Table to fill out in your mind for a psychological condition.
| Biological | Psychological | Social | |
|---|---|---|---|
| Predisposing | |||
| Precipitating | |||
| Perpetuating | |||
| Protective |
Introduction
- Wash hands (and don PPE if needed)
- Introduce yourself (name and role)
- Confirm patient’s name and DOB
- Establish rapport with the patient early on - explain that some of the questions may be difficult to answer
- Reassure that everything will be kept confidential (unless there is a risk to them or another person)
- Make sure to signpost that you will be covering many areas - may need to interrupt if you already have enough information to keep to time
Presenting complaint
Use open questions and provide the patient enough time to answer
- “What’s brought you in to see me today?”
- “Ok, can you tell me more about that?”
Once the patient has finished speaking, it’s helpful to check if there are any other issues - multiple presenting complaints and work with them to establish a shared agenda
Depending on the situation, information may be need to be gathered from a collateral history
History of presenting complaint
- Low mood (Depression)
- Self-harm/suicidal ideation
- Elevated mood and energy (hypomania and mania)
- Anxiety, panic attacks, or phobias
- Delusions and hallucinations (psychosis)
- Obsessions or compulsions
- Alcohol or substance abuse
- Issues around food or weight (eating disorders)
When exploring symptoms, you can use the acronym NOTEPAD:
- Nature
- Onset
- Triggers
- Exacerbating/relieving factors
- Progression
- Associated symptoms
- Disability
Depression
When taking a history from a patient presenting with a low mood, look at the core symptoms of Depression: low mood, lack of pleasure and low energy levels
- “How has your mood been recently?”
- “Have you felt little interest or pleasure in doing things”
- “Have you been feeling more tired than usual?”
Associated symptoms include:
- Disturbed sleep,
- Change in appetite (and/or weight up or down)
- Thoughts of self-harm, death or suicide
- Poor concentration
- Reduced libido
- Waking up early in the morning
- Diurnal variation of mood
- Feelings of guilt, worthlessness, hopelessness
Hypomania/mania
Episodes of mania and hypomania are part of the diagnostic criteria for Bipolar disorder
- “Have you noticed any change in your mood or energy levels?”
- “Can you describe the change”
Other symptoms assocated with mania/hypomania include:
- Increased self-esteem
- Reduced social inhibitions
- Over-familiarity
- Inappropriate sexual encounters
- Spending recklessly
- Loss of insight
May not be able to concrentrate enough of the assessment to give complete answers.
Collateral history is also very useful to know how they’ve changed
Anxiety disorders
Anxiety is an unpleasant physical and psychological set of symptoms that occur in response to a potential/uncertain threat.
There are several anxiety disorders, including Generalised anxiety disorder, specific phobias and panic disorder.
- “Have you been worrying a lot about things recently?”
- “Are you always anxious or does it happen at certain times?”
- “Are you able to put your worries out of your mind”
Physical symptoms that may be associated:
- Palpitations
- Chest tightness
- Breathlessness
- Sweating
- Sympathetic nervous system stimulation
Psychosis
Psychosis occurs when a patient has lost touch with reality so assessing them can be challenging and daunting.
” I have to ask you some questions that may seem strange. These are question was ask everyone. Would that be okay?”
Symptoms of psychosis include hallucinations, thought abnormalities and delusions. All present in Schizophrenia but can be found in other disorders
Hallucinations
Any form of sensory modality. Schizophrenia is generally a/w auditory hallucinations whereas Lewy-body dementia is more a/w visual hallucinations
- “Do you ever hear noises or voices when there is nobody else?”
- “Do you ever feel or see that someone or something when there is nobody there?”
Illusion
Unlike a hallucination - a false perception of a real stimulus
Delusions
Fixed beliefs that are out of keeping with norms. These beliefs are still held, even in the face of contradictory evidence.
Whilst it may be necessary to gently challenge a delusional belif to establish if its fixed in nature, it should be done carefully to not breakdown rapport.
A common delusion is persecutory delusion, in which the patient beliees another person is trying to harm them
- “Do you sometimes have thoughts that others tell you are false?”
- “Do you have anoy beliefs that aren’t shared by others you know?”
