Psychiatric Interview

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Psychiatric InterviewMental State Examination

• Selected Issues
• Dr. J. Lereya
• Director of the emergency ward

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• Interview (contrary to conversation is a special
  form of communication (words, body language)
  which is intended for the achievement of a
  defined goal by concentrating on certain specific
  themes and contents while omitting other,
  irrelevant, ones.
• The interviewer and interviewee roles are clearly
  defined and rigidly fixed.

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• The Psychiatric Interview Aim
• Collecting information about the revealed
  (behavior, intentions, prospects etc.) as well as
  concealed (emotions, drives, conflicts) aspects
  of the interviewees world.
• The interviewer as an well trained and dedicated
  observer (signs) and a collector (symptoms).

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Psychiatric Interview Techniques based on the
medical-model

• Investigate the circumstances of the referral.
• Obtain detailed description of chief complaint.
• Obtain detailed description of the disorders
  long-term history.
• Observations which may be clues for physical
  disease (goiter, tremor, skin patches etc).
• Past history, etc.

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What qualities should psychiatric interviewer
possess in order to accomplish the aims of the
psychiatric interview?

• Common stereotypes of a
• medic-interviewer

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• The detective.systematically examines and
  cross-examines his witness, to the tiniest
  detail Dose not skip a detailbut the witness
  might grow hostile.

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• 2. The Confessor.
• Full with sympathy and compassion for the
  sinner, eager to protect, refrains from
  difficult questions. very popular among
  patients.
• no systematic investigation of the
• problem.

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• 3. The scientist.
• Fills up a standardized questionnaire based
  on a premeditated hypothesis which, now, should
  be verified.
• makes a well made differential-diagnosis
  based on facts.
• misses the complexity of compound human
  conditions.

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• So who, the hell,
• is the a suitable
• interviewer?

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• 4. The empathic Medic
• The detective puts steps into the
  suspects shoes trying to find out what he
  would have felt in such a situation.
• The confessor identifies with the sinner
  in order to understand him. He actually
  fills what the sinner fills while
  expressing love and an desire to help.
• The scientist sympathizes with his
  subject of investigation. In order to
  understand him he is nice and friendly and
  accepts the gathered information and the
  interviewees point of view as it is presented to
  him.

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• so what, the hell,
• is empathy?

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• Empathy is an acquired ability of 2 dimensions
• The ability to understand (specifically
  accurately) the subjective view-point (emotions,
  drives, conflicts, compromises, etc.) of another
  person, combined with
• The ability to express this understanding in
  such a way that the other one fills he is
  understood.

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Interview techniques

1. Closed vs. Open(from a talking-questionnaire to
   an unbounded(projective) conversation
   closed scientific, measures, yields standard
   information, ambience of exam
   (investigation). open stimulates in general,
   prompting the interviewee to expose himself
   and project conflicts on the interviewer
   (can you tell me about yourself ? What do
   you think in general about) .
   half-structured Tell me about your childhood.
   Can you describe you father ? Was he a bad
   or a good person ?

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• 2. focused vs. screened
• focusing on a specific event/subject
  (exploring suicide attempt/leaving hospital
  without permission etc.)
• screening developmental milestones etc.
• 3. Diagnostic vs. therapeutic
• About 80 of the interview deals with
  obtaining suitable information in favor of
  comprehensive D.D. procedure.
• The rest can be educative or amending
  (Have you ever previously had such an
  experience? Is the depression you feel today
  resembles previous depressive episodes? etc.

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The examination of the mental state

• General considerations
• Be sure to stick with the medic model1. You are
  an observer and collector of signs and
  symptom.2. Each item of the MSE should be
  examined passively (signs) and actively
  (symptoms).3. Each symptom/sign should be
  scrutinized.
• Always keep in mind to examine those items of MSE
  which may indicate the possibility of physical
  disorder or disease (consciousness, awareness,
  attention memory, intellectual functioning).
• No psychiatric examination is completed without
  thorough examination of suicidal risk (at present
  and in the past).

