Approach-to-psychiatric-history-and-risk-assessment.pptx

osce psychiatry

1. Approach to psychiatric history and risk assessment OSCE tutorials Jacynta Batt

2. Outline Clinical scenario Psych history outline Risk assessment Symptoms of syndromes/illness Mood disorders Anxiety disorders Psychosis Basic management

3. Clinical Scenario You are an intern in ED. You have gone to see Mr Craig Moody, a 56 year old man who was brought in to ED by his wife who was concerned about him being down and constantly expressing negative thoughts. Could you please interview the patient and then give a basic management plan to the examiner?

4. Psychiatric History Patient profile is important! Occupation Living conditions Partner/spouse/family History of presenting complaint Detail focussing on theme of PC (see later slides) Timeframe of symptoms + related triggers ?effect on ADLs + relationships ?prior episodes Screen for depression, mania, anxiety and psychosis

5. Psychiatric History Always do a risk assessment! Past history Psychiatric ? prev psych intervention Medical Medications Allergies Drug + alcohol + smoking history Family history

6. Psychiatric History Developmental history (brief/omitted in an OSCE!) Level of education Household stability growing up Childhood trauma (+ in later life) Relationships Forensic history (if relevant in OSCE) Social history Hobbies Supports

7. Risk Assessment Thoughts of harming self Suicidal ideation Thoughts of harming others What thoughts? When did they start? Any trigger? Any change? Intent, plans, actions taken towards plans Any prior history? (esp. previous suicide attempts) Any plans for after? E.g., suicide note, evading police

8. Risk Assessment Access to firearms/other weapons Alcohol/illicit drug use Protective factors Family/friends Hobbies/social groups Hope/plans for future Afraid of death/consequences ? Other risky behaviour – gambling, erratic driving, sexual misadventure, vulnerability, etc *

9. Mood disorders - depression DIGSPACES Depressed mood Loss of Interest Guilt/worthlessness Sleep disturbance Psychomotor agitation/retardation Appetite change or weight gain Concentration difficulties Decreased energy Suicidal ideation/thoughts of self harm

10. Mood disorders - depression Identifiable trigger Adjustment disorder with depressed mood trigger within 3 months, duration < 6 months Melancholic features Profound depressed mood with inability to feel pleasure Diurnal variation + early morning waking Severe guilt (may be to delusional degree) Marked psychomotor change (observable) Significant anorexia/weight loss Screen for mania, psychosis, substance abuse

11. Mood disorders - mania Elevated mood (or irritability) Grandiosity Decreased sleep/↑ energy Pressured/↑ speech Flight of ideas Distractibility ↑ goal directed activities Risk taking behaviour* ? Psychotic features

12. Anxiety disorders Excessive apprehension/worry regarding normal life events Restlessness Concentration difficulty “blank mind” Sleep disturbance* Pattern: generalised, social, phobia Panic attack Cognitive – Impending doom, fear of no control, derealisation Autonomic – palpitations, diaphoresis, tremor, dyspnoea, dizziness Somatic – chest pain, nausea, choking, paraesthesia, chills/heat PTSD Flashbacks + hyperarousal + negative cognition/mood OCD Obsessions – intrusive thoughts/urges/images Compulsions – repetitive behaviour to relieve distress of obsession

13. Psychosis Positive symptoms (hallmark symptoms) Delusions – many types! Hallucinations – auditory/visual (?command features) Formal thought disorder Catatonia Negative symptoms Anhedonia Avolition Affective blunting Poverty of speech ( Alogia ) Asociality + neurocognitive impairment (↓concentration/attention)

14. Psychosis differentials Drug induced Other organic cause (infection, hyperthyroid, SOL, autoimmune encephalitis, corticosteroids) Delirium Post partum psychosis Schizophrenia/Schizoaffective disorder Delusional disorder Mood disorder with psychotic features Borderline personality with extreme dissociation

15. Psychosis differentials Consider prodromal phase in a young person Often milder symptoms May have only negative or only positive symptoms May appear like depression: isolation, ↓motivation, affective blunting, sleep disturbance May have subtle odd beliefs, rather than overt delusions or thought disorder E.g., paranoid ideas or ideas of reference (not delusions), unusual perceptual experiences (without clear hallucination)

16. Symptom Screening Depression Depressed mood Anhedonia Guilt/worthlessness SI/TOSH (if not asked previously!) Anxiety Anxious mood/restless Panic attacks Flashbacks (if evidence of trauma) Mania Grandiosity Elevation ↓sleep/↑energy Psychosis Hallucinations Delusions: persecutory/ideas of reference

17. Clinical Scenario

18. Management Ask advice! ED consultant Psych consult Admission if at significant risk ITO if warranted* Medications Acute agitation: benzos/antipsychotics (consider need for IM) SSRIs for depression/anxiety Antipsychotics for psychosis/mania Mood stabilisers for mania Consider other: psychology (CBT), DASSA, etc Prompt CMHT (or GP + MHCP) follow up if not for admission + MH triage contact Firearms notification

19. Summary Psych Hx can seem overwhelming! Follow Hx taking system Learn key features for each type of presentation Risk assessment Screen for likely comorbid conditions/symptoms Broad list of differentials Manage acute risk (with expert advice!) #1 pro tip: plan questions and phrasing