Clinical examination in Psychiatry

Psychiatric interview
• Prepare the setting
– Office setup
– Materials
– Sitting arrangement
– Avoid interruptions
 General principles
• Agreement to the process
– The doctor should introduce himself/herself
– Consent to proceed with the interview
– Amount of time for the interview should be stated
• Privacy and confidentiality
– Confidentiality is an essential component of the patient–doctor
relationship.
– The interviewer should make every attempt to ensure that the
content of the interview cannot be overheard by others
• Time and number of sessions
– an initial interview, 45 to 90 minutes
– For inpatients on a medical unit or at times for patients who are
confused, in considerable distress, or psychotic, the length of time
that can be tolerated in one sitting may be 20 to 30 minutes or less
 The initial interview
• The diagnostic interview is about treatment, not only
diagnosis.
• As you ask questions, you formulate possible diagnoses, and
thinking through diagnoses leads naturally to the process of
negotiating a treatment plan.
 Our task during the initial interview
• Build a therapeutic alliance
• Obtain the psychiatric history
• Interview for diagnosis
• Negotiate a treatment plan with your patient
• To build a therapeutic alliance – the very act of inquiry is an
alliance builder
– Be warm and emotionally sensitive
• Use empathic and sympathetic statements
• Direct feeling questions
• Reflective statements
– Actively defuse the strangeness of the clinical situation
– Gain your patient’s trust by projecting competence
 The three phases of interview
• Opening phase
– 5 to 10 minutes
– you will come up with some initial diagnostic hypotheses
• Body of the interview
– 30 to 40 minutes
• Closing phase
– 5 to 10 minutes
– Discuss your assessment with patient
– an effort to come to a negotiated agreement about treatment or follow-up
plans
 Elements of Psychiatric Interview
I. Identifying Data
I. Name, age, gender
II. Educational status
III. marital status (or significant other relationship)
IV. race or ethnicity, religion
V. occupation
VI. Source of referral, history of previous admission for psychiatric illness
VII. Who they came with
VIII.Source of history and Reliability
II. Chief Complaint- in patient’s own words and attendant’s
reason if necessary
 “ I don’t have any problem, they brought me here”
 “ people are discussing about me”
 “ I have trouble sleeping”
III. History of Present Illness
– a chronological description of the evolution of the symptoms of the
current episode
– duration , intensity, severity, course of the illness
– factors that alleviate or exacerbate symptoms
– precipitating factors
– changes in the patient's interests, interpersonal relationships,
behaviors, personal habits, and physical health
– a psychiatric review of systems
– treatment history including compliance during current presentation
(include traditional or spiritual healing)
– risk assessment (suicidal ideation, homicidal ideation)
V. Past Psychiatric History
– Age of first onset
– number of episodes
– description of episode (symptoms, duration, type of drug, dose, side
effects, hospitalization, compliance to treatment, precipitating
factors).
– the time gap between each episodes
– inter-episode level of functioning
– treatment with ECT
– history of violence, suicidal, non-suicidal self-injurious behavior
including the seriousness of the intent.
– can describe the first, the most severe and last episode if multiple
and similar episodes.
VII. Past Medical History
– major medical illnesses and conditions as well as treatments
– Any past surgeries
– special attention to neurological issues including seizures and head
injury.
– HIV
– allergies, side effects to medications
– medical review of symptoms
– In women, a reproductive and menstrual history , current or future
pregnancy.
VIII. Family History
– Psychiatric diagnoses, medications, hospitalizations, substance use
disorders, and history of suicide.
– potential support as well as stresses
– patient’s relationship with family members
– family members functional state, age
– can use a pedigree
IX. Developmental and Social History(Personal history)
– perinatal history and developmental milestones
– Childhood history (childhood home & social environment, childhood
physical and sexual abuse)
– A detailed school history including behavioral problems at school,
