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CLINICAL METHODS IN PSYCHIATRY

A Guide to Examining the Patient With Stress related Problems

Dr. M PARAMESHVARA DEVA Professor of Psychiatry Faculty of Medicine and Health Sciences University Tunku Abdul Rahman MALAYSIA

2nd Edition AFPA EDITION 2013

COPYRIGHT RESERVED @ 2013.

This book may not be copied in any form nor quoted without written permission of the author

Published by Ophir Medical Publishers 2, Jalan Pos Bahru, 41300, Kelang Malaysia Printed by Boon Yin EnterPrise 16 Jalan 2/16 40000 Shah Alam , MALAYSIA

ISBN No. 983 99635 8-9

PREFACE to First edition It is sad but true that psychiatry and the mentally ill have received over the centuries a raw deal in the eyes of the community and even the medical profession. Despite its common occurrence - the point prevalence is estimated to be not less than 9% and as high as 20% - in general practice, mental or emotional problems have been almost cruelly lumped with the 1% or less of the very severe psychosis and relegated to the province of mental asylums and institutions. This reality is in fact enshrined in the definition of health that appears in the very first paragraph of the constitution of the World Health Organisation, which states, Health is a state of complete physical, psychological and social well being and not merely the absence of disease or infirmity WHO constitution 1946 The reasons for the continuing and gross unfairness in the treatment of mental illnesses as opposed to physical ones are largely the result of ignorance that has been steeped in prejudice. The few severe psychotics have been associated with the 8 - 19% of anxious, depressed or others and become the untouchables of the medical world. It is sadder still that the healing profession has turned a blind eye towards the psychological and emotional aspects of numerous physical illnesses from bronchial asthma and skin diseases to coronary artery diseases and carcinoma. That all this is the result of prejudice is understandable and sad but that it is also the result of medical ignorance is very difficult to excuse. It is therefore most timely if not long overdue for all medical students and doctors to acquire without prejudice the skills and knowledge involved in examining the psychiatric patient. The psychiatric patient is not the severely ill psychotic alone but the 9 - 20% of all patients in general practice settings and the numerous patients in medical, surgical, obstetric gynaecological or other settings outside the psychiatric ward. Every medical doctor will invariably see patients with emotional distress - but perhaps not recognize them as such. As common sense backed by scientific studies point to emotional components of illnesses the need to understand the patient's behaviour, mind and emotion demands a rethinking on current or old clerking procedures interviewing techniques and history and examination methods to include a psychological orientation. This is the reason for the following chapters. The psychiatric examination in clinical practice is not merely for the severely ill mental patients but for all in whom a psychological problem is suspected. This book is the result of experience in teaching medical students and trainee psychiatrists for the past three decades and realizing their need for a simple introduction to psychiatric clinical methods. The transition from the clinical methods taught in physical medicine to psychological ones is handicapped by a lack of a holistic approach in the teaching of illnesses in patients. The dichotomy between physical and psychological medicine is an artificial one that needs concerted effort to overcome. One day physician and surgeon colleagues will teach psychiatric clinical methods as integral parts of their teaching of introduction to clinical medicine and surgery and psychiatrists will do likewise for the physical side of medicine
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Until then the gap in the knowledge and emphasis on psychological aspects of clinical clerkship has to be emphasized by a guide book such as this for students and doctors .It is hoped that this guide to the examining of a patient with emotional or psychological problems will not only help medical students for whom it is primarily intended but also general practitioners, non psychiatrist doctors in any field, nurses and other health workers interested in the psychological aspect of illnesses in their patients. .I also fervently hope that this brief introduction to examining the emotional problems in patients will help reduce the prejudice held by health professionals towards the mentally ill and sad lack of concern for mental aspects of health.

M Parameshvara Deva. At Perak College of Medicine, Ipoh 7, Pesiaran Gopeng 2 31350 IPOH Malaysia devaparameshvara@hotmail.com

1 May 2002

Preface to 2nd edition This book has run out of stock after distribution on over a dozen countries of the Asia Pacific and other parts of the world. Many offset copies have also come out with permission of the Author. If response to needs in the developing countries of the world a second AFPA Edition has to be printed. This is the second edition with some corrections and additions such as the LIMA approach to psychiatric diagnoses and management. The textbook of 140 pages of the same name SIMPLI LIMA is in its second edition and widely distributed in the Pacific and some Asian Countries where LIMA means Five referring to the 5 Fingers Classification of Primary care Psychiatry by the Author. M P Deva parameshvara@utar.edu.my 1 May 2013 UTAR Sg. Long Campus.

CONTENTS

Preface References CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 CHAPTER 7 CHAPTER 8 Introduction The Clinical Interview Specific Techniques in Interviewing Taking the His-Story Personal & Family history Psychiatric Examination Physical Examination Psychiatric Formulation and Investigations Verbal Scans to assist in examination Sample Psychiatric Clerking Sheet LIMA Approach Psychiatry 8 9 23 37 43 53 66 68

CHAPTER 9 Appendix 1 Appendix 2

73 79 84

Dedication. This book is dedicated to my late parents who inspired me to persevere, my students who constantly pose challenges in teaching, my teachers who opened up new vistas and many horizons and most of all my patients who teach me so much each and every day about ,the art and science of human behaviour.

.Acknowledgement This book would not have been possible had it not been for the unstinted and selfless management and organisation of my best friend JGPN and the warm hospitality of Herr and Frau Schmidt and Dr. med. Holger Schmidt of Munchen, Germany . I would also like to express my grateful thanks to Mr Mah for his dedicated typing of the manuscript from my undecipherable handwriting..

Apologies Writing a book is not easy, making mistakes while writing and typing is much easier. My humble apologies to the reader for the mistakes may appear. My apologies too for the use of unidentified examples are used to illustrate this book to help the reader understand.

References Eistein AS Schulmann, IS SPrafka SA, Allal L, Gordon M, Jason H, Kagan N, Loupe MJ and Jordan RD (1978) Medical Problem Solving Harvard Univ. Press Cambridge Mass. Walton H (1982) History taking (Editorial) on Medical education Vol 16 p245-246. Byrne PS, Long BE (1970) Doctors talking to Patients. HMSO London. Krietman N (Ed) 1977 Parasuicide Johanskey Cluchester Lancet 1974 Self injury (936937) Roy Alec (1986) Self destructive behaviour on Essentials of Postgraduate Psychiatry 2nd Ed Grune Stratton Publisher page 445. Paul E Mullen (1986) Mental state and states of the mind in Essentials of Postgraduate Psychiatry ed. P. Hill R. Murray, Grunet Stratton Inc London pages 3-36. American Psychiatric Association (APA) 1980DSM III an APA Publication M P Deva The LIMA approach to Understanding Mental Ill;nesses ISBN 976-963-339204-9

CHAPTER ONE

INTRODUCTION Even before seeing a patient who is thought to have an emotional problem it is important to think a little about one's own attitude to the emotionally ill. Illnesses of the emotion or mind or psychological illnesses are by no means rare. Most adults if not everyone has had experiences of disappointments, emotional distress, facing crises and feeling sad. Emotional stress is not a rare phenomena. Emotional reactions such as anger, quarrels or spells of crying are everyday occurrence in any society. These expressions of emotion sometimes take on unusual forms. Some people who are more emotional cannot handle stress or face more stress in ways different from us. Some of these reactions to stress appear strange by our own standards - some may even appear weird; a few may appear violent. The underlying reasons for these are almost invariably stresses of one sort or the other. Just as all of us face stresses of one sort or the other and react to them so do those we see as suffering from a mental illness. Perhaps the difference is that these same if not larger stresses cause an exaggerated response in some vulnerable people or those more prone to a psychological illness. The stresses may come from any source and be at work, at home or within ones self. One's expectations in life in a situation involving others or within oneself may not be met and lead to disappointments. These disappointments may be mild moderate or severe. The reaction that follows may be influenced by one's proneness to mental illness - this being determined by genetic, biochemical or other social and psychological factors of nurture and nature. Prejudice The long history of prejudice or prejudging an issue that is psychological by knowing smiles, giggles, jokes or laughter is only compensated by blissful ignorance unworthy of the medical professional calling given to the art of healing that should not have prejudice towards illness, race, colour or creed. It is therefore with an open mind that the clinician must approach his patient - no matter what illness he suffers from. Every patient deserves a clinician and a healer who is not prejudiced .Having said that there will remain a kind of fear in those who have been brought up to fear the mentally ill. It is

wise to remember that such fear is incompatible with the healing arts and what is more when the patient has no fear of the doctor and hopes that the doctor can help him heal,

should not the doctor behave in a like manner to the patient ? Overcoming prejudice should therefore be the first step in the examining the patient. The clinician must learn to control his prejudice his fears and his doubts to heal the patient in the best tradition of the medical profession. Myths Although the population of those with chronic mental illness at any one time in the community is around 11%, not all of these are actually seriously disturbed. Even among these, extremely few are disturbed aggressive or a danger to the those around them. The vision of a mentally ill person running amok or irrationally violent is that of an exception rather than the rule. The majority of the mentally ill are not only not violent but in fact quite rational and coherent. The novice in psychiatric care will be surprised to see that psychiatric patients he talks to are very capable of talking to the interviewer as well as any of his other patients who have no psychiatric problem. Psychiatric patients respond to civility with like behaviour. They may have an illness but also a healthy part that responds well to the interviewer. The technique is to concentrate on the healthy part in an examination to obtain a good history and examine the patient. In the case of those with less severe illnesses the patient is often no different from those without an illness and the interviewer will be pleasantly surprised to be able to converse with him or her without much difficulty. The myth therefore of the difficult psychiatric patient who is difficult to reach is one perpetuated by those unable to get over the ignorance and prejudice against the mentally ill. There is no experience as enlightening as that of trying to converse with a person with mental illness to explode the many myths that surround psychiatry. Examining the Patient The psychiatric examination is similar to other medical examinations in that it consists of a psychiatric interview and history taking, a psychiatric examination, a physical examination and relevant investigations to confirm a provisional diagnosis The psychiatric interview however plays an unusually important role in the psychiatric examination as it is the cornerstone of the psychiatric examination. In earlier days the elicitation of peculiar signs or symptoms was considered more important but this has gradually diminished in importance as chronic mental illnesses have become rarer in first presentations in a clinic. By and large skills in interviewing and accuracy in carrying out psychiatric examination will be of greatest help in formulating a case and arriving at a correct diagnosis. The following pages will therefore emphasize these aspects of the psychiatric examination the problems of difficult interviews difficult areas of interviewing and difficulties of interviewers in the process of interviewing.

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CHAPTER TWO
CLINICAL INTERVIEWING The Internal Viewing of The Patients problem.

Doctors and Communication - " ... If only the doctor had listened ..." The young doctor in his student days is exposed to a period of introduction to the clinical clerkship by a course in clinical methods that emphasises what to elicit by way of history and examination. In most older medical schools the method of that elicitation of history or the way a doctor should communicate with a patient is not emphasised. It is assumed that once a question is asked of the patient (no matter how that is done) he should give the correct answer. This assumption that patients are standard and unwavering automatons who deliver answers uninfluenced by emotions, feelings or the way questions are asked is to say the least, a naive one. Both doctors and patients are feeling animals and have moods and sensitivities. Merely being a patient or being a doctor does not result in abandonment of one's feelings. As such any communication between doctor and patient must take into account the possibility that both doctors and patients can and are influenced by their emotions and what they say need not necessarily be all that they are communicating. That is to say for example a patient may say he feels all right and yet (to an astute doctor) appear distressed. Many a patient may deny feeling upset when asked in so many words and yet have tears brimming in her eyes. Many a patient with clear evidence of sexually transmitted disease (STD) may vehemently deny having had sexual contact. These are not necessarily indicative of a tendency to tell lies but attempts to hide one's feelings or protect one's image - all very understandable when one puts oneself in the patient's shoes.

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The ways these sensitive questions are asked are also of great importance as a crude and feeling-less approach may produce bland denials. On the other hand a gradual approach with use of less painful alternative words that are less judgemental may produce a different response. A man may be reluctant to admit he hates his father when asked "Do you hate your father" as in Asian culture it is almost sinful to express hatred towards one's parents. But the same man may be more willing to say he and his father "didn't get along well" Further exploration may reveal examples of hatred - although the word hate is not used at all. These and numerous other examples show that communication in a medical setting is not a stereotyped rapid fire of bland questions and glowingly correct answers. Techniques have to be developed by the clinician to elicit useful and accurate information with the human patent in mind. Another equally important issue is that of doctors' behaviour in interviewing. Elstein et al (1978) have shown that the clinician rushes into a couple of hypothesis soon after meeting the patient based on the first few clues he gets. He then focuses his interview and clinical exam on these hunches that he derives from very scanty information. This jumping into conclusions by clinicians are often derived from the first quarter of the total interview. Many a question that follows such jumps into conclusion are covertly coercive and "direct" the patient to give "correct" answers to justify the doctor's predetermined conclusions. A true history should contain facts on complaints stated by the patient without direction of the doctor, no matter how well meaning these may be. If a history is meant to be that of the patient's story this is hardly worth the name - as the doctors enthusiasm and coercion has muddied the patient's story by premature judgements. It is no wonder that sometimes soon after the `forced history' the diagnosis runs aground and a battery of expensive investigations begin to try and force out a diagnosis that a patient's own history could have revealed. If only the doctor had listened to the patient !

Doctors as Interviewers Most doctors learnt how to interview by default - as most clinical teachers concentrate on teaching what to ask the patient, what symptoms what signs e.g. pain before meals or after meals, vomiting with blood or without bile. Few clinical teachers actually teach the "how" of interviewing. As such the students unconsciously learn the "how" by watching their teachers interviewing their patients or other senior colleagues eliciting information from their patients .In fact interviewing as a technique in history taking is rarely mentioned and not often thought about as an important skill. Walton (1982) feels that often medical teachers who are supposed to be models whom students follow have learnt their interviewing from their teachers by observing them. They are often not the best examples on how to talk to patients Active instruction rather than passive

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observation is necessary. When communication skills are acquired some teachers use simulated patients where the interview that is being conducted can be stopped or started at will and discussed. Doctors as interviewers without proper training are found to often plunge straight into the interview without putting the patient at ease. Few introduce themselves to the patient - taking for granted their importance and widespread knowledge by others. The attitude varying from indifference in some to arrogance in others is usually not conducive to a trusting and empathetic view the patient is expecting of his doctor. The flow of information and history from the patient likewise is unlikely to be all that exciting or revealing. Doctors who are not aware of the importance of listening, how to tolerate silences and when to ask or not ask questions may rattle off a series of predetermined questions that sounds more like a rapid fire MCQ rather than a clinical interview. The doctor then ends up with a list of signs and symptoms dates and occurrences which he promptly stitches into a convincing story - it is undoubtedly a story and not as claimed often a history (his - story i.e. the patient's story). What is even more sad is that in the hurry to obtain or induce the patient to give a series of facts the doctor often cuts the patient off when he tries often desperately to tell his story. This is particularly so with patients who are anxious or depressed and who by their history reveal emotional symptoms of their illness. All this points to major defects in doctors who have not been trained as interviewers and reinforces the need for doctors to be trained in the art and science of interviewing. Merely pointing to a long list of correct diagnosis by past practices on doctor-patient communication does not prove that learning the correct technique of interviewing is irrelevant. What many older techniques of patient doctor communication don't reveal is the missed diagnosis and the non detection of emotional aspects of the patient's problems. In general practice where 5 - 20% of patients at least are estimated to have significant emotional problems the correct interview technique has more importance in correct diagnosis .Byrne and Long (1976) feel that some doctors by dominating an interview may prevent the patient from talking about the problems that really bother them.

A list of commonly observed defects in clinical interviewing *Little or no introduction to the interview *Little or no effort at establishing rapport *Rapid fire questions

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*Closed ended questions dominate interview *Dominating style of interview by doctor *Not picking up patient's non-verbal cues *Not picking up verbal cues form patient's history *Not allowing patient to complete saying what he wants to say *Not monitoring patient's emotional state *Not asking about patient's social and personal problems *Use of technical terms patient does not understand

Purposes of interviewing 1. To obtain an understanding of the patients problems so that it helps to arrive at the correct diagnosis and treatment either initially or on follow up 2. To provide support and therapy in diagnostic or follow up interviews 3. .For research purposes in studies, e.g. of a particular diagnostic group.

General Principles of Interviewing Although a well written history of illness presented by a student or doctor is written with flair and great continuity, the history that is obtained may have been a quagmire of cuts, changes, questions and counter questions with a lot of memory gaps. It is important to note that the main principle guiding all interviewing is to get a history, HIS STORY, from the patient. Just as we don't interrupt a story teller to get the full benefit of the story, the patient must be allowed to tell his story in his own words with the minimum of interruption from the over anxious highly educated and scientifically trained doctor. To do this the doctor has to be prepared to let the patient tell an unscientific story full of gaps and deviations. When he has told his-story the doctor can

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clarify the history with doctor's scientific mind and knowledge to try and fit it into one of the many syndromes he has learnt theoretically. No matter how unscientific the his-story seems to the doctor it is salutary to remember that the patients are our best teachers - if only we are a little less arrogant and a little more willing to listen and learn. Many a missed diagnosis, messed treatment and fumbled case has its root in the doctor not listening to the patient and when he listens he refuses to believe and when he believes he does not accept The other important point to remember in history taking is that the history taking through clinical interviewing need not - or should not follow the way a history is finally written for presentation. Let the patient tell his story. The job of writing it in a coherent way is a later exercise. Hence when the patient says his main reason for coming to hospital was for headache - the doctor should not jump in to quickly ask the duration - thereby interrupting the patient's flow of thought then to return abruptly to the second chief complaint and chop it up again with another question "how long" .The principle is that the more the doctor interrupts to fill his imaginary clerking sheet requirements the less the patient will give his-story; it will be the doctors story. Patients out of respect for their doctors will not argue and end up losers.

