Psychiatry History
PC
HPC:
• For each complaint record its nature, chronology, severity, associated Sx, associated life events.
• Note precipitating, aggravating and relieving factors.
• Has it happened before? What does the patient think? Explore delusions/hallucinations/mood/thoughts (disorder)
PPH:
• “Have you ever seen a psychiatrist before?” “Have you ever been in contact with mental health services before?”
• “Have you ever taken medication for your mental health (problem)?”
• “Have you ever been admitted to hospital for your mental health?”
• “Have you ever been detained under the mental health act?” (don’t say sectioned). If so, why?
• “Have you ever had any contact with the police?”
• “Have you ever had impulsions or thoughts to harm yourself/others?” “Have you ever had suicidal thoughts?”
o Explore when, why, how did they resolve/get better
FH of mental health problems
PMH
DH and allergies
Personal history:
• Birth: place of birth, delivery, obstetric complications
• Milestones and developmental delays: “did you reach your childhood milestones at the same age that your siblings did?”
“did you learn to walk and talk at the usual age?” = important RE learning disability
• Home: “what was growing up like at home?” “Did you ever suffer any abuse as a child?”
• School: “did you enjoy school”, start and end of education and qualifications. If they left a course, ask why
• Employment: occupational history, present job satisfaction
• Relationships: current or previous major relationships
• Children/dependents? “do you have any children?” if under 18 where are they and who is looking after them? Other
dependents e.g. elderly bedbound mother – are they at risk?
• Premorbid personality: “how would the people who know you best describe you normally?”
SH:
• ADL, recreational activities, friends, social network/feel isolated? Family and community support, neighbours, finances,
accommodation, occupation, driving
• Recreational drug use: ask about drug misuse, type of drug, ROA, source, cost à ask specifically about cannabis (?schizo)
• Alcohol use: record units of alcohol used: use CAGE questionnaire as a screening tool
• Tobacco
• Family history
• Forensic history: “have you ever been in trouble with the law?”
MSE:
• Appearance and behaviour
• Speech
• Mood – “how’s your mood been lately?” objective, subjective, affect + biological symptoms (sleep, appetite). Can also ask
about anhedonia, anergia
• Thought – content and form. Thought disorder and thought manipulation “do you ever feel like someone is controlling your
thoughts?”:
o TI: “do you ever feel like someone is putting ideas in your head?” à likely to have schizophrenia
o TW: “do you ever feel like someone is removing thoughts from your head?”
o TB: “do you ever feel like other people can read your thoughts?”
o Ideas of reference: “when you watch the television or read the newspaper, do you ever feel that someone is trying
to communicate with you?”
• Perception – delusions, hallucinations “do you ever hear people talking to you when no one else is in the room?” “do you
ever see things that other people don’t seem to notice?”
• Cognition
• Insight
,Contents
Affective Disorders.............................................................................................................................................. 2
Psychosis ............................................................................................................................................................ 7
Anxiety disorders .............................................................................................................................................. 13
Personality Disorders ........................................................................................................................................ 20
Eating Disorders ................................................................................................................................................ 22
Suicide and self-harm ........................................................................................................................................ 27
Substance use disorder ..................................................................................................................................... 28
Delirium ............................................................................................................................................................ 37
Dementia .......................................................................................................................................................... 39
Reproductive Psychiatry.................................................................................................................................... 46
Child and Adolescent Psychiatry........................................................................................................................ 48
Unusual Psychotic Disorders ............................................................................................................................. 65
Mental Health and the Law ............................................................................................................................... 68
Psych Phraseology ............................................................................................................................................ 72
Depression ................................................................................................................................................................................ 72
Insomnia ................................................................................................................................................................................... 72
Appetite .................................................................................................................................................................................... 72
Concentration ........................................................................................................................................................................... 72
Mania ....................................................................................................................................................................................... 72
Self-harm/risk assessment ....................................................................................................................................................... 73
Psychosis .................................................................................................................................................................................. 74
Anxiety...................................................................................................................................................................................... 75
OCD .......................................................................................................................................................................................... 75
PTSD ......................................................................................................................................................................................... 76
Eating Disorders ....................................................................................................................................................................... 76
Insight ....................................................................................................................................................................................... 76
Personality ................................................................................................................................................................................ 76
Alcohol Abuse ........................................................................................................................................................................... 77
Others ....................................................................................................................................................................................... 77
MSE........................................................................................................................................................................................... 78
Executive Function Testing ....................................................................................................................................................... 79
Example questions and PACES stations ............................................................................................................. 83
1
, Affective Disorders
DEPRESSION
Definition A triad of low mood, anhedonia (loss of enjoyment in previously pleasurable activity), and low energy
/increased fatigability. Unipolar affective disorder.
