Download Psychiatric examination

Psychiatric examination
dr Natalia Widiasih R, SpKJ
Forensic Psychiatry Division
Department of Psychiatry
Univesity of Indonesia/
Cipto Mangunkusumo General Hospital
Lecture for Neurology and Psychiatry Module
Dec ember 4, 2009
Consist of
• Psychiatric interview
• Mental state examination
Psychiatric History
• The psychiatric history is the record of the patient's life; it
allows a psychiatrist to understand who the patient is,
where the patient has come from, and where the patient is
likely to go in the future.
• The history is the patient's life story told to the psychiatrist
in the patient's own words from his or her own point of
view.
• Many times, the history also includes information about
the patient obtained from other sources, such as a parent
or spouse or other family members.
• Obtaining a comprehensive history from a patient and, if
necessary, from informed sources is essential to making a
correct diagnosis and formulating a specific and effective
treatment plan.
• A psychiatric history differs slightly from histories taken in
medicine or surgery.
• In addition to gathering the concrete and factual data
related to the chronology of symptom formation and to the
psychiatric and medical history, a medical doctor strives to
derive from the history the elusive picture of a patient's
individual personality characteristics, including both
strengths and weaknesses.
• The psychiatric history provides insight into the nature of
relationships with those closest to the patient and includes
all the important persons in his or her life.
• Usually, a reasonably comprehensive picture can be elicited
of the patient's development from the earliest formative
years until the present.
• The most important technique for obtaining a psychiatric
history is to allow patients to tell their stories in their own
words in the order that they consider most important.
• As patients relate their stories, skillful interviewers
recognize the points at which they can introduce relevant
questions about the areas described in the outline of the
history and mental status examination.
• The structure of the history and mental status examination
presented in this section is not intended to be a rigid plan
for interviewing a patient; it is meant to be a guide in
organizing the patient's history prior to its being written.
Outline of Psychiatric History
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Identifying data
Chief complaint
History of present illness
– Onset
– Precipitating factors
Past illnesses
– Psychiatric
– Medical
– Alcohol and other substance
history
Family history
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Personal history (anamnesis)
– Prenatal and perinatal
– Early childhood (Birth through age 3)
– Middle childhood (ages 3 - 11)
– Late childhood (puberty through
adolescence)
– Adulthood
• Occupational history
• Marital and relationship history
• Military history
• Educational history
• Religion
• Social activity
• Current living situation
• Legal history
– Sexual history
– Fantasies and dreams
– Values
Outline of a Developmental History
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Prenatal and perinatal
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Infant - mother relationship
Problems with feeding and sleep
Significant milestones
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Other caregivers
Unusual behaviors (e.g., head-banging)
Preschool and school experiences
Separations from caregivers
Friendships/play
Methods of discipline
Illness, surgery, or trauma
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Onset of puberty
Academic achievement
Organized activities (sports, clubs)
Areas of special interest
Romantic involvements and sexual experience
Work experience
Drug/alcohol use
Symptoms (moodiness, irregularity of
sleeping or eating, fights and arguments)
Young adulthood
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Standing/walking
First words/two-word sentences
Bowel and bladder control
Middle childhood
Adolescence
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Full-term pregnancy or premature
Vaginal delivery or caesarian
Drugs taken by mother during pregnancy
(prescription and recreational)
Birth complications
Defects at birth
Infancy and early childhood
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Meaningful long-term relationship
Academic and career decisions
Military experience
Work history
Prison experience
Intellectual pursuits and leisure activities
Middle adulthood and old age
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Changing family constellation
Social activities
Work and career changes
Aspirations
Major losses
Retirement and aging
Sexual History
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Screening questions
– Are you sexually active?
– Have you noticed any changes or problems with sex recently?
Developmental
– Acquisition of sexual knowledge
– Onset of puberty/menarche
– Development of sexual identity and orientation
– First sexual experiences
– Sex in romantic relationship
– Changing experiences or preferences over time
– Sex and advancing age
– Clarification of sexual problems
– Desire phase
Presence of sexual thoughts or fantasies
When do they occur and what is their object?
Who initiates sex and how?
– Excitement phase
Difficulty in sexual arousal (achieving or maintaining erections, lubrication), during foreplay and
preceding orgasm
– Orgasm phase
Does orgasm occur?
Does it occur too soon or too late?
How often and under what circumstances does orgasm occur?
If orgasm does not occur, is it because of not being excited or lack of orgasm despite being aroused?