Place of interview. The place of interview is an important factor in the interview process as most patients with emotional problems are reluctant to reveal or discuss their distress unless it is in an atmosphere that is conducive to a confidential interview. The place of the interview therefore should be quiet and preferably in a room away from others. When interviews are conducted in medical clinics with medical students or trainee psychiatrists this must be explained to the patient and assurance of the confidentiality of the proceedings given. Any doubt by the patient as to the confidentiality must be accepted and appropriate measures made. The practice of conducting interviews in open ward in view of other patients and visitors has no merits for the proper conduct of interviews of patients with emotional distress.

Seating position in interviewing Although the rather limited atmosphere and furnishings of hospital or private clinics in many countries do not allow much innovation to make the interview setting more conducive, the seating position of the interviewer and the interviewee can be made more so. The facing of the patient directly across a clinic table can be made less formal and more conducive to communication by facing the patient without the table or facing each other diagonally from the table. Better still , the two chairs can be put away from the table facing each other a casual distance from each other. If costs can be overcome a more

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comfortable and less formal set of chairs or soft furniture around a low table may be used to better effect the interview. The principle is to make the patient less anxious and more comfortable in the process of telling his story.

Phases of the interview All clinical interviews have a number of phases, they go through even though one blends into the other almost imperceptible. Their division into distinct phases is merely to learn their importance and their function. The phases can be divided into,

1.Introductory phase 2.Main phase 3.Termination phase

Introductory phase of the interview This is the beginning of the interview and the phase at which the interviewer and the interviewee meet and begin their communication. It is important for the interviewer to start by introducing himself - a shaking of hands may be customary where it is acceptable and then get a brief introduction to the interview, his name, where he comes form what he does for a living and whether he is married or single. There is no need at this stage to obtain his address, number of children, their ages, etc. The introductory phase usually lasts about 2-3 minutes but its genuineness should be more effective in establishing rapport than the length of time spent in introductions. The enthusiasm of the interviewer to get to know the patient and the story the patient has to tell is perhaps the central issue in good clinical interviewing and can seldom be feigned successfully. Given the practical problems of working in a pressured environment in a developing country the place of interview should as far as is practical be interference-free and ensure privacy for the patient to express his feelings and complaints without disturbance or being overheard. Thus a separate room for interviewing is essential.

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Main Phase of the interview The main phase of the interview is the phase where the bulk of the history of the illness is obtained. It is not only the larger part of the interview but also the part where the interviewer hast to be an astute listener and where he uses both the material he has gathered and the knowledge of the theory of the subject to help the patient put forward his problem. It consists of the, 1 the body of the reasons why the patient came to the clinician 2 the explorations of those reasons and 3.additions in the form of specific history that is important for a formulation and diagnosis but not volunteered by the patient in his initial story. (The psychological examination and cognitive function tests are dealt with after the interview).

The main phase of the interview may be divided as follows into 1.Open ended phase and phase of listening 2.Phase of clarifying issues that arise in the listening phase 3.Phase of asking specific questions e.g. family and personal history not covered in 1 and 2 but important for formulation.

Open-ended phase of the interview and useful techniques in the process of interviewing Perhaps the biggest single mistake made by many interviewers in talking to patients is their reluctance or inability to listen to the patient. They are so keen to fire questions at him that they fail to realise that the patient can most of the time tell you a pretty coherent history if only you would listen to him To facilitate the patient's talking the interviewer should limit his own talking to open ended questions e.g. `what brought you to see the doctor today'. These types of questions are called `open ended' because they do not limit the patient to `yes' or `no' answers (as seen in closed ended questions) and in

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fact allow the patient to feel free to tell his own story in his own words. In this phase the barest minimum of questions and as far as possible open ended ones should be asked allowing the patient ample opportunity to tell his story (his-story). Technique of prompting the patient to tell more Sometimes the patient may be hesitant to go on and may answer only very briefly to the first questions. When this happens the interviewer must not be tempted to break in and ask more questions. The correct approach is to tolerate the silence that follows the end of the patient's brief reply and encourage him to continue e.g. when asked what brought him to hospital the patient may reply "I have not been able to sleep well recently and stop almost expecting the doctor to ask the next question (e.g. why can't you sleep or when did it start ...). But by being silent or at most responding by an interested "ah huh" (meaning "yes please go on ..") the patient gets the cue and almost always goes on after a hesitation. "Yes I used to be Okay but lately I sleep very late. I think it may be due to the noise of the video next door. Also my son is studying for his SPM ..." and so on. An interviewer has only to try out this strategy of prompting a patient to continue to see that most patients except those with retarded depression elective mutism, severe brain damage or catatonia will readily continue after the prompting. In any conversation silence by one person often makes the other talk. But the over anxious interviewer who does not try this silent strategy will see his role as a source of a steady stream of questions. At times it may be necessary to improve the prompting by nodding one's head in a gesture indicating you follow what the patient is saying. Rarely the last few words spoke by the patient may be repeated e.g. "your son is studying for SPM ..." and then allow the patient to pick up where he stopped. Even more rarely the interviewer may actually ask a further open ended question e.g. `why do you think you are unable to sleep ...'. Non-verbal cues in interviewing Many patients tell their history of illness with emotion - few don't. While the doctor is busy monitoring the content of the patient's verbal replies it is equally important for him to monitor non verbal cues. These include facial expressions, body movements, the way the person is groomed or dressed. Some may appear very well dressed, groomed and even over dressed while others may neglect their dressing and grooming. Anxious patients may keep wringing their hands, tapping their fingers or rock their legs nervously. The inconsistency between the verbal responses and non verbal cues must be noted in the drawing of conclusions about the patients\s problems and diagnosis. Over dependence on verbal responses can be the cause of wrong diagnoses in many a patient.

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Making sense of the interview Traditionally patients' words are taken for granted and without question. In psychiatry with a heavier emphasis on patients' emotions the history that is given has to be tested against reality, against nonverbal cues and what the patient may not have said. A 38 year old engineer, married with one child came as a patient suffering from a depressive illness. He had suffered a great deal since his father died when he was 10. His mother fostered him to an uncle who ill treated him and made him work like a servant. His life has been one long misery. Listening to the patient telling his story the interviewer cannot but feel sad and feel sorry for the patient and angry with both the mother and the uncle for what they allegedly did to him.. What the patient has not said however is how such a deprived child became an engineer and got married and why after all this time he is here as a patient. The story he tells must be tested against reality. When often happens is that a patient pours out his heart in a moment of depression, concentrating on the most painful part of his life in a self pitying and emotional way often because of a recent rather than the past disappointment. His ruminations often skip the more successful and balancing aspects of the same person's life .To simply swallow the first part of the history without asking the relevant unspoken and obvious begging questions indicates a bland clerical style (or a biased empathy for the patient) that may lead to a wrong formulation. and management strategies. Clearly clerking and interviewing are both dynamic and active processes. They are not merely exercises in recording verbatim statements, in a bland unthinking style or for that matter to simply sympathise or empathise with the woes of the patient.. When to be silent and when to ask questions. The problem of history taking is one of when to be quiet and when to ask questions. The rule is generally to first ask open ended questions then keep quiet or almost quiet for about 10 minutes (in a one hour clerking exercise). During these 10 minutes (also called the "Patient's 10 minutes") the interviewer should record, observe and note important questions that should come to mind. He should note inconsistencies in verbal and non verbal areas and questions that beg answers. When the patient has told most of what he has to say the time is ripe to clarify areas that have not been clear or inconsistent in a gentle (and not belligerent) way e.g. `I did not quite understand what you mentioned about your uncle being a difficult person, could you explain it a little more'. It is also an opportunity to ask questions on issues that have been avoided or not mentioned at all but stand out and need asking. On each occasion the patient should as far as possible be asked open ended questions except when precise details are sought e.g. year or month he had sleep problems. To confront or not A cardinal point in interviewing is not to confront a patient who may even give the most blatantly inconsistent answers. Patients may sometimes give obviously false or strange answers. Responding to this by laughing, ridiculing or confronting them is strategically not wise as the patient is often trying to seek help yet protect himself from an embarrassing situation. Once the interviewer understands the reasons behind his

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manouvre he is able to take a more gentle approach probing while clearly remembering the patient's ability to give inconsistent stories. These are important techniques as confrontation may get your emotion off the chest but make the patient even more defensive and often trust you less with his most sensitive or even more strange doings or feelings. The history taking and interviewing after all are attempts to get glimpses into the truth behind his distress (an internal viewing) and anything that negates this effort is a wrong strategy. Note keeping and following up on leads Even the most brilliant among clinicians needs to keep records of his clinical contact with patients as his memory like all human memory is fallible. In clinical interviewing and particularly in psychiatry there is a real need to keep notes. The problem however is to keep notes or take notes in an unobtrusive way as possible so as not to affect the smooth flow of the interview. With practice it is not too difficult to jot down points or notes while paying full attention to the patient. The problem in writing long notes while an interview is in progress is that the patient out of respect for the interviewer often stops talking to allow notes to be written - thus chopping the interview's smooth flow. Taking of notes. Taking of notes is invaluable in an interview, as important points crop up unexpectedly, and need further exploration. Once important points are forgotten their absence in a story often gives it an incomplete look. Patients also use "heavy" words when expressing their feelings toward incidents or people that gives the interviewer clues to the key areas that underlie those words. The patient's choice of words is his own (and all things being equal and his or her language being fairly good) the choice of "heavy" words more often than not betrays the direction in which deep feelings lay e.g. a woman describing her boyfriend's leaving her after two years of courtship didn't say much except that it was unfortunate. When asked how she got on with his mother, she sighed, then smiled and said the boyfriend's mother was very protective of her son and made all decisions for him "... as if she wants to marry her son ...". She then switched to her bland story about her headaches and insomnia. For a person to say that the boy she had courted for two years was going to be married to his own mother is not simply a slip of the tongue but a deliberate and carefully chosen attack. As it turned out she had her chances of marriage destroyed by a woman who thought the patient was not good enough for her son - and the son obeyed his mother's wishes and dropped her.. It is clear such brief sentences or words or phrases have to be remembered and to be explored later. Just what is important and what is not so in a interview is difficult to define in a first or second interview if the interviewer has little experience with clerking of patients with emotional problems. Even then an interviewer who is astute about human behaviour and common human emotions and reactions to stress will be able to see the wood for the trees. One has only to ask oneself - would I use such words to

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describe my mother in law to be ?... - unless of course I was terribly unhappy. With a little experience it would be fairly easy to spot important phases of the interview and important views, words or phrases that point to areas of conflict or stress the patient faces No interview should lead to a bland recording of what the patient says without the interviewer's follow up of leads given during the interview. The noting of such important responses verbatim, says she thinks mother wants to marry her boyfriend goes a long way to understanding the issues that trouble the patient. Noting these and other observations however should be done unobtrusively without affecting the smooth flow of the interview and certainly not interrupting the patients flow of thoughts The conclusions when made should however be based on what the patient has volunteered and responded to when asked and not merely on the interviewer's bias or prejudices. Separating the useful from the rest The patient being interviewed is usually not scientifically trained and does not often distinguish what is important in his story from what the interviewer may consider unimportant and often uses the conversation with his doctor to pour out his distress. As such the doctor has often to wade through a lot of material that he may not consider useful to get at material that he may consider significant or important. Some verbose patients may tend to give a lot of detail and take a long time to reach important points. Moreover, early in the interview it may be difficult to make a judgement on just what is useful and what is not. When it is clear that the patient is taking a round about course to the important facts, a gentle reminder or even a firm but polite reminder to stick to the point would be useful and not out of place. Some patients go into extreme details and length discourses into every day occurrences with "he said this and said that and she said this and he then said that" type of detail. It may be indicative of anxiety or loneliness but can delay good interviewing and intervention. This needs to be dealt with by reminders to stick to the point and then if still persisting, use of a questions and answers session. This is one of the few exceptions to be the general rule of using open ended questions. Problems of language. In many countries such as Malaysia with at least half a dozen main languages and dozens of dialects it is extremely important that the interview be conducted either in the patient's language or in one that he is fluent in. Clearly many occasions will arise when the services of a translator will have to be sought. Not everyone is a born translator simply because he knows several languages. Sensitive subjects are often condensed mutilated modified or simply mistranslated to avoid embarrassment e.g. "How often do you and your wife have sexual relations" may be translated by a shy nurse as "do you sleep well". While it is good to have a working knowledge of several languages to check on such defects in translation, this may not always be possible. Good translators are more difficult to find than good doctors. The use of words in different languages have different emphasis that are not easily translated into English. Thus in

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interviewing the peculiarities and problems of language are important to note when a translator is being used. Up against a blank wall The novice in psychiatry will often come up against a patient with emotional problems who denies any stress or conflict. For instance a patient may have been admitted for an attempted suicide and yet deny any problems. She may say it was an accident or that she was depressed about the death of a friend 1 yr ago .Many of the failures in diagnosis and management in psychiatry present with the patient denying problems and the doctor believing the patient..When the evidence of an emotional problem is clear and obvious the search for a cause should be energetic and not be put off by vaguely plausible denials. One must take into account that although the patient is distressed, revelation of the source of stress may be even more distressing. The careful questioning should note denials but continue to concentrate on common sources of distress occurring in that age, sex and work or marital state. Thus a 16 yr old girl who has attempted suicide may likely have problems with parents over her unacceptable adolescent behaviour. A 24 yr old single girl who is depressed is often having problems with the opposite sex. A 68 yr old widower who denies all problems but attempted suicide may have problems of ill health or with children over his upkeep. Exploring obvious areas of distress and confirming their absence or presence often helps understand and treat the seemingly well person who is ill. .Too often the "blank wall" illness is a clear failure of interview techniques. A 40 yr old housewife was admitted twice in the months for attempted suicide. On the first admission the husband came two days later to see her. She denied marital problems and so did he. They blamed the event on mistaking the poison for headache pills. On the second occasion she took a liquid detergent apparently mistaking it for cough mixture. This time the husband did not turn up for 3 days. She seemed very tense when he came but again both denied any problems. The interviewer had not explored possible areas of differences between husband and wife e.g. quarrels or financial problems or other women in his life, upbringing of children, in-laws etc. What the interviewer did was ask was, "Do you have any marital problem and the answer was a ready `No. Later on when asked if they ever quarrelled at all - they both denied it until the interviewer commented that they must be the first couple in the world who never quarrelled whereupon some of their problems came out more easily. Many patients and relatives do not want to wash dirty linen in public. The method of achieving a cure is to them worse than the disease. A 40 year old policeman attempted suicide twice rather than reveal he was impotent. Another 35 yr old man was admitted twice for depression before he admitted to being impotent. The history of the problems as viewed by the patient's family is often not as serious as the present crisis and a detailed past or recent history should be taken as a routine when crises present themselves. Many a convincing history by the patient may be turned around by the relatives' story and vice versa. The interviewer has to play

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judge and jury to arrive at the truth but it is in fact better to get 2 stories (or three) than one when one has to make a decision on a diagnosis that is difficult. Whom do you see first ? As a rule it is the patient who should be interviewed first. This is because the patient is the person with the illness. Seeing a relative before the patient may be seen by the patient as the doctor pre-judging the illness and not trusting the patient enough, and instead trusting the family member . On the other hand the relative may give an unbiased story of the problems the patient has. It is also true that sometimes the other informant may know nothing about the patients illness and may contribute little to the history. Different families have different life styles and different degrees of closeness with members of their family.. One father was not quite sure which child was born before the war another forget he had two daughters when he told of his children. Truth is stranger than fiction. It is worth remembering that the ideal view of the relative is not always borne out in the process of interviewing by an astute clinician. So the best thing to do is to see the patient first, establish rapport, and get his story. Then see the relative, always confirming his relationship with the patient, and his closeness to the patient and familiarity with recent events in the patients life. Confidentiality In medical communication confidentiality must be observed even when one is talking to relatives. It is important to get the patient's permission when talking to relatives and not to reveal matters revealed by the patient to the doctor in confidence. If the matter revealed by one or the other is important in therapy and crucial in the management and may need to be brought up in discussions with relatives, the patient should be told of this problem and focus of treatment. The patients sensitivities need to be respected and he be given the opportunity to tell his story in confidence to the interviewer. When this has been done his or her permission should be obtained to talk to his or her relatives, explaining that this is essential for the doctor to make a diagnosis. .Although family members in Malaysia are by and large concerned for their ill relative and keen to contribute in any way to help, they are by no means uniformly knowledgeable or positively disposed towards the patient. Strange as this might seem to novices in psychiatry some relatives who come with the patient may not know much about the patients problems or habits. It is not rare to get the following response. Doctor to patient's relative: How is your son sleeping these days.? Relative to Patient: How are you sleeping these days? Doctor to relative : Do you both stay in the same house? Relative to Doctor : Yes but I am very busy or I am asleep

Sometimes to avoid problems it is better to see relatives and patient together so that one or the other party can reveal what he or she has to say in the presence of the doctor.

