Psychiatry Symposium 1 - History Taking and Mental State Examination Flashcards
What are the two fundamental components of Psychiatric Interviewing ?
Collection of clinical data
Intuitive understanding of the patient as an individual (Including Empathy and Descriptive Psychopathology)
E.g E.g medical student cant go to lecture, hearing voices for years and someone new moves in next door
What is Descriptive Psychopathology?
Fancy term, describing pathology happening in mind/psyche (might be an exam question)
How do we collect clinical data?
Taking a clinical history
Examining the mental state (Do this during the history taking - testing for things you can objectively see. E.g if being distracted while talking to them are they hearing voices?)
What is the difference between Psychiatry and Psychology ?
Psychiatrists can prescribe and are medically trained
Psychology can do things like CBT, DBT, MBT
What is important about the setting of a psychiatric assessment ?
Importance of privacy, avoid interruptions —
phones, pagers
Informal setting, avoid barriers, respect personal space
Easy exit — if only one exit interviewer should have immediate access
What is important about Safety during a psychiatric assessment ?
Treating team/primary nurse
Violence is unusual
Inform staff who you are going to interview & where
During i/ V - autonomic overactivity; posture; verbal aggression
* if uncomfortable end interview
What is the overview of a Psychiatric History ?
PC
HPC
Past Psychiatric History (PPH)
PMH
DH
SH - alcohol and drug use, smoking, social circumstances, occupation
FH
Forensic History (have presented to other agencies)
Personal History;
- Developmental milestones
- Schooling/Education
- Occupational History
- Relationships
- Pre-morbid Personality
Presented before, under mental health act?
What should you include in your introduction ?
- Greet verbally & introduce self
- Non-verbal cues
- Orientate & check (purpose of interview, likely duration of interview, note taking, confidentiality, part of team)
*Building rapport is important, adjust your style according to patient, e.g if aggressive speak softly to deescalate, can discuss their interests etc
What is important to remember in your Style of interview?
- Eye contact helps rapport.
- Adopt relaxed non-threatening posture and appear unhurried
- Use facilitative noises, “l see” “okay”
- Pick up on non-verbal cues and acknowledg% “that sounds painful……“you look upset about that
- Control any over talkativeness with polite authority
at the right juncture - Do not offer advice or opinion too early
- Clarification and summary demonstrate interest and
willingness to try to understand. This also allows for any misperceptions to be rectified.
What are the most important things to ask in psych history ?
Psychotic symptoms and Suicidal Ideation
What types of questions should you ask initially in an interview?
Initially open questions where there is not a closed answer (yes/no)
Advantages of Open Questions;
- Allows patients to start talking about themselves and puts them at ease as they have the floor
- Allows you time to think and plan areas of questioning as you assess their style and content of their response
- Allows a period of non-verbal response from interviewer; listening and facilitating
What are the objectives of a Psychiatric History Taking?
- Form rapport and gather information
- Explore possible biological and social factors related
to the symptoms - Examine mental state
- Establish & explore
symptoms in context of
personality and
circumstances - Inform & motivate patient
- Begin formulation
What should you cover in presenting complaint?
“Can you tell me in your own
words why you are here?”
Record each presenting
complaint in their own words
List the main ones - tell the patient you will come back to
each in more detail
What should you cover in history of presenting complaint?
- Clarify each complaint in turn
- Onset, precipitants, course, severity
- Associated symptoms, effects on daily living
- Is it getting worse or better?
- Has it responded to any treatment?
SOCRATES
What should you ask about Related Symptoms?
After patient has finished volunteering symptoms
- “What other changes have your partner/ family/ friends
noticed in you?”
Ask about specific symptoms - may be closed questions
Systematic enquiry to screen for other symptoms eg
depression, obsessions, anxiety, psychosis
What Psychotic Symptoms should you explore?
- Percepts
- Beliefs/thoughts
What questions should you ask around Percepts?
All about any hallucination, lack of insight and delusion
“Have you seen or heard anything that other people
have not been aware of?”
“Have you heard any people talking when there was
nobody around?”
What do they think is causing them?
Does it seem possible?
Beware commands - Potential risk of harm
What questions should you ask around Beliefs/Thoughts?
“Has anything particular been playing on your mind?”
“Do you know why is this happening?”
“Have you noticed any change in your thoughts?”
“Has anyone interfered with your thoughts?”
“Does anyone else have access to your thoughts?”
What questions should you cover in the Past
psychiatric
history ?
- Past episodes/ diagnoses / contacts
- Previous treatments (psychological,
drug and physical) - Inter-episode functioning
- Previous admissions to hospital
- Attempted suicide/ repeated DSH (deliberate self harm)
- Previous detentions under Mental
Health Legislation
What questions should you cover in the Past
medical
history ?
- Developmental problems
- Head injuries
- Endocrine abnormalities
- Liver damage, oesophageal
varices, peptic ulcers - Vascular risks factors
What questions should you cover in the current and recent medication?
- Ask about tablets and injections (Can get injections twice a year to manage schizophrenia)
- Ask about medication recently
- Any drugs discontinued (within
past 6 months) - Ask how long medication has been
taken for and at what dose - Ask about adverse reactions and
allergies
What questions should you cover in the Family History?
- Parents, siblings, grandparents
etc - Age, employment,
circumstances, health
problems, quality of
relationship - Major mental illness in more distant relatives is important
- Genogram can be helpful (Picture to outline timeframe and keep thread of story)
What questions should you cover in the Social History?
- Social circumstances including occupation
- Current financial
situation/stressors - Smoking/Alcohol/illicit drug use
- Current relationship/stressors
- Children - contact
What questions should you cover in the Alcohol/Illicit drug History?
- Regular or intermittent
- Amount (know the units)
- Pattern
- Dependence/ withdrawal symptoms
- Impact on work, relationships,
money, police - Screening questionnaires eg. CAGE
What questions should you cover in the Forensic History?
- “Have you ever been in contact with the police? Charged with
any crime?” - Offences including sentences
- Recidivism
- Particular attention to violent or sexual crimes
What is covered in the Mental State Examination (MSE)?
- Appearance & Behaviour
- Speech
- Mood
- Thoughts
- Beliefs
- Perceptions
- Cognitive function
- Suicide/Homicide (Might not be in mental state examination but is a safety net so you double check here in Aberdeen, check for you to remember and protect yourself)
- Insight
How should you Formulate the Case?
Allows consideration of the diagnosis in the context of the individual’s particular personal and medical history.
Feedback of the formulation; the patient’s
“story”, is an invaluable basis to lead on to discussion of management and treatment options.
Organic, social and psychological factors are assessed as either predisposing, precipitating or perpetuating factors.