– Resolution phase
What happens after sex is over (e.g., contentment, frustration, continued arousal)?
Outline for the Mental Status Examination
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Appearance
Overt behavior
Attitude
Speech
Mood and affect
Thinking
– Form
– Content
• Perceptions
• Sensorium - cognition
– Alertness
– Orientation (person, place,
time)
– Concentration
– Memory (immediate,
recent, long term)
– Calculations
– Fund of knowledge
– Abstract reasoning
• Insight
• Judgment
Interviewing Techniques with
Special Patient Populations
• Various types of patients fall under the rubric of special
patient populations. They include patients with urgent issues,
the severely mentally ill, patients from different cultural
backgrounds who are unassimilated, those who cannot
communicate well because of difficulties with the language,
and patients whose personality problems make them,
difficult, demanding, uncooperative, or likely to engage in
power struggles.
• Inherent in the management of all such cases is the doctor's
understanding of the emotions, fears, and conflicts that the
patient's behavior represents.
• Different patient types and special situations and guidelines
for handling them are discussed in this lecture.
Psychotic Patients
• By definition, psychotic patients have poor or absent reality
testing abilities.
• Therefore, 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.
• Thought Disorders
– Disorders of thought can seriously impair effective
communications.
– The evaluating psychiatrist/medical doctor should note formal
thought disorders while minimizing their adverse impact on the
interview.
– When derailment is evident, the psychiatrist /medical doctor
typically proceeds with questions calling for short responses.
– For a patient experiencing thought blocking, the psychiatrist
/medical doctor 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.
• Hallucinations
– Hallucinations are false sensory perceptions.
– 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.
– Hallucinations are perceived as real sensory stimuli and should
not be dismissed as fanciful; however, the doctor 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? What do you think is causing the voices?
• For example, in response to the question,
‘ Why did you come to the clinic?’
a patient responded: ‘When I got up this morning, I showered
and dressed. I was angry at my landlord for not fixing the faucet
in my bathroom. I tried to get him on the phone. He wouldn't
talk to me. I'll call my lawyer. You see, my rent is supposed to be
paid by the Department of Welfare, but they're so nasty.
[But why did you come to the clinic?]
I'm coming to that, Doctor. You see, they don't care about an
upright citizen. I did so much for my community. No one can say
I wasn't a hard worker, etc.
• After repeated questioning, she finally stated she was
worried about being constipated.
• Delusions
– Delusions are fixed, false beliefs not in keeping with the culture.
– 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 “Do you believe there is a plot to hurt you?”).
– Careless use of psychiatric jargon should be avoided, particularly in
evaluating delusions. 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 do not 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?’).
Suspicious Patients
• Some persons, usually those with a paranoid personality, have a chronic,
deeply ingrained suspicion that other people want to cause them harm.
• Although their suspiciousness does not crystallize into a delusion, they
misinterpret neutral events as evidence of a conspiracy against them.
• They are critical and evasive, and are sometimes called ‘grievance
collectors’ because they tend to blame other people for everything bad in
their lives.
• They are extremely mistrustful and may question everything the doctor
says or does. The physician should try to maintain a respectful but
somewhat formal and distant approach with these patients. Expressions of
warmth often heighten their suspicions.
• The doctor should explain in detail every decision and planned procedure
and should try to respond non-defensively to the patient's suspiciousness.
Depressed and Potentially Suicidal Patients
• Severely depressed patients may have difficulty
concentrating, thinking clearly, and speaking spontaneously.
• The psychiatrist evaluating a depressed patient may need to
be more forceful and directive than usual. Although
depressed patients should not be badgered, long silences are
seldom useful, and the examiner may need to repeat
questions more than once.
• Ruminative patients for example, ‘those who continually
repeat how worthless or guilty they are’ need to be
interrupted and redirected.
• All patients must be asked about suicidal thoughts; however,
depressed patients may need to be questioned more fully.
• A thorough assessment of suicide potential addresses intent,
plans, means, and perceived consequences, as well as history
of attempts and family history of suicide.
• The examiner must feel sufficiently comfortable to ask simple,
straightforward, non-euphemistic 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.
• 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. At the most
extreme level of determination are the patients who are the most
difficult to help, those who tell no one about their suicidal plans and
proceed in a deliberate, systematic manner.
– It is useful to ask about restraining influences, internal and external
(e.g., ‘Do you worry that you might not be able to resist those
impulses?’•or ‘How have you been able to keep from hurting yourself
so far?’•
).
