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Yr4: Psychiatry > Psychiatric History Taking & MSE > Flashcards

Psychiatric History Taking & MSE Flashcards

1
Q

Taking a psychiatric history is similar to any other history however teh personal history and past psychiatric history are covered in more detail; remind yourself of the main sections of your psychiatric history

A
  • Reason for referral
  • Presenting complaint
  • ICE
  • Past psychiatric history
  • Current and past medical history
  • Current and past drug histroy
  • Family history
  • Personal history
  • Social history
  • Premorbid personality
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2
Q

What should you ask in reason for referral?

A
  • When was pt admitted (date & time)?
  • Why as pt admitted?
  • Who was involved in admission?
  • Is pt voluntarily in hospital or detained under MHA?
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3
Q

What should you explore in the presenting complaint section?

A
  • Onset
  • Duration
  • Progression
  • Severity
  • Precipitatingn events
  • Associated symptoms (always screen for depression, psychosis and suicidal ideation)
    • Screen for depression by asking about core symptoms
    • Screen for psychosis by asking about hallucinations or delusions
    • Ask about suicidal thoughts
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4
Q

State example ways you could phrase your questions in ICE

A
  • Ideas: do you have any thoughts as to what could be making you feel this way/happening?
  • Concerns: is there anything in particular that is worrying or concerning you at the moment?
  • Expectations: do you have any thoughts as to how we can best help you/about what we can do to best help you going forward?
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5
Q

What should you explore in past psychiatric history?

A
  • Any similar problems before
  • Previoius or ongoing psychiatric diagnosis
    • Dates and duration of episode if present
    • Hospitalisations?
  • Psychiatric treatments including medications, psychotherapy, ECT etc…
    • Response to treatments
    • Side effects
  • Whether ever been detained under MHA
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6
Q

What should you explore in current and past medical history and drug history?

A
  • Previous medical illnesses
    • Neurological conditions e.g. epilepsy
    • Endocrine abnoramlities e.g. thyroid disease
  • Previous surgeries
    • Particularly cranial surgeries
  • Previoius injuries
    • E.g. head injury
  • Medications (prescribed and OTC)
  • Allergies and nature of allergy
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7
Q

What should you explore in family history?

A
  • History of psychiatric illness
  • PMH of family
  • Enquire about structure of family and quality of relationships:
    • Spouse?
    • Children?
    • Siblings
    • Parents together or divorced
    • How do you get on with your family?
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8
Q

Personal history makes up a large part of a psychiatric history; state some key aspects to explore in personal history

HINT: CEERFF

A
  • Early childhood
    • Pregnancy (complications, planned)
    • Developmental milestones
    • Childhood illness
    • Childhood psychiatric illness (e.g. unusually aggressive, struggle with social interaction)
    • Family dynamics/home atmosphere
    • Childhood abuse
  • Education
    • Mainstream or special school
    • Did you enjoy school? If not why?
    • Bullied?
    • Behavioural problems?
    • Did you finish school?
    • Academia?
    • Higher education?
  • Employment
    • Chronologicla list of jobs
    • Duration in each job
    • Why moved jobs?
    • Work environement
  • Relationships
    • Current relationship
    • History of relationships
    • Children? If so who with? Who do they live with? Relationship? Coping?
  • Forensic history
    • Any involvement with police?
    • Any convictions? Punishment?
    • Outstanding charges or convictions?
  • FEMALE ONLY
    • Menstrual patterns
    • Miscarriages
    • Stillbirths
    • Terminations
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9
Q

What should you explore in social history?

