Block 6 - Psychiatry Flashcards
Psychiatric History Protocol? (14)
Psychiatric History Protocol
1. Introduction
2. Demographic Data
3. Presenting Complaint - Screen: Mood, Anxiety, Psychosis, Suicidality
4. Past Psychiatric History
5. Family Psychiatric History
6. Past Medical History
7. Medications/Adverse drug reactions
8. Drug and Alcohol History
9. Forensic History
10. Developmental History
11. Social History
12. Asessment of Risk to Self and Others
13. Cognitive Screen
14. Collateral History
Psychiatric History - Introduction & Demographic Data?
Psychiatric History - Introduction & Demographic Data
“Hi, my name is Kitty, I’m one of the medical students. I’ve been asked to come and have a chat with you about what’s brought you in today and get a bit of history from you about any medical conditions you have. Would that be ok?
Before we get started please can I confirm your name and age? Are you happy for me to call you Liz?
Great thank you Liz, now Before I ask about some specific symptoms, I just wanted to find out a little bit about you as a person”
- Who do you live with? Family?
- Do you work?
- Hobbies & Interests?
Psychiatric History - Presenting Complaint?
- MAPS Screening Qs?
“Thank you for that Liz, now what is it that’s brought you in today?”
1. MOOD: screening Qs = depression, mania
2. ANXIETY: screening Qs = 6
3. PSYCHOSIS: screening Qs = 3
4. SUICIDALITY: screening Qs = 5
- Establish any precipitants: common precipitants include stress, interpersonal conflicts, medical illness, drug/ alcohol use, ceasing medication, insomnia.
- Establish level of distress and disablement
Psychiatric History - MOOD screening Questions?
- Depression = 4
- Mania = 3
MOOD: screening questions - Depression
1. “How has your mood been?”
2. “Have you been feeling sad or low
of late, or been more teary than usual?”
3. “Have you had any problems getting to sleep or staying asleep at night?”
4. “Has your appetite or weight changed of late?”)
Mania
1. “Has your mood been too good of late, such that you feel ‘high’ or euphoric?”
2. “Have your thoughts been racing, or jumping from one idea to the next?”
3. “Have you felt full of energy, and been needing less sleep of late?”
Psychiatric History - ANXIETY Screening Questions? (6)
ANXIETY: screening questions
1. “Would you describe yourself as a worrier?”
2. “Have you found yourself being more anxious of late, and having difficulty controlling it?
3. “Do you ever get attacks of anxiety, or panic attacks?”
4. “Are there any thoughts or images that keep going through your mind that you can’t control?”
5. “Are there rituals or habits you must carry out every day?”
6. “Do you experience vivid memories of traumatic events from your past?”
Psychiatric History - PSYCHOSIS Screening Questions? (4)
PSYCHOSIS: screening questions
1. Do you ever have the experience of hearing a voice when no one is in the
room?
2. Do you feel people want to harm you?
3. Can people read your mind?
4. Do you feel the TV is talking to you or trying to send you a message?
Psychiatric History - SUICIDALITY Screening Questions? (5)
SUICIDALITY: Screening Questions
1. Have things been so bad that you have had thoughts about not wanting to be alive anymore?
2. Have you had thoughts of wanting to end your life?
3. Have you made plans to end your life?
4. Have you tried to end your life?
5. What has stopped you from trying to end your life?
Psychiatric History - What questions should you ask about Past Psychiatric History? (5)
Past Psychiatric History
1. First symptoms/ first diagnosed?
2. How many episodes?
3. Success or otherwise of any pharmacological & psychological treatments? ECT?
4. Admission to a psychiatric hospital/ involuntary patient?
5. Suicide attempts?
Understand relapse signature and early warning signs.
Psychiatric History - What questions should you ask about Family Psychiatric History? (3)
Family Psychiatric History
1. Previous mental disorders
2. Treatments
3. Hospitalizations (involuntary, ECT, suicide).
“In terms of a family history Liz, is there anyone in your family that you’re aware of who has had similar problems? Is there anyone who has depression?
We know there can be a genetic link with these disorders so it’s helpful for us to get a full picture.”
