Transcript Psychiatric History Taking

Psychiatric History Taking
and
Mental State Examination
Dr Sati Sembhi
Consultant Psychiatrist, Suffolk.
24th August 2010
General Principles of History Taking
• Aim to understand problems/symptoms and
effect on life
• To put presenting problems into context by
enquiring about background history and
previous treatment
• Is followed by MSE
• Enables formulation to be reached
• Is therapeutic in itself
• Will vary according to setting (MHAA v A&E v
OPD)
Preparing The Setting
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Safety
Privacy
Try to avoid interruptions
Arrange seating so sitting at angle to
patient
• Writing materials
• Box of tissues.
Starting the Interview
• Put patient at ease
• Introduce yourself and explain role
• Introduce to anyone who is accompanying
patient
• Inform them about the length of interview
• Need to take notes
• Confidentiality
Interview Style
• Relaxed even if under time pressure
• Appropriate eye contact, appear interested
• Begin with a general question eg “tell me about
your problem”
• Have a systematic but flexible plan – at
beginning can be helpful to take a list of
headings as prompt
• Keep in control. May need to interrupt “I’m sorry
but I need to move on to other things” “We can
come back to this if we have time later”
Interview Techniques (1)
• Use of open questions where possible,
especially at beginning eg “ how is your
appetite?”
• Closed questions are useful if time is short
eg “is your appetite good?”
• Avoid leading questions eg “You have a
poor appetite, don’t you?”
Interview Techniques (2)
• Encourage patient by leaning forward,
nodding, saying “go on” “tell me more
about…..”
• Help them talk about painful or
embarrassing subjects by being nonjudgmental, acknowledging distress and
explaining why you are asking, eg “I can
see this is difficult to talk about…”
Interview Techniques (3)
• Summarise key points to check understanding
• As experience grows start to select questions
according to emerging diagnostic possibilities
and management options. This is becomes more
important when time is limited or patient
uncooperative
• Don’t take words at face value eg “paranoid”
• Pick up non-verbal cues
• Watch experienced clinicians and get them to
watch you!
• Video yourself
Interviewing Informants
• Always useful and more so if patient is
cognitively impaired, patient is concealing
information
• Gain patient consent
• Often best to see patient alone first and then
informant
• Establish confidentiality (and limits)
• Ascertain informants concerns as well as gain
information.
• May need to help informant if stressed carer
(carer assessment)
Interviewing patients from other
cultures (Cultural competency)
• Interview patients in first language where
possible. May need interpreter.
• Using interpreter is skill. Discuss approach first.
Manageable chunks of information. 2nd person,
direct translation is most useful.
• Distress is shown via different symptoms eg
physical rather then psychological symptoms
• Cultural beliefs may include ideas that appear
delusional but are culturally acceptable
eg witchcraft. Need collateral information.
• Treatment expectations may differ
Records
• Good notes are vital
• Record for you, aids formulation
• Record for others so history taking does
not have to be repeated, as a record of
presentation for future clinicians
• Patients may request access to them
• Life charts may be therapeutic way of
recording information together
The History
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Presenting Complaint
History of presenting complaint
Family History
Personal History
Past Psychiatric History
Past Medical History
Substance Use
Drug History
Forensic History
Personality
Current Social Situation
Presentation/Referral and
Presenting Complaint(s)
• Who referred patient and what is their
concern/request
• Where is patient being seen.
• Are they voluntarily present or detained
under MHA (which section)
• What is their problem, in their own words
History of presenting complaint
• Nature of problem
• Precipitant
• Onset, time span, development of
symptoms, fluctuations, factors worsening
or improving
• Degree of functional impairment
• Level of distress
• Treatments trialled
Family History
• Parent: age (now or at death), occupation,
relationship with patient
• Siblings: as above
• Psychiatric history in family members
(genetic and effect on home life).
Substance use, suicide.
• Genogram
Personal history
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Mother’s pregnancy, birth
Early development, illness
Childhood separation, emotional problems
Relationships with family members, atmosphere at home
Schooling – academic performance and peer
relationships. (Bullying, school refusal, shyness, conduct
disorders)
Qualifications. Further education
Occupation(s), work performance
Sexual relationships, marriage, children
History of abuse (physical, sexual, emotional) in
childhood or adulthood
Past Psychiatric History
• History of similar or other symptoms in past
• Previous diagnosis
• History of treatment – include from primary care,
counselling, CAMHS, complementary therapy as
well as mental health services
• Previous hospitalisation, MHA, medications,
ECT.
• Recovery between episodes
• Previous DSH and suicide attempts
Past Medical History
• Chronology of illness and treatment
Substance Use
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Alcohol, other substances, tobacco.
Pattern of use
Age at onset
Relationship to symptoms
Harmful use
Psychological dependency
Physical dependency
Previous detox
Patient view
Drug History
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Current medications
Allergies
Check with GP
Ask to bring list to appointment
Forensic History
• Record all offences – convicted or not.
• Violence/Anger, sexual offences
particularly important
• Persistent offending
• Probation
• Relationship to symptoms
Personality (1)
• Hard to assess at one-off interview and
collateral information should be sought.
• GP may have useful information
• Ask patient how others see them/would
describe them
• Prevailing mood; how they get on with
people; deal with stress; hobbies;
standards.
Personality (2)
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Impulsive
Prone to worry
Strict, fussy
Seek attention
Untrusting, resentful
Irritable
Sensitive
Suspicious
Argumentative
Lack concern for others
Current social circumstances
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Who they live with
Current employment
Stressors
Social supports
Typical day
Mental State Examination
What is the MSE
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“Here and now” record of presentation
History will give clues as to likely symptoms
Systematic
Until more experienced carry out full mental
state
• Be observant but also learn the terminology to
describe symptoms/signs
• Use conventional headings to structure
examination – other colleagues and examiners
will expect it
MSE
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Appearance and Behaviour
Speech
Mood
Affect
Thought
Perception
Cognition
Insight
Appearance and Behaviour
• Describe what you see.
