YL6: 02.

24 Psychiatric Assessment
09/03/2019 Family and Community Health
03:45-04:30 Hannah Martella Maddatu-Pajarillo, MD, DSBPP
PSYCHIATRY

TABLE OF CONTENTS IV. TECHNIQUES IN PSYCHIATRIC INTERVIEW

Facilitating Interventions
I. OBJECTIVES ...........................................................................................1 • Reinforcement – convey your interest in the patient continuing
II. THE PSYCHIATRIC INTERVIEW ..........................................................1 → Leaning forward to make the patient continue talking
III. GENERAL PRINCIPLES OF THE PSYCHIATRIC INTERVIEW ........1  Brief phrases such as: “I see”, “Go on”
IV. TECHNIQUES IN PSYCHIATRIC INTERVIEW...................................1 • Reflection – using the patient’s words; statement of a fact
V. ELEMENTS OF THE INITIAL PSYCHIATRIC INTERVIEW ................2
→ Nod, no judgmental tone
A. THE HISTORY ...............................................................................2
B. OVERVIEW ....................................................................................2
• Summarizing – opportunity for patient to clarify or modify the
C. PARTS OF THE PSYCHIATRIC INTERVIEW ............................2 physician’s understanding
VI. MENTAL STATUS EXAMINATION ......................................................3 → Summarize what has been identified about the certain topic
VII. TOWARDS END OF THE PSYCHIATRIC INTERVIEW ....................5 • Reassurance – to strengthen resolve to continue in treatment
QUICK REVIEW ..........................................................................................5 → Emphasize confidentiality
SUMMARY OF TERMS .....................................................................6 → Example: Sa ngayon, ang mga itatanong ko po ay sensitibo.
MNEMONICS .....................................................................................6 Kung ‘di po kayo komportable, sabihan nyo lang po ako.
REVIEW QUESTIONS .......................................................................6 • Encouragement – providing positive feedback about patient’s
REFERENCES ............................................................................................7 efforts
REQUIRED .........................................................................................7
• Acknowledgement of emotion – leads to the patient sharing
APPENDIX ...................................................................................................7
more feelings
→ Example: kumunot ang noo
▪ State fact/observation: “Napansin ko po na kumunot
I. OBJECTIVES yung noo mo” or “mukhang nagalit ka, pwede mo bang
• To give an overview about the psychiatric interview sabihin ang dahilan?”
• To differentiate a medical history and a psychiatric history → Note: Avoid asking “why” questions
• To give an overview of the general principles of the psychiatric • Humor – laughing with the patient, not at the patient
interview  Sharing of humor can decrease the anxiety and reinforce the
• To review different interview techniques interviewer’s genuineness
• To review the parts of a psychiatric history • Silence – careful use can facilitate the progression of the interview
• To learn how to conduct a proper mental status examination
Non-verbal Communication
II. THE PSYCHIATRIC INTERVIEW  In interviews, the most common facilitating interventions are non-
• The MOST important element in the evaluation and care of verbal. These indicate that the psychiatrist is concerned, listening
persons with mental illness attentively, and engaged in the interview.
• Obtain information necessary to establish a criteria-based → Nodding of head
diagnosis → Body positioning (open stance)
• A well-conducted interview must result in an understanding of the ▪ Avoid crossing of arms
BIOPSYCHOSOCIAL elements of the disorder → Moving chair closer
• The interview is an essential part of the treatment process → Putting down pen or folder
→ Facial expressions
Medical history vs Psychiatric history
• Medical History Expanding Interventions
→ Subjective findings can be directly observed • Clarifying
▪ Complain about shortness of breath → Check chest and  Clarifying what the patient has said can lead to unrecognized
lungs issues or psychopathology
▪ Complain about abdominal pain → Check abdomen • Associations
• Psychiatric History  As the patient describes his or her symptoms, there are other
→ Subjectively revealed but CANNOT be directly observed areas that are related to a symptom that should be explored
▪ Hallucinations  Example: symptom of nausea leads to questions about
▪ Phobias appetite, bowel habits, weight loss
▪ Obsessions • Leading
 The story can be facilitated by asking a “what”, “when”,
III. GENERAL PRINCIPLES OF THE PSYCHIATRIC “where”, “who” question
INTERVIEW • Probing
• It is the job of the psychiatrist to make the patient comfortable  The interviewer can gently encourage the patient to talk about
the topic at hand
How to make the patient comfortable • Transitions
• Privacy and Confidentiality  Example: the patient is talking about her education degree in
→ Break only if there is a threat to themselves college, and the interviewer can ask, “Did that lead to your
▪ A lot of patients express they want to kill themselves but work after college?”
psychiatrists use suicide risk assessment • Redirecting
• Agree to the process  Can be used when the patient changes the topic or when the
→ Make sure the patient comes voluntarily. Otherwise, they will patient continues to focus on areas that have not been
not talk covered yet
• Establish rapport and empathy
→ Rapport – harmonious relationship between the physician and Obstructive Interventions
the patient • Close-ended questions – questions answerable by yes or no
→ Empathy – Putting yourself in the shoes of the patient • Compound questions – difficult for patients to respond because
• Safety and comfort more than one answer is being asked from the patient
→ The Physician’s safety is priority → Example: umiinom ka ba? Kung oo, anong iniinom mo? Ilang
→ There should be 2 mode of exits in the psychiatrist’s office baso?
▪ 1st door close to the psychiatrist, 2 nd door close to the • “Why” questions
patient → Example: “Bakit mo ginawa ‘yun?”
→ If only 1 door is available, physician should be closest to the → Avoid these types of questions because patients would be
door defensive. It would seem like you (physician) are accusing
them of something

