RAULENCIA MENTAL HEALTH. pptx

Mental health

1. MENTAL HEALTH PSYCHIATRIC HISTORY TAKING AND MENTAL STATE EXAMINATION

2. INTERVIEW TECHNIQUE History taking interview is important in psychiatry. Most physicians also have to talk with (or at least to) patients and they are never taught how to talk with them . Skillful interview results in obtaining better information, making a more accurate diagnosis, stabling a better rapport, and Ensuring greater compliance with treatment . Psychiatric interview is different from routine medical interview in several ways, some of them are:

3. Cont ……. Presence of disturbances in thinking and behavior , interfering with meaningful communication. Need for information from significant others . More important to obtain information regarding personal history and pre-morbid personality . More need for astute observation of patient. ( ASTUTE: very clever and quick at seeing what to do in a particular situation, especially how to get an advantage). Difficulties in establishing rapport (poor rapport) may be encountered more often. Patient may lack insight into his illness and have poor judgment More important to elicit information regarding stressors .

4. Cont …. A complete psychiatric interview may often require more than one session. Assessment conducted under the following headings, Identification data Informants Presenting chief complaints History of the present illness Past psychiatric and medical history Treatment history

5. Cont.…… Family history Personal history Forensic history Pre-morbid Personality Physical examination Mental status examination

6. A. PSYCHIATRIC HISTORY TAKING IDENTIFICATION DATA It is best to start the interview by obtaining the identification data, such as Name including aliases and pet name ALIASES : names used instead of usual names and PET NAME is a name used to express fondness or familiarity. - Age, Sex, Marital status, Education, Occupation, Income, Residential and office addresses, Religion, and Socio-economic background. It is useful to also record the source referral of the patient. In medico-legal cases, in addition two identification marks should also be recorded.

7. 2. INFORMANTS Sometimes the history provided by a psychiatric patient may be incomplete due to absent insight and uncooperativeness , relatives or friends are used to get the history. Their identification data should be recorded along with their relationship to the patient, whether they stay with the patient or not , and the duration of stay together :

8. Cont ….. Lastly confirm the reliability of the information provided by the use of Relationship with the patient ( ndugu wa mgonjwa) Intellectual and observational ability (awe na uwezo wa kiakili na uchunguzi ) Familiarity and length of stay with the patient and Degree of concern regarding the patient NB. The source of referral may also provide the valuable information regarding the patient’s condition

9. 3. PRESENTING CHIEF COMPLAINTS Patient’s and informant’s versions concerning the presenting complaints or reasons for consultation should be recorded separately. If the patient says that he has no complaints, it should be also recorded. Use the patient’s own words and not the duration of each presenting complaint. Additional points to be noted are: 1. Onset of the present illness 2. Duration of the present illness 3. Course of the illness 4. Precipitating factors (include life stressors if any). 5. Aggravating, maintaining, and or relieving factors, if any.

10. 4. HISTORY OF THE PRESENT ILLNESS Note the following points: When the patient was last well The time of onset The symptoms 000...of the illness from the earliest time until the present time in chronological order and coherent manner. The presenting chief complaints should be expanded In particular, like any disturbances in the physiological functions like sleep, appetite, and sexual functioning, should be required. Always enquire about the presence of suicidal ideation. Important negative history should be recorded example “no history of head injury before the onset of the illness”. A life chart provides a valuable display of the course of illness and episodic sequence, polarity (if any), severity, frequency, and relationship if (if any) to stressors and response to treatment.

11. 5. PAST PSYCHIATRIC AND MEDICAL HISTORY PAST PSYCHIATRIC History of similar or any other psychiatric illness in the past, if present, should be obtained. Past history of psychotropic medication, alcohol, and drug abuse or dependence and psychiatric hospitalization should be asked for.

12. PAST MEDICAL HISTORY Past history of any serious medical , neurological or surgical illness, surgical procedure , accident , and hospitalization should be obtained . The nature of treatment received, if any, should ascertain. Past history of head injury , convulsions , unconsciousness , diabetes mellitus, hypertension , coronary artery disease, acute intermittent porphyria, syphilis and HIV positive or AIDS should particularly looked for.

