Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
in Psychiatry
Developed and produced by Margot Phillips, Jeffrey Streimer and Joanne Shaw
HETI | RESOURCE
Authors
Dr. Margot Phillips
Consultant Psychiatrist
Joanne Shaw
HETI Project Manager
Acknowledgements
Dr. Agnes Chan
Consultant Psychiatrist
Contents
Who? What? When? Where? Why?....................................................................02
An area of unmet need.......................................................................................03
Our vision...........................................................................................................04
Learning goals....................................................................................................05
About this material..............................................................................................06
Confidentiality and Consents..............................................................................08
Session 1: The Psychiatric Assessment: An Overview.............................................. 09
Session 2: Introduction to Psychiatric History-Taking................................................ 19
Session 3: Cognitive Assessment I........................................................................... 51
Session 4: Cognitive Assessment II.......................................................................... 75
Session 5: Movement Disorders............................................................................... 97
Session 6: Phenomenology.................................................................................... 109
Session 7: Mental State Examination I.................................................................... 123
Session 8: Mental State Examination II................................................................... 129
Session 9: Mental State Examination III................................................................... 135
Session 10: Personality Style I................................................................................ 139
Session 11: Personality Style II............................................................................... 149
Session 12: Reflective Interview Skills I................................................................... 153
Session 13: Reflective Interview Skills II.................................................................. 165
Session 14: The Therapeutic Alliance..................................................................... 175
Session 15: Introductory Formulation I.................................................................... 185
Session 16: Introductory Formulation II................................................................... 205
Session 17: Cognitive-Behavioural Approach and Formulation............................... 211
Session 18: Psychodynamic Formulation I.............................................................. 225
Session 19: Psychodynamic Formulation II............................................................. 239
Session 20: History and Formulation in Child and Adolescent Psychiatry................ 257
01
Who?
This manual and its accompanying USBs are for Psychiatric Trainees of all levels and for their tutors.
However, any Mental Health Professional who wants to enhance their clinical assessment skills will
benefit from these sessions and exercises.
What?
02
This program targets all aspects of the clinical psychiatric assessment in a clear, concise and
easy-to-follow format.
It moves fluidly from the basics of the psychiatric history and mental state examination to the
more complex and subtle aspects of psychiatric assessment.
It will guide junior trainees embarking upon the daunting task of assessing patients. It will assist
senior trainees in developing a greater degree of sophistication.
When?
There are twenty sessions. Sessions run for a maximum of two hours.
While sessions can be run at any interval, the manual is designed to fit in with either a weekly
six-month program or a fortnightly twelve-month program.
Where?
For most sessions, all you need is a space free from interruption plus equipment to play the
accompanying USB to the group.
Why?
This program was developed in response to the recognition that the Clinical Psychiatric
Assessment is an area of unmet need in the current system of Psychiatry Training.
This program is a guide both for those wanting to teach, and those wanting to learn or expand upon
their skills in psychiatric assessment. It provides a program that is standardised and replicable with
specific learning goals and objectives, yet at the same time is flexible and responsive to the learning
needs of participants.
03
Our vision
This manual is a tool for those wanting both to teach and to learn the clinical assessment in psychiatry.
This manual is unique in targeting the unmet needs of psychiatry trainees, offering a program that
is standardised enough to be replicable and easy to use, yet flexible enough to be responsive to
the individual learning needs of its participants.
04
The material in this manual employs a wide range of teaching methods. It includes conventional
lectures and presentations but the main emphasis is on the hands-on discussions, role-plays and
exercises. The degree of active involvement in the learning process will vary from group to group,
but the material is designed in such a way that more active involvement in the learning process will
give better results.
The manual embraces the principles of adult learning. It encourages active participation in a highly
relevant, experiential learning process. It aims to facilitate a safe and welcoming environment for
trainees of all levels, a non-critical environment in which reflection, contemplation and discussion
are fostered.
The exercises in this manual aim to cultivate the skills at every level of the clinical psychiatric
assessment from the basics to the complex and subtle. They encourage the integration of theoretical
and practical knowledge, and promote the reflective practice that then fosters clinical thinking.
Learning goals
Overall learning goal
To guide the development of the skills involved at every level of the clinical psychiatric assessment,
focussing particularly on those skills not specifically addressed in the current psychiatry training scheme.
Content knowledge:
To know the core contents of a complete psychiatric history and mental state
examination, including
Phenomenology
The cognitive assessment
Assessment of movement disorders, e.g., AIMS test
To know and understand definitions and concepts relevant to the psychiatric
assessment, such as
Phenomenology and psychopathology,
Specific phenomenological concepts, e.g., pseudo-hallucinations
Transference and countertransference
The therapeutic alliance
The assessment of personality style and structure
Process knowledge:
To be aware of some of the challenges that may arise when applying theoretical
knowledge to clinical practice
T
o understand different interviewing techniques and how these vary according to
the situation
To enable the practice of interview skills through role plays and observed interviews
To enable the development of cognitive assessment skills
To encourage reflection on clinical assessment skills and the clinical assessment process
To increase awareness and understanding of what is happening at multiple levels of an
interaction
To increase skills of observation
To increase awareness of non-verbal communication, including transference
and countertransference
To learn to respond to relational aspects of the interview
To begin to use clinical reasoning skills during the assessment process
Formulation
Content knowledge
To understand the elements of a formulation
To know the various schema used in formulation
To understand how a formulation will vary depending on its function,
for example:
Diagnostic formulation
Cognitive-behavioural formulation
Psychodynamic formulation
Process knowledge
To become familiar with using data from the clinical assessment to understand
the patients predicament
To synthesise the data into a coherent formulation
To learn to begin to formulate from early in the assessment process
05
06
The manual
For each session, the manual contains:
A session outline
Detailed instructions to guide you in the preparation and running of the session
Trainee handouts
Suggested discussion prompts
Facilitator notes to guide you in leading discussions
For some sessions there is a choice of options each clearly outlined in the manual
Facilitator notes
Facilitator notes have been provided for most sessions. These notes are intended to highlight
certain key issues and to guide you in the leading of discussions.
The notes are not intended to be comprehensive and we do not propose that they be rigidly
adhered to. During group discussions other pertinent issues will undoubtedly arise. The focus
of each discussion will depend upon your area of expertise as facilitator, on the trainees level
of experience, and the particular interests of the group.
Group size
We are aware that group size will vary depending on the setting but recommend that ideally
there is a minimum of four trainees to facilitate discussion, and a maximum of sixteen to ensure
the requisite intimacy and confidence within the group.
07
Confidentiality
The material presented in this publication and USB series is strictly intended for the training of
Mental Health Professionals. This material is not for release to the public in its present or a modified
form.
08
Written consent has been obtained from all patients interviewed, lecturers and seminar leaders for
the ongoing use of their material, both verbal & written, and of their images, for teaching purposes.
The participants in the USB have all freely given informed consent for the use of this material without
time-limitation or mode-of-publication constraints. We thank them for this, and trust that all material
will be treated with respect.
All interviewed patients had capacity to consent. Capacity to consent was assessed by the authors,
and it was also discussed with the patients treating doctors. Where relevant it was discussed with
family members. The authors have attempted as far as possible to protect patients confidentiality by
omitting all potential references to their identity and by maintaining anonymity within the limitations
of live recorded material.
We advise that all facilitators and trainees using this material strictly adhere to the conditions of
use of the USB and manual and do not allow unauthorised distribution, publication or viewing.
In addition, we advise a facilitator who chooses an option in the manual/USB that requires them to
organise their own interviews and make their own recordings of interview material to observe the
same rules of confidentiality, and to obtain and keep a record of appropriate informed consent for
the interview and/or recording.
Consents
When a patient agrees to be interviewed for educational purposes you must ensure that adequate
consent is obtained. When a recording is made of the interview the consent process must
specifically address this aspect of the process.
We advise that you check with relevant hospital authorities before proceeding with any recording
of interviews. Many hospitals have approved consent forms that must be completed prior to any
recording being made. Your hospital will also have a privacy policy to which you should refer.
A patient who agrees to be interviewed and recorded must be informed of what will happen to
the material following the session. Again, you should check your specific hospital policy but, in
general, unless the material can be guaranteed to be kept secure in a confidential place, the
material should be destroyed after use.
09
Session 1
10
OR
OPTION B
Watch the interview on
the accompanying USB
Session Summary
This session provides an introductory overview of the complete clinical assessment in psychiatry.
It begins with the observation of a doctor-patient interview. This is followed by a group discussion
of the information gathered in the interview and the clinical assessment process.
There are two options for this session:
Option A: Organise your own doctor-patient interview
Option B: Watch the interview on the accompanying USB
The trainee conducting the interview should not take notes while interviewing the patient
*If the group is present in the room during the interview, the number of observers should be limited. Ensure that
observers sit out of the direct line of sight of the patient and that they remain passive throughout the interview.
12
Appendices listing
For use with Option A (Organising your own interview)
Appendix 1.1.1 Discussion prompts for trainees
For use with Option B (Watching the interview on the accompanying USB)
Appendix 1.2.1 Discussion prompts for trainees
Appendix 1.2.2 Facilitator notes
Appendices
Appendix 1.1.1 Discussion prompts for trainees
For use with Option A (Organising your own interview)
1. Comment on the interaction between the interviewer and the patient in the interview
2. Was there a change in rapport as the interview progressed? What accounted for this?
3. What do the shifts tell us about the patient?
4. Can you recall any segments where there was a deepening of the rapport?
5. Can you recall any segments where there was a disjunction or failure in the rapport?
(These may be major or minor disjunctions)
6. How did the interviewer manage these disjunctions?
7. How else might these disjunctions have been managed?
8. What interview techniques were used in this interview? Which of these had the most
productive effect?
9. Comment on the patients affect
10. Comment on the patients thought-form
11. Does the interview permit an assessment of risk? What is your risk assessment?
12. Was this interview sufficient to make a provisional diagnosis? What is your provisional diagnosis?
13. What are your differential diagnoses? Discuss these.
14. What additional information would you like to clarify the diagnosis?
15. What do you see as important issues in ongoing management?
Learning Point
The bio-psycho-social framework is useful when deciding on management. However it is
important to also think beyond this, and to consider in greater depth what is unique to this
patient, in this circumstance.
13
14
5. Can you think of any points in the interview where an attempt to deepen rapport did not work?
Excerpt One
6. Comment on any shifts in rapport in this excerpt
7. How else could you respond if a patient says they would rather not talk about a sensitive topic
such as their suicidality? Role play this scenario
Excerpt Two
8. What do you notice in this excerpt?
9. Do you think it is valuable to ask a patient why they have never been in an intimate relationship?
Why is this useful?
10. Are there any risks involved in asking about this topic?
11. How might you ask about this topic? Role play this scenario
Excerpt Three
12. What do you notice in this excerpt?
Now think back to the full-length interview
13. Comment on the patients affect
14. Comment on the patients thought-form
15. Does the interview permit an assessment of risk? What is your risk assessment?
16. What is your provisional diagnosis?
17. What are your differential diagnoses? Discuss these
18. What additional information would you like to clarify the diagnosis?
19. What do you see as important issues in ongoing management?
Learning Point
The bio-psycho-social framework is useful when deciding on management. However, it is
important to also think beyond this, and to consider in greater depth what is unique to this
patient, in this circumstance.
15
7. How else could you respond if a patient says they would rather not talk about a
sensitive topic, such as their suicidality? Role play this scenario
There are several possible ways to manage when a patient wishes to avoid a painful or
sensitive area.
One way is to allow the avoidance. This can have negative consequences, for example, that
important aspects of history are missed.
Another is to acknowledge the difficulty: I can see that is a painful area for you. It is important
for me to know, though Or, I see how hard it is for you to talk about this. Maybe we can
come back to it later.
