psychiatric examination · 2019-02-28 · 1 psychiatric examination psychiatry 1 –practical # 2...
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PSYCHIATRIC EXAMINATION
Psychiatry 1 – Practical # 2
Author: MUDr. Michal Turček, PhD.
Supervisor: prof. MUDr. Ján Pečeňák, CSc.
Psychiatrická klinika LFUK a UNB, Bratislava
Podporené grantom KEGA č. 099UK-4/2012
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Learning objectives
to introduce the principles of psychiatric interview
to explain step-by-step of the interview flow & content
to introduce useful standardized assessment methods
to explain workup procedures useful in differential diagnosis
follow the examination manual provided
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PSYCHIATRIC INTERVIEW
RATING SCALES
(standardized assessments)
WORKUP
(special examination procedures)
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PSYCHIATRIC INTERVIEW
RATING SCALES
(standardized assessments)
WORKUP
(special examination procedures)
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Psychiatric Interview – overview
Set of skills required to perform the initial assessment and
to start complex intervention of the patient
Important & unique part of establishing a rapport and
therapeutic relationship with the patient
Goals of the interview:
To elicit the information needed to make a diagnosis
To understand the causes and context of the disorder
To form a therapeutic relationship with the patient
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Preparation before the Interview
Identify where the interview will take place
Consider the room size, lighting and seating
Ensure that the area is (and will stay) free of interruptions
Ensure that you have every necessary equipment for the interview
Assure safety (staff, telephone access, openable door)
for emergency situations
Inform the staff (nurses, caregivers)
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The Interview start
Introduction
Welcome the patient
Introduce yourself
Explain the interview process
Inform about expected duration
Emphasize confidentiality
Explain notes taking
Your appearance
Sit in a relaxed posture
Be aware of your body language
Maintain appropriate eye contact
Appear unhurried
Manage your time effectively
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The Interview flow: what to adhere
Listen to the patient Let them describe their problems in their own way
Ask the patient Use open-ended questions If necessary, add questions with choices → questions with yes / no answer
Follow-up to have the detailed picture In each topic, add sufficient number of additional questions Ask for examples Use patient’s language whenever possible
Clarify the information Clarify contradictory or ambiquous information Summarize relevant information
Establish appropriate rapport with the patient Show understanding by active listening Show empathy by supportive comments
Observe the patient Notice any verbal / nonverbal cues, mimics, behaviour
Make notes Your notes with verbatim examples enable you to illustrate symptoms & signs
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The Interview flow: what to avoid
Being destructive during the interview Using technical terms Asking provocative questions Skipping the topics before the patient has ended in one
Showing unappropriate behaviour Showing disinterest (in hurry or no feedback) Being rigid (showing poker face) Being too familiar (flirting) Downing dignity (inappropriate laughing) Making conflicting verbal reactions or gestures
Making premature responds Giving premature advice Giving definite statements about diagnosis / therapy / management
Overestimating own skills Not making enough notes Not clarifying / summarizing (presuming answers) Engaging in discussion about difficult topics without taking advice from colleagues /
teacher
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The Interview structure
Basic information
Objective history
Subjective history
Presenting complaints
Objective findings
Psychopathological analysis & discussion
Conclusions
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The Interview structure
Basic information
Objective history
Subjective history
Presenting complaints
Objective findings
Psychopathological analysis & discussion
Conclusions
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Name / Initials
Age
National / Racial / Ethnic / Cultural background
Occupation
Marital status
Route of referral
Date of admission
Date of examination
Basic information
Objective history
Information gathered from enclosed documentation, family members, police / rescue system or other peers.
Focuse on patient’s history, presenting complaints, personality, adherence to medication & use of addictive substances.
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The Interview structure
Basic information
Objective history
Subjective history
Presenting complaints
Objective findings
Psychopathological analysis & discussion
Conclusions
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Family history Explore the family tree
Parents, siblings, children (at least)
Age, occupation, health conditions (or age and cause of death)
Neurological and psychiatric disorders
Problems with alcohol / other drugs
Suicidal attempts
Violent or strange behaviour
Current family relationships
Recent events within the family
History 1/4
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General medical history Problems in mother’s pregnancy and during delivery
Problems in psychomotor development
Chronological list of diseases, injuries, traumas, major surgery, epileptic seizures, states of unconsciousness and other somatic problems & nonpsychiatric hospitalizations or examinations at specialized professional since birth till present
Menarche, pregnancies (deliveries, abortions), menopause – in women
Current medical conditions (and their status)
Allergies
Past psychiatric history Previous psychiatric diagnoses and treatment
Chronological list of episodes of psychiatric inpatient, day hospital, and outpatient care (including the reason, symptoms and received treatment)
History of self harm / suicidal attempts
History of harm to others / homicidal attempts
History of neglect of relatives
History 2/4
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Medication history List names and doses of current prescribed medication (have they been taking it?)