13. 6. TREATMENT HISTORY Details of the treatment given in the present episode and the previous episode should be obtained

14. 7. FAMILY HISTORY It usually includes “family of the origin” such as patient’s parents, siblings, grandparents, uncles etc. However, “the family of procreation” such as the parent’s spouse, children and grandchildren can also be included here instead of under personal history. It should be recorded under the following headings 7.1 Family Structure Drawing of a ‘family tree’ (pedigree chart) helps in recording all the relevant information in very little space and easily readable. It should state whether the family is nuclear or extended nuclear (or joint) family. If consanguineous relationship is present, it should be recorded. Age and cause of death (if any) of the family members should be asked

15. Cont ….. 7.2 Family history of similar or other psychiatric illnesses, major medical illnesses, alcohol or drug dependence and suicide and suicidal attempts to be recorded . 7.3. Current social situation: Home circumstances , per-capita income, social-economic status, leader of the family (nominal as well as functional) and current attitude of the family members towards the patient’s illness . The communication patterns in the family , range of affectivity, cultural and religious values and social support system to inquired about when relevant.

16.   8. PERSONAL HISTORY The younger the patient, it is possible to give more attention to details. In order patients there may be considerable retrospective falsification . Parents, if alive, can often provide much additional information regarding the past personal history, and relevant information regarding the personal history, under the following sub-headings:

17. 8.1 Perinatal History Any febrile illness; medications, and / or alcohol use; trauma to abdomen and any physical or psychiatric illness during pregnancy (particularly in the first trimester ). Ask if whether the patient was a wanted or unwanted child , date of birth, normal or abnormal delivery, any instrumentation, hospital or home delivery, any complications like ( cyanosis, convulsions, and jaundice ); Apgar score ; (if available); birth cry ( immediate or delayed ); any birth defects; and any prematurity.

18. 8.2. Childhood History Whether the patient was brought up by mother or someone else ; breastfeeding ; weaning; any history suggestive o f maternal deprivation . The age of passing each important developmental milestone . The age and ease of toilet training . The occurrence of neurotic traits ; including stuttering, stammering, tics, enuresis , E ncompresis , night terrors, thumb sucking, nail biting , head banging, body rocking, morbid fears or phobias, somnambulism, temper tantrums , and food fads.

19. 8.3. Educational History Age of beginning and finishing formal education , A cademic achievements R elationships with peers and teachers . Any school phobia, non-attendance, truancy , any learning difficulties and reasons for termination of studies ( if occurs pre-maturely)

20. 8.4. Play History What games were used to play, at what age with whom and where. Relationships with peers Particularly the opposite sex.

21. 8.5. Puberty: The age at menarche, and reaction to menarche (in females ), T he age at appearance of secondary sex characteristics, nocturnal emissions (in males), M asturbation and any anxiety related to puberty changes.

22. 8.6. Menstrual and Obstetric History The regularity and duration of menses , the length of each cycle , any abnormalities , T he last menstrual period , The number of children born, termination of pregnancy if any.

23. 8.7. Occupational History: The age at starting work ; jobs held in chronological order ; reasons for changes ; job satisfactions; ambitions ; relationships with authorities, peers and subordinates ; present income ; and whether the job is appropriate to the educational and family background.

24. 8.8. Sexual and Marital History: Sexual information , how acquired and of what kind; masturbation (fantasy and activity); sex play if any; adolescent sexual activity; pre- marital and extramarital sexual relationships if any; sexual practices (normal and abnormal); and any gender identity disorder. The duration of marriage ; marriage arranged by parents with or without consent, or by self choice or without parental consent, number of marriages, divorces or separations, role in marriage , interpersonal and sexual relations, contraceptive measures used; sexual satisfaction ; mode and frequency of sexual intercourse ; psychosexual dysfunction if any. NB: Although conventionally the details of the “family of procreation” are recorded here, they can also be recorded in the family tree.

