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Psychhistory taking AlexPhillips and Fionn Kelly Learning objectives • Common psychiatric histories • Low mood • Anxiety • Hallucinations/delusions • Forgetfulness • Alcohol history • Suicide history • Mental state examination • Risk assessment Generalhistory 1. Introduction 2. Timeline 3. Core symptoms – mood, energy, enjoyment 4. BiologicalSx – sleep, libido, appetite, concentration, memory 5. ICE 6. Risk assessment 7. PMH DHSH FH 8. Conclusion SAD MOPP • Substance • Anxiety • Depression • Mood • Organic – important to rule out an organic cause • Personality • Psychosis Low moodhistory Differentials: 1. Depression 2.Bipolardisorder 3.Schizoaffective disorder • Lowmood • EasyDxtomiss • Askaboutprevious • Anhedonia • Askaboutprevious delusions • Fatigue manicepisodes and depressiveepisodes Hypothyroidism–simplescreeningquestions • Intolerance tocold, constipation, oligomenorrhoea, weight gain Anxietyhistory Differentials 1. Generalisedanxietydisorder 2. Panicattack 3. PTSD 4. Hyperthyroidism 5. Alcoholwithdrawal Hallucinations/delusionshistory Differentials: 1. Schizophrenia 2. Drug-inducedpsychosis 3. Delirium 4. Depressionwithpsychosis 5. Mania Forgetfulnesshistory Often a collateral history Differentials: 1. Alzheimer’s 2. Vascular dementia 3. Dementia with Lewy Body 4. Frontotemporal dementia 5. Severe depression Mania history Differentials: 1. Bipolardisorder 2. Schizoaffective disorder 3. Drug-inducedpsychosis Alcoholhistory(1) • Testing your communication skills • Can be difficult to start • ‘I’ve beenaskedtocome andspeaktoyoutodayregardingyouralcohol intake-is that okay?Iappreciate that some ofthese questions maybe difficult toanswersoifyou’dlike tostopat anytime,let me knowandwe can’ Alcoholhistory(2) CAGEquestionnaire: 1. HaveyoueverfeltthatyoushouldCut down on your drinking? 2. HavepeopleAnnoyed youbycriticisingyourdrinking? 3. HaveyoueverfeltGuilty about your drinking? 4. Haveyoueverhadadrinkfirstthinginthemorningtosteadyyournerves or get ridofahangover(knownas an Eye-opener)? Alcoholhistory(3) Features of dependence: • Tolerance “Do you have to drink more to get the same effect that you used to?” • Withdrawal– “What happens when you don’t drink?” • Compulsion – “Do you get any cravings or urges for alcohol?” • Primacy– “Would you say that drinking has become your main priority in life?” • Previous treatment- ”Have you ever had previous treatment for alcohol?What cause you to relapse?” Alcoholhistory(4) Consequences of drinking: • How has it caused problems in their life? • Work • Relationships • Problems with the law Complications: • Depression/anxiety • Psychosis • Self-harm/suicide (more later) Suicideattempthistory(1) Again,adifficultcommunicationstation ‘Howare youfeelingtoday?Iunderstandthat you(tooksome tablets last night). I’mreallysorrythat things got sobadthat youthought that was onlywayout’ Suicideattempthistory(2) Before, during andafterthe event. so they be found?Didyoutell anyone?Carry out any final acts?he only way out. Hadthey plannedthis?Didthey try to make it During:What actually happened? • Askspecific questions regarding the method • Overdose-Onwhat?Howmany tablets?Didthey lose consciousness? • Establish the severity ofa patients suicide attempt Was it theirintentionto die?Were they underthe influence ofalcohol? see yourfuture?re they found?Howdo they feel about it now?Do they have any thoughts ondoing it again?Howdo they RiskAssessment • Please do this- you will failJ • This is arguably the most important part of any psychiatric history • The type of history will inform the questions you’ll ask • Risk assessments by nature require us to ask patients difficult questions • Its important not to jump straight into them without a warning shot • E.g “Some of the questions I’m about to ask you might be upsetting and difficult to need to answer them”estions we ask everyone and please take as much time as you BasicStructure • Risk to self • Self-harm • Suicide • SelfCare and Risk-taking behavior • Protective factors • Risk to others • Violent thoughts • Safeguarding issues • Risk from others RiskAssessment–suicide • Ask about suicidal thoughts • Again, are they intrusive and the impact on the patients • Cause? – • Low self worth • stressful life event/ bereavement • Addiction • Unemployment • Have they made plans to end their life? • Final acts? - leaving a will to cancelling a phone contract • History of previous suicide attempt. RiskAssessment-self harm • Ask the patient have they ever considered/attempted self-harm? • Thoughts • What triggers them?Are they intrusive? Impact on patients? • Hx ofSelf Harm • When/How often? • Cause? Planned or Impulsive? • How does it make them feel? • Alcohol or Drugs? • Did they make anyone aware? • Would they do it again? • Cutting – where, how deep (treatment needed?)SelfCare Risk taking behavior Patient’s hygiene Gamblingandspending sprees Patient’s weight Risk takingsexualbehavior Livingsituation Drug and alcoholuse ProtectiveFactors • “Isanythingstoppingyou?” • “Whyhaven’tyoutakenyourownlife?” • ”Doyoufeellikeyouhaveanythingworthlivingfor?” • Assesssocialisolation Risk toOthers • ”Haveyoueverhadthoughtsofharminganyone?” • Have they made a plan? • Their intent • Do they carry a weapon? • Consideralcohol