The Clinical Interview


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The Clinical Interview

  1. 1. 1 The Clinical Interview Carolyn R. Fallahi, Ph. D. Introduction to Clinical Psychology The Clinical Interview Assessment important for psychologists Competency of a defendant How? Tests, interviews, observations. Neurological disorder vs. mental disorder? Unique contribution of psychologists. What does the clinical interview involve? Evaluation of strengths & weaknesses Conceptualization of problem Thoughts about etiology? Thoughts about alleviating the problem? A one time shot? No…ongoing. Example case. The Referral Who? Parent Teacher Psychiatrist Judge Psychologist Poses a question The Referral Question Sometimes needs rephrasing. Is this patient capable of murder? Why is the patient having trouble in school? Assessment Notcompletely standardized set of procedures. Describe the client in a useful way.
  2. 2. 2 General Characteristics of the interview The Interaction Introduce yourself & make an assessment of any potential communication problems. Talk about what the session will involve. Obtained informed consent. Get an understanding of the chief complaint or issue. What is your understanding of the problem? Case History Outline Identifying data. Reason for coming to the agency & expectations for service. Present situation. Family constellation. Early recollections. Birth & development. Case History Outline Health. Education & training. Work Record. Recreation & Interests. Sexual development. Marital & family data. Self-description. Choices & turning points in life. Case History Outline View of the future. Anything else? Mental Status Examination General presentation. State of consciousness. Attention & concentration. Speech: clarity, goal-directedness, language deficits. Orientation: person, place, time Mood & Affect Form of thought; formal thought disorder
  3. 3. 3 Mental Status Examination Thought content: preoccupations, obsessions, delusions. Ability to think abstractly. Perceptions: Hallucinations. Memory: immediate, recent, remote Intellectual functioning Insight & judgment Appearance & Behavior Lookat appearance, manners & behavior. Keep socioeconomic group in mind. Remember individuality. Appearance & Personality: High degree of attention to tidiness. High degree of attention to fashion. High degree of attention to flamboyant or seductive behavior. Appearance & mental disorders Omega sign = depression? Long face. Bizarre appearance is quite rare. Psychosis? Self-neglect. Dementia? Retarded depression? Neurological disturbance? Chronic schizophrenia? Colorful dressing. Mania? Somber dressing. Depression? Behavior Marked agitation. Anxiety? Agitated depression? Psychosis? Mania? Irritability. Mania? ADHD? Delirium? Stimulant abuse? Decreased activity. Acute depression, chronic schizophrenia, mental retardation, Parkinson’s, Hypothyroidism? Repetitive movements. Tics? Vocal productions? Tourette’s? OCD? ADHD? Intellectual disability? Movements Echopraxia – movements that are replicated, e.g. crossing the legs, touching the face.
  4. 4. 4 Drug intoxication? Psychosis? Schizophrenia? Catatonic stupor. Catatonic posturing. Catatonic rigidity. Waxy flexibility. Suicidal Behavior Self-cuttingor slashing. Depression? Psychosis? Personality disorder? Hallucinations? Delusions? Other suicidal behavior. Depression? Factitious disorder? Malingering? Desire for death? Speech or talk Articulation – Dysarthria or mumbling. Mechanical problems? Neurological disorders? Chronic Schizophrenia? Fatigue, sedation, medication, intoxication? Speech Volume – Loud talk. Mania? Personality traits? Quiet talk. Depression? Unassertive individual. Speed – Rapid talk. Mania? Anxiety? Stimulants? Slow talk. Depression? Sedation? Intoxication? Pressure of speech/thought/talk – Increase in the speed of talk. Talk over. Mania? Stimulant intoxication? Pitch High pitched talk. Anxiety? Fear? Arousal? Constant low-pitched talk. Depression? Hypothyroidism? Dysprosody. Depression? Schizophrenia? Brain damange? Associated with disorders of affect. Mood
  5. 5. 5 Definitional issues. Sustained for months Pervasive character Subjectively experienced Observable by interviewer Is the subjective response congruent with interviewer’s findings? Subjective experience Patient experience Objective findings Elation, Irritability, Anxiety, Subjective experience Objective findings Affect • Difference of opinion, e.g. affective versus mood • Internal feeling state. • Observation of feeling. • Subtle changes expected. • Mood & affect in depression. • Loss of emotions in Schizophrenia. • Affect assessed during the entire examination. • Appropriate affect. • Restricted and blunted affect? Flat affect? Thought • Examined through speech. • Reflected in behavior. o Form: arrangement of parts. Disturbances in the logical connections between ideas. o Formal thought disorder. o What is normal range? Need to let the patient speak freely – periods where there is little structure. o Abstract questions.
