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o E.g. 20y/o vs. 50y.o patient with head & neck tumor
GENERAL PSYCHIATRIC EVALUATION
o They are at different stages of development
A general psychiatric evaluation has as its central according to Erik Erikson
component an interview with the patient o How would that tumor and issues of disfigurement
The interview-based data are integrated with affect them considering at what particular stage they
information obtained through other components of the are in psychosocial development
evaluation - review of medical records, a physical Assess & treat somatization & somatoform disorders
examination, diagnostic tests, and history from collateral
Assess & manage common neuropsychiatric disorders
sources
o E.g. patient with SLE would develop cerebritis and
In the course of any evaluation, it may be necessary to would also present with behavioral changes
obtain history from other individuals
Understand needs of special populations with psychiatric
o Particularly psychiatric patients, they might be very
& psychosocial morbidity in medical settings
difficult to interview and some of them might not be
o Special populations: pregnant women, children,
able to give you reliable information
geriatric patients
The aims of a general psychiatric evaluation are:
Assess and manage acute & emergency presentations of
o To establish whether a mental disorder or other
psychiatric morbidity in the general medical setting
condition requiring the attention of a psychiatrist
(i.e. psychiatric care and management) is present
o To collect data sufficient to support differential
PSYCHIATRY IN THE GENERAL HOSPITAL
diagnosis and a comprehensive clinical formulation CATEGORIES OF PSYCHIATRIC DIFFERENTIAL DIAGNOSIS
o To collaborate with the patient to develop an initial Psychiatric Presentations of Medical Conditions
treatment plan that will foster treatment adherence, Psychiatric Complications of Medical Conditions or
with particular consideration of any immediate Treatment
interventions that may be needed to address the Psychological Reactions to Medical Conditions or
safety of the patient and others—or, if the Treatments
evaluation is a reassessment of a patient in long- Medical Presentation of Psychiatric Conditions
term treatment, to revise the plan of treatment in Medical Complications of Psychiatric Conditions or
accordance with new perspectives gained from the Treatments
evaluation Co-morbid Medical and Psychiatric Conditions
o To identify longer-term issues (e.g., premorbid
personality) that need to be considered in follow-up THE ART OF PSYCHIATRIC CONSULTATION
care Determining where on the vast border between
One thing you need to remember with regards to a psychiatry and medicine a patient’s pathologic condition
medical psychiatric consult is evaluations are usually is located is the psychiatric consultant’s fundamental task
requested by other physicians & healthcare professionals As for any physician, his or her chief responsibility is
Purpose: to assist in the diagnosis, treatment, and diagnosis
management of an individual with a suspected mental or o Diagnosis should be justified by a really good history
behavioral problem on top of or along with a medical of psychiatric illness
illness 4 key differences between general hospital psychiatry
Psychiatric evaluations for consultative purposes use the and practice in other venues (e.g. OPD)
same data sources as general evaluations o clinical approach
Information about illness, treatment, and prognosis are o environment
always relevant o style of interaction
o use of language
MEDICAL-PSYCHIATRIC CONSULT
The aim of the consultative psychiatric evaluation is to CLINICAL APPROACH
provide clear and specific answers to the questions posed by ENVIRONMENT
the party requesting the consultation Must be prepared to work in an atmosphere less formal,
rigid, and predictable than one typically found in an
SCOPE: office or a clinic
Understand impact of medical illness & how this affects Flexibility and adaptability are crucial.
the presentation, experience & impact of psychiatric &
psychosocial morbidity STYLE OF INTERACTION
Conduct biopsychosociocultural assessment, create Permit themselves to crouch at the bedside
formulation & implement appropriate treatment Lowering themselves to the recumbent patient’s level
Assess reactions to illness can diminish apprehension and can minimize the
Understand combined trajectories of illness & inherent power differential between doctor and patient
developmental issues of the person with mental health Shaking hands or otherwise laying on of hands may
problems & mental illness achieve the same end.