Psychiatric History - What questions should you ask about Past Medical History? (6)
Psychiatric History - Past Medical History
1. Any known medical conditions?
2. Any neurological conditions such as stroke?
3. Head injury where you lost conciousness?
4. Seizures
5. Cerebrovascular risk factors - Hypertension? Heart problems? Diabetes? High cholesterol?
6. Previous neuroimaging?
Psychiatric History - What questions should you ask about Medications? (3)
Medications/ Adverse drug reactions
1. Prescription?
2. Non-prescription medications - eg. OTC, herbal?
2. Side effects from psychiatric or other medications.
3. Risk for stroke - Oral Contraceptive Pill, anti-hypertensives, diabetes medications, anti-arrythmias
Psychiatric History - What questions should you ask about Drug and Alcohol History? (5)
Psychiatric History - Drug and Alcohol History
1. Nicotine - pack hx?
2. Ethanol - CAGE?
3. Illicit substances (first used, last used, heavy use, problems arising).
4. Establish abuse or dependence.
5. The relation of substance use to psychiatric symptoms.
Psychiatric History - What questions should you ask about Forensic History? (3)
Psychiatric History - Forensic History
“Have you ever been in trouble with the law?”
- Previous or pending charges, convictions and time spent in prison.
Psychiatric History - What questions should you ask about Developmental History? (8)
Psychiatric History - Developmental History
1. Pregnancy and birth/ developmental milestones
2. Any childhood illnesses?
3. Relationships within the family (“who did you go to for a hug?”)
4. Parental discipline?
5. Any childhood abuse (emotional or physical) or other traumatic experiences?
6. Experience of school (academic achievement, sports, friends, bullying, truancy, relations with authority figures)?
7. Higher education/ qualifications/ employment history (longest job held)?
8. Past relationships
“How would you describe yourself as a person?”; “How do you cope with stress normally?”
“Did you grow up in Australia? Please can you tell me a bit about your childhood?”
Psychiatric History - What questions should you ask about Social History? (9)
Psychiatric History - Social History
1. Important relationship?
2. Current occupation
3. Liiving arrangements?
4. Available supports/ friendship networks?
5. How they spend their free time (hobbies, interests, sport, cultural events.
6. Spirituality?
7. Their ability to manage their self-care (e.g., showering, dressing, toileting, feeding)?
8. Ability to manage their household (managing finances/ paying bills, shopping, cleaning, transport)?
9. Dependents in need of care (young children, elderly parents, or someone with a disability)?
Psychiatric History - What questions should you ask to assess their risk of harm to self and to others?
Psychiatric History - Assessment of Risk to Self and Others
“Have you had any thoughts of ending your life? Have you ever thought of how you would do this? Do you have any thoughts of harming others?
Do you belief you are unsafe or that someone else is trying to harm you?
Is anyone telling you to harm yourself?”
Psychiatric History - How would you perform a cognitive screen?
Psychiatric History - What sort of collateral history would you try to obtain from your patient?
Psychiatric History - Collateral History
“It sounds like you’ve been dealing with alot Liz and there are some symptoms that you’re telling me about that I am slightly concerned about so I feel like it would be good to get a bit more of an understanding about them from the people around you. Would it be possible to have a chat with your partner about the situation to hear his thoughts on everything? Although I woud find this really helpful, if you’d prefer we didn’t then of course I won’t. Perhaps you could book an appointment together?”
Approach to the Depressed Patient Protocol
- 3 symptoms domains & Qs you would ask for each?
**Approach to the Depressed Patient **
1. Psychiatric History
2. MOOD/SUICIDALITY screening questions
3. Depression protocol
4. Screen for the common comorbidities of depression: anxiety, psychosis, substance abuse and dependence (alcohol, benzodiazepines, illicit substances)
5. Understand the disablement (the impact of the depression on the patient’s life and any dependents in need of
care)
Approach to the Depressed Patient Protocol
- 5 Disorders to consider in your differentials?
Depression
1. Major depressive disorder
2. Persistent depressive disorder (dysthymia)
3. Seasonal affective disorder
4. Peripartum depression
5. Bipolar disorder
Approach to the Anxious Patient Protocol
- 4 symptom domains & Qs you would ask for each?
Approach to the Anxious Patient Protocol
1. Psychiatric History
2. ANXIETY screening questions
3. Anxiety protocol
4. Screen for the common comorbidities of anxiety disorders: depression and suicidality, abuse and dependence (alcohol, benzodiazepines, illicit substances
5. Understand the disablement (the impact of the anxiety on the patient’s life and any dependents in need of care)
What are the physical symptoms someone with anxiety might experience?
Anxiety - Physical Symptoms
1. Cardiac: palpitations, dizziness, chest pain or discomfort
2. Respiratory: shortness of breath, difficulty breathing, choking sensation,
hyperventilation
3. Gastrointestinal: abdominal churning, nausea, diarrhoea o Temperature: chills, hot flushes, sweating
4. Somatic: tremor, tension, shaking, numbness & tingling
5. Do you get panic attacks?
What are 4 behavioural changes associated with anxiety?
