Symposium 1 - Psychiatric History Taking, Mental State Examination and Diagnosis Flashcards
Clinical Method in Psychiatric Interviewing - what are the 2 fundamental components?
(2 fundamental things you are trying to do)
Collection of clinical data
Intuitive understanding of the patient as an individual:
- Empathy
- Descriptive Psychopathology
how is collection of data done?
Taking a clinical history
Examining the mental state
(Getting some of your info for your mental state examination all the way through your history but only record it in the mental state examination at the end and when you get to the end this is a chance to cover any area sof the mental state exmaination that you havnt managed during the history tkaing session)
Psychiatry is often confused with….
- psychology
- psychotherapy
- freudian images
- counsellors
what is psychotherapy?
Psychotherapists help people to overcome stress, emotional and relationship problems or troublesome habits
History taking in psychiatry:
- Similar to ______ history taking
- Useful in all branches of ______
- Importance of _____
- Not just ________ - the person is not there for a chat
general
medicine
rapport
listening
what should the setting be like when taking a history?
Importance of privacy, avoid interruptions – phones, pagers
Informal setting, avoid barriers, respect personal space
Easy exit – if only one exit interviewer should have immediate access
headings for taking a history:
What might be different in a psychiatric history?
developmental milestones - e.g. did you first talk and walk at the right time/age
Open and closed questions and establishing rapport - how hsould you start a consultation?
An initial OPEN question is one for which there is not a closed yes/no answer:
Compare: “Tell me about how you were feeling before admission?”
With “Were you okay before admission?”
what are the advantages of an open question?
Allows patients to start talking about themselves and puts them at ease as they have the floor
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 interviewer; listening and facilitating
what should you objectives be when you are with a patient?
Form rapport and gather information
Establish & explore symptoms in context of personality and circumstances
Explore possible biological and social factors related to the symptoms
Inform & motivate patient
Examine mental state
Begin formulation
what do you need to cover in the history of presenting complaint
Clarify each complaint in turn
Onset, precipitants, course, severity
Associated symptoms, effects on daily living
Is it getting worse or better?
Has it responded to any treatment?
After patient has finished volunteering symptoms, what do you do?
Ask about related symptoms
What other changes have your partner/ family/ friends noticed in you?”
Ask about specific symptoms - may be closed questions. Systematic enquiry to screen for other symptoms eg depression, obsessions, anxiety, psychosis
How do you explaore psychotic symptoms - percepts?
“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?
Beware commands
How do you explaore psychotic symptoms - beliefs/thoughts?
“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?”
what information do you want to gather in teh Past psychiatric history?
Past episodes/diagnoses /contacts
Previous treatments (psychological, drug and physical)
Inter-episode functioning
Previous admissions to hospital
Attempted suicide/repeated DSH (deliberate self harm)
Previous detentions under Mental Health Legislation
what are some important bits of information to gather in your past medical history relating to psychiatric problems?
Developmental problems
Head injuries
Endocrine abnormalities
Liver damage, oesophageal varices, peptic ulcers
Vascular risks factors
how should you explore current adn recent medication?
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
what information is important to get in the family history?
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
what information is important to get in the social history?
Social determinants of health are very important
Social circumstances including occupation
Current financial situation/stressors
Smoking/Alcohol/illicit drug use
Current relationship/stressors
Children - contact
what information is important to get in regards to a patients alcohol/ilicit drug history?
Regular or intermittent
Amount (know the units)
Pattern
Dependence/withdrawal symptoms
Impact on work, relationships, money, police
Screening questionnaires eg CAGE
what is a patients forensic history?
“Have you ever been in contact with the police? Charged with any crime?”
Offences including sentences
Recidivism (the tendency of a convicted criminal to reoffend)
Particular attention to violent or sexual crimes
what information would you want to gather as part of the personal history?
Developmental milestones
Early life
Schooling
Occupational
Relationships (sexual & marital history)
Financial
Friendships, hobbies and interests
how do you figure out what a patients premorbid personality was like?
