psych history taking Flashcards
(311 cards)
1
Q
What should you do before starting the consultation?
A
Wash your hands and don PPE if appropriate.
2
Q
What should you include when introducing yourself to the patient?
A
Include your name and role.
3
Q
What should you confirm about the patient at the start of the consultation?
A
Confirm the patient’s name and date of birth.
4
Q
How should you address the confidentiality of the consultation?
A
Explain that what they tell you will be kept confidential unless there is a risk to them or another person.
5
Q
What should you say to the patient about difficult questions?
A
I appreciate that some questions may be difficult to answer – if there’s anything you don’t want to answer right now, we can come back to it another time. Does that all sound ok?
6
Q
Why is it important to explain the areas you will cover in a psychiatric assessment?
A
Patients may not know that their life story, family background, etc., are important parts of the assessment.
7
Q
What should you establish about the time available for the consultation?
A
Establish how much time you have and explain that you may need to interrupt to move on to another area if you have enough information.
8
Q
What should you ask the patient at the start of the consultation?
A
Ask the patient if they’d be happy to talk with you about their current issues.
9
Q
What are some general communication skills relevant to all patient encounters?
A
Demonstrating empathy, active listening, appropriate eye contact, open body language, establishing rapport, signposting, and summarising.
10
Q
How can you demonstrate empathy in a consultation?
A
Respond to patient cues both verbal and non-verbal.
11
Q
How can you practice active listening?
A
Through body language and verbal responses to what the patient has said.
12
Q
What is important about eye contact during a consultation?
A
Maintain an appropriate level of eye contact throughout the consultation.
13
Q
What kind of body language should you use during the consultation?
A
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward).
14
Q
How can you establish rapport with the patient?
A
Ask the patient how they are and offer them a seat.
15
Q
What is signposting in a consultation?
A
Explaining to the patient what you have discussed so far and what you plan to discuss next.
16
Q
What is summarising and why is it important?
A
Summarising at regular intervals ensures the patient and you are on the same page.
17
Q
Why should you establish the status of the patient’s admission in inpatient settings?
A
It gives you information regarding their current mental state and helps you consider any risk that may be present.
18
Q
What is an example of an open question to explore the patient’s presenting complaint?
A
What’s brought you in to see me today?
19
Q
Why should you provide the patient with enough time to answer?
A
To allow them to fully express their issues without interruption.
20
Q
How can you facilitate the patient to expand on their presenting complaint?
A
Ok, can you tell me more about that?
21
Q
What should you do after the patient has finished speaking about their presenting complaint?
A
Check if there are any other issues.
22
Q
What is the purpose of establishing a shared agenda in the consultation?
A
To prioritize multiple presenting complaints with the patient.
23
Q
When might a collateral history be necessary?
A
If the patient has been detained under the Mental Health Act.
24
Q
What is the role of open questions in history taking?
A
Allow the patient to tell you what has happened in their own words.
25
What is the role of closed questions in history taking?
To explore symptoms in more detail and identify relevant risk factors.
26
What range of symptoms can patients present with?
"Patients can present with mania, low mood hallucinations anxiety delusions and memory loss.”
27
What are the key psychiatric symptoms/presentations?
"Low mood, self-harm/suicidal ideation elevated mood and energy anxiety delusions and hallucinations obsessions or compulsions alcohol or substance abuse issues around food or weight.”
28
What does the acronym NOTEPAD stand for when exploring symptoms?
“Nature, Onset Triggers Exacerbating/relieving factors Progression Associated symptoms Disability."
29
What are the core symptoms of depression?
"Low mood, lack of pleasure (anhedonia) and low energy levels.”
30
How should you ask about a patient's mood in depression?
"How has your mood been recently? Have you felt low in yourself?"
31
What questions can you ask to assess anhedonia?
"Have you felt little interest or pleasure in doing things?"
32
What questions can you ask to assess energy levels in depression?
"Have your energy levels been lower than normal? Have you been feeling more tired than normal?"
33
What associated symptoms should you ask about in depression?
"Disturbed sleep, change in appetite and/or weight agitation or slowing down poor concentration lack of hope feelings of worthlessness excessive guilt reduced libido thoughts of self-harm thoughts of death or suicide.”
34
What is essential to carry out in any patient presenting with low mood?
"A risk assessment."
35
How can you introduce questions about suicidal thoughts?
"It is not uncommon that people who have been feeling and thinking in this way start thinking about suicide. Have you had any similar thoughts?"
36
What are some characteristic symptoms of hypomania and mania?
"Increased self-esteem, reduced social inhibitions over-familiarity reduced attention spending recklessly inappropriate sexual encounters extravagant plans persecutory delusions incomprehensible speech self-neglect loss of insight.”
37
What are some questions to ask a patient about mania/hypomania?
"Have you noticed any change in your mood or energy levels recently? Can you describe the change? Have you felt more irritable or impatient than usual?"
