Category Archives: psychiatry

A Guide to taking a Psychiatric History

A good history is a fundamental part of any diagnosis. There are some areas like Psychiatry however, where taking a good and thorough history can be more of a challenge for a medical student. The purpose of taking a Psychiatric History can split into three main things;

  • Diagnostic
  • To gain a biopsychosocial understanding of the patient’s problem
  • Therapeutic & psycho-educational

Although while taking a history the structure may appear disjointed, the end result is usually under a set of headings which have a worldwide similarity.

The basic components of a Psychiatric History that I’ll use here are;

  • Identification
  • History of Presenting Complaint
  • Systems Review
  • Past Psychiatric History
  • Past Medical History
  • Family History
  • Personal History
    • Childhood
    • Occupational
    • Psycho-sexual
    • Drug & Alcohol
    • Forensic
  • Pre-morbid Personality

The key to psychiatric assessment is a comprehensive history & mental state examination.
A Primer of Clinical Psychiatry.

Please note this guide does not include everything that you should ask in a  Psychiatric History, but rather some components that I feel are key. It is also assumed that you are familiar with taking history’s in general, and this post just highlights the salient features of a Psychiatric History. A typical psychiatric interview can take 40 minutes or more.

Identification
Name, age, occupation, marital status, etc
Refereral: By Who, Why, When

HPC – History of Presenting Complaint
(in patients own words – including duration)

  • How are you? How long have you been here?
  • Why are you here? Why did you seek help?
  • Current Symptoms: onset, stressors, duration & course
  • Sleep: currently, changes over time?
  • Appetite: normal / increased / decreased?
  • Memory & concentration changes?
  • Current Mood:
    • Rate from 1-10.
    • Classify: Anxious? Depressed? Obsessional? Psychotic?
  • Screen for relevant events: e.g. recent death of a loved one, back from a war, etc
  • Details of any help-seeking behaviour.

SR – Other Psychiatric Symptoms
Much like doing a Systems Review for organic causes of disease, it is important to go through a check-list of other Psychiatric Symptoms, noting the positive & negative findings.

For example, a patient with an exacerbation of psychotic symptoms could also have depression in conjunction, and possibly suicidal ideologies.

It can also be useful to ask your standard Systems Review questions to rule out any organic causes of the patient’s presentation.

PΨHx – Past Psychiatric History
Full details are required of past psychiatric illnesses (e.g. depression, anxiety, etc)
Things to particularly ask about;

  • Admissions: How many? What for? How long?
  • Self-harm/Suicide attempts
  • Treatments: medication, psychotherapy, etc
  • Adverse reactions or events due to treatments
  • Support:  regular GP/Psychologist

PMHx – Past Medical History
Past medical history is useful to ascertain the general health of the patient. In particular, chronic medical conditions can often cause a decrease in the quality of life for that individual, which can manifest as psychiatric symptoms. Other points of interest;

  • Hospitalisations
  • Surgeries
  • Allergies, medication sensitivities and current medication (note those with psychiatric side-effects)

FHx – Family History
Many psychiatric disorders have a genetic component and the biological family history is thus relevant. It can also be useful in guiding treatment and management. It can be useful to draw a genogram with the patient.

Collecting information from other family members can sometimes allow you to develop a clearer picture.

Personal History
When taking a personal history it helps to map out the patient’s life in a longitudinal manner.

Childhood: Birth, development (e.g. motor, verbal & social milestones), family atmosphere? Happy or Sad childhood?

School: Enjoyed? Got on well with others? Other schooling? Truancy? Academic/sporting endeavours?
Drug & alcohol use during these years?

Occupation: Level of education completed? Jobs? How long? Why did they leave? Unemployment?

Psychosexual: Puberty (attitude towards & onset)? Sexual orientation? First experience? Relationships (past & current)? Marriage? Pregnancies?

It is also important to get a good grasp of the individual’s current life situation.

