Taking a Psych History Flashcards
Before you even start a Psychiatric Interview how should you arrange the setting?
Note* - A psych interview covers all the same areas as any medical history, i will only be referring to the extra bits here
1) In a private space
2) Ensure no interruptions
3) Keep it informal by arranging the seats informally etc
4) Make sure you have an easy exit
What should you do at the start of the interview before you start asking questions?
Patient’s in a psych interview may be confused, suspicious or nervous etc so make sure to:
- Explain the reason for the interview
- Explain why you’re taking notes
- Reassure about confidentiality
How might you open a psych history
A nice open question e.g. Can you tell me in your own words why you’re here?
It’s helpful to know if the patient is an informal (voluntary) patient or has been referred under order
When doing HoPC you want to cover it just like any other. An important extra to remember
Ask about the complaint’s response to any other treatments
In term’s of exploring psychoses in the systemic enquiry, how might you ask about hallucinations?
Avoid the phrase “Do you hear voices”
Try something clear but diplomatic like:
- Have you ever seen or heard something others weren’t aware of?
- Have you ever heard someone speaking with no one around?
Be concerned about anyone hearing commands
Also exploring Psychoses, what else might you ask
You want to know if they feel anyone is controlling their mind in some way e.g.:
- Is there anything particular playing on your mind?
- Does anyone else ever have access to your thoughts?
What areas would you want to cover when asking a the psych part of the PMH?
- When/duration of episodes
- Treatments they received
- Any admissions or detentions
- Inter-episode functioning
- any suicide or self harm
What none-psych PMH is particularly important?
- Developmental problems
- Head Injuries
- Endocrine abnormalities (particularly thyroid)
- Vascular Risk factors
- Liver damage, peptic ulcers or oesophageal varices
What’s different about a psych FH?
with relative with a psych problem you want to know about their:
- Circumstances
- Relationships
- Age
- employment
- Health etc
What’s different about a psych med history?
Make sure to see if any drugs have been started or discontinued in the last 6 months as this may cause symptoms
what areas are particularly important in a psych social history?
Think about anything that could trigger or worsen mental illness:
- Employment/finance
- Relationships
- Substance abuse
- Parent or carer
- Other stressors
What do we want to know about any substance abuse?
Amount
Reg vs Intermittent and Pattenr
Any dependance or symptoms on withdrawal
Impact on work, relationships etc
Police involvement
Can use screening questions e.g. CAGE
During a psych social history we would also ask a personal history, what does this include?
- Developmental milestones (mainly in younger patients)
- Relationships/friendships
- Education & Occupation
- Financial history
In a psych history we also ask a forensic history, how do we do this?
Be sensitive, open with:
- “Have you ever had any contact with the police?” And go from there
Why is it particularly helpful to ask about sentences during a forensic history?
Gives you a more objective measure of any crime the patient was convicted of
What is pre-morbid personality and how do we ask about it?
the person’s behaviour, mood and interactions prior to the illness (i.e. “normally”)
We need corroboration so if possible get it 3rd party. Otherwise ask “How would your best friend or partner describe you?”
A major part of a psych history is assessing the patient’s mental state.
what are the different domains of this?
REMEMBER. this is not so much a section of the history but something you start doing the second you clap eyes or ears on them
- Appearance
- Behaviour
- Mood
- Speech
- Abnormal Thoughts
- Abnormal Percepts
- Suicide/Homicide
- Cognitive Function
- Insight
What parts of the patient’s appearance can contribute to a Mental State exam?
Clothing
Hygiene
Make up, jewellery, accessories etc
What parts of their behaviour are you observing for the mental state?
- How they greet you i.e. are they disinhibited, fearful, apathetic etc
- Their gesturing i.e. very still, expansive or bizarre
- Abnormal movements e.g. akathisia or tremors
- How well they cooperate/build rapport
How do you assess their mood for the mental state exam?
Do they make/seek eye contact?
Obvious manifestations e.g. smiling, crying, shouting etc
Get them to tell you! Both just how they’re feeling and on a scale
What parts of their speech can tell you about their mental state?
- Do they speak spontaneously or need prodding?
- How fast?
- Rhythm
- Tone and volume (e.g. monotonous and quiet)
also look for problems like dysphasia and dysarthria
What kind of abnormal thoughts can tell you about their mental state?
Phobias or obsessions Flight of ideas Knight's move or derailment Formal thought disorder e.g. a thought block Delusions
What are the stages of a delusion?
A pre-occupation e.g. keep thinking about their neighbour saying hi this morning
Then an over valued idea e.g. That was suspicious they’re hiding something
then a full on delusion e.g. It must mean they are a spy (the delusion is fixed, 100% certain and abnormal)
What are abnormal percepts/
Illusions and hallucinations of any domain
What’s the difference between an illusion and a hallucination?
An illusion is essentially mistaking one thing for another. e.g. seeing a glass of water as a vase of flowers
A hallucination is completely observing something that isn’t there e.g. seeing the vase of flowers where there’s nothing
It is essential that you ask about suicidal/homicidal thoughts. What do you want to know?
Do they have any?
do they have intent to commit?
Have they made a plan?
Have they taken any steps e.g. writing a will etc.
How do we assess cognitive function?
Observe their orientation, attention and short/long memory
If you’re concerned do a MOCA
What questions do we want to ask to assess their insight?
Are the symptoms down to an illness?
Is it a mental illness?
Do you agree with our treatment plan?
It’s especially important during a psych history to signpost and summarize
Not only will this help keep the patient calm and aware of what’s going on but it allows you to pick up anything you missed or misconstrued
Quick summary of history:
- Do everything to make the patient comfortable
- Social & Personal history (& during the FH) is essential
- A forensic history is important
- Cover potential organic cause in the PMH, meds & substances
- Do not forget to ask about suicide
Quick summary of Mental State Exam: Ensure you observe everything about he patient and ask specific questions to assess their mental state, covering the following domains: - Appearance - Behaviour - Mood - Speech - Abnormal thoughts - Abnormal percepts - Delusions - Suicide - Cognitive function - Insight
