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The Complete Clinical Assessment

in Psychiatry

Developed and produced by Margot Phillips, Jeffrey Streimer and Joanne Shaw

HETI | RESOURCE

Authors
Dr. Margot Phillips

Dr. Jeffrey Streimer

Consultant Psychiatrist

Consultant Psychiatrist & Psychotherapist

NSW Institute of Psychiatry Special


Fellow, Royal North Shore Hospital,
Sydney

RANZCP NSW Director of Advanced


Training in Psychotherapy

Staff Specialist South Eastern Sydney


and Illawarra Area Health Service
Site Coordinator of Training, St George
and Sutherland Hospitals, Sydney

Joanne Shaw
HETI Project Manager

Senior Staff Specialist Northern Sydney


Central Coast Health Service
Director of Consultation-Liaison
Psychiatry, Royal North Shore Hospital,
Sydney
Clinical Senior Lecturer, Discipline of
Psychological Medicine, University of
Sydney

Research Psychologist, Discipline


of Psychological Medicine, University
of Sydney

Acknowledgements
Dr. Agnes Chan

Dr. Jeanette Martin

Consultant Psychiatrist

Consultant Psychiatrist & Psychotherapist

Staff Specialist Consultation-Liaison


Psychiatry Northern Sydney Central
Coast Health Service Staff Specialist
Consultation-Liaison Psychiatry Sydney
South West Area Health Service

Psychotherapy Educator Northern Sydney


Central Coast Health Service

Site Coordinator of Training, Royal


North Shore Hospital, Sydney

Dr. Ralf Ilchef


Consultant Psychiatrist
Senior Staff Specialist Northern
Sydney Central Coast Health Service
Clinical Senior Lecturer, Discipline
of Psychological Medicine,
University of Sydney

Dr. Lisa Lampe


Consultant Psychiatrist

Member of the Committee for Advanced


Training in the Psychotherapies

Dr. Robert Russell


Consultant Psychiatrist &
Psychogeriatrician
Senior Staff Specialist, Northern Sydney
Central Coast Health Service

Dr. Steven Spielman


Consultant Psychiatrist & Psychotherapist
Senior Staff Specialist, Child and
Adolescent Psychiatry, Northern Sydney
Central Coast Health Service

Staff Specialist Northern Sydney


Central Coast Health Service

Dr. James Telfer

Senior Lecturer, Discipline of


Psychological Medicine, University
of Sydney

Senior Staff Specialist Northern Sydney


Central Coast Health Service

Dr. Loyola McLean


Consultant Psychiatrist & Psychotherapist
CADE clinic and Amaranth Centre, Sydney
Lecturer, Discipline of Psychological
Medicine, University of Sydney

Consultant Psychiatrist & Psychotherapist

Clinical Lecturer, Discipline of


Psychological Medicine, University of
Sydney
Clinical Director C. J. Cummins Unit,
Royal North Shore Hospital

Contents
Who? What? When? Where? Why?....................................................................02
An area of unmet need.......................................................................................03
Our vision...........................................................................................................04
Learning goals....................................................................................................05
About this material..............................................................................................06
Confidentiality and Consents..............................................................................08
Session 1: The Psychiatric Assessment: An Overview.............................................. 09
Session 2: Introduction to Psychiatric History-Taking................................................ 19
Session 3: Cognitive Assessment I........................................................................... 51
Session 4: Cognitive Assessment II.......................................................................... 75
Session 5: Movement Disorders............................................................................... 97
Session 6: Phenomenology.................................................................................... 109
Session 7: Mental State Examination I.................................................................... 123
Session 8: Mental State Examination II................................................................... 129
Session 9: Mental State Examination III................................................................... 135
Session 10: Personality Style I................................................................................ 139
Session 11: Personality Style II............................................................................... 149
Session 12: Reflective Interview Skills I................................................................... 153
Session 13: Reflective Interview Skills II.................................................................. 165
Session 14: The Therapeutic Alliance..................................................................... 175
Session 15: Introductory Formulation I.................................................................... 185
Session 16: Introductory Formulation II................................................................... 205
Session 17: Cognitive-Behavioural Approach and Formulation............................... 211
Session 18: Psychodynamic Formulation I.............................................................. 225
Session 19: Psychodynamic Formulation II............................................................. 239
Session 20: History and Formulation in Child and Adolescent Psychiatry................ 257

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

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Who?
This manual and its accompanying USBs are for Psychiatric Trainees of all levels and for their tutors.
However, any Mental Health Professional who wants to enhance their clinical assessment skills will
benefit from these sessions and exercises.

What?
02

This program targets all aspects of the clinical psychiatric assessment in a clear, concise and
easy-to-follow format.
It moves fluidly from the basics of the psychiatric history and mental state examination to the
more complex and subtle aspects of psychiatric assessment.
It will guide junior trainees embarking upon the daunting task of assessing patients. It will assist
senior trainees in developing a greater degree of sophistication.

When?
There are twenty sessions. Sessions run for a maximum of two hours.
While sessions can be run at any interval, the manual is designed to fit in with either a weekly
six-month program or a fortnightly twelve-month program.

Where?
For most sessions, all you need is a space free from interruption plus equipment to play the
accompanying USB to the group.

Why?
This program was developed in response to the recognition that the Clinical Psychiatric
Assessment is an area of unmet need in the current system of Psychiatry Training.
This program is a guide both for those wanting to teach, and those wanting to learn or expand upon
their skills in psychiatric assessment. It provides a program that is standardised and replicable with
specific learning goals and objectives, yet at the same time is flexible and responsive to the learning
needs of participants.

An area of unmet need


A fundamental and often neglected skill in psychiatry training is that of the Clinical Psychiatric
Assessment. This includes interview, mental state examination and formulation. While the basic
skill level required for day-to-day clinical work is adequately achieved by most registrars, a
sophisticated approach encompassing a true understanding of biological, psychological,
psychodynamic and social issues is more difficult to attain.
Mastery of the skills of the clinical assessment forms the very foundation of sound psychiatric
practice. The clinical assessment in psychiatry functions as:
1. A diagnostic tool

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2. The basis of an individualised management plan


3. A therapeutic tool
it can be therapeutic in and of itself, establishing the beginnings of a therapeutic alliance
and thus enhancing compliance with proposed interventions, and
many skills of the assessment are generalisable to any ongoing therapy relationship.
Some areas of the Clinical Psychiatric Assessment are currently better taught than others. A
qualitative research process questionnaires and unstructured interviews was used to delineate
the areas that trainees view as relatively neglected by the current training scheme. It is on these
areas that this manual focuses.
An integral component of sound clinical assessment is the development of the skill of clinical
thinking, also known as clinical reasoning. This is something not easily taught. These two terms both
refer to the expert method of processing raw clinical data as opposed to the textbook organisation
of knowledge. Research suggests that this skill is best developed through exposure to quality clinical
experiences matched with an opportunity for guidance and reflection. This is something that we
hope to provide through this manual.

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

Our vision
This manual is a tool for those wanting both to teach and to learn the clinical assessment in psychiatry.
This manual is unique in targeting the unmet needs of psychiatry trainees, offering a program that
is standardised enough to be replicable and easy to use, yet flexible enough to be responsive to
the individual learning needs of its participants.

04

The material in this manual employs a wide range of teaching methods. It includes conventional
lectures and presentations but the main emphasis is on the hands-on discussions, role-plays and
exercises. The degree of active involvement in the learning process will vary from group to group,
but the material is designed in such a way that more active involvement in the learning process will
give better results.
The manual embraces the principles of adult learning. It encourages active participation in a highly
relevant, experiential learning process. It aims to facilitate a safe and welcoming environment for
trainees of all levels, a non-critical environment in which reflection, contemplation and discussion
are fostered.
The exercises in this manual aim to cultivate the skills at every level of the clinical psychiatric
assessment from the basics to the complex and subtle. They encourage the integration of theoretical
and practical knowledge, and promote the reflective practice that then fosters clinical thinking.

Learning goals
Overall learning goal
To guide the development of the skills involved at every level of the clinical psychiatric assessment,
focussing particularly on those skills not specifically addressed in the current psychiatry training scheme.

Specific learning goals


History and mental state examination

Content knowledge:
To know the core contents of a complete psychiatric history and mental state
examination, including
Phenomenology
The cognitive assessment
Assessment of movement disorders, e.g., AIMS test

To know and understand definitions and concepts relevant to the psychiatric
assessment, such as
Phenomenology and psychopathology,
Specific phenomenological concepts, e.g., pseudo-hallucinations
Transference and countertransference
The therapeutic alliance
The assessment of personality style and structure

Process knowledge:
To be aware of some of the challenges that may arise when applying theoretical
knowledge to clinical practice


T
o understand different interviewing techniques and how these vary according to
the situation

To enable the practice of interview skills through role plays and observed interviews

To enable the development of cognitive assessment skills

To encourage reflection on clinical assessment skills and the clinical assessment process

To increase awareness and understanding of what is happening at multiple levels of an
interaction

To increase skills of observation

To increase awareness of non-verbal communication, including transference
and countertransference

To learn to respond to relational aspects of the interview

To begin to use clinical reasoning skills during the assessment process
Formulation



Content knowledge
To understand the elements of a formulation
To know the various schema used in formulation
To understand how a formulation will vary depending on its function,
for example:
Diagnostic formulation
Cognitive-behavioural formulation
Psychodynamic formulation



Process knowledge
To become familiar with using data from the clinical assessment to understand
the patients predicament
To synthesise the data into a coherent formulation
To learn to begin to formulate from early in the assessment process

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About this material


There are twenty sessions. Each session runs for a maximum of two hours. Sessions can be
run at any interval that suits, but the manual is designed to fit in with either a weekly six-month
program or a fortnightly twelve-month program.
The material is in two parts:
A manual
Accompanying CD and USB material for each session

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The manual
For each session, the manual contains:
A session outline
Detailed instructions to guide you in the preparation and running of the session
Trainee handouts
Suggested discussion prompts
Facilitator notes to guide you in leading discussions
For some sessions there is a choice of options each clearly outlined in the manual

The CD and USB


Enclosed is a CD formatted to play via a computer and will not play on a standard DVD player.
The USB material varies in content. It may contain:
Lectures and/or presentations
Recorded role-plays
Patient interviews
Other stimulus material such as group discussions, and
Suggested discussion prompts

How to use the material


The sessions are designed to run sequentially. They move logically through the entire clinical
assessment from history, mental state examination and formulation, and from basic to more
sophisticated subject matter. Each session builds on learning from previous sessions.
Unless specifically indicated in the manual each session can stand alone and it is possible to
modify the order or to omit sessions depending on the requirements of your group, environment
and setting. Against the background of your own qualifications, the trainees level of experience,
and practical considerations such as the environment, you may choose the sessions and the
exercises that best suit.
In keeping with the manuals stated goal of encouraging an active, experiential learning process
you should encourage maximum involvement of all trainees. This means thinking carefully about the
options for the running of each session. In choosing between these options remember that trainees
should have the opportunity to do their own interviews and role-plays, if possible, rather than only
the experience of watching interviews and role-plays on the USB provided.

What is required of you as facilitator


You must familiarise yourself with both the written material in the manual and the USB footage.
This will give you a thorough knowledge of the contents of the session and enable you to conduct
the sessions in a natural, confidence-inspiring manner.
For sessions in which there is a choice of options it is necessary that, prior to the session, you
choose which option to follow.
An amount of preparation is required for all of the teaching sessions. Ensure you leave enough time
for these necessary preparations. For some sessions you need to select a trainee(s) who also needs
to prepare for the session.
The fundamental approach of this material is to embrace principles of adult learning, including that
of encouraging active involvement of all participants in a clinically-relevant learning process. Your role
as facilitator, therefore, is to encourage discussion and reflection in a non-critical space, where each
individuals point of view is respected.
For exercises involving role-plays and interviews, or at other times when trainees may be under
scrutiny, it is necessary to take care to ensure participants feel sufficiently secure, and that the
exposed trainee feels safe and supported rather than exposed to the group. The purpose of the
interview segments, role-plays or other activities, is to generate discussion rather than to lead into
a critique of the individuals skills and techniques.

Facilitator notes
Facilitator notes have been provided for most sessions. These notes are intended to highlight
certain key issues and to guide you in the leading of discussions.
The notes are not intended to be comprehensive and we do not propose that they be rigidly
adhered to. During group discussions other pertinent issues will undoubtedly arise. The focus
of each discussion will depend upon your area of expertise as facilitator, on the trainees level
of experience, and the particular interests of the group.

Group size
We are aware that group size will vary depending on the setting but recommend that ideally
there is a minimum of four trainees to facilitate discussion, and a maximum of sixteen to ensure
the requisite intimacy and confidence within the group.

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Confidentiality
The material presented in this publication and USB series is strictly intended for the training of
Mental Health Professionals. This material is not for release to the public in its present or a modified
form.