Drug & Alcohol History
Although Drug and Alcohol history can be considered part of Personal History, it requires special consideration as patients will often avoid discussing this topic. It is important to ask about alcohol, tobacco and common recreational drugs (e.g. marijuana).

Investigate: first exposure, patterns of use, effects, withdrawal symptoms, impacts on life, failed treatments or quitting attempts.

A common non-threatening screening tool for assessing alcohol abuse is the CAGE Questionnaire. It can also be adapted for other drugs.

Two “yes” responses indicate that the respondent should be investigated further. The questionnaire asks the following questions:

  • Have you ever felt you needed to Cut down on your drinking?
  • Have people Annoyed you by criticizing 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 to get rid of a hangover?

Forensic History
Forensic history should be obtained in a non-threatening way (e.g. have you ever been in trouble with the law?). A history of any misdemeanours and any consequences (e.g. prison) should be attained.

Premorbid Personality
Premorbid Personality may assist in diagnostic clarification and provides insight into what strengths/reserves the person may have. A good lead into this is, “What sort of person were you before you developed X?”

Other aspects to investigate:

  • Attitudes to others (social, family, etc) and to self.
  • Predominant mood
  • Hobbies & interests
  • Reactions to stress

References

  • A Primer of Clinical Psychiartry (2010) by David Castle & Darryl Bassett
  • Oxford handbook of Psychiatry (2005) by David Semple, Roger Smyth & Jonathan Burns
  • Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984

Psychiatry Mcqs 2

1. Re: NICE guidelines on depression
  1. Mild depression antidepressants (ADs) are the first line treatment
  2. Dysthymia antidepressants are effective
  3. Antidepressants are recommended for moderate to severe depression
  4. In severe depression antidepressants or CBT is recommended
  5. Patient with one episode of depression with functional impairment should receive prophylaxis for 2 years
2. NICE guidelines on treatment resistant depression
  1. Combination of antidepressants are supported
  2. Augmentation with lithium is not useful
  3. ECT is recommended
  4. Augmentation with antipsychotic is recommended
3. Re: Treatment of depression
  1. People with depression are at increased risk of cardiovascular disease
  2. 2/3rd of patient who have a single episode of depression will go on to have another episode of depression
  3. Dose for prophylaxis – Adults should receive the same dose as used for acute treatment
  4. Lithium also has some efficacy in the prophylaxis of unipolar depression
  5. Patients with more than two episodes are recommended 2 years prophylactic treatment
4. Re: Treatment of depression
  1. Poor response at 2 weeks predicts no response in the future for that drug
  2. If there is poor tolerability switching between drug classes is a good option
  3. If there is non-response switching to another drug in the same class will not have any effect
  4. A single episode of depression has be treated for at least 6-9 months after full remission
  5. 50% of patients will relapse if treatment is discontinued on remission

5. True/False

  1. Relapse rates after ECT is lesser than after ADs
  2. In the elderly a lower dose of AD may be used in prophylaxis than what was used in acute treatment
  3. Each episode of depression increases the chances of having another episode
  4. Schizophrenia increases the possibility of having depression

Answers                                                                                                        

1. Re: NICE guidelines on depression
  1. Mild depression antidepressants (ADs) are the first line treatment – F, Not recommended, active monitoring, individual guided self help, CBT, exercise
  2. Dysthymia antidepressants are effective – T
  3. Antidepressants are recommended for moderate to severe depression – T, first line – SSRI
  4. In severe depression antidepressants or CBT is recommended – F, ADs and CBT is recommended
  5. Patient with one episode of depression with functional impairment should receive prophylaxis for 2 years – F, if the patient had 2 episodes 2 years are recommended
2. NICE guidelines on treatment resistant depression
  1. Combination of antidepressants are supported – T
  2. Augmentation with lithium is not useful – F, useful recommended
  3. ECT is recommended – T
  4. Augmentation with antipsychotic is recommended – T
3. Re: Treatment of depression
  1. People with depression are at increased risk of cardiovascular disease – T
  2. 2/3rd of patient who have a single episode of depression will go on to have another episode of depression – T
  3. Dose for prophylaxis – Adults should receive the same dose as used for acute treatment – T, in the elderly the dose may be reduced
  4. Lithium also has some efficacy in the prophylaxis of unipolar depression – T, but should not be used as a single agent. May be used in combination with a AD
  5. Patients with more than two episodes are recommended 2 years prophylactic treatment – T
4. Re: Treatment of depression
  1. Poor response at 2 weeks predicts no response in the future for that drug – T, Taylor et al, 2006, meta analysis
  2. If there is poor tolerability switching between drug classes is a good option – T, but not much evidence
  3. If there is non-response switching to another drug in the same class will not have any effect – F, some evidence
  4. A single episode of depression has be treated for at least 6-9 months after full remission – T
  5. 50% of patients will relapse if treatment is discontinued on remission – T, within 3-6 months

