Download Psychiatric Interview Study Guide: CMN 548 Module 1 and more Exams Psychiatry in PDF only on Docsity!
1 / 62
CMN 548 Module 1 study guide
1. GUIDE SADOCK Chapter 7.1 - 7.2, 7.6: Complete the following table which outlines the elements of
the initial psychiatric interview:
2. Identifying data Topic: Name, age, sex, marital status, religion, education, address, phone number,
occupation, source of referral
3. Identifying data Questions: Be direct in obtaining identifying data. Request specific answers.
4. Identifying data Comments and helpful hints: If patient cannot cooperate, get information
from family member or friend; if referred by a physician, obtain medical record.
5. Chief complaint (CC) topic: Brief statement in patient's own words of why patient is in the hospital or is
being seen in consultation
6. Chief complaint (CC) questions: Why are you going to see a psychiatrist? What brought you to
the hospital? What seems to be the problem?
7. Chief complaint (CC) comments and helpful hints: Record answers verbatim; a
bizarré complaint points to psychotic process.
8. History of present illness (HPI):: Development of symptoms from time of onset to present; relation
of life events, conflicts, stressors: drugs; change from previous level of functioning
9. History of present illness (HPI): questions: When did you first notice something happening to
2 / 62 you? Were you upset about anything when symptoms began? Did they begin suddenly or gradually?
10. History of present illness (HPI): comments and helpful hints: Record in
patient's own words as much as possible. Get history of previous hospitalizations and treatment. Sudden onset of symptoms may indicate drug-induced disorder.
11. Previous psychiatric and medical disorders:: Psychiatric disorders; psychosomatic;
medical, neurologic illnesses (e.g., craniocerebral trauma, convulsions).
12. Previous psychiatric and medical disorders: QUESTIONS: Did you ever lose
conscious- ness? Have a seizure?
13. Previous psychiatric and medical disorders: comments and helpful hints:
As- certain extent of illness, treatment, medications, outcomes, hospitals, doctors. Determine whether illness serves some additional purpose (secondary gain).
14. substance use/abuse: Substance use disorders can mimic or induce psychiatric syndromes, elevate
risk of suicide and violence, and have important impact on safe medication prescribing. Various tools can be used to aid in gathering the substance use history. Examples include the commonly used CAGE questionnaire which has been modified to include other drugs (and now called CAGE-AID)
15. Past medical history: The interviewer is interested in obtaining an accounting of major medical
disorders both to develop a complete history and to identify illness that could mimic a psychiatric disorder, contribute to the context of the presentation or factor into treatment planning.
4 / 62 current physical signs and symptoms not already identified in the HPI or past medical history (including Table 7.1- and is organized by asking sentinel questions about the major systems of the body).
21. review of systems: sleep: Sleep phase problems (initial, middle, terminal insomnia), total sleep
time, abnormal sleep events
22. review of systems: mood depression: Depression: persistent sadness, reduced
interest or pleasure in usual activities, tearfulness, reduced or excessive sleep, reduced or increased appetite, weight loss or gain, low energy, reduced concentration, low libido, excessive or inappropriate guilt, psychomotor change (slowing or agitation), negative self-appraisal, helpless and hopeless thinking thoughts of death or suicide. A common mnemonic used to remember the symptoms of major depression is SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor agitation or slowing, Suicidality).
5 / 62
23. review of systems: mood Hypomania/mania: Hypomania/Mania: elevated,
expansive or irritable mood, decreased need for or inability to sleep, excessive energy, marked increase in goal and pleasure directed activity, increase amount and pace of speech and thought, grandiosity, heightened libido, impulsivity and/or recklessness in behaviors such as spending and sex
24. review of systems: anxiety: Anxiety
Experience of panic attacks, somatic symptoms of anxiety, phobic, or social avoidance
25. review of systems: psychosis: Experience of hallucinations, delusions, disorganized behavior,
speech or thought, negative symptoms
26. review of systems: obsessive-compulsive: Repetitive intrusive and unwanted thoughts,
com- pulsive behaviors to neutralize anxiety, hoarding behaviors
27. review of systems: trauma: Traumatic exposure; intrusive and avoidance symptoms, negative
alter- ations in cognitions and mood, excessive arousal and reactivity
28. review of systems: behavior: Substance use, gambling, impulse control problems, disordered
eating, repetitive self-harm
29. mental status exam: The MSE is the functional equivalent of the physical examination in other
areas of medicine. It is a systematic collection of the observations (e.g., signs such as blunt attect or rapid speech) and reported mental experiences (e.g., symptoms such as depressed mood or hallucinations) that produce a picture of the patient's current
7 / 62 recommended treatments and information that addresses stigma and adherence. It is wise to involve significant others in these conversations especially if there are concerns that the patient may need assistance in processing information and making decisions to ensure that decisions are consistent with the patient's best interest. Recommendations may include referral to other professionals or peer supports such as the National Alliance for Mental Illness (NAMI), the Mental Health Association (MHA), or Alcoholics Anonymous (AA). Plans for crisis contacts and supports are typically addressed. All of these counseling and coordination of care ettorts should be documented in the medical record.