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Interviewing, other family members, employers friends or colleagues. Invariably many sources of information about a patient may come from other important people in his life who are not related to him. Confidentiality here has to maintained at an even higher level. Sometimes these may be close or intimate friends who may insist on knowing the truth about his illness at other times employers want to know if he is mad'. One employer was adamant that the doctor reveal what her staff came to him for. The fact of the matter is that no information about a patient can be revealed to a third party without the patients expressed permission - often in writing. .Friends and employers or teachers can nonetheless give valuable information on the patient's performance at work or socially and the problems he may face that relatives may not know and patient may not reveal. To get at a comprehensive picture their information should be routinely sought in all difficult cases, after getting the patient's permission. On the other hand resort to history form relatives, friends or employers should not be used as a substitute for poor technique in interviewing that the doctor uses as the most important single source of information - i.e. from the patient himself.

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CHAPTER THREE
SPECIFIC TECHNIQUES USED IN THE MAIN PHASE OF THE INTERVIEW
The Main Phase of the Interview The main phase of the interview follows the introductory phase of the interview, and consists of the bulk of the interview process of asking clarifications and getting more information on the problems the patient comes with. The main phase takes more time, about 70 % of the time of the interview process leaving just 30 % or less for the Introductory phase and the Termination phase Not all interviews in mental health are easy to conduct although the vast majority of persons with emotional problems are fairly easy to talk to and respond to questions with ease. There are various reasons for some persons to be difficult interviewees, including the state of the illness, neurological disorders and the response to a non-conducive environment in which the interview is being conducted.. Some persons with emotional problems may not talk at all whereas others may talk in spurts or talk only a little. Some of these difficult interviews encountered and the ways to try and cope with them are worth looking at. Patients who talk little or are mute,. Very rarely fully conscious patients who talk very little or are virtually mute may be encountered. The common causes of this rare condition are 1.severe depression and rarely retarded depression 2.schizophrenia with catatonia 3.elective mutism 4 severe degree of brain damage A simple test to find out the level of non response or response to question is to stop asking about his problem and ask what his name is or where he is from. Most patients should be able to respond to these basic questions. If they seem to be able to try but take very long or cannot it is usually due to one of the three reasons. History from relatives can usually clarify which of these they are.. Elective Mutism usually comes on

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suddenly after acute stress whereas depression or catatonia are more gradual in onset with neglect of work, food, grooming, and hygiene. In catatonic illness there maybe a previous history of catatonic excitement or bizarre behaviour. In depression the history may be that of a recent loss followed by gradual difficulty with sleep, work, appetite and depressive thoughts. .In brain damage there is often a history and physical signs of either head injury or findings of brain disease such as stroke, tumour or dementia. Restless or aggressive patients Although the fear of aggression and violence among psychiatric patients has preceded them, in reality a very small percentage are aggressive and fewer still violent. When interviewing a patient who is restless and potentially aggressive or violent it is important to, 1.identify and introduce yourself as a doctor or student doctor or health professional as the case may be 2.explain briefly your willingness to help him over his problem 3.avoid confronting, threatening or warning the patient 4..be calm and confident in your dealing with the patient 5..talk to the patient in an atmosphere where threats and sources of attention or the need for him to prove his aggressiveness are not present e.g. a host of bystanders, policemen. Most patients except with those brain damage respond genuinely to doctors or health professionals who are sincere. Using ploys to engage the patient in conversation while preparing to trap him or capture him is not part of medical practice. The patient in tears. or the crying patient Tears in emotionally distressed patients are as common as pain is in physically ill patients. Emotional distress is common in patients but despite this most health care professionals are uneasy about tears in their patients. Their unease is often the result of lack of proper training in dealing with emotional distress in their undergraduate days. Patients who are about to cry can easily be detected by careful monitoring of the patient who is being interviewed, and noticing the reddening of the eyes and the welling of tears in the lower eyelids. As soon as this is noticed the interviewer should respond to this by referring to the distress the patient is experiencing by saying for instance, .You appear to be distressed by the events you mentioned This would usually lead to the beginning of tears in the patients eyes or a further outpouring of tears if they were welling in the eyes of the patient. The oft repeated but useless advice Please dont cry should not be offered at this stage but instead a box of tissues should be offered

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by the interviewer. The effect of this gesture is clear. The message is, it is alright to cry, I understand and empathise with what you are going through. This has another effect on

the distressed patient; that of establishing a hand of help in the moment of distress of the patient, unlike the advice not to cry would. The suicidal patient Suicidal patients and those who have a recent history of parasuicide (attempted suicide or deliberate self harm) pose perhaps the commonest psychiatric emergency that has potential for mortality. As such it's prevention is of particular importance and urgency. Although the patient, relatives and medical staff are often busy trying to save the patient's life the underlying reasons for the suicidal patient's attempt are often complex and very often remain unfathomed. In patients who are suicidal or have expressed suicidal ideas, those around them are quick to say "don't do it" but are unable or unwilling to understand the patient's problem that led to his suicidal mood. To understand the wish, no matter how temporary, of a patient to voluntarily take his own life, one has to begin to understand the human emotions that lead to loss of hope and loss of the will to continue living. Essentially the subject of suicide can be divided into parasuicide - or attempts at suicide (that for the most part ended in injury but not death) and successful suicides - that end in death. Suicidal ideas occur in both with varying degrees of severity. In between the two are a host of failed suicides and accidental parasuicides. The suicidal idea. Suicidal ideas in a patient often arises as a result of sadness, depression and loss. loss of a loved object, position, status, person and self respect or failure to achieve any of these leads to varying degrees of depression. Most people who experience loss of a very personal kind find it difficult to overcome that loss and may only vaguely think of "running away" from it all. Some think of ending it all fewer still actually think actively of ways in which they could take their own life. Parasuicide attempted suicides Since the 1970s when Dr. N Krietman first introduced the term, parasuicide has been used to describe attempts at self injury that do not result in death. Most parasuicides occur in women (3 women to every man who attempts suicide) and about 60% occur in the younger adults below the age of 35. It is estimated that 1% of women attempt suicide in any one year (Krietman 1977). The origin of their decision to take their lives is often related to acute stress usually of a personal and sensitive nature. In one major general hospital in Malaysia about 350 patient with attempted suicide are admitted each year - or about one every day. Most of them give a history of a recent acute stress. In most of these the stress is related to often a heated and sometimes violent quarrel with a loved one. In single women it is often over a boyfriend. In married women the issue is

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very often related to the husband, or husband's affair with another woman. Less common are parental restrictions on a girl's movement because of her relationship with a boy. The disappointments or stressful issues are often present for sometime but the suicidal attempt is made after an acute disappointment e.g. a girl found out her boyfriend was secretly having a relationship with another girl, and confronted him. After denying it initially he admitted the other girl was just a friend, whom he gave lift to in his car. He assured her there was nothing else between them and agreed he would not give her anymore lifts. The shock of the girlfriend discovering the secret relationship was not enough to make her suicidal, nor was her confrontation with him. Two weeks later when their relationship was getting closer she found a letter dated only 3 days earlier from the girl to her boyfriend. In it the girl addressed him as darling and wrote of their meeting the previous night. The girl friend was furious she confronted him straight away and a violent quarrel ensued - she told him to go to hell with his other woman and walked out. He called her the next day and tried to make up. They both cried and made up. A week later he rang up to say their affair was over and he had decided to get engaged to the other girl. This time the girlfriend was dumbstruck. She pleaded with him to return to her. He was polite but firm. He had made up his mind. After a few hours of ruminating she went to the bathroom and took an overdose following that she rang him up wished him and his new girl friend all the very best and casually told him this was the last time she would disturb him on the phone until they met in heaven. The boyfriend suspecting that she may try to commit suicide, rushed to find her drowsy with an empty pill bottle by her bed. He rushed her to hospital. Thus it is clear that bad news alone, nor disappointments lead to suicidal attempts in many cases. What often leads to the decision to end it all is a sense of loss of all hope. In this case the feeling that with the boyfriend's decision to get engaged all hope was lost, was the final straw that broke her resolve to fight for him. At first she blamed the other girl but her discovery that it was her boyfriend's change of mind and willingness to get engaged to the other girl was too overwhelming that she felt it was no use going on. In such cases the presenting facts at the emergency room would often be "a quarrel with her boyfriend over another girl". Without knowing the sequence of events the story looks very bland, simple and deceptively easy to solve with some casual "please don't quarrel " advice. In reality even if the suicidal attempt was overcome there will remain the bleak future for the girl - who not only has to face the loss of her boyfriend but the stigma of being an ex-girl friend and a suicide attempter and psychiatric patient. Counselling here must be geared to understanding and overcoming real problems and not merely advice giving. The interviewing must take account of :background events leading up to the attempt at suicide, an almost hour by hour account of what happened in the last 24 - 48 hours. Often patients attempt parasuicide with mixed feelings of wanting to die and yet not wanting to: wanting to "sleep for ever" but not quite wanting to die. Few plan their suicidal attempts in advance with great care so that their attempt is often with pills, poisons or a knife easily available and not necessarily very lethal. The interview should establish:-

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1.the source of the material used for self injury 2.when it was bought and why 3.whether the material was expressly bought with suicidal intent Mere lethal power of the pill is no indication of the seriousness or lack of seriousness of the attempt. One patient took an overdose of a mixture of paracetamol and laxatives when she was depressed. She was confused and convinced people were accusing her of some loss of money and preferred to die. After she was treated in hospital for depressive psychosis she climbed to the 14th floor of a block of flats and jumped down to her death.. People who treated her suicidal attempt as a joke or an attempt to be attention seeking (as she took only tablets of a common laxative!) could not understand why she jumped from a high building. Too late the attention seeking theory proved fatal. The common lay man's view that people who make casual attempts at suicide are "attention seeking" and should be treated casually ignores the degree of distress the person faces. Even attention seeking people do not attempt suicide everyday. What is important is to see a suicidal attempt as a major symptom of a big problem. Suicide attempts are not diagnoses. They are symptoms or signs of deeper and always severe distress. It is the distress that needs to be treated. And that should be judged by the method used. The leaving of suicide notes is also not necessarily an indication of seriousness as many people in distress do not leave suicide notes and many others do. Parasuicide or accident ? To the busy emergency room doctor the arrival of a patient with an overdose of 20 tablets of diazepam or 1/2 a cup of kerosene accompanied by relatives pleading it was all an accident, can be an embarrassing situation. There is, it appears no way of being sure whether it was a suicidal attempt or an accident. So many doctors take the easy way out and simply label these as accident poisoning. As both patients and family deny it was suicidal the doctor is "safe" - or is he? Common sense it is said is the rarest sense, rarely found in common man. To swallow 20 tablets of anything one has to make a determined attempt to force it down the throat with copious amount of water on more than one swallowing - it cannot be "accidental". Furthermore most people with any common sense will treat 5 tablets as dangerous, what more twenty! As for kerosene even the drowsiest of people will sit bolt upright fully awake when one drop of kerosene passes their lips and spit it all out - 1/2 a cup of kerosene can hardly be `accidentally' swallowed. Furthermore how did 1/2 a cup get "mistaken" (as often proposed) for water. Surely kerosene and water (though both colourless) smell different and are kept in different places. Thus simple common sense questioning in the interview will give a glimpse behind the bland facade of many a so called accidental

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poisoning. The interview must concentrate on how the person could have done what she did - whether it is feasible, common or extremely unusual. .A girl who was dying of paraquat poisoning said it was accidental revealed on careful interviewing that 1 1/2 hours had lapsed after she look what she "thought was stomach medicine" vomited it and then informed her father of the ingestion. She also then admitted quarrels earlier with her sister. Needless to say she eventually died. The Suicidal risk in a patient Unlike the patient who has attempted suicide, the suicidal patient who has thoughts of committing suicide is far commoner. Many patients express suicidal ideas and many other admit such ideas when asked. The suicidal patient in most cases is depressed and has often lost all hope. He or she thinks it's better to end it all. The patient who becomes suicidal may be of any age, usually depressed but sometimes schizophrenic. Successful suicides (those who die by suicide) are usually older with men predominating. Men also use more violent methods such as hanging, shooting, jumping from a height although many still use self poisoning .The methods used in killing ones self varies from one country to another with use of guns being common in some countries where firearms are more easily available and jumping from high rise buildings more common where more people live in high rise buildings. Asking a patient whether he has ideas of ending his or her life is not, as believed by some a dangerous question. Patients who have ideas of suicide often feel relieved that they can share their innermost thoughts with a concerned health professional.. The question however should be posed gently e.g. "How depressed do you feel?" followed by "have you felt like crying or cried when you are very depressed" and " do you sometimes feel there is no use going on or that it's better to die". "When you feel that way do you think how you would die", "have you made efforts to try and take your life", etc. The genuine concern and care of the interviewer is of paramount importance in the interviewing of a person with suicidal thoughts.. Many doctors feel uneasy about asking about suicidal ideas because they do not know how to handle the subject. If a patient does admit suicidal thoughts, more should be asked of those ideas. When the patient give details, (even if the interviewer is only a student) it is most useful and acceptable to say that no matter how hopeless the patient feels no situation is hopeless. When his depression lifts he will find an answer out of his problems. The suicidal patient has usually lost hope - the task is to inject back that hope. Many other people face similar problems and yet are not suicidal - because they are hoping somehow things will change .In a suicidal patient too details of the reasons for his feeling hopeless, the sources his stress and disappointment have to be asked in the interview. Of particular interest is finding out when was the last time he was well - i.e. not depressed. Often when a patient is depressed and suicidal his views are gloomy and negative, so that even bright points in his life will appear useless to him. It is therefore not possible for him to determine the source of his disappointment that led to his suicidal mood. Asking when he was last well can help determine the onset and

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hopefully the factors related to the depression .The question of how suicidal a person is, can be determined by exploring his ideas methods he plans to use to kill himself. Whether he has tried getting the means to kill himself. These have to be done gently (see earlier notes in this section) Also important are the reasons for suicidal moods the patient sees them, and whether any stresses preceded these feelings. Marital Problems Surprisingly few references in medical studies pay any attention to marriage and its relationship to health. A large number of emotional problems have in reality a very close relationship to the emotional lives of the patient and his relationships rather than often purely physical presentations of illness. It would be useful to consider a few simple but everyday occurrences that escape the notice of most doctors. A 43 yr old man was brought to the Emergency room of a hospital at 11.30 pm with a fracture right femur sustained in a bad motor vehicle accident in which he was the sole occupant of his car. As far as the doctor was concerned it was a case of a motor vehicle accident. An astute house officer smelt the smell of alcohol in the patient's breath and on questioning found out he had been drinking at a pub until 11 pm and was probably intoxicated when he left the pub - thus alcohol had an important role to play in the motor vehicle accident - and the fracture of his right femur. A medical student who was with both the medical officer and the house officer when they questioned the patient, went a step further and asked him. `Do you always drink in the pub?' and learnt that he had not been to a pub for over 6 yrs. . When she complained of not having enough money for this or that. I had enough - so I went out and got drunk. There must be thousands of such problems presenting to medical, surgical, ENT or orthopaedic or other clinics every year with physical problems, physical illness or physical complains that have origins in marriage and marital problems. And yet identifying or eliciting marital distress in an interview is very difficult- for 3 reasons 1.Doctors are often not aware of the connection between marriage, stress and medicine 2.Doctors are not comfortable with the exploration of marital problems as they are not knowledgeable in this area themselves There is no special teaching on marriage in medical schools although marriage like birth, death and illnesses are clearly human events. 3..Doctors do not know what to do if they do find there is a marital problem related to the illness. The clinical interview that focuses on marital issues will quickly run into problems as most people are very averse to discussing their marriage and are not knowledgeable.