Recent changes in medication (why?)
Previous psychiatric drug treatments (did they help?), reasons for discontinuation Adverse effects Any non-prescribed or alternative medications taken
Use of addictive substances Always ask: alcohol, tobacco, caffeine, anxiolytics, hypnotics, cannabinoids Ask if experience with cannabinoids: other illicit substances (unless presented
spontaneously) Explore the following in each substance:
First experience (reason & situation context) Amount and frequency (in alcohol: concentration; in illicit drugs: way of administration) Ability to control the use Craving for substance Use of the drug in the mornings, time spent by use during the day Intoxications (with abnormal experiences or consciousness alteration) & blackouts Withdrawal symptoms (after dose reduction or use discontinuation) Any physical / psychological / social / legal problems due to use of specific substance
History 3/4
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Social history Childhood & Adolescence
Description of developmental milestones and the environment in which the patient was raised
Education Education progress, attended schools, grades, subjects of interest, adaptation, relationships Highest level of education and qualifications achieved
Employment List of jobs, periods of unemployment, current occupation
Relationships & sexual history Past and current relationships; Sexual life
Legal history Previous, pending or current convictions, charges, sentences
Social background information Description of living place, family relationships, financial situation
Premorbid personality How would they describe themselves? How would others have described them?
Activities Describe main recreational activities (and their change):
their spectrum, interest in them, frequency of performing them or in their enjoyment Describe typical day for patient
Physiological functions Sleeping, eating, urination, defecation (any problems or alterations?)
History 4/4
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The Interview structure
Basic information
Objective history
Subjective history
Presenting complaints
Objective findings
Psychopathological analysis & discussion
Conclusions
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Presenting complaints
Introduce the topic: „What has brought to you here?“ or „Why did you search for psychiatric help?“
Make a list and description of presenting complaints. Which is the most troublesome complaint?
In each complaint ask for its dimensions: Nature / Triggers Intensity / Severity Frequency / Duration Persistence / Reactivity Association / Co-occurence with other symptoms Impact on patient’s functioning
Have these or similar symptoms occurred before? To what does the patient attribute their symptoms? What was the reason for current hospitalization? What are their expectations from treatment / hospitalization?
Document the presenting complaints using examples of patient’sverbatim statements.
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The Interview structure
Basic information
Objective history
Subjective history
Presenting complaints
Objective findings
Psychopathological analysis & discussion
Conclusions
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Objective findings 1/4
Description of the patient’s appearance & manifestations during examination Contact
What is the quality of different aspects of the contact with the patient?
Appearance Describe the patient’s physical appearance as if describing their photo
Are there any abnormalities on body, clothes, make-up / hair / dress style?
Speech Describe the formal speech characteristics: rate, fluency, volume, tone, rhythm, articulation, quantity
Describe the contents of the speech: appropriateness of answers to questions, delays in answers, preferred contents and their meaningfulness, ability to follow the storyline, abnormal use of language
Face play (mimics) and pantomimics Describe the underlying face expression of the patient and their face play during the interview
Describe the level of gesticulation in context
Behaviour during the interview Describe patient’s level of activity during the interview
Are there any abnormal movements or unexpected actions?
Does the patient appear to be responding to hallucinations?
Is the patient’s behaviour threatening, aggressive, or violent?
Attitude toward examination and cooperation Does the patient cooperate appropriately?
Does the patient show critical insight on their disorder?
