THE PSYCHIATRIC INTERVIEW - CARLAT (NOTES)

THE PSYCHIATRIC INTERVIEW - CARLAT (NOTES) what are the 4 tasks of the interview? - CORRECT ANSWER-build an alliance obtain the Psychiatric database (hx relevant to their presentation today, PHx, Fhx, PMHx etc) interview for dx negotiate a tx plan what is our intitaly first job? how do we do this? - CORRECT ANSWER-to ease their suffering, this is before making a dx. all our pts are suffering, you have to address this first. how: depression is different for everybody and may present with different sxs. For a 24 y/o college graduate who has been floundering around, may just need help clarifying her goals. this is what we can help them do in their first visit. spend most of this first visit thinking about their lives and not their dx. this alone is an alliance booster, just be sure to ask about their life and that starts it all. what is the overall goal of the interview? - CORRECT ANSWER-to figure out treatment not to figure out a dx. what percentage drop out of tx brute they're 4th visit? - CORRECT ANSWER-50% what is the most important part of the interview? - CORRECT ANSWER-negotiating a tx plan. if they don't feel comfortable with it then the interview might as well not have been done. length of time for the 3 phases of the interview - CORRECT ANSWER-opening: 5-10 min body: 30-40 min closing: 5-10 min explain what the 3 phases of the interview - CORRECT ANSWER-intro: - learn about their life - give a few minutes to tell why they came body: - est. interviewing priorities - HPI - Hx of depression, SI, substance abuse - FHx - determine whether they meet criteria - if have time: social/developmental Hx, PMHx, psych ROS closing: - discuss assessment (w/ pt education) - negotiated tx plan what to put in your office - CORRECT ANSWER-make it homie: photos of family, plants, decorations on wall arrange seating: put clock easy for you to see ( just behind pt) guidelines for patient contact - CORRECT ANSWER-- never give home or cell phone number - if giving a contract number specify times they may call you - instruct what to do in emergency when you can't be contacted - leave a voicemail system for them to call and let them know if it's emergent you'll call back within 24 hrs - sign pts out to another clinician when you're on vacation and inform him of more severe pts or chronically suicidal pts. change voicemail to have instruction to contact this clinician. - use email but this too needs ground rules (limit to scheduling needs and refills, anything more has to be added to their EMR). - for HIPPA add note saying: "please be aware that email communication can be intercepted in transmission or misdirected. your use of email to communicate protected health information to us indicate that you acknowledge and accept the possible risks associated with such communication. please consider communicating any sensitive information by telephone, fax, or mail. if you do not wish to have your information sent by email, please contact the street immediately." - get pts number and email. ask if it's okay to identify yourself when you call because some people don't want family or employers knowing they're in tx. hey contact info for energy contact people, need consent before doing this. rapport building techniques - CORRECT ANSWER-- empathic or sympathetic statements: "you must have felt Truckee when she left you". communicate your average and understanding of painful emotions. but don't over use them. - direct feeling questions: "how did you feel when she left you?" - reflective statements: "you sound dad when you talk about her". don't overuse because it sounds like you're stating the obvious. - if you notice countertransference happening, see them as psychopathology and develop compassion for them on that basis first techniques to make the patient comfortable - CORRECT ANSWER-- greet naturally: introduce yourself and make small talk for a minute (unless in emotional distress) - ask what they wanna be called and use their name a few times during the interview - learn something about them so they're more comfortable sharing about themselves: "before we get into what brought you here, if like to know a little about you as a person, where you live, what you do, that sort of thing." - explain what will happen in the interview: many think they're just here for psychotherapy. start by asking if they know why they're here and then give your explanation (length of interview, what info you'll be asking about, and follow up going forward). - then give them 5 minutes of free speech to explain what is going on. Ask them to explain the most troubling symptoms first and go from there. if they're giving you articulate info let them keep going but if they aren't you have to cut them off and direct the interview more but give them the inital 5 minutes. - after this make a goal with your patient by asking them: what would make this visit the most helpful for you today, what would you like to get it of it? -- if they're reluctant ask the miracle scenario: "imagine that tonight you go to bed, like you normally do. Then, imagine that while you're asleep, a miracle happens