MENTAL HEALTH (H+E)
Psychiatry Case Presentation Psychosis definition:
1) History Ø Where the patient incorrectly evaluates the accuracy of their perceptions and thoughts and makes incorrect
2) MSE inferences about external reality (e.g. may hallucinate but can operate normally)
3) Physical Exam Ø RF: self-harm, homeless, substance abuse, PMHx
4) Formulation DDx: Rx plan:
5) DDx
Ø Delusions = firm fixed beliefs Ø Stabilise Haem + de-escalate behaviour
6) Management
Ø NMDA encephalitis Ø ID medical cause
Ø Mineral issues- Cu (Wilson) Ø Admit under MH act – scheduled? Sectioned?
Psychiatric History Ø Infection and drug use Ø Call SW + NOK
• Check where duress alarms and closest exits are
Safety • Obtain parental consent when interviewing child /adolescent
• Explain purpose of interview - med student, really keen to learn more and become a better junior doctor. Would I able to take a medical history from you?
• Confidentiality – “I want to tell you that we discuss today is private, but if I feel that what you are telling me puts your safety or other’s safety at risk, I may need to ask for further
Intro •
help. Would that be ok?”
Obtain consent: “I’m going to ask a lot of personal questions today that may feel tough or tricky. If you feel uncomfortable or need a break, please let me know and we can stop.”
• If you/patient are feeling distressed – I’m wondering if this is unsettling for you, why don’t we finish up here and I’ll get one of the nurses to come and have a chat”
1. DEMOGRAPHICS – NAME, age, occupation, home life- what do you do for work?, who lives with you?
PC 1. Presenting complaint - Tell me about you? How can I help you? (avoid obvious questions) Diagnostic hierarchy
2. When were you last well? - what changed? 1) Organic
1) How old were you when you 1st started noticing you had difficulties with your MH?
2) Medication / substance abuse
3. What are the most troubling symptoms for you right now?
1) If I have a magic wand (which I don’t), what do you think I could fix for you right now? 3) Psychotic spectrum disorder - delusion,
hallucination, hypomania, overvalued ideas
4. Specific symptoms (appetite, sleep, mood changes, weight)
4) Affective spectrum (e.g. depression –
HPC 1)
2)
Emotional - mood swings,
Somatic/physical – chest pain, SOB, palp, abdo pain, altered bowel habits unipolar, bipolar)
3) Behavioural ® concentration, irritable, flat, anhedonia 5) Anxiety, PTSD, OCD and eating disorders
4) Cognitive è ?metabeliefs (beliefs about beliefs), persistent, episodes 6) Personality disorders (PD)
5. Risk assessment (SAD PERSONS)
1) Non-modifiable – (SAD) ® sex (male), age (older), depression
2) Modifiable – (PERSONS) ® Previous attempts, EtoH usage, Rational thinking, Single, Organized plan, NO spouse/support, Future suicidal plans
Drugs /EtOH Hx Ø EtOH CAGE question – considered quitting, annoyed about drinking guilty, eye-opener
Ø Qty Ø Illicit drugs What drug?
Ø Why? Ø When started? Who with?
Ø With who? Ø Last time used?
Ø Have you had any trouble with the law? – tell me more about that
Forensic Hx Ø Previously driving under the influence
Ø If mania – have you had any trouble with police before?
• Tell me about your upbringing in childhood – where ABOUTs were you born?
– cultural background
• Who was in your family? Any separations
Ø Hx of early family life
• Complications in pregnancy/birth
• Past-trauma/abuse/ACE – Was there anything difficult in your childhood that
still affects you now?
Developmental
Hx Ø Personal relationships Tell me something about your personal relationships
• How was school for you? How far did you get into school?
SHx Ø Work and education
• Have you had any trouble getting along with colleagues / peers?
• What do you do for work? Do you enjoy it?
• Are there are any challenges currently at work?
Ø History of traumatic events Were there any traumatic things that happened to you?
Ø RELATIONSHIP status (significant others) • What is your current living situations?
• Are you in any intimate relationship at the moment?
Ø Parental /carer status (children, ages, contact, custody) Do you have to take care of anyone at the moment?
Ø ADLs (domestic tasks, personal care and mobility) How are you managing things at the moment?
Ø Social support and network • Is there anyone who supports you?
Social Hx • Who would you call if you were in trouble?
Ø Financial status and occupation • What do you do for a living?
• How do you support yourself?
Ø Accommodation (occupants, living situation) • Tell me about your living situation?
