The Interview

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The Interview

• Psychosocial-Behavioral Assessment and Mental
  Status Examination

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Brian Romalis, MD

• Private Practice, General Psychiatry
• Clinical Assistant Professor, KUMC - Wichita

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Private Office

• 1431 S. Bluffview
• Wichita, KS 67218
• 316.682.5069

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Goals of Interviewing

• Make a diagnosis
• Syndrome
• Dynamics
• Psychosocial economic situation
• Evaluate dynamics
• Formulate a treatment plan
• Insurance statistics

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Medical/Psychiatric History

• PI cross-sectional view
• PMH longitudinal view
• Tests memory
• What was the problem?
• How was it treated?
• Following up taking medications?
• If so, prescribed by whom?
• Does her think he should resume follow up?

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Awareness Psychosocial-Behavioral Issues

• May be be expressed directly
• Unrelated purpose for visit
• Reluctance to discuss emotional problems
• Denial of emotional problems
• Somatic symptoms
• Know when to refer

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Fundamentals of Interviewing

• Rapport
• Warm-up
• NO technical jargon
• Let patient talk - open ended
• Silence
• Use patient language if comfortable

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Fundamentals of Interviewing

• Control rambling
• Expect personal questions
• Be pleasant - not witty
• No leading questions
• Do not ask why?
• Request permission for family
• Conclusion summary and questions

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Common Conflict Areas for Families

• Submission
• Autonomy
• Rationality
• Distancing
• Disease
• Mismanagement
• Irresponsibility
• Non-sharing

• Dominance
• Closeness
• Emotion
• Over involvement
• Health
• Adequacy
• Responsibility
• Sharing

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Common Family Problems

• Domestic conflict sexual difficulties
• Substance abuse dependence
• Domestic violence
• Abuse of women children - physical/sexual
• Divorce
• Financial

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People who abuse

• Perception of parental deprivation
• History of being abuse victim
• Poor impulse control
• Substance abuse
• Unrealistic expectation

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Reference Materials Behavioral Changes

• Childrens reaction to divorce
• Signs of child sexual abuse

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Common PresentationsEmotional Social Problems

• Stress-related physical symptoms
• Somatoform disorders
• Psychiatric symptoms
• Disturbances of mood or affect
• Disturbances of memory consciousness
• Psychiatric disorders

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Stress-Related Physical Symptoms

• Urinary frequency
• Diarrhea
• Sweating
• Stomach ache
• Headache

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Somatoform Disorders

• Common not in DSM-IV
• Asthma, peptic ulcer, ulcerative colitis,
  obesity
• Somatization disorder
• Conversion disorders (pseudoneurologic symptoms)
• Hypochondriasis

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Psychiatric Symptoms

• Perceptual distortions
• Thought disturbances
• Blocking
• Flight of ideas
• Psychomotor retardation
• Perseveration
• Obsession
• Phobias

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Disturbances of Mood or Affect

• Depression
• Elation
• Anxiety
• Inappropriateness

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Disturbances of Memory Consciousness

• Confusion
• Stupor
• Amnesia
• Dementia

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Psychiatric Disorders

• Anxiety
• Phobic
• Conversion (hysteria)
• Obsessive-Compulsive
• Depressive
• Dissociative

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Assessment Summary SOAP

• S symptoms, medications/drugs, habits, PMH
• O thought content, stream, intellect
  sensorium, affect-mood, behavior, personal
  insight
• A likely diagnosis, psychodynamics,
  psychosocial situation
• P know when to refer

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Mental Status Examination

• General Appearance
• Affect (feeling state)
• Flow of thought
• Thought content

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General Appearance

• Hygiene
• Grooming
• Nutrition
• Style of clothing
• Appropriateness of dress
• Movements
• Mannerisms

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Affect Feeling State

• Type depression, anger, fear, anxiety
• Lability changes of affect
• Appropriateness of thought expressed
• Intensity duration

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Flow of Thought

• Rate
• Rhythm
• Form logic coherency or deviations
• Amount excess or poverty
• Blocking sudden stoppage of thought