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Written consent has been obtained from all patients interviewed, lecturers and seminar leaders for
the ongoing use of their material, both verbal & written, and of their images, for teaching purposes.
The participants in the USB have all freely given informed consent for the use of this material without
time-limitation or mode-of-publication constraints. We thank them for this, and trust that all material
will be treated with respect.
All interviewed patients had capacity to consent. Capacity to consent was assessed by the authors,
and it was also discussed with the patients treating doctors. Where relevant it was discussed with
family members. The authors have attempted as far as possible to protect patients confidentiality by
omitting all potential references to their identity and by maintaining anonymity within the limitations
of live recorded material.
We advise that all facilitators and trainees using this material strictly adhere to the conditions of
use of the USB and manual and do not allow unauthorised distribution, publication or viewing.
In addition, we advise a facilitator who chooses an option in the manual/USB that requires them to
organise their own interviews and make their own recordings of interview material to observe the
same rules of confidentiality, and to obtain and keep a record of appropriate informed consent for
the interview and/or recording.

Consents
When a patient agrees to be interviewed for educational purposes you must ensure that adequate
consent is obtained. When a recording is made of the interview the consent process must
specifically address this aspect of the process.
We advise that you check with relevant hospital authorities before proceeding with any recording
of interviews. Many hospitals have approved consent forms that must be completed prior to any
recording being made. Your hospital will also have a privacy policy to which you should refer.
A patient who agrees to be interviewed and recorded must be informed of what will happen to
the material following the session. Again, you should check your specific hospital policy but, in
general, unless the material can be guaranteed to be kept secure in a confidential place, the
material should be destroyed after use.

Session 1: The Psychiatric Assessment: An Overview

09

Session 1
10

The Psychiatric Assessment: An Overview


OBSERVATION OF INTERVIEW AND GROUP DISCUSSION
OPTION A
Organise your own
interview

OR

OPTION B
Watch the interview on
the accompanying USB

Session Summary
This session provides an introductory overview of the complete clinical assessment in psychiatry.
It begins with the observation of a doctor-patient interview. This is followed by a group discussion
of the information gathered in the interview and the clinical assessment process.
There are two options for this session:
Option A: Organise your own doctor-patient interview
Option B: Watch the interview on the accompanying USB

Focus of the Session


1. To provide an introduction to the process of analysing and discussing clinical assessments
in psychiatry
2.  To provide an overview of a complete psychiatric assessment (including both data-gathering
and data-synthesis)
3.  To note and discuss some of the challenges that may arise, both in real-life settings and in
artificial settings such as teaching sessions and exams

Materials Required for the Session


Option A: Video camera if pre-recording your own interview
Equipment to watch the pre-recorded interview during the session
Option B: Computer, with either a data projector or TV monitor, and external speakers

The Psychiatric Assessment: An Overview

OPTION A: Organise your own interview


Preparation for Session
Please note that there are no Facilitator Notes for this option

Please note that this option requires significant preparation time.


1. Select a trainee to be interviewer
2. Select a patient to be interviewed by the trainee

NB. Patient selection is important


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Can be an inpatient or an outpatient


Must be co-operative
Must have capacity to consent to the interview
Ideally non-psychotic, but if psychosis is present please, ensure there is minimal blunting
of affect and emotional reactivity

3. Prior to the interview


Explain the interview to the patient and obtain written consent
Check with your relevant hospital authority about the procedures relating to confidentiality
and consent in your hospital
4. The interview
A forty-minute assessment interview
The interview can either be pre-recorded and then watched by the group during the session,
or it can be observed live by the group:
through a one-way screen
via a monitor in another room
by having the group present in the room during the interview*

The trainee conducting the interview should not take notes while interviewing the patient
*If the group is present in the room during the interview, the number of observers should be limited. Ensure that
observers sit out of the direct line of sight of the patient and that they remain passive throughout the interview.

5. After the Interview


 Immediately after the interview the interviewer and observers should jot down any points in
the interview where they noticed a change or shift in rapport, or any other illustrative moments
6.  If you selected that the interview be pre-recorded for viewing during the session, it is
recommended that you watch the interview prior to the session to familiarise yourself with
the content
7.  Review the discussion prompts (appendix 1.1.1), and photocopy them to distribute to
trainees during the session

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

Conducting the Session


1. Hand out the discussion prompts (appendix 1.1.1) and allow reading time (5 minutes)
2. Watch the full-length interview: either live or play the recording (40 minutes)
3. Ask trainees to think about the questions (discussion prompts) in light of the interview
(10 minutes)
4. Lead a group discussion of the interview guided by the discussion prompts (55 minutes)
5.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

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OPTION B: Use the recorded interview on the accompanying USB


Preparation for Session
1. Review the 40-minute interview on the accompanying USB
2. Photocopy the discussion prompts (appendix 1.2.1) to distribute to trainees during the session
3. Review the facilitator notes (appendix 1.2.2)

Conducting the Session


1. Hand out the discussion prompts (appendix 1.2.1) and allow reading time (5 minutes)
2. Play the USB of the interview (30 minutes)
3. Ask trainees to think about the questions (discussion prompts) in light of the interview
(10 minutes)
4.  Lead a group discussion of the interview guided by the discussion prompts and the facilitator
notes (appendix 1.2.2) (55 minutes)
5.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any
remaining questions

Appendices listing
For use with Option A (Organising your own interview)
Appendix 1.1.1 Discussion prompts for trainees

For use with Option B (Watching the interview on the accompanying USB)
Appendix 1.2.1 Discussion prompts for trainees
Appendix 1.2.2 Facilitator notes

The Psychiatric Assessment: An Overview

Appendices
Appendix 1.1.1 Discussion prompts for trainees
For use with Option A (Organising your own interview)
1. Comment on the interaction between the interviewer and the patient in the interview
2. Was there a change in rapport as the interview progressed? What accounted for this?
3. What do the shifts tell us about the patient?
4. Can you recall any segments where there was a deepening of the rapport?
5.  Can you recall any segments where there was a disjunction or failure in the rapport?
(These may be major or minor disjunctions)
6. How did the interviewer manage these disjunctions?
7. How else might these disjunctions have been managed?
8.  What interview techniques were used in this interview? Which of these had the most
productive effect?
9. Comment on the patients affect
10. Comment on the patients thought-form
11. Does the interview permit an assessment of risk? What is your risk assessment?
12. Was this interview sufficient to make a provisional diagnosis? What is your provisional diagnosis?
13. What are your differential diagnoses? Discuss these.
14. What additional information would you like to clarify the diagnosis?
15. What do you see as important issues in ongoing management?

Learning Point
The bio-psycho-social framework is useful when deciding on management. However it is
important to also think beyond this, and to consider in greater depth what is unique to this
patient, in this circumstance.

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Appendix 1.2.1 Discussion prompts for trainees


For use with Option B (Watching the interview on the accompanying USB)
The full-length interview
1. Comment on the interaction between the interviewer and the patient in the interview
2. Was there a change in rapport as the interview progressed? What accounted for this?
3. What do the shifts tell us about the patient?
4.  What interview techniques were used in this interview? Which of these had the most productive
effect?

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5. Can you think of any points in the interview where an attempt to deepen rapport did not work?
Excerpt One
6. Comment on any shifts in rapport in this excerpt
7.  How else could you respond if a patient says they would rather not talk about a sensitive topic
such as their suicidality? Role play this scenario
Excerpt Two
8. What do you notice in this excerpt?
9.  Do you think it is valuable to ask a patient why they have never been in an intimate relationship?
Why is this useful?
10. Are there any risks involved in asking about this topic?
11. How might you ask about this topic? Role play this scenario
Excerpt Three
12. What do you notice in this excerpt?
Now think back to the full-length interview
13. Comment on the patients affect
14. Comment on the patients thought-form
15. Does the interview permit an assessment of risk? What is your risk assessment?
16. What is your provisional diagnosis?
17. What are your differential diagnoses? Discuss these
18. What additional information would you like to clarify the diagnosis?
19. What do you see as important issues in ongoing management?

Learning Point
The bio-psycho-social framework is useful when deciding on management. However, it is
important to also think beyond this, and to consider in greater depth what is unique to this
patient, in this circumstance.

The Psychiatric Assessment: An Overview

Appendix 1.2.2 Facilitator notes


For use with Option B (Watching the interview on the accompanying USB)
The full-length interview
1. Comment on the interaction between the interviewer and the patient in the interview
  The interaction is polite and pleasant. There are no major disruptions. The patient is
co-operative and, to an extent, able to be engaged. Trust develops as seen when the
patient confides her psychotic experiences.
2. Was there a change in rapport as the interview progressed? What accounted for this?
 Initially there is an exaggerated politeness but rapport develops rapidly and the politeness
softens.
  Rapport deepens slightly but it remains superficial for much of the interview.
  Changes or shifts in rapport are slight. Moments of intimacy are closed off again and
affect-laden topics are largely avoided.
3. What do the shifts tell us about the patient?
This interview is an example of one where, despite an apparent ease of engagement,
the doctor-patient alliance remains tentative. Also it shows only minor shifts in rapport.
This gives us useful information and can guide us in our understanding of the patient.
For example, taken in context it:
makes us wonder about the quality of her interpersonal relationships
gives information about personality style
suggests a more longstanding illness process
4.  What interview techniques were used in this interview? Which of these had the most
productive effect?
The interviewer uses a gentle, enquiring and non-judgemental approach
She uses both open and closed-ended questions
She uses non-verbal techniques to acknowledge and affirm
The patient responds to a non-confrontational style and to more open-ended questioning
However, she did not demonstrate much spontaneity and so required an amount of external
direction
5. Can you think of any points in the interview where an attempt to deepen rapport did not work?
One point where this occurs is when the patient is asked about her interests. She responds
with an open smile and rapport momentarily deepens. There is a rare demonstration of
spontaneity: I got three books for Christmas! This deepening of rapport is not sustained
and the conversation falters.
Excerpt One
6. Comment on any shifts in rapport in this excerpt
First, we see a deepening of rapport as the patient confides her psychotic experiences.
Second, we see a minor derailment of the engagement when the patient states a preference
not to answer questions about her past suicidality. The interviewer allows this topic to be
side-stepped and rapport is quickly re-established.

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7.  How else could you respond if a patient says they would rather not talk about a
sensitive topic, such as their suicidality? Role play this scenario
There are several possible ways to manage when a patient wishes to avoid a painful or
sensitive area.
One way is to allow the avoidance. This can have negative consequences, for example, that
important aspects of history are missed.
Another is to acknowledge the difficulty: I can see that is a painful area for you. It is important
for me to know, though Or, I see how hard it is for you to talk about this. Maybe we can
come back to it later.

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Excerpt Two
8. What do you notice in this excerpt?
Met with obstruction the interviewer falters, discards this line of questioning and moves onto
another topic.
This segment is a good example of how deceptive the initial superficial ease of engagement
can be. It is an example of how a patients anxiety and reticence can make the whole
atmosphere tentative.
This interaction gives an insight into the challenges we might face in an ongoing avoidant
therapy relationship.
9.  Do you think it is valuable to ask a patient why he/she has never been in an intimate
relationship? Why is this useful?
It is important to ask about this topic as the information can be useful for formulation and
diagnosis (of both Axis I and Axis II diagnoses). In addition, the act of entering into such
intimate subject matter tests and can deepen rapport.
10. Are there any risks involved in asking about this topic?
Yes, there are real risks. There is a risk of disrupting rapport. The patient may feel confronted,
even intruded upon or persecuted.
Whatever the response, be it a deepening of or a rupture in rapport, it gives valuable
information to the treating team about the patients defenses, sensitivities and the ease with
which she will trust and form a working alliance.
11. How might you ask about this topic? Role play this scenario
This is a potentially difficult topic that can be hard to broach, especially for novice interviewers.
Framing the question in such a way as to acknowledge the sensitivity is useful:
I wonder if thats hard for you to talk about.
That seems to be a sensitive area.
It sounds like you dont want to talk about that topic right now.
Excerpt Three
12. What do you notice in this excerpt?
Involuntary mouth movements pouting: this is an example of rabbit syndrome, a form
of tardive dyskinesia that has been commonly reported with risperidone.