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Objective findings 2/4
Assessment of cognitive functions Use standardized tests or set of equivallent objective tasks to assess:
Orientation
Attention
Short-term memory
Long-term memory
Logic and judgment skills
Always assess all mentioned functions
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Objective findings 3/4
Clinical symptomatology Systematically evaluate all psychic functions (and consider their alterations):
Consciousness – disturbances in vigility, lucidity, idiognosia, self-reflection
Perception – quantitative and qualitative disturbances
Attention – disturbances in concentration, tenacity, capacity, distractibility
Memory – short term & long term, explicit & implicit
Intellect – premorbid & present intellect functioning
Thinking – speed, quality of structure & coherence, contents (incl. pathological)
Emotivity – mood, affectivity, higher emotions
Psychomotorics – disturbances of will, speed, conation & behaviour & activity, qualitative disturbances
Drives – disturbances in appetite, sexual drive, self-protection drive
Physiological functions & vegetative signs – disturbances in sleep-wake cycle, somatic signs
Personality – personality traits and their differentiation & stability, character, format, temperament
Before the end of the interview, always check if you have enough information to evaluate each psychic function
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Objective findings 4/4
General physical examination Focus mainly (but not limited) on examination of the following systems:
Nervous
Endocrine
Cardiovascular
Respiratory
Gastrointestinal
Excretory
Note any positive signs and incorporate them in your diagnostic consideration
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The Interview structure
Basic information
Objective history
Subjective history
Presenting complaints
Objective findings
Psychopathological analysis & discussion
Conclusions
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Psychopathological analysis & discussion
Summary of the most important information obtained from:
subjective & objective history
reason for admission & presenting complaints
objective findings
description of the patient
clinical symptomatology
symptoms
& signssyndrome clinical diagnosis
nosological diagnosis
differential diagnosis
consider
personality
& physical status
consider
hierarchy / association
of multiple syndromes
consider
further workup
& therapy
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The Interview structure
Basic information
Objective history
Subjective history
Presenting complaints
Objective findings
Psychopathological analysis & discussion
Conclusions
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Conclusions
After the consideration, state your final decisions:
Syndromological diagnosis
Working clinical diagnosis
Differential diagnosis
Diagnostic plan
Therapeutic plan
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PSYCHIATRIC INTERVIEW
RATING SCALES
(standardized assessments)
WORKUP
(special examination procedures)
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Standardized assessments – overview
Types of standardized assessment methods: Rating scales (Semi-)Structured interviews Questionnaires
Use of standardized assessments: Screening Diagnostic confirmation Severity evaluation
Advantages of standardized assessments: Rater-independent way of evaluating patients Comparable results across different patients Comparable results across different time in the same patient
Standardized assessments – although helpful additional way of evaluating patients – can never fully replace the psychiatric interview!
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M.I.N.I.
Full title: Mini International Neuropsychiatric Interview
Description: Structured diagnostic interview for DSM-IV and ICD-10 major psychiatric disorders
Required qualification (minimum): Study of manual
Versions: M.I.N.I. – Standard □ Screen □ Kid □ Plus
Assessment duration: ~ 20 minutes
Outcome: Y/N to specific diagnoses
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CGI
Full title: Clinical Global Impression
Description: Simple scale measuring the global clinical impression of severity (by default) of particular mental disorder (in comparison to rest of the patients with that disorder)
Required qualification (minimum):Clinical experience with wide range of patients
Versions: CGI-Severity □ CGI-Improvement
Assessment duration: ~ 5 minutes
Score range: 1 – 7
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CGI-S
Considering your total clinical experience with this particular subject population, how mentally ill is the subject at this time?
1 – Normal, not at all ill
2 – Borderline mentally ill
3 – Mildly ill
4 – Moderately ill
5 – Markedly ill
6 – Severely ill
7 – Among the most extremely ill patients
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Full title: Standardised Mini-Mental State Examination
Description: Screening test for cognitive impairment. Assessment of different cognitive dimensions.
Alternative version: Severe-MMSE
Required qualification (minimum): Study of the manual
Assessment duration: ~ 12 minutes
Score range: 0 – 30
Cut off score: ≤ 25
MMSE
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MMSE
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MoCA
Full title: Montreal Cognitive Assessment
Description: Screening test for cognitive impairment. Assessment of different cognitive dimensions. More sensitive than MMSE.
Versions: Available alternative versions
Required qualification (minimum): Study of the manual
Assessment duration: ~ 15 minutes
Score range: 0 – 30
Cut off score: ≤ 25
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MoCA
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CDT
Full title: Clock Drawing Test
Description: Screening test for cognitive impairment
Versions: Alternative scoring systems
Required qualification (minimum): Study of the manual
Assessment duration: ~ 2 minutes
Score range: 0 – 4
Cut off score: ≤ 2
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CDT
1) Please draw a circle of approximately 10 cm in diameter.
2) Inside the circle, please draw the hours of a clock as they normally appear.
3) Place the hands of the clock to represent the time:
“ten minutes after eleven o’clock”.
