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The Complete Clinical Assessment

in Psychiatry

Developed and produced by Margot Phillips, Jeffrey Streimer and Joanne Shaw

HETI | RESOURCE

Authors
Dr. Margot Phillips

Dr. Jeffrey Streimer

Consultant Psychiatrist

Consultant Psychiatrist & Psychotherapist

NSW Institute of Psychiatry Special
Fellow, Royal North Shore Hospital,
Sydney

RANZCP NSW Director of Advanced
Training in Psychotherapy

Staff Specialist South Eastern Sydney
and Illawarra Area Health Service
Site Coordinator of Training, St George
and Sutherland Hospitals, Sydney

Joanne Shaw
HETI Project Manager

Senior Staff Specialist Northern Sydney
Central Coast Health Service
Director of Consultation-Liaison
Psychiatry, Royal North Shore Hospital,
Sydney
Clinical Senior Lecturer, Discipline of
Psychological Medicine, University of
Sydney

Research Psychologist, Discipline
of Psychological Medicine, University
of Sydney

Acknowledgements
Dr. Agnes Chan

Dr. Jeanette Martin

Consultant Psychiatrist

Consultant Psychiatrist & Psychotherapist

Staff Specialist Consultation-Liaison
Psychiatry Northern Sydney Central
Coast Health Service Staff Specialist
Consultation-Liaison Psychiatry Sydney
South West Area Health Service

Psychotherapy Educator Northern Sydney
Central Coast Health Service

Site Coordinator of Training, Royal
North Shore Hospital, Sydney

Dr. Ralf Ilchef
Consultant Psychiatrist
Senior Staff Specialist Northern
Sydney Central Coast Health Service
Clinical Senior Lecturer, Discipline
of Psychological Medicine,
University of Sydney

Dr. Lisa Lampe
Consultant Psychiatrist

Member of the Committee for Advanced
Training in the Psychotherapies

Dr. Robert Russell
Consultant Psychiatrist &
Psychogeriatrician
Senior Staff Specialist, Northern Sydney
Central Coast Health Service

Dr. Steven Spielman
Consultant Psychiatrist & Psychotherapist
Senior Staff Specialist, Child and
Adolescent Psychiatry, Northern Sydney
Central Coast Health Service

Staff Specialist Northern Sydney
Central Coast Health Service

Dr. James Telfer

Senior Lecturer, Discipline of
Psychological Medicine, University
of Sydney

Senior Staff Specialist Northern Sydney
Central Coast Health Service

Dr. Loyola McLean
Consultant Psychiatrist & Psychotherapist
CADE clinic and Amaranth Centre, Sydney
Lecturer, Discipline of Psychological
Medicine, University of Sydney

Consultant Psychiatrist & Psychotherapist

Clinical Lecturer, Discipline of
Psychological Medicine, University of
Sydney
Clinical Director C. J. Cummins Unit,
Royal North Shore Hospital

Contents
Who? What? When? Where? Why?....................................................................02
An area of unmet need.......................................................................................03
Our vision...........................................................................................................04
Learning goals....................................................................................................05
About this material..............................................................................................06
Confidentiality and Consents..............................................................................08
Session 1: The Psychiatric Assessment: An Overview.............................................. 09
Session 2: Introduction to Psychiatric History-Taking................................................ 19
Session 3: Cognitive Assessment I........................................................................... 51
Session 4: Cognitive Assessment II.......................................................................... 75
Session 5: Movement Disorders............................................................................... 97
Session 6: Phenomenology.................................................................................... 109
Session 7: Mental State Examination I.................................................................... 123
Session 8: Mental State Examination II................................................................... 129
Session 9: Mental State Examination III................................................................... 135
Session 10: Personality Style I................................................................................ 139
Session 11: Personality Style II............................................................................... 149
Session 12: Reflective Interview Skills I................................................................... 153
Session 13: Reflective Interview Skills II.................................................................. 165
Session 14: The Therapeutic Alliance..................................................................... 175
Session 15: Introductory Formulation I.................................................................... 185
Session 16: Introductory Formulation II................................................................... 205
Session 17: Cognitive-Behavioural Approach and Formulation............................... 211
Session 18: Psychodynamic Formulation I.............................................................. 225
Session 19: Psychodynamic Formulation II............................................................. 239
Session 20: History and Formulation in Child and Adolescent Psychiatry................ 257

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

01

Who?
This manual and its accompanying USBs are for Psychiatric Trainees of all levels and for their tutors.
However, any Mental Health Professional who wants to enhance their clinical assessment skills will
benefit from these sessions and exercises.

What?
02

This program targets all aspects of the clinical psychiatric assessment in a clear, concise and
easy-to-follow format.
It moves fluidly from the basics of the psychiatric history and mental state examination to the
more complex and subtle aspects of psychiatric assessment.
It will guide junior trainees embarking upon the daunting task of assessing patients. It will assist
senior trainees in developing a greater degree of sophistication.

When?
There are twenty sessions. Sessions run for a maximum of two hours.
While sessions can be run at any interval, the manual is designed to fit in with either a weekly
six-month program or a fortnightly twelve-month program.

Where?
For most sessions, all you need is a space free from interruption plus equipment to play the
accompanying USB to the group.

Why?
This program was developed in response to the recognition that the Clinical Psychiatric
Assessment is an area of unmet need in the current system of Psychiatry Training.
This program is a guide both for those wanting to teach, and those wanting to learn or expand upon
their skills in psychiatric assessment. It provides a program that is standardised and replicable with
specific learning goals and objectives, yet at the same time is flexible and responsive to the learning
needs of participants.

An area of unmet need
A fundamental and often neglected skill in psychiatry training is that of the Clinical Psychiatric
Assessment. This includes interview, mental state examination and formulation. While the basic
skill level required for day-to-day clinical work is adequately achieved by most registrars, a
sophisticated approach encompassing a true understanding of biological, psychological,
psychodynamic and social issues is more difficult to attain.
Mastery of the skills of the clinical assessment forms the very foundation of sound psychiatric
practice. The clinical assessment in psychiatry functions as:
1. A diagnostic tool

03

2. The basis of an individualised management plan
3. A therapeutic tool
− it can be therapeutic in and of itself, establishing the beginnings of a therapeutic alliance
and thus enhancing compliance with proposed interventions, and
− many skills of the assessment are generalisable to any ongoing therapy relationship.
Some areas of the Clinical Psychiatric Assessment are currently better taught than others. A
qualitative research process – questionnaires and unstructured interviews – was used to delineate
the areas that trainees view as relatively neglected by the current training scheme. It is on these
areas that this manual focuses.
An integral component of sound clinical assessment is the development of the skill of clinical
thinking, also known as clinical reasoning. This is something not easily taught. These two terms both
refer to the expert method of processing raw clinical data as opposed to the textbook organisation
of knowledge. Research suggests that this skill is best developed through exposure to quality clinical
experiences matched with an opportunity for guidance and reflection. This is something that we
hope to provide through this manual.

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

The manual embraces the principles of adult learning. . offering a program that is standardised enough to be replicable and easy to use.Our vision This manual is a tool for those wanting both to teach and to learn the clinical assessment in psychiatry. yet flexible enough to be responsive to the individual learning needs of its participants. The degree of active involvement in the learning process will vary from group to group. This manual is unique in targeting the unmet needs of psychiatry trainees. role-plays and exercises. They encourage the integration of theoretical and practical knowledge. It encourages active participation in a highly relevant. It includes conventional lectures and presentations but the main emphasis is on the hands-on discussions. experiential learning process. a non-critical environment in which reflection. 04 The material in this manual employs a wide range of teaching methods. The exercises in this manual aim to cultivate the skills at every level of the clinical psychiatric assessment – from the basics to the complex and subtle. but the material is designed in such a way that more active involvement in the learning process will give better results. and promote the reflective practice that then fosters clinical thinking. contemplation and discussion are fostered. It aims to facilitate a safe and welcoming environment for trainees of all levels.

Specific learning goals • History and mental state examination ­ Content knowledge: º To know the core contents of a complete psychiatric history and mental state examination. such as ­ – Phenomenology and psychopathology.g. including ­ – Phenomenology ­ – The cognitive assessment ­ – Assessment of movement disorders. including transference and countertransference – To learn to respond to relational aspects of the interview ­ º To begin to use clinical reasoning skills during the assessment process • Formulation Content knowledge º To understand the elements of a formulation º To know the various schema used in formulation º To understand how a formulation will vary depending on its function. e. pseudo-hallucinations ­ – Transference and countertransference ­ – The therapeutic alliance ­ – The assessment of personality style and structure ­ Process knowledge: º To be aware of some of the challenges that may arise when applying theoretical knowledge to clinical practice  T º o understand different interviewing techniques and how these vary according to the situation ­ º To enable the practice of interview skills through role plays and observed interviews ­ º To enable the development of cognitive assessment skills º To encourage reflection on clinical assessment skills and the clinical assessment process º To increase awareness and understanding of what is happening at multiple levels of an interaction – To increase skills of observation – To increase awareness of non-verbal communication. ­ – Specific phenomenological concepts.Learning goals Overall learning goal To guide the development of the skills involved at every level of the clinical psychiatric assessment... focussing particularly on those skills not specifically addressed in the current psychiatry training scheme. e. AIMS test ­ º To know and understand definitions and concepts relevant to the psychiatric assessment. for example: – Diagnostic formulation – Cognitive-behavioural formulation – Psychodynamic formulation Process knowledge º To become familiar with using data from the clinical assessment to understand the patient’s predicament º To synthesise the data into a coherent formulation º To learn to begin to formulate from early in the assessment process HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 05 .g.

Against the background of your own qualifications. The USB material varies in content. the manual contains: • A session outline • Detailed instructions to guide you in the preparation and running of the session • Trainee handouts • Suggested discussion prompts • Facilitator notes to guide you in leading discussions For some sessions there is a choice of options – each clearly outlined in the manual The CD and USB Enclosed is a CD formatted to play via a computer and will not play on a standard DVD player. environment and setting. . experiential learning process you should encourage maximum involvement of all trainees. Unless specifically indicated in the manual each session can stand alone and it is possible to modify the order or to omit sessions depending on the requirements of your group. and • Suggested discussion prompts How to use the material The sessions are designed to run sequentially. In keeping with the manual’s stated goal of encouraging an active. The material is in two parts: • A manual • Accompanying CD and USB material for each session 06 The manual For each session. rather than only the experience of watching interviews and role-plays on the USB provided. and from basic to more sophisticated subject matter. It may contain: • Lectures and/or presentations • Recorded role-plays • Patient interviews • Other stimulus material such as group discussions. Each session runs for a maximum of two hours. you may choose the sessions and the exercises that best suit. This means thinking carefully about the options for the running of each session. mental state examination and formulation. but the manual is designed to fit in with either a weekly six-month program or a fortnightly twelve-month program. In choosing between these options remember that trainees should have the opportunity to do their own interviews and role-plays. the trainees’ level of experience. Each session builds on learning from previous sessions. if possible.About this material There are twenty sessions. They move logically through the entire clinical assessment from history. Sessions can be run at any interval that suits. and practical considerations such as the environment.

Group size We are aware that group size will vary depending on the setting but recommend that ideally there is a minimum of four trainees to facilitate discussion. confidence-inspiring manner. on the trainees’ level of experience. role-plays or other activities. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 07 . Facilitator notes Facilitator notes have been provided for most sessions. The fundamental approach of this material is to embrace principles of adult learning. Ensure you leave enough time for these necessary preparations. where each individual’s point of view is respected. For exercises involving role-plays and interviews. These notes are intended to highlight certain key issues and to guide you in the leading of discussions. The notes are not intended to be comprehensive and we do not propose that they be rigidly adhered to. including that of encouraging active involvement of all participants in a clinically-relevant learning process. An amount of preparation is required for all of the teaching sessions. or at other times when trainees may be under scrutiny. and a maximum of sixteen to ensure the requisite intimacy and confidence within the group. therefore. For sessions in which there is a choice of options it is necessary that. you choose which option to follow. The focus of each discussion will depend upon your area of expertise as facilitator. Your role as facilitator. it is necessary to take care to ensure participants feel sufficiently secure. This will give you a thorough knowledge of the contents of the session and enable you to conduct the sessions in a natural. and that the exposed trainee feels “safe” and “supported” rather than exposed to the group. During group discussions other pertinent issues will undoubtedly arise. For some sessions you need to select a trainee(s) who also needs to prepare for the session.What is required of you as facilitator You must familiarise yourself with both the written material in the manual and the USB footage. The purpose of the interview segments. prior to the session. is to generate discussion rather than to lead into a critique of the individual’s skills and techniques. is to encourage discussion and reflection in a non-critical space. and the particular interests of the group.

and to obtain and keep a record of appropriate informed consent for the interview and/or recording. In addition. Many hospitals have approved consent forms that must be completed prior to any recording being made. When a recording is made of the interview the consent process must specifically address this aspect of the process. All interviewed patients had capacity to consent. A patient who agrees to be interviewed and recorded must be informed of what will happen to the material following the session. Consents When a patient agrees to be interviewed for educational purposes you must ensure that adequate consent is obtained. and it was also discussed with the patients’ treating doctors. for teaching purposes. Capacity to consent was assessed by the authors. both verbal & written. lecturers and seminar leaders for the ongoing use of their material. We advise that you check with relevant hospital authorities before proceeding with any recording of interviews. in general. we advise a facilitator who chooses an option in the manual/USB that requires them to organise their own interviews and make their own recordings of interview material to observe the same rules of confidentiality. The participants in the USB have all freely given informed consent for the use of this material without time-limitation or mode-of-publication constraints. the material should be destroyed after use. and of their images. publication or viewing.Confidentiality The material presented in this publication and USB series is strictly intended for the training of Mental Health Professionals. and trust that all material will be treated with respect. Where relevant it was discussed with family members. you should check your specific hospital policy but. We advise that all facilitators and trainees using this material strictly adhere to the conditions of use of the USB and manual and do not allow unauthorised distribution. Your hospital will also have a privacy policy to which you should refer. . 08 Written consent has been obtained from all patients interviewed. Again. We thank them for this. This material is not for release to the public in its present or a modified form. unless the material can be guaranteed to be kept secure in a confidential place. The authors have attempted as far as possible to protect patients’ confidentiality by omitting all potential references to their identity and by maintaining anonymity within the limitations of live recorded material.

Session 1: The Psychiatric Assessment: An Overview 09 .

with either a data projector or TV monitor. It begins with the observation of a doctor-patient interview. To provide an introduction to the process of analysing and discussing clinical assessments in psychiatry 2.  To provide an overview of a complete psychiatric assessment (including both data-gathering and data-synthesis) 3. There are two options for this session: Option A: Organise your own doctor-patient interview Option B: Watch the interview on the accompanying USB Focus of the Session 1. both in real-life settings and in “artificial” settings such as teaching sessions and exams Materials Required for the Session Option A: Video camera if pre-recording your own interview Equipment to watch the pre-recorded interview during the session Option B: Computer. and external speakers .Session 1 10 The Psychiatric Assessment: An Overview OBSERVATION OF INTERVIEW AND GROUP DISCUSSION OPTION A Organise your own interview OR OPTION B Watch the interview on the accompanying USB Session Summary This session provides an introductory overview of the complete clinical assessment in psychiatry.  To note and discuss some of the challenges that may arise. This is followed by a group discussion of the information gathered in the interview and the clinical assessment process.

ensure there is minimal blunting of affect and emotional reactivity 3.  If you selected that the interview be pre-recorded for viewing during the session. Ensure that observers sit out of the direct line of sight of the patient and that they remain passive throughout the interview. or any other illustrative moments 6. Select a trainee to be interviewer 2. or it can be observed live by the group: º through a one-way screen º via a monitor in another room º by having the group present in the room during the interview* • The trainee conducting the interview should not take notes while interviewing the patient *If the group is present in the room during the interview.The Psychiatric Assessment: An Overview 1 OPTION A: Organise your own interview Preparation for Session Please note that there are no Facilitator Notes for this option Please note that this option requires significant preparation time. Select a patient to be interviewed by the trainee NB. Patient selection is important 11 – Can be an inpatient or an outpatient – Must be co-operative – Must have capacity to consent to the interview – Ideally non-psychotic. The interview • A forty-minute assessment interview The interview can either be pre-recorded and then watched by the group during the session. and photocopy them to distribute to trainees during the session HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Prior to the interview • Explain the interview to the patient and obtain written consent • Check with your relevant hospital authority about the procedures relating to confidentiality and consent in your hospital 4.  Review the discussion prompts (appendix 1. it is recommended that you watch the interview prior to the session to familiarise yourself with the content 7. the number of observers should be limited. but if psychosis is present please. After the Interview  Immediately after the interview the interviewer and observers should jot down any points in the interview where they noticed a change or shift in rapport.1). 1.1. 5.

Review the facilitator notes (appendix 1. Hand out the discussion prompts (appendix 1.2.  Lead a group discussion of the interview guided by the discussion prompts and the facilitator notes (appendix 1. Ask trainees to think about the questions (discussion prompts) in light of the interview (10 minutes) 4.2) (55 minutes) 5.1 – Discussion prompts for trainees Appendix 1.Conducting the Session 1.1.2.2) Conducting the Session 1. Hand out the discussion prompts (appendix 1. Photocopy the discussion prompts (appendix 1.1) and allow reading time (5 minutes) 2.1) to distribute to trainees during the session 3.1) and allow reading time (5 minutes) 2. Watch the full-length interview: either live or play the recording (40 minutes) 3.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions 12 OPTION B: Use the recorded interview on the accompanying USB Preparation for Session 1. Play the USB of the interview (30 minutes) 3.2.1 – Discussion prompts for trainees For use with Option B (Watching the interview on the accompanying USB) Appendix 1.2.1.2 – Facilitator notes . Review the 40-minute interview on the accompanying USB 2.2. Ask trainees to think about the questions (discussion prompts) in light of the interview (10 minutes) 4. Lead a group discussion of the interview guided by the discussion prompts (55 minutes) 5.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any remaining questions Appendices listing For use with Option A (Organising your own interview) Appendix 1.2.

Comment on the patient’s affect 10.  Can you recall any segments where there was a disjunction or failure in the rapport? (These may be major or minor disjunctions) 6. Was this interview sufficient to make a provisional diagnosis? What is your provisional diagnosis? 13. What are your differential diagnoses? Discuss these. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 13 .The Psychiatric Assessment: An Overview 1 Appendices Appendix 1. in this circumstance. What additional information would you like to clarify the diagnosis? 15. Was there a change in rapport as the interview progressed? What accounted for this? 3. However it is important to also think beyond this. 14.1. Comment on the patient’s thought-form 11.1 – Discussion prompts for trainees For use with Option A (Organising your own interview) 1.  What interview techniques were used in this interview? Which of these had the most productive effect? 9. Can you recall any segments where there was a deepening of the rapport? 5. What do the shifts tell us about the patient? 4. What do you see as important issues in ongoing management? Learning Point The bio-psycho-social framework is useful when deciding on management. How else might these disjunctions have been managed? 8. How did the interviewer manage these disjunctions? 7. Does the interview permit an assessment of risk? What is your risk assessment? 12. Comment on the interaction between the interviewer and the patient in the interview 2. and to consider in greater depth what is unique to this patient.

Comment on the patient’s thought-form 15. Does the interview permit an assessment of risk? What is your risk assessment? 16. Was there a change in rapport as the interview progressed? What accounted for this? 3. What additional information would you like to clarify the diagnosis? 19. Comment on any shifts in rapport in this excerpt 7.  What interview techniques were used in this interview? Which of these had the most productive effect? 14 5. What do you notice in this excerpt? Now think back to the full-length interview 13. Comment on the interaction between the interviewer and the patient in the interview 2. Comment on the patient’s affect 14. Are there any risks involved in asking about this topic? 11. in this circumstance. it is important to also think beyond this.1 – Discussion prompts for trainees For use with Option B (Watching the interview on the accompanying USB) The full-length interview 1. . and to consider in greater depth what is unique to this patient. What is your provisional diagnosis? 17.  Do you think it is valuable to ask a patient why they have never been in an intimate relationship? Why is this useful? 10. What do you notice in this excerpt? 9.Appendix 1. Can you think of any points in the interview where an attempt to deepen rapport did not work? Excerpt One 6. What are your differential diagnoses? Discuss these 18. What do you see as important issues in ongoing management? Learning Point The bio-psycho-social framework is useful when deciding on management. However. What do the shifts tell us about the patient? 4.2.  How else could you respond if a patient says they would rather not talk about a sensitive topic such as their suicidality? Role play this scenario Excerpt Two 8. How might you ask about this topic? Role play this scenario Excerpt Three 12.

Trust develops as seen when the patient confides her psychotic experiences. For example. Comment on the interaction between the interviewer and the patient in the interview   The interaction is polite and pleasant. we see a deepening of rapport as the patient confides her psychotic experiences. There are no major disruptions. What do the shifts tell us about the patient? This interview is an example of one where. we see a minor derailment of the engagement when the patient states a preference not to answer questions about her past suicidality.The Psychiatric Assessment: An Overview 1 Appendix 1. enquiring and non-judgemental approach • She uses both open and closed-ended questions • She uses non-verbal techniques to acknowledge and affirm • The patient responds to a non-confrontational style and to more open-ended questioning • However. 3. Excerpt One 6. Also it shows only minor shifts in rapport. Can you think of any points in the interview where an attempt to deepen rapport did not work? One point where this occurs is when the patient is asked about her interests. She responds with an open smile and rapport momentarily deepens.2 – Facilitator notes For use with Option B (Watching the interview on the accompanying USB) The full-length interview 1.  What interview techniques were used in this interview? Which of these had the most productive effect? • The interviewer uses a gentle. despite an apparent ease of engagement. Second. to an extent. The interviewer allows this topic to be side-stepped and rapport is quickly re-established. 2. she did not demonstrate much spontaneity and so required an amount of external direction 5. able to be engaged. There is a rare demonstration of spontaneity: “I got three books for Christmas!” This deepening of rapport is not sustained and the conversation falters. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 15 .   Changes or shifts in rapport are slight. taken in context it: • makes us wonder about the quality of her interpersonal relationships • gives information about personality style • suggests a more longstanding illness process 4.2. The patient is co-operative and.   Rapport deepens slightly but it remains superficial for much of the interview. Comment on any shifts in rapport in this excerpt First. Moments of intimacy are closed off again and affect-laden topics are largely avoided. the doctor-patient alliance remains tentative. Was there a change in rapport as the interview progressed? What accounted for this?  Initially there is an exaggerated politeness but rapport develops rapidly and the politeness softens. This gives us useful information and can guide us in our understanding of the patient.

