Session 8. Psychiatric Interview and Mental Status Examination.ppt

Psychiatric Interview

1. PSTCHIATRIC INTERVIEWPSTCHIATRIC INTERVIEW
ByBy
Dr. Rabie A. HawariDr. Rabie A. Hawari
Consultant PsychiatristConsultant Psychiatrist
Clinical Assistant ProfessorClinical Assistant Professor

2. PSYCHIATRIC INTERVIEWPSYCHIATRIC INTERVIEW
The purpose of interview isThe purpose of interview is-:-:
11 . .to obtain historical perspective of patientto obtain historical perspective of patient’’s lifes life,,
22 . .to establish rapport and therapeutic allianceto establish rapport and therapeutic alliance,,
33 . .to develop mutual trust and confidenceto develop mutual trust and confidence,,
44 . .to understand present functioningto understand present functioning,,
55 . .to make diagnosisto make diagnosis,,
66 . .to establish treatment planto establish treatment plan..

3. INTERVIEW TECHNIQUESINTERVIEW TECHNIQUES
- -Arrange a comfortable setting with privacyArrange a comfortable setting with privacy,,
- -Introduce yourself, greet pt. by name, tell reason of i/vIntroduce yourself, greet pt. by name, tell reason of i/v . .
- - Put pt. at ease, establish rapport by showing empathyPut pt. at ease, establish rapport by showing empathy . .

- -Do not make value judgmentDo not make value judgment..
- -Carefully observe pt.Carefully observe pt.’’s nonverbal behavior, postures nonverbal behavior, posture , ,
mannerisms, and physical appearancemannerisms, and physical appearance..
- -Avoid excessive note-makingAvoid excessive note-making..
- -Do not argue or get angryDo not argue or get angry..

4. Cont. i/v techCont. i/v tech-:.-:.
- -Use language suitable with pt.Use language suitable with pt.’’s intelligences intelligence..
- -Length of i/v.:- 15-90 mint. ( average 45-60 mint)Length of i/v.:- 15-90 mint. ( average 45-60 mint)
less with delirious or uncooperative ptless with delirious or uncooperative pt..
more with verbal, cooperative ptmore with verbal, cooperative pt..
- -QuestionsQuestions -: -:
* * open-ended Q?- for neurotic, verbal, intelligent pt. open-ended Q?- for neurotic, verbal, intelligent pt.
““ ““tell me more about thattell me more about that..””
* * closed-ended Q?- (yes or no) for psychotic, closed-ended Q?- (yes or no) for psychotic,
delirium, dementia, limited-time i/vdelirium, dementia, limited-time i/v..
* * avoid suggesting answers (you feel depressed, avoid suggesting answers (you feel depressed,
dondon’’t you?)t you?)..

5. PSYCHIATRIC EXAMINATIONPSYCHIATRIC EXAMINATION

6. PsychiatricPsychiatric ExaminationExamination
Consist of two partsConsist of two parts -: -:
HistoryHistory:- is the chronologic story of the :- is the chronologic story of the
pt.pt.’’s life from birth to presents life from birth to present. .
Mental StatusMental Status:- is a cross-section of :- is a cross-section of
pt.pt.’’s psychological life and represents s psychological life and represents
the sum total of the psychiatristthe sum total of the psychiatrist’’s s
observation and impressions at the observation and impressions at the
moment, and for future comparisonmoment, and for future comparison..

7. Psychiatric HistoryPsychiatric History
Identifying dataIdentifying data:- name, age, sex, religion, marital :- name, age, sex, religion, marital
status, education, address, occupation, source of status, education, address, occupation, source of
referral and informationreferral and information..

Chief complaint (cc):-Chief complaint (cc):- brief statement in brief statement in ““ pt. pt.’’s own s own
wordswords”” of why he is in hospital or seen in of why he is in hospital or seen in
consultation. consultation. ““ what seems to be the problem what seems to be the problem??””..

8. cont. psych, hxcont. psych, hx-:.-:.
History of Present Illness (hpi):-History of Present Illness (hpi):- development of development of
symptoms from time of onset to present, symptoms from time of onset to present,
relationship to events, stressors, drugs, relationship to events, stressors, drugs,
change from previous level of functioning. change from previous level of functioning.
h/o previous hospitalization and treatmenth/o previous hospitalization and treatment..
Past Psychiatric / Medical Illness:-Past Psychiatric / Medical Illness:- psychosomatic, psychosomatic,
medical, neurological illness, extent of illness, medical, neurological illness, extent of illness,
treatment, outcome, hospital etctreatment, outcome, hospital etc..

