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Open-ended questions: Can you tell me why you were admitted? Open-ended
questions are often used in the initial phase of the interview to produce
spontaneous responses from the patient, which are potentially what feel most
important to the patient. They convey a sense of genuine interest to the patient. 2)
Closed-ended Questions : Did you attempt to end your life prior to admission?
Closed-ended questions often follow open-ended questions to efficiently elicit
specific details. 3) Summation refers to the brief summary of what the person has
said so far and is done periodically to ensure the interviewer understands the
person correctly. E.g. I would like to make sure that I understand you correctly so
far. You are saying that you do not think your experience is part of schizophrenia
based on your own readings (in a man who does not believe that he suffers from
schizophrenia and wants to seek a second opinion) 4) Transition is a useful
technique to gently inform the person that the interview is going onto another topic.
5) Empathic statement s convey the message that the psychiatrist finds the
patients concern is important and acknowledge the patients sufferings. E.g. I can
imagine that you were terrified when you realized that you could not move half of
your body (to a man suffering from post-stroke depression).
Psychiatric History Purpose Demonstration Introduction : Before you start the
interview, ensure the person understands the purpose and make that there is no
hearing impairment. Hello, my name is Dr. Zhang. Has anyone told you about the
nature of this interview? Let me explain
Identifying Information and demographics : Key demographic data include: 1.Full
name. 2.Age. 3.Gender. 4.Marital status: married, divorced, single, widow.
5.Occupation (if the person is unemployed, the interviewer should explore previous
job and duration of unemployment; if the person is a housewife, explore her spouse
or partners occupation. 6.Current living arrangement: living alone, homeless, with
family. 7.Current status: inpatient or outpatient. Before we start the interview, it is
important for me to ensure that I got your name right May I know your current
age? Example for presentation: Mr. Tan is a 36-year-old taxi driver, married and
stays with his family in a 3-room HDB flat. He is currently an inpatient at ward 33,
National University Hospital.
Presenting complaint
The presenting compliant can be part of a first episode of illness or as one of a
series of episodes. For patients who are hospitalised, it is important to enquire
whether this admission is voluntary or under the Mental Disorder and Treatment Act.
Seek the persons view in his or her own words about the admission. List the
symptoms in lay term in the order of decreasing severity and state the duration
during presentation. What have brought you here to this hospital or clinic? Can you
tell me what has happened before that? Example for presentation: Mr. Tan
presents with an intention to end his life, hopelessness, low mood, poor sleep, poor
appetite and poor concentration for 3 months.
History of present illness
Enquire the precipitating factors, symptoms severity, duration and context of the
current episode in a chronological order. Enquire maintaining and protective factors.
Assess impact on relationships and functioning. Enquire significant negatives (e.g.
psychotic symptoms in severe depression). Seek his or her views towards previous
psychiatric treatments, assess efficacy and explore previous side effects. Assess for
common psychiatric comorbidity and differential diagnosis associated the history of
present illness. Start with allowing the person to talk freely for 5 minutes and
demonstrate eagerness to hear the persons concerns. Questions like What made
you seek treatment this time? may reveal current stressors; and What are the
problems that your illness has caused you? assesses functional impairments.
What do you think may have caused you to feel like this? may reveal patients
perception of symptoms.
Past psychiatric history
Enquire the precipitating factors, symptoms severity, duration and context of the
current episode in a chronological order. Enquire maintaining and protective factors.
Assess impact on relationships and functioning. Enquire significant negatives (e.g.
psychotic symptoms in severe depression). Seek his or her views towards previous
psychiatric treatments, assess efficacy and explore previous side effects. Assess for
common psychiatric comorbidity and differential diagnosis associated the history of
present illness. Start with allowing the person to talk freely for 5 minutes and
demonstrate eagerness to hear the persons concerns. Questions like What made
you seek treatment this time? may reveal current stressors; and What are the
problems that your illness has caused you? assesses functional impairments.
What do you think may have caused you to feel like this? may reveal patients
perception of symptoms.
Past psychiatric history
Enquire past psychiatric diagnoses, past treatments (medication, psychotherapy or
ECT); side effects associated with psychotropic medications, adherence to
treatment, previous hospitalizations (including involuntary admissions) and
treatment outcomes. History of suicide, self-harm, violence and homicide attempts
is essential to predict future risk. It is important to identify the precipitating and
maintaining factors of each episode, as this would provide important information in
formulation. Example for presentation: This current episode is in the context of 20year history of depressive illness. 20 years ago, Mr. Tan first consulted a
psychiatrist in private practice because of low mood, poor sleep and loss of interest
Enquire past and current medical problems and physical symptoms, in particular
pain (e.g. migraine), seizures (e.g. temporal lobe epilepsy), stroke, head injury,
endocrine disorders and heart diseases. Indicate medications that the patient has
been prescribed for the above problems. Enquire past surgical problems and
surgery received. Explore drug allergy (especially to psychotropic medication and
clarify the allergic reactions) Example for presentation, Mr. Tan suffers from
hypertension and hyperlipidaemia. The polyclinic doctor has prescribed atenolol
50mg OM and simvastatin 40mg nocte. Mr. Tan has no past history of surgery. He
has no past history of drug allergy.The physical problems may be due to the
medication effect (e.g. prolonged QTc resulted from antipsychotics).