The Psychiatric Assessment: An Overview

Now think back to the full-length interview


13. Comment on the patients affect
1) Limited range of affect
There is some reactivity with genuine warm smiles at moments of engagement.
Some causes and contributors to the reduced range are:
Age-related restriction of affect
Personality-style (e.g. reserved personality, schizoid, avoidant, anxious)
Depressive disorder
Residual paranoia (guarded and suspicious)
Negative feature of a schizophrenia-spectrum disorder
Extra-pyramidal side-effects of medication
2) Incongruity of affect
 Incongruous smiling, probably indicating shame and embarrassment, for example she
smiles and laughs while describing being taken to hospital against her will by the police.
More extreme forms of incongruity occur in grossly psychotic patients.
14. Comment on the patients thought-form
Thought-form is coherent. There is no formal thought-disorder.
15. Does the interview permit an assessment of risk? What is your risk assessment?
Immediate suicide risk
Low
E
 ngaged in treatment, displays insight, is fairly candid, and is able to establish
reasonable rapport
Denies any recent thoughts of suicide
Medium to long-term risk
Less certain
T
 reatment under the Mental Health Act 2007 involuntary admissions, multiple renewals
of Community Treatment Orders suggests past risk and associated impaired insight
The patients fragility, seen by the reticence to enter into painful subject matter,
suggests a thin veneer of wellness
Harm to others
Needs to be considered, although it was not specifically addressed in this interview.
16. What is your provisional diagnosis?
Late-onset schizophrenia.
17. What are your differential diagnoses? Discuss these




Other schizophrenia-spectrum disorders such as schizo-affective disorder


Delusional disorder
Depression with psychotic features
Dementia with psychotic features
Psychosis secondary to a general medical condition

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Poverty of thought and reduced affective range makes the diagnosis of an episodic illness,
such as depression, less likely. Relative preservation of thought-form and some preservation
of affective warmth supports the diagnosis of a later onset of illness rather than a burnt-out
paranoid schizophrenia.
18. What additional information would you like to clarify the diagnosis?
The temporal relationship of mood and psychotic symptoms:

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Will assist in determining if this is a primary mood or psychotic disorder


Will assist in differentiating between schizophrenia, schizo-affective disorder, and
the mood disorders

The presence or absence of any manic features


Premorbid function: has there been a decline in function?
Cognitive function
19. What do you see as important issues in ongoing management?
There are many aspects of management that can be discussed here.
One aspect of management that could be discussed is the incongruities or inconsistencies
that presented themselves during the interview and how these may be useful clues to the
development of an individualised management plan.
In this interview there was a marked disparity between the image presented to us of a lady
who is doing well, has insight, and is in agreement with her treatment plan (says Im very
happy with it, how things are going at the moment!) and the history of involuntary hospital
admissions and Community Treatment Orders. The patient tells us that she is doing well but
does not really let us into her emotional world.
The disparities suggest that the patient is at higher risk than suggested by her superficial
presentation and that, when well, her risk could easily be underestimated. For example,
the patient may come across as co-operative and agreeable but then drop out of care and
experience a relapse.

Learning Point
The bio-psycho-social framework is useful when deciding on management. However, it is
important to also think beyond this, and to consider in greater depth what is unique to this
patient, in this circumstance.

Session 2: Introduction to Psychiatric History-Taking

19

Session 2
Introduction to Psychiatric History-Taking
20

PART 1: LECTURES
Dr Agnes Chan
The Psychiatric Interview:
(History Taking)

Dr James Telfer
The Diagnostic Interview
in Psychiatry

PART 2: ROLE PLAYS AND GROUP DISCUSSION


OPTION A
Organise your own
role plays

OR

OPTION B
Watch role plays on
the accompanying USB

Session Summary
This session provides an introduction to the history-taking component of the clinical psychiatric
assessment.
The session is divided into two parts:
PART ONE: Two lectures on psychiatric history-taking
PART TWO: Two role-plays of history-taking, each followed by a group discussion.
There are two options for Part Two.
Option A: Organise your own group to perform role-plays
Option B: Watch the role-plays on the accompanying USB

Focus of the Session


1. To introduce trainees to the core contents of a complete psychiatric history
2. To enable trainees to observe and/or practice history-taking through role play
3.  To use role play as a launch pad for discussion of history-taking, the challenges that may arise,
as well as techniques to overcome these challenges

Materials Required for the Session


PART ONE: Computer, with either a data projector or TV monitor, and external speakers
PART TWO: Option A: no extra materials required
Option B: Computer, with either a data projector or TV monitor, and external speakers.

Introduction to Psychiatric History-Taking

PART ONE: Lectures


Preparation for Session
1. Review the recorded lectures to ensure you are able to discuss relevant aspects of the topic
2. Photocopy the lecture slides (appendix 2.1.1) to distribute to trainees during the session

Conducting the Session


1. Hand out copies of the lecture slides to trainees (appendix 2.1.1)
2. Play the lectures on the accompanying USB
Lecture One: The Psychiatric Interview: (an overview)
Dr Agnes Chan (20 minutes)

21

Lecture Two: The Diagnostic Interview in Psychiatry


Dr James Telfer (10 minutes)
3. Allow question and discussion time (10 minutes)

PART TWO: Role-plays


OPTION A: Organise your own role-plays using provided vignettes
Preparation for session
Please note that there are no Facilitator Notes for this option

1. Select two trainees to be simulated patients


2. Select two trainees to be interviewers
3.  Make a photocopy of the vignettes (appendices 2.2.1 and 2.2.2) to give to simulated patients
and interviewers so that they can learn their roles prior to the session
4.  Review the discussion prompts (appendix 2.2.3) and photocopy them and the page on
interviewing techniques (appendix 2.3.5) to distribute to trainees during the session

Conducting the Session


IMPORTANT: Note to Facilitator
Trainees participating in the role-play must feel safe and supported. The purpose of the
role plays is to generate discussion about interview content and interview technique. It is
NOT a critique of the skill of the trainee.
1.  Prior to the start of the role plays it is important to explain to the group that the trainee
conducting the interview is in a difficult position and may feel nervous and exposed; that
the purpose of the role play is to facilitate discussion surrounding history taking and is not
a critique of the interviewers performance
2.  Select a trainee who is not participating in either role-play to be the moderator of the roleplays and give the moderator their instructions (appendices 2.2.1 and 2.2.2)
3. Hand out the discussion prompts (appendix 2.2.3) and the page on interviewing techniques
(appendix 2.3.5) and allow reading time (5 minutes)

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

4. Refer to appendices 2.2.1 and 2.2.2 for the role-plays


Case 1: A 30-year-old male diagnosed with depression
Focus: History of presenting illness
Case 2: A 40-year-old woman with schizophrenia/schizoaffective disorder
Focus: Past psychiatric history: Case 2
5. Conduct role-play 1 (17 minutes)
6.  At the completion of the role-play ask the interviewer and the simulated patient to return
to their seats within the group

22

7. Lead a group discussion guided by the discussion prompts (20 minutes)


8. Conduct role-play 2 (17 minutes)
9.  At the completion of the role-play ask the interviewer and the simulated patient to return to
their seats within the group.
10. Lead a group discussion guided by the discussion prompts (20 minutes)
11.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

Note to Facilitator
It may be necessary to redirect discussions if the trainees individual technique is becoming
a focus.

OPTION B: Watch the role-plays on the accompanying USB


Preparation for Session
1.  Review the two role plays on the accompanying USB. The role-plays are based on the same
vignettes as those supplied for option A of this session
2.  Photocopy the discussion prompts for both role plays (appendices 2.3.1 and 2.3.2) and the
page on interviewing techniques (appendix 2.3.5) to distribute to trainees during the session
3. Review the facilitator notes for both role-plays (appendices 2.3.3 and 2.3.4)

IMPORTANT: Note to Facilitator


The purpose of the role-plays is to generate discussion surrounding interview content and
interview technique. It is NOT to critique the skill of the trainees conducting the simulated
patient interviews on the USB.

Conducting the Session


1.  Hand out the discussion prompts for both role-plays (appendices 2.3.1 and 2.3.2) and the
page on interviewing techniques (appendix 2.3.5) and allow reading time (5 minutes)
2.  Watch role-play 1 on the USB (10 minutes)
3.  Lead a group discussion of the role-play guided by the discussion prompts (appendix 2.3.1)
and facilitator notes (appendix 2.3.3) (30 minutes)

Introduction to Psychiatric History-Taking

4. Watch role-play 2 on the USB (10 minutes)


5.  Lead a group discussion of the role-play guided by the discussion prompts (appendix 2.3.2)
and facilitator notes (appendix 2.3.4) (30 minutes)
6.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

Appendices listing

23

For use with Part One (Lectures)


Appendix 2.1.1 Lecture slides for The Psychiatric Interview: (History Taking) by Dr Agnes Chan
Appendix 2.1.2 The Diagnostic Interview in Psychiatry by Dr James Telfer

For use with Part Two Option A (Organising your own role plays)
Appendix 2.2.1 Vignette for Role-play 1 (History of presenting illness)
- Instructions to simulated patient
- Instructions to moderator
- Instructions to interviewer
Appendix 2.2.2 Vignette for Role-play 2 (Past psychiatric history)
- Instructions to simulated patient
- Instructions to moderator
- Instructions to interviewer
Appendix 2.2.3 Discussion prompts for trainees for use with both Role-play 1 and Role-play 2

For use with Part Two Option B (Watching role-plays on the accompanying USB)
Appendix 2.3.1 Discussion prompts for trainees for Role-play 1 (History of presenting illness)
Appendix 2.3.2 Discussion prompts for trainees for Role-play 2 (Past psychiatric history)
Appendix 2.3.3 Facilitator notes for Role-play 1 (History of presenting illness)
Appendix 2.3.4 Facilitator notes for Role-play 2 (Past psychiatric history)

For use with Part Two Option A and B


Appendix 2.3.5 Interviewing Techniques

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Appendices
Appendix 2.1.1 Lecture slides
For use with Part One (Lectures)
The Psychiatric Interview: (History Taking) by Dr Agnes Chan

24

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Introduction to Psychiatric History-Taking

25

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

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Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Introduction to Psychiatric History-Taking

Appendix 2.1.2
For use with Part One (Lectures)
The Diagnostic Interview by Dr Telfer

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Page 1

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Introduction to Psychiatric History-Taking

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Introduction to Psychiatric History-Taking

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Introduction to Psychiatric History-Taking

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Introduction to Psychiatric History-Taking

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Appendix 2.2.1 Vignette for Role-play 1 (History of presenting illness)


For use with Part Two Option A (Organising your own role-plays)
Role Play 1 Instructions to simulated patient
How to play the role
You are visibly down and depressed, appear sad and flat, and smile very little if at all. You are a
little slow in both your speech and your movements.

36

Although you are finding it difficult to summon the energy for this interview, you want to help the
doctor by answering as much as you can. You would really like to feel better, but it is hard to see
out of this slump.
Your GP has referred you here. You trust her advice but you find it hard to believe that anything is
going to help you.
Remain as true to the information given in this scenario as you can. Do not expect to cover all of the
information that you have been given. If you are asked specific questions that are not covered here
you may improvise so long as it is consistent with the character and the rest of the information with
which you have been provided.

This is the information you need to memorise for your role


Your name is David Banks. You are a thirty-year-old accountant living with your girlfriend in a
rental unit.
You have been referred to the community mental health centre by your general practitioner who
has been concerned about your level of depression, and more recently about your risk of suicide.
You have been depressed for two months. This depression has been getting worse, especially in
the last week. Your mood is worse in the mornings. The whole day stretches ahead of you and you
dont know how you are going to get through it. You feel like you are wading in mud. You are heavy
and slow and you cant think straight. You seem to be forgetting things and not concentrating. The
other day, you couldnt find your keys for a whole hour and then found them in the fridge with the
milk. It was lucky it was the weekend and you didnt have to be anywhere special but it still made
you feel hopeless and useless.
You havent been sleeping well. You lie awake at night worrying about the day thats been, and then
about 2am you fall into this deep, half-dead slumber for three or four hours. You wake with a start,
as though somethings woken you, but its all quiet and your girlfriend is fast asleep.
You are not sure if youve lost weight, but your appetite hasnt been up to much.
You have always been conscientious, even a perfectionist, but the last two weeks you have missed
a few days of work. You cant make a single decision. Not even about what tie to wear with what
shirt in the morning. Thats partly why you dont go to work sometimes. You just go back to bed. If
you go to work, you dont seem to be getting much done. It seems like your colleagues resent you
for dragging them down, not pulling your weight. You are pretty sure theyve been looking at you
strangely, wondering if somethings up, and also where youve been on days off. The other day you
were pretty sure they were talking about you in the hallway because they went quiet as you walked
past. But then you know you have been more sensitive than usual lately, so you dont want to make
too much of it. You definitely havent heard anything theyve said no hallucinations, no secret
conspiracies, nothing odd like that.