16
Excerpt Two
8. What do you notice in this excerpt?
Met with obstruction the interviewer falters, discards this line of questioning and moves onto
another topic.
This segment is a good example of how deceptive the initial superficial ease of engagement
can be. It is an example of how a patients anxiety and reticence can make the whole
atmosphere tentative.
This interaction gives an insight into the challenges we might face in an ongoing avoidant
therapy relationship.
9. Do you think it is valuable to ask a patient why he/she has never been in an intimate
relationship? Why is this useful?
It is important to ask about this topic as the information can be useful for formulation and
diagnosis (of both Axis I and Axis II diagnoses). In addition, the act of entering into such
intimate subject matter tests and can deepen rapport.
10. Are there any risks involved in asking about this topic?
Yes, there are real risks. There is a risk of disrupting rapport. The patient may feel confronted,
even intruded upon or persecuted.
Whatever the response, be it a deepening of or a rupture in rapport, it gives valuable
information to the treating team about the patients defenses, sensitivities and the ease with
which she will trust and form a working alliance.
11. How might you ask about this topic? Role play this scenario
This is a potentially difficult topic that can be hard to broach, especially for novice interviewers.
Framing the question in such a way as to acknowledge the sensitivity is useful:
I wonder if thats hard for you to talk about.
That seems to be a sensitive area.
It sounds like you dont want to talk about that topic right now.
Excerpt Three
12. What do you notice in this excerpt?
Involuntary mouth movements pouting: this is an example of rabbit syndrome, a form
of tardive dyskinesia that has been commonly reported with risperidone.
17
Poverty of thought and reduced affective range makes the diagnosis of an episodic illness,
such as depression, less likely. Relative preservation of thought-form and some preservation
of affective warmth supports the diagnosis of a later onset of illness rather than a burnt-out
paranoid schizophrenia.
18. What additional information would you like to clarify the diagnosis?
The temporal relationship of mood and psychotic symptoms:
18
Learning Point
The bio-psycho-social framework is useful when deciding on management. However, it is
important to also think beyond this, and to consider in greater depth what is unique to this
patient, in this circumstance.
19
Session 2
Introduction to Psychiatric History-Taking
20
PART 1: LECTURES
Dr Agnes Chan
The Psychiatric Interview:
(History Taking)
Dr James Telfer
The Diagnostic Interview
in Psychiatry
OR
OPTION B
Watch role plays on
the accompanying USB
Session Summary
This session provides an introduction to the history-taking component of the clinical psychiatric
assessment.
The session is divided into two parts:
PART ONE: Two lectures on psychiatric history-taking
PART TWO: Two role-plays of history-taking, each followed by a group discussion.
There are two options for Part Two.
Option A: Organise your own group to perform role-plays
Option B: Watch the role-plays on the accompanying USB
21
22
Note to Facilitator
It may be necessary to redirect discussions if the trainees individual technique is becoming
a focus.
Appendices listing
23
For use with Part Two Option A (Organising your own role plays)
Appendix 2.2.1 Vignette for Role-play 1 (History of presenting illness)
- Instructions to simulated patient
- Instructions to moderator
- Instructions to interviewer
Appendix 2.2.2 Vignette for Role-play 2 (Past psychiatric history)
- Instructions to simulated patient
- Instructions to moderator
- Instructions to interviewer
Appendix 2.2.3 Discussion prompts for trainees for use with both Role-play 1 and Role-play 2
For use with Part Two Option B (Watching role-plays on the accompanying USB)
Appendix 2.3.1 Discussion prompts for trainees for Role-play 1 (History of presenting illness)
Appendix 2.3.2 Discussion prompts for trainees for Role-play 2 (Past psychiatric history)
Appendix 2.3.3 Facilitator notes for Role-play 1 (History of presenting illness)
Appendix 2.3.4 Facilitator notes for Role-play 2 (Past psychiatric history)
Appendices
Appendix 2.1.1 Lecture slides
For use with Part One (Lectures)
The Psychiatric Interview: (History Taking) by Dr Agnes Chan
24
Slide 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
25
Slide 7
Slide 8
Slide 9
Slide 10
Slide 11
Slide 12
26
Slide 13
Slide 14
Slide 15
Slide 16
Slide 17
Appendix 2.1.2
For use with Part One (Lectures)
The Diagnostic Interview by Dr Telfer
27
Page 1
28
Page 2
29
Page 3
30
Page 4
31
Page 5
32
Page 6
33
Page 7
34
Page 8
35
Page 9
36
Although you are finding it difficult to summon the energy for this interview, you want to help the
doctor by answering as much as you can. You would really like to feel better, but it is hard to see
out of this slump.
Your GP has referred you here. You trust her advice but you find it hard to believe that anything is
going to help you.
Remain as true to the information given in this scenario as you can. Do not expect to cover all of the
information that you have been given. If you are asked specific questions that are not covered here
you may improvise so long as it is consistent with the character and the rest of the information with
which you have been provided.
You feel like you were always reliable. At least you had that. Maybe not the most exciting guy,
but steady. Now, youre not even that. You feel a bit guilty about work and about neglecting your
girlfriend and about being so useless.
You havent spoken to anyone at work about what is happening. Your boss hasnt said anything.
He doesnt seem like hed get it. Hes a bit of a bloke. Not into the touchy-feely stuff. You arent
into that either. So you cant figure out whats wrong now.
You have a few friends, but you have always kept a little to yourself. You might meet up maybe for a
beer or to watch the sport. Or if your girlfriend organises things you usually go along. Lately youve
stopped calling your friends back and you havent been to anything your girlfriend has organised.
You speak to your mum every couple of weeks but you dont want to worry her or your dad. Your
brother lives overseas.
Your girlfriend is really worried about you. She keeps asking whats wrong and it gets on your nerves
a bit. You know she is only trying to help but you need some space right now. She was the one that
got you to go to the GP a month ago.
The GPs been great. Shes seen you once a week since then. Started you on Cipramil three weeks
ago. One tablet. You cant remember the dose. But you dont think its working. You havent noticed
anything. No side-effects, but the depression is just getting worse.
Why did this all start? You wish you knew. There was a promotion at work that fell through about
three months ago. Something about you being too inexperienced. You were upset at the time but
youre not that concerned about it. It probably wouldnt look good for the next promotion though if
your boss knew you get down and cant cope. That goes through your mind a bit.
Its only been in the last week, when you are lying in bed at night thinking about things, that youve
started to wonder what the point of all this is. Sometimes you think that if you had a gun youd just
blow your brains out. God no, youd never do it. You dont have a gun. They scare you. Its just
a thought. Its gone as quickly as it comes. You sure havent made any plans or preparations, or
thought about any other ways. You dont think youd ever actually do it. Its not in your nature, you
dont think. And youd hate to upset the people around you. Itd be awful.
You havent been paranoid about anything else (apart from the people at work maybe talking about
you). Theres been nothing suspicious and you havent heard any noises, seen anything, smelt
anything unusual. You are not going crazy.
You think your girlfriend would be better off without you. You know she wants to get married some
day, and you feel kind of stuck and obligated. Shed probably be better off with someone else. You
think shes too good for you. But you dont want to let her down, either. You cant really talk to her
about this. You arent good at talking about stuff, and anyway itd just upset her.
You got depressed at high-school once, but never got any treatment. It sure wasnt this bad. It
seemed like acne and teenage angst kicked in and you were on your own all the time. You werent
teased or anything. Just always on the edge of the group. Your mum said they were the best years
of your life and you should be enjoying yourself. Instead you lay on your bed reading science fiction
and playing computer games. Your dad said hed been through the same and not to worry about it.
He was right. Somehow you got out of it when university came around.
There is no other past psychiatric history. The only medical history is an appendicitis. Apart from
the Cipramil you are on no regular medication and have no known allergies.
37
38
39
You see your case-manager every couple of months and the psychiatry registrar when you need to
get scripts. They thought maybe you could stop coming to the health centre and just see your GP
but then you got sick again. You cant remember how long ago this was.
The first time was the worst. Because no one knew what was going on. Youd dropped out of
university and were all depressed, and your parents were annoyed at you, because you were sitting
at home all the time, really scared and not eating any of the food they made. You did think there
were cameras in the house, and also things on the TV and radio about you, but thats all gone now
and you dont really want to talk about the past. You cant remember it that well.
40
You have had times when youve been too high. All giggly and full of energy. You cant remember
the details but your parents have told you that once you thought you were Princess Diana.
Mostly now, when you start to get sick, you start fighting with Mum and Dad. You start to think they
are against you. They notice right away and get onto your case-manager quickly.
You get worse and then better but it seems more steady these days. You sometimes wonder if you
could stop the medication.
You have never thought of suicide. You have never been physically aggressive to anyone. The most
youve done is shout at your parents.
Most of the time you dont have any symptoms. When you go out you sometimes get paranoid that
people are talking and laughing about you, but you know its just the schizophrenia.
Youve got some friends. One friend from school that you talk to every couple of months and a few
friends youve met in hospital and at the coffee shop. You talk to your mum and dad nearly every
day and see them about once a week when they come over. Mum gives the place a clean and
checks the fridge. You see your sister once a month. Shes pretty busy, but you talk on the phone
a few times a week.
You are a bit vague about how you spend your time, but you say you go for coffee and go to the
movies and sometimes watch TV. You do all the housework, cooking and shopping yourself, apart
from a bit of help from your mum.
Sometimes you get a bit down about how things have turned out. You were doing marine biology
when you first got sick you love animals. You thought youd get married and have a family but
you dont think thats going to happen now. You have a cat called Mustard and she cheers you up.
Mostly youre okay and you are thinking of doing animal studies at TAFE next year.
41
42
5. What were the main techniques the interviewer used to elicit information?
6. Which techniques worked best, and why?
7. Are there any other techniques that could have been used?
The question/answer approach is comfortable, and is the technique most readily adopted by
trainees. However, it is important to develop a range of approaches to interviewing. Experiment
with different techniques, but trust your own style. Use techniques that are comfortable for you.
8. What are some of the difficulties the interviewer faced in this interview? Discuss these
9. How did the interviewer manage these difficulties? What other ways could you manage
these difficulties?
43
44
45
The question/answer approach is comfortable, and is the technique most readily adopted
by trainees. However, it is important to develop a range of approaches to interviewing. Trainees
should be encouraged to experiment with different techniques, but trust their own style,
using techniques that are comfortable and work for them.
6. The interviewer began the interview by asking the patient How are you going today?
Why might the interviewer have begun like this?
People often resort to colloquialisms through anxiety.
7. What effect might this have had on the doctor-patient interaction?
Informal and laid-back which might put the patient at ease. However, this statement may
not demonstrate serious professional concern.
8. How else might you begin such an interview? Role play alternative beginnings
46
47
9. How else might you manage this situation? Role play alternative approaches
When avoiding an area, it can signal to the patient that you also dont want to talk about
difficult topics, cant deal with their pain and negative affects. This may make them reluctant
to confide negative affects in the future.
Sometimes it is helpful to acknowledge their difficulty This is a painful thing to talk about
even if this is followed up by We can come back and talk about this later.
48
Summaries or paraphrasing of what the patient has said, and then inviting the patient
to comment on this
Interpretation: noticing a parallel or a connection
Appropriate reassurances
49
NOTES
50
51
Session 3
Cognitive Assessment I
52
PART 1: LECTURE
Dr Agnes Chan
Bedside Cognitive Testing
PART 2: WORKSHOP
Session Summary
This session is the first of two sessions on the Cognitive Assessment in Psychiatry.