History of substance misuse
Enquire type (alcohol, benzodiazepine, and recreational drugs), amount, frequency,
onset of and past treatment for substance misuse. Explore biological (e.g. delirium
tremens/ head injury) and psychosocial complications (e.g. drunk driving, domestic
violence) associated with substance misuse. Explore the use of tobacco (quantity
and frequency). Look for dual diagnosis e.g. depression with alcohol misuse. Explore
the financial aspect (i.e. the funding of substance misuse). Maintaining a nonjudgmental attitude is essential in enquiring substance misuse. Normalise the
experience of substance misuse, When people are under stress, they may use
recreational drugs. I would like to find out from you whether you have such
experience. Avoid a direct question like, Do you use drugs? which may prompt
the person to deny any drug use.
Family history
Enquire the family psychiatric and medical histories. Look for substance misuse
(e.g. alcohol) among family members. Look for early and unnatural deaths which
may indicate suicide. Briefly assess the quality of interpersonal relationship in the
family. Demonstrate empathy if a close family member suffers from severe
psychiatric illness. Identify the aetiology of psychiatric illness in family members.
E.g. What made you think that your mother may suffer from depression?
Background history
Relationship or marital history (current and past); wellbeing of children (e.g. child
protection issues); psychosexual history (sexual orientation, STDs if relevant, issues
related to infertility, for women, candidate needs to explore the last menstrual
The interpersonal nature of rapport include establishing the mutual experience and
awareness of the presence of the other, the mutual sharing of thoughts and
feelings, the notion of empathy and the development of mutual trust between the
interviewers and patients.
Appearance and behaviours :General appearance includes the observation of dress,
grooming, facial expression and ancillary objects (e.g. handcuffs, weapons, etc)
often provide information about attitude and other non-verbal communications
relevant to rapport. Behaviours: Observation of non-verbal behaviours includes
commenting on the eye contact, gestures and other useful communications.
(a)Disinhibition refers to behavioural and social manifestations of undue familiarity,
coarseness, and aggressive behaviours. (b) Mannerisms (repetitive behaviours
without serving any purpose), stereotypies (repetitive behaviours serving a
purpose) and uncontrolled aggression may indicate impairment in reality testing. (c)
Childlike behaviour or regression: This may occur in an adult with personality
disorder. The person may hold a toy or stuffed animal as transitional object.
Speech(a)The rate, volume and pressure of speech (e.g. increased rate in mania
and decreased rate in depression). Loss of tone is seen in people with Aspergers
syndrome. c)Dysarthria involving slurred speech. (d) Dysphasias (e.g. Wernickes
and Brocas dysphasias). e) Stuttering and cluttering of speech. f) Explosive quality
with forced vocalization (in agitated and angry patient). g)Preservative features in
speech (e.g. difficulty in changing topics in people with frontal shame, guilt or
humiliation) as well as in a number of psychiatric disorders (e.g. depressive
disorder, adjustment disorder, acute stress disorder).
Perceptual disturbances
1. Illusions (affect illusions, completion illusions, and pareidolic illusions). 2.
Hallucinations (auditory, visual, olfactory, gustatory, tactile and haptic
hallucinations). 3. Pseudohallucinations.
Insight , A psychiatric patient may have impaired insight if: 1.He/she believes that
she is not ill. 2.
He/she does not believe that his/her signs/symptoms are due to a psychiatric
condition. 3.He/she does not believe that psychiatric treatment is helpful.
Cognitive function: Students need to comment on the level of consciousness and
orientation. If dementia is suspected, students need to test general knowledge of
the person (e.g. the name of prime minister), short-term memory (by recall of an
address or 3 objects) and to perform Mini mental state examination (MMSE). 2.
Assess orientation to time, place and person. 3. Assess attention and concentration.
Attention is the ability of a person to maintain his or her conscious awareness on an
external stimulus and to screen out irrelevant stimuli. Concentration refers to
sustained and focused attention 4. Level of consciousness refers to alertness and
arousal and awareness of self and external environment and stimuli 5. Abstract
1.
Students are advised to provide the diagnosis based on the DSM-IV-TR or ICD-10
criteria. DSM-IV-TR uses the five axis approach (Axis I main psychiatric illness; Axis
II personality disorder or mental retardation; Axis III general medical condition;
Axis IV psychosocial and environmental problems; Axis V Global assessment of
functioning (GAF score). Students are advised to rule out the conditions at the upper
part of the pyramid before concluding the conditions at the bottom part of the
pyramid. The conditions at the upper part of the pyramid are given the diagnostic
priority because these conditions are treatable and reversible by biological
treatments.
Investigations
1.
Routine investigations in psychiatry: FBC, LFTs, U & Es or RFTs, TFTs, Urine drug
screen and ECG (to look for prolonged QTc). 2.
With the patients permission, the psychiatrist may obtain collateral history from
partner or spouse, friends, family, GPs and other professionals. 4.