38
What are common physical symptoms associated with anxiety disorders?
“Palpitations, chest tightness breathlessness sweating dizziness dry mouth nausea vomiting insomnia paraesthesia.”
39
What should you screen for in patients presenting with anxiety?
"Co-existing depression."
40
What are common symptoms of psychosis?
“Hallucinations, thought abnormalities delusions.”
41
What are some screening questions for hallucinations?
"Do you ever hear noises or voices when there is nobody else there? Do you ever feel that someone or something is touching you when there is nobody there?"
42
What are some screening questions for delusions?
"Do you sometimes have thoughts that others tell you are false? Do you have any beliefs that aren’t shared by others you know?"
43
What are obsessions and compulsions?
"Obsessions are recurrent intrusive thoughts images or impulses. Compulsions are repetitive mental processes or physical acts performed in response to an obsession."
44
What are some questions to ask about obsessions?
"Do you get repeated unpleasant thoughts or images coming into your mind? Do you get these thoughts despite trying to keep them out?"
45
What are some questions to ask about compulsions?
"Do you feel that you need to repeatedly check things you have already done? Do you need to arrange touch or count things repeatedly?”
46
What are the CAGE screening questions for alcohol use?
"Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about drinking? Have you ever felt you needed a drink first thing in the morning to steady your nerves or get rid of a hangover?"
47
What are some key questions to screen for substance dependence?
"Do you feel a strong desire or compulsion to take __? Do you often take more than intended? Have you ever experienced withdrawal symptoms? Do you need more to achieve the same effect? Has your use caused any physical or mental health problems?"
48
What are some questions to explore eating disorders?
"Can you describe a typical day’s food intake? Are you on a diet? What has your weight been like? How often do you weigh yourself? How do you feel about your body?"
49
What should you ask about adaptive behaviours in eating disorders?
"What sort of exercise do you do and how much? Do you engage in purging behaviours like vomiting or medication use? What do you eat in a binge and are there any triggers?"
50
What are some physical signs and symptoms to explore in eating disorders?
“Amenorrhoea, fatigue constipation dizziness haematemesis seizures.”
51
What does ICE stand for in patient history taking?
“Ideas, Concerns Expectations.”
52
What are some questions to explore a patient's ideas about their issue?
"What do you think the problem is? What are your thoughts about what is happening?"
53
What are some questions to explore a patient's concerns?
"Is there anything, in particular that’s worrying you? What’s your number one concern?”
54
What are some questions to explore a patient's expectations?
"What were you hoping I’d be able to do for you today? What would make today's consultation a success?"
55
Why is summarising important in a patient consultation?
"It allows you to check your understanding and provides an opportunity for the patient to correct any inaccuracies."
56
What should you explore after the patient’s presenting complaint?
Other areas of the history, including past psychiatric history.
57
Why is a past psychiatric history important?
It may help with reaching a diagnosis.
58
What questions should you ask about past psychiatric history?
Have you ever experienced symptoms like this before? Have you ever had any problems with your mental health before? Have you ever been diagnosed with a mental health problem? Have you ever had any treatment for your mental health before? Have you ever had any contact with mental health services before? Have you ever been admitted to hospital due to your mental health before?
59
What should you do if the patient has a relevant past psychiatric history?
Explore it in more detail.
60
What should you find out if a patient has an existing psychiatric diagnosis?
When it was diagnosed and any significant details.
61
Why is it important to know about an existing psychiatric diagnosis?
The current presentation could be a relapse of an existing condition or lead to a change in diagnosis.
62
What should you explore about previous treatments?
Any previous treatments the patient may have received, particularly in those with complex histories.
63
Why should you clarify the effectiveness of previous treatments?
It may change the medication given depending on their experiences.
64
Why should you ask if the patient has received electroconvulsive therapy (ECT) in the past?
It may signify that they are relatively resistant to treatment.
65
What should you explore about past contact with mental health services?
Whether it has been through primary care, the community mental health team, or the crisis team/home treatment team.
66
What should you determine about specific community teams?
If the patient is under the care of a mental health team and who they see.
67
What should you clarify if the patient has been admitted to the hospital due to their mental health?
The number of admissions, the dates or rough length of stay, if they were informal admissions or under a section of the mental health act, and if they have ever been admitted to a psychiatric intensive care unit (PICU).
68
Why is a forensic history important?
It helps to formulate a risk assessment and may give clues to help with diagnosis.
69
What questions should you ask about contact with the police?
Have you ever had any contact with the police? If yes, what happened? Were you charged?
70
What should you ask if the patient has had contact with the police?
What happened? Were you charged?
71
What should you document about charges?
Document all past and pending charges.
72
Why is it important to know about episodes of violent or aggressive behaviour?
They may be associated with previous episodes of mental illness and impact your risk assessment and management.
73
What should you find out about aggression or violence without police contact?
It is useful to know if there is a history of aggression or violence without contact with the police, which may be easier to find out from a collateral history.