Introduction to Psychiatric History-Taking

You feel like you were always reliable. At least you had that. Maybe not the most exciting guy,
but steady. Now, youre not even that. You feel a bit guilty about work and about neglecting your
girlfriend and about being so useless.
You havent spoken to anyone at work about what is happening. Your boss hasnt said anything.
He doesnt seem like hed get it. Hes a bit of a bloke. Not into the touchy-feely stuff. You arent
into that either. So you cant figure out whats wrong now.
You have a few friends, but you have always kept a little to yourself. You might meet up maybe for a
beer or to watch the sport. Or if your girlfriend organises things you usually go along. Lately youve
stopped calling your friends back and you havent been to anything your girlfriend has organised.
You speak to your mum every couple of weeks but you dont want to worry her or your dad. Your
brother lives overseas.
Your girlfriend is really worried about you. She keeps asking whats wrong and it gets on your nerves
a bit. You know she is only trying to help but you need some space right now. She was the one that
got you to go to the GP a month ago.
The GPs been great. Shes seen you once a week since then. Started you on Cipramil three weeks
ago. One tablet. You cant remember the dose. But you dont think its working. You havent noticed
anything. No side-effects, but the depression is just getting worse.
Why did this all start? You wish you knew. There was a promotion at work that fell through about
three months ago. Something about you being too inexperienced. You were upset at the time but
youre not that concerned about it. It probably wouldnt look good for the next promotion though if
your boss knew you get down and cant cope. That goes through your mind a bit.
Its only been in the last week, when you are lying in bed at night thinking about things, that youve
started to wonder what the point of all this is. Sometimes you think that if you had a gun youd just
blow your brains out. God no, youd never do it. You dont have a gun. They scare you. Its just
a thought. Its gone as quickly as it comes. You sure havent made any plans or preparations, or
thought about any other ways. You dont think youd ever actually do it. Its not in your nature, you
dont think. And youd hate to upset the people around you. Itd be awful.
You havent been paranoid about anything else (apart from the people at work maybe talking about
you). Theres been nothing suspicious and you havent heard any noises, seen anything, smelt
anything unusual. You are not going crazy.
You think your girlfriend would be better off without you. You know she wants to get married some
day, and you feel kind of stuck and obligated. Shed probably be better off with someone else. You
think shes too good for you. But you dont want to let her down, either. You cant really talk to her
about this. You arent good at talking about stuff, and anyway itd just upset her.
You got depressed at high-school once, but never got any treatment. It sure wasnt this bad. It
seemed like acne and teenage angst kicked in and you were on your own all the time. You werent
teased or anything. Just always on the edge of the group. Your mum said they were the best years
of your life and you should be enjoying yourself. Instead you lay on your bed reading science fiction
and playing computer games. Your dad said hed been through the same and not to worry about it.
He was right. Somehow you got out of it when university came around.
There is no other past psychiatric history. The only medical history is an appendicitis. Apart from
the Cipramil you are on no regular medication and have no known allergies.

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37

Role-play 1 Instructions to interviewer


You have 17 minutes to complete this task.
You are a psychiatry registrar working in the community mental health centre. The patient you are
about to see, David Banks, is a new patient. His general practitioner has referred him to the centre.
There is a brief accompanying letter.
Dear Doctor,

38

Thank you for reviewing Mr. David Banks. He is a 30-year-old accountant


that I have been seeing for DEPRESSION.
I have done bloods and can find no organic cause for the depression.
I commenced him on Citalopram three weeks ago. I am concerned about
worsening depression and suicide risk.
CURRENT MEDICATIONS:
Citalopram 20mg po daily
No known medication allergies
PAST MEDICAL HISTORY
Appendicectomy 1997
Thank you for your assessment and advice.
Regards,
Dr. X
Your task is to take a history from this patient, focussing primarily on the history of the
presenting illness.
At 14 minutes provide the group with a brief summary of your history, including any gaps,
present your provisional diagnosis and any differential diagnoses.

Role-play 1 Instructions to moderator


Your role is to ensure the role-play runs smoothly and to keep time
Begin the role-play when the group is ready
Observe the interviewer taking a history this should be 14 minutes
At 14 minutes, if the interviewer has not moved on to the second task, say Please
present a summary of your history, your gaps and your differential diagnoses.
At 17 minutes, stop the task

Introduction to Psychiatric History-Taking

Appendix 2.2.2 Vignette for Role-play 2 (Past psychiatric history)


For use with Part Two Option A (Organising your own role-plays)
Role-play 2 Instructions to simulated patient
How to play the role
You are polite and pleasant and mostly cooperative. You answer questions when asked, but are a
little vague on the particulars. You have difficulty recalling specific times and dates and dont like
talking in detail about the times when you were very unwell. Nor do you like talking about depressive
themes. This is partly because you have a poor memory for the times when you are depressed and
unwell, but you also dont like thinking about those times now that you are better.
You get frustrated if pushed for details, but are certainly never threatening or aggressive.
Your mood is neutral.
You hope to come off your medications and ask about this at least once during the interview.
Remain as true to the information given in this scenario as you can. Do not expect to cover all of the
information that you have been given. If you are asked specific questions that arent covered here
you may improvise so long as it is consistent with the character and the rest of the information with
which you have been provided.

This is the information you need to memorise for your role


Your name is Simone. You are a forty-year-old woman living alone in a Department of Housing unit.
You are on a Disability Support Pension and you supplement this with part-time work at a local
coffee shop two days a week. The work is especially for people with mental health problems.
You were diagnosed with schizophrenia twenty years ago. Now they say its schizoaffective disorder
or something like that.
When you were first diagnosed it was really bad. You were in hospital for two months. You thought
your mum and dad were trying to kill you and you wouldnt go to sleep at all because you thought
theyd come into your room and you dont really know, kill you or something. You heard voices all
the time. You cant remember it, that well. The memory is blurred. But they put you on heaps of
medication and you got all stiff and then couldnt sit still. Eventually, they got it right and you went
home with your parents.
Since then youve been in hospital about five times, every two years at first. Most times were on a
schedule. But now youve been out of hospital for eight years. You think thats pretty good.
Youve tried a lot of different medications and you have had ECT (shock treatment) twice. Youve had
a lot of trouble with medication. Zyprexa made you put on weight and sleep all the time. Then this
other one made you leak milk (Risperdal, you think). And one made you restless. They seem to have
gotten it right now. Youre on lithium (250mg morning and night) and Seroquel (600mg at night).
Youve been on them for ages.
You dont really like being on medication. The lithium gives you a tremor and it makes it hard to serve
in the coffee shop, sometimes. The Seroquel helps you sleep but then youre sluggish in the day.
Still, you know you need it because if you ever stop it you get sick again.
Youre pretty good at taking your medication. You always have been. When you first got sick you
sometimes forgot and sometimes you thought the medicine was poison, but mostly you took it.
Now youre in a routine. Mum is always checking up on you, too.

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You see your case-manager every couple of months and the psychiatry registrar when you need to
get scripts. They thought maybe you could stop coming to the health centre and just see your GP
but then you got sick again. You cant remember how long ago this was.
The first time was the worst. Because no one knew what was going on. Youd dropped out of
university and were all depressed, and your parents were annoyed at you, because you were sitting
at home all the time, really scared and not eating any of the food they made. You did think there
were cameras in the house, and also things on the TV and radio about you, but thats all gone now
and you dont really want to talk about the past. You cant remember it that well.

40

You have had times when youve been too high. All giggly and full of energy. You cant remember
the details but your parents have told you that once you thought you were Princess Diana.
Mostly now, when you start to get sick, you start fighting with Mum and Dad. You start to think they
are against you. They notice right away and get onto your case-manager quickly.
You get worse and then better but it seems more steady these days. You sometimes wonder if you
could stop the medication.
You have never thought of suicide. You have never been physically aggressive to anyone. The most
youve done is shout at your parents.
Most of the time you dont have any symptoms. When you go out you sometimes get paranoid that
people are talking and laughing about you, but you know its just the schizophrenia.
Youve got some friends. One friend from school that you talk to every couple of months and a few
friends youve met in hospital and at the coffee shop. You talk to your mum and dad nearly every
day and see them about once a week when they come over. Mum gives the place a clean and
checks the fridge. You see your sister once a month. Shes pretty busy, but you talk on the phone
a few times a week.
You are a bit vague about how you spend your time, but you say you go for coffee and go to the
movies and sometimes watch TV. You do all the housework, cooking and shopping yourself, apart
from a bit of help from your mum.
Sometimes you get a bit down about how things have turned out. You were doing marine biology
when you first got sick you love animals. You thought youd get married and have a family but
you dont think thats going to happen now. You have a cat called Mustard and she cheers you up.
Mostly youre okay and you are thinking of doing animal studies at TAFE next year.

Introduction to Psychiatric History-Taking

Role-play 2 Instructions to the interviewer


You have 17 minutes to complete this task.
You are a psychiatry registrar who has just begun a rotation at the community mental health centre.
Simone is a long-term client of the community centre. She has a case-manager who keeps in
regular contact with her.
Simone sees a psychiatry registrar for a routine review once every six months. She has come to see
you for a routine appointment. This is the first time you have met her.
Your task is to take a history from Simone focussing on the past psychiatric history.
At 14 minutes provide the group with a brief summary of your history including any gaps and briefly
describe the barriers you might face in managing this patient based on the history you have attained
today.

Role-play 2 Instructions to moderator


Your role is to ensure the role play runs smoothly and to keep time
Begin the role play when the group is ready
Observe the interviewer taking a history this should be 14 minutes
At 14 minutes, if the interviewer has not moved on to the second task, say Please present
a summary of your history, your gaps and your differential diagnoses.
At 17 minutes, stop the task

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41

Appendix 2.2.3 Discussion prompts for trainees for Role-play 1


and Role-play 2
For use with Part Two Option A (Organising your own role-plays)
1. How did the interview feel for the interviewer? (Ask the interviewer)
2. How did the interview feel for the simulated patient? (Ask the simulated patient)
3.  Bearing in mind that this was a time-limited interview, what aspects of the history of presenting
illness (Role Play 1) or past psychiatric history (Role Play 2) were not covered here?
4. Comment on the interaction between interviewer and interviewee

42

5. What were the main techniques the interviewer used to elicit information?
6. Which techniques worked best, and why?
7. Are there any other techniques that could have been used?
The question/answer approach is comfortable, and is the technique most readily adopted by
trainees. However, it is important to develop a range of approaches to interviewing. Experiment
with different techniques, but trust your own style. Use techniques that are comfortable for you.
8. What are some of the difficulties the interviewer faced in this interview? Discuss these
9.  How did the interviewer manage these difficulties? What other ways could you manage
these difficulties?

Introduction to Psychiatric History-Taking

Appendix 2.3.1 Discussion prompts for trainees for Role-play 1


(History of presenting illness)
For use with Part Two Option B (Using role-plays on the accompanying USB)
1.  This was a time-limited interview and not all aspects of the history of presenting illness
were covered. What aspects were not covered?
2. Comment on the interaction between interviewer and interviewee
3. What were the main techniques the interviewer used to elicit information?
4. Which techniques worked best, and why?
5. Discuss other interviewing techniques that could have been used
The question/answer approach is comfortable and is the technique most readily adopted
by trainees. However, it is important to develop a range of approaches to interviewing.
Experiment with different techniques, but trust your own style. Use techniques that are
comfortable for you.
6.  The interviewer began the interview by asking the patient How are you going today?
Why might the interviewer have begun like this?
7. What effect might this have had on the doctor-patient interaction?
8. How else might you begin such an interview? Role-play alternative beginnings
9.  What are some of the difficulties the interviewer faced in this interview? How did she
manage these?
10. Were there any leads that the interviewer could have taken up? Role-play how you
could take up some of the missed leads

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43

Appendix 2.3.2 Discussion prompts for trainees for Role-play 2


(Past psychiatric history)
For use with Part Two Option B (Using role-plays on the accompanying USB)
1.  This was a time-limited interview and not all aspects of past psychiatric history were covered
What aspects were not covered?
2. Comment on the interaction between the interviewer and interviewee
3. What were the main techniques the interviewer uses to elicit information?
4. Which techniques worked best, and why?

44

5. Discuss other interviewing techniques that could have been used?


6.  What were some of the difficulties the interviewer faced in this interview? How did she manage
these?
7.  On a few occasions the simulated patient said she would prefer to not talk about a particular
topic. How did the interviewer manage this?
8. Why do you think she managed in this way?
9. How else might you manage this situation? Role play alternative approaches

Introduction to Psychiatric History-Taking

Appendix 2.3.3 Facilitator notes for Role-play 1 (History of


presenting illness)
For use with Part Two Option B (Using role plays on the accompanying USB)
1.  This was a time-limited interview and not all aspects of the history of presenting
illness were covered. What aspects were not covered?
Pattern of mood over last four weeks
Cognitive symptoms such as excessive guilt
Psychomotor symptoms

45

Triggers/precipitants to the depression


Presence or absence of psychotic symptoms
Presence or absence of anxiety symptoms
2. Comment on the interaction between interviewer and interviewee
Initial difficulty with engagement (clumsy and embarrassed)
Rapport then developed rapidly
A cooperative interviewee (patient) was readily forthcoming with information and showed
trust in the interviewer
The interviewer was gentle and displayed empathy and understanding
3. What were the main techniques the interviewer used to elicit information?
Predominant technique
Questions both closed and open-ended in a calm yet inquiring manner
Other techniques
Expressions of empathy, both verbal and non-verbal, such as:
Summaries of the patients responses
Nodding
Eye contact held but non-confrontational
4. Which techniques worked best, and why?
5. Discuss other interviewing techniques that could have been used
There are a number of techniques that can be used in any interview:
Perhaps, after summarising what the patient told her, the interviewer could have put this
back to patient and then asked for clarification
Perhaps the interviewer could have, instead of specific questions, alternated this with
collaborative statements. For example. I wonder how it felt for you, coming here today.
I wonder if you could tell me some more about that
Perhaps the interviewer could have put observations about the patient to him, such as
You seem to be struggling with that
You seem very down today

The question/answer approach is comfortable, and is the technique most readily adopted
by trainees. However, it is important to develop a range of approaches to interviewing. Trainees
should be encouraged to experiment with different techniques, but trust their own style,
using techniques that are comfortable and work for them.