and your depression (or whatever problem) goes away. what will your day be like tomorrow?" techniques to help the pt elicit sensitive material - CORRECT ANSWER-Most common - normalization: normalize it by introducing your question with a normalizing statement, 2 ways to do this: - start question by implying the behavior is normal or understandable response to mood or situation: "With all the stress you've been under, I wonder if you've been drinking more lately?" or "Sometimes when people are very depressed, they think of hurting themselves. Has this been true for you?" - describe another pt who has had this behavior to show your pt they're not alone: "I've seen a number of pts who've told me that their anxiety causes them to avoid doing things, like driving on the highway or going to the grocery store. Has that been true for you?" Note: do not normalize severely abnormal behaviors such as extreme violence or sexual abuse. Others: - symptom expectation: aka gentle assumption. you infer that a behavior is expected by stating your question implying you assume the pt is having some behavior and you won't be offended with a positive response. Especially good if suspect self destructive activity like drug use or suicide. Ex: "what sorts of drugs do you usually use when you're drinking?" or "what kinds of ways to hurt yourself have you thought about?" Note: only use this when you suspect behavior, don't be asking every 70 y/o women what drugs they're using. - symptom exaggeration: often used with sx expectation helps clarify severity of sxs. You suggest a frequency of a behavior that is higher than you expectation, then their lower frequency will seem not as bad. Ex: "How often do you binge and purge each day? 5 times, 10 times?" Note: again only do this when appropriate for the pt and only if you suspect they're already doing the behavior. - Reduction of guilt: begin by asking about other people (have they had friends involved in these situations etc) -- for domestic viol Terms to use to be more familiar with your pts - CORRECT ANSWER-Instead of = say - Do you have a hx of IV drug use? = Have you ever shot up? - do you smoke marijuana? = do you get high/smoke dope? - do you use cocaine? = do you snort or smoke coke? Note: using these terms increases honesty by 15% Tips to improve pt recall (accurate memories) - CORRECT ANSWER-Anchor Qs to memorable events: pts forget dates of events that occurred more than 10 days in the past. We remember events in relation to memorable events (graduations, birthdays, holidays, accidents, major purchases, seasonal events or public events [elections]). So instead of asking how many years ago they began drinking, ask "Did you drink when you graduated from high school?" Then just keep on going back in time in relation to events to see when it began and if sxs began prior for example. Tag Qs with specific examples: tag a list of examples onto the end of your question "what were the names of the medications you took back then? was it proxac, paxil, Zoloft, Elavil etc? Define technical terms: sometimes pts just don't understand terms you use. ex: you ask a pt when they first felt depressed, they say they always have been depressed. You explain what clinical depression is (seriously affects functioning), when did you first experience that? they respond with 1 month ago. Tips for transitioning in the interview - CORRECT ANSWER-smooth transition: cue off something the pt just said to introduce a new topic - "John has been good to me, but I can't stand the way his daughters expect me to go out of my way to make their lives easy; after all, they're adults!" respond with "speaking of family, has anyone else in your family been through the kind of depression you've been going through?" Referred transition: refer to something the pt said earlier in the interview to move to a new topic. - "My doctor tried me on some medication for a while but it didn't do much good." respond with "Earlier, you mentioned that you didn't know how much more of this you could take. Have you had the thought that you'd be better off dead?" Introduced transition: introduce the next topic or series of topics before actually going into it. - "now I'd like to switch gears and ask about different psychological symptoms people sometimes have. Many of these may not apply to you at all, and that's a useful thing to know in itself" Techniques for the reluctant pt vs talkative pt - CORRECT ANSWER-reluctant: - use open ended Qs - use continuation techniques: "go on", "uh huh", "continue with what you were saying about...", "really?", "wow." these are combined with positive body language showing active listening - neutral ground: some pts get turned off when the questions become more "psychiatric", when this happens change topics to non - psychiatric (normal talk about your pts life) and once pt is involved again return to psychiatric Qs - second interview: if all else fails cut the interview short and try again next time saying "Why don't we stop for now and meet again next week. That will give you a chance to think more about the sorts of things that are bothering you, and we can take it from