Transcript Document 723396

Mental state assessment
Dr hab. med. Wiktor Drózdz
Basic contradiction
during psychiatric examination
need to establish
interpersonal relationship
with a patient
OR
need to obtain data
necessary for
diagnosis
and intervention
Patients do not always cooperate
• Open refusal to comply during examination of mental state
• Problem of „shame cooperation”
Mental state examination
• Crucial circumstances:
– conversation in a quiet room with no other
persons
– TIME
• Format: interview + observation of behavior
• Additional information:
– Medical documents
– General medical examination
– Lab tests
– Inteview with near relative, friend or somebody
who has observed patient (hospital staff)
Five Phases of the Psychiatric Interview
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Phase 1: Warm-up and Chief Complaint
Phase 2: The Diagnostic Decision Loop
Phase 3: History and Database
Phase 4: Diagnosing and Feedback
Phase 5: Treatment Plan and Prognosis
Mental state examination
aspects that must be considered
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Reason for examination
Current mental health problem and course of the problem
Somatic interview
Interview toward substance abuse/other forms of addiction
Interview concerning past psychosocial development
Interview concerning past social functiong
Interview concerning past school/occupational functiong
Family interview
Current general medical sufferings
General medical examination
Examination of current mental state
Current level of functiong in social roles
Lab tests performed lately
Impressions from the examination
Openers
• Opening questions or statements target a problem of
varying scope.
• Narrow scope: “What troubles bring you here to see me?”
– The interviewer expects a prioritized brief list of difficulties.
– Problem: The patient rambles.
– Solution: The interviewer narrows the scope of the question or
curbs the response. For instance (if patient cooperates):
— P: (Responds with a long list of events that went wrong in
his or her life).
— I: Just tell me what problem has troubled you most during
the last 3 days.
— P: That I can't sleep.
• Broad scope: “Give me a sense of how your life is going.”
Continuation
• The interviewer tends to the patient's talk by
raising eyebrows or uttering hmmms to signal to
the patient nonverbally to continue. If his or her
nonverbal signals get ignored the interviewer
may use short tracking phrases, such as
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“And?”
“Then what?”
“How is that?”
“That's interesting,” “
“Really?”
“Oh, no!”
to reward the patient with his or her attention
and to encourage the patient to continue.
Five Ws of interviewing
• What?
• When?
• Where?
• Who?
• Why?
Cues in psychiatric examination
• Verbal
– Vocabulary
– Fluency?
– Narration: structuralised? informative?
• Non-verbal
– eye contact
– facial expression
– gesticulation, body language
– cadence, intonation
– dress code
Methods to gain information
1.
2.
3.
4.
Conversation
Additional sources of information
Application of structuralised tools
Application of medical tests: EEG, MRI, urine test
for psychoactive compounds, MDD Score(?)
5. Cooperation with other physicians/health care
workers
6. Examination of medicated/intoxicated patient
and/or under constraint (i.e. in emergency)
7. General medical examination
Some suggestions concerning
interview
• Decrease patient’s anxiety, create feeling of
comfort
• Decrease your own anxiety
• Be patient, be commiserate and consolate
• Things to be avoided:
– Confrontation/argument
– Medical jargon, scientific jargon, sophisticated
terminology, weird sentences
– Jokes (but sense of humour is OK)
• Extract the time as much as possible
• Learn from patients
• Create adequate type of conversation
OCET
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Observation
Exploration
Conversation
Testing
Mental state assessment
1. Appearance, attitude & behavior
2. Cognitive status: awareness, memory,
attention, IQ
3. Disorders of perception
4. Thought disorders
5. Obsessions and compulsions
6. Speech disorders
7. Mood, affect and emotions
8. Psychophysiological (vegetative) symptoms
9. Stressful life situations
10. Suicide risk assessment
1. Appearance (O)
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Well-groomed? dowdy?
Reek of sweat? of alcohol?
Needle marks?
Scars (on forearm, wrist)?
Inappropriate attire?
Missing eyelashes, eyebrows, hair?
Bitten-off nails?
Reddened, chapped hands?
Excessive piercing or tattoos?
1. Patient attitude
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Cooperative? Frank?
Eye contact: appropriate?
Withdrawn? Defensive?
Anxious?
Hostile? Angry?
Too friendly? Evasive?
Suspicious? Distrustful? Seductive?
Claim?
Apathetic?
1. Insight & criticism
• Slight awareness?
• Blames others?
• Complete denial?
Level of cooperation:
» Withdrawn?
» Guarded?
» Passive?
» Acting Out?
» Oppositional?
» Hostile?
1. Insight & criticism
• awareness of morbid change in oneself and a
correct attitude to this change including a
realization that it indicates for a mental disorder
– Is the patient aware of phenomena that others have
observed?
– If so, does he recognize the phenomena as abnormal?
– If so, does he/she consider that they are caused by
mental illness?
– If so, does he/she think that treatment is needed?
• degree of insight indicates whether a patient is
likely to comply with treatment.
