Clinical Examination of the Psychiatric Patient

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Clinical Examination of the Psychiatric Patient

• Jeff Baker, Ph.D.
• Chief Psychologist
• Anesthesiology, Cardiothoracic Surgery,
  Orthopaedic Spine Surgery, Adult Rehabilitation
  Unit

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Interview of a Psychiatric Patient

• Interviews explore the following factors
• Genetic temperamental, biological,
  developmental, social, and psychological.

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In Successful Interviews the OT
Communicates/Creates

• Empathy Respect Competence Interest
• Define
• An atmosphere of trust that encourages the
  patient to talk honestly about his or her
  innermost feelings and thoughts.
• How do we do that? Analyze This Chap 8
• An opportunity for the patient to reveal the
  signs and symptoms that make up the potentially
  definable and treatable syndromes.
• Possible ideas?

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In Successful Interviews the OT
Communicates/Creates Continued

• Basic techniques of interviewing that work for
  most patients.
• Name them / Basic Ins Chap 4
• Must be prepared to interview a wide range of
  patients.
• Open Mind about individual and group differences
  is what makes life so interesting.
• What happens to the provider if not

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Depressed and Potentially Suicidal Patients

• Depressed patients are often unable to provide an
  adequate account of their illness spontaneously
  because of such factors as psychomotor
  retardation and hopelessness. Girl I Chap 1
• Need to ask history and symptoms related to
  depression including suicidal ideation.

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Depressed and Potentially Suicidal Patients

• Typical symptoms include feelings of
  hopelessness, sleep disturbance, appetite change,
  concentration problems, lack of energy or problem
  solving.
• SIS Chapter 10 / Girl I Chap 1

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Suicidality

• Evaluating Suicide potential is imperative when
  interviewing any depressed patient.
• Inquire about suicidal thoughts Are you
  suicidal now, or do you have plans to take your
  own life?
• Other risk factors suicide note, family hx of
  suicide, or previous suicidal behavior, evidence
  of impulsivity or of pervasive pessimism about
  the future also places the patient at higher risk
  for suicide.

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Suicidality

• If no immediate plan but the clinician still
  feels the patient is at risk, a contract or plan
  should be agreed upon with the patient written
  contract, ask family members to assist and agree
  to monitor the patient, ER resource, local MHMR
  resource, 800 crisis hotline resource, clinic
  phone number are all preventative techniques in
  suicide.

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Aggressive Patients

• Similar approach as suicide should be taken with
  aggressive patients.
• Assure the patient you can assist them in
  managing their behavior through the interview.
• Must establish whether effective verbal contact
  can be made with the patient or whether the
  patients sense of reality is so impaired that
  effective interviewing is impossible.

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Aggressive Patients Continued

• May have to medicate the patient before the
  interview begins.
• Have to make the decision whether it is safe to
  remove restraints.
• With or without restraints a violent patient
  should not be interviewed alone.
• Other precautions include leaving the door open
  and sitting between the patient and the door.

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Aggressive Patients Continued

• Must make it clear that the patient may say or
  feel anything but is NOT free to act in a violent
  way.
• OT must remain calm, and have additional staff
  able to maintain control, by physical means if
  necessary.
• Confrontation is to be avoided.
• The interviewer should respect as much as
  possible the patients need for space.
• Questions need to be asked regarding previous
  acts of violence, violence experienced as a
  child, under what specific conditions the patient
  resorts to violence, with corroboration from
  friends and family members.
• AGAIG Chap 2 (Verbal aggression)

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Delusional Patients

• The patients delusions should never be directly
  challenged.
• Challenging only increases a patients anxiety
  and often leads the threatened patient to defend
  the belief ever more desperately.
• It is also inadvisable to believe the patients
  delusion.

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Delusional Patients Continued

• The OT can help by indicating that he or she
  understands that the patient believes the
  delusion to be true but that the OT does not hold
  the same belief.
• Focus on the feelings, fears, and hopes that
  underlie the delusional belief to understand the
  delusions particular function.

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Delusional Patients Continued

• Delusions may be excessively fixed, immutable,
  and chronic, or they may be subject to question
  and doubt by a patient and may last only a
  relatively brief time.
• A patient may or may not be influenced by the
  delusional beliefs and may be able to recognize
  their effects.
• OFOTCN Chapter 4

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Case

• A man with chronic schizophrenia revealed the
  simple delusion that his ultimate mission in life
  was to raise the dead to herald the coming of a
  new age. He denied ever seeing signs in his
  environment that referred to his mission, nor did
  he have auditory hallucinations telling him about
  it.

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Case Continued

• The delusion persisted as an isolated psychotic
  symptom during long, quiescent phases of his
  disorder. The delusion appeared during his
  schizophrenic exacerbations, at which times the
  patient had many other complicated and bizarre
  psychotic ideas.

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Case Continued

• During the chronic phases of his disorder, the
  patient worked at low-level jobs and had a few
  ongoing but superficial relationships. The
  patients behavior in no way revealed the
  presence of his delusion.

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Psychiatric History

• Identifying data
• age, marital status, ethnicity, gender, children,
  etc.
• Chief complaint and problem
• Can you tell me why you are here?
• Present Illness
• Onset
• Precipitating factors

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Psychiatric History Continued

• Past Illness
• Psychiatric
• Medical
• Alcohol and other substance history.
• Personal History
• Prenatal and perinatal
• Early childhood (through age 3)
• Middle childhood (ages3-11)
• Late childhood (puberty through adolescence)

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Psychiatric History Continued

• Adulthood
• Occupational history
• Marital and relationship history
• Military History
• Educational history
• Religion
• Social activity
• Current living situation
• Legal history
• Sexual history
• Family history
• Fantasies and dreams

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Difficult Patients to Interview(Behavioral
Characteristics)

• Histrionic (BI Chap 12)
• Obssessive (AGAIG Chap 3)
• Dependent (OFOTCN Chap 2)
• Malingering (OFOTCN Chap 3)
• Sociopath (AThis Chap 8)
• Psychopath (SOTL Chap 11)
• Others

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Interviewing

• Practice Interviews
• Role Plays

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Referrals

• Make sure you identify possible resources for the
  patient such as a 1 800 hotline or reminding them
  of the ER, PCP, and local MH/MR.