Quiz 3

THE PSYCHIATRIC ASSESSMENT- MENTAL STATE AND RISK

 

1. Appearance and behaviour: What would you consider writing about? Brainstorm anything you can think of mentioning

 

2. Speech:Select which of the following should not be recorded in speech: Rate, rhythm, volume, content, flow, tone?

 

3. Mood: Depression. A 28-year-old female presents to the clinic complaining of low mood. She has been feeling like this for the last 6 months and is unable to identify any triggers. She feels tearful and does not seem to enjoy things she once did. She finds it hard to find the energy to go to work and when she does she cannot concentrate. Her appetite has decreased and she has lost weight. She finds it hard to get to sleep and wakes by 3am each morning. She has started to experience suicidal thoughts as she says she feels she is letting her family down and has no hope that things will change. She denies hearing any voices or experiencing any unusual thoughts.

How would you classify her depressive symptoms? Mild, moderate or severe? You can use the ICD10 criteria following to help you

4. Mood - Manic symptoms: Select all the following that would be suggestive of a manic episode:

  • grandiose delusions

  • overfamiliarity

  • psychomotor retardation

  • restlessness

  • pressure of speech

  • reduced eye contact

  • elevated mood, 

  • nihilistic delusions

  • decreased need for sleep, 

  • increased energy, 

  • hypochondriasis

  • increased libido

  • irritability

  • overspending

  • disinhibition

  • flight of ideas

 

5. Thought disorder:What might be the best way of describing these phenomena?

 

  • Answering with a lot of irrelevant detail but eventually getting back to the point

  • Repetition of the same words or phrases, or behaviour

  • Sudden and total change of topic

  • Continuity is disrupted and incoherent thoughts that don’t make sense. There may be some vague association between the thoughts

  • Found with pressure of speech, ideas rapidly follow each via odd topic shifts, driven by mood

  • Linking ideas by rhyme, assonance or alliteration

  • Veering off topic 

  • Made up words

 

 

6. Psychotic symptoms: Essay question (write max 200 words)- What are the First Rank Symptoms of Schizophrenia? Why are these important?

This often does come up in exams and is something you have to learn. It was covered in the T year lectures as well as on the P year slides

 

7. Elements of cognitive examination: Can you write down what all these terms mean and how would you test them?

 

Orientation- 

Registration and recall -

Semantic memory -

Working memory- 

Visuospatial – 

Language – 

Attention – 

Calculation – 

 

 

8. Insight:What sort of questions would you ask to assess insight? (brain storm at least 6 questions)

 

 

9. Risk factors: What are the risk factors for suicide? Tick all that apply

 

  • Male?

  • Being married?

  • Schizophrenia?

  • Alcohol abuse?

  • Active religious beliefs?

  • Unemployed?

  • Aged 50?

  • Chronic pain? 

  • Living alone?

  • Has a job that is repetitive?

  • Family history of suicide?

  • Stalking history?

 

For further information on how to assess risk, please refer to the Risk Assessment lecture. 

ANSWERS

 

  1. Appearance and behaviour

What would you consider writing about?

 

Imagine it’s like dermatology: description builds a picture. Start with age, sex, build, ethnicity. Then note hair, make-up, clothing, any physical problems, scars, piercings, tattoos, self-care. 

 

Moving on to behaviour. Comment on body language, facial expression, eye contact, posture, psychomotor agitation/retardation, EPSEs, other unusual movements, rapport engagement, distractibility, calm/agitated/hostile etc. 

 

 

2.

Speech:

Select which of the following should not be recorded in speech: Rate, rhythm, volume, content*,flow, tone

 

The odd one out is Content.  This should usually be recorded under thought content as what they are talking about is our way of understanding to nature of the patient’s thoughts.  If you note that they have tangentiality, circumstantiality, flight of ideas- this should be recorded under thought form- as it helps us understand how their thoughts are structured.

 

3. Mood: Depression

 

Depressive disorders are classified into mild, moderate, severe without psychotic features, and severe with psychotic features according to ICD-10. The severity of the episode is dependent on the number and intensity of the depressive symptoms, and must be present for at least 2 weeks: 

Core depressive symptoms are low mood, decreased energy, anhedonia. 

Associated symptoms are disturbed sleep, diminished appetite, self-harm impulses, disturbed attention/concentration, feelings of guilt/worthlessness, hopelessness, low self-esteem. 