A
  • Accomodation (where, is it nice/enjoy it/good living conditions)
  • Social support system
  • Hobbies & leisure
  • Religous?
  • Financial cirumstances (e.g. debts)
  • Alcohol
    • How often?
    • How much?
    • What?
    • Morning?
    • Why drink?
    • How do they feel about drinking?
    • Ever beeen told to stop
    • Ever received help/advice
    • CAGE questions
  • Smoking
    • Calculate pack year
  • Recreational/illicit drugs
    • Drug name
    • Route
    • Frequency
    • Duration
    • Why?
    • How do they feel about it?
    • Ever received support

*Ask how much they spend on alcohol, cigarrettes and drugs

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10
Q

You can ask pt’s about their personality prior to onset of mental illness to get an idea of premorbid personality. State another way you could gain an understanding of premorbid personality

A

Collateral history

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11
Q

Summary of psychiatric history

A
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12
Q

What is the mental state examination? (MSE)

A

MSE is structured/systematic method used to assess a patient’s current state of mind. It uses domains such as appearance & behaviour, speech, mood, perception, thougths, insight and cognition

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13
Q

State the 8 areas assessed in a MSE

*HINT: mneumnoic ASEPTIC

A
  • Appearance
  • Behaviour
  • Speech
  • Mood
  • Thought
  • Perception
  • Cognition
  • Insight

*NOTE: you may not need to formally assess cognition if they appear cognitively sound. If think there may be impaired cognition you should explore in more detail using a cognitive screening tool

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14
Q

What should you assess in appearance section of your MSE?

A
  • Age
  • Ethnic origin
  • Look physically well
    • Stigmata of disease e.g. jaundice
    • Weight
  • Unkempt/hygiene
  • Clothing (extravagant, not appropriate for weather etc..)
  • Distinguishing features e.g.
    • Signs of self harm
    • Signs of IVDU
  • Objects they have with them
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15
Q

What should you assess in the behaviour section of your MSE?

A
  • Body language (e.g. relaxed, tense)
  • Facial expression
  • Motor activity (e.g. psychomotor retardation, psychomotor agitation, tremor, tics, catatonia, tardive dyskinesia, dystonia)
  • Disinhibition (e.g. touching doctors leg/invading personal space)
  • Eye contact
  • Engagement
  • Rapport
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16
Q

What should you asses in the speech section of MSE?

A
  • Rate: rapid & pressured (mania), mumbline & slow (depression, dementia)
  • Rhythm
  • Quantity: increased (mania
  • Volume: loud (mania), quiet (depression)
  • Tone: monotonous (depression), tremulous (anxiety)
  • Content: excessive punning (mania), clang association (mania), monosyllabic
  • Evidence of formal thought disorder

*add evidence of formal thought disorder if not covered elsewhere

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17
Q

Define mood

Define affect

A
  • Mood is a pt’s sustained, experienced emotional state over a period of time (can be sujective or objective)
  • Affect is the pt’s immediate expression of emotion/transient flow of emotion in response to a particular stimulus (what you observe)

*Can think of mood as the season and weather being the affect

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18
Q

What should you assess in the mood and affect section of your MSE?

A
  • Assess mood (euthymic, eleated, depressed)
    • Subjectively: pt’s impression of their mood
    • Objectively: your impression of their mood
  • Assess affect
    • Range & mobility (fixed, restricted, labile, heightened)
    • Intensity (flat, blunted, heightened)
    • Appropriateness/congruency
  • *Incongruous: affect not in keeping with context of thoughts e.g. smiling when taking about suicide*
  • **Labile: exaggerated changes in emotion which may or may not relate to external triggers.*
19
Q

When describing range and mobility of affect what do we mean by:

  • Restricted affect
  • Fixed affect
  • Labile affect
A
  • Restricted affect: affect changes slighlty but doesn’t have the normal range of emotion we would expect
  • Fixed affect: affect remains same throughout
  • Labile affect: exaggerated changes in emotion which may or may not relate to external triggers.
20
Q

When describing intensity of affect what do we mean by:

  • Flat affect
  • Blunted affect
  • Heighted affect
A
  • Flat affect: absence of affective expression
  • Blunted affect: decrease in amplitude of emotional expression
  • Heightened: increased affective expression
21
Q

If there are no abnormalities of affect, how do we describe this?