25. 8.9. Pre-morbid Personality It is important to elicit details regarding the personality of the individual (temperament, if the age is less than 16 years). Rather than giving labels like schizoid or histrionic, it is more useful to describe the personality in details, under the following sub-headings : Interpersonal Relational ship Use of Leisure Time Hobbies; interests intellectual activities, critical faculty energetic or sedentary.  

26. Cont … Predominant Mood: Optimistic ( matumaini )or pessimistic ( kukata tamaa ) stable or prone to anxiety; cheerful or despondent ; and reaction to stressful life events . Altitude to self and others Self-confidence level, self-criticism, self-consciousness, selfish or thoughtful of others, self-appraisal of abilities, achievements and failures

27. Cont … Altitude to work and responsibility Decision making , acceptance of responsibility, flexibility, perseverance, and foresight Religious beliefs and moral altitudes Religious belief, toleration of others’ beliefs and standards, conscience and altruism Fantasy life Sexual and non-sexual fantasies, daydreaming frequency and content , recurrent or favorite daydreams , and dreams  

28. Cont … Habits Food fads, alcohol, tobacco, drugs, sleep. NB. The most reliable method of pre-morbid personality assessment is, interviewing an informant familiar with the patient prior to the onset of illness.

29. B. PHYSICAL EXAMINATION A detailed general physical examination (GPE) and systemic examination is a must in every patient. Physical disease which is etiologically important (for causing psychiatric symptomatology), accidentally co-existent, or secondarily caused by the psychiatric condition, is often present and can be detected by a good physical examination. Including vital signs BMI

30. C. MENTAL STATUS EXAMINATION

31. 1. GENERAL APPEARANCE AND BEHAVIOR A rich deal of information can be elicited from the general appearance and behavior. While examining it is important to remember the socio-cultural background and personality of the patient . Understandably , general appearance and behavior needs to given more emphasis in the examination of an uncooperative patient.

32. Cont …….. General Appearance The points to be noted are: Physique and body habits (build) and physical appearance (approximate, weight and appearance ) ( Is it Appropriate with age) Looks comfortable or uncomfortable Physical health Groom, hygiene, and self-care Dressing ( appropriate in hospital uniforms , any peculiarities).

33. Cont ….. Attitude Towards The Examiner Cooperation/ guardedness/ evasiveness/ hostility/ combativeness/ haughtiness/ Attentiveness/ Appears interested/ disinterested/ apathetic Any ingratiating behavior (Influence others become more likable to their target) Perplexity   (confusion) Comprehension( ufahamu ) Intact/ impaired (partially/ fully)

34. Cont …… Gait and Posture Normal or abnormal (way of sitting standing, walking, lying) Motor Activity Increased/ decreased Excitement/ stupor Abnormal involuntary movements (AIMs) like pica, tremors, akathisia Restlessness/ ill at ease,

35. Cont …… Catatonic signs Mannerisms -stereotype movement such as blinking , grimace, gesture Stereotype s-persistent repetition of motor activity posturing waxy flexibility- rigidity of extremities making them to remain in one position in long period negativism- opposition/resistance to accept reasonable suggestion Echopraxia - repetition of another persons movement Ambitendency , automatic obedience, stupor , psychological, pillow, forced grasping) Conversion and dissociative, signs ( pseudo seizures, possession states). Social withdrawal , autism, compulsive acts, rituals or habits (e.g. nail biting) Reaction time.

36. Cont …… Social Manner and non-verbal behavior Increased, decreased, or inappropriate, eye contact (gaze aversion, staring vacantly, staring at the examiner, hesitant eye contact, or normal eye contact ). Rapport Whether a working and empathic relationship Hallucinatory Behavior Smiling or crying without reason, muttering or talking to self (non-social speech) and odd gesturing in response to auditory or visual hallucinations.