The session is divided into two parts:
PART ONE: A lecture about bedside testing of cognitive function
PART TWO: A workshop in which trainees practice the cognitive assessment
Cognitive Assessment I
Appendices listing
For use with Part One (Lecture)
Appendix 3.1 Lecture slides for Bedside Cognitive Testing by Dr Agnes Chan
53
Appendices
Appendix 3.1 Lecture Notes
For use with Part One (Lecture)
Bedside Cognitive Testing by Dr Agnes Chan
54
Slide 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
Cognitive Assessment I
55
Slide 7
Slide 8
Slide 9
Slide 10
Slide 11
Slide 12
56
Slide 13
Slide 14
Slide 15
Slide 16
Slide 17
Slide 18
Cognitive Assessment I
57
Slide 19
Slide 20
Slide 21
Slide 22
Slide 23
Slide 24
58
Slide 25
Slide 26
Slide 27
Slide 28
Slide 29
Slide 30
Cognitive Assessment I
Appendix 3.2
For use with Part Two (Workshop)
Checklist for testing cogitive function: Testing Cognitive Function at the Bedside.
p113
59
p114-115
60
Cognitive Assessment I
p116-117
61
p118-119
62
Cognitive Assessment I
p120-121
63
p122-123
64
Cognitive Assessment I
p124-125
65
p126-127
66
Cognitive Assessment I
p128-129
67
p130-131
68
Cognitive Assessment I
p132-133
69
p134-135
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Cognitive Assessment I
p136-137
71
p138-138
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Cognitive Assessment I
p140-141
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p142-143
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Session 4
76
Cognitive Assessment II
OBSERVATION OF A COGNITIVE ASSESSMENT AND GROUP DISCUSSION
Summary of Session
This session is the second of two sessions on the Cognitive Assessment in Psychiatry.
The group watches and discusses selected segments of a recorded cognitive assessment by an
experienced psychogeriatrician. The interview contains both formal and informal tests of cognition.
Prior to this recorded interview informed consent was obtained from the patient and his wife. The
patients capacity to give informed consent was assessed by the interviewing psycho-geriatrician.
Remember that cognitive findings form only one part of the picture. They should be used in
conjunction with history and with neuro-imaging.
Cognitive Assessment II
77
Appendices listing
Appendix 4.1 Discussion prompts for trainees
Appendix 4.2 Facilitator notes
Appendix 4.3 Addenbrookes Cognitive Examination (ACE-R) (blank and completed assessment)
Appendix 4.4 Carers Assessment of Executive Function (blank and completed assessment)
Appendices
Appendix 4.1 Discussion prompts for trainees
Segment One
1. Comment on speech and thought-form
2. Can you identify any examples of language difficulties in this segment?
Segment Two
3. Asking someone how they spend a typical day is an important question. What do we learn
in this segment?
78
Segment Three
4. The interviewer asks the patient, Are you in good spirits most of the time? This is another
important question. Are you familiar with the questionnaire that this question comes from?
5. What do you make of the patients autobiographical account?
6. What do you make of the fluency of his speech in this segment?
7. Which aspects of history not covered so far are relevant to the assessment of cognitive
function?
Segment Four
8. Briefly discuss what you saw in this segment
9. Discuss the problems with assessing general knowledge
Segments Five
10. When trying to recall the address, the patient responds to cueing. What does this tell us?
11. Comment on the patients performance on the Trail-Making Test.
12. What other cognitive assessment tools do you know?
13. What cognitive assessment tool would you use when prescribing a cholinesterase inhibitor
for Alzeimers disease?
14. What are the benefits of formal neuropsychological testing?
15. Why is the carer questionnaire important?
16. Which area of the brain is responsible for:
Language and memory?
Visuo-spatial function and praxis?
Visual gnosis (visual recognition)?
Executive function?
17. Which brain area would you expect to be affected in:
Alzheimers Disease?
Lewy-Body Dementia?
Vascular Dementia?
Cognitive Assessment II
Inherit this and Slip into this [when talking about the onset of his memory disturbance]
Dont have much of an intake [regarding the reduction in his social and other activities]
When youre mixing around, such as sailing
Segment Two
3. Asking someone how they spend a typical day is an important question. What do we
learn in this segment?
There is a lack of depth in the patients descriptions of how he spends his day. From this,
we can begin to form some hypotheses. For example, we might wonder if it reflects that the
patient leads an impoverished lifestyle and, if so, if this is related to the amotivation often seen
with dementia syndromes (frontal lobe impairment). Or, we might wonder if it reflects that the
patient lacks the cognitive capacity to recall and/or to accurately describe his daily activities.
Segment Three
4. The interviewer asks the patient Are you in good spirits most of the time? This is
another important question
Are you familiar with the questionnaire that this question comes from?
The Trail Making Test that the interviewer uses is not a Trail Making Test that has been psychometrically validated. Therefore,
while it provides useful qualitative information, it does not give quantitative data. By contrast, the Trail Making Tests that are
used in formal psychometric assessments have been validated and these do provide quantitative results.
1.
79
The question is from the Geriatric Depression Scale (GDS), a screening instrument for
depression. It is a useful question in that it often gives a good indication of the pervasiveness
of the mood pattern.
5. What do you make of the patients autobiographical account?
He is able to give a reasonable chronological history but there is mild confusion and
chronological inconsistency when he is describing the details of his two marriages.
6. What do you make of the fluency of his speech in this segment?
80
He remains fluent in speech and does not exhibit the breakdown of language that we saw
earlier in the interview. The anxiety he felt at the commencement of the interview may have
exacerbated his language dysfunction.
7. Which aspects of history not covered so far are relevant to the assessment of cognitive
function?
Past Medical History
Although not shown in the video, the patient has a history of hypertension a vascular
risk factor for both Vascular Dementia and for Alzheimers Dementia
Routine medications
Substance use
Segment Four
8. Briefly discuss what you saw in this segment
Patchy general knowledge
Word-finding difficulties
9. Discuss the problems with assessing general knowledge
General knowledge depends on many factors. For example, cultural background, baseline
intelligence, level of interest and the environment/setting.
It is important to ensure your expectations are appropriate to that person and that setting.
This man described a genuine interest in current affairs and so his lack of recall is likely to
be significant.
Segment Five
Pause for discussion as required while watching this segment
10. When trying to recall the address, the patient responds to cueing. What does this tell us?
The response to cueing tells us about the density of memory disturbance.
If cueing does not help with recollection it indicates a more severe memory problem.
A lack of recollection despite cueing is common in advanced Alzheimers Dementia.
11. Comment on the patients performance on the Trail-Making Test
The patient began well but derailed after reaching number four. However, he was able to
go back and rectify the problem.
This indicates mild to moderate dysexecutive function.
12. What other cognitive assessment tools do you know?
A large number of neuropsychological tests are available. The specific tool used and the
amount of cognitive testing undertaken depends on the patient as well as the setting/context.
Cognitive Assessment II
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No. 1
Cognitive Assessment II
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No. 2
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No. 3
Cognitive Assessment II
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No. 4
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No. 5
Cognitive Assessment II
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No. 6
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No. 7
Cognitive Assessment II
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No. 8
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No. 9
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No. 10
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No. 11
Cognitive Assessment II
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No. 12
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No. 1
Cognitive Assessment II
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No. 2
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97
Session 5
Movement Disorders
98
PART 1: GROUP DISCUSSION AND ROLE-PLAY
PART 2: (OPTIONAL) CD EXAMPLES OF MOVEMENT DISORDERS
IMPORTANT
This session contains an OPTIONAL Part Two that does not follow the format of the
other sessions in this manual. The CD material for Part Two of this session was produced
independently by Professor Tim Lambert who has kindly allowed its reproduction here.
It was not developed as part of this training program.
Please note that production of the CD was sponsored by a pharmaceutical company.
Due to the different format of the CD for this session, Part Two will require an additional
one hour of preparation time as you will need to orientate yourself to the material in order
to decide how best to make use of it during the session.
Summary of Session
This session is about Extrapyramidal Movements Disorders.
The session is divided into two parts:
PART ONE: Discussion and role-play on the clinical assessment of movement disorders
PART TWO: (Optional) CD examples of movement disorders
Movement Disorders
99
7. Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions
100
Appendices listing
For use with Part One (Group Discussion and Role Play)
Appendix 5.1.1 Extrapyramidal Syndrome Summary
Appendix 5.1.2 AIMS Examination procedure
Appendix 5.1.3 RANZCP Clinical Memorandum #10 (May 2007, GC2/02, R37). Tardive
Dyskinesia
Recommended reading
Dayalu, P. Chou, K.L. (2008) Antipsychotic-induced extrapyramidal symptoms and their
management. Expert Opinion, Pharmacotherapy 9 (9) 1451-1462
Movement Disorders
Appendices
Appendix 5.1.1 Extrapyramidal Syndrome Summary
For use with Part One (Group discussion and role-play)
EXTRAPYRAMIDAL SYNDROMES
Syndromes with motor side-effects resulting from disturbance to the extra pyramidal motor system
Associated with all first-generation antipsychotic medication, with some second generation
antipsychotics as well as with some other psychotropic and non-psychotropic agents, e.g.
anticonvulsants, lithium, metoclopramide
101
Acute syndromes
Akathisia
Subjective feeling of inner restlessness, often associated with observed movements such as
rocking, pacing, and shifting the weight from foot to foot
Usually occurs within hours to days of treatment commencement or of increasing the dose
Postural tremor
Tardive Syndromes
Tardive refers to delayed onset. This term is used to refer to syndromes that develop later, after
three or more months of treatment. In these syndromes there is a risk of persistence after cessation
of the causative medication.
Tardive syndromes may take on many forms, for example tardive dystonias and perioral tremor,
but the most common is tardive dyskinesia.
102
Tardive dyskinesia
Choreiform, dystonic, athetoid or stereotypic movements
Frequently affect the mouth and tongue, e.g. lip-smacking, sucking, puckering and facial
grimacing
Seriously disabling dyskinesia is uncommon but a small proportion may affect walking, talking,
eating and breathing
Movement Disorders
103
1. Ask the patient whether there is anything in his or her mouth (i.e. gum, candy etc) and, if so,
to remove it
2. Ask about the current condition of the patients teeth. Ask if he or she wears dentures. Ask
whether teeth or dentures bother the patient now
3. Ask whether the patient notices any movements in his or her mouth, face, hands, or feet.
If yes, ask the patient to describe them and to indicate to what extent they currently bother
the patient or interfere with activities
4. Have the patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor.
(Look at the entire body for movements while the patient is in this position.)
5. Ask the patient to sit with hands hanging unsupported if male, between his legs, if female
and wearing a dress, hanging over her knees. (Observe hands and other body areas)
6. Ask the patient to open his or her mouth. (Observe the tongue at rest within the mouth.)
Do this twice
7. Ask the patient to protrude his or her tongue. (Observe abnormalities of tongue movement)
Do this twice
8. Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15
seconds, first with right hand, then with left hand. (Observe facial and leg movements) [activated]
9. Flex and extend the patients left and right arms, one at a time
10. Ask the patient to stand up. (Observe the patient in profile. Observe all body areas again, hips
included)
11. Ask the patient to extend both arms out in front, palms down. (Observe trunk, legs, and mouth)
[activated]
12. Have the patient walk a few paces, turn, and walk back to the chair. (Observe hands and gait.)
Do this twice [activated]
Scoring Procedure
Complete the examination procedure before making ratings.
For the movement ratings (the first three categories below) rate the highest severity observed.
0 = none, 1 = minimal (may be extreme normal), 2 = mild, 3 = moderate, and 4 = severe. According
to the original AIMS instructions, one point is subtracted if movements are seen only on activation,
but not all investigators follow that convention.
104
1.
01234
2.
01234
3.
01234
4.
01234
Extremity Movements
5.
01234
6.
01234
Trunk Movements
7.
01234
Global Judgments
8.