9. Cont. psych hxCont. psych hx-:.-:.
Family History:-Family History:- age of parents & occupation, if age of parents & occupation, if
deceased.. date & caused, separated, no. of deceased.. date & caused, separated, no. of
siblings, pt.siblings, pt.’’s birth order, feelings about each s birth order, feelings about each
member, psychiatric & medical hx. member, psychiatric & medical hx.
medications hx. financesmedications hx. finances..

10. ContCont. . psychpsych. . hxhx-:-:
Personal HistoryPersonal History-:-:
* * Birth & InfancyBirth & Infancy:- hx. of pregnancy delivery as known by pt., :- hx. of pregnancy delivery as known by pt.,
developmental landmarks-developmental landmarks- standing, walking, talking, standing, walking, talking,
temperamenttemperament..
* * ChildhoodChildhood:- feeding habits, toilet training, conduct and :- feeding habits, toilet training, conduct and
behavior, personality- shy, outgoingbehavior, personality- shy, outgoing
relationship with parent or caregivers, peer. Fearrelationship with parent or caregivers, peer. Fear,,
separation, night-mares, bedwettingseparation, night-mares, bedwetting..
* * AdolescenceAdolescence:- peer & authority relationship, school, drug:- peer & authority relationship, school, drug
use, pubertyuse, puberty..
* * AdulthoodAdulthood:- work, career, marriage, children, education, :- work, career, marriage, children, education,
finances, religion, legal recordfinances, religion, legal record..

11. Cont. psych hxCont. psych hx..
Sexual HistorySexual History:-:- sexual development, orientation, sexual development, orientation,
masturbation, anorgasmia, p.m.ejaculationmasturbation, anorgasmia, p.m.ejaculation..
““ How did you learn about sex?How did you learn about sex?”…”… ““ are there or have there are there or have there
been any problems or concerns about your sex lifebeen any problems or concerns about your sex life??””..
Premorbid personality:-Premorbid personality:- sociable, extrovert, friends, sociable, extrovert, friends,
hobbies, habits, tense, anxious, short tempered, hobbies, habits, tense, anxious, short tempered,
perfectionist, easy going, otherperfectionist, easy going, other’’s opinions opinion..

12. Mental StatusMental Status
General AppearanceGeneral Appearance-:-:
note appearance, gait, dress, grooming (neat or unkempt)note appearance, gait, dress, grooming (neat or unkempt),,
posture, gestures, facial expressions. Does pt. appear older posture, gestures, facial expressions. Does pt. appear older
or younger than stated ageor younger than stated age .? .?
introduce yourself, direct pt. to take a seatintroduce yourself, direct pt. to take a seat..
* * unkempt and disheveled unkempt and disheveled  organic mental disorder organic mental disorder,,
* * pin-point pupils pin-point pupils  narcotic addiction narcotic addiction,,
* * withdrawn psychomotor retardation withdrawn psychomotor retardation  depression depression..

13. Cont. MSECont. MSE..
BehaviorBehavior-: -:
Activity Activity –– psychomotor agitation or retardation psychomotor agitation or retardation , ,
Emotional Emotional –– anxious, tense, panicky, sad anxious, tense, panicky, sad , ,
Voice Voice –– loud, hoarse, faint loud, hoarse, faint,,
Eye Eye –– contact contact,,
Other behavior Other behavior –– tics, tremors, mannerism, negativism tics, tremors, mannerism, negativism,,
automatism, apraxia, echopraxiaautomatism, apraxia, echopraxia,,
* * fixed posturing, odd behaviorfixed posturing, odd behavior schizophrenia schizophrenia,,
* * hyperactivehyperactive mania, stimulant (cocaine) mania, stimulant (cocaine),,
* * hypoactivehypoactive depression depression,,
* * tremortremor anxiety anxiety..

14. Cont. MSECont. MSE..
Attitude during i/vAttitude during i/v-:-:
How pt. relate to examiner How pt. relate to examiner –– irritable, aggressive, irritable, aggressive,
seductiveseductive
guarded, defensive, apathetic, cooperative, guarded, defensive, apathetic, cooperative,
sarcasticsarcastic
* * suspiciousness suspiciousness  paranoia paranoia,,
* * seductive seductive  hysterionic traits hysterionic traits,,
* * apathetic apathetic  Organic Mental Disorder Organic Mental Disorder
- - Q? Q? ““ you seem irritated about some thing, is that an you seem irritated about some thing, is that an
accurate observationaccurate observation??””..