– Patients with auditory hallucinations commanding them to kill
themselves often describe the hallucinations as irresistible despite not
having any real desire to die.
• 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.
– The examiner should also ask about preparatory actions,
such as giving away goods and putting one's estate in
order.
• Means
– Asking patients about the intended means of suicide is
helpful in two ways.
– First, it clarifies the urgency of the situation.
– Second, the understanding of intent is sharpened by
knowing whether a patient has thought through the steps
necessary to carry out the action.
• Perceived Consequences
– Patients who see something desirable resulting from their deaths are
at increased risk for suicide (e.g., reunion fantasy, the belief that a
person will be reunited with a deceased loved one).
– 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’•
).
– The psychiatric history and the family history for all patients, even
those not currently suicidal, should mention any previous suicide
attempt or suicides by family members. Both circumstances are
recognized to increase the current risk, even if previous attempts were
thought to be superficial.
– In rare circumstances, the threat of suicide is so imminent that
immediate action must be taken to hospitalize the patient. Even
during a first evaluation session, the examiner must be prepared to
make whatever professional response is necessary to safeguard the
well-being of the patient.
Agitated and Potentially Violent Patients
• When interviewing potentially violent patients, the task is to
conduct an assessment and to contain behavior and limit the
potential for harm.
• Most unpremeditated violence is preceded by a prodrome of
accelerating psychomotor agitation. Researchers and
clinicians in emergency psychiatry suggest that the prodrome
lasts from 30 to 60 minutes before erupting into physical
violence.
• Thus, the psychiatric evaluator has early signals of impending
violence and a period of time in which the agitation may be
quieted.
• Several steps can be taken to minimize the agitation and potential risk.
The interview should be conducted in a quiet, non-stimulating
environment.
• Sufficient space should be available for the comfort of the patient and the
examiner, with no physical barrier to leaving the examination room for
either of them.
• During the interview, the psychiatrist should avoid any behavior that could
be misconstrued as menacing: standing over the patient, staring, or
touching.
• The psychiatrist should ask whether the patient is carrying weapons and
may ask the patient to leave the weapon with a guard or in a holding area.
• The examiner should not request that the patient hand over any weapons.
If the patient's agitation continues to increase, the psychiatrist 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 heeded.
Seductive Patients
• Seductiveness can be manifested in a patient's dress,
behavior, and speech. It runs the gamut from gentle
suggestion to explicit proposition.
• Of course, sex is not the only enticement with which examiner
can be seduced. Patients may offer insider information for
profitable trading in the stock market, may promise an
introduction to a movie star friend, or may suggest that they
will dedicate their next novel to the examiner.
• Whatever the offer, the examiner's response is the same. In
the course of ongoing psychotherapy and in the context of an
established relationship, seductive behavior is discussed and
examined in an effort to understand its meaning.
• The examiner should make it clear that what is being offered
will not be accepted, in a way that preserves good rapport
and does not unnecessarily assault the patient's self-esteem.
• Seductive behavior during an initial psychiatric assessment
must be handled somewhat differently. When the behavior is
mild and indirect, it may be best to ignore it. More explicit
propositions call for more direct responses and may afford the
examiner the chance to explain the nature of the therapeutic
relationship and the need to establish boundaries.
• The examiner should also make clear that it is the violation of
those boundaries that is being rejected and not the patient.
Obsessive Patients
• Obsessive patients are orderly, punctual, and so concerned with
detail that they often do not see the larger picture.
• They may appear unemotional, even aloof, especially when
confronted with anything disturbing or frightening.
• They have a strong need to be in control of everything in their lives
and may struggle with their doctor whenever they feel that
decisions are being imposed.
• Underneath, obsessive patients are often frightened of losing
control and of becoming helpless and dependent.
• Their physicians should try to include them in their own care and
treatment as much as possible.
• Doctors should explain in detail what is going on and what is being
planned, allowing the patient to make choices on his or her own
behalf.
Patients from Different Cultures and Backgrounds
• Differences in race, nationality, and religion and other significant
cultural differences between patient and interviewer can impair
communication and can lead to misunderstandings.
• In addition, it may be difficult for a culturally naive examiner to
evaluate symptoms that are relative rather than absolute.
• There is usually no difficulty in documenting the presence of
auditory hallucinations regardless of cultural differences. Assessing
whether a delusion is bizarre (as required by DSM-IV-TR for
delusional disorder) is more difficult, however, because the term
bizarre has meaning only in reference to cultural norms.