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The interviewer as part of his clerking of a married patient should ask about his marriage. When he was married and how long he had known his spouse before marriage and the circumstances leading to the marriage. Then the questions should focus of the couples area of disagreements or quarrels. Many couples hate to use words like quarrels and say they have small disagreements. Who starts and who ends these quarrels and how. Who punishes the children and whom do the children turn to when they have problems. .These little details give an indication of the dynamics of who is the more dominant in the relationship and whether this causes distress to the partner. Another area is to ask about the frequency of quarrels and their seriousness. Have there been separations, cessation of sexual relations, threats of divorce, attempted suicide and other relationships outside of the marriage.. What are the main causes of disagreements. Problems that are particularly serious are not as might be expected financial ones but ones related to another girl friend, or boy friend in the marriage, heavy drinking, unemployment of the husband and physical violence. Dominance by a wife is something few men accept passively just as violence by husband or infidelity is seldom accepted by a wife. These behaviour problem often account for most of the marital problems in clinical practice. They may present in other ways, such as physical complaints which do not have physical bases such as complaints of, headache anxiety attacks panic attacks spells of dizziness insomnia gastric complaints nervous diarrhoea asthmatic attacks chest pain, angina myocardial infarcts alcoholism and related physical consequences pathological gambling attempted suicide depressive illness impotence premature ejaculation backache recurrent skin problems Psychotic illnesses Although most young students or doctors are averse interviewing psychotic patients because of prejudicial fear of dealing with a "mad" person, interviewing a psychotic patient is generally not difficult if one puts prejudice aside. Most psychotic patients talk well. Their history may be disjointed at times and interspersed with

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abnormal smiles, giggles, gaps in attention or even restless behaviour and odd speech. They may talk nonsense when questioned. The technique is not to allow such clinical realities to interfere with one's purpose in carrying out the interview as far as possible. Often when one sees a patient who is behaving in a psychotic way one should still introduce oneself as usual find out the patient's name, background and explain the purpose of the interview. While asking questions one should deal with the healthy side of his personality and not the obvious psychotic behaviour. If one does not follow his odd or strange replies one should say so without hesitation e.g. "I am sorry I can't follow what you mean" or " I'm sorry you haven't answered my question" in a gentle but firm way. Most psychotic patients will respond well to such question and their psychotic behaviour often temporarily diminishes. The rule is never to agree to strange arguments that are out of context with common sense or reality out of politeness or so as not to "offend the patient" or assume that psychotic patients are not capable of rational behaviour. It often surprises many a novice to realise that a patient with psychosis is rational in his behaviour most of the time. The tales of woe the histrionic patient. To those used to seeing dramatic but intensely sad Asian films on TV and on cinema the hearing of sad and tragic tales from patients will have a familiar ring. Some patients, often young females, but also young males, may pour out tales of woe - of tragedy, abandonment, exploitation by others with a heavy dose of sexual abuse. Often the story is more in the distant past than in the recent past. Their admission or contact with the clinician may be for depression or attempted suicide. The problem with interviewing patients with what are called histrionic personalities or hysterical personalities are that they give very convincing and sad tales that the interviewer is spellbound to listen and accept. The interviewer feels very sorry for the patient and when vulnerable ceases to maintain the doctor-patient relationship and exercise his or her judgement properly. They may sometimes "latch" on to the doctor for more than medical help -often manipulating one staff against another by telling different things to different people and wanting attention. When listening to a story that is very one sided - i.e. the whole world being against the patient with a never ending tale of exploitation one has to keep one's balance and sense of proportion and ask the question `why?'. Everyone has had their share of woes and tragedies - some perhaps more than others but why is this person always suffering as she or he says. Has the person's personality got something to do with the tale of woe? While in the ward often the reasons will emerge. The patient has difficulty forming an adult relationship with others. Often it is a superficial and sometimes seductive one with a member of the opposite sex. In this relationship there is no evidence of woe only stylish flirtatious and attention seeking activity. In fact quite a few of these make good actors and actresses. In front of the doctor they put on an act of terrible wrongs done to them. The glaring differences in behaviour should make the interviewer sit back and think if he is rapidly feeling sorry for the patient.

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Cross checking the patient's story with other significant people often reveals a long lists of broken relationships - even broken marriages and a string of false histories modified to suit the patient's needs. Anyone who has had contact with the patient will remember the histrionic seductive and yet false acting quality of the person's stories Often the current contact with the doctors is one in a long line usually following a crisis and a broken relationship or the threat of one. The recovery is fairly quick unless the patient develops another relationship with the doctor in which case the doctor becomes the next victim of the histrionic personality. The Medical or Surgical Psychiatric Problem. There was a time when most if not all psychiatric problems ended in an asylum for the mentally ill or on the streets. Psychiatry's reluctant acceptance or at least acknowledgement by colleagues in other medical disciplines can be closely related to the gradual emergence of psychiatry as a subject taught in medical schools. Prejudice and ignorance have gradually yielded to the recognition that not all disorder must have physical signs and symptoms. The role of emotion and psyche in causation of symptoms is gradually being accepted as more and more psychiatrists are involved in consultation and liaison psychiatric practice and clinics. Thus psychiatric problems are referred from a variety of outpatient and inpatient settings. These referrals pose slightly different interview problems as for the most part they are not labelled as psychiatric patients. The commonly encountered difficulties are, 1..Patient not being told by the attending doctor that he or she is being referred to a psychiatrist. Patients are sometimes angry, that someone has considered them `mental' enough to be seen by psychiatrist. The common misconception is that all patients who see psychiatrists must be psychotic (mad). In fact most patient who are referred may have anxiety or depression and such non-psychotic problems as attempted suicide, alcoholism or marital problems. Hopefully the attending physician, the neurologist or neurosurgeon is aware of the numerous other types of illnesses other than psychosis the psychiatrist treats and informs his patient of these. 2. The interviewee may stick to his or her physical symptoms and deny psychological problems. This is particularly true of patients with long standing physical complaints who have been thoroughly and often over investigated at numerous hospitals and at great cost. Their doctor shopping ( and occasional vaguely positive results on some tests) have often convinced them they are physically ill - with cancer, Aids or heart disease. The longer a patient has had his physical symptoms (without physical illness) the more resistant he is likely to be to accept a psychological assessment. One way to overcome this is to point out the truth that despite numerous investigations he is no nearer to the physical diagnosis and there is nothing to be lost by a psychiatric interview and history taking. Also that many psychological stresses cause physical symptoms and signs. A common experience of everyone that can be used is that of

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anxiety before and examination and frequency of micturition or sweating of the palms that are associated with that anxiety. From that it is clear the mind and the body are connected. Such simple but true to life examples may help the patient to cooperate with the interview. 3. Many patients with physical symptoms may blandly deny any stress although all clinical signs point to a psychological rather than a physical cause for the complaints. In these cases a brief checklist of common areas of stress can be gone through to explore possible sources for his complaints .Problems at home with spouse, children, finances, In-laws, problems at work e.g.

1. recent change of job, position, or failure in position 2. problems outside, financial, girlfriend or boyfriend, gambling, 3..problems within oneself, personality, difficulties, drug or alcohol problems sexual

Acutely disturbed physically ill patients Acutely disturbed behaviour of sudden onset in physically ill patients is usually the result of acute organic brain syndromes. Commonly they are seen postoperatively, following major surgery or in ICU or CICU settings. Interviewing such patients may reveal very little compared to an accurate and carefully done mental status examination and a test of cognitive functions .Sometimes out of ignorance of the In medical or surgical problems of grossly abnormal behaviour such as paranoia or restlessness are method and function of a psychiatric examination and out of a sense of desperation a patient may be referred by a physician or surgeon with a diagnosis of ? depression. These patients may be actually brain damaged or in a state of confusion - as borne out by a quick test of cognition e.g. orientation, short term memory attention and concentration which are usually grossly impaired. Taking a sexual history. There are some areas of medical and clinical practice and examination many doctors instinctively avoid. The sexual history is one such. In general unless the patient complains about sexual difficulties the taking of a detailed sexual history may not be important. The exceptions to this general rule are those cases where male patients give other indication of 1. persistent hypochondriac complaints 2. recurrent depression without the external stressors 3. alcoholism

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When other sources of stress and conflict are confidently excluded in history taking the sexual history needs exploration in greater detail .Being a sensitive area, gentleness and choice of correct words are important. Many patients with sexual difficulties are naturally very shy to reveal their problems as they have fears of being ridiculed as having lost their manhood etc. When the interviewer takes a history crude questions such as "do you have impotence" or bland generalisations "do you have sexual problems" are of little use. What may be required and more useful are questions starting with how often do you have sexual relations. In unmarried men or even married men suspected of visiting prostitutes the word prostitutes should be avoided, "Do you visit massage parlours" or "do you go to bar-girls "may be more acceptable and yet carry the same general meaning. When asking about sexual performance again "how is your sexual function" is unlikely to produce answers except `OK'. What may be needed is to ask "do you notice any change in your usual sexual performance over the past few months (duration related to his physical or other psychiatric complaint and "Has there been any weakness in sexual activity e.g. slower erections or softer erections or taking longer to achieve ejaculation, or not interested in sex so much as before?" Many patients with impotence will continue to deny the problem even while being severely depressed over it. One patient became severely depressed over his impotence and tried to jump out of the hospital window - but never breathed a word about his sexual dysfunction. Sometimes the therapists relating the experiences of others experiences (without identification of course) may help the patient - as did happen in this patient. He was told that in severe depression not only does sleep, appetite and function at work diminish in quality, but also sexual function. This in fact is true. And also it was mentioned that most of these sexual problem will disappear once the depression lifts with treatment and there is nothing to worry about. The sexual organ is tired. With this explanation the patient was able to share that he had virtually become impotent since he became depressed. No attempt was made to connect his attempted suicide with his impotence and the word impotence was not used at all throughout the interview Common local ways of expressing a man's sexual problems is to complain of backache, weakness of the legs and tiredness. A young male with these complaints and no physical disorders should be asked about his sexual function, masturbation and guilt over masturbation or sexual activity or venereal diseases as gently as possible. Delusion or the Truth. One of the bug bears of psychiatry is the process of avoiding gullibility and yet getting at the truth. When a psychiatric patient complains people are trying to harm him or that his wife is having an affair it is easy for someone to dismiss these as delusions. But are they? How does one distinguish a delusion from reality. Often most doctors simply feel they know but cannot explain". A more accurate way is to ask details of the strong belief e.g. that a patient's husband is having an affair - like

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with whom how do you know have you seen the other woman. What is her name have you spoken to her. In delusions more of the time the details are sketchy and the further the interview progresses the more the suspicion fades into a delusion. In beliefs based on facts dates times names events are repeatedly consistent .Then one has to confront the husband in front of the patient with the beliefs and see his response. In complaints based on facts the husband seldom explains away everything and admits part of the events or facts but denies its meaning or implication. One has then to clarify the inconsistencies and make conclusions. The process is not an easy one and is full of pitfalls but certainly an improvement on the doctor's mysterious judgement based on his own view of what is likely and what is not. The history taking must go into details of the events rather than summary conclusions and pre-occupations that sadly sometimes may be the sole basis for a diagnosis. The Termination Phase pf the Interview. At the end of the interview process the patient must be given the opportunity to ask the doctor questions he would want to ask of the doctor. These may relate to his anxieties over his illness, diagnosis, treatment, the effect of the medicines on other treatments and food he takes and so on. When the patient has had a chance to clarify his thoughts with the doctor the doctor can then give him or her a summary of the interview process and the main problems as well as a summary of the future plans for the patient. The interview should end with thanks and farewell as is customary in the particular culture.

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CHAPTER FOUR
TAKING THE HIS-STORY
HISTORY TAKING IN PSYCHOLOGICAL MEDICINE. Introduction The clerking of a psychiatric patient is similar to that of any of the patient in that preliminary data are followed by a list of chief complaints and a history of present illness start the process. However all psychiatric histories must also have a history from a relative or other person close to the patient. This is followed by important and functional history of the patient, his past illness and present treatment. A family and family detailed personal history are then taken. These are followed by the psychiatric and physical examination. A detailed sample clerking sheets are appended at the end of this book. Preliminary Identifying data In this the name sex, age, address, occupation, envelopment, marital status and faith are usually recorded by the clerical staff in a hospital where these are unavailable the doctor should record these himself or check what has been recorded to avoid mistakes that are not by any means rare. Source of Referral Many patients these days come through referral from other agencies and a record of this will be helpful in getting details of previous illness and treatment so as not to repeat a whole battery of investigations and gathering of information that has already been done elsewhere. Language spoken in interview (and if translated) With so many languages in use in Malaysia and many other countries these days the accuracy of the history is bound to be affected if translation is used in history taking. To cover these problems a note should be made of the language in which the history was given by the patient and whether translation was made.

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Chief complaints The chief complaints should as far as possible be limited to four or less complaints that brought the patient to hospital, clinic or into contact with the doctor .The chief complaints should be recorded verbatim as far as is possible thus,

headache feeling its better to die cannot sleep rather than, headache suicidal ideation insomnia

3 months 2 weeks 4 days

3 months 2 weeks 4 days

The purpose of the chief complaint is just that i.e. chief complaint. It should be the main problem of the patient requiring attention and it would be good to remember that even if the final diagnosis is depression the chief complaints must be catered for as soon as possible for the patient to feel relief before his depression lifts. The chief complaints should also be recorded in chronological order with either the longest standing complaint first and the most recent complaint last or vice versa. A person reading the chief complaint should immediately be able to grasp the gist of the reason for his contact with the doctor or clinic. Often a psychotic or angry patient comes to the clinic and says he has no complaints and he came for a check up or there is nothing wrong and he was forced by relatives to come. Here the chief complaint should be recorded as such and the relatives complaint recorded below, thus, Patient says There is nothing wrong with me (Mother of patient says he tried to stab her with a kitchen knife today) History of Present illness The history of present illness that is obtained should be the result of an interview with the patient that covers the patient's own history 1. as he sees it, if possible in his own words 2. as seen by relatives, friends and significant others. 3. and including specific points asked for by the interviewer.

The history is not a conclusion of findings but a wide statement of events that brought him to hospital, the patients own story with elaboration from other available

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sources. In the writing of the history of present illness the writer must convey to the reader or listener a summary that conveys the essence of the problem and patient comes with. The chronological order of events in the patient's history should be carefully arranged so that the story unfold as it most likely occurred - and not as haphazardly obtained during the series of interviews. The history should start with the first or earliest significant event related to the patient's present illness. Thus in a case of depression the history may be written as follows Lee Chin Kiat is a 23 yr old single Chinese male timber worker who was well till 2 yrs ago when he was transferred to Gua Musang. He was unhappy over the transfer and tried hard to get the transfer order cancelled. When he eventually reported for duty at the site office he complained of dizzy spells ...."Although exact dates for remote events may be sketchy, attempts should be made to clarify the sequence of recent events accurately, thus "..He did not improved with treatment. On 15th November of this year he was seen at the ENT department of Ipoh Hospital for the same complaints when the Medical Officer noted that the patient was fearful. He however refused a psychiatric referral and was put on a low dose of diazepam and given a further appointment to the ENT clinic for 26th November. However, on the 24th November he was brought to the A & E unit of the hospital with a suspected overdose of diazepam tablets. To make the long prose of the history easier to grasp at a glance an events chart or events charts may be used. This is particularly useful for presentations at the case discussions or conferences. Thus the events chart should read somewhat like this. _____________________________________________________________ I I I I I 1980 1997 1998 1998-9 September 30th, 2001 Sent to Gua Musang Born Left worked for worked in to work in Timber extraction Full term school uncle in Indonesia worked camp - c/o dizzy spells Delivery Form 5 ship as timber supervisor in October Rx by GP in KAPAS. PT Kota Bahru. and ref to Ipoh ENT clinic Ipoh Hospital Nov.

It will be noted from the above that apart from the transfer to Gua Musang no other possible areas of stress are evident. Being a young man of 23 is it possible he had or has a girl friend and is this a problem area. Thus seeing a chart like this an observer can quickly `see' questions that arise and need further exploration. A more detailed chart may be needed if past history of several admissions, psychiatric contacts, suicidal

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attempts and the like, are present. Sometimes charts of present events and past events may be needed to clarify the history in graphical form. The history often goes off at a tangent into particular areas of personal history that may overlap with the section under personal history. These can usually be dealt with by noting that details of e.g. marital or work or drinking problems will be discussed under the relevant personal history. The history of present illness should not in normal clerking exceed 1 1/2 pages although lengthier histories are required for department case conferences or when discussions are conducted at postgraduate conferences. Getting a good history of Present illness Although the history of present illness is only a part of the whole process of examining the psychiatric patient, its importance cannot be over emphasised. This is particularly so because of the unusual reliance psychiatric diagnosis has on the history of the present illness. In the past, about 25 years ago, the strange phenomenology of psychiatric syndromes held precedence over the history. Doctors looked for phenomena such as authoctonous delusions echopraxia and de-realisation rather than listen to the patient and his history. It was as if the patient and his history did not matter. Early clerking sheets in psychiatry as the Kalamazoo clerking sheet (so named after the place in USA where these were printed) used in large mental hospitals like Bahagia and Permai even in the 1980s put more emphasis on observed phenomenon, reported facts and police or criminal behaviour before the patient's history. Over the years the emphasis has turned to the patient's own experiences rather than that of the experts looking at the strange phenomenon and drawing conclusions based on textbooks written on theoretical bases. Getting a good history is therefore of utmost importance. Histories of patient's illnesses are unique in each individual case although familiar patterns may emerge. The key to getting a good history is to be genuinely interested in the patient's problem - and have an unconditional positive regard for the patient to be an excellent and astute listener not to be prejudicial or pre-judgemental and to be willing to learn from the patient before drawing conclusions. Another dont is to ones views and values on the patient during the process of getting the history

Economy of Time in History Taking In a one hour history taking exercise,. 1.The first 3-5 minutes should be spent on a brief introduction of the interviewer to the patient and getting to know the patient and giving explanations on the purpose of the history taking exercise.

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2.This should be followed by a 10 min period of relative silence by the interviewer asking only open-ended questions and listening to the patient tell his story in his own words. Interruptions by the interviewer to ask when, how long ago why, who is related to whom must wait till these 10 minutes are over. This phase of the interview should preferably have only one or two questions, thus . Tell me what are the reasons why you came to hospital today and then the interviewer should refrain from any further questions for the next 10 minutes or so. 3.After the patient has had time to tell the gist of his story a further exploration of what the patient has said may take another 10 minutes. Thus about 20 minutes are spent on the history of present illness.

4.Following this a further 15-20 minutes are spent getting a factual account of his family and personal history and relevant past history. 5.While the patient is giving his history a mini mental state exam is already in progress the way he co-operates, talks, his mood and any unusual aspects of his behaviour such as the way he is dressed and whether he is smiling or laughing or crying appropriately or inappropriately as well as certain phenomenon he may reveal. 6.The rest of the mental state such as perceptual and thought processes and cognitive functions are easily tested in 5 minutes, leaving 7. 5 minute for the quick physical exam relevant to psychiatry and focussing on any obvious area of problem. In practical circumstances the whole procedure of clerking a new psychiatric patient may take about 30 minutes but still leaving 10 minute for the patient to tell his-story without interruption. The importance of listening to the patient's story cannot be compromised by a. rapid fire MCQ type of closed ended questioning by an arrogant interviewer. Such an interview does not give a history, but only gives a your-story and a poor one at that.