33. Carlat, Chapter 14: ch 14
34. 1. How is the history of present illness different from the past
psychiatric history?:
35. Why is it important to have an understanding of the history of present
illness if I'm going to obtain the psychiatric history anyway?:
36. What time period should be covered in the history of present illness?:
Often, psychiatric crises occur over a 1- to 4-week period.
37. What are some common mistakes made by beginners in obtaining the
history of present illness?: The most common pitfall for beginners is spending too much time on the HPI
38. What are some examples of questions that can be asked to obtain a
history of present illness when the patient is in a crisis?: What has been happening over the
8 / 62 past week or two that has brought you into the clinic? Have there been any events that you think have caused your problem or made it worse? Have you sought any treatment for this problem?
39. How would you approach a patient when obtaining a history of present
illness when you're simply trying to explore symptoms?: Many patients automatically jump into a chronologic narrative of their problems when prompted by one of the preceding questions. If this happens, it is a time to fall silent for a while and listen. Remember, this is your "scouting period" (see Chapter 3), during which you are observing, listening, and hypothesizing. However, if your patient begins to jump around into other issues or time frames, you may want to refocus him.
40. What are some key points to remember in conducting a well executed
interview?: At its best, a well-conducted interview resembles a dance in which the give and take between clinician and patient flow ettortlessly throughout the hour, giving the patient the sense that he just participated in a fascinating conversation about his life rather than a "psychiatric" interview. One way to set the stage for this type of experience is to begin the interview by showing genuine interest and curiosity about the patient's job, hobbies, or life situation and to allow the patient to steer the discussion toward clinical topics.
41. Why is it important to obtain the history of present illness in a
chronological fashion?: Ensuing questions track the course of the illness through months or years, arriving eventually at the present.
42. What are some examples of ways to keep patients on track when
10 / 62
44. Why is it important to have an understanding of how the patient was
func- tioning prior to this exacerbation of their mental illness?: Asking about current versus baseline functioning is important diagnostically. The classic example is the ditterence between schizophrenia and bipolar disorder. In schizophrenia, the patient's level of functioning gradually decreases over months or years, whereas in bipolar disorder, the patient may have been functioning dramatically better within the past few weeks. Determining baseline functioning is also important in setting treatment goals. You might aim to help the patient achieve his best level of functioning over the past year.
45. Carlat Chapter 15: Chapter 15
46. What is the purpose of obtaining the past psychiatric history?: goals of
establishing a diagnosis and formulating a treatment plan.
47. Why is it important to obtain a chronological view of the patient's
past psychiatric history?: Specific psychiatric disorders have specific natural histories, with characteristic risk factors, prodromal signs, ages at onset, and prognoses. Obtaining a detailed PPH for a particular patient allows you to compare the course of her illness with the textbook's version of the course of illness, increasing the likelihood that you will make a correct diagnosis.
11 / 62
48. What are some important points to cover in the past psychiatric history?:
Include questions about the severity of episodes and exacerbations, as well as the duration of episodes. Often, this information comes out when you are obtaining the treatment history. For example, episodes of mania or exacerbation of schizophrenia often correspond with hospitalizations. As with hospitalizations, a time-eflcient method of asking about episodes is to ask about the first one, the latest one, and the total number of episodes.
49. About how long should the psychiatric history take to complete?: one or
two 50-minute sessions for PPH. HPI between 5-10 minutes
50. Complete the following table which summarizes the components of
the psychiatric history:
51. Age of onset of symptoms: Knowing the age at onset may help you to decide between
potential diagnoses, with anxiety disorders having a much earlier onset than either mood disorders or schizophrenia
52. Premorbid functioning: p. 94, 90- 91
To assess overall functioning, ask about the three basic aspects of life: love, work, and fun. Love includes all-important relationships: family, spouse, and close friends.
13 / 62
55. Treatment History 2: I suggest the following format for obtaining the treatment history:
General questions
14 / 62 Current caregivers Hospitalization history Medication history Psychotherapy history Use the mnemonic Go CHaMP so that you don't miss any category. You won't necessarily ask your questions in the above order—in fact, you will obtain much of this information during the HPI—but it's helpful to think about these five aspects of the treatment history to make sure that you haven't neglected to ask important questions. At some point during the interview, mentally review whether you have obtained enough information about each of these categories.
