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Psychiatric History Cath Ann Rees (F2Doctor)WARNING Text-Heavy Content DO NOT NEED TO COVERALL I will skip the slides with a yellow background as you can read these in your own timePsych Histories – Common Stations Mood Disorders • Depression +/- psychosis Substance/Alcohol misuse • Bipolar (depression and mania) Psychotic Disorders Suicide/ Self Harm • Schizophrenia • Overdose • Drug-induced Psychosis Anxiety Disorders EatingDisorders • GAD • Anorexia Nervosa • Phobic anxiety disorder • Bulimia Nervosa • Panic disorders • PTSDPSYCH Hx = Normal Patient Hx + Extras • PCx + HPCx SOCIAL Hx • Alcohol • PMHx including past psych Hx • Sm•kiPack year: (No of cigs a day xduration in years) / 20 • DHx + allergies • Drugs (illicit) • FHx (including psych) • Family • Children? • Social Hx (on steroids) • Employment • Home life /accommodation / • Risk assessment / Screening (see later) streets / sofa-surfing • Finances • RISK ASSESS harm to self + others • Social support • SCREEN for depression, mania, psychosis • Prison • ICEPRESENTING COMPLAINT • Start with open questions: How have you been feeling? • Onset: When did you first notice things have changed? • Severity: How has this affected your life? • Duration: How long has this been going on for? • Progression: Have you had any fluctuations in the way you are feeling? • Precipitating/ Aggravating and Relieving Factors: Has anything happened in your life recently which can explain how you are feeling? • Associated Sx: ALWAYS screen for depression, mania, psychosis etc • Biological Sx: Weight changes, appetite changes, sleeping more/less, agitated, concentration, libido, apathy • Insight: Do you think your experiences / beliefs could be due to a mental health condition? From: Psychiatry - A Clinical Handbook SCREENING + RISK ASSESSMENT • SCREENING (regardless of PCx) • Depression • Mania/Hypomania DRIPS • Death wish: genuinewish to die? Or • Psychosis just wantto hurtself? • Any other co-morbid MH condition • Relief:seeking unconsciousnessor pain as a meansof temporaryreliefand escape • RISK ASSESSMENT!! (to self and others) from problems • Influencing others: trying to influence • Self harm (intentional or unintentional) – DRIPS others’ viewsor behaviours e.g making a • Suicide (6 Ps – see next slide) sufferingelguilty, proving that pt is • Punishment: punish self • Harm to others • command hallucinations,abuse to others, any children? • or seekattention fromothers(expression of emotional distress) SUICIDE RISK ASSESSMENT – 6 Ps Exploring suicideideation- But how do you word that? • Howdo you feel about thefuture? Do you feel that lifeis worth living?Have you ever thought about taking your own life? • When peoplefeelreallylow, they can sometimes feelthat lifejust isn’t worth living. Is that something you havefelt? 6 Ps • Planning vs Impulsivity: Were they drunk/intoxicated? Pre-planned? How long haveyou been planning? • Perception of lethality: Did you thinkyou would certainlydie? Did you seek medical attention? Did someone else call an ambulance? • Preparations: Suicide note, will arranging childcare, writing down bank details • Performance: Isolated or in company • Precautions to avoid discovery: Alone? Locked door? • Planning to do again: Regret it? Wish you had completed suicide? Do it again?Tried before? • ALSO: Consider 3 morePs (predisposing, precipitating, protective/preventative factors)Ways of wording Risk Assessments From: Psychiatry - A Clinical HandbookI AM SAD PERSON(S) - Risk factors for Self-harm Previous Attempts/ Plan to Reattempt Institutionalised Ethanol/Elicit drug use Age >40 or <19 Rational Thinking loss Mental Health Disorder Social isolation/ Single/ Separated Sex (Males > suicide, Females > self-harm) Order + Will/ Occupation Alone No hobbies Depression Sickness From: Psychiatry - A Clinical HandbookINVESTIGA TIONS (generic) • BBOXES • B: Diagnostic questionnaires: • PHQ-9, HADs and Beck’s depression inventory, Mood Disorder Questionnaire (bipolar) • B: Rule out organic DDx • WHY? Infection, thyroid, electrolyte abnormalities, Cushing's, anaemia, confusion screen, diabetes, hypoglycaemia, uraemia, hepatic encephalopathy • O: Orifice • Urine dip: UTI