psychiatric history taking

Question 1

2 fundamental components in psychiatric hx

Answer 1

collection of clinical data

intuitive understanding of the patient as an individual - empathy, descriptive psychopatholohy

Question 2

how do we collect clinical data

Answer 2

taking a clinical hx

examining the mental state

Question 3

the setting for psychiatric hx taking

Answer 3

importance of privacy
avoid interruption - phones etc
informal setting, avoid barriers, respect personal space
easy exit - interviewer should have immediate access if only one exit

Question 4

safety/risk assessment

Answer 4

speak to treating team/ 1y nurse
violence is unusual
inform staff who you are going to interview and where
look out for warning signs - posture, verbal aggression, signs of aggression

Question 5

sections of psychiatric hx

Answer 5

PC
HPC
Past psychiatric Hx
PMH
current and recent medication 
SHx - alcohol and drug use, smoking, social circumstances, occupation
Fhx
forensic hx - contact w/ police etc
personal hx - developmental milestones, schooling/education, occupational hx, relationships, pre-morbid personality

Question 6

introduction

Answer 6

greet verbally and introduce yourself 
look for non-verbal cues 
orientate and check 
- purpose of interview
- likely duration
- note taking, confidentiality, part of a team

Question 7

important general skills

Answer 7

eye contact helps rapport
adopt relaxed non-threatening posture and appear unhurried
use facilitative noises
pick up on non-verbal cues and acknowledge
control any over-talkativeness (polite authority and at the right time)
don’t offer advice or opinion too early
clarification and summary

Question 8

advantages of open questions

Answer 8

allows patients to start talking about themselves and puts them at ease
allows you time to think and plan areas of questioning as you assess their style and content of their response
allows a period of non-verbal response from the interviewer - listening and facilitating

Question 9

how to start off the consultation - what types of questions

Answer 9

open

however closed questions can be useful for very paranoid/depressed patients

Question 10

what is an informal referral

Answer 10

not subject to any legislation

Question 11

HPC

Answer 11

clarify each complaint from the PC in turn
onset, precipitants, course, severity
associated symptoms, effects on daily living
is it getting worse/better
has it responded to any treatment

Question 12

asking about related symptoms

Answer 12

after patient has finished volunteering symptoms

what other changes have partner/family/friends noticed in you
ask about specific symptoms - may be closed questions
systematic enquiry to screen for other symptoms

Question 13

exploring psychotic symptoms - percepts

Answer 13

have you seen/heard anything that other people haven’t been aware of
have you heard any people talking when there was nobody around

what do they think is causing them
does it seem possible
beware commands - are the voices telling people to do things (red flag symptom)

Question 14

exploring psychotic symptoms - beliefs/thoughts

Answer 14

has anything particular been playing on your mind
do you know why this is happening
have you noticed any change in your thoughts
has anyone interfered with your thoughts
does anyone else have access to your thoughts

Question 15

past psychiatric hx

Answer 15

past episodes/diagnoses/contacts
previous treatments (psychological, drug and physical)
inter-episode functioning
previous admissions to hospital
attempted suicide/repeated DSH
previous detentions under mental health legislation

Question 16

PMH

Answer 16

developmental problems 
head injuries
endocrine abnormalities
liver damage, oesophageal varices, peptic ulcers
vascular risk factors

medical problems can sometimes present with psychiatric symptoms
person might have been out of contact with medical services for a while

Question 17

current and recent medication

Answer 17

tablets and injections
medication recently
drugs discontinued (within past 6mths) - why was it stopped (i.e. by doctor or did you stop taking it)
how long medication has been taken for and at what dose
adverse reactions and allergies

Question 18

FHx

Answer 18

parents, siblings, grandparents etc
age, employment, circumstances, health problems, quality of relationship
major mental illness in more distant relatives is important
genogram can be helpful

Question 19

SHx

Answer 19

social circumstances incl occupation
current financial situation/stressors
smoking, alcohol, illicit drug use
current relationship, stressors
children - contact, where are children