74
What should you ask about time spent in prison?
Have you spent any time in prison?
75
What should you ask about medical conditions?
Do you have any medical conditions?
76
What should you ask about regular medical care?
Are you currently seeing a doctor or specialist regularly?
77
What should you ask about surgical history?
Have you ever had any operations?
78
Why is it important to know the patient's past medical history?
There can be significant overlap between mental and physical health, and it is important to exclude physical causes for the patient’s symptoms.
79
Give an example of a physical condition that can present with psychiatric symptoms.
Hypothyroidism may present as low mood, or encephalitis can present as psychosis.
80
What medical conditions are risk factors for mental health disorders?
Chronic illness (e.g. chronic pain or cancer) is a major risk factor for depression.
81
Why is it important to know about medical conditions when considering psychiatric medication?
Some medical conditions, such as cardiovascular, renal, or hepatic disorders, are often contraindications for psychiatric medication.
82
How might a new psychiatric diagnosis affect a patient's physical health management?
A patient with bipolar disorder who has co-existing asthma or inflammatory bowel disease may need their treatment plans altered to avoid or reduce the use of steroids.
83
What should you ask about allergies?
Do you have any allergies?
84
What should you clarify if a patient has allergies?
Clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
85
What should you ask about current medications?
Are you currently taking any prescribed medications or over-the-counter treatments?
86
What details should you document for prescribed or over-the-counter medications?
Document the medication name, dose, frequency, form and route.
87
Why should you ask specifically about injectable medications?
Patients may be on depot medications (e.g. depot antipsychotics).
88
Why is it important to ask about recent medication changes?
Dose changes may precipitate new issues, such as a relapse of symptoms or metabolism changes due to enzyme inhibitors and inducers.
89
What should you ask about side effects from medication?
Have you noticed any side effects from the medication you currently take?
90
Name some commonly prescribed SSRIs.
Sertraline, citalopram, escitalopram, fluoxetine.
91
Name some commonly prescribed SNRIs.
Venlafaxine, duloxetine.
92
Name a commonly prescribed tetracyclic antidepressant.
Mirtazapine.
93
Name some commonly prescribed TCAs.
Amitryptiline, nortriptyline.
94
Name some mood stabilisers.
Lithium, sodium valproate, carbamazepine.
95
Name some first-generation (typical) antipsychotics.
Chlorpromazine, flupentixol, haloperidol, levomepromazine, zuclopenthixol.
96
Name some second-generation (atypical) antipsychotics.
Amisulpride, aripiprazole, clozapine, olanzapine, quetiapine.
97
What should you ask about family history of psychiatric disease?
Have any of your parents or siblings had problems with their mental health in the past?
98
What should you ask to specify the type of mental health problems in the family?
Do you know what type of mental health problems they had?
99
What should you ask about family history of physical disease?
Do any medical problems run in the family?
100
What specific physical health problems should you ask about in the family history?
Diabetes, cardiovascular conditions, or any genetic conditions.
101
What is the aim of taking a personal history?
To get an understanding of the patient’s life experiences and their impact.
102
What structure is suggested for taking a personal history?
Chronologically, starting in childhood and moving on to education and employment.
103
What should you ask about childhood?
Do you know if there were any problems during your mother’s pregnancy with you? Are you aware of any problems around your birth? As far as you know, did you meet the normal milestones growing up? How would you describe your childhood?
104
Why is childhood environment important?
It significantly impacts personality and mental health as an adult.
105
What should you explore if the patient reports difficulties during childhood?
Try to find out more about the difficulties, acknowledging that it may be difficult for them to discuss.
106
What should you ask about schooling and education?
Did you enjoy school? Did you have a lot of friends at school? Did you have any problems with bullies at school? At what age did you leave school? What qualifications did you leave school with?
107
What aspects of school experience should be explored?
Whether they enjoyed primary and secondary school, difficulties with schoolwork, relationships with teachers, and bullying.
108
What should you ask if the patient attended college or university?
Ask about their experience, what they studied, and how they coped with responsibilities like finances and deadlines.
109
What should you ask about the patient’s occupation?
Are you employed at the moment? How long have you been at your current job? What jobs have you had in the past? Why did you leave your previous jobs? Have you ever been dismissed from a previous job?
110
What can an employment history indicate in psychiatric history?
How they cope at work gives a good indication of their current level of function and impact of mental health on employment.
111
What should you ask about relationships?
How do you get on with your family? Do you find it easy to make friends? Do you feel like you have a good social support system? Are you in a romantic relationship at the moment? What have your previous romantic relationships been like? Have your current problems affected your relationships?
112
What aspects of family relationships should be explored?
Immediate family, childhood circumstances, relationship with family both past and present, and any recent significant family events.
113
What can a patient's relationship history indicate?
It can give clues to a diagnosis and relevance to ongoing management, such as patterns of turbulent relationships suggesting borderline personality disorder.