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• Judgmental questions or statements – inhibit the patient from History of Present Illness
sharing even more private or sensitive material • Chronological description of the evolution of symptoms of the
→ Example: Patient tells you that she had 5 sexual partners. current episode
Don’t react by saying “limaaa??” • What to note:
• Minimizing patient’s concerns → Onset and duration
→ Don’t belittle their worries/concerns → Other symptoms
→ Patient may feel that the physician does not understand what → Stressors
he/she is trying to express → Factors that alleviate or exacerbate symptoms
• Premature advice → Severity
→ Psychiatrists do not give advice. They make the patient realize → Why seek help now?
what they’re supposed to do, NOT tell the patient what to do ▪ Note: this was emphasized by Doc
→ Counselors tell patients what to do ▪ E.g. Patient comes to you with a complaint that started 5
• Premature interpretation years ago
 May be counterproductive because the patient may feel o How to properly ask: “Bakit ngayon lang po? Ano
misunderstood pong nangyari para masabi niyo sa sarili niyo na
• Transitions kailangan ko na magpacheck-up kung 5 years niyo
 May interrupt important issues that the patient is discussing na po palang nararamdaman?”
• Non-verbal communication o Do not bluntly ask: “So why seek help only now?”
 The physician that repeatedly looks at a watch, yawns, or
turns away from the patient conveys disinterest Past Psychiatric History
 Obtain all information about all psychiatric illnesses and their
Transference course over the patient’s lifetime, including symptoms and
• Patient's unconscious feelings projected towards physician treatment.
→ Example: Patient is used to her mother having no time for her. • Past symptoms/episodes:
Now she’s thinking twice about seeing her therapist because → When they occurred
the therapist might think she’s too needy → How long they lasted
→ Frequency and severity of episodes
Countertransference • Past Treatments
• Occurs when the physician transfers emotions to the patient → Medications and dosages
→ Example: During a psychiatric interview, Patient Jude shares → Side effects
how he had a bad childhood. The doctor would react by being ▪ Important reference for future prescriptions
emotional and saying he feels the same way. • Past Diagnosis

