Unstructured interview (most common)

Standard general interview structure

• Establishing rapport
• Non-directive interaction (Pt talks; open-ended questions)
• Direct questioning (focus in on a particular point)

Establishing rapport

• Reasonable explanation of the interview (I am 4th yr. medical student; thank you for coming to my exam)
• Purpose of interview
• Duration
• What is expected to happen: eg. tell him you need to fill out questionnaire
• What is expected of the patient: eg. Filming the Pt interview
• Help the patient to relax: if Pt is really uptight, he won't tell you much
• Relieve anxiety

Non-directive interaction

• Attempt to secure the spontaneous production of content of speech and behaviour
• Non-directive leading questions, follow up with supportive remarks, further questions inviting elaboration and clarification
• Observing the behaviour while questioning & listening to the verbal content of the patient

Direct questioning

• Direct probing to fill in the gaps

• History of Mental Illness
• Physical Examination
• Mental State Examination
• Use of Rating Instruments

Effects of mental illness on physical health

• Side effect of medication

Psychiatric Interview

• Bases on either observation during interview or verbal report

Direct Observation

• Grooming
• Posturing
• Motor retardation
• Abnormal movements
• Emotion
• Tension
• Co-operativeness

Verbal Report

• Somatic concern
• Anxiety
• Guilty feeling
• Depressed Mood
• Speech
• Suspiciousness
• Unusual thought content
• Hallucination
• Orientation
• Insight

Muscular

Underweight

• Anorexia nervosa
• Anorexia due to depressive illness
• Poor feeding in chronic schizophrenic
• Physical illness

Overweight

• Patients taking neuroleptic, antidepressant, Lithium

Evidence of self-neglect

• Unshaved
• Hair not combed
• Unusually long hair
• Untidiness
• Crumbled clothing
• Foul odour
• No make-up in women
• Could be schizophrenia, dementia, depression, alcoholism, drug addict)

Colour

• Drab, grey, black in depressed patients
• bright colour in manic patients

Unusual combination of clothing

• Unusual accessories: may have symbolic meaning

Facial Expression

• Indicator of mood state
• Depression
• Anxiety
• Perplexity

Depression

• Turning down of corners of eyes & mouth
• Eyebrows drawn together, medial ends raised obliquely
• Vertical furrows between eyebrows
• Forehead shows horizontal furrows
• Head bent forward, gaze directed at ground
• Shoulders hunched, arms close to body
• body bent forward

Anxiety

• Vertical furrows across forehead
• Eyebrows raised
• Lips slightly parted
• Body held rigidly upright
• Hands gripping chair or held tightly
• Knees pressed together

Abnormal facial movements

• Tics: Turret's Syndrome (multi-tic disorder)
• Tardive dyskinesia

• Indicator of mood state
• Depression: gaze directed to the floor
• Anxiety: sits upright with head erect
• Odd posture in catatonia: disorder of motor

Increased motor activity

• Mania
• Anxiety: picking at finger nails, touching the jewellery, adjusting clothing
• Agitation, anger
• Akathesia: motor restlessness (common EPS side-effect of neuroleptic drugs)

Reduced activity

• Depression
• Psychomotor retardation
• Dementia

Unusually fast motor activity

• Mania

Unusually slow motor activity

• Depression
• Dementia
• On antipsychotic medication

• Tics
• Tremor
• Bizarre movements
• Catatonic symptoms

Co-operativeness

Non-social vocalisation: talking to oneself, screaming

Increased social contact

• Mania: engage everyone around in conversation, over-friendly, over-familiarity, flirtatious

Decreased social contact

• Chronic schizophrenia
• Depression
• Dementia
• On antipsychotic medication

Inappropriate social manner

• Disinhibition
• Stripping off in public
• Urinate in public
• Aggression

• Hallucinatory experience
• Patient may talk to himself or behave as if he is talking to somebody around
• Behaved as if responding to somebody or something around

Rate & Quantity of speech

• Spontaneous, copious amount, pressure of speech in mania
• Slow, hesitant, long pause in depression
• Poverty of speech in schizophrenia
• Circumsferential in obsessional patients

Tone of speech

• Low pitch, monotonous in depressed patients
• Non-verbal speech: talking to the air, muttering to oneself, shouting aloud
• Disorder of form of thought
• loosening of association, flight of idea

Recording Speech

• Quote example
• Record the exact verbatim

Non-verbal expression of mood

Thought arising out from the mood state

• Depression: worthless, hopelessness, self-blaming, guilty
• Anxiety: apprehension, fear, worry

Blunted Affect

• Stability of Affect: labile = one minute laughing, the next crying
• Appropriateness of affect

• Thought which is unusual, odd, strange or bizarre

• Delusion
• Obsession
• Overvalue Idea
• Preoccupation

• Abnormal belief which is firmly held by the patient despite the evidence is proven to the contrary
• It cannot be accounted for by the education background, cultural background and religious belief of the patient

Delusions: Type & Content (thought)

More common:

• Delusion of persecution: a delusion that one is being attacked, harassed, persecuted, cheated, or conspired against.
• Delusion of reference: a delusional conviction that ordinary events, objects, or behaviours of others have particular and unusual meanings specifically for oneself.
• Delusion of control: the delusion that one's thoughts, feelings, and actions are not one's own but are being imposed by someone else or other external force.
• Delusion of guilt
• Delusion of grandiose: delusional conviction of one's own importance, power, or knowledge or that one is, or has a special relationship with, a deity or a famous person.
• Delusion of love: believe someone else is in love with you when they are not
• Delusion of thought being known by others