” Excerpt Three 12. . This interaction gives an insight into the challenges we might face in an ongoing avoidant therapy relationship. even intruded upon or persecuted. What do you notice in this excerpt? Involuntary mouth movements – pouting: this is an example of “rabbit syndrome”. for example. Framing the question in such a way as to acknowledge the sensitivity is useful: “I wonder if that’s hard for you to talk about. 10. especially for novice interviewers. It is important for me to know. Maybe we can come back to it later. sensitivities and the ease with which she will trust and form a working alliance. One way is to allow the avoidance. discards this line of questioning and moves onto another topic. Whatever the response. The patient may feel confronted.7.  How else could you respond if a patient says they would rather not talk about a sensitive topic.  Do you think it is valuable to ask a patient why he/she has never been in an intimate relationship? Why is this useful? It is important to ask about this topic as the information can be useful for formulation and diagnosis (of both Axis I and Axis II diagnoses). “I see how hard it is for you to talk about this. There is a risk of disrupting rapport. there are real risks.” “That seems to be a sensitive area. 11. 9. What do you notice in this excerpt? Met with obstruction the interviewer falters. Another is to acknowledge the difficulty: “I can see that is a painful area for you. This segment is a good example of how deceptive the initial superficial ease of engagement can be. In addition. This can have negative consequences.” “It sounds like you don’t want to talk about that topic right now. though…” Or. the act of entering into such intimate subject matter tests and can deepen rapport. It is an example of how a patient’s anxiety and reticence can make the whole atmosphere tentative. it gives valuable information to the treating team about the patient’s defenses. such as their suicidality? Role play this scenario There are several possible ways to manage when a patient wishes to avoid a painful or sensitive area. be it a deepening of or a rupture in rapport. a form of tardive dyskinesia that has been commonly reported with risperidone. Are there any risks involved in asking about this topic? Yes. that important aspects of history are missed. How might you ask about this topic? Role play this scenario This is a potentially difficult topic that can be hard to broach.” 16 Excerpt Two 8.

g. 14. Some causes and contributors to the reduced range are: º Age-related restriction of affect º Personality-style (e. reserved personality. and is able to establish reasonable rapport • Denies any recent thoughts of suicide Medium to long-term risk • Less certain • T  reatment under the Mental Health Act 2007 – involuntary admissions. Comment on the patient’s affect 1) Limited range of affect There is some reactivity with genuine warm smiles at moments of engagement. Does the interview permit an assessment of risk? What is your risk assessment? Immediate suicide risk • Low • E  ngaged in treatment. suggests a thin veneer of wellness Harm to others • Needs to be considered. anxious) º Depressive disorder º Residual paranoia (guarded and suspicious) º Negative feature of a schizophrenia-spectrum disorder º Extra-pyramidal side-effects of medication 2) Incongruity of affect  Incongruous smiling. displays insight. Comment on the patient’s thought-form Thought-form is coherent. probably indicating shame and embarrassment. avoidant. 17. schizoid. 16. although it was not specifically addressed in this interview. What are your differential diagnoses? Discuss these • Other schizophrenia-spectrum disorders such as schizo-affective disorder • Delusional disorder • Depression with psychotic features • Dementia with psychotic features • Psychosis secondary to a general medical condition HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 17 .The Psychiatric Assessment: An Overview 1 Now think back to the full-length interview 13. What is your provisional diagnosis? Late-onset schizophrenia. is fairly candid. for example she smiles and laughs while describing being taken to hospital against her will by the police. 15. More extreme forms of incongruity occur in grossly psychotic patients. multiple renewals of Community Treatment Orders – suggests past risk and associated impaired insight • The patient’s fragility. seen by the reticence to enter into painful subject matter. There is no formal thought-disorder.

In this interview there was a marked disparity between the image presented to us of a lady who is doing well. One aspect of management that could be discussed is the incongruities or inconsistencies that presented themselves during the interview and how these may be useful clues to the development of an individualised management plan. and is in agreement with her treatment plan (says “I’m very happy with it. and to consider in greater depth what is unique to this patient. less likely. has insight. The patient tells us that she is doing well but does not really let us into her emotional world. What do you see as important issues in ongoing management? There are many aspects of management that can be discussed here. and the mood disorders • The presence or absence of any manic features • Premorbid function: has there been a decline in function? • Cognitive function 19. when well. such as depression. how things are going at the moment!”) and the history of involuntary hospital admissions and Community Treatment Orders. Relative preservation of thought-form and some preservation of affective warmth supports the diagnosis of a later onset of illness rather than a “burnt-out” paranoid schizophrenia. For example. Learning Point The bio-psycho-social framework is useful when deciding on management. The disparities suggest that the patient is at higher risk than suggested by her superficial presentation and that. 18. schizo-affective disorder. . her risk could easily be underestimated. it is important to also think beyond this. However. the patient may come across as co-operative and agreeable but then drop out of care and experience a relapse.Poverty of thought and reduced affective range makes the diagnosis of an episodic illness. in this circumstance. What additional information would you like to clarify the diagnosis? • The temporal relationship of mood and psychotic symptoms: 18 º Will assist in determining if this is a primary mood or psychotic disorder º Will assist in differentiating between schizophrenia.

Session 2: Introduction to Psychiatric History-Taking 19 .

The session is divided into two parts: PART ONE: Two lectures on psychiatric history-taking PART TWO: Two role-plays of history-taking. and external speakers. as well as techniques to overcome these challenges Materials Required for the Session PART ONE: Computer. with either a data projector or TV monitor.Session 2 Introduction to Psychiatric History-Taking 20 PART 1: LECTURES Dr Agnes Chan The Psychiatric Interview: (History Taking) Dr James Telfer The Diagnostic Interview in Psychiatry PART 2: ROLE PLAYS AND GROUP DISCUSSION OPTION A Organise your own role plays OR OPTION B Watch role plays on the accompanying USB Session Summary This session provides an introduction to the history-taking component of the clinical psychiatric assessment. each followed by a group discussion. the challenges that may arise. . To enable trainees to observe and/or practice history-taking through role play 3. To introduce trainees to the core contents of a complete psychiatric history 2. and external speakers PART TWO: Option A: no extra materials required Option B: Computer. There are two options for Part Two.  To use role play as a launch pad for discussion of history-taking. Option A: Organise your own group to perform role-plays Option B: Watch the role-plays on the accompanying USB Focus of the Session 1. with either a data projector or TV monitor.

Select two trainees to be simulated patients 2.5) to distribute to trainees during the session Conducting the Session IMPORTANT: Note to Facilitator Trainees participating in the role-play must feel ‘safe’ and ‘supported’.2. Allow question and discussion time (10 minutes) PART TWO: Role-plays OPTION A: Organise your own role-plays using provided vignettes Preparation for session Please note that there are no Facilitator Notes for this option 1.2.Introduction to Psychiatric History-Taking 2 PART ONE: Lectures Preparation for Session 1.  Review the discussion prompts (appendix 2.3) and photocopy them and the page on interviewing techniques (appendix 2. Review the recorded lectures to ensure you are able to discuss relevant aspects of the topic 2.  Make a photocopy of the vignettes (appendices 2.2) to give to simulated patients and interviewers so that they can learn their roles prior to the session 4. Select two trainees to be interviewers 3. It is NOT a critique of the skill of the trainee.1) 2.  Select a trainee who is not participating in either role-play to be ‘the moderator’ of the roleplays and give the moderator their instructions (appendices 2.1 and 2. Play the lectures on the accompanying USB Lecture One: The Psychiatric Interview: (an overview) Dr Agnes Chan (20 minutes) 21 Lecture Two: The Diagnostic Interview in Psychiatry Dr James Telfer (10 minutes) 3. Photocopy the lecture slides (appendix 2.3. Hand out copies of the lecture slides to trainees (appendix 2.3) and the page on interviewing techniques (appendix 2.2. The purpose of the role plays is to generate discussion about interview content and interview technique.2.1.2.1 and 2.1. 1. that the purpose of the role play is to facilitate discussion surrounding history taking and is not a critique of the interviewer’s performance 2.1) to distribute to trainees during the session Conducting the Session 1.3.  Prior to the start of the role plays it is important to explain to the group that the trainee conducting the interview is in a difficult position and may feel nervous and exposed.2.5) and allow reading time (5 minutes) HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Hand out the discussion prompts (appendix 2.2) 3.

 Hand out the discussion prompts for both role-plays (appendices 2. The role-plays are based on the same vignettes as those supplied for option A of this session 2.  Review the two role plays on the accompanying USB.3.3.3.  Lead a group discussion of the role-play guided by the discussion prompts (appendix 2.3.3.3.2.3) (30 minutes) . Conducting the Session 1.4. Conduct role-play 1 (17 minutes) 6.2 for the role-plays Case 1: A 30-year-old male diagnosed with depression Focus: History of presenting illness Case 2: A 40-year-old woman with schizophrenia/schizoaffective disorder Focus: Past psychiatric history: Case 2 5.3.1 and 2.  At the completion of the role-play ask the interviewer and the simulated patient to return to their seats within the group 22 7.1 and 2.3.1 and 2.3 and 2. Review the facilitator notes for both role-plays (appendices 2. OPTION B: Watch the role-plays on the accompanying USB Preparation for Session 1.  At the completion of the role-play ask the interviewer and the simulated patient to return to their seats within the group. 10.  Photocopy the discussion prompts for both role plays (appendices 2. Conduct role-play 2 (17 minutes) 9. It is NOT to critique the skill of the trainees conducting the simulated patient interviews on the USB. Lead a group discussion guided by the discussion prompts (20 minutes) 11.2.2) and the page on interviewing techniques (appendix 2. Lead a group discussion guided by the discussion prompts (20 minutes) 8.2) and the page on interviewing techniques (appendix 2.1) and facilitator notes (appendix 2.5) to distribute to trainees during the session 3.5) and allow reading time (5 minutes) 2. Refer to appendices 2.  Watch role-play 1 on the USB (10 minutes) 3.3.4) IMPORTANT: Note to Facilitator The purpose of the role-plays is to generate discussion surrounding interview content and interview technique.3.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions Note to Facilitator It may be necessary to redirect discussions if the trainee’s individual technique is becoming a focus.

3.Instructions to interviewer Appendix 2.2 – The Diagnostic Interview in Psychiatry by Dr James Telfer For use with Part Two Option A (Organising your own role plays) Appendix 2.1 – Vignette for Role-play 1 (History of presenting illness) .3 – Facilitator notes for Role-play 1 (History of presenting illness) Appendix 2.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions Appendices listing 23 For use with Part One (Lectures) Appendix 2.1.4 – Facilitator notes for Role-play 2 (Past psychiatric history) For use with Part Two Option A and B Appendix 2.2 – Vignette for Role-play 2 (Past psychiatric history) . Watch role-play 2 on the USB (10 minutes) 5.3.1.2.  Lead a group discussion of the role-play guided by the discussion prompts (appendix 2.Instructions to interviewer Appendix 2.4) (30 minutes) 6.3.3.2) and facilitator notes (appendix 2.Instructions to moderator .Instructions to moderator .3.5 – Interviewing Techniques HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .3.Introduction to Psychiatric History-Taking 2 4.Instructions to simulated patient .3 – Discussion prompts for trainees for use with both Role-play 1 and Role-play 2 For use with Part Two Option B (Watching role-plays on the accompanying USB) Appendix 2.2.3.Instructions to simulated patient .1 – Discussion prompts for trainees for Role-play 1 (History of presenting illness) Appendix 2.2.2 – Discussion prompts for trainees for Role-play 2 (Past psychiatric history) Appendix 2.1 – Lecture slides for The Psychiatric Interview: (History Taking) by Dr Agnes Chan Appendix 2.

Appendices Appendix 2.1.1 – Lecture slides For use with Part One (Lectures) The Psychiatric Interview: (History Taking) by Dr Agnes Chan 24 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 .

Introduction to Psychiatric History-Taking 2 25 Slide 7 Slide 8 Slide 9 Slide 10 Slide 11 Slide 12 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

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Introduction to Psychiatric History-Taking 2 Appendix 2.1.2 For use with Part One (Lectures) The Diagnostic Interview by Dr Telfer 27 Page 1 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

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you don’t seem to be getting much done. but your appetite hasn’t been up to much. You can’t make a single decision. This depression has been getting worse. The other day. You have always been conscientious. You lie awake at night worrying about the day that’s been.2. Do not expect to cover all of the information that you have been given. Not even about what tie to wear with what shirt in the morning. Your GP has referred you here. especially in the last week. and then about 2am you fall into this deep. You feel like you are wading in mud. You are a little slow in both your speech and your movements. and also where you’ve been on days off. You have been referred to the community mental health centre by your general practitioner who has been concerned about your level of depression. The other day you were pretty sure they were talking about you in the hallway because they went quiet as you walked past. as though something‘s woken you. You haven’t been sleeping well. wondering if something’s up. It was lucky it was the weekend and you didn’t have to be anywhere special but it still made you feel hopeless and useless. no secret conspiracies. You wake with a start. . and more recently about your risk of suicide. You have been depressed for two months. even a perfectionist. You would really like to feel better. you want to help the doctor by answering as much as you can. Remain as true to the information given in this scenario as you can. You just go back to bed. but the last two weeks you have missed a few days of work. You trust her advice but you find it hard to believe that anything is going to help you. You are a thirty-year-old accountant living with your girlfriend in a rental unit. You are not sure if you’ve lost weight. But then you know you have been more sensitive than usual lately. half-dead slumber for three or four hours. Your mood is worse in the mornings. and smile very little if at all. so you don’t want to make too much of it. That’s partly why you don’t go to work sometimes. You are heavy and slow and you can’t think straight. but it is hard to see out of this slump. 36 Although you are finding it difficult to summon the energy for this interview. If you are asked specific questions that are not covered here you may improvise so long as it is consistent with the character and the rest of the information with which you have been provided.Appendix 2. It seems like your colleagues resent you for dragging them down.1 – Vignette for Role-play 1 (History of presenting illness) For use with Part Two Option A (Organising your own role-plays) Role Play 1 – Instructions to simulated patient How to play the role You are visibly down and depressed. If you go to work. You definitely haven’t heard anything they’ve said – no hallucinations. nothing odd like that. You are pretty sure they’ve been looking at you strangely. you couldn’t find your keys for a whole hour and then found them in the fridge with the milk. but it’s all quiet and your girlfriend is fast asleep. You seem to be forgetting things and not concentrating. not pulling your weight. The whole day stretches ahead of you and you don’t know how you are going to get through it. This is the information you need to memorise for your role Your name is David Banks. appear sad and flat.

You can’t remember the dose. No side-effects. Lately you’ve stopped calling your friends back and you haven’t been to anything your girlfriend has organised. You can’t really talk to her about this. Your girlfriend is really worried about you. Your dad said he’d been through the same and not to worry about it. You think she’s too good for you. You know she is only trying to help but you need some space right now. either. Just always on the edge of the group. God no. He’s a bit of a bloke. So you can’t figure out what’s wrong now. It seemed like acne and teenage angst kicked in and you were on your own all the time. You aren’t into that either. That goes through your mind a bit. It sure wasn’t this bad. when you are lying in bed at night thinking about things. smelt anything unusual. and anyway it’d just upset her. She’s seen you once a week since then. It’s gone as quickly as it comes. It’s just a thought. But you don’t think it’s working. you’re not even that.Introduction to Psychiatric History-Taking 2 You feel like you were always reliable. you don’t think. You weren’t teased or anything. Now. but never got any treatment. Maybe not the most exciting guy. You sure haven’t made any plans or preparations. You haven’t been paranoid about anything else (apart from the people at work maybe talking about you). You feel a bit guilty about work and about neglecting your girlfriend and about being so useless. You haven’t noticed anything. She’d probably be better off with someone else. And you’d hate to upset the people around you. She was the one that got you to go to the GP a month ago. It probably wouldn’t look good for the next promotion though if your boss knew you get down and can’t cope. or thought about any other ways. Sometimes you think that if you had a gun you’d just blow your brains out. At least you had that. The GP’s been great. There is no other past psychiatric history. Not into the “touchy-feely” stuff. You think your girlfriend would be better off without you. She keeps asking what’s wrong and it gets on your nerves a bit. You might meet up maybe for a beer or to watch the sport. There was a promotion at work that fell through about three months ago. Instead you lay on your bed reading science fiction and playing computer games. You are not going crazy. that you’ve started to wonder what the point of all this is. You have a few friends. It’s only been in the last week. You know she wants to get married some day. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 37 . He was right. You speak to your mum every couple of weeks but you don’t want to worry her or your dad. and you feel kind of stuck and obligated. You aren’t good at talking about stuff. But you don’t want to let her down. but the depression is just getting worse. Somehow you got out of it when university came around. Apart from the Cipramil you are on no regular medication and have no known allergies. Why did this all start? You wish you knew. There’s been nothing suspicious and you haven’t heard any noises. You don’t think you’d ever actually do it. but steady. It’s not in your nature. Something about you being too inexperienced. You got depressed at high-school once. One tablet. Your mum said they were the best years of your life and you should be enjoying yourself. you’d never do it. You don’t have a gun. They scare you. He doesn’t seem like he’d “get it”. but you have always kept a little to yourself. It’d be awful. The only medical history is an appendicitis. Started you on Cipramil three weeks ago. You haven’t spoken to anyone at work about what is happening. You were upset at the time but you’re not that concerned about it. Or if your girlfriend organises things you usually go along. Your boss hasn’t said anything. Your brother lives overseas. seen anything.

There is a brief accompanying letter. stop the task . David Banks. present your provisional diagnosis and any differential diagnoses. say ‘Please present a summary of your history.’ • At 17 minutes. The patient you are about to see. I commenced him on Citalopram three weeks ago. 38 Thank you for reviewing Mr. is a new patient. X Your task is to take a history from this patient. I have done bloods and can find no organic cause for the depression. He is a 30-year-old accountant that I have been seeing for DEPRESSION. focussing primarily on the history of the presenting illness. At 14 minutes provide the group with a brief summary of your history. Dear Doctor. David Banks. if the interviewer has not moved on to the second task. I am concerned about worsening depression and suicide risk. You are a psychiatry registrar working in the community mental health centre.Role-play 1 – Instructions to interviewer You have 17 minutes to complete this task. Dr. His general practitioner has referred him to the centre. including any gaps. Regards. your gaps and your differential diagnoses. CURRENT MEDICATIONS: Citalopram 20mg po daily No known medication allergies PAST MEDICAL HISTORY Appendicectomy 1997 Thank you for your assessment and advice. Role-play 1 – Instructions to moderator • Your role is to ensure the role-play runs smoothly and to keep time • Begin the role-play when the group is ready • Observe the interviewer taking a history – this should be 14 minutes • At 14 minutes.

that well. You always have been. You’ve been on them for ages. Then this other one made you leak milk (Risperdal. Zyprexa made you put on weight and sleep all the time. You’ve tried a lot of different medications and you have had ECT (shock treatment) twice. If you are asked specific questions that aren’t covered here you may improvise so long as it is consistent with the character and the rest of the information with which you have been provided. They seem to have gotten it right now. The memory is blurred. You have difficulty recalling specific times and dates and don’t like talking in detail about the times when you were very unwell. You were diagnosed with schizophrenia twenty years ago. The Seroquel helps you sleep but then you’re sluggish in the day. Since then you’ve been in hospital about five times. You don’t really like being on medication. You’ve had a lot of trouble with medication. Still.2 – Vignette for Role-play 2 (Past psychiatric history) For use with Part Two Option A (Organising your own role-plays) Role-play 2 – Instructions to simulated patient How to play the role You are polite and pleasant and mostly cooperative. When you first got sick you sometimes forgot and sometimes you thought the medicine was poison. you know you need it because if you ever stop it you get sick again. every two years at first. But they put you on heaps of medication and you got all stiff and then couldn’t sit still. Most times were on a schedule. You get frustrated if pushed for details. When you were first diagnosed it was really bad. And one made you restless. You hope to come off your medications and ask about this at least once during the interview. You can’t remember it. You were in hospital for two months. kill you or something. You are a forty-year-old woman living alone in a Department of Housing unit. Mum is always checking up on you. Remain as true to the information given in this scenario as you can. but mostly you took it. Now they say it’s schizoaffective disorder or something like that. You think that’s pretty good. The lithium gives you a tremor and it makes it hard to serve in the coffee shop. they got it right and you went home with your parents. but are certainly never threatening or aggressive. This is the information you need to memorise for your role Your name is Simone. You thought your mum and dad were trying to kill you and you wouldn’t go to sleep at all because you thought they’d come into your room and you don’t really know. but you also don’t like thinking about those times now that you are better. but are a little vague on the particulars. Eventually. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 39 . This is partly because you have a poor memory for the times when you are depressed and unwell. You’re pretty good at taking your medication. Now you’re in a routine. too. You’re on lithium (250mg morning and night) and Seroquel (600mg at night). The work is especially for people with mental health problems.Introduction to Psychiatric History-Taking 2 Appendix 2. You are on a Disability Support Pension and you supplement this with part-time work at a local coffee shop two days a week. sometimes. Your mood is neutral. You heard voices all the time. Do not expect to cover all of the information that you have been given. Nor do you like talking about depressive themes. you think). You answer questions when asked.2. But now you’ve been out of hospital for eight years.

All giggly and full of energy. She’s pretty busy. You get worse and then better but it seems more steady these days. 40 You have had times when you’ve been too high. You have a cat called Mustard and she cheers you up. . You do all the housework. but you talk on the phone a few times a week. The most you’ve done is shout at your parents. Most of the time you don’t have any symptoms. You can’t remember how long ago this was. You were doing marine biology when you first got sick – you love animals. You are a bit vague about how you spend your time. and also things on the TV and radio about you. They thought maybe you could stop coming to the health centre and just see your GP but then you got sick again. but that’s all gone now and you don’t really want to talk about the past. you start fighting with Mum and Dad. You can’t remember the details but your parents have told you that once you thought you were Princess Diana. Sometimes you get a bit down about how things have turned out. Mostly you’re okay and you are thinking of doing animal studies at TAFE next year. You talk to your mum and dad nearly every day and see them about once a week when they come over. You see your sister once a month. When you go out you sometimes get paranoid that people are talking and laughing about you. You can’t remember it that well. The first time was the worst.You see your case-manager every couple of months and the psychiatry registrar when you need to get scripts. You’d dropped out of university and were all depressed. You start to think they are against you. apart from a bit of help from your mum. really scared and not eating any of the food they made. but you know it’s just the schizophrenia. and your parents were annoyed at you. Because no one knew what was going on. Mostly now. but you say you go for coffee and go to the movies and sometimes watch TV. You sometimes wonder if you could stop the medication. You have never been physically aggressive to anyone. You did think there were cameras in the house. when you start to get sick. You thought you’d get married and have a family but you don’t think that’s going to happen now. cooking and shopping yourself. because you were sitting at home all the time. One friend from school that you talk to every couple of months and a few friends you’ve met in hospital and at the coffee shop. You have never thought of suicide. You’ve got some friends. They notice right away and get onto your case-manager quickly. Mum gives the place a clean and checks the fridge.

say ‘Please present a summary of your history. She has a case-manager who keeps in regular contact with her.’ • At 17 minutes. This is the first time you have met her. your gaps and your differential diagnoses. Your task is to take a history from Simone focussing on the past psychiatric history. Role-play 2 – Instructions to moderator • Your role is to ensure the role play runs smoothly and to keep time • Begin the role play when the group is ready • Observe the interviewer taking a history – this should be 14 minutes • At 14 minutes. At 14 minutes provide the group with a brief summary of your history including any gaps and briefly describe the barriers you might face in managing this patient based on the history you have attained today. stop the task HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 41 . You are a psychiatry registrar who has just begun a rotation at the community mental health centre. Simone is a long-term client of the community centre. She has come to see you for a routine appointment. if the interviewer has not moved on to the second task.Introduction to Psychiatric History-Taking 2 Role-play 2 – Instructions to the interviewer You have 17 minutes to complete this task. Simone sees a psychiatry registrar for a routine review once every six months.