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6. The interviewer began the interview by asking the patient How are you going today?
Why might the interviewer have begun like this?
People often resort to colloquialisms through anxiety.
7. What effect might this have had on the doctor-patient interaction?
Informal and laid-back which might put the patient at ease. However, this statement may
not demonstrate serious professional concern.
8. How else might you begin such an interview? Role play alternative beginnings

46

There are a number of ways to begin an interview. For example


Tell me about what brought you here today
I wonder how it felt for you, coming here today
9.  What were some of the difficulties the interviewer faced in this interview? How did
she manage these?
10. Were there any leads that the interviewer could have taken up?
The patient has a concern that people at work are talking about him. This may be realitybased, or may be an overvalued idea or a delusion.
Role-play how you could take up some of the missed leads.

Introduction to Psychiatric History-Taking

Appendix 2.3.4 Facilitator notes for Role-play 2 (Past psychiatric illness)


For use with Part Two Option B (Using role plays on the accompanying USB)
1. This was a time-limited interview and not all aspects of the past psychiatric history
were covered. What aspects were not covered?
How current psychiatric status compares with baseline level
Presence/absence of current psychotic symptoms?
If no psychotic symptoms, then when were they last present?
Relapses not requiring hospital admission including the timing of the last relapse
Length of relapses/time to recovery
Inter-episodic psychiatric symptoms
Inter-episodic function
Past treatments other than medications, e.g. ECT, psychological treatments
Past history of self-harm and suicide attempts
Other risky behaviour when unwell
2. Comment on the interaction between the interviewer and interviewee
Reasonably rapidly established rapport
Mildly anxious patient who is cooperative and forthcoming with much of the history.
A polite and reassuring interviewer
Minor disjunctions, such as when the patient asks to stop all medication, or when
she avoids talking about difficult topics
3. What were the main techniques the interviewer used to elicit information?
Predominant technique
Questions predominantly closed-ended questions, to which the patient responds
with a lot of information
Other techniques
Some open-ended questions
Explanations of the interview process
 Reassurances
I can understand why you dont want to talk about that
Thats great you have been good for a long period of time
4. Which techniques worked best, and why?
5. Discuss other interviewing techniques that could have been used?
6.  What were some of the difficulties the interviewer faced in this interview? How
did she manage these?
7.  On a few occasions the simulated patient said she would prefer to not talk about
a particular topic. How did the interviewer manage this?
Initially, the interviewer attempted to ask more about this. Then she conceded with
Thats okay, I can understand why you dont want to talk about that.
8. Why do you think she managed in this way?
Met with resistance the interviewer conceded, possibly to avoid further disruption to
the rapport and possibly because of time pressures or shared embarrassment.

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47

9. How else might you manage this situation? Role play alternative approaches
When avoiding an area, it can signal to the patient that you also dont want to talk about
difficult topics, cant deal with their pain and negative affects. This may make them reluctant
to confide negative affects in the future.
Sometimes it is helpful to acknowledge their difficulty This is a painful thing to talk about
even if this is followed up by We can come back and talk about this later.

48

Introduction to Psychiatric History-Taking

Appendix 2.3.5 Interviewing techniques


For use with Part Two Option B (Watching role plays on the accompanying USB)
When discussing interviewing techniques, consider:
Use of verbal and non-verbal communication
Open-ended and closed-ended questions
Empathic responses that validate the patients experience

That must have been hard for you

Making observations and feeding them back to the patient

On their physical appearance, e.g. scars, injuries, signs of fatigue


On something they have said, Just now you mentioned, I wonder if you
could say some more about that

On affective style, You seem sad

Summaries or paraphrasing of what the patient has said, and then inviting the patient
to comment on this
Interpretation: noticing a parallel or a connection

It seems to me there may be a pattern here. In each of these relationships

Putting hypotheses to the patient

So, when you feel hurt you respond by getting angry?

Appropriate reassurances

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NOTES

50

Session 3: Cognitive Assessment I

51

Session 3
Cognitive Assessment I
52

PART 1: LECTURE
Dr Agnes Chan
Bedside Cognitive Testing

PART 2: WORKSHOP

Session Summary
This session is the first of two sessions on the Cognitive Assessment in Psychiatry.
The session is divided into two parts:
PART ONE: A lecture about bedside testing of cognitive function
PART TWO: A workshop in which trainees practice the cognitive assessment

Focus of the Session


1. To introduce trainees to the essential components of bedside cognitive testing
2. To enable trainees to practice the cognitive assessment under supervision with an opportunity
for discussion and feed-back on their techniques

Materials required for the Session


PART ONE: Computer, with either a data projector or TV monitor, and external speakers
PART TWO: Nil

PART ONE: Lecture


Preparation for Session
1. Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic
2. Photocopy the lecture slides (appendix 3.1) to distribute to the trainees during the session

Conducting the Session


1. Hand out copies of the lecture slides to trainees (appendix 3.1)
2. Play the lecture on the accompanying USB: Bedside Cognitive Testing Dr Agnes Chan (40mins)
3. Allow question and discussion time (5-10mins)

Cognitive Assessment I

PART TWO: Workshop


Preparation for Session
1.  Ensure that you are familiar with the bedside cognitive tests covered in this session so that
you are able to supervise the workshop
2.  Photocopy the Checklist for testing cognitive function: Testing Cognitive Function at the
Bedside (Appendix 3.2) to distribute to trainees during the session

Conducting the Session


1.  Hand out copies of the Checklist for testing cognitive function: Testing Cognitive Function at
the Bedside to trainees (appendix 3.2)
2.  Divide trainees into pairs to practise performing the cognitive assessment on each other. Using
the checklist, they should practise: orientation, attention and concentration, memory, executive
function, language, praxis and visuospatial function
3. Take 5-10 minutes at the end of the session to summarise session outcomes and answer any
questions

Appendices listing
For use with Part One (Lecture)
Appendix 3.1 Lecture slides for Bedside Cognitive Testing by Dr Agnes Chan

For use with Part Two (Workshop)


Appendix 3.2 C
 hecklist for testing cognitive function: Testing Cognitive function at the Bedside.
In: Cognitive Assessment for Clinicians. Hodges, J.R. Oxford University Press:
144-154, 1994

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53

Appendices
Appendix 3.1 Lecture Notes
For use with Part One (Lecture)
Bedside Cognitive Testing by Dr Agnes Chan

54

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Cognitive Assessment I

55

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

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56

Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Cognitive Assessment I

57

Slide 19

Slide 20

Slide 21

Slide 22

Slide 23

Slide 24

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58

Slide 25

Slide 26

Slide 27

Slide 28

Slide 29

Slide 30

Cognitive Assessment I

Appendix 3.2
For use with Part Two (Workshop)
Checklist for testing cogitive function: Testing Cognitive Function at the Bedside.
p113

59

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p114-115

60

Cognitive Assessment I

p116-117

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p118-119

62

Cognitive Assessment I

p120-121

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p122-123

64

Cognitive Assessment I

p124-125

65

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p126-127

66

Cognitive Assessment I

p128-129

67

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p130-131

68

Cognitive Assessment I

p132-133

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p134-135

70

Cognitive Assessment I

p136-137

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p138-138

72

Cognitive Assessment I

p140-141

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p142-143

74

Session 4: Cognitive Assessment II

75

Session 4
76

Cognitive Assessment II
OBSERVATION OF A COGNITIVE ASSESSMENT AND GROUP DISCUSSION

Summary of Session
This session is the second of two sessions on the Cognitive Assessment in Psychiatry.
The group watches and discusses selected segments of a recorded cognitive assessment by an
experienced psychogeriatrician. The interview contains both formal and informal tests of cognition.
Prior to this recorded interview informed consent was obtained from the patient and his wife. The
patients capacity to give informed consent was assessed by the interviewing psycho-geriatrician.
Remember that cognitive findings form only one part of the picture. They should be used in
conjunction with history and with neuro-imaging.

Focus of the Session


1. To demonstrate clinical application of the cognitive assessment on a real patient
2. To explore some of the practical limitations of performing cognitive assessments
3. To introduce and discuss the various available cognitive assessment tools

Materials Required for the Session


Computer, with either a data projector or TV monitor, and external speakers

Preparation for Session


1.  Review the accompanying USB material. It contains a recorded interview and cognitive
assessment by an experienced psychogeriatrician. Ensure that you are able to discuss
relevant aspects of this topic
2.  Photocopy the discussion prompts (appendix 4.1) to distribute to trainees during the session
3.  Photocopy the ACE-R (Addenbrookes Cognitive Examination) (appendix 4.3) and Carers
Assessment of Executive Function (appendix 4.4) to distribute to trainees during the session
Two copies of each assessment tool have been provided: a blank copy and a copy of the
completed assessments by the patient on the USB
4. Review the facilitator notes (appendix 4.2)

Cognitive Assessment II

Conducting the Session


1.  Hand out the blank and the completed copies of the ACE-R forms (appendix 4.3) and the
Carers Assessment of Executive Function (appendix 4.4)
2.  Hand out the discussion prompts (appendix 4.1) and allow reading time (5 minutes)
3.  Watch the recorded segments of the patient and pause for discussion where indicated in the
USB using the discussion prompts and facilitator notes the USB footage is 35 minutes in total
4.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any
outlying questions

77

Appendices listing
Appendix 4.1 Discussion prompts for trainees
Appendix 4.2 Facilitator notes
Appendix 4.3 Addenbrookes Cognitive Examination (ACE-R) (blank and completed assessment)
Appendix 4.4 Carers Assessment of Executive Function (blank and completed assessment)

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Appendices
Appendix 4.1 Discussion prompts for trainees
Segment One
1. Comment on speech and thought-form
2. Can you identify any examples of language difficulties in this segment?
Segment Two
3. Asking someone how they spend a typical day is an important question. What do we learn
in this segment?

78

Segment Three
4. The interviewer asks the patient, Are you in good spirits most of the time? This is another
important question. Are you familiar with the questionnaire that this question comes from?
5. What do you make of the patients autobiographical account?
6. What do you make of the fluency of his speech in this segment?
7. Which aspects of history not covered so far are relevant to the assessment of cognitive
function?
Segment Four
8. Briefly discuss what you saw in this segment
9. Discuss the problems with assessing general knowledge
Segments Five
10. When trying to recall the address, the patient responds to cueing. What does this tell us?
11. Comment on the patients performance on the Trail-Making Test.
12. What other cognitive assessment tools do you know?
13.  What cognitive assessment tool would you use when prescribing a cholinesterase inhibitor
for Alzeimers disease?
14. What are the benefits of formal neuropsychological testing?
15. Why is the carer questionnaire important?
16. Which area of the brain is responsible for:
Language and memory?
Visuo-spatial function and praxis?
Visual gnosis (visual recognition)?
Executive function?
17. Which brain area would you expect to be affected in:
Alzheimers Disease?
Lewy-Body Dementia?
Vascular Dementia?

Cognitive Assessment II

Appendix 4.2 Facilitator notes


The interviewing psychogeriatrician uses the Revised Version of the Addenbrookes Cognitive
Examination (ACE-R) as his main instrument for cognitive testing.
The psychogeriatrician supplements the ACE-R with an introductory interview, a brief assessment
of general knowledge and with the Trail Making Test1.
The interviewing psychogeriatrician often uses the ACE-R in his clinical practice for the following reasons:
It is relatively time-efficient
It is practical in an outpatient setting, whereas a comprehensive psychometric assessment can
take up to four hours, and is both expensive and exhausting for patients
It includes a wide range of tests encompassing the various areas of cognitive function
It has the Folstein Mini-Mental State Examination (MMSE) embedded within it so that the MMSE
score can be extracted from the ACE-R
Note that the entire interview and cognitive assessment is not shown in this session for
time reasons
Segment One
1. Comment on speech and thought-form
 Even before embarking on formal cognitive testing, we see evidence of an early breakdown
in language function.
 The patient is mostly fluent but sometimes uses inappropriate words and phrases. When
unable to think of a particular word he demonstrates circumlocution.
Circumlocution is the use of indirect language, using many words to describe something
simple.
2. Can you identify any examples of language difficulties in this segment?

Inherit this and Slip into this [when talking about the onset of his memory disturbance]
Dont have much of an intake [regarding the reduction in his social and other activities]
When youre mixing around, such as sailing
Segment Two
3.  Asking someone how they spend a typical day is an important question. What do we
learn in this segment?
 There is a lack of depth in the patients descriptions of how he spends his day. From this,
we can begin to form some hypotheses. For example, we might wonder if it reflects that the
patient leads an impoverished lifestyle and, if so, if this is related to the amotivation often seen
with dementia syndromes (frontal lobe impairment). Or, we might wonder if it reflects that the
patient lacks the cognitive capacity to recall and/or to accurately describe his daily activities.
Segment Three
4.  The interviewer asks the patient Are you in good spirits most of the time? This is
another important question
Are you familiar with the questionnaire that this question comes from?