Aetiology & Risk BIOLOGICAL
Factors 1. Genetics: complex genetic-environmental interactions, predisposition such as serotonin receptor gene
(people with short S allele at greater risk of depression with more life events compared to L allele)
2. Neurochemical theories: monoamine hypothesis – deficiency of noradrenaline, serotonin, dopamine in
CSF and urine, coupled with antidepressants increasing monoamine availability
3. Endocrine theories: chronic stress causes cortisol levels, which ¯ neurotrophin expression à damage
hippocampal neurons (hippocampus is smaller than average in a depressed person)
4. Illness: can directly cause depression (Cushing’s, hypothyroidism), others as an effect (chronic disease,
cancer)
5. Medication: steroids, antihypertensives, OCP, beta-blockers, accutane
PSYCHOSOCIAL
1. Childhood (psychoanalytic): adverse childhood events – child abuse, criticism, parental separation
2. Vulnerability: these reduce resilience – unemployment, lack of support, lower socio-economic status,
social isolation
3. Life events: death of spouse, divorce, marital separation, jail, death of close relative, loss of role
4. Substance misuse
5. Beck’s negative cognitive triad (behavioural & cognitive): negative views about self (worthlessness),
world (helplessness), future (hopelessness)
Epidemiology F>M
Average age at first episode = mid-20s
Psychiatric History ICD-10 criteria requires 2 of 3 core features:
CORE features: low mood, anergia, anhedonia persisting for ≥2 weeks.
BIOLOGICAL FEATURES: ¯ attention/concentration, ¯self-esteem/confidence, ideas of guilt, hopelessness,
worthlessness, disrupted sleep (¯/, early morning waking, insomnia), ¯/ appetite, thoughts of self-harm,
loss of libido, diurnal variation
MILD: 2 core + 2 bio
MODERATE: 2 core + 6 bio
SEVERE: ≥8 symptoms, inc all 3 core
*Any psychotic symptoms (hallucinations, delusions)
*Be on the lookout for suicidality, self-neglect (ceasing to eat and drink), psychosis
Can be with or without somatic symptoms: constipation, pain, dysmenorrhoea
Subtypes:
Seasonal affective disorder: worse in winter. Reversed biological symptoms – sleep & eating
Atypical depression: no seasonal variation. May retain mood reactivity, reversed biological symptoms, in
adolescence. Anxiety-induced insomnia à sleep & eating à mood
Agitated depression: psychomotor agitation instead of retardation (restlessness, pacing, hand-wringing)
Depressive stupor: psychomotor retardation so severe, grinds to a halt – stop eating/drinking/moving
Mental State A: signs of severe neglect, dehydration, will look miserable, disinterested, movements might indicate
Examination anxiety, poor eye contact, posture, tearful, agitated depression can show activity: restless, pacing, hand-
wringing
S: slow, quiet; psychomotor retardation can à mute
E: restricted range of affect
P: in very severe depression. Hallucinations – visual of evil images, auditory with unpleasant derogatory
voices. Delusions – guilt, nihilistic (nothingness), persecutory
T: concerned with worthlessness, helpless; negative triad, suicidal thoughts, can be slow
I:
C: psychomotor retardation can mimic cognitive impairment
DDx • Physical causes: hypothyroid, head injury, cancer, quiet delirium, meds etc
• Adjustment disorder: following a life event, but not as severe
• Normal sadness: part of life!
