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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RATING SCALES


WORKUP


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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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Basic information

Objective history

Subjective history


Objective findings


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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Basic information

Objective history

Subjective history


Objective findings


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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Basic information

Objective history

Subjective history


Objective findings


Conclusions

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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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Basic information

Objective history

Subjective history


Objective findings


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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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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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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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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Basic information

Objective history

Subjective history


Objective findings


Conclusions

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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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Basic information

Objective history

Subjective history


Objective findings


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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RATING SCALES


WORKUP


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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


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



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





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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





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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


Assessment duration: ~ 10 – 20 minutes


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


Assessment duration: ~ 20 – 30 minutes



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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




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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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RATING SCALES


WORKUP


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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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psychiatric examination · 2019-02-28 · 1 psychiatric examination psychiatry 1 –practical # 2...

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