Download to read offline
More Related Content
Similar to Psychiatric Interview for psychiatric patients .pptx
Psychiatric Interview for psychiatric patients .pptx
- 1.
- 2. Purpose of psychiatricinterview • 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 fora 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 • Learnthe 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 earlypatient 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 psychiatricpatients There are 4 components to assess psychiatric patients 1. Psychiatric history 2. Mental status examination 3. Physical examination 4. Investigations
- 11. Psychiatric history • Pastmedical 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’sstated 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 presentillness • Time of onset • Mode of onset • Chronological order of different symptoms • Positive & negative statements • Psychosocial stressors, substance abuse & any contributing medical condition
- 16. • Learn asmuch 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 theinitial 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 arethe 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 • Asuicidal 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 ofrelapse • ?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 – Pervasiveand 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 • Havea 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 mentaldisorders 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 2classification 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 psychiatricdisorders 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.