114
What sensitive topic should be screened for during a psychiatric assessment?
Experience of sexual abuse.
115
What should you ask about pre-morbid personality?
How would you describe yourself? How would others describe you? Do you think this would have changed at all recently? Do you have any hobbies or interests? Are you religious?
116
What emotional traits should be explored in pre-morbid personality?
Would they describe themselves as happy or sad? Do they experience mood swings? How do they manage anger?
117
What cognitive traits should be explored in pre-morbid personality?
How is their self-esteem? Are they a confident person? Do they see themselves as an optimist or pessimist? Are they naturally suspicious of others? How do they cope with decision-making?
118
What behavioural traits should be explored in pre-morbid personality?
Would they describe themselves as an introvert or extrovert? Would they say they are impulsive? Do they enjoy socialising?
119
Why is the social history important in a psychiatric history?
Social circumstances are often significant risk factors for developing psychiatric conditions.
120
What should you ask about living circumstances?
Where do you live currently? Do you live with anyone else? Are there any children at home?
121
What should you find out if a patient is homeless?
Why did they become homeless? How long have they been homeless? Do they have access to hostels, or are they sleeping on the streets?
122
Why is it important to ask about homelessness in a psychiatric assessment?
Homelessness can both be caused by and cause mental health problems, and it is essential to include accommodation in your assessment and management plan.
123
Why should you ask about children at home?
To ensure they are still being cared for and in case any safeguarding issues arise from the assessment.
124
What should you ask about activities of daily living?
How are you coping at home at the moment? Do you feel able to look after yourself? Do you have any worries at the moment?
125
What aspects of daily living should you inquire about?
Diet, personal hygiene, housework, and financial concerns.
126
What should you record about the patient's smoking history?
Type and amount of tobacco used.
127
What should you record about the patient's alcohol consumption?
Frequency, type and volume of alcohol consumed on a weekly basis.
128
What should you ask about recreational drug use?
Do you use recreational drugs? If so, determine the type of drugs used and their frequency of use.
129
What does insight refer to in a psychiatric assessment?
The ability of a patient to understand that they have a mental health problem and that what they’re experiencing is abnormal.
130
How might severe depression affect insight?
Patients with severe depression may demonstrate a loss of insight into their illness.
131
What is a question you can ask to assess the patient's understanding of the cause of their problem?
What do you think the cause of the problem is?
132
What is a question you can ask to determine if the patient recognizes they have a problem?
Do you think you have a problem at the moment?
133
What is a question you can ask to assess if the patient feels they need help?
Do you feel you need help with your problem?
134
What should you do to summarise the consultation?
Summarise the key points back to the patient.
135
What should you ask the patient before closing the consultation?
Ask if they have any questions or concerns that have not been addressed.
136
What should you do to show appreciation to the patient?
Thank the patient for their time.
137
What should you do after closing the consultation?
Dispose of PPE appropriately and wash your hands.
138
What should you do before starting the consultation?
Wash your hands and don PPE if appropriate.
139
What should you include when introducing yourself to the patient?
Introduce yourself to the patient including your name and role.
140
What should you confirm about the patient at the start of the consultation?
Confirm the patient's name and date of birth.
141
What should you explain to the patient about the questions you will ask?
Explain that some questions may be difficult to answer.
142
What should you ask the patient before starting the consultation?
Ask the patient if they’d be happy to talk with you about their current issues.
143
What should you establish about the patient's admission status?
Establish the status of their admission (informal or detained under Mental Health Act).
144
What type of questioning should you use to explore the presenting complaint?
Use open questioning to explore the patient’s presenting complaint.
145
What should you do after identifying the presenting complaint?
Explore the presenting complaint in more detail.
146
What should you conduct to assess potential dangers to the patient or others?
Conduct a risk assessment.
147
What should you consider when gathering information about the presenting complaint?
Consider taking a collateral history.
148
What should you explore about the patient's thoughts on their condition?
Explore the patient's ideas, concerns and expectations.
149
What should you do to ensure understanding of the presenting complaint?
Summarise the patient's presenting complaint.
150
What should you ask about the patient's past psychiatric history?
Ask the patient about their past psychiatric history.
151
What details should you establish about past psychiatric issues?
Establish past psychiatric diagnoses, treatments, and past contact with mental health services.
152
What should you ask about the patient's legal history?
Ask the patient about their forensic history.
153
What should you ask about the patient's physical health?
Ask if the patient has any medical conditions.
154
What should you clarify if the patient has allergies?
Clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).
155
What should you ask about the patient's medication use?
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies.
156
What should you inquire about regarding medication changes?
Ask about recent medication changes.
157
What should you ask about medication effects?
Ask the patient if they’re currently experiencing any side effects from their medication.
158
What should you ask about family health history?
Ask the patient if there is any family history of psychiatric or physical disease.
159
What aspects of childhood should you ask about in personal history?
Ask the patient about their childhood.
