Psychiatry - History Taking PDF

Psychiatry - history taking Identifying information: Name: Age: Sex: Marital status: Education: Occupation: Residency: Reason & Source of referral: Was admitted to the hospital through: ER/Referral on (day/date): at...

Psychiatry - history taking Identifying information: Name: Age: Sex: Marital status: Education: Occupation: Residency: Reason & Source of referral: Was admitted to the hospital through: ER/Referral on (day/date): at (time):. History was taken from: on (day/date): at (time): Chief Complaint: Duration: -The patient was brought to the hospital by his ----------. -he is a known case of schizoaffective disorder. - The patient has been on multiple antidepressants, and all have failed. - “I feel hopeless and need help.” -The patient reports that he has not been taking his medications. HOPI: Past Psychiatric History: Current condition: Actual condition: Precipitations :Triggering factors for the problem - When was your first visit to psychiatric doctor? Stress , death of close person , trauma , unemployment , sexual abuse Onset Intensity Duration Associated S&S -Permanent symptoms Suicidal or homicidal ideas -Potential contributors (e.g: drug abuse) Cover all possible associated symptoms , as following : 1. first intake ** only if its related to the chief complaint 2. last intake Depression Mania 3. frequency & amount A SAD FACES DIG FAST 4. longest period of abstinence D: Distractability 5. withdrawal symptoms A: appetite (weight gain) I: Irresponsibility Not being able to sleep. S: sleep disturbances G: Grandiosity Changing moods. A: anhedonia F: Flight of ideas Anxiety D: Dysphoria (depressed mood) A: agitation S: sleep ( decrees in need) Tremor F: fatigue T: talkativeness or pressured speech Irritability. A: agitation/ retardation Depression. C: concentration E: esteem (low) / guilt Aches and pains. S: suicidal thoughts Sweating Delusions Obsession and compulsion 6. road traffic accidents * Paranoid : * Doubt : 7. Any psychotic symptoms? * Reference : * Contamination : *If hospitalization occurred: * Grandiose : * Symmetry: Name of the institution: * Guilt : * Intrusive thought : ‫بالك مشغول بأفكار سخيفة‬ Reason for admission * Control : ( ask about triggering and relieving factors ) Discharge diagnosis Phobias Hallucination Treatment: * Specific : * Auditory: -Efficacy: * Social : * Olfactory: *Avoidance: ‫بتتجنب تعمل الشغالت يلي‬ * Somatic: ‫بتخوفك؟‬ * Gustatory: Hostility Panic attack Ask about nervousness - Palpitations -sweating - flushing -SOB Depersonalization - tremor -dizziness Derealization -chest pain -chills Illusion -choking - Fear of dying , losing control , going crazy Drug history: Drug Frequency Dosage Side effect Withdrawal symptoms Personal Developmental history: pregnancy -any complications during pregnancy -vaginal or C/S , at home or hospital -complications during birth - neonatal intensive care unit NICU admission * Cesarean section is associated with more psychiatric disease, hypoxia as well Preschool head trauma , infection , attention , milestones , epilepsy School : At any age enter the school, performance, relation with peers, relation with teachers Sexual history: puberty at any age? / relation with the partner Premorbid history: interpersonal relationship -With family members , friends, work-mates & superiors - introverted / extraverted - ease of making and keeping social relations Use of leisure time -Hobbies -interests - intellectual activities - energetic/ sedentary Attitude to moral and religious issues impact of current illness in his life: Family (relation with his wife , father , mother , brothers , sisters , siblings ) sociality ( relation with other people ) occupation *Any history of head trauma * Psychosocial trauma: war, rape Forensic history: --------------------------------------------------------------------------------------------------------------------------------------------------------- Family history: Mother Father Siblings : 1 2 3 Sex: Age Education Occupation Medical diseases Mental disorders Medications Drug abuse ( tobacco / alcohol..) *Relatives might respond to the same drug Mental Status Examination (MSE) Mental status examination (MSE) is equivalent to physical examination in the rest of medicine. Most does not require direct questioning. 