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- 1. BASIC PSYCHIATRIC HISTORY ANDMENTAL STATE EXAMINATION-1 Dr DAYANG ZURYIANI BT ABANG MOUHAMMAD HASHIM PSYCHIATRIST HOSPITAL UMUM SARAWAK
- 2. INTRODUCTION • To educateand prepare medical officers and staff: o Basic knowledge of common PSYCHOLOGICAL ISSUES in general setting o Systemic review local studies in Malaysia prevalence of depression in primary care range 6.7 to 14.4% *CPG MDD (2nd edition ) 2019 Ø Among elderly in community between 6.3% and 18% Ø Woman higher rates than man Ø Prevalence depression clinical setting post partum woman to be 20.7% ; post stroke 36%; breast ca 19.1% o To encourage the primary health care services to DETECT EARLY MENTAL HEALTH ISSUES/ MINOR PSYCHIATRY ILLNESSES ( generalized anxiety disorder, schizophrenia, depression etc) and improve help seeking behaviour among the public o Reduce stigma among staff as well as public via psychoeducation.
- 3. Depression is often under-recognised andunder-treated. • It is estimated that about 30-50% of cases of depression in primary care and medical settings are not detected*CPG MDD 1ST EDITION 2007
- 4. COMMON MENTAL HEALTH PROBLEMS ANXIETY/ PANIC? MOOD SYMPTOMS? PSYCHOSIS? SOMATIC COMPLAINT? SUICIDAL ACUTE STRESS REACTION?
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- 7. Psychiatric Interview Obtain informationto establish diagnosis Plan for further evaluation and treatment Therapeutic Most important element in psychiatry
- 8. Initiation of the Interview •Address patient warmly • Put the patient at ease – smile • Introduce yourself and anyone accompanying you • Explain the role of the interview • Length of the interview • Appropriate eye contact, appear interested • Begin with a general question e.g. “tell me about your problem” • Have a systematic but flexible approach • May need to interrupt
- 9. HOW DO YOUAPPROACH? HISTORY TAKING • Chief complaint • Onset of the symptoms • Duration • Triggering factor • Protective factor • Psychosocial • Family history • Premorbid personality • Substance use • Suicidal risk • Aggression risk • * Collaborative history MENTAL STATE EXAMINATION/PHYSICAL EXAMINATION • General appearance ( abnormal movement/ behaviour) • Cooperative • Speech • Mood/ Affect • Perceptual/Thought disturbance • Orientation • Judgement • Insight • Any signs of self-harm • Vital signs INVESTIGATION • Baseline investigation ( FBC/ BUSE /CREAT/LFT) • ECG • UPT • Thyroid function test • Biohazard screening • Dementia work-out ( Vit B12/ folate/ VDRL/ Ct brain) • CT brain ( TRO organicity)
- 10. (History of) Present Illness •Nature of problem • Chronology of each symptom • Onset and duration • Severity of symptoms and degree of functional impairment • Precipitating factors • Perpetuating factors • Protective factors • Factors worsening or improving
- 11. Psychiatric Review of Systems Four majorcategories of mood, anxiety, psychosis, and other
- 12. Past Psychiatric History •Similar or other symptoms in the past • Psychiatric diagnosis, comorbids • Onset, duration, frequency, severity • Psychiatric admission • Reason (voluntary vs involuntary) • Any treatments • Drugs (compliance, dosage, adequate trial, reason stopped, complications, side effects e.g. EPS) • Others (e.g. ECT, psychotherapy) • Outcome of treatment, recovery, remission • Suicidal or homicidal ideation, attempt, violence
- 13. Substance Use /Abuse / Addiction Substances • alcohol, drugs (e.g. syabu, ganja), medications (prescribed or not) Routes of use (e.g. oral, snorting, intravenous) Frequency and amount, tolerance, withdrawal symptoms • determine abuse vs dependence, e.g. standardized questionnaire CAGE Impact of use on social interactions periods of sobriety • length of time and setting such as in jail History of treatment (e.g. detox, rehab), patient keen for treatment Other substances and addictions e.g. tobacco and caffeine use, gambling, eating behaviours (binge eating disorder)
- 14. Past Medical History/ Medications • Major medical illnesses and conditions (e.g. CNS, endocrine, systemic illness, head injury / trauma) • Past surgeries • For women, reproductive (pregnancy) and menstrual history • Review of medications • Allergies to medications
- 15. Family History • Familytree • Parents, siblings, relatives, biological vs adopted, separation, divorce, steps • Relationship with family, among family members • Known or suspected history of mental illness • Nature of death if anyone not alive, suicides • Suicidal or homicidal behaviours, violence in relatives • Potential support vs stressor • Availability and adequacy of potential caregivers
- 16. Developmental and Social History •Premorbid history • Prenatal or birth history • Developmental milestones • Childhood separation or emotional problems • Childhood physical and sexual abuse • School history (e.g. learning disorders, behavioural problems at school, academic performance)