V. ELEMENTS OF THE INITIAL PSYCHIATRIC INTERVIEW Substance Use, Abuse, and Addiction
A. THE HISTORY • Expect some reluctance to share
• Usually more important than physical examination • Use CAGE questionnaire for alcohol abuse (Note: Doc
• Must be familiar with the characteristic landmarks and emphasized this)
milestones of each period of the past history → Have you ever felt the need to CUT down your drinking?
→ Include anamnesis: complete history from conception, pre- → Has anybody been ANNOYED because of your drinking?
natal care until present time → Have you ever felt GUILTY about your drinking?
• Should convey a picture of a person and his individual → Have you ever felt you need to drink this in the morning as an
characteristics EYE-OPENER?
• Periods of sobriety
B. OVERVIEW • History of treatment
I. Identifying data
II. Source and reliability Past Medical History
III. Chief complaint • Important consideration when determining potential causes of
IV. Present illness mental illness
V. Past psychiatric history • Medical illness can:
VI. Substance use/abuse → Precipitate a psychiatric disorder
VII. Past medical history ▪ E.g. A patient comes to the ER at nagwawala (flies into
VIII. Family history a rage)
IX. Developmental and social history o Labs showed sodium levels= 112 mmol/L (normal
X. Review of systems range = 135-145 mmol/L)
XI. Mental status examination o The patient is in delirium because of the low sodium
XII. Physical examination levels (medical condition) and not psychiatric
XIII. Formulation concern
XIV. DSM-5 diagnoses → Mimic a psychiatric disorder
XV. Treatment plan ▪ E.g. A patient comes to the ER very happy, hyper, and
greets everyone
Mnemonic: I See Cool People Portray Some Pretty Faces During o Thyroid levels were checked. Hyperthyroidism
Reality Movies. Please Free Download the Torrent. can mimic manic episodes
o Upon checking, patient was already tachycardic
C. PARTS OF THE PSYCHIATRIC INTERVIEW and is about to have a thyroid storm
Identifying data → Be precipitated by a psychiatric disorder or its treatment
• Must be clearly established during initial interview ▪ Some treatments can cause metabolic syndromes
 Typically includes patient’s name, age, gender, marital status, race → Influence the choice of treatment for a psychiatric disorder
or ethnicity, and occupation.
Family History
Source and reliability • Many psychiatric illnesses are familial
• Clarify where the information came from • There is a familial response to medications
→ Especially when people other than the patient has provided → When a patient’s family member has depression and is taking
information (e.g. relative, yaya, boyfriend) medications for it, usually, the same medication would work
• Write the reliability whether it is good or poor for the patient
• Look at relationships
Chief complaint → Clarify terms clearly
• Written using the patient’s own words
• E.g. Patient comes to you and says “Doc hindi po ako nakakatulog” Developmental and Social History
→ You do NOT write: Patient has insomnia • Also known as ANAMNESIS
→ You write: “Hindi nakakatulog” • Reviews the stages of the patient’s life