1. Insight & criticism
• ANOSOGNOSIA present in:
– Psychosis
– Dementia
– Mania
– Dependence
– Anorexia
1. Motor activity
• Slowed
• Restless
• Agitated
1. Psychomotor disturbances (O, C, T)
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Rigidity
Tremor
Tics (motor, vocal)
Restless fidgeting,
mannerisms
Choreatic, athetotic
movements
Buccolingual movements
Catalepsy
Opposing movements
Echopraxia
• Pseudoaphonia,
pseudoparalysis,
pseudoseizures
• Avoidance of touching
• Apraxia
• Seizures
• Cataplexy
• Micrographia
• Stereotypical movements
• Picking
1. Dangerous?
• DANGER TO OTHERS:
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Violent temper
Threatens others
Physical abuser
Hostile
Assaultive
Homicidal ideation, homicidal threats, homicide attempt
• DANGER TO SELF:
– Self-injury
– Self-mutilation
2. Consciousness (O, T)
• Consciousness - awareness of the self and the
environment. Orientation:
– personal
– external (time, place, situation)
• Hyperalertness?
• Lethargy? Stupor? Coma?
2. Confusion & delirium
• Confusion- an inability to think clearly.
It occurs in states of impaired consciousness but
may occur when consciousness is normal.
• Clouding of conciousness?
• Delirium?
• Confused: periodically? permanently?
2. Stupor
• the patient is immobile, mute, and
unresponsive but appears to be fully
conscious (eyes are usually open and
follow external objects), reflexes are also
normal and resting posture is maintained
2. Memory
• Immediate memory - the retention of information over a
short period measured in minutes.
• Recent memory - events that took place in last few days.
• Long term memory - events over longer periods of time.
• Ecmnesia?
• Hypermnesia?
• Confabulation- reporting memories as current events, or
fulfilling memory gaps with description of events that
never took place. It is characteristic for amnestic
syndrome.
• Criticism toward memory dysfunctions preserved?
2. Attention
Concentration: ability to focus the attention
•Impaired concentration may be present in a
wide variety of psychiatric disorders i.e.
depression, mania, anxiety, schizophrenia
and delirium
•It is crucial symptom of ADHD
2. Cognitive functions assessment
• Digit Span (forward and reverse):
– “I will recite a series of numbers to you, and then I will ask you to repeat
them to me, first forward and then backwards.” [Begin with 3 numbers – not
consecutive numbers, and advance to 7-8 numbered sequence.]
• Spelling Backwards:
– “Spell the word ‘world.’ Now spell the word ‘world’ backwards.”
• Calculations:
– (Serial 7’s) “Starting with 100, subtract 7 from 100, and then keep subtracting
7 from that number as far as you can go.”
– (Serial 3’s) “Starting with 20, subtract 3 from 20, and then keep subtracting 3
from that number as far as you can go.” [Monitor for speed, accuracy, effort
required, and monitor patient reactions to the request]
– “Add these numbers: (15 + 12 + 7)”
– “Multiply these numbers: (25 x 6)”
2. IQ
• Approximate assessment of intellect
important in patients with intellectual
disability
– Mild
– Moderate
– Severe
3. Disorders of perception
• Illusions: perception of a real object or
event, which is misinterpreted. May be
present in delirium
• Hallucinations: sensory perceptions
occuring without external stimuli
– Auditory, visual, tactile, olfactory, gustatory
– Complexity: elementary or complex
– Pseudohallucitations: identified in patient’s
psychic space. Real hallucinations: identified
in external space
3. Disorders of perception
• The most common hallucination are auditory
hallucinations, usually in the form of voices.
• Voices talking to each other about the patient, and
voices commenting about the patient‘s ongoing acting or
thinking, are considered to be typical to schizophrenia
(third-person hallucination).
• Voices which anticipate, speak or repeat (echo of
thoughts) the patient’s thoughts also suggest
schizophrenia.
3. Disorders of perception- examples
• „I can see a snake in the corner”- in fact it
is a length of rope.
Illusion
• „I can hear some people talking with each
other about my very private affairs just
outside of the room” – other people in the
same room hear nothing.
Auditory hallucination (third-person)
4. Thinking (C, E, T)
• Linear, logical?
• Goal-directed?
4. Thought disorders
• PACING:
– increased? decreased?
• CONTENT:
• FORM:
– Coherent thinking?
– Incoherent? loosening of associations,
lack of consistency, chaotic
4. Thought disorders
• Disorders of content of thinking
(adequacy): delusion- a belief that is firmly
held on inadequate grounds, it could not
be affected by rational argument or
evidence to the contrary, and is not a
conventional belief that the person might
be expected to hold given his/her
educational, cultural and religious
background. Briefly- a false unshakable
belief hold against the evidence
4. Thought disorders
• Delusional mood is preceding unclear
conviction that some as yet unidentified
change or event is about to take place,
then the delusion follows, and the delusion
is perceived like explaining of this mood.
• Delusional perception is the attaching the
new significance to a familiar percept
without any rational reason.
• Delusional memory is a delusional
interpretation attached to past event.