• Apart from diagnostic categories, the vocabulary used to describe
emotional distress varies from culture to culture. Sometimes,
symptoms that are commonplace within a culture are unheard of to
outsiders.
• Additional problems are encountered when doctor and patient speak
different languages. When an interpreter is needed, the person should be
a disinterested third party, unknown to the patient.
• Translators must be instructed to translate verbatim what the patient say
”a difficult task for even the most experienced professional translators.
Some words and expressions are simply untranslatable. It may be
impossible to convey a formal thought disorder through translation.
• An additional difficulty can arise in establishing rapport between doctor
and patient of different ethnic or cultural groups. Patients from minority
groups may be guarded in speaking with a doctor from the majority group.
• The evaluating psychiatrist must proceed with humility and respect.
Rather than offer reassurances of understanding and acceptance, it is
usually better to ask, ‘Have I understood this in the way that you meant
it?’•
Patients Who Do not Cooperate
• Lack of patient cooperation can take many forms: failure to keep
appointments, refusal to talk or to take the session seriously, failure to pay
for services.
• Causes of non-cooperation include manifestations of the patient's
underlying pathology, anger at the psychiatrist, feelings of being coerced
into an evaluation or treatment against one's will, or manifestations of
transference. How the examiner responds depends on the setting and
context.
• The evaluation of an uncooperative patient during an emergency
necessarily proceeds differently from that during non-emergencies; an
emergency psychiatric evaluation must often proceed without full
cooperation or even against the patient's will.
• In such situations, sedation or restraint is sometimes necessary to
complete even a basic triage assessment. The patient's refusal to
cooperate is superseded by concern for the patient's life and the safety of
others.
• The patient who has been engaged in a meaningful therapy
for some time and then becomes uncooperative is sending a
powerful signal to the examiner, the meaning of which must
be explored.
• The change in behavior may be a manifestation of resistance
to upsetting material that is beginning to emerge in therapy or
of transference. It may also be in response to real life
interactions between doctor and patient.
• Although transference and counter-transference are
important concepts in psychoanalytic psychotherapies, their
use in other modalities, such as cognitive-behavioral therapy,
may be inappropriate and counterproductive.
• Little basis exists for pursuing the meaning of uncooperative
behavior when a examiner is meeting with a patient for the
first time.
• The examiner may need to insist on change in the patient's
behavior as a precondition for proceeding. This can be done in
a nonjudgmental and non-punitive manner.
• For patients who cannot or will not cooperate, the treatment
contract may need to be renegotiated, for example, by
changing the frequency of sessions, switching to a different
psychotherapeutic modality, or focusing on medication
management rather than psychotherapy.
• In certain circumstances however, the initial assessment or
therapy has to be terminated because of a patient's
uncooperative behavior.
Practical Aspects of the Psychiatric Interview
Session Length
• The initial consultation lasts for 30 minutes to 1 hour,
depending on the circumstances.
• Interviews with patients who are psychotic or medically ill are
brief because patients may find the interview stressful.
• Similarly, emergency room interviews vary in length.
• Initial interviews to evaluate patients for pharmacotherapy or
psychotherapy tend to be longer; second visits and ongoing
therapeutic interviews vary in length.
• The American Board of Psychiatry and Neurology, in its
clinical oral examination in psychiatry, allows 30 minutes for
candidates to conduct a psychiatric examination.
Seating and Arrangement of Office
• The arrangement of chairs in the psychiatrist's office
affects the interview.
• Both chairs should be of approximately equal height,
so that neither person looks down on the other.
• Most psychiatrists think that it is desirable to place the
chairs without any furniture between the clinician and
the patient.
• If the room contains several chairs, the psychiatrist
indicates his or her own chair and then allows the
patient to choose the chair in which he or she will feel
most comfortable.
Types of Interventions
• Psychiatrists do much more during an interview than ask
questions.
• They provide feedback and information, offer
reassurances, and respond emotionally to what the
patient is saying.
• The psychiatrist's facial expression and body posture also
convey information to the patient. Interventions are
described as supportive or obstructive•depending on the
extent to which they increase the flow of information
and enhance or diminish rapport.
Ending the Interview
• At the end of the evaluation, the psychiatrist must
give the patient his or her impressions and
suggestions, even if they are preliminary.
• Patients seeing a psychiatrist for the first time are
often apprehensive. They wonder if they are crazy,•if
their problems can be understood, if they will be
judged, and most importantly whether they can be
helped.