The following are the diagnostic guidelines for ICD-10: 

Mild: Total of four core and associated (at least two core symptoms). 

Moderate: Six core and associated symptoms (at least two core symptoms). 

Severe: Eight core and associated symptoms (all core symptoms needed).

 

You would classify this lady as either moderate or severe.We might need further details and to see her in person to fully decide. She is still able to go to work and manage (which might suggest moderate rather than sever), bit is struggling with it. She does not appear to have psychotic symptoms.

 

4. Manic symptoms: 

The following would be suggestive of a manic episode:

grandiose delusions

overfamiliarity

restlessness

pressure of speech

elevated mood, 

decreased need for sleep, 

increased energy,

increased libido

irritability

overspending

disinhibition

flight of ideas

 

 

5. Thought disorder

 

Circumstantiality – answering with a lot of irrelevant detail but eventually getting back to the point

Perseveration – repetition of the same words or phrases, or behaviour

Derailment – sudden and total change of topic

Loosening of associations or ‘knight’s move thinking’ – continuity is disrupted and incoherent thoughts that don’t make sense. There may be some vague association between the thoughts

Flight of ideas – found with pressure of speech, ideas rapidly follow each via odd topic shifts, driven by mood

Clang association – linking ideas by rhyme, assonance or alliteration

Tangentiality – veering off topic 

Neologism – made up word

 

 

 

6. Schneider first rank symptoms- essay

First Rank Symptoms of Schizophrenia:

  • Third person auditory hallucinations

  • Running commentary auditory hallucinations

  • Echo de la pensee (thought echo) auditory hallucinations

  • Delusions – thought insertion/withdrawal/broadcasting

  • Passivity phenomenon/delusions of control

  • Delusional perception (part of a primary delusion) – a delusion that can arise ‘out of the blue’ with no prior symptoms, or as a two-stage process where a normal perception occurs first and then a delusion if formed around it e.g. ‘When I saw the red car passing by me yesterday, I knew I was going to be killed.’ 

 

Significance? 

First rank symptoms occur with reasonable frequency in schizophrenia but lower frequency in other conditions. They are relatively straightforward to detect. They are not pathognomic of schizophrenia, they do not constitute a syndrome, and they do not inform a theoretical model of schizophrenia. Their significance is purely statistical: their presence increases the likelihood that schizophrenia is the diagnosis, and they therefore inform prognosis and management. There is an overlap between the first rank symptoms and the ICD criteria for schizophrenia

 

 

 

7. Elements of cognitive examination

Orientation- time (do they know the time), date, place (do they know where they are) and person (who they are/their age/address etc)

Registration and recall –remembering list or address- saying it back immediately and then after a few minutes

Long term episodic memory – remembering previous life events 

Semantic memory - general knowledge- facts and figures

Working memory- digit span- this link explains it well- https://www.cambridgebrainsciences.com/science/tasks/digit-span

Visuospatial – drawing shapes

Language – naming animals and objects (eg pen and watch), verbal fluency (have a look here if you’re interested https://www.sciencedirect.com/topics/nursing-and-health-professions/verbal-fluency-test) , writing a sentence, repetition

Attention – Counting backwards in serial 7s from 100

Calculation – simple arithmetic

 

8. insight

What sort of questions would you ask to assess insight? No specific answer, depends on your style and the patient. Here are some ideas:

 

What do you think is wrong with you?

What is normal for you?

Do you think you could have a mental health problem?

Do you think your friends would say that you’re different to usual? 

What treatment would help?

What treatment would you accept?

 

 

9. What are the risk factors for suicide?

Tick all that apply

Suicide

Male

Being married

Schizophrenia

Alcohol abuse

Active religious beliefs

Unemployed

Aged 50

Chronic pain 

Living alone

Has a job that is repetitive

Family history of suicide

Stalking history

 

For further information on how to assess risk, please refer to the Risk Assessment lecture. 

 

Also, it is helpful to remember the ‘SAD PERSONS’ mnemonic

 

  • Sex: Male

  • Age: <19 or >45 years old

  • Depression: any symptoms?

  • Previous attempts

  • Ethanol (alcohol or drugs?)

  • Rational thinking loss: e.g. psychosis

  • Separated Divorced or Widowed

  • Organised plan

  • No Social Support

  • Stated Future Attempt

Copyright 2012 RevisePsych

Last updated March 2020

www.elu.sgul.ac.uk

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