Psychiatric Interview for psychiatric patients .pptx

Psychiatric interview

1. Psychiatric Interview

2. Purpose of psychiatric interview to gather information that will enable the examiner to make a diagnosis. psychiatry has no external validating criteria, no laboratory tests diagnosis can never be better than the judgment made by individual clinicians. Therapeutic Third party interest (for medico legal aspect, for medical board certificate)

3. The need for a comprehensive information We are seeing a human being, not a disorder To view each patient from biological, dynamic, social, cognitive & behavioral perspective

4. Important caveats Learn the skills early in your training before ineffective habits became fixed styles Don’t assume but ask every possible question The best textbook is your patient, learning interview skill as well as psychopathology, spend good enough time with patients Observe interview done by experienced personnel. Be ready to accept & incorporate feedbacks

5. General points Setting Concern for patient’s comfort & privacy Beginning the relationship Greeting, introducing yourself, address by name Indicate the seating arrangement Inform about the interview process Taking notes Indicate that you will be taking notes & keep it to the minimum Stop note taking when patient breaks in to emotions When patient indicated a certain information not to be recorded

6. Cont…. Developing rapport The feeling of harmony & trust that should exist between patient & clinician Facilitate obtaining good information Help to develop trust so that patient tries any suggestion & treatment How to develop it Appear relaxed, interested & empathic Monitor your facial expression, node & smile when appropriate Use praise, “I understand you” & other similar comments carefully

7. Patients demeanor Drooping shoulder, a clenched fist, tears – draw a little closer to show concern, if you sense hostility – withdraw physically even a few inches Humor – be careful not to laugh at your patient, but laugh with the patient Adopt a none judgmental & an empathic attitude Keep the professional boundary clean & limit self disclosure Empathy On some level you can feel as your patient feels, that you can put yourself at your patient’s place Express it appropriately Be in control of your emotion

8. Managing the early patient interview Much of the task is to keep patient talking Try to intrude as little as you can Nonverbal encouragement Differentiate a brief pause from a long gap Don’t break eye contact; a smile or nod will say, “it is all right to proceed at your own pace” Lean a little closer to show attentiveness & interest

9. Cont… Verbal encouragement “yes”, “ Ahaa ” etc.. “go on”, “I am listening” Repeat the patient’s last word or two “I was so angry that for hours I was hearing voices” pause = “voices” Elaborate on a word the patient used earlier = ”you said you felt desperate” pause Directly request more information =“Tell me more” =“How do you mean” Offer brief summaries =“so you felt that …”, “Do you mean that…”

10. Assessment of psychiatric patients There are 4 components to assess psychiatric patients Psychiatric history Mental status examination Physical examination Investigations

11. Psychiatric history Past medical history – divided into past psychiatric history and medical history There is an additional section called personal history Personal and social history are significant –strong bearing in the etiology, treatment and prognosis of psychiatric disorders ??Keep in mind The aim of the psychiatric history is not so much to go through a long list of headings rather to facilitate the patient’s telling of his or her story.

12. Interview format ID Chief compliant History of the present illness Past psychiatric history Past medical/ surgical history Family history Personal history Mental status examination Physical examination

13. Identification data Name Sex Age Marital status Occupational status Educational level Religion ??? Ethnicity Source of referral First vs. repeated visit/ admission Came alone, accompanied with, escorted/ brought by, Helps to know the person well Sometimes the crucial issue would spring up while taking ID Shade light in to important areas to explore further Ask in a casual manner, don’t interrogate

14. Chief compliant Patient’s stated reason to seek help Use patient’s own words Patient may give a list of problems, select the most important & the main reason for the visit Questioning =“Please tell me what problems made you come for treatment” Open-ended & clear Try to learn the real reason for coming Some may not recognize it Others may feel ashamed or fearful An acute problem/ availability of money may triggered a visit in a chronically sick but untreated patient “I have no problem it is them who have a problem” =“why do you think they brought you?” =“Is anything else bothering you?”

15. History of present illness Time of onset Mode of onset Chronological order of different symptoms Positive & negative statements Psychosocial stressors, substance abuse & any contributing medical condition

16. Learn as much as you can about each symptom What does nervous/ depressed mean to the patient? Characterize symptoms as much as possible Continuous/ episodic How intense & variation with time Context Why now? Psychosocial, environmental, life event Vegetative symptoms – appetite, sleep, weight, energy & sex

17. In the initial period, be nondirective & use open-ended questions Don’t agree or collude with the patient’s belief system Positive-negative statement Consequences of illness Occupational function Social functioning Personal functioning Marital & legal problems Subjective distress Diagnostic implication Severity of the illness Management implication

18. Cont.…. What are the main problems? Which of these are the worst? When did you first notice that? What did other people say? How did that affect you? When did you last feel well?

19. Cont… Risk assessment Suicide Violence Patient & family expectation

20. Risk assessment A suicidal patient Plan Understanding of the lethality of the means used Reaction of patient for being rescued or surviving Is she/ he planning to try again Past history of attempt & family history of suicide A reason to live?