• Who is at home with you?
Ø Domestic violence
1. Time-course (Temporal nature) = When were you 1st concerned about your diagnosis?
a. Acute vs gradual onset AND stable vs progressive (has anything changed since 1st or index attack)
b. Episodic (how are they between episodes? – panic attacks, calm) vs Persistent (with or without fluctuations)
Past Psych Hx c. When did you look up about your condition online? How did you feel?
2. Severity = How many times were you admitted to hospital?
a. What were the main diagnoses that you understand you have diagnosed with?
b. How managed? – specialist looking after them? How has it affected your ADLs?
• Endocrine (thyroid, diabetes, pheo)
• Chronic issue – CCF, HTN (avoid SNRI, TCA) Liver disease, CKD, IBD, Parkinson’s, SLE
PMHX
PMHx • Metabolic syndrome (T2DM) è beware of use of anti-psychotics (elevates BSL), insulin usage (over-medicate)
• Chronic pain / cancer
• Check compliance ® Misuse and polypharmacy usage Drug seeking behaviours
• Past consultations (GP, psych) • Selling prescription drugs
o Frequency, outcome, therapy (CBT, ECT) • Forging prescriptions
Medications /
Treatments • Lifestyle measures (?effectiveness) • Doctor shopping
(past/present) • Meds = Name, type and dose ( BZD, Anti-psych, Anti-depr)
• Recurrent dose escalation
o Do you take it everyday? (anti-dep), taken PRN (BZD)
o Caffeine, alcohol, cannabis, vaping • Recurrent prescription loss
• Abuse of alcohol and other drugs
“Do you think anyone in your family has a psychiatric disorder or behaves similar to you?” (usu. OCD patients are right)
• Intergenerational trauma – ATSI
Family Psych Hx
FHx •
•
Depression + anxiety + Bipolar + schizophrenia + suicide + mood disorders
Recent sig. emotional event where family member is unwell
FHx • Chronic pain
, Mental State Examination (Psychiatric Physical Exam) – occurs DURING interview
Goal-directed Circumstantiality Tangentiality Flight of ideas Loose Thought Blocking
?mania associations “brief stop” ?schizo
• Age & Ethnicity = appears younger/older than stated age.
• Clean = neatly groomed/shaen, unkempt, malodorous, signs of • FORM (HOW are they thinking?)
neglect (hair, teeth, skin)
• Linear and Goal-directed (logical vs illogical thinking)
• Build = emaciated --> thin --> normal --> overweight
• Circumstantiality (takes a long time to make point - over inclusion of trivial details)
• Facial expression = absent --> appropriate --> exaggerated
• Tangentiality - on topic then indirectly off-topic (no answer to question)
Appearance • Artefacts = tattoo, track marks, cuts, scars, • Flight of ideas (concescutive thoughts moved from idea to next - pressured speech)
• Dress = dishevelled --> appropriate --> neat/immaculate -->
(how they look?) bright / flamboyant /colourful
• Thought blocking (suddenly stop),
• Perseveration - repetition of phrases and ideas/actions out of context
• Echolalia = patient repeats words from therapist
• Loose associations (derailment) - logical flow then breakdown (words make sentences but
sentneces don't make sense)
• Clanging = sentences continue based on sound asscoiations rather than meaning
• Attention: distracted vs engaged vs seeker • Neologisms = new words
• Body language - sedated (?drug-induced) psychomotor • Word salad- random string of words with no relation to one another
(agitation, tremor), Gestures/Tics/catatonia, rocking motion
(?dissociated)
• CONTENT (WHAT is the main theme)
• Cooperative = - guarded -> normal --> overfamiliar / disinhibited
Thought • Theme types (depressive, guilt, hopelessness, regret, homicidal, persecutory, grandiose,
• Eye contact - absent, intermittent, acceptable
jealousy, erotomanic, somatic, mixed, religious, paranoia, nihilistic)
Behaviour • EPSE - Parkinsonian, tardive dyskinesia, dystonia, akathisia Form and • over-valued ideas (acceptable idea that dominates their life)
• Posture / Pacing content • Delusions (firm fixed unshakeable beliefs about education, culture and social issue)
• Response = teary, deflective, defensive, intimidating,
• somatic passivity phenomenon = delusion of someone controlling their actions
manipulative,
• Ideas of reference - innocuous bleiefs referred to have direct personal significance
• Misidentification (capgras, fregoli's, intermetamorphosis, doppelganger)
• obsessions /compulsions- (persistent intrusive thoughts/idea/images causing distress)
• How do you feel right now? • phobias/plans/suicidal ideation (thoughts of self-harm) => sexual safety / financial
• How has your mood been in the last few days?