Use techniques that are comfortable for you. 8. How did the interview feel for the simulated patient? (Ask the simulated patient) 3. Experiment with different techniques. what aspects of the history of presenting illness (Role Play 1) or past psychiatric history (Role Play 2) were not covered here? 4. Which techniques worked best. Comment on the interaction between interviewer and interviewee 42 5. What were the main techniques the interviewer used to elicit information? 6.Appendix 2.  Bearing in mind that this was a time-limited interview. Are there any other techniques that could have been used? The question/answer approach is comfortable.2. What are some of the difficulties the interviewer faced in this interview? Discuss these 9. it is important to develop a range of approaches to interviewing. but trust your own style.3 – Discussion prompts for trainees for Role-play 1 and Role-play 2 For use with Part Two Option A (Organising your own role-plays) 1. However. and why? 7. How did the interview feel for the interviewer? (Ask the interviewer) 2. and is the technique most readily adopted by trainees.  How did the interviewer manage these difficulties? What other ways could you manage these difficulties? .

How else might you begin such an interview? Role-play alternative beginnings 9. it is important to develop a range of approaches to interviewing. What aspects were not covered? 2. Comment on the interaction between interviewer and interviewee 3. and why? 5.Introduction to Psychiatric History-Taking 2 Appendix 2. Discuss other interviewing techniques that could have been used The question/answer approach is comfortable and is the technique most readily adopted by trainees.1 – Discussion prompts for trainees for Role-play 1 (History of presenting illness) For use with Part Two Option B (Using role-plays on the accompanying USB) 1.  The interviewer began the interview by asking the patient “How are you going today?” Why might the interviewer have begun like this? 7. However.  What are some of the difficulties the interviewer faced in this interview? How did she manage these? 10. 6. What effect might this have had on the doctor-patient interaction? 8. Were there any leads that the interviewer could have taken up? Role-play how you could take up some of the missed leads HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 43 . but trust your own style. Experiment with different techniques.  This was a time-limited interview and not all aspects of the history of presenting illness were covered. What were the main techniques the interviewer used to elicit information? 4.3. Use techniques that are comfortable for you. Which techniques worked best.

What were the main techniques the interviewer uses to elicit information? 4. and why? 44 5. Why do you think she managed in this way? 9.Appendix 2. How else might you manage this situation? Role play alternative approaches .2 – Discussion prompts for trainees for Role-play 2 (Past psychiatric history) For use with Part Two Option B (Using role-plays on the accompanying USB) 1.  What were some of the difficulties the interviewer faced in this interview? How did she manage these? 7.3. Discuss other interviewing techniques that could have been used? 6.  This was a time-limited interview and not all aspects of past psychiatric history were covered What aspects were not covered? 2. Which techniques worked best. How did the interviewer manage this? 8.  On a few occasions the simulated patient said she would prefer to not talk about a particular topic. Comment on the interaction between the interviewer and interviewee 3.

using techniques that are comfortable and work for them. such as: − Summaries of the patient’s responses − Nodding − Eye contact held but non-confrontational 4. What aspects were not covered? − Pattern of mood over last four weeks − Cognitive symptoms such as excessive guilt − Psychomotor symptoms 45 − Triggers/precipitants to the depression − Presence or absence of psychotic symptoms − Presence or absence of anxiety symptoms 2. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . For example. both verbal and non-verbal. Trainees should be encouraged to experiment with different techniques. Discuss other interviewing techniques that could have been used There are a number of techniques that can be used in any interview: • Perhaps. instead of specific questions. such as º “You seem to be struggling with that” º “You seem very down today” The question/answer approach is comfortable.3 – Facilitator notes for Role-play 1 (History of presenting illness) For use with Part Two Option B (Using role plays on the accompanying USB) 1. coming here today. but trust their own style. alternated this with collaborative statements. it is important to develop a range of approaches to interviewing.  This was a time-limited interview and not all aspects of the history of presenting illness were covered. after summarising what the patient told her. However. and why? 5. What were the main techniques the interviewer used to elicit information? Predominant technique Questions – both closed and open-ended – in a calm yet inquiring manner Other techniques Expressions of empathy.3.” “I wonder if you could tell me some more about that” • Perhaps the interviewer could have put observations about the patient to him. and is the technique most readily adopted by trainees.Introduction to Psychiatric History-Taking 2 Appendix 2. Comment on the interaction between interviewer and interviewee Initial difficulty with engagement (clumsy and embarrassed) Rapport then developed rapidly A cooperative interviewee (patient) was readily forthcoming with information and showed trust in the interviewer The interviewer was gentle and displayed empathy and understanding 3. the interviewer could have put this back to patient and then asked for clarification • Perhaps the interviewer could have. “I wonder how it felt for you. Which techniques worked best.

6. However. The interviewer began the interview by asking the patient “How are you going today?” Why might the interviewer have begun like this? People often resort to colloquialisms through anxiety. This may be realitybased. What effect might this have had on the doctor-patient interaction? Informal and laid-back which might put the patient at ease. 8. Were there any leads that the interviewer could have taken up? The patient has a concern that people at work are talking about him.  What were some of the difficulties the interviewer faced in this interview? How did she manage these? 10. this statement may not demonstrate serious professional concern. How else might you begin such an interview? Role play alternative beginnings 46 There are a number of ways to begin an interview. coming here today” 9. Role-play how you could take up some of the missed leads. 7. or may be an overvalued idea or a delusion. . For example • “Tell me about what brought you here today” • “I wonder how it felt for you.

Why do you think she managed in this way? Met with resistance the interviewer conceded.3. I can understand why you don’t want to talk about that. Comment on the interaction between the interviewer and interviewee • Reasonably rapidly established rapport • Mildly anxious patient who is cooperative and forthcoming with much of the history. How did the interviewer manage this? Initially. Then she conceded with “That’s okay.4 – Facilitator notes for Role-play 2 (Past psychiatric illness) For use with Part Two Option B (Using role plays on the accompanying USB) 1. or when she avoids talking about difficult topics 3.  What were some of the difficulties the interviewer faced in this interview? How did she manage these? 7. to which the patient responds with a lot of information Other techniques • Some open-ended questions • Explanations of the interview process • Reassurances “I can understand why you don’t want to talk about that” “That’s great you have been good for a long period of time” 4. psychological treatments • Past history of self-harm and suicide attempts • Other risky behaviour when unwell 2. e.” 8. then when were they last present? • Relapses not requiring hospital admission – including the timing of the last relapse • Length of relapses/time to recovery • Inter-episodic psychiatric symptoms • Inter-episodic function • Past treatments other than medications. such as when the patient asks to stop all medication. • A polite and reassuring interviewer • Minor disjunctions. possibly to avoid further disruption to the rapport and possibly because of time pressures or shared embarrassment. What aspects were not covered? • How current psychiatric status compares with baseline level • Presence/absence of current psychotic symptoms? • If no psychotic symptoms. This was a time-limited interview and not all aspects of the past psychiatric history were covered. What were the main techniques the interviewer used to elicit information? Predominant technique Questions – predominantly closed-ended questions. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 47 . Discuss other interviewing techniques that could have been used? 6.g. and why? 5. ECT. the interviewer attempted to ask more about this. Which techniques worked best.Introduction to Psychiatric History-Taking 2 Appendix 2.  On a few occasions the simulated patient said she would prefer to not talk about a particular topic.

9. it can signal to the patient that you also don’t want to talk about difficult topics. Sometimes it is helpful to acknowledge their difficulty – “This is a painful thing to talk about” even if this is followed up by “We can come back and talk about this later. can’t deal with their pain and negative affects. How else might you manage this situation? Role play alternative approaches When avoiding an area.” 48 . This may make them reluctant to confide negative affects in the future.

and then inviting the patient to comment on this • Interpretation: noticing a parallel or a connection º “It seems to me there may be a pattern here. “Just now you mentioned…. scars. In each of these relationships…” • Putting hypotheses to the patient º “So.3.5 – Interviewing techniques For use with Part Two Option B (Watching role plays on the accompanying USB) When discussing interviewing techniques. “You seem sad” • Summaries or paraphrasing of what the patient has said. when you feel hurt you respond by getting angry?” • Appropriate reassurances HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 49 .Introduction to Psychiatric History-Taking 2 Appendix 2. I wonder if you could say some more about that” º On affective style. e. consider: • Use of verbal and non-verbal communication • Open-ended and closed-ended questions • Empathic responses that validate the patient’s experience º “That must have been hard for you” • Making observations and feeding them back to the patient º On their physical appearance.g. injuries. signs of fatigue º On something they have said.

NOTES 50 .

Session 3: Cognitive Assessment I 51 .

Photocopy the lecture slides (appendix 3. Allow question and discussion time (5-10mins) . with either a data projector or TV monitor. Play the lecture on the accompanying USB: Bedside Cognitive Testing – Dr Agnes Chan (40mins) 3. and external speakers PART TWO: Nil PART ONE: Lecture Preparation for Session 1. Hand out copies of the lecture slides to trainees (appendix 3.Session 3 Cognitive Assessment I 52 PART 1: LECTURE Dr Agnes Chan Bedside Cognitive Testing PART 2: WORKSHOP Session Summary This session is the first of two sessions on the Cognitive Assessment in Psychiatry.1) 2. Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic 2.1) to distribute to the trainees during the session Conducting the Session 1. The session is divided into two parts: PART ONE: A lecture about bedside testing of cognitive function PART TWO: A workshop in which trainees practice the cognitive assessment Focus of the Session 1. To introduce trainees to the essential components of bedside cognitive testing 2. To enable trainees to practice the cognitive assessment under supervision with an opportunity for discussion and feed-back on their techniques Materials required for the Session PART ONE: Computer.

Hodges.  Hand out copies of the Checklist for testing cognitive function: ‘Testing Cognitive Function at the Bedside’ to trainees (appendix 3.2) to distribute to trainees during the session Conducting the Session 1. they should practise: orientation. language.R. praxis and visuospatial function 3.2) 2.2 – C  hecklist for testing cognitive function: ‘Testing Cognitive function at the Bedside’. Oxford University Press: 144-154. executive function.  Photocopy the Checklist for testing cognitive function: ‘Testing Cognitive Function at the Bedside’ (Appendix 3.Cognitive Assessment I 3 PART TWO: Workshop Preparation for Session 1.1 – Lecture slides for ‘Bedside Cognitive Testing’ by Dr Agnes Chan For use with Part Two (Workshop) Appendix 3. J.  Ensure that you are familiar with the bedside cognitive tests covered in this session so that you are able to supervise the workshop 2. attention and concentration. memory. Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions Appendices listing For use with Part One (Lecture) Appendix 3. In: Cognitive Assessment for Clinicians. Using the checklist.  Divide trainees into pairs to practise performing the cognitive assessment on each other. 1994 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 53 .

1 – Lecture Notes For use with Part One (Lecture) Bedside Cognitive Testing by Dr Agnes Chan 54 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 .Appendices Appendix 3.

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Session 4: Cognitive Assessment II 75 .

The interview contains both formal and informal tests of cognition. Ensure that you are able to discuss relevant aspects of this topic 2. To explore some of the practical limitations of performing cognitive assessments 3. They should be used in conjunction with history and with neuro-imaging. The patient’s capacity to give informed consent was assessed by the interviewing psycho-geriatrician.  Review the accompanying USB material. To demonstrate clinical application of the cognitive assessment on a real patient 2.3) and Carers Assessment of Executive Function (appendix 4. Remember that cognitive findings form only one part of the picture.4) to distribute to trainees during the session • Two copies of each assessment tool have been provided: a blank copy and a copy of the completed assessments by the patient on the USB 4. Focus of the Session 1.  Photocopy the discussion prompts (appendix 4. and external speakers Preparation for Session 1.1) to distribute to trainees during the session 3. Prior to this recorded interview informed consent was obtained from the patient and his wife.2) . Review the facilitator notes (appendix 4. with either a data projector or TV monitor. It contains a recorded interview and cognitive assessment by an experienced psychogeriatrician. To introduce and discuss the various available cognitive assessment tools Materials Required for the Session Computer.Session 4 76 Cognitive Assessment II OBSERVATION OF A COGNITIVE ASSESSMENT AND GROUP DISCUSSION Summary of Session This session is the second of two sessions on the Cognitive Assessment in Psychiatry.  Photocopy the ACE-R (Addenbrooke’s Cognitive Examination) (appendix 4. The group watches and discusses selected segments of a recorded cognitive assessment by an experienced psychogeriatrician.

3 – Addenbrooke’s Cognitive Examination (ACE-R) (blank and completed assessment) Appendix 4.3) and the Carers Assessment of Executive Function (appendix 4.1 – Discussion prompts for trainees Appendix 4.Cognitive Assessment II 4 Conducting the Session 1.  Hand out the discussion prompts (appendix 4.4 – Carers’ Assessment of Executive Function (blank and completed assessment) HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .2 – Facilitator notes Appendix 4.  Watch the recorded segments of the patient and pause for discussion where indicated in the USB using the discussion prompts and facilitator notes – the USB footage is 35 minutes in total 4.1) and allow reading time (5 minutes) 3.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any outlying questions 77 Appendices listing Appendix 4.  Hand out the blank and the completed copies of the ACE-R forms (appendix 4.4) 2.

Asking someone how they spend a typical day is an important question.  What cognitive assessment tool would you use when prescribing a cholinesterase inhibitor for Alzeimer’s disease? 14. 12. What other cognitive assessment tools do you know? 13. What does this tell us? 11. The interviewer asks the patient. the patient responds to cueing. Discuss the problems with assessing general knowledge Segments Five 10. What do you make of the patient’s autobiographical account? 6. What do we learn in this segment? 78 Segment Three 4. “Are you in good spirits most of the time?” This is another important question. Why is the carer questionnaire important? 16. Can you identify any examples of language difficulties in this segment? Segment Two 3. What are the benefits of formal neuropsychological testing? 15. Which aspects of history not covered so far are relevant to the assessment of cognitive function? Segment Four 8. Comment on the patient’s performance on the Trail-Making Test.Appendices Appendix 4. Briefly discuss what you saw in this segment 9. Which area of the brain is responsible for: • Language and memory? • Visuo-spatial function and praxis? • Visual gnosis (visual recognition)? • Executive function? 17. Are you familiar with the questionnaire that this question comes from? 5. Which brain area would you expect to be affected in: • Alzheimers Disease? • Lewy-Body Dementia? • Vascular Dementia? . Comment on speech and thought-form 2.1 – Discussion prompts for trainees Segment One 1. When trying to recall the address. What do you make of the fluency of his speech in this segment? 7.

if so. Therefore.  Asking someone how they spend a typical day is an important question. From this. What do we learn in this segment?  There is a lack of depth in the patient’s descriptions of how he spends his day. Segment Three 4. 1. we might wonder if it reflects that the patient lacks the cognitive capacity to recall and/or to accurately describe his daily activities.  The interviewer asks the patient “Are you in good spirits most of the time?” This is another important question Are you familiar with the questionnaire that this question comes from? The Trail Making Test that the interviewer uses is not a Trail Making Test that has been psychometrically validated. Can you identify any examples of language difficulties in this segment? º “Inherit this” and “Slip into this” [when talking about the onset of his memory disturbance] º “Don’t have much of an intake” [regarding the reduction in his social and other activities] º “When you’re mixing around.2 – Facilitator notes The interviewing psychogeriatrician uses the Revised Version of the Addenbrooke’s Cognitive Examination (ACE-R) as his main instrument for cognitive testing. By contrast.Cognitive Assessment II 4 Appendix 4.  HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 79 . 2. the Trail Making Tests that are used in formal psychometric assessments have been validated and these do provide quantitative results.  The patient is mostly fluent but sometimes uses inappropriate words and phrases. The psychogeriatrician supplements the ACE-R with an introductory interview. The interviewing psychogeriatrician often uses the ACE-R in his clinical practice for the following reasons: • It is relatively time-efficient • It is practical in an outpatient setting. and is both expensive and exhausting for patients • It includes a wide range of tests encompassing the various areas of cognitive function • It has the Folstein Mini-Mental State Examination (MMSE) embedded within it so that the MMSE score can be extracted from the ACE-R Note that the entire interview and cognitive assessment is not shown in this session for time reasons Segment One 1. Comment on speech and thought-form  Even before embarking on formal cognitive testing. whereas a comprehensive psychometric assessment can take up to four hours. a brief assessment of general knowledge and with the Trail Making Test1. When unable to think of a particular word he demonstrates circumlocution. Or. we might wonder if it reflects that the patient leads an impoverished lifestyle and. using many words to describe something simple. we can begin to form some hypotheses. such as sailing…” Segment Two 3. Circumlocution is the use of indirect language. it does not give quantitative data. if this is related to the amotivation often seen with dementia syndromes (frontal lobe impairment). we see evidence of an early breakdown in language function. For example. while it provides useful qualitative information.

Which aspects of history not covered so far are relevant to the assessment of cognitive function? • Past Medical History º Although not shown in the video. It is a useful question in that it often gives a good indication of the pervasiveness of the mood pattern.  This man described a genuine interest in current affairs and so his lack of recall is likely to be significant. The anxiety he felt at the commencement of the interview may have exacerbated his language dysfunction. 12. cultural background. 11. Discuss the problems with assessing general knowledge  General knowledge depends on many factors. It is important to ensure your expectations are appropriate to that person and that setting. he was able to go back and rectify the problem.  When trying to recall the address. For example. a screening instrument for depression. 6. Briefly discuss what you saw in this segment • Patchy general knowledge • Word-finding difficulties 9.  The question is from the Geriatric Depression Scale (GDS). The specific tool used and the amount of cognitive testing undertaken depends on the patient as well as the setting/context. the patient has a history of hypertension – a vascular risk factor for both Vascular Dementia and for Alzheimer’s Dementia • Routine medications • Substance use Segment Four 8. 7. . the patient responds to cueing. Comment on the patient’s performance on the Trail-Making Test  The patient began well but derailed after reaching number four. This indicates mild to moderate dysexecutive function. Segment Five Pause for discussion as required while watching this segment 10. What does this tell us? The response to cueing tells us about the density of memory disturbance. What other cognitive assessment tools do you know?  A large number of neuropsychological tests are available. 5. What do you make of the patient’s autobiographical account?  He is able to give a reasonable chronological history but there is mild confusion and chronological inconsistency when he is describing the details of his two marriages. level of interest and the environment/setting. baseline intelligence. What do you make of the fluency of his speech in this segment? 80  He remains fluent in speech and does not exhibit the breakdown of language that we saw earlier in the interview. However. A lack of recollection despite cueing is common in advanced Alzheimer’s Dementia.  If cueing does not help with recollection it indicates a more severe memory problem.

This is because. a repeat PBS prescription requires a demonstrable improvement in cognitive function. 13. It gives a score out of seventy. Which area of the brain is responsible for • Language and memory? Temporal region • Visuo-spatial function and praxis? Parietal region • Visual gnosis (visual recognition)? Occipital region • Executive function? Frontal region 17. • The CAMCOG: This is the cognitive and self. However. This assessment tool is commonly used in research and. It is much easier to show an improvement on the ADAS-Cog. after six months. eg competence assessments 15. • Alzheimers Disease Assessment Scale – cognition: (ADAS-Cog): This scale is used both clinically and in research. the MMSE by itself is a screening tool and is not sufficient to make a diagnosis of dementia. with a higher score indicating a greater degree of impairment. 14. including executive function 16. clinically.Cognitive Assessment II 4 Some cognitive assessment tools are: • Folstein Mini-Mental State Examination: A score of less than 24 out of 30 is considered indicative of a cognitive deficit.contained part of the CAMDEX.  What cognitive assessment tool would you use when prescribing a cholinesterase inhibitor for Alzeimer’s disease?  Until recently PBS guidelines stated that anyone who scored above 24 on the MMSE had to have an ADAS-Cog in order to receive a PBS prescription for a cholinesterase-inhibitor. less commonly.  Even though an ADAS-Cog is no longer required for the initial PBS prescription it is still frequently used. The CAMDEX is the Cambridge Examination for Mental Disorders of the Elderly. What are the benefits of formal neuropsychological testing? • Neuropsychological testing can provide additional detail about areas of relative strength and weakness in an individual. This constitutes either an improvement of two points on the MMSE or of four points on the ADAS-Cog. Why is the carer questionnaire important? It gives an indication of day-to-day function. Which area would you expect to be affected in • Alzheimers Disease? Temperoparietal region • Lewy-Body Dementia? Occipital region • Vascular Dementia? Patchy deficits in all areas but may see predominantly frontal/executive dysfunction HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 81 . This can help with diagnosis and with developing a management plan that targets specific areas • It can be used to monitor progress • It can be used in medicolegal settings.

1 .Appendix 4.3 – Addenbrooke’s Cognitive Examination (ACE-R) – Blank copy 82 No.

Cognitive Assessment II 4 83 No. 2 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

3 .84 No.

Cognitive Assessment II 4 85 No. 4 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

86 No. 5 .

6 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Cognitive Assessment II 4 87 No.

3 – Addenbrooke’s Cognitive Examination (ACE-R) – Completed assessment 88 No.Appendix 4. 7 .

Cognitive Assessment II 4 89 No. 8 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

90 No. 9 .

10 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Cognitive Assessment II 4 91 No.

92 No. 11 .

Cognitive Assessment II 4 93 No. 12 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

Appendix 4. 1 .4 – Carers’ Assessment of Executive Function – Blank copy 94 No.

2 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Cognitive Assessment II 4 Appendix 4.4 – Carers’ Assessment of Executive Function – Completed assessment 95 No.

NOTES 96 .

Session 5: Movement Disorders 97 .