BEHAVIOURAL CHANGES ASSOCIATED WITH ANXIETY
1. Avoidance: avoid the feared situation or stimulus (e.g. social phobia, avoid crowds. PTSD)
2. Agoraphobia: avoid leaving home (the place of safety) as you fear something bad will happen, and no help will be available
3. Compensatory behaviours: compulsions (e.g., hand washing)
4. Decreased interest in activities (not answering phone or the door), withdrawal
Approach to the Anxious Patient Protocol
- 5 Disorders to consider in your differentials?
Don’t forget cardiac pathologies as a differential - palpitations = arrythmias!
1. Panic disorder
2. Generalised anxiety disorder (GAd)
3. Social anxiety disorder
4. Post-traumatic stress disorder (PTSD)
5. Obsessive–compulsive disorder (OCD)
Approach to the Psychotic Patient Protocol
- Positive Symptoms?
- Negative Symptoms?
- Neurocognitive Symptoms?
Approach to the Psychotic Patient Protocol
1. Complete the psychiatric history
2. PSYCHOSIS Screening Qs
3. Screen for the common comorbidities of psychosis: anxiety, mood disturbance, substance abuse and dependence (alcohol, benzodiazepines, illicit substances)
4. Understand the disablement (the impact of the psychosis on the patient’s life and any dependents in need of
care)
5. Cognitive screen important (e.g. MOCA)
Psychiatric Mental State Exam Protocol?
Psychiatric Mental State Exam Protocol
1. Appearance
2. Behaviour and co-operation
3. Speech
4. Mood
5. Affect
6. Thought form
7. Thought content
8. Perceptual disturbance
9. Insight
10. Judgment
11. Cognition
What would you comment on in terms of Appearance in the Psychiatric Mental State Exam? (2)
Psychiatric Mental State Exam - Appearance
Give brief description is given of the patient’s appearance (so someone who is not in the room can visualise the patient). Comment on:
1. Appropriately dressed (or overdressed/ underdressed/ wearing excessive make up/ jewellery)
2. Grooming and Hygiene - (dishevelled or unkempt).
What would you comment on in terms of Behaviour & Co-operation in the Psychiatric Mental State Exam? (4)
Psychiatric Mental State Exam - Behaviour & Co-operation
1. Abnormal posture
2. Abnormal movements (tremor, mannerisms, tics, repeated movements, restless, pacing, agitated, slow movements)
3. Abnormal behaviours (psychomotor retardation or agitation; if they are behaving in an anxious way).
4. Describe their co-operation: friendly and co-operative/ appropriate for the context (or may be unco-operative, oppositional, hostile, seductive).
What would you comment on in terms of Speech in the Psychiatric Mental State Exam? (5)
Psychiatric Mental State Exam - Speech
1. Spontaneous or not?
2. Tone?
3. Rate?
4. Volume?
5. Rhythm?
What would you comment on in terms of Mood in the Psychiatric Mental State Exam? (2)
What would you comment on in terms of Affect in the Psychiatric Mental State Exam? (2)
**Psychiatric Mental State Exam - Affect
**1. Is it appropriate?
2. What is the range - normal? restricted? flattened? blunted?
What would you comment on in terms of Perceptual Disturbances in the Psychiatric Mental State Exam? (3)
What would you comment on in terms of Thought form in the Psychiatric Mental State Exam? (5)
Psychiatric Mental State Exam - Thought Form
1. Linear?
2. Circumstantial?
3. Tangential?
4. Evidence of derailment (loosening of association), or word salad?
5. Provide an example of what the patient said to justify your statement.
What would you comment on in terms of Thought content in the Psychiatric Mental State Exam? (4)
Psychiatric Mental State Exam - Thought Content
1. Overvalued ideations and any delusions?
2. Depressive cognitions (e.g., hopeless, worthless, suicidal thoughts)?
3. Anxious cognitions (e.g., fears, obsessions, hypochondriacal preoccupations)?
4. Any suicidality/ homicidality!!
What would you comment on in terms of Insight in the Psychiatric Mental State Exam? (3)
Psychiatric Mental State Exam - Insight
3 important components:
1. Awareness there is a problem
2. The ability to attribute the problem appropriately (e.g., to a mental illness)
3. The willingness to seek help/ get treatment.
If all three are present, then the patient has ‘good insight’; if less than three are present insight is reported as ‘partial’. The patient lacks insight if all three components are absent.
List several symptoms of psychiatric illness?
4 Classes of psychiatric drugs and their major indications?
3 COMMON SIDE EFFECTS OF THE ANTIPSYCHOTIC DRUGS?
7 MEDICAL CONDITIONS THAT MAY RESEMBLE DEPRESSION?