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Thought Content

• Suicide (plan?)
• Homicide (victim?)
• Delusions (fixed, false beliefs)
• Phobias (intense, unreasonable fear)
• Obsessions (intrusive, repetitious)
• Insight (realization of problem)
• Judgement (awareness, foresight)

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Rapid Screening for Mental Status

• Mini-Mental Status Examination (MMSE)
• Clock Drawing Task (CDT)

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Mini-Mental Status Examination (MMSE)

• When organicity suspected, irrespective of age
• Age 40 or older, with first presentation of
  psychiatric symptoms
• Anyone over 65

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MMSE

• Orientation
• Time
• Location
• Registration
• Name Repeat 3 objects
• Attention Calculation
• Serial 7s backwards from 100 (X 5)
• Spell WORLD backwards
• Recall 3 objects previously named

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MMSE Language

• Name (show items)
• Watch
• Pencil
• No ifs, and or buts repeat
• 3 stage verbal command for paper
• Take this paper in your right hand,
• fold it in half
• put it on the floor

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MMSE Language

• Written command, printed on blank paper
• CLOSE YOUR EYES
• Write a sentence
• (subject, verb, sensiblity)

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MMSE Visual-Spacial Testing

• Copy Intersecting pentagons
• 10 total
• angles
• 2 intersection angles

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MMSE Scoring for Intellectual Impairment

• 24-30 Normal
• lt24 Dementia-Impairment
• 25-30 Normal
• 21-24 Mild
• 16-20 Moderate
• lt15 Severe

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Clock Drawing Task CDT

• Brief screening test
• Freehand clock drawing
• Scoring system can compare with MMSE

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CDT Instructions

• Draw face of clock
• Put numbers in correct position
• Draw time (1110 or 820)

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CDT Scoring

• Closed circle 1
• Numbers in correct position 1
• 12 correct numbers 1
• Hands in correct position 1

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(No Transcript)
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Example Clock Drawing Task

• CDT 4
• Normal
• MMSE 30
• Normal

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Example Clock Drawing Task

• CDT 2
• MMSE 20

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Example Clock Drawing Task

• CDT 2
• Moderate Impairment
• MMSE 19
• Moderate Impairment

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Example Clock Drawing Task

• CDT 1
• Severe Impairment
• MMSE 14
• Severe Impairment

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Assessment for Organic Brain Disease

• Pregnancy delivery
• Head injury
• Seizures
• Unsafe sexual practice

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Changes in

• Vision
• Recent memory intellect
• Consciousness alertness
• Personality
• Reasoning, planning, judgment

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Assessment for Organic Brain Disease

• Note changes presenting after age 40
• Non-apparent head trauma
• elderly
• alcohol abusers dependent

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Assessment for Organic Brain Disease

• Prescribed medications
• Substance abuse
• Family history - CNS diseases
• Alzheimers
• Huntingtons
• Other

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Alzheimers Disease

• Does H P match Alzheimers profile
• Other disorders can mimic Alzheimers
• Exclusion may be 88 accurate
• List on hand-out

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Stages of Alzheimers Disease

• Onset is gradual, insidious Progressive
• Stage 1 (2-4 years) Losses in memory,
  decision-making, financial management
  
• Stage 2 (2-10 years) Further losses in memory,
  thought/language facility, social skills,
  recognition of family/friends
• Stage 3 (1-3 years) Little capacity for self
  care

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Delirium

• Acute, rapid onset change in mental status
• Alertness orientation lost consciousness
  cloudy
• Suspect acute change in physical health status

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Family Practice Behavioral History

• Birth delivery
• Developmental delay
• Drug abuse
• Brain trauma

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Family Practice Behavioral History

• Walk talk at about 1 year?
• Attend regular school?
• Trouble with the law before age 15?
• Did problems continue up to now?

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Family Practice Behavioral History

• Military discharge other than honorable?
• Longest job held?
• Length of present job?
• How many marriages? Children?
• Minor children being supported?