160
What should you ask about the patient's education?
Ask about schooling and education.
161
What should you ask about the patient's employment history?
Ask the patient about their occupation and employment history.
162
What should you ask about the patient's relationships?
Ask the patient about their current and previous interpersonal relationships.
163
What should you ask about the patient's personality before the onset of illness?
Ask the patient about their pre-morbid personality.
164
What should you ask about the patient's current living situation?
Ask about the patient’s current living circumstances.
165
What should you inquire about regarding children in the home?
Ask about any children at home and identify any safeguarding issues.
166
What should you ask about the patient's daily activities?
Ask the patient about their activities of daily living.
167
What should you record about smoking?
Take a smoking history.
168
What should you record about alcohol use?
Take an alcohol history.
169
What should you ask about drug use?
Ask about recreational drug use.
170
What should you assess regarding the patient's understanding of their condition?
Assess the patient’s insight.
171
What should you do to close the consultation?
Summarise the salient points of the history back to the patient and ask if they feel anything has been missed.
172
What should you do to show appreciation for the patient's time?
Thank the patient for their time.
173
What should you do after the consultation?
Dispose of PPE appropriately and wash your hands.
174
What key communication skill involves understanding the patient?
Active listening.
175
What key communication skill involves summarising information?
Summarising.
176
What key communication skill involves explaining what will happen next?
Signposting.
177
What should you do before starting the consultation?
Wash your hands and don PPE if appropriate.
178
What should you include when introducing yourself to the patient?
Introduce yourself to the patient including your name and role.
179
What should you confirm about the patient at the start of the consultation?
Confirm the patient's name and date of birth.
180
What should you explain to the patient before asking questions?
Explain that you’d like to take a history and that some questions may seem bizarre.
181
What should you do before proceeding with history taking?
Gain consent to proceed with history taking.
182
What is a hallucination?
A perception in the absence of an external stimulus that has qualities of real perception.
183
What is an auditory hallucination?
A patient hearing voices despite the absence of any actual sound.
184
What questions can you ask to explore auditory hallucinations?
Do you ever hear noises or voices when there is nobody else there? Can you hear them in your ears, or are they in your mind? How many voices are there? Do you recognize the voices? What do they say? Do they tell you to do things and do you obey? Do they tend to comment on what you are doing or thinking? Are the voices present all the time? Does anything make them better or worse? Do you ever find yourself having a conversation with them? Do you smell or see anything at the same time that you hear these voices?
185
What is a somatic hallucination?
A perception of being touched in the absence of a sensory stimulus.
186
What questions can you ask to explore somatic hallucinations?
Do you ever feel that someone or something is touching you when there is nobody there? Have you ever felt like you’ve been assaulted despite nobody being present? Have you ever felt like insects are crawling beneath your skin?
187
What is thought blocking?
Sudden cessation of thought, typically mid-sentence, with the patient being unable to recover what was previously said.
188
What questions can you ask to explore thought blocking?
Do you feel able to think clearly? Do you ever experience your thoughts suddenly stopping as though there were no thoughts left? What is it like? How do you explain it?
189
What is thought withdrawal?
A patient's belief that thoughts can be removed from their mind by others.
190
What questions can you ask to explore thought withdrawal?
Is there anything like hypnosis or telepathy going on? Is there anyone or anything taking thoughts out of your head?
191
What is thought insertion?
A patient's belief that thoughts can be inserted into their mind by others.
192
What questions can you ask to explore thought insertion?
Are your thoughts your own? Is there anyone/anything putting thoughts into your head that you know are not your own? How do you know they aren’t yours? Where do they come from?
193
What is thought broadcasting?
A patient's belief that others can hear their thoughts.
194
What questions can you ask to explore thought broadcasting?
Can anyone hear your thoughts? For example, can I hear what you are thinking right now? Do you ever hear your own thoughts echoed or repeated?
195
What is a delusional perception?
Firm, fixed beliefs based on inadequate grounds, not amenable to rational argument or evidence to the contrary and not in sync with regional and cultural norms.
196
What questions can you ask to explore delusional perception?
Do you sometimes have thoughts that others tell you are false? Do you have any beliefs that aren’t shared by others you know? Do you ever feel that people are out to do you harm? Do you ever feel that specific events in the world are related to you in some way? When you watch the television/listen to the radio/hear something, do you feel that the stories are referring to you or something that you have done?
197
What is passivity in a psychiatric context?
The feeling of not being in control of one's actions, thoughts, and perceptions, believing them to be influenced by an external agent.
198
What questions can you ask to explore passivity?
Do you ever feel as though you are being controlled by someone or something? Do you ever think that someone or somebody is controlling you? Are your thoughts/mood/actions under your control or is someone forcing you to behave in this way?
199
What should you ask before closing the consultation?
Ask if the patient has any questions or concerns that have not been addressed.
200
What should you do to show appreciation for the patient's time?
Thank the patient for their time.