01234
(based on the highest single
score on the above items)
9.
0 = none, normal
1 = minimal
2 = mild
3 = moderate
4 = severe
10.
0 = no awareness
1 = aware, no distress
2 = aware, mild distress
3 = aware, moderate distress
4 = aware, severe distress
Dental Status
11.
0 = no
1 = yes
12.
0 = no
1 = yes
Movement Disorders
Appendix 5.1.3
For use with Part One (Group discussion and role-play)
RANZCP Clinical Memorandum #10. Tardive Dyskinesia
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Page 2
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Page 3
NOTES
108
Session 6: Phenomenology
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Session 6
Phenomenology
PART 1: INTERACTIVE DISCUSSION
PART 2: ROLE-PLAY
Summary of Session
This session provides an overview of phenomenology.
The session is divided into two parts:
PART ONE: An interactive discussion about phenomenology
PART TWO: A role-play and discussion focussing on the clinical skills involved in
exploring and understanding phenomenology
Materials Required
PART ONE: NIL
PART TWO: NIL
Phenomenology
111
2. The trainees should then be divided into groups for a 20-minute discussion about the
differences between:
A delusion and an overvalued idea
A hallucination and a pseudo-hallucination
3. The groups should then come together and discuss their ideas
2) Presenting symptoms are important, even if they do not clearly fit an illness pattern,
as a key part of both mental state and formulation. There is a tendency for trainees to be
formulaic, to not present perplexities, conundrums and incongruencies.
Appendices listing
For use with Part One (Interactive discussion)
112
Appendix 6.1 Journal article: Andreasen, N.C., (2007) DSM and the death of phenomenology
in America: an example of unintended consequences. Schizophrenia Bulletin
33(1):108-12
Appendix 6.2 Discussion prompts for trainees
Appendix 6.3 Facilitator notes
Phenomenology
Appendices
Appendix 6.1 For use with Part One (Interactive discussion)
Andreasen, N.C. (2007) DSM and the death of phenomenology in America: an example
of unintended consequences. Schizophrenia Bulletin 33(1):108-12
113
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No. 2
Phenomenology
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No. 3
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No. 4
Phenomenology
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No. 5
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Phenomenology
119
It is important in a patient with depression who describes hearing a critical voice in his/her
head to understand if this is a true hallucination. The treatment for psychotic depression
as opposed to non-psychotic depression will be significantly different.
120
In a patient with known schizophrenia, who suffers a relapse of psychosis, the specific
phenomena will be less important.
11. Break up into groups and discuss the difference between the following:
A delusion and an overvalued idea
How does this hold for anorexia nervosa?
How does this hold for body dysmorphic disorder?
A hallucination and a pseudo-hallucination
Bring the groups together to discuss their ideas.
Phenomenology
121
How to play the role
You are polite and co-operative, and forthcoming about your reason for presenting.
You are perplexed and concerned about this new-onset sleep disturbance, but apart from that
there are no abnormalities in your mental state.
You are expected to improvise on any information that is not covered here, but maintain that you
are a person with no suggestion of psychiatric illness whatsoever, apart from the unexplained sleep
disturbance.
NOTES
122
123
Session 7
Mental State Examination I
OBSERVATION OF A RECORDED PRESENTATION AND A RECORDED GROUP DISCUSSION
124
Summary of Session
This session provides an introduction to the Mental State Examination in psychiatry.
In this session the group watches the USB about the Mental State Examination, pausing for
discussion where indicated in the USB. The recorded material shows a psychiatry trainee presenting
an account of a psychiatric interview followed by a group discussion of the patients mental state.
1. Review the accompanying USB material showing a registrar presenting their account of a patient
interview followed by a group discussion of that patients mental state. Ensure that you are able
to discuss relevant aspects of the topic
2. Photocopy the Mental State Examination (appendix 7.1) and the Classification of Defense
Mechanisms (appendix 7.2) to hand out to trainees during the session
Appendices listing
Appendix 7.1 Mental State Examination
Appendix 7.2 Classification of Defense Mechanisms
Appendices
Appendix 7.1 Mental State Examination
Appearance
Relaxed, young, Filipino male in casual dress: t-shirt, tracksuit pants, rubber sandals, and with
slicked back hair
Appears younger than his stated age this is congruent with his ethnicity
No obvious physical abnormalities
Reasonably well-groomed
Behaviour
125
A steady direct gaze that remains unchanged even through affect-laden material. Unnerving, but
not threatening
There is a lack of emotional exchange through his eyes with an absence of affect reflected in them
Easy smiles, big laughs and giggling. A performance mask
He is not agitated. There is no psychomotor retardation
Somewhat expressive in body language
Speech
Fluent accented English, reasonably articulate, normal rate, rhythm and tone
There is some unusual idiosyncratic usage of language perhaps related to his Filipino background
There is a humorous (sarcastic) quality
Striking use of the word it to describe his suicidality that is, being unable or unwilling to name
the experience indicates the traumatic nature of his experience
Mood
Apprehensive
Mildly dysphoric
Affect
Mildly incongruent with his mood
Restricted in range, displaying only positive affects, and being jovial, even flippant despite the
gravity of situation. This is somewhat forced and he is at times dismissive of serious material.
There is a humorous edge but this is not of an infectious quality
Performance mask
Thought-content
Concise description of events, divorced from emotion, with a paucity of detail. Practised/rehearsed
quality
Recent hardships (including financial and relationship) and past traumas were themes of this
interview but, despite a depressive history, the associated loss and sadness were largely glossed
over and there isnt an overt sense of worthlessness, hopelessness or nihilism
He reports some agency and control
No frank delusions
Thought form
No formal thought disorder.
Defense mechanisms:
minimising
repression
some denial
humour
isolation of affect?
Perception
126
Cognition
Clear sensorium. No formal testing. Appears grossly intact and of at least average intelligence
Insight
Not entirely aware of his diagnosis, but he self-presented and feels hospitalisation has been
helpful for him
While there is a limited appreciation of the level of severity of his illness, there is a sense of his
developing insight
Judgement
Judgement may have been impaired recently, for example, his trading on the share-market despite
being in substantial debt. It was almost certainly impaired when he made the near-attempt at suicide
Risk
The short-term risk to self is low to moderate, while he is in hospital, in a contained environment.
The long-term risk remains medium to high given his dismissive attachment status and the
difficulty he may have asking for help in the future
His long-term risk will be reduced if he can form a meaningful connection with someone so that
he again feels comfortable to ask for help
Immature Defenses
Neurotic Defenses
Mature Defenses
127
NOTES
128
129
Session 8
Mental State Examination II
130
OBSERVED INTERVIEW FOLLOWED BY A PERIOD OF REFLECTION
Summary of Session
This session is the second session on the Mental State Examination.
In this session the group observes a trainee interview a patient. The purpose of the interview is to
assess the Mental State Examination of the patient.
Following the observed interview, the interviewer and observers will make notes about the interview
in order to prepare them for the discussion that will take place in the next session, Mental State
Examination III.
IT IS IMPORTANT THAT, AS FACILITATOR OF THIS SESSION, YOU HAVE WATCHED
THE USB MATERIAL OF MENTAL STATE EXAMINATION I.
131
Neither interviewer nor observers should take notes while interviewing the patient
*If the group is present in the room during the interview the number of observers should be limited. Ensure that observers
sit out of the direct line of sight of the patient and that they remain passive throughout the interview
3. Following the interview, once the patient has been safely seen out, gather the group together
again and ask the interviewer and observers to make notes on the interview using the handout
in appendix 8.2 as a guide
Appendices listing
Appendix 8.1 Instructions for interviewer and observers
Appendix 8.2 Guide to reflecting on the interview
Appendices
Appendix 8.1 Instructions for interviewer and observers
Instructions for interviewers
In the next session on the Mental State Examination (Session Nine), you will be expected to present
a detailed chronological account of the interview that you perform today. The notes you make today
after the interview will assist you in that task.
132
The presentation that you will be expected to make to the group is a moment-by-moment account
of the interview in as much detail as you can recall. It should include a description of both verbal
and non-verbal communication, and also your thoughts and impressions during the interview itself.
Expect the account to be approximately fifteen minutes in length.
The account should include recalled transcripts of selected portions of the interview. The transcripts
are not expected to be entirely accurate this would not be possible and is not the point of the
exercise.
The presentation that you make to the group should not include a summary of the interview and
should not include a formulation. That is, this presentation is entirely different from that which you
would present to a colleague or a senior consultant when asking for advice on a patients care and
it is entirely different to the presentation you would make for the purposes of an exam.
An example of what you might say is:
I walked into the room. I went to shake Johns hand and he grasped my hand firmly with both
of his and smiled broadly. I felt disconcerted by this. I pulled my hand free and sat down.
John was sitting back in his chair with his legs crossed. He was neatly-attired, wearing a checked
shirt with tan pants and sneakers.
I said, Hello. My name is Tim. I am a psychiatry registrar. Thanks for agreeing to do this interview
today.
He said, loudly, No problem. Not at all. Once again he smiled broadly too broadly, and I smiled
back but in a reserved manner.
Then John started laughing.
133
134
6. Record excerpts (recalled transcripts) of the interview. Try to be as precise as possible in
recording what was said, and by whom (though of course a verbatim transcript is not expected)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------7. Any striking use of words or phrases?
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------8. Other observations
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
135
Session 9
136
Summary of Session
This session is the third session on the Mental State Examination. In this session your group
will have an in-depth discussion about the Mental State Examination of a patient, similar to the
discussion seen on the USB of Mental State Examination I. This session uses the interview
performed in Mental State Examination II as the basis for the discussion.
The session begins with a trainee presenting their account of the interview they performed last
session. The presentation is followed by a facilitated group discussion about the mental state
examination of that patient.
IT IS IMPORTANT THAT, AS FACILITATOR OF THIS SESSION, YOU HAVE WATCHED
THE USB MATERIAL OF MENTAL STATE EXAMINATION I
1. As facilitator, ensure that you have watched the USB material of Mental State Examination I
This session follows a similar format and should draw directly on the learning points and
discussions of that session
2. Prior to this session reflect on what you observed during the interview performed during the
last session. Ensure you are able to guide a discussion regarding conducting a Mental State
Examination
137
appearance
behaviour
speech
affect
thought content
thought-form
perception
cognition
insight
judgement
risk
4. Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions
NOTES
138
139
Session 10
140
Personality Style I
PART 1: LECTURE
Dr Jeffrey Streimer
Personality
Summary of Session
This is the first of two sessions on Personality Style. The session is divided into two parts:
PART ONE: A lecture giving an overview of personality structure
PART TWO: An interactive exercise using the first five minutes of a recorded doctor-patient
interview to guide trainees in:
Openly observing an interaction
Registering responses (cognitive, affective and intuitive)
Thinking about these responses from a clinical perspective, and
Using clinical reasoning skills to form a provisional hypothesis about the patients personal
and interpersonal style
Personality Style I
10
141
Appendices listing
For use with Part One (Lecture)
Appendix 10.1 Lecture slides for Personality by Dr Jeffrey Streimer
Appendices
Appendix 10.1 Lecture slides
For use with Part One (Lecture)
Personality by Dr Jeffrey Streimer
142
Slide 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
Personality Style I
10
143
Slide 7
Slide 8
Slide 9
Slide 10
Slide 11
Slide 12
144
Slide 8
Slide 13
Personality Style I
10
145
5. What feelings and responses are evoked in this segment? What could this tell us about aspects
of his personality?
Segment Two (10 minutes)
6. What strikes you in this segment? What words, images and affective responses come to mind?
Keep in mind your initial speculations
7. Discuss any forming hypotheses
8. In this segment, the patient talks about others exploding, breaking out and killing. What do you
think this is about? Is he talking about himself?
