Psychiatric History, Physical and the Mental State Examination

Question 1

What are the KEY steps of a psychiatric assessment

Answer 1

1) History
2) Mental State Examination
3) Formulation
4) Plan

Question 2

What are the 4 important things to remember before beginning the interview for a psychiatric assessment?

Answer 2

1) Arrange the room well - well-lit room that is built for purpose, with panic alarm and with your chair nearest the door in case you need to leave quickly and safely
2) Read the referral as to why they have been sent to you and read old notes to gather as much information as possible prior to the assessment.
3) Introduce yourself to the patient and to anyone else accompanying them to the appointment
4) Explain the AIM of the assessment to the patient and any people accompanying the patient.

Question 3

What are the 9 aspects of the psychiatric assessment?

Answer 3

1) Presenting complaint
2) History of presenting complaint
3) Past Psychiatric History
4) Medical History
5) Family History
6) Personal History
7) Social history
8) Forensic History
9) Pre-morbid personality

Question 4

What is a ‘personal history’ and what sort of questions should you ask to elicit a personal history in the psychiatric assessment?

Answer 4

Personal History allows you to get to know the patient more personally and to understand what may have contributed to the development of any mental health problems in the past.
Questions that you could ask includes:
-Narrative of a person’s life
-Obstetric history
-Milestones and childhood development
-Childhood experience
-Education - academic achievement, social experience at school
-Employment history - ability to hold down a job, getting on with colleagues
-Psychosexual history - LGBTQ+ have a higher probability of mental health illness

Question 5

What would we be looking for in the Forensic part of the psychiatric assessment?

Answer 5

Arrests
Charges
Convictions
Undetected crimes - breaking the law even if the person has not been caught for their offence e.g. not being caught for drink driving etc.

Question 6

When taking a psychiatric history, what are five difficult questions that you must ask?

Answer 6

Suicidal thoughts - thoughts of ending things
Psychotic symptoms - hearing things that other people can’t
Childhood experiences - Any experiences that were frightening or upsetting
Forensic history - anything that might have got you in trouble with the police
Pre-morbid personality - describing the patient’s ‘normal self’

Question 7

What does the Mental State examination assess?

Answer 7

It is the equivalent of the psychiatrist’s ‘physical examination’
It is an assessment of the patient’s current state of mind
An objective description of the patient’s conscious experience including abnormal phenomena

Question 8

What are the components of the MENTAL STATE examination

Answer 8

Appearance and behaviour - Gender, personal care, distinctive characteristics, behaviour
Speech - Rate, volume, tone, coherence
Mood - Subjective, objective
Thoughts - form and content
Perception - sensory distortion, illusion, hallucination
Cognitive Function
Insight

Question 9

What are the different types of loss of coherence/connectivity of speech?

Answer 9

1) Acceleration - flight of ideas - increased speed speech and a logical connection between each sequential idea
2) Circumstantial - Important facts are not differentiated from non-important details - too much information
3) Loosening of associations/derailment - loss of logical connections between sequential ideas
4) Thought blocking - sudden stop in thought flow, as though the thought has been removed

Question 10

What is the name of the thought symptom when important facts are not differentiated from irrelevant details.

Answer 10

Circumstantial thought

Question 11

What is the name of the thought symptom when there is loss of logical connections between sequential ideas

Answer 11

Loosening of associations or derailment

Question 12

What is the name of the thought symptom when there is a sudden stop in thought flow as if their thoughts have been plucked out of their head.

Answer 12

Thought blocking

Question 13

What is the definition of an obsession?

Answer 13

Recurrent
Intrusive
Usually unpleasant thoughts
Person recognises the thoughts as their own
The person tries to resist these thoughts

Question 14

What is the definition of an overvalued idea?

Answer 14

Acceptable, comprehensible idea
Persued by the person beyond the bounds of reason
Causes distress or disturbed functioning

Question 15

What is the definition of a delusion?

Answer 15

Usually false, unshakeable idea or belief
Out of keeping with the patient’s educational, cultural and social background
Held with extraordinary conviction and subjective certainty

Question 16

What is the difference between a primary and secondary delusion?

Answer 16

Primary: Not occuring in response to another psychopathology (such as a mood disorder)
Secondary: Occuring secondarily to another psychopathology - delusion is understandable given the present circumstances.

Question 17

What is a sensory distortion?

Answer 17

Increase in intensity or quality of perception

Such as hyperacusis, visual hyperparaesthesia

Question 18

What is an illusion?

Answer 18

Misperception of a real object or stimulus

Question 19

What is a hallucination?

Answer 19

Perception without an object

Can occur in all 5 sensory modalities

Question 20

Which type of hallucination is most common in delerium tremens?

Answer 20

Visual hallucinations

Question 21

What is the most common type of hallucination?

Answer 21

Auditory hallucination

Question 22

What are the two types of hallucinations that are connected with sleep?

Answer 22

Hypnopompic - Hallucinations preceding waking up

Hypnogogic - Hallucinations immediately before falling asleep.

Question 23

What are the types of risks that have to be taken into account in psychiatry?

Answer 23

Suicide
Self harm
Violence
Self-neglect
Non-compliance
Substance misuse
Adverse medications effects
Relapse or deterioration

Question 24

How do you calculate risk?

Answer 24

Likelihood of event occurring X Severity of event

Question 25

How do you define suicide?

Answer 25

Verdict by a coroner: Wilful self-inflicted life-threatening act which has resulted in death.

Question 26

What is the definition of deliberate self-harm?

Answer 26

Harmful act with a non-fatal outcome. Deliberate non-habitual behaviour, that will cause harm without intervention from others or deliberately ingests a substance in excess of prescribed dosage

Question 27

How many suicides occur per year?