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MADRS
Full title: Montgomery-Åsberg Depression Rating Scale
Description: 10-item observer-rated scale for measurement of depression severity
Versions: SIGMA
Required qualification (minimum): Study of the manual
Assessment duration: ~ 10 – 20 minutes
Score range: 0 – 60
Cut off score: ≥ 10
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MADRS
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BPRS
Full title: Brief Psychiatric Rating Scale
Description: Tool for observer-rated measurement of major psychotic and non-psychotic symptoms.
Versions: 18- (original) or 24- (new) item version
Required qualification (minimum): Study of the manual
Assessment duration: ~ 20 – 30 minutes
Score range: 18 – 126
Cut off score: ≥ 55
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BPRS (18-item version)
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CAGE
Full title: „Cut Annoyed Guilt Eye-opener“ questionnaire
Description: Brief screening test for alcohol problems
Required qualification (minimum): None
Assessment duration: ~ 2 minutes
Score range: 0 – 4
Cut off score: ≥ 2
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CAGE
Have you ever felt the need to Cut down on your drinking?
Have you ever felt Annoyed by criticism of your drinking?
Have you ever felt Guilty about your drinking?
Have you ever felt the need to drink in the morning? (Eye opener)
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PSYCHIATRIC INTERVIEW
RATING SCALES
(standardized assessments)
WORKUP
(special examination procedures)
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Workup procedures – overview
Psychodiagnostics
Laboratory tests
Toxicology
Imaging procedures
Electroencephalography
Other diagnostic methods
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Psychodiagnostics
Various methods of assessment the state and trait features
Set of specialized diagnostic procedures that identify and
quantify degrees of psychopathology (virtually for any
psychic function)
Instruments of written / oral / drawing performance
Usefull to identify, differentiate or quantify symptoms
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Laboratory tests
Complete Blood Count
Basic biochemical screening (glycemia, urea, creatinine, minerals,
enzymes)
Medication concentration (Li, antiepileptics)
Endocrine functions (thyroid, adrenal)
Vitamins (B9, B12)
Genetics (ApoE)
Oncomarkers
Inflammation & Immunity markers (CRP, TNF-α, IL-6)
Microbial agents (cultivation, antigenes, antibodies)
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Toxicology
Principle: Confirmatory analysis of addictive substances
Samples: blood, urine, other body fluids, hair / nail
When to use: Consciousness alteration
Psychosis of unknown origin
Control of abstinence (in substance use disorders)
How to interpret: Positive findings may point to etiology of disorder
Negative findings do not exclude substance use in all cases
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Imaging procedures
Principle: Visualization of structural alterations of brain
Procedures: CT, MRI, PET
When to use: Newly developed mental disorder with comorbid neurotopic signs
Acute conscioussness alteration of unknown origin
Dementia or cognitive impairment of unknown origin
Generally all first episodes of major mental disorders
How to interpret: Positive findings may point to organic etiology of disorder
Negative findings do not exclude brain changes in all cases
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EEG
Principle: Analysis of electrical activity of the brain cortex
Procedures: standard EEG, cerebral evoked potentials, quantitative EEG, LORETA
When to use: Newly developed psychosis with unusual / fluctuating signs
Confusional states and cognitive impairment of unknown origin
Epilepsy or seizures of unknown origin
Generally all first episodes of major mental disorders
How to interpret: Positive findings may support some diagnoses
Negative findings have relatively small diagnostic value
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Other diagnostic methods
ECG Standard screening in risk population or within specific treatment procedures
Phalopletysmography Volumetric measurement of penis during sexual arousal to different stimuli
Narcoanalysis Interview during sub-sedative doses of i.v. anesthetic
Doppler Ultrasonography Measurement of carotid blood flow
Magnetic resonance spectroscopy Spectral identification of atoms / molecules in brain
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Recommended literature
American Psychiatric Association: Practice guideline for the Psychiatric
Evaluation of Adults. Second Edition. Arlington: American Psychiatric
Association, 2006. 62 pp.
Cepeda, C.: Clinical Manual for the Psychiatric Interview of Children and
Adolescents. Arlington: American Psychiatric Association, 2010. 475 pp.
Sadock, B. J. – Sadock, V. A.: Kaplan and Sadock's Synopsis of Psychiatry. 10th
Edition. New York: Lippincott Williams & Wilkins, 2010. 1470 pp.
Semple, D. – Smyth, R.: Oxford Handbook of Psychiatry. Second Edition.
Oxford: Oxford University Press, 2009. 1008 pp.
World Health Organization: The ICD-10 Classification of Mental and
Behavioural Disorders. Diagnostic criteria for research. Geneva: World Health
Organization, 1993. 262 pp.
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Any questions?