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LANGUAGE The practice of narrative medicine involves an ability to
Allowance for flexibility also extends to the use of acknowledge, absorb, interpret, and act on the stories
language and struggles of others
They can feel freer than they might in other practice The process of listening to patients’ stories is a process of
settings to use humor, slang expressions, and perhaps following the biological, familial, cultural, and existential
even foul language. thread of the situation
o As the doctor, take your cue from the patient, It encompasses recognizing the multiple meanings and
particularly those with space-occupying lesions. If contradictions in words and events; attending to the
they are not yet aware of what that mass is, use silences, pauses, gestures, and nonverbal cues; and
whatever term they use. Do not approach the patient entering the world of the patient, while simultaneously
and say “cancer” outright, especially if they do not arousing the doctor’s own memories, associations,
know their diagnosis yet. creativity, and emotional responses
o E.g. ask the patient “Ano po ‘yang bukol na ‘yan na Narratives, like all stories, are co-created by the teller
nasa leeg niyo?” if the patient says “Ah, cancer daw and the listener
ito.” Ask about what know about “cancer” because Storytelling is an age-old part of social discourse that
there’s a possibility that their understanding of that involves sustained attention, memory, emotional
term isn’t the proper definition of their term. It could responsiveness, nonverbal responses and cues,
be an opportunity to correct misconceptions. collaborative meaning-making, and attunement to the
listener’s expectations
PROCEDURAL APPROACH TO PSYCHIATRIC If a physician can assist the patient in telling his or her
CONSULTATION story effectively, reliable and valid data will be collected
1. Speak directly with the referring clinician and the relationship solidified
2. Review the current and pertinent past records Narratives are facilitated by authentic, compassionate,
3. Review the patient’s medications and genuine engagement.
4. Gather collateral data
5. Interview and examine the patient FACTORS INFLUENCING THE FORM AND CONTENT
6. Formulate a diagnosis and management plan OF THE INTERVIEW
7. Write a note SETTING
8. Speak directly with the referring clinician The setting must be comfortable for the patient and the
9. Provide periodic follow-up physician
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o Develop a partnership with the patient and form an accurate behavioral data as well as of ensuring that staff
alliance in which the patient participates in decision- implement recommendations
making. If the patient has an unclear sensorium or other cognitive
One of the psychological reactions to illness of impairments, it is critical to interview people in the
patients, particularly those who have to be patient’s relational network to see if these symptoms
admitted in the hospital to undergo treatment is were present before hospitalization or have developed
loss of control. since treatment was begun
So, letting them take an active part in decision In interviewing family members, it is very useful to
making with regards to their treatment discuss their beliefs about the patient’s illness and prior
somehow gives them a semblance of control treatment, the patient’s record of adherence to
o Work with patients’ families and support networks. medication treatment, and concerns about discharge
o Open the discussion planning
o Allow the patient to express his or her opening Information written in general medical charts should be
statement without interruption. confined to that necessary for the general medical team
o Encourage the patient to describe a full set of and should be conveyed with a level of detail and
concerns. specificity that will be most helpful to the overall
Begin with more open-ended questions during management of the patient
the start of the interview to encourage them to It is also important that documentation be of sufficient
expound detail to establish a diagnosis and treatment plan
o Maintain a personal connection during the Information written in general medical charts should be
interview. confined to that necessary for the general medical team
o Gather information and should be conveyed with a level of detail and
o Use both open- and closed-ended questions. specificity that will be most helpful to the overall
o Provide structure, clarification, and a summary of management of the patient
the information collected. It is also important that documentation be of sufficient
Listen actively, using verbal and nonverbal methods (e.g., detail to establish a diagnosis and treatment plan
eye contact).
Understand the patient’s perspective DOMAINS OF CLINICAL EVALUATION
o Explore contextual issues (e.g., familial, cultural, REASON FOR THE EVALUATION
spiritual, age, gender, and socioeconomic status). What is the patient’s chief complaint and its duration?
o Elicit beliefs, concerns, and expectations about
What reason does the patient give for seeking evaluation
health and illness.
at this specific time?
o Validate and respond appropriately to the patient’s
What reasons are given by other involved parties (e.g.,
ideas, feelings, and values.
family, other health professionals) for seeking evaluation
Share information
at this specific time?
o Avoid technical language and medical jargon.
o Determine if the patient understands your
HISTORY OF PRESENT ILLNESS
explanations.