37. 2. SPEECH Speech can be examined under the following heading : Rate and Quantity of Speech Whether speech is present or absent (mutism), if present, whether it is spontaneous, productivity Rate or slow (its appropriateness), pressure of speech or poverty of speech Rate should be reported whether increased or decreased Quantity should be reported whether spontaneous, productivity , or mutism Volume and Tones of Speech Increased/ decreased/moderate ((its appropriateness ), Low/ high/ moderate pitch .   Flow and Rhythm of Speech Smooth/ hesitant, Blocking (sudden) Dyprosody , stuttering/ stammering

38. 3 . MOOD AND AFFECT Mood is the pervasive feeling tone which sustained (lasts for some length of time) and colors the total experience of the person. Affect , on the other hand, is the outward expression ( objective ) of the immediate (cross-sectional) experience of emotion at a given time .   The assessment of mood includes testing the quality of mood, which is assessed subjectively ( how do you feel) and objectively (by examination). The other components are stability of mood (over a period of time) reaction of mood The affect is similarly described under quality of affect , range of affect (of emotional changes displayed over time), death or intensity of affect ( increased or blunted ) and a ppropriateness of affect (in relation to thought and surrounding environment

39. Cont …… Mood is described as general warmth, euphoria (mud happiness), elation, exaltation and/ or ecstasy (seen in mania phase) anxious and restless in anxiety and depression; sad, irritable, a ngry and / or despaired in depression; shallow , blunted, indifferent, restricted, inappropriate and/ or labile in schizophrenia. Anhedonia may occur in both schizophrenia and depression. NB After assess MOOD and AFFECT LASTLY YOU MAKE A CONCLUSION IF MOOD AND AFFECT WERE CONGRUENT OR INCONGRUENT

40. MOOD Euthymic Normal range of mood, implying absence of depressed or elevated mood Elevated mood Air of confidence and enjoyment; a mood more cheerful than normal but not necessarily pathological. Expansive mood Expression of feelings without restraint, frequently with an overestimation of their significance or importance. Seen in mania. Euphoria Exaggerated feeling of well-being that is inappropriate to real events. Can occur with drugs such as opiates, amphetamines, and alcohol. Elation Mood consisting of feelings of joy, euphoria, triumph, and intense self- satisfaction or optimism. Occurs in mania when not grounded in reality.

41. AFFECT Affect can be defined as the patient's present emotional responsiveness, inferred from the patient's facial expression, including the amount and the range of expressive behavior. Affect can be described as within normal range. In the normal range of affect can be variation in facial expression, tone of voice, use of hands, and body movements. Affect can be classified as restricted, blunted, flattened, appropriate , or inappropriate. Restricted affect Reduction in intensity of feeling tone Blunted affect Disturbance of affect manifested by a severe reduction in the intensity of externalized feeling tone; one of the fundamental symptoms of schizophrenia Flat affect Absence or near absence of any signs of affective expression. The patient's voice is monotonous and the face should be immobile and expressionless. The patient has difficulty in initiating, sustaining, or terminating an emotional response.

42.   4. THOUGHT Stream and Form of Thought Content of Thought Stream and Form of Thought Stream of thought overlaps with examination of speech , Spontaneity, productivity, flight of ideas , prolixity, poverty of content of speech, and thought block should be mentioned and questions asked. Any loosening of associations, tangentially, circumstantialities , illogical thinking, perseveration, or verbigeration is noted .  

43. Cont ….. Content of Thought Any preoccupations Obsessions (recurrent, irrational, intrusive, ego-dystonic, ego-alien ideas ), C ontents of phobias (irrational fears) Delusions , (false, unshakable beliefs) or over-valued ideas . Explore for delusions/ ideas of persecution, reference, grandeur , love, jealousy (infidelity), guilt, nihilism , and poverty, somatic (hypochondriacally) S ymptoms , hopelessness , helplessness, worthlessness, and suicidal ideation . Delusions of control, thought insertion , thought withdrawal , thought broadcasting are schneiderian first rank symptoms (SFRS). The presence of neologisms should be recorded here.