5. True/False

  1. Relapse rates after ECT is lesser than after ADs – F, Similar, thus need prophylaxis with ADs
  2. In the elderly a lower dose of AD may be used in prophylaxis than what was used in acute treatment – T, but not recommended for adults
  3. Each episode of depression increases the chances of having another episode – T, through kindling
  4. Schizophrenia increases the possibility of having depression – T, all non-affective illness increase possibility

Psychiatry Mcqs 1

1. True or False Re: APs in schizophrenia
  1. The response to APs vary greatly between individuals
  2. There is no first choice AP for all
  3. SGAs are not superior to FGAs
  4. When non-clozapine SGAs are compared to each other Olanzapine is superior
  5. Risperidone is superior to other SGAs except olnz. and cloz.
2. When compared with FGAs the following SGAs have proven more efficacious
  1. Olanzapine
  2. Ziprazidone
  3. Aripiprazole
  4. Risperidone
  5. Amisulpride
3. True or false Re: APs in schizophrenia
  1. Depot preparations are associated with better global outcome and reduction in the frequency of hospital admission
  2. GASS and LUNSERS are questionnaires used to detect drug side effects in pts. on APs
  3. Following Depot administration it would take close 6-12 week reach a steady plasma concentration
  4. AP polypharmacy can cause sudden death
4. True of False Re: Neuroleptic equivalent doses
  1. Closely follows the drugs efficacy
  2. Related the maximum dose that can be prescribed
  3. Related to chlorpromazine equivalents
  4. Based on dopamine studies
  5. Only has value in FGAs
5. True of False Re: Maximum licensed doses
  1. Chlorpromazine – 1000 mg/day
  2. Haloperidol – 30 mg/day
  3. Clozapine 900mg/day
  4. Olanzapine 20mg/day
  5. Risperidone – 24mg/day

Answers                                 

1. True or False Re: APs in schizophrenia
  1. The response to APs vary greatly between individuals – T
  2. There is no first choice AP for all – T, due to above reason
  3. SGAs are not superior to FGAs – T, After reviewing the CATIE and CUTLES studies the world psychiatric association made this statement
  4. When non-clozapine SGAs are compared to each other Olanzapine is superior – T, Leucht et al 2009 Meta analysis, head-to-head comparison of SGAs
  5. Risperidone is superior to other SGAs except olnz. and cloz. – T, Leucht et al 2009 Meta analysis, head-to-head comparison of SGAs
2. When compared with FGAs the following SGAs have proven more efficacious
  1. Olanzapine – T
  2. Ziprazidone – F
  3. Aripiprazole – F
  4. Risperidone – T
  5. Amisulpride – T
3. True or false Re: APs in schizophrenia
  1. Depot preparations are associated with better global outcome and reduction in the frequency of hospital admission – T, Schooler (2003)
  2. GASS and LUNSERS are questionnaires used to detect drug side effects in pts. on APs – T, Glasgow Antipsychotic Side-Effect Scale (GASS) And the Liverpool University Neuroleptic Side-Effect Ratings Scale (LUNSERS), can be a useful first step in this process.
  3. Following Depot administration it would take close 6-12 week reach a steady plasma concentration – T
  4. AP polypharmacy can cause sudden death – T
4. True of False Re: Neuroleptic equivalent doses
  1. Closely follows the drugs efficacy – F, not related
  2. Related the maximum dose that can be prescribed – F, not related
  3. Related to chlorpromazine equivalents – T
  4. Based on dopamine studies – T, also clinical experience and guess work
  5. Only has value in FGAs – ?T, not useful for SGA
5. True of False Re: Re: maximum licensed doses
  1. Chlorpromazine – 1000 mg/day – T
  2. Haloperidol – 30 mg/day – T
  3. Clozapine 900mg/day – T
  4. Olanzapine 20mg/day – T
  5. Risperidone – 24mg/day – F, 16mg/day

