The Psychiatric Interview - Carlat (notes) Questions with Answers 2024, Exams of Psychology

Download The Psychiatric Interview - Carlat (notes) Questions with Answers 2024 and more Exams Psychology in PDF only on Docsity! The Psychiatric Interview - Carlat (notes) Questions with Answers 2024 what are the 4 tasks of the interview? ✔ build an alliance obtain the Psychiatric database (hx relevant to their presentation today, PHx, Fhx, PMHx etc) interview for dx negotiate a tx plan what is our intitaly first job? how do we do this? ✔ to ease their suffering, this is before making a dx. all our pts are suffering, you have to address this first. how: depression is different for everybody and may present with different sxs. For a 24 y/o college graduate who has been floundering around, may just need help clarifying her goals. this is what we can help them do in their first visit. spend most of this first visit thinking about their lives and not their dx. this alone is an alliance booster, just be sure to ask about their life and that starts it all. what is the overall goal of the interview? ✔ to figure out treatment not to figure out a dx. what percentage drop out of tx brute they're 4th visit? ✔ 50% what is the most important part of the interview? ✔ negotiating a tx plan. if they don't feel comfortable with it then the interview might as well not have been done. length of time for the 3 phases of the interview ✔ opening: 5-10 min body: 30-40 min closing: 5-10 min explain what the 3 phases of the interview ✔ intro: - learn about their life - give a few minutes to tell why they came body: - est. interviewing priorities - HPI - Hx of depression, SI, substance abuse - FHx - determine whether they meet criteria - if have time: social/developmental Hx, PMHx, psych ROS closing: - discuss assessment (w/ pt education) - negotiated tx plan what to put in your office ✔ make it homie: photos of family, plants, decorations on wall arrange seating: put clock easy for you to see ( just behind pt) guidelines for patient contact ✔ - never give home or cell phone number - if giving a contract number specify times they may call you - instruct what to do in emergency when you can't be contacted - leave a voicemail system for them to call and let them know if it's emergent you'll call back within 24 hrs - sign pts out to another clinician when you're on vacation and inform him of more severe pts or chronically suicidal pts. change voicemail to have instruction to contact this clinician. - use email but this too needs ground rules (limit to scheduling needs and refills, anything more has to be added to their EMR). - for HIPPA add note saying: "please be aware that email communication can be intercepted in transmission or misdirected. your use of email to communicate protected health information to us indicate that you acknowledge and accept the possible risks associated with such communication. please consider communicating any sensitive information by telephone, fax, or mail. if you do not wish to have your information sent by email, please contact the street immediately." - get pts number and email. ask if it's okay to identify yourself when you call because some people don't want family or employers knowing they're in tx. hey contact info for energy contact people, need consent before doing this. rapport building techniques ✔ - empathic or sympathetic statements: "you must have felt Truckee when she left you". communicate your average and understanding of painful emotions. but don't over use them. - direct feeling questions: "how did you feel when she left you?" - reflective statements: "you sound dad when you talk about her". don't overuse because it sounds like you're stating the obvious. - if you notice countertransference happening, see them as psychopathology and develop compassion for them on that basis first techniques to make the patient comfortable Referred transition: refer to something the pt said earlier in the interview to move to a new topic. - "My doctor tried me on some medication for a while but it didn't do much good." respond with "Earlier, you mentioned that you didn't know how much more of this you could take. Have you had the thought that you'd be better off dead?" Introduced transition: introduce the next topic or series of topics before actually going into it. - "now I'd like to switch gears and ask about different psychological symptoms people sometimes have. Many of these may not apply to you at all, and that's a useful thing to know in itself" Techniques for the reluctant pt vs talkative pt ✔ reluctant: - use open ended Qs - use continuation techniques: "go on", "uh huh", "continue with what you were saying about...", "really?", "wow." these are combined with positive body language showing active listening - neutral ground: some pts get turned off when the questions become more "psychiatric", when this happens change topics to non - psychiatric (normal talk about your pts life) and once pt is involved again return to psychiatric Qs - second interview: if all else fails cut the interview short and try again