Session 5 Movement Disorders 98 PART 1: GROUP DISCUSSION AND ROLE-PLAY PART 2: (OPTIONAL) CD EXAMPLES OF MOVEMENT DISORDERS IMPORTANT This session contains an OPTIONAL Part Two that does not follow the format of the other sessions in this manual. Due to the different format of the CD for this session. GATES 4.  To increase awareness of the movement disorders – a common and often unrecognised side-effect of neuroleptic medication 2. To learn how to perform the AIMS test (AIMS Examination Procedure) Materials Required for the Session PART ONE: Computer. The session is divided into two parts: PART ONE: Discussion and role-play on the clinical assessment of movement disorders PART TWO: (Optional) CD examples of movement disorders Focus of the Session 1. Please note that production of the CD was sponsored by a pharmaceutical company. Part Two will require an additional one hour of preparation time as you will need to orientate yourself to the material in order to decide how best to make use of it during the session. and external speakers PART TWO: nil . Summary of Session This session is about Extrapyramidal Movements Disorders.  To discuss the movement disorders including the associated distress and disability. with either a data projector or TV monitor. The CD material for Part Two of this session was produced independently by Professor Tim Lambert who has kindly allowed its reproduction here. To learn about assessment tools for movement disorders – AIMS. It was not developed as part of this training program. prevention and management 3.

1.2) with the group. au/open/pdfs/GATES65r. and • Any questions the trainees may have regarding EPS 3.pdf 2.1.  Start the session with a brief summary of movement disorders based on the Extrapyramidal Syndrome Summary (appendix 5.L.1 to 5. Chou. Ask the trainee to perform the AIMS and then discuss this 6. cultural. This is a less commonly used test than the AIMS. Review how to conduct the AIMS examination based on the AIMS Examination Procedure Conducting the Session 1.  Discuss the GATES test (appendix 5. K.1. type of antipsychotic. It is a relatively brief and easy to administer screening tool 4. Pharmacotherapy 9 (9) 1451-1462 4. The AIMS test looks primarily for dystonic and dyskinetic movements.1.  Download a copy of the GATES 6. sex.  Select two trainees: one to act as a patient and a second trainee to conduct the AIMS examination based on the AIMS Examination Procedure 5. It may be beneficial to develop your own battery of tests using a combination of the GATES and AIMS.psychiatry. The GATES test: • Is a more comprehensive rating scale than the AIMS • Is often used in research settings • Examines for side-effects not examined through the AIMS.1-1: a new instrument for clinical and research assessment of neuroleptic-induced movement disorders using this link: http://www. there are many useful tests within this screening tool. P.unimelb.  Review the article in the recommended reading list and then provide trainees with a copy of the article or with the reference: Dayalu.3).Movement Disorders 5 PART ONE: Group Discussion and Role-play Preparation for Session 1.1. age. Discuss assessment and management of movement disorders in general Discuss: • Risk factors for Extrapyramidal Syndromes (EPS) (genetic.  Review the session handouts to ensure you are familiar with them and can lead a discussion on the topic of movement disorders (appendices 5. Expert Opinion. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY 99 . duration of treatment.edu. (2008) Antipsychotic-induced extrapyramidal symptoms and their management. Photocopy the handouts to distribute to trainees during the session 3. Invite trainees to describe their own experiences • Management of EPS. Read through the AIMS Examination Procedure (appendix 5.1) 2. For example it examines for bradykinesia and hypersalivation (associated with clozapine) in addition to dystonic and dsykinetc movements • Is much longer than the AIMS and is therefore less practical to administer in the standard community outpatient setting Despite the length of the GATES making it often impractical. etc) • Clinical cases where EPS have been observed.3).

1. Tardive Dyskinesia Recommended reading Dayalu. (2008) Antipsychotic-induced extrapyramidal symptoms and their management.1.1 – Extrapyramidal Syndrome Summary Appendix 5.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions PART TWO: CD Examples of Movement Disorders Preparation and Conducting the Session 1.7.2 – AIMS Examination procedure Appendix 5.3 – RANZCP Clinical Memorandum #10 (May 2007.L.  Review the accompanying CD: Movement Disorders by Professor Tim Lambert and decide how best to use the material for your session 100 Appendices listing For use with Part One (Group Discussion and Role Play) Appendix 5. R37). Chou. GC2/02. K. Pharmacotherapy 9 (9) 1451-1462 .1. Expert Opinion. P.

limbs or trunk º Occurs within the first few days of treatment commencement or of increasing the dose º E. fever.g. the Pisa-syndrome Acute dyskinesias º Repetitive. neck. torticollis. e. hyperkinetic movements º Often in the face and mouth region º More commonly occurs after more than three months of treatment commencement when it is called tardive dyskinesia (see below) Neuroleptic Malignant Syndrome º A medical emergency º Severe muscle rigidity. involuntary. muscular rigidity and bradykinesia º May be associated with mental symptoms such as apathy and mental slowing º Occurs within 5-30 days of treatment commencement or of increasing the dose Focal Dystonias º Sustained abnormal posture secondary to involuntary muscle spasm º May affect a single muscle or a group of muscles: head. and other related findings (such as diaphoresis. lithium.1. often associated with observed movements such as rocking. with some second generation antipsychotics as well as with some other psychotropic and non-psychotropic agents.g. anticonvulsants. oculogyric crisis. pacing.1 – Extrapyramidal Syndrome Summary For use with Part One (Group discussion and role-play) EXTRAPYRAMIDAL SYNDROMES • Syndromes with motor side-effects resulting from disturbance to the extra pyramidal motor system • Associated with all first-generation antipsychotic medication.Movement Disorders 5 Appendices Appendix 5. elevated creatinine phosphokinase. changes in level of consciousness ranging from confusion to coma and labile blood pressure) M  º ay occur at any time during treatment with neuroleptic medication though more commonly occurs early in treatment HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . metoclopramide 101 Acute syndromes Akathisia º Subjective feeling of inner restlessness. and shifting the weight from foot to foot º Usually occurs within hours to days of treatment commencement or of increasing the dose Postural tremor º Fine tremor that develops when trying to maintain a postural stance Parkinsonism º Parkinsonian tremor.

sucking. talking. but the most common is tardive dyskinesia. Tardive syndromes may take on many forms. dystonic. athetoid or stereotypic movements º Frequently affect the mouth and tongue. 102 Tardive dyskinesia º Choreiform.Tardive Syndromes “Tardive” refers to delayed onset.g. lip-smacking. e. after three or more months of treatment. for example tardive dystonias and perioral tremor. In these syndromes there is a risk of persistence after cessation of the causative medication. puckering and facial grimacing º Seriously disabling dyskinesia is uncommon but a small proportion may affect walking. eating and breathing . This term is used to refer to syndromes that develop later.

between his legs.) Do this twice 7.  Ask the patient to extend both arms out in front. (Observe hands and other body areas) 6. 3 = moderate.) Do this twice [activated] Scoring Procedure Complete the examination procedure before making ratings. (Observe hands and gait. if so. (Observe the tongue at rest within the mouth. (Observe abnormalities of tongue movement) Do this twice 8.  Ask whether the patient notices any movements in his or her mouth. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .2 – AIMS Examination Procedure For use with Part One (Group discussion and role-play) INSTRUCTIONS There are two parallel procedures. face. and 4 = severe.  Ask about the current condition of the patient’s teeth.  Ask the patient whether there is anything in his or her mouth (i. hands. Flex and extend the patient’s left and right arms. Examination Procedure Either before or after completing the examination procedure.1. ask the patient to describe them and to indicate to what extent they currently bother the patient or interfere with activities 4. The chair to be used in this examination should be a firm one without arms.  Ask the patient to protrude his or her tongue. candy etc) and. and mouth) [activated] 12.  Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15 seconds. the examination procedure. if female and wearing a dress. or feet. (Observe trunk. then with left hand. 0 = none. to remove it 2. 103 1.  Have the patient walk a few paces. palms down. in the waiting room). Ask whether teeth or dentures bother the patient now 3.  Ask the patient to sit with hands hanging unsupported – if male. (Observe facial and leg movements) [activated] 9. 2 = mild. and feet flat on floor. gum. and walk back to the chair. legs slightly apart. (Look at the entire body for movements while the patient is in this position.  Ask the patient to open his or her mouth. first with right hand. legs. If yes. one point is subtracted if movements are seen only on activation. Ask if he or she wears dentures. one at a time 10. and the scoring procedure.Movement Disorders 5 Appendix 5. (Observe the patient in profile. which tells the patient what to do.e. 1 = minimal (may be extreme normal). but not all investigators follow that convention. For the movement ratings (the first three categories below) rate the highest severity observed. According to the original AIMS instructions.  Have the patient sit in chair with hands on knees. hips included) 11.) 5. turn.g. hanging over her knees. observe the patient unobtrusively at rest (e. which tells the clinician how to rate what he or she observes.  Ask the patient to stand up. Observe all body areas again.

Upper (arms. e. mouth opening. Patient’s awareness of abnormal movements 0 = no awareness 1 = aware.g. serpentine). Severity of abnormal movements 01234 (based on the highest single score on the above items) 9. Does patient usually wear dentures? 0 = no 1 = yes . moderate distress 4 = aware. chewing. e. Include frowning. grimacing of upper face 01234 2. pouting. squirming. irregular. inversion and eversion of foot 01234 Trunk Movements 7.g. pelvic gyrations. Do not include tremor (repetitive. rhythmic movements) 01234 6. eyebrows. smacking 01234 3. foot tapping. Include movements that are choreic (rapid. hips e. rocking. toes). twisting.g.Facial and Oral Movements 104 1. clenching. complex. severe distress Dental Status 11. Include diaphragmatic movements 01234 Global Judgments 8. foot squirming. ankles. normal 1 = minimal 2 = mild 3 = moderate 4 = severe 10. blinking. heel dropping. Lower (legs.g. Lips and perioral area e. wrists. lateral movement 01234 4. objectively purposeless. regular. movements of forehead. Jaw. lateral knee movement. shoulders. cheeks. mild distress 3 = aware. knees. spontaneous) or athetoid (slow. puckering. Incapacitation due to abnormal movements 0 = none. not inability to sustain movement 01234 Extremity Movements 5. no distress 2 = aware. irregular. Neck. fingers). hands. biting. Rate only increase in movement both in and out of mouth. Muscles of facial expression e. Current problems with teeth and/or dentures 0 = no 1 = yes 12. periorbital area.g. Tongue.

3 For use with Part One (Group discussion and role-play) RANZCP Clinical Memorandum #10. Tardive Dyskinesia 105 Page 1 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Movement Disorders 5 Appendix 5.1.

106 Page 2 .

Movement Disorders 5 107 Page 3 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

NOTES 108 .

Session 6: Phenomenology 109 .

The session is divided into two parts: PART ONE: An interactive discussion about phenomenology PART TWO: A role-play and discussion focussing on the clinical skills involved in exploring and understanding phenomenology Focus of the Session 1. Broadening understanding of the definition and origins of the term phenomenology 2. including clinically-relevant psychiatric phenomena 3.110 Session 6 Phenomenology PART 1: INTERACTIVE DISCUSSION PART 2: ROLE-PLAY Summary of Session This session provides an overview of phenomenology. Inviting thought and discussion about the relevance of phenomenology in modern psychiatry. Using role-play to explore the clinical skills relevant to phenomenology: • Interviewing (dissecting phenomena). and • Formulation (making sense of phenomena) Materials Required PART ONE: NIL PART TWO: NIL .

The groups should then come together and discuss their ideas PART TWO: Role-play Preparation for Session 1. 1. Prior to the session.4) 2. who they have never met before (10 minutes) 2. a trainee needs to be assigned the role of a patient and given a simulated history to memorise for the session (appendix 6. discussion prompts (appendix 6. provide a copy of the journal article by Andreasen (appendix 6. or when unsure if the reported symptom is pathological HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .  A second trainee needs to be assigned the role of interviewer.2) and facilitator notes (appendix 6. The purpose of the role-play is to generate discussion surrounding interview technique.  Start the session with a group discussion based on the journal article using the discussion prompts to facilitate discussion (40 minutes) 111 2.  The trainees should then be divided into groups for a 20-minute discussion about the differences between: • A delusion and an overvalued idea • A hallucination and a pseudo-hallucination 3.  Prior to the session. It is NOT to critique the skill of the trainee.  Ask the interviewer to do a brief presentation of the mental state examination and formulation to the group (5 minutes) 3. The interviewer’s role will be to take a history from the simulated patient during the session Conducting the Session IMPORTANT: Note to Facilitator It is essential to ensure that the trainees participating in the role-play feel ‘safe’ and ‘supported ’rather than exposed to the group.  Review the journal article.Phenomenology 6 PART ONE: Interactive Discussion Preparation for session 1.  Guide the group discussion of the role play using the following key learning points as discussion prompts (10 minutes) Key learning points: 1) How to take a history of a particular symptom in order to dissect out the psychopathology: • This requires a degree of tenacity • It is particularly important when unsure of the diagnosis.1) to trainees and advise them that they will be expected to have read the article before the session 2.  Conduct the role-play – the trainee who has been assigned the role of interviewer is to take a psychiatric history from the simulated patient.3) to ensure you are able to discuss relevant aspects of the topic Conducting the Session 1.

1 – Journal article: Andreasen. 2) Presenting symptoms are important. N.3 – Facilitator notes For use with Part Two (Role-plays) Appendix 6. There is a tendency for trainees to be formulaic. as a key part of both mental state and formulation. even if they do not clearly fit an illness pattern.4 – Vignette for role-play . conundrums and incongruencies. Schizophrenia Bulletin 33(1):108-12 Appendix 6. to not present perplexities. Appendices listing For use with Part One (Interactive discussion) 112 Appendix 6. (2007) DSM and the death of phenomenology in America: an example of unintended consequences..2 – Discussion prompts for trainees Appendix 6.C.

C. Schizophrenia Bulletin 33(1):108-12 113 No. (2007) DSM and the death of phenomenology in America: an example of unintended consequences. N.Phenomenology 6 Appendices Appendix 6. 1 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .1 – For use with Part One (Interactive discussion) Andreasen.

2 .114 No.

3 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Phenomenology 6 115 No.

116 No. 4 .

Phenomenology 6 117 No. 5 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

Appendix 6.2 – Discussion prompts
For use with Part One (Interactive discussion)
1. What is phenomenology?
2. What is the difference between phenomenology and psychopathology?
3. What is the mind? How does it differ from the brain?
4. How do we assess the mind?
5. When do we face difficulties assessing someone’s mind?

118

6. What is the difference between signs and symptoms?
7. Can you think of any “signs” in psychiatry?
8. Are signs or symptoms more important in psychiatry?
9. Are any symptoms in psychiatry pathognomonic of a disease or are they all on a spectrum?
• What about Schneiderian first-rank symptoms?
• What about a primary delusion such as Jasper described?
10. In a clinical interview, when is phenomenology particularly important? When might it be
less important?
11. Break up into groups and discuss the difference between the following:
• A delusion and an overvalued idea

º How does this hold for Anorexia Nervosa?
º How does this hold for Body Dysmorphic Disorder?

• A hallucination and a pseudo-hallucination

Phenomenology

6

Appendix 6.3 – Facilitator notes
For use with Part One (Interactive discussion)
1. What is phenomenology?
2. What is the difference between phenomenology and psychopathology?
3. What is the mind? How does it differ from the brain?
4. How do we assess the mind? 
eing unable to directly observe the mind, we are dependent on particular patterns of
B
communication, such as speech.
5. When do we face difficulties assessing someone’s mind?

119

1. When someone lacks awareness of their own mental state
2. When someone lacks the capacity to express their own mental state
3. In someone who is physically unable to speak, for example through mutism and catatonia
4. When there is a language barrier 
e can use other tools such as observing behaviours but because of the lack of objective
W
tests and a relative lack of other objective signs we are limited.
6. What is the difference between signs and symptoms? 
symptom is any subjective evidence of disease. It is a phenomenon that is subjectively
A
experienced by an individual – sensations that only the patient can perceive. Anxiety, pain
and fatigue are all symptoms.
In contrast a sign is objective evidence of disease. A bloody nose is a sign. It is evident to
the patient, doctor, nurse, and other observers.
7. Can you think of any signs in psychiatry?
8. Are signs or symptoms more important in psychiatry? 
he lack of objective assessment tools makes psychiatry, more than many other medical
T
specialties, heavily reliant on symptoms. 
hen a sign is present, such as psychomotor impairment, or catatonia, it usually indicates
W
severe abnormality and so is given a lot of weight.
9. Are any symptoms in psychiatry pathognomonic of a disease? Or are they all on a spectrum?
What about Schneiderian first-rank symptoms?
What about a primary delusion such as Jasper described?
J aspers defined a primary or autochthonous delusion as a delusion arising without apparent
cause. For example, suddenly, without apparent cause, having the delusional belief that you
are an alien. 
lthough delusions are diagnostically nonspecific, some types of delusions are more prevalent
A
in one disorder than another. For example, although delusions of control and delusional
percepts are often seen in schizophrenia, they also occur, albeit less frequently, in psychotic
mood disorders. Similarly, classic mood-congruent delusions, with grandiose themes seen in
mania or delusions of poverty characteristic of depression, may also be seen in schizophrenia. 
chneiderian first-rank symptoms and primary delusions were once seen as pathognomonic
S
of schizophrenia but this is no longer thought to be the case.

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

10. In a clinical interview, when is phenomenology particularly important?

When might it be less important?
It is particularly important to understand the phenomenology in instances when it will impact
on the diagnosis and management of that individual.
For example:

º It is important in a patient with depression who describes hearing a critical voice in his/her
head to understand if this is a true hallucination. The treatment for psychotic depression
as opposed to non-psychotic depression will be significantly different.

120

º In a patient with known schizophrenia, who suffers a relapse of psychosis, the specific
phenomena will be less important.

11. Break up into groups and discuss the difference between the following:
• A delusion and an overvalued idea
• How does this hold for anorexia nervosa?
• How does this hold for body dysmorphic disorder?
• A hallucination and a pseudo-hallucination
Bring the groups together to discuss their ideas.

Phenomenology

6

Appendix 6.4 – Vignette for Role-play
For use with Part Two (Role-plays)
Instructions to simulated patient
You have presented to the doctor with middle insomnia. You wake at 2 am every night and can’t
get back to sleep for two hours. The rest of your sleep is completely undisturbed, and you have
no other psychiatric symptoms at all.
You have no past history of any medical or psychiatric illnesses. You are on no regular medication.
There is no history of substance misuse.

121
How to play the role
You are polite and co-operative, and forthcoming about your reason for presenting.
You are perplexed and concerned about this new-onset sleep disturbance, but apart from that
there are no abnormalities in your mental state.
You are expected to improvise on any information that is not covered here, but maintain that you
are a person with no suggestion of psychiatric illness whatsoever, apart from the unexplained sleep
disturbance.

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NOTES

122

Session 7: Mental State Examination I 123 .

 Photocopy the Mental State Examination (appendix 7. Ensure that you are able to discuss relevant aspects of the topic 2. Pause for discussion as needed.1) and the Classification of Defense Mechanisms (appendix 7.  To give trainees an opportunity to see and learn from an in-depth discussion about the mental state examination 3.1) and the Classification of Defense Mechanisms (appendix 7.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions Appendices listing Appendix 7.1 – Mental State Examination Appendix 7.  To increase awareness of more complex aspects of the Mental State Examination. with either a data projector or TV monitor.  Hand out copies of the Mental State Examination (appendix 7. where this opportunity may not otherwise be available Materials Required for the Session Computer.2) to hand out to trainees during the session Conducting the Session 1.2 – Classification of Defense Mechanisms . To learn the components of the Mental State Examination 2. 2. pausing for discussion where indicated in the USB. The USB footage is 85 minutes. The recorded material shows a psychiatry trainee presenting an account of a psychiatric interview followed by a group discussion of the patient’s mental state.  Watch the accompanying USB showing a registrar presenting their account of a patient interview and a group discussion about the mental state of that patient. Focus of the Session 1.2) 3.Session 7 Mental State Examination I OBSERVATION OF A RECORDED PRESENTATION AND A RECORDED GROUP DISCUSSION 124 Summary of Session This session provides an introduction to the Mental State Examination in psychiatry. and external speakers Preparation for Session Please note that there are no Facilitator Notes for this option 1. In this session the group watches the USB about the Mental State Examination.  Review the accompanying USB material showing a registrar presenting their account of a patient interview followed by a group discussion of that patient’s mental state.

A ‘performance mask’ He is not agitated. hopelessness or nihilism He reports some agency and control No frank delusions HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . despite a depressive history. This is somewhat forced and he is at times dismissive of serious material. normal rate. young. being unable or unwilling to name the experience – indicates the traumatic nature of his experience Mood Apprehensive Mildly dysphoric Affect Mildly incongruent with his mood Restricted in range. with a paucity of detail. rubber sandals. rhythm and tone There is some unusual idiosyncratic usage of language perhaps related to his Filipino background There is a humorous (sarcastic) quality Striking use of the word “it” to describe his suicidality – that is. even flippant – despite the gravity of situation. There is no psychomotor retardation Somewhat expressive in body language Speech Fluent accented English. There is a humorous edge but this is not of an infectious quality Performance mask Thought-content Concise description of events.1 – Mental State Examination Appearance Relaxed. Practised/rehearsed quality Recent hardships (including financial and relationship) and past traumas were themes of this interview but. and with slicked back hair Appears younger than his stated age – this is congruent with his ethnicity No obvious physical abnormalities Reasonably well-groomed Behaviour 125 A steady direct gaze that remains unchanged even through affect-laden material. tracksuit pants. the associated loss and sadness were largely glossed over and there isn’t an overt sense of worthlessness. big laughs and giggling. but not threatening There is a lack of emotional exchange through his eyes with an absence of affect reflected in them Easy smiles. Filipino male in casual dress: t-shirt. and being jovial. displaying only positive affects. Unnerving. divorced from emotion.Mental State Examination I 7 Appendices Appendix 7. reasonably articulate.

No formal testing. The long-term risk remains medium to high given his dismissive attachment status and the difficulty he may have asking for help in the future His long-term risk will be reduced if he can form a meaningful connection with someone so that he again feels comfortable to ask for help . Appears grossly intact and of at least average intelligence Insight Not entirely aware of his diagnosis.Thought form No formal thought disorder. for example. Defense mechanisms: • minimising • repression • some denial • humour • isolation of affect? Perception 126 No perceptual abnormalities identified Cognition Clear sensorium. in a contained environment. his trading on the share-market despite being in substantial debt. there is a sense of his developing insight Judgement Judgement may have been impaired recently. while he is in hospital. It was almost certainly impaired when he made the near-attempt at suicide Risk The short-term risk to self is low to moderate. but he self-presented and feels hospitalisation has been helpful for him While there is a limited appreciation of the level of severity of his illness.

asceticism. dissociation. distortion Immature Defenses Acting out. denial. reaction formation. intellectualization.Mental State Examination I 7 Appendix 7. suppression 127 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . repression. blocking. isolation. schizoid fantasy. anticipation. humour. sexualisation Mature Defenses Altruism. sublimation. hypochondriasis. somatisation Neurotic Defenses Controlling. displacement. introjection. externalization. inhibition.2 – Classification of Defense Mechanisms Classification of Defense Mechanisms Narcissistic Defenses Projection. projection. regression. passive-aggressive behaviour. rationalization.