9. When the interviewer asks the patient if he is talking about himself, the patient flatly denies it.
Why might this be? What defense mechanisms is he using?
10. This man is simultaneously guarded and attacking. What personality style does this remind you of?
11. What is the difference between the control exerted by an obsessional person and that exerted
by a paranoid person?
12. Do you think there is an anti-social element here? What are key features of an antisocial
personality structure?
13. What is his affective state? What effect does this have on you?
14. Do you think he is able to use help?
15. Do you notice the dilemma that his persecutory world view presents you with?
16. He mentioned that he owns firearms. How does this make you feel?
17. Do you notice the grandiosity in his descriptions? Discuss where this might come from
18. To what extent is the grandiosity an example of unhealthy narcissism and to what extent does
it reflect healthy aspirations?
19. Despite a rough facade, this man is seeking to form attachment. If you engaged in a treatment
contract with him, what are the difficulties you might face? Reflect on his future prognosis,
particularly in regards to co-operative relationships, including a therapeutic alliance
146
2. With your observations and associations in mind, discuss tentative hypotheses about
personality style and traits.
Spend at least ten minutes on this section.
3. What do you notice about the mans appearance?
4. What do you notice about his clothing? Do you notice any contrasts or contradictions
in his attire and general appearance?
He is wearing a police-shirt with casual shorts.
This man does not work, nor has he ever worked, for the police force.
The police-shirt contrasts with the long ponytail and shorts.
he police-shirt is likely to be important, though we can only guess at its significance.
T
There are many possible explanations for this. It may be a deliberate statement. Perhaps it
reflects an anti-authoritarian attitude and/or a wish for power.
5. What feelings and responses are evoked in this segment? What could this tell us about
aspects of his personality?
People feel wariness or fear. At the same time, they attack him, sometimes in a ridiculing manner.
This man might likely evoke a similar response in others.
his is probably a direct reflection of how he responds to the world. He attacks others through
T
his own fear and defensiveness.
Segment Two (10 minutes)
6. What strikes you in this segment? What words, images and affective responses come to mind?
Keep in mind your initial speculations.
Note down the words, images and affects that arise. Use a white-board or butchers paper for this.
Spend at least five minutes on this section.
7. Discuss any forming hypotheses
Spend at least ten minutes on this section.
Notice that the paranoia is highlighted and reinforced.
8. In this segment, the patient talks about others exploding, breaking out and killing.
What do you think this is about? Is he talking about himself?
9. When the interviewer asks the patient if he is talking about himself, the patient
flatly denies it. Why might this be? What defense mechanisms is he using?
He is putting unwanted feelings into others, including his own children.
The defense mechanisms include denial, projection and displacement.
Personality Style I
10
10. This man is simultaneously guarded and attacking. What personality style does
this remind you of?
Paranoid. When feeling under threat, a paranoid personality will respond with a counter-attack.
11. What is the difference between the control exerted by an obsessional person and that
exerted by a paranoid person?
12. Do you think there is an anti-social element here? What are key features of an antisocial
personality structure?
hile there are many features of an antisocial personality disorder, many of which are listed
W
in DSM, perhaps the most important of these is a lack of empathy and concern for others.
13. What is his affective state? What effect does this have on you?
147
e demonstrates marked ambivalence. This leaves him frustrated and helpless in dealing with
H
the world and its challenges. Those involved with him, including his carers, find themselves in
the same situation helpless and frustrated.
14. Do you think he is able to use help?
15. Do you notice the dilemma that his persecutory world view presents you with?
This man wants his persecutory world view confirmed.
ou are forced to either join him in his persecutory position or to reject his viewpoint and
Y
thus threaten to reject him.
ither of these two options reinforces his paranoid stance and leaves him isolated and lonely
E
in a persecutory world.
16. He mentioned that he owns firearms. How does this make you feel?
Afraid? Suspicious? Threatened? Cautious? Angry?
17. Do you notice the grandiosity in his descriptions? Discuss where this might come from.
18. To what extent is the grandiosity an example of unhealthy narcissism and to what extent
does it reflect healthy aspirations?
19. Despite a rough facade, this man is seeking to form attachment.
If you engaged in a treatment contract with him, what are the difficulties you might face?
eflect on his future prognosis particularly in regards to co-operative relationships including
R
a therapeutic alliance.
he difficulty is that for this man, feeling vulnerable is likely to be intolerable. He will therefore
T
avoid affect states that make him feel vulnerable and needy.
If he is forced to confront these negative emotions he will respond with either:
depression, or
acting under threat, become aggressive and reassert control.
NOTES
148
149
Session 11
150
Personality Style II
OBSERVATION OF RECORDED SEGMENTS OF AN INTERVIEW
AND GROUP DISCUSSION
Summary of Session
This is the second of two sessions on Personality Style. It draws on the lecture and other material
discussed in the first of these two sessions and then goes more deeply into the interpersonal and
trans-generational impact of personality structure and personality disorder.
In this session, a pre-recorded interview between a consultant psychiatrist and a patient is used
as a launch pad for discussion.
1. Review the accompanying USB material containing six segments of an interview between a
consultant psychiatrist and a patient, and recorded group discussions
Ensure that you are able to discuss relevant aspects of the topic
2. Photocopy the discussion prompts (appendix 11.1) to distribute to trainees during the session
Personality Style II
11
151
Appendices listing
Appendix 11.1: Discussion prompts for trainees
Appendices
Appendix 11.1: Discussion prompts for trainees
1. What do you notice about the interviewers approach to the patient?
Why do you think he approaches him in this way?
Consider
affects
patients somatic state
interviewers body language
152
2. What do you think of the young female registrar being sent out of the room?
3. Discuss what you noticed in Segment Three
4. Discuss what you noticed in Segment Four. Why do you think he has raised his children in
this way?
5. What precipitated the suicide attempt?
How does it relate to his personality style?
How does it relate to his relationship with his wife and children?
6. What is the aetiology of his childrens narcissism and grandiosity in terms of their upbringing?
7. What is the aetiology of his (the patients) narcissism and grandiosity in terms of his upbringing?
8. What do you think of the hair-cutting episode?
9. Summarising discussion: Discuss the trans-generational transmission of personality issues
153
154
Session 12
Reflective Interview Skills I
OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION
OPTION A
Organise your own
interview
OR
OPTION B
Watch the interview segments
on the accompanying USB
Summary of Session
This session is an introduction to the concept of reflective interviewing.
In this session the group watches and discusses several brief segments of a doctor-patient
interview. There are two options for this session:
Option A: Organise your own doctor-patient interview
Option B: Watch the interview material on the accompanying USB
12
Check with your relevant hospital authority about the procedures relating to confidentiality
and consent in your hospital
4. The interview
A fifty-minute assessment interview
The interview must be recorded prior to the session
NB. The interview needs to be done in sufficient time for the interviewer (trainee) to watch
the recording and to select segments from the interview for discussion during the session
see below
The trainee conducting the interview should not take notes while interviewing the patient
5. After the Interview
The interviewer should watch the recording of their interview and select three segments of
two-five minutes duration to be watched by the group during the session
Selected segments should include poignant moments, for example where transference/
countertransference was particularly strong, where there was a shift or change in rapport,
or other illustrative moments
The interviewer should prepare a very brief (ten second) introduction to their interview one
that does not include diagnosis or formulation, but one that orientates viewers to the interview.
e.g. This is an interview with a 39-year-old man who I saw on the day of his admission to the
psychiatric unit.
6. Watch the segments selected by the trainee to ensure you are familiar with the content
7. Review the discussion prompts (appendix 12.1.1), and photocopy them to distribute to
trainees during the session
156
Note to Facilitator 1
It is important that the trainee who conducted the interview limit their input into the initial
part of the discussion. This is to ensure uncontaminated responses from the group in the
relative absence of background information.
Refrain from asking the interviewer for additional content or history not covered in that
segment. Instead the focus should remain on the information that can be gleaned from the
moment-to-moment interaction.
Note to Facilitator 2
It is essential to ensure that the trainee who conducted the interview feels safe and
supported rather than exposed to the group. The purpose of the interview segments
is to generate discussion surrounding interview technique and NOT to critique the skill
of the trainee. Therefore the discussion should not involve feedback or criticism of the
interviewers technique and as session facilitator you must ensure that the discussion does
not head down this path.
4. Ensure that there is sufficient time at the end of the session for summarising discussion refer
to discussion prompts and facilitator notes (15 minutes)
Note to Facilitator
The interview segments on the accompanying USB contain subject matter of a particularly
horrific and shocking nature.
12
157
5. Ensure that there is sufficient time at the end of the session for a summarising discussion
refer to discussion prompts and facilitator notes (15 minutes)
Appendices listing
For use with Option A (Organising your own interview)
Appendix 12.1.1 Discussion prompts for trainees
For use with Option B (Watching the interview segments on the accompanying USB)
Appendix 12.2.1 Discussion prompts for trainees
Appendix 12.2.2 Facilitator notes
158
Note all words, images and affective responses on a white board or butchers paper
2. Begin to formulate tentative hypotheses about the patients diagnoses on various axes on the
basis of your observations and associations.
3. What do you notice about the patients general appearance?
4. What do you notice about the patients tone of speech?
5. What do you notice about the patients content of speech?
6. Discuss any incongruities
For example:
contradictions within the content of the segment parts of the narrative that dont quite fit together
incongruities between the tone of speech and the content
incongruities between the verbal and non-verbal communication
incongruities between the way the patient presents him/herself to you and what the content
of the narrative suggests (e.g. a patient reports that they are compliant but the history includes
police presentations, lengthy involuntary admissions and community treatment orders)
7. Discuss your affective responses to the patient
8. Do you feel empathy for the patient? Why, or why not?
9. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
10. With your observations and associations in mind, discuss and elaborate on your early
tentative hypotheses
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others, including the
treating team, are likely to respond to that patient, and about their early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences
12
159
Begin to formulate tentative hypotheses about the patients diagnoses on various axes on
the basis of your observations and associations
3. What do you notice about the patients general appearance?
4. The patients face is blurred out of this recording. He specifically requested this. In view of this,
does it surprise you that he agreed to be recorded?
5. What do you notice about the patients tone of speech?
6. What do you notice about the patients content of speech?
7. What do you notice about the patients thought-form?
8. Discuss any incongruities
9. Discuss your affective responses to the patient
10. How do you feel when the patient mentions these traumatic and shocking things?
11. Do you feel empathy for the patient? Why or why not?
12. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss these
Discuss what the interviewers responses to the patient might reflect
Segment Two
13. What strikes you in this segment? What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions
to remain
Note all words, images and affective responses on a white board or butchers paper
14. With your observations and associations in mind, discuss tentative hypotheses
15. What do you notice about the patients tone of speech?
16. What do you notice about the patients content of speech?
17. Discuss any incongruities
18. In terms of diagnostic possibilities, what is the interviewer exploring in this segment?
19. What techniques is the interviewer using in this segment?
20. Discuss your affective responses to the patient
21. What is your response to the shocking content?
1
ourgeois, M. (1994) The First Few Minutes: Original Contact and the Speed of Psychiatric Diagnosis. In The Clinical Approach
B
in Psychiatry. Pierre Pichot and Werner Rein (eds).
22. Do you feel empathy for the patient? Why, or why not?
23. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
24. Does the patient feel empathy for the boys?
25. Do you see a parallel between the patients lack of empathy and our difficulty in empathising
with him?