44. 5. PERCEPTION Hallucinations The presence of hallucinations should be noted. Whether hallucinations are auditory, visual, olfactory, gustatory or tactile should be asked. Auditory hallucinations are comment type hallucinations in non-organic psychiatric disorders. Clarify whether they are elementary (only sounds are heard) or complex (voices heard). It should be further inquired what was heard, how many voices. Were heard, in which part of the day, male or female voices, how interpreted and whether second person or third person hallucinations (i.e. whether the voices were addressing the patient or were discussing him in third person); enquire about command (imperative) hallucinations. Enquire whether the hallucinations occurred during wakefulness, or hypnagogic (occurring while going to sleep) and/ or hypnopompic (occurring while getting up from sleep) hallucinations.

45. Cont …… Illusions and Misinterpretations Whether visual, auditory, or in other sensory fields; whether occur in clear consciousness or not; whether any steps taken to check the reality of distorted perceptions. Depersonalization / DE realization Depersonalization and DE realization are abnormalities in the perception of a person’s reality . Depersonalisation (sense of unreality in relation to self) and De- realisation (sense of unreality in relation to surroundings/Environment(STRANGER)

46. 6 . COGNITION Assessment Cognitive or higher mental function of the MSE, Their significant disturbance commonly points to the presence of an organic psychiatric disorder Consciousness The intensity of stimulation needed to arouse the patient should be indicated to demonstrate the level of alertness , e.g. By calling patient’s name in a normal voice, calling in a loud voice, light touch on the arm vigorous shaking of the arm, or painful stimulus.

47. Cont …. Orientation Whether the patient is well oriented to people, place and time (test by asking the time, date, day, month, year season and the time spent to hospital) place (test by asking the present location). Disorientation in time usually precedes disorientation in place and person Que huu ni muda gani,(time) hapa ni wapi,(place) sisi ni wakina nani(people) Orientated /Disorientation(PPT)

48. cont ….. Attention Is the attention easily aroused and sustained . Ask the patient to repeat digits forwards and back (digit span test; digit forward and backward test) One at a time e.g . patient may be able to repeat 5 digits forward and 3 digits backwards). Start with two digits numbers; increasing gradually up to digit eight digits numbers or till failure occurs on three consecutive occasions

49. Cont …. Concentration Concentration is complex form of attention and patient can be attentive but not concentrative We look if patient is concentrate or easily distractible. Ask to subtract serial seven from hundred (100-7) test ), ana minize na haumtajii ele namba aliyoipata na kama ana concentration atakumbuka ili aweze kutoa saba nyingine or serial threes from forty (40 – 3 test) or serial three from forty (40 – 3 test) or to count backwards from 20, or enumerate the names of the months (or days of the week) in the reverse order. Note down the answers and the time taken to perform the test. 100-7=93,86,79,72,65,58,51,44,37,30,23,16,9,2 40-3=37,34,31,28,25,22,19,16,13,10,7,4,1

50. Cont …… Memory Immediate Retention and Recall (IR and R ) not more than 15 mins Use the digit span test to assess the immediate memory, digit forwards and digit backwards subtests (also used for testing attention are described under attention ).   Recent Memory ( muda mfupi uliopita )15Mins to 24 hrs Ask how the patient came to the room/hospital what he ate for dinner the day before or the breakfast the same morning. Give an address to be memorized and asked it to be recalled 15 minutes later or at the end of the interview. Remote Memory( muda mrefu )1yr to yrs Note any amnesia (anterograde/retrograde) or confabulations if present eg kombe la dunia mara ya mwisho lilichezwa lini

51. Cont ….. Intelligence is the ability to think logically, act rationally , and deal effectively with the environment . ( Use simple mathematical questions) ( In case of intellectual disability disorders WE USE IQ FORMULA Abstract Thinking (thinking beyond capability) Abstract thinking testing assesses patient’s concept formation. The methods used are: a. Proverb Testing : The meaning of simple proverbs (at least 3 ) should be asked. b. Similarities (and so difference) between familiar objects should be asked like: table/chair, banana/orange, dog/lions; eye/ear