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• Important tool in determining the context of psychiatric symptoms
• Parts emphasized by Doc (see Appendix A for full version)
→ Early childhood
▪ Was the patient breastfed? (feeding habits)
▪ During the mother’s pregnancy, how was the relationship
of the mother and father? (prenatal history)
o Was there a father figure?
▪ Who took care of the patient when he/she was a child?
▪ How was the child disciplined?
→ Middle childhood
▪ Related to school
▪ Was the patient sent to the principal’s office?
▪ How was the school performance? Average, above
average?
→ Later childhood
▪ Peer relationships
▪ Check for depression (15-24 years old)
→ Adulthood
Review of Systems
NOTE: This part was not discussed by Doc
 Attempts to capture any current physical or psychological signs and
symptoms not already identified in the present illness
 Particular attention is paid to neurological and systemic symptoms
VI. MENTAL STATUS EXAMINATION
• The psychiatric equivalent of the physical exam in the rest of
medicine
• Explores all areas of mental functioning including the cognitive
functioning
• Gives a clinical snapshot of the patient’s mental status at the
time of examination
• Must not be confused with MMSE (mini-mental status examination)
→ MMSE: used to check for patient’s cognitive functioning
→ MMSE more neurological than psychiatric
• Has 16 parameters
Appearance & Behavior
• Describing the patient’s distinguishing features
→ Keep in mind that after describing patient’s appearance, the
doctor should be able to identify which one is the patient in a
room full of people
• Appropriateness of attire and accessories
• Grooming and hygiene
• Appears of stated age?
• Behavior: patient’s approach to the interview
• Examples:
→ “A 60-year-old woman who is wearing excessive number of
accessories”
→ “A 15-year-old dark-skinned boy with tattered clothing seating
in a wheelchair”
Motor Activity
• Normal, slowed, or agitated
• Gait, limitations in movement, posturing
• Examples:
→ Tics: Habitual spasmodic contraction of the muscles
→ Mannerisms: Habitual characteristic way of doing something
(not discussed)
→ Stereotypes: Ritualistic movement in response to a certain
stimulus like body rocking (not discussed)
Speech
• How the patient says it (the physical quality of the speech)
• Fluency: has full command of native language
• Production
→ Hyperproductive: Talkative
→ Lag/Hypoproductive: Responds slowly
→ Normoproductive: normal rate
• Rate: Fast or Slow
 Tone and Volume
 Decrescendo: From loud to soft volume
 Crescendo: From soft to loud volume
 Quantity
 Talkative? With poverty of speech? Mute?
 Quality
 Pressure (rate/speed)? Monotonous (tone)? Loud/Mumbled
(volume)? Comprehensible (fluency)?
 Coherence can be noted here, but it is more appropriate
to observe the thought process
YL6: 02.24 Family and Community Health: Psychiatric Assessment
 Impairments in the speech
 Stuttering
 Spontaneous or not?
Mood & Affect
• How do you feel today?
• Mood: Internal and sustained emotional state
→ How patient describes his state
→ Use patient’s own words
• Affect: External state; Inferred from the patient’s facial expression
→ What the clinician perceives
• Is the patient’s mood inappropriate to her affect?
→ The patient said he feels empty (mood) but he is
inappropriately laughing (affect)
Elements of Affect
NOTE: This part was not discussed by Doc but part of her powerpoint
 Quality: dysphoric, happy, euthymic, irritable, angry, agitated,
tearful, sobbing, flat, labile (seesaw shift of emotions)
 Quantity: measure of intensity (compared to others with same
condition)
 Range: normal, restricted, labile or flat
 Normal range, constricted (parang pinipilit), blunted
(nagpapatawa ka but then ayaw tumawa; example: grimacing
instead of a laugh), or flat (same emotion all throughout)
 Arranged from “highest” to “lowest”
 Flat: monotonous voice, immobile face, no sign of expression
 Appropriateness: Is the affect appropriate with the mood or the
situation?
 Congruence
 Is the affect congruent with the mood?
 If mood is happy, the external expression may be to
smile
 Does it correlate to the setting?
Thought Content
• What thoughts are occurring to the patient
• Questions asked: What is the patient thinking about?
• Inferred by what the patient spontaneously expresses, as well as
responses to specific questions aimed at eliciting particular
pathology
Problems with thought content
• Obsessions: Unwelcome and repetitive thoughts that intrude into
the patient’s consciousness.
• Delusion: Fixed false beliefs that are not shared with other people
→ “Galit siya sa akin” pero wala namang galit sa kanya
• Suicidality and homicidality: Thoughts about suicide, death and
of hurting other people. Don't be afraid to ask because it opens the
door for discussion
→ They realise “may nakakapansin pala” so nagdadalawang isip
sila
 Paranoia
 Can be closely related to delusional material
 Soft paranoia: general suspiciousness
 Severe paranoia: negative effect on day-to-day functioning
 Questions that elicit paranoia include asking about the patient
worrying about cameras, microphones, or the government.
 Preoccupations
 Compulsions
 Repetitive, ritualized behaviors that patients feel compelled to
perform to avoid an increase in anxiety or some dreaded
outcome
 Phobias
 Ideas of reference
 The feeling that a patient has something negative being
remarked about him/her
 “Do you feel that the TV or radio has a special message for
you?”
 Poverty of content
 Reduction in the quantity of thought
Thought Process
• Describes how the patient’s thoughts are formulated, organized,
and expressed
• Normal thought process is described as linear, organized, and
goal-directed
3 of 7
• Ex. When asked “Ano mga ginawa mo para maka-get over sa → Organic brain disorders can present as symptoms of some
kanya?” illnesses such as psychosis, depression, delirium, dementia