15. Cont MSECont MSE..
MoodMood-:-:
Steady or sustained emotional state Steady or sustained emotional state –– gloomy, tense, sad gloomy, tense, sad,,
hopeless, elated, happy, depressed, resentful, hopeless, elated, happy, depressed, resentful,
anhedonicanhedonic
Qs?:- Qs?:- ““ How do you feel? How do you feel?””, - , - ““ How are your spirits How are your spirits??””,,
- - ““ Do you have thoughts that life is not worth livingDo you have thoughts that life is not worth living??””
- - ““ Do you have plans to finish your own lifeDo you have plans to finish your own life??””,,
* * suicidesuicide in 25% of depressed pt in 25% of depressed pt . .
* * elation elation  mania mania..

16. Cont. MSECont. MSE
AffectAffect-:-:
Feeling tone associated with idea Feeling tone associated with idea –– labile, blunt, flat, labile, blunt, flat,
appropriate to content, inappropriate, appropriate to content, inappropriate, la belle la belle
indifferenceindifference..
* * changes in affect changes in affect  schizophrenia schizophrenia..
SpeechSpeech-:-:
Slow, fast, pressured, mute, spontaneous, aphasia, pitchSlow, fast, pressured, mute, spontaneous, aphasia, pitch,,
Paucity, slurredPaucity, slurred..
* * pressured pressured  manic. - Slurred manic. - Slurred  Organic Mental Disorder Organic Mental Disorder
* * paucity paucity  depression depression..

17. Cont. MSECont. MSE..
Perceptual disordersPerceptual disorders-:-:
- - Hallucinations (olfactory, auditory, tactile, gustatory, Hallucinations (olfactory, auditory, tactile, gustatory,
visual). visual). –– Illusions. Illusions. –– Hypnopompic or Hypnagogic Hypnopompic or Hypnagogic..
- - ddééjjàà vu, vu, macroposia, feelings of unrealitymacroposia, feelings of unreality..
* * Hallucin. Visual Hallucin. Visual  organicity - auditory organicity - auditory  schizophrenia schizophrenia
- - tactile tactile  cocaine, delirium tremens (DT) cocaine, delirium tremens (DT)..
Q?:- Q?:- ‘‘ Do you ever see things or hear voices when alone Do you ever see things or hear voices when alone
and no one else can see or hearand no one else can see or hear??’’
- - ‘‘ Do you have strange experiences as you fall asleepDo you have strange experiences as you fall asleep
or upon awakeningor upon awakening? ? ’’

18. Cont. MSECont. MSE..
Thoughts DisordersThoughts Disorders-:-:
a- Forms:- a- Forms:- goal directed, loose of association, flight of goal directed, loose of association, flight of
ideas, circumstantial, knightideas, circumstantial, knight’’s move, derailment, s move, derailment,
clang association, perseveration, ability to abstractclang association, perseveration, ability to abstract..
* * loose of association loose of association  schizophrenia schizophrenia,,
* * flights of idea flights of idea  mania mania . .
* * inability to abstract inability to abstract  SZ. & Organic Mental Disorder SZ. & Organic Mental Disorder..
Q? Q? –– proverbs proverbs ‘‘ people in glass houses should not throw people in glass houses should not throw
stonesstones’’
- - similarity similarity ‘‘ car and train car and train’’ (transportation) (transportation)

19. Cont. MSECont. MSE
Thoughts DisordersThoughts Disorders-:-:
b- content:- b- content:- Delusions Delusions ––(persecutory, paranoid, guilt, (persecutory, paranoid, guilt,
grandiose, nihilistic, infidelity, hypochondriasis). -- grandiose, nihilistic, infidelity, hypochondriasis). --
Thought broadcasting or insertion. Thought broadcasting or insertion. –– ideas of ideas of
reference. reference. –– obsessions. obsessions.–– suicide or homicide ideas suicide or homicide ideas..
* * Delusion congruent with mood Delusion congruent with mood  grandiose = elated grandiose = elated..
* * Mood-incongruent delusion Mood-incongruent delusion  schizophrenia schizophrenia..
Qs? Qs? –– ‘‘Do you feel people want to harm youDo you feel people want to harm you??’’
- - ‘‘ Do you have special powersDo you have special powers??’’
- - ‘‘ Are there thoughts that you canAre there thoughts that you can’’t get out of yourt get out of your
mindmind??’’

