Psychiatric History And Mental State Examination PDF

Psychiatric History and Mental State Examination A/Prof Nicola Warren: [email protected] Overview Why do a psychiatric history? What are the clusters of psychiatric symptoms? What do you gather in a developmental and social history? What are the key features of a mental state exam...

Psychiatric History and Mental State Examination A/Prof Nicola Warren: [email protected] Overview Why do a psychiatric history? What are the clusters of psychiatric symptoms? What do you gather in a developmental and social history? What are the key features of a mental state examination? Content Warning Overview Why do a psychiatric history? What are the clusters of psychiatric symptoms? What do you gather in a developmental and social history? What are the key features of a mental state examination? Objective Gain information Confirm diagnosis Develop rapport Psychoeducation The therapeutic history Objective Gain information Develop rapport Confirm diagnosis Psychoeducation Rule out differentials The therapeutic history Risk Consider comorbidities Information to base treatment on Objective Gain information Develop rapport Confirm diagnosis Psychoeducation Rule out differentials The therapeutic history Risk Consider comorbidities Information to base treatment on Therapeutic History Containment provided from sitting with someone’s distress Brené Brown on Empathy: https://www.youtube.com/watch?v=1Evwgu369Jw How can you make an interview ‘therapeutic’? This is a skill that is learnt Complex cognitive task Gets better with intentional practice Psychiatric History Current presentation Past psychiatric history Medical history Medications Substance use history Family history Forensic history Developmental/personal history Overview Why do a psychiatric history? What are the clusters of psychiatric symptoms? How do you gather a developmental and social history? What are the key features of a mental state examination? Diagnosis and differentials Mood Anxiety Psychosis Substance Organic Presentation Symptoms Time course/Fluctuation (last time they felt well/baseline) Triggers/what helped Distress Functional impact Mood Depressed/sad/teary Hedonic tone Depressive cognitions Suicidal ideation Neurovegetative symptoms Mood Depressed/sad/teary Hedonic tone Depressive cognitions: guilt, hopeless, helpless, worthless Suicidal ideation Neurovegetative symptoms Mood Depressed/sad/teary Hedonic tone Depressive cognitions Suicidal ideation Neurovegetative symptoms Sleep Appetite Motivation Energy levels Concentration Sex drive Mania/Hypomania Elevated mood Decreased need for sleep Increased activity/talking/thoughts/energy Risky/impulsive/out of character behaviour Special gift/ability Risk Static Dynamic Risk Static Dynamic Past history Cognitions Family history Intent Comorbidities Planning Access Substance use Delusions Protective factors Anxiety Worries Panic attacks Obsessions Phobias Avoidance Re-experiencing phenomena Anxiety tone: hypervigilance, poor concentration, startle, keyed up, fatigue, dissociation Presentation Symptoms Time course/Fluctuation (last time they felt well/baseline) Triggers/what helped Distress Functional impact Anxiety Worries Panic attacks Obsessions Phobias Avoidance Re-experiencing phenomena Anxiety tone: hypervigilance, poor concentration, startle, keyed up, fatigue, dissociation Psychosis Delusions Hallucinations/Illusions Passage and presence phenomena Delusion Fixed (false) belief Held with intense conviction Impermeable to logic Out of keeping with social norms Delusions Persecutory Jealousy Erotomania Grandiose Misidentification Somatic Poverty Religious Reference Delusions Persecutory Jealousy Erotomania Capgras: a familiar person has been replaced by an identical Grandiose imposter Fregoli: different people/strangers are in fact the same person who Misidentification changes appearance or is in disguise Somatic Intermetamorphosis: an individual has the ability to take the form of Poverty another in appearance and personality Religious Reference Delusions Persecutory Jealousy Erotomania Grandiose Misidentification Somatic Poverty Religious Reference Organic Neurological Current symptoms/signs Head injury, seizures, stroke, Past history Parkinson’s Medications Endocrine Thyroid, diabetes Cardiac Arrhythmias, CVD, blood pressure Substance use Ask about each substance individually Over-estimate and round down Medicinal cannabis and hallucinogens Type/amount/length of use/triggers/quit attempts Further history Past psychiatric history Medical history Medications Substance use history Family history Forensic history Developmental/personal history Further history Past psychiatric history Past diagnoses Medical history Admissions: voluntary/involuntary Medications Medications ECT Substance use history Periods of mood/anxiety/psychosis Family history Forensic history Developmental/personal history Further history Past psychiatric history Medical history Medications Substance use history Family history Forensic history Developmental/personal history Overview Why do a psychiatric history? What are the clusters of psychiatric symptoms? How do you gather a developmental and social history? What are the key features of a mental state examination? Why gain a developmental history? Developmental History Explain why you are getting this history Major childhood events? Family history of physical/mental health and substances Academic? Bullying? Jobs? Trouble with police/go to court? Relationships? Overview Why do a psychiatric history? What are the clusters of psychiatric symptoms? How do you gather a developmental and social history? What are the key features of a mental state examination? Why do a MSE? Snapshot description Aid diagnosis and differentials Track changes over time Communicate with colleagues MSEx Appearance and Behaviour Speech Mood and Affect Thought Perception Cognition Insight and Judgement Depressed MSEx Elevated MSEx Bright/unusual/inappropriate clothing, excess accessories, disinhibited behaviour, intrusive, psychomotor agitation Fast paced, loud speech Elevated mood, labile affect Flight of ideas, grandiose delusions Anxious MSEx Pensive or worried facial expression, psychomotor agitation Faster paced speech Circumlocutory, overly detailed Anxious content, obsessions, worries Psychosis MSEx Poor self care, distracted, guarded, responding to internal stimuli, akathisia, parkinsonism/TD Latency of speech, monotonous tone Blunt, Restricted affect FTD – loose associations, derailment, thought blocking Delusions Perceptual phenomena Art of history taking and examination Attentive to appearance and behaviour when considering presenting complaint Attentive to thought form when screening for psychosis Attentive to cognition when screening for organic Signaling where you are in the history/examination and why Recounting/summarizing Normalisation and gentle assumption Agree with emotion, not necessarily with the content Please… Don’t: “I understand” or “That must be….” Limit: “I’m sorry” Tolerate silence It’s ok to make mistakes Notice Apologise Continue on  Be honest Be human Thanks [email protected]