56. Current caregivers: 96
You will need to know who your patient is seeing currently. If he is a new patient, you may be the only caregiver. If you are interviewing a patient with a chronic mental illness, he will likely have both a therapist and a psychopharmacologist, and he may also have a case worker (usually a social worker), a group therapist, and a primary care doctor (a family practitioner or an internist) and may be involved in day treatment or residential treatment
57. Hospitalization history: 96- 97
For patients who have had multiple hospitalizations, do not spend your time ascertaining the names of the hospitals and dates of each admission; this could take the entire 50 minutes. Instead, find out when they were first and last hospitalized and
16 / 62
59. Medication history: 97- 98
The most important limit on the bio-availability of medication has nothing to do with pharmacodynamics or pharma- cokinetics; rather, it is patient noncompliance. Have you been on medications for your depression? For how many weeks did you take your medications?
60. Medication History: To the extent possible, document all the medications the patient has tried.
Many patients will not remember generic names or may only remember what the pill looked like or the side ettect it caused. Obviously, the more you know about alternative names, shapes, and side ettects of medication, the more eflciently you will be able to obtain this history. I find smartphone apps such as Epocrates to be helpful, because they have photographs of medications, which help patients identify them. For psychologists and social workers, a number of books have been published that teach the basics of psychopharma- cology to non-MDs, and I recommend that you become familiar with this information. Many psychiatric medications take several weeks to have a therapeutic ettect. Antidepressants take 4 to 6 weeks. Antipsychotics may take 1 to 2 weeks or longer, depending on the clinical situation. Thus, merely documenting that a
17 / 62 patient has tried a particular medication does not mean that he's had an adequate trial. At this point, a normalizing question may be helpful: Often, people do not necessarily take their medications every day but will take them every so often, depending on how they feel. Was that true for you? HOW ACCURATE ARE PATIENTS WHEN RECALLING PRIOR TREATMENTS? A fascinating study examined this clinically relevant but underexplored question (Posternak and Zimmerman 2003). An independent evaluator interviewed 73 patients who had been treated in an academic psychiatric clinic for an average of 3.5 years. After the interview, researchers reviewed clinic charts to determine how accurately the patients recalled their antidepressant trials. The results? They did pretty well, overall, recalling 80% of the monotherapy (single medication) trials over the prior 5 years. However, they only remembered 26% of augmentation trials (i.e., when a second medication is added to the first to boost the response). And augmentation trials that were over 2 years old were not remembered by anybody. The bottom line is that your patient will accurately recall medications tried if the regimen has always been simple, but those who have taken combinations of medications will be much less reliable. CLINICAL VIGNETTE A resident was doing a psychopharmacologic evaluation of a 46-year-old married Latino woman with a several-year history of depression and anxiety. During the treatment history, the patient stated that she had taken a number of ditterent antidepressants from ditterent classes with only minimal ettectiveness. The resident asked a normalizing question about whether the patient had taken her medications
19 / 62 Did your therapist focus on "automatic thoughts" that make you more anxious or depressed? Did she give you homework assignments between sessions? Did she have you practice doing things that caused you anxiety? (For cognitive-behavioral therapy.) Did your therapist focus on your childhood experiences and how those affect your current life? (For psychodynamic therapy.) You can also ask a more open-ended question: Without going into too much detail, what sorts of things did you focus on in therapy? Was your therapist a psychologist, a psychiatrist, or a social worker?
62. psychotherapy history: Knowing this may or may not be useful. For example, a patient may say
she had a therapist, when in fact she was seen by a psychiatrist once a month for brief visits. This was more likely psychopharmacologic management than psychotherapy. How did you like working with your therapist? Was the therapy helpful? In what ways was it helpful? This information will be particularly valuable in assessing the patient's suitability for further therapy.
20 / 62 How did you leave treatment? The way a patient ended treatment may tell you much about how he viewed treatment and may help you plan how to proceed with your own treatment of the patient. Some patients, for instance, have a history of ending therapy by simply not showing up for the next session. Others may have had a stormy termination. Others may have terminated "by the book" but continue to feel unexpressed sad or angry feelings toward the therapist.
63. Why is it important to screen for general medical conditions when
conduct- ing a psychiatric interview: Medical conditions can attect psych conditions p ascertain the patient's inherited risk of developing a psychiatric or medical disorder
64. screen for general medical conditions: medication: Obtain a list of all
medications, including those for general medical conditions. Ascertain whether the patient has been taking them as prescribed.
65. screen for general medical conditions: History of medical illness: You can
begin with a screening question such as Do you have any medical problems? Have you ever had a medical illness? However, a common problem with this approach occurs when the patient says "no" without thinking carefully, as the following vignette illustrates.
66. screen for general medical conditions: primary care provider: In the
preceding