→ Linear thought process: answers questions directly
▪ I unfollowed him sa Twitter at Instagram, binenta ko Levels of Alertness
yung bags na bigay nya and I just focused sa studies ko • The skill needed here is observation
→ Problems with thought process 1. Awake
a. Patient is alert
Problems with thought process b. Responds fully and appropriately
• Circumstantial: Answers questions but gives a lot of unnecessary 2. Drowsy/ Lethargic/ Somnolence
information a. Extreme decrease in activity
→ It was hard though. We’ve been together tor 3 weeks, gabi- b. The quality or state of being drowsy; state of obtrusion
gabi kami magka-chat. She even watched me compete sa jiu- 3. Obtunded
jitsu. She has this unique cheer for me so I would know sya 4. Stuporous
a. Arouses from sleep only after painful stimuli
yung sumisigaw. Minsan kita sa mall, she cheers me, papa-
b. Lapses into an unresponsive state when stimuli ceases
cute. But I just have to move-on. Play video games, watch
c. Minimal awareness of environment
movies, among others. 5. Coma
• Clang association: Did not answer the question. Association by → No evident response to inner need or external stimuli
sound (rhyming) of words rather than meaning
→ “Siya si Mr. Bean, manhinhin, walang pinapansin. Hiwalay? Orientation
Eh di waley! Babay!!” • To time
• Flight of ideas: Patient moves rapidly from one thought to another → Ask about time of the day, day of the week, month, season,
at a fast pace. Challenges the listener to keep up with ideas that date and year, duration of hospitalization
are logically connected → Usually the first to be affected in cases of delirium and
→ “Nagpunta sa ano... Sa MOA! Emote emote. Nakakita pa nga dementia
ako ng puting bulaklak, sign yun na kailangan ko mag move- • To place
on. Dati binibigyan nya ako ng bulaklak, violet tulips. For me, → Ask about patient’s residence and names of the hospital, city
tulips are the best flowers. When I was in Seattle sa US, I saw and state the patient is currently in
tulips during spring....” • To person
• Thought blocking: Patient is unable to complete a thought. May → Ask about the patient’s own name and names of relatives and
stop mid-thought or mid-sentence personal personnel
→ Not to be confused with delusion (fixed false belief that is not
→ “I called up my parents, tapos sabi nila sa akin that I should...”
culture-bound)
• Neologism: Answers questions using words that are made-up, not
understandable, or undefined in the dictionary Concentration and Attention
→ Neo = New (words) • Test through serial subtraction by 7’s from 100s
→ “Hagardo Versoza lang. I accept that we are like waterola. → Give the patient the instruction to test their concentration if
You know like water and minola. We just don’t mix. Iniisip ko they follow well enough.
lang, na-Duterte ako.” ▪ “Mula 100, magbabawas po tayo ng 7. Yung sagot po
• Perseveration: Patient will go back to the topic despite examiner’s doon, babawasan niyo uli ng 7. Yung sagot po uli doon,
attempts to change the subject. Focuses on a specific idea or babawas uli tayo ng 7. Bawas lang nang bawas ng 7
content hanggang sabihin kong tama na.”
→ “ I just sleep it off when I’m sad” “Some may say I am just → Also, if the patient is having a difficult time (or is illiterate), they
escaping but, I just feel better when I get to sleep” may subtract in 3s or use 20 as a starting number.
• Tangentiality: Reply is appropriate but did not directly answer • Patient can also be asked to spell “world” or “karne” normal or
backward/reverse.
questions
• Patient can also be asked to name 5 things starting with a certain
→ “Ang hirap, but I know God will not forsake me.”
letter
• Loosening of association: No logical flow of thinking. Do not • Usually used to test patients suspected of having delirium
answer the question and makes no sense • Can also be important for patients suspected of depression,
→ Unlike word salad, loosening of association still has subject bipolarity, or ADHD
and predicate but together, makes no sense → Patients with these conditions may have impaired attention
→ “I wanted to go away. Far way, near the seashore. Where fire span
and water and the bed with all its wonders. Sometimes you
win, but you better watch out. The rabbits will eat you alive.” Calculation
• Word salad: Just tossing words out without making any sense, • For common Filipino people, ask in the context of a day to day
babbling interaction:
→ “Step cellphone in the hair. The cellphone! Rainbows and → “Binigyan ka ng 10 biscuits, kumuha ako ng 5 sa iyo. Ilan na
curtains, smell baby cellphone rocking!” ang natira sa iyo?”
→ “Sa palengke, pinabili kayo ng bigas; isang kilo, 45 pesos.
Perceptual Disturbances Magkano ang 3 kilo ng bigas?”
• Perception of the 5 basic senses
Memory
• Hallucinations: False sensory perceptions in the absence of a
• Immediate memory: few seconds to minutes
stimuli
→ Repeats 3 words after 3-5 minutes (ex. bola, mangga, puno)
→ Wala namang bumubulong pero sinasabi niyang meron
→ Repeats 5 figures after examiner dictates them, forward and
→ Wala namang lason pero nalalasahan niyang may lason backward
• Illusions: there is a perception but you misperceive a real external • Recent memory: few hours to few days
sensory stimulus → e.g. “What did you eat for breakfast?”
→ Mukhang palaka pero tao pala • Recent past: the past few months
• Depersonalization: The feeling that the person is unreal, strange, • Remote: years
unfamiliar → Childhood data, important events, personal matters
→ “Am I real? Am I really here?”
• Derealization: The feeling that the environment is unreal, feeling Reading and Writing
like one is in a dream • Ask the patient to read a task and ask him to do what they just read
→ (e.g. “Close your eyes”)
Cognition • Ask the patient to write a simple but complete sentence with
• Seeks to assess organic brain function coherent thought