• General appearance and behaviour. Striking physical
features. Posture.
• Physique, clothing, cleanliness, self-care, posture
• Eye contact, rapport
• Motor activity: agitation, retardation, stuperose (akinesic
and mute), abnormal movements (tic, tardive dyskinesia,
chorea, stereotypy, catatonic features), mannerism,
restlessness
• Tearfulness
• Distractibility
• Disinhibition
• Appears to hear voices, preoccupied.
Speech
• Rate: slow in depression; pressure of speech in mania.
• Quantity: reduced (poverty) in depression and chronic
schizophrenia; flight of ideas in mania
• Volume
• Pattern: spontaneous, coherence, rationality,
circumstantial (trivial detail eg obsessional traits),
perseveration
• Neologisms, puns, clang associations (word that sounds
the same).
• Formal thought disorder: loosening of associations;
knight’s move thinking, word salad (schizophrenia)
• Thought blocking: arrest of train of thought leading to
blank. Different to losing train of thought
Mood
• Patient description: Sad, happy, top of the world,
worried
• Accompanying symptoms
Depression: early morning wakening, diurnal
variation, anhedonia, loss of appetite, loss of
weight, fatigue, loss of concentration.
Hopelessness,
Suicidal thoughts, plans, intent
Anxiety: palpitations, dry mouth, sweating, tremor
Elation: Overactivity, excessive self-confidence,
reduced sleep, distractibility, increased libido
Affect
• Your objective description of emotion
• Depressed, anxious, fearful, irritable,
suspicious, perplexed, elated, angry
• Fluctuations: reactivity, lability (mania),
blunting (chronic schizophrenia)
• Consistent with thoughts/behaviour?
Incongruity seen in schizophrenia
Thought Content (1)
• Preoccupations: thoughts that recur frequently
but can be put out of mind
• Obsessional thoughts/compulsive rituals.
Obsessional thoughts are ideas, images,
impulses that repeatedly enter mind in
stereotyped form, seen as senseless,
distressing, recognised as own thought even if
repugnant. Compulsions are obsessional motor
acts, often resulting from obsession, may be
attempt to “neutralise” obsession.
• “Do you have to keep on repeating the same
action which most people would only do once?”
Thought Content (2)
Delusion is a false, unshakeable, belief that is out of
keeping with the patient’s social and cultural
background.
Primary Delusion:
used to be thought diagnostic of schizophrenia.
• delusional mood: something going on but not sure what
it is
• delusional perception: attribution of new meaning to
normally perceived object eg traffic light change means
chosen to be Messiah.
• sudden delusional idea (autochthonous delusion):
sudden arrival of fully formed delusion, like a “brainwave”
Thought Content (3)
• Secondary Delusion: explains another
experience eg to explain auditory
hallucinations
• Mood Congruent
• Content: persecution, infidelity, grandiose,
hypochondriacal, love, guilt, nihilistic,
poverty, reference, infestation.
Thought Content (4)
• Thought Interference - “loss of boundary with outside
world”, usually found in schizophrenia
Thought withdrawl: thoughts taken away (link with thought block)
Thought insertion: another agency’s thoughts implanted
Thought broadcasting: thought’s leaking, escaping, other people know what
thinking in unison (not thought echo)
• Passivity – humans usually experience actions, thoughts,
feelings as under their control but may (usually in schizophrenia)
experience them as being under control of another agency
Derealisation and
Depersonalisation
• Depersonalisation - feeling unreal
and unable to feel emotion; “as if cut off
from world” “watching self”
• Derealisation – feeling world is unreal
• Can occur in healthy people if tired
• Occurs in anxiety, depression,
schizophrenia, TLE
• Unpleasant and very distressing
Perception (1)
• Illusion - Misperception of stimulus
• Hallucination – Perception experienced in
the absence of an external stimulus to the
corresponding sense organ.
• Can occur in any sensory modality:
auditory, visual, olfactory, gustatory, tactile,
deep sensation
Perception (2)
• Visual: more likely in organic conditions
• Gustatory: unpleasant taste. In schizophrenia,
TLE. May lead to delusion is being poisoned
• Olfactory: Schizophrenia, organic, TLE. May
believe result of gas being pumped into dwelling
• Tactile: touched, pricked, insects crawling on
skin (formication, drug withdrawal/cocaine
addiction)
• Deep Sensation: often in schizophrenia. May be
sexual.
Auditory Hallucinations
• May be noises, whispers, partially organised
• 2nd person voices: depression
Characteristic, but not diagnostic of schizophrenia:
• 3rd person discussing
• Running commentary
• Thought echo (echo de pensee,
gedankenlautwerden)
Cognition
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Orientation – time, place and person
Attention – digit span
Concentration – serial 7’s, WORLD
STM – name and address recall after 3 mins
LTM – history
Frontal Lobe – verbal fluency, similarities/differences,
Luria’s three stage task.
• General knowledge and intelligence – from interview and
PM, events
• Can use screening instruments: MMSE or ACE
Insight
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Awareness of abnormal state of mind
Understanding of cause
Understanding of benefits of treatment
Awareness of effects of not having
treatment
Useful Reading
• Shorter Oxford Textbook of Psychiatry (ed)
Gelder, Harrison & Cowen
• Cognitive Assessment for Clinicians, 2nd edition,
Hodges.
• Fish’s Clinical Psychopathology, 3rd Edition,
Casey & Kelly
• Sims’ Symptoms in the Mind, Femi Oyebode
• Psychiatric Inteviewing and Assessment, Poole
& Higgo