What symptoms is the patient experiencing (e.g.,
o Encourage questions.
worries; preoccupations; changes in mood; delusions or
Reach agreement on problems and plans
hallucinatory experiences; recent changes in sleep,
o Welcome participation in decision-making.
appetite, concentration, memory, including suicidal or
o Determine patient’s amenability to following a plan.
aggressive behaviors)?
o Identify and enlist resources and supports.
What is the severity of the patient’s symptoms?
o Provide closure
Over what time course have these symptoms developed
o Ask if the patient has questions or other concerns.
or fluctuated?
o Summarize and solidify the agreement with a plan of
Are associated features of specific psychiatric syndromes
action.
(i.e., pertinent positive or negative factors) present or
o Review the follow-up plans.
absent during the present illness?
Data Collection
What factors does the patient believe are precipitating,
Psychiatric database
aggravating, or otherwise modifying the illness or are
temporally related to its course?
IN-PATIENT SETTING
Did the patient receive prior treatment for this episode
Evaluation should include assessment of the patient’s
of illness?
access to appropriate treatment following
Are other clinicians who care for the patient available to
hospitalization.
comment?
The patient’s living arrangements should also be
assessed to determine whether they will continue to be
INFORMATION DERIVED FROM THE INTERVIEW PROCESS
suitable after discharge
Are symptoms minimized or exaggerated by the patient
If the post-hospitalization disposition is not apparent, the
or others?
evaluation should identify both patient factors and
Does the patient appear to provide accurate
community resources that would be relevant to a viable
information?
disposition plan and should identify the problems that
Do particular questions evoke hesitation or signs of
could impede a suitable disposition
discomfort?
Family involvement, when appropriate, can also be
Is the patient able to communicate about emotional
initiated
issues?
Developing an ongoing relationship with staff on medical
How does the patient respond to the psychiatrist’s
inpatient units will increase the likelihood of obtaining
comments and behaviors?
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FUNCTIONAL ASSESSMENT What strategies for coping has the patient used
What are the patient’s functional strengths, and what is successfully during times of stress or adversity?
the disease severity? During childhood or adolescence, did the patient have
To what degree can the patient perform physical risk factors for any mental disorders?
activities of daily living (e.g., eating, toileting, What has been the patient’s capacity to maintain
transferring, bathing, dressing)? interpersonal relationships, and what is the patient’s
To what degree can the patient perform instrumental history of marital and other significant relationships?
activities of daily living (e.g., driving, using public What is the patient’s sexual history, including sexual
transportation, taking medications as prescribed, orientation, beliefs, and practices?
shopping, managing finances, keeping house, Does the patient have children?
communicating by mail or telephone, caring for What past or current psychosocial stressors have
dependents)? affected the patient (including primary support group,
social environment, education, occupation, housing,
PAST PSYCHIATRIC HISTORY economic status, and access to health care)?
What is the chronology of past episodes of mental illness, What is the patient’s capacity for self-care?
regardless of whether such episodes were diagnosed or What are the patient’s sociocultural supports (e.g.,
treated? family, friends, work, religious, community groups)?
What are the patient’s previous sources of treatment, What are the patient’s own interests, preferences, and
and what diagnoses were given? values with respect to health care?
With respect to somatic therapies (e.g., medications,
electroconvulsive therapy), what were the dose or QUESTIONS IN THE ANAMNESIS FOR WHICH AN
treatment parameters, efficacy, side effects, treatment AFFIRMATIVE ANSWER MAY INCREASE THE LIKELIHOOD OF
duration, and adherence? A PSYCHIATRIC ILLNESS
With respect to psychotherapy, what were the type, Did the patient lose a parent at an early age?
frequency, duration, adherence, and patient’s perception Was there unusual or excessive separation anxiety during
of the therapeutic alliance and helpfulness of the childhood or adolescence?
psychotherapy? Were there significant problems with sleep?
Is there a history of psychiatric hospitalization? Were there eating disturbances?
Is there a history of suicide attempts or aggressive Were there problems making or keeping friends?
behaviors? Was severe shyness a problem, including when
Are past medical records available to consult? interacting in peer groups?
Were there problems with being bullied or bullying?
GIVEN MEDICAL HISTORY/PAST MEDICAL HISTORY Were there frequent disciplinary problems in school?
What general medical illnesses are known, including Were there serious difficulties with temper?
hospitalizations, procedures, treatments, and Were there many school absences for medical problems
medications? or any other problems?
