The Psychiatric Interview
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- Leo Parker
- 5 years ago
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4 The Psychiatric Interview
5 What are the goals of the psychiatric interview? Establishment of a working relationship Gathering relevant data Diagnosis and formulation Assessing change in mental status and illness WHO IS THIS PERSON??? WHY NOW???
6 Pre-interview considerations Purpose/setting of the interview Assessment of the interviewee ( sizing up ) The environment Privacy Comfort Safety The diagnosis
7 Common Problems (for the medical student interviewer) The patient who talks too much talks too little doesn t want to talk at all doesn t want to talk to a student
8 Common Problems (for the medical student interviewer) Anger and agitation Tears Boundaries Interviewing in front of others
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10 What kinds of questions can you ask? Open ended Close ended Multiple choice Leading Directive
11 How do you ask about Suicide Homicide Self-injury Trauma
12 How do you ask about Psychosis Sexual history Substance Abuse Others?
13 Self-disclosure What is self-disclosure? What role does it play in an interview? When is this appropriate?
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15 What are techniques to facilitate interviews? Verbal cues (echoing, summarizing) Interruption Demonstrating empathy Emotions and body language Avoiding distracting mannerisms and selfawareness
16 Reference A Longitudinal "Teaching-to-Teach" Curriculum for Psychiatric Residents Susan W. Lehmann, M.D. Acad Psychiatry 34: , July-August 2010
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18 Why do we write notes? Communication between providers Communication to our patients Communication to our future selves Medicolegal reasons Research tools $$$ Organize our diagnosis and plan
19 Why are notes organized the way they are?
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21 What s the purpose of the Mental Status Exam? Support psychiatric diagnosis Track progress
22 Appearance, Behavior, and Attitude Psychomotor changes Speech and Language Mood and Affect Thought Process Thought Content and Perceptions Cognition Insight and Judgement
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24 Lack of consensus Some areas overlap Lack of objectivity/precision When in doubt, be descriptive Avoid assessments and diagnosis Avoid passing judgement
25 Appearance, Behavior and Attitude Age Appears stated age Race Gender Grooming/hygiene Clothes/Attire Eye contact Alertness
26 Example: 51 year old caucasian female, appears older than stated age, neatly dressed and groomed wearing jeans and red and white striped collared shirt and sandals, maintained good eye contact throughout interview, alert, calm and cooperative, pleasant and engagable with exam
27 Another example: 29 year old African American male appearing younger than stated age, disheveled, dressed in hospital scrubs and socks, malodorous, odor of alcohol detectable on breath, irritable, intense eye contact at times during interview, at other times avoidant of eye contact, alert, guarded and suspicious, minimally cooperative with interview
28 Psychomotor changes Retardation: stuporous, comatose, negativistic Activation: Agitated, excited Catatonic phenomena Abnormal involuntary movements Tics Peculiarities of voluntary movement Restlessness
29 Example: The 51 year old female No psychomotor changes noted upon exam Mild psychomotor slowing noted upon interview Pt appeared moderately restless, tapping her foot at times throughout interview
30 Another example: the 29 year old African American male Pt was noted to be agitated during the interview, pacing, clenching his fists, and eventually slammed the door to his room Pt was noted to exhibit random movements during interview without clear purpose, such as standing and sitting without clear relationship to thought content Pt was noted to be minimally responsive to external stimuli with profound psychomotor slowing
31 Speech and Language Production of speech rather than content Rate Volume Prosody (rhythm, stress, and intonation) Articulation Spontaneity Latency
32 Language Aphasias Dysarthrias (problems with articulation) Stuttering, mutism, aphonia
33 Example: 51 year old female Speech: Normal rate and volume, clear and spontaneous. Normal prosody and latency. Language: Fluent, unaccented English. No dysarthria, aphasia, or stuttering
34 Example: 29 year old male Speech: Pressured speech noted, loud volume, some slurring noted, only speaks when asked questions. Speech: Slow rate, low volume, normal articulation and clarity. Lacks normal prosody of speech, speaks in monotone. Prolonged speech latency when asked questions.
35 Mood and Affect: Mood? Affect? Emotion conveyed by pt s nonverbal behavior Range Mobility Congruent with mood Appropriate for situation
36 Example: 51 year old female Mood: I feel like I am just beginning to understand my feelings I feel great about that! Affect: Moderately anxious at times, at other times euthymic, normal range and mobility, congruent with mood and appropriate for situation
37 Example: the 29 year old male Mood: Fuck off! Affect: Irritable, angry at times, range: restricted to irritability; mobility: fixed; mood congruent; inappropriate for situation Mood: I I Affect: Depressed appearing, obviously intoxicated, range: blunted; mobility: unreactive; not obviously congruent with mood; inappropriate for situation
38 Thought Process Organization Logic Speed/quantity
39 Example: Thought form: Organized and goal directed No flight of ideas or loosening of associations No circumstantiality or tangentiality
40 Example: Thought form: Significant tangentiality and flight of ideas noted. Disorganized and perseverative. Thought form: Goal directed, but severely impoverished, minimal connections between ideas. No loosening of associations.
41 Thought content: Suicidality (ideation, means, intent, plan) Homicidality Delusions Hallucinations/Illusions/Pseudohallucinations Obsessions Compulsions
42 Example: Thought content: No suicidality or homicidality. Not currently presenting as a risk to herself or others. No delusions or hallucinations, no guardedness, suspiciousness, odd behavior noted. No response to internal stimuli. No obsessions or compulsions.
43 Example: Thought content: Denied suicidality and homicidality, but presenting as aggressive and agitated. +delusions consisting of grandiose ideas that pt is a Space God and that he created the world. Denies auditory hallucinations, but obvious response to internal stimuli and distraction noted at times.
44 Cognition Typically found in MMSE
45 Insight Judgement
46 Example: Insight: Pt appears to understand her diagnosis appropriately Judgement: Pt appears to be making appropriate medical decisions based on her understanding of her illness
47 Example: Insight: Pt does not appear to have any appreciation about the nature of his illness, stating I am not mentally ill. Judgement: Pt presently appears to lack the ability to make informed medical decisions regarding treatment
48 Mini-Mental Status Exam
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