Disorders of thought content can also be considered delusions. These include:
- thought withdrawal (the belief that thoughts can be removed from their mind)
- thought insertion (thoughts can be placed into their mind)
- thought broadcasting (others can hear their thought)
Obsession and compulsions
Thoughts, images, or impulses that are recurrent and intrusive. They enter the mind despite resistance and recognised by the patient as their own thought.
Compulsions are repetitive mental processes or physical acts a patient feels compelled to perform due to an obsession or rule to attempt to reduce the distress and anxiety associated with them.
These two symptoms are characteristic of Obsessive-compulsive disorder but can occur in other illnesses.
- “Do you get repeat unpleasant thoughts or images coming into your mind”
- “Do you ever feel that you need to repeatedly check things you have already done?”
Alcohol or substance abuse
The use of alcohol or recreational drugs is common and may be a trigger for a condition, an attempt to manage the symptoms of a condition or a Substance Misuse Disorder
There are several screening questions for alcohol use, for example, “CAGE“:
- “Have you ever felt you ought to Cut down on your drinking?”
- “Have people Annoyed you by criticising your drinking?”
- “Have you ever felt Guilty about drinking?”
- “Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?”
For recreational drugs, the amount of money spent tends to be a good guide to intake.
Eating disorders
The patient uses the control of food to cope with feelings and/or other situations. Generallyinvolve eating too little or too much, purging behaviours or worrying excessively about body weight or shape
Most common eating disorders are Anorexia nervosa, Bulimia nervosa, and binge eating disorder
- “Can you describe a typical day’s food intake”
- “How do you feel about your body?”
- “What sort of exercise do you do and how much?”
- “Are you sick often?”
- “What do you are in a binge, are there any triggers.? How do you feel after?”
ICE + Summarise
Past psychiatric history, existing diagnosis and previous treatments
- “Have you ever experienced symptoms like this before?”
- “Have you ever had any problems with your mental health before?”
Past contact with mental health services
For previous contact with mental health services, you should explore whether this has been through primary care, the community mental health team, or the crisis team/home treatment team.
Forensic history
A forensic history helps to formulate a risk assessment and may give clues to help with diagnosis.
- “Have you ever had any contact with the police?”
- “If yes, what happened? Were you charged?”
- “Have you spent any time in prison?”
Past medical history
Ask if the patient has any medical conditions:
- “Do you have any medical conditions?”
- “Are you currently seeing a doctor or specialist regularly?”
- “Have you ever had any operations?”
Some medical conditions are also risk factors for mental health disorders, such as chronic illness (e.g. chronic pain, cancer or Tinnitus), for Depression.
Additionally, some medical conditions will affect treatment options. For example, cardiovascular, renal, or hepatic disorders are often contraindications for psychiatric medication.
Drug history + allergies, family history, personal history
- Prescribed or over the counter medication
- Family history of psychiatric or physical disease
- About about childhood and school, education and occupation
- Ask about relationships
Pre-morbid personality
How the patient was before the morbidity. Asking the patient directly or from a collateral history is extremely important
- Emotional traits: would they describe themselves as happy or sad? Do they experience mood swings? How do they manage anger?
- Cognitive traits: how is their self-esteem? Are they a confident person? Do they see themselves as an optimist or pessimist? Are they naturally suspicious of others? How do they cope with decision-making?
- Behavioural traits: would they describe themselves as an introvert or extrovert? Would they say they are impulsive? Do they enjoy socialising?
Social history
- Living circumstances - who they live with, children at home, homeless
- Can they carry out activities of daily living?
- Smoking and alcohol - frequency, type and volume
Insight
Insight refers to the ability of a patient to understand that they have a mental health problem and that what they’re experiencing is abnormal. Patients with severe Depression may demonstrate a loss of insight into their illness.
Some examples of questions which can be used to assess insight include:
- “What do you think the cause of the problem is?”
- “Do you think you have a problem at the moment?”
- “Do you feel you need help with your problem?”
To Complete the Exam
- Summarise your findings.
- Explain to the patient that the examination is now finished.
- Thank the patient for their time.
- Dispose of PPE appropriately and wash your hands.