Psychiatry History Taking

1. Psychiatry History Taking Andriana harris Chieun han

2. Common history stations Anxiety – GAD, panic disorder, phobic disorder, PTSD, OCD, depression Psychosis – schizophrenia, delusional disorder, bipolar disorder, psychotic depression, delirium, dementia with Lewy bodies Low mood – depression, bipolar disorder, adjustment disorder, psychotic depression, post-natal depression Memory loss – dementia, depression, delirium Eating disorder – anorexia, bulimia Suicide history Alcohol history Will most likely be asked to present back the MSE and the end of the history

3. Presenting complaints • Low mood • Core symptoms – low mood, anhedonia, reduced energy • Biological symptoms – sleep • Future – risk, hopelessness • Psychiatric screen – bipolar, recent child birth • Organic screen – hypothyroidism, drugs, SOL

4. Presenting complaints • Anxiety • Full timeline of symptoms – before, during and after • Somatic symptoms – palpitation, SOB, tight chest, sweating, dizziness, tingling • Psychiatric screen – depression • Organic screen – hyperthyroidism, acute coronary syndrome, arrhythmias

5. Presenting complaints • Psychosis • Hallucinations – auditory, visual, olfactory, tactile • Auditory hallucinations – voice detail, in or out of head, 1st/2nd/3rd person, what is said • Delusions – fully explore and challenge (should not be able to break) • Psychiatric screen – personality disorders, delirium, dementia • Organic screen – drugs, alcohol, withdrawal, SOL, hypoxia

6. Presenting complaints • Eating disorder • BMI, food diary • Symptoms – avoidance of weight gain, need to lose weight, look in the mirror a lot • Purging – vomiting, laxatives, diuretics, exercise • Biological symptoms – menstrual disturbance, hair growth • Psychiatric screen – depression • Organic screen – hyperthyroidism • Red flags – BMI <13 or 2nd centile, weight loss >1kg/week, temp <34.5, BP <80/50, pulse <40, o2 <92%, limbs blue and cold, unable to stand without arm use, purpura rash, hypokalaemia, hyponatraemia, hypophosphatasaemia, long QT or flat T waves on ECG

7. Suicide and self-harm • Before • Events leading up to the suicide attempt – both long term and immediately before e.g. depression v recent events • Planning, note making and precautions • During • Where, when and how? • How were they discovered? • Were they also drinking or taking drugs? • After • How they feel now – angry, regretful, relieved • Future feelings • Would they try again at home now? • Have they changed their minds re. suicide and why?

8. Completed suicide

9. Extras for the psychiatric history • Remind about confidentiality • Present situation • Housing, finance, work, friends, family • Birth, growth and development • How was school, hobbies, religion, jobs, • Trouble with the law • Did they easily make friends • Premorbid personality • Personality before current episode • Happy go lucky ⬌ driven, gentle ⬌ sadistic, tense ⬌ laid back, happy ⬌ depressed, social ⬌ antisocial

10. Rest of the history • Past psychiatric history • Previous psychiatric problems or previous episodes of current problem • Issues with police or crisis team • Past medical history • Chronic medical conditions • Drug history • Family history • Social history • Alcohol and drug use • CAGE • Have you ever thought about cutting down? • Do you ever get annoyed when other criticise your drinking? • Have you ever felt guilty about your drinking habits? • Do you ever start the day with a drink as an eye opener?

11. Make a plan with the patient • It is a very good idea to make a plan with your psychiatric patients so they know exactly what will be happening next • Options for depression include: • Medications and talking therapies – offer both • Options for suicide attempt include: • GP follow up – rarely done, only for low risk patients • Discharge to community mental health – if the patient is already known to them • Crisis or home treatment team – high risk, can liaise with inpatient services if deterioration • Informal admission – voluntary by patient • Section admission – patient is not safe to go home, mental health act – section 2

12. Mental health act

13. MSE • Introduction – WIPE • Appearance – You don’t need to ask this (Clues to patient’s lifestyle and ability to self care) • Clothing • Posture/gait • Grooming hygiene • Evidence of self harm

14. Behaviour • Are they suspicious, irritable, aggressive or paranoid? • Are they preoccupied, distract able, quiet or withdrawn? • Eye contact • Facial expression • Body language/gestures/mannerism • Level of arousal – calm? Agitated? • Rapport/engagement Again you don’t need to ask this

15. Speech Rate of speech – Pressured/Slowed Quantity of speech – Minimal/Excessive speech/Complete absence of speech Tone of speech – Monotonous/Tremulous Volume of speech – Loud/Quiet Fluency and rhythm of speech – Articulate/Clear/Slurred You don’t need to ask this

16. Mood and Affect Mood and affect are both related to emotions but they are NOT the same thing! Affect – immediately expressed or observed emotion (pt’s facial expression or overall demeanour) (weather) Mood – sustained emotion over long period of time that can alter an individual’s perception of the world (climate)

17. Mood and Affect • Mood, you need to ask: • How are you feeling today? • Have you been feeling low/depressed lately? • With affect, you need to observe the patient • Quality of affect: sad, agitated, euphoric, animated • Range of affect: restricted, normal, expansive • Intensity of affect: Normal, blunted, flat • Fluctuations in affect: labile

