Transcript Psychiatry: Clinical Propedeutics

Communication Skills for Psychiatry
Lucie Bankovská Motlová
Basic Skills
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Observe
Listen
Inquire
Judge
Generall Skills in Inteviewing
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eye contact
relaxed posture
not appear hurried
picking-up verbal and non-verbal cues of
distress
• dealing with over-talkativeness
• dealing with reslessness and agression
Establishing Rapport
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welcome the patient
state purpose of the meeting
privacy
basic human comforts
calming and respectful demeanor
encourage open communication
acknowledge and validate patient´s
distress/concerns
Phases of the Interview
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Warm-up
Screening of the problem
Follow-up of preliminary impressions
Completion of data base
Feedback
Treatment contract
Interviewing Techniques
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Establish rapport as early in the interview as
possible.
Determine the patient’s chief complaint.
Use the chief complaint to develop a provisional
differential diagnosis.
Rule the various diagnostic possibilities out or in
by using focused and detailed questions.
Follow up on vague or obscure replies with enough
persistence to accurately determine the answer to
the question.
Interviewing Techniques
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Let the patient talk freely enough to observe how
tightly the thoughts are connected.
Use a mixture of open-ended and closed-ended
questions.
Ask about suicidal thoughts.
Give the patient a chance to ask questions at the
end of the interview.
Conclude the initial interview by conveying a sense
of confidence and, if possible, of hope.
Supportive Interventions
• Encouragement. Patient: I am not very good at putting things into
words.
• Doctor: I think you have described the situation very well.
• Reassurance. Doctor: I can understand how those experiences
must have frightened you, but I think it is very likely they'll respond
to treatment.
• Acknowledging emotion. Doctor: Even now it brings tears to your
eyes when you talk about your mother.
• Nonverbal communication. Body posture and facial expression
that convey interest, concern, and attentiveness.
Obstructive Interventions
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Closed-ended „double“ questions
Doctor: Have you experienced any change in your appetite and sleeping?
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Judgmental questions.
Doctor: How do you think your wife felt when she found out about your affair?
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Not following the patient's lead.
Patient: I have trouble sleeping through the night.
Doctor: Any change in appetite?
Patient: I keep waking up out of nightmares about my daughter.
Doctor: Do you have less energy than usual?
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Minimization or dismissal.
Patient: I'm not able to keep my checkbook balanced the way I need to.
Doctor: Oh, I wouldn't worry about it. Lots of people don't even try.
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Premature advice.
Patient: Work is almost unbearable. My supervisor watches me like a hawk and criticizes the
tiniest little mistake I make.
Doctor: Why not write her a memo and outline your grievances?"
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Nonverbal communication.
Yawning, checking one's watch. Patients can often detect an interviewer's inattention by the
absence of facial expression or body movement.
Special Clinical Skills
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Acute psychosis
Acute psychosis with agression
Dementia
Mania
Depression
Suicidal patient
Stupor
Acute Psychosis
Video: „Nemesis“
Psychotic patient: Rules for Communication
how
why
Use short sentences
Short attention span
One sentence, one information
Information processing disorder
Use models, draw, write and
repeat frequently
Memory and attention problems
Do not speak out delusions, pay Delusion cannot be corrected
attention to emotional problems by reasoning, but usually is
connected to delusion
distressing
Dealing with Acute Psychosis
with Agression
Video: Management and
treatment of acute psychosis
Dementia: Rules for Communication
Dementia screening:
• „What is your birthday?“
• „How old are you?“
Close-ended short questions
Video:
Mr B with Bartoš
Useful tests:
• Clock Test
• MMSE (Mini Mental State Examination)
Clock Test: 2:45
Video
Clock test: 0 point
Normal
Mild Cognitive
Disorder
Moderate Cognitive
Disorder
Severe Cognitive
Disorder
Mania
Video: Renata
Mania: Rules for Communication
• Keep calm, low voice
• Do not argue with the patient
• If patient uses vulgar expressions, ask
him not to do so
• If patient does not cooperate, do not
continue with the interview
Depression: Rules for Communication
• Structured communication, short sentences
• Do not regret the patient and do not try to tell
him jokes to make him laugh
• Ask about apetite, loss of weight and
sleeping pattern
• Ask about hopelessness feelings
• Ask about suicidal thougts, ideas and plans
Suicide: Questions
• Have you ever felt that life was not worth living?
• Did you ever wish you could go to sleep and just
not wake up?
• Have things ever reached the point where you
´ve thought about harming yourself?
• When did you first notice such thoughts?
• Have you made a specific plan to harm or kill
yourself?
• If so, what does the plan include?
Source: APA Practice Guidelines for Assessment of Patients with Suicidal behaviors
Risk of Suicide Assessment
S sex: male
A age: >45, <19
D depression
P previous attempts
E ethanol abuse
R rational thinking loss (psychosis?)
S social suppot lacking
O organized plan
N no spouse
S sickness (somatic illness with pain)
Management
Each positive answer = 1 point
Write it to the
medical record!
• 0-2: low risk
• 3-4: medium risk; outpatient treatment,
observation
• 5-6: high risk; hospitalization, especially in
cases without social support
• 7-10: very high risk; hospitalization
Stupor
• Somatic condition
• Dehydration, bedsores, embolia