Psychiatric History Taking, Mental State Examination and Diagnosis Flashcards by Michael Gray

What are some important factors in setting?

Privacy
No interruptions like phones or pagers
Informal setting to avoid barriers and respect personal space
Interviewer should have first access to exit

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What are some safety measures you can take before and during a psych history?

Inform staff who you are going to interview and where

Note posture and any other aggressive behaviour and end interview if you are uncomfortable

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What are some differences in psychiatric compared to regular?

Past psychiatric history before pmh
Medication/drug history especially important
Forensic history after family
Personal history

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What is included in personal history?

Developmental milestones
Schooling/Education
Occupational history
Relationships
Pre-morbid Personality

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What are some good questions for exploring psychiatric symptoms?

Have you seen or heard anything that other people have not 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?
Has anything particular been playing on your mind?
Do you know why is this happening?
Have you noticed any change in your thoughts?
Has anyone interfered with your thoughts?
Does anyone else have access to your thoughts?

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What are some key features of past psychiatric history?

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

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What are some key parts of past medical history in psychiatry?

Developmental problems
Head injuries
Endocrine abnormalities
Liver damage, oesophageal varices, peptic ulcers 
Vascular risks factors

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What should you ask about in terms of current and recent medications?

Ask about tablets and injections
Ask about medication recently
Any drugs discontinued (within past 6 months)
Ask how long medication has been taken for and at what dose
Ask about adverse reactions and allergies

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What should you ask about alcohol and illicit drug use?

Regular or intermittent
Amount (know the units) 
Pattern
Dependence/ withdrawal symptoms
Impact on work, relationships, money, police
Screening questionnaires eg CAGE

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What is included in the forensic history?

Have you ever been in contact with the police?
Charged with any crime?
Offences including sentences
Recidivism
Particular attention to violent or sexual crimes

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What are we trying to gauge for a mental state examination?

Appearance 
Behaviour
Mood
Speech
Thoughts
Beliefs
Percepts
Suicide/Homicide
Cognitive function
Insight

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What are some features of behaviour we’d look out for in a mental state examination?

Greeting 
Non verbal cues
Gesturing - normal, expansive, bizarre
Abnormal movements 
Cooperative, rapport

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What are some abnormal movements to look out for?

Tremor
Choreioathetoid movements
Posturing
Akathisia

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What is “Knight’s move thinking”?

Thought disorder where in speech the usual logical sequence of ideas is lost, the sufferer jumping from one idea to another with no apparent connection

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What is a delusional belief?

Fixed, false belief out of cultural context; extraordinary conviction

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What are some possible abnormal beliefs?

Preoccupations
Over valued ideas
Delusional beliefs

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What are some abnormal percepts?

Illusions
Hallucinations
Many domains (Auditory visual, tactile, olfactory, gustatory)
Some are associated with specific conditions

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What are hallucinations?

Perceptions that occur in the absence of a corresponding external sensory stimulus
Full force and clarity of true perception
Located in external space

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What are illusions?

Illusions are misinterpretations of a true sensory stimulus

Should you always ask about suicidal thoughts?

Yes
Ideation
Intent
Plans

What is psychopathology concerned with?

Abnormal experience, cognition and behaviour

How could you ask about hearing voices?

I would now like to ask you a question which we ask to everybody. Do you ever seem to hear noises or voices when there is no one about and nothing else to explain it?

What is catatonia?

Increased muscle tone at rest
Abolished by voluntary activity
E.g. forced grasp, waxy flexibility, opposition, negativism

What are some speech features to look out for?

Very soft
Mainly monosyllabic responses
Nothing offered spontaneously in 80 mins

How do we rate mood?

Self rating scale “where 0/10 is the most depressed you have ever felt and 10/10 is best” is helpful as a baseline record and for longitudinal comparison through treatment

What is affect?

Emotions conveyed and observed objectively during interview in terms of types. range, reactivity and congruity

Which conditions is closely associated with blunted affect?

Schizophrenia

How might we categorise thinking for consideration?

Speed and tempo of thoughts Types of thoughts demonstrated Linkage and thought form Possession of thoughts

What might cause decrease speed of thought?

Psychomotor retardation from severe depression

What may cause increased speed of thought?

Hypomania Mania May come with rapid speech to the point of incoherence

What are some different kinds of thoughts displayed at MSE?

``` Preoccupations Phobias Obsessions Overvalued ideas e.g. body image distortion Delusions ```

How might we differentiate partial and full delusion?

“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?”

Give an example of persecutory delusion?

Paranoia

What are some different kinds of thought disorders?

``` Thought blocking Fusion Loosening of associations Tangential thinking Derailment/Knight's move ```

How does schizophrenia often affect thought?

Thought insertion and withdrawal Thought blocking Thought broadcasting

What are the 3 broad classes of perceptual disturbance?

Hallucinations Pseudohallucinations Illusions

What are the main features of cognitive function?

Orientation (time, place, person) Attention/concentration Short term memory Long term memory

What is the difference between delusion and illusion?

Illusion is misperception of real stimulus, delusion is a fixed and false belief

What is the MOCA?

Montreal Cognitive Assessment Better for assessing frontal cognition than MMS Useful for head injury and drug abuse

What are three questions to indicate patient's 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?

How do we formulate cases in order to consider diagnosis in context of the individual?

Consider biological, psychological and social factors which may be acting as predisposers, precipitants or perpetuators Organise and consider

What are the key symptoms of a depressive episode?

Persistent sadness or low mood Loss of interests or pleasure Fatigue or low energy

What are some associated symptoms of a depressive episode?

``` 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 ```

How do you ask about forensic history or contact with the police?

Can be fairly direct | Just gauge the situation and maybe pretext by saying you need to ask everyone about it

How do you ask about substance abuse?

We need to ask everyone about this If they deny use then you can come back to it with different questions like if they've bought anything Some people have different definitions i.e. not thinking cannabis counts

How do you gauge insight?

Ask what they think is going on Ask what they were hoping to achieve MOCA MSQ