1.General A description of the person’s general appearance is typically the first element of a appearance mental status examination. & behavior It consists predominantly of the assessor’s impressions and observations of what the person looks like and how they behave throughout the assessment and can provide the clinician with cues by which to further investigate other areas of the mental status. Age: Does the patient appear to be his or her stated age, younger or older? Commonly used descriptions include “appears stated age” or “appears older/ younger than stated age”. Apparent health: under weight, chronic disorder, eating disorder, cancer Level of hygiene: -low self care level in severely depressed patient, chronic alcoholic, schizophrenic patient ( bad dental hygiene: heavy smoker) - high level of hygiene in OCD patients Mode of dress: appropriate dressing to age, gender, season -manic patient dresses colorful clothes with bizarre makeup & accessories Any physical abnormalities or striking features should also be recorded, such as tattoos, needle marks, scars, skin lesions or discoloration. Facial expressions: May convey happy, sad, anxious, fearful or perplexed states of mind. Behavior: 1. Eye contact - Suspicious persons—>may avoid eye contact. (schizophrenics) - Depressed patients—>often look downwards. - Hallucinating patients—>may look in unexpected directions in response to their own internally produced visual or auditory stimuli. 2. Movement 3. Motor activity: - May be described as normal, slowed, or agitated. Psychomotor retardation: physically & mentally slowed: depression 4. Expressive gestures -Pacing, hand wringing, fist clenching or shaking, grimacing, repetitive touching of the face and so forth. 5. Cooperativeness -Adjectives such as friendly, trusting, preoccupied, suspicious, arrogant, sarcastic, guarded, vigilant, threatening, hostile, impatient etc are good descriptions to summarize the overall cooperativeness of the patient. 2. speech Volume Amount -from sparse to talkative -Mutism is the absence of speech and can result from psychiatric or neurologic causes -Alogia: poverty in speech (amount) and/or poverty in the content of the speech (meaningless speech) we can see it in: -schizophrenic patients ( negative symptoms ) ** Talkative patient with a loud voice, pressured speech, spontaneous & very difficult to interrupt them?? Manic patients Rate Normal Slowed : in depressed patients Rapid ( pressured) Spontaneity -Is the degree to which the patient initiates and engages in conversation. -Depressed patients commonly demonstrate decreased spontaneity of speech. -Paranoid or suspicious patients may be hesitant to initiate conversation. 3. mood & Mood is a person’s internal (described by the patient) and sustained emotional state, it’s affect Subjective "How have you been feeling lately?" Affect Stability of -The rate at which affect changes is the mobility of Are terms is the affect affect. used to external (fluctuation) “ mobile affect”: A normal capacity to change describe (described by “Labile affect”: excessively rapid and unprovoked emotional or the Doctor) changes feeling states and dynamic - A brain damaged (e.g., pseudobulbar palsy) or manifestation delirious patient's affect can be labile from minute to of a person's minute. It is not unusual for these patients abruptly internal to grimace, cry, or sob, only to return to a calm emotional expression a few seconds later. state, Its Appropriateness Affect is normally appropriate to, or congruent with, objective And Congruity the environment, topic of conversation, or situation. Schizophrenics: inappropriate *Described in Range of affect. “full affect”: a variety of normal emotions are terms of: noted during the interview; like:sadness, happiness, anger, laughter, seriousness, and so on, depending on the context. “Restrictive affect” he can’t express full happiness “Blunted affect” worse than restrictive “Flat affect” A state in which there is no emotional expression. The patient with flat affect also has minimal variability of facial expression, shows no gesticulations, and speaks in a monotone voice. Schizophrenics “apathy” Severe form of Flat affect 4. thought Form of thought Loosening of Loss of the normal Knight’s Transition from one topic to association structure of thinking move / another with no logical The way in which thoughts flow, (LOA) – Muddled and illogical derailment connection between the two. are connected to one another, and conversation that -schizophrenics are expressed to the listener. cannot be clarified by Word salad: ▪ severe form of derailment further enquiry affecting the grammatical Was the conversation logical and structure of speech goal directed, or was it confusing ▪ words are no longer and vague? meaningfully connected to one Was it easy to gather another information, or did the examiner Flights of ideas -Each sentence is more