Mental Status Exam (MSE) - a description of all the areas of mental functioning of the patient
Affect
- emotions or feelings as expressed by the patient and observable by others; an objective sign observable on MSE
Mood
- the subjective experience of feelings or emotion as described by the patient; a pervasive and sustained emotion
distinct from affect, which is a feeling state noted by the examiner
Thought Disorder
-any disturbance of thinking that affects language, communication, thought content, or thought process
disorder of thought content
is characterized by delusions or marked illogicality
formal thought disorder
is a disorder in form or process of thinking (such as blocking, circumstanciality, loosening of associations, etc.)
The goal of all communication between doctor and patient is to facilitate diagnosis and treatment and further the aims of the working alliance between doctor and patient
Core Concepts
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
Barriers to an effective interview
discomfort or embarrassment may lead to withdrawal or missing information
too narrow a focus may exclude important information
ineffective alliance may lead to noncompliance with treatment
The interview itself may be therapeutic
The working alliance
an agreement between patient and physician based on mutual rapport and trust to undertake treatment together
creating atmosphere conducive to expression of questions and concerns, anxieties and fantasies, education and following up
should never be assumed or taken for granted
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"
Various impediments to the effective interview
:
the anxious or depressed patient
the psychotic patient
the sociopathic patient
the stigma of mental illness
Limited opportunities to test out hypotheses through laboratory evaluations
observation is the psychiatrist’s most critical tool
- serial observations often necessary (ex. manic depression)
Observation and "Critical Listening"
Active Vigilance and "Even-hovering Attention" - necessity to pay attention to all details and pay careful attention from the moment the patient walks in the door until the time he/she leaves
Barriers to observation:
task orientation
balancing skepticism and openness
assumptions about shared perceptions
assumptions about quality of interview
Content and Process
: ("Words and Music") - must not only listen to what is said, but in the manner in which it is said
The "ART" of Interviewing
Assessment - first opportunity for evaluation, "what brings you here"; allow patient to set the pace
Ranking - determine order of importance of problems; may recap interview to confirm priorities
Transitions - prepare patient for transitions to new phases of interview or different lines of questioning, avoids confusion
Specific Techniques
:
Attend to the patient's comfort
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
Be yourself
Encourage expression of feelings
Consider the patient in developmental terms
Remember that the patient is more scared than you
Reflect what you think the patient is feeling
When bogged down, try repeated the patient's last words
Ask the "unaskable"
Learn to be quiet
Pay attention to body language
Start broadly, then focus in
Ask the patient what you may have forgotten to ask!