academic performance, peer relationships and extracurricular
activities.
– Work history
– Military history
– Sexual history, intimate relationships and marital history
– Current social support network
– Leisure time activities.
– Substance Use/Abuse and Addictions
– type, route of administration, frequency, amount
– Any periods of sobriety, a history of treatment
 XI. Mental Status Examination
• Data for the MSE are gathered throughout the interview
 Appearance and Behavior
 Clothes
 general description of how the patient looks (hygiene, weight, in respect to their stated
age, any odor)
 eye contact
 behavior during the interview and attitude towards the interviewer
• cooperative, friendly, attentive, interested, perplexed, apathetic, hostile
 mannerisms, tics, gestures,, stereotyped behavior, echopraxia, rigidity,
 Motor Activity
 may be described as normal, slowed (bradykinesia), or agitated (hyperkinesia)
 MSE
 Speech
 fluency, rate, tone, and volume
 latency to response
 talkative, unspontaneous
 rapid or slow, pressured, hesitant, monotonous, loud, whispered, slurred, or mumbled
 stuttering
 Mood
 is defined as the patient's internal and sustained emotional state. Its
experience is subjective, and hence it is best to use the patient's own words.
 Euthymic, depressed, irritable, anxious, angry, euphoric
 MSE
 Affect
 is an objective expression of mood.
 Quality, stability, range, appropriateness.
 Terms used to describe the quality (or tone) of a patient's affect
include dysphoric, happy, euthymic, irritable, angry, agitated, tearful,
sobbing, and flat
 Range of affect can be constricted, normal, blunt or flat.
 MSE
 Thought Content
 is essentially what thoughts are occurring to the patient.
 rumination or preoccupations on specific content or thoughts
 obsessive or compulsive thoughts
 Delusions
 Suicidality and homicidally .
 MSE
 Thought Process
 how the thoughts are formulated, organized, and expressed.
 flight of ideas
 circumstantial
 Tangentiality
 Loose thoughts or associations - it is difficult or impossible to see the
connections between the sequential content
 Perceptual Disturbances/ Perception-
 include hallucinations (auditory, visual, tactile, olfactory, and
gustatory (taste),
 illusions, depersonalization, and derealization.
 Depersonalization is a feeling that one is not oneself or that
something has changed.
 Derealization is a feeling that one's environment has changed in some
strange way that is difficult to describe.
 MSE
 Cognition
 alertness, orientation
 attention and concentration
 Subtracting serial 7s from 100 or 3s
 Counting days of the week or months of the year backwards
 memory
 Recall- ask them to repeat six figures after dictating them first forward, then backward
or ask them to repeat three words immediately and 3 to 5 minutes later
 Recent-The past few days, what the patient did yesterday, the day before ….
 Remote-Childhood data, important events known to have occurred when the patient
was younger.
  calculation
 fund of knowledge
 abstract reasoning ( the ability to shift back and forth between
general concepts and specific examples)
 Ask them to interpret proverbs
 insight ( refers to the patient's understanding of how they are
feeling, presenting, and functioning as well as what the
potential causes of their psychiatric presentation may be)
 Judgment refers to the person's capacity to make good
decisions and act on them.

XII. Physical Examination

XIII. Laboratory tests

XIV. Formulation
XV. DSM-IV-TR Multiaxial Diagnosis
– Using the DSM-IV-TR classification a multiaxial diagnostic assessment
includes:
 Axis I: Major psychiatric diagnoses such as major depression,
schizophrenia, and generalized anxiety disorder
 Axis II: Personality disorders and mental retardation
 Axis III: Medical conditions
DM, CHF, MENINGITIS
 Axis IV: Stressors
ALCOHOL
 XVI. Treatment Planning
• Therapeutic relationship
• Psychosocial interventions
• A thorough discussion of safety planning
• Immediate plan
– Safety
– Psychoeducation
– Investigation
– Acute case management with medication
– Monitor side effects
– Building rapport
• Intermediate plans
– Adjust and maintain medications
– Monitor side effects and appropriate lab investigations
– Continued psychoeducation and appropriate psychotherapy
• Long term plan
– Similar to intermediate plan
– Family therapy
– Rehabilitation