* Delusions of nihilism - thinks body is rotting, dead
| Type of delusions = significant
31
What is overvalued idea?
* An understandable/comprehensible idea that preoccupies a patient and is pursued by them beyond usual expectations
* Not part of psychosis
32
What is obsession?
Unwanted, intrusive (egodystonic - uncomfortable for them) thought that the patient attempts to resist (and that they are aware is their own thought) and causes them distress.
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Examples of thought content problems
* Delusions
* Overvalued ideas
* Obsessions
34
Perception problems
* Illusions - misinterpretation of sensory stimulus that can occur in any modality eg curtains moving in a room to be an intruder
* Hallcuination - auditory, visual (LBD, Alzheimers or other neurodegenerative disease, unusual in schizophrenia), olefactory, somatic, gustatory
35
Auditory hallucinations types
* 2nd person - talks directly to patient eg you're worthless
* 3rd person - talks about patient (eg we will get him)
* Running commentary - constant commentary of actions
* Command - voices tell you to do things (risk to self or others)
36
Cognition
* Are they orientated in time place and person
* Further tests can be done if this abnormal - ACE, addenbrookes
37
Insight
* Not normally yes or no
* Do they believe they are unwell?
* Do they believe they have a mental disorder? - if so what impact has it had on them?
* Attitude to treatment?- helpful?
38
Risk assessment
* Risk to self - self harm, suicide, or self neglect
* Risk to health - worsening mental illness, deteriorating physical health
* Risk to others - paranoid delusions, command hallucinations
| What we consider when using MHA
39
Where to present if formal thought disorder?
Can do when presenting speech
40
Asking re insight?
* Is there a possibility what you're experiencing is due to an underlying mental health problem?
41
Case formulation - to try and understand patient and best management
Can use bio-psycho-social model
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