- 17. Developmental and Social History Work history Marriageand relationship history Sexual history and preference Legal history Cultural and religious belief Others e.g. hobbies, interests, pets, and leisure time
- 18. MENTAL STATE EXAMINATION/PHYSICAL EXAMINATION Generalappearance ( abnormal movement/ behaviour) Cooperative Speech Mood/ Affect Perceptual/Thought disturbance Orientation Judgement Insight Any signs of self-harm Vital signs
- 19. Appearance and Behaviour • Bodylanguage (e.g., calm, cooperative) • Rapport and eye contact • Appropriateness of dress, grooming, evidence of self-neglect • Facial expression – dilated pupils, rigidity • Abnormal movements, behaviour or posture – EPS, catatonia • Under or over psychomotor activity – excitation or retardation • Distractibility • Any – tattoos, prominent scars, injection marks
- 20. Speech Relevance, coherence (e.g., relevant, coherent) Fluency,amount, rate, tone, and volume Amount: e.g., poverty of speech in depression and schizophrenia Rate: e.g., slow in depression, pressured in mania Tone and volume: e.g., irritable, loud, timid
- 21. Mood • Definition: Patient’sinternal and sustained emotional state • Subjective • Best to use the patient’s own words • Sad • Angry • Anxious
- 22. Affect • Definition: Expressionof mood or what the mood appears to be • Objective • Quality, quantity, range, appropriateness, and congruence • Quality: dysphoric, happy, euthymic, irritable, angry, agitated, tearful, sobbing, and flat • Quantity: mildly depressed • Range: restricted (flat), normal, labile • Congruence: congruent with thoughts / behaviour
- 23. Thought Process • Formal thoughtdisorder • Disturbance in the form of thought • Examples: Circumstantiality, Clang associations, Derailment, Flight of Ideas, Neologism, Perseveration, Tangential, Thought Blocking, Echolalia, Word Salad
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- 25. Thought Content • Delusion •Definition: An abnormal belief which is held with absolute subjective certainty, which requires no external proof, which may be held in the face of contradictory evidence, and which has personal significance and importance to the individual concerned, and cannot be understood as part of the subject’s cultural or religious background • Based on their content, 12 types of primary delusion are commonly recognized: persecutory, grandiose, delusions of control, of thought interference (insertion, broadcast, withdrawal), of reference, of guilt, of love, delusional misidentification, jealousy, hypochondriacal delusions, nihilistic delusions, and delusions of infestation.
- 26. Thought Content Over-valued ideas Aform of abnormal belief, which are reasonable and understandable in themselves but which come to unreasonably dominate the patient’s life E.g. concern over weight and body shape in anorexia nervosa Obsessional thoughts / Obsessions unwelcome and repetitive thoughts that intrude into the patient’s consciousness Compulsions repetitive, ritualized behaviours that patients feel compelled to perform to avoid an increase in anxiety or some dreaded outcome Others: Paranoia, Magical thinking, Phobias, Preoccupations
- 27. Perceptual Disturbance • Hallucinations •Perceptions in the absence of stimulus • Auditory (e.g. running commentary, 2nd or 3rd person), visual, tactile, olfactory, and gustatory (taste) • Hypnagogic (occur on falling asleep) or hypnopompic (on waking) • Lilliputian hallucination (visual hallucination in which the subject sees miniature people or animals) • Pseudo hallucination (false perception which is perceive as occurring as part of one’s internal experience, not external world)
- 28. Perceptual Disturbance • Illusions • Misperceptionof stimuli • Depersonalization • feeling that one is not oneself or that something has changed • Derealization • feeling that one’s environment has changed in some strange way that is difficult to describe.
- 29. Cognition • Alertness • Orientation:time, place, person • Concentration: Serial 7 • Memory: immediate – repeat, recent, long- term • Calculation • Basic of knowledge • Abstract reasoning: proverbs
- 30. Insight -3As • Awarenessof abnormal state of mind • Attribute the abnormal symptoms due to mental illness • Accept the benefit of treatment and advice by doctor
- 31. Judgement • person’s capacityto make good decisions and act on them • A patient may have no insight into his or her illness but have good judgment • Use hypothetical examples to test judgment, for example, “What would you do if you found a stamped envelope on the sidewalk?”
- 32. Closing of Interview Alert • Alertthe patient to the remaining time • “We have to stop in about 10 minutes.” • patient to bring up important issues not yet discussed Give • Give the patient an opportunity to ask a question • “I’ve asked you a lot of questions today. Are there any other questions you’d like to ask me at this point?” Discuss • Discuss summary of the diagnosis and options for treatment with the patient Thank • Thank the patient
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