Are undiagnosed illnesses causing major distress or Were there delays in learning to read, write, or do math?
functional impairment? Were there serious problems paying attention, finishing
Does the patient engage in high-risk behaviors that school work, or completing homework?
would predispose him or her to a medical illness? Did the above problems lead to grade retention or
Is the patient taking any prescribed or over-the-counter special education intervention?
medications, herbal products, supplements, and/or
vitamins? HISTORY OF ALCOHOL AND OTHER SUBSTANCE USE
Has the patient experienced allergic reactions to or What licit and illicit substances have been used, in what
severe adverse effects of medications? quantity, how frequently, and with what pattern and
route of use?
FAMILY HISTORY What functional, social, occupational, or legal
What information is available about general medical and consequences or self-perceived benefits of use have
psychiatric illnesses, including substance use disorders, in occurred?
close relatives? Has tolerance or withdrawal symptoms been noted?
Is there a family history of suicide or violent behavior? Has substance use been associated with psychiatric
Are heritable illnesses present in family members that symptoms?
relate to the patient’s presenting symptoms? Are family members available who could provide
corroborating information about the patient’s substance
DEVELOPMENTAL, PSYCHOSOCIAL, AND SOCIOCULTURAL use and its consequences?
HISTORY (ANAMNESIS)
What have been the most important events in the OCCUPATIONAL AND MILITARY HISTORY
patient’s life, and What is the patient’s occupation, and what jobs has the
What were the patient’s responses to them? patient held?
What is the patient’s history of formal education? What is the quality of the patient’s work relationships?
What are the patient’s cultural, religious, and spiritual What work skills and strengths does the patient have?
beliefs, and how have these developed or changed over Is the patient unable to work due to disability?
time?
Regarding military service, what was the patient’s status
Is there a history of parental loss or divorce; physical, (volunteer, recruit, or draftee), did the patient
emotional, or sexual abuse; or exposure to other experience combat, and did the patient suffer injury or
traumatic experiences? trauma?
Is the patient preparing for or adjusting to retirement?
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LEGAL HISTORY The level of detail for assessment of cognitive function
Does the patient have any past or current involvement varies depending upon the patient's combined medical
with the legal system (e.g., warrants, arrests, detentions, and psychiatric condition
convictions, probation, parole)? The mental status examination can be tailored to the
Do past or current legal problems relate to aggressive patient's clinical presentation, which may include
behaviors or substance intoxication? judgment about the patient's capacity to participate in
Has the patient had other significant interactions with exams with formal rating scales
the court system (e.g., family court, workers’
compensation dispute, civil litigation, court-ordered DIAGNOSTIC TESTS
psychiatric treatment)? What diagnostic tests are necessary to establish or
Is past or current legal involvement a significant social exclude a diagnosis, aid in the choice of treatment, or
stressor for the patient? monitor treatment effects or side effects?
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ASSESSMENT FOR THE EXTENT THE PSYCHIATRIC EVALUATION OF THE PATIENT’S COPING STYLE
DISTURBANCE IS CAUSED BY MEDICATION OR SUBSTANCE Illness is a stress that requires both the afflicted patients
ABUSE and the systems that surround them them to adapt via
The patient's medication list and recent changes in improvements in coping strategies and interpersonal
medication are critically important to review relationships
Psychiatric symptoms are frequently produced by Coping is best defined as problem-solving behavior that
medications (e.g., corticosteroids) prescribed for medical is intended to bring about relief, reward, quiescence, and
disorders equilibrium.
Analgesics, sedatives, anticonvulsants, anesthetics, Implies a combination of knowing what the problems are
psychotropics, and anticholinergics are groups of and how to go about reaching a correct direction that
medications commonly associated with psychiatric will help resolution.
disturbances. Coping is not a simple judgment about how some
The type, quantity, and frequency of prescription drug difficulty worked out. It is an extensive, recursive process
use as well as illicit drug and alcohol use should be of self-exploration, self-instruction, self-correction, self-
assessed rehearsal, and guidance gathered from outside sources.