Less common:

• Nihilistic Delusion: depressive delusion that the self or part of the self, part of the body, other persons, or the whole world has ceased to exist.
• Hypochondriacal Delusion
• Morbid Jealousy: the delusion that one's partner is unfaithful
• Capgras Delusion: individuals believe an individual close to them has been replaced by a duplicate
• Fregoli's Delusion: the belief that you are continually being followed by a group of people whom you cannot recognize because they are disguised
• Thought Insertion: the delusion that thoughts that are not one's own are being inserted into one's mind.
• Thought Withdrawal: the delusion that someone or something is removing thoughts from one's mind.
• Thought Broadcast: the feeling that one's thoughts are being broadcast to the environment.

• Deeply held personal convictions that are understandable when the person's background is known

1. Intrusive

2. Alienation

3. Repetitive

4. Resistance

Need to fill these 4 criteria

• Hallucination (perception)
• Perception without stimulus
• Auditory hallucination
• Can also be visual, olfactory, gustatory, somatic

• Orientation: time, place , person
• Memory: immediate recall, short-term, long term
• Abstract thinking
• General Intelligence
• Mini Mental State Examination (MMSE)

• Awareness of the problem
• Depth of insight
• The client's awareness of the phenomena that other people have observed
• Does the client recognise the phenomena being abnormal
• Does the client consider that the phenomena are caused by mental illness
• Does the client think treatment is needed and whether he would accept the treatment

• Antipsychotic medications
• Antidepressant medications
• Mood stabilising agents
• Anti-anxiety drugs
• Anti-Parkinsonian drugs

• Dystonia, Rigidity, Tremor (Parkinsonism)
• Slowness of movement
• Festinant gait
• Blunting of affect

Akathesia: psychological & motor restlessness

Tardive Dyskinesia: chewing & sucking movements, grimacing, choreo-athetoid movements; may be irreversible

Other observable drug adverse effects in MSE

• Sedation
• Weight gain

Examples of commonly used instruments

• Assessment of symptoms & Behaviour
• Brief Psychiatric Rating Scale (BPRS)
• Scale for the Assessment of Negative Symptoms (SANS)
• Scale for the Assessment of Positive Symptoms (SAPS)
• Hamilton Depression Scale (Ham-D)

Follow standard questions vs. free style

Can you think clearly or is there any interference with your thoughts?

Do your thoughts tend to be muddled or slow? (Can you make up your mind about simple things quite easily?) (Make decisions about everyday matters?)

What has your concentration been like recently? (Can you read an article in the paper or watch a TV programme right through?) (Do your thoughts drift off so that you don't take things in?)

• Skills in Observation & Talking to the patient
• Assessment begins from the first moment the client is seen, even before there is any verbal interchange
• Should be systematic, following a scheme
• A skill that can be learnt only by
• Watching experienced person interviewing the client
• Practising repeatedly under supervision

Language problems

• Get an interpreter

Mute patients or patient who did not talk much

• Restrict to a few key questions
• Try a variety of topic
• Allow adequate time for reply
• Observation is more important

Speech disorder

• Note the form of speech disorder
• Observe non-verbal behaviour

Overactive patients

• Restrict to a few key questions
• Observe non-verbal behaviour

Impaired concentration

• Spend more time to listen
• Allow the patient to collect & organise his thought
• Repeat question if necessary
• Prompt gently for their answer

Suspicious patients

• Reassurance
• Never smile at or joke with paranoid patients

Emotional patient

• To acknowledge the patient's emotion
• Allow the patient to discuss it
• Stay calm & reassuring
• Not to respond with similar feelings

Interviewing patient at his/her home

• Get more information before going (eg. Does Pt have violent history, what are the home's surroundings like?)
• Be accompanied: co-worker; family member
• Watch out for dangerous objects (eg. Knife hidden in newspaper)
• Escape route (eg. Sit closer to the door that the Pt)

Hostile or violent patients

• May be threatening
• Show of force: male nurses, policeman
• Make sure that you are safe (if you feel it is unsafe, you can refuse to see the Pt)
• Assistance should be available at any time to control the patient & an escape route should be make available
• Never see a patient who has a weapon; they should be disarmed by trained personnel first
• Express respect for the patient so that the client may feel more secure
• Try to "talk down" the patient: sympathetic listening & discussion; give reassurance
• Avoid yielding to undue demand or making concession
• Stand firm while avoid direct confrontation

• Gain co-operation of the client; give explanation and reassurance
• Establish a good rapport
• Be a good observant
• Be patient, ready to listen, show interest
• Be empathetic
• Be sensitive to the patients emotion, feeling, reaction, etc
• Have good control of the interview (eg. Final MBBS: 15m to discuss 2 points)
• Ask the right & appropriate questions
• Have a sound knowledge of what to expect (know different disorders)
• Not to put words into patient's mouth (especially in passive patients)
• Not to take all the patient says
• Not to guess what the patient says (some Pt's try to use technical terms to impress you, but use them incorrectly)
• Clarify unclear, ambivalent answers or if you are not certain; make sure the symptom is really present
• Ask the patient to give examples to illustrate his/her experience