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 Fund of knowledge and intelligence Treatment Planning
• Patient can be asked to enumerate the last 5 presidents of the • Discussed with the patient or family or companion
Philippines
• Ask for a list of presidents, cities in Metro Manila, national Closing the Interview
heroes, etc. • The last 5-10 minutes is very important
• Remember to tailor your test based on your patient’s educational • What happens:
level and socioeconomic background → Patient brings up something important
→ Issues that the patient wants to share
Abstract thinking/reasoning ▪ Acknowledge the importance of the issue, but educate
• Ability to reason and to shift back and forth between general the patient by telling them that the issue may be
concepts and specific examples discussed in the next session because the current
• Tests understanding of concepts session is about to end.
• Can be examined by asking for similarities and differences → Give patient opportunity to ask questions
between two things
→ E.g. Apples vs. oranges QUICK REVIEW
• Patient can also be asked to interpret a proverb Psychiatric Interview
→ Sometimes better because it also tests morality • Most Important element in the evaluation of mental illness
→ Patients with psychiatric problems are often unable to • Medical history – subjective findings can be observed
interpret • Psychiatric history – subjectively revealed but can not be directly
→ Example given in class: “Better a diamond with a flaw than observed
a pebble without one. -Chinese Proverb”
• Assessment: How to Make patient comfortable
→ There is no right or wrong answer; it only assesses if the • Privacy and confidentiality
thinking is abstract or not • Agree to the process
→ If explanation is too concrete or literal, there is poor abstract • Establish rapport and empathy
thinking • Safety and comfort
▪ “Okay lang maging dyamanteng may gasgas kaysa sa
makinis na bato, wala namang value” Interview Techniques
→ If explanation is on the level of concept, good abstract thinking • Facilitating interventions
▪ Ex. Concept applied to yourself – Career, education, etc. → Reinforcement
• Cultural and educational factors and limitations must be kept in → Reflection
mind → Summarizing
→ Reassurance
Judgement → Encouragement
• Refers to the person’s capacity to make good decisions and act → Acknowledgement of emotion
on them → Humor
• 2 types: → Silence
→ Test judgement: uses traditional hypothetical examples • Non-verbal communication
▪ “Kapag nakaamoy ka ng usok sa sinehan, anong → Nodding of head
gagawin mo?” → Body positioning
o Good judgment: Look where the smoke is coming → Moving chair closer
from. → Putting down pen and folder
o Bad judgment: Run immediately. (No inspection → Facial expressions
done) • Expanding interventions
→ Social judgement: uses real situations from patient’s own → Clarifying
experience
→ Associations
→ Leading
Insight
→ Probing
• Degree of personal awareness and understanding of the disease
 Patient may NOT have good insight but has good judgment → Transitions
• Levels: → Redirecting
→ 1 – Complete denial • Obstructive interventions
 Patient refuses to acknowledge the situation or → Close-ended questions
circumstance he/she is in → Compound questions
→ 2 – Slight awareness but still denying → “Why” questions
 Patient partly acknowledges circumstances but insists → Judgmental questions or statements
that his/her condition will improve soon → Minimizing patient’s concerns
→ 3 – Blames others → Premature advice
 Patient refuses to acknowledge own mistake; blames → Premature interpretation
other people for current condition → Transitions
→ 4 – Intellectual insight → Non-verbal communication
 Patient acknowledges and accepts his condition but
refuses to do anything about it Elements of the Initial Psychiatric Interview
→ 5 – True emotional insight • Identifying data
 Patient acknowledges and accepts his condition and • Source and reliability
tries to do something about it • Chief complaint
 Highest level of emotional awareness that initiates → Use the patient’s own words
change in behavior • Present illness
→ Chronological description of the evolution of symptoms of the
VII. TOWARDS END OF THE PSYCHIATRIC INTERVIEW current episode
Physical Exam → Why seek help now?
• In the OPD setting – little or no PE done • Past psychiatric history
→ Usually get vital signs → Past symptoms/episodes
→ If the patient presents difficulty in breathing, then we are → Past treatments
expected to attend to them → Past diagnosis
▪ e.g. Auscultation and other procedures necessary for the
situation.
• Focused neurological evaluation is an important part

