Transcript הראיון-הפסיכיאטרי ובדיקת המצב

Psychiatric Interview
&
Mental State Examination
Selected Issues
Dr. J. Lereya
Director of the emergency ward
Interview (contrary to
conversation is a special
form of communication
(words, body language)
which is intended for the
achievement of a defined
goal by concentrating on
certain specific themes and
contents while omitting
other, irrelevant, ones.
The interviewer and interviewee
roles are clearly defined and
rigidly fixed.
The Psychiatric Interview Aim:
Collecting information about the
revealed (behavior,
intentions, prospects etc.) as
well as concealed
(emotions, drives, conflicts)
aspects of the interviewee’s
world.
The interviewer as an well trained
and dedicated observer
(signs) and a collector
(symptoms).
Psychiatric Interview Techniques
based on the medical-model
1.
2.
3.
4.
5.
Investigate the circumstances of the referral.
Obtain detailed description of chief complaint.
Obtain detailed description of the disorder’s long-term
history.
Observations which may be clues for physical disease
(goiter, tremor, skin patches etc…).
Past history, etc.
What qualities should psychiatric interviewer
possess in order to accomplish the aims of the
psychiatric interview?
Common stereotypes of a
medic-interviewer:
1. The detective.
systematically examines and
cross-examines his “witness”,
to the tiniest detail:
Dose not skip a detail
but the “witness” might grow
hostile.
2. The Confessor.
Full with sympathy and
compassion for the
“sinner”, eager to protect,
refrains from “difficult”
questions.
* very popular among
patients.
* no systematic
investigation of the
problem.
3. The scientist.
Fills up a standardized
questionnaire based on a
premeditated hypothesis
which, now, should be
verified.
* makes a well made
differential-diagnosis
based on facts.
* misses the complexity of
compound human
conditions.
So who, the hell,
is the a suitable
interviewer?
4. The empathic Medic:
* The detective puts steps into the suspect’s shoes
trying to find out what he would have felt in
such a situation.
* The confessor identifies with the “sinner” in
order to understand him. He actually fills what
the “sinner” fills while expressing love and an
desire to help.
* The scientist sympathizes with his subject
of investigation. In order to understand him he is nice
and friendly and accepts the gathered information and
the interviewee’s point of view as it is presented to him.
so what, the hell,
is empathy?
Empathy is an acquired ability of 2 dimensions:
• The ability to understand (specifically & accurately) the
subjective view-point (emotions, drives, conflicts,
compromises, etc.) of another person, combined with
* The ability to express this understanding in such a way
that the other one fills he is understood.
Interview techniques
1.
Closed vs. Open
(from a talking-questionnaire to an unbounded
(projective) conversation:
* closed: scientific, measures, yields standard
information, ambience of exam (investigation).
* open: stimulates in general, prompting the
interviewee to expose himself and project
conflicts on the interviewer (can you tell me about
yourself ? What
do you think in general about…) .
* half-structured: Tell me about your childhood. Can
you describe you father ? Was he a bad or a good
person ?
2. focused vs. screened
* focusing on a specific event/subject (exploring
suicide attempt/leaving hospital without
permission etc.)
* screening developmental milestones etc.
3. Diagnostic vs. therapeutic
* About 80% of the interview deals with
obtaining suitable information in favor of
comprehensive D.D. procedure.
* The rest can be educative or “amending”
(Have you ever previously had such an
experience? Is the depression you feel today
resembles previous depressive episodes? etc.
The examination of the mental state
General considerations:
A. Be sure to stick with the medic model:
1. You are an observer and collector of signs
and symptom.
2. Each item of the MSE should be examined passively (signs)
and actively (symptoms).
3. Each symptom/sign should be scrutinized.
B. Always keep in mind to examine those items of MSE which may
indicate the possibility of physical disorder or disease
(consciousness, awareness, attention & memory, intellectual
functioning).
C. No psychiatric examination is completed without thorough
examination of suicidal risk (at present and in the past).