can cause confusion, especially in elderly, Urine drug test (mimic mania) • PR – constipation can cause delirium (esp in elderly) • X: Imaging: MRI or CT head (SOL, bleed), CXR (chest infection especially in elderly) • E: ECG (may need to start Citalopram, Quetiapine, Haloperidol, TCAs) • S: Mental State Examination, Lumbar Puncture (meningitis, encephalitis)MANAGEMENT (generic) • Conservative – watchful waiting (feeling low) • Bio Psycho Social • Leaflet • Follow up appts (esp in GP land) • Psych referrals • Sectioning • TIP: remember the main sections • 2 – admission for assessment +/- treatment, up to 28 days, not renewable, needs 2 doctors (psychiatrist and Drwho’s seenpt) • 3 – Admission fortreatment, first3 months againstwill and can extend for further3 months if 2 doctor assesses), can be renewed usually after section 2 • 4 – Emergency assessment, for 72 hours, used when section 2 would cause delay, only needs 1 doctor(gives timeto arrange section 2) • 5(2) – can’t be used in A&E or GP as not inpatient, up to 72 hours, not renewable, pt or others at risk / threat, doctor • 5(4)- can’tbe used in A&EorGPas notinpatient, up to 6 hours, MH nurse , ptorothers in imminentdanger • 135 – police can break into property and taketo place of safety, hold for 24 hours, can extend further12 hours • 136 – Police can remove ptfrom public placeto place of safety, hold for 24 hours, can extend further12 hoursDEPRESSION Depression (Core Sx) 1. Low Mood DEPRESSION 2. Anergia 3. Anhedonia Core Sx of depression? – SCREENING Qs Symptoms Core Sx Cognitive Sx Biological Sx Psychotic Sx • ↓ mood • ↓ Concentration • Diurnal variation in mood - Ear• Hallucinations (usually second • Guilt morning awakening person auditory) • Anhedonia • Suicide ideation • ↓ libido • Delusions (usually • Anergia • Negative thinking • Weight / appetite changes, hypochondriacal, guilt, • Psychomotor ↓ persecutory) • ICD-10 Classification of Depression • Mild – 2 core + 2 other • Moderate – 2 core + 3-4 other • Severe – 3 core and > 4 other • Severedepression with psychosis = 3core Sx + > 4 other + psychosis • Rule out other DDx • Organic – thyroid, anaemia • Bipolar – any Sx ofmania? • Co-existing psychosis? • Screening and risk assessment – mania, psychosis, self-harm, suicide From: Psychiatry - A Clinical HandbookFrom: Psychiatry - A Clinical Handbook Depression Sx – SAW EMAILS Things to Ask: DEPRESSION: Dead Swamp - D: Decreased/ depressed mood most of the day - E: Energy Loss - A: Anhedonia - D: Death thoughts – suicidal ideation/ attempts - S: Sleep disturbances (early morning awakening, insomnia) - W: Worthlessness or Excessive Guilt - A: Appetite or weight change - M: Mentation decreased – ability to think/concentrate - P: Psychomotor agitation or retardation MANAGEMENT of Depression • BIO: Antidepressants, adjuvants (e.g antipsychotics or Lithium), ECT* • PSYCHO: • Psychotherapies (CBT), psycho-education, counselling, self helpprogrammes, physical activity • Crisis resolution team – for severely unwell and often suicidal psych patients in community. 24/7. Can visitpatients daily. Aimis shorttermintervention (usually no more than 6weeks) to prevent hospital admission • SOCIAL: Socialsupport groups, self help groups, social services eg finances, housing etc STEPWISE approach to Mx • Watchful waiting – follow-up after 2 weeks • Antidepressants – NOT first line for mild depression • WARNPATIENTS of sideeffects – which are? • Needto followupin 2weeks • SSRIsarefirst line – should be continuedfor 6monthsafter resolutionof Sxfor first depressive episode, 2years afterresolution of second episodeand long termin individuals who havehad multiplesevereepisodes • Psychotherapy/Counselling • Psych referral • MHA (section) if high risk *ECT Indications:acute treatment of severe depression, rapid responserequired, depression with psychotic features, severe psychomotor retardation or stupor, failureof other Tx From: Psychiatry - A Clinical HandbookBipolar Affective Disorder (used to be known as manic depression)BIPOLAR AFFECTIVE DISORDER • At least 1 episode of mania or hypomania and a further episode of mania or depression • Either can occur first – but includes those who have only have one episode of mania and no