The Psychiatric
Interview
Evaluation and techniques
DR: RAED BELLAIL
Psychiatry:
is a branch of medicine sciences which is concerned by study of
mental disorders .
A Mental Disorder
A mental disorder is a syndrome characterized by clinically
significant disturbance in an individual’s cognition, emotion
regulation, or behavior that usually associated with significant
distress or disability in social, occupational, or other important
activities.
Introduction
❑One supreme skill of any physician is
active listening.
❑ Physicians should monitor :
1)the content of the interaction (what
patient and doctor say to each other)
2)the process (what patient and doctor
may not say but clearly convey in
many other ways).
Goals for psychiatric interview:
1. to obtain historical perspective of
patient’s life,
2. to establish rapport and therapeutic
alliance,
3. to develop mutual trust and
confidence,
4. to understand present functioning,
5. to make diagnosis,
[Link] provide feedback and formulate a
treatment plan.
Six strategies to develop rapport
putting patients and interviewers at ease.
finding patients' pain and expressing
compassion.
evaluating patients' insight and becoming
an ally
showing expertise
establishing authority as physicians and
therapists
balancing the roles of empathic listener,
expert, and authority.
Techniques
Directiveness in the Interviewer
Open-ended questions
Nonverbal “Uh-huh”; nodding of head.
Attentive listening .
Broad-focus questions
Narrow-focus questions.
Redirection.
Change of topics .
Limit-setting (interrupt ).
Supportive Interventions.
Address patient's main concerns first.
Encouragement .
Reassurance.
Empathic statements
Nonverbal communication (Smiling, attentive body posture….)
Obstructive Interventions
Suggestive or biased questions.
Judgmental questions or statements.
Ignoring the patient’s leads.
Crowding the patient with questions.
Nonverbal questions (Sitting at a distance, yawning, looking at watch…)
THE PSYCHIATRIC HISTORY
It is the chronological story
of the patient’s life from birth to present.
It includes information about who the
patient is, his problem and its possible
causes and available support (bio
psycho-social aspects).
Information elicited both from the patient
and other informants.
Identifying Data
necessary: name, age, sex/gender, marital status,
occupation/source of financial support, place/type of
residency
adjunct: makeup of household, education, ethnicity,
nationality, immigration history (if applicable), religion,
current professional supports (GP, psychiatrist, case
manager, therapist, etc), referral source, known or
unknown to treatment team
Reliability of Patient as a Historian
indicate if, and for what content; utilize collateral source
(i.e. parent, teacher, partner) if patient unable/ unwilling
to be interviewed
Chief Complaint
in patient’s own words, with duration of symptoms
History of Present Illness
reason for seeking help (that day) and hopes/expectations for treatment
current symptoms (onset, duration, fluctuation, progression, and course) and relevant
associated symptoms (pertinent positives and negatives)
potential precipitants for current problem, stressors, supports
functional status: consider impact of current problems on personal care and survival, family
functioning, occupational functioning, and broad social functioning
safety screen: endangering self or others, dependents at home (i.e. children, pets), ability to
drive safely, ability to care for self (i.e. eating, hygiene, taking medications)
active medical problems
Psychiatric Functional Inquiry
mood: depression, mania
anxiety: worries, panic attacks, phobias, or social anxiety
history of trauma
obsessive-compulsive: obsessions, compulsions
psychosis: hallucinations, delusions
risk assessment: suicidal ideation, plan, intent, and history of attempts and history of any
violent
organic: illness, dementia
Substance Use: smoking, EtOH/drug use
current treatment: medications, doses, duration and adherence
Past Psychiatric History
all previous psychiatric diagnoses, psychiatric contacts, treatments
(pharmacological and nonpharmacological), and hospitalizations
include past suicide attempts, severity, necessity for medical
intervention
Substance Use History
smoking, EtOH/drug use or withdrawal
past treatments, periods of sobriety
Past Medical/Surgical History
all medical, surgical, neurological (i.e. head trauma, seizures), and
psychosomatic illnesses
current medications, doses, adherence, allergies
Family Psychiatric/Medical History
any current or past psychiatric illnesses, suicide and
hospitalizations,
family members: ages, occupations, personalities
relationships with parents/siblings/partner/friends
Personal History:
prenatal and perinatal history (desired vs. unwanted pregnancy, maternal
and fetal health, domestic violence, maternal substance use and exposures,
complications of pregnancy/delivery)
Birth & Infancy:- hx. of pregnancy delivery as known by pt., developmental
landmarks, standing, walking, talking, temperament.