201
What should you do after closing the consultation?
Dispose of PPE appropriately and wash your hands.
202
What should you do to summarize your findings?
Summarize your findings to the examiner using the mental state examination structure.
203
What is the mental state examination (MSE)?
A structured way of assessing a patient’s current state of mind.
204
What is the purpose of the MSE as defined by the Royal College of Psychiatrists?
Providing a clear, objective snapshot of someone’s mental functioning at a given time-point.
205
What should you do before starting the consultation?
Wash your hands and don PPE if appropriate.
206
What should you include when introducing yourself to the patient?
Introduce yourself to the patient including your name and role.
207
What should you confirm about the patient at the start of the consultation?
Confirm the patient's name and date of birth.
208
What should you ask the patient before starting the consultation?
Ask if they’d be happy to talk with you about their current issues.
209
What should you observe about the patient's appearance?
Personal hygiene, clothing, physical signs of difficulties, stigmata of disease, weight, and objects they brought.
210
What should you note about the patient's behaviour?
Engagement, rapport, eye contact, facial expression, body language, psychomotor activity, and signs of paranoia.
211
What should you observe about psychomotor activity?
Psychomotor retardation, restlessness, and abnormal movements or postures.
212
What should you assess about the patient's speech?
Rate, quantity, tone, volume, fluency, and rhythm of speech.
213
What are some abnormalities in speech rate?
Pressure of speech (rapid speech) and slow speech.
214
What are some abnormalities in speech quantity?
Poverty of speech and excessive speech.
215
What are some abnormalities in speech tone?
Monotonous speech and tremulous speech.
216
What are some abnormalities in speech volume?
Quiet speech and loud speech.
217
What are some abnormalities in speech fluency and rhythm?
Stammering, stuttering, slurred speech, and stilted speech.
218
What is the difference between mood and affect?
Affect is an immediately expressed emotion, and mood is the patient's predominant internal state.
219
What questions can you ask to explore mood?
How are you feeling? What is your current mood? Have you been feeling low/depressed/anxious lately?
220
What are some examples of mood states?
Low mood, anxious, angry, enraged, euphoric, guilty, apathetic.
221
What should you observe to assess affect?
Facial expressions, overall demeanor, range and mobility of affect, intensity of affect, and congruency of affect.
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What are some abnormalities in the range and mobility of affect?
Fixed affect, restricted affect, labile affect.
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What are some abnormalities in the intensity of affect?
Heightened affect and blunted or flat affect.
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What does congruent affect mean?
The patient's affect appears in keeping with the content of their thoughts.
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What is thought form?
The processing and organization of thoughts.
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What are some abnormalities of thought form?
Loose associations, circumstantial thoughts, tangential thoughts, flight of ideas, thought blocking, perseveration, neologisms, word salad.
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What are delusions?
Firm, fixed beliefs based on inadequate grounds, not amenable to a rational argument or evidence to the contrary.
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What are obsessions?
Thoughts, images, or impulses that occur repeatedly and feel out of the person’s control.
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What are compulsions?
Repetitive behaviors that the patient feels compelled to perform despite recognizing the irrationality of the behavior.
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What are overvalued ideas?
A solitary, abnormal belief that is neither delusional nor obsessional but preoccupying to the extent of dominating the person’s life.
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What are some questions to screen for thought content abnormalities?
What’s been on your mind recently? Are you worried about anything? Do you sometimes have thoughts that others tell you are false? Do you have any beliefs that aren’t shared by others you know? Do you ever feel that people are out to harm you? Do you ever feel that specific events in the world relate to you somehow? Are there any thoughts you have a hard time getting out of your head? Do you sometimes feel the need to perform certain behaviors repetitively, despite understanding these are irrational? Do you ever think about ending your life? Have you ever felt your life was not worth living? Have you ever attempted to end your life? Have you ever harmed yourself to cope with difficult emotions? Do you ever think about harming others?
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What is thought possession?
Abnormalities such as thought insertion, thought withdrawal, and thought broadcasting.
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What are some questions to screen for thought possession abnormalities?
Do you think people can put ideas in your head without your control? Have you ever felt like people have removed memories or thoughts from your mind? Do you ever feel like others can hear your thoughts?
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What is perception?
The organization, identification, and interpretation of sensory information to understand the world around us.
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What are some abnormalities of perception?
Hallucinations, pseudo-hallucinations, illusions, depersonalization, derealization.
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What are some questions to screen for perceptual abnormalities?
Do you ever see, hear, smell, feel or taste things that are not really there? Did you think this was real at the time? Do you still believe it was real? Do you ever feel as though you’re not real? Do you ever feel like you’ve changed or that you don’t recognize the person you currently are? Do you ever feel like the world around you isn’t real?
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What is cognition?
The mental action or process of acquiring knowledge and understanding through thought, experience, and the senses.
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What are some validated clinical tests for cognition?
