Transcript 8-PSYCHIATRIC INTERVIEW

PSTCHIATRIC INTERVIEW
By
Dr. Rabie A. Hawari
Consultant Psychiatrist
Clinical Assistant Professor
PSYCHIATRIC INTERVIEW
The purpose of interview is:1. to obtain historical perspective of patient’s life,
2. to establish rapport and therapeutic alliance,
3. to develop mutual trust and confidence,
4. to understand present functioning,
5. to make diagnosis,
6. to establish treatment plan.
INTERVIEW TECHNIQUES
- Arrange a comfortable setting with privacy,
- Introduce yourself, greet pt. by name, tell reason of i/v.
- Put pt. at ease, establish rapport by showing
empathy.
- Do not make value judgment.
- Carefully observe pt.’s nonverbal behavior, posture,
mannerisms, and physical appearance.
- Avoid excessive note-making.
- Do not argue or get angry.
Cont. i/v tech.:- Use language suitable with pt.’s intelligence.
- Length of i/v.:- 15-90 mint. ( average 45-60 mint)
less with delirious or uncooperative pt.
more with verbal, cooperative pt.
- Questions:* open-ended Q?- for neurotic, verbal, intelligent pt. “
“tell me more about that.”
* closed-ended Q?- (yes or no) for psychotic, delirium,
dementia, limited-time i/v.
* avoid suggesting answers (you feel depressed, don’t
you?).
PSYCHIATRIC EXAMINATION
Psychiatric Examination
Consist of two parts:History:- is the chronologic story of the
pt.’s life from birth to present .
Mental Status:- is a cross-section of
pt.’s psychological life and represents the
sum total of the psychiatrist’s observation
and impressions at the moment, and for
future comparison.
Psychiatric History
Identifying data:- name, age, sex, religion,
marital status, education, address, occupation,
source of referral and information.
Chief complaint (cc):- brief statement in “ pt.’s
own words” of why he is in hospital or seen in
consultation. “ what seems to be the problem?”.
cont. psych, hx.:-
History of Present Illness (hpi):- development of
symptoms from time of onset to present,
relationship to events, stressors, drugs, change
from previous level of functioning. h/o previous
hospitalization and treatment.
Past Psychiatric / Medical Illness:- psychosomatic,
medical, neurological illness, extent of illness,
treatment, outcome, hospital etc.
Cont. psych hx.:-
Family History:- age of parents & occupation, if
deceased.. date & caused, separated, no. of
siblings, pt.’s birth order, feelings about each
member, psychiatric & medical hx. medications
hx. finances.
Cont. psych. hx:-
Personal History:-
* Birth & Infancy:- hx. of pregnancy delivery as known by pt.,
developmental landmarks- standing, walking, talking,
temperament.
* Childhood:- feeding habits, toilet training, conduct and behavior,
personality- shy, outgoing
relationship with parent or caregivers, peer. Fear,
separation, night-mares, bedwetting.
* Adolescence:- peer & authority relationship, school, drug
use, puberty.
* Adulthood:- work, career, marriage, children, education,
finances, religion, legal record.
Cont. psych hx.
Sexual History:- sexual development, orientation,
masturbation, anorgasmia, p.m.ejaculation.
“ How did you learn about sex?”… “ are there or
have there been any problems or concerns
about your sex life?”.
Premorbid personality:- sociable, extrovert,
friends, hobbies, habits, tense, anxious, short
tempered, perfectionist, easy going, other’s
opinion.
Mental Status
General Appearance:note appearance, gait, dress, grooming (neat or unkempt),
posture, gestures, facial expressions. Does pt. appear older
or younger than stated age?.
introduce yourself, direct pt. to take a seat.
* unkempt and disheveled  organic mental disorder,
* pin-point pupils  narcotic addiction,
* withdrawn psychomotor retardation  depression.
Cont. MSE.
Behavior :Activity – psychomotor agitation or retardation,
Emotional – anxious, tense, panicky, sad,
Voice – loud, hoarse, faint,
Eye – contact,
Other behavior – tics, tremors, mannerism, negativism,
automatism, apraxia, echopraxia,
* fixed posturing, odd behavior schizophrenia,
* hyperactive mania, stimulant (cocaine),
* hypoactive depression,
* tremor anxiety.
Cont. MSE.
Attitude during i/v:How pt. relate to examiner – irritable, aggressive, seductive
guarded, defensive, apathetic, cooperative, sarcastic
* suspiciousness  paranoia,
* seductive  hysterionic traits,
* apathetic  Organic Mental Disorder
- Q? “ you seem irritated about some thing, is that an
accurate observation?”.
Cont MSE.