4. Thought disorders: types of delusions
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Paranoid
(bizarre)
persecutory
delusion of reference
delusion of control
thoughts insertion
thoughts withdrawal
thoughts broadcasting
delusions of marital
infidelity
Affective (mood
congruent & coherent)
• Depressive: guilt,
punishment, catastrophic,
hypochondric,
• Maniacal: grandiosity,
charismatic, exceptional
abilities/features
4. Thought disorders: paranoid
• The most common theme of delusion is
persecution
– The patient believes/is sure that some persons
or organizations are trying to inflict harm on the
patient, damage his/her reputation, or make
him/her insane.
4. Thought disorders: paranoid
• Delusion of reference
– the unwarranted idea based upon a trivial occurrence
(e.g. the person at the next table looked at the patient)
that a person is talking about you, watching you, or
noticing you (the belief continues in spite of no evidence
supporting the belief)
– the idea that objects, events or people have a personal
significance for and association with the patient (usually
of very strong intensity) but in fact these events, objects
or people (also: messages in TV, internet, news) have in
common with the patient
4. Thought disorders: paranoid
• Delusion of control: beliefs that patient’s actions,
movements or thoughts are controlled by an
external agency, people or power and not driven
by himself/herself
• Delusion of possession of thoughts: i.e. thoughts
insertion (thoughts are not the patient’s own but
implanted from outside), thoughts withdrawal
and thoughts broadcasting (due to lack of
normal convictions that thoughts are private and
cannot be shared unwillingly)
4. Thought disorders: paranoid
• Thought insertion – insertion of a thought
into one’s mind by an outside agent
• Thought withdrawal – having one’s
thought withdrawn from one’s mind
• Thought broadcasting – being able to
broadcast one’s thoughts
4. Thought disorders: maniacal delusions
• Grandiose delusions: beliefs of
exaggerated self-importance
• Charismatic delusions: beliefs of kind of
mission, special task and exceptional
abilities to do this
• Delusion of power: the patient is sure to
have extraordinary strengths and
capacities and therefore does not need to
care for money, rules, other people etc.
4. Thought disorders: depressive delusions
• Guilty delusions: beliefs of deep, unbearable
sinfulness
• Punishment delusions: beliefs of penalty which is
impossible to avoid because of great fault (without
real reason)
• Catastrophic delusions: beliefs that everything
has gone wrong and there is no future due to lack
of money, house, family etc.
• Hypochondric delusions: beliefs of serious (even
fatal) illness without evidence of disease
4. Thought disorders
• Overvalued idea: an acceptable
comprehensible idea pursued by the patient
beyond the bounds of reason.
– The content of the overvalued idea is usually
understandable and acceptable considering the
person’s background
• Hypochondria: preoccupation with (usually
exagerrated or unreal) problems associated
with organism and health
4. Thought disorders
• In pressure of thought: occurs in mania, ideas
arise in unusual variety and abundance , thought
pass through the mind rapidly.
• In poverty of thought which occurs in
depression, the patient has few thoughts and
these lack variety and richness , thoughts seem
to move slowly through the mind.
• In thought block the stream of thoughts is
interrupted suddenly, and the patient feels that
his mind has gone blank. It suggests
schizophrenia
4. Formal thought abnormalities
• Paralogy: ignoring rules of logic and common
sense
• Metonyms (paraphasia): words used in a new,
private and unconventional way
• Ambivalency
• Catathymia
• Evasive, racing thinking, flight of ideas
• Blocking
• Perseveration: persistent and inappropriate
repetition of the same thought content
4. Formal thought disorders
• Loose associations, incoherent thinking,
derailment (ideas slip off the track and onto
another one that is obliquely related): a loss of the
normal structure of thinking; thinking (constantly)
missing the point and senseless; rules of syntax
and grammar are ignored
– Example: „My friend has an electric-radio receiver, but
he never told me where it is. In fact, I have been to
nuclear power plant, and there is nothing dangerous”
• Circumstantiality (inclusion of too many trivial
details, seriously indirect)
• Tangentiality (oblique or irrelevant answers)
4. Thought disorders
• Derealization: feeling that the world surrounding is
unreal/substantially changed in some alien way
• Depersonalization: feeling that the body and/or
personal identity is
unreal/substantially changed/lost
both may be associated with
anxiety or psychosis
Examples of questions about
thought disorders
• “What’s been on your mind lately?”
• “Do you find yourself ruminating about things?”
• “Are there thoughts or images that appear really difficult if
getting out of your head?”
• “Are you worried/scared/frightened about something or sb?”
• “Do you have beliefs that are not shared by others?”
• “Do you ever feel detached/removed/changed/different from
others around you?”
• “Do things seem unnatural/unreal to you?”
Examples of questions about thought
disorders & hallucinations
• “Do you think someone or some group intend to harm you in some
way?”
• [In response to something the patient says] “What do you think they
meant by that?”
• “Does it ever seem like people are stealing your thoughts, or perhaps
inserting thoughts into your head? Does it ever seem like your own
thoughts are broadcast out loud?”
