1. Clincial Hx MSE

Question 1

Question Styles?

Answer 1

1. Non-leading open questions. ‘Tell me about your sleep’?
2. Non-leading closed questions. ‘ Do you have any problems with your appetite’?
3. Leading Questions. ‘you’re eating less aren’t you?’

Question 2

Name some facilitating Techniques?

Answer 2

1. Silence, can be helpful if used judiciously
2. Verbal facilitation
3. Non-verbal facilitation:
   Nodding, smiling, leaning forward etc.
   Not too much eye-contact as this can be threatening.
   Try to avoid giving cues of disapproval.

Question 3

‘The interview will last 45 minutes’.

Answer 3

Informative

Question 4

I know this is difficult for you to discuss’

Answer 4

Empathic (do not overuse)

Question 5

‘So you started to feel depressed after your mother died’

Answer 5

Summarising

Question 6

‘So you’ve told me that you’re feeling anxious’

Answer 6

Clarifying

Question 7

‘You seemed uncomfortable when you were speaking about your father’.

Answer 7

Commenting re non-verbal communication

Question 8

‘I’ve been upset myself when I’ve failed at things’

Answer 8

Self-relevant. (Careful!)

Question 9

What should the interviewer control in an interview?

Answer 9

Rate, flow, direction.

Question 10

How is control achieved?

Answer 10

Encouraging (examples, guesses, motives)

Discouraging (Interruptions, Not Now)

Question 11

What are the stages of a patient psychological pt interview

Answer 11

Setting the scene.
Introduction & orientation.
Psychiatric History.
Mental State Examination (MSE).
Cognition (e.g. MMSE).
Physical examination.
Finishing the interview.

Question 12

What is involved in setting the scene?

Answer 12

Environment.
Safety.
Reason for referral.

Question 13

What is involved in the introduction and orientation?

Answer 13

Purpose.
Time.
Notes.
Confidentiality.
Ask if patient happy to proceed.

Question 14

What should be elicited as part of the standard history?

Answer 14

Presentation (who, what, when, where why)

History Presenting complaints (+screen for other problems)

Question 15

What should be elicited as part of the past psychiatric history?

Answer 15

Episodes of illnesses (Treated or untreated, By whom GP, psychiatrist, counsellor etc).

Past diagnoses & treatments (biological, psychological, social).

Number of in patient admissions, first and last.

Functioning between episodes?

Question 16

What should be elicited as part of the past medical history?

Answer 16

Medications: (Psychiatric, Non psychiatric)
Allergies
Medical/Surgical illnesses & Treatments.
Surgery

Question 17

What should be elicited as part of the family history?

Answer 17

Genogram useful

1st degree

Question 18

What should be elicited as part of the personal history?

Answer 18

Childhood
School
Occupational History
Sexual/Marital/Relationship Hx
Social History
Forensic History

Question 19

What should be elicited as part of the pre-morbid personality assessment?

Answer 19

Attitudes to self.
Attitudes to others in social, family, sexual relationships.
Predominant mood.
Leisure activities & interests.
Religious beliefs
Reaction pattern to stress.

Question 20

What is an MSE?

Answer 20

Mental State Exam
‘Here & Now’ observation of patient.
Avoid the term ‘normal’ where possible.
Use the conventional headings.
Concentrate on positive findings unless the absence of a specific symptom is relevant

Question 21

What are the headings for the MSE?

Answer 21

Appearance & Behaviour.
Speech.
Mood.
Thought.
Perception.
Cognition (MMSE).
Insight.

Question 22

What is meant by cognition?

Answer 22

Orientation
Attention
Concentration
Memory.

If >65yo or you suspect cognitive impairment then a more comprehensive assessment of cognition may be needed

Question 23

What are the limitations of the Mini MSE?

Answer 23

Does not test long-term memory

Also insensitive to Frontal Lobe pathology.

Question 24

What is meant by insight?

Answer 24

Not all or nothing.
Subjective

Questions:
Is the patient aware that anything is wrong?
If there is something wrong, does the patient think it is due to an illness or an external agency?
If an illness, is it physical or psychological/psychiatric?
If psychological, can it be helped?
Is the patient willing to accept help?

Question 25

What is involved in the review of the psychiatric history?

Answer 25

Summarise the patient’s account of problems briefly and seek clarification if necessary Ask a final question: ‘Is there anything else you wish to tell me’? Explore any issues raised.

Question 26

What is the purpose of the physical examination?

Answer 26

Full physical including neurological assessment. Looking for physical manifestations of psychiatric disorder, physical causes of psychiatric disorder, evidence of DSH/ substance abuse/side effects of treatment.

Question 27

How should Ddx be presented?

Answer 27

Present in order of decreasing probability. Don’t be tempted to give diagnoses for which there is no evidence. Use standard diagnostic terms only-ICD 10 or DSM V, not “depression” but “moderate depressive episode” for example Don’t forget to outrule organic & substance abuse as causes of symptomatology.

Question 28

What is the Multi-Axial (DSM-V) System?

Answer 28

``` Axis 1-Mental disorders, Axis 2-Personality disorders, Axis 3-Physical illness, Axis 4-Psychosocial stressors, Axis 5-Level of functioning (GAF scale). ```

Question 29

What should be considered as part of the risk assessment?

Answer 29

Especially if DSH is the presenting event. Also consider if need to assess risk of violence

Question 30

What are Predisposing Factors?

Answer 30

WHAT MAKES IT MORE LIKELY TO OCCUR? ``` Family hx mental disorder Birth complications Childhood adversity Social circumstances Past psychiatric illnesses etc. ```

Question 31

What are precipitating factors?

Answer 31

WHAT MAKE IT COME ABOUT? ``` Recent life events Physical illness Medication with psychiatric adverse effects Alcohol & substance misuse Non-compliance with treatment etc. ```

Question 32

What are perpetuating factors?

Answer 32

WHAT MAKE IT CONTINUE? Poor insight Lack of compliance Ongoing social adversity/relationship problems etc.

Question 33

What investigations should be performed?

Answer 33

History: (Patient+Collateral (family, GP, etc)). MSE Relevant blood tests Urine drug screen if appropriate, Alcometer if appropriate Other: ECG, CXR, EEG, CT/MRI etc. Psychological assessment: (Cognitive,Personality)

Question 34

What form should Tx take?

Answer 34

Bio-Psycho-Social: Biological (Medication+Physical: E.g. ECT) Treat co-morbid disorders & substance abuse.

Question 35

Some examples of PSYCH Tx?

Answer 35

PSYCHOLOGICAL ``` Psychoeducation Supportive Compliance monitoring Psychodynamic psychotherapy CBT (Cognitive Behavioural Therapy) IPT (Interpersonal Therapy) DBT (Dialectical Behavioural Therapy) Family Therapy Anxiety Management & Relaxation training, Marital/Couples counselling ```

Question 36

Some examples of SOCIAL Tx?

Answer 36

``` Address family issues Education Support Accommodation, Social Welfare supports, Day Centre Social/support groups, Occupational support e.g. retraining ‘Fresh Start’ etc. ```