Psychiatric examination

dr Natalia Widiasih R, SpKJForensic Psychiatry DivisionDepartment of Psychiatry

Univesity of Indonesia/Cipto Mangunkusumo General Hospital

Lecture for Neurology and Psychiatry ModuleDec 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

• Identifying data • Chief complaint • History of present illness

– Onset – Precipitating factors

• Past illnesses – Psychiatric – Medical – Alcohol and other substance

history• Family history

• 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

• Prenatal and perinatal – 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 – Infant - mother relationship – Problems with feeding and sleep – Significant milestones

• Standing/walking • First words/two-word sentences • Bowel and bladder control

– Other caregivers – Unusual behaviors (e.g., head-banging)

• Middle childhood – Preschool and school experiences – Separations from caregivers – Friendships/play – Methods of discipline – Illness, surgery, or trauma

• Adolescence – 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

– Meaningful long-term relationship – Academic and career decisions – Military experience – Work history – Prison experience – Intellectual pursuits and leisure activities

• Middle adulthood and old age – Changing family constellation – Social activities – Work and career changes – Aspirations – Major losses – Retirement and aging

Sexual History• 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 fantasiesWhen do they occur and what is their object?Who initiates sex and how?

– Excitement phaseDifficulty in sexual arousal (achieving or maintaining erections, lubrication), during foreplay and preceding orgasm

– Orgasm phaseDoes 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 phaseWhat happens after sex is over (e.g., contentment, frustration, continued arousal)?

Outline for the Mental Status Examination

• 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.