NOTES 128 .

Session 8: Mental State Examination II 129 .

IT IS IMPORTANT THAT. YOU HAVE WATCHED THE USB MATERIAL OF MENTAL STATE EXAMINATION I. Mental State Examination III. Select a trainee to be interviewer 2. In this session the group observes a trainee interview a patient.Session 8 Mental State Examination II 130 OBSERVED INTERVIEW FOLLOWED BY A PERIOD OF REFLECTION Summary of Session This session is the second session on the Mental State Examination. the interviewer and observers will make notes about the interview in order to prepare them for the discussion that will take place in the next session. chronic psychotic disorder . The purpose of the interview is to assess the Mental State Examination of the patient. Focus of the Session 1.  To watch and reflect in-depth on an interview with a patient. Select a patient to be interviewed by the trainee NB: Patient selection is important – Can be an inpatient or an outpatient – Must be co-operative – Must have capacity to consent to the interview – Ideally the patient should not have a severe. with a view to understanding the Mental State Examination of the patient 2. AS FACILITATOR OF THIS SESSION. Following the observed interview. To prepare for the next session on the Mental State Examination Materials Required for the Session Nil Preparation for Session Please note that there are no Facilitator notes for this option 1.

The interview is to be a fifty minute assessment interview • The interview can be observed º through a one-way screen º via a monitor in another room º by having the group present in the room during the interview* 131 • Neither interviewer nor observers should take notes while interviewing the patient *If the group is present in the room during the interview the number of observers should be limited.  Provide the interviewer and observers with their instructions (appendix 8. confirming that patient confidentiality will be maintained • Obtain written consent from the patient Conducting the Session 1. Prior to the interview • Explain the interview to the patient.1 – Instructions for interviewer and observers Appendix 8.  Following the interview.2 – Guide to reflecting on the interview HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Mental State Examination II 8 3. 2. once the patient has been safely seen out.1). gather the group together again and ask the interviewer and observers to make notes on the interview using the handout in appendix 8. Ensure that observers sit out of the direct line of sight of the patient and that they remain passive throughout the interview 3.2 as a guide Appendices listing Appendix 8.  Set up an interview with interviewer and patient.

That is.’ He said. Not at all. this presentation is entirely different from that which you would present to a colleague or a senior consultant when asking for advice on a patient’s care and it is entirely different to the presentation you would make for the purposes of an exam. ‘Hello. wearing a checked shirt with tan pants and sneakers. John was sitting back in his chair with his legs crossed. The transcripts are not expected to be entirely accurate – this would not be possible and is not the point of the exercise. The notes that you make today. you will be expected to present a detailed chronological account of the interview that you perform today. will assist you in the discussion of the Mental State Examination next session. ‘No problem. An example of what you might say is: “I walked into the room.’ Once again he smiled broadly – too broadly. The presentation that you make to the group should not include a summary of the interview and should not include a formulation. My name is Tim. I pulled my hand free and sat down. Following that presentation there will be a discussion about the Mental State Examination of the interviewed patient. Thanks for agreeing to do this interview today. The notes you make today after the interview will assist you in that task. Then John started laughing.Appendices Appendix 8. and also your thoughts and impressions during the interview itself. It should include a description of both verbal and non-verbal communication. I went to shake John’s hand and he grasped my hand firmly with both of his and smiled broadly. I said. and I smiled back but in a reserved manner. Expect the account to be approximately fifteen minutes in length. I am a psychiatry registrar. This presentation is not a summary of the interview and is not a formulation. The account should include recalled transcripts of selected portions of the interview. He was neatly-attired. .1 – Instructions for interviewer and observers Instructions for interviewers In the next session on the Mental State Examination (Session Nine).” Instructions for observers In the next session on the Mental State Examination (Session Nine) the interviewer will present a detailed chronological account of the interview that they performed today. loudly. 132 The presentation that you will be expected to make to the group is a moment-by-moment account of the interview in as much detail as you can recall. I felt disconcerted by this. after observing the interview.

Mental State Examination II 8 Appendix 8. What happened during the interview? (Try to record the order of events as accurately as you can recall them) ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 133 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------2. Your feelings and impressions during the interview. The patient’s appearance ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3. of − the patient − the interaction − yourself ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .2 – Guide to reflecting on the interview For both interviewer and observers Make notes under the following headings 1. Body language (both interviewer’s and patient’s) ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------4.

Any striking use of words or phrases? ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------8.5. Try to be as precise as possible in recording what was said. and by whom (though of course a verbatim transcript is not expected) ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------7. Record details of any illuminating moments ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 134 6. Other observations ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- . Record excerpts (recalled transcripts) of the interview.

Session 9: Mental State Examination III 135 .

 To encourage discussion about complex aspects of the Mental State Examination and to invite questions and discussion around any poorly understood concepts or phenomena Materials Required for the Session Whiteboard or butcher’s paper Preparation for Session Please note that there are no Facilitator notes for this option 1.  Prior to this session reflect on what you observed during the interview performed during the last session. To practise an in-depth approach to the Mental State Examination 3. YOU HAVE WATCHED THE USB MATERIAL OF MENTAL STATE EXAMINATION I Focus of the Session 1. AS FACILITATOR OF THIS SESSION. IT IS IMPORTANT THAT. The presentation is followed by a facilitated group discussion about the mental state examination of that patient. similar to the discussion seen on the USB of Mental State Examination I. This session uses the interview performed in Mental State Examination II as the basis for the discussion. ensure that you have watched the USB material of Mental State Examination I This session follows a similar format and should draw directly on the learning points and discussions of that session 2. The session begins with a trainee presenting their account of the interview they performed last session.  As facilitator. To teach the process of synthesising information about the mental state of a patient 2.Session 9 136 Mental State Examination III INTERACTIVE EXERCISE INVOLVING A PRESENTATION OR AN INTERVIEW Summary of Session This session is the third session on the Mental State Examination. In this session your group will have an in-depth discussion about the Mental State Examination of a patient. Ensure you are able to guide a discussion regarding conducting a Mental State Examination .

to the group This presentation is a moment-by-moment chronological account of the interview that took place in Mental State Examination II. Use group process. It is not a summary of the interview and should not include a formulation (15 minutes) 2.Mental State Examination III 9 Conducting the Session 1. Ask observers to provide any additional observations 3.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .  Ask the interviewer to present their pre-prepared account of the interview. including segments of interview transcripts. with input from both the interviewer and the observers. including: 137 • appearance • behaviour • speech • affect • thought content • thought-form • perception • cognition • insight • judgement • risk Make notes under each of these headings on a white-board or on butcher’s paper 4. Ensure all aspects of the mental state examination are covered.  Lead a group discussion about the mental state of the patient.

NOTES 138 .

Session 10: Personality Style I 139 .

To introduce trainees to templates for assessing and understanding personality structure 2.Session 10 140 Personality Style I PART 1: LECTURE Dr Jeffrey Streimer Personality PART 2: INTERACTIVE EXERCISES Summary of Session This is the first of two sessions on Personality Style. and external speakers . with either a data projector or TV monitor. The session is divided into two parts: PART ONE: A lecture giving an overview of personality structure PART TWO: An interactive exercise using the first five minutes of a recorded doctor-patient interview to guide trainees in: • Openly observing an interaction • Registering responses (cognitive. To develop inductive reasoning skills 5. and • Using clinical reasoning skills to form a provisional hypothesis about the patient’s personal and interpersonal style Focus of the Session 1. To learn to use minimal stimulus material to develop hypotheses about personality 3. affective and intuitive) • Thinking about these responses from a clinical perspective. and external speakers PART TWO: Computer. with either a data projector or TV monitor. To develop powers of observation 4. To reflect on transference and countertransference Materials Required for the Session PART ONE: Computer.

2) to distribute to trainees during the session 3. Photocopy the lecture slides (appendix 10. Play segment one on the USB (2 minutes) 3. Play segment two on the USB (10 minutes) 6. Play the lecture on the accompanying USB: Personality – Dr Jeffrey Streimer (30 minutes) 3. Appendices listing For use with Part One (Lecture) Appendix 10.1) to distribute to the trainees during the session Conducting the Session 1. Hand out the discussion prompts (appendix 10. Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic 2. Allow question and discussion time (10 minutes) 141 PART TWO: Interactive Exercise Preparation for Session 1.  Lead a group discussion guided by the discussion prompts (appendix 10.2) and allow reading time 2. Hand out copies of the lecture slides to trainees (appendix 10.3) 5.2) and facilitator notes (appendix 10. Photocopy the discussion prompts (appendix 10.2) and facilitator notes (appendix 10.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions. Ask trainees to think about the questions (discussion prompts) in light of the interview (5 minutes) 4.2 – Discussion prompts for trainees Appendix 10. Ask trainees to think about the questions (discussion prompts) in light of the interview (5 minutes) 7.3 – Facilitator notes HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .3) Conducting the Session 1. Review facilitator notes (appendix 10. Lead a group discussion guided by the discussion prompts (appendix 10.Personality Style I 10 PART ONE: Lecture Preparation for Session 1.1 – Lecture slides for Personality by Dr Jeffrey Streimer For use with Part Two (Interactive exercise) Appendix 10.1) 2.3) 8. Review the accompanying USB material of the two interview segments 2.

1 – Lecture slides For use with Part One (Lecture) Personality by Dr Jeffrey Streimer 142 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 .Appendices Appendix 10.

Personality Style I 10 143 Slide 7 Slide 8 Slide 9 Slide 10 Slide 11 Slide 12 See larger version on next page HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

144 Slide 8 Slide 13 .

 In this segment. images and affective responses come to mind? Keep in mind your initial speculations 7. particularly in regards to co-operative relationships.Personality Style I 10 Appendix 10. What do you notice about the man’s appearance? 4. Do you notice the grandiosity in his descriptions? Discuss where this might come from 18. breaking out and killing. He mentioned that he owns firearms. What strikes you in this segment? What words. What do you notice about his clothing? Do you notice any contrasts or contradictions in his attire and general appearance? 145 5.  When the interviewer asks the patient if he is talking about himself.  What is the difference between the control exerted by an obsessional person and that exerted by a paranoid person? 12.  To what extent is the grandiosity an example of unhealthy narcissism and to what extent does it reflect healthy aspirations? 19. this man is seeking to form attachment. what are the difficulties you might face? Reflect on his future prognosis.  What strikes you in this segment? What words. If you engaged in a treatment contract with him. What personality style does this remind you of? 11.  Do you think there is an anti-social element here? What are key features of an antisocial personality structure? 13. Why might this be? What defense mechanisms is he using? 10.  This man is simultaneously guarded and attacking. including a therapeutic alliance HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Do you notice the dilemma that his persecutory world view presents you with? 16. Allow apparent contradictions to remain 2.  With your observations and associations in mind.  What feelings and responses are evoked in this segment? What could this tell us about aspects of his personality? Segment Two (10 minutes) 6. discuss tentative hypotheses about personality style and traits 3. Do you think he is able to use help? 15. Discuss any forming hypotheses 8. the patient flatly denies it. What is his affective state? What effect does this have on you? 14. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. How does this make you feel? 17. What do you think this is about? Is he talking about himself? 9.2 – Discussion prompts for trainees For use with Part Two (Interactive exercise) Segment One (1 minute) 1. the patient talks about others exploding.  Despite a rough facade.

 What feelings and responses are evoked in this segment? What could this tell us about aspects of his personality? People feel wariness or fear. This man does not work. 5. What strikes you in this segment? What words.  In this segment. 146 2.Appendix 10.  When the interviewer asks the patient if he is talking about himself. Note A down the words. The police-shirt contrasts with the long ponytail and shorts. Spend at least five minutes on this section. nor has he ever worked. Segment Two (10 minutes) 6. The defense mechanisms include denial. He attacks others through T his own fear and defensiveness. Spend at least five minutes on this section.3 – Facilitator notes For use with Part Two (Interactive exercise) Segment One (1 minute) 1. 3. It may be a deliberate statement. they attack him. Notice that the paranoia is highlighted and reinforced. projection and displacement. images and affective responses come to mind? Keep in mind your initial speculations.  his is probably a direct reflection of how he responds to the world. Perhaps it reflects an anti-authoritarian attitude and/or a wish for power. 7. Allow apparent contradictions to remain. the patient flatly denies it. images and affects that arise. Use a white-board or butcher’s paper for this. breaking out and killing. Note down the words. This man might likely evoke a similar response in others. Why might this be? What defense mechanisms is he using? He is putting unwanted feelings into others. the patient talks about others exploding. What strikes you in this segment? What words.  With your observations and associations in mind. for the police force. discuss tentative hypotheses about personality style and traits. What do you notice about the man’s appearance? 4. Discuss any forming hypotheses Spend at least ten minutes on this section. Spend at least ten minutes on this section. Use a white-board or butcher’s paper for this. images and affective responses come to mind?  void prematurely foreclosing on your impressions. sometimes in a ridiculing manner.  What do you notice about his clothing? Do you notice any contrasts or contradictions in his attire and general appearance? He is wearing a police-shirt with casual shorts. T There are many possible explanations for this. including his own children. What do you think this is about? Is he talking about himself? 9. 8.  he police-shirt is likely to be important. . images and affects that arise. though we can only guess at its significance. At the same time.

this man is seeking to form attachment. Do you notice the grandiosity in his descriptions? Discuss where this might come from. Those involved with him. 18. 13. He will therefore T avoid affect states that make him feel vulnerable and needy.  To what extent is the grandiosity an example of unhealthy narcissism and to what extent does it reflect healthy aspirations? 19. or • acting under threat.  This man is simultaneously guarded and attacking.Personality Style I 10 10. what are the difficulties you might face?  eflect on his future prognosis particularly in regards to co-operative relationships including R a therapeutic alliance. 16. Do you think he is able to use help? 15. When feeling under threat. What personality style does this remind you of? Paranoid. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . This leaves him frustrated and helpless in dealing with H the world and its challenges.  ou are forced to either join him in his persecutory position or to reject his viewpoint and Y thus threaten to reject him. If he is forced to confront these negative emotions he will respond with either: • depression. What is his affective state? What effect does this have on you? 147  e demonstrates marked ambivalence.  Do you think there is an anti-social element here? What are key features of an antisocial personality structure?  hile there are many features of an antisocial personality disorder.  he difficulty is that for this man.  ither of these two options reinforces his paranoid stance and leaves him isolated and lonely E in a persecutory world. How does this make you feel? Afraid? Suspicious? Threatened? Cautious? Angry? 17. Do you notice the dilemma that his persecutory world view presents you with? This man wants his persecutory world view confirmed. become aggressive and reassert control. perhaps the most important of these is a lack of empathy and concern for others. including his carers. 11. a paranoid personality will respond with a counter-attack. 14. He mentioned that he owns firearms. feeling vulnerable is likely to be intolerable.  What is the difference between the control exerted by an obsessional person and that exerted by a paranoid person? 12. find themselves in the same situation – helpless and frustrated. Despite a rough facade. many of which are listed W in DSM. If you engaged in a treatment contract with him.

NOTES 148 .

Session 11: Personality Style II 149 .

Photocopy the discussion prompts (appendix 11.  Review the accompanying USB material containing six segments of an interview between a consultant psychiatrist and a patient.Session 11 150 Personality Style II OBSERVATION OF RECORDED SEGMENTS OF AN INTERVIEW AND GROUP DISCUSSION Summary of Session This is the second of two sessions on Personality Style. and recorded group discussions Ensure that you are able to discuss relevant aspects of the topic 2. with either a data projector or TV monitor. To expand on what was learned in Personality Style I 2. It draws on the lecture and other material discussed in the first of these two sessions and then goes more deeply into the interpersonal and trans-generational impact of personality structure and personality disorder. In this session. including one’s children • the impact of trauma through generations Materials Required for the Session Computer. and external speakers Preparation for Session Please note that there are no Facilitator Notes for this option 1. a pre-recorded interview between a consultant psychiatrist and a patient is used as a launch pad for discussion. To explore and understand the trans-generational impact of personality style in terms of: • the genesis of personality style and personality disorder in an individual • the impact of personality style on significant others. To reflect on interview techniques in response to a patient’s style 4. To encourage attunement to a patient’s interpersonal style 3.1) to distribute to trainees during the session . Focus of the Session 1.

1) and allow reading time 2.  Take 5-10 minutes at the end of the session to summarise session outcomes and to answer any questions 151 Appendices listing Appendix 11.1: Discussion prompts for trainees HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .  Hand out the discussion prompts (appendix 11.  Watch the accompanying USB material containing interview segments and relevant recorded group discussion. pausing for discussion when discussion prompts appear on the screen 4.  Follow the prompts on the USB. The USB contains about 30 minutes of interview material and 30 minutes of recorded group discussions 3.Personality Style II 11 Conducting the Session 1.

 Discuss what you noticed in Segment Four. Discuss what you noticed in Segment Three 4. Summarising discussion: Discuss the trans-generational transmission of personality issues . Why do you think he has raised his children in this way? 5. What do you think of the hair-cutting episode? 9. What is the aetiology of his (the patient’s) narcissism and grandiosity in terms of his upbringing? 8. What do you notice about the interviewer’s approach to the patient? Why do you think he approaches him in this way? Consider • affects • patient’s somatic state • interviewer’s body language 152 2. What do you think of the young female registrar being sent out of the room? 3.Appendices Appendix 11.1: Discussion prompts for trainees 1. What precipitated the suicide attempt? • How does it relate to his personality style? • How does it relate to his relationship with his wife and children? 6. What is the aetiology of his children’s narcissism and grandiosity in terms of their upbringing? 7.

Session 12: Reflective Interview Skills I 153 .

There are two options for this session: Option A: Organise your own doctor-patient interview Option B: Watch the interview material on the accompanying USB Focus of the Session 1. emotions.  To encourage trainees to reflect upon the many layers of communication and their meaning − Verbal communication − Non-verbal communication – subtext. To increase trainees’ awareness of the many layers of communication in any interaction 2. and external speakers . affects. transference and countertransference Materials Required for the Session Option A: Video camera if pre-recording your own interview Equipment to watch the pre-recorded interview during the session Option B: Computer. In this session the group watches and discusses several brief segments of a doctor-patient interview.154 Session 12 Reflective Interview Skills I OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION OPTION A Organise your own interview OR OPTION B Watch the interview segments on the accompanying USB Summary of Session This session is an introduction to the concept of reflective interviewing. body language. with either a data projector or TV monitor.

After the Interview • The interviewer should watch the recording of their interview and select three segments of two-five minutes duration to be watched by the group during the session º Selected segments should include poignant moments. Select a trainee to be interviewer 2.Reflective Interview Skills I 12 OPTION A: Organise your own interview Please note that there are no Facilitator Notes for this option Preparation for Session Please note that this option requires significant preparation time and requires video/DVD prerecording 1. 3. e. or other illustrative moments • The interviewer should prepare a very brief (ten second) introduction to their interview – one that does not include diagnosis or formulation. please ensure there is minimal blunting of affect and emotional reactivity.  Review the discussion prompts (appendix 12. The interview needs to be done in sufficient time for the interviewer (trainee) to watch the recording and to select segments from the interview for discussion during the session – see below • The trainee conducting the interview should not take notes while interviewing the patient 5. if psychosis is present. but one that orientates viewers to the interview.1. where there was a shift or change in rapport. for example where transference/ countertransference was particularly strong. Watch the segments selected by the trainee to ensure you are familiar with the content 7. Prior to the interview • Explain the interview to the patient and obtain written consent º Check with your relevant hospital authority about the procedures relating to confidentiality and consent in your hospital 4. Select a patient to be interviewed by the trainee NB.g. The interview • A fifty-minute assessment interview • The interview must be recorded prior to the session • NB.1).” 6. “This is an interview with a 39-year-old man who I saw on the day of his admission to the psychiatric unit. and photocopy them to distribute to trainees during the session HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Patient selection is important 155 – Can be an inpatient or an outpatient – Must be co-operative – Must have capacity to consent to the interview – Ideally non-psychotic but.

Instead the focus should remain on the information that can be gleaned from the moment-to-moment interaction.  Play the selected interview segments one at a time.2) Note to Facilitator The interview segments on the accompanying USB contain subject matter of a particularly horrific and shocking nature. . The purpose of the interview segments is to generate discussion surrounding interview technique and NOT to critique the skill of the trainee.1. Photocopy the discussion prompts (appendix 12.1) to distribute to trainees during the session 3. Therefore the discussion should not involve feedback or criticism of the interviewer’s technique and as session facilitator you must ensure that the discussion does not head down this path. It contains four segments from an interview between a psychiatry registrar and a patient 2. 4.Conducting the Session 1.1). with a discussion after each segment using the discussion prompts provided (appendix 12.1. Allow 30 minutes for viewing each interview segment and subsequent discussion 156 Note to Facilitator 1 It is important that the trainee who conducted the interview limit their input into the initial part of the discussion. Note to Facilitator 2 It is essential to ensure that the trainee who conducted the interview feels ‘safe’ and ‘supported ’rather than exposed to the group.2. Hand out the discussion prompts (appendix 12.1) and allow reading time (5 minutes) 3. Refrain from asking the interviewer for additional content or history not covered in that segment. This is to ensure uncontaminated responses from the group in the relative absence of background information.  The interviewer should provide a brief introduction to the interview that they have prepared to orientate the group 2. Review the facilitator notes (appendix 12.  Ensure that there is sufficient time at the end of the session for summarising discussion – refer to discussion prompts and facilitator notes (15 minutes) OPTION B: Watch the recorded interview segments on the accompanying USB Preparation for Session 1.  Review the USB material.2.

