Srivastava, Amresh

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Western UniversityScholarship@WesternPsychiatry Presentations Psychiatry Department2009Clinical Interview for Psychiatric AssessmentAmresh SrivastavaUniversity of Western Ontario, amresh.srivastava@sjhc.london.on.caFollow this and additional works at: https://ir.lib.uwo.ca/psychiatrypresPart of the Psychiatry and Psychology CommonsCitation of this paper:Srivastava, Amresh, "Clinical Interview for Psychiatric Assessment" (2009). Psychiatry Presentations. 28.https://ir.lib.uwo.ca/psychiatrypres/28Clinical interview for psychiatric assessmentAmresh Srivastavadr.amresh@gmail.comInterview skills • For diagnosis• Skill- is main objective of psychiatrist’s training• 1.history taking• 2.mental state examination- systematic record of patent's current psychopathology• Onset and development  of therapeutic relationship.• can not be learnt from text books• Observe others• Review your own sessions• Carry out as many as possible• Experience Personal safeteySetting the scene• Observe normal social and cultural norms• Seating • Explanation • Documentation • Interviewing patients speaking different languagesProcess Interview structure Questioning techniques Giving advise After the interview; provisional diagnosis,Objective data, gathering information from relatives, GP, Previous record, witness,Clarifying symptoms with staffModified techniques in ER situationProcess • Initiate • Patient-led history• Doctor-led history • Background history • Summing-up • Questioning techniques • Open Vs. closed questions• Non-directive vs. leading questionsStep by step Mental Status Examination  7Personal & Developmental History 6Medical History 5Past psychiatric History 4History of present illness3Chief Complains2Identification 1Discussing management • Establish therapeutic relationship.• Communicate effectively ▫ be specific, ▫ avoid ambiguity, ▫ avoid jargon, ▫ connect the advise to the patients,▫ use repetition / recapitulation, write down]• Instill Hope• Encourage self-helpHistory • Basic information• Presenting complains• History of presenting complains• Past psychiatric & medical history• Drug history• Family history• Personal history [ childhood, education, employment, relationship, forensic]• Social background information• Premorbid personalityFamily tree IndexcaseFemale Male Deceased Affected Twins Mental status examinationParameters Necessary detailsAppearance : age, Race, Style of dress, level of cleanliness, general physical condition Behavior  clang & punning, flight of ideaappropriateness, level of motor activity, apparent level of anxiety, eye contact, rapport, abnormal movement or posture, episodes of aggression distractibilitySpeech : volume, rate, & tone, quantity & fluency, abnormal association, Mood : subjective and objective assessment of moodRISK thought of Suicide or DSH. Thoughts of harm Signs • Anxiety : anxiety & panic symptoms, obsessions and compulsions• Perception : hallucinations, pseudo-hallucination, depersonalization, derealization• Thought : form & Content• Cognition : orientation, level of comprehension, short-term memory, concentration.• Insight •Case summary • Synopsis : salient pints, basic data, CC, Past history, description of presentation, description of current symptoms, positive feature on MSE, risk, attitude to illness.• Differential diagnosis • Formulation : why the person has become ill & why now, 3 P ‘ predisposing, precipitating, perpetuating’.• Management plan : document, investigation, initial drug treatment, instructions to nursing staff, comment on risk- detainable or not MHAWhat is the description of symptoms or sign?What is it called?What is the measurement?What does it mean?What dysfunction it points to?What is the illness is it suggestive of?Personal & developmentalEarly Childhood 1. Milestones 2.Intrafamilial RelationshipMiddle Childhood (3-11 years). 1.Friends2. SchoolAdolescence 1.pubert 2.Psychosexual3.Dating & peer relation 4. School performance 5.drug & Alcohol useEarly Adulthood 1. Marital , Relationship 2.work 3.recreational, vocational,4. military, PrisonMiddle & old adulthood 1. Changing family constellation 2.Retirement 3. Losses4. agingMSEAppearance SpeechEmotional Expression ( mood and affect) 1.Subjective2. ObjectiveThinking & Perception: 1. Form 2. Content 3. perceptionSensorium : 1. Alertness 2.Orientation3.Concentration 4. Memory 5. calculation 6. Fund of knowledge 7. Abstract reasoningInsight JudgmentObservations of appearance and behavior• What is the appearance?