Case taking in mental illness

1

• Case taking in mental illness
• Objective
• To obtain the most accurate possible account of
  the patients illness
• To obtain the events in the patients life that
  are relevant to the illness
• (To be done within a reasonable short time)

2

• SKILLS TO BE ACQUIRED
• To take a history
• From a patient in such a way that you are able to
  asses the importance of psychological factors
• To make an assessment of a patients personality
  and to distinguish it from illness
• To carry out a mental state examination of a
  patient with psychiatric illness
• To adapt the interview techniques
• with children,old people, and those with
  communication problem
• To take a history from a relative or friend

3

• History of the present condition
• Symptoms and events in chronological order
• Starting from the time the patient last felt well
• I need to know the order in which things happened
  to you.
• What was the first thing you noticed that was
  wrong
• And what happened after that
• And what happened after that
• Uh-hun
• Yes I see or is that so.

4

• Mr./Mrs./Miss/Master
• Im going to have to ask you quite a lot of
  questions about yourself, but Id like to start
  by asking you to tell me about the illness that
  has brought you here. Ill need to jot down a few
  notes while you are talking, but the notes I make
  are confidential, and will be kept with me with
  other reports.

5

• Patients non verbal behaviour that should alert
  us to the possibility that he or she is
  psychologically unwell.
• These are non verbal cues
• The posture may be dejected, with the patient
  slumped in his chair, or it may indicate anxiety,
  with the patient being so tense that either the
  back of his chair does not take the weight of his
  body, or as he lies on in bed the weight of his
  head is unsupported by his pillow
• Valuable cues are also in the handshake the
  warm, dry feeling of health contrasting with the
  cold, clammy feeling of anxious over-arousal.

6

• Show consideration
• Remember to ask permission to make notes
• Dont dream of writing down anything yet
• Look at your patient and, as you listen to the
  first few sentences, notice as much as you can
  about the sick person who is seeking help
• There is great deal to take in, and eventually it
  will become as automatic as the complex series of
  actions taken by the driver as he starts a car
  and drives off into a busy city street.

7

• The voice also contains valuable information
  quite apart from what is being said
• The monotonous, uninflected sound of depression
  the strained, distressed sound of pain and
  anxiety, and whining note of some who feels he is
  always left with the dirty end of the stick.
• The patient may avoid eye-contact with you,
  sometimes because he is distressed and perhaps
  ambivalent about confiding emotional problems,
  but sometimes just because he is feeling ill.
  There may be motor activities which suggest inner
  tension either tremor or restlessness.

8

• Recapitulate the history to the patient.
• Patient frequently correct things which you have
  got wrong, and often reminded to put in something
  important that they forgot to tell you the first
  time

9

• The Family History is a
• Voyage of discovery
• Now that Ive heard about your present problems
  Id like to go on to ask you a few questions
  about your family. Could we start with your
  father? Is he still alive?
• We are aiming to get the following questions
  about each parent
• Age, or age at death and year of death (so that
  you can work out how old the patient was at the
  time) occupationhealth whether parent suffered
  with nerves (if so, details were they seen by
  a psychiatrist did they have any treatment?)
  what the parent was like how the patient got on
  with them

10

• Subjective Mood
• Always ask first the patients subjective mood
  state with an open ended question
• How have you been feeling recently? Or
• How have you been in your spirits?
• If the response is non-committal follow up with
• Have you been feeling mainly happy or sad?

11

• The Examination of Mood has 4 main components
• Subjective mood
• Objective observation
• Autonomic activity
• Thought contents

12

• ? Objective observation of mood
• Mood of sadness, anxiety, or happiness are
  conveyed through
• Facial expression
• Posture
• Motility
• Normal mood modulates frequently, depending on
  the thoughts and experiences of the individual
• There are two separate points to note
• What is the prominent mood during the course of
  the interview?
• To what extent does the mood fluctuate, are
  fluctuations appropriate, ad in what direction
  are these fluctuations?