Reflective Interview Skills I 12 Conducting the Session 1. If there is time.2. Play the first three segments allowing 30 minutes for each segment and its discussion.2.2) 157 5.1) and facilitator notes (appendix 12.  Give a brief introduction to the interview on the USB to orientate the group. Warn the group that the interview segments contain subject matter of a particularly horrific and shocking nature 2.  Lead a group discussion of each interview segment guided by the discussion prompts (appendix 12.  Hand out the discussion prompts (appendix 12.2.  Play the USB.2 – Facilitator notes HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . watch segment four and discuss following a similar format 4.1.  Ensure that there is sufficient time at the end of the session for a summarising discussion – refer to discussion prompts and facilitator notes (15 minutes) Appendices listing For use with Option A (Organising your own interview) Appendix 12. The USB contains four interview segments each of 2-6 minutes duration.2.2.1 – Discussion prompts for trainees For use with Option B (Watching the interview segments on the accompanying USB) Appendix 12.1) and allow reading time (5 minutes) 3. pausing for discussion where indicated in the USB.1 – Discussion prompts for trainees Appendix 12.

a patient reports that they are compliant but the history includes police presentations. and about their early life experiences. discuss the following (in the last fifteen minutes of the session): The effect a patient has on us gives us useful information about the way others. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Discuss what the interviewer’s responses to the patient might reflect 10. discuss and elaborate on your early tentative hypotheses Summarising the discussion After watching all segments. Allow apparent contradictions to remain 158 Note all words.1 – Discussion prompts for trainees For use with Option A (Organising your own interview) The following discussion prompts should be applied to each interview segment Watch the segment 1. Reflect on: • the effect the patient has on you • how this reflects the effect they would have on others • what this might tell us about their early life experiences .  With your observations and associations in mind.  Even with minimal stimulus material.Appendix 12. including the treating team. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. or why not? 9. Discuss your affective responses to the patient 8.  Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations. lengthy involuntary admissions and community treatment orders) 7. 3. What do you notice about the patient’s general appearance? 4. Discuss any incongruities For example: • contradictions within the content of the segment – parts of the narrative that don’t quite fit together • incongruities between the tone of speech and the content • incongruities between the verbal and non-verbal communication • incongruities between the way the patient presents him/herself to you and what the content of the narrative suggests (e. your unconscious mind has begun to make links and associations What strikes you in this segment? What words.1. are likely to respond to that patient. images and affective responses on a white board or butcher’s paper 2. What do you notice about the patient’s tone of speech? 5. Do you feel empathy for the patient? Why. What do you notice about the patient’s content of speech? 6.g.

What is your response to the shocking content? 1  ourgeois. discuss tentative hypotheses 15.  “The first few minutes” of a psychiatric assessment are critical in forming early impressions and diagnostic hypotheses1 159 Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations 3. Discuss any incongruities 9. Pierre Pichot and Werner Rein (eds). What strikes you in this segment? What words. What do you notice about the patient’s tone of speech? 16. He specifically requested this. does it surprise you that he agreed to be recorded? 5. In view of this. How do you feel when the patient mentions these traumatic and shocking things? Do you feel disturbed? 11. Discuss your affective responses to the patient 21.Reflective Interview Skills I 12 Appendix 12. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . What do you notice about the patient’s thought-form? 8. What do you notice about the patient’s content of speech? 7. Discuss your affective responses to the patient 10. Even in this short segment. What do you notice about the patient’s content of speech? 17. In terms of diagnostic possibilities. With your observations and associations in mind. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions to remain 2. What do you notice about the patient’s tone of speech? 6. (1994) The First Few Minutes: Original Contact and the Speed of Psychiatric Diagnosis. What strikes you in this segment? What words. In The Clinical Approach B in Psychiatry.2. Allow apparent contradictions to remain Note all words. your unconscious mind has begun to make links and associations. What techniques is the interviewer using in this segment? 20. images and affective responses on a white board or butcher’s paper 14. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss these Discuss what the interviewer’s responses to the patient might reflect Segment Two 13. what is the interviewer exploring in this segment? 19.  The patient’s face is blurred out of this recording. Discuss any incongruities 18. What do you notice about the patient’s general appearance? 4. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions.1 – Discussion prompts for trainees For use with Option B (Watching the interview segments on the accompanying USB) Segment One 1. M. Do you feel empathy for the patient? Why or why not? 12.

or why not? 23. What do you notice about the patient’s understanding of actions and consequences? 34.  Do you see a parallel between the patient’s lack of empathy and our difficulty in empathising with him? 160 26. What problems might treating teams face in the management of this patient? 39. discuss and elaborate on your early tentative hypotheses Segment Three 27. Discuss any incongruities that are apparent 32. Allow apparent contradictions to remain Note all words. What do you notice about the patient’s content of speech? 31. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Discuss what the interviewer’s responses to the patient might reflect 35. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. Do you feel empathy for the patient? Why. Does the patient feel empathy for the boys? 25. and their early life experiences. Is this man trying to make a connection with others? 36. What does this tell us about his early life experiences? 38. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Discuss what the interviewer’s responses to the patient might reflect 24. If there is time.  With your observations and associations in mind. With your observations and associations in mind. What strikes you in this segment? What words. watch segment four and discuss following a similar format to above Summarising the discussion After watching all segments. images and affective responses on a white board or butcher’s paper 28. Discuss your affective responses to the patient 33. What do you notice about the patient’s tone of speech? 30. How do treating teams experience this man? 37.22. discuss tentative hypotheses 29. Reflect on: • the effect the patient has on you • how this reflects the effect they would have on others • what this might tell us about their early life experiences . discuss the following (in the last fifteen minutes of the session): The effect a patient has on us gives us useful information about the way others (including the treating team) are likely to respond to that patient.

2. 6. He then mentions the “mutilation. It lacks affective range. What strikes you in this segment? What words. the topics are emotionally neutral.2. What do you notice about the patient’s content of speech? Initially. a patient reports that they are compliant. or perhaps detached from himself. 5. 7. torture and murder of young boys”. We wonder about shame and embarrassment. but the history includes police presentations.g. The patient sounds almost bored. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions.Reflective Interview Skills I 12 Appendix 12. lengthy involuntary admissions and community treatment orders) The shame communicated by the preservation of his anonymity contrasts with his willingness to be recorded The tone of speech is incongruous with the dramatic content – it remains unchanged in a way that is surprising and somewhat jarring. images and affective responses on a white board or butcher’s paper. What do you notice about the patient’s thought-form? 8. Even in this short segment. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Discuss any incongruities For example: • contradictions within the content of the segment – parts of the narrative that don’t quite fit together • incongruities between the tone of speech and the content • incongruities between the verbal and non-verbal communication • incongruities between the way the patient presents him/herself to you and what the content of the narrative suggests (e. Each piece of information is given the same weight. does it surprise you that he agreed to be recorded? This is an incongruity and should be kept in mind.2 – Facilitator notes For use with Option B (Using the interview segments on the accompanying USB) Segment One 1. What do you notice about the patient’s general appearance? 4. In view of this. The blurring of the face creates a sense of anonymity. or convey a low-grade dysphoria and low self-esteem.  The patient’s face is blurred out of this recording in response to his request.  “The first few minutes” of a psychiatric assessment are critical in forming early impressions and diagnostic hypotheses 161 Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations 3. your unconscious mind has begun to make links and associations. What do you notice about the patient’s tone of speech? Speech is low key and toneless. Allow apparent contradictions to remain Note all words.

images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. What techniques is the interviewer using in this segment? The patient initially appears to disown his symptoms but the interviewer brings him back to them. What do you notice about the patient’s content of speech? The content is increasingly shocking and dramatic. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss these Discuss what the interviewer’s responses to the patient might reflect When the patient brings up the topic of the torture of young boys. then poses alternatives. Ego-dystonic: characteristic of obsessions. These include the defenses of detachment. but it is hard to feel empathy at this stage. 20. You may feel paradoxically bored and/or detached. reflecting an obsessive-compulsive disorder. images and affective responses on a white board or butcher’s paper. and then uses clarification to hone in on the specific psychopathology. The interviewer probably found this topic unthinkable at this point and was reacting in a defensive manner. neither he nor the interviewer react the way you would expect someone to react to something so sensational. When someone reacts in an unusual way it usually indicates something important. What strikes you in this segment? What words. Discuss your affective responses to the patient 10. and the story increasingly brutal. 162 11. . She asks first open-ended questions.9. In terms of diagnostic possibilities. or they might feel strangely unaffected. Allow apparent contradictions to remain Note all words. You may feel repulsion. isolation of affect and deliberate suppression. Discuss any incongruities 18. Alternative explanations include empathic mirroring or suppression to maintain rapport. 15. 12. With your observations and associations in mind. 14. There are several reasons for not responding with anxiety to an alarming piece of information. Do you feel empathy for the patient? Why or why not? Perhaps it is partly because of the blurring of the face – the lack of facial features. Discuss your affective responses to the patient 21. People might feel incredibly anxious in the face of this incongruity. What is your response to the shocking content? You may feel anxious and alarmed. or 2. Ego-syntonic: characteristic of a paraphilia 19. discuss tentative hypotheses. What do you notice about the patient’s tone of speech? 16. what is the interviewer exploring in this segment? The interviewer is attempting to determine whether the disturbing thoughts are: 1. 17. Segment Two 13. The interviewer is clear and persistent.  How do you feel when the patient mentions these traumatic and shocking things? Do you feel disturbed? The patient drops the shocking content into the conversation in an affect-less way. dissociation.

concrete understanding of actions and their consequences. What do you notice about the patient’s tone of speech? 30. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Does the patient feel empathy for the boys? No. What do you notice about the patient’s content of speech? 31. 28. Do you feel empathy for the patient? Why. He has no ability to think about how things might feel to another. What do you notice about the patient’s understanding of actions and consequences? He has a very primitive. She becomes less empathic and appears angry with him and while not quite punitive is certainly challenging. that he did it in order to see what it would feel like to a little boy. Discuss your affective responses to the patient 33. Up to this point.  What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Discuss what the interviewer’s responses to the patient might reflect The interviewer is not showing much reaction. Discuss any incongruities that are apparent 32. he does not feel real empathy. the interviewer seems to be oscillating between empathy and distaste but in this segment it is as though she has “given up”. Allow apparent contradictions to remain Note all words. 163  An extreme example of this is his explanation for electrocuting himself. What strikes you in this segment? What words. the capacity to make sense of ourselves and others in terms of mental states. She is no longer trying to create a moral awareness in the patient.  This man lacks the capacity for what Peter Fonagy refers to as “mentalization” – the fundamental capacity to understand mental states such as thoughts and feelings.  With your observations and associations in mind. but is completely unable to create this connection. or why not? While you might feel some empathy for the patient. 34. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions.Reflective Interview Skills I 12 22. to imagine what it would be like to be in his shoes 23. discuss tentative hypotheses 29. Is this man trying to make an emotional connection with others? This man appears to want a connection with others. as he is very alone in this predicament. 24. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Discuss what the interviewer’s responses to the patient might reflect There is a shift in rapport. Any attempt at empathy is very concrete. images and affective responses on a white board or butcher’s paper.  Do you see a parallel between the patient’s lack of empathy and our difficulty in empathising with him? 26. discuss and elaborate on your early tentative hypotheses Segment Three 27. non-judgemental and understanding. it is very hard to genuinely relate to him. With your observations and associations in mind. 35. She appears to be trying to remain calm. 25.

cruel and/or sadistic and lacking in empathy. What does this tell us about his early life experiences? Our response to a patient gives us useful information about: 1. It is likely that his only experience of emotional connection was through pain and that he has learnt to experience pain as love. and 2. We can imagine that in his formative years he experienced others as confusing. 39. their early life experiences Therefore we can use our responses to form tentative hypotheses 164 Our response to this man tells us that he has been very damaged from a very young age. the way others respond to them. punitive. Any successful treatment program would require that this man make a connection on a level other than that of pain and sadism. . Reflect on: • the effect the patient has on you • how this reflects the effect they would have on others • what this might tell us about their early life experiences. watch segment four and discuss following a similar format to above. rather than develop empathy. we can imagine that he is trying to make emotional contact with others the only way he knows – through perversity and horror. Summarising the discussion After watching all segments. What problems might treating teams face in the management of this patient? Without on any level justifying what this man does. and their early life experiences. 38. A difficulty faced in Victim Empathy Programs is that some sadistic patients. 37. This is something that would need to be monitored closely. If there is time. discuss the following (in the last fifteen minutes of the session): The effect a patient has on us gives us useful information about the way others (including the treating team) are likely to respond to that patient. get gratification from seeing victims suffer.36. How do treating teams experience this man? Those who meet him possibly experience him as cruel and they respond with a lack of empathy that mirrors his cruelty.

Session 13: Reflective Interview Skills II 165 .

Select a trainee to be interviewer 2. To encourage trainees to use this awareness in their day-to-day practice of psychiatry Materials Required for the Session Option A: Video camera to record the interview OR Video camera if pre-recording your own interview Equipment to watch the pre-recorded interview during the session Option B: Computer.  To continue to increase trainees’ awareness of the layers of communication in any interaction 2. with either a data projector or TV monitor. There are two options for this session: Option A: Organise your own doctor-patient interview Option B: Watch the interview material on the accompanying USB Focus of the Session 1. and external speakers OPTION A: Organise your own interview Preparation for Session Please note that i) There are no Facilitator Notes for this option ii) This option requires significant preparation time and requires a video/DVD prerecording 1. It follows a similar format to the previous session on reflective interviewing.Session 13 166 Reflective Interview Skills II OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION OPTION A Organise your own interview OR OPTION B Watch the interview segments on the accompanying USB Summary of Session This session is the second of two sessions on reflective interviewing. During the session the group watches and discusses several brief segments of a doctor-patient interview. Select a patient to be interviewed by the trainee .

e. for example where transference/ countertransference was particularly strong.1).” 6.1) and allow reading time (5 minutes) 3.g. if psychosis is present. where there was a shift or change in rapport. The interview • A fifty-minute assessment interview • The interview must be recorded prior to the session • NB. R  eview the discussion prompts (appendix 13. and photocopy them to distribute to trainees during the session Conducting the Session 1. The interview needs to be done in sufficient time for the interviewer (trainee) to watch the recording and to select segments from the interview for discussion during the session – see below • The trainee conducting the interview should not take notes while interviewing the patient 5. or other illustrative moments.  Hand out the discussion prompts (appendix 13.  Ask the interviewer to present the brief (10 second) introduction that they pre-prepared to orientate the group to the setting and context of the interview 2.Reflective Interview Skills II 13 NB. please ensure there is minimal blunting of affect and emotional reactivity. 3. but one that orientates viewers to the interview. • The interviewer should prepare a very brief (ten second) introduction to their interview – one that does not include diagnosis or formulation. “This is an interview with a 39-year old man who I saw on the day of his admission to the psychiatric unit. After the Interview • The interviewer should watch the recording of their interview and select three segments of two-five minutes duration to be watched by the group during the session º Selected segments should include poignant moments. Allow 30 minutes for the viewing of each interview segment and its discussion HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Patient selection is important – Can be an inpatient or an outpatient – Must be co-operative – Must have capacity to consent to the interview – Ideally non-psychotic but. Prior to the interview • Explain the interview to the patient and obtain written consent 167 º Check with your relevant hospital authority about the procedures relating to confidentiality and consent in your hospital 4.  Play the selected interview segments one at a time and lead a group discussion after each segment guided by the discussion prompts. Watch the segments selected by the trainee to ensure you are familiar with the content 7.

 Review the accompanying USB material of the five segments of an interview between a psychiatry registrar and a patient 2. As session facilitator you must ensure that the group discussion does not head down this path.2. OPTION B: Watch the recorded interview segments on the accompanying USB Preparation for Session 1. 168 Note to Facilitator The trainee who conducted the interview must feel ‘safe’ and ‘supported ’rather than exposed to the group.1 – Discussion prompts for trainees Appendix 13.1 – Discussion prompts for trainees For use with Option B (Watching the interview segments on the accompanying USB) Appendix 13.  Ensure that there is sufficient time at the end of the session for a summarising discussion – refer to discussion prompts and facilitator notes (15 minutes). Refrain from asking the interviewer for additional content or history not covered in the segment. Hand out the discussion prompts (appendix 13. watch segment three to five and discuss following a similar format 4.2.1) and allow reading time (5 minutes) 3. The purpose of the interview segments is to generate discussion. It is NOT a critique of the skill of the trainee. Instead.  Lead a group discussion of each interview segment guided by the discussion prompts and facilitator notes (appendix 13.Note to Facilitator The trainee who conducted the interview is to remain silent for the initial part of each discussion.  Ensure that there is sufficient time at the end of the session for a summarising discussion – refer to discussion prompts and facilitator notes (15 minutes) Appendices listing For use with Option A (Organising your own interview) Appendix 13.2. This is to ensure uncontaminated responses from the rest of the group.2) Conducting the Session 1.2.2) 5.  Play the USB pausing for discussion where indicated in the USB.2 – Facilitator notes . the focus should be on the information that can be gleaned from the segment itself and from the moment-to-moment interaction between the interviewer and interviewee. Give a brief introduction to the interview on the USB to orientate the group 2. The USB contains five interview segments each of 2-5 minutes duration.2. Review the facilitator notes (appendix 13. Play the first two segments allowing 30 minutes for each segment and its discussion.2. Photocopy the discussion prompts (appendix 13. If there is time.1) to distribute to trainees during the session 3. 4.

Discuss any incongruities apparent in this segment For example: • contradictions within the content of the segment – parts of the narrative that don’t quite fit together • incongruities between the tone of speech and the content • incongruities between the verbal and non-verbal communication • incongruities between the way the patient presents him/herself to you and what the content of the narrative suggests (e. What do you notice about the patient’s general appearance? 4.Reflective Interview Skills II 13 Appendix 13. Watch the segment 1.g. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Discuss what the interviewer’s responses to the patient might reflect 10. discuss the following (in the last fifteen minutes of the session): The effect a patient has on us gives us useful information about the way others. a patient reports that they are compliant. and about their early life experiences. or why not? 9.1 – Discussion prompts for trainees For use with Option A (Organising your own interview) The following discussion prompts should be applied to each interview segment. but the history includes police presentations. What do you notice about the patient’s tone of speech? 5.  Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations 3. discuss and elaborate on your early tentative hypotheses Summarising the discussion After watching all segments.  With your observations and associations in mind. your unconscious mind has begun to make links and associations What strikes you in this segment? What words. lengthy involuntary admissions and community treatment orders) 7. images and affective responses come to mind? 169 Avoid prematurely editing or foreclosing on your impressions. What do you notice about the patient’s content of speech? 6. including the treating team. Do you feel empathy for the patient? Why. Allow apparent contradictions to remain 2. Discuss your affective responses to the patient 8. Reflect on: • the effect the patient has on you • how this reflects the effect they would have on others • what this might tell us about their early life experiences HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . are likely to respond to that patient.  Even with minimal stimulus material.

What do you notice about the patient’s general appearance? 4. discuss tentative hypotheses. Discuss your affective responses to the patient 9. your unconscious mind has begun to make links and associations What strikes you in this segment? What words. Discuss your affective responses to the patient 19. With your observations and associations in mind.2. What strikes you in this segment? What words. Discuss any incongruities 8.  Even with minimal stimulus material. Discuss any incongruities 18. Does anyone feel sad? . How might you see a punitive reaction in the hospital setting? 21. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. What do you notice about the patient’s thought-form? 7. Allow apparent contradictions to remain 14. What do you notice about the patient’s tone of speech? 5.  With the above observations and associations in mind.1 – Discussion prompts for trainees For use with Option B (Watching the interview segments on the accompanying USB) Segment One 1. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Discuss what the interviewer’s responses to the patient might reflect 11. discuss and elaborate on your early tentative hypotheses Segment Two 13. “The first few minutes” of a psychiatric assessment are critical in forming early impressions 170 Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations 3. What do you notice about the patient’s content of speech? 6. What do you notice about the patient’s content of speech? 17. Do you feel empathy for the patient? Why.Appendix 13. Do you feel empathy for the patient? Why. Allow apparent contradictions to remain 2. or why not? 10. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. What do you think this segment tells us about the patient’s view of herself? 12. 15. What do you notice about the patient’s tone of speech? 16. or why not? 20.

or does the patient take control of the interview herself? Discuss what the interviewer’s responses to the patient might reflect 23.  In which personality type do we characteristically see the communication of vast amounts of detail in the absence of emotional content? 24. watch segments three. How might treating teams respond to this woman? 26. Reflect on: • the effect the patient has on you • how this reflects the effect they would have on others • what this might tell us about their early life experiences HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Does the interviewer direct the patient much. the patient describes many inadequate caregivers. what do you think about her recurrent medical and psychiatric complaints? 171 28.  In view of this discussion. four and five and discuss following a similar format to above Summarising the discussion After watching all segments. What might this tell you about her early life? 27. In this segment.Reflective Interview Skills II 13 22. discuss the following (in the last fifteen minutes of the session): The effect a patient has on us gives us useful information about the way others. What do you make of this? 25. are likely to respond to her and her early life experiences. including the treating team.  If there is time.

lip cream. Allow apparent contradictions to remain 172 Note all words. What do you notice about the patient’s thought-form? Circumstantial/over-inclusive – long and detailed response to a single question. “The first few minutes” of a psychiatric assessment are critical in forming early impressions.2 – Facilitator notes For use with Option B (Watching the interview segments on the accompanying USB) Segment One 1. if any.Appendix 13.She has set herself up comfortably for the interview – a blanket. and was passive. 7. What do you notice about the patient’s general appearance? She is dressed as a patient would dress. I’ve had thirty-nine general anaesthetics. events in which she was a victim. 2.2. What do you notice about the patient’s tone of speech? Low. . images and affective responses on a white board or butcher’s paper. mention of the feelings associated with the above events. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. For example “…raped by an ex-best friend at the age of eight and a bit. monotonous and lacking inflection. Discuss any incongruities For example: • c ontradictions within the content of the segment – parts of the narrative that don’t quite fit together • incongruities between the tone of speech and the content • incongruities between the verbal and non-verbal communication • incongruities between the way the patient presents herself to you and what the content of the narrative suggests There is a marked incongruity between her monotonous tone of speech and the content of speech.  Even with minimal stimulus material. never had sex. 5. I had a total abdominal hysterectomy…” There is little. 4. a bottle of water – things that may be comforting for her There is something young about this appearance and set-up. your unconscious mind has begun to make links and associations What strikes you in this segment? What words. her account detailing seemingly endless traumatic events since birth. Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations 3. What do you notice about the patient’s content of speech? She is versed in medical terminology The content is dramatic. have no interest in sex. 6. It appears as though she is uninterested in her own life story and has been through it many times before. I’ve never had a boyfriend. wearing a nightgown rather than street clothes.