The Trail Making Test that the interviewer uses is not a Trail Making Test that has been psychometrically validated. Therefore,
while it provides useful qualitative information, it does not give quantitative data. By contrast, the Trail Making Tests that are
used in formal psychometric assessments have been validated and these do provide quantitative results.

1. 

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79

 The question is from the Geriatric Depression Scale (GDS), a screening instrument for
depression. It is a useful question in that it often gives a good indication of the pervasiveness
of the mood pattern.
5. What do you make of the patients autobiographical account?
 He is able to give a reasonable chronological history but there is mild confusion and
chronological inconsistency when he is describing the details of his two marriages.
6. What do you make of the fluency of his speech in this segment?

80

 He remains fluent in speech and does not exhibit the breakdown of language that we saw
earlier in the interview. The anxiety he felt at the commencement of the interview may have
exacerbated his language dysfunction.
7. Which aspects of history not covered so far are relevant to the assessment of cognitive
function?
Past Medical History

Although not shown in the video, the patient has a history of hypertension a vascular
risk factor for both Vascular Dementia and for Alzheimers Dementia

Routine medications
Substance use
Segment Four
8. Briefly discuss what you saw in this segment
Patchy general knowledge
Word-finding difficulties
9. Discuss the problems with assessing general knowledge
 General knowledge depends on many factors. For example, cultural background, baseline
intelligence, level of interest and the environment/setting.
It is important to ensure your expectations are appropriate to that person and that setting.
 This man described a genuine interest in current affairs and so his lack of recall is likely to
be significant.
Segment Five
Pause for discussion as required while watching this segment
10.  When trying to recall the address, the patient responds to cueing. What does this tell us?
The response to cueing tells us about the density of memory disturbance.
 If cueing does not help with recollection it indicates a more severe memory problem.
A lack of recollection despite cueing is common in advanced Alzheimers Dementia.
11. Comment on the patients performance on the Trail-Making Test
 The patient began well but derailed after reaching number four. However, he was able to
go back and rectify the problem.
This indicates mild to moderate dysexecutive function.
12. What other cognitive assessment tools do you know?
 A large number of neuropsychological tests are available. The specific tool used and the
amount of cognitive testing undertaken depends on the patient as well as the setting/context.

Cognitive Assessment II

Some cognitive assessment tools are:


Folstein Mini-Mental State Examination: A score of less than 24 out of 30 is considered
indicative of a cognitive deficit. However, the MMSE by itself is a screening tool and is not
sufficient to make a diagnosis of dementia.
Alzheimers Disease Assessment Scale cognition: (ADAS-Cog): This scale is used both
clinically and in research. It gives a score out of seventy, with a higher score indicating a
greater degree of impairment.
The CAMCOG: This is the cognitive and self- contained part of the CAMDEX. The CAMDEX
is the Cambridge Examination for Mental Disorders of the Elderly. This assessment tool is
commonly used in research and, less commonly, clinically.
13.  What cognitive assessment tool would you use when prescribing a cholinesterase
inhibitor for Alzeimers disease?
 Until recently PBS guidelines stated that anyone who scored above 24 on the MMSE had
to have an ADAS-Cog in order to receive a PBS prescription for a cholinesterase-inhibitor.
 Even though an ADAS-Cog is no longer required for the initial PBS prescription it is still
frequently used. This is because, after six months, a repeat PBS prescription requires a
demonstrable improvement in cognitive function. This constitutes either an improvement of
two points on the MMSE or of four points on the ADAS-Cog. It is much easier to show an
improvement on the ADAS-Cog.
14. What are the benefits of formal neuropsychological testing?
Neuropsychological testing can provide additional detail about areas of relative strength
and weakness in an individual. This can help with diagnosis and with developing a
management plan that targets specific areas
It can be used to monitor progress
It can be used in medicolegal settings, eg competence assessments
15. Why is the carer questionnaire important?
It gives an indication of day-to-day function, including executive function
16. Which area of the brain is responsible for
Language and memory?
Temporal region
Visuo-spatial function and praxis?
Parietal region
Visual gnosis (visual recognition)?
Occipital region
Executive function?
Frontal region
17. Which area would you expect to be affected in
Alzheimers Disease?
Temperoparietal region
Lewy-Body Dementia?
Occipital region
Vascular Dementia?
Patchy deficits in all areas but may see predominantly frontal/executive dysfunction

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81

Appendix 4.3 Addenbrookes Cognitive Examination (ACE-R) Blank copy

82

No. 1

Cognitive Assessment II

83

No. 2
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No. 3

Cognitive Assessment II

85

No. 4

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No. 5

Cognitive Assessment II

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No. 6

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Appendix 4.3 Addenbrookes Cognitive Examination (ACE-R) Completed assessment

88

No. 7

Cognitive Assessment II

89

No. 8
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No. 9

Cognitive Assessment II

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No. 10

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No. 11

Cognitive Assessment II

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No. 12

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Appendix 4.4 Carers Assessment of Executive Function Blank copy

94

No. 1

Cognitive Assessment II

Appendix 4.4 Carers Assessment of Executive Function Completed assessment

95

No. 2
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NOTES

96

Session 5: Movement Disorders

97

Session 5
Movement Disorders
98
PART 1: GROUP DISCUSSION AND ROLE-PLAY
PART 2: (OPTIONAL) CD EXAMPLES OF MOVEMENT DISORDERS

IMPORTANT
This session contains an OPTIONAL Part Two that does not follow the format of the
other sessions in this manual. The CD material for Part Two of this session was produced
independently by Professor Tim Lambert who has kindly allowed its reproduction here.
It was not developed as part of this training program.
Please note that production of the CD was sponsored by a pharmaceutical company.
Due to the different format of the CD for this session, Part Two will require an additional
one hour of preparation time as you will need to orientate yourself to the material in order
to decide how best to make use of it during the session.

Summary of Session
This session is about Extrapyramidal Movements Disorders.
The session is divided into two parts:
PART ONE: Discussion and role-play on the clinical assessment of movement disorders
PART TWO: (Optional) CD examples of movement disorders

Focus of the Session


1.  To increase awareness of the movement disorders a common and often unrecognised
side-effect of neuroleptic medication
2.  To discuss the movement disorders including the associated distress and disability,
prevention and management
3. To learn about assessment tools for movement disorders AIMS, GATES
4. To learn how to perform the AIMS test (AIMS Examination Procedure)

Materials Required for the Session


PART ONE: Computer, with either a data projector or TV monitor, and external speakers
PART TWO: nil

Movement Disorders

PART ONE: Group Discussion and Role-play


Preparation for Session
1.  Download a copy of the GATES 6.1-1: a new instrument for clinical and research assessment of
neuroleptic-induced movement disorders using this link: http://www.psychiatry.unimelb.edu.
au/open/pdfs/GATES65r.pdf
2.  Review the session handouts to ensure you are familiar with them and can lead a discussion
on the topic of movement disorders (appendices 5.1.1 to 5.1.3). Photocopy the handouts to
distribute to trainees during the session
3.  Review the article in the recommended reading list and then provide trainees with a copy
of the article or with the reference: Dayalu, P. Chou, K.L. (2008) Antipsychotic-induced
extrapyramidal symptoms and their management. Expert Opinion, Pharmacotherapy
9 (9) 1451-1462
4. Review how to conduct the AIMS examination based on the AIMS Examination Procedure

Conducting the Session


1.  Start the session with a brief summary of movement disorders based on the Extrapyramidal
Syndrome Summary (appendix 5.1.1)
2. Discuss assessment and management of movement disorders in general
Discuss:
Risk factors for Extrapyramidal Syndromes (EPS) (genetic, cultural, age, sex, duration of
treatment, type of antipsychotic, etc)
Clinical cases where EPS have been observed. Invite trainees to describe their own
experiences
Management of EPS, and
Any questions the trainees may have regarding EPS
3. Read through the AIMS Examination Procedure (appendix 5.1.2) with the group. The AIMS
test looks primarily for dystonic and dyskinetic movements. It is a relatively brief and easy to
administer screening tool
4.  Select two trainees: one to act as a patient and a second trainee to conduct the AIMS
examination based on the AIMS Examination Procedure
5. Ask the trainee to perform the AIMS and then discuss this
6.  Discuss the GATES test (appendix 5.1.3). This is a less commonly used test than the AIMS.
The GATES test:
Is a more comprehensive rating scale than the AIMS
Is often used in research settings
Examines for side-effects not examined through the AIMS. For example it examines for
bradykinesia and hypersalivation (associated with clozapine) in addition to dystonic and
dsykinetc movements
Is much longer than the AIMS and is therefore less practical to administer in the standard
community outpatient setting
Despite the length of the GATES making it often impractical, there are many useful tests within
this screening tool. It may be beneficial to develop your own battery of tests using a combination
of the GATES and AIMS.

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99

7.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

PART TWO: CD Examples of Movement Disorders


Preparation and Conducting the Session
1.  Review the accompanying CD: Movement Disorders by Professor Tim Lambert and decide
how best to use the material for your session

100

Appendices listing
For use with Part One (Group Discussion and Role Play)
Appendix 5.1.1 Extrapyramidal Syndrome Summary
Appendix 5.1.2 AIMS Examination procedure
Appendix 5.1.3 RANZCP Clinical Memorandum #10 (May 2007, GC2/02, R37). Tardive
Dyskinesia

Recommended reading
Dayalu, P. Chou, K.L. (2008) Antipsychotic-induced extrapyramidal symptoms and their
management. Expert Opinion, Pharmacotherapy 9 (9) 1451-1462

Movement Disorders

Appendices
Appendix 5.1.1 Extrapyramidal Syndrome Summary
For use with Part One (Group discussion and role-play)
EXTRAPYRAMIDAL SYNDROMES
Syndromes with motor side-effects resulting from disturbance to the extra pyramidal motor system
Associated with all first-generation antipsychotic medication, with some second generation
antipsychotics as well as with some other psychotropic and non-psychotropic agents, e.g.
anticonvulsants, lithium, metoclopramide

101

Acute syndromes
Akathisia
Subjective feeling of inner restlessness, often associated with observed movements such as
rocking, pacing, and shifting the weight from foot to foot
Usually occurs within hours to days of treatment commencement or of increasing the dose
Postural tremor

Fine tremor that develops when trying to maintain a postural stance


Parkinsonism
Parkinsonian tremor, muscular rigidity and bradykinesia
May be associated with mental symptoms such as apathy and mental slowing
Occurs within 5-30 days of treatment commencement or of increasing the dose
Focal Dystonias
Sustained abnormal posture secondary to involuntary muscle spasm
May affect a single muscle or a group of muscles: head, neck, limbs or trunk
Occurs within the first few days of treatment commencement or of increasing the dose
E.g. oculogyric crisis, torticollis, the Pisa-syndrome
Acute dyskinesias
Repetitive, involuntary, hyperkinetic movements
Often in the face and mouth region
More commonly occurs after more than three months of treatment commencement when it is
called tardive dyskinesia (see below)
Neuroleptic Malignant Syndrome
A medical emergency
Severe muscle rigidity, fever, elevated creatinine phosphokinase, and other related findings
(such as diaphoresis, changes in level of consciousness ranging from confusion to coma and
labile blood pressure)
M

ay occur at any time during treatment with neuroleptic medication though more commonly
occurs early in treatment

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Tardive Syndromes
Tardive refers to delayed onset. This term is used to refer to syndromes that develop later, after
three or more months of treatment. In these syndromes there is a risk of persistence after cessation
of the causative medication.
Tardive syndromes may take on many forms, for example tardive dystonias and perioral tremor,
but the most common is tardive dyskinesia.

102

Tardive dyskinesia
Choreiform, dystonic, athetoid or stereotypic movements
Frequently affect the mouth and tongue, e.g. lip-smacking, sucking, puckering and facial
grimacing
Seriously disabling dyskinesia is uncommon but a small proportion may affect walking, talking,
eating and breathing

Movement Disorders

Appendix 5.1.2 AIMS Examination Procedure


For use with Part One (Group discussion and role-play)
INSTRUCTIONS
There are two parallel procedures, the examination procedure, which tells the patient what to
do, and the scoring procedure, which tells the clinician how to rate what he or she observes.
Examination Procedure
Either before or after completing the examination procedure, observe the patient unobtrusively
at rest (e.g. in the waiting room).
The chair to be used in this examination should be a firm one without arms.