next time saying "Why don't we stop for now and meet again next week. That will give you a chance to think more about the sorts of things that are bothering you, and we can take it from there." Just make sure they are not in imminent risk of suicide or unsafe behaviors. Talkative: key is to have a highly controlling style - close ended or multiple choice Qs (limit choices even more than close ended, try not to bias the answers in how you ask the Q though) Note: don't only use these or you will alienate the pt and they will just become reluctant to share important info, have to sprinkle them in - redirecting questions to another topic: this is the art of gentle interruption (often pts appreciate this because they get anxious and angry with their train of though if left loose to speak for too long) -- empathic interruption: add empathic statement to soften blow. Like "I can tell that this situation's been really hard for you to deal with. Have you been drinking lately, to cope with it?" -- delaying interruption: you assure the pt their topic is important and you'd like to come back to it "I can see you feel strongly about your daughter's school troubles, that something we can talk about later, but right now I need to ask you about some of those signs of depression you were experiencing. Was your appetit clues it's a malingering (lying for personal gain) pt ✔ Tale is too perfect: sxs in near perfect dsm 5 order - avoid this by keeping questions open ended. then ask something unexpected like "did you parents have this?" and follow up with "that's odd, in my experience that's very uncommon for parents to also have it, are you sure?" watch for a change in response. Tale is too vague: some don't give detail so they don't slip up - avoid this by using very close end questions. "in my experience, pts with panic get tingling lips do you?" if now become very specific they may be lying. sxs are unrealistic: voices should be almost always outside their head, almost never vague, usually intermittent not constant, not common to have command hallucinations and those who do almost never obey them, if questioning they almost always chastise not info seek. Ask specific questions to investigate. nothing works: pts may just want to keep disability payments coming. they need 4-6 wks of compliant meds or 8 therapy sessions. then offer aggressive txs, if they decline for vague reasons is a tip off. state you can't keep filling out disability form if they keep rejecting tx options, they usually stop coming after that. "I heard about a thing called Klonopin from a friend who has what I have": red flag if they ask for controlled meds really in interview, insist early all non addictive txs don't work for them, they report they tried their friends meds, has Hx of abuse. - say "are you aware that is very dangerous and addictive?" seekers will be dramatic and say "really?" or be super calm and say "I know people say that but I've never had a problem". then ask to speak with prior prescribers, if hesitant then you know. how to initiate a family interview with c&a pts? ✔ go out to greet the pt and say: "why don't we all go in for the first part of the hour, then maybe I can have some time to chat with ___ afterward." how do you address a family interview when one party is talking over the other? ✔ "everyone obviously had a lot of feelings about this issue but it is important that I get a chance to hear everyone's viewpoint without to much interrupting." how do you transition from a family interview to an individual interview with the adolescent? ✔ "I enjoyed meeting you and now id like to talk about done things with Matthew. afterward, we'll get back together and discuss what we've talked about " how do you start an Adolescent individual interview? ✔ "okay, now I get to hear your side of the story. we have a half hour to so to talk confidentially. I got you'll feel comfortable telling me your side of the story of what's been going on at home." if family interview was heated say "whew, things got pretty hot there; what do you think?" after that initial question what do you say to make Adolescents more comfortable as you ask personal questions? ✔ "do you mind if I ask you some personal questions? I may ask some you're uncomfortable answering and you don't have to answer if you don't want to." how to explain confidentiality to an Adolescent ✔ "I won't tell your parents about anything you say unless I'm worried that your life might be in danger." then before bringing family back in ask: "is there anything you don't want me to tell your parents?", "it's it okay I tell your parents these things?", "do you want to or do you want me to?" how do you get around the "I don't know" syndrome with Adolescents? ✔ "look if you really don't know something, that fine. but if you don't want to tell me something, that okay too. just say "I don't want to say." then use fly on the wall analogy: "if I were a fly on the real when you get into one of your moods, what would I see?" can also use displacement defense mechanism to your advantage: "do you have any friends