there." Just make sure they are not in imminent risk of suicide or unsafe behaviors. Talkative: key is to have a highly controlling style - close ended or multiple choice Qs (limit choices even more than close ended, try not to bias the answers in how you ask the Q though) Note: don't only use these or you will alienate the pt and they will just become reluctant to share important info, have to sprinkle them in - redirecting questions to another topic: this is the art of gentle interruption (often pts appreciate this because they get anxious and angry with their train of though if left loose to speak for too long) -- empathic interruption: add empathic statement to soften blow. Like "I can tell that this situation's been really hard for you to deal with. Have you been drinking lately, to cope with it?" -- delaying interruption: you assure the pt their topic is important and you'd like to come back to it "I can see you feel strongly about your daughter's school troubles, that something we can talk about later, but right now I need to ask you about some of those signs of depression you were experiencing. Was your appetit clues it's a malingering (lying for personal gain) pt - CORRECT ANSWER-Tale is too perfect: sxs in near perfect dsm 5 order - avoid this by keeping questions open ended. then ask something unexpected like "did you parents have this?" and follow up with "that's odd, in my experience that's very uncommon for parents to also have it, are you sure?" watch for a change in response. Tale is too vague: some don't give detail so they don't slip up - avoid this by using very close end questions. "in my experience, pts with panic get tingling lips do you?" if now become very specific they may be lying. sxs are unrealistic: voices should be almost always outside their head, almost never vague, usually intermittent not constant, not common to have command hallucinations and those who do almost never obey them, if questioning they almost always chastise not info seek. Ask specific questions to investigate. nothing works: pts may just want to keep disability payments coming. they need 4-6 wks of compliant meds or 8 therapy sessions. then offer aggressive txs, if they decline for vague reasons is a tip off. state you can't keep filling out disability form if they keep rejecting tx options, they usually stop coming after that. "I heard about a thing called Klonopin from a friend who has what I have": red flag if they ask for controlled meds really in interview, insist early all non addictive txs don't work for them, they report they tried their friends meds, has Hx of abuse. - say "are you aware that is very dangerous and addictive?" seekers will be dramatic and say "really?" or be super calm and say "I know people say that but I've never had a problem". then ask to speak with prior prescribers, if hesitant then you know. how to initiate a family interview with c&a pts? - CORRECT ANSWER-go out to greet the pt and say: "why don't we all go in for the first part of the hour, then maybe I can have some time to chat with ___ afterward." how do you address a family interview when one party is talking over the other? - CORRECT ANSWER-"everyone obviously had a lot of feelings about this issue but it is important that I get a chance to hear everyone's viewpoint without to much interrupting." how do you transition from a family interview to an individual interview with the adolescent? - CORRECT ANSWER-"I enjoyed meeting you and now id like to talk about done things with Matthew. afterward, we'll get back together and discuss what we've talked about " how do you start an Adolescent individual interview? - CORRECT ANSWER-"okay, now I get to hear your side of the story. we have a half hour to so to talk confidentially. I got you'll feel comfortable telling me your side of the story of what's been going on at home." if family interview was heated say "whew, things got pretty hot there; what do you think?" after that initial question what do you say to make Adolescents more comfortable as you ask personal questions? - CORRECT ANSWER-"do you mind if I ask you some personal questions? I may ask some you're uncomfortable answering and you don't have to answer if you don't want to." how to explain confidentiality to an Adolescent - CORRECT ANSWER-"I won't tell your parents about anything you say unless I'm worried that your life might be in danger." then before bringing family back in ask: "is there anything you don't want me to tell your parents?", "it's it okay I tell your parents these things?", "do you want to or do you want me to?" how do you get around the "I don't know" syndrome with Adolescents? - CORRECT ANSWER-"look if you really don't know something, that fine. but if you don't want to tell me something, that okay too. just say "I don't want to say." then use fly on the wall analogy: "if I were a fly on the real when you get into one of your moods, what would I see?" can also use displacement defense mechanism to your advantage: "do you have any friends who are in trouble? what's going on with them?" how can you get Adolescents to reveal personal info? - CORRECT ANSWER-attitude of