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Family Practice Behavioral History

• Problems - attention impulse control?
• Recent problems?
• Death
• Departures
• Disappointments
• Marital or job related
• With the law

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Alcohol Other Substance Abuse

• C - Thoughts of cutting down?
• A - Anger/annoyance if drinking criticized?
• G - Guilt about drinking?
• E - Eye-opener or morning drink

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Common Psychiatric Conditions

• Suicide
• Depression
• Anxiety
• Manic symptoms

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Common Psychiatric Key Words

• Suicide
• Depression
• Anxiety
• Manic symptoms
• Somatization
• Hypochondriasis
• Borderline Personality
• ADHD

• Attempts, feelings
• 1/2 time X 2 weeks
• worry apprehension
• ltsleep, /- depression
• bodily concern, vague
• fear of disease
• affective instability
• hyper or inattentive

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Suicide

• Attempts? How many? When last time?
• Do you feel like it now?
• Plan how, when, where would you do it?
• Anyone or anything to live for now?
• Would you have them in time if you lived?

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Depression

• Depressed mood
• Loss interest/pleasure
• Worthlessness, guilt
• lt Concentration
• Fatigue, energy loss
• Insomnia or
• Hypersomnia

• Psychomotor retardation or agitation
• Significant weight loss or gain
• Recurrent thoughts of death/suicide
• Hopelessness

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Anxiety

• Fatigue
• Irritability
• Edginess
• Tension
• Sleep disturbance
• Difficulty concentrating

• Excessive apprehensive expectations or worry
• Cannot be controlled

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Depression - Anxiety Overlap

• Both have
• Fatigue
• Irritability
• Insomnia
• Difficulty concentrating

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Manic Symptoms

• Excessive confidence
• Alternate with depression
• May become obsessional or bizarre

• Bipolar
• Elated
• Irritable
• Loud voice
• Loss of inhibitions
• Rapid, excessive speech

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Somatization Disorder

• Bodily preoccupation vs. discomfort
• Not fear of disease
• Onset 30 or younger
• History vague
• Multi-system complaints

• Dramatic description
• Seductive
• Suicidal threats or gestures
• Substance abuse common
• Antisocial

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Somatization Symptom List

• 4 PAIN symptoms in different sites
• 2 GI symptoms other than pain
• 1 SEXUAL symptom
• 1 PSEUDONEUROLOGICAL symptom

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Somatization Mnemonic

• S omatization
• D isorder
• B esets
• L adies
• A nd
• V exes
• P ractitioners - Physicians

• S hortness of breath
• D ysmenorrhea
• B urning in vagina
• L ump in throat
• A mnesia
• V omiting
• P ain in back limbs

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Hypochondriasis

• Fear of serious disease
• Onset afte30 years

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Borderline Personality Disorder

• Often present depressed or suicidal
• Can look manic or depressed due to affective
  instability

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Borderline History

• Frequent suicidal gestures self-lacerated arms
• Frequent drug abuse
• Under stress/drugs can dissociate from reality or
  become psychotic

• Feel empty, bored angry
• Dont do well alone
• Fear abandonment frantically avoid
• Affective instability impulsively provoke
  abandonment

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Psychosocial-Behavioral Issues Children

• Divorce
• Abuse
• ADHD
• Depression
• Learning Disorders
• Educational Issues
• Eating Disorders

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Attention Deficit Hyperactivity Disorder

• DSM IV criteria require 6 or more symptoms
  present for at least 6 months maladaptive
  inconsistent with developmental level
• Inattention
• Hyperactivity
• Impulsivity

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Referral Indications

• Drug/alcohol
• Gambling/spending
• Sexual abuse
• Physical abuse

• Undetermined DX
• Suicidal
• Self-destructive behavior
• Danger to others
• Disorganization
• Overwhelmed
• Regression

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Referral Indications

• Drug/alcohol/gambling/spending
• Problems require more time than available
• Sexual abuse
• Physical abuse

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Common Psychiatric Differentials

• Recurrent Unipolar Affective Disorder
• Somatization Disorder
• Borderline Personality Disorder
• Delusional Disorder

• Chronic legal social problems
• Substance abuse /or alcohol dependence
• Depression-Anxiety
• Bipolar Affective Disorder
• Schizophrenia

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Differential Importance

• Make important distinctions between conditions
• Aim specific treatment
• Dont want patient untreated
• Dont want patient incorrectly treated