History of Past illness Not all patients come into contact with a psychiatric clinic or doctor on their very first illness at an early stage. One study in Malaysia showed 65 percent of patients who came to a psychiatric clinic had seen a traditional healing agency and about 85% had seen other source of help before seeking psychiatric help. Hence it is the rule for patients to have had contact and often treatment from other sources - sometimes for more that one illness in the past. It is important to get this information in some detail in the early phases of the present history as the patient's present history may be wrongly presented or interpreted by the patient or the interviewer. Some patients are reluctant to

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reveal their past history -particularly those with chronic psychotic illness with denial of their illnesses.

Details essential in past history 1.number of previous psychiatric illness and their diagnoses, dates and duration 2.place, type of treatment for each episode and outcome 3.sources of stress preceding each episodes 4..follow up after previous episodes 5.physical illnesses in the past Sometimes serious illnesses may be spoken of lightly by relatives or patients using such words as "nervous exhaustion", "was charmed", "could not sleep", insomnia, "under stress" etc. The way to find out the significance is to ask about the effect of such illness on the work, studies or functioning of the individual . One 25 yr old clerk blamed difficult and vindictive colleagues and bosses for leaving his last job. 3 yrs ago and since then had been "resting". Careful questioning revealed he had had three episodes of mental illness characterised by paranoid ideas and disruption in his normal work and requiring admission to mental hospitals twice. Following this he was simply unable to work and medically boarded out by the government department .In many cases it is useful to ask patients whether they have ever been admitted to hospital for any reason. This will usually unearth episodes of serious illnesses as most admissions are for fairly serious conditions. And then follow up with questioning on details of each admission focussing on the type of illness its effects on work functioning and behaviour. Significant immediate Problems Although the history of present illness and chief complaints may point to immediate problems a routine enquiry into certain key indication of mental ill health are important and need noting separately. These include: Sleep pattern and problems if present Appetite and problems if present, bowel movements restlessness, aggressiveness, violence ability to work, function current treatment, details and source, suicidal ideas and or attempts These details that follow past history should alert the doctor to key areas needing urgent attention that the patient may not mention on his own. By the time the interviewer

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has reached this stage of the examination of the patient he should have a rough idea of the nature of the patient's problem. Essentially the thoughts that should go through his mind are whether this patient is mainly suffering from one of the following. Is patient's illness due to I _________________________________I________________________________ I I I I I Anxiety or related disorder? Depression related disorder Psychotic disorder 1. Personality Childhood related or adolescent problem? Mental disorder 2. Substance addiction or abuse 3. Sexual identity disorder or or paraphilias

There will be problems that straddle more than one of these categories but the details are for later resolution. The purpose of this early hypothesis is to keep the interviewers mind open to possibilities when taking the next part of the history taking i.e. the Family and Personal History

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CHAPTER FIVE
FAMILY AND PERSONAL HISTORY
The taking of the Family and Personal history often seems a tedious jumble of people, events dates and details whose significance many a student never quite understands. Actually the excess details of this part of the history are not only unnecessary but actually detract from the significance of the history of illness .Just what is important and what is not? The answer lies in knowing a little about the nature of mental illnesses. 1.Genetic and developmental factors in mental illnesses 2.Early signs of mental illness 3.Stressors in life related to mental illness Genetic and developmental factors Many studies show that schizophrenic and affective disorders have genetic bases, although its effect on actual precipitation of illness in an individual is not entirely established. Hence in the family history family members who have similar or other mental illness should be looked for. Evidence of mental illness in a family is not only through admission of a member to a mental illness but in some cases dropping out of school and not being employed or functioning usefully. Mental illnesses in parents are particularly important as they point not only to genetic possibilities but of possible early problems in the bringing up of children. Other aspects of development, such as intelligence levels, ability in school, and ability to adjust to the family environment and outside the family, may also affect the development of mental illnesses in an individual. Early signs of mental illness Mental illness usually does not occur all of a sudden. There is early evidence in behaviour or personality of an individual which can be seen as predisposing a person to possible mental illness - or sometimes seen as distant prodromal signs of mental illness. Many patients diagnosed as suffering from schizophrenia in young adult life in retrospect appeared to their classmates as odd people in childhood or adolescence. On the other

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hand many strange school boys go through adult life being odd but not mentally ill in a formal sense. Severe mental illness in adolescence is often preceded by decline in school performance. Inability to relate to others and to the opposite sex is often seen in early life, and different from that of other adolescent children. Borderline mental retardation often presents in childhood with poor school performance that leaves the student at the bottom end of the class. Moderate mental retardation also becomes obvious in primary schools and leads to leaving the normal schooling process very early. Hyperactive and accident prone children are also evident early. Frequent changes in jobs, frequent broken relationships with friends of same and opposite sex and poor participation in games and activities are often related to problems in later life. Stresses in life Failures, losses, disappointments and wrong decision often pose stresses in life that may in certain vulnerable individuals precipitate or contribute to mental illnesses from anxiety and depression to psychosis. Clearly vulnerability to mental illness is a complex issue that has seldom a single cause. Early childhood deprivation loss of a parent, economic hardships ,painful sibling rivalry, failure in love, wrong decisions in marriage wrong investments, wrong career choices and disappointment with children or relatives are some of the numerous sources of stresses in life. In the personal history a scan should be made for such obvious sources of distress that may have contributed to the precipitated the illness. The more personal the source of stress and the more sensitive it is seen in the eyes of the person the less likely is he to reveal or admit them. When taking a history of problems in sexual areas, marital difficulties, failures in decision making or quarrels with children, gentleness and full confidentiality should be assured as many of these difficulties are not even shared by the patient with the spouse. Although most people expect stresses like death of a parent or sibling and even sometimes a spouse to be the source of stress that leads to major mental illness, it is surprising to see how seldom this itself is the case. Clearly stresses such as death are not as illness producing as conflict. A 40 year old divorcee would be admitted to the psychiatric ward at least once a year invariably following the return of her ex-husband from overseas and visits to her and their children. The first few days would be pleasant but the next week would invariably lead to quarrel and a relapse of her depression. The quarrel always revolved around the ex husband's live-in girlfriend overseas and the possibility of his returning to his former wife - ending with a eventual negative decision. This went on every year for seven years after his divorce. When he suddenly died of a heart attack, although she was very upset over his death the death ended the painful cycle of yearly reunions hopes and dashed hopes not to mention relapses of depression and admissions to the psychiatric unit..

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In many others severe grief reactions through death of a loved one with whom the relationship has been intense and dependent can precipitate depressive and rarely psychotic reaction .If one considers the many stresses many people go through a lifetime it will become obvious that those that lead to a breakdown are not necessarily the most gravest that mankind ever faced. Stresses that precipitate breakdowns in one person may be weathered, though painfully by dozens of others. Clearly individual vulnerability plays an important role in determining the kind of psychological ability or disability to cope with the stress. For instance each year in a fair sized university about 100 out of 10,000 students who sit for their annual examination will present with a variety of psychological illnesses around the time nearing or during the examinations. Some are related to problems at home some with girl or boy friends others over money and yet others with poor scholastic ability. If exam stress was the only stress there should be a much higher rate of illness considering that a much higher number than 100 students fail each year. Failure in exams may be considered a much higher stress than merely facing the exam and yet the breakdown occurs in certain (albeit a few) students who cannot cope with this and other stresses at that period before the examinations.. Family history. The recording of a family history is best done by a chart that shows the relevant genealogy called a genealogical chart. The chart should as far as possible cover generations relevant to the history. Thus if a patient's illness is related to her grandmother and grand aunt who control her mother's household and this led to mother's attempting suicide - which led to her own behaviour problems the relationship should be reflected in the chart. In other cases the two generations may suffice. Also included should be the other marriages of either parent if these are relevant. A sample of a genealogical chart follows. /\ O shopkeeper housewife died aged 74 71 cancer 1999 diabetic I______________________I I ________________________________________I____________________________ 1 1 1 1 1 1 1 O O O O O O

H/W

H/W

single 29 died MVA 1999

H/W 31M husband teacher Sarawak

teacher 29M husband labourer

*28S

23M

43 40 husband business- husband man in driver Singapore

*patient music teacher U/E husband owns shop

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Looking at this simple chart it is obvious two factors stand out in the patient's life and that of her siblings. She is single although her younger sister 5 years her junior is married. The question that arises is why? In most traditional Asian cultures being single in women is frowned upon and even more so when a younger sibling is married. Another point is that of an elder sister who although a teacher married a labourer.

Marrying below one's status is unusual for most women. Thus it can be seen that a chart highlights the areas that need further questions which otherwise may be missed in a prosaic essay type of presentation. Significant points to note in family history include 1.relationship with parents 2.number of siblings and patient's position in family 3.patient's social and educational level in family 4.family history of mental illness include suicidal attempts and suicides 5..broken marriages, desertions 6..addictions or drugs and alcohol abuse 7.deaths due to unusual causes

Personal History Birth and early childhood history should include any abnormal birth and early childhood happenings such as pre-maturity, recurrent illnesses, hospitalisation, hyperactivity and mental retardation. Family circumstances that are stable or unstable whether the patient was adopted or fostered in childhood need to be recorded if there are indications of these. School and education The school performance and later education if present are what is important. If there was discontinuation of schooling reasons for this should be recorded. This may indicate economic or intellectual other reasons. Although many may answer that they were ok in school, an understanding of school performance such as grades obtained, levels passed is important in trying to understand the ability of the person. One simple way to ascertain the scholastic ability of a person is to ask if he was in the first third second third or the third in his form in school .With free and compulsory schooling there should be little reason for a person to drop out of school unless there was abject poverty, or of course the child simply could not cope.. Work record Following school most people these days start on higher education or start working. Was the work up to his level of education higher or lower? Has his work record been good or have there been frequent changes of jobs. If there were changes were these as

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natural and in higher progression as would be normal in his line of work? Or were these changes for no reason or because of frequent disagreements or always "because people are jealous of me". Such patterns of job changes because "people were against him" or "jealous of him" are unusual and need exploration as persons with personality or psychotic illnesses often present in this way. Untreated mental illness with irritable behaviour can be difficult to tolerate in a work situations and often leads to termination of the job as the employers may feel the person is a difficult (rather than ill) person.

People holding jobs well above their level of competence may have got these jobs through influence of relatives or friends and may find it difficult to cope leading sometimes to job related problems. People who hold jobs far below the level of education may be doing so because of lack of confidence, personality factors and sometimes mental illness. Unexplained gaps between jobs during which the person was unemployed or on long holidays lasting years may indicate possible mental illness. Alcoholic related job problems are not uncommon in alcoholics - e.g. lack of punctuality, poor work record. Sexual relations, courtship and Marriage Most adolescents make the transition from adolescence to adulthood without too much difficulty - although no doubt with many a mini crisis. Among the major changes that occur are a healthy and strong interest in the opposite sex often leading in later years to love and marriage. There are many exceptions to this transition and not all are pathological. Some adolescents become shy adults although normal in every other way. The large number of arranged marriages and single people who remain unmarried cannot be considered to be abnormal by any means. However a small number of persons have difficulties in accepting their sexuality, participating in sexual activities and relationships with the opposite sex even when they are otherwise able to function reasonably well in other areas. As long as the sexual side of their life comes to an equilibrium and does not affect their day to day living style it is not stressful. In some cases it does .Being single is not pathological but being single at an age when the majority of that age are married may be a stress to some. Being homosexual is not pathological as long as one is able to come to terms with it. When one is unable to this is a source of conflict and may be stressful. .In marriage too, many people are able to comes to terms with what others may consider unhappy or unacceptable situations - from marrying someone below the status , to marry a divorcee to marrying a hot tempered spouse. Some however are not able to come to terms with these same and many other marital situations - when it then becomes a source of stress. There are thousands of examples of marital conflicts from a spouse's gambling, punishment of children, unfaithfulness to alcoholism and over religiousness .In the taking of a marital history the clinician must not only ask for previous love affairs , period of courtship - long or short, marriage and parental attitudes to marriage children or lack of and why children's upbringing and problems there are also areas of conflict that occur in marriage. These include

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* previous marriages, love affairs * what do the quarrels usually relate to e.g. money, in-laws, drinking * who starts quarrels and why and how * who ends these quarrels usually and how * how serious are these * whether there are threats of divorce * whether there have been actual separations * sexual problems, difficulties and accusations of infidelity. (a full list of questions is given in the section on History Scans)

The idea is to establish if the problems in marriage are serious and if so what the reasons for these quarrels or conflicts are and how they contribute or even primarily relate to the illness. In all marriages there are power relationships as indeed in all close relationships of any kind. One partner is usually more dominant than the other. The absolutely equal relationship or partnership with a 50% - 50% control is all but non existent. In most relationships that are healthy and viable an approximately 45 -55 or a 40 - 60 split of power is noticed. However in unhealthy situations the power may be excessively in the hand of one person - or spouse in the case of marriages. As long as the other spouse is able to come to terms the marriage will progress even if a dominated relationship is the order of the day. But when one spouse objects to being dominated the seeds of conflict are sown. Marital conflicts are notoriously difficult to fathom as most couples see them as something very private and not the subject to discussion by a third person. Indeed marital problems and therapy of marriages is a very complex subject beyond the scope of this brief reference and details should be sought in a book of problems in marriage. The important thing to note is whether problems in marriage are related to the psychiatric problems that the patient presents with and if so in what areas they lie Children and problems related to them Children are the normal outcome of marriage but this is not necessarily the case in every couple. Some couples decide not to have children by choice. Others want but due to gynaecological or other reasons cannot have children. Yet others may be forced to marry because of children - whether because of premarital pregnancy or widowhood Children themselves bring joy most of the time but not always. Some pregnancies are not planned but accepted, others may be planned but not accepted and yet others not

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accepted by one spouse. Children's birth, growth and behaviour are sources of numerous joys as well as unhappiness depending on a large number of factors .In old age of parents, children are once again the source of joy or distress when they get jobs, lose jobs, have children, do not have children, look after parents or neglect them or finally when the children fall ill or even die before their parents. The history should contain details of the children their birth order, ages and occupations or levels of schooling thus;

Housewife Rubber Trader 43 45 O A I________________________I I _________________I_________________ I I I I O O O /\ 17 15 14 12 Form 5 Form 3 Form 2 Std 6

Habits, alcohol, drug, cigarette consumption With growing awareness that substance abuse and dependence are sources of physical illness there is a reluctant but gradual realisation that there are psychological and behavioural basis for these too. Stress is often relieved by substance intake whether it be food or a stimulant or a sedative. Use of sleeping pills, cigarettes, alcohol or illicit drugs should be viewed with caution as a symptom of a disease or a disease itself. In history taking the 1 .start of the substance abuse 2. current pattern of abuse 3. psychological and social effects 4. criminal or legal consequences 5. physical effects 6. occupational effects 7. financial effects are important points that need to be looked into carefully..

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Often excess substance consumption or use leads to conflicts between the family and the individual .Other habits that can be an indication of or a cause of distress concerns sexual habits, such as visiting massage parlours or prostitutes by a married man. Gambling in excess and late nights when neglecting family responsibilities. Most details of habits except for smoking are usually not easily revealed by patients as they are seen to be socially unacceptable and sensitive but as long as they are a source of stress to the patient or his family these should be gently explored. It is also important to ascertain if there have been recent increase or decrease in normal intake of alcohol or other drugs and why these have occured. Pre-morbid Personality When doctors see patients in mental ill health it is sometimes difficult to imagine that the same patient could at one time have been well, healthy and productive and held a responsible job. And yet every patient seen has a morbid personality and a pre-morbid personality. The pre-morbid personality is difficult to assess from the patient himself especially as he is ill at the time of the examination. Often a relative should be asked in this assessment whether the patient before his illness, 1.was a good social mixer 2.had a wide circle of good friends he liked and who liked him 3.had participated in and contributed to extra curricular activities 4.had a reputation as a stable and reliable person in work and social life .or was a recluse with few friends and activities or was an unreliable and difficult person. Personality is a difficult assessment to make in anyone - as evidenced almost everyday by revelations of the sordid and scandalous side of peoples' lives. Nonetheless an assessment has to be made to help with a diagnosis that may be difficult. A 30 yr old bachelor was admitted to a psychiatric unit with complaint of withdrawn behaviour and vague paranoid ideas. He said he had been working at a part time job in a press but not been working for over 5 months. He spent his days alone in his room and only came out for meals. On examination he talked little, admitted one previous illness of a similar nature that lasted for over 6 months and had some delusions then too. It was difficult to come to a definite diagnosis. What was missing was details of his pre-morbid personality as his family members were not very supportive and seldom visited him. The patient was and diagnosed to be schizophrenic on the basis of his withdrawn behaviour chronic course of his illness and supposed strange phenomenon observed in his speech.

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An accurate clinical interviewing and details of his pre-morbid personality and functioning revealed a bright young man with a thick file full of printed contributions to international magazines and variety of topics from health to golf written when he was well. His problems and (most likely an affective) illness had started following a series of failed love affairs .Thus, the pre-morbid personality and parameters of functioning in occupational and social spheres are important in overall assessment of the patient's illness which may present a somewhat different picture in its acute or chronic phase.