 The sense that she may be responsible for her own incapacity or is “using the system” for secondary gain. low self-esteem and indifference about her experiences • pride in what she has endured. and the list-like recitation of ordeals. She allows the flow to continue for some time but towards the end of this segment makes an attempt to direct the patient. can induce a sense of detachment or boredom despite what is. another common response may be to become moralistic and punitive.  Those directly involved in her care may have a similar response and could feel increasingly helpless and frustrated. How might you see a punitive reaction in the hospital setting?  This may be acted out. further disrupts empathy. What do you think this segment tells us about the patient’s view of herself? She seems to be demonstrating two things: • worthlessness. discuss and elaborate on your early tentative hypotheses Segment Two 13. What do you notice about the patient’s content of speech? 17. What do you notice about the patient’s tone of speech? 16. 14. and the interviewer is passive. or why not? It can be difficult to sustain empathy for the patient. the patient is largely in control of the direction of the interview. With your observations and associations in mind. By the time she gets to the point of a story. 11. a traumatic life story. we are fatigued and overwhelmed by relentless detail. images and affective responses on a white board or butcher’s paper. Note all words. images and affective responses come to mind? Avoid prematurely editing or foreclosing on your impressions. This has become her primary identity as a patient 12. Does anyone feel sad? It is as though we should feel sad but don’t. As frustration builds. Allow apparent contradictions to remain. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Discuss your affective responses to the patient 19. The monotonous tone of speech. 173 The interviewer is perhaps overwhelmed by the quantity of content that is impassively related to her. Discuss your affective responses to the patient 9. Do you feel empathy for the patient? Why. objectively. by treatments or operations that aren’t medically required. This is surprising in view of the tragic life picture she paints. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Discuss what the interviewer’s responses to the patient might reflect In this segment. 10. 20. or by refusing treatment such as pain medication even when medically-indicated. for example. What strikes you in this segment? What words. Do you feel empathy for the patient? Why. With your observations and associations in mind. discuss tentative hypotheses 15. 21. Discuss any incongruities 18. or why not? It remains difficult to feel empathy for this patient.Reflective Interview Skills II 13 8.

a controlling quality. and • their early life experiences. four and five and discuss following a similar format to above.  In which personality type do we characteristically see the communication of vast amounts of detail in the absence of emotional content? This is typical of cluster C – Obsessive Compulsive Personality Disorder. for example to insist on certain details. the patient describes many inadequate caregivers. 27. we may wonder if this is a communication of her early experiences of the world as the youngest of six children. What do you make of this? There is a devaluation of those who fail her. What do you notice in the interaction between interviewer and interviewee? Were there any changes or shifts in rapport in this segment? Discuss Does the interviewer direct the patient much. albeit subtly. There would likely be frustration. It is unconscious. She appears to enjoy the attention focussed on herself. the patient talks without requiring any direction from the interviewer. what do you think about her recurrent medical and psychiatric complaints? Perhaps it is only through illness that she is able to evoke a response from others. She is tolerating the patient without being actively engaged. In view of this discussion. or does the patient take control of the interview herself? Discuss what the interviewer’s responses to the patient might reflect The interviewer allows the patient to talk.22. In this segment. weariness and helplessness in response to her recurrent presentations. Therefore we can use our responses to form tentative hypotheses. 28. 25. What might this tell you about her early life? Our response to a patient gives us useful information about: • the way others respond to them. For example. watch segments three. How do treating teams respond to this woman? We would anticipate that many who come in contact with this patient would respond in a similar way. The interviewer is relatively passive. might feel threatening to her fragile sense of self. 174 The patient would probably not tolerate any loss of this control. with an overloaded. are likely to respond to her and her early life experiences. Summarising the discussion After watching all segments. including the treating team.  If there is time. both with superior knowledge and expertise. Reflect on: • the effect the patient has on you • how this reflects the effect they would have on others • what this might tell us about their early life experiences. In this setting she is attempting to form a bond with the interviewer and does so by uniting herself with the interviewer. This is an example of splitting. Meanwhile. . She is demonstrating. 24. 23. The patient is not aware of this process. To interrupt her. In this segment the patient communicates times when she has lashed out against unhelpful others and is communicating her potential to lash out again. fatigued and overwhelmed mother. 26. discuss the following (in the last fifteen minutes of the session): The effect a patient has on us gives us useful information about the way others.

Session 14: The Therapeutic Alliance 175 .

with either a data projector or TV monitor. Materials Required for the Session Computer. including • definition • clinical relevance • the relationship between the therapeutic alliance and attachment styles 2.2) to distribute to the trainees during the session . Focus of the Session 1.  Review the recorded lectures to ensure you are able to discuss relevant aspects of the topic 2. To provide an overview of the therapeutic alliance.1 and 14.  Photocopy the lecture slides (appendices 14. The session consists of two lectures that detail/discuss different aspects of the therapeutic alliance. and external speakers Preparation for Session 1. It includes definitions. theory and clinical applications.176 Session 14 The Therapeutic Alliance LECTURES Dr Jeanette Martin The Therapeutic Alliance Dr Loyola McLean Working the Therapeutic Alliance Summary of Session This session is an overview of the therapeutic alliance.  To use real examples to demonstrate how our understanding of the therapeutic alliance and of attachment styles can be applied to clinical work.

1 – Lecture slides for The Therapeutic Alliance by Dr Jeanette Martin Appendix 14.The Therapeutic Alliance 14 Conducting the Session 1. Hand out copies of the lecture slides to trainees (appendices 14. At the end of each lecture allow question and discussion time (10 minutes) 177 Appendices listing Appendix 14.2) 2.2 – Lecture slides for Working the Therapeutic Alliance by Dr Loyola McLean HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .1 and 14. Play each lecture on the accompanying USB Lecture One: The Therapeutic Alliance – Dr Jeanette Martin (50 minutes) Lecture Two: Working the Therapeutic Alliance – Dr Loyola McLean (10 minutes) 3.

1 – Lecture slides The Therapeutic Alliance by Dr Jeanette Martin 178 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 .Appendices Appendix 14.

The Therapeutic Alliance 14 179 Slide 7 Slide 8 Slide 9 Slide 10 Slide 11 Slide 12 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

180 Slide 13 Slide 14 Slide 15 Slide 16 Slide 17 Slide 18 .

The Therapeutic Alliance 14 181 Slide 19 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

2 – Lecture slides Working the Therapeutic Alliance by Dr Loyola McLean 182 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 See larger version on page 180 Slide 6 .Appendix 14.

The Therapeutic Alliance 14 183 Slide 7 Slide 8 Slide 9 Slide 10 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

184 NOTES .

Session 15: Introductory Formulation I 185 .

and external speakers PART TWO: Computer.  To create an awareness of the importance of formulation in day-to-day practice. This component is based on segments of a recorded doctor-patient interview and relevant recorded group comments and discussion Focus of the Session 1.  Photocopy the lecture slides (appendix 15. To provide an introductory grounding in the essential skill of formulation 2.  Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic 2. The session is divided into two parts: PART ONE: A lecture – an overview of formulation PART TWO: An interactive component where the group discusses and practices formulation with a real clinical example. with either a data projector or TV monitor. in understanding the patient’s predicament and in communicating with other professionals 4. and external speakers PART ONE: Lecture Session Preparation 1.Session 15 Introductory Formulation I 186 PART 1: LECTURE Dr James Telfer Formulation PART 2: OBSERVATION OF INTERVIEW SEGMENTS INTERACTIVE GROUP EXERCISE AND DISCUSSION Summary of Session This is the first of two sessions on formulation. with either a data projector or TV monitor. To introduce the various schema used in developing a formulation 5.  To introduce formulation as something unique to the profession of psychiatry and as distinct from a “summary” of clinical information 3.1) to distribute to trainees during the session . To practise a formulation based on real clinical material Materials Required for the Session PART ONE: Computer.

2.3) 8.1 – Lecture slides for Formulation by Dr James Telfer For use with Part Two (Interactive exercise) Appendix 15.3 – Example of a formulation Using the Three P Model Appendix 15. Allow question and discussion time (10 minutes) PART TWO: Interactive Exercise Preparation for Session 187 1.2. Review facilitator notes (appendix 15.4 – RANZCP Clinical Examinations Formulation Guidelines for Trainees HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .1) 2.4) and allow time for reading the discussion prompts (5 minutes) 2.2.  Advise trainees to take notes while watching the USB material as they will be expected to write their own formulations 3. Hand out copies of the lecture slides to trainees (appendix 15.2.Introductory Formulation I 15 Conducting the Session 1.2.2.1) and the RANZCP Clinical Examinations Formulation Guidelines for Trainees (appendix 15.2.  Hand out the discussion prompts (appendix 15. the example of a formulation using the Three P Model (appendix 15.2.1).3) to distribute to trainees during the session 3.2 – Facilitator notes Appendix 15.2) Conducting the Session 1. Allow 5-10 minutes after watching the USB for trainees to write their own formulations 6. Play the lecture on the accompanying USB Formulation – Dr James Telfer (10 minutes) 3. Lead a group discussion guided by the USB and the discussion prompts Note: For some of the discussion prompts a brief group discussion has also been included on the USB.1 – Discussion prompts for trainees Appendix 15.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions. Ask trainees to think about the questions (discussion prompts) in light of the interview 5.2.2.2.  Review the accompanying USB segments of an interview – these segments do not comprise a complete interview (25 minutes) 2. 7.  Play the interview segments sequentially without pausing for discussion between segments (25 minutes) 4.2) and the RANZCP Clinical Examinations Formulation Guidelines for Trainees (appendix 15. This extra footage is approximately 15 minutes in total. Appendices listing For use with Part One (Lecture) Appendix 15.  Photocopy the discussion prompts (appendix 15. Hand out the example formulation (appendix 15.

1 – Lecture slides For use with Part One (lecture) Formulation by Dr James Telfer 188 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 .Appendices Appendix 15.

Introductory Formulation I 15 189 Slide 7 Slide 8 Slide 9 Slide 10 Slide 11 Slide 12 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

190 Slide 13 Slide 14 Slide 15 Slide 16 Slide 17 Slide 18 .

Choose a trainee to read out a formulation that follows the Three P Model.e. Discuss the trainee’s formulation 10. One particular model is the Three P Model. See the formulation from the RANZCP Clinical Examinations Formulation Guidelines for Trainees (appendix 15. What are relevant gaps in the history? 191 3.  Discuss elements of the case that have not been discussed so far that could be included in your formulation HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .  There are a number of well-known schema or frameworks that can be used in formulation. In this interview. for example chronic schizophrenia or chronic personality disorder.1 – Discussion prompts for trainees For use with Part Two (Interactive Exercise) 1.  Choose one of the trainees to read out their formulation to the group.2. What are the issues relevant to the developmental stage of this man? Discuss these 12. what is the patient’s predicament? 5. The process of formulation starts at the very moment that you begin interviewing a patient – sometimes even earlier than this With this in mind. Think about this man’s behaviour during the interview and the information we may take from this 7.  A patient’s behaviour during an interview also informs your formulation.  Discuss any pertinent themes that came up in the trainees’ formulation that have not yet been raised 9. think about why he is in this predicament – why is this happening at this particular time? Specifically consider: • predisposing factors • precipitating factors • perpetuating factors 6. what interviewing techniques help you in your formulation (i.Introductory Formulation I 15 Appendix 15.5) for an example of a formulation in chronic illness 14.  Consider how the formulation might differ in someone with a chronic mental illness. Can you think of any other schema for organising a formulation? Discuss these 11. in coming to an understanding of the patient and their predicament)? What techniques does the interviewer use in this interview? 2. Now. Discuss the key issues raised in this interview 4. Most formulations utilise several frameworks. This may follow a similar format and contents to the issues just discussed or it may bring in different themes and ideas 8. Discuss the risk issues in this man 13.

2 – Facilitator Notes For use with Part Two (Interactive exercise) 1. In this interview. we see a few examples of the interviewer putting hypotheses to the patient. and his doubt over whether he should ever have married in the first place. A This should include a combination of: • the patient being invited to put forward his/her own hypotheses (for example. For example. It is important not to rely entirely upon a question-and-answer approach to interviewing. he then reveals important information regarding his feelings of guilt. the interviewer poses the hypothesis that the patient has been thinking a lot about the loss of his family and of his marriage. With this in mind.Appendix 15. Although the patient denies this. and • the interviewer posing hypotheses. or the stresses he has been under).2. The process of formulation starts at the very moment that you begin interviewing a patient – sometimes even earlier than this. 2. on his predisposition to mental illness. think about why he is in this predicament – why is this happening at this particular time? Specifically consider: a) Predisposing factors • genetic loading • demographics (male sex. and noting the response. Discuss the key issues raised in this interview? The issues seen as key will vary somewhat from person to person. In this interview.e. What are relevant gaps in the history? • medical history including changes in physical health • significant anniversaries and their significance to the patient • drug and alcohol history 3. what interviewing techniques help you in your formulation (i. putting these back to the patient. Now. age-bracket) • social isolation • psychological vulnerability – early life trauma/mother overdosing – and likely insecure attachment status • may mention here that we would want to know about alcohol and its role . in coming to an understanding of the patient and their predicament)? What techniques does the interviewer use in this interview? It is important to begin forming hypotheses from the moment that you sit down with a patient. 192  collaborative style helps in coming to an understanding of the patient’s predicament. what is the patient’s predicament? • relapse of depression • socially-isolated • history of losses • suicidal ideas 5. They may include: • depressed man • strong family history of bipolar disorder • risk– suicide risk (always a key issue) • social isolation 4.

We may hypothesise that H this is consistent with his having left his wife and children.Introductory Formulation I 15 b) Precipitating factors • recent loss of employment • eviction from his unit • relationship breakdown • we might hypothesise that his impending 50th birthday could have a role c) Perpetuating factors • social isolation • ongoing stressors such as financial strain from his loss of employment 6.  Discuss any pertinent themes that came up in the trainees’ formulation that have not yet been raised 9.  Consider how the formulation might differ in someone with a chronic mental illness. intimacy versus isolation. for example chronic schizophrenia. Choose a trainee to read out a formulation that follows the Three P Model. for example. 12. One particular model is the Three P Model. chronic personality disorder Rehabilitation issues become paramount. Trainees can be provided with this example when they have finished their own formulations 10. 7. This may follow a similar format and contents to the issues just discussed. or it may bring in different themes and ideas 8. Discuss the trainee’s formulation An example of a formulation that follows the Three P Model is given in appendix 15.2. Most formulations utilise several frameworks. Consider: • strengths and how to optimise these • accommodation • occupation • social and living skills • morale HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . This man’s difficulty in negotiating the earlier life stages. Can you think of any other schema for organising a formulation? Discuss these 11. and an avoidant-dismissive attachment style. and cut-off emotionally. has had an impact on his ability to now negotiate new developmental stages. Think about this man’s behaviour during the interview and the information we may take from this 193  e is somewhat difficult to engage. his mother having left him.3.  There are a number of well-known schema or frameworks that can be used in formulation. What are the issues relevant to the developmental stage of this man? Eriksonian stage – Generativity versus Stagnation: The task of this stage is to create something independent of oneself that will live on past one’s individual lifespan.  Choose one of the trainees to read out their formulation to the group. Discuss the risk issues in this man 13.  A patient’s behaviour during an interview also informs your formulation.

2. Discuss elements of the case that have not been discussed so far that could be included in your formulation • culture: Anglo-celtic male (sense of identity and worth focussed on family and employment success) • spirituality • cognitive style 194 • coping mechanisms e.4) for an example of a formulation in chronic illness.g. 14. problem-solving skills • defense mechanisms .See the formulation from the RANZCP Clinical Examinations Formulation Guidelines for Trainees (appendix 15.

his recent loss of accommodation and his loss of employment with a subsequent financial burden. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . and leaving his job – exacerbating his financial stressors. This resulted in significant functional impairment with Tom being absent from work and spending all day in bed.2. This is his second episode this year. suggest ongoing attachment issues possibly of an avoidant-dismissive style. and this would have resulted in a lack of the validation required for him to develop a healthy sense of self.3 – Example of a Formulation Using the Three P Model For use with Part Two (Interactive Exercise) Tom (not his real name) is a forty-nine-year-old divorced male who self-presented to hospital two days ago with a one-month history of depressive symptoms. This would have further predisposed Tom to developing a major depressive disorder. In addition to the genetic factors. anhedonia. There are a number of perpetuants – social withdrawal. He describes a low mood. These strengths may have had a role in Tom seeking treatment. the loss of his mother would have constituted a major disruption in Tom’s attachment to his primary caregiver. and the ongoing strain in Tom’s relationship with his wife and children since that time. We might also hypothesise that his mother’s mental illness prior to her suicide would have resulted in a lack of attunement to Tom. He is also able to identify some strengths and talents that he has. and are potentially good prognostic indicators. Tom does have strengths – he is well-engaged with the community mental health team. 195 We don’t know very much about Tom’s earlier life but his mother attempting suicide when Tom was a child is suggestive of significant major mental illness. a wish to die and social withdrawal. reduced contact with his girlfriend. The current episode is likely to have been precipitated by the recent relationship break-up with his girlfriend of six years. A marital breakdown ten years ago. showing the ability to form some helpful attachments.Introductory Formulation I 15 Appendix 15. Tom is likely to have a genetic predisposition to mood disorders as evidenced by a family history of bipolar disorder and a number of attempted suicides among his relatives. and makes reference to ongoing relationships with his siblings.

2. 1 .Appendix 15.4 – RANZCP Clinical Examinations Formulation Guidelines for Trainees For use with Part Two (Interactive exercise) 196 No.

2 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Introductory Formulation I 15 197 No.

198 No. 3 .

Introductory Formulation I 15 199 No. 4 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

5 .200 No.

Introductory Formulation I 15 201 No. 6 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

202 No. 7 .

Introductory Formulation I 15 203 No. 8 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

NOTES 204 .

Session 16: Introductory Formulation II 205 .

To encourage trainees to explore the patient’s predicament from a number of angles Materials Required for the Session Option A: Video camera if pre-recording your own interview Equipment to watch the pre-recorded interview during the session Option B: Computer. Option A: Organising your own doctor-patient interview Option B: Watching the interview segments on the accompanying USB Focus of the Session 1. and external speakers . In the session. There are two options for this session. To encourage trainees to be active in developing a formulation 3. the group watches clinical material and then discusses and develops a formulation. To encourage trainees to practice the various formulation schemata 4.206 Session 16 Introductory Formulation II OBSERVATION OF AN INTERVIEW FOLLOWED BY AN INTERACTIVE GROUP EXERCISE AND DISCUSSION OPTION A Organise your own interview OR OPTION B Watch the interview on the accompanying USB Summary of Session This session is the second session on formulation. It draws on the knowledge and skills introduced in the previous session. To cement and applying the learning goals of the last session 2. with either a data projector or TV monitor.

and photocopy them to distribute to trainees during the session HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Select a trainee to be interviewer 2. Prior to the interview • Explain the interview to the patient and obtain written consent º check with your relevant hospital authority about the procedures relating to confidentiality and consent in your hospital 4. 40 minutes). The interview • A forty-minute assessment interview The interview can either be pre-recorded and then watched by the group during the session. or it can be observed live by the group: º º º through a one-way screen via a monitor in another room by having the group present in the room during the interview* • The trainee conducting the interview should not take notes while interviewing the patient *If the group is present in the room during the interview. There should however be sufficient history to enable the group to formulate. 5.e.Introductory Formulation II 16 OPTION A: Organise your own interview Preparation for Session Please note that there are no Facilitator Notes for this option 1. Patient selection is important – Can be an inpatient or an outpatient 207 – Must be co-operative – Must have capacity to consent to the interview 3. Ensure that observers sit out of the direct line of sight of the patient and that they remain passive throughout the interview Note to Facilitator The focus of this session is formulation rather than the interview itself. Select a patient to be interviewed by the trainee N.  Review the discussion prompts (appendix 16. it is recommended that you watch the interview prior to the session to familiarise yourself with the content 6.1). The interview is short (i. the number of observers should be limited.  If you selected that the interview be pre-recorded for viewing during the session. therefore it will not be possible to take a full history.B.

 Lead a group discussion guided by the discussion prompts 6.  Advise trainees to take notes while watching the interview as they will be expected to write their own formulations 3. Hand out the discussion prompts (appendix 16.1 – Discussion prompts for trainees . Watch the interview either live or play it in full on a video/USB player (40 minutes) 4.1) and allow reading time (5 minutes) 2.1) to distribute to trainees during the session Conducting the Session 1.  Review the accompanying USB material of three interview segments.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions OPTION B: Watch the interview segments on the accompanying USB Please note that there are no Facilitator Notes for this option Preparation for Session 1. Note that these segments do not comprise a complete interview 2. Photocopy the discussion prompts (appendix 16.  Advise trainees to take notes while watching the interview as they will be expected to write their own formulations 3. Lead a group discussion guided by the discussion prompts 208 6. Allow 5-10 minutes after watching the USB for trainees to write their own formulations 5.  Allow 5-10 minutes after watching the USB for trainees to write their own formulations 5.Conducting the Session 1.1) and allow reading time (5 minutes) 2.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions Appendices listing For use with both Option A and Option B Appendix 16. Hand out the discussion prompts (appendix 16.  Watch the interview – play the three interview segments sequentially without pausing for discussion between segments (30 minutes) 4.

What are relevant gaps in the history? 3. Discuss the key issues raised in this interview 4. what is the patient’s primary predicament? 5. Why is the patient in this predicament – why is this happening at this particular time? 209 Consider: • predisposing factors • precipitating factors • perpetuating factors 6. quality of life.Introductory Formulation II 16 Appendices Appendix 16.  Discuss any pertinent themes that came up in the trainees’ formulation that have not yet been raised 9. How does the patient’s behaviour inform us? 7. Have you considered: • bio-psycho-social issues • cultural context • spiritual beliefs • cognitive style • developmental stages • coping/defense mechanisms • risk assessment • countertransference • prospects of rehabilitation (strengths. What techniques does the interviewer use in this interview? Are these helpful? 2. morale)? HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Choose a member of the group to read out their formulation 8.1 – Discussion prompts for trainees For use with both Options A and B 1.  A patient’s behaviour during an interview also informs your formulation. In this interview.

NOTES 210 .

Session 17: Cognitive-Behavioural Approach and Formulation 211 .

Session 17 Cognitive-Behavioural Approach and Formulation 212 PART 1: LECTURE Dr Lisa Lampe The Cognitive Formulation in Anxiety PART 2: OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION Summary of Session This session is about a cognitive-behavioural approach to understanding a patient’s presentation. Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic 2. particularly in relation to anxiety disorders Materials Required for the Session PART ONE: Computer. The session is divided into two parts: PART ONE: A lecture: an overview of developing a cognitive-behavioural model or formulation PART TWO: An interactive component using segments of a pre-recorded interview between a consultant psychiatrist and a patient to integrate the concepts introduced in the lecture Focus of the Session 1. with either a data projector or TV monitor. To understand what constitutes a cognitive-behavioural model in psychiatry 2. and external speakers PART TWO: Computer. Photocopy the lecture slides (appendix 17. To discuss a patient from a cognitive-behavioural perspective 3. To develop a cognitive-behavioural model for a patient 4. and external speakers Whiteboard or butcher’s paper PART ONE: Lecture Preparation for Session 1.1) to distribute to trainees during the session .1. with either a data projector or TV monitor. To discuss some cognitive-behavioural concepts.