13

• Occasionally pt. deny unpleasant mood states,,
  such as depression, perplexity, or suspicion,
  although there may be ample alternative evidence
  to show this is present. In particular there may
  be a deliberate attempt to conceal depression by
  refusing to answer questions, and this should
  alert the physician to the risk of suicide.
• Sadness is a feature of depressed mood, but it is
  not of course in itself indicative of mental
  illness.
• Weeping is commonly associated with sadness,
  although it may merely be a way of releasing
  pent-up tension.
• In less severe depressive states the mood may
  improve when the patient is distracted by amusing
  incidents, that is to say

14

• The mood reacts to the circumstances (this is the
  proper meaning of reactive depression)
• In more severe depressive states weeping is less
  common, and there tends to be a more constant
  melancholic mood, lacking normal modulation,
  which may easily be mistaken for affective
  blunting. The patient may describe the
  experience of an inability to have feelings or to
  care about others, such as family members or
  friends

15

• Smiles and laughter are associated with
  cheerfulness and euphoria, in which case they
  usually have an infectious quality. However
  they can also be produced in the unhappy as an
  indication of irony or of social expectation,
  when they fail to convey real enjoyment. The
  manic patient is not always cheerful he will
  often display irritability and impatience if
  frustrated by those trying to to limit his
  activities.
• Irritability is commonly seen in all affective
  illnesses

16

• Autonomic activity
• Affective changes are accompanied by fluctuations
  in autonomic activity
• You may have noticed cold, sweaty palms as you
  shook hands with the patient.
• Increased arousal is characterized by sweating,
  palpitation, dry mouth, hyperventilation,
  frequency of micturition which may be evident
  during mental state examination, while raised
  diastolic and systolic blood pressure,
  tachycardia and increased gastrointestinal
  motility may be found on physical examination
• High arousal commonly occurs in all psychiatric
  disorders associated with anxiety, including
  anxiety states, depressive illness, and both
  acute and chronic schizophrenia.

17

• Thought Content
• Pre-occupations
• suicidal ideas
• Abnormal beliefs
• Over valued ideas
• Delusions
• Perceptions
• illusions
• Hallucinations
• visual
• Auditory

18

• The patient may display labile mood in that he
  has little control of emotion. Less commonly, you
  may notice examples of inappropriate or
  incongruous affect or he may display blunting of
  affect in that the capacity to experience emotion
  seems to have been lost.

19

• The content of thinking is evident primarily
  through the patients talk, but also through
  aspects of behaviour. In this respect action
  speak louder than words For example, the patient
  may deny that he is suspicious of others, but
  opens the office door to see if any one is
  listening outside.
• Preoccupations
• Themes which are predominant in a patients
  thought content are likely to be revealed in his
  spontaneous speech. Note any topics to which he
  may return repeatedly during the course of the
  interview and the difficulty which you encounter
  in

20

• trying to steer him from these subjects back to
  other aspects of the history and mental state
  examination. If preoccupations are not evident,
  ask
• What are your main worries? Or
• Do you have some thoughts that you just dont
  seem to be able to get out of your head?
• Many people have preoccupations, but these are
  appropriate to the circumstances. For wxample, it
  is appropriate for a patient about undergo mjor
  surgery to be occupied with the possible hazards,
  the likely outcome, , the provision for
  dependants and so on, even though there may be
  encouragement from others to keep these thoughts
  to himself.

21

• However, some preoccupations are morbid, and
  their contents may be important in understanding
  the diagnosis of the disorder
• Ruminations are repetitive ideas and themes,
  usually having an unpleasant content, on which
  the patient may brood for prolonged periods. They
  commonly occur in anxiety states And depressive
  illnesses when their content reflects the
  affective state
• For example, they may include ideas of guilt, low
  self esteem, or hypochondriasis These should be
  differentiated from delusions in which the
  contents may be the same but the form is
  different. Ruminations also occur in obsessional
  states in which case they reflect the state of
  indecision.

22

• Suicidal ideas are of special importance, because
  of the risk to the patients life. A patient who
  has said that life is not worth living should be
  asked
• Have you ever thought of ending your life?
• Have you planned what you will do?
• Do you intend to carry it through?
• Perhaps surprisingly most patients answer such
  questions honestly, but be particularly wary of
  the patient who avoids answering. Although
  commonest in depressive illness, suicidal ideas
  are by no means limited to that disorder.