• “Do you ever see (visual), hear (auditory), smell (olfactory), taste
(gustatory), and feel (tactile) things that are not really there, such as
voices or visions?” (Hallucinations are false perceptions)
• “Do you sometimes think that real things around you, such as muffled
noises or shadows may denote something special?” (Illusions are
misinterpreted perceptions)
5. Obsessions & compulsions
• Obsessions: recurrent persistent thoughts,
impulses, or images that enter the mind despite
efforts to exclude them. Obsessions are regarded
as untrue, useless, or senseless.
• The characteristic feature of obsessions is the
subjective sense of a struggle, the patient resists
the obsession, which nevertheless intrudes into
awareness.
• There may be obsessional thoughts, ruminations,
impulses or doubts
5. Obsessions & compulsions
• Compulsions: repetitive purposeful
behaviors, performed in a stereotyped way
(which is also called compulsive ritual), in
response to an obsession.
• Recognized as absurd and senseless but
the compulsive behavior must be carried
out: checking, cleaning, counting, dressing
• Compulsive behavior transiently reduces
the anxiety associated with the obsession
5. Questions about obsessions &
compulsions
• Have you ever been bothered by certain
embarrassing, scary, or ridiculous thoughts that
came into your mind over and over even though
you tried to ignore or stop them?
• If yes: Please describe them.
• Have you ever felt you had to repeat a certain act
over and over even though it did not make much
sense? Like checking or counting something over
and over or washing your hands over and over
again, although you knew they were clean?
6. Disorders of speech
• Quantity:
– talkative, spontaneous, expansive, rapid
– paucity, poverty of speech – restriction in the amount of
spontaneous speech
– (poverty of content of speech – speech that conveys little
information even though amount is adequate)
• Rate:
– Fast, slow, hesitant, pressured?
• Volume (tone):
– Loud, strong, soft, monotonous, mumbled, weak?
• Fluency and rhythm:
– slurred, clear, with appropriately placed inflections,
hesitant, with good articulation, aphasic?
6. Disorders of speech (C, E, T)
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Dysarthria
Stuttering, stammering
Vocal tics
Aphasias
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Lack of coherence
Neologisms
Ambisentences
Poverty of speech
• Clang association
(choice of words based
on their sounds)
• Verbigeration
• Echolalia
• Word salad
7. Affect & mood disorders
(O, C, E, T)
• Mood - prevailing and prolonged emotional
state that determines a person’s overall
perception, feeling, thinking and behaviour
for a considerable period of time:
– Elevated
– Decreased
– Dysphoric
7. Affect & mood disorders
• Affect - short-lived and changeable
emotions that emerge in immediate
reaction to a particular aspect or object &
expression of a subjectively experienced
feeling state (emotion)
– Appropriateness to situation?
consistency with mood?
congruency with thought content?
– Fluctuations: labile? even?
– Range: broad? restricted (flat, blunted)?
7. Mood disorders
• Depressive mood is abnormal when it is
out of proportion to the misfortune, or is
unduly prolonged. Usually associated with:
– Lowering self-esteem
– Pessimistic or negative thinking
• Anhedonia: marked reduction or loss of the
experience of pleasure.
7. Mood disorders: questions about depression
• Have there ever been times when you felt
unusually depressed, empty, sad, or hopeless for
several days or weeks at a time?
• Have there ever been times when you felt very
irritable or tired most of the time for hardly any
reason at all?
• Have there ever been times when you felt no or
markedly decreased satisfaction and pleasure
doing things which usually were pleasant for you?
• Have these feelings ever stayed with you most of
the time for as long as 2 weeks?
7. Mood disorders
• Elation - an extreme degree of happy mood
often coupled with other changes, including
increased feeling of
– self-confidence
– well-being
– increased activities
• Dysphoria: angriness as a dominant
emotion and type of reaction; usually
associated with tendency for agression
7. Mood disorders- mania
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Distractible
Irritability
Grandiosity
Flight of ideas
Activity (increase)
Sleep (decrease)
Talkative
7. Mood disorders: questions about mania
• Have there ever been times when you felt
unusually high, charged up, excited, or
restless for 1 week at a time?
• Have there ever been times when other
people said that you were too high, too
charged up, too excited, or too talkative?
• Have these high, excitable moods ever
stayed with you most of the time for at least
1 week?
7. Mood & emotions disorders
• Anxiety is abnormal when its severity is out
of proportion to the threat of danger or
when it outlasts the threat.
– Mental symptoms of anxiety: restlessness,
narrowing attention, worrying thoughts,
increased alertness and irritability
– Somatic (vegetative) symptoms of anxiety:
tachycardia, sweating, dread, tachypnoe
(hyperventilation) and/or feeling of suffocation,
muscle tension, urge to urinate or defecate
7. Mood & emotions disorders
• Types of anxiety disorders:
– Panic attacks
– General anxiety (long-lasting worrying)
– Phobias:
• intense, unreasonable fear associated with some
situation or object
• simple or complex
7. Questions about panic attacks
• Have you ever had sudden spells or
attacks of nervousness, panic, or a strong
fear that just seems to come over you all
of a sudden, out of the blue, for no
particular reason?
