| A |
Appearance |
Neat / untidy / eccentric / unsuitable etc. Bear in mind
cultural norms
|
| Brainy |
Behaviour |
Appropriateness
Responding to hallucinations
Body language: aggressive, sexual, histrionic etc.
|
| Senior |
Speech |
Rate e.g. pressure of speech (hypomania) or poverty
(depression)
Volume
Difficulty speaking e.g. indicative of aphasia / dysphasia or dysarthria
Neologisms - words invented by the patient
Flow e.g. sudden stops (possible thought block) or rapid shift of topic
(possible flight of ideas)
|
| Medic |
Mood |
Mnemonic = MAID - Moody And In
Depression
Mania - spending
money; gambling; libido
Anxiety -
continuous or with a trigger; what trigger; getting worse?
Irritation
- continuous
or with a trigger; what trigger; getting worse?
Depression -
appetite; sleep; hobbies and interests; feelings of worthlessness;
memory and concentration
Always note subjective (patient's view) and objective mood
|
| Seriously |
Suicidal
Ideation |
NOTE: There is a false belief that asking about suicide
may 'put the idea into the patients head'. There is no evidence that
this is the case - asking about suicidal ideation is rather an
important part of the management of risk in vulnerable patients.
You can start off with 'have you ever thought of harming
or kiling yourself?' - some schools of thought feel this to be a bit
direct and advocate something like 'have you ever had dark thoughts?'
and then elaborating if the answer is positive.
Self harm
Method - knife, tablets
Intent - relief of anger
or stress; to die
Suicide
Impulsive or carefully planned?
Inluence of alcohol or drugs?
What method was used
What stopped it being successful - did the patient take
any steps to ensure success
What was the aim (to die, to get attention etc.)
Does the patient regret the attempt?
Is there an intent to repeat? - ask how this would be done
|
| Thought |
Thoughts |
Stream of thought
Normal thought is like a calmly running stream - in abnormal
states it
may rush like floodwater (pressure), flow like a sluggish drip of water
in a drought (poverty of tought); or be stopped temporarily by dams
(though block).
- Pressure of thought
is expressed through pressure of speech - a rich flow of ideas is
expressed at speed.
- Poverty of thought
is expressed though poverty of speech - thoughts and ideas seem to be
slow and sluggish in coming.
- Thought block may
be seen
if speech stops suddenly in mid flow - often multiple times. Even if
this is not observed you can ask: "do thoughts ever seem to vanish from
your head?"; "where do they go". Those with thought block may attribute
this phenomenon to someone else 'stealing' their thoughts.
Form of thought
Where stream of though can be
thought of as the speed and volume of
thoughts, form
of thought is the content
- what the thoughts and ideas actually are. As with stream of thought,
these will mostly be detected through the patients speech.
- Loosening of associations:
is a
loss of the normal structure of thinking. Thoughts move from one to
another by abnormal paths that are diffuicult or impossible to follow:
- Knight's move thinking
(named after the move
of the chess piece
of that name) is thinking that seems to arrive at a conclusion with no
logical pathway for getting there, or moving rapidly between thoughts
that appear unlinked. You can only discern Knight's move thinking
through what the patient says in assessment.
- Talking past the point
(Vorbeireden): the patient talks but never gets to the point -
they may get near it and veer of to another matter.
- Verbigeration:
this is
the deterioration of speech to senseless repetition of words and
sounds. When especially severe it is called word salad.
- Flight of ideas is
the
rapid progression from one thought to another - again it can be seen
only though what the patient says - he will move from one topic to
another. Unlike Knight's move thinking, the link between the topics can
be seen by most observers - these links may take the form of Clang
associations, puns, or rhymes.
- Clang associations:
words
that sound the same - these
are used as jumping points to a new concept e.g. "... and then I rang
the bell sell - that's what I used to do - I
worked at a little shop in town
brown was always my favourite colour..."
- Puns: words that
have several different meanings
used as jumping points to different ideas.
- Rhymes
- Other problems in form of thought
- Overinclusion:
this is the
inability to preserve conceptual boundaries, so that extra irrelevant
items become incorporated in concepts, rendering the patient's thinking
less precise and more abstract.
- Neologisms: these
are new words
created by the patient - often to describe symptoms. Before diagnosing
neologisms exclude dialect, jargon and foreign language words. Ask
where the word comes from. This is mostly found in schizophrenia.
- Perseveration:
this occurs when
one thing that has been said my be repeated, often several times. e.g.
a question may recieve a sensible answer but the next question yields
the exact same answer and the next and so on. This is mostly found in
schizophrenia.
Obsessions
- "do you have thoughts that you can't get rid
of?"
- "what are these?"
- "are they there all the time?"
Compulsions
- "are there any actions that you have to do but
don't want to?"
- "what are these?"
- "what happens if you try not to do these?"
- "are they there all the time?"
Delusions (those below are
first rank symptoms of schizophrenia)
- Of thought withdrawal
"do you think other people take thoughts
from your head?"; "How do they do this?"; "Why do they do this?"
- Of thought insertion
"do you think other people put thoughts
into your head?"; "do you think some of the thoughts in your head
are not your own?" "How does this happen?"; "Why would someone do this?"
- Of thought broadcast
"do you think other people hear your
thoughts withou you saying anything?" "How do they do this?"; "Why
do they do this?"
- Of control "Do you
feel that something else controls your actions sometimes" ; "Who does
this" ; "why do they do that?" ; "what do they try to make you do?" ;
"Can you resist this control?"
- See the delusions
article for more (less common) types of delusion.
|
| Pete |
Perceptions |
Illusions
Hallucinations:
Auditory, Visual, Somatic
Depersonalisation
(alternately, this may be asked about under mood as it is often related
to anxiety states) "Do you ever feel that you are not quite real"
Derealisation
(alternately, this may be asked about under mood as it is often related
to anxiety states) "Do you ever feel that the world around you is not
quite real / lacks colour and reality / seems like it's behind a shield
of glass"
|
| Cog |
Cognition |
Mnemonic = COMA: Concentration, Orientation, Memory, Attention
These are assessed by the MMSE (see below)
|
| Got |
General
IQ |
Assesed crudely by MMSE (see below) and general responses during
interview.
|
| It |
Insight |
Does patient think they are ill; is the illness mental or physical;
what is the cause of illness (do they think alcohol, relationships etc.
may play a role); do they need
treatment; are they willing to accept treatment?
In psychodynamic therapy, insight may be split into 'intellectual' and
'emotional' insight:
- In intellectual insight the patient understands that they
are ill and that treatment is needed but does not engage - it is akin
to the 'new years resolution' a statement of intent with no real
probility of being accomplished.
- Emotional insight on the other hand is the intellectual
components with a real emotional investment in improving and getting
better and a concrete decision to engage with treatment and a belief
that this will be successful.
|
| Right |
Rapport |
Is the patient engaging; making / avoiding eye contact?
|