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CHAPTER SIX

THE PSYCHIATRIC EXAMINATION

The second part of the clinical methods used in psychiatry after history taking is the psychiatric examination. The psychiatric examination consists of , The current Mental Status Examination (MSE) Tests of Cognitive Function. The difference between the two section is essentially that the mental status deals with the state of the person's mind in areas of appearance, cooperativeness, speech, mood, perception and thoughts while the tests of cognition deals with mental ability such as orientation, memory or judgement. Both these aspects of psychiatric examination need some specialised knowledge and are conducted more in a question and answer fashion and by observation unlike that of the psychiatric interview where the patient tells a story or history and where the doctor does the listening.

EXAMINING THE CURRENT MENTAL STATE General appearance and Behaviour: In clinical medicine the art of detecting illness and pathology by merely looking at a patient's face, gait and posture of limbs or build is all but dead. Today's high tech doctor is urged to look at dials, scopes, meters and printouts to spot what may sometimes be equally evident by more natural observations. Be that as it may the discipline of psychiatry is fortunately dependent on a doctor's power of observation. The general appearance of a patient with psychiatric illness reveals more than many would care to give credit for. For example.

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Anxious patients may show a nervous look on the face, be fidgety, with fingers twisting, voice hesitant, asking questions repeatedly, clothes neat, tidy. A state of constant worry and self doubts over the outcome of everything is the prominent feature of people who are anxious. Depressed patients may wear clothes carelessly and may not be well groomed. .The clothing may be of dull colours. They may look sad, dejected and be slow to respond to questions and show negative attitudes. Manic patients may show excess cheerfulness and may be overdressed in bright colours and show excess confidence,. They may be talkative loud, and be dominant, boisterous and sometimes aggressive. Their excessive cheerfulness may be mistaken by friends and relations as a sign of good health until their aggressiveness or other unacceptable behaviour makes them suspect that something is wrong. A manic patient who came to a psychiatric clinic in a hot tropical country was over dressed in leather fur lined boots, a bright read sweater and a blue overcoat and a very large feathered hat. Needless to say she attracted strong stares and giggles from other patients and staff in the waiting room. Schizophrenic patients may be: :preoccupied with their own thoughts, often withdrawn and may be smiling or talking to themselves or glancing about without reason appear difficult in fathoming their feelings, in a world of their own flat in his affect may be restless or aggressive .In assessment of a patient his general appearance, his cooperativeness, cleanliness, grooming, facial expressing and clothes should be noted. In normal persons, the dressing is appropriate and grooming consistent with a person coming to a hospital. The contrast in a patient with chronic schizophrenia is obvious once the doctor is aware of features of the illness in relation to general appearance of such patients who may be inappropriately dressed, unkempt or untidy . Agitated patients are patients who are restless and uneasy with both a physical and emotional state of unease. This often happens in patients who are suffering from acute psychotic illnesses such as schizophrenia Aggressive, Violent and threatening patients are not seen often on most clinics but may appear. In these instances the patient may be both verbally as well as physically threatening and sometimes aggressive and threatening to assault or actually assaulting in behaviour. Most of the time the patient is suffering from an acute psychotic illness, including the occasional organic brain syndrome resulting from drugs ingestion, or epilepsy or other causes.. although assaulting patients, aggressive patients and verbally abusive patients are not common, the strong prejudice and fear of mental illnesses has overtaken the reality about them in minds of carers.

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Speech: When a patient's speech is assessed the examiner should look for , coherence in language spoken irrelevance in topic that is discussed circumstantiality in speech, loose association between subjects pressure of speech - a tendency to talk under pressure and non stop . use of clang association - sound associated words with very different meanings seen in manic illness. Neologisms - nonsensical invented words . perseveration repeating the same words or phrase several times repetitively . thought blocking - the mind going blank in mid sentence, . concrete thinking - in interpretation of words, concepts flight of ideas - jumping from one topic to another rapidly seen in manic illness drivelling of of thinking - muddled thoughts with obscuring of meaning. Although many of these speech disorders such as neologisms are rarely seen these days perhaps with the reduction of institutionalised and untreated chronic patients, phenomenon such as word salad - a jumble of words with no connection and no meaning being conveyed when spoken together, are occasionally seen in organic brain syndromes and among very chronic wandering schizophrenic patients. In recording the nature and peculiarities of speech it is useful to quote verbatim a sample of the patient's speech e.g. "I feel people are watching me from behind trees and pillars ..." or "It's no use what's the use its no point going on ...."The aim is to give the listener an example of the kind of speech the patient with a paranoid illness in the first example and a depressive illness in the second example .Patients who talk excitedly excessively, jumping from topic to topic, usually indicate underlying pressure of speech seen in manic phase of bipolar affective disorders. Patients who talk very little, take a long time to respond or seem unable to respond even when they seem to understand the interview may be suffering from severe depression. But this has to be differentiated from catatonia, elective mutism and rarely brain damage or acute organic confusional states .Mood: The term mood and affect have been used differently by different psychiatrists and authors at different times.. Indeed the two terms have different definitions in different textbooks of psychiatry. There is however very little doubt that what is basically meant by the two terms is "an emotional feeling state of a person i.e. how a person feels emotionally. For example a person may feel sad, may feel happy excited or anxious or indifferent or angry. In psychiatric description of this feeling state of the emotion the more sustained feeling state that are related to psychiatric disorders are more important and recognised as,

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1. depressed mood or affect - sad and depressed, 2. feeling anxious mood or affect - anxious feeling 2. flattered mood or affect - difficult to assess and lacking in expression (like talking through glass) , a milder form is sometimes called blunting of affect. Words such as flat or blunt to describe affect are reserved for schizophrenic or organic psychoses only 3. labile mood or affect - highly variable swinging from tears to laughter or 4. normal mood or affect (sometimes also termed euthymic - with a normal responses 5. elated mood or affect - as seen in excess jollity seen in hypomania or mania

The term mood is generally used to described a subjective and a prolonged expression of the emotional feeling state that a person feels and can describe by himself or herself. The term affect is generally used to describe an objective assessment of a patient's mood by another person at a given moment in time. As mentioned there is some difference of opinion about the usage of these two words .In the assessment of affect what is important is that it be assessed on a wide variety of ways and not only by visual observation. The assessment can be done through the history and specific questions that may be asked. They are usually assessed by Observations. 1. observing the person's face, 2. dressing, grooming 3. movements or lack of movements, 4. to see if he looks anxious, depressed, labile, psychotic in behaviour Asking questions and observing responses 1. asking him how he feels and allowing him to express his emotional feeling state in his own words 2.observing anger, tearfulness, anxiety when he relates his responses to the question 3. seeing his response to specific questions relating to sad, happy and neutral events in his life. Asking him about specific depressive anxious or happy events or possibilities and seing his reactions. These last include asking about suicidal thoughts or ideas that the patient may have had in the case of a depressed persons. The purpose in assessing the affect of the patient is to glimpse into his emotional state so that additional material can be gathered over and above the history he has given. For instance a patient may deny he has any problems and insist he came only because his brother forced him to see a psychiatrist; but on assessment of affect and being asked how he felt over the death of his wife 2 years ago he may burst into tears

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uncontrollably taking sometime to recover. Most people recover over the death of a spouse in 2 yrs and any mention of the past event may bring sadness but not uncontrolled sobbing. Flatness of affect is a concept that many students and doctors find difficult to grasp unless they have seen many patients with schizophrenic or organic psychosis and see the sort of "glass like" affect the patients with these conditions display; Flatness of affect is not indicative of depression. It is an unvarying emotion lacking in feeling - like an automaton or a robot. The words flattened affect or blunting of affect are reserved for use in schizophrenia or psychotic states in organic illness. Occasionally a patient may show an affect that has some features of one emotion and also another. By and large these are exceptions to the rule. Usually one emotion dominates and this is the one that must be taken as the main affect with or without other features that may be mentioned additionally. The terms flatness and blunting of affect are reserved for use in psychoses of schizophrenic or organic origins. Common mistakes made by students are to say that a patient is depressed and has a flat affect. While depressed conveys sadness, flatness conveys a robot like emotion. The two can seldom co-exist. In this context it is important to be clear what sadness means in real life situations. Most people can remember sadness in their lives no matter how transient e.g. death of a pet, death of a classmate or even a sibling or parent attending a funeral, reading of a tragedy seeing a sad film. That is sadness. Now increase that several fold and allow it to continue for weeks and months and it is not difficult to visualise depression. Anxious affect is an unpleasant state of tension, expectation of the worst and uncertainty like waiting for the results of an exam you have not done well in. Normal affect (sometimes also called euthymic) is the term used to describe the feeling state of normal people without psychiatric illness. When in doubt about the use of the term normal affect in a patient who has recovered is well or had a previous illness a simple test is to compare his mood with that of yourself or your friends who are normal. If there is any doubt it will become obvious.

Thought Content Perceptual and Thought disorder .The thoughts of a patient with mental illness are important in that the more serious mental illnesses such as the psychoses and major affective disorders show major disturbances in perception and thoughts whereas in anxiety and minor depressions the thought content is fairly intact. The Perceptual disturbances are: 1.Hallucinations. These are defined as false perceptions in any of the 5 sensory modalities hearing, sight, smell, touch and taste i.e. the person may hear voices that are not there see things that are not there, smell things that are not there etc. Hallucinations

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especially auditory hallucinations are a feature of psychosis .In schizophrenic psychosis patients may complain of voices commenting on their actions or asking them to do things or saying bad things about them. Auditory hallucinations are rarer in affective psychoses or psychotic depression. Organic psychoses like alcoholic psychoses may also present with auditory hallucinations. Visual hallucination are unusual phenomenon rarely seen by patients with temporal lobe epilepsy and sometimes organic psychoses. Visual hallucinations or pseudo hallucinations are also reported by hysterical patients. They are also reported in some patients with chronic schizophrenia. Olfactory, gustatory and tactile hallucinations are sometimes seen in organic psychoses, such as delirium tremens Temporal lobe Epilepsy or acute or chronic organic brain syndromes. 2.Illusions Illusions are misinterpretations of actual stimuli in any of the sensory modalities. These may occur in patients with acute confusional states and acute organic brain syndromes e.g. a patient with alcoholic delirium - tremens may misinterpret a nurse in uniform to be a soldier out to arrest him or the curtain blowing in the wind to be a ghost coming to kill him. Illusions usually occur in circumstances of poor light and reduced awareness especially at night in patients who suffer from compromised brain function. 3.Delusions Delusions are false beliefs held by a patient that are out of context of his educational, social and cultural norms and held on to despite all evidence to the contrary .Delusions are found in patients with schizophrenic illness, paranoid illnesses, major affective disorders and some organic psychoses. Delusions may be commonly, paranoid - pathological suspiciousness of others nihilistic - e.g. of parts of their person rotting away or absent somatic - e.g. of wires in their body, worms crawling under their skin grandiose - e.g. of their own imagined wealth, power or greatness guilt - e.g. of having committed the greatest sin or crime on earth

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jealousy - e.g. of the imagined infidelity of a spouse Paranoid delusions or delusions of jealousy may be secondary to organic mental illnesses, depressive illnesses or sexual dysfunctions. Primary delusions are usually seen in schizophrenic illnesses.

Techniques of Examination of Thought Disorders. When examining a patient to find out if he has hallucinations, delusions or illusions it is important that the patient be put into proper perspective, e.g. when asking about auditory hallucinations he should be asked "When you are awake and alone do you hear voices of a third person commenting on your actions, talking about you or scolding you?" "Do you hear those voices as you hear my voice now?" The wrong way of questioning used by some doctors is "do you hear voices" - to which the patient may quite rightly reply "yes, I hear your voice" .Details of what he hears, whose voice it is and when he hears them and whether he hears them at that very moment should be ascertained .With delusions there is also a need to explain what is wanted of the patient - whether he has a conviction that people are trying to spy on him or harm him and how. And why he thinks this is so, or if he is convinced he is powerful etc. Repetitive thoughts, ruminations, nightmares Some patients preoccupied with some fears may continue to ruminate and even have nightmares or dreams on a particular subject repeatedly. These need to be asked for and noted. They usually indicate anxiety. Obsessive thoughts In obsessive compulsive disorders obsessive thoughts about dirt or checking thing recur repeatedly. These should be asked for.

TESTS OF COGNITIVE FUNCTION

Cognitive tests are tests used to assess the functioning of the brain and are very useful in assessing mental disorders of organic origin . Common tests done in clinical assessments of patients with emotional symptoms and where organic disorders are suspected are, orientation memory immediate recall, short, medium and long term attention and concentration Intelligence abstraction judgement insight

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In most other psychiatric illnesses such as depression anxiety schizophrenia or affective disorders the cognitive functions are largely intact. It may be possible in some cases of severe depressive illnesses to observe what is called pseudo-dementia with cognitive impairment. In hysterical amnesia too there may be memory impairment. In very disturbed distractible or restless patients these test may be difficult or impossible to do. Orientation By orientation is meant the ability of the person to place himself or herself in time and space, place and society. For instance a person with his or her cognition intact should be able to say- roughly what time of the day it is - what day, date, month and year it is - what place he is in and where - who the people around him are Patients with impaired cognitive function have difficulty doing this. Patients who are fully conscious with acute organic brain syndromes following motor vehicle accidents, alcoholic delirium tremens, post operative psychoses toxic confusional states etc may not be able to tell where they are or remember only part of the date. Patients who are drowsy or with clouding of consciousness for whatever reason may not be able to cooperate with this test and may only be able to say if it is night or day. Patients with Korsakoffs psychosis (sub-acute organic brain syndrome) often confabulate to

cover up memory gaps in recognition of people .Orientation may be mildly, moderately or severely impaired depending on the degree of affliction of the brain for whatever reason. Memory Next to orientation, memory is the most important test of cognition. Memories to be tested are immediate recall, short term memory, medium term memory and long term memort. Immediate recall of new information is the first to be affected in acute organic brain syndromes .Short term, medium term memories follow and the last to disappear in very chronic organic brain syndromes is the long term memory. Thus many young doctors (and non psychiatrists) are very surprised that someone diagnosed as having dementia or chronic organic brain syndromes can remember very clearly events that occurred 20 or 40 years ago very clearly. This part of a person's memory is the very last to be impaired. The very same patient will not be able to remember what he had for breakfast or what the name of the doctor he was just introduced to several times only minutes ago

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The immediate recall This is tested by giving the patient a name or phrase and recalling it immediately from him. Sometimes a 6 or 7 digit number may be given and immediately asked for. Patients with more chronic organic brain syndromes or in the severely impaired states of acute organic brain syndromes often have difficulty with immediate recall . Short term memory. This is tested by what is called the 5 minute memory test. The idea is, to give the patient names, 5 unrelated objects that are not easily visible to him, explain that he is to recall them 5 minutes later. Failure to remember 1 or more objects should arouse suspicion of short term memory impairment. The names of objects should be repeated by the patient when they are told to him so that problems of comprehension and hearing may be excluded in the test. This is particularly important in the testing of elderly patients who may be hard of hearing A more useful test is to give the patient a) a name and address in his own language b) ask him to repeat it after the examiner item by item c) explaining that he will be asked to recall it in 5 minutes d) ensuring patient is of average intelligence and with at least primary level education Failure to recall the name and address may indicate problems with short term memory. A typical but fictitious name and address in Malay for this test should include full name, street number, street name, town and state, thus: Ariffin bin Ujang or Lee Beng Chong 169 Jalan Payamas Dua 128 Chow Cheng Road, Tanah Merah Penang Johor Darul Takzim Malaysia

Most people with average intelligence and with primary education should be able to remember this, 5 minutes later. If needed the name and address can be repeated several times to ensure registration when they are first mentioned and the time of 5 minutes taken from the time he agrees he fully understands the names and addresses in a different language should not be given .Most patients with acute organic brain syndromes have difficulty remembering this even after a lapse of 2 minutes and after 2 or 3 repetitions. The difficulty with short term memory is characteristic and obvious in patients with organic brain syndromes.. Asking the patient to recall his identity card number, own address, own telephone number etc are not tests of short term memory as these are (very) long term memories that can easily be recalled except in severe dementia or extreme drowsiness or states semi conciousness.