who are in trouble? what's going on with them?" how can you get Adolescents to reveal personal info? ✔ attitude of curiosity and reflect are key: "do you like music? who do you like?" if you don't know that band tell them that and day what you like. be real, most Adolescents like goofy more than cool. then go into questions about school: "where do you go to school? what's it like? is it fun? easy? what are the kids like there? who do you hang out with?" ask about grades: "how's school going? is that the same as you've always done it have your grades changed recently? are there subjects that are particularly hard?" ask about hobbies: "what do you do with free time after school?", "are you in any sports or clubs?" - expressing interest in things is a big rule out for depression Gage their social isolation: "how many hours of TV do you watch on a school night? how many hours do you spend on the computer?" how do you ask Adolescents about drug use? ✔ "I hear there's a lot of dying and drug use at your school. do you know anyone who uses drugs?", "90% of kids use drugs these days. do you ever use drugs?" or: "how often do you drink?", "what drugs do you use?" psych Hx questions ✔ 1. when did you have your first episode? when was your last episodes? how many have you had in between? 2. tx Hx: Go CHaMP - general questions: what tx have you had? what worked? - current caregivers: doctors, therapists, social workers etc. - hospitalization Hx: first and last, and total number; cause - medication Hx: doses and how many weeks they stayed on them; antidepressants need 6 wks, antipsychotics need 2 wks, did you take them everyday? - psychotherapy Hx: how often, type, length, with who; was it a psychiatrist or a social worker?; did it help? why did it end? note: a lot of this you will get during HPI medical hx questions ✔ MIDAS - medications: get a list, taking as prescribed? - illness hx: medical problems - PCP: do you see a regular Dr.? what did he control? get a release to share info with him/her - allergies: have you had any allergies, reactions or SEs to any medications? what happened? Document specifics - surgical hx ROS questions ✔ who to do it on - brief: young and middle to upper class - full: elderly or chronic ill brief: "I'm going to ask about problems with various parts of the body head to toe. any problems with headaches or seizures? vision or hearing? smelling, taste it throat? thyroid? problems with lungs like pneumonia or coughing? heart? stomach problems like ulcer or constipation? problems with urination? joint problems? problems walking?" full: - general: overall do you feel healthy? joint or skin problems (may indicate Lupus)? excessive bleeding or anemia (anemia can cause depression)? dm or thyroid problems (dm can cause lethargy; thyroid can cause depression/mania)? hx of cancer? any infections, HIV, or TB (HIV mimics psych disorders, TB mimics depression) - HEENT: do you get headaches (possible brain tumor)? have you ever had a head injury? any problems with vision or hearing? ever see or hear things other people don't? get nose bleeds? do you she'll things others don't (sign of temporal lobe epilepsy)? how are your teeth? do you get sore throats often? - CV/Respiratory: any heart problems (R/O HF as cause for fatigue that presents like depression)? chest pains or palpitations (rule out cause for panic attacks)? HTN? SOB? cough excessively (R/O lung cancer that causes anorexia and wt loss that resembles depression)? wheezing? - GI: n/v? make yourself vomit ever? problems with swallowing? constipation/diarrhea (IBS often accompanies psych and would not do TCAs if constipated)? change in stool? - GU: problems with urination (burning or excessive)? increased frequency (don't give anticholinergics with prostate issues) or incontinence? issues with sexual function? ever had HIV or syphilis? are you sexually active? are you dating this person? when did you start dating? how many sexual partners have you had in the past year? are yo family psych/medical hx questions ✔ bare bones - psych: "has any blood relative ever had nervousness, nervous breakdown, depression, mania, psychosis or schizophrenia, alcohol or drug abuse, suicide attempts, or hospitalization for nervousness?" - medical: "has any blood relative ever had a medical or neurological illness, like heart disease, DM, cancer, seizures, or senility?" tips: if unsure ask about txs like medications, if had ECT heritability of major Disorders with first degree relative ✔ BPAD: 25x Schizophrenia: 19x Bulimia: 10x Panic: 10x Alcohol abuse: 7x GAD: 6x AN: 5x Phobia: 3x Social anxiety: 3x MDD: 3x Agoraphobia: 3x social and developmental hx questions ✔ family life: - can you tell me a bit about your background, where you grew up, and how you grew up? - how many siblings do you have? where are you in the order? - what did your parents do for a living? - how did you get along with your parents? - what did they do when you disobeyed? - were you ever abused physically or sexually? - were there any other adults in the home growing up? - how did you get along with