• If yes: Did you have these attacks even
though a doctor said that there was
nothing seriously wrong with your heart?
7. Questions about generalized anxiety
• Have there ever been days at a time when
you felt extremely nervous, anxious, or tense
for no special reason?
• If yes: Have you sometimes felt this way
even when you were at home with nothing
special to do?
• If yes: Have these nervous or anxious
feelings ever bothered you off and on for as
long as 6 months or more at a time?
7. Questions about phobias
• Have you ever been much more afraid of things the
average person is not afraid of? Like flying, heights,
animals, needles, thunder, lightning, the sight of blood, or
things like that?
• Have you ever been so afraid to leave home by yourself
that you would not go out, even though you knew it was
really safe?
• Have you ever been afraid to go into places like
supermarkets, tunnels, or elevators because you were
afraid of not getting out?
• Have you ever been so afraid of embarrassing yourself in
public that you would not do certain things most people do?
Like eating in a restaurant, using a public restroom, or
speaking out in a room full of people?
• If yes to any of the above: When your fears were the
strongest, did you try to avoid or stay away from (name
feared stimulus) whenever you could?
8. Vegetative (psychophysiological) disturbances
aka medically unexplained symptoms
Abnormalities of:
– Sleep
– Appetite
– Sex
– Pain
Questions about MUS:
• Have you had a lot of physical problems in your
life that forced you to see different doctors?
• If yes: Have doctors had trouble finding what
caused these physical problems?
8. Questions about anorexia & bulimia
• Have you ever deliberately lost so much weight on a diet
that people started to seriously worry about your health?
• If yes: Were you afraid of getting fat even when other
people said you were thin enough?
• Did you ever have a problem with binge eating, when you
would eat so much food so fast that it made you feel sick?
• If yes: When you were doing this, did you feel your eating
binges were not really normal?
• If yes: Was the urge to binge sometimes so strong that you
could not stop, even though you wanted to?
• If yes: Did you ever vomit after eating, use laxatives, or
excessively exercise?
9. Stressful events: current and past
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Unemployment
Bad financial situation
Legal problems
Loss of close relative, health, reputation,
social position
• Substantial change of life situation, i.e.
marriage/relationship breakdown
• Rape, sexual harrasment
10. Suicide risk assessment: levels
1. Suicidal thoughts (passing through)
2. Suicidal ideations:
a. Unspecific (exploring possibility)
b. Precise
3. Suicidal preparations: collecting drugs,
choosing place for fall, etc.
4. Farewell: testimony, dispensing things,
good-bye letters (tweets, sms),
unexpected reconcile with enemies etc.
10. Suicide risk assessment
• It is NOT true that:
– Patient considering suicide does not want to
talk about it
– Open talking about suicide increases risk of
sucide attempt
• It is true that c.a. 70% suicide victims
visited a doctor in a month before an
attempt
10. Suicide risk assessment
• Risk factors for sucide
– Male gender
– Psychosis and/or depression
– Substance dependence
– Loneliness (lack of a social support )
– Insomnia
– Chronic intractable pain
– Serious stressful situation, loss of sb or sth
very important for patient
– Age: teen or elderly
– History of sucicide attempts and or familial
history of suicide
The ICD-10 definition of mental disorder
• Clinically recognizable set of symptoms
and/or behaviors associated in most cases
with distress and worsening personal
functions.
• Important: social deviance or conflict alone,
without personal dysfunction, should not be
included in mental disorder
DSM-IV
– Axis I- clinical syndromes
– Axis II- developmental/personality problems
– Axis III- general medical problems
– Axis IV- social and environmental problems
– Axis V- level of social adjustment (GAFGlobal Assessment of Functioning: 0- 100)
Family History
• Psychiatric Axis I and II disorders are familial.
Monozygotic twin and adoption studies suggest
that the familial occurrence is not merely learned
but follows a genetic disposition.
– having a parent with bipolar disorder, for example,
raises the patient’s risk of developing the same disorder
by at least 7-fold
• The familial occurrence in first-degree relatives
and their treatment response can therefore
confirm the patient's diagnosis and predict the
treatment response.
• Therefore, family history is the most important
predisposing factor of the biological part of the
patient's biopsychosocial condition.
Developmental History
Even if a psychiatric diagnosis during childhood or
adolescence is not made, the interviewer should
consider five important areas:
• Developmental milestones: delayed psychomotor and
speech development and toilet training may point to
early developmental problems.
• Ability to learn in school: slow learning or repetition of the
first grade may point to mental retardation; circumscribed
deficits, such as dyslexia or acalculia, may indicate a
learning disorder.
• Attention problems with hyperactivity and poor impulse
control may contribute to substance abuse and to the
development of a personality disorder, such as antisocial
personality disorder.
Developmental History
• Disciplinary problems may cover a broad range. Arguments with
teachers, objections to rules, temper tantrums, resentfulness,
and vindictiveness point to oppositional defiant disorder.