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• Substance use/abuse SUMMARY OF TERMS
→ CAGE questionnaire • Anamnesis: complete history from conception, pre-natal care until
▪ Have you ever felt the need to CUT down your drinking? present time
▪ Has anybody been ANNOYED because of your
drinking? MNEMONICS
▪ Have you ever felt GUILTY about your drinking? • I See Cool People Portray Some Pretty Faces During Reality
▪ Have you ever felt you need to drink this in the morning Movies. Please Free Download the Torrent.
as an EYE-OPENER? → Identifying data
• Past medical history → Source and reliability
→ Medical illness can → Chief complaint
▪ Precipitate a psychiatric disorder (e.g. low sodium levels) → Present illness
▪ Mimic a psychiatric disorder (e.g. hyperthyroidism) → Past psychiatric history
▪ Be precipitated by a psychiatric disorder or its treatment
→ Substance use/abuse
▪ Influence the choice of treatment for a psychiatric
→ Past medical history
disorder
→ Family history
• Family history
→ Developmental and social history
→ familial response to medications
→ Review of systems
• Developmental and social history
→ Mental status examination
→ Anamnesis
→ Physical examination
→ Early childhood
▪ Pre-natal → Formulation
▪ Discipline → DSM-5 diagnoses
→ Late childhood → Treatment plan
▪ School-related concerns • CAGE
→ Later childhood → Cutoff
▪ Peer relationships → Annoyed
▪ Depression → Guilty
→ Adulthood → Eye-opener
• Review of systems
REVIEW QUESTIONS
Mental Status Examination 1. During the initial psychiatric review, the following must be done
• Appearance & Behavior: features, appropriateness and hygiene EXCEPT
• Motor Activity: normal, slowed, agitated a) Clarify where the information came from
• Speech: fluency, production, rate b) Write the chief complaint in the patient’s own words
• Mood & Affect: emotions feeling inside and showing outside c) Enumerate the evolution of symptoms of the current condition
• Thought Content depending on magnitude
d) Look at relationships of family members
→ Obsessions: unwelcome and repetitive thoughts
2. Which of the following is asked in the CAGE questionnaire?
→ Delusion: fixed false beliefs
a) Have you ever felt guilty about your drinking?
→ Homicidality: thoughts on hurting other people b) Have you ever felt the need to drink in the morning as an ear-
→ Suicidality: thoughts on hurting yourself opener?
• Thought Process c) Have you ever felt the need to cool your drink?
→ Circumstantial: answered but too much info 3. All of the statements are obstructive interventions in interviewing,
→ Clang association: rhyming EXCEPT:
→ Flight of ideas: one topic to another a) Bakit ka galit?
→ Thought blocking: sudden end b) Saan ka pumunta kagabi? Sinong kasama mo? Paano ka
→ Neologism: made-up words pumunta doon?
→ Perseveration: keeps going to the same topic c) Ahh, ganoon po ba. Ano pa pong nangyari?
→ Tangentiality: not directly answered but appropriate d) *silence for 5 seconds*
→ Loosening of association: no sense 4. True or False. Psychiatrists give advice. They tell the patients what
→ Word salad: babbling they’re supposed to do.
• Perceptual Disturbances 5. What is the most important element in evaluating a person’s mental
→ Hallucinations: absence of stimuli illness?
→ Illusions: perception is misperceived a) Psychiatric interview
→ Depersonalization: feeling that a person is unreal b) Family map
→ Derealization: feeling that the environment is unreal c) Diet
• Cognition d) Family lifeline
→ Alertness: awake, drowsy/lethargic, obtunded, stuporous, 6. Which one is not a way to make the patient comfortable?
coma a) Privacy and confidentiality
→ Orientation: time, place, person b) Agree to process
→ Concentration and attention: serial 7 c) Safety and comfort
→ Calculation d) Offering gifts
→ Fund of knowledge and intelligence: enumerate 5 names of 7. These are all kinds of perceptual disturbances, except
PH presidents or 5 cities in Metro Manila a) Hallucinations
→ Abstract thinking/ reasoning: concrete thinking vs abstract b) Delusion
thinking; general concepts and specific examples c) Illusions
• Judgment d) Depersonalization
→ Test judgment: traditional hypothetical examples 8. What is a kind of thought process that uses rhyming words in a
→ Social judgment: real life situation from patient’s experience sentence?
• Insight a) Neologism
→ Deepest level of personal awareness and understanding of b) Perseveration
disease c) Clang association
→ 5 levels: complete denial, slight awareness but still denying, d) Tangentiality
blame others, intellectual insight, true emotional insight