or less logically connected to the preceding one, have to work hard at asking but the topic repeatedly changes before elaboration of each thought can questions to elicit information? occur. This is seen most often in manic patients, typically in conjunction with ▫ Normal form of thought: logical , pressured speech. coherent , Goal directed, relevant 3 components have to be there: to the topic. – pressure of speech – shifting topics Formal thought disorder(FTD) – apparent association (can be followed) Any disorder in the form (structure Echolalia Repetition of statements and questions made by the examiner, of thoughts) it’s not easy to sometimes more than once. understand speech or way of For example, when the examiner asks "What is today's date?" the thinking of the patient. patient replies "What is today's date?" ▪ can be seen in: -schizophrenia -autism perseveration -Words, phrases or ideas persist beyond the point at which it is relevant, e.g. same answer to each question (stimulus). -Differs from verbal stereotypy *Verbal stereotypy (verbigeration): words, sounds or phrase repeated in a senseless way (no stimulus). any patient who having perseveration we have to rule out any neurological causes Tangentiality The topic of conversation had strayed down another path or direction (tangent) without eventually returning to the original topic. can be seen in: -mania -schizophrenia Circumstantiality -Means "talking around" a topic. Such speech is digressive and overly detailed, but eventually returns to the original topic or makes the relevant point (if it fails to accomplish this, the speech should be described as circumstantial and tangential). -Can occur in: -Epilepsy -Learning disability -Obsessional personality traits. -Mania or psychotic patients Thought process Neologism Use of novel words or of existing words in a novel fashion. seen in: -schizophrenia Thought block Sudden arrest of the train of thought, leaving a “blank”. Clang associations Speech based on sound such as rhyming and punning (i.e., My car is red. I’ve been in bed. It hurts my head.). seen in: -mania Content Overvalued ideas Ideas held with a lot of emotion (highly charged) but with some degree of ambivalence and doubts about the belief. (Emotions are expressed to compensate for the ambivalence). *In anorexia nervosa in which an underweight individual may believe she is too fat. -Seen in: anorexia nervosa, morbid jealousy, paranoid litigious states Suicidal/ —Ask if the patient feels like harming him/herself or others. homicidal ideation —Identify if the plan is well formulated. —Ask if the patient has an intent (i.e., if released right now, would he go and kill himself or herself or harm others?) —Ask if the patient has means to kill himself ( firearms in the house/ multiple prescription bottles). preoccupation Ideas which come to mind, again and again and may prevent the patient from performing his day to day activities. Obsession —Recurrent persistent thoughts, impulses or images that enter the mind despite efforts to exclude them. —Subjective sense of struggle to resist them. —Recognized as his own (not implanted). —Regarded as untrue and senseless. Phobia Persistent, irrational fears. Delusions False, unshakeable belief that is out of keeping with the patient’s social and cultural background. Delusions Persecutory (paranoid) The commonest delusions & seen in : schizophrenic and manic patients Others/organizations trying to inflict harm on him. Believe that he is being conspired against or persecuted in some way. Have you had trouble getting along with people? Have you felt that people are against you? Has anyone been trying to harm you in any way? Do you think people have been conspiring or plotting against you? Who? Grandiose (expansive) Beliefs of exaggerated selfimportance 🦜 ▪ e.g. wealth, special powers, beauty seen in Manic patient Delusion of Reference - idea that objects/ events/ people have a personal significance for patient e.g. TV ▪The patient believes that insignificant remarks, statements, or events have some special meaning for him or her. Religious delusion The patient is preoccupied with false beliefs of a religious nature. ▪ Have you had any unusual religious experiences? We see it in manic Patient & schizophrenia Delusion of Love “erotomania”(De – being loved by a man who is inaccessible, high status, never spoken before, unable to reveal his love for Clerambault’s her Syndrome) * seen in female especially Manic patients or it may be as only Delusion disorder Delusion of Jealousy(Delusion Common in men (middle age). of infidelity) ▪ May develop