Fighting, stealing, vandalism, and school discipline problems
characterize males; lying, truancy, running away from home,
substance use, and prostitution characterize females with
conduct disorder. Furthermore, symptoms such as violent
behavior toward superiors, peers, or animals and fire setting also
suggest conduct disorder, which, in later adolescence, may
progress to antisocial personality disorder. The earlier the onset
of conduct disorder, the worse the prognosis and the greater the
risk for later mood, anxiety, somatoform, and substance-related
disorders.
• During childhood and adolescence, social withdrawal with
decline in hygiene, truancy, and anger outbursts may herald
schizophrenia; phobias, obsessions, compulsions, and
depressive symptoms may precede adulthood psychiatric
disorders.
Medical History (Axis III)
• The medical history is of importance to the
psychiatric interviewer for three reasons:
(1) medical disorders can cause symptoms of
panic, anxiety, depression, and delusional
thinking diagnosed as “psychiatric disorder due
to a medical condition;”
(2) side effects of medications prescribed for
medical disorders may mimic psychiatric
symptoms and disorders;
(3) any medical disorder and its treatment can
complicate course and treatment of psychiatric
disorders and vice versa. Drug–drug interactions
can range from mild to severe.
Burden of somatic illness
• Somatic illness may be reason of delirium
or psychosis: tumors, infections, metabolic
diseases, cardiac arrythmias
• Pharmacologic treatment may be reason of
– delirium (hypoglicaemia, dehydratation)
– psychosis (steroid therapy)
– mania (steroid therapy)
– depression (steroid therapy, interferon)
Social history
• Premorbid versus postmorbid psychosocial functioning:
family life and work, including school and military,
friends, and community functions such as church and
social organizations
• Social factors as risks for psychiatric disorders: physical,
sexual, and emotional abuse, rejection and neglect
during upbringing, and provision of poor role models (be
careful! patients with dissociative disorders, often report
a history of physical and sexual abuse, especially during
childhood barring memory distortions, the presence of
abuse can often be confirmed by outside evidence).
• Negative impact of psychiatric disorders on social
advancement: psychiatric disorders can impede the
patient's social development and can lead to demotion,
job loss, and divorce
GAF
• Global Assessment of Functioning
Biopsychosocial conditions presenting as predisposing, precipitating,
perpetuating, and protective factors of psychatric disorders
Factor
Psycho
Social
Predisposing
Positive psychiatric family
history; delay in reaching
developmental milestones;
psychiatric disorders first
diagnosed in infancy,
childhood, or adolescence;
medical history (head injury,
central nervous system
disorders Axis III)
Impaired premorbid
personality, isolation,
suspiciousness, poor impulse
control, anxiousness,
perfectionism, presence of
personality disorders (Axis II),
low adaptive defense
mechanisms
Neglect, abuse, low
education, poor parental
role models, antisocial
behavior, substance use,
poverty
Precipitating
Onset of severe medical
disorders
Stress intolerance, poor
impulse control, self-pity,
blaming (projection)
Trauma, loss of job or
partner, increased stress
(Axis IV)
Chronic medical illness
Poor insight, judgment, and
impulse control; low IQ;
noncompliance with Rx.
Social isolation,
unemployment, poverty
Good health maintenance,
absence of chronic medical
disorders
Good insight, judgment, and
impulse control; high IQ;
Extended support
compliance with Rx. (high ego system; well-paying,
strength, high adaptive
satisfying job
defense mechanisms)
Perpetuating
Protective
Bio
Structuralised methods
of psychiatric examination
• SCID-I
• SCAN (self-reported screening tool)
• M.I.N.I. Neuropsychiatric Interview v. 6.0
• PRIME-MD
SAD PERSONS
• The comorbidity of major depression and substance use disorder
leads to the highest risk of suicide. A mnemonic for risk factors of
suicide is helpful:
– Sex: Women are more likely to be attempters, men more likely to
be committers.
– Age: Highest rate of suicide is in teenagers and the elderly.
– Depression: 15 percent commit suicide.
– Previous attempts: 10 percent of previous attempters finally
succeed.
– Ethanol abuse: 15 percent of alcoholics commit suicide.
– Rational thinking loss, psychosis. 10 percent of chronic
schizophrenics commit suicide.
– Social support is lacking.
– Organized plan increases the suicide risk.
– No spouse increases the suicide risk.
– Sickness. Chronic illness increases the risk.
Questions for alcohol problems

wrong
And what
about
alcohol?

right
Does your wife
say sometimes
that you drink
too much?
Questions for alcohol problems
wrong
How often
do you drink
alcohol?
right
How long did
you not drink
at all during
last year?
CAGE
• C Have you ever felt you needed to Cut down on
your drinking?
• A Have people Annoyed you by criticizing your
drinking?
• G Have you ever felt Guilty about drinking?
• E Have you ever felt you needed a drink first thing in
the morning ( Eye-opener) to steady your nerves or to
get rid of a hangover?