Difficult to be comprehensive
Emphasis on consistent patterns of behaviour, interaction, mood
Importance of corroboration
“How would your best friend describe you as a person?”
If you can get some assessment form someone else then that is better
What examination might be required when you have taken the psychiatric history?
mental state examination
what is involved in a mental state examination?
during a MSE, what should you gather about a patients apperance?
Height/Build
Clothing - appropriate/inappropriate, kempt, bizarre
Personal hygiene - clean/unshaven/malodorous (Personal hygiene is important as if they are not looking after themselves then they may have been unwell for longer)
Make up, jewellery, accessories
during a MSE, what should you gather about a patients behaviour?
Greeting
Non verbal cues
Gesturing - normal, expansive, bizarre
Abnormal movements - tremor, choreioathetoid movements, posturing, akathisia
Cooperative, rapport
during a MSE, what should you gather about a patients mood?
Eye contact
Affect – objective manifestation of mood at i/v
Mood rating – subj & obj; rate out of 10;
Psychomotor function - retarded, agitated
during a MSE, what should you gather about a patients speech?
Spontaneity
Volume - loud, quiet, poverty
Rate - pressured, slowed
Rhythm - rhyming and punning
Tone - monotonous, lilting
Dysarthria
Dysphasia - expressive/receptive
during a MSE, what are some abnormal thoughts a patient may be having?
Close relationship to speech - external manifestation of thoughts
Phobias
Obsessions
Flight of ideas
Formal thought disorder – broadcast, echo, insertion, block, withdrawal
Knight’s move, derailment, loosening
during a MSE, what are some abnormal beliefs a patient may be having?
Preoccupations
Over valued ideas
Delusional beliefs - fixed, false belief out of cultural context; extraordinary conviction
during a MSE, what are some abnormal percepts a patient may be having?
Illusions
Hallucinations – pseudo, true
Many domains - auditory, visual, somatic/tactile, olfactory & gustatory
Specific types may be associated with certain conditions eg complex visual hallucinations in DLB (Dementia with ley bodies)
in a MSE, what information do you want to gather in regards to suicide/homocide?
Must always ask about suicidal thoughts
Ideation (How do they plan to do it)
Intent
Plans - vague, detailed, specific, already in motion (More specific = higher the risk)
Also homicidal risk
in a MSE, what information do you want to gather in regards to cognative function and how do you test it?
Orientation - time, place, person
Attention/concentration - throughout i/v
Short term memory - 3 objects; name & address
Long term memory - personal history
If any concerns - perform objective tests eg MSQ, MMSE, MOCA, FAS, Clock drawing, executive function tests
in MSE, what is insight?
Best seen as spectrum
Very rarely 100% present/absent
Varies over time/illness
3 questions – Are symptoms due to illness? Is this a mental illness? Do they agree with treatment/Mx plan?
what is Psychopathology?
Psychopathology is concerned with abnormal experience, cognition and behaviour
what is Descriptive Psychopathology?
Descriptive Psychopathology describes and categorizes the abnormal experience as described by the patient
what is Phenomenology?
Phenomenology in psychiatry 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
Empathy as a clinical instrument - how should it be used?
Empathy as a psychiatric term means literally “feeling oneself into”.
“In descriptive psychopathology the concept of empathy is as a clinical instrument that needs to be used with skill to measure a patient’s internal subjective state using your own emotional and cognitive experience as a yardstick”
Empathy is achieved by precise insightful questioning until the doctor is able to give an account of the patient’s subjective experience. This questioning continues until the patient recognises the account as accurate.
Present State Examination; SCAN
how is it done?
“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?”
“Also is that true of visions or other unusual experience which some people have with touch or taste or smell?”
what is involved in the mental state examination?