• Behavior during interview? • Patients level of activity during the interview?• Is there any evidence of self-neglect?• Is behavior totally appropriate?• Is the behavior threatening, aggressive or violent?• Are there any abnormal movements?• Is the patient distractible or appearing responding to hallucinations?Speech • Is there any speech at all?• What is the quantity of speech?• What is the rate of speech.?• What is the volume and quantity of speech?• What is the tone and rhythm ?• How appropriate is the speech?• Is there abnormal use of language?Abnormal mood • Affect:  emotional state prevailing at a given time.[ weather]• Mood : emotional state over a long period.[ climate] Asking about depressed mood• How has your mood been lately?• Does your mood vary over the course of the day?• Can you still enjoy things that you used to enjoy?• How are you sleeping?• How is your appetite like at the moment?• How is your concentration?• How is your memory like?• How is the sexual side of your relationship?• Do you have any worries on your mind at the moment?• Do you feel guilty about any thing at the moment?Asking about thoughts of self-harm• How do you feel about the future?• Have you ever thought that life is not worth living?• Have you ever wished that you go to bed and not get up in the morning?• Have you had thoughts of ending your life?• Have you thought about how you would do it?• Have  you made any preparations?• Have you tried to take your own life?• Self-injurious behaviors ?Asking about elevated mood• How has your mood been lately?• Do you find your mood is changeable at the moment?• What is your thinking like at the moment?• Do you have any special gifts or talents?• How are you sleeping?• What is your appetite like at the moment?• How is your concentration?• How is the sexual side of your relationship?Anxiety symptoms• Psychic anxiety-an unpleasant effect, subjective tension, increased arousal, • Somatic anxietyAbnormal perceptions• Altered perceptions-sensory distortions and illusions• False perceptions-hallucination and pseudo hallucination• Sensory distortion-▫ hyper acusis,▫ micropsia• Illusions-▫ affect illusion, ▫ completion illusion,▫ paridolic illusions, • Hallucinations:▫ auditory, visual, ▫ olfactory, gustatory, ▫ Hypnagogic-hypnopompic, ▫ elemental hallucination,▫ extracampine, ▫ functional, ▫ reflexAsking about abnormal perception• Have you ever had the sensation that you were unreal- or that the world had become unreal?• Have you ever had the experience of hearing noises or voices, when there was no one about to explain it?• Have you seen any visions ?• Do you ever notice smells or tastes that other people are not bothered by?Abnormal beliefs• Delusions [false unshakable belief]• Out of cultural or religious background• Secondary delusion • Primary delusion• Over valued ideasAsking about abnormal beliefs• Do you have any particular worries preying on your mind at the moment?• Do you ever feel that people are watching you or paying attention at what you are doing?• When you watch the television or read the newspaper do you ever feel that the stories refer to you directly, or to things that you have been doing?• Do you ever feel that people are trying to harm you in any way?• Do you feel that you are to blame for anything that you are responsible for anything going wrong?• Do you worry that there is anything wrong with your body or that you have a serious illness?Asking about first rank symptoms• Auditory hallucination [‘voices heard arguing’, thought echo, ‘running commentary’]• Delusion of thought interference [thought insertion, thought withdrawal, thought broadcasting]• Delusions of control [passivity of affect, passivity of impulse, passivity of volitions, somatic passivity]• Delusional perceptionAsking about first rank symptoms• Voices commenting • Discussing you between themselves• Repeating your own thoughts back to you• Someone interfering with your thoughts• Putting thoughts in your head or taking them away• Your thoughts can be transmitted • You being controlled • Thoughts, mood or action are being forced on you by someone elseDisorders of form of thought• Disturbance of association between thoughts▫ Snapping off, ▫ fusion, ▫ muddlling and ▫ derailmentFormal Thought Disorder• Circumstantiality• Clang association• Derailment • Flight of ideas• Neologism • Perseveration • Tangentiality• Thought blocking  Abnormal cognitive function• Level of consciousness• [pathological,• physiological]• Confusion • [disorientation, • misinterpretation,• memory impairment, • impaired clarity of thought]• Memory• [working memory,• short term memory, • long term memory-episodic procedural and emotional]• Intelligence• Acute versus chronic brain failureAssessing cognitive function• Level of conciousness [glasgow coma scale]• Confusion• Memory• Mmse• IQMMSE• Orientation, max 10 points• Registration/concentration/recall, max 11 pts• Language/drawing max 9 pointsSupplementary test for cerebral functioning• Frontal lobe functioning [frontal assessment battery, visconsin card sorting task, digit span, trail making test, cognitive estimate testing]• Parietal lobe functioning, test for dominant lesions [finger agnosia, astereoagnosia, dysgraphaethesia]• Test for non dominant lesion [asomatognosia, constructional dyspraxia]• Visual field • Speech• Reading writingInsight • Does the patient believe that their abnormal experiences are symptoms. • Their symptoms are attributable to illness• That the illness is psychiatric• That psychiatric treatment might benefit them• Would they be willing to accept advise from a doctor regarding their treatmentPhysical examination• General examination• Systemic examination• Neurological examinationPhysical signs Possible causes‘Parkinson’s facies’ APD, psychomotor retardation-depressionAbnormal pupil size opiateArgyll-Robertson pupil neurosyphilisEnlarged parotids Bulimia nervosaHyper salivation Clozapine/EPSgynaecomastia APD/alcoholic liver diseaseClinical investigationsCommon assessment instrument• GHQ• PSE• SCAN• SCID• DIS• GFHoNoS• QOL• HAM-D• MADRaS• BDI• PANSSHARA• Y-BOCS• CAGE questionnaire• MMPI• IPDEDescriptive psychopathology• Subjective versus objective• Form vs. contact• Primary versus secondary• Endogenous vs. reactive• Psychotic vs. neurotic• Congruent vs. incongruent• Structural vs. functional•Selected neuropsychological deficitsLeft hemisphere Right hemisphereaphasia Visuospatial deficitsRight-left Disorientation Impaired visual perceptionFinger agnosia NeglectDysgraphia (aphasic) Dysgraphia (spatial, Neglect)Constructional apraxia (details) Constructional apraxia (Gestalt)Limb Apraxia Dressing apraxiaAnosognosiaLanguage disorders• Broca’s aphasia ( impaired verbal fluency, intact auditory comprehension, somewhat impaired repetition. Left inferior frontal convolution area 44)• Wernick’s aphasia( intact verbal fluency, impaired comprehension,  somewhat impaired repitions,superior temporal gyrus ( area 22)• Conduction Aphasia ( intact auditory comprehension, spontaneous speech ability to repeat is impaired, acruate fasciculus, which connects Wenicks & Broca.)• Global Aphasia ( impairment of all three fluency, comprehension & repetition,Cognition • Limb apraxia• Arithmetic • Spatial disorders ▫ Visuospatial▫ Neglect ▫ Dressing apraxiaMemory disordersencodingRetrivalStorage Executive function Some issues in neuropsychiatric referral • Level of functioning• Differential diagnosis▫ Age/stress related cognitive change▫ Mild traumatic brain injury▫ Poststroke syndromes▫ Detecting early dementia▫ Distinguishing dementia & depression• Changes in functioning Over Time• Assessment of competence• Forensic evaluationDomains of formal neuropsychiatric assessment• Battery approach• Hypothesis-testing approach• Integration of qualitative and quantitative methods• Neuropsychological examination techniques• Interview • Intellectual functioning • Attention • Memory • Language • Visuospatial functions• Sensory & Motor functions• Executive functions Area of function commentIntellectual functioningWechsler Intelligence scaleAge-stratified, up to 89 years, adolescents & Shipley scale Brief, MCQ, open ended verbal abstractionAttention & concentrationDigit span Auditory verbal measureVisual memory span Ability for spatial sequencesPaced auditory serial addition test Subtle processing deficitsMemory WMS-III Subtests: attention, encoding, retrival, recognition,California verbal learning test Encoding, possible learning strategiesFuld object memory evaluationSelective reminding format, older peopleLanguage Boston diagnostic aphasia examinationComprehensiveassessment of expressive & repetitive functionsBoston naming test revisedWord finding difficulty in confrontation formatVerbal fluency Ability to generate wordsVisuospatial constructionalJudgment of line