Tolerance, withdrawal, and loss of control in the
amount or time of use can all be signs of dependence.
SOAP
Four risk factors for the patient's and others' safety:
• Suicidality, homicidality, physically assaultive, unpredictable,
explosive, and self-injurious behaviors and implied or overt threats.
• Organic disturbances of cognitive functions: disorientation, memory
disturbances, decline of executive functions, aphasias and apraxias
that prevent the patient from exercising the activities of daily living
(ADL).
• Alcohol and other substance abuse, ranging from occasional social
use to uncontrollable addictive behavior and dependency that may
endanger the patient's and others' safety on the road and in legal,
marital, occupational, and financial status.
• Psychotic features, such as delusions, especially delusions of
control, and hallucinations, especially command hallucinations, and
their dangerousness and the patient's obedience to these
experiences. Included here are illogical thinking and speech and
catatonic behavior.
How to deal with difficult patients
type: dependent
• Seem to need an inordinate amount of
attention and yet never seem reassured.
• Likely to make repeated urgent calls
between scheduled appointments and to
demand special consideration.
• The doctor needs to be firm in establishing
limits while reassuring the patient that his
or her needs are taken seriously and are
treated professionally.
How to deal with difficult patients
type: demanding
• Some patients have a difficult time delaying gratification and
demand that their discomfort be eliminated immediately. They
are easily frustrated and can become petulant or even angry
and hostile if they do not get what they want when they want it.
They may impulsively do something self-destructive if they feel
thwarted, and they appear manipulative and attention seeking.
Beneath their surface behavior, they may fear that they will
never get what they need from others and thus must act in that
inappropriately aggressive way.
• The doctor must be firm with these patients from the outset and
must clearly define acceptable and unacceptable behavior.
These patients must be treated with respect and care, but they
must also be confronted with their behavior.
How to deal with difficult patients
type: isolated
• Isolated and solitary patients do not appear to need or to
want much contact with other people. Intimate contact
with the doctor is viewed with distaste, and such patients
would prefer to take care of themselves entirely without
the doctor's help if it were possible. Some isolated
patients would receive a diagnosis of schizoid personality
disorder. They are withdrawn, absorbed in a world of
fantasy, and are unable to talk about their feelings.
• The doctor should treat these patients with as much
respect for their privacy as possible and should not
expect them to respond to the doctor's concern in kind.
How to deal with difficult patients
type: psychotic
• Patients with psychotic symptoms have difficulty thinking
clearly and reasoning logically. Their ability to concentrate
may be impaired, and they may be distracted by
hallucinations and delusional beliefs. Psychotic patients
are often frightened and may be quite guarded.
• Quite often, the evaluation of a patient with psychotic
symptoms needs to be more focused and structured
than that of other patients. Open-ended questions and
long periods of silence are apt to be disorganizing. Short
questions are easier to follow than long ones. Questions
calling for abstract responses or hypothetical conjectures
may be unanswerable.
How to deal with difficult patients
type: psychotic
• For patients with hallucinations, the full phenomenology of the
hallucination should be explored. The patient is asked to describe
the sensory misperception as fully as possible. For auditory
hallucinations, this includes content, volume, clarity, and
circumstances; for visual hallucinations, this includes content,
intensity, the situations in which they occur, and the patient's
response.
• The evaluator should distinguish between true hallucinations, on
the one hand, and illusions, hypnagogic and hypnopompic
hallucinations, and vivid imaginings, on the other.
• Hallucinations are perceived as real sensory stimuli and should
not be dismissed as fanciful; however, the psychiatrist should ask
questions about their fixity and the patient's level of insight: “Does
it ever seem that the voices are coming from your own thoughts?”
or “What do you think is causing the voices?”
How to deal with difficult patients
type: psychotic
• Delusions, by definition, are fixed, false beliefs.
Delusional patients often come to psychiatric evaluation
having had their beliefs dismissed or belittled by friends
and family. They are on guard for similar reactions from
the examiner. It is possible to ask questions about
delusions without revealing belief or disbelief (e.g.,
“Does it seem that people are intent on hurting you?”
rather than “Is there a plot to hurt you?”).
• Careless use of psychiatric jargon should be avoided,
particularly in evaluating delusions. Words such as
grandiose and paranoid and, indeed, the word delusion
itself seem harsh and judgmental and are unlikely to be
helpful in eliciting information.
How to deal with difficult patients
type: psychotic
• Many psychiatrists have found that patients can
speak more freely when asked to talk about the
accompanying emotions rather than the belief
itself
(“It must be frightening to think there are people
you don't know who are plotting against you”).
• Although the psychiatrist does not attempt to
reason them away, a gentle probe may determine
how tenaciously the beliefs are held (“Do you ever
wonder whether those things might not be true?”).
How to deal with difficult patients
type: psychotic
• Patients with paranoid delusions (and patients
with high levels of nondelusional
suspiciousness) are best evaluated with a
respectful, but somewhat distant, formality and
with scrupulous honesty. Efforts to reassure or
to ingratiate often increase suspicion. The
psychiatrist must keep in mind the possibility of
being incorporated into a delusional belief and
should ask about it directly (“Are you concerned
that I might try to hurt you?”).