your siblings? - who were you closest to growing up? education and work: - did you enjoy school? - did you have many friends or did you keep to yourself? did you have a best friend? - what kind of grades did you get? - what did you do after you graduated or dropped out? - how do you support yourself? - did you ever work? did you like work? - how have you gotten along with coworkers? did you have a hard time dealing with authority figures? relationships: get intimate relationship status with HIV questions - when did you have your first important relationship? - what attracted you to that person? - what attracted you to your current significant other? - how has your relationship/marriage gone? - do you have any close friends? - are you in touch with your family? - what do you do for fun? - what do you see yourself doing in 5 years from now? what would you like to be doing? 7 major diagnostic categories mnemonic ✔ Depressed Patients Sound Anxious, So Claim Psychiatrists. - Depression and other mood disorders: MDD, BPAD, dysthymia - Psychotic disorders: schizophrenia, schizoaffective, delusional DO - Substance abuse disorders: alcohol/drug use, psych syndromes induced by drug/alcohol use - Anxiety disorders: panic, agoraphobia, GAD, OCD - Somatic disorders: somatic sx DO, eating DOs - Cognitive disorders: dementia, mental retardation, ADHD - Personality disorders MDD criteria ancronym ✔ SIGECAPS: 4/8 sxs + depressed mood for 2+ wks - Sleep: increased or decreased - Interest deficit: anhedonia - Guilt: worthlessness, hopelessness, regret - Energy deficit - Concentration deficit - Appetite disorder: increased or decreased - Psychomotor: retardation or agitation - Suicidality PDD (dysthymia) criteria ancronym ✔ ACHEWS: 2/6 sx + depressed mood for 2+ yrs - Appetite disorder: increased or decreased - Concentration deficit - Hopelessness - out of control feeling while eating - concern with body shape - purging Anorexia mnemonic ✔ Weight Fear Brothers Anorexic: 3/3 - weight significantly low - fear of fat - body image distortion Dementia mnemonic ✔ Memory LAPSE: 1/6 - memory - language - attention (complex) - perceptual-motor - social cognition - executive function delirium mnemonic ✔ Medical FRAT: 5/5 - medical cause of cognitive impairment - fluctuating course - recent onset - attention impairment - thinking (cognitive) disturbance note: delirium is caused by medical illness, so becoming part of the medical fraternity helps diagnose it. ADHD mnemonic ✔ 4 categories of sxs: 6/9 inattentive/disorganized or 6/9 impulsive/hyperactive needed before 12 y/o in 2+ settings MOAT - movement excess - organization problems: difficulty finishing tasks - attention problems - talking impulsively note: you'll need a moat around the classroom for the hyperactive child How do you interview using pattern matching? ✔ Start with the pts chief complaint and ask open ended questions. Based on this info you develop your diagnostic hypothesis (usually 4). This is done within the first 5 minutes of the interview. Then you ask close ended questions to test out if each hypothesis is true. Its called pattern matching because you compare the pts sxs (pattern) with the sxs required for a diagnosis. To do this break your interview down into 4 phases: 1. free speech period: observe her behavior to form hypotheses (is she depressed or manic, does she smell like alcohol etc.) 2. screening questions: if you think she may be manic use a screening question like "have you ever had a period of a week or so when you felt so happy and energetic that your friends said you were talking too fast or you were behaving strangely?" 3. Probing questions: close ended questioning to rule out a hypotheses, like DIGFAST for manic, if most are no's then move on from that diagnosis. In general you want to know frequency, severity, duration, onset, context, and qualities of the sxs. 4. diagnostic questions: much of this will be done with the probing questions but cover anything that wasn't. mnemonic for MSE ✔ All Borderline Subjects Are Tough, Troubled Characters: - Appearance - Behavior - Speech - Affect - Thought Process - Thought Content - Cognitive exam These are the components of the MSE there are roughly 7 mnemonic for suicide risk factors ✔ SAD PERSONS - Sex: women more attempts, men higher success - Age: teenagers and elderly highest risk - Depression: 15% die by suicide - Previous attempt: 10% of those who die by suicide had a previous attempt - Ethonal abuse: 15% of alcoholics commit suicide - Rational thinking loss: psychosis; 10% of chronic schizophrenics die by suicide. - Social supports are lacking - Organized plan: a well organized plan is a red flag - No spouse: divorced, separated, widowed; responsible for children is protective though - Sickness: chronic illness Imminent risk factors for suicide ✔ Rage Recklessness Feeling trapped Increased substance use Social withdrawal Anxiety/agitation Insomnia/hypersomnia Mood change Lack of purpose or reason for living CASE approach to suicide assessment ✔ CASE: Chronological Assessment of Suicidal Events 1. Assess