Question 20

alcohol, illicit drug hx

Answer 20

regular or intermittent
amount - units
pattern 
dependence, withdrawal symptoms 
impact on work, relationships, money, police
screening questionnaires e.g. CAGE

Question 21

forensic hx

Answer 21

have you ever been in contact w/ police
ever charged with any crime 
offences incl sentences
recidivism 
particular attention to violent or sexual crimes

Question 22

personal hx

Answer 22

any difficulties during mother's pregnancy
developmental milestones
early schooling 
occupational 
relationships - sexual and marital hx
financial 
friendships, hobbies, interests

Question 23

pre-morbid personality

Answer 23

difficult to be comprehensive
emphasis on consistent patterns of behaviour, interaction, mood
importance of corroboration
e.g. how would your best friend describe you

Question 24

mental state examination - components

Answer 24

appearance
behaviour 
mood 
speech 
thoughts
beliefs
percepts
suicide/homicide
cognitive function
insight

Question 25

MSE - appearance

Answer 25

height/build clothing - appropriate/inappropriate, kempt, bizarre personal hygiene - clean, unshaven, malodorous makeup, jewellery, accessories

Question 26

MSE - behaviour

Answer 26

``` greeting non-verbal cues gesturing - normal, expansive, bizarre abnormal movements - tremor, choreioathetoid movements, posturing, akathisia cooperative, rapport ```

Question 27

what are choreioathetoid movements

Answer 27

defined as rapid (chorea) or slow (athetosis) involuntary movements of the fingers or toes (flexion–extension, adduction–abduction, writhing, sometimes piano-playing movements) which are irregular, nonrhythmic, and purposeless

Question 28

what is akathisia

Answer 28

movement disorder that makes it hard for you to stay still. It causes an urge to move that you can't control. You might need to fidget all the time, walk in place, or cross and uncross your legs. Usually, akathisia is a side effect of antipsychotic drugs

Question 29

MSE - mood

Answer 29

eye contact affect - objective manifestation of mood at interview mood rating - subjective and objective, rate out of 10 (record what 0 and 10 are) psychomotor function - retarded (slowing down of function), agitated

Question 30

MSE - speech

Answer 30

``` spontaneity volume - loud, quiet, poverty rate - pressured, slowed rhythm - rhyming and punning tone - monotonous, lilting dysarthria dysphasia - expressive, receptive ```

Question 31

MSE - abnormal thoughts

Answer 31

close relationship to speech - external menifestation of thoughts phobias obsessions flight of ideas formal thought disorder - broadcast, echo, insertion, block, withdrawal Knight's move, derailment, loosening

Question 32

what is Knight's move thinking

Answer 32

A form of formal thought disorder, common in psychosis, in which connections between sentences or parts of sentences are without a coherent train of thought.

Question 33

MSE - abnormal beliefs

Answer 33

preoccupations over valued ideas delusional beliefs - fixed, false belief out of cultural context, extraordinary conviction

Question 34

MSE - abnormal perceptions

Answer 34

illusions hallucinations - pseudo, true many domains - auditory, visual, somatic/tactile, olfactory and gustatory specific types may be associated w/ certain conditions e.g. complex visual hallucinations in DLB

Question 35

MSE - suicide/homicide

Answer 35

``` MUST ALWAYS ask about suicidal thoughts ideation intent plans - vague, detailed, specific, in motion also homicidal risk ```

Question 36

MSE - cognitive function

Answer 36

orientation - time, place, person attention, concentration throughout interview short term memory - 3 objects, name and address long term memory - personal hx if any concerns - perform objective tests e.g. MSQ, MMSE, MOCA, FAS, clock drawing, executive function tests

Question 37

MSE - insight

Answer 37

``` best seen as a spectrum very rarely 100% present/absent varies over time/illness 3 questions - any symptoms due to illness - is this a mental illness - do they agree with the treatment/management plan ```

