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In this essay we will discuss about: 1. Meaning of Psychiatric Interview 2. Goals of Psychiatric Interview 3. Factors.
Essay # 1. Meaning of Psychiatric Interview:
The Psychiatric interview is the central vehicle for assessment of the psychiatric patient. Reaching a diagnosis in a psychiatric patient relies on an accurate case history and mental-state examination. Laboratory investigations are helpful in a minority of cases only.
The Psychiatric evaluation differs from a routine medical examination in that it is mainly a mental status examination rather than a mere physical examination. The examiner inquires about the patients feelings, behaviour and relationships, not just historical facts.
Essay # 2. Goals of Psychiatric Interview:
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The goals of psychiatric interview are:
1. To build relationship of trust and openness.
2. To collect historical information in details relevant to the presenting problems.
3. To assess personality of the patient.
4. To conduct a mental status examination and assess psychopathology.
5. To write a diagnostic formulation and list the differential diagnoses.
6. To explain to the patient what the clinician thinks is wrong with him and discuss the action he intends to take.
The psychiatric interview consists of:
a) Gathering information from a careful detailed history of the patient’s problems from multiple sources (not only from patient but also from close relatives, friends, previous records etc.).
b) Conduction of a mental status (and physical) examination of the patient.
c) Developing a differential diagnosis for further management.
d) Constructing a treatment plan.
The types of questions used in Psychiatric Interview are given in Table 4.1:
Special skill is needed in taking a psychiatric history because:
a) Confidentiality is important especially when psychiatric issues are discussed (Clinicians should not discuss their problems in front of others)
b) Exceptions to the rule of Confidentiality are made when there is need for safety such as in cases of suicidal or homicidal ideation, in cases of child abuse.
c) Not only patients, the reliable informants are also to be interviewed.
d) Specific interview situations may arise when the patient is:
(i) Excited:
(ii) Delusional:
Delusional i.e., Patient’s beliefs cannot be challenged.
(iii) Stupor:
Stupor Detailed mental status examination cannot be done.
(iv) Psychotic:
Psychotic i.e., patient is not aware about his illness and thus unwilling to accept his symptoms and the treatment prescribed.
(v) Suicidal:
Suicidal Skill is needed to explore and assess the risk of suicide.
(vi) Hysterical and Psychosomatic Patient:
Hysterical and Psychosomatic Patient it requires to know how to explain to the relatives and the patient psychological basis of their physical problems.
(vii) Adjustment disorders:
Adjustment disorders especially when there is risk of legal consequences e.g., in a newly married couple.
(viii) A child or Adolescent:
A child or Adolescent it is difficult to convince the parents or caretakers that they are contributing to the onset or precipitation or exacerbation of a psychiatric disorder.
(ix) Improving:
Improving and he wants to know-about the course of the illness, and its effect on this socio occupational functioning e.g., What kind of job he should do, whether he should get married or not etc.
Essay # 3. Factors affecting Psychiatric Interview:
A psychiatric interview is a purposeful interaction between physician and patient. It depends on many factors. (See Table 4.4).
A. Physician-Patient Relationship:
One should approach each patient with an understanding of the complexities of the human experience and how it contributes to doctor-patient interaction.
It depends on the following factors:
B. Interview Techniques:
(a) The interviewer must lead the interview, using both open-minded and specific questions.
i. Open-ended questions:
Open-ended questions allow the patients to use their own language e.g., “Tell me about your marital life.”
ii. Direct specific questions:
Direct specific questions they are also important e.g., “Do you have ideas about killing yourself?”
(b) How to communicate by listening to the patient?
The facilitative and obstructive factors are shown in Table 4.5 and 4.6 respectively.
C. Specific Interviewing Situations:
The therapist learns to adapt his interviewing techniques on the basis of multiple presentations with which any patient may present.
Some specific situations are:
(a) Interviewing the deluded patient:
i. A deluded patient is most often brought to treatment by a third patient against his will.
ii. Therapist should emphatically acknowledge the patient’s wishes not to be a patient but point out how he may be helpful to a patient and encourage him to communicate.
iii. Never try to convince the deluded patient that his false beliefs make no logical sense but rather take a neutral stand with the patient and neither agree with a delusional belief nor openly challenge its variety.
iv. Focus on other signs and symptoms on which the patient may want help.
v. With patients overall improvement, he stops talking about delusions and it is not necessary to repeatedly explore them.
vi. Before talking to relatives take patient’s consent.