Mini-mental state exam (MMSE), Abbreviated mental test score (AMTS), Addenbrooke’s cognitive examination III (ACE-III), Montreal Cognitive Assessment (MOCA).
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What is insight in a mental state examination?
The ability of a patient to understand that they have a mental health problem and that what they’re experiencing is abnormal.
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What are some questions to assess insight?
What do you think the cause of the problem is? Do you think you have a problem at the moment? Do you feel you need help with your problem?
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What is judgement in a mental state examination?
The ability to make considered decisions or come to a sensible conclusion when presented with information.
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What is an example scenario to assess judgement?
What would you do if you could smell smoke in your house?
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What are the two subdivisions of risk assessment in an MSE?
Risk to self and risk to others.
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What are some questions to assess risk to self?
Sometimes, when people are going through difficult things, they might have thoughts of wanting to harm themselves – is this something you’ve experienced? Do you have any plans to act on those thoughts? People can sometimes hurt themselves to manage overwhelming emotions or feelings of numbness – is this something you’ve ever done? If so, how do you cope with these feelings?
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What are some questions to assess risk to others?
Sometimes, when people are going through difficult things, they might have thoughts to harm someone else. Is this something you’ve experienced? Do you have any plans to act on those thoughts?
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What should you ask before closing the consultation?
Ask if the patient has any questions or concerns that have not been addressed.
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What should you do to show appreciation for the patient's time?
Thank the patient for their time.
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What should you do before starting the consultation?
Wash your hands and don PPE if appropriate.
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What should you include when introducing yourself to the patient?
Introduce yourself to the patient including your name and role.
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What should you confirm about the patient at the start of the consultation?
Confirm the patient's name and date of birth.
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What should you explain to the patient before starting the MSE?
Explain that you’d like to have a chat with the patient to see how they’re currently feeling.
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What should you do before proceeding with the MSE?
Gain consent to proceed with a mental state examination.
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What should you observe about the patient's appearance?
Observe the patient’s appearance.
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What should you note about the patient's engagement and rapport?
Note how the patient engages and if there seems to be rapport.
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What should you observe about the patient's eye contact?
Observe the patient's level of eye contact.
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What should you observe about the patient's facial expressions?
Observe the patient's facial expressions.
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What should you observe about the patient's body language?
Observe the patient's body language.
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What should you identify in terms of psychomotor activity?
Identify any evidence of abnormal psychomotor activity (e.g. psychomotor retardation or restlessness).
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What should you note about movements or postures?
Note any abnormal movements or postures.
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What should you note about speech?
Note the rate and quantity of the patient’s speech. Note the tone and volume of the patient’s speech. Note the fluency and rhythm of the patient’s speech.
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What should you explore about the patient's mood?
Explore the patient's current mood by asking appropriate questions.
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What should you observe about the patient's affect?
Observe the patient's affect.
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What should you note about the patient's thoughts?
Note the speed, flow, and coherence of the patient’s thoughts.
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What should you explore about thought content?
Explore the content of the patient’s thoughts for abnormalities.
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What should you ask about thought possession?
Ask about thought possession to screen for abnormalities.
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What should you explore about perception?
Explore the patient’s current perception.
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What should you do to assess cognition?
Formally assess the patient’s cognition (e.g. AMTS, MMSE, ACE-III).
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What should you assess about insight?
Assess the patient's current insight into their problems.
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What should you assess about judgement?
Assess the patient's current judgement skills.
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What should you assess about risk to self?
Assess the patient's risk to self.
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What should you assess about risk to others?
Assess the patient's risk to others.
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What should you ask before closing the consultation?
Ask if the patient has any questions or concerns that have not been addressed.
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What should you do to show appreciation for the patient's time?
Thank the patient for their time.
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What should you do after closing the consultation?
Dispose of PPE appropriately and wash your hands.
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What are key communication skills for the MSE?
Active listening, summarising, and signposting.
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What should you do before starting the consultation?
Wash your hands and don PPE if appropriate.
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Why is it important to establish rapport early in the consultation?
To allow you to perform an accurate assessment of their mental health.
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What should you include when introducing yourself to the patient?
Introduce yourself and explain why you are reviewing the patient.
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What should you explain about confidentiality?
Anything that’s said will be confidential unless there is a risk to another person.
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What is the purpose of a suicide risk assessment?
To establish the patient’s intent, assess the seriousness and perceived seriousness of their attempt, and assess how they feel about the attempt at the time of assessment.
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What type of questions should you start with when establishing intent?
Open questions.
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What are some key questions to ask about the current episode of self-harm?
Was there a precipitant? Was the self-harm planned or impulsive? Did the patient carry out any final acts? Were any precautions taken against discovery? Was alcohol used?
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What should you ask about the method of self-harm?
What method of self-harm was involved? Was the patient alone? Where were they when they self-harmed? What was going through their mind at the time? Did they think their self-harm would end their life? What did they do straight after the self-harm?
