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PAN > Psychiatric History, Physical and the Mental State Examination > Flashcards

Psychiatric History, Physical and the Mental State Examination Flashcards

Learning Outcomes 2-12

1
Q

What are the KEY steps of a psychiatric assessment

A

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

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2
Q

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

A

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.

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3
Q

What are the 9 aspects of the psychiatric assessment?

A

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

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4
Q

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

A

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

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5
Q

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

A

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.

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6
Q

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

A

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’

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7
Q

What does the Mental State examination assess?

A

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

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8
Q

What are the components of the MENTAL STATE examination

A

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

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9
Q

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

A

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

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10
Q

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

A

Circumstantial thought

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11
Q

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

A

Loosening of associations or derailment

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12
Q

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.

A

Thought blocking

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13
Q

What is the definition of an obsession?

A

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

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14
Q

What is the definition of an overvalued idea?

A

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

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15
Q

What is the definition of a delusion?

A

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

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16
Q

What is the difference between a primary and secondary delusion?

A

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.

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17
Q

What is a sensory distortion?

A

Increase in intensity or quality of perception

Such as hyperacusis, visual hyperparaesthesia

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18
Q

What is an illusion?

A

Misperception of a real object or stimulus

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19
Q

What is a hallucination?

A

Perception without an object

Can occur in all 5 sensory modalities

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20
Q

Which type of hallucination is most common in delerium tremens?

A

Visual hallucinations

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21
Q

What is the most common type of hallucination?

A

Auditory hallucination

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22
Q

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

A

Hypnopompic - Hallucinations preceding waking up

Hypnogogic - Hallucinations immediately before falling asleep.

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23
Q

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

A 
Suicide
Self harm
Violence
Self-neglect
Non-compliance
Substance misuse
Adverse medications effects
Relapse or deterioration
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24
Q

How do you calculate risk?

A

Likelihood of event occurring X Severity of event

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25
Q

How do you define suicide?

A

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

26
Q

What is the definition of deliberate self-harm?

A

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

27
Q

How many suicides occur per year?

A

5000

28
Q

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

A

25%

29
Q

When is the highest risk for suicide for inpatients?

A

14 days post discharge

30
Q

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

A

Men: Hanging, Poison, Jumping
Women: Poisoning

31
Q

What are the sub-categories of risk for suicide?

A

Biopsychosocial
Environmental
Sociocultural

32
Q

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

A 
Planning
Attempts to conceal/avoid detection
Expectation of outcome
Help seeking
Final acts
Lethality of attempt
Feeling following survival
33
Q

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

A 
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
34
Q

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

A

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

35
Q

Define homicide

A

The killing of one human being by another human being

36
Q

Define violence

A

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.

37
Q

What are the factors increasing risk of violence?

A 
Substance misuse
Childhood trauma
Poor social network
Recent major life events
Unstable housing
Unemployment
Availability of weapons
In-patients - under/over-stimulation
38
Q

What is the strongest predictor of future violence?

A

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

39
Q

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

A

Schizophrenia

40
Q

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

A

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

41
Q

What is the management of violent patients?

A 
Be alert to it
Interview room layout - alarms, projectiles
Avoid isolation
De-escalation
Rapid tranquilisation
Assess and plan for future violence
42
Q

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

A 
Personal attack alarms
Sit close to the door
Go in pairs
Let people know where you are
Rapport
43
Q

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

A

10%

44
Q

What are the two different types of mood disorders?

A

Depression

Bipolar disorder

45
Q

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

A

Depression - mood disorder

46
Q

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

A

Mania

47
Q

What is the mean age of onset for depression?

A

27 years

48
Q

What is the ratio of clinically depressed women to men?

A

2:1

49
Q

What are the three cardinal symptoms of depression?

A

Depressed mood
Anhedonia
Reduced energy levels, easy fatigability

50
Q

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

A 
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
51
Q

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

A

2 weeks

52
Q

How can mood changes be masked?

A

Irritability
Excessive consumption of alcohol
Effect of illicit substances

53
Q

What is diurnal variation in depression?

A

Depression worse in the mornings

54
Q

List some somatic symptoms in depression.

A

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

55
Q

What is the classification of mild depression?

A

2 of cardinal symptoms + 2 other symptoms

Patients are usually able to continue ordinary work and social activities

56
Q

What is the classification of moderate depression?

A

2 cardinal symptoms + 3-4 other symptoms

Considerable difficulties with continuing social, work or domestic activities

57
Q

What is the classification of severe depression WITHOUT psychotic symptoms?

A

All 3 of the cardinal symptoms and at least 5 other symptoms

Unlikely to continue with social, work or domestic activities

58
Q

Define severe depression WITH psychotic symptoms

A

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

59
Q

What are clinical variants of depression?

A

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

60
Q

What are the diagnostic criteria for recurrent depressive disorders?

A

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.

PAN (2 decks)

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