2
, • Bereavement: becomes a concern when grief (numbness, pining, depression, recovery) is extremely
intense, prolonged (>6/12) or delayed
• Chronic schizophrenia: blunted affect
• Substance withdrawal
• Bipolar disorder – must ask about previous manic episodes in any patient presenting with depression.
Avoid antidepressants in these pts!
• Postnatal depression/puerperal illness
• Dementia: changes from depression can mimic dementia, dementia can also start with affective changes
• Dysthymia: low-intensity but chronic low mood
• Often co-morbid with panic disorder, agoraphobia, OCD, eating/personality dis.
Ix Collateral history
Physical examination: rule out organics
Blood test: TFT, FBC, glucose/HbA1c – rule out hypothyroid, anaemia, diabetes (causes fatigue)
Assess severity on Becks Depression Inventory (BDI) or Hospital Anxiety and Depression Scale (HADS)
Mx Primary Largely managed in primary care
(NICE) care Depressive episodes that don’t qualify as diagnosis (subthreshold) or mild that don’t want treatment:
watch & wait, advice on sleep hygiene, exercise, provide info about depression, follow up in 2 weeks.
NB: social stressors must be addressed e.g. time off work, debt advice, support groups
Persistent subthreshold symptoms/mild-moderate depression: low intensity psycho-social interventions:
CBT, computerised CBT, structured group physical activity programme
Do not use antidepressants routinely for subthreshold/ mild depression because risk-benefit ratio is poor,
but consider for people with: past history of moderate/ severe depression, 2 years of subthreshold, sub
threshold/mild persisting after other interventions
If not responsive: consider high-intensity therapy – individual CBT, interpersonal therapy, couples
behavioural therapy, behavioural activation OR antidepressant (SSRI: fluoxetine, sertraline, paroxetine,
citalopram, escitalopram)
Initial presentation of moderate: high-intensity therapy
Initial presentation of severe: high-intensity therapy AND antidepressant. Treat until no longer depressed
No responsive to antidepressant: CHECK COMPLIANCE, SIDE EFFECTS before changing
*S/E of SSRIs: D/V, weight change, blurred vision, anxiety, agitation, insomnia, tremor, dizziness, headache,
sweating
* Antidepressants cannot be stopped suddenly, wean over weeks to prevent discontinuation symptoms –
flu-like symptoms, “electric shock sensations”, headaches, vertigo, irritability)
SSRIs increased risk of bleeding, especially in older people (consider prescribing gastroprotective in older
people who are also taking NSAIDs or aspirin)
Warn patients of the gradual development of full antidepressant effect (takes 4-6 weeks)
Continue treatment after remission
They are not addictive
CBT
• Relatively short-term intervention.
• Targets thoughts and behaviours. Aim is to make changes that have a knock-on effect on mood.
• Psychological problems are viewed as a result of the patient’s distorted way of looking at themselves and
the world.
• The therapist helps the patient notice negative automatic thoughts that are triggered by day-to-day
situations, and that result in unhelpful moods and behaviours.
• Vicious circle in depression = negative perception of events leads to lowered mood and to unhelpful
behaviour that withdraws the person from the world around them, reinforcing their view that they are
useless and unloveable.
• Examples of common thinking errors in depression are:
o Generalisation – “I always mess everything up”
o Minimisation – “I only passed that exam by chance, it doesn’t mean I’m actually any good”
• These distorted beliefs are challenged through discussion during sessions (e.g. “how do you know nobody
likes you?”), and behavioural experiments in between sessions (e.g. inviting a friend round for dinner and
seeing if they come, and if they have a nice time).
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