Symposium 1 - Hx taking and MSE Flashcards
What are the two main components of psychiatric history taking?
Collection of clinical data
Intuitive understanding of patient (empathy, descriptive psychopathology)
List important factors for the setting of a psychiatric exam.
Privacy Avoid interruptions Easy exit Informal setting Avoid barriers Respect personal space
When would a past psychiatric history be taken in a history?
Before past medical and after HPC
Along with psychiatric history, what else is added to a normal history?
Personal history
What is included in a personal history?
Developmental milestones Schooling/education Occupational history Relationships Pre-morbid personality
What is a formal and informal patient?
Informal - there on own behalf i.e voluntary
Formal - not on own behalf i.e involuntary
How can you ask about psychotic symptoms?
“Have you seen or heard anything that other people are not aware of?”
“Have you heard anyone talking when there was nobody there?”
“What do you this is causing them?”
What do you want to know about past psychiatric history?
Past episodes/diagnoses/contact s Previous Rx Inter-episode functioning Previous hospital admissions Attempted suicide/repeated DSH Previous detentions
What is important of a family history in a psychiatric exam?
Age, employment, circumstances, health problems, quality of relationship
What do you want to know about with regards to social history?
Employment Current financial situation Stressors Alcohol/drugs/smoking Relationships Children
What will you ask about in relation to drugs/alcohol?
Regular/intermittent, amount, pattern, dependence, withdrawal symptoms, impact on work/relationships/money/police
What do you want to know with regards to forensic history?
Contact with police
Offences
Recidivism
Violent and sexual crimes
What is pre-morbid personality?
Emphasis on consistent patterns of behaviour, interaction, mood.
“How would your best friend describe you?”
What are the 10 points to consider in a mental state examination?
- Appearance
- Behaviour
- Beliefs
- Cognitive function
- Insight
- Mood
- Percepts
- Speech
- Suicide
- Thoughts
What do you consider with regards to appearance?
Height/build
Clothing
Personal hygiene
Make-up/jewellery
What do you consider with regards to behaviour?
Greeting Non-verbal cues gesturing Abnormal movements Cooperative Rapport
What do you consider with regards to mood?
Eye contact
Affect
Mood rating
Psychomotor unction - retarded agitation
What do you consider with regards to speech?
Spontaneity Volume Rate Rhythm Tone Dysarthia Dysphasia
What do you consider with regards to abnormal thoughts ?
Phobias
Obsessions
Flight of ideas
Formal thought disorders
What is formal thought disorder and what is it associated with abnormal thoughts?
Schizophrenia
Broadcast, echo, insertion, block, withdrawal
What is delusional belief/intensity?
Unshakeable/fixed/can’t be persuaded from it
What is formal thought disorder and what is it associated with abnormal percepts?
Illusions
Hallucinations
Auditory/visual/somatic/olfactory/gustatory domains
What is formal thought disorder and what is it associated with suicide/homicide?
Suicidal thoughts
Ideation
Intent
Plans
How do you assess cognitive function?
Orientation (time, place person)
Attention/concentration
Short term memory
If concerns about cognitive function, what detailed assessments are available?
MSQ, MMSE, MOCA, FAS, Clock drawing, executive function tests
What 3 questions would you ask a patient with regards to insight?
- Are symptoms due to illness?
- Is this mental illness?
- Do they agree with treatment/Mx plan?
Patient J is an informal (voluntary) emergency admission from GP with sever depression, suicidal ideation and alcohol misuse. List 3 areas to be explored in HPC.
Mood problem; depression
Suicidal thinking
Alcohol
What psychiatric symptoms are associated with hypothyroid and hyperthyroid?
Hyper = manic symptoms
Hypo = psuedodepression
What is psychopathology?
Symptoms and signs you are finding
What is descriptive psychopathology?
Describes and categorises the abnormal experience as described by the patient
What is phenomenology?
Observation and understanding of psychological event or phenomenon so the observer knows as much as possible how patient feels.
What is SCAN used in a present sate examination?
Schedules for Clinical Assessment in Neuropsychiatry
What should you think about if visual symptoms?
Organic causes
What should risk assessments include in a mental state examination?
Suicide/homicide
When should you do a mental state examination?
During history taking
What does responding to unseen stimuli suggest?
Hallucinations
What is catatonia?
Abnormality of movement and behaviour arising from a disturbed mental state. It may involve repetitive or purposeless overactivity, or catalepsy, resistance to passive movement, and negativism.
Forced grasping Waxy flaccidity Opposition Increased resistance Negativism including eversion
What treatment is given for catatonia?
Benzodiazepines
What is monosyllabic responses and whispers almost diagnostic of?
depression
What is mood?
Subjective patient’s account
What is affect?
How emotion conveys normally e.g anxiety, anger, euphoria
Loose thoughts is linked to what?
Manic
What 4 sections can be associated with thinking?
- Speed and tempo of thoughts
- Types of thoughts demonstrated
- Linkage and thought form
- Possession of thoughts
What thinking speed would you see in severe depression?
Psychomotor retardation p decreased sleep
What are potential causes of slowing thought with limited content termed “poverty” of thought?
Schizophrenia
Dementia
List different types of thoughts displayed at MSE?
Preoccupations Phobias Obsessions Delusions Overvalued ideas
What is the difference between primary and secondary delusions?
Primary delusions arise from disorders e.g being pursued by CIA
Secondary delusions = Comes out of something e.g someone speaking to you in the car and you begin to decide they have inserted a chip in your ear.
What is a delusion?
“Unshakeable idea or belief which is out of keeping with person’s social and cultural background; it is held with extraordinary conviction.”
Give examples of delusions.
Grandiose
Paranoid
Hypochondriacal
Self referential
A patient presents with delusional perception. What is this and what is it a sign of?
Real perception then sudden delusional belief
Sign of schizophrenia
What is Nihilistic delusion?
Guilt, rotting, being dead - everything is terrible
Give an example of a persecutory delusion screening questioning?
Is anyone deliberately trying to harm you?
How do you differentiate partial or full delusions?
Ask “even when you seem to be most convinced, do you really feel in the back of your mind that it may not be true?”
How is a formal thought disorder described specifically?
Thought blocking Fusion Loosening associations Tangential thinking Derailment of thought or knights move thinking
What abnormal possession of thoughts is associated with schizophrenia?
Thought blocking, thought insertion and withdrawal, thought broadcasting
List three classes of perceptual disturbance?
Hallucinations
Pseudohallucinations
Illusions
What is the difference between illusion and hallucinations?
Illusion = perception in presence of stimulus misperceived
Hallucinations = perception in absence of stimulus, not willed or controlled
What senses can hallucinations occur in?
Auditory or visual
Tactile
Olfactory and gustatory
What is the difference between hypnopompic and hypnagogic?
Hypnopompic on awakening
Hypnagogic before falling asleep
How can you test short term memory?
name 3 objects or name and address
How can you test long term history?
Personal history
List objective tests.
MSQ MOCA MMSE FAS Clock drawing Executive function tests
Would you give someone a dementia diagnosed if you think they are depressed?
NO
Treat depression first
What three questions can indicate place on the spectrum 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?
What does ‘formulating the case’ mean?
Allows consideration of the diagnosis in the context of the individual’s particular personal and medical history
Organic, social and psychological factors are assessed as either predisposing, precipitating or perpetuating factors