103

1.  Ask the patient whether there is anything in his or her mouth (i.e. gum, candy etc) and, if so,
to remove it
2.  Ask about the current condition of the patients teeth. Ask if he or she wears dentures. Ask
whether teeth or dentures bother the patient now
3.  Ask whether the patient notices any movements in his or her mouth, face, hands, or feet.
If yes, ask the patient to describe them and to indicate to what extent they currently bother
the patient or interfere with activities
4.  Have the patient sit in chair with hands on knees, legs slightly apart, and feet flat on floor.
(Look at the entire body for movements while the patient is in this position.)
5.  Ask the patient to sit with hands hanging unsupported if male, between his legs, if female
and wearing a dress, hanging over her knees. (Observe hands and other body areas)
6.  Ask the patient to open his or her mouth. (Observe the tongue at rest within the mouth.)
Do this twice
7.  Ask the patient to protrude his or her tongue. (Observe abnormalities of tongue movement)
Do this twice
8.  Ask the patient to tap his or her thumb with each finger as rapidly as possible for 10 to 15
seconds, first with right hand, then with left hand. (Observe facial and leg movements) [activated]
9. Flex and extend the patients left and right arms, one at a time
10.  Ask the patient to stand up. (Observe the patient in profile. Observe all body areas again, hips
included)
11.  Ask the patient to extend both arms out in front, palms down. (Observe trunk, legs, and mouth)
[activated]
12.  Have the patient walk a few paces, turn, and walk back to the chair. (Observe hands and gait.)
Do this twice [activated]
Scoring Procedure
Complete the examination procedure before making ratings.
For the movement ratings (the first three categories below) rate the highest severity observed.
0 = none, 1 = minimal (may be extreme normal), 2 = mild, 3 = moderate, and 4 = severe. According
to the original AIMS instructions, one point is subtracted if movements are seen only on activation,
but not all investigators follow that convention.

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Facial and Oral Movements

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1.

Muscles of facial expression


e.g. movements of forehead, eyebrows, periorbital area,
cheeks. Include frowning, blinking, grimacing of upper face

01234

2.

Lips and perioral area e.g. puckering, pouting, smacking

01234

3.

Jaw, e.g. biting, clenching, chewing, mouth opening, lateral


movement

01234

4.

Tongue. Rate only increase in movement both in and


out of mouth, not inability to sustain movement

01234

Extremity Movements
5.

Upper (arms, wrists, hands, fingers). Include movements


that are choreic (rapid, objectively purposeless, irregular,
spontaneous) or athetoid (slow, irregular, complex,
serpentine). Do not include tremor (repetitive, regular,
rhythmic movements)

01234

6.

Lower (legs, knees, ankles, toes), e.g. lateral knee


movement, foot tapping, heel dropping, foot squirming,
inversion and eversion of foot

01234

Trunk Movements
7.

Neck, shoulders, hips e.g. rocking, twisting, squirming,


pelvic gyrations. Include diaphragmatic movements

01234

Global Judgments
8.

Severity of abnormal movements

01234
(based on the highest single
score on the above items)

9.

Incapacitation due to abnormal movements

0 = none, normal
1 = minimal
2 = mild
3 = moderate
4 = severe

10.

Patients awareness of abnormal movements

0 = no awareness
1 = aware, no distress
2 = aware, mild distress
3 = aware, moderate distress
4 = aware, severe distress

Dental Status
11.

Current problems with teeth and/or dentures

0 = no
1 = yes

12.

Does patient usually wear dentures?

0 = no
1 = yes

Movement Disorders

Appendix 5.1.3
For use with Part One (Group discussion and role-play)
RANZCP Clinical Memorandum #10. Tardive Dyskinesia

105

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106

Page 2

Movement Disorders

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Page 3

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NOTES

108

Session 6: Phenomenology

109

110

Session 6
Phenomenology
PART 1: INTERACTIVE DISCUSSION
PART 2: ROLE-PLAY

Summary of Session
This session provides an overview of phenomenology.
The session is divided into two parts:
PART ONE: An interactive discussion about phenomenology
PART TWO: A role-play and discussion focussing on the clinical skills involved in
exploring and understanding phenomenology

Focus of the Session


1. Broadening understanding of the definition and origins of the term phenomenology
2. Inviting thought and discussion about the relevance of phenomenology in modern
psychiatry, including clinically-relevant psychiatric phenomena
3. Using role-play to explore the clinical skills relevant to phenomenology:
Interviewing (dissecting phenomena), and
Formulation (making sense of phenomena)

Materials Required
PART ONE: NIL
PART TWO: NIL

Phenomenology

PART ONE: Interactive Discussion


Preparation for session
1. Prior to the session, provide a copy of the journal article by Andreasen (appendix 6.1) to trainees
and advise them that they will be expected to have read the article before the session
2.  Review the journal article, discussion prompts (appendix 6.2) and facilitator notes (appendix 6.3)
to ensure you are able to discuss relevant aspects of the topic

Conducting the Session


1.  Start the session with a group discussion based on the journal article using the discussion
prompts to facilitate discussion (40 minutes)

111

2.  The trainees should then be divided into groups for a 20-minute discussion about the
differences between:
A delusion and an overvalued idea
A hallucination and a pseudo-hallucination
3. The groups should then come together and discuss their ideas

PART TWO: Role-play


Preparation for Session
1.  Prior to the session, a trainee needs to be assigned the role of a patient and given a simulated
history to memorise for the session (appendix 6.4)
2.  A second trainee needs to be assigned the role of interviewer. The interviewers role will be to
take a history from the simulated patient during the session

Conducting the Session


IMPORTANT: Note to Facilitator
It is essential to ensure that the trainees participating in the role-play feel safe and
supported rather than exposed to the group. The purpose of the role-play is to generate
discussion surrounding interview technique. It is NOT to critique the skill of the trainee.
1.  Conduct the role-play the trainee who has been assigned the role of interviewer is to take a
psychiatric history from the simulated patient, who they have never met before (10 minutes)
2.  Ask the interviewer to do a brief presentation of the mental state examination and formulation
to the group (5 minutes)
3.  Guide the group discussion of the role play using the following key learning points as
discussion prompts (10 minutes)
Key learning points:
1) How to take a history of a particular symptom in order to dissect out the psychopathology:
This requires a degree of tenacity
It is particularly important when unsure of the diagnosis, or when unsure if the reported
symptom is pathological

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

2) Presenting symptoms are important, even if they do not clearly fit an illness pattern,
as a key part of both mental state and formulation. There is a tendency for trainees to be
formulaic, to not present perplexities, conundrums and incongruencies.

Appendices listing
For use with Part One (Interactive discussion)
112

Appendix 6.1 Journal article: Andreasen, N.C., (2007) DSM and the death of phenomenology
in America: an example of unintended consequences. Schizophrenia Bulletin
33(1):108-12
Appendix 6.2 Discussion prompts for trainees
Appendix 6.3 Facilitator notes

For use with Part Two (Role-plays)


Appendix 6.4 Vignette for role-play

Phenomenology

Appendices
Appendix 6.1 For use with Part One (Interactive discussion)
Andreasen, N.C. (2007) DSM and the death of phenomenology in America: an example
of unintended consequences. Schizophrenia Bulletin 33(1):108-12

113

No. 1
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114

No. 2

Phenomenology

115

No. 3

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116

No. 4

Phenomenology

117

No. 5

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Appendix 6.2 Discussion prompts


For use with Part One (Interactive discussion)
1. What is phenomenology?
2. What is the difference between phenomenology and psychopathology?
3. What is the mind? How does it differ from the brain?
4. How do we assess the mind?
5. When do we face difficulties assessing someones mind?

118

6. What is the difference between signs and symptoms?


7. Can you think of any signs in psychiatry?
8. Are signs or symptoms more important in psychiatry?
9. Are any symptoms in psychiatry pathognomonic of a disease or are they all on a spectrum?
What about Schneiderian first-rank symptoms?
What about a primary delusion such as Jasper described?
10. In a clinical interview, when is phenomenology particularly important? When might it be
less important?
11. Break up into groups and discuss the difference between the following:
A delusion and an overvalued idea

How does this hold for Anorexia Nervosa?


How does this hold for Body Dysmorphic Disorder?

A hallucination and a pseudo-hallucination

Phenomenology

Appendix 6.3 Facilitator notes


For use with Part One (Interactive discussion)
1. What is phenomenology?
2. What is the difference between phenomenology and psychopathology?
3. What is the mind? How does it differ from the brain?
4. How do we assess the mind?
 eing unable to directly observe the mind, we are dependent on particular patterns of
B
communication, such as speech.
5. When do we face difficulties assessing someones mind?

119

1. When someone lacks awareness of their own mental state


2. When someone lacks the capacity to express their own mental state
3. In someone who is physically unable to speak, for example through mutism and catatonia
4. When there is a language barrier
 e can use other tools such as observing behaviours but because of the lack of objective
W
tests and a relative lack of other objective signs we are limited.
6. What is the difference between signs and symptoms?
 symptom is any subjective evidence of disease. It is a phenomenon that is subjectively
A
experienced by an individual sensations that only the patient can perceive. Anxiety, pain
and fatigue are all symptoms.
In contrast a sign is objective evidence of disease. A bloody nose is a sign. It is evident to
the patient, doctor, nurse, and other observers.
7. Can you think of any signs in psychiatry?
8. Are signs or symptoms more important in psychiatry?
 he lack of objective assessment tools makes psychiatry, more than many other medical
T
specialties, heavily reliant on symptoms.
 hen a sign is present, such as psychomotor impairment, or catatonia, it usually indicates
W
severe abnormality and so is given a lot of weight.
9. Are any symptoms in psychiatry pathognomonic of a disease? Or are they all on a spectrum?
What about Schneiderian first-rank symptoms?
What about a primary delusion such as Jasper described?
J aspers defined a primary or autochthonous delusion as a delusion arising without apparent
cause. For example, suddenly, without apparent cause, having the delusional belief that you
are an alien.
 lthough delusions are diagnostically nonspecific, some types of delusions are more prevalent
A
in one disorder than another. For example, although delusions of control and delusional
percepts are often seen in schizophrenia, they also occur, albeit less frequently, in psychotic
mood disorders. Similarly, classic mood-congruent delusions, with grandiose themes seen in
mania or delusions of poverty characteristic of depression, may also be seen in schizophrenia.
 chneiderian first-rank symptoms and primary delusions were once seen as pathognomonic
S
of schizophrenia but this is no longer thought to be the case.

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10. In a clinical interview, when is phenomenology particularly important?



When might it be less important?
It is particularly important to understand the phenomenology in instances when it will impact
on the diagnosis and management of that individual.
For example:

It is important in a patient with depression who describes hearing a critical voice in his/her
head to understand if this is a true hallucination. The treatment for psychotic depression
as opposed to non-psychotic depression will be significantly different.

120

In a patient with known schizophrenia, who suffers a relapse of psychosis, the specific
phenomena will be less important.

11. Break up into groups and discuss the difference between the following:
A delusion and an overvalued idea
How does this hold for anorexia nervosa?
How does this hold for body dysmorphic disorder?
A hallucination and a pseudo-hallucination
Bring the groups together to discuss their ideas.

Phenomenology

Appendix 6.4 Vignette for Role-play


For use with Part Two (Role-plays)
Instructions to simulated patient
You have presented to the doctor with middle insomnia. You wake at 2 am every night and cant
get back to sleep for two hours. The rest of your sleep is completely undisturbed, and you have
no other psychiatric symptoms at all.
You have no past history of any medical or psychiatric illnesses. You are on no regular medication.
There is no history of substance misuse.

121
How to play the role
You are polite and co-operative, and forthcoming about your reason for presenting.
You are perplexed and concerned about this new-onset sleep disturbance, but apart from that
there are no abnormalities in your mental state.
You are expected to improvise on any information that is not covered here, but maintain that you
are a person with no suggestion of psychiatric illness whatsoever, apart from the unexplained sleep
disturbance.

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NOTES

122

Session 7: Mental State Examination I

123

Session 7
Mental State Examination I
OBSERVATION OF A RECORDED PRESENTATION AND A RECORDED GROUP DISCUSSION

124

Summary of Session
This session provides an introduction to the Mental State Examination in psychiatry.
In this session the group watches the USB about the Mental State Examination, pausing for
discussion where indicated in the USB. The recorded material shows a psychiatry trainee presenting
an account of a psychiatric interview followed by a group discussion of the patients mental state.

