Interviewing a patient with a psychiatric issue

1. Interviewing a patient with a psychiatric issue Himalee Abeya Psychiatrist

2. Similarities between psychiatric and general medical interviewing • Goals of medical interviewing • establish a working alliance • gather information leading to diagnostic formulation • develop appropriate treatment plan • The working alliance • The interview itself may be therapeutic

3. Differences between psychiatric and general medical interviewing "The psychiatric patient must communicate personal concerns about disturbed mental functioning through language that can only be formed as a process of mentation"

4. Differences between Psychiatric and general medical interviewing • Limited opportunities to test out hypotheses through laboratory evaluations. • Observation is the psychiatrist’s most critical tool • Observation and "Critical Listening" Active Vigilance and "Even-hovering Attention” • Barriers to observation: • task orientation • balancing skepticism and openness • assumptions

5. Remember the basics: • don't ask two questions at once • open ended questions are preferable • don't ask "negative" questions • avoid being judgmental • use facilitating remarks • ask for clarification

6. Specific techniques – but be yourself! Attend to the patient's comfort Remember that the patient is more scared than you Pay attention to body language Encourage expression of feelings Learn to be quiet Start broadly, then focus in Reflect what you think the patient is feeling When bogged down, try repeating the patient's last words Ask the "unaskable" Consider the patient in developmental terms Ask the patient what you may have forgotten to ask!

7. Rapport • Watch your patient’s and your own demeanour • Speak plainly and with compassion. Not -“I know how you feel…” Try “I can see that it upset you terribly.”“You must have felt miserable.” • Your own feelings can heavily influence rapport PATIENT: I don’t care about women. I’d like to see every one of them burn in hell. INTERVIEWER: Sounds like you’re awfully angry. Have you had some bad experiences? PATIENT: Well, let me tell you. You got a few hours? • You can offer praise “You’ve really given me a good overview of your problem. I think we can move on to some other information, now.” “That’s about the best ‘serial sevens’ I’ve heard this week!” • But see it is both accurate and heartfelt. No BS

8. Maintaining boundaries PATIENT: Were you raised in this city? INTERVIEWER: What makes you ask? PATIENT: My mother told me to be sure to get a therapist who grew up here. She says no one else could really understand what it was like, growing up in a ghetto, and all. INTERVIEWER: I see. Actually, I didn’t grow up here, but I got most of my training here. so I have a pretty good idea of what some of your experiences must have been. But I have the feeling you’ll be able to tell me a lot more. “YOU SEEM SO YOUNG FOR THIS KIND OF WORK— HOW OLD ARE YOU?”

9. Handling the excessively emotional patient • Label the emotion. Just saying, “You really feel angry about this. Angry and frustrated!” conveys your understanding, which may allow the patient to turn down the heat. • Speak quietly yourself. If your patient shouts, lower the volume of your own voice. • Re-explain what you want. “I know your ex-wife infuriates you, and perhaps later we can discuss that some more. Right now, I need to learn about your current relationship.” • Switch to close-ended questions. INTERVIEWER: Can you tell me about your previous marriage? PATIENT: It was god-awful! That bitch should rot in hell. She wouldn’t even let me— INTERVIEWER (interrupting): Did you and she have any kids?

10. Impediments to the effective interview: • The confused patient • the anxious or depressed patient • the psychotic patient • the sociopathic patient • the stigma of mental illness

12. The confused patient

13. Remember! Delirium is a Clinical Diagnosis Five Components: Disturbance of consciousness and attention Reversal of sleep-wake cycle Psychomotor changes Emotional disturbances- perplexity, irritability, dullness Perceptual/ Thought disturbances Investigations may be normal or only mildly abnormal in 1/3 cases

14. Frail Elderly persons are particularly vulnerable to delirium: WHY? Decreased physiological reserves Greater fragility of normal Blood Brain Barrier Age related changes to excretion, metabolism and to response to meds Increased # meds = more med: med interactions and med: disease interactions Higher chronic disease burden

15. Confusion Assessment Method (CAM) • 1. History of acute onset of change in patient’s normal mental status & fluctuating course? • AND • Lack of attention? • AND EITHER • 3. Disorganized thinking? • Altered Level of Consciousness? Sensitivity: 94-100% Specificity: 90-95% Kappa: 0.81 Inouye SK: Ann Intern Med 1990;113(12):941-8 Arch Intern Med. 1995; 155:301

16. Once you identify Delirium, now what? Identify the acute medical problem/s could be either triggering the delirium, or prolonging it! Clarify pre-morbid functional status and sequence of events Identify all predisposing and precipitating factors, and consider the differential

17. Delirium Workup On History: time course of mental status changes? association with other events (i.e.. meds, illness)? Pre-existing impairments of cognition or sensory modalities?

18. Medication review: Look at all prescriptions include PRNs, regular, ETOH and OTC meds Ask if anything has been added, changed or stopped Particularly bad are long acting narcotics (demerol is the worst!), anticholinergics (Gravol), benzo and older psychotropics.

19. Physical Exam Vitals: normal range of BP, HR Spo2, Temp? Good physical exam: particular emphasis on Cardiac, pulmonary and neurologic systems Hydration status ? (dry axilla=dehyd!) Also rule out fecal impaction urinary retention (bladder U/S, in-and-out catheter) Infected decubatis ulcer

20. Delirium workup: Lab testing Basic labs most helpful! FBC, SE, BUN/Cr, glucose TSH, B-12, LFTs Calcium, & albumen Infection workup (Urinalysis, CXR) +/- blood cultures

21. Other Investigations selected additional testing; drug levels, toxic screen, ABG EKG CT Head if focal signs ? EEG (if suspect seizure) ? role for LP (do last, and only if history suggests)

22. Things to avoid RESTRAINTS; physical or chemical High dose or IV Haldol (risk of NMS, hypotension, CVA, arrythmia) Excess anticholinergics or sedatives, (TCAs, benzos) which can trigger or maintain delirium PRN analgesics Premature labelling of dementia Stopping cholinesterase inhibitors in demented patients

23. Delirium Reduction: You can get up to a 30% reduction of delirium with such simple measures as: cleaning glasses Using hearing aids feeding reducing noise Early mobility Non drug sleep S Inouye A multicomponent intervention to prevent delirium in hospitalized older patients.N Engl J Med. 1999 Mar 4;340(9):669-76.

24. Pharmacological Rx: Goals Reverse psychotic signs and symptoms stop dangerous or potentially dangerous behavior To calm the patient sufficiently to conduct the necessary evaluation and treatment

25. Pharmacological Rx If scared or frightened, consider atypical neuroleptic (Olanzapine (Zyprexa) 2.5-5 mg po, or Rispiridone 0.25 to 0.5 mg po) To help sleep, may need: short acting benzos (lorazepam 0.5 mg) If pain use non-prn non-narcotic analgesics first; paracetomol 500 mg po QID If ETOH withdrawal delirium, give Thiamine/Folate, and benzodiazapines.

26. IF SEVERE AND LIFE THREATENING, consider conservative Rx w/ high potency antipsychotic: Haloperidol: 0.25-0.5 mg IM; AND Lorazapam 1 mg SL/IM Observe patient for 20-30 minutes: if patient remains unmanageable without adverse events, repeat dose and continue monitoring repeat cycle until acceptable response or adverse events occur max suggested Haldol dose in frail elderly 2 mg/24 hr May also try: Risperidone 0.25-0.5 mg po Olanzapine 2.5-5 mg po SL (WAFER) or IM

27. Thank you