present SI or event 2. Elicit info about any SI over past 2 months 3. Explore past SI 4. Return to present and explore any immediate suicidality. Goal is to build rapport but getting present state then exploring the past and then returning to explore the present and hopefully due to the rapport built they will express any present plans which is the most important task. who do you need to assess homicide in? ✔ those at risk or make you suspicious for it. At risk: paranoid, antisocial, or substance abusers who tell you they are angry at someone what is the Tarasoff decision and what do we have to do for it? ✔ Its the decision that we have to protect potential victims. So we have to contact the victim as well as the police. We should also inform our pt we are doing this by saying: "The law requires me todo what I can to keep this person safe. That means I'm going to try to call him and also call the police." How long do you spend assessing mood? ✔ Recommended time: 1 minute if screening is negative; 5 minutes if positive what is apathy syndrome? who is it likely to be found in? ✔ those on SSRIs, it looks like anhedonia. Occurs in 20-30% of people due to low levels of DA in the brain. More common in newer antidepressants. If they come to you on SSRIs watch out for this if they are experiencing anhedonia. describe atypical depression, why is it important to differentiate? ✔ increased appetitie hypersomnolence mood reactivity (cheered up by positive events) pattern of rejection sensitivity throughout adulthood weighed down (laden paralysis) what are the 2 main types of delusions? which is more common? ✔ Paranoid delusions: 60% of schizophrenics (more common) Grandiose delusions Types of delusions: - paranoid delusions - delusion of reference - delusion of control - delusion of replacement - delusion of jealousy - somatic delusions - grandiose delusions - religious delusions - technological delusions ✔ paranoid delusion: people are harassing them, shasing them, spying on them, spreading rumors about them, trying to kill them. Types are below. - delusion of reference: casual events have special (usually dangerous) significance in reference to them. People walking by are talking about them, on TV or radio they're discussing or speaking to/about them. - delusion of control/influence: being controlled by some outside force. - delusions of replacement (Capgras syndrome): belief important people in their life have been replaced by imposters. - delusion of jealousy: on'es spouse is unfiathful, despite no evidence. - somatic delusions: believes they have an illness or are being poised despite lack of evidence. (occur often with depression) Grandiose delusions: usually in manic episode. believe you have special powers or will accomplish extraordianry things. Usually either religious or technological. - religious delusions: believes they're god-like. - technological delusions: believees they're connected to computers or other electrical appliances allowing him to have immense power. Whats the rule of thumb when asking probing questions in each category? ✔ Ask 9 questions, if they are all no's then you can move on and rule that out of your diagnosis. whats a counterprojective statement? ✔ when pts are extremely paranoid that that distrust you as well and incorporate you into their delusional system. You use a counterprojective statement where you acknolwedge and sympathize with your pts projections. heres an example: "And then here I come, looking all official in my coat and tie, saying I'm a psychiatrist. You probably think I'm part of the secret service too, which would be understandable." whats reality testing and how do you do it? ✔ refers to seeing how strongly your pt believes their delusion. Helps to determine severity of a psychotic disorder and helps monitor response to tx. 3 phases of delusion: 1. initial phase where the pt is totally convinced of the belief 2. intermediate "double-awareness" phase where the pt begins to quesiton the delusion 3. nondelusional phase To test: - "Do you think your imagination has been working in overdrive?" - "Do you think you might have been fantasizing any of this?" How to assess for AH with depression ✔ "Sometimes when people get very depressed, their mind plays tricks on them, and they think they hear things that others can't hear. Has that happened to you?" what is looseness of association and what is the range of it? Define the terms - circumstantiality - tangentiality - rambling - looseness of association - derailment - disjointed speech - loss of goal - flight of ideas - racing thoughts - word salad - non sequiturs - neologisms - clang associations ✔ veering off from the subject. Goes from circumstantiality to word salad. If they exhibit any of these things they have disorganized speech. Examples: - circumstantiality: adds extraneous details and gets off topic but usually digressions are related to topic. (common with anxious pts) - tangentiality: similar to circumstantiality but now begins to approach being incoherent. Digressions are abrupt and less relevant and they never return