Terminating the Interview

• Physical exam
• Treatment and planning
• Closing the interview

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9. Which response shows good judgment on what to do when there
is sound of gunshot nearby?
a) Cover your ear and hope that the sound would go away.
b) Immediately dash towards the source of the sound to confirm
if it’s gun which shot it.
c) Drop down the floor to avoid the bullet.
d) Staying vigilant of the surrounding while mobilizing to a safe
place.
10. True or false. In doing serial 7 during OSCE, you have to give the
full instruction to the patient on how to do it.

Answers
1. C. History of present illness must be written in chronological order not
depending on the magnitude.
2. B
3. C and D. Both are examples of facilitating interventions. C –
reinforcement, D – silence
4. False. Psychiatrists make patients realize what they’re supposed to
do, NOT tell them what to do. Counselors tell patients what to do
5. A
6. D
7. B
8. C
9. D. Because the person is heading to a safe place while staying low in
case that the sound was really from a gun.
10. True. Because you are already testing for the concentration in giving
the instructions.

REFERENCES
REQUIRED
(1) ASMPH Batch 2022. 2017. Trans Format.
(2) Maddatu-Pajarillo, H. 2019. Psychiatric Assessment [Lecture
slides].
(3) Sadock, Benjamin, and Pedro Ruiz. Kaplan & Sadock's synopsis
of psychiatry: behavioral sciences. Walters Kluwer, 2015.

IMPORTANT LINKS

Trans evaluation link: https://tinyurl.com/AcadsTransFeedback

Link to Word document: https://tinyurl.com/23YL6FCH[Lecture#]

APPENDIX
Appendix A. Developmental and Social History

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