Psychiatry

Question 1

What are the components of a psychiatric history?

Answer 1

• PC
• HPC
• Past Psychiatric Hx
• PMHx
• DHx - Substance misuse is key
• FHx
• Personal Life
• Premorbid personality
• SHx
• Forensic Hx
• Collateral Hx

Question 2

What questions should you ask for suspected postpartum mental disorders?

Question 3

What questions should you ask for suspected mania/if you are suspecting BPAD?

Answer 3

• You seem so happy, is this usual for you?
• You seem to have a lot of energy, is this usual for you?
• How much sleep are you actually getting?
• Do you feel special/better than others?
• Can you do things that other people can’t? Do you have special powers?
• How are you getting on with people these days?
• Sounds like you’ve been incredibly busy recently, do you have time to eat or sleep?

Question 4

In a psych history, what do you need to find out about the history of PC?

Answer 4

• Begin with patient’s own narrative and explore
• Clarify terms - e.g. patient says she is “depressed”
• Timing - onset, triggers, progression
• Severity, frequency, duration
• Screen for other possible associated symptoms
• Has treatments been initiated
• Changes and effects
• Impact of illness

Question 5

In a psych history, what must be assessed surrounding PPH?

Answer 5

• Nature
• Duration of illness
• Previous treatments – Did it work?
• Admissions/MHA – dates/lengths of admissions
• Suicide attempts or self harm/other risks

Question 6

In a psych history, what must be assessed surrounding PMH?

Answer 6

• Breif full medical history including medications
  
  • Endocrine
  • Neurological
  • Head injury
  • Infections

Question 7

In a psych history, what must be assessed surrounding FH?

Answer 7

• Ages
• Occupations
• Physical health
• Psychiatric history
• Relationship with patient
• Divorces/separations/conflicts
• Genogram

Question 8

In a psych history, what must be assessed surrounding the patients personal history?

Answer 8

• Pregnancy and birth details
• Early childhood development
• Childhood health
• Early emotional stresses (separation/abuse)
• Education
• Occupational history
• Key relationships and psychosexual history
• Realtionship

Question 9

In a psych history, what must be assessed surrounding the patients premorbid personality?

Answer 9

• Relationships – how relate to others
• Predominant mood
• Moral/religious beliefs
• Activities and interests
• Reaction to stressors

Question 10

In a psych history, what must be assessed surrounding SH?

Answer 10

• Current occupation
• Finances
• Residence - Who are you currently living with
• Social contacts
• Interests and hobbies

Question 11

In a psych history, what must be assessed surrounding Forensic history?

Answer 11

• Arrests
• Cautions/charges
• Convictions/sentences
• Crimes of violence
• Associated factors
• Have incidences been linkec with episodes of psychiatric illness

Question 12

What are the components of a Mental state exam?

Answer 12

• Appearance and behaviour
• Speech
• Emotion/mood
• Perception
• Thoughts
• Insight
• Cognitive function

Question 13

In a Mental state exam, what should be assessed under Appearance and behaviour?

Answer 13

• Describe a ‘picture of patient’
  
  • Assess self-care/clothing
  • Eye contact
  • Posture and movements
    
    • Psychomotor agitation/retardation/EPSE:akathisia/TD
  • Level of activity
  • Appropriateness of behaviour
  • Responsiveness - distractibility
  • Rapport/Guarded

Question 14

In a Mental state exam, what should be assessed under Speech?

Answer 14

• Rate (fast/slow)
• Tone (emotional quality – sarcastic/angry)
• Flow (spontaneous/prompted/hesitant/long pauses/uninterruptible)
• Volume (loud/soft)
• Link to thoughts:
  
  • Pressure of speech – pressure of thought
  • Poverty of speech – poverty of thought
  • Sudden stop – thought block
  • Organic: Dysarthria, Dysphasia, Perseveration
  • Unusual Content: neologisms, clang associations(rhyming), punning

Question 15

In a Mental state exam, what should be assessed under Emotion?

Answer 15

• Subjective assessment
  
  • Rating scale
    
    • How much are you able to enjoy things that you used to like?
    • Do you feel happier than usual?
  • Record verbatim
• Objective/Affect assessment
  
  • Restricted, blunted, flattened
  • Depression
  • Elation
  • Anxiety
• Guilt/worthlessness
• Suicidal ideation/Risk to others

Question 16

What questions would you ask to assess emotions in suspected mania?

Answer 16

• You seem so happy, how are you feeling, is this usual for you?
• You seem to have a lot of energy today, is this usual for you?
• Sounds like you’ve been incredibly busy recently, do you have time to eat/sleep?
• How much sleep are you actually getting?
• Do you feel special? Better than other people? Can you do things that other people can’t do? Do you have special powers?
• How are you getting on with other people these days?

Question 17

What is the difference between Affect and Mood?

Answer 17

• Affect = objective, short lived
• Mood = subjective and objective, more pervasive
• Affect = Weather
• Mood = Climate

Question 18

What questions should you ask about suicide?

Answer 18

• ‘Have you ever had thoughts of harming yourself /ending it all?’
  
  • If a patient has had specific thoughts, ask:
    
    • ‘What particular thoughts went through your mind?’
    • ‘Have you made any plans?’
    • ‘How close have you come?’
    • ‘What has stopped you doing anything?’
    • ‘Have you actually tried to harm yourself?’
      