Answer 27

5000

Question 28

What proportion of patients who commit suicide have had recent contact with mental health services (contact in last 12 months)

Answer 28

25%

Question 29

When is the highest risk for suicide for inpatients?

Answer 29

14 days post discharge

Question 30

What are the top methods of suicide in: Men (3)? Women?

Answer 30

Men: Hanging, Poison, Jumping Women: Poisoning

Question 31

What are the sub-categories of risk for suicide?

Answer 31

Biopsychosocial Environmental Sociocultural

Question 32

What are the categories for assessment of the seriousness of a suicide attempt? (7)

Answer 32

``` Planning Attempts to conceal/avoid detection Expectation of outcome Help seeking Final acts Lethality of attempt Feeling following survival ```

Question 33

What are the short term management plans for a suicidal patient?

Answer 33

``` Physical treatment of the patient Assessment by MDT member Check capacity Calculate risk of further attempts - history of previous attempts, drugs/alcohol misuse, psychiatric history, personality disorder Assess seriousness of attempt ```

Question 34

What are the medium-term management goals of a patient with a suicide attempt?

Answer 34

Assess protective factors Admission/home treatment for serious attempt - observation Treat underlying mental illness Psychological help and follow up

Question 35

Define homicide

Answer 35

The killing of one human being by another human being

Question 36

Define violence

Answer 36

Actual, attempted or threatened harm to a person or persons | Behaviour which is likely to cause harm to another person or be fear-inducing to the average person.

Question 37

What are the factors increasing risk of violence?

Answer 37

``` Substance misuse Childhood trauma Poor social network Recent major life events Unstable housing Unemployment Availability of weapons In-patients - under/over-stimulation ```

Question 38

What is the strongest predictor of future violence?

Answer 38

History of violence increases the risk of future violence by 20 fold

Question 39

If a psych patient commits a homicide, which disorder are they most likely to have?

Answer 39

Schizophrenia

Question 40

How much more likely is a patient with a mental health disorder likely to be violent than a person from the general population?

Answer 40

Patient 4x more likely to be violent than the general population

Question 41

What is the management of violent patients?

Answer 41

``` Be alert to it Interview room layout - alarms, projectiles Avoid isolation De-escalation Rapid tranquilisation Assess and plan for future violence ```

Question 42

What are the personal factors contributing to personal safety that staff should take?

Answer 42

``` Personal attack alarms Sit close to the door Go in pairs Let people know where you are Rapport ```

Question 43

What % of homicides are committed by people who had previous contact with mental health services?

Answer 43

10%

Question 44

What are the two different types of mood disorders?

Answer 44

Depression | Bipolar disorder

Question 45

What diagnosis would you put to a person with a depressed mood, negative thinking, lack of enjoyment, reduced energy and slowness.

Answer 45

Depression - mood disorder

Question 46

How would you diagnose a patient with elevated mood, overactivity and self-important ideas

Answer 46

Mania

Question 47

What is the mean age of onset for depression?

Answer 47

27 years

Question 48

What is the ratio of clinically depressed women to men?

Answer 48

2:1

Question 49

What are the three cardinal symptoms of depression?

Answer 49

Depressed mood Anhedonia Reduced energy levels, easy fatigability

Question 50

Name some associated symptoms of depression that can menifest along with depressed mood, anhedonia and reduced energy levels.

Answer 50

``` Feelings of guilt and worthlessness Disturbed sleep Reduced concentration and attention Reduced self-esteem and self-confidence Bleak and pessimistic view of life Ideas or acts of self-harm or suicide Disturbed sleep Change in appetite - up or down with an associated change in weight Change in psychomotor activity with agitation or retardation - subjective or objective ```

Question 51

How long must patients have depressive symptoms for a clinical diagnosis?

Answer 51

2 weeks

Question 52

How can mood changes be masked?

Answer 52

Irritability Excessive consumption of alcohol Effect of illicit substances

Question 53

What is diurnal variation in depression?

Answer 53

Depression worse in the mornings

Question 54

List some somatic symptoms in depression.

Answer 54

Anhedonia Lack of emotional reactivity to normally pleasurable surroundings Early wakening - 2+ hours before normal time Diurnal variation - Depression worse in mornings Objective evidence of psychomotor retardation or agitation Poor appetite and weight loss Loss of libido

Question 55

What is the classification of mild depression?

Answer 55

2 of cardinal symptoms + 2 other symptoms | Patients are usually able to continue ordinary work and social activities

Question 56

What is the classification of moderate depression?

Answer 56

2 cardinal symptoms + 3-4 other symptoms | Considerable difficulties with continuing social, work or domestic activities

Question 57

What is the classification of severe depression WITHOUT psychotic symptoms?

Answer 57

All 3 of the cardinal symptoms and at least 5 other symptoms | Unlikely to continue with social, work or domestic activities

Question 58

Define severe depression WITH psychotic symptoms

Answer 58

All three cardinal symptoms of depression with at least 5 more symptoms PLUS Psychotic symptoms - delusions, hallucinations or depressive stupor

Question 59

What are clinical variants of depression?

Answer 59

Agitated depression Depressive stupor Atypical depression - variably depressed mood, overeating and oversleeping, extreme fatigue, pronounced anxiety

Question 60

What are the diagnostic criteria for recurrent depressive disorders?

Answer 60

2+ episodes - separated from the current episode by at least 2 months free from any significant mood symptoms Mean age of onset in 5th decade Individual episodes last 3-12 months Recovery usually complete between episodes, however, the interval between episodes becomes progressively shorter 10-20% develop a chronic unremitting course Individual episodes often precipitated by stressful life events.