A

Reactive affect

22
Q

Thought has three characteristics; state these

A
  • Thought form
  • Though content
  • Thought stream

When assessing a pt’s thought you must assess all three

23
Q

State some abnormalities of thought content

A
  • Delusions
  • Obessional thoughts
  • Preoccupations/overvalued ideas
  • Compulsions
  • Morbid thoughts e.g. suicidal ideation
24
Q

Define each of the following:

  • Delusions
  • Obessional thoughts
  • Overvalued ideas
  • Obsessions
  • Compulsions
  • Rumination
A
  • Delusions: fixed, firmly held beliefs that is (usually) false that cannot be reasoned away and is held despite evidence to the contrary and is out of keeping with a person’s sociocultural norms
  • Obessional thoughts: distressing thoughts that repeatedly enter pt’s mind despite their attempted resistance
  • Overvalued ideas: strongly held beliefs, that are neither delusional or obsessive, but are preoccupying to the extent of dominating the sufferer’s life (e.g. the perception of being overweight in a patient with anorexia nervosa)
  • Compulsions: repetitive behaviours that the patient feels compelled to perform despite recognising the irrationality of the behaviour.
  • Rumination: sustained processing of negative material that dominates ones attention
25
Q

Describe each of the following:

  • Delusional parasitosis
  • Capgras delusion
  • Cotard’s syndrome
  • Formication
A
  • Delusional parasitosis: delusion that they are infected by parasites or bugs
  • Capgras delusion: delusion that friend or family member has been replaced by identical imposter
  • Cotard’s syndrome: delusion that their body or part of their body is dead or dying
  • Formication: type of parasthesia in which it feels like insects are crawling on skin
26
Q

What do we mean by thought form?

A

Thought form refers to the processing and organisation of thoughts/in what manner the thought is brought about/the way in which a person puts together ideas and associations

27
Q

State some examples of abnormalities of thought form

A
  • Loosening of association
    • Tangential thinking
    • Derailment of thought (Knight’s move thinking)
    • Word salad
  • Circumstantiality
  • Neologisms
  • Perseveration
  • Flight of ideas
28
Q

An example of abnormality of thought form is loosening of association. What is loosening of assocation?

What are the three types? Describe each.

A

Loosening of association= loss of the normal structure of thinking. Mainly occurs in schizophrenia. Three types:

  • Derailment of thought: sequence of unrelated or remotely related ideas
  • Tangential thinking: diverts from original train of thought but never returns to it
  • Word salad: speech that is just a senseless repetition of sounds & phrases
29
Q

Other examples of abnormalities of thought form are:

  • Circumstantiality
  • Neologisms
  • Perseveration
  • Flight of ideas

… define each

A
  • Circumstantiality: think slowly and add many unnecessary details and digressions before returning to original point (often seen in obsessional personalities & learning disability)
  • Neologisms: words and phrases devised by pt or a new meaning to an already known word (common schizophrenia & autism)
  • Perseveration: uncontrollable & inappropriate repetition of a particular response such as a word, phrase or gesture (common in dementia). e.g. ask patient their name once and they answer all other questions with their name
  • Flight of ideas: thoughts move quickly from one topic to another so that one train of thought is not completed before the next begins. Change is so rapid that links between one topic and another may be difficult to follow HOWEVER links are present. Links may be through rhyme/clang associations, puns, distraction e.g. objects in room. If no links then it is formal thought disorder. Common in mania.
30
Q

State some examples of abnormalities of thought stream/flow

A
  • Pressure of thought
  • Retardation
  • Thought blocking
31
Q

For each of the examples of abnormalities in thought stream/flow, describe what it is:

  • Pressured thought
  • Retardation/poverty of thought
  • Thought blocking
A
  • Pressured thought: thoughts are rapid, abundant and varied (occurs in mania)
  • Retardation/poverty of thought: thoughts are slow, few (poverty of thought) and unvaried (occurs in depression)
  • Thought blocking: sudden cessation of flow of thoughts. Mind is suddenly empty of thoughts. Do not confuse with normal experience of forgeting a particular word, being distracted etc… common schizophrenia
32
Q

Alongside assessing the three characteristics of thought (content, form and stream/flow) you must also assess thougth posession. What are the 3 examples of thougth posession?

A
  • Thought insertion “does it feel like your thoughts are your own?”
  • Thougth withdrawal “does it feel like your own thoughts are being taken away from you?”
  • Thought broadcast“does it feel as though your thoughts are being heard out loud”
33
Q

What is meant by perception?