Previous episodes of structured outpatient or inpatient At virtually every step of patient care, physicians and
treatment should be inquired about, as well as prior patients actively assess coping ability.
experiences associated with drug withdrawal The conclusions drawn about how a patient is processing
his or her illness has a tremendous impact on therapeutic
ASESSMENT FOR DISTURBANCES IN COGNITION decisions, on psychological well- being, and indeed on
The search for even subtle disturbances in cognition is the overall course of illness.
crucial to every psychiatric evaluation of the medically ill Coping with illness and its ramifications cannot help but
patient be an inescapable part of medical practice.
If a disturbance in cognition is identified, determine if the Therefore the overall purpose of any intervention,
change in mental status is chronic and due primarily to physical or psychosocial, is to improve coping with
the consequences of an underlying disorder OR acute potential problems beyond the limits of illness itself.
and arising secondary to the effects of illness, Such interventions must take into account both the
medication, or a combination of factors problems to be solved and the individuals most closely
o E.g. patient with dementia, who, prior to admission, affected by the difficulties.
was already exhibiting cognitive symptoms vs. a How anyone copes depends on the nature of a problem
patient undergoing a delirious process as effect of as well as on the mental, emotional, physical, and social
the medical condition or medical treatment resources one has available for the coping process.
Characteristics of good copers:
ASSESSMENT OF PSYCHIATRIC SYMPTOMOLOGY AND o They are optimistic about mastering problems and,
BEHAVIOR despite setbacks, generally maintain a high level of
"Is the patient's behavior a normal response to the stress morale.
of illness and/or hospitalization and, therefore, likely to o They tend to be practical and to emphasize
resolve with improvement in physical health?” immediate problems, issues, and obstacles that must
o E.g. is the sadness/depressed mood being be conquered, even before visualizing a remote or
experienced by the patient a reaction to the current ideal resolution.
medical situation or is it a separate diagnosis (i.e. o They select from a wide range of potential strategies
already experiencing major depressive disorder and tactics, and their policy is not to be at a loss for
instead of a depressive reaction to the illness) fallback methods. In this respect, they are
The patient's perspective of possible precipitating, resourceful.
exacerbating, or resolving factors is most pertinent o They heed various possible outcomes and improve
Review of prior response to illness or psychiatric coping by being aware of consequences.
treatment can facilitate proper diagnosis and treatment o They are able to mobilize mature defense
Assess how well the patient is coping and whether mechanisms (e.g. anticipation)
he/she will be able to endure the course of illness o They are generally flexible and open to suggestions,
but they do not give up the final say in decisions.
EVALUATION OF THE PATIENT’S CHARACTER STYLE o They are composed, although vigilant, in avoiding
“What kind of patient has the illness?” emotional extremes that could impair judgment.
Information from several domains (e.g., developmental Characteristics of poor copers:
history, social history, occupational history) must be o They tend to be excessive in self-expectation, rigid in
integrated to form a dynamic life narrative leading up to outlook, inflexible in standards, and reluctant to
the current illness compromise or to ask for help.
Medical illness, surgery, and the many stresses of o Their opinion of how people should behave is
hospitalization are managed differently by individuals narrow and absolute; they allow little room for
with different character styles or DSM-IV Axis II tolerance.
personality disorders o Although prone to firm adherence to
Understanding how character influences the experience preconceptions, they may show unexpected
of physical illness is critical for explaining abnormal compliance or be suggestible on specious grounds,
patient behaviors, emotions, and demands with little cause.
o They are inclined to excessive denial and elaborate
rationalization; in addition, they are unable to focus
on salient problems.
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o Because they find it difficult to weigh feasible Submit, yield, and surrender to the inevitable
alternatives, they tend to be more passive than usual (passivity/fatalism)
and they fail to initiate action on their own behalf. Do something, anything, reckless/impractical (acting out)
o Their rigidity occasionally lapses, and they subject Look for feasible alternatives to negotiate (if x, then y)
themselves to impulsive judgments or atypical Drink, eat, take drugs, and so on, to reduce tension
behavior that fails to be effective. (tension reduction)
o They tend to be more passive than usual and fail to Withdraw, get away, and seek isolation (stimulus
initiate action on their own behalf reduction)
o They then to make impulsive decisions Blame someone or something (projection/
No one copes exceptionally well at all times, especially disowning/externalization)
with problems that are associated with risk and that Go along with directives from authority figures
might well be overwhelming. (compliance)
However, effective copers appear able to choose the Blame self for faults; sacrifice or atone (undoing self-pity)
kind of situation in which they are most likely to prosper.