23

• Abnormal beliefs
• Ideas which are shard by many people within a
  particular cultural or ethnic group may seem
  strange to others, for example, particular
  religious beliefs and practices. Individuals too
  may have ideas which seem idiosyncratic or
  eccentric, but are not necessarily symptomatic of
  mental illness.

24

• Over-valued ideas

25

• To diagnose the psychiatric illness of the
  patient
• To find out similar remedy for the patient
• To assess suicidal risk

26

• Appearance and Behaviour
• General description
• Reaction to interviewer
• Motor activity
• Disorders of Talking and Thinking
• The speed of talk
• Retardation of speech
• Mutism
• Pressure of speech
• Continuity of talk
• Schizophrenic thought disorder
• Flight of Ideas
• Perseveration

27

• If the reply indicates sadness, ask
• How sad? Can you snap out of it?
• If the patient describes depressed mood, always
  remember to ask
• What do you find yourself thinking about when you
  feel like that?
• How do you feel about the future?
• Do you ever feel completely hopeless?
• (If yes to previous question)
• As though life isnt worth living?
• (If yes continue with questions about suicide,

28

• Abstraction
• Insight and Judgment

29

• We all have our ups and downs in terms of MOOD
• Life would be dull indeed if ones emotional
  tenor were a constant
• All of us experience depression occasionally, and
  all of us have days that we sail through on an
  emotional high
• Although such fluctuations are natural, some
  people are prone to severe distortions of mood
  known as
• AFFECTIVE DISORDERS

30

• The classification of mood disorders underwent a
  significant re-organisation with the development
  of DSM III in 1980
• Specific Syndromes are
• Bipolar mood disorder
• (Manic depressive psychosis)
• Depressive disorder
• Delusion
• Hallucination

31

• Disorders of Mood
• Thought Contents
• Preoccupations
• Abnormal beliefs
• Perception
• Illusions
• Hallucinations
• Intellectual Functions
• Orientation
• Attention and concentration
• Registration and short term
• memory
• Long term memory
• Intelligence

32

• Psychiatric History
• History of Present Condition
• Duration, chronological
• development of symptoms
• associated disability systems
• review, treatment received
• Family History
• Parents, siblings, list in order age
• age and year of death, cause,
• occupation, physical and mental
• health, relationship

33

• Personal History
• Childhood experience, stability,
• separations
• Schooling duration and types,
• higher education, qualification
• Sexual development menarche,
• information, menopause
• Marriage age, separation, other
• problems, sexual and other
• relationship, spouse, age,
• occupation, health
• Children List names, age,
• health, problems

34

• Occupation number of jobs,
• longest, problems, present
• employment
• Present social circumstances
• housing, members of household,
• relationships, financial difficulties,
• friends
• Forensic trouble with police,
• charges,convictions, in chronological
• order
• Past medical history physical and
• psychiatric illnesses Life chart
• Pre-morbid personality
• Interest, mood, friendships, alcohol,
• drugs

35

• Examination of the Mental State
• Appearance and behaviour
• General Description
• Reaction to interviewer
• motor activity
• Speech
• Speed quality continuity relevance
• Mood
• Subjective accountobserved
• moodautonomic reactivity
• Thought content
• Preoccupations morbid thoughts
• abnormal beliefs
• Perception
• Illusions Delusions Hallucinations
• Depersonalization

36

• Intellectual Function
• Orientation
• Time Place Person
• Attention and Concentration
• Days of weekmonths of year
• backward Serials 7 or 3
• Registration and Short term memory
• Recent news your name
• Name, address, flowers
• Long-term memory
• Early life, six cities
• National leaders Important
• events
• Intelligence

37

• Abstraction
• Insight and Judgment
• Nature of illness causes of
• illness
• Physical ailments (Concomitants)
• Interviewers Reaction to
• Patient

38

• Interviews with special groups
• Children
• Old people
• Deaf people
• People who do not understand
• the language very well