The Psychiatric History & Interview

DR. MELISSA V. MARIANO

Introduction
y The purpose of the interview is to gather information

that will enable the examiner to make a diagnosis, which will then guide treatment. y The process of the interview is wholly guided by the skills and the knowledge of the individual psychiatrist.

Components of the Psychiatric History
y Identification y Chief Complaint y History of Present Illness y Past Psychiatric History y Medical History y Family History y Personal History y Mental Status Examination

Components of the Psychiatric History
y Identification  Establishes the basic demographics of the patient y Chief Complaint  Verbatim recording of the patient¶s reason for seeking evaluation  Usually obtained from two sources: the patient and the informant  Can convey valuable information about the patient¶s capacity for insight and self-observation

Components of the Psychiatric History
y History of the Present Illness  Chronological description of how symptoms in the current episode developed over time  Includes the characteristic nature of the symptoms as well as how they have progressed  Attention should be paid to pertinent negatives as well as pertinent positives  If applicable, should include treatment compliance and substance use

Components of the Psychiatric History
y Past Psychiatric History  Describes all previous episodes and symptoms, whether treated or not  Progresses chronologically from the oldest to the most recent episode  It is important to include all possible information on prior treatments, such as therapeutic benefits and adverse reactions y Medical History  Major illness can be a precipitant of a psychiatric disturbance  Underlying medical conditions may also inform treatment decisions

Components of the Psychiatric History
y Family History 


Determine the presence of other psychiatric illnesses in the family Can show the basic structure of the family, such as who is available for support, as well as who may be exacerbating symptoms Highlights events of major significance in the patient¶s life Major items include early childhood friendships, education, romantic involvements, work history, and leisure activities Also includes the patient¶s developmental history and a description of functional capacity over time Helps identify key events that may have helped precipitate current symptoms over time

y Personal History 
  

The Mental Status Examination
y Analogous to the physical examination in medicine y The systematic observation and recording of

information about a person¶s thinking, emotions, and behavior y It is important to note that historical information is excluded and only those findings present at the time of the interview is noted. y However, much of the MSE is observational and can be made in the course of taking the history.

The Mental Status Examination
y Appearance  Appearance, behavior, and manner of relating to the examiner  Obvious signs of physical illness are also mentioned y Speech  Describes the physical production of speech  Observations are made about volume, rate, spontaneity, and syntax y Emotional Expression  Described in terms of mood and affect  Mood: pervasive emotional state of the person  Affect: more transitory and external manifestation of mood

The Mental Status Examination
y Thought Form  Refers to the way that ideas are linked, not the ideas themselves  Examples include circumstantiality, flight of ideas, and clang association y Thought Content  Refers to the patient¶s ideas  Includes delusions, ideas of reference, preoccupations, and obsessions, as well as an assessment of suicide potential y Perception  Includes hallucinations and illusions, as well as depersonalization and derealization

Formal Thought Disorders
y Circumstantiality 

Overinclusion of trivial or irrelevant details that impede the sense of getting to the point. Thoughts are associated by the sound of words rather than their meaning, through rhyming or assonance. There is a breakdown in both the logical connection between ideas and the overall sense of goal-directedness. A succession of multiple associations so that thought seems to move abruptly from idea to idea, often expressed through rapid, pressured speech.

y Clang association 

y Derailment 

y Flight of ideas 

Formal Thought Disorders
y Neologism  Invention of new words or phrases, or the use of conventional words in idiosyncratic ways y Perseveration  Repetition out of context of words, phrases, or ideas y Tangentiality  In response to a question, the patient gives a reply that is appropriate to the general topic without actually answering the question y Thought blocking  A sudden disruption of thought or break in the flow of ideas

Mental Status Examination
y Alertness  The degree of wakefulness y Orientation  Conventionally described in three spheres  Person, place, and time y Concentration  The ability to sustain attention over time  Formally tested by µserial 7s¶, spelling backwards, or naming the months of the year backwards y Memory  Evaluated across the spectrum of immediate to remote

Mental Status Examination
y Calculations 

Describes the ability to manipulate numbers mentally Must be tailored to the unique circumstances and educational level of the individual Describes the ability to mentally shift back and forth between general concepts and specific examples Describes the patient¶s capacity to recognize and understand their own symptoms and illness Recognition and compliance to prevailing social norms Cooperation with medical evaluation and treatment

y Fund of Knowledge 

y Abstract Reasoning 

y Insight 

y Judgment 


Levels of Insight
y 1. Complete denial of illness y 2. Slight awareness of being sick and needing help but y y y

y

denying it at the same time 3. Awareness of being sick but blaming it on others, on external factors, or on organic factors 4. Awareness that illness is caused by something unknown to the patient 5. Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are caused by the patient¶s own irrational feelings without applying this knowledge to future experiences 6. True emotional insight: emotional awareness of the motives and feelings within the patient, which can lead to basic changes in behavior

Techniques for the Psychiatric Assessment
y Time and Setting  Initial interview usually lasts between 45 to 90 minutes  Should be conducted in a comfortable room with pleasant lighting y Interview  It is best to begin with general, open-ended questions  Allow the patient to talk freely for several minutes before interposing further questions  Keep in mind the categories of information needed to formulate a diagnosis and treatment plan

Techniques for the Psychiatric Assessment
y Open-Ended and Closed-Ended Questions  A good psychiatric interview commonly uses both  However, open-ended questions should be used in the beginning of the interview and closed-ended questions as the interview progresses  Open-ended questions:
Disorders of thought form are more likely to be revealed Ù Emotional responses are more obvious
Ù 

Closed-ended questions:
Used to clarify information and describe the absence of key symptoms Ù Also used to gather factual data efficiently
Ù

Techniques for the Psychiatric Assessment
y Supportive and Obstructive Interventions 


Provide feedback and information Offer reassurances and respond emotionally to what the patient is saying Encouragement Reassurance Acknowledging emotion Compound questions Judgmental questions Nonverbal communication

y Supportive Interventions 
 

y Obstructive Interventions 
 

Recording and Note-taking
y Psychiatrists have a medical and legal obligation to

maintain a written record of every patient encounter. y The record contains the historical and mental status data on which a diagnosis and treatment recommendations are based. y Requests by the patient that notes should not be taken may be explored but should always be respected.

Special Problems in Interviewing