In addition, effective copers often maintain enough RESOLUTION: HOW HAS IT WORKED OUT SO FAR?
confidence to feel resourceful enough to survive intact. Not at all
Finally, it is our impression that those individuals who Doubtful relief
cope effectively do not pretend to have knowledge that Limited relief, but better
they do not have; therefore they feel comfortable Much better; actual resolution
turning to experts that they trust.
The better we can pinpoint which traits a patient seems INQUIRY ABOUT THOUGHTS OF DYING
to lack, the better we can help a patient cope. Many patients think about dying, especially when their
illness is protracted, exhausting, or critical
THE MEDICAL PREDICAMENT – BRINGING IT ALL TOGETHER Thoughts of dying related to life-threatening physical
Coping refers to how a patient responds and deals with illness and suicidal ideation related to depression need to
problems within a complex of factors that relates to be distinguished
disease, sickness, and vulnerability Inquiry about the patient's understanding of the physical
In approaching medically ill patients, it is helpful to illness—its course and prognosis—allows the consultant
conceptualize disease as the categorical reason for being a unique opportunity to correct cognitive distortions on
sick, sickness as the individual style of illness and the part of the patient
patienthood, and vulnerability as the tendency to be In some situations, it is necessary to assess the capacity
distressed and to develop emotional difficulties in the of the patient to refuse treatment and to help the
course of trying to cope patient set reasonable limits on further treatment
Given these definitions, the psychiatrist needs to first ask Must be familiar with the medical treatment and/or
why now? hospital course to ascertain the patient's understanding
What has preceded the request for consultation? of his/her illness and its possible course, with or without
How does the patient show his or her sense of futility treatment
and despair?
How did the present trouble, both the medical and the FACTORS INFLUENCING THE FORM AND CONTENT
corresponding coping challenges, come about?
OF THE INTERVIEW
Was there a time when such problems could have been
SHARING INFORMATION AND PREPARING PATIENT FOR
thwarted?
TREATMENT
It is also important to note that not infrequently the
The conclusion of the psychiatric interview requires
treatment team is even more exasperated than the
summarizing the symptoms and history and organizing
patient.
them into a coherent narrative that can be reviewed and
The clinician must also assess the motivation of staff and
agreed on by the patient and the clinician
patients when a psychiatric intervention is requested.
This involves recapitulating the most important findings
Additionally, clinicians need to be aware that the real
and explaining the meaning of them to the patient
question is not always the problem for which one is
This part of the interview should involve explaining one
consulted.
or more diagnoses to the patient, as well as a
formulation of the patient’s strengths, weaknesses, and
PROBLEM
style of managing stress
In your opinion, what has been the most difficult for you
o Ethical consideration: you can explain psychiatric
since your illness started? How has it troubled you?
diagnosis but if there are other medical conditions
that is not clear to the patient but is not within your
STRATEGY: WHAT DID YOU DO (OR ARE DOING) ABOUT THE
scope of expertise, refer to one with more expertise
PROBLEM?
o Disclosure of diagnosis such as CA should be done by
Get more information (rational/intellectual approach)
the attending physician
Talk it over with others to relieve distress (share concern)
The latter part of the summary is intended to help ensure
Try to laugh it off; make light of it (reverse affect) Put it
that the patient feels understood
out of mind; try to forget (suppression/denial)
Education about treatment should include reviewing the
Distract myself by doing other things
pros and cons of various options. This is a good time to
(displacement/dissipation) dispel myths about psychiatric treatments, either
Take a positive step based on a present understanding pharmacotherapy or psychotherapy
(confrontation) Letting the patient know that treatment decisions are
Accept, but change the meaning to something easier to collaborative and patient-centered is absolutely essential
deal with (redefinition) in a discussion of this order.
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DISAGREEMENTS ABOUT ASSESSMENT AND TREATMENT END OF TRANSCRIPTION
There are times when a patient disagrees with a
clinician’s formulation, diagnosis, and treatment
recommendations.
Or the disagreement may be between the patient and Life before death.
the medical staff, with the psychiatrist in the challenging Strength before weakness.
position of the intermediary. Journey before destination.