curiosity and reflect are key: "do you like music? who do you like?" if you don't know that band tell them that and day what you like. be real, most Adolescents like goofy more than cool. then go into questions about school: "where do you go to school? what's it like? is it fun? easy? what are the kids like there? who do you hang out with?" ask about grades: "how's school going? is that the same as you've always done it have your grades changed recently? are there subjects that are particularly hard?" ask about hobbies: "what do you do with free time after school?", "are you in any sports or clubs?" - expressing interest in things is a big rule out for depression Gage their social isolation: "how many hours of TV do you watch on a school night? how many hours do you spend on the computer?" how do you ask Adolescents about drug use? - CORRECT ANSWER-"I hear there's a lot of dying and drug use at your school. do you know anyone who uses drugs?", "90% of kids use drugs these days. do you ever use drugs?" or: "how often do you drink?", "what drugs do you use?" how to ask Adolescents about sex - CORRECT ANSWER-has to come across as important for your assessment not of out of curiosity. approach this as romantic relationships not sex - "do you have any romantic relationships? how long have you been seeing this person? what's his/her name? what do you like about ___?" - "would you feel comfortable if we talked about your sex life?" are you active? are you using protection? do you know about AIDS? do you ever do things sexually that you later regret like not using protection or have sex with people you don't know that well? have you ever wondered whether your sexual feelings are normal?" how do you address legal issues with Adolescents? - CORRECT ANSWER-"it looks like your mom feels there's been a lot of ____ (stealing etc). I have no way of knowing if it's true, but if you were stealing, I'm sure there was a good reason for it. maybe it was the only way to get something out your friends dared you to?" if humor has been effective then brag: "so, I hear you're an excellent thief. what's the best thing you've stolen?" remember the ultimate goal is not confession but just finding out why they're doing it. what to say when wanting to interview family - CORRECT ANSWER-"as part of my evaluation of patients, I find it helpful to talk to someone else involved in your life. would that be okay with you?" what to say in individual family interview? - CORRECT ANSWER-1. what do you think has caused the problems? 2. has anyone given you a dx for this? what's your understand if that dx? 3. what makes things better? 4. what makes things worse? 5. what is a typical day like for them? 6. do you feel like I've been able to help ___ at all? do you have any ideas for how I could help ____ more? negative transference questions and responses - CORRECT ANSWER-"you're not a very helpful doctor" - hidden message: no one's ever cared for me and you're no exception or that I'm a very special patient and should be treated special - answer: "You know, that's not the first time I've heard that, and when I'm not being helpful to a pt I always ask how I can be more helpful? because I really want to help. So how can I help you more?" or "I bet it feels disappointing to have a doctor who doesn't come up to snuff. Is it possible though that you're judging prematurely?" "You look bored" - meaning: I'm a boring person or if you don't respond immediately positively to everything I say then you're having negative feelings towards me - response: "I'm actually not bored but do you think the things you're saying are boring to me?" or "in my profession silence never means boredom, it means concentration and interest." "It's that all you're going to do, just sit there silently and nod?" - meaning: you're just like my parents who never had interest in me - response: "does that seem unhelpful? I actually have a lot to say but I try to bite my tongue so my patients get to share their whole story. I'm most helpful when I understand their whole story." "what kind of credentials do you have?" - meaning: I'm in a lot of pain and I'm not sure anyone can help me or my whole life no one has cared and I want you to taste how that feels - response: "I'm an NP, I graduated from Vanderbilt University. Are you concerned about my ability to help you?" or "I'm an NP, I graduated from Vanderbilt University, but my main credential is that I'm here with you; I want to understand you and help you as best I can." "you don't show much understanding of what I'm saying" - meaning: I'm angry you understand without me having to explain, I want you to be the empathic parent I never had - response: you know, I couldn' classes of defense mechanisms - CORRECT ANSWER-mature: suppression, altruism, sublimation, humor neuotic: denial, repression, reaction formation, displacement, rationalization immature: passive aggressive, acting out, dissociation, projection, splitting psychotic: denial of external reality, distortion of external reality note: if using more immature defenses then they may have a personality disorder. pts using higher level defense mechanisms have better prognosis. HPI questions - CORRECT ANSWER-1. what has been happening over the past couple weeks - month that has brought you into the clinic? 