Tips for GP trainees working in psychiatry

Tips for GP trainees working in psychiatry

Many doctors approach psychiatry with a sense of trepidation and, occasionally, fear. The aim of this article is to give some concrete advice to help trainees to relax and enjoy this fascinating rotation. A spell in psychiatry has the potential to be one of the most useful rotations on the general practice training scheme. Much of psychiatry is now managed in the community and so will form a significant part of your work following qualification. As increasing pressure comes to bear on mental health trusts to cut costs and close inpatient beds this is only likely to increase. When people suffer mental health issues it is very often the GP who is their first port of call, and so a good working knowledge of the area, as well as insight into the mechanisms and frameworks of secondary care, is an asset. During the job, you will also have the opportunities and time to develop your communication skills, occasionally in crisis situations. Continue reading

Internal Med Residency 1

My 12 Best Tips on Psychiatric Diagnosis

Below are my 12 tips on how best to ensure accurate and safe diagnosis:

(1) The less severe the presentation, the more difficult it is to diagnose. There is no bright line demarcating the very heavily populated boundary between mental disorder and normality. Milder problems often resolve spontaneously with time and without need for diagnosis or treatment.

(2) When in doubt, it is safer and more accurate to underdiagnose. It’s easier to step up to a more severe diagnosis than to step down from it.

(3) Children and teenagers are especially hard to diagnose. They have a short track record, varying rates of maturation, may be using drugs, and are reactive to family and environmental stresses. The initial diagnosis is likely to be unstable and inappropriate.

(4) Mental illness is hard to diagnose in the elderly. Their psychiatric symptoms may be caused by medical and neurological illness and they are prone to drug side effects, interactions, and overdose.

(5) Take the time and make the effort. It takes time to make the right diagnosis—adequate time for each interview and often multiple interviews over time to see how things are evolving. Except for classic presentations, a quick diagnosis is usually the wrong diagnosis.

(6) Get all the information you can. No one source is ever complete. Triangulation of data from multiple information sources leads to a more reliable diagnosis.

(7) Consider previous diagnoses—but don’t blindly believe them. Based on their tenure, incorrect diagnoses tend to have a long half-life and unfortunate staying power. Always do your own careful evaluation of the patient’s entire longitudinal course.

(8) Constantly revisit the diagnosis. This is especially true when someone is not benefiting from a treatment that is based on it. Clinicians can get tunnel vision once they’ve fixed on a diagnosis, become too married to it, and are blinded to contradictory data.

(9) Hippocrates said that knowing the patient is just as important as knowing the disease. Don’t get so caught up in the details of the symptoms that you miss the context in which they occur.

(10) If you hear hoof-beats on Broadway, think horses, not zebras! When in doubt, go with the odds. Exotic diagnoses may be fun to think about—but you almost never see them. Stick with the bread and butter.

(11) Accurate diagnosis can bring great benefits; inaccurate diagnosis can bring disaster.

(12) Remember the other enduring dictum from Hippocrates: First, Do No Harm.

– See more at: http://www.psychiatrictimes.com/blogs/dsm-5/my-12-best-tips-psychiatric-diagnosis#sthash.euXPGPmL.dpuf