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What should you ask about the patient's actions after the self-harm?
Did the patient call anyone? How did they get to A&E? Who were they found by? How did they feel when help arrived? How does the patient feel about the attempt now? Do they regret it? What is the patient’s current mood? Does the patient still feel suicidal?
285
What should you ask if the patient were to go home today?
What would they do? If the patient were to feel like this again, what might they do differently? What does the patient think might prevent them from doing this again in the future? Does the patient feel there is anything to live for? Will the patient accept treatment?
286
What specific questions should you ask about overdose?
What medication or medications did the patient take? Where did the patient get the medication from? How much of the medication did the patient take? What did the patient take the medication with? What did the patient think that amount of medication would do? What made the patient decide to take the medication/how long had they been thinking about taking an overdose for? What did the patient do after taking the medication? How did the patient get to the hospital?
287
What specific questions should you ask about cutting?
Where are the cuts? How many cuts are there? How deep are the cuts? How did the patient feel whilst they were cutting? How did the patient feel when they saw blood? What was the patient hoping the cutting would do?
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What should you screen for to identify other mental health disorders?
Depression, psychosis, anorexia.
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What questions can you ask to screen for depression?
Do you feel that you no longer enjoy activities that you previously used to? How has your mood been recently? What have your energy levels been like recently?
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What questions can you ask to screen for psychosis?
Are the thoughts to harm ever not your own? Do you ever feel like there are voices that you can hear telling you to harm yourself, that no one else can hear? How do you know these are other peoples voices and not your own worries in your head?
291
What questions can you ask to screen for anorexia?
How would you describe your eating habits? Do you feel you’re eating enough at the moment? What’s your appetite like at the moment? Have you lost weight recently? Are you satisfied with your current weight?
292
What should you ask about previous episodes of self-harm?
Has the patient ever carried out self-harm in the past? What methods of self-harm were involved? Did they get any help from their support network or other agencies as a result of their self-harm?
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What should you ask about past psychiatric history?
Does the patient have any psychiatric diagnoses? Has the patient had any previous admissions to a psychiatric hospital?
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What should you ask about past medical history?
Ask about past medical history as it may be relevant to their current episode of self-harm (e.g. bleeding disorder/liver dysfunction).
295
What should you ask about drug history?
Take a thorough drug history as it may be relevant to the current episode of self-harm (e.g. anticoagulants/overdose/interactions).
296
What should you ask about family history?
Have any of the patient’s family members ever attempted or completed suicide? Are there any psychiatric conditions present in close family members?
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What should you ask about social history?
Who does the patient live with? Where does the patient live? Does the patient have a good support network? Is the patient able to manage all their activities of daily living independently?
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What should you consider if the patient has children?
If the children are being neglected and if the patient has thoughts of harm towards the children.
299
What should you ask about occupation?
What job does the patient have? If none, ask if coping financially? Does the patient have any debt?
300
What should you ask about alcohol use?
Does the patient drink alcohol? How much does the patient drink in an average week? What is the pattern of drinking? (e.g. every day vs binge drinking)
301
What should you ask about recreational drug use?
Does the patient use recreational drugs? What drugs does the patient use? How often and how much of the drugs does the patient use?
302
What should you do before closing the consultation?
Thank the patient for taking the time to speak with you. Tell the patient how you see their difficulties.
303
What should you do after closing the consultation?
Dispose of PPE appropriately and wash your hands.
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What should you do if the patient is not suicidal and you intend to send them home with no follow-up?
Formulate a safety plan with the patient and signpost to appropriate agencies.
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What should a safety plan include?
Seek the support of their family and friends, recognize stressors and address them where possible, avoid harmful alcohol use when stressed, ask the patient who they could tell if they felt like this again.
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What should you suggest if the patient feels like this again?
Seek help from personal support network, GP, local support line (e.g. Samaritans), A&E, local mental health services that see people who self-refer.
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What agencies can you signpost the patient to?
GP, housing services, Citizen’s Advice Bureau, alcohol and drugs services, domestic violence services, counseling services.
308
What should you do if the patient requires support from a mental health team?
Discuss whether the patient could manage safely at home with the support of an intensive home treatment team or will accept voluntary admission to a psychiatric hospital.
309
What should you do if the patient is unsafe to send home?
A Mental Health Act assessment will need to be carried out.
310
What factors increase suicide risk?
Demographics: Male, older, widowed/separated/single, living alone/social isolation, low income/unemployed, certain occupation (e.g. doctor, farmer), family history of suicide. Diagnoses: A previous suicide attempt, severe depression, anorexia, haemodialysis, recreational opiate use/dependence, alcohol dependence.
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What actions or perceptions of the act itself increase suicide risk?
The patient carried out final acts, researched methods and prepared for the act, perceived the act to have a high lethality, took precautions against being found, used a violent method of suicide, the attempt is discovered by chance, resists/tries to evade medical intervention, downplays the seriousness of the attempt.