In either case, it is wise to listen to the patient and hear -The First Ideal, Oathbringer by Brandon Sanderson
where there is conflict.
This can serve to reestablish the alliance. Transcription Team 2019
It may also diffuse the patient’s need to defend himself Transcribed by: Sharmaine Tablada
or herself against what he or she may perceive as doctors Edited by:
“ganging up” on him or her. References: Lecture handout,
Evaluator should systematically review what was said recordings
and how he or she interpreted the clinical findings. Remarks: Underlined text were
The patient should be encouraged to correct underlined by Doc in
misrepresentations the handout and ppt.
At other times, the patient may deny or minimize a Must be must knows
problem. In this case additional interviews may be
necessary. Factors influencing the form and content of the interview:
It is sometimes useful to involve a close relative or friend situation (sample situations)
If the patient is a danger to self or others, protective “Hi, Ms. Jones. I know you really don’t want to be here. I
measures will be needed, short of any agreement. understand that your doctor and family are concerned about
If there is no imminent danger, explaining one’s clinical your weight. I assure you that my job is first and foremost to
opinion and respecting the right of the patient to choose understand your point of view. Can you tell me why you think
treatment must be observed they wanted you to see me?”
It may also be necessary to work with the medical team
“Good morning, Mr. Jones. I heard from your wife that she is
to reach a compromise that takes into consideration the
really concerned about your drinking, and your safety,
patient’s goals and wishes when they differ from that of
especially when driving. First, let me tell you that neither I nor
the medical team.
anyone else can stop you from drinking. That is not my
o We encourage the patient to take a more
mission today. I do want to know what your drinking pattern
collaborative role in their treatment
is, but more than that, I want to get the picture of your entire
life to understand your current situation.”
ERRORS IN PSYCHIATRIC INTERVIEWING
Premature closure and false assumptions about
“Hi, Ms. Carter, my name is Dr. Beresin. I am terribly sorry
symptoms
you are strapped down, but the police and your family were
False reassurance about the patient’s condition or
very upset when you locked yourself in the car and turned on
prognosis
the ignition. They found a suicide note on the kitchen table.
Defensiveness around psychiatric diagnoses and
Everyone was really concerned about your safety. I would like
treatment, with arrogant responses to myths and
to discuss what is going on, and see what we can do together
complaints about psychiatry
to figure things out.”
Omission of significant parts of the interview
Recommendations for treatment when diagnostic “Good morning, Mr. Harris. My name is Dr. Beresin. I heard
formulation is incomplete about your surgery from Dr. Rand and understand you have
Inadequate explanation of psychiatric disorders and their been having some experiences that may seem kind of strange
treatment, particularly not giving the patient multiple or frightening to you. Sometimes after surgery, people have a
options for treatment reaction to the procedure or the medications used that
Minimization or denial of the severity of symptoms, due causes difficulties with sleep, agitation, and mental confusion.
to overidentification with the patient; This is not unusual, and it is generally temporary. I would like
countertransference phenomenon to help you and your team figure out what is going on and
Failure to establish a genuine, empathic rapport (e.g., by what we can do about this.”
using brusque language, tone, or body posture)
Use of an angry or dismissive style in response to a PAST-E 2018
patient who is guarded or hostile 35. Elements of the psychiatric interview of the medically ill:
Inadvertently shaming or embarrassing a patient, and not a. Clarification of the reason for referral
offering an apology b. Review of the medical chart for pertinent medical factors
c. Description of the behavior noted by the medical staff
d. All of the above
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37. True regarding evaluation of the medically ill patient’s 29. Purpose of the Mental Status Examination in the
character style: medically ill patient:
a. Based solely on information obtained from the history of a. To obtain information about how pain contributes to the
present illness illness
b. Reaction to illness Is influenced by an existing personality b. To address feeling of unattended suffereing and
disorder helplessness
c. Understanding of the factors that contribute to under c. To elicit the patient’s capacity to understand the illness
treatment of pain d. To form a dynamic life narrative leading up to the current
d. All of the above illness
ANSWER KEY
2018 35 D 36 C 37 B 38 C 39 C 40 C
2017 21 D 23 C 26 B 27 C 29 C
2016 51 C 52 C 53 C 54 B 55 C
56 A 57 D 58 B 59 C 60 C
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