Symposium - History taking Flashcards
Components of history taking within Psychiatry?
NAME
ADDRESS
AGE
GP
STATUS Informal/formal
PRESENTING COMPLAINT
HISTORY OF PRESENTING COMPLAINT
MEDICATION AND ALLERGIES
PREVIOUS PSYCHIATRIC HISTORY
PREVIOUS MEDICAL HISTORY
FAMILY MEDICAL AND PSYCHIATRIC HISTORY
PERSONAL HISTORY
SOCIAL HISTORY
DRUGS AND ALCHOL
FORENSIC HISTORY
MENTAL STATE EXAMINATION
Components of mental state examination?
1) Appearance & Behaviour
2) Mood
- Subjective,
- Objective & Affect
3) Speech
4) Thought-form
4) Thought-content (delusions)
5) Abnormal Perceptions
6) Thoughts of self harm
7) Suicidal and homicidal ideation
8) Insight
9) Cognition
10) Risk assessment
Components of history taking within Psychiatry - Personal history?
PERSONAL HISTORY
- Early development
- Childhood experiences
- Educational attainment
- Occupational history
- Relationship and marital history-children
- Sexual history
Components of history taking within Psychiatry - Social history?
SOCIAL HISTORY
Current social circumstances, accommodation, work, who lives with them, financial support, family/friends, interests and activities.
Components of history taking within Psychiatry - drugs and alcohol?
DRUGS AND ALCHOL
Current and past use of alcohol / drugs.
Types, quantity, duration, whether this has led to any problems with withdrawal / dependence.
Components of history taking within Psychiatry - previous medical history?
Record all illnesses that have required medical attention, operations and hospital admissions.
Particular interest in head injuries, birth trauma and epilepsy.
Components of history taking within Psychiatry - previous psychiatric history?
Record previous episodes of illness, their treatment, and duration.
Especially comment on any episodes requiring the use of the Mental Health Act.
Components of history taking within Psychiatry - Forensic history?
Record instances of contact with the police / criminal justice services leading to a charge or conviction.
State the charge / conviction and the outcome.
Also record any contact with forensic psychiatry.
Components of history taking within Psychiatry - pre morbid personality?
Information of patient’s character prior to the illness.
Exploring psychotic symptoms?
“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
“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?”
Which screening questionnaire is used with alcohol use?
CAGE questionnaire
Question to get an idea of pre-morbid personality?
“How would your best friend describe you as a person?”
Mental state examination - appearance?
Height/Build
Clothing - appropriate/inappropriate, kempt, bizarre
Personal hygiene - clean/unshaven/malodorous
Make up, jewellery, accessories
Mental state examination - behaviour?
Greeting
Non verbal cues
Gesturing - normal, expansive, bizarre
Abnormal movements -
tremor, choreioathetoid movements, posturing, akathisia
Cooperative, rapport
Mental state examination - mood?
Eye contact
Affect – objective manifestation of mood at i/v
Mood rating – subj & obj; rate out of 10;
Psychomotor function - retarded, agitated
Mental state examination - speech?
Spontaneity
Volume - loud, quiet, poverty
Rate - pressured, slowed
Rhythm - rhyming and punning
Tone - monotonous, lilting
Dysarthria
Dysphasia - expressive/receptive
Mental state examination - abnormal thoughts?
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
Mental state examination - abnormal beliefs?
Preoccupations
Over valued ideas
Delusional beliefs - fixed, false belief out of cultural context; extraordinary conviction
Mental state examination - abnormal perceptions?
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
Mental state examination - Suicide/homicide risk?
Must always ask about suicidal thoughts
Ideation
Intent
Plans - vague, detailed, specific, already in motion
Also homicidal risk
Mental state examination - Cognition?
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
Mental state examination - insight?
Best seen as spectrum
Very rarely 100% present/absent
Varies over time/illness
3 questions –
1) Are symptoms due to illness?
2) Is this a mental illness?
3) Do they agree with treatment/Mx plan?
What is psychopathology?
Psychopathology is concerned with abnormal experience, cognition and behaviour.
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.
Congruity of affect ?
Congruity of affect i.e. observation of congruity to themes; may be grossly incongruous in schizophrenia.
Blunted affect?
“blunted affect” almost pathognomic of schizophrenia. “Loss of social grace”
Type of affect?
anxiety, anger, euphoria etc
Range and reactivity of affect?
Range from flattened to labile. Record reactivity to themes.
Thinking; May be organised into 4 sections for consideration?
Speed and tempo of thoughts
Types of thoughts demonstrated
Linkage and thought form
Possession of thoughts
Examples of delusions?
Grandiose
Paranoid (correctly persecutory)
Hypochondriacal
Self referential
Thought disorder and linkage of thought?
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.
Common abnormal thoughts in schizophrenia?
Thought insertion and withdrawal
Thought blocking
Thought broadcasting
Question for abnormal thoughts, especially in schizophrenia?
“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
1) Hallucinations
2) Pseudohallucinations
3) Illusions
Questions to 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?”
Three questions to test 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?
Biological predisposed to mental health issues?
Possible thyroid disease and head injury.
Genetic: FH depression
Alcohol and substance misuse
Psychological predisposed to mental health issues?
Low self-esteem from teenage issues.
Diffident socially reclusive style.
Social predisposed to mental health issues?
Loss of relatives, friend’s absence
Biological precipitants to mental health issues?
Alcohol intoxication and withdrawal
Biological Perpetuators to mental health issues?
Thyroid, ? post concussion syndrome.
Psychological precipitants to mental health issues?
Bereavement reaction
Social precipitants to mental health issues?
Warning at work, other sequelae of alcohol use.
Loss of father to household.
Psychological Perpetuators to mental health issues?
Coping style and depressive cognitions
Social Perpetuators to mental health issues?
Mother’s bereavement, fall out with brother over drinking.
ICD 10 Diagnostic Criteria: Depressive Episode?
> Key symptoms:
- persistent sadness or low mood; and/or
- loss of interests or pleasure
- fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
> If any of above present, ask about associated symptoms: - disturbed sleep - poor concentration or indecisiveness - low self-confidence - poor or increased appetite - suicidal thoughts or acts agitation or slowing of movements - guilt or self-blame
> the 10 symptoms then define the degree of depression and management is based on the particular degree
1) Mild depression (four symptoms)
2) Moderate depression (five to six symptoms)
3) Severe depression (seven or more symptoms, with or without psychotic symptoms)