2. when was the last time you remember feeling perfectly well? when did the current episode start? 3. have the been any events that have caused your problem or made them worse? 4. how has this impacted work, relationships or having fun? what were these like before? what was life like before? note: focus on dsm criteria when asking questions so illicit them in a way that gives criteria. psych Hx questions - CORRECT ANSWER-1. when did you have your first episode? when was your last episodes? how many have you had in between? 2. tx Hx: Go CHaMP - general questions: what tx have you had? what worked? - current caregivers: doctors, therapists, social workers etc. - hospitalization Hx: first and last, and total number; cause - medication Hx: doses and how many weeks they stayed on them; antidepressants need 6 wks, antipsychotics need 2 wks, did you take them everyday? - psychotherapy Hx: how often, type, length, with who; was it a psychiatrist or a social worker?; did it help? why did it end? note: a lot of this you will get during HPI medical hx questions - CORRECT ANSWER-MIDAS - medications: get a list, taking as prescribed? - illness hx: medical problems - PCP: do you see a regular Dr.? what did he control? get a release to share info with him/her - allergies: have you had any allergies, reactions or SEs to any medications? what happened? Document specifics - surgical hx ROS questions - CORRECT ANSWER-who to do it on - brief: young and middle to upper class - full: elderly or chronic ill brief: "I'm going to ask about problems with various parts of the body head to toe. any problems with headaches or seizures? vision or hearing? smelling, taste it throat? thyroid? problems with lungs like pneumonia or coughing? heart? stomach problems like ulcer or constipation? problems with urination? joint problems? problems walking?" full: - general: overall do you feel healthy? joint or skin problems (may indicate Lupus)? excessive bleeding or anemia (anemia can cause depression)? dm or thyroid problems (dm can cause lethargy; thyroid can cause depression/mania)? hx of cancer? any infections, HIV, or TB (HIV mimics psych disorders, TB mimics depression) - HEENT: do you get headaches (possible brain tumor)? have you ever had a head injury? any problems with vision or hearing? ever see or hear things other people don't? get nose bleeds? do you she'll things others don't (sign of temporal lobe epilepsy)? how are your teeth? do you get sore throats often? - CV/Respiratory: any heart problems (R/O HF as cause for fatigue that presents like depression)? chest pains or palpitations (rule out cause for panic attacks)? HTN? SOB? cough excessively (R/O lung cancer that causes anorexia and wt loss that resembles depression)? wheezing? - GI: n/v? make yourself vomit ever? problems with swallowing? constipation/diarrhea (IBS often accompanies psych and would not do TCAs if constipated)? change in stool? - GU: problems with urination (burning or excessive)? increased frequency (don't give anticholinergics with prostate issues) or incontinence? issues with sexual function? ever had HIV or syphilis? are you sexually active? are you dating this person? when did you start dating? how many sexual partners have you had in the past year? are yo family psych/medical hx questions - CORRECT ANSWER-bare bones - psych: "has any blood relative ever had nervousness, nervous breakdown, depression, mania, psychosis or schizophrenia, alcohol or drug abuse, suicide attempts, or hospitalization for nervousness?" - medical: "has any blood relative ever had a medical or neurological illness, like heart disease, DM, cancer, seizures, or senility?" tips: if unsure ask about txs like medications, if had ECT heritability of major Disorders with first degree relative - CORRECT ANSWER-BPAD: 25x Schizophrenia: 19x Bulimia: 10x Panic: 10x Alcohol abuse: 7x GAD: 6x AN: 5x Phobia: 3x Social anxiety: 3x MDD: 3x Agoraphobia: 3x social and developmental hx questions - CORRECT ANSWER-family life: - can you tell me a bit about your background, where you grew up, and how you grew up? - how many siblings do you have? where are you in the order? - what did your parents do for a living? - how did you get along with your parents? - what did they do when you disobeyed? - were you ever abused physically or sexually? - were there any other adults in the home growing up? - how did you get along with your siblings? - who were you closest to growing up? education and work: - did you enjoy school? - did you have many friends or did you keep to yourself? did you have a best friend? - what kind of grades did you get? - what did you do after you graduated or dropped out? - how do you support yourself? - did you ever work? did you like work? - how have you gotten along with coworkers? did you have a hard time dealing with authority figures? relationships: get intimate relationship status with HIV questions - when did you have your first important relationship? - what attracted you to that person?