orientationFacial recognition Clock drawingRey-Osterreith Complex figure testMotorFinger tappingGroovedpegboardGrip strength Executive function WCSTCategory testTrail making testMedical conditions presenting as neuropsychiatric symptoms• Neurological • Endocrine • Metabolic & systemic• Toxic • Nutritional • Infection • Autoimmune • Neoplasm •• Vascular• Infections• Endocrine• Toxic • Neoplasm • Autoimmune • Metabolic • Deficiency• TraumaClinical manifestations of psychiatric disorders• Predisposing vulnerabilities▫ Genetic & intrauterine factors▫ Constitutional factors▫ Physiological stressors▫ Environmental stressors• Characteristics of psychiatric signs and symptoms▫ Reliability problem▫ Nonspecific nature▫ Sign symptoms catagories State vs.trait Primary vs. secondary Form vs content Context  Problems & impairments Need for comprehensive perspectiveSomatic manifestations of psychiatric disorders• Sleep • Appetite • Weight • Energy disturbances • Sexual drive • Appearance Disturbance in thinking • Thought disturbances▫ Flow and form ▫ Continuity • Thought contents▫ Delusions▫ Overvalued ideas▫ Ideas of reference▫ Self-mutilatory, suicidal, aggressive and homicidal preoccupationsDelusions Characteristics of delusions Classic type• Sample vs complex• Complete vs partial• Systematized vs nonsystamatized• Primary vs secondary• How they affect behavior• Persecution• Grandeur • Influence • Having sinned • Nihilistic • Somatic • Doubles • Jealousy • Mood • Perception • Memory • Erotic attachment • Replacement of significant others• Disguise Disturbance of judgment • Analytical • Ethical • Social • Insight • Self-deception• Impulsive judgment Altered state of consciousness Disturbance of level of  consciousness• Mystical state• Hypnosis • Suggestibility • Dissociative phenomenon • Psychological ,Physiological ,Alertness , Awareness , Attentiveness • Clouding of consciousness• Torpor • Stupor • Coma• Akinetic mutism or coma vigil• Delirium Disorder of sense of  self • Disturbance of orientation • Disturbance of memory • Disturbance of perception • Illusions• Body image disturbance • Mood • Depression • Elation • Aggression hostility impulsiveness violence • Inappropriateness of mood Motor aspect of behavior • Over activity • Decreased activity motor disturbance▫ Tremor▫ Parkinsons▫ Dystonia▫ Akathisia▫ TD▫ NMS▫ Rabbit syndrome▫ Tics▫ Serotonin syndrome• Motor disturbance in schizophrenia ▫ Catatonia▫ Seizure-like behavior▫ Compulsive behaviorLanguage disorders• Speech disorders• Aphasia • Disturbance of interpersonal relationship• Personality traits and disordersTechniques for Psychiatric assessment• Time & setting • Interview:▫ Open-ended & closed –ended questions▫ Supportive & obstructive intervention▫ Interpreting behavior during initial diagnostic interview▫ Recording & notes taking• Therapeutic interview• Contractual & non-contractual  • Analytical • Educative• Confrontational Special Problems in interviewing• Psychotic Patient• Depressed potentially suicidal• Agitated & potentially violent • From different cultures• Seductive patients• Patients who lieDocumentation issues• Is patient’s area of dysfunction described? From biological, Psychological & Social point of view?• Is alcohol or Substance abuse addressed• Are issues identified in treatment plan and followed in progress notes?• When there is a variance in the patient’s outcome: Is there a note in the progress note to that effect,? Is there also a note reflecting the clinical strategies to overcome the impediment• If new clinical strategies are implemented, how is their impact evaluated?Documentation issues• Is there MDT input• Do progress notes indicate the patient’s functioning in the therapeutic community and its relationship to discharge criteria.• Can one extrapolate from therapeutic community how they will behave in community at large?• Are there notes indicating patients understanding of discharge planning• Do progress notes bridge the differences in thinking of other disciplines?• Are patients needs addressed in treatment plan• Are the patients family needs evaluated and implemented.• Is alcohol & substance mentioned as a possible contributor to readmission?• Are  types  of medication listed• Are medication effects documented 

Clinical Interview for Psychiatric Assessment

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Clinical Interview for Psychiatric Assessment

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