Appearance and Behaviour
Affect
Mood
Speech
Thinking
Perceptual Anomaly
Cognitive function
Insight
Risk assessment including suicide/homicide
ALSO CONSIDER RESULTS OF PHYSICAL EXAM AND BLOOD and other TEST RESULTS
Example for appearance and behaviour - Need to think about things which might be clinical signs, such as what?
Responding to unseen stimuli
Evidence of side effects of medication
Evidence of intoxication
Movement disorder
how do you record mood?
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
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
mood and affect:
what is the affect?
AFFECT held to be the emotions conveyed and observed objectively during interview in terms of
- Types of affect observed; anxiety, anger, euphoria etc
- Range and reactivity of affect. Range from flattened to labile. Record reactivity to themes
- Congruity of affect i.e. observation of congruity to themes; may be grossly incongruous in schizophrenia
NB Term “blunted affect” almost pathognomic of schizophrenia. “Loss of social grace”
Thinking; May be organised into 4 sections for consideration - what are they?
Speed and tempo of thoughts
Types of thoughts demonstrated
Linkage and thought form
Possession of thoughts
when may thinking speed be decreased or increased?
Decreased speed of thought e.g. in severe depression may see psychomotor retardation. Slowing with limited content termed “Poverty” of thought is a negative symptom of schizophrenia and is also seen in dementia and some other organic brain diseases.
Conversely in hypomania or mania there may be “flight of ideas” with rapid speech to the point of incoherence.
what are some Different types of thoughts displayed at MSE?
Preoccupations
Phobias (Anxiety disorders lecture)
Obsessions (As above)
Overvalued ideas e.g. hypochondriacal ideas or body image distortion in Eating Disorder
Delusions - Primary, Secondary
what is a delusion?
“ a delusion is an unshakeable idea or belief which is out of keeping with the person’s social and cultural background; it is held with extraordinary conviction.”
Examples - grandiose, paranoid (correctly persecutory), hypochondriacal, self referential
SCAN and asking about delusional beliefs - how do you ask about delusional beliefs?
E.g. Persecutory delusion screening question:
“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?”
Thought Disorder and linkage of thoughts - what is a thoguht disorder?
A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and can be described more specifically as:
- thought blocking,
- fusion,
- loosening of associations,
- tangential thinking,
- derailment of thought, or knight’s move thinking
Abnormal possession of thoughts; thought alienation:
Commonly reported in schizophrenia - what forms may it appear in?
Thought insertion and withdrawal (thoughts coming in or being taken away from your mind)
Thought blocking (suddenly there is a block in thoughts)
Thought broadcasting
Abnormal possession of thoughts; thought alienation - how may you ask about it?
SCAN
“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?”
Perceptual Anomalies :
Broadly 3 classes of perceptual disturbance - what are they?
Hallucinations
Pseudohallucinations
Illusions
what are Hallucinations?
Have the full force and clarity of true perception
located in external space
no external stimulus
not willed or controlled
5 special senses - auditory or visual, tactile, olfactory and gustatory
Present State Examination; SCAN
how do you ask about hallucinations?
“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?”
“Also is that true of visions or other unusual experience which some people have with touch or taste or smell?”
how do you test Cognitive Function?
Orientation - time, place, person
Attention/concentration - throughout i/v
- Standard concentration test is Reversed Months DNOSAJJMAMFJ
Short term memory - 3 objects or name & address
Long term memory - personal history
If any concerns - perform objective tests eg MSQ, MOCA, MMSE, FAS, Clock drawing, executive function tests
how do you determine a patients insight?
This should be conceptualised as a spectrum; rarely 100% absent or present.
Three questions can indicate place on this continuum:
- 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 is formulation of the case?
Allows consideration of the diagnosis in the context of the individual’s particular personal and medical history. Feedback of the formulation; the patient’s “story”, is an invaluable basis to lead on to discussion of management and treatment options.
Organic, social and psychological factors are assessed as either predisposing, precipitating or perpetuating factors.
what is used to classify mental and behavioural disorders?
ICD 10 Diagnostic Criteria: Depressive Episode