52. 7. INSIGHTS   Insights are the degree of awareness and understanding his illness (condition) and its management.   Ask the patient’s attitude towards his present state; whether there is an illness or not if yes, which kind of illness (physical, psychiatric or both) is any treatment needed; is there hope for recovery; what is the cause of illness. Depending on the patient’s responses, grade the insight . Reported as good/partial/poor insight

53. 8. JUDGMENT Judgment is the ability to assess a situation correctly and act appropriately within that situation . Both social and test judgment are assessed . Social Judgment is observed during the hospital stay and during the interview session. Both social and test judgment are assessed. Test Judgment is assessed by asking the patient what he would do in certain test situations, ‘like a house on fire’ or ‘a man lying on the road’ or ‘a sealed stamped’ addressed envelope is rated as Good /Intact/Normal or Poor/I mpaired/ Abnormal.

54. PSYCHIATRIC DIAGNOSTIC FORMULATION After complete psychiatric assessment, diagnostic formulation summarized the detailed positive (and important negative) information regarding the patient under the focus of care, before listing a differential diagnosis, plan

55. DESCRIPTIVE FORMULATION/ FEATURES SUPPORTING THE DIAGNOSIS List all possible features that supports the formulated diagnosis, and these are from example the psychiatric history, MSE and any other observations Eg SCHIZO Persecutory d elusions Hallucinations[auditory ,visual] Disorganized speech[ Loosening of association, circumstantiality ] Catatonic symptoms[stupor , excitement or bizarre posture] Negative symptoms ( Alogia , Asociality , Anhedonia, Avolition

56. PSYCHITRIC DIAGNOSTIC FORMULATIONS and DIFFERENCIAL DIAGNOSIS With their supportive features DESCRIPTIVE FORMULATION- Short summary of your patient BIOPSYCHOSOCIAL FORMULATION OR CAUSE OF THE ILLNESS Mention the possible cause[s] of mental illness to this particular patient . PROGNOSTIC FEATURES Prognosis influenced by compliance with treatment , the disorder itself and support in the family/community ( good or poor prognosis)  NURSING CARE PLAN Prepare the nursing care plan; implement it in order to resolve the patient’s observed health problems .   Descriptive of your diagnosis

57. The  biopsychosocial model  for psychiatry is a way to formulate what factors are in play in an individual’s illness. It can also be used as a way to approach what aspects you need to consider when deciding on a  treatment plan . The  biological factors  include things such as genetics, general medical conditions and drugs (pharmacotherapy ). The  psychological factors  include a person’s coping strategies, personality and therapy (cognitive behavioural therapy, psychodynamic psychotherapy, dialectic behavioural therapy, etc ). The  social factors  include a person’s living situation, their support (both family and friends), finances, situation at work/school, etc.

58. PREDISPOSING {factors at risk of developing problem) PRECIPITATING factors tat cause or trigger the onset of diseases (STRESSOR S TRIGGERS) PERPITUATING Factors that maintain the established problem} PROTECTING BIOLOGICAL Genetic vulnerability Family medical HX Birth defect Developmental delay Age Sex Sexual Onset of acute illness/infection Onset of severe medical disorder Physical Trauma Substance Use Disorders Substance Misuse Immune Suppression Chronic physical illness Drug adherence PSYCHOLOGICAL Personality traits Temperature Psychopathology Distress tolerance Family with mental HX Poor coping style/problem solving Maladaptive Psychopathology Lack Coping style Lack of Social support Avoidance behaviors Compensatory behaviors CBT and coping mechanism skills SOCIAL/ENVIRONMENT Poverty Childhood experiences Education level Chronic Job Stress Life events(car accident ) Natural disasters Work/Life schedule rigidity Social stigma Financial obligations Poverty Unemployment Good family relationship