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Psychiatry > Symposium 1 - Psychiatric History Taking, Mental State Examination and Diagnosis > Flashcards

Symposium 1 - Psychiatric History Taking, Mental State Examination and Diagnosis Flashcards

1
Q

Clinical Method in Psychiatric Interviewing - what are the 2 fundamental components?

(2 fundamental things you are trying to do)

A

Collection of clinical data

Intuitive understanding of the patient as an individual:

  • Empathy
  • Descriptive Psychopathology
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2
Q

how is collection of data done?

A

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)

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3
Q

Psychiatry is often confused with….

  • psychology
  • psychotherapy
  • freudian images
  • counsellors

what is psychotherapy?

A

Psychotherapists help people to overcome stress, emotional and relationship problems or troublesome habits

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4
Q

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
A

general

medicine

rapport

listening

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5
Q

what should the setting be like when taking a history?

A

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

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6
Q

headings for taking a history:

What might be different in a psychiatric history?

A

developmental milestones - e.g. did you first talk and walk at the right time/age

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7
Q

Open and closed questions and establishing rapport - how hsould you start a consultation?

A

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?”

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8
Q

what are the advantages of an open question?

A

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

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9
Q

what should you objectives be when you are with a patient?

A

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

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10
Q

what do you need to cover in the history of presenting complaint

A

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?

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11
Q

After patient has finished volunteering symptoms, what do you do?

A

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

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12
Q

How do you explaore psychotic symptoms - percepts?

A

“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

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13
Q

How do you explaore psychotic symptoms - beliefs/thoughts?

A

“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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14
Q

what information do you want to gather in teh Past psychiatric history?

A

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

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15
Q

what are some important bits of information to gather in your past medical history relating to psychiatric problems?

A

Developmental problems

Head injuries

Endocrine abnormalities

Liver damage, oesophageal varices, peptic ulcers

Vascular risks factors

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16
Q

how should you explore current adn recent medication?

A

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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17
Q

what information is important to get in the family history?

A

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

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18
Q

what information is important to get in the social history?

Social determinants of health are very important

A

Social circumstances including occupation

Current financial situation/stressors

Smoking/Alcohol/illicit drug use

Current relationship/stressors

Children - contact

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19
Q

what information is important to get in regards to a patients alcohol/ilicit drug history?

A

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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20
Q

what is a patients forensic history?

A

“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

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21
Q

what information would you want to gather as part of the personal history?

A

Developmental milestones

Early life

Schooling

Occupational

Relationships (sexual & marital history)

Financial

Friendships, hobbies and interests

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22
Q

how do you figure out what a patients premorbid personality was like?

A

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

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23
Q

What examination might be required when you have taken the psychiatric history?

A

mental state examination

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24
Q

what is involved in a mental state examination?

A
25
Q

during a MSE, what should you gather about a patients apperance?

A

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

26
Q

during a MSE, what should you gather about a patients behaviour?

A

Greeting

Non verbal cues

Gesturing - normal, expansive, bizarre

Abnormal movements - tremor, choreioathetoid movements, posturing, akathisia

Cooperative, rapport

27
Q

during a MSE, what should you gather about a patients mood?

A

Eye contact

Affect – objective manifestation of mood at i/v

Mood rating – subj & obj; rate out of 10;

Psychomotor function - retarded, agitated

28
Q

during a MSE, what should you gather about a patients speech?

A

Spontaneity

Volume - loud, quiet, poverty

Rate - pressured, slowed

Rhythm - rhyming and punning

Tone - monotonous, lilting

Dysarthria

Dysphasia - expressive/receptive

29
Q

during a MSE, what are some abnormal thoughts a patient may be having?

A

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

30
Q

during a MSE, what are some abnormal beliefs a patient may be having?

A

Preoccupations

Over valued ideas

Delusional beliefs - fixed, false belief out of cultural context; extraordinary conviction

31
Q

during a MSE, what are some abnormal percepts a patient may be having?

A

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)

32
Q

in a MSE, what information do you want to gather in regards to suicide/homocide?

A

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

33
Q

in a MSE, what information do you want to gather in regards to cognative function and how do you test it?

A

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

34
Q

in MSE, what is insight?

A

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?

35
Q

what is Psychopathology?

A

Psychopathology is concerned with abnormal experience, cognition and behaviour

36
Q

what is Descriptive Psychopathology?

A

Descriptive Psychopathology describes and categorizes the abnormal experience as described by the patient

37
Q

what is Phenomenology?

A

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

38
Q

Empathy as a clinical instrument - how should it be used?

A

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.

39
Q

Present State Examination; SCAN

how is it done?

A

“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?”

40
Q

what is involved in the mental state examination?

A

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

41
Q

Example for appearance and behaviour - Need to think about things which might be clinical signs, such as what?

A

Responding to unseen stimuli

Evidence of side effects of medication

Evidence of intoxication

Movement disorder

42
Q

how do you record mood?

A

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

43
Q

mood and affect:

what is the affect?

A

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”

44
Q

Thinking; May be organised into 4 sections for consideration - what are they?

A

Speed and tempo of thoughts

Types of thoughts demonstrated

Linkage and thought form

Possession of thoughts

45
Q

when may thinking speed be decreased or increased?

A

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.

46
Q

what are some Different types of thoughts displayed at MSE?

A

Preoccupations

Phobias (Anxiety disorders lecture)

Obsessions (As above)

Overvalued ideas e.g. hypochondriacal ideas or body image distortion in Eating Disorder

Delusions - Primary, Secondary

47
Q

what is a delusion?

A

“ 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

48
Q

SCAN and asking about delusional beliefs - how do you ask about delusional beliefs?

A

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?”

49
Q

Thought Disorder and linkage of thoughts - what is a thoguht disorder?

A

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
50
Q

Abnormal possession of thoughts; thought alienation:

Commonly reported in schizophrenia - what forms may it appear in?

A

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

51
Q

Abnormal possession of thoughts; thought alienation - how may you ask about it?

A

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?”

52
Q

Perceptual Anomalies :

Broadly 3 classes of perceptual disturbance - what are they?

A

Hallucinations

Pseudohallucinations

Illusions

53
Q

what are Hallucinations?

A

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

54
Q

Present State Examination; SCAN

how do you ask about hallucinations?

A

“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?”

55
Q

how do you test Cognitive Function?

A

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

56
Q

how do you determine a patients insight?

A

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?
57
Q

what is formulation of the case?

A

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.

58
Q

what is used to classify mental and behavioural disorders?

A
59
Q

ICD 10 Diagnostic Criteria: Depressive Episode

A

Psychiatry (25 decks)

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