andsubstance misuse aroundchildren • Drunkdriving • Domesticabuse Risk fromOthers • Important to consider if patient is vulnerable • ”Does anyone ever hurt you physically?” • “Does anybody make you do things you don’t want to do?” • ”Do you feeling like anybody ever takes advantage of you? (steal or take money)” • Important to consider abusive relationships, people with intellectual disabilities and other vulnerable groups OSCEchecklist • “Have you attempted self harm?” • If yes, brief self-harm Hx • “Have you considered/attempted suicide?” • If yes, explore thoughts and previous suicide attempt • “Why haven’t you taken your own life?” • “Have you ever had thoughts of harming someone?” • If yes, ask if they’ve made a plan or carry a weapon? • “Is their anyone ever anyone else at home?” • Risk to children (neglect/alcohol/abuse), Risk from/to partner • “Does anyone ever hurt you or exploit you?” Presenting RiskAssessment • Will likely be the follow-up question after a psych station. • Example:‘Thispatientisalow/moderate/highrisktothemselves/others becauseongoingsuicidal idealation/iscurrentlyexperiencingpersecutory delusionsandcarryingaweapontodefendthemselves’ MentalStateExamination • ThisisverylikelyanOSCEstation • You will most likely be shown a vide- f i utesandthenaskedto present the patient ASEPTIC • Appearance + Behavior • Speech • Emotion/Affect • Perception • Thought • Form/Content/Possession • Insight • Cognition AppearanceandBehavior • Age,Gender,Clothing(appropriateness?),Kempt/unkempt,hygiene,hair • Rapport,eyecontact,facialexpression,gait,arousal(calmoragitated), abnormal movements (tics,tremors,rockingetc.) Speech • Rate:pressured(mania),slow(depression), • Quantity:alot(mania),minimal(depression), • Volume: • Tone: monotonous (depression), loud, whispered, tremulous (manic) • Fluency: Emotion/Affect • Subjective: ‘onascale of1-10,howwouldyourateyourmood’ • Objective: How you(as the doctor) woulddescribe theirmood • Is it in-keeping/congruent with what they are saying? • E.g.high,low,euthymic,apathetic,blunted? • Rangeinemotion Perception • Do they hear or see anything that other people don’t • Pseudo-hallucinations • Auditory: Do they hear a voice, how many voices, second or third person, content of speech, order them to do anything and does patient conform to the order • Visual:Common in certain kinds of dementia • Tactile: substance misuse • Depersonalisation: Depression ThoughtForm • Form: process and organization of thought • Loose associations: topic to topic no association. Psychosis • Circumstantial thoughts- struggling to arrive at the point. Psychosis, Mania • Flight of ideas - accelerated speech, limited association between topics Mania • Thought blocking - sudden cessation of thought Psychosis,OCD • Preservation- repetition of a particular response Brian injury • Poverty of thoughtDepression • Neologisms – made up words Psychosis ThoughtContent • Abnormalities ofthought content caninclude: • contrary andnot insync with regional andcultural norms.These may include persecutory delusions, inwhich the patient erroneously believes anotherindividual orgroup is trying to harmthemorideas ofreference, inwhich the individual incorrectly believes specific events relate to them. • Obsessions: thoughts, images orimpulses that occurrepeatedly andfeel out ofthe person’s control.The patient is aware these obsessions are irrational, but the thoughts continue to entertheirhead. • Compulsions: repetitive behavioursthat the patient feels compelledto performdespite recognisingthe irrationality of the behaviour. • Overvalued ideas: a solitary, abnormal beliefthat is neitherdelusional norobsessional innature, but which is preoccupying to the extent ofdominating the sufferer’s life (e.g. the perceptionofbeing overweight ina patient with anorexia nervosa). • Suicidal thoughts • Homicidal/violent thoughts ThoughtControl • Thought insertion:abeliefthatthoughtscanbeinsertedintothepatient’s mind. • Thought withdrawal:abeliefthatthoughtscanberemovedfromthe patient’s mind. • Thought broadcasting:abeliefthatotherscanhearthepatient’sthoughts. Insight • Refers to the ability of a patient to understand that they have a mental healthproblemandthat what they’re experiencingis abnormal • Oftenpatients withactive psychosis will displaynoinsight, as theyare full arerealdintheirdelusionsandbelievethehallucinationstheyexperience Cognition • whethertheyareorientatedintime,placeandperson • whattheirattentionspanandconcentrationlevelsarelike • whattheirshort-termmemoryislike • To show off, “In order to further examine this patient I would perform a Mini-mental state exam(MMSE)” PracticeMentalState • Start bywritingout aseptic • https://www.youtube.com/watch?v=zA- fqvC02oM&ab_channel=UniversityofNottingham • Afterthisvideotakeaminutetofinishwritingdownanythingyounoticed • We will then ask you some questionsDiagnosis: First episode mania A+B- patient is eccentrically dressed, excitable demeanor and expressive facial expressions S- pressured speech, a lot, tremulous E- very excitable, gets angry at end, patient feels fantastic P-God talks to him, auditory hallucinations T- flight of ideas!Circumstantiality?, delusions of grandeur – cure for cancer, ideas of reference I- little to no insight C- 0rientated to time place and person