      • If yes, ask:
        
        • ‘What happened exactly?

Question 19

What two things are essential to assess following an episode of DSH?

Answer 19

• Intent
• How did they feel afterwards

Question 20

In a Mental state exam, what should be assessed under Thoughts?

Answer 20

• Thought Form - Formal Thought Disorder
  
  • Circumstantial speech – over-inclusive thinking (but you get to the goal)
  • Flight of ideas (don’t get to the goal)
  • Derailment – change topic, no logical connection (don’t get to the goal)
  • Loosening of associations (also derailment, knights move thinking)
  • Word salad
• Thought Content
  
  • Preoccupations – worries and concerns
  • Overvalued ideas
    
    • Body image, belief they have a serious illness
  • Obsessional thoughts and Compulsions
  • Delusions
  • Interference

Question 21

What questions would you ask to assess emotions in a suspected anxiety disorder?

Answer 21

• Can you tell me what else you worry about?
• Is there anything specific that you are very scared of? Any particular situations?
• How do you feel in your body when you are worrying?
• Do you feel your heart racing? Do your palms gets sweaty? Do you sometimes find it hard to breathe?
• Do you avoid particular things/situations because of these unpleasant feelings?
• How do you cope in these situations?

Question 22

What questions would you ask to assess emotions for suspected obsessions?

Answer 22

• Do you have any unpleasant thoughts that don’t go away however hard to try to ignore them?
• Do you worry about cleanliness, not having checked something, bad religious thoughts, doing something bad to someone, etc
• Where do these thoughts come from?
• Do you believe them?
• How do they make you feel?
• How do you manage these feelings?

Question 23

What is the difference between delusional mood and delusional perception?

Answer 23

• Mood = ‘When you go somewhere, everything seems already set up for you like in a theatre – it’s really eerie, and you get terribly frightened’
• Perception = Objects/events gain a new meaning

Question 24

What questions would you ask to assess emotions for suspected psychosis?

Answer 24

• Do you ever feel something strange is going on?
  
  • ‘Do you ever feel that people are trying to harm you or hurt you?’
  • ‘Do you ever feel that you are being watched or followed?
• Have you had any unusual experiences?
  
  • Ideas of Reference - ‘Have you ever felt as if you were receiving messages from television, radio, newspapers?’
• Have you felt suspicious about things recently?

Question 25

What questions would you ask to assess emotions for suspected thought interference?

Answer 25

* Thought Interference * ‘Do you ever feel that your thoughts are being interfered with?’ * Thought Broadcasting * ‘Do you ever feel that people can read your mind or that your thoughts are available to others?’ * ‘Thought Withdrawal * Have you ever felt as if thoughts are being taken out of your head?’ * Thought Insertion * ‘Do you feel that people are putting thoughts into your head?’

Question 26

In a Mental state exam, what should be assessed under Perception?

Answer 26

* Illusions * Depersonalisation/derealisation * Hallucinations * Auditory * Visual * Tactile * Olfactory * Gustatory

Question 27

What questions would you ask to assess emotions for suspected hallucinations?

Answer 27

* ‘Do you ever hear someone talking when there seems to be no one around?’ * ‘Could you tell me more about what you hear?’ * Auditory * ‘What do they say?’ * ‘Is there one person/voice or more than one person/voice?’ * ‘Do you recognize them?’ * ‘Do they seem to talk to you, like I’m talking to you or about you, as if you’re not there?’ – second or third person * ‘Where do they seem to be coming from?’ * ‘Do they seem to come from inside or outside your head?’ – pseudo hallucinations versus hallucinations * 'Are they real or do you feel they are part of you?’ – hallucinations versus pseudo hallucinations * ‘How much of the time are they there?’ * ‘Do you hear them in certain situations?’ * ‘How do they affect you?’ * ‘Do you ever hear your own thoughts spoken aloud?’ – thought echo * ‘Do the voices ever tell you to do things?’ – commanding voice * ‘What do they instruct you to do?’ * Do they ever tell you to do bad things, for example hurt yourself or others?’ * ‘Do you feel you have to act on them?’

Question 28

What questions should you ask to determine whether a patients thoughts are a fixed delusion or overvalued idea?

Answer 28

* ‘Are you absolutely sure that that there is a plot against you, or is it possible that you might be mistaken?’ * ‘If somebody else said that to you, what would you make of it?’ * ‘Is there any chance you mind could be playing tricks on you?’

Question 29

In a Mental state exam, what should be assessed under Cognition?

Answer 29

* Ideally a MMSE or MOCA * Can do a short assessment of orientation, attention, concentration, memory for consult

Question 30

In a Mental state exam, what should be assessed under Insight?

Answer 30

* Do others/you think you might be unwell? * What do you think the problem is? * Do you think you might need treatment? * What do you think will help/has helped?

Question 31

How might you counsel a patient with Bulimia nervosa?

Answer 31

* Explain the diagnosis (characterised by episodes of excessive eating followed by guilt and purging) * Explain the complications (low self-esteem, depression, problems with relationships, dehydration, tooth and gum disease, heart problems) * Explain the psychological management (guided self-help for 4 weeks to CBT-ED or just FT-BN) * Consider medical (high-dose fluoxetine)