gradually. ▪ Delusion of unfaithfulness of spouse (infidelity). ▪ Spying, checking on spouse, examine for sexual secretions, may progress to violence against the spouse and even to murder. ▪The patient believes that his or her spouse or partner is having an affair with someone. ▪Random bits of information are constructed as “evidence”. ▪Morbid jealousy makes a major contribution to the frequency of wife battering, and is one of the most common motivations for homicide Delusion of Guilt and ▪ e.g. minor past faults will be exposed, being sinful, deserves to be punished. Worthlessness ▪ We usually see it in depressed patients Nihilistic Delusion Belief about non-existence of some person / thing + pessimistic ideas e.g. career is gone ▪ Cotard’s Syndrome: failures of bodily functions e.g. bowels are rotting etc. - We usually see it in depressed patients Hypochondriacal Belief of ill health despite contrary medical evidence. ▪ others/ Delusions ▪ Usually of a particular theme & may have relative/ friend suffering the supposed. - We usually see it in depressed patients Possession Thought Insertion: Delusion that some thoughts have been implanted by outside agency. Thought Delusion that thoughts have taken out of his mind (may accompany/ Withdrawal explain thought block). Thought Delusion that his unspoken thoughts are known to other people. Broadcasting 5. perception Illusions – misperceptions of external (objective) stimuli – conditions more likely to occur: The reduced level of sensory stimulation (e.g. at dusk) understanding reduced level of consciousness (e.g. delirious pts.) of a sensory when attention is not focused on the sensory modality (e.g. in darkness) stimulus. when there is a strong affective state (e.g. stressed up / angry) *seen in schizophrenic patient Hallucinations – Sensory perception without an objective stimulus but with a similar quality to a true percept. – experienced as originating in the outside world and not in the mind (like imagery) *the commonest: auditory hallucinations seen in schizophrenic patients Auditory Elementary ‫ تكسير او تخبيط‬/ complex ‫كالم‬ Voices - single/multiple - male/female - known/unknown person - person – 1st person: “thought echo” - hearing own thoughts spoken aloud (Gedankenlautwerden, echo de la pensee) – 2nd person: calling patient by ‘you’ (depression) – 3rd person: calling patient by ‘he’ or ‘she’ (schizophrenic patients) Voices - commanding / running commentary / arguing with each other timing: – day / night / all the time – circumstances when it occurs – continuous / intermittent / frequency theme: – friendly, derogatory patient’s response to the voices Visual elementary (e.g. flashes of light) complex - semi-formed: with some structure - fully-formed: e.g. human figures, trees black and white / coloured (intense colors in LSD abusers) static / mobile stable form / changing design size (e.g. Lilliputian) commonly associated with organicity *Usually if the patient have presentation as only visual hallucinations we have to rule out Organic causes(esp. elderly); because usually it combined with auditory hallucinations Olfactory and often experienced together gustatory often unpleasant in nature (e.g. rotten fish, bitter) common in temporal lobe epilepsy *sometimes gustatory hallucinations are physiological symptom in pregnancy Tactile Superficial( haptic): touched, pricked e.g. insect crawling under the skin (e.g. formication in cocaine abuse) deep sensation: e.g. viscera being pulled out, sexual stimulation, electric shock in schizophrenic patients Autoscopic seeing own body projected into objective space (can happen in depression) “negative autoscopy” also can occur! Extracampine –perceiving a sensation from beyond the limits of the sense organ –e.g. visions from outside visual field, hearing voices from far away *seen in patients with schizophrenia Functional -are triggered by a stimulus in the same modality, and co-occur with it -Example: the patient hear sound like water he will hear sounds similar to the water sound. Reflex –stimulus in one sensory modality causing a hallucination in a different sensory modality –e.g. music causing visual hallucination (LSD abuse) Hypnogogic ▪ occurs at the point of falling to sleep. (can occur in normal individual) hypnopompic ▪ Occurs at point of Waking from sleep ▪ usually brief and elementary Description of hallucinations: According to complexity – Elementary – complex According to sensory modality According to special features – auditory: 2nd or 3rd person (most common) Depersonalization a feeling that his body parts are abnormal, unreal both can occur in e.g. “my brain becomes big until it fills the room” -tiredness Derealization a feeling that the external environment is abnormal, -temporal lobe epilepsy unreal -depression e.g. people are two dimensional card board figures -Depersonalization/Derealization Syndrome -Borderline personality Disorder -schizophrenia. 