160
26. With your observations and associations in mind, discuss and elaborate on your early tentative
hypotheses
Segment Three
27. What strikes you in this segment? What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions to
remain
Note all words, images and affective responses on a white board or butchers paper
28. With your observations and associations in mind, discuss tentative hypotheses
29. What do you notice about the patients tone of speech?
30. What do you notice about the patients content of speech?
31. Discuss any incongruities that are apparent
32. Discuss your affective responses to the patient
33. What do you notice about the patients understanding of actions and consequences?
34. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
35. Is this man trying to make a connection with others?
36. How do treating teams experience this man?
37. What does this tell us about his early life experiences?
38. What problems might treating teams face in the management of this patient?
39. If there is time, watch segment four and discuss following a similar format to above
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others (including
the treating team) are likely to respond to that patient, and their early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences
12
161
Begin to formulate tentative hypotheses about the patients diagnoses on various axes
on the basis of your observations and associations
3. What do you notice about the patients general appearance?
4. The patients face is blurred out of this recording in response to his request. In view
of this, does it surprise you that he agreed to be recorded?
This is an incongruity and should be kept in mind.
The blurring of the face creates a sense of anonymity.
We wonder about shame and embarrassment.
5. What do you notice about the patients tone of speech?
Speech is low key and toneless. It lacks affective range.
Each piece of information is given the same weight.
The patient sounds almost bored, or perhaps detached from himself.
6. What do you notice about the patients content of speech?
Initially, the topics are emotionally neutral, or convey a low-grade dysphoria and low
self-esteem.
He then mentions the mutilation, torture and murder of young boys.
7. What do you notice about the patients thought-form?
8. Discuss any incongruities
For example:
contradictions within the content of the segment parts of the narrative that dont quite fit together
incongruities between the tone of speech and the content
incongruities between the verbal and non-verbal communication
incongruities between the way the patient presents him/herself to you and what the content
of the narrative suggests (e.g. a patient reports that they are compliant, but the history includes
police presentations, lengthy involuntary admissions and community treatment orders)
The shame communicated by the preservation of his anonymity contrasts with his willingness
to be recorded
The tone of speech is incongruous with the dramatic content it remains unchanged in a way
that is surprising and somewhat jarring.
162
11. Do you feel empathy for the patient? Why or why not?
Perhaps it is partly because of the blurring of the face the lack of facial features,
but it is hard to feel empathy at this stage.
12. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss these
Discuss what the interviewers responses to the patient might reflect
When the patient brings up the topic of the torture of young boys, neither he nor the
interviewer react the way you would expect someone to react to something so sensational.
When someone reacts in an unusual way it usually indicates something important.
The interviewer probably found this topic unthinkable at this point and was reacting in a
defensive manner. Alternative explanations include empathic mirroring or suppression to
maintain rapport.
Segment Two
13. What strikes you in this segment? What words, images and affective responses come
to mind? Avoid prematurely editing or foreclosing on your impressions. Allow apparent
contradictions to remain
Note all words, images and affective responses on a white board or butchers paper.
14. With your observations and associations in mind, discuss tentative hypotheses.
15. What do you notice about the patients tone of speech?
16. What do you notice about the patients content of speech?
The content is increasingly shocking and dramatic, and the story increasingly brutal.
17. Discuss any incongruities
18. In terms of diagnostic possibilities, what is the interviewer exploring in this segment?
The interviewer is attempting to determine whether the disturbing thoughts are:
1. Ego-dystonic: characteristic of obsessions, reflecting an obsessive-compulsive disorder, or
2. Ego-syntonic: characteristic of a paraphilia
19. What techniques is the interviewer using in this segment?
The patient initially appears to disown his symptoms but the interviewer brings him back to them.
The interviewer is clear and persistent. She asks first open-ended questions, then poses
alternatives, and then uses clarification to hone in on the specific psychopathology.
20. Discuss your affective responses to the patient
21. What is your response to the shocking content?
You may feel anxious and alarmed. You may feel repulsion.
You may feel paradoxically bored and/or detached.
12
22. Do you feel empathy for the patient? Why, or why not?
While you might feel some empathy for the patient, as he is very alone in this predicament,
it is very hard to genuinely relate to him, to imagine what it would be like to be in his shoes
23. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
The interviewer is not showing much reaction.
She appears to be trying to remain calm, non-judgemental and understanding.
24. Does the patient feel empathy for the boys?
No, he does not feel real empathy. Any attempt at empathy is very concrete.
163
An extreme example of this is his explanation for electrocuting himself, that he did it in
order to see what it would feel like to a little boy.
This man lacks the capacity for what Peter Fonagy refers to as mentalization the
fundamental capacity to understand mental states such as thoughts and feelings. He has no
ability to think about how things might feel to another. the capacity to make sense of ourselves
and others in terms of mental states.
25. Do you see a parallel between the patients lack of empathy and our difficulty in
empathising with him?
26. With your observations and associations in mind, discuss and elaborate on your early
tentative hypotheses
Segment Three
27. What strikes you in this segment? What words, images and affective responses come
to mind? Avoid prematurely editing or foreclosing on your impressions. Allow apparent
contradictions to remain
Note all words, images and affective responses on a white board or butchers paper.
28. With your observations and associations in mind, discuss tentative hypotheses
29. What do you notice about the patients tone of speech?
30. What do you notice about the patients content of speech?
31. Discuss any incongruities that are apparent
32. Discuss your affective responses to the patient
33. What do you notice about the patients understanding of actions and consequences?
He has a very primitive, concrete understanding of actions and their consequences.
34. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
There is a shift in rapport. Up to this point, the interviewer seems to be oscillating between
empathy and distaste but in this segment it is as though she has given up. She is no longer
trying to create a moral awareness in the patient.
She becomes less empathic and appears angry with him and while not quite punitive is
certainly challenging.
35. Is this man trying to make an emotional connection with others?
This man appears to want a connection with others, but is completely unable to create
this connection.
164
Our response to this man tells us that he has been very damaged from a very young age.
We can imagine that in his formative years he experienced others as confusing, punitive,
cruel and/or sadistic and lacking in empathy. It is likely that his only experience of emotional
connection was through pain and that he has learnt to experience pain as love.
38. What problems might treating teams face in the management of this patient?
Without on any level justifying what this man does, we can imagine that he is trying to make
emotional contact with others the only way he knows through perversity and horror.
Any successful treatment program would require that this man make a connection on a
level other than that of pain and sadism.
A difficulty faced in Victim Empathy Programs is that some sadistic patients, rather than
develop empathy, get gratification from seeing victims suffer. This is something that would
need to be monitored closely.
39. If there is time, watch segment four and discuss following a similar format to above.
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others (including
the treating team) are likely to respond to that patient, and their early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences.
165
Session 13
166
OR
OPTION B
Watch the interview segments
on the accompanying USB
Summary of Session
This session is the second of two sessions on reflective interviewing. It follows a similar format
to the previous session on reflective interviewing.
During the session the group watches and discusses several brief segments of a doctor-patient
interview. There are two options for this session:
Option A: Organise your own doctor-patient interview
Option B: Watch the interview material on the accompanying USB
13
167
Check with your relevant hospital authority about the procedures relating to confidentiality
and consent in your hospital
4. The interview
A fifty-minute assessment interview
The interview must be recorded prior to the session
NB. The interview needs to be done in sufficient time for the interviewer (trainee) to watch the
recording and to select segments from the interview for discussion during the session see below
The trainee conducting the interview should not take notes while interviewing the patient
5. After the Interview
The interviewer should watch the recording of their interview and select three segments
of two-five minutes duration to be watched by the group during the session
Selected segments should include poignant moments, for example where transference/
countertransference was particularly strong, where there was a shift or change in rapport,
or other illustrative moments.
The interviewer should prepare a very brief (ten second) introduction to their interview one
that does not include diagnosis or formulation, but one that orientates viewers to the interview.
e.g. This is an interview with a 39-year old man who I saw on the day of his admission to the
psychiatric unit.
6. Watch the segments selected by the trainee to ensure you are familiar with the content
7. R
eview the discussion prompts (appendix 13.1), and photocopy them to distribute to trainees
during the session
Note to Facilitator
The trainee who conducted the interview is to remain silent for the initial part of each
discussion. This is to ensure uncontaminated responses from the rest of the group.
Refrain from asking the interviewer for additional content or history not covered in the
segment. Instead, the focus should be on the information that can be gleaned from the
segment itself and from the moment-to-moment interaction between the interviewer and
interviewee.
168
Note to Facilitator
The trainee who conducted the interview must feel safe and supported rather than
exposed to the group. The purpose of the interview segments is to generate discussion.
It is NOT a critique of the skill of the trainee. As session facilitator you must ensure that the
group discussion does not head down this path.
4. Ensure that there is sufficient time at the end of the session for a summarising discussion
refer to discussion prompts and facilitator notes (15 minutes).
Appendices listing
For use with Option A (Organising your own interview)
Appendix 13.1 Discussion prompts for trainees
For use with Option B (Watching the interview segments on the accompanying USB)
Appendix 13.2.1 Discussion prompts for trainees
Appendix 13.2.2 Facilitator notes
13
169
170
Begin to formulate tentative hypotheses about the patients diagnoses on various axes on the
basis of your observations and associations
3. What do you notice about the patients general appearance?
4. What do you notice about the patients tone of speech?
5. What do you notice about the patients content of speech?
6. What do you notice about the patients thought-form?
7. Discuss any incongruities
8. Discuss your affective responses to the patient
9. Do you feel empathy for the patient? Why, or why not?
10. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
11. What do you think this segment tells us about the patients view of herself?
12. With the above observations and associations in mind, discuss and elaborate on your early
tentative hypotheses
Segment Two
13. What strikes you in this segment?
What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions to remain
14. With your observations and associations in mind, discuss tentative hypotheses.
15. What do you notice about the patients tone of speech?
16. What do you notice about the patients content of speech?
17. Discuss any incongruities
18. Discuss your affective responses to the patient
19. Do you feel empathy for the patient? Why, or why not?
20. How might you see a punitive reaction in the hospital setting?
21. Does anyone feel sad?
13
22. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Does the interviewer direct the patient much, or does the patient take control of the interview herself?
Discuss what the interviewers responses to the patient might reflect
23. In which personality type do we characteristically see the communication of vast amounts
of detail in the absence of emotional content?
24. In this segment, the patient describes many inadequate caregivers. What do you make of this?
25. How might treating teams respond to this woman?
26. What might this tell you about her early life?
27. In view of this discussion, what do you think about her recurrent medical and psychiatric complaints?
171
28. If there is time, watch segments three, four and five and discuss following a similar format to above
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others, including the
treating team, are likely to respond to her and her early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences
172
Note all words, images and affective responses on a white board or butchers paper.
2. The first few minutes of a psychiatric assessment are critical in forming early impressions.
Begin to formulate tentative hypotheses about the patients diagnoses on various axes on
the basis of your observations and associations
3. What do you notice about the patients general appearance?
She is dressed as a patient would dress, wearing a nightgown rather than street clothes.She
has set herself up comfortably for the interview a blanket, lip cream, a bottle of water things
that may be comforting for her
There is something young about this appearance and set-up.
4. What do you notice about the patients tone of speech?
Low, monotonous and lacking inflection.
5. What do you notice about the patients content of speech?
She is versed in medical terminology
The content is dramatic, her account detailing seemingly endless traumatic events since birth,
events in which she was a victim, and was passive.
For example raped by an ex-best friend at the age of eight and a bit. Ive never had a
boyfriend, never had sex, have no interest in sex. Ive had thirty-nine general anaesthetics.
I had a total abdominal hysterectomy
There is little, if any, mention of the feelings associated with the above events.
6. What do you notice about the patients thought-form?
Circumstantial/over-inclusive long and detailed response to a single question.
7. Discuss any incongruities
For example:
c ontradictions within the content of the segment parts of the narrative that dont quite fit
together
incongruities between the tone of speech and the content
incongruities between the verbal and non-verbal communication
incongruities between the way the patient presents herself to you and what the content of the
narrative suggests
There is a marked incongruity between her monotonous tone of speech and the content of
speech. It appears as though she is uninterested in her own life story and has been through it
many times before.