21. Aggression & violence Patients with severe mental illness are largely none violent Past history of violence, use of weapon, under the influence of substance Follow your gut feeling – it is the best indicator of an imminent violence & aggression Interview patient in the presence of others?? Get out of the interview room if you sense an imminent attack by the patient, arrange the room so that both you & the patient has an easy access for the door

22. Past psychiatric history When, how many & how long Characterization Past suicidal or violence history Treatment Hx . – compliance, response, side effect Inter episode symptomatic & functional status

23. Pattern of relapse ?substance related ?Specific stressors ?Life event ? None compliance to medication Past medical/ surgical history Etiologic relationship - the disease itself or medication used to treat it Drug-drug interaction Impact on psychological health & self-esteem Integrated care

24. Family history Structure & interaction Parents, siblings, spouse & children Support system Family history of mental illness or suicide “Blood relatives!” Characterization of symptoms, course & outcome Medication that worked best

25. Personal history Prenatal & postnatal period Growth & development Childhood illness Childhood period – life events, lose & separation, traumatic experience etc… Schooling – age started, separation anxiety, attendance & performance Peer relationship Frequent move between care givers & residency

26. Cont… Teenage - relationships, substance use, sexual relationship Adulthood – occupational, marital, sexual, religious, living situation & legal

27. Mental Status Examination Appearance Overt behavior Attitude Speech Mood and affect Thought Form Content Perceptions Cognition Alertness Orientation (person, place, time) Concentration Memory (immediate, recent, long term) Calculations Fund of knowledge Abstract reasoning Insight Judgment

28. Cont.…. Appearance Posturing Dressing & grooming Hair & fingernails Walked in, forced in or carried in Behavior Attitude cooperative, friendly, attentive, interested, frank, seductive, defensive, contemptuous, perplexed, apathetic, hostile, playful, ingratiating, evasive, or guarded

29. Cont.…. Speech Quantity, rate of production, and quality Talkative, voluble, taciturn, Rapid or slow, pressured, hesitant, emotional Dramatic, monotonous, loud, whispered, slurred, or mumbled Speech impairments - stuttering Affect Patient's present emotional responsiveness, inferred from the patient's facial expression Congruency with mood, appropriateness Normal range, constricted, blunted, or flat

30. Cont.…. Mood Pervasive and sustained emotion that colors the person's perception of the world Depressed, despairing, irritable, anxious, angry, expansive, euphoric, empty, guilty, hopeless, futile, self-contemptuous, frightened, perplexed & labile Perception Hallucination & illusion Derealization & depersonalization

31. Cont.…. Thought Process/ form Circumstantiality Clang association Derailment Flight of ideas Neologism Perseveration Tangentiality Thought blocking

32. Cont.…. Content Delusions, preoccupations, obsessions, compulsions Suicide & self harm Violence, aggression & homicidal Judgment Capability for social judgment Insight Degree of awareness and understanding about being ill

33. General skills Have a listening attitude Open vs. closed ended question Don’t interrupt patient unless it is important Guide the rumbling patient Show respect to patients, their explanatory model Facilitate emotional expression Show a genuine empathy Use body gestures, praise, reassurance & advise wisely Summarization Smooth shift from an area of inquire to another

34. Investigation 1-Hematology - WBC - Hemoglobin - ESR 2-Urinalysis 3-Thyriod,liver and renal function test 4-VDRL 5-Urine toxicology screening 6-ECG 7-EEG 8-Brain imaging

35. Comparison of Assessments Medical Hx. Lab./Tech. P/E Hx. MSE P/E Psychiatric Assessment Lab/Tech.

36. Classification of mental disorders I - Introduction . Most of the diseases diagnosed in psychiatry are syndromes. E.G syndromes could be Neurosis or Psychosis 1-Neurosis – chronic or recurrent non psychotic disorder characterized mainly by anxiety ,it appears as symptoms such as an obsession, compulsion, phobia. 2-Psychosis - Is a state with the loss of reality testing and impairment of mental function–manifested by - Hallucination. - Delusion. - Confusion. - Impaired memory - Severe impairment of social or personal functioning .

37. Cont.…. There are 2 classification systems used – 1- DSM-Diagnostic and statistical manual of mental disorders. -It is developed by American psychiatric Association. -Includes all the psychiatric disorders. -The last edition is DSM-V 2 - ICD-International classification of diseases. -Developed by World health organization in Europe. -Involves all the categories included in DSM-V. -The ICD -11 is the last edition. - Both the manuals specify the symptoms that must be present to make a particular diagnosis , together in to a classification system.

38. Types of psychiatric disorders 1- Disorders usually first diagnosed in infancy, childhood or adolescence(mostly neurodevelopmental disorders) 2- Cognitive disorders 3- Substance related disorders 4- Schizophrenia and other psychotic disorders 5- Mood disorders 6- Anxiety disorders 7- Somatic symptom disorders 8- Illness Anxiety disorders

39. Cont.…. 9- Dissociative disorders 10- Sexual and gender identity disorders 11- Eating disorders 12- Sleep disorders 13- Impulse control disorders. 14- Adjustment disorders . 15- Psychiatric disorders secondary to medical conditions. 16- Personality disorders.