• dysphoric (depressed, irritable, angry ) • POSSESSION (Thought alienation)
• Euthymic (normal mood) thought insertion (thought inserted into patient's mind),
Mood • euphoric (elevated, alated, anxious)
thought withdrawal (thoughts removed from patient's mind),
thought broadcasting (pts believes their thoughts are understood by strangers without
(subjective - how • Labile telling them) - thoughts read by others
patient feels)
• Hallucinations = abnormal (Can you hear, see, touch and/or taste things that other people
cannot? - specific to person) - running commentatory, commands (big risk)
• Reactivity: reduced --> normal --> increased
• MOST auditory (?# of voices, 2nd or 3rd person (known?), gender)
• Quality : depressed --> euthymic --> euphoric/elevated
• Pseudo-hallucinations - same as hallucinations but patient AWARE it is not real
• Anxious, irritable, perplexed, suspicious
Perception • Illusions = normal (mispereception of external sensory stimuli e.g. thinking wire is a snake )
• Range: restricted --> normal --> expansive
• Dissociative / Depersonalisation (patient no longer their "true self" and are someone different -
• Intensity of affect (spectrum from typical --> atypical) "do you ever feel that you are not real or recognise the person you currently are?"
• Broad/full - normal (shows emotion they are feeling) • Derealisation (do you feel this world around you isn't real?) -
• restricted - reduced emotion
Affect • blunted - shows SOME emotion visually • Orientated to Current date (DD/MM/YY), people and location (place, suburb country)
• flat (nothing) - shows NO emotion visually
(objective - • Fixed vs restricted vs labile - degree of changing emotions Cognition
• Cognistive testing: MMSE, MoCA, RUDAS, ACE-III
• Attention span - say days of week backwards or subtract 7 from 100
stable vs labile) • Congruence: with mood vs content (incongruent = schizo?) (exc. • Short-term memory - 3-item memory recall (apple, basket, coat) + naming (language)
• La Belle indifference (nonchalant) = conversion disorder delirium) • Semantic memory - DOB, name of PM, US president that got killed
• Frontal lobe = Luria's test (fist --> edge --> palm),
• Spontaneous vs latent
• capacity to recognise and appreciate their problems and the implications of their problems.
• Volume
• Insights into symptoms? into illness? need for Rx?
• quiet (depression) vs loud (mania)
• Do you think you have a problem? - pre-contemplation
• Rate/Speed
• Do you think you need help? Have you sought for help?
• slow (depression) Insight & • stages: 1) denial 2) slight awareness 3) blaming other 4) aware illness caused by something
• pressured = speaks quickly BUT still makes sense
(NOT flight of ideas = many ideas unrelated to each other)
Risk unknown 5) intellectual insight (cannot adapt) 6) emotional insight (can modify behaviour)
• Are there risks of suicide and self-harm? ==> SAD PERSONS QUESTIONS
• Rhythm/ Quality -
• Previous attempts --> EtOH intoxication --> Rational thinking / hope --> Single --> Organised
• Articulate plan (access to weapons location) --> NO spouse, social support, --> suicidal attempts
• slurred (enceph?, PD?, MDD (psychomotor) or intoxicated)
• Prosody - musicality of language
Speech • Quantity
• Poverty of speech (speaking a lot but does not make sense
Judgement • Assess what patient has said so far?
• What would you do if you smelt smoke in your house?
(depression), & Risk
• What would you do if you had to cross the road?
• Excess (mania, schizophrenia)
• Longorrhea = XS repetition in topics
• Tone
• monotonous (depression, psychosis, autism),
• tremulous /stuttering (anxiety),
General physical General Ix
• General inspection – Vitals • Bedside – ECG, Urine dipstick, bladder scan
• CVS / RESP / ABDO • Bloods – FBC, EUC, CMP, LFT, BSL, HbA1C, TFT, lipids,
• FULL NEURO – (esp. if TBI) • Septic screen (if febrile) – CXR, urine M/C/S, swabs, blood culture
• THYROID EXAM (peripheral and central), STI?
• Urine drug screen AND STI screen
• Infection – HIV, Hep B/C, serology
• Imaging – non-contrast CTB, MRI
• Additional ® autoimmune, , EEG, LP, porphyria, Wilson’s (Cu), Mg, PO4