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Medium term memory Asking what the patient had for lunch yesterday when he was admitted to hospital or what the recent important news was in the past months are not very reliable tests of medium term memory but used nonetheless. The items asked have to be confirmed and substantiated by the examiner and consistent with the patient and other's level of education culture etc. To a rubber tapper the recent news of the death of human rights activist in USA may not be news worth remembering, or knowing about. Long term memory Long term memory is usually tested in the grossly demented to confirm their poor ability to recall long established memory for events and incidents to dates. As mentioned these are the last memories to be lost. Cases of long term memory disturbances include general paresis of the insane (GPI) in neurosyphilis, Alzheimers type Senile Dementia and Multi-infarct Dementia. Korsakoff's Psychosis Korsakoffs syndrome or psychosis or subacute organic brain syndrome occurs with alcoholism of long standing in some persons and shows typical memory defects. Here the patient has some patchy memory losses while other areas of his memory may be relatively intact. The patient may be aware of his failing memory and may keep notes or a diary to help in his memory. Often a test of his ability may be to ask him if he remembered seeing you at a certain fictitious place and time e.g. Mr Raman do you remember seeing me last November outside the post office in Jalan Tuanku Abdul Rahman when I met you with your son. Although this is totally fictitious as you can testify, the patient with Korsakoff's psychosis is not sure if it actually happened. As you appear to be sure with your exact details he assumes it must be true and to hide his memory defects may agree with you with a hearty "yes, yes I remember". This type of attempt at covering up memory defects is termed confabulation. Attention and concentration The tests of attention and concentration refer to the alertness and selectiveness in perception. attention and concentration are affected adversely in acute organic brain syndromes and the patient is slow to grasp and concentrate on simple mental exercises. The common test given to test attention and concentration is the subtraction of 7 serially from 100. This test can be done by anybody with an elementary education in about 2 minutes or less with 2 mistakes or less. In patients who have difficulty with this a serial 5 (or subtraction of 5 serially from 100) test may be given. Although this test is far easier those with very poor attention and concentration are unable to do even this test. Thus while the successful test of serial sevens indicates an intact attention and concentration level, those unable to do so may still be able to do the serial 5s successfully indicating a poorer level of attention and concentration but not quite as that seen in normal persons .Those unable to do even the serial 5s are most likely grossly affected in

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their attention and concentration - provided they have a primary level of education in the first place. Intelligence Accurate tests of intelligence require a more detailed psychological assessment such as the WAIS Wechsler Intelligence Scale or the WISC - Wechsler Intelligence Scale for Children. In clinical practice however simple arithmetic sums are used to differentiate obvious retardation from a normal range of intelligence. Another informal but useful tool is to get a summary of school achievements. By current educational standards someone who has failed his Std 6 or Form 3 exams several times may be suspected to have intelligence problems as is someone who is consistently at the bottom end of his C or D class in school. In most others with an average achievement, intelligence may be taken to be normal. Those with high intelligence would be consistently high achievers in school and college. These are rough and ready assessments and by no means accurate or foolproof. Abstraction The ability to interpret abstract concept is found to be impaired in schizophrenic illness and other psychoses. Tests used traditionally are interpretation of common proverbs or sayings the patient is familiar with e.g. in Bahasa Malayu, one may ask what is meant by kaki ayam or katak bawah tempurong or ask the meaning of English proverbs to those familiar with English proverbs, for example a rolling stone gathers no moss or people in glass houses should not throw stones Judgement Patients with schizophrenic illnesses in the acute psychotic phase may often have poor judgement related to a delusion or a hallucination they experience. They are out of contact with reality. However the traditional tests for judgement such as what a person would do if he smells smoke in a cinema are usually unable to reveal poor judgement. Judgement in a wider context e.g. judging who is right or wrong in an argument are notoriously difficult to exercise correctly even among so called highly qualified intellectuals. Often streetwise youngsters and salesmen are able to exercise judgement that is far more accurate than an intellectual can. The ability to judge a situation that is tested is in the psychiatric setting is somewhat more gross and related to that which is lost in psychotic states e.g. in delusional and hallucinatory experiences. Nonetheless a common test that is used is to ask what the person would do if he found a stamped addressed envelope on the road. Insight Insight is a person's ability to understand the current state of things around a person and within himself. For instance a person who has been told his leg will be amputated usually has good insight - of the implications consequences and problems he will face. This understanding is usually missing in persons with psychotic illnesses who may feel there is nothing wrong with them even though they may be totally irrational and behaving in a grossly ridiculous way.

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Once again lack of insight like being out of touch with reality is by no means limited to the mentally ill. Many a so- called normal or highly intellectual person may do things that are grossly wrong and unjustifiable and be strangely convinced they are right. Their lack of insight is often noticed by those around them although very few may be brave enough to contradict them. A historical example from the past is that of an emperor who was convinced he was wearing the best clothes ever made when in fact he was stark naked. No one dared to point out the naked truth to the powerful and vindictive emperor except an innocent child who spoke the bare truth! Thus, lack of insight is a peculiarly universal truth that many including the severely mentally ill and the people in power may share. As such the judgement of the interviewer on a persons insight or lack of it has to be considered with caution .

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CHAPTER

SEVEN

THE PHYSICAL EXAMINATION

The traditional dichotomy between psychiatry and physical medicine in an age when psychiatrists were called alienists is long gone. As minds open up, traditions die hard. Physical illnesses have many psychological features and effects as psychiatric illnesses have physical presentations and effects. A physical examination is therefore an integral part of psychiatric clerking of a patient with emotional problems .Perhaps one day the psychiatric examination will become an integral part of the physical examination of every patient in clinical medicine and clinical surgery. The physical examination in psychiatry is not as detailed as the physical examination in a clearly physically ill patient for obvious reasons. It concentrates on obvious areas of common problems relating to the particular psychiatric presentation of the patient while covering vital and general aspects of any physical examination. It should start with , 1.a brief questioning of any obvious recent or part physical illness of the CNS, CVS, R.S, GIT, Endocrine System, Genito-urinary System and locomotion that the patient may have had. This is done so that the patient's history may help the doctor concentrate on a particular area that has problems. 2.an examination of vital signs, anaemia, jaundice, cyanosis, oedema and a brief review of the systems to exclude obvious detectable pathology such as tumours, portal hypertension, CVS disorders. 3.The next is to concentrate on the CNS which has closest relationship to the psychiatric group of illnesses. The focus of the examination of the CNS should be to exclude cranial nerve lesion effects of brain lesions such as tumours demyelinating lesions, obvious head injuries and impairment of motor functions to exclude lesions

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affecting motor areas and nerves as well as conditions such as Parkinsonism. ,cerebellar lesions. Examination of the eye and fundus should also be done. 4.Examination of the Endocrine System to exclude problems of the thyroid function including hypo and hyperthyroidism and their effects on CNS, CVS - Adrenal functions and effects on the body - Pituitary functions and effects on the body There are particular physical disorders that present more frequently than others in a psychiatric setting and need particular attention. 1.Alcoholic hepatitis, gastritis and cirrhosis 2.Parkinsonian symptoms mostly medication related 3.Cerebrovascular disorders e.g. hemiplegia and effects of head injuries malignancies and atherosclerosis. The recording of the physical examination at a minimum should include a summary of vital signs a review systems and a summary of the CNS exams and endocrine exams with detailed reports of any pathology found. Thus the physically normal patient's report in a psychiatric clerkship should read , On physical examination the patient was of normal build and height and generally healthy .His blood pressure was 120 by 80 mm Hg with a steady and regular pulse rate of 80 per minute. Pupils were normal equal and reactive to light. There was no evidence of anaemia, jaundice, cyanosis or pitting oedema. A review of the CVS showed normal heart sounds, no murmurs. Respiratory system was clear. There were no palpable masses in the abdomen and genito-urinary system was normal .On examination of the CNS the cranial nerves were intact, reflexes normal and equal, plantars down going. No obvious evidence of CNS lesions. The endocrine system showed no evidence of hypo or hyper-function .In conclusion the patient shows no clinical evidence of physical illness. On a detailed clerking form for physical examination all items listed have to be filled and not crossed with diagonal lines. If any section was not examined a note "not examined" should be written so that the reader is aware of its non examination.

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CHAPTER

EIGHT

PSYCHIATRIC FORMULATION AND INVESTIGATIONS

PSCHIATRIC FORMULATION The term formulation is usually used to denote a final summary of the patient's problems including A. Findings 1. 2. 3. 4. a one sentence introduction of the patient his chief complaint a brief summary of his present and past history of illness significant family and personal history

5. significant findings on mental status and cognitive functions 6. significant physical findings B. C. D. E. features supporting a provisional diagnosis provisional diagnosis outline of further investigations suggested outline of possible treatment

In actual practice the formulation can be condensed to 1 paragraph and should not exceed 1 page . Differential diagnosis Whenever a patient's disorder is being considered all possible disorders that could be related to the complaints and findings need to be listed. Then a series of arguments for or against each possible condition should be made towards arrival at a provisional diagnosis.

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Provisional diagnosis The provisional diagnosis is termed provisional because it has to be confirmed by investigations and observations and tests to arrive at the final diagnosis .The provisional diagnosis should be written in the 5 axes to clarify the different aspects of the patients problems, although in actual practice the working diagnosis is the psychiatric diagnosis. The 5 axes as proposed in the American Psychiatric Associations Diagnostic and Statistical Manual are, Axis I Psychiatric diagnosis (may be more than one) Axis II Personality diagnosis if applicable Axis III Physical diagnosis Axis IV Psychosocial stressor in past six months. Axis V Highest level of adaptive functioning in past 1 year The student should as far as possible follow the ICD- X or DSM-IV for writing the diagnosis in psychiatry, personality diagnosis and if possible write the specific code numbers of these disorders. If no diagnosis is found in a particular area this should be noted as such and not simply left blank.

INVESTIGATIONS IN PSYCHIATRY Psychiatry unlike its other medical co-disciplines does not have a long list of laboratory or radiological tests and investigations that can help the clinician arrive at a diagnosis. Despite the many decades of searches for a biochemical test for depression and markers for schizophrenia these still elude psychiatrists. Laboratory investigations. However biochemical, serological, endocrine, radiological and microbiological laboratory investigations to exclude physical illnesses that present with psychiatric symptoms are routinely carried out when these disorders are suspected. The routine ordering of a battery of tests is not good clinical practice Having said that every patient admitted to a psychiatric ward should have routine total white and differential count, Haemoglobin and ESR and routine urine investigations are done to exclude common infections. Radiological investigations and scans X-ray of skull or chest are only ordered when specific or some lesions are suspected. CT scans and MRI investigations are ordered only when there are clear indications of pathologies that can be detected by these tests.

Electroencephalograph (EEG) and other studies The use of EEGs to detect epileptic discharges and sometimes brain tumours is again to be determined by specific indications. Of late computerised EEG (EEG) and brain

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mapping has also come into experimental use for testing effectiveness of drugs and distinguishing organic from non-organic mental illnesses. These are not used currently for clinical diagnosis in routine work. Similarly the use of Positron Emission Tomography (PET scanning) for experimental brain metabolic studies is not yet a routine diagnostic aid. Social and clinical investigation By and large observation of the patient over time and social investigation by interviews of the patient and his family as well as home visits and work, school or college reports add much to the completeness of a psychiatric clerking than laboratory investigations in everyday clinical practice .Unfortunately poor clinical and social investigation skills and knowledge coupled with the trend towards instrumentation has neglected social and clinical investigation resources. The earlier generations of teachers of psychiatry bent on looking for weird syndromes and making rigid final pronouncements are reluctant to allow information about the patient's home, family or work to interfere with their diagnostic decisions, let alone initiate investigation along these lines. There are a number of other sources of information other than laboratory that are very important in understanding the problem faced by the patient 1) good nurses observations in the ward over a period in the inpatient setting 2) good occupational therapy reports by occupational therapists who have worked with the patient 3) good social work report on family school or work with visits to home, work place or school 4) good follow up interviews with patient family members based on astute interview techniques 5) good family or relatives' interviews 6) interview techniques still form the mainstay of psychiatric investigations in clinical practice Psychological assessments In the examination of persons with emotional illnesses a number of psychological tests are useful The psychological tests in current practice including Wechsler Adult Intelligence Scale or WAIS and Wechsler Intelligence Scale for Children or WISC for testing of intelligence in children .The Minnesota Multi-Phasic inventory or the MMPI and the Eyesenc Personality inventory or the EPI are used for assessment of patient's personality. The administration , validation of the tests in a particular setting and skills in the interpretation of the results are very important factors in their usefulness in the understanding of a persons problems The importance of these and dozens of other tests are as adjuncts to a clinical examination and in research settings. They do not replace a good clinical assessment that is far more broad based and comprehensive in clinical practice. The value of good history taking as well as good interview-technique cannot be over emphasised..

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The Mini-Mental State. In many busy clinical settings rather than go through the full mental state examination a Mini-Mental State examination is done . It is a rough and ready test of cognition and not a comprehensive examination. The test itself varies from one country to another, and even from one psychiatric teaching centre to another. It consists usually of tests for Orientation Attention and concentration serial 7s Recall of 3 objects Copy a simple design Points given for these tests. A low score shows clear impairment of cognitive functions, as may be seen in acute or chronic organic brain syndromes.

PITFALLS IN HISTORY TAKING Among the many problems students encounter in clerking a patient with emotional problems are the inappropriate ways in which the history is taken from the patient. This may relate to a lack of understanding of sources of common human stresses and problems. But it also reflects the sadly prevalent attitude among students and doctors that mental patients are different from the rest of us and behave inherently different ways. This prejudice often underlies the rather skimpy history taking approaches that yield very little by way of useful information Among the many difficulties students in psychiatry face are, 1.Emotional block, fear and prejudice towards mental illness. One has to overcome this by reminding oneself that mental illness is not badness or dangerousness but an illness and the mentally ill are suffering like other persons with other illnesses. The student who goes into the examination of a patient with emotional distress and sees him as something other than a patient with suffering and in distress waiting to be healed, is reacting to the patients behaviour and not his distress 2.Failing to see the social, psychological or occupational problems the patient faces that are central to the illness. This may sometimes be the result of inexperience it may be difficult for a 23 yr old student to perceive the psychological environment, problems and fears of a 40 year old man, problems o marriage, children or family finance, in-laws, or infidelity as he has not experienced these future bridges of life. However once he sets his mind to the problems it is not too difficult to become astute and pick these up. Indeed not a small number of medical students are sharper at asking questions of the patient that reveal problem areas than quite a few less astute and disinterested doctors who are looking at laboratory tests rather that the human being with human problems before their eyes.

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3. Getting many facts but not knowing how they influence the illness process. This is particularly true of neurotic problems that patients face. There are often patients who reveal and even emphasise their problems in the interview but these may be missed by the student who may not realise their significance e.g. a 17 year old girl revealed that she had attempted suicide 3 times in the past 2 yrs. She said there were many violent quarrels between her alcoholic father and her stepmother with whom she got on very well. each attempt at suicide was not a very serious one. The student who clerked this patient felt that the girl was an "attention seeking adolescent with an adjustment problem of adolescence .He had not gone beyond the attempted suicide to ask what precipitated each attempt. Had he done so he would have found that the girl had been living in fear that her alcoholic father would kill her only friend in the house - her stepmother. The father had actually threatened to kill her several times and thrown glasses and a knife at her and once had even threatened her with a gun. The suicidal attempts followed each of these very violent quarrels. On hearing of this additional history one could see the patient's problem at home and not her seeking attention for her adjustment problem 4 Skipping over history taking areas that are listed e.g. marital or sexual history when they find it difficult or embarrassing - this is often because they cannot grasp what the areas of conflict or problems are and miss clues pointing to these areas of difficulty. 5 .Being deflected by defensive patients who do not allow exploration or who avoid answering questions e.g. when asked if she has any problems with her husband a 40 yr old woman denied it but kept complaining of vague somatic complaints for which she had taken many weeks of medical leave form her general practitioners. Common sense would indicate a closer look at her marriage beyond a bland denial e.g. when they were married, what the husband does for a living, if they have any quarrels. 6. Asking bland general questions such as: do you have sexual problems? do you have marital problems? do you have a drinking problems? do you have problems at work?

is a naive and simplistic way of getting a sexual, marital, drinking or work history respectively. .It is sometimes said that if you ask a silly question, you will get a silly answer, or as is nowadays said, garbage in, garbage out If problems are suspected in these areas it is best to go through details of each and as the history unfolds, make an assessment. Once a patient denies a problem he may find it very difficult to admit it

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later on. When problem are still suspected it is better to ignore the defensive responses and go ahead and get a detailed history as if there was no denial in the first place. The very human tendency of not wanting to expose even to the doctor painful but sensitive and embarrassing points must be understood and catered for.

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CHAPTER NINE

VERBAL SCANS TO ASSIST STUDENTS IN HISTORY TAKING

THE NEED FOR SCANS IN HISTORY TAKING In the practice of taking a history of illness in a patient one often finds that it is not easy to remember all the different questions that one needs to ask to ensure a thorough evaluation of the problems faced by the patient. This is especially so when the interviewer is new to the understanding of emotional distress and its numerous presentations in clinical practice. There are many facets to both people and their problems . To assist students in getting adequate information that will help them arrive at a satisfactory formulation a list of scan questions that should be asked in some of the common problems that present in clinical situations , is listed below.. The list is not by any means comprehensive as there are numerous aspects of any condition that patients may not reveal and only an astute clinician can succeed ,with the help of years of experience, to arrive at a reasonable understanding of the patients problems

1.

HISTORY SCAN FOR PATIENTS WHO MAY BE SUICIDAL

. HISTORY SCAN TO DETECT SUICIDAL IDEAS - Have you felt sad and dejected recently? - Have you felt sadness for sometime? - How bad are your sad feelings? - Do you cry? Do you feel so sad at times that you feel it is better to end you life How often do these feelings of ending your life come? - When did these feelings of ending your life stop?

