Psychiatric history.pptx regarding history taking and presenting a case

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1. Psychiatric history

2. Aims Diagnostic To gain a bio-psychosocial u nderstanding of the patient’s problem Therapeutic and psychoeducational

3. Presenting Complaint Past History: Psychiatric and medical Medication: Find out about compliance Family History: both medical and psychiatric Personal History: Birth and early life Education Employment Forensic history Substance abuse Premorbid personality

4. Risk assessment Assessing risk for suicide/homicide Asking the questions don’t increase risk Ask direct questions: Has the patient contemplated suicide? If yes or any positive finding: find out about plan, any attempt,

5. Mental state examination

6. MSE is a systematic appraisal of the appearance, behaviour, mental functioning and overall demeanor of a person. In some ways it reflects a "snapshot" of a person's psychological functioning at a given point in time . A - Appearance and Behaviour  S - Speech  E - Emotion [mood and affect]  P - Perception [Hallucination and illusion]  T - Thought content and process  I - Insight and Judgement  C - Cognition 

7. General Description Appearance : A person's appearance can provide useful clues into their quality of self-care, lifestyle and daily living skills - grooming, clothes, body type (dishevelled, neat, childlike) Behaviour: quantitative & qualitative aspects of motor behaviour (restless, tics) Attitude toward the examiner: (cooperative, frank & seductive) Speech The physical characteristics of speech (Rate, clarity, volume, rhythm, relevancy, coherency, fluency)

8. Emotion Mood: Is a patient’s description of pervasive and sustained subjective feeling, which may not match his/her affect . happiness ( eg , ecstatic, elevated, lowered, depressed) irritability (e.g. explosive, irritable, calm) stability Affect : is the examiners observation of the patients current emotional expression range (e.g. restricted, blunted, flat, expansive) appropriateness (e.g. appropriate, inappropriate, incongruous) stability (e.g. stable, labile)

9. Thought Form (Process) of thought: The way in which a person thinks (flight of ideas, loose associations, Tangentially “point of conversation never reached” & circumstantiality) Content of thought :What the person thinking about (delusions, idea of reference, thought insertion/withdrawal , broadcasting, paranoia, obsession, compulsion, phobia, suicidal ideas) Appropriateness :In reference to the context of the subject (appropriate or inappropriate) Perceptual Disturbances : Experienced in reference to self or the environment (hallucinations, illusions, dissociative states “depersonalization & derealization ”)

10. Thought Process highly irrelevant comments (loose associations or derailment) frequent changes of topic (flight of ideas or tangential thinking) excessive vagueness (circumstantial thinking) nonsense words (or word salad) pressured or halted speech (thought racing or blocking)

11. Thought Content delusions (rigidly held false beliefs not consistent with the person's background) overvalued ideas (unreasonable belief, e.g. a person with anorexia believing they are overweight) preoccupations depressive thoughts self-harm, suicidal, aggressive or homicidal ideation obsessions (preoccupying and repetitive thoughts about a feared or catastrophic outcome, often indicated by associated compulsive behaviour) anxiety (generalised, i.e. heightened anxiety with no specific referent; or specific, e.g. phobias)

12. Perceptual disturbance Dissociative symptoms : derealisation (feeling that the world or one's surroundings are not real) depersonalisation (feeling detached from oneself) Illusions: the person perceives things as different to usual, but accepts that they are not real, or that things are perceived differently by others Hallucinations : probably the most widely known form of perceptual disturbance hallucinations are indistinguishable by the sufferer from reality can affect all sensory modalities, although auditory hallucinations are the most common in children it is common to experience self-talk or commentary as an internal " voice“ command hallucinations (voices telling the person to do something) should be investigated important to note the degree of fear and/or distress associated with the hallucinations

13. Judgment & Insight Judgment: refers to a person's problem-solving ability in a more general sense can be evaluated by exploring recent decision-making or by posing a practical dilemma (e.g. what should you do if you see smoke coming out of a house?) Insight : acknowledgement of a possible mental health problem understanding of possible treatment options and ability to comply with these ability to identify potentially pathological events (e.g. hallucinations, suicidal impulses )

14. Appearance Age, sex, race, body build, posture, eye contact, dress, grooming, manner, attentiveness to examiner, distinguishing features, prominent physical abnormalities, emotional facial expression, alertness Motor Retardation, agitation, abnormal movements, gait, catatonia Speech Rate, rhythm, volume, amount, articulation, spontaneity Affect Stability, range, appropriateness, intensity, affect, mood Thought content Suicidal ideation, death wishes, homicidal ideation, depressive cognitions, obsessions, ruminations, phobias, ideas of reference, paranoid ideation, magical ideation, delusions, overvalued ideas Thought process Associations, coherence, logic, stream, clang associations, perseveration, neologism, blocking, attention Perception Hallucinations, illusions, depersonalization, derealization Insight Awareness of illness Adapted from Zimmerman M: Interviewing Guide for Evaluating DSM-IV Psychiatric Disorders and the Mental Status Examination. Philadelphia, Psychiatric Press Products, 1994, pp 121–122.

15. Diagnosis Put the case together with a good 1 liner mentioning the lead diagnosis. Then give supporting positives and negatives from the interview and MSE to support your lead diagnosis and other diagnoses on your differential. Mention that you would like more info (collateral/labs) to make an accurate diagnosis. Remember substance induced and psych sx secondary to medical problems.

16. Management Plan Admit/Discharge Patient Safety Level Medical wk up (labs/imaging) Collateral information Medications to start/continue Think about a safe d/c plan including appropriate outpatient care and a safe place to live. This may include shelter, group home placement, case manager, psychiatrist +/- psychotherapist, substance abuse treatment, psychosocial rehab (day program/clubhouse).

17. CASE 1:INFORMATION FOR CANDIDATES You are a registrar in the Emergency Department of a metropolitan hospital. You have been assigned a 25 year old female patient who has been brought into the department at 3AM by her family. The family express concerns about their loved one being uncharacteristically irritable and agitated. She has not been sleeping. She is speaking very rapidly and often illogically. They describe that earlier today she was propositioning the postman, which is again out of character. They are adamant she does not use illicit substances. Your task is to : Attempt to take a history of the patient (spend no more than 5 minutes on this – then turn to the Examiner ) Suggest possible diagnosis of this patient Specify to the examiner how the patient’s presentation is to be managed .

18. CASE 2: INFORMATION FOR CANDIDATE You are the HMO in the emergency department when the police brings in a 27 year old Michael Simmons from a boarding house where he had been in a fight with another resident, which he seemed to have started, and he dislocated his left middle finger. The police wants him to be medically checked before they take him to the police station for charging him with assault of the other person. Michael is well known to your hospital. YOUR TASK IS TO: Review the hospital record via the examiner Take a focused history Examine the patient Manage the police request