Psychiatric Interview & Mental State Examination

1. Psychiatric Interview&Mental State Examination Selected Issues Dr. J. Lereya Director of the emergency ward

2. Interview (contrary to conversation is a special form of communication (words, body language) which is intended for the achievement of a defined goal by concentrating on certain specific themes and contents while omitting other, irrelevant, ones. The interviewer and interviewee roles are clearly defined and rigidly fixed.

3. The Psychiatric Interview Aim: Collecting information about the revealed (behavior, intentions, prospects etc.) as well as concealed (emotions, drives, conflicts) aspects of the interviewee’s world. The interviewer as an well trained and dedicated observer (signs) and a collector (symptoms).

4. Psychiatric Interview Techniques based on the medical-model • Investigate the circumstances of the referral. • Obtain detailed description of chief complaint. • Obtain detailed description of the disorder’s long-term history. • Observations which may be clues for physical disease (goiter, tremor, skin patches etc…). • Past history, etc.

5. What qualities should psychiatric interviewer possess in order to accomplish the aims of the psychiatric interview? Common stereotypes of a medic-interviewer:

6. The detective.systematically examines and cross-examines his “witness”, to the tiniest detail: Dose not skip a detailbut the “witness” might grow hostile.

7. 2. The Confessor. Full with sympathy and compassion for the “sinner”, eager to protect, refrains from “difficult” questions.* very popular among patients. * no systematic investigation of the problem.

8. 3. The scientist. Fills up a standardized questionnaire based on a premeditated hypothesis which, now, should be verified. * makes a well made differential-diagnosis based on facts. * misses the complexity of compound human conditions.

9. So who, the hell, is the a suitable interviewer?

10. 4. The empathic Medic: * The detective puts steps into the suspect’s shoes trying to find out what he would have felt in such a situation. * The confessor identifies with the “sinner” in order to understand him. He actually fills what the “sinner” fills while expressing love and an desire to help. * The scientist sympathizes with his subject of investigation. In order to understand him he is nice and friendly and accepts the gathered information and the interviewee’s point of view as it is presented to him.

11. so what, the hell, is empathy?

12. Empathy is an acquired ability of 2 dimensions: • The ability to understand (specifically & accurately) the subjective view-point (emotions, drives, conflicts, compromises, etc.) of another person, combined with * The ability to express this understanding in such a way that the other one fills he is understood.

13. Interview techniques • Closed vs. Open(from a talking-questionnaire to an unbounded(projective) conversation:* closed: scientific, measures, yields standard information, ambience of exam (investigation).* open: stimulates in general, prompting the interviewee to expose himself and project conflicts on the interviewer (can you tell me about yourself ? What do you think in general about…) . * half-structured: Tell me about your childhood. Can you describe you father ? Was he a bad or a good person ?

14. 2. focused vs. screened * focusing on a specific event/subject (exploring suicide attempt/leaving hospital without permission etc.) * screening developmental milestones etc. 3. Diagnostic vs. therapeutic * About 80% of the interview deals with obtaining suitable information in favor of comprehensive D.D. procedure. * The rest can be educative or “amending” (Have you ever previously had such an experience? Is the depression you feel today resembles previous depressive episodes? etc.

15. The examination of the mental state General considerations: • Be sure to stick with the medic model:1. You are an observer and collector of signs and symptom.2. Each item of the MSE should be examined passively (signs) and actively (symptoms).3. Each symptom/sign should be scrutinized. • Always keep in mind to examine those items of MSE which may indicate the possibility of physical disorder or disease (consciousness, awareness, attention & memory, intellectual functioning). • No psychiatric examination is completed without thorough examination of suicidal risk (at present and in the past).

16. The structured MSE 1. Consciousness 5. Mood and Affect 2. General Description * general expression * appearance * congr/not congr.(situation, content) * motor behavior * responsiveness * rapport 6. Cognition 3. Thought * intellectual functioning * form (speech) * orientation * process * attention and memory * content 7. Judgment & reality-testing 4. Perception 8. Insight * illusions * hallucinations

17. consciousness • Full consciousness – AAA • Disordered consciousness (2 types): 1. Dist. in the level of cons. (states of alertness) Ac. Conf. state → coma2. Dist. in the quality of cons. (states of awareness) disturbed cognition (isolated → global) aphatic-amnestic syndromes → Dementia

18. General Description of the patient Beside examining: • Physical-emotional appearance (deteriorated/unsuitable dress, eye-contact, vaso-motor changes, etc.). • Psycho-motor behavior (agitation, retardation, etc.). One should pay special attention to: C. Quality of rapport with the patient:* Dissimulation vs. evasiveness* transference, counter-transference.

19. Disorder of thought One examines thought indirectly thought a screen of speech and language: • Speech (form of thought, a sign) • Thought processes (a symptom)1. blocking as a sign and a symptom 2. “Pressure of speech” (a sign) as a possible clinical representation of either “pressure of thoughts” (psychosis) or “flight of ideas” (manic episode).

20. C. Thought content: 1. Dismantling of the language(desymbolization of words – neologism – sentences/words salad – clung association). 2. rigidity of thought (obsessive thoughts). 3. Delusionsare recognized by four co-existing criteria: * fixed false belief * uncorrectable by reasoning * inconsistent with the patient’s cultural, educational background. * cause dramatic change in life

21. Classification of delusions by their content (most common): reference, persecution, grandiose, somatic, etc.D.D. always investigate the origin of a detected delusion: * persecuted for being special/unique etc. tends to initiate protective acts (a schizophrenic ?). * persecuted because of being a inner/guilty/disturbing, etc. tends to withdraw (depressed ?)

22. Disorder of perception * hallucinations * illusions

23. Mood and Affect • Do mind the distinction:(1) mood (a symptom) – The examinee’s report about his emotional tone over a period of time.(2) affect (a sign) – The examinee’s emotional expressions as observed by the examiner during the examination. • Use the following parameters while evaluating the affect:(1) passive observation (depressed, disphoric, elated, labile, flat, perplexed, etc.) and estimation (congruent/not congruent with the situation/thought content).(2) active examination of the examinee’s emotional responses: 1. to humor (severity of depression, MR) 2. to provocation (level of impulsivity, efficacy of inhibitions, aggressiveness, dangerousness).

24. Disorder of cognition (high level mental functioning) • Intellectual functioning* General information* Calculation* Abstract thinking using adages is probing one’s ability: * to swap concrete and general * to swap inanimate and human * to draw a moral/lesson • Orientationtime, placeidentification (of oneself and others). • Memory* immediate (attention, distractibility)* short (the ability to learn new material.* long (highly learned material).

25. Judgment vs. Reality Testing Judgment Is the ability (for given social circumstance) to Perform compound mental process including: • Circumstances evaluation with respect to a required social task. • Identification and inspection of various options (e.g. “in favor” and “against” considerations). • Choosing an option which prompts a socially (prohibition vs. permission)and ethically (good vs. evil) normative response.

26. Pathology (like illusions): Reality is acknowledged but misinterpreted (with respect to social norms). J. examination: • Does the examinee understands possible consequences of his behavior? • To what extent his responses are influenced by his understanding? • Imagined situations: Is he able to anticipate how would he react if, for example, he found a purse in the street ? etc.

27. Reality-testing is the ability (for given social circumstances) to perform compound mental process including: • Distinction between “self” and “non self”. • Distinction between inner and outer source of stimuli and emotions. • Realistic evaluation of emotions, thoughts, behaviors with respect to accepted social norms. Pathology (like hallucinations): Reality denial combined with genesis of substitutive reality.