psychiatric history taking Flashcards
2 fundamental components in psychiatric hx
collection of clinical data
intuitive understanding of the patient as an individual - empathy, descriptive psychopatholohy
how do we collect clinical data
taking a clinical hx
examining the mental state
the setting for psychiatric hx taking
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
safety/risk assessment
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
sections of psychiatric hx
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
introduction
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
important general skills
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
advantages of open questions
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
how to start off the consultation - what types of questions
open
however closed questions can be useful for very paranoid/depressed patients
what is an informal referral
not subject to any legislation
HPC
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
asking about related symptoms
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
exploring psychotic symptoms - percepts
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)
exploring psychotic symptoms - beliefs/thoughts
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
past psychiatric hx
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
PMH
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
current and recent medication
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
FHx
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
SHx
social circumstances incl occupation current financial situation/stressors smoking, alcohol, illicit drug use current relationship, stressors children - contact, where are children
alcohol, illicit drug hx
regular or intermittent amount - units pattern dependence, withdrawal symptoms impact on work, relationships, money, police screening questionnaires e.g. CAGE
forensic hx
have you ever been in contact w/ police ever charged with any crime offences incl sentences recidivism particular attention to violent or sexual crimes
personal hx
any difficulties during mother's pregnancy developmental milestones early schooling occupational relationships - sexual and marital hx financial friendships, hobbies, interests
pre-morbid personality
difficult to be comprehensive
emphasis on consistent patterns of behaviour, interaction, mood
importance of corroboration
e.g. how would your best friend describe you
mental state examination - components
appearance behaviour mood speech thoughts beliefs percepts suicide/homicide cognitive function insight
MSE - appearance
height/build
clothing - appropriate/inappropriate, kempt, bizarre
personal hygiene - clean, unshaven, malodorous
makeup, jewellery, accessories
MSE - behaviour
greeting non-verbal cues gesturing - normal, expansive, bizarre abnormal movements - tremor, choreioathetoid movements, posturing, akathisia cooperative, rapport
what are choreioathetoid movements
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
what is akathisia
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
MSE - mood
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
MSE - speech
spontaneity volume - loud, quiet, poverty rate - pressured, slowed rhythm - rhyming and punning tone - monotonous, lilting dysarthria dysphasia - expressive, receptive
MSE - abnormal thoughts
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
what is Knight’s move thinking
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.
MSE - abnormal beliefs
preoccupations
over valued ideas
delusional beliefs - fixed, false belief out of cultural context, extraordinary conviction
MSE - abnormal perceptions
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
MSE - suicide/homicide
MUST ALWAYS ask about suicidal thoughts ideation intent plans - vague, detailed, specific, in motion also homicidal risk
MSE - cognitive function
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
MSE - insight
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
what is psychopathology
concerned with abnormal experience, cognition and behaviour
what is descriptive psychopathology
described and categorises the abnormal experience as described by the patient
what is phenomenology
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
what is mood
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
what is affect
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
4 sections of thinking
speed and tempo of thoughts
types of thoughts demonstrated
linkage and thought form
possession of thoughts
decreased thinking speed
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
different types of thoughts displayed at MSE
preoccupations phobias obsessions overvalued ideas e.g. hypochondriacal ideas or body image distortion in eating disorder delusions - 1y, 2y
delusions
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
what is a thought disorder
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
abnormal possession of thoughts and thought alienation
commonly reported in sz
thought insertion and withdrawal
thought blocking
thought broadcasting
present state examination - SCAN questions for hallucinations
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
SCAN and asking about delusional beliefs
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?
SCAN questions - abnormal possession of thoughts
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
what are hallucinations
have the full force and clarity of true perception
located in external space
no external stimulus
not willed or controlled
three questions to ask to indicate a patient’s level of insight
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
ICD 10 diagnostic criteria: depressive episode
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
