Psychiatric History and MSE Flashcards
Basic structure of psychiatric history - where to do it
- HPC
- Psychiatric history
- PMH
- DH
- SH
- Drug and alcohol history
- FH
- Personal history
- Pre-morbid personality - what like before became unwell
How do people access secondary care MH services
- Self refer - call central access point
- Referred by GP
- From police
- Concerns from friends and family
Symptoms patients may present with
- Low mood
- Anxiety
- Paranoia
- Self harm/suicide attempt
- Memory loss
- Weight loss
- Personality change - aggressive, irritable
- Hallucinations
- Poor sleep
HPC for psychiatric symptoms
- Onset and precipitants
- Duration
- Progression/severity
- Aggravating
- Relieving
- Associated symptoms
Explore each presenting complaints individually (eg overdose and low mood seperately)
Open questions for overdose
- Whats brought you into hospital today?
- I understand that you took some extra medications - would you be able to tell me about that?
Focused questions re overdose
- Key question - how did you get here, eg did someone find you (worrying more if found by chance, no self preservation)
Open questions for patient alleges family are poisoning him
- 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?
Clarifying questions for patient alleges family are poisoning him
Then may want to ask questions re psychosis eg hallucinations etc
Risk assessment for patient alleges family are poisoning him
This sounds very frightening, have you ever taken steps to protect yourself - eg knife etc need to check
If talk about low mood, what to ask about?
- Sleep
- Appetite
- Thoughts about future
Specific PMH to ask about and DH
- Cardiac disease and DM - antipsychotics higher
- TFTs and renal function affected by lithium
- Epilepsy
- Vascular history for dementia
- Ask re drug compliance?
SH
- Who’s at home with you?
- What type of property do they live in?
- Owned, rented or council
- Employed?
- Benefits?
- Any package of care?
DH
- Smoking
- Alcohol
- Illicit drugs - what, when and how frequent
- History of dependence - alcohol and drugs
Know when to ask more detailed questions
FH
- Medical and psychiatric
- Sometimes can draw family tree if needed
Personal history elements
- 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
Pre-morbid personality
- Description by them or their family of personality before unwell
- Predominant mood/emotions eg worrier, laid back
- Can consider religious beliefs/attitudes
MSE and history - how do they work together
- 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
Domains of MSE
- Appearance and behaviour
- Speech
- Mood - subjective, objective, affect
- Thought - form and content
- Perception
- Cognition
- Insight
- Risk
ABS MAT PCI
Appearance and behaviour
- 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
Speech
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?
Mood
Subjectively
* How do they describe their mood?
* If struggling – can they rate it 0-10
Objectively
* Depressed
* Anxious
* Manic
* Irritable
* Euthymic (‘normal’).
Affect = emotional responsiveness
- 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
Formal thought disorder
- 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
Mood vs affect
- Mood = climate eg supposed to be cold and grey in winter
- Affect = weather - may get a sunny day in winter
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
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
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
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)
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
What is overvalued idea?
- An understandable/comprehensible idea that preoccupies a patient and is pursued by them beyond usual expectations
- Not part of psychosis
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.
Examples of thought content problems
- Delusions
- Overvalued ideas
- Obsessions
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
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)
Cognition
- Are they orientated in time place and person
- Further tests can be done if this abnormal - ACE, addenbrookes
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?
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
Where to present if formal thought disorder?
Can do when presenting speech
Asking re insight?
- Is there a possibility what you’re experiencing is due to an underlying mental health problem?
Case formulation - to try and understand patient and best management
Can use bio-psycho-social model