Childhood:- activity/attention level, family stability, or attachment figures,
feeding habits, toilet training, fear, separation, night-mares, bedwetting,
personality- shy, outgoing, relationship with parent or caregivers, conduct
behavior, sexual, physical abuse and school performance, peer relationships,
behavioural challenges.
Adolescence:- peer & authority relationship, school, drug use, puberty.
Adulthood:- education, work, career, marriage, children, finances, religion.
Sexual History:- sexual development, orientation, puberty, gender roles,
masturbation , first sexual encounter, romantic relationships……
Marital history.
Current social situation:
Tobacco and substance abuse.
legal (forensic) problems.
Premorbid personality:- sociable, extrovert, friends, hobbies, habits, tense,
anxious, short tempered, perfectionist, easy going, other’s opinion.
◦ Personality Traits:
❑Attitude to self (self-appraisal, performance, satisfaction, past
achievements and failures, future..)
❑Moral and religious attitudes and standards.
❑Prevailing mood and emotions.
❑Reaction to stress (ability to tolerate frustration and
disappointments, pattern of coping strategies).
❑Personal interests, habits, hobbies and leisure activities.
❑Interpersonal relationships.
The Mental Status Examination t
Appearance,Behaviour &Attitude
Speech
Mood & Affect
Thoughts
Perception
Cognitive functions and consciousness
Consciousness level
attention
concentration
orientation(time, place, person)
memory
Abstract thinking
Visuospatial ability
Language and reading.
Judgment
Insight
Mental Status Examination t
General Appearance
posture, gait, grooming, hygiene, manner of dress, body habitus,
facial expression, chronological vs. apparent age, and relaxed or in
distress, alertness
Attitude
disposition in interview (i.e. uncooperative, suspicious, or hostile)
Behaviour
psychomotor activity (agitation, retardation), abnormal movements
or lack thereof (tremors, akathisia, tardive dyskinesia, paralysis),
attention level and eye contact
Speech
rate (i.e. pressured, slowed), rhythm/fluency, volume, tone,
articulation, quantity, spontaneity
The Mental Status Examination t
Mood and Affect
mood: subjective emotional state (in patient’s own words)
affect: objective emotional state inferred from emotional responses
to stimuli; described in terms of
_ quality (euthymic, depressed, elevated, anxious, irritable)
_ range (full, restricted, _at, blunted)
_ stability (_fixed, labile)
_ mood congruence (inferred by comparing the patient’s subjective
mood with their affect)
_ appropriateness to thought content
many clinicians use a 0-10 scale (0; worst; 10: best) when rating
mood to get a subjective norm for each patient that can help to
monitor changes over time and with treatment
The Mental Status Examination t
Thought Process/Form
coherence (coherent, incoherent)
logic (logical, illogical)
stream
_ goal-directed: clearly answers questions in a linear, organized, logical
fashion
_ circumstantial: speech that is indirect and delayed in reaching its goal;
eventually comes back to the point
_ tangential: speech is oblique or irrelevant; does not come back to the
original point
_ loosening of associations/derailment: illogical shifting between topics
_ flight of ideas: quickly skipping from one idea to another where the ideas
are marginally connected, usually associated with mania
_ word salad: jumble of words lacking meaning or logical coherence
perseveration: repetition of the same verbal or motor response to stimuli
echolalia: repetition of phrases or words spoken by someone else
thought blocking: sudden cessation of flow of thought and speech
clang associations: speech based on sound such as rhyming or punning
neologism: use of novel words or of existing words in a novel fashion
The Mental Status Examination t
Thought Content
suicidal ideation/homicidal ideation
_ frequency and pervasiveness of thoughts, formulation of plan, means to plan,
intent, active vs. passive, protective factors
preoccupations, ruminations: reflections/thoughts at length, not fixed or false