The structured MSE
1. Consciousness
2. General Description
* appearance
* motor behavior
* rapport
3. Thought
* form (speech)
* process
* content
4. Perception
* illusions
* hallucinations
5. Mood and Affect
* general expression
* congr/not congr.(situation, content)
* responsiveness
6. Cognition
* intellectual functioning
* orientation
* attention and memory
7. Judgment & reality-testing
8. Insight
consciousness
A.
Full consciousness – AAA
B.
Disordered consciousness (2 types):
1. Dist. in the level of cons. (states of alertness)
Ac. Conf. state → coma
2. Dist. in the quality of cons. (states of awareness)
disturbed cognition (isolated → global)
aphatic-amnestic syndromes → Dementia
General Description of the patient
Beside examining:
A. Physical-emotional appearance
(deteriorated/unsuitable dress, eye-contact, vasomotor changes, etc.).
B. Psycho-motor behavior (agitation, retardation, etc.).
One should pay special attention to:
C. Quality of rapport with the patient:
* Dissimulation vs. evasiveness
* transference, counter-transference.
Disorder of thought
One examines thought indirectly thought a
screen of speech and language:
A. Speech (form of thought, a sign)
B. Thought processes (a symptom)
1. blocking as a sign and a symptom
2. “Pressure of speech” (a sign) as a
possible clinical representation of
either “pressure of thoughts”
(psychosis) or “flight of ideas” (manic
episode).
C. Thought content:
1. Dismantling of the language
(desymbolization of words – neologism –
sentences/words salad – clung association).
2. rigidity of thought
(obsessive thoughts).
3. Delusions
are recognized by four co-existing criteria:
* fixed false belief
* uncorrectable by reasoning
* inconsistent with the patient’s cultural,
educational background.
* cause dramatic change in life
Classification of delusions by their content (most common):
reference, persecution, grandiose, somatic,
etc.
D.D. always investigate the origin of a detected
delusion:
* persecuted for being special/unique etc.
tends to initiate protective acts (a schizophrenic ?).
* persecuted because of being a
inner/guilty/disturbing, etc. tends to withdraw
(depressed ?)
Disorder of perception
* hallucinations
* illusions
Mood and Affect
A.
B.
Do mind the distinction:
(1) mood (a symptom) – The examinee’s report
about his emotional tone over a period of time.
(2) affect (a sign) – The examinee’s
emotional expressions as observed by the examiner
during the examination.
Use the following parameters while evaluating the affect:
(1) passive observation (depressed, disphoric, elated,
labile, flat, perplexed, etc.) and estimation
(congruent/not congruent with the situation/thought
content).
(2) active examination of the examinee’s emotional
responses:
1. to humor (severity of depression, MR)
2. to provocation (level of impulsivity, efficacy of
inhibitions, aggressiveness, dangerousness).
Disorder of cognition
(high level mental functioning)
1.
2.
3.
Intellectual functioning
* General information
* Calculation
* Abstract thinking
using adages is probing one’s
ability:
* to swap concrete and general
* to swap inanimate and human
* to draw a moral/lesson
Orientation
time, place
identification (of oneself and others).
Memory
* immediate (attention, distractibility)
* short (the ability to learn new material.
* long (highly learned material).
Judgment vs. Reality Testing
Judgment
Is the ability (for given social circumstance) to
Perform compound mental process including:
1. Circumstances evaluation with respect to
a required social task.
2. Identification and inspection of various
options (e.g. “in favor” and “against”
considerations).
3. Choosing an option which prompts a
socially (prohibition vs. permission)
and ethically (good vs. evil) normative
response.
Pathology (like illusions):
Reality is acknowledged but
misinterpreted (with respect to
social norms).
J. examination:
1. Does the examinee understands
possible consequences of his
behavior?
2. To what extent his responses are
influenced by his understanding?
3. Imagined situations: Is he able to
anticipate how would he react if, for
example, he found a purse in the
street ? etc.
Reality-testing
is the ability (for given social
circumstances) to perform
compound mental process
including:
1. Distinction between “self” and “non
self”.
2. Distinction between inner and outer
source of stimuli and emotions.
3. Realistic evaluation of emotions,
thoughts, behaviors with respect to
accepted social norms.
Pathology (like hallucinations):
Reality denial combined with genesis of
substitutive reality.