(b) Interviewing the depressed and potentially suicidal patient:
i. Depression can be a primary psychiatric disorder or it can be secondary to medical disorders.
ii. Encourage the patient to verbalize what he is experiencing and avoid prolonged silences.
iii. Enquire about kinds of thoughts the patient has had regarding suicide, whether he has ever acted on these thoughts. What plans he currently has and what has kept him from acting on these, e.g., have things ever gone so bad that you have had thoughts of ending your life.
iv. By pursuing the topic of suicide, eminent danger of suicide can be assessed.
v. Never try to convince the patient at the first instance that his physical symptoms (of depression) have no physiological basis.
(c) Interviewing the violent patient:
i. It is most often seen in hospital emergency room, the police or relatives bring the patient tied up.
ii. Before removing hand cuffs, assess the patient’s ability to verbalise and his reality-testing.
iii. The patient can be put in a quiet room with physical or chemical restraints. When the restraints are removed ask the attendant to stand nearby until the patient is calmer.
iv. Never confront or challenge a violent patient.
v. The key factor in the approach to the violent patient is safety (of the patient, the staff and other patients).
(d) The patient refuses to be seen:
i. Interview the patient in the circumstances the patient would agree to be seen, e.g., with friends or at home.
ii. Consider the risk factors resulting due to possible mental illness.
iii. If patient does not agree, get him admitted (against wish) by taking the relatives into confidence.
(e) The patient is unforthcoming:
i. This may be because of anxiety, depressed mood or persecutory beliefs.
ii. The history from relatives is critically important as will gaining the patient’s trust.
iii. Focus on important areas, needing immediate care,
(f) The patient “takes over” the interview:
i. This is due to over talkativeness as a result of anxiety concerning the interview.
ii. Avoid ‘cutting across the patient but tell him how much time is available, and how it will be used.
iii. Acknowledge the importance of what patient is saying and then remind him of other areas needing exploration.
(g) The over demanding patient:
i. It may be due to disinhibition (alcohol intoxication or mania), anxiety of a worried relative or an immature personality under stress.
ii. It is important not be cold or rejecting in the face of unrealistic demands.
iii. Reassurance, clear information and the setting of firm (and caring) limits.
(h) Tearfulness:
i. Acknowledge the tears and explain that is part of the reason he has come to you.
ii. The trigger setting off tears is an important clue into patient’s problem.
iii. One should never try to ignore/harass a tearful patient.
(i) Hostility or suspiciousness:
This may be due to persecutory delusions or patient’s personality:
i. First build up a relationship with the patient, to gain his trust.
ii. Avoid too many questions initially but concentrate on facilitative comments.
iii. If there is history of violent behaviour, take precautions (never keep throwable items (e.g., paper weights), important documents or yourself along with a violent patient.
(j) Patient is restless, distractible or overactive:
This may be due to mania, hyperkinetic syndrome.
i. Concentrate on important areas.
ii. Arrange brief interviews if appropriate.
(k) When patient and interviewers see the problem differently:
i. Acknowledge the distress of the patient.
ii. Never contradict the patient by saying that all his physical symptoms have no physiological basis. At the same time, treat the underlying cause by telling the patient that the medication is for what he has complained.
(e) If patient refuses help:
i. Check whether the patient understand the nature of the help offered.
ii. Review alternative forms of help.
iii. If patient is unlikely to accept any form of the help, he may be hospitalized.
(m) Diagnosis and management plan remains unclear after assessment:
i. Consider further sources of information.
ii. Do repeated examinations.
(n) Interviewing the psychosomatic patient:
A psychosomatic patient may interpret psychiatrie consultation as a signal that his primary physician has given him up or he is going “crazy”.
i. Review the patient’s medical history, treatment and investigations.
ii. Ask about physical complains as well as any emotional concomitants or psychosocial stresses.
iii. Review the circumstances under which the illness started, infer his level of functioning, and any gains.
iv. Acknowledge the importance of physical complaints Clarify any questions or misunderstandings.