to the topic. (either psychosis or dementia) - Rambling: same as tangentiality but reserved for dementia. - looseness of association: more severe tangentiality. Makes statement that leads to another statement that is barely connected. Usually almost incoherent. Likely can't obtain a meaningful history from these pts. -- terms equal to LOA: derailment, disjointed speech -- loss of goal: speech that doesn't lead to any point and doesn't come close to answering your Q, cause is usually LOA -- flight of ideas: LOA when thoughts are moving rapidly -- racing thoughts: coherent thoughts that are moving rapidly - word salad: extereme LOA. Changes are so extreme its completely incoherent. Digressions occur within a sentence or between words in addition to between sentences. -- non sequiturs: out of context words placed into sentences -- neologisms: made up words that often accompany word salad -- clang associations: associations based on the sounds of words Note: in general just state they have looseness of association and say whether it is mild, moderate, or severe. Then give a brief example verbatim from the interview. define the terms in the velocity cluster: - mutism - poverty of thought - poverty of speech - lack of spontaneous speech - thought blocking - poverty of content - perseveration - racing thoughts - pressured speech - flight of ideas ✔ LOA + abnormal speed or rate of thoughts. Ranges from mutism - flight of ideas. - mutism: doesn't speak. May be having few, if any thoughts which is a negative sx of schizophrenia. - poverty of thought: little spontaneous speech adn with minimum words required. If psychotic then they usually have other negative sxs like poor hygiene, flat affect or hx of isolation. -- equivalent terms: poverty of speech, lack of sponatneous speech -- thought blocking: begins to speak then stops and forgets what they were saying - poverty of content: talks a lot but communicates very little info or discernible meaning (usually due to overly abstractness). -- perseveration: talks but dwells on a single idea over and over (seen with OCD, dementia, and psychosis) - Racing thoughts: thought going so fast they're hard to keep track of, may or may not be associated with pressured speech. (with anxiety may not speak but have racing thoughts, also common in pts detoxing) -- pressured speech: rapid speech that difficult to interrupt, often loud and intense. (almost always mania) - Flight of ideas: LOA when invoherent associations are very rapid. Like pressured speech but usually incoherent. strategy for overcoming poverty of thought with schizophrenia ✔ - the 2 techniques used are not mutually exclusive (symptoms window technique vs ground up technique). You can use whatever is useful and may use different techniques at different times. - Make it clear when assessing that you are looking for the long term view. Not over the last few years but since they were teenagers through now. BPD: mnemonic, typical statement, behavioral clues ✔ mnemonic: I DESPAIRR - Identity disturbance - Disordered: unstable affect owing to marked reactivity of mood - Emptiness: chronic feelings of emptiness - Suicide/Self mutilating behavior: recurrent behaviors, threats etc - Paranoid: transient, stress related paranoid ideation or severe dissociative sxs - Abandonment: frantic efforts to avoid real or imagined abandonment - Impulsivity: in at least 2 areas that's potentially damaging - Rage: inappropriate intense rage or difficulty controlling anger - Relationships: pattern of unstable and intense interpersonal relationships with alternating idealization and devaluation Self statement: I need people desperately, and when people reject me I fall apart completely. I have them, and I get suicidal, behavioral clues: may alternatively idealize and devalue you over the course of the interview; may be unusually emotionally labile. cluster A PDs ✔ Odd: - paranoid - schizoid - schizotypal Paranoid personality disorder: mnemonic, typical statement, behavioral clues ✔ mnemonic: SUSPECT (4/7) - spousal infidelity suspected - unforgiving (holds grudges) - suspicious of others - perceives attacks - views everyone as either an enemy or a friend - confiding in other feared - threats perceived in benign events self statement: others are untrustworthy, and they try to take advantage of me. behavioral clues: appears guarded and suspicious; patient answers questions reluctantly and with an air of suspicion Schizoid PD: mnemonic, typical statement, behavioral clues ✔ mnemonic: DISTANT (4/7) - Detached (flat) affect - Indifferent to criticism or praise - Sexual experiences of little inerest - Tasks (activities) performed solitarily - Absense of close friends - Neither desires nor enjoys close relations - Takes pleasure in few actvities self statement: I prefer to be alone; my world is completely empty behavioral clues: appears shy and aloof. seems to be preoccupied in their own world. Schizotypal PD: mnemonic, typical statement, behavioral clues ✔ mnemonic: ME PECULIAR (5/9 + R/O) - Magical thinking or odd beliefs - Experiences unusual perceptions - Paranoid ideation - Eccentric behavior or appearance - Constricted (or inappropriate) affect - Unusual (odd) thinking and speech - Lacks of reference - Anxiety in social situations - Rule out psychotic disorder and autistic disorder self statement: I'd like to have friends but it's hard, because people find me pretty strange. behavioral clues: Patient appears odd in any number of ways - for example, she may be disheveled, wearing strange clothes, or have odd mannerisms. Patient describes strange ideas that border on psychotic. Antisocial PD: mnemonic, typical statement, behavioral clues ✔ Mnemonic: CORRUPT (3/7) - Conformity to law lacking - Obligations ignored - Reckless disregard for safety of self or others - Remorse lacking - Underhanded (decitful, lies, cons others) - Planning insufficient (impulsive) - Temper self-statement: I love to take advantage of other people, and I never feel bad about it. behavioral clues: the pt is excessively cocky and arrogant. The pt always portrays self as innocent and a victim in violent or criminal circumstances. Histrionic PD: mnemonic, typical statement, behavioral clues ✔ Mnemonic: PRAISE ME (5/8) - Provocative (or sexually seductive) behavior - Relationships (considered more intimate than they are) - Attention (unfomfortable when not the center of attention) - Influenced easily - Style of speech (impressionistic, lacks detail) - Emotions (rapidly shifting and shallow) - Made up (physical appearance used to draw attention to self) - Emotions exaggerated (theatrical) self-statement: I'm quite an emotional and sexually charming person, and I need to be the center of attention! behavioral clues: the pt is flamboyantly and seductively groomed or dressed. The pt is rapidly and dramatically self-revealing to the point of inappropriateness, even in the context of a psychiatric evaluation. Narcissistic PD: mnemonic, typical statement, behavioral clues ✔ mnemonic: SPEEECIAL (5/9) - Special (believes they're special and unique) - Preoccupied with fantasies (of unlimited success, power) - Envious - Entitlement - Excessive admiration required - Conceited - Interpersonal exploitation - Arrogant - Lacks empathy Self Statement: I'm an extremely talented and special person, better than most people, and yet I get angry and depressed because people don't recognize how great I am! behavioral clues: the pt may appear haughty and excessively critical of your credentials or experience. She may begin the interview with a litany of angry complaints about how unfairly others have treated her. Cluster B PDs ✔ Dramatic: - BPD - Antisocial - Histrionic - Narcissistic hallucinations/illusions feeling fidgety restless agitation anxiety nervousness seizures Stimulant withdrawal ✔ depressed/irritable moods fatigue vivid unpleasant dreams increased/decreased sleep increased appetite feeling fidgety/restless/agitated or feeling slowed down What is involved in a detailed psychoeducation? ✔ 1. Define illness: have pt write down all their sxs on a piece of paper. You then define the disorder as an illness that has many sxs including the ones they wrote down. While explaining you protray it as an illness similar to medical illnesses DM or HTN (to decrease stigma) 2. Discuss prevalence and course of illness 3. Discuss causes (or theories if unknown) 4. Discuss options for tx 5. Discuss SEs and explain different people experience different SEs. 6. Address Reluctance to medication: If you sense that they are reluctant ask them "Is there anything that your (dx) is keeping you from doing that you really wish you could do again?" This could make that possible and thats my hope for you. How to decrease likelihood they will miss their follow-up appointment? ✔ - wait for follow-up appointment is short - Referrals are made to specific clinicians rather than to a clinic - Specific appointments are amde at the time of disposition - Pt speaks directly to someone at the referral clinic during the evaluation session take-aways: - have efficient system for booking follow-up apts - have list of specific clinicians who do not have excessive waiting periods - have list of referral clinics with phone numbers so your pt can call and make apts from your office How to increase medication compliance ✔ 1. Determine financial stress of paying for medication 2. Explain the SE profile 3. Explain regimen extremely simple, so say "take 1 green capsule in the morning and 1 white pill at night" instead of 20mg prozac and 50mg of trazodone. 4. Have pt repeat what you say. what is the bare minimum for the social history? ✔ - Where your pt was born and raised - number of siblings - birth order of pt and siblings - who was present in houshold during formative years - education level - work hx - marital and parenting history of pt - typical daily activities other than work what were the 5 axes of DSM4? ✔ Axis 1: main psych dx Axis 2: personality disorders and developmental disabilities Axis 3: medical issues Axis 4: psychosocial issues Axis 5: global assessment of functioning Note: DSM5 did away with these and they are all under 1 axis now