Question 38

what is psychopathology

Answer 38

concerned with abnormal experience, cognition and behaviour

Question 39

what is descriptive psychopathology

Answer 39

described and categorises the abnormal experience as described by the patient

Question 40

what is phenomenology

Answer 40

refers to the observation and understanding of the psychological event or phenomenon so that the observer can as far as possible know what the patient's experience feels like

Question 41

what is mood

Answer 41

generally held to be the patient's subjective report on their current mood state in terms of how they rate themselves from depressed through euthymic (neutral) to elated

Question 42

what is affect

Answer 42

the emotions conveyed and observed objectively during interview in terms of: - types of affect observed: anxiety, anger, euphoria etc - range and reactivity of affect from flattened to labile, record reactivity to themes - congruity of affect i.e. observation of congruity to themes, may be grossly incongruous in Sz - the term blunted affect is almost pathognomic of Sz

Question 43

4 sections of thinking

Answer 43

speed and tempo of thoughts types of thoughts demonstrated linkage and thought form possession of thoughts

Question 44

decreased thinking speed

Answer 44

decreased speed of thought (e.g. in severe depression) may see psychomotor retardation slowing with limited content = poverty - a negative symptom of Sz - also seen in dementia and some other organic brain diseases

Question 45

different types of thoughts displayed at MSE

Answer 45

``` preoccupations phobias obsessions overvalued ideas e.g. hypochondriacal ideas or body image distortion in eating disorder delusions - 1y, 2y ```

Question 46

delusions

Answer 46

fixed, unshakable ideas or beliefs which is out of keeping with the person's social and cultural background, it is held w/ extraordinary conviction can be 1y (arise themselves) or 2y (result of something else) e.g. grandiose, paranoid, hypochondriacal, self referential

Question 47

what is a thought disorder

Answer 47

a pattern of interruption or disorganisation of though processes can be described more specifically: - thought blocking - fusion - loosening of associations - tangential thinking - derailment of thought, or Knight's move thinking mania

Question 48

abnormal possession of thoughts and thought alienation

Answer 48

commonly reported in sz thought insertion and withdrawal thought blocking thought broadcasting

Question 49

present state examination - SCAN questions for hallucinations

Answer 49

I would now like to ask you a question which we ask to everybody. Do you ever seem to hear noises/voices when there is no one about and nothing else to explain it? also is that true of visions or other unusual experience which some people have with touch or taste or smell

Question 50

SCAN and asking about delusional beliefs

Answer 50

e.g. persecutory delusion screening - is anyone deliberately trying to harm you e.g. trying to poison you or kill you? differentiation partial and full delusions - even when you seem to be most convinced, do you really feel in the back of your mind that it might not be true, it might be your imagination?

Question 51

SCAN questions - abnormal possession of thoughts

Answer 51

can you think clearly or is there any interference with your thoughts can anyone read your mind is anything like hypnotism or telepathy going on

Question 52

what are hallucinations

Answer 52

have the full force and clarity of true perception located in external space no external stimulus not willed or controlled

Question 53

three questions to ask to indicate a patient's level of insight

Answer 53

do you think you are ill if you are ill is it a mental illness if you are ill and it is a mental illness, do you agree broadly with the current treatment plan

Question 54

ICD 10 diagnostic criteria: depressive episode

Answer 54

``` KEY SYMPTOMS: - persistent sadness or low mood; and/or - loss of interests or pleasure - fatigue or low energy (at least one of above present, most days, most of the time for at least 2 weeks) ``` - if any of above present, ask about associated symptoms: - disturbed sleep - poor concentration or indecisiveness - low self-confidence - poor or increased appetite - suicidal thoughts or acts - agitation or slowing of movements - guilt or self blame the 10 symptoms then define the degree of depression 4 - mild 5-6 - moderate ≥7 - severe, w/ or w/o psychotic symptoms