18. Thought Thought form: • Speed: accelerating, racing, retarded • Flow/coherence: • Linear (logical) • Incoherent – makes no logical sense • Circumstantial – lots of irrelevant, unnecessary information (not to the point) • Tangential – goes off in tangent, flight of ideas • Perseveration – repetition of a particular response

19. Thought Thought content: Ask for abnormal beliefs/delusions Obsessions Overvalued ideas – e.g. the perception of weight in patient with anorexia Suicidal thoughts* Homocidal thoughts/Violent thoughts* * Must risk assess all psych patients

20. Thought Thought possession: Thought insertion Thought withdrawal Thought broadcasting “Do you think people can put ideas in your head?” “Have you ever felt like people have removed/erased things/memories from your mind?” “Do you ever feel like others can hear what you’re thinking?

21. Risk Assessment – Factors to consider • History • Previous experience of violence • Lack of supportive relationship • Alcohol or substance misuse • Recent stressors? Are risk factors stable? • Any factors that have stopped the patient from acting violently in the past? • Are the family in risk? Hx of domestic violence • Environment • Risk on release from the restricted setting • Protective factors and loss of protective factors • Access to potential victims • Access to potential weapons • Involvement in radicalisation

22. During MSE for risk assessment Specific threats or ideas of retaliation Grievance thinking Thoughts linking violence and suicide (homicide–suicide) Thoughts of sexual violence Evolving symptoms and unpredictability Signs of psychopathy Restricted insight and capacity Patient’s own narrative and view of their risks to others

23. Example of questions to assess thought content “What’s been on your mind recently?” “Are you worried about anything?” “Do things seem unreal to you?” “Are there any thoughts you have a hard time getting out of your head?” “Have you noticed any strange thoughts? Or thoughts that others might find strange?” “Can anyone interfere with or hear your thoughts?” “Do you think anyone is trying to harm you?” “Do you have any beliefs that aren’t shared by others you know?” “Do you ever think about ending your life?” “Have you ever felt your life was not worth living?” “Have you ever attempted to end your life?” “Do you ever think about harming other people?”

24. Perception • Hallucinations – false sensory perception without any external stimulation that the patient believes IS real • Auditory • Visual • Pseudo-hallucinations – patient is aware that it is NOT real • Illusions – misinterpreted perception • “Do you ever see, hear, smell, feel, or taste things that are not really there?” • “Did you think this was real at the time?” • “Do you still believe it was real?”

25. Cognition • Basic testing • Orientation (time/place/person) • Attention and Concentration • Short-term memory • Detailed testing – MMSE/ACE-III

26. Insight Is the patient able to recognise they have a problem or recognise what they’re experiencing is abnormal? What does the patient think is the cause of the problem? Does the patient want help with their problem?

27. ICD 10 criteria for diagnoses • Depression • Core – low mood, anhedonia, reduced energy • At least 1 on most days for most of the time for at least two weeks • Other – disturbed sleep, poor concentration, low self-confidence, poor or increased appetite, suicidal thoughts, agitation or slowing of movements, guilt • Not depressed - <4 symptoms • Mild depression – 4 symptoms • Moderate depression – 5-6 symptoms • Severe depressions – 7 or more symptoms with or without psychotic symptoms

28. ICD 10 criteria for diagnoses • Anxiety • Autonomic – palpitations, tremor, sweating • Physical – SOB, chest pain, sensation of choking • Psychiatric – loss of control, depersonalisation • GAD • Not specific to any situation • Feelings of tension, exaggerated response to minor surprise, poor concentration, difficulty sleeping • Panic disorder • Recurrent, unpredictable attacks NOT secondary to medical conditions or substances • Phobia • Provoked in well-defined situations • OCD • Obsessional thoughts – ideas, mental images, impulses; patient aware that these are their own thoughts • Compulsive acts – cleaning, checking, tidiness; acts to prevent an unlikely event • PTSD • Follows trauma <6m ago, flashbacks, dreams, nightmares

29. ICD 10 criteria for diagnoses • Mania • Elevated mood, increased energy, thought disorder (pressured, racing, flight of ideas), reduced attention, grandiosity • Reckless behaviour – spending, sexual, loss of social inhibitions • Psychosis symptoms – delusions (mood congruent), hallucinations • Hypomania • As above but without psychosis symptoms

30. ICD 10 criteria for diagnoses • Schizophrenia • First rank – auditory hallucinations (third person, running commentary, thought echo), thoughts (insertion, withdrawal, broadcasting), delusions (control, influence, passivity) • Other • Catatonia • Persistent hallucination • Negative symptoms – apathy, emotional blunting, poverty of speech

31. ICD 10 criteria for diagnoses • Anorexia • Self induced weight loss – restrict diet, exercise, suppressants • Dread of fatness • Low body weight • Endocrine – amenorrhoea, impotence, delayed puberty • Bulimia • Preoccupations with body weight and eating • Binges • Counteracts binge – starvation, laxatives, diuretics, vomiting • Dread of fatness