Psychiatry - History Taking

Psychiatry - history taking 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. Past Psychiatric History: Actual condition: - When was your first visit to psychiatric doctor? HOPI: Current condition: • Precipitations :Triggering factors for the problem Stress , death of close person , trauma , unemployment , sexual abuse • Onset • Intensity • Duration • Associated S&S • Suicidal or homicidal ideas -Permanent symptoms Cover all possible associated symptoms , as following : ** only if its related to the chief complaint Depression A SAD FACES A: appetite (weight gain) S: sleep disturbances A: anhedonia D: Dysphoria (depressed mood) F: fatigue A: agitation/ retardation Mania DIG FAST D: Distractability I: Irresponsibility G: Grandiosity F: Flight of ideas A: agitation S: sleep ( decrees in need) T: talkativeness or pressured speech -Potential contributors (e.g: drug abuse) 1. first intake 2. last intake 3. frequency & amount 4. longest period of abstinence 5. withdrawal symptoms Not being able to sleep. Changing moods. Anxiety Tremor Irritability. Depression. C: concentration E: esteem (low) / guilt Aches and pains. S: suicidal thoughts Sweating Delusions Obsession and compulsion * Paranoid : * Reference : * Grandiose : * Guilt : * Control : * Doubt : * Contamination : * Symmetry: * Intrusive thought : ‫بالك مشغول بأفكار سخيفة‬ ( ask about triggering and relieving factors ) Phobias * Specific : * Social : *Avoidance: ‫بتتجنب تعمل الشغالت يلي‬ ‫بتخوفك؟‬ Hallucination * Auditory: * Olfactory: * Somatic: * Gustatory: Hostility Ask about nervousness Panic attack - Palpitations -sweating - flushing -SOB - tremor -dizziness -chest pain -chills -choking - Fear of dying , losing control , going crazy Depersonalization Derealization Illusion Drug history: Drug Frequency Dosage Side effect 6. road traffic accidents 7. Any psychotic symptoms? *If hospitalization occurred: • Name of the institution: • Reason for admission • Discharge diagnosis • Treatment: -Efficacy: 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 Age Education Occupation Medical diseases Mental disorders Medications Drug abuse ( tobacco / alcohol..) *Relatives might respond to the same drug Father Siblings : 1 Sex: 2 3 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 appearance & behavior • A description of the person’s general appearance is typically the first element of a mental status examination. • 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 2. speech 3. mood & affect -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. 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. Mood is a person’s internal (described by the patient) and sustained emotional state, it’s 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 • The way in which thoughts flow, are connected to one another, and are expressed to the listener. • Was the conversation logical and goal directed, or was it confusing and vague? • Was it easy to gather information, or did the examiner have to work hard at asking questions to elicit information? Loosening of association (LOA) Flights of ideas ▫ Normal form of thought: logical , coherent , Goal directed, relevant to the topic. Formal thought disorder(FTD) Any disorder in the form (structure Echolalia of thoughts) it’s not easy to understand speech or way of thinking of the patient. perseveration Tangentiality Circumstantiality Thought process Neologism Thought block Clang associations Content Overvalued ideas Suicidal/ homicidal ideation preoccupation Obsession Phobia Loss of the normal structure of thinking – Muddled and illogical conversation that cannot be clarified by further enquiry Knight’s move / derailment Transition from one topic to another with no logical connection between the two. -schizophrenics Word salad: ▪ severe form of derailment affecting the grammatical structure of speech ▪ words are no longer meaningfully connected to one another -Each sentence is more or less logically connected to the preceding one, but the topic repeatedly changes before elaboration of each thought can occur. This is seen most often in manic patients, typically in conjunction with pressured speech. 3 components have to be there: – pressure of speech – shifting topics – apparent association (can be followed) Repetition of statements and questions made by the examiner, sometimes more than once. For example, when the examiner asks "What is today's date?" the patient replies "What is today's date?" ▪ can be seen in: -schizophrenia -autism -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 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 -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 Use of novel words or of existing words in a novel fashion. seen in: -schizophrenia Sudden arrest of the train of thought, leaving a “blank”. 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 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 —Ask if the patient feels like harming him/herself or others. —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). Ideas which come to mind, again and again and may prevent the patient from performing his day to day activities. —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. Persistent, irrational fears. Delusions False, unshakeable belief that is out of keeping with the patient’s social and cultural background.