13
173
The interviewer is perhaps overwhelmed by the quantity of content that is impassively related
to her. She allows the flow to continue for some time but towards the end of this segment
makes an attempt to direct the patient.
11. What do you think this segment tells us about the patients view of herself?
She seems to be demonstrating two things:
worthlessness, low self-esteem and indifference about her experiences
pride in what she has endured. This has become her primary identity as a patient
12. With your observations and associations in mind, discuss and elaborate on your early
tentative hypotheses
Segment Two
13. What strikes you in this segment?
What words, images and affective responses come to mind? Avoid prematurely editing
or foreclosing on your impressions. Allow apparent contradictions to remain.
Note all words, images and affective responses on a white board or butchers paper.
14. With your observations and associations in mind, discuss tentative hypotheses
15. What do you notice about the patients tone of speech?
16. What do you notice about the patients content of speech?
17. Discuss any incongruities
18. Discuss your affective responses to the patient
19. Do you feel empathy for the patient? Why, or why not?
It remains difficult to feel empathy for this patient.
The sense that she may be responsible for her own incapacity or is using the system for
secondary gain, further disrupts empathy.
Those directly involved in her care may have a similar response and could feel increasingly
helpless and frustrated.
As frustration builds, another common response may be to become moralistic and punitive.
20. How might you see a punitive reaction in the hospital setting?
This may be acted out, for example, by treatments or operations that arent medically required,
or by refusing treatment such as pain medication even when medically-indicated.
21. Does anyone feel sad?
It is as though we should feel sad but dont. By the time she gets to the point of a story, we
are fatigued and overwhelmed by relentless detail.
22. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Does the interviewer direct the patient much, or does the patient take control of the
interview herself?
Discuss what the interviewers responses to the patient might reflect
The interviewer allows the patient to talk. The interviewer is relatively passive. She is tolerating
the patient without being actively engaged.
Meanwhile, the patient talks without requiring any direction from the interviewer. She appears to
enjoy the attention focussed on herself. She is demonstrating, albeit subtly, a controlling quality.
174
The patient would probably not tolerate any loss of this control. To interrupt her, for example to
insist on certain details, might feel threatening to her fragile sense of self.
In this segment the patient communicates times when she has lashed out against unhelpful
others and is communicating her potential to lash out again.
23. In which personality type do we characteristically see the communication of vast amounts
of detail in the absence of emotional content?
This is typical of cluster C Obsessive Compulsive Personality Disorder.
24. In this segment, the patient describes many inadequate caregivers. What do you make of this?
There is a devaluation of those who fail her.
In this setting she is attempting to form a bond with the interviewer and does so by uniting
herself with the interviewer, both with superior knowledge and expertise.
This is an example of splitting. The patient is not aware of this process. It is unconscious.
25. How do treating teams respond to this woman?
We would anticipate that many who come in contact with this patient would respond in a
similar way. There would likely be frustration, weariness and helplessness in response to her
recurrent presentations.
26. What might this tell you about her early life?
Our response to a patient gives us useful information about:
the way others respond to them, and
their early life experiences.
Therefore we can use our responses to form tentative hypotheses.
For example, we may wonder if this is a communication of her early experiences of the world
as the youngest of six children, with an overloaded, fatigued and overwhelmed mother.
27. In view of this discussion, what do you think about her recurrent medical and psychiatric
complaints?
Perhaps it is only through illness that she is able to evoke a response from others.
28. If there is time, watch segments three, four and five and discuss following a similar format
to above.
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others, including the
treating team, are likely to respond to her and her early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences.
175
176
Session 14
The Therapeutic Alliance
LECTURES
Dr Jeanette Martin
The Therapeutic Alliance
Dr Loyola McLean
Working the Therapeutic
Alliance
Summary of Session
This session is an overview of the therapeutic alliance. It includes definitions, theory
and clinical applications.
The session consists of two lectures that detail/discuss different aspects of the therapeutic alliance.
14
177
Appendices listing
Appendix 14.1 Lecture slides for The Therapeutic Alliance by Dr Jeanette Martin
Appendix 14.2 Lecture slides for Working the Therapeutic Alliance by Dr Loyola McLean
Appendices
Appendix 14.1 Lecture slides
The Therapeutic Alliance by Dr Jeanette Martin
178
Slide 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
14
179
Slide 7
Slide 8
Slide 9
Slide 10
Slide 11
Slide 12
180
Slide 13
Slide 14
Slide 15
Slide 16
Slide 17
Slide 18
14
181
Slide 19
182
Slide 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
14
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Slide 7
Slide 8
Slide 9
Slide 10
184
NOTES
185
Session 15
Introductory Formulation I
186
PART 1: LECTURE
Dr James Telfer
Formulation
Summary of Session
This is the first of two sessions on formulation. The session is divided into two parts:
PART ONE: A lecture an overview of formulation
PART TWO: An interactive component where the group discusses and practices formulation with a
real clinical example. This component is based on segments of a recorded doctor-patient interview
and relevant recorded group comments and discussion
Introductory Formulation I
15
187
1. Review the accompanying USB segments of an interview these segments do not comprise
a complete interview (25 minutes)
2. Photocopy the discussion prompts (appendix 15.2.1), the example of a formulation using the
Three P Model (appendix 15.2.2) and the RANZCP Clinical Examinations Formulation Guidelines
for Trainees (appendix 15.2.3) to distribute to trainees during the session
3. Review facilitator notes (appendix 15.2.2)
Appendices listing
For use with Part One (Lecture)
Appendix 15.1 Lecture slides for Formulation by Dr James Telfer
Appendices
Appendix 15.1 Lecture slides
For use with Part One (lecture)
Formulation by Dr James Telfer
188
Slide 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
Introductory Formulation I
15
189
Slide 7
Slide 8
Slide 9
Slide 10
Slide 11
Slide 12
190
Slide 13
Slide 14
Slide 15
Slide 16
Slide 17
Slide 18
Introductory Formulation I
15
191
192
Introductory Formulation I
15
b) Precipitating factors
recent loss of employment
eviction from his unit
relationship breakdown
we might hypothesise that his impending 50th birthday could have a role
c) Perpetuating factors
social isolation
ongoing stressors such as financial strain from his loss of employment
6. A patients behaviour during an interview also informs your formulation. Think about
this mans behaviour during the interview and the information we may take from this
193
See the formulation from the RANZCP Clinical Examinations Formulation Guidelines
for Trainees (appendix 15.2.4) for an example of a formulation in chronic illness.
14. Discuss elements of the case that have not been discussed so far that could be
included in your formulation
culture: Anglo-celtic male (sense of identity and worth focussed on family and
employment success)
spirituality
cognitive style
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Introductory Formulation I
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We dont know very much about Toms earlier life but his mother attempting suicide when Tom was
a child is suggestive of significant major mental illness. In addition to the genetic factors, the loss of
his mother would have constituted a major disruption in Toms attachment to his primary caregiver.
We might also hypothesise that his mothers mental illness prior to her suicide would have resulted in
a lack of attunement to Tom, and this would have resulted in a lack of the validation required for him
to develop a healthy sense of self.
A marital breakdown ten years ago, and the ongoing strain in Toms relationship with his wife and
children since that time, suggest ongoing attachment issues possibly of an avoidant-dismissive style.
This would have further predisposed Tom to developing a major depressive disorder.
There are a number of perpetuants social withdrawal, reduced contact with his girlfriend, and
leaving his job exacerbating his financial stressors.
Tom does have strengths he is well-engaged with the community mental health team, and
makes reference to ongoing relationships with his siblings, showing the ability to form some helpful
attachments. He is also able to identify some strengths and talents that he has. These strengths
may have had a role in Tom seeking treatment, and are potentially good prognostic indicators.
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HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY
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No. 5
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No. 7
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No. 8
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Session 16
Introductory Formulation II
OBSERVATION OF AN INTERVIEW FOLLOWED BY
AN INTERACTIVE GROUP EXERCISE AND DISCUSSION
OPTION A
Organise your own
interview
OR
OPTION B
Watch the interview on
the accompanying USB
Summary of Session
This session is the second session on formulation. It draws on the knowledge and skills
introduced in the previous session.
In the session, the group watches clinical material and then discusses and develops a formulation.
There are two options for this session.
Option A: Organising your own doctor-patient interview
Option B: Watching the interview segments on the accompanying USB
Introductory Formulation II
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Must be co-operative
Must have capacity to consent to the interview
3. Prior to the interview
Explain the interview to the patient and obtain written consent
check with your relevant hospital authority about the procedures relating to confidentiality
and consent in your hospital
4. The interview
A forty-minute assessment interview
The interview can either be pre-recorded and then watched by the group during the session,
or it can be observed live by the group:
The trainee conducting the interview should not take notes while interviewing the patient
*If the group is present in the room during the interview, the number of observers should be limited.
Ensure that observers sit out of the direct line of sight of the patient and that they remain passive throughout
the interview
Note to Facilitator
The focus of this session is formulation rather than the interview itself. The interview is short
(i.e. 40 minutes), therefore it will not be possible to take a full history. There should however
be sufficient history to enable the group to formulate.
5. If you selected that the interview be pre-recorded for viewing during the session, it is recommended
that you watch the interview prior to the session to familiarise yourself with the content
6. Review the discussion prompts (appendix 16.1), and photocopy them to distribute to trainees
during the session
208
6. Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions
Appendices listing
For use with both Option A and Option B
Appendix 16.1 Discussion prompts for trainees
Introductory Formulation II
16
Appendices
Appendix 16.1 Discussion prompts for trainees
For use with both Options A and B
1. What techniques does the interviewer use in this interview? Are these helpful?
2. What are relevant gaps in the history?
3. Discuss the key issues raised in this interview
4. In this interview, what is the patients primary predicament?
5. Why is the patient in this predicament why is this happening at this particular time?
209
Consider:
predisposing factors
precipitating factors
perpetuating factors
6. A patients behaviour during an interview also informs your formulation. How does the
patients behaviour inform us?
7. Choose a member of the group to read out their formulation
8. Discuss any pertinent themes that came up in the trainees formulation that have not
yet been raised
9. Have you considered:
bio-psycho-social issues
cultural context
spiritual beliefs
cognitive style
developmental stages
coping/defense mechanisms
risk assessment
countertransference
prospects of rehabilitation (strengths, quality of life, morale)?
NOTES
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211
Session 17
Cognitive-Behavioural Approach and Formulation
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PART 1: LECTURE
Dr Lisa Lampe
The Cognitive Formulation
in Anxiety
Summary of Session
This session is about a cognitive-behavioural approach to understanding a patients presentation.