A

Perception is the process of being aware of what is presented to the body through the sense organs.

34
Q

What should you assess in the perception section of your MSE?

A
  • Illusions
  • Hallucinations
  • Pseudo-hallucinations
  • Depersonalisation
  • Deralisation
35
Q

Define each of the following abnormalities of perception:

  • Illusions
  • Hallucinations
  • Pseudo-hallucinations
  • Depersonalisation
  • Derealisation
A
  • Illusions: false mental image produced by misinterpretation of an external stimulus
  • Hallucinations: perception in the absence of an external stimulus
  • Pseudo-hallucinations: perception in absence of an external stimulus but pt knows it’s not real e.g. they hear a voice but they know it’s inside their head, not an actual person’s voice
  • Depersonalisation: feeling of detachment from the normal sense of self/no longer their true self (ask do you ever feel unreal or that part of your body is unreal?)
  • Derealisation: sense that the environment and people around you are unreal (ask do you ever feel like the world around you is unreal?)
36
Q

State the 5 types of hallucinations

*Hint: 5 senses

A
37
Q

If a person has:

  • Visual hallucinations
  • Third person auditory hallucinations particulary running commentary

… what pathology should you be thinking of?

A
  • Visual= organic brain disease or substance misuse
  • Third person auditory hallucinations particularly running commentary= shcizophrenia
38
Q

Do you always have to use a tool to assess cognition?

A

Throughout the process of performing a mental state examination, you will develop a vague idea of the patient’s cognitive performance including:

  • whether they are orientated in time, place and person
  • what their attention span and concentration levels are like
  • what their short-term memory is like

A formal assessment of cognition can be achieved through a variety of different validated clinical tests including:

  • Mini-mental state exam (MMSE)
  • Abbreviated mental test score (AMT-10)
  • Addenbrooke’s cognitive examination III (ACE-III)
39
Q

What is insight?

A

Ability of a patient to understand that they have a mental health problem and if they are in agreement with treatment.

40
Q

Insight can be intact, partial or non-existent; describe each

A
  • Intact: accept have mental disorder and willing to accept treatment
  • Partial: accept have mental disorder but decline treatment or deny they have mental disorder but accept treatment
  • Non-existent: deny any mental disorder and decline treatment
41
Q

Although not typically part of the MSE, risk should be explored in MSE; explain what you should consider when exploring risk

A
  • Risk to self (self-harm, suicide, self-neglect, financial)
  • Risk to health (worsening mental illness, worsening physical health)
  • Risk to others (e.g. paranoid delusions, command hallucinations, driving, children)
42
Q

Summary of MSE

A

Example presentation

43
Q

When would you say that someone has formal thought disorder?

A

If they have disorder of thought form or stream

CHECK

44
Q

Notes from End of Block OSCE/VIVA

A
  • Your history must inlcude all questions necessary to help you complete a MSE (i.e. even if very unlikely that hallucinations are present must still ask so you can comment on this in perception)
  • Always be thinking about differential diagnoses and ask questions to rule in or rule out conditions (this is your weak point in all histories. If trying to rule out e.g. depression, don’t just ask about low mood ask about other symptoms to be sure)
  • When assessing risk categorise into mild, moderate or severe (remember we don’t ever say no risk so mild is used for very minimal risks, if there is a clearly identifiable risk likely that they are moderate or severe)
  • Low threshold for safeguarding and include referral to safeguarding in management if necessary
  • Structure management as:
    • Risk assessment to allow you to determine ​w​here/how will you manage?(e.g. inpatient, outpatient, MHA)
    • Rule out organic causes (blood tests, imaging etc…)
    • Biopsychosocial (Can you grade the severity of the disorder and does this affect your management? Don’t just think about the mental disorder think about any co-morbid physical problems which may or may not be as a consequence of mental disorder)

*Dr Kinnair said to think about Bella test (Bella is his mum). If it’s an answer she could give it’s not detailed enough.

Yr4: Psychiatry (17 decks)

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