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- Were they related to any events, e.g. disappointments - Have you thought of how you are going to take your life? - Have you ever gone beyond thinking about taking your life to doing something like buying tablets? Looking for a place to end your life in. - Have you ever gone to almost trying to take your life? - Have you ever attempted to take your life? - Have you ever told anyone about your ideas or plans to take your life or written about it. 2 HISTORY SCAN FOR PATIENTS WHO HAVE ATTEMPTED SUICIDE

- What were the thoughts going through your mind when you tried to take your own life/poison yourself/harm yourself. - Have you been feeling sad, miserable or down in your spirits recently. - When were you last happy and free of those feelings - What made things different recently. - Have you ever felt like taking your life/taking an overdose/harming yourself before - if so when. - Have you noted any connection between these attempts and emotional problems, disappointments or unhappy events in your life. - At this (latest) attempt what do you think was the main reason for the attempt. - How were you feeling a month/a week/3 days ago - (ask about events that led to the suicide up to the actual event (Many patients will deny anything significant occurred. You should ask them anyway) What did you do on Monday morning ..., were there any phone calls, then at midday who came to see you, what did you do in the afternoon How did you spend the evening. How was your appetite. Were there any quarrels. Did you go to work, could you concentrate on your work. Did you feel sad, or cry. How was your sleep, did you fall off to sleep easily? Was your sleep disturbed. Did you wake up in the night. Why. Could you return to sleep easily. If not what thoughts crossed your mind.[These questions have to be asked in detail for the 24 - 48hrs prior to the actual attempt on the persons life]

What happened [the 6 hrs] before the actual attempt on your life, overdose, self injury. Did you talk to anyone, were there any phone calls, letters, comments. What made you finally decide to take the tablets/injure yourself (in psychosis did you hear voices etc)

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How did you actually take the pills/poison, injure yourself. Where were you when this happened Did you write any letters to anyone/try to phone anyone immediately before this. Where did you get the tablets/poison/instrument from. Did you buy it yourself, collect it, - all together or one at a time or few at a time. When did you start collecting the poison pills, instrument. Did you actually feel you wanted to die. Did you give any thought to the consequences to yourself, family children etc. Have any members of your family ever attempted to take or taken their own lives.

HISTORY SCAN FOR PATIENTS WITH MARITAL PROBLEMS - How long have you been married - Was it an arranged or love marriage - (If it was an arranged marriage) what were the circumstances leading to the arrangement - (If the marriage took place at a late age) why was the marriage delayed - Were there objections/problems from either families over the marriage

(For those marriages that followed love and courtship) - How did you first meet your spouse - How long did the courtship last - Were there quarrels during courtship - if so over what

- Were there other boy or girl friends before this love affair - How serious were quarrels over these previous love affairs - What were the points in your spouse's characters that you were are attracted to - Were there any aspects of your spouse you did not like - Were there periods of separation in your courtship that were the result of quarrels - When you did marry were there any problems related to the wedding ceremony e.g. disagreements between in-laws on either

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side, financial problems etc - Where did you stay after marriage and why (if with in-laws of either side - special reasons for this) - How were the first 6 months, 1 yr of your marriage - When problems arose what were they related to finance, in-laws, jobs, children, pregnancy, old girl or boy friends - How serious were these quarrels - Was there any period when one spouse left the other or threatened to do so - Were inlaws actively involved in these quarrels - Was drinking, drug taking or gambling big problems in marital difficulties - When there were quarrels who usually started them - Who usually ended these quarrels by making up, how and why - When there are problems that children face whom do they approach - father and mother and why - Who punishes the children when they are disciplined - Have there been any physical injuries, suicidal attempts related to problems in marriage 4.

HISTORY SCANS FOR MALE PATIENTS WITH ERECTILE DYSFUNCTION

- Have you felt depressed in the past few months - Have you felt tiredness or weakness or back problems in the past few months - Have you had sleep problems in the past few months - Sometimes people who have depression sleep problems and tiredness also complain of disinterest in work and recreational activities have you had these - Do you notice a recent lack of interest in sexual activity - Have you noticed that it takes longer to get sexually aroused recently especially when you are tired - Do you notice that erections are not as hard as before - Have you sometimes tried to have sexual relations and not been able to because of reduced erections or tiredness - Have there been early morning erections - Since when have erections stopped completely (if the answer to the last two questions are `yes') - Have you sought treatment for you sexual difficulties from any source - Have you told your wife about this difficulty

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5.

HISTORY SCAN FOR PATIENTS WITH ALCOHOL RELATED PROBLEMS - Do any members in your immediate family drink and if so how heavily - When (what age) did you first take alcohol how and why - How often do you take alcohol since then number of times a week on average and how much you spend per week - What do you normally drink (beer, samsu, spirits, illicit liquor) and how much. Beer in small or large bottles, cans or pegs of whiskey, brandy, 1/4 bottle, 1/2 bottle of spirits - What is the largest amount you have taken at one sitting - Do you drink alone, at home or in company of others - Do you get boisterous, aggressive or get into quarrels or fights when you drink - Have you sustained cuts, bruises, fractures or injuries as a result of fights or falls after drinking - Have you been involved in motor vehicle accidents because of heavy drinking - Have you been involved with the police because of drinking related offences - Have you been absent from work, late for work, warned at work or had to leave your job because of your drinking - Do you have financial problems because of drinking - Have there been quarrelling with your wife and children and family violence because of drinking. - Has there been threat of your wife or children leaving you because of drinking or are you divorced, separated - Have there been times when you drank heavily returned home by yourself without any accidents e.g. by car, drove car, carefully parked car in driveway, opened door, locked door changed your dress and went to sleep and the next morning could not recollect any of these things you did? (Blackouts) - Do you get up several times or more per week with hands trembling and you need a drink to calm yourself - Have you stopped regular drinking for more than a year and drink only occasionally or socially after that - Do you find reduced sexual desire and sexual performance (poor erections) lately after long periods of drinking -Do you sometimes feel intensely jealous of your wife for no reason and suspect she may be having affairs with other men - Have you ever had very bad vomiting after drinking bouts - Have you heard voices when people are not around or seen frightening figures especially at night when you have

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stopped drinking suddenly after a long period of heavy drinking - Have you ever been treated for mental illness of any sort especially related to your drinking - Do you feel you have any drinking problems - Do you drink because you feel sad, anxious or cannot sleep .

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APPENDIX 1

SAMPLE PSYCHIATRIC CLERKING SHEET

PRELIMINARY DATA Name: Sex: Age: Ethnic group: Hospital / Clinic Number Identity Card Number Religion

Married/ single/ divorced/widowed /separated Occupation: Current address Language spoken (translated/not) HISTORY OF ILLNESS Chief complaints 1 2 3 duration duration duration Current employment status Home address, phone, work address

History of Present illness (from patient)

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History of Present illness (from relative/friend) (relationship to patient)

Sleep Work ability Brief history of past illness (psychiatric) nature, duration treatment source admissions 1 2 3 History of past (physical) illness, brief notes sleep problems self care - able or not appetite

agitated/violent or not suicidal or not

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Family History Family history Geneological chart Family history of , mental illness any other significant and family history Personal History Brief birth history born where, normal delivery or not schooling - primary where performance - secondary where performance - exam results Std 6 SRP SPM Post-school education up to what grade Results, distinctions Work record 1st job, when, where, what, salary other jobs current job reasons for change of job(s) Sexual history masturbation heterosexual or homosexual girl friends, boyfriends who, where, how close how many, currently Marital history - when to whom, courtship or arranged Children (chart) problems in marriage

Alcohol, cigarettes, drugs - when started current consumption, any psychological or social effects

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Pre-morbid personality (history to be obtained preferably from relative)

PSYCHIATRIC EXAMINATION Current Mental State General Appearance and Behaviour Dress grooming, cooperative or not, restless or aggressive Talk, speech sample of speech language, coherence, relevance abnormal speech e.g. pressure loose association, mute, slow Mood, Affect anxious, depressed, flat, normal labile, elated Thought content Perceptual disturbances hallucination, auditory, visual others Delusions, paranoid grandiose nihilistic, somatic Obsessional thoughts recurrent dreams, ideas nightmares, preoccupations

Tests of Cognitive Function Orientation, to time, day, date, month, year place, person

Memory, immediate recall short term 5 min memory test, medium term, long term Attention and concentration

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serial 7s, serial 5s, test ,digit span Intelligence - brief school record exams passed, simple arithmetic Abstraction: interpret proverbs Judgement Insight

SUMMARY OF PHYSICAL EXAMINATION

Formulation of case

List of Differential Diagnosis

Provisional Diagnosis AXIS I Psychiatric Diagnosis To Include AXIS II Personality Diagnosis AXIS III Physical Diagnosis AXIS IV Psychosocial Stressors AXIS V Highest Level of Functioning Investigations suggested

Provisional treatment and other orders for patient care

Name of Student/ Doctor ___________________ Signature _______________________________ Date ____________________________________

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SIMPLI

LIMA
Depression Antidepressants

Psychosis Personality, Subs Antipsychotics Abuse, addictions

Anxiety Anti-anxiet y medicines

Child and Adolescent problems

COMMONEST MENTAL PROBLEMS IN PRIMARY CARE

@ copyright reserved

A PRIMARY CARE GUIDE TO PSYOCHOLOGICAL STRESS MANAGEMENT

Dr. M P Deva
FAMM, FRANZCP, FRCPsych DPM Eng

Professor of Psychiatry, Faculty of Medicine, University Tunku Abdul Rahman, Malaysia

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SIMPLI
SIMPLIFIED MANAGEMENT OF PSYCHIATRIC AND RELATED ILLNESSES
Pre-requisite : Get Good History, Do GOOD Asessment, PLEASE !! No Psychiatric illness can be managed by guess work, prejudice and casual and poor clinical skills learnt by observation, and theoretical lectures and acting ONLY !!

First Level

IS THE PRESENTING PROBLEM

NORMAL BEHAVIOUR Counsel complainant Manage anxiety

ABNORMAL BEHAVIOUR

Second Level THE SIMPLI

LIMA WAY
5.Child
&Adolesc Family Therapy Some medicines

------------------------------------------------------------------------1.Anxiety 2.Depression3.Psychoses 4.Substance

Related Related Related Abuse/personality Disorders Anxiolytics Anti-depressants Anti Psychotics Rehab, Med, Counselling Counselling Rehabilitation Counseling

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The commonest psychological illnesses in the clinic setting are anxiety, depression and stress related emotional reactions that occur in 20-30% of all general or Primary Health Care patients clinic patients. But these psychological conditions are very seldom detected by primary care clinic staff as their symptoms of anxiety or depression (see details below) such as stomach pains, headache, chest pains, are also similar to symptoms of physical conditions. Together they form over 80% of all mental illnesses but remain poorly detected- and very poorly treated. Their recognition is poor because of poor training of all health care staff. They are often present in chronic clinic attenders in whom definite diagnoses are unclear.
Psychosis

Depression

Personality, Suns Abuse, addictions

Anxiety

Child and Adolescent problems

Details of Second Level

1.

COMMONEST MENTAL PROBLEMS IN PRIMARY CARE

Anxiety

is a psycho-physiological response to a psychosocial threat. Anxiety is normal and gets us ready to fight or flight when we face threats. But when that psycho-physiological problem is not resolved it may become a disease called Anxiety Disorder. Anxiety disorders consist over 60% of mental illnesses and present with symptoms of

Worry, tension Recent poor sleep Preoccupation with gastric, chest, heart disease Headache, neck ache, backache, stomach ache BUT, All physical examinations tests are essentially normal Worry of serious disease despite reassurances, doctor shopping Symptoms started after onset of psycho-social threat. (history is difficult to elicit- what is recent
stress)

Treatments. Anxiety problems (worry) understand source of worries, reduce symptoms with Anxiolytic medicines, like diazepam, teach relaxation exercises, try and overcome conflicts, through Counselling process. Behaviour modification to reduce problem behaviours. Prolonged anxiety can be associated with depressive symptoms. 2.

Depression is a term used to describe a Psycho-physiological response to

a Loss. When a person loses something dear and near to himself or herself there is a negative effect on the emotion. First there is worry overcome but when it is clear that the loss cannot be overcome sadness, then depression sets in. The symptoms occur soon after a loss. Depression like anxiety causes both mental and physical symptoms. Depression in one form or another accounts for 20% of all mental illnesses

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Feeling sad, miserable, moved to tears. In acute depression there may be selfharm (Parasuicide) Decreased interest in work, pleasurable activities and social commitments Neglect of personal needs, grooming, dressing Rational and coherent but negative in thoughts and speech Tendency to avoid others, keeping to oneself , seen crying Negative ideas, leave job, go far away In late stages thinking of ending it all, of suicide Loss of good sleep , difficulty going to sleep, very early awakening and inability to sleep again Sometimes excess sleep No interest work, recreation, no interest in food, lack of appetite, leading to loss of weight Depressive problems and illnesses can be mild, moderate, or severe 1 Mild -brief adjustment problems like recent loss in but able to carry on with work, social life Acute but mild depressive reactions include failing exams, loss of a relationship, death of a loved one. In acute loss of a relationship there may be attempts at suicide (self- harm) but these for the most part resolve and do not progress to severe depression. Symptoms of sleep, appetite problems are short lasting from a few days to a few weeks.. These usually do not require anti-depressant medicines and do well usually with anti-anxiety medicines and counseling 2 Moderate, - longer depressive symptoms affecting sleep appetite, loss of weight work and social life result from difficulty in overcoming acute losses and last many weeks and include sleep problems, appetite problems and loss of weight 3 Severe, -much longer, affecting sleep, eating, bowel movements, sexual function, work, social life, with suicidal ideas occur with unresolved acceptance of the loss. They may be not working for some time before they present themselves for assessment 4 Some depressed persons although basically depressed may present with psychotic behaviour agitation, irritability, hyper-excitability, talkativeness or even violence These are often features of Bipolar Affective Disorders (see below) Treatments. Most milder illnesses will need Anxiolytic medicines and counseling. Those with moderate to severe illnesses will need Anti-depressant medicines and when better, counseling. Cognitive Behaviour Therapy has an important role for those recovering from Depressive illnesses For treatments of psychotic depressive illnesses see below are psycho-physiological responses to inability to cope with stress in vulnerable persons. The Psychoses commonly seen are a. Psychogenic psychoses schizophrenia, manic depressive psychoses (Bipolar disorder) paranoid illnesses b. Organic psychoses, such as due to physical diseases, toxic substances, infections of the brain, head injury, endocrine problems or dementias . Psychoses are usually easy to recognise as they present with :
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3 Psychoses

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Abnormal thoughts such false beliefs that people are going to harm them Abnormal perceptions such as hearing voices, seeing things that are not there Abnormal behaviour, such as talking, laughing to ones self for no reason Occasional restlessness and rarely aggression and more rarely violence Psychoses are rare in the community occurring in less than 1% of the population In Bipolar Affective disorders there are 2 phases one of depression usually severe with delusions and paranoid ideas and occasionally hearing voices asking him to die, or accusing him etc. and two of cheerful overactive behaviour with abnormal talkativeness, confidence and racing thoughts.
These 2 phases of the same psychotic illnesses may alternate in presentation in the same person

Treatments for psychoses Anti-Psychotic medicines such as haloperidol, depot anti-psychotics and Rehabilitation. For bipolar disorders mood stabilisers such as sodium valproate, carbamazepine or lithium with properly monitored blood levels are used with or without anti-psychotic medicines. Counseling. 4.Personality, substance abuse and deviation- related disorders are conditions Characterized by what society sees as difficult behaviours that are on the whole very difficult to treat with medicines and counseling . Although some medicines such as naltrexone for opioid addiction or antabuse for alcoholism are available along with counseling the success rate is far below that of the treatments for anxiety, depression or psychoses. The main features are prolonged and recurrent behaviour problems with possible physical and long term complications. There are many persons with depression or anxiety disorders who also abuse drugs or abuse alcohol in attempts at self-treatments and may end up with 2 diseases rather than one. For chronic opioid addiction, maintenance on such drugs as methadone is nowadays preferred.

5.Child and adolescent emotional problems are emotional and behavioural problems of children and adolescents resulting from a. Developmental difficulties of childhood such as dyslexia, learning disorders, spasticity b. Behaviour problems of childhood and adolescent such as bedwetting, Attention Deficit Hyperactivity Disorder (ADHD) stealing, violence, truancy often resulting from stresses in family, and school the child or adolescent is unable to cope with c. Psychoses of childhood such as Autism, schizophrenia d.

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Treatments for Child and adolescent disorders Treatment are largely family counselling for the developmental problems and remedial help for the child, and overcoming the behaviour problems through family and individual counselling for behaviour problems. For the more severe illnesses medicines and behaviour modification by trained staff may be needed
Principles of Management of All Emotional problems Medicines for distressing symptoms Counselling for psychological aspects of distress Psychosocial rehabilitation using Psychological, Social and Occupational methods Medication maintenance Relapse prevention Prognosis (chances of recovery), depend on 1. Early detection 2. Accurate history taking, accurate diagnosis 3. Appropriate medicines, as advised 4.Effective counselling to overcome psychosocial problems, conflicts 5.Effective Relapse Prevention Strategies, Family involvement.
*Note: Please see Latest edition of Essential Medicines list of WHO in website www. who.int

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About the Author

Dr. M Parameshvara Deva has been a psychiatrist for 42 years and taught in 7 Medical Schools in Malaysia and overseas. He has published 15 books on psychiatry and numerous scientific journal articles in psychiatry and made numerous scientific presentations in the field of psychiatry. He was the founder of the Malaysian Psychiatric Association and the Asian Federation of Psychiatric Associations and been president of Malaysian, ASEAN and World associations dealing with psychiatry and mental health . He was acting Regional Adviser in Mental Health for the Western Pacific Region of WHO and written 36 Reports for the WHO.

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