20. Cont MSECont MSE
SensoriumSensorium-: -:
consciousnessconsciousness –– alert, confused, clouded, alert, confused, clouded,
stuporous, comatose. stuporous, comatose. –– orientation ( T.P.P) orientation ( T.P.P)..
Qs? Qs? –– ‘‘ What place is this? What place is this?’’, , –– ‘‘ What is the date What is the date??’’
- - ‘‘ Do you know who I amDo you know who I am??’’..
* * clouded consc. clouded consc.  Organic Mental Disorder Organic Mental Disorder
* * orientation to person remain intact longerorientation to person remain intact longer
than time or placethan time or place..

21. Cont. MSECont. MSE
Sensorium (cont.)Sensorium (cont.)-:-:
MemoryMemory -: -:
RemoteRemote (long-term) (long-term) -: -:
Qs?. Qs?. –– ‘‘ where were you born? where were you born?’’ –– ‘‘ Date of marriage Date of marriage??’’
* * AlzheimerAlzheimer’’s s  remote remain longer than recent remote remain longer than recent..
* * confabulation confabulation  filling gaps in memory filling gaps in memory..
RecentRecent-: -:
Qs?. Qs?. –– ‘‘ where were you yesterday where were you yesterday??’’ . .
* * organic mental diso. organic mental diso.  recent lost before remote recent lost before remote..
Immediate (short-term)Immediate (short-term)-:-:
Qs?.- Name 6 digits forward then backward. Remember 3 non-related Qs?.- Name 6 digits forward then backward. Remember 3 non-related
items after 5 minutesitems after 5 minutes . .
* * loose of memory loose of memory  anxiety, dissociative, conversion, organicity anxiety, dissociative, conversion, organicity
* * anterograde M. loss anterograde M. loss  drugs e.g. Benzo drugs e.g. Benzo
* * retrograde M loss retrograde M loss  after trauma after trauma..

22. Cont. MSECont. MSE
Attention & ConcentrationAttention & Concentration-:-:
Qs?.- Qs?.- ‘‘ days of the week days of the week’’ –– ‘‘ serial 7 (100 serial 7 (100 –– 7 ) and keep 7 ) and keep
subtractingsubtracting’’ –– ‘‘ simple math ( 3+4 ) simple math ( 3+4 )’’
* * poor poor  anxiety, depression. * impaired anxiety, depression. * impaired  OMD OMD..
KnowledgeKnowledge-:-:
Qs?.- Qs?.- ‘‘ Name the last 3 kings Name the last 3 kings’’ –– ‘‘ Capital of UAE Capital of UAE’’
* * check educational level to r/o mental retardationcheck educational level to r/o mental retardation..
JudgmentJudgment-:-:
ability to understand relationships b/w facts and drawability to understand relationships b/w facts and draw
conclusionsconclusions..
Qs?.- Qs?.- ‘‘ if you find an envelopment in the street that is sealed, if you find an envelopment in the street that is sealed,
stamped & addressed what are you going to do with itstamped & addressed what are you going to do with it ? ?
* * impaired impaired  OMD, schizophrenia, intoxication, low I.Q OMD, schizophrenia, intoxication, low I.Q..

23. Cont. MSECont. MSE
InsightInsight-:-:
= = realize that he/she has an illnessrealize that he/she has an illness,,
= = is it physical or mental problemis it physical or mental problem,?,?
= = dose it need treatmentdose it need treatment.?.?
Qs? - Qs? - ‘‘ Do you think you have a problem Do you think you have a problem??’’
- - ‘‘ What could the nature of the problemWhat could the nature of the problem??’’
- - ‘‘ Do you need treatmentDo you need treatment??’’
* * Impaired Impaired  OMD, pychosis, low I.Q OMD, pychosis, low I.Q..

24. MEDICALMEDICAL ANDAND NEUROLOGICALNEUROLOGICAL
EXAMINATIONEXAMINATION

25. Medical & Neurological examinationMedical & Neurological examination-:-:
Some psychiatrics disorders may have an organic causeSome psychiatrics disorders may have an organic cause..
therefore neurological and/or medical examinations and therefore neurological and/or medical examinations and
investigations my be indicated in most cases investigations my be indicated in most cases
examplesexamples -; -;
* * Medical Medical Psychosis Psychosis  Thyrotoxicosis, Cushing Thyrotoxicosis, Cushing’’s ds d,.,.
intoxication, anticholinergicsintoxication, anticholinergics..
* * Medical Medical  Depression Depression  DM, Flu, Hypothyroidism, Ca DM, Flu, Hypothyroidism, Ca..
SLE,Hepatitis,HypoglycemiaSLE,Hepatitis,Hypoglycemia..
* * Drugs Drugs  Depression Depression  Antihypertensive(Reserpine) Antihypertensive(Reserpine),,
Levodopa, HormonesLevodopa, Hormones , ,
cortisonecortisone..