Investigations do not limit to the clinical setting. The treatment team may consider
doing a home visit to understand the interaction between home environment and
current psychiatrist illness. Occupational therapist can assess the activity of daily
living of an individual while social worker can assess social support. 5.
1.
Treatment can be divided as immediate, short term, medium term and long term. 2.
Immediate treatment
may include
a.
Biological treatments:
b.
if necessary, the psychiatrists may obtain input from other experts in medicine,
surgery, paediatrics, geriatrics, and obstetrics and gynaecology.
c.
Risk management
involves modifying and managing risk factors. (E.g. treat the underlying depressive
disorder to prevent suicide and to advise caregivers to remove sharp items at home
to prevent self-harm). It is important to prevent harm to other people (for example,
inform the social agency to ensure the safety of the patients children).
d.
Psychoeducation and supportive counselling can be offered while the patient stays
in the ward. More sophisticated therapy e.g. cognitive behaviour therapy requires
further work after discharge.
e.
Discharge planning
a.
Psychological treatments
b.
Social treatments
MCQs
1.
You are assessing a 30-year-old man who is aggressive towards staff in the Accident
and Emergency Department. The following are appropriate approaches except: A.
Adopt non-confrontation approach B. Advise patient to sit near the door C. Minimize
eye contact D. Leave examination door open E. Lower your own voice Answer: B In
this scenario, the psychiatrist should sit near the door to ensure there is an escape
route. This will allow the psychiatrist to mobilize resources easily. If the patient sits
near to the door, he or she can make the psychiatrist a hostage by blocking the exit.
3.
EMIS
Question 3: I understand that you are very frustrated with your father. I am
wondering if you blame her for all that has happened to you Ans: Interpretation
Reference: Poole R, Higgo R.
Perceptual disturbances
Insight
He/she does not believe that his/her signs/symptoms are due to a psychiatric
condition. 3.
Cognitive function
1.
Level of consciousness refers to alertness and arousal and awareness of self and
external environment and stimuli 5.
Physical examination
Physical examination is important for psychiatric practice and students are advised
to look for tell-tale signs for underlying physical conditions.
General inspection
1.
General well-being and body size (e.g. cachexia in anorexia nervosa, obesity which
may suggest metabolic syndrome). 2.
Atypical facial features may suggest syndromes associated with learning disability
(e.g. Downs syndrome). 4.
Extremities: scars on the arms may indicate deliberate self-harm in people with
borderline personality disorder. Needle tracks may indicate intravenous drug use.
Neurological examination
1.
Look for tremor due to thyrotoxicosis, withdrawal from alcohol, extrapyramidal side
effects). 2.
Look for involuntary movements (e.g. restlessness in lower limbs is also known as
akathisia which is induced by antipsychotics). 3.
Look for abnormal gait (e.g. shuffling gait in people with Parkinsons disease; broadbased gait as a cerebellar sign in people who misuse alcohol).
Cardiovascular examination
5.
Blood pressure and postural change in blood pressure (some antipsychotics such as
quetiapine cause postural change in blood pressure). 7.
Abdominal examination
1.
Students are advised to provide the diagnosis based on the DSM-IV-TR or ICD-10
criteria. DSM-IV-TR uses the five axis approach (Axis I main psychiatric illness; Axis
II personality disorder or mental retardation; Axis III general medical condition;
Axis IV psychosocial and environmental problems; Axis V Global assessment of
functioning (GAF score). Students are advised to rule out the conditions at the upper
part of the pyramid before concluding the conditions at the bottom part of the
pyramid. The conditions at the upper part of the pyramid are given the diagnostic
priority because these conditions are treatable and reversible by biological
treatments.
Formulation
Psychological factors
Social factors
Investigations
1.
Routine investigations in psychiatry: FBC, LFTs, U & Es or RFTs, TFTs, Urine drug
screen and ECG (to look for prolonged QTc). 2.
With the patients permission, the psychiatrist may obtain collateral history from
partner or spouse, friends, family, GPs and other professionals. 4.
Investigations do not limit to the clinical setting. The treatment team may consider
doing a home visit to understand the interaction between home environment and
current psychiatrist illness. Occupational therapist can assess the activity of daily
living of an individual while social worker can assess social support. 5.
1.
Treatment can be divided as immediate, short term, medium term and long term. 2.
Immediate treatment
may include
a.
Biological treatments:
b.
if necessary, the psychiatrists may obtain input from other experts in medicine,
surgery, paediatrics, geriatrics, and obstetrics and gynaecology.
c.
Risk management
involves modifying and managing risk factors. (E.g. treat the underlying depressive
disorder to prevent suicide and to advise caregivers to remove sharp items at home
to prevent self-harm). It is important to prevent harm to other people (for example,
inform the social agency to ensure the safety of the patients children).
d.
Psychoeducation and supportive counselling can be offered while the patient stays
in the ward. More sophisticated therapy e.g. cognitive behaviour therapy requires
further work after discharge.
e.
Discharge planning
a.
Psychological treatments
b.
Social treatments
MCQs
1.