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The structured MSE

• 1. Consciousness 5. Mood and
  Affect
• 2. General Description general
  expression
• appearance
  congr/not congr.(situation, content)
• motor behavior
  responsiveness
• rapport 6.
  Cognition
• 3. Thought
  intellectual functioning
• form (speech)
  orientation
• process
  attention and memory
• content 7.
  Judgment reality-testing
• 4. Perception 8.
  Insight
• illusions
• hallucinations

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• consciousness
• Full consciousness AAA
• Disordered consciousness (2 types)
• 1. Dist. in the level of cons. (states of
  alertness) Ac. Conf. state ? coma2. Dist.
  in the quality of cons. (states of awareness)
  
• disturbed cognition (isolated ?
  global) aphatic-amnestic syndromes ?
  Dementia

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General Description of the patient

• Beside examining
• Physical-emotional appearance (deteriorated/unsuit
  able dress, eye-contact, vaso-motor changes,
  etc.).
• Psycho-motor behavior (agitation, retardation,
  etc.).
  
• One should pay special attention to
• C. Quality of rapport with the patient
  Dissimulation vs. evasiveness transference,
  counter-transference.

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• Disorder of thought
• One examines thought indirectly thought a screen
  of speech and language
• Speech (form of thought, a sign)
• Thought processes (a symptom)1. blocking as a
  sign and a symptom
• 2. Pressure of speech (a sign) as a
  possible clinical representation of either
  pressure of thoughts (psychosis) or flight of
  ideas (manic episode).

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• C. Thought content
• 1. Dismantling of the language
  (desymbolization of words neologism
  sentences/words salad clung association).
• 2. rigidity of thought
• (obsessive thoughts).
• 3. Delusions are recognized by four
  co-existing criteria fixed false belief
• uncorrectable by reasoning
• inconsistent with the patients
  cultural, educational background.
• cause dramatic change in life

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• Classification of delusions by their content
  (most common)
  reference, persecution, grandiose, somatic,
  etc.D.D. always investigate the
  origin of a detected delusion
  persecuted for being special/unique etc.
  tends to initiate protective acts (a
  schizophrenic ?). persecuted because of
  being a inner/guilty/disturbing, etc.
  tends to withdraw (depressed ?)

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• Disorder of perception
• hallucinations
• illusions

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• Mood and Affect
• Do mind the distinction(1) mood (a symptom)
  The examinees report about his emotional
  tone over a period of time.(2) affect (a sign)
  The examinees emotional expressions as
  observed by the examiner during the
  examination.
• Use the following parameters while evaluating the
  affect(1) passive observation (depressed,
  disphoric, elated, labile, flat, perplexed,
  etc.) and estimation (congruent/not
  congruent with the situation/thought
  content).(2) active examination of the
  examinees emotional responses 1. to
  humor (severity of depression, MR) 2. to
  provocation (level of impulsivity, efficacy of
  inhibitions, aggressiveness,
  dangerousness).

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• Disorder of cognition
• (high level mental functioning)
• Intellectual functioning General information
  Calculation Abstract thinking using adages
  is probing ones ability to swap
  concrete and general to swap inanimate and
  human to draw a moral/lesson
• Orientationtime, placeidentification (of
  oneself and others).
• Memory immediate (attention, distractibility)
  short (the ability to learn new material. long
  (highly learned material).

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• Judgment vs. Reality Testing
• Judgment
• Is the ability (for given social circumstance) to
• Perform compound mental process including
• Circumstances evaluation with respect to a
  required social task.
• Identification and inspection of various options
  (e.g. in favor and against considerations).
• Choosing an option which prompts a socially
  (prohibition vs. permission)and ethically (good
  vs. evil) normative response.

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• Pathology (like illusions)
• Reality is acknowledged but misinterpreted (with
  respect to social norms).
• J. examination
• Does the examinee understands possible
  consequences of his behavior?
• To what extent his responses are influenced by
  his understanding?
• Imagined situations Is he able to anticipate how
  would he react if, for example, he found a purse
  in the street ? etc.

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Reality-testing

• is the ability (for given social circumstances)
  to perform compound mental process including
• Distinction between self and non self.
• Distinction between inner and outer source of
  stimuli and emotions.
• Realistic evaluation of emotions, thoughts,
  behaviors with respect to accepted social norms.
• Pathology (like hallucinations)
• Reality denial combined with genesis of
  substitutive reality.