  6. 6. 6 o Proverbs. o The use of silence. o Record verbatim examples of a formal thought disorder in the patient’s file. o Derailment: deviation in the train of thought. This has replaced the old term, “loosening of associations”. o Tangentiality: inability to have goal-directed associations of thought. o Derailment. Mania? Depression? Schizophrenia? Schizophreniform disorder? Schizotypal personality disorder? o Flight of ideas. Mania? Schizophrenia? Intoxication with stimulants? o Pressured speech. o Incoherence. Why? Derailment? Neurological problem? Often not due to a psychiatric disorder. o Why not schizophrenia? o Neologism: words are invented by the speaker or distorted. Schizophrenia? o Thought block or thought withdrawal. Rare phenomenon. Thoughts withdrawn from the head – only identified if it occurs in mid-thought and if the patient volunteers or admits on question that the thought was lost. Differential: Schizophrenia versus Mania. o Perseveration & echolalia: Perseveration is the repetitive expression of a particular word or phrase. Echolalia: pathological repeating of words or phrases. Organic conditions? Mania? Schizophrenia? o Poverty of thought (speech): speech decreased amount. Hyperthyroidism? Dementia? Brain damage? Depression? Chronic Schizophrenia?
  7. 7. 7 o Poverty of content: little information given. Derailment? o Illogicality: erroneous conclusions or internal contradictions in thinking. Psychotic? Intoxication? o Content. o Delusion: false beliefs that are sustained despite evidence to the contrary. Somatic, persecutory, guilt. o Bizarre delusions. o Grandiose delusions. o Persecutory delusions. o Delusions of reference. o Delusions of control. o Thought withdrawal. o Thought insertion. o Thought broadcasting. o Nihilistic delusion. o Somatic delusion. o Delusions of guilt. o Delusional jealousy. o Erotomanic delusions. o Mood-congruent delusion. o Systematised delusions. o Obsession & compulsions. o Phobias. o Agoraphobia. o Social Phobia. o Simple Phobia. o Hypochondria. o Suicidal thoughts. o Homicidal thoughts. Perception
  8. 8. 8 • Perception: transferring physical stimulation into psychological information. • Depersonalization and derealization. • Delusional mood. • Heightened perception. • Changed perception. • Hallucinations. • Non-pathological hallucinations. • Alcoholic hallucinosis. • Illusions – misperceptions of stimuli. Usually transitory. Intelligence • The ability to think and act rationally and logically. • Mental retardation. • Cognition is the new term. Cognition • Thinking and mental processes of knowing and becoming aware. • Cognitive testing. • Memory, orientation, concentration, & language. • Mini-mental status examination (MMSE, Folstein) – standardized & internationally accepted screening test of cognitive functions. • Memory. Includes 3 basic mental processes. The ability to perceive, recognize, and establish information in the CNS, retention , and recall. Measurement includes Immediate memory, STM, LTM. • Tests of memory. o History & conversation. Can the patient give a clear account of their life from the remote to the recent past?
  9. 9. 9 o Short-term memory: repeat sequences of digits. Reverse digits? o Recent memory test. Have patient learn 3 or 4 unrelated words. Tell the patient that his/her memory will be tested. Ask them to repeat to make sure registered properly. Some minutes later, ask to recall the words. o Remote memory test. Some issues with what to include. Highly learned material, like DOB can be problematic. o Loss of memory.  Organic origin.  Dementia.  Head injury.  Amnestic Disorder.  Loss of memory when there is a psychological explanation: psychogenic amnesia; psychogenic fugue; MPD; Paramnesia; Confabulation; depersonalization & derealization. o Orientation.  Time, person, place. o Attention/Concentration. o Attention: context of consciousness. A state of awareness of the self & environment.  Disorders that show subtle attention problems.  Severe disorders of attention: schizophrenia, depressive psychosis, delirium, dementia, brain damage, severe attention disorders.  Tests of attention: History & conversation. Subtraction. Reversing components.
  10. 10. 10  Language: • Aphasia – impairment. • Dysphasia – dysfunction of speech. • Broca’s aphasia – output sparse, effortful, short-phrased & agrammatical. Patient is aware of and frustrated by his/ her expressive difficulties. • Wernicke’s aphasia: word finding problems & problems with comprehension. • Conduction aphasia – severe disturbance in repetition. • Transcortical aphasia –preservation of repeating in the presence of marked language impairment. • Nominal aphasia – word finding. Reading & writing disturbances. • Dysarthria – mechanical problem. • Testing aphasia – mechanics of speech; fluency, phrase length & paraphasic substitutions; comprehension; repetition; naming; writing ability; reading ability. Rapport Insight