The session is divided into two parts:
PART ONE: A lecture: an overview of developing a cognitive-behavioural model or formulation
PART TWO: An interactive component using segments of a pre-recorded interview between a
consultant psychiatrist and a patient to integrate the concepts introduced in the lecture
17
213
1. Prior to the session, review the USB and discussion prompts to familiarise yourself with the
material
2. Photocopy the session discussion prompts (appendix 17.2.2), the patient history (appendix
17.2.1) and the Cognitive-Behavioural Model for Jenny (appendix 17.2.4) to distribute to
trainees during the session
3. Review facilitator notes (appendix 17.2.3)
Appendices listing
For use with Part One (Lecture)
Appendix 17.1 Lecture slides for The Cognitive Formulation in Anxiety by Dr Lisa Lampe
Appendices
Appendix 17.1.1 Lecture slides
For use with Part One (lecture)
The Cognitive Formulation in Anxiety by Dr Lisa Lampe
214
Slide 1
Slide 2
Slide 3
Slide 4
Slide 5
Slide 6
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Slide 7
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Slide 9
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Slide 11
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Currently
Married twenty-one years
Children aged fifteen years, thirteen years and nine years
Her husband is supportive and they have a good relationship
Many stressors recently including recent sale of her house and building a new one, and
assisting her parents with the sale of their property
Chronic, ongoing stressors with her in-laws
Close to her parents but they are emotionally dependent on Jenny and unable to be supportive of her
A few months ago Jenny gave up her one day per week job at a coffee-shop as she had too
much on her plate
Psychiatric treatment
Outpatient treatment has not given any relief to her symptoms. She has had very brief trials of
Alprazolam and Escitalopram
Continues to see her psychologist of one year regularly
Routine GP visits
Has also sought treatment during this episode from numerous other medical and alternative
health providers
Past history
She has a past history of post-natal depression/anxiety nine years ago full recovery
Commenced antidepressant medication approximately one to two years ago, and then ceased
these six months ago
Family history
Father: alcoholism
Mother: anxious
Premorbid Personality
An anxious temperament but usually functions well (social, occupational and family)
Developmental History
From early childhood Jenny felt she had to be an adult that she was responsible for her
parents safety and well-being
1.
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4. Watch and discuss an excerpt of Segment One. In this excerpt the interviewer is posing a
hypothesis to the patient.
What is Jennys response to the interviewers hypothesis? What does Jennys response tells us?
5. Why does the interviewer put forward hypotheses to the patient?
Segment Two
Beginning to conceptualise the patient in terms of a cognitive model
6. Are you getting a picture of what is going on with this patient? What is the history so far?
Discuss in terms of predisposing, precipitating and perpetuating factors
7. What are Jennys cognitions around her fear i.e. what does she fear?
8. Are these cognitions typical of an anxiety disorder?
9. Thinking about the history attained thus far and the mental state of the patient what are your
differential diagnoses?
Difficulties associated with anxious patients
10. Discuss how to manage each of the following difficulties associated with anxious patients:
high levels of distress during the interview
requesting or demanding reassurance from the interviewer
increased frequency of medication side-effects
a contagious sense of anxiety and urgency
a level of distress and urgency that propels patients into seeking treatment from a number
of different health care providers
Segment Three
11. Discuss the interview techniques that were used in this segment
Segment Four
Watch the interviewer posing the following hypothesis in Segment Four
12. What is the patients response to the hypothesis?
Segment Five
Watch the interviewer posing the following hypothesis in Segment Five
13. What is the patients response to the hypothesis?
218
17. Why does avoidance (including safety behaviours) perpetuate the problem?
18. What are attributions? What is an attributional bias?
17
219
2. Why do you think the interviewer keeps returning to the precipitating incident?
Your first assessment of a patient is often your best chance of gaining a clear understanding of:
The exact sequence of events
The patients response to these events, including their cognitive reactions
How the patients response to the precipitating event might have affected future outcomes
This understanding affects your cognitive model/formulation, and influences your management plan
3. What are some of the difficulties the interviewer faces in this segment of the interview?
How does she manage these?
his is an extremely anxious and distressed patient, with outbursts of tears, coughing, and
T
even retching
She says, When Im with someone like you, I dont want to leave you
The patients level of distress impacts on her ability to give a clear account of recent events
Her distress means she requires a lot of containment by the interviewer
4. Watch and discuss an excerpt of Segment One. In this excerpt the interviewer is posing
a hypothesis to the patient. What is Jennys response to the interviewers hypothesis?
What does Jennys response tells us?
The patient doesnt respond to the hypothesis posed. This could either be because:
It does not ring true for her, or
She is too overwhelmed by distress and anxiety to take in what the interviewer has said
5. Why does the interviewer put forward hypotheses to the patient?
It is part of the collaborative approach of cognitive-behavioural therapy models that the patient
and the doctor work together to come to an understanding of the presenting problem, and its
causes
It is important that the doctor notices and listens to the patients responses and adjusts future
hypotheses accordingly
Segment Two
Beginning to conceptualise the patient in terms of a cognitive model
6. Are you getting a picture of what is going on with this patient? What is the history so far?
Discuss in terms of predisposing, precipitating and perpetuating factors
Write the factors the group comes up with on a white-board or on butchers paper
Predisposing factors:
Past history of depression/anxiety
Family history suggests a biological predisposition
Early life experiences may make her psychologically vulnerable
Precipitating:
The event in the car
Other life-stressors e.g. moving house
220
Perpetuating:
Perhaps the stress of ongoing conflict with her husbands family plays a role though we
would need to explore this further
At this stage in the interview we are beginning to form hypotheses about the perpetuating
cognitions and perpetuating behaviour:
a. Behaviours, particularly avoidance behaviours, are common perpetuants of anxiety
disorders. At this point in the history we dont see that as a major factor. Jenny did try and
get in her car and drive again so she tried to face her fears, but the anxiety persisted.
b. It is typical of anxiety that the cognitions ensuing from the precipitating event perpetuate
the disorder. The cognitions are discussed in more detail below.
7. What are Jennys cognitions around her fear. That is, what does she fear?
Precipitating event: In the car Jenny feared loss of control
On an ongoing basis Jenny fears others seeing her anxious, and of letting others down
8. Are these cognitions typical of an anxiety disorder?
The initial fear of loss of control is typical of an anxiety disorder.
he ongoing fears of others seeing her in a distressed state, of never getting better, and the
T
sense of failure, worthlessness and guilt at letting others down are not typical of an anxiety
disorder.
9. Thinking about the history attained thus far and the mental state of the patient, what
are your differential diagnoses?
s well as an anxiety disorder, it is important to have major depression high up on the list of
A
differentials.
upporting the diagnosis of depression is the extreme distress that the patient exhibits, the
S
sense of failure, worthlessness and guilt at letting her family down, the reported diurnal
variation, and that her cognitions as above are not typical of those of an anxiety disorder.
Difficulties associated with anxious patients
10. Discuss how to manage each of the following difficulties associated with anxious
patients:
high levels of distress during the interview
requesting or demanding reassurance from the interviewer
increased frequency of medication side-effects
a contagious sense of anxiety and urgency
a level of distress and urgency that propels patients into seeking treatment from
a number of different health care providers
17
Segment Three
More on interviewing techniques
11. Discuss the interview techniques in this segment
There are appropriate reassurances
There are no false reassurances. For example, the interviewer is honest when she replies
I cant predict the future
Socratic dialogue, asking questions and involving Jenny
Grounds with firm and definite statements when possible and appropriate, for example she
tells Jenny with certainty that she will not end up in hospital for the rest of her life
Gives appropriate information and education
221
Segment Four
Watch the interviewer posing the following hypothesis in Segment Four
12. What is the patients response to the hypothesis?
While the patient doesnt openly disagree with the interviewer, she doesnt agree with her either.
Segment Five
Watch the interviewer posing the following hypothesis in Segment Five
13. What is the patients response to the hypothesis?
Jenny is listening and nodding.
Here we see interviewer and interviewee working collaboratively on a shared hypothesis.
Continue to conceptualise the patient in terms of a cognitive-behavioural model
14. Add to your initial formulation in terms of predisposing, precipitating and perpetuating
factors, and cognitive-behavioural factors. Think particularly about the perpetuating factors.
Return to your white-board or your butchers paper and add to your initial formulation
See appendix 17.2.4 for an example of a cognitive-behavioural model for this patient.
15. What is your diagnosis?
Provisional Diagnosis:
The provisional diagnosis is a Major Depressive Episode. The history is of a non-psychotic
depression, though Jenny refers at one stage in the interview to critical voices that would
need to be explored further.
There is probably an underlying Generalised Anxiety Disorder (GAD). There is often a
significant overlap between GAD and depression.
Differential diagnoses:
Panic disorder is on the list of differentials but is less likely than depression.
Be cautious about the diagnosis of a primary anxiety disorder (even as a comorbidity) in
the context of significant depression.
222
17
Predisposing
Strengths
Family history
Reasonable insight
Anxious, sensitive
temperament
223
DEPRESSION/ANXIETY
PERPETUATING
Environmental
Cognitions
Behaviours
I am worthless and a
failure
Seeing a number
of different health
professionals who give
different advice
I dont deserve to be
happy
NOTES
224
225
Session 18
Psychodynamic Formulation I
226
LECTURES
Dr Jeffrey Streimer
Psychological Formulation in
the Assessment Interview
Dr Loyola McLean
Psychodynamic Formulation:
Aspects of Attachment and
Development
Summary of Session
This is the first of two sessions on psychodynamic formulation. It provides trainees with an
introduction on how to formulate from a psychodynamic perspective.
In this session there are two lectures, each on a different aspect of psychodynamic formulation.
Please Note
There are no generally agreed formats that all psychodynamic formulations should follow.
Therefore the following two sessions introduce and explore the various themes and
concepts of psychodynamic formulation but do not provide a prescriptive framework.
Use the concepts and ideas introduced herewith to practise and develop your own style,
appropriate to your level of experience, the particular patient and to the context.
Psychodynamic Formulation I
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227
Appendices listing
Appendix 18.1 Lecture slides for Psychological Formulation in the Assessment
Interview by Dr Jeffrey Streimer
Appendix 18.2 Lecture slides for Psychodynamic Formulation: Attachment and
Development by Dr Loyola McLean
Recommended reading:
Kassaw K, Gabbard G: Creating a Psychodynamic Formulation from a clinical examination.
Am.J.Psychiatry 159:5, May 2002
Perry S, Cooper A, Michaels R: The Psychodynamic Formulation: Its Purpose, Structure
& Clinical Application. Am J Psychiatry 144:5, May 1987
Summers R: The Psychodynamic Formulation Updated. Am J Psychotherapy 59:1, 2003
Mace C, Binyon S: Teaching Psychodynamic Formulation to psychiatry trainees: Part 1:
Basics of Formulation. Advances in Psychiatric Treatment 11:416-423, 2005
Appendices
Appendix 18.1 Lecture slides
Psychological Formulation in the Assessment Interview by Dr Jeffrey Streimer
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Session 19
240
Psychodynamic Formulation II
OBSERVATION OF A RECORDED INTERVIEW FOLLOWED
BY AN INTERACTIVE EXERCISE AND GROUP DISCUSSION
Summary of Session
This is the second session on psychodynamic formulation. It builds on the concepts introduced
in the previous session.
This session uses a recorded interview between a consultant psychiatrist and a patient to develop
a psychodynamic formulation.
Psychodynamic Formulation II
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5. Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions
Appendices listing
Appendix 19.1 Case summary
Appendix 19.2 Tables: Attachment Style Summary and Level of Maturation
Appendix 19.3 Formulation summary sheet for trainees
Appendix 19.4 Formulation summary sheet for facilitators
Appendices
Appendix 19.1 Case summary
Kylie: Introductory Case Outline
This information is a summary of the history revealed at interview
Kylie1 nineteen-year old, unemployed single woman
Presenting Problems
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Session 20
History and Formulation in Child
and Adolescent Psychiatry
258
LECTURE
Dr Steven Spielman
Assessment in Child and
Adolescent Psychiatry
Summary of Session
This session is on assessment in child and adolescent psychiatry. It is a lecture and includes
some group discussion.
Appendices Listing
Appendix 20.1 Lecture slides for Assessment in Child and Adolescent Psychiatry
by Dr Steven Spielman
20
Appendices
Appendix 20.1 Lecture slides
Assessment in Child and Adolescent Psychiatry by Dr Steven Spielman
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Building 12
Gladesville Hospital
Shea Close off Victoria Road
Gladesville NSW 2111
Tel: (02) 9844 6551
Fax: (02) 9844 6544
email: info@heti.nsw.gov.au
www.heti.nsw.gov.au