6. insight -Refers to the patient’s understanding of how he or she is feeling, presenting, and functioning as well as the potential causes of his or her psychiatric presentation. -Knowledge of the illness and presenting problem -Knowledge about medication -Amenable to treatment Person -Likelihood of compliance Assessment of insight focuses on: 1)whether patients recognize that they are ill 2)comprehend that their problems are deviations from normal 3)understand that their behavior may affect others 4) Appreciate that treatment may be helpful in alleviating symptoms. no insight : psychiatric & manic patients partial insight Full insight: OCD, bipolar, depression, anxiety, panic. **This information is elicited through direct questions, for example: "Are you ill?" "What has brought you to see me?" "Have you had thoughts that other people view as abnormal, or are not normal for you?" "Do you realize that your family thinks you have been depressed?" 7. judgment -Refers to the person’s capacity to make good decisions and act on them. The level of judgment may or may not correlate to the level of insight (A patient may have no insight into his or her illness but have good judgment). “What would you do if you found a stamped envelope on the sidewalk?” The important issues in assessing judgment include whether a patient is doing things that are dangerous or going to get him or her into trouble and whether the patient is able to effectively participate in his or her own care. *manic patients have a poor judgment 8. cognition Orientation Orientation to person, place, and time is a basic cognitive function. Memory immediate recall Is essentially an assessment of attention The ability to Is most often tested by asking patients to repeat the names of three unrelated objects use intellect, (e.g., apple, table, penny). thought, and short-term memory Recent or short-term memory is typically tested by asking the patient to recall after a ideas to few minutes the three objects repeated. comprehend The inability to recall after 3- 5 minutes does necessarily indicate the loss of short inner and outer term memory but could instead reflect inattention or amotivation. realities. long-term memory Assessed during the course of interview through the patient’s ability to accurately recall events in recent months and throughout the course of a lifetime. Attention And Attention is the ability to sustain interest in a stimulus, whereas concentration involves the ability to Concentration maintain mental effort. Counting backward by 7s (serial 7s) requires that the patient retain interest in the task, recall the last number, and then continue to the next number. The task also requires competence at math. Spelling world backward is another test. For other patients, it is preferable to use a test that is less dependent on education, such as reciting the months backward. Abstraction Is the capacity to conceptualize meanings of words beyond the most literal (concrete) interpretation. This includes the ability to: 1. Analyze information according to themes. 2. to generalize according to categories 3.to appreciate double meanings 4. to make comparisons 5.to hypothesize 6.to reason using deductive and inductive thinking. Assessment of the ability to identify similarities and interpret proverbs is a common approach to testing abstraction. "In what way are an apple and an orange alike?" The correct answer is that they are both fruit; this is an abstract answer. An answer that they both are round is concrete; that they can both be eaten is somewhat less concrete. Proverb interpretation is another way to test abstraction. Key clinical points Nonverbal communication and observation are crucial. Without a strong fund of knowledge, the interviewer will get lost. Information is useful only when interpreted. Not all information is relevant. The interview should be adapted to fit the patient and the situation. The history of present illness is a creation of the interviewer. The history of present illness is longitudinal. The mental status examination is cross-sectional. It is difficult to balance the many mandates of the psychiatric interview. but the task is made easier through the active cultivation of such interpersonal characteristics as curiosity and warmth.