Mood:-
Steady or sustained emotional state – gloomy, tense, sad,
hopeless, elated, happy, depressed, resentful, anhedonic
Qs?:- “ How do you feel?”, - “ How are your spirits?”,
- “ Do you have thoughts that life is not worth living?”
- “ Do you have plans to finish your own life?”,
* suicide in 25% of depressed pt.
* elation  mania.
Cont. MSE
Affect:Feeling tone associated with idea – labile, blunt, flat,
appropriate to content, inappropriate, la belle
indifference.
* changes in affect  schizophrenia.
Speech:Slow, fast, pressured, mute, spontaneous, aphasia, pitch,
Paucity, slurred.
* pressured  manic. - Slurred  Organic Mental
Disorder
* paucity  depression.
Cont. MSE.
Perceptual disorders:- Hallucinations (olfactory, auditory, tactile, gustatory,
visual). – Illusions. – Hypnopompic or Hypnagogic.
- déjà vu, macroposia, feelings of unreality.
* Hallucin. Visual  organicity - auditory  schizophrenia
- tactile  cocaine, delirium tremens (DT).
Q?:- ‘ Do you ever see things or hear voices when alone
and no one else can see or hear?’
- ‘ Do you have strange experiences as you fall asleep
or upon awakening ?’
Cont. MSE.
Thoughts Disorders:a- Forms:- goal directed, loose of association, flight of
ideas, circumstantial, knight’s move, derailment, clang
association, perseveration, ability to abstract.
* loose of association  schizophrenia,
* flights of idea  mania.
* inability to abstract  SZ. & Organic Mental Disorder.
Q? – proverbs ‘ people in glass houses should not throw
stones’
- similarity ‘ car and train’ (transportation)
Cont. MSE
Thoughts Disorders:b- content:- Delusions –(persecutory, paranoid, guilt,
grandiose, nihilistic, infidelity, hypochondriasis). -Thought broadcasting or insertion. – ideas of reference.
– obsessions.– suicide or homicide ideas.
* Delusion congruent with mood  grandiose = elated.
* Mood-incongruent delusion  schizophrenia.
Qs? – ‘Do you feel people want to harm you?’
- ‘ Do you have special powers?’
- ‘ Are there thoughts that you can’t get out of your
mind?’
Cont MSE
Sensorium :consciousness – alert, confused, clouded,
stuporous, comatose. – orientation ( T.P.P).
Qs? – ‘ What place is this?’, – ‘ What is the date?’
- ‘ Do you know who I am?’.
* clouded consc.  Organic Mental Disorder
* orientation to person remain intact longer
than time or place.
Cont. MSE
Sensorium (cont.):-
Memory:Remote (long-term) :Qs?. – ‘ where were you born?’ – ‘ Date of marriage?’
* Alzheimer’s  remote remain longer than recent.
* confabulation  filling gaps in memory.
Recent :Qs?. – ‘ where were you yesterday?’.
* organic mental diso.  recent lost before remote.
Immediate (short-term):Qs?.- Name 6 digits forward then backward. Remember 3 non-related items
after 5 minutes.
* loose of memory  anxiety, dissociative, conversion, organicity
* anterograde M. loss  drugs e.g. Benzo
* retrograde M loss  after trauma.
Cont. MSE
Attention & Concentration:-
Qs?.- ‘ days of the week’ – ‘ serial 7 (100 – 7 ) and keep
subtracting’ – ‘ simple math ( 3+4 )’
* poor  anxiety, depression. * impaired  OMD.
Knowledge:-
Qs?.- ‘ Name the last 3 kings’ – ‘ Capital of UAE’
* check educational level to r/o mental retardation.
Judgment:-
ability to understand relationships b/w facts and draw
conclusions.
Qs?.- ‘ if you find an envelopment in the street that is sealed,
stamped & addressed what are you going to do with it?
* impaired  OMD, schizophrenia, intoxication, low I.Q.
Cont. MSE
Insight:= realize that he/she has an illness,
= is it physical or mental problem?,
= dose it need treatment?.
Qs? - ‘ Do you think you have a problem?’
- ‘ What could the nature of the problem?’
- ‘ Do you need treatment?’
* Impaired  OMD, pychosis, low I.Q.
MEDICAL AND NEUROLOGICAL
EXAMINATION
Medical & Neurological examination:Some psychiatrics disorders may have an organic cause.
therefore neurological and/or medical examinations and
investigations my be indicated in most cases
examples;* Medical Psychosis  Thyrotoxicosis, Cushing’s d.,
intoxication, anticholinergics.
* Medical  Depression  DM, Flu, Hypothyroidism, Ca.
SLE,Hepatitis,Hypoglycemia.
* Drugs  Depression  Antihypertensive(Reserpine),
Levodopa, Hormones,
cortisone.