2. Allow question and discussion time (10 minutes) PART TWO: Interactive Exercise Preparation for Session 213 1.2). pausing where indicated. the patient history (appendix 17.  Prior to the session.Cognitive-Behavioural Approach and Formulation 17 Conducting the Session 1. and lead a group discussion guided by the discussion prompts and facilitator notes (appendix 17. Hand out copies of the lecture slides to trainees (appendix 17.  Photocopy the session discussion prompts (appendix 17.1) and the Cognitive-Behavioural Model for “Jenny” (appendix 17.2.2. Allow reading time (5 minutes) 2.  Play the USB of the interview.  Hand out the discussion prompts (appendix 17.2.2. Review facilitator notes (appendix 17.4 – Cognitive-Behavioural Model for “Jenny” HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .1) 2.2.3) Conducting the Session 1.1.1 – Summary of the patient’s history Appendix 17.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions Appendices listing For use with Part One (Lecture) Appendix 17. the patient history (appendix 17.2.2.2. Play the lecture on the accompanying USB (15 minutes): The Cognitive Formulation in Anxiety – Dr Lisa Lampe 3.2.2).1) and the Cognitive-Behavioural Model for “Jenny” (appendix 17.1 – Lecture slides for The Cognitive Formulation in Anxiety by Dr Lisa Lampe For use with Part Two (Interactive exercise) Appendix 17. review the USB and discussion prompts to familiarise yourself with the material 2. 3.3 – Facilitator notes Appendix 17.2. Included on the USB are five interview segments (15 minutes in total) and additional footage of discussion (12 minutes). a brief group discussion has also been included on the USB.2 – Discussion prompts for trainees Appendix 17.2.4) to distribute to trainees during the session 3.3)  Note: For some of the discussion prompts.4).

Appendices Appendix 17.1.1 – Lecture slides For use with Part One (lecture) The Cognitive Formulation in Anxiety by Dr Lisa Lampe 214 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 .

Cognitive-Behavioural Approach and Formulation 17 215 Slide 7 Slide 8 Slide 9 Slide 10 Slide 11 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

thirteen years and nine years – Her husband is supportive and they have a good relationship – Many stressors recently including recent sale of her house and building a new one.1 – Summary of the patient’s history For use with Part Two (Interactive exercise) Identifying data: Jenny1.Appendix 17. occupational and family) Developmental History – From early childhood Jenny felt she “had to be an adult” – that she was responsible for her parents’ safety and well-being Not her real name. She has had very brief trials of Alprazolam and Escitalopram – Continues to see her psychologist of one year regularly – Routine GP visits – Has also sought treatment during this episode from numerous other medical and alternative health providers Past history – She has a past history of post-natal depression/anxiety nine years ago – full recovery – Commenced antidepressant medication approximately one to two years ago.  .2. ongoing stressors with her in-laws – Close to her parents but they are emotionally dependent on Jenny and unable to be supportive of her – A few months ago Jenny gave up her one day per week job at a coffee-shop as she had too much on her plate Psychiatric treatment – Outpatient treatment has not given any relief to her symptoms. thirty-nine-year-old married woman living with her husband and three children Presenting Problems – Severe anxiety and distress – Triggering event – a panic attack while driving – Inability to function in her role as a wife and mother 216 Currently – Married twenty-one years – Children aged fifteen years. 1. and assisting her parents with the sale of their property – Chronic. and then ceased these six months ago Family history – Father: alcoholism – Mother: anxious Premorbid Personality – An anxious temperament but usually functions well (social.

What is Jenny’s response to the interviewer’s hypothesis? What does Jenny’s response tells us? 5. Why does the interviewer put forward hypotheses to the patient? Segment Two Beginning to conceptualise the patient in terms of a cognitive model 6. Discuss the interview techniques that were used in this segment Segment Four Watch the interviewer posing the following hypothesis in Segment Four 12.e. precipitating and perpetuating factors 7.2.  Thinking about the history attained thus far and the mental state of the patient what are your differential diagnoses? Difficulties associated with anxious patients 10. Are you getting a picture of what is going on with this patient? What is the history so far? Discuss in terms of predisposing. Are these cognitions typical of an anxiety disorder? 9. In this excerpt the interviewer is posing a hypothesis to the patient. Discuss how to manage each of the following difficulties associated with anxious patients: • high levels of distress during the interview • requesting or demanding reassurance from the interviewer • increased frequency of medication side-effects • a contagious sense of anxiety and urgency • a level of distress and urgency that propels patients into seeking treatment from a number of different health care providers Segment Three 11.Cognitive-Behavioural Approach and Formulation 17 Appendix 17. What is the patient’s response to the hypothesis? Segment Five Watch the interviewer posing the following hypothesis in Segment Five 13.  What are some of the difficulties the interviewer faces in this segment of the interview? How does she manage these? 217 4. What are Jenny’s cognitions around her fear – i. What is the patient’s response to the hypothesis? HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .  Watch and discuss an excerpt of Segment One. what does she fear? 8.2 – Discussion prompts for trainees For use with Part Two (Interactive exercise) Read the Patient History on the handout before proceeding Segment One Interviewing techniques 1. What do you notice about the interviewing style? 2. Why do you think the interviewer keeps returning to the precipitating incident? 3.

what behaviours would we watch for as potential perpetuants? 218 17.  Moving away from this particular patient: were Jenny to have typical panic disorder with driving as the precipitant.  Add to your initial formulation in terms of predisposing. Why does avoidance (including safety behaviours) perpetuate the problem? 18. What is your diagnosis? Anxiety disorders in general 16. What are attributions? What is an attributional bias? . precipitating and perpetuating factors. Think particularly about the perpetuating factors 15.Continue to conceptualise the patient in terms of a cognitive-behavioural model 14. and cognitive-behavioural factors.

In this excerpt the interviewer is posing a hypothesis to the patient. Why does the interviewer put forward hypotheses to the patient? It is part of the collaborative approach of cognitive-behavioural therapy models that the patient and the doctor work together to come to an understanding of the presenting problem. coughing. including their cognitive reactions • How the patient’s response to the precipitating event might have affected future outcomes This understanding affects your cognitive model/formulation. or • She is too overwhelmed by distress and anxiety to take in what the interviewer has said 5. What do you notice about the interviewing style? • The interviewer has a directive style of interviewing • She asks clear and specific questions in order to piece together the precipitating incidents • We also see the interviewer begin to put forward hypotheses to the patient 219 2. Are you getting a picture of what is going on with this patient? What is the history so far? Discuss in terms of predisposing. and T even retching She says. and its causes It is important that the doctor notices and listens to the patient’s responses and adjusts future hypotheses accordingly Segment Two Beginning to conceptualise the patient in terms of a cognitive model 6.Cognitive-Behavioural Approach and Formulation 17 Appendix 17. precipitating and perpetuating factors HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . “When I’m with someone like you. This could either be because: • It does not ring true for her.3 – Facilitator notes For use with Part Two (Interactive exercise) Read the Patient History before proceeding Segment One Interviewing techniques 1.  What are some of the difficulties the interviewer faces in this segment of the interview? How does she manage these?  his is an extremely anxious and distressed patient.2. with outbursts of tears. I don’t want to leave you” The patient’s level of distress impacts on her ability to give a clear account of recent events Her distress means she requires a lot of containment by the interviewer 4.  Watch and discuss an excerpt of Segment One. What is Jenny’s response to the interviewer’s hypothesis? What does Jenny’s response tells us? The patient doesn’t respond to the hypothesis posed. and influences your management plan 3. Why do you think the interviewer keeps returning to the precipitating incident? Your first assessment of a patient is often your best chance of gaining a clear understanding of: • The exact sequence of events • The patient’s response to these events.

 he ongoing fears – of others seeing her in a distressed state. worthlessness and guilt at letting her family down. but the anxiety persisted. Behaviours. and of letting others down 8. what does she fear? Precipitating event: In the car – Jenny feared loss of control On an ongoing basis Jenny fears others seeing her anxious.  upporting the diagnosis of depression is the extreme distress that the patient exhibits.Write the factors the group comes up with on a white-board or on butcher’s paper Predisposing factors: • Past history of depression/anxiety • Family history suggests a biological predisposition • Early life experiences may make her psychologically vulnerable Precipitating: • The event in the car • Other life-stressors e. What are Jenny’s cognitions around her fear. the S sense of failure.g. the reported diurnal variation. Are these cognitions typical of an anxiety disorder? The initial fear of loss of control is typical of an anxiety disorder. and the T sense of failure. It is typical of anxiety that the cognitions ensuing from the precipitating event perpetuate the disorder.  Thinking about the history attained thus far and the mental state of the patient. Difficulties associated with anxious patients 10. At this point in the history we don’t see that as a major factor. 7. That is. Jenny did try and get in her car and drive again – so she tried to face her fears. are common perpetuants of anxiety disorders. and that her cognitions as above are not typical of those of an anxiety disorder. 9. particularly avoidance behaviours. it is important to have major depression high up on the list of A differentials. of never getting better. b. worthlessness and guilt at letting others down – are not typical of an anxiety disorder. The cognitions are discussed in more detail below. what are your differential diagnoses?  s well as an anxiety disorder. moving house 220 Perpetuating: • Perhaps the stress of ongoing conflict with her husband’s family plays a role though we would need to explore this further • At this stage in the interview we are beginning to form hypotheses about the perpetuating cognitions and perpetuating behaviour: a. Discuss how to manage each of the following difficulties associated with anxious patients: • high levels of distress during the interview • requesting or demanding reassurance from the interviewer • increased frequency of medication side-effects • a contagious sense of anxiety and urgency • a level of distress and urgency that propels patients into seeking treatment from a number of different health care providers .

Here we see interviewer and interviewee working collaboratively on a shared hypothesis. Continue to conceptualise the patient in terms of a cognitive-behavioural model 14. • Be cautious about the diagnosis of a primary anxiety disorder (even as a comorbidity) in the context of significant depression. HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . What is the patient’s response to the hypothesis? While the patient doesn’t openly disagree with the interviewer.Cognitive-Behavioural Approach and Formulation 17 Segment Three More on interviewing techniques 11. 15.4 for an example of a cognitive-behavioural model for this patient.  Add to your initial formulation in terms of predisposing. Think particularly about the perpetuating factors. the interviewer is honest when she replies ‘I can’t predict the future’ • Socratic dialogue. asking questions and involving Jenny • Grounds with firm and definite statements when possible and appropriate. precipitating and perpetuating factors. Return to your white-board or your butcher’s paper and add to your initial formulation See appendix 17. for example she tells Jenny with certainty that she will not end up in hospital for the rest of her life • Gives appropriate information and education 221 Segment Four Watch the interviewer posing the following hypothesis in Segment Four 12. Discuss the interview techniques in this segment • There are appropriate reassurances • There are no false reassurances. The history is of a non-psychotic depression. What is the patient’s response to the hypothesis? Jenny is listening and nodding. There is often a significant overlap between GAD and depression. Segment Five Watch the interviewer posing the following hypothesis in Segment Five 13. • There is probably an underlying Generalised Anxiety Disorder (GAD).2. though Jenny refers at one stage in the interview to critical “voices” that would need to be explored further. For example. What is your diagnosis? Provisional Diagnosis: • The provisional diagnosis is a Major Depressive Episode. Differential diagnoses: • Panic disorder is on the list of differentials but is less likely than depression. and cognitive-behavioural factors. she doesn’t agree with her either.

What are attributions? What is an attributional bias? Attribution means the ascribing of meaning to explain the cause of events. For example. A type of avoidance behaviours that are easy to miss are “safety behaviours.  Moving away from this particular patient: were Jenny to have typical panic disorder with driving as the precipitant. an attributional bias means an incorrect explanation of who or what was responsible for a particular event or action. An attributional bias is a form of faulty reasoning. a safety behaviour could be making sure you always have someone with you in the car when you drive.” For example. It is a cognitive bias that leads to faulty attribution of the cause of events. what behaviours would we watch for as potential perpetuants? We look for avoidance behaviours. in OCD someone may believe that washing their hands fifty times each hour is the reason that they are safe from disease. Why does avoidance (including safety behaviours) perpetuate the problem? 222 It perpetuates the panic because there is no disconfirmatory evidence of your irrational beliefs. 18. That is.Anxiety disorders in general 16. . 17. Safety behaviours are powerful perpetuants of panic disorder.

4 – Cognitive-Behavioural Model for “Jenny” For use with Part Two (Interactive exercise) Cognitive Behavioural Model Precipitating Predisposing Strengths • The event in the car • Past psychiatric history • Supportive relationship with husband • Other life stressors e.Cognitive-Behavioural Approach and Formulation 17 Appendix 17. sister-in-law DEPRESSION/ANXIETY PERPETUATING Environmental Cognitions Behaviours • Conflict with in-laws • I am worthless and a failure • Withdrawal from usual duties and activities • I am letting others down • Seeing a number of different health professionals who give different advice • Own family unable to give emotional support • I don’t deserve to be happy HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .g.2. moving • Family history • Good premorbid function • Early life experiences • Reasonable insight • Issues raised with private psychologist • Anxious.g. sensitive temperament • Feels loved by her own family 223 • Some other good relationships. e.

NOTES 224 .

Session 18: Psychodynamic Formulation I 225 .

It provides trainees with an introduction on how to formulate from a psychodynamic perspective. Use the concepts and ideas introduced herewith to practise and develop your own style.Session 18 Psychodynamic Formulation I 226 LECTURES Dr Jeffrey Streimer Psychological Formulation in the Assessment Interview Dr Loyola McLean Psychodynamic Formulation: Aspects of Attachment and Development Summary of Session This is the first of two sessions on psychodynamic formulation. the particular patient and to the context. To introduce key ideas and themes of psychodynamic formulation Please Note There are no generally agreed formats that all psychodynamic formulations should follow. Materials Required for the Session Computer.  Review the recorded lectures to ensure you are able to discuss relevant aspects of the topic 2. To introduce trainees to the concept of psychological and psychodynamic formulation as distinct from formulation in general psychiatry 2. Focus of the Session 1.2) to distribute to trainees during the session . Therefore the following two sessions introduce and explore the various themes and concepts of psychodynamic formulation but do not provide a prescriptive framework. with either a data projector or TV monitor.1 and 18. and external speakers Preparation for Session 1. In this session there are two lectures.  Photocopy the lecture slides (appendices 18. each on a different aspect of psychodynamic formulation. appropriate to your level of experience.

Am.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions. Cooper A.Psychodynamic Formulation I 18 Conducting the Session 1.Psychiatry 159:5. Michaels R: The Psychodynamic Formulation: It’s Purpose. Play each lecture on the accompanying USB Lecture One: Psychological Formulation in the Assessment Interview Dr Jeffrey Streimer (40 minutes) Lecture Two: Psychodynamic Formulation: Attachment and Development Dr Loyola McLean (30 minutes) 3.J. Structure & Clinical Application.2) 2.1 and 18. Am J Psychotherapy 59:1.2 – Lecture slides for Psychodynamic Formulation: Attachment and Development by Dr Loyola McLean Recommended reading: Kassaw K. 227 Appendices listing Appendix 18. May 2002 Perry S. At the end of each lecture allow question and discussion time (10 minutes) 4. Hand out copies of the lecture slides to trainees (appendices 18. Advances in Psychiatric Treatment 11:416-423.1 – Lecture slides for Psychological Formulation in the Assessment Interview by Dr Jeffrey Streimer Appendix 18. 2003 Mace C. Binyon S: Teaching Psychodynamic Formulation to psychiatry trainees: Part 1: Basics of Formulation. May 1987 Summers R: The Psychodynamic Formulation Updated. Gabbard G: Creating a Psychodynamic Formulation from a clinical examination. Am J Psychiatry 144:5. 2005 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

1 – Lecture slides Psychological Formulation in the Assessment Interview by Dr Jeffrey Streimer 228 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 .Appendices Appendix 18.

Psychodynamic Formulation I 18 229 Slide 7 Slide 8 Slide 9 Slide 10 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

2 – Lecture slides Psychodynamic Formulation: Attachment and Development by Dr Loyola McLean 230 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 .Appendix 18.

Psychodynamic Formulation I 18 231 Slide 7 Slide 8 Slide 9 Slide 10 Slide 11 Slide 12 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

232 Slide 13 See larger version on page 230 Slide 14 Slide 15 Slide 16 Slide 17 Slide 18 .

Psychodynamic Formulation I 18 233 Slide 19 Slide 20 Slide 21 Slide 22 Slide 23 Slide 24 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

234 Slide 25 Slide 26 Slide 27 Slide 28 Slide 29 Slide 30 .

Psychodynamic Formulation I 18 235 Slide 31 Slide 32 Slide 33 Slide 34 Slide 35 Slide 36 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

236 Slide 37 See larger version on page 230 Slide 38 Slide 39 Slide 40 Slide 41 Slide 42 .

Psychodynamic Formulation I 18 237 Slide 43 Slide 44 Slide 45 Slide 46 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

238 Slides 13 & 37 .

Session 19: Psychodynamic Formulation II 239 .

1) and the formulation summary sheet (appendix 19.3) . This USB contains an interview between a consultant psychiatrist and a patient. as well as relevant comments and group discussion. Review the facilitator’s copy of the formulation summary sheet (appendix 19.2) to distribute to trainees during the session 3. ideas and themes introduced in the last session 2. with either a data projector or TV monitor. To learn to apply the concepts. Ensure that you are able to discuss the material covered 2. This session uses a recorded interview between a consultant psychiatrist and a patient to develop a psychodynamic formulation. and external speakers Preparation for Session 1. To practise developing a psychodynamic formulation based on real clinical material Materials Required for the Session Computer.  Review the accompanying USB material. Focus of the Session 1.Session 19 240 Psychodynamic Formulation II OBSERVATION OF A RECORDED INTERVIEW FOLLOWED BY AN INTERACTIVE EXERCISE AND GROUP DISCUSSION Summary of Session This is the second session on psychodynamic formulation.  Photocopy the case summary (appendix 19. It builds on the concepts introduced in the previous session.

Psychodynamic Formulation II 19 Conducting the Session 1.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any questions Appendices listing Appendix 19.  Hand out the case summary (appendix 19.3 – Formulation summary sheet for trainees Appendix 19.2) and allow reading time (5 minutes) 3. This additional footage is 40 minutes in total 241 5. Hand out the formulation summary sheet for trainees (appendix 19.  Lead a group discussion about how to formulate the patient using the facilitator copy of the formulation summary sheet (appendix 19.1 – Case summary Appendix 19. Watching some or all of these group discussions is optional.4 – Formulation summary sheet for facilitators HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY . Play the USB of the interview (50 minutes) 4.3) as a guide Note: For some of the discussion prompts a group discussion has also been included on the USB.2 – Tables: Attachment Style Summary and Level of Maturation Appendix 19.1) and allow reading time (5 minutes) 2.

Oppositional. 1. the last four months with a supportive boyfriend − Additional support from: a. and b.  . Her brother who lives in Queensland Past History − Oppositional defiant disorder – fighting and drug & alcohol abuse ex-13yrs − Reported marked mood swings dating back to early childhood − Six rural hospitalisations for depression and associated deliberate self-harm since her mid-teens − Diagnosed by GPs with Bipolar Affective Disorder Premorbid personality − ‘Tomboy’. abandonment and loss Developmental History − Family disharmony from early years − Mother always Kylie’s ‘best friend’ and confidant − Father alcohol & cannabis abuser – frequent mood swings − Mother abused by husband (Kylie’s father) who abandoned the family for another woman when Kylie was young − Kylie has a highly ambivalent relationship with him and his new partner − An “A” student until father left with decline in grades and behaviour thereafter − Dropped out of school. criticism. unskilled worker − Has been living six months in a capital city. These mood swings are related to and reactive to environmental factors − Reports hearing voices − Seeks a definitive admission for expert assessment and improved management of the above Currently − An inpatient: a voluntary admission to a General Teaching Hospital Mental Health Unit − Unemployed. unemployed single woman Presenting Problems 242 − Recurrent suicidal ideation − Significant rapid mood swings: episodes of depression and brief episodes of elevated mood.Appendices Appendix 19. Her mother who still lives in the small rural town in which the patient was raised. left home aged seventeen years to live with thirty-year-old boyfriend – left him after 3 years and moved to another city Not her real name.1 – Case summary Kylie: Introductory Case Outline This information is a summary of the history revealed at interview ‘Kylie’1 – nineteen-year old. rivalrous and moody − Overly sensitive to control.

Psychodynamic Formulation II 19 Appendix 19.2 – Tables 243 No. 1 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

3 – Formulation summary sheet for trainees 244 No.Appendix 19. 1 .

Psychodynamic Formulation II 19 245 No. 2 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

3 .USB 246 USB No.

4 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Psychodynamic Formulation II 19 USB 247 USB USB No.

USB 248 USB USB USB USB No. 5 .

Psychodynamic Formulation II 19 USB 249 USB No. 6 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

1 .Appendix 19.4 – Formulation summary sheet for facilitators 250 No.

Psychodynamic Formulation II 19 USB 251 USB No. 2 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

3 .USB 252 USB USB USB No.

Psychodynamic Formulation II 19 253 USB USB No. 4 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

5 .USB 254 USB USB USB USB No.

6 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .Psychodynamic Formulation II 19 255 No.

NOTES 256 .

Session 20: History and Formulation in Child and Adolescent Psychiatry 257 .

Handout copies of the lecture slides to trainees (appendix 20.1) 2. It is a lecture and includes some group discussion.  To highlight key differences between the assessment of children. Focus of the Session 1. Allow question and discussion time (10 minutes).  Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic 2. Appendices Listing Appendix 20.1 ) to distribute to trainees during the session Conducting the Session 1. Photocopy the lecture slides (appendices 20. Play the lecture on the accompanying USB Assessment in Child and Adolescent Psychiatry – Dr Steven Spielman (90 minutes) 3. To provide an overview of the assessment of adolescents in psychiatry 3. adolescents and adults in psychiatry Materials Required for the Session Computer. and external speakers Preparation for Session 1.1 – Lecture slides for Assessment in Child and Adolescent Psychiatry by Dr Steven Spielman . To provide an overview of the assessment of children in psychiatry 2. with either a data projector or TV monitor.Session 20 History and Formulation in Child and Adolescent Psychiatry 258 LECTURE Dr Steven Spielman Assessment in Child and Adolescent Psychiatry Summary of Session This session is on assessment in child and adolescent psychiatry.

History and Formulation in Child and Adolescent Psychiatry 20 Appendices Appendix 20.1 – Lecture slides Assessment in Child and Adolescent Psychiatry by Dr Steven Spielman 259 Slide 1 Slide 2 Slide 3 Slide 4 Slide 5 Slide 6 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

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History and Formulation in Child and Adolescent Psychiatry 20 261 Slide 13 Slide 14 Slide 15 Slide 16 Slide 17 Slide 18 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

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History and Formulation in Child and Adolescent Psychiatry 20 267 Slide 49 See larger version on page 261 Slide 50 Slide 51 See larger version on page 262 Slide 52 Slide 53 See larger version on page 262 Slide 54 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

268 Slide 55 Slide 57 Slide 56 .

History and Formulation in Child and Adolescent Psychiatry 20 269 Slide 48 Slide 49 HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

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HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY .

nsw.nsw.heti.au .gov.gov.H ETI THE COM PLE T E CLI NI CAL AS S E S S M E NT I N P SYC H I AT RY Building 12 Gladesville Hospital Shea Close off Victoria Road Gladesville NSW 2111 Tel: (02) 9844 6551 Fax: (02) 9844 6544 email: info@heti.au www.