depression yet - they will eventually develop depression • Clinical features: I DIG FASTER – see table on next slide • Inflated self esteem/ grandiosity, decreased sleep, pressure of speech, flight of ideas, distractibility, psychomotor agitation (restlessness), reckless behavious (e.g spendingsprees, reckless driving, betting), loss of social inhibitions (leading to inappropriate behaviour), marked sexual energy • Types: Hypomania, Mania without psychosis, Mania with psychosis (see table on next slide) • Mania: Requires 3/9 Sx to be present for < 1 week • Screen for mania + psychosis in all depression histories Hypomania vs Mania Symptoms of Mania From: Psychiatry - A Clinical HandbookHow do you ask these questions? From: Psychiatry - A Clinical HandbookMANAGEMENT of Bipolar • See table • Antipsychotics • Olanzapine, Risperidone, Quetiapine = more rapid onset than Lithium • Mood stabilisers (Lithium > Valproate) • Benzos • Rapid tranquilisation in acute setting (haloperidol, lorazepam) • Lithium - 4 weeks after an acute episode has resolved • Antipsychotics? • Avoid antidepressants alone → can induce mania • Need to be given in conjunction with anti- mania meds From: Psychiatry - A Clinical HandbookLithium - Pharmacology station Side effects of Lithium • Standard long-term therapy for bipolar – minimises the (therapeutic range) = risk of relapse and improves quality of life. LITHIUM • Before lithium treatment is started: Lithium TOXICity Leukocytosis (high WBC) • U&Es - renally excreted and nephrotoxic (1.5-2.0 mmol/L) • TFTs - thyrotoxic • Pregnancy test Impaired renal function Tremor (coarse) • Baseline ECG • Side effects and Toxicities (see figures) Tremor(fine)/Teratogen (1 trimester)/Thirst(diabetes Oliguria (low u/o) • Therapeutic range: 0.4 – 1 (narrow therapeutic window) insipidis) ataXia • Monitoring Lithium levels: 12 hours following first dose Hypothyroid/Hairloss then weekly untiltherapeuticlevel reached (0.4-1.0 mmol/L) has been stable for 4 weeks. Once stable check Increased reflexes every 3 months. Increased weight (fluid retention) • Lithiumisnephrotoxic and thyrotoxic Coma/Convulsions • U&Es - every 6 months Urinatingmore (diabete insipidis, Also N&V, muscle • TFTs - every 12months polydipsia and polyuria) weakness MetallictastePsychosis (inc Schizophrenia)PSYCHOSIS • Psychosis is not a diagnosis • It is an umbrella term/ symptom • “Loss ofcontact with reality“ • Spsych PCx psychosis in any pt with Psychosis is characterised by: Characterised by; 1. Hallucinations 2. Delusions 3. Formal thought disorder From: Psychiatry - A Clinical Handbook Psychosis - “Loss of contact with reality“ 1. Delusions 2. Hallucinations PSYCHOSIS SCREENING 3. Formal thought disorder What are the CORE SxofPsychosis? Howdo you ask about psychosis Sx? Hallucinations • Hallucinations: Do you ever feel that you can seeor hear things that others don’t seem to beable to see or hear? • Visual and auditory • Delusions: Areyou afraid that someone is trying to harmyou or your family? • Do you ever see or hear things that others don’t seem Do you feel safe? Have you noticed that people are doing or saying things that to see or hear? havea special meaning to you? Do you ever feel that thoughts are being taken out or put into your mind? • 3 person: Talking about you (e.g Running commentary) - schizophrenia – one of Schneider’s Delusions first rank Sx - you do not see third person auditory • Fixed, falsebeliefs – firmlyheld despite evidence to thecontrary hallucinations in other psychotic conditions • Types of delusions • 2 person: Talking to you – derogatory in nature • Grandiose (schizophrenia,depression with psychosis,mania with • Persecutory (aka paranoid delusions) psychosis) • Compared to preoccupations and overvalued ideas – strongly held beliefs but • Command: Telling you what to do can accept that they may not betrue • Compared to obsessional thoughts: distressing thoughts that enter mind Formal thought disorder = refers to abnormalities despite pt’s effort to resist them (OCD) – Certain ideas / images keep entering of the way thoughts are linked together: your mind even when you try to keep them out?’ • see next slide • ‘Do you have anyspecific worries at the moment? Do you feel you are in danger / safe? Formal thought disorder • Z = Knight’s move (aka derailment of thought) • F = Tangential (never returns to original idea) F • B = Circumstantiality (all around the houses but eventually returns – seen in obsessional personalities and LDs) A B • Word salad – nonsense • Neologisms – made up by pts – schizophrenia and LDs ZHow to wordquestions inpsychosis Hx? From: Psychiatry - A Clinical HandbookSchizophrenia TYPE of PsychosisSCHIZOPHRENIA(type of psychotic disorder) Positive vs negative Sx • Positive (Shneider’s first-rank Sx): • See image on right • Negative: Avolition (low motivation), Asocial behavior Anhednonia, Alogia (poverty of speech), Affect blunted, Attention (cognitive) deficit • Most common type of schizophrenia is Paranoid schizophrenia (most likely to come up in ISCE) – dominated by hallucinations and delusions Antipsychotics (atypical eg Risperidone, Olanzapine) Clozapine iftreatment-resistant (failureto respond to 2other antipsychotics) BIO: Adjuvants (benzos for short term, antidepressants, lithium) ECT (resistant to pharmacological or catatonic schizophrenia) MANAGEMENT CBTstrongly recommended by NICE BIOPSYCHO Family intervention PSYCHO: Early intervention in psychosis team SOCIAL Support groups SOCIAL: peer support supported employment programmesFrom: Psychiatry - A Clinical Handbook T reatment Resistant Schizophrenia - Clozapine Indications • Treatment-resistant schizophrenia (failure to respond to 2 other antipsychotics) Side effects to be aware of • Myocarditis (usually in first 2months) From: Psychiatry - A Clinical Handbook MONITORING Pts will be registered with mandatory blood monitoring service CLOZAPINE → so have to have bloods done and registered on system OR the clozapine will not be dispensed • WBC: weekly for first 18 weeks → fortnightly up to 1 year → monthly SIDE EFFECTS • Lipids: baseline, 3 months forfirst year, then yearly • Most common s/e • Drowsiness, dizziness, tachycardia, constipation, • Weight: baseline, every 3 months, then yearly hypersalivation • Fasting blood glucose: Baseline, 1 month, 4-6 months, • Most serious s/e yearly • AGRANULOCYTOSIS and neutropenia, Seizures, Fever, cardiomyopathytruction (ileus), myocarditis, • Prolactin: baseline, 6 months, yearly • Physical health monitoring (including CVD risk assess) at • Withdrawal-rebound psychosis least every year • medicationfor signs and symptoms ofrelapse.er withdrawalof antipsychotic • Myocarditis and cardiomyopathy– usuallyfirst 2 • Close medical supervision during initiation – risk of collapse months because of hypotension and convulsions • Hypersalivation • Monitor more /change dose if; • Reduced seizure threshold • Stops smoking / switches to e-cigarette • Intestinal obstruction, faecal impaction, paralytic ileus • Othermeds may increase clozapine levels - smedical attention if constipated • Pneumonia or otherserious infection • Rechallenge not warranted • Reduced clozapine metabolism suspected • Toxicity suspectedEating Disorders Eating disorders: SCOFFquestionnaire Sick: Do you ever make yourself sick because you feel uncomfortably full? Clinical Features of EatingDisorders Control: Do you worry that you have lost Amenorrhoea, Loss of libidLanugo hair control over how much you eat? One stone: Have you recently lost more than one stone in a 3-month period? Distorted body iFatigue Hypothermia Fat: Do you believe yourself to be fat when others say you are too thin? Bradycardia Arrhythmia Peripheral oedema (hypoalbuminaemia) Food: Would you say that food dominates your life?Anorexia Nervosa • Screen for other co-morbid psych conditions • Depression,anxiety,OCD etc • Occupation: ballerina, sports • Compensatory behaviours: exercise,self-induced vomiting, laxatives • Investigations: • FBC (anaemia, thrombocytopenia,leukopenia), U&Es (high urea and creatinine uf dehydrated,low K,low Mg,low P), TFTs (hypothyroid), LFTs (low albumin), lipids (high cholesterol), high cortisol, low sex hormones (LH, FSH, oestrogens and progesterones), lowglucose • VBG: metabolic alkalosis (vomiting),metabolic acidosis (laxatives) • ECG: sinus brady, prolonged QT • DEXAscan: osteopenia/osteoporosis • Questionnaires: eating attitudes test (EAT) • Management • Screen for other co-morbid conditions • BIO: treatment of medical complications eg electrolyte disturbance,weight restoration, SSRIs for depression or OCD. *risk of refeeding syndrome (eg low P)* - May need hospitalization if severe,MHA or Children’s Act • PSYCHO: psycho-ed about nutrition,dietician,CBT, Family therapy • SOCIAL: self help groupsBulimia Nervosa • Screen for other co-morbid psych conditions – depression, anxiety, OCD etc • Clinical Features • Compensatory behaviours: self-induced vomiting, laxatives,exercise,diabetics may omit/reduce insulin dose (diabulimia) • Preoccupation with eating – compulsion. Craving to eat • Fear of fatness • Overeating: at least 2 episodes per weekover period of 3months • Can havenormal BMI • Irregular periods • Complications: Dehydration, hypokalaemia (secondary to vomiting) • Investigations: • Same as for anorexia nervosa. VBG may show metabolic alkalosis (low k),ECGs: arrhythmias dueto hypokalaemia • Complications • Dofdental enamel secondaryto vomiting ofgastric acid, amenorrhoea/irregular menses, Russell’s signs (calluses on back of hands due to abrasion against teeth – see pics) • DDx: organic cause ofvomiting eg gastric outlet obstruction Alcohol Dependence: CAGE Questionnaire > 2= Alcoholdependencesyndrome C: Felt the need to Cut drinking? A: Havepeople Annoyed you bycriticism? G: Guiltyabout drinking? E: Eye openerMental State Exam(MSE) Very unlikely to be askedtocomplete these components duringpsych Hxnk of Mental State Exam ASEPTIC - Time frame preceding 2 weeks Thoughts • Content: Delusions (grandiose, persecutory Appearanceand behaviour etc)/preoccupations/overvalued ideas/obsessions/compulsions • Unkempt, sweaty, weight, posture, clothing, personal hygiene, eye contact, facial expressions, motor activity, level of arousal (salm, agitated) • Form: Loosening of association/circumstantiality/perseveration/neologisms Speech • Rate, volume, content, quantity • Stream / Flow: Acceleration (pressured thought,flight ofideas), retardation (povertyof thought), thoughtblocking Emotion (mood) Insight • elated, depressed, climatee emotion over a period of time – euthymic, • Does pt understand nature of their problem • Affect: assessed by observing pt’s posture, facial expression, emotion • Do you think you aresuffering froma mental illess? Ifso, would you reactivityand speech- immediate expressionsof emotion eg smiling at a take medsfor it or letus help you in anotherway?If we were to give joke. Normal affect is ‘reactive’- weather you some medsto help,would you takethem? Perception Cognition • Hallucinations (different types) • Visual: more common in organic brain disease or substance misuse (rarer • Consciousness, orientation, attention, concentration,memory in schizophrenia) • Orientated to time,place and person • 2 person auditory: • Tools: AMT, ACE, MMSETIPS for PSYCH ST A TIONS • DDx • Organic– delirium, dementia, substancerelated, hormonal(ALWAYS THYROID), electrolytes, stroke, cushing’s, hepaticencephalopathy , meningitis, encephalitis • Personality disorder • Otherpsych conditions • Management: Bio Psycho Social • Conservative – followup appts • Leaflet • Self-help – yoga, exercise, eating healthily, self-help online, apps (Headspace) and other online resources • MDT • Treatco-morbid conditions (e.g depression +alcoholmisuse + anxiety + self-harmetc) • Crisis resolution team – severely unwell and often suicidal psych patients in community. 24/7. Can visitpatients daily. Aim is shortterm intervention (usually no more than 6 weeks) to preventhospital admission • duration of untreated psychosis (strongprognostic indicator)usually under35yo)in theirfirstepisodeof psychosis. Aimis to provide interventions targeted atreducing • patients in your position.’u about some experiences that some people sometimes have but find it difficult to talk about. They’re questions I ask all • Normalise situations – Patients sometimes have thoughts of XYZ when they feel the way you are • Pick up on non verbal cues • Have a rough idea of sections • Read up on Lithium and Clozapine (more for meds review station) • Paracetamol overdose – potential ISCE stationASSESSING CAPACITYRecommended Reading: Psychiatry - A Clinical HandbookANY QUESTIONS?