obsession: recurrent and persistent thought, impulse, or image which is
intrusive or inappropriate and unwanted
_ cannot be stopped by logic or reason
_ causes marked anxiety and distress
_ common themes: contamination, orderliness, sexual, pathological
doubt/worry/guilt
magical thinking (i.e. superstition, belief that thinking something will make it
happen), normal in children and certain cultures
ideas of reference: similar to delusion of reference, but less fixed (the reality
of the belief is questioned)
overvalued ideas: unusual/odd beliefs that are not of delusional proportions
first rank symptoms of schizophrenia: thought insertion, withdrawal, and
broadcasting
delusion: a fixed false belief that is out of keeping with a person’s cultural or
religious background and is firmly held despite incontrovertible proof to the
contrary
The Mental Status Examination t
• Delusion Types
Reference: unrelated events apply to them
Persecutory: others are trying to cause harm
Grandiose: inflated sense of self-worth, power or wealth
Jealous (unreasonable belief that a partner is unfaithful)
Religious (false belief that the person has a special link with God)
Somatic: patient has a physical defect
Erotomanic: a person, usually of higher status, is in love with the patient
Nihilistic (belief that self or part of self, others, or the world does not exist)
Control: outside forces are controlling actions
Thought alienation
Delusions of thought broadcasting- the belief that others can hear the
patient’s thoughts
Delusions of thought insertions-the belief that someone else’s thoughts
have been inserted into the patient’s mind
Delusions of thought withdrawal -the belief that someone else’s thoughts
have been withdraw from the patient’s mind
The Mental Status Examination t
Perception
Hallucination: sensory perception in the absence of external stimuli
that is similar in quality to a true perception
_ auditory (most common), visual, gustatory, olfactory, tactile
Illusion: misperception of a real external stimulus (such as
mistaking a coat on a rack as a person late at night)
Depersonalization: change in self-awareness such that the person
feels unreal, distant, or detached from his or her body, and/or
unable to feel emotion
Derealization: feeling that the world/outer environment is unreal
The Mental Status Examination t
Cognition
Level of consciousness (alert, reduced, obtunded)
Orientation: time, place, person
Memory: immediate, recent, or remote
Global evaluation of intellect (below average, average, above
average, in keeping with person’s education)
Intellectual Functions: attention, concentration, calculation,
abstraction (proverb interpretation, similarities test) and knowledge
MMSE/MOCA useful as standard screening assessments of
cognition
Insight
patient’s ability to realize that he or she has a physical or mental
illness and to understand its implications (none, limited, partial, or
full)
Judgment
patient’s ability to understand relationships between facts and draw
conclusions that determine one’s actions
Medical & Neurological examination
Some psychiatrics disorders may have an organic
cause.
therefore neurological and/or medical
examinations and investigations my be indicated
in most cases
ask the patient want to say anything
Thank the patient
Good by the patient
Problem Formulation
Problem Formulation
identify predominant symptom cluster (mood, anxiety,
psychosis, organic) causing the most distress/ interference,
persist when other symptom categories not present (i.e.
psychosis in the absence of mood symptoms)
Differential Diagnosis
dominating symptoms will direct differential
consider current issues as they relate to an individual
considering three domains: biological, psychological, and social
for each category: predisposing, precipitating, perpetuating, and
protecting factors are considered
Approach to Management
consider short-term and long-term, and three types: biological
(i.e. pharmacotherapy, ECT), psychological (i.e. CBT), and social
(i.e. supports, finance/employment/return to work, social activity,
medication coverage, psychotherapy coverage)