Psychiatry - History taking and Mental state exam (III) Flashcards
Define the 3 objectives of psychiatric diagnostic interview
1) Introduce yourself, build rapport
2) Communicate clearly
3) Demonstrate empathy
What style of questioning should you use for psychiatric Hx?
Open-ended first, then closed questions
Reasons to demonstrate empathy during psychiatric interview
- Rapport
- Facilitate Hx-taking by connecting questions
- Improve Dx accuracy
- Improve adherence
- Improve outcome
What to do if patient is uncooperative during psychiatric interview
Stay calm
Review questions later
What to do if patient gives unclear info during psychiatric interview
Document everything
remain objective
review later
What to do if time runs out during psychiatric interview
Summarize condition
Set priorities
Ask about the main complaint
Ask about his/ her expectation of help
2 Diagnostic criteria for psychiatric interview
ICD-10
DSM-5
4 questions to assess history of presenting complaint during psychiatric interview
1) How are you feeling? Please describe.
2) What has been happening to upset you?
3) How long have you felt unwell?
4) Any other symptoms/ effects on daily functioning?
4 questions to assess risk of suicide/ harm during psychiatric interview
Hopeless: How do you see the future?
Helpless: Can anyone help you?
Worthlessness: Some people feel useless or lose confidence, do you feel that way?
Self-harm/ harm to others:
Any thoughts that life is not worth living?
Any thoughts/plans to harm self or other?
Any previous attempt of suicide?
3 types of Mental state exams.
Cross-sectional (at time of exam)
Continuous (done throughout interview)
Dynamic (stable history)
7 components of mental state exam
Appearance and behavior Speech Mood Thoughts Perception Cognition Insight
Assessment of appearance and behavior during psychiatric interview
1) Self-care/ grooming
2) Attire
3) Expression
4) Build
5) Posture
6) Movement
Patient:
- Frown
- Recent weight loss
- slowed movement
- Hunched posture with downward gaze
Likely psychiatric condition?
Depression
Patient:
- Sweaty/ tense
- No eye contact
- Recent weight loss
- agitated movements
Likely psychiatric condition?
Anxiety
3 types of restless movement?
Akathisia - motor restlessness, side effect of neuroleptic medication
Catatonia - abnormal repetitive or purposeless overactivity, disturbed mental state
Dyskinesia - abnormal involuntary movement
Assessment of speech during psychiatric interview
Form: ideas, association
Flow: pauses, hesitant
Rate: fast or slow
Amount: More or less
Content
Patient:
- Fast flow, constant and non-stop speech
- Flight of ideas that continuous evolve
Likely psychiatric condition?
Mania
Patient:
- Slow speech with lots of pauses and hesitancy
- Reluctant speech with very short replies
Likely psychiatric condition
Depression
Shyness?
Define mood and Affect
Pervasive and sustained emotion that colors one’s perception of the world
Subjective - described by self
Affect = individual’s present emotional responsiveness
Objective - described by observer
Define congruity
Consistency between mood and thoughts
Incongruity may suggest schizophrenia
e.g. laughing when talking about deeply tragic events
How to describe abnormal thought
Form: association of ideas
Flow: stream of thought, broken or interrupted
Rate: Speed of though
Content: any hopelessness, helplessness, worthlessness, guilt, harm
List 6 types of abnormal thought
Obsession and compulsion
Negative rumination/ views
Phobias
Suicidal or homicidal ideas
Preoccupation and worries
Delusion
Define delusion
Abnormal belief (false reasoning) that is unshakable (fixed) and not shared with people from the same culture and religious background
List some types of delusion
Paranoid Though broadcast Thought insertion Thought withdrawal Grandiose Jealous Erotic
Define Hallucination and Illusion
Hallucination = abnormal perception without sensory stimulus (visual, auditory, tactile…etc)
Illusion = abnormal perception with sensory stimulus
Difference between Abnormal and physiological hallucinations
Abnormal = occur in clear consciousness
Physiological = related to sleep and wake cycle (Hypnagogic or Hypnopompic hallucination), both are normal
Assessment of perception during psychiatric interview
1) What is the experience/ complaint?
2) Find source of stimulus
3) Assess character of abnormal perception (e.g. how vivid, loudness, controllability of halluncination…etc)
4) Setting (where does it occur? which people?)
5) Level of consciousness during abnormal perception (sleep/wake?)
6) Forms of auditory hallucination
7) Beliefs of origin of voices
8) Frequency and duration
9) Impact of hallucination: emotional, behavioral, cognitive, functional
List a few forms of auditory hallucination
- Elementary: simple sounds like phone ringing, knocking
- 2nd person pronoun
- 3rd person pronoun
- Running commentary on actions
- Command hallucination
- Thought echo
Assessment of cognition during psychiatric interview
- Alertness and orientation
- Attention, concentration, memory
- Visuospatial ability
- Abstract thinking
Define attention and concentration
How to test?
Attention = ability to focus on specific issue
Test with immediate recall/ memory
Concentration - ability to sustain attention
Test with serial 7s or 3s (Count back from 100 in 7 or 3 intervals)
Spell some words backwards
List 4 types of memory.
How to test during psychiatric interview?
Immediate = telephone number recall
Short term = Simple address repeated immediately, and again after 3 mins
Recent memory = verifiable news in the last 2 days
Remote memory = ask about verifiable past events e.g. world events
Assessment of Insight during psychiatric interview
Degree of understanding of the problem/ illness
- Awareness of problem
- Is it physical or mental
- Is the diagnosis correct
- Is treatment needed
- Consequences or complications