How to deal with difficult patients
type: thought disorder
• Disorders of thought form can seriously impair
effective communications. The evaluating
psychiatrist should note formal thought disorders
while minimizing their adverse impact on the
interview. When derailment is evident, the
psychiatrist typically proceeds with questions
calling for short responses. For a patient
experiencing thought blocking, the psychiatrist
needs to repeat questions, to remind the patient of
what was already said, and, in general, to provide
an organization for thinking that the patient is
unable to provide.
How to deal with difficult patients
type: depressed and potentially suicidal
• Severely depressed patients may also have
difficulty concentrating, thinking clearly, and
speaking spontaneously.
• The intensity of mood disturbance may well lead
to distortions in thinking and perception. Some
depressed patients have psychotic symptoms in
addition to cognitive difficulties.
• The psychiatrist evaluating a depressed patient
may need to be more forceful and directive than
usual.
How to deal with difficult patients
type: depressed and potentially suicidal
• A thorough assessment of suicide potential
addresses intent, plans, means, and perceived
consequences, as well as history of attempts and
family history of suicide. Many patients mention
their thoughts of suicide spontaneously. If not, the
examiner can begin with a somewhat general
question, such as
– “Do you ever have thoughts of hurting yourself?” or
– “Does it ever seem that life isn't worth living?”
These questions can then be followed up
with more specific questions.
How to deal with difficult patients
type: depressed and potentially suicidal
• The examiner must naturally ask simple,
straightforward, noneuphemistic
questions.
• Asking about suicide does not increase
the risk. The psychiatrist is not raising a
topic that the patient has not already
contemplated.
• Specific, detailed questions are essential
for prevention.
How to deal with difficult patients
type: depressed and potentially suicidal
• Intent:
The examiner must determine the seriousness of the wish
to die. Some patients report that they wish that they were
dead but would never intentionally do anything to take
their own lives. This level of intent is sometimes referred
to as passive suicidal ideation. Other patients express
greater degrees of determination. Near the other end of
the spectrum of intent is the patient who says,
“I've decided that I have to kill myself and nothing you can
say or do will change that.”
• Patients who are the most difficult to help: those who tell
no one about their suicidal plans and proceed in a
deliberate, systematic manner
How to deal with difficult patients
type: depressed and potentially suicidal
• Plans
Patients with well-formulated plans are generally at greater
risk than patients who do not know what they would do, but
the method of suicide is not always a reliable indication of
the risk. Even though some actions, such as jumping or
shooting, are much more likely to be fatal than others,
patients make mistakes. A pill overdose taken at the time
at which a spouse is expected to arrive home may become
deadly if the spouse is delayed in traffic.
The psychiatrist should also ask about preparatory actions,
such as giving away goods and putting one's estate in
order.
How to deal with difficult patients
type: depressed and potentially suicidal
• Means
Asking patients about the intended means of
suicide is helpful in two ways. First, it clarifies the
urgency of the situation; persons wanting to
shoot themselves who own a loaded gun are
more dangerous than those who have no idea
where to find a gun. Second, the understanding
of intent is sharpened by knowing whether a
patient has thought through the steps necessary
to carry out the action.
How to deal with difficult patients
type: depressed and potentially suicidal
• Perceived Consequences
– Patients who see something desirable resulting from
their deaths are at increased risk for suicide.
– A reunion fantasy, the belief that a person will be
reunited with a deceased loved one, may be a powerful
motivating force toward suicide.
– On the other hand, some potentially suicidal patients
are restrained by what they see as negative
consequences (e.g., “My children need me too much;
they'd never be able to get along without me”)
How to deal with difficult patients
type: agitated and potentially violent
• Most unpremeditated violence is preceded by a prodrome
of accelerating psychomotor agitation: i.e. pacing and
pounding the fist in a hand, loud, abusive, obscene, and
threatening speech
• Prodrome usually lasts from 30 to 60 minutes before
erupting into physical violence
How to deal with difficult patients
type: agitated and potentially violent
• How to minimize the agitation and potential risk:
– The interview should be conducted in a quiet, nonstimulating
environment.
– There should be enough space for the comfort of the patient
and the psychiatrist, with no physical barrier to leaving the
examination room for either of them.
– Be non-provocative.
– During the interview, the examiner should avoid any behavior
that could be misconstrued as menacing: standing over the
patient, staring, speaking loud or touching. Constant control
should be kept on non-verbal communication cues.
– Only necessary questions to complete an adequate evaluation
How to deal with difficult patients
type: agitated and potentially violent
• The examiner should ask whether the patient is
carrying weapons and may ask the patient to
leave the weapon.
• If the patient's agitation continues to increase, the
examiner may need to terminate the interview.
• Depending on the setting, assistance from
security personnel or physical or chemical
restraints may be appropriate.
• The physician's own subjective sense of comfort
or fear should be rational hint.