Focus of the Session


1. To learn the components of the Mental State Examination
2.  To give trainees an opportunity to see and learn from an in-depth discussion about the mental
state examination
3.  To increase awareness of more complex aspects of the Mental State Examination, where this
opportunity may not otherwise be available

Materials Required for the Session


Computer, with either a data projector or TV monitor, and external speakers

Preparation for Session


Please note that there are no Facilitator Notes for this option

1.  Review the accompanying USB material showing a registrar presenting their account of a patient
interview followed by a group discussion of that patients mental state. Ensure that you are able
to discuss relevant aspects of the topic
2.  Photocopy the Mental State Examination (appendix 7.1) and the Classification of Defense
Mechanisms (appendix 7.2) to hand out to trainees during the session

Conducting the Session


1.  Watch the accompanying USB showing a registrar presenting their account of a patient interview
and a group discussion about the mental state of that patient. Pause for discussion as needed.
The USB footage is 85 minutes.
2.  Hand out copies of the Mental State Examination (appendix 7.1) and the Classification of
Defense Mechanisms (appendix 7.2)
3.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any
questions

Appendices listing
Appendix 7.1 Mental State Examination
Appendix 7.2 Classification of Defense Mechanisms

Mental State Examination I

Appendices
Appendix 7.1 Mental State Examination
Appearance
Relaxed, young, Filipino male in casual dress: t-shirt, tracksuit pants, rubber sandals, and with
slicked back hair
Appears younger than his stated age this is congruent with his ethnicity
No obvious physical abnormalities
Reasonably well-groomed

Behaviour

125

A steady direct gaze that remains unchanged even through affect-laden material. Unnerving, but
not threatening
There is a lack of emotional exchange through his eyes with an absence of affect reflected in them
Easy smiles, big laughs and giggling. A performance mask
He is not agitated. There is no psychomotor retardation
Somewhat expressive in body language

Speech
Fluent accented English, reasonably articulate, normal rate, rhythm and tone
There is some unusual idiosyncratic usage of language perhaps related to his Filipino background
There is a humorous (sarcastic) quality
Striking use of the word it to describe his suicidality that is, being unable or unwilling to name
the experience indicates the traumatic nature of his experience

Mood
Apprehensive
Mildly dysphoric

Affect
Mildly incongruent with his mood
Restricted in range, displaying only positive affects, and being jovial, even flippant despite the
gravity of situation. This is somewhat forced and he is at times dismissive of serious material.
There is a humorous edge but this is not of an infectious quality
Performance mask

Thought-content
Concise description of events, divorced from emotion, with a paucity of detail. Practised/rehearsed
quality
Recent hardships (including financial and relationship) and past traumas were themes of this
interview but, despite a depressive history, the associated loss and sadness were largely glossed
over and there isnt an overt sense of worthlessness, hopelessness or nihilism
He reports some agency and control
No frank delusions

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Thought form
No formal thought disorder.
Defense mechanisms:
minimising
repression
some denial
humour
isolation of affect?

Perception
126

No perceptual abnormalities identified

Cognition
Clear sensorium. No formal testing. Appears grossly intact and of at least average intelligence

Insight
Not entirely aware of his diagnosis, but he self-presented and feels hospitalisation has been
helpful for him
While there is a limited appreciation of the level of severity of his illness, there is a sense of his
developing insight

Judgement
Judgement may have been impaired recently, for example, his trading on the share-market despite
being in substantial debt. It was almost certainly impaired when he made the near-attempt at suicide

Risk
The short-term risk to self is low to moderate, while he is in hospital, in a contained environment.
The long-term risk remains medium to high given his dismissive attachment status and the
difficulty he may have asking for help in the future
His long-term risk will be reduced if he can form a meaningful connection with someone so that
he again feels comfortable to ask for help

Mental State Examination I

Appendix 7.2 Classification of Defense Mechanisms


Classification of Defense Mechanisms
Narcissistic Defenses

Projection, denial, distortion

Immature Defenses

Acting out, blocking, hypochondriasis, introjection, passive-aggressive


behaviour, projection, regression, schizoid fantasy, somatisation

Neurotic Defenses

Controlling, displacement, dissociation, externalization, inhibition,


intellectualization, isolation, rationalization, reaction formation,
repression, sexualisation

Mature Defenses

Altruism, anticipation, asceticism, humour, sublimation, suppression

127

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NOTES

128

Session 8: Mental State Examination II

129

Session 8
Mental State Examination II
130
OBSERVED INTERVIEW FOLLOWED BY A PERIOD OF REFLECTION

Summary of Session
This session is the second session on the Mental State Examination.
In this session the group observes a trainee interview a patient. The purpose of the interview is to
assess the Mental State Examination of the patient.
Following the observed interview, the interviewer and observers will make notes about the interview
in order to prepare them for the discussion that will take place in the next session, Mental State
Examination III.
IT IS IMPORTANT THAT, AS FACILITATOR OF THIS SESSION, YOU HAVE WATCHED
THE USB MATERIAL OF MENTAL STATE EXAMINATION I.

Focus of the Session


1.  To watch and reflect in-depth on an interview with a patient, with a view to understanding the
Mental State Examination of the patient
2. To prepare for the next session on the Mental State Examination

Materials Required for the Session


Nil

Preparation for Session


Please note that there are no Facilitator notes for this option

1. Select a trainee to be interviewer


2. Select a patient to be interviewed by the trainee

NB: Patient selection is important


Can be an inpatient or an outpatient
Must be co-operative
Must have capacity to consent to the interview
Ideally the patient should not have a severe, chronic psychotic disorder

Mental State Examination II

3. Prior to the interview


Explain the interview to the patient, confirming that patient confidentiality will be maintained
Obtain written consent from the patient

Conducting the Session


1.  Provide the interviewer and observers with their instructions (appendix 8.1).
2.  Set up an interview with interviewer and patient. The interview is to be a fifty minute
assessment interview
The interview can be observed

through a one-way screen


via a monitor in another room
by having the group present in the room during the interview*

131

Neither interviewer nor observers should take notes while interviewing the patient
*If the group is present in the room during the interview the number of observers should be limited. Ensure that observers
sit out of the direct line of sight of the patient and that they remain passive throughout the interview

3.  Following the interview, once the patient has been safely seen out, gather the group together
again and ask the interviewer and observers to make notes on the interview using the handout
in appendix 8.2 as a guide

Appendices listing
Appendix 8.1 Instructions for interviewer and observers
Appendix 8.2 Guide to reflecting on the interview

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

Appendices
Appendix 8.1 Instructions for interviewer and observers
Instructions for interviewers
In the next session on the Mental State Examination (Session Nine), you will be expected to present
a detailed chronological account of the interview that you perform today. The notes you make today
after the interview will assist you in that task.

132

The presentation that you will be expected to make to the group is a moment-by-moment account
of the interview in as much detail as you can recall. It should include a description of both verbal
and non-verbal communication, and also your thoughts and impressions during the interview itself.
Expect the account to be approximately fifteen minutes in length.
The account should include recalled transcripts of selected portions of the interview. The transcripts
are not expected to be entirely accurate this would not be possible and is not the point of the
exercise.
The presentation that you make to the group should not include a summary of the interview and
should not include a formulation. That is, this presentation is entirely different from that which you
would present to a colleague or a senior consultant when asking for advice on a patients care and
it is entirely different to the presentation you would make for the purposes of an exam.
An example of what you might say is:
I walked into the room. I went to shake Johns hand and he grasped my hand firmly with both
of his and smiled broadly. I felt disconcerted by this. I pulled my hand free and sat down.
John was sitting back in his chair with his legs crossed. He was neatly-attired, wearing a checked
shirt with tan pants and sneakers.
I said, Hello. My name is Tim. I am a psychiatry registrar. Thanks for agreeing to do this interview
today.
He said, loudly, No problem. Not at all. Once again he smiled broadly too broadly, and I smiled
back but in a reserved manner.
Then John started laughing.

Instructions for observers


In the next session on the Mental State Examination (Session Nine) the interviewer will present
a detailed chronological account of the interview that they performed today. This presentation
is not a summary of the interview and is not a formulation.
Following that presentation there will be a discussion about the Mental State Examination of the
interviewed patient.
The notes that you make today, after observing the interview, will assist you in the discussion of
the Mental State Examination next session.

Mental State Examination II

Appendix 8.2 Guide to reflecting on the interview


For both interviewer and observers
Make notes under the following headings
1. What happened during the interview? (Try to record the order of events as accurately as you
can recall them)
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

133

------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------2. The patients appearance


----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3. Body language (both interviewers and patients)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------4. Your feelings and impressions during the interview, of
the patient
the interaction
yourself
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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5. Record details of any illuminating moments


-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

134
6. Record excerpts (recalled transcripts) of the interview. Try to be as precise as possible in
recording what was said, and by whom (though of course a verbatim transcript is not expected)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------7. Any striking use of words or phrases?
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------8. Other observations
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Session 9: Mental State Examination III

135

Session 9
136

Mental State Examination III


INTERACTIVE EXERCISE INVOLVING A PRESENTATION OR AN INTERVIEW

Summary of Session
This session is the third session on the Mental State Examination. In this session your group
will have an in-depth discussion about the Mental State Examination of a patient, similar to the
discussion seen on the USB of Mental State Examination I. This session uses the interview
performed in Mental State Examination II as the basis for the discussion.
The session begins with a trainee presenting their account of the interview they performed last
session. The presentation is followed by a facilitated group discussion about the mental state
examination of that patient.
IT IS IMPORTANT THAT, AS FACILITATOR OF THIS SESSION, YOU HAVE WATCHED
THE USB MATERIAL OF MENTAL STATE EXAMINATION I

Focus of the Session


1. To teach the process of synthesising information about the mental state of a patient
2. To practise an in-depth approach to the Mental State Examination
3.  To encourage discussion about complex aspects of the Mental State Examination and to
invite questions and discussion around any poorly understood concepts or phenomena

Materials Required for the Session


Whiteboard or butchers paper

Preparation for Session


Please note that there are no Facilitator notes for this option

1.  As facilitator, ensure that you have watched the USB material of Mental State Examination I
This session follows a similar format and should draw directly on the learning points and
discussions of that session
2.  Prior to this session reflect on what you observed during the interview performed during the
last session. Ensure you are able to guide a discussion regarding conducting a Mental State
Examination

Mental State Examination III

Conducting the Session


1.  Ask the interviewer to present their pre-prepared account of the interview, including segments
of interview transcripts, to the group
This presentation is a moment-by-moment chronological account of the interview that took
place in Mental State Examination II. It is not a summary of the interview and should not include
a formulation (15 minutes)
2. Ask observers to provide any additional observations
3.  Lead a group discussion about the mental state of the patient. Use group process, with input
from both the interviewer and the observers. Ensure all aspects of the mental state examination
are covered, including:

137

appearance
behaviour
speech
affect
thought content
thought-form
perception
cognition
insight
judgement
risk

Make notes under each of these headings on a white-board or on butchers paper

4.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

NOTES

138

Session 10: Personality Style I

139

Session 10
140

Personality Style I
PART 1: LECTURE
Dr Jeffrey Streimer
Personality

PART 2: INTERACTIVE EXERCISES

Summary of Session
This is the first of two sessions on Personality Style. The session is divided into two parts:
PART ONE: A lecture giving an overview of personality structure
PART TWO: An interactive exercise using the first five minutes of a recorded doctor-patient
interview to guide trainees in:
Openly observing an interaction
Registering responses (cognitive, affective and intuitive)
Thinking about these responses from a clinical perspective, and
Using clinical reasoning skills to form a provisional hypothesis about the patients personal
and interpersonal style

Focus of the Session


1. To introduce trainees to templates for assessing and understanding personality structure
2. To learn to use minimal stimulus material to develop hypotheses about personality
3. To develop powers of observation
4. To develop inductive reasoning skills
5. To reflect on transference and countertransference

Materials Required for the Session


PART ONE: Computer, with either a data projector or TV monitor, and external speakers
PART TWO: Computer, with either a data projector or TV monitor, and external speakers

Personality Style I

10

PART ONE: Lecture


Preparation for Session
1. Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic
2. Photocopy the lecture slides (appendix 10.1) to distribute to the trainees during the session

Conducting the Session


1. Hand out copies of the lecture slides to trainees (appendix 10.1)
2. Play the lecture on the accompanying USB: Personality Dr Jeffrey Streimer (30 minutes)
3. Allow question and discussion time (10 minutes)

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PART TWO: Interactive Exercise


Preparation for Session
1. Review the accompanying USB material of the two interview segments
2. Photocopy the discussion prompts (appendix 10.2) to distribute to trainees during the session
3. Review facilitator notes (appendix 10.3)

Conducting the Session


1. Hand out the discussion prompts (appendix 10.2) and allow reading time
2. Play segment one on the USB (2 minutes)
3. Ask trainees to think about the questions (discussion prompts) in light of the interview
(5 minutes)
4.  Lead a group discussion guided by the discussion prompts (appendix 10.2) and facilitator
notes (appendix 10.3)
5. Play segment two on the USB (10 minutes)
6. Ask trainees to think about the questions (discussion prompts) in light of the interview
(5 minutes)
7. Lead a group discussion guided by the discussion prompts (appendix 10.2) and facilitator
notes (appendix 10.3)
8.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer any
questions.

Appendices listing
For use with Part One (Lecture)
Appendix 10.1 Lecture slides for Personality by Dr Jeffrey Streimer

For use with Part Two (Interactive exercise)


Appendix 10.2 Discussion prompts for trainees
Appendix 10.3 Facilitator notes

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Appendices
Appendix 10.1 Lecture slides
For use with Part One (Lecture)
Personality by Dr Jeffrey Streimer

142

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Personality Style I

10

143

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

See larger version on next page

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144

Slide 8

Slide 13

Personality Style I

10

Appendix 10.2 Discussion prompts for trainees


For use with Part Two (Interactive exercise)
Segment One (1 minute)
1. What strikes you in this segment? What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions to remain
2.  With your observations and associations in mind, discuss tentative hypotheses about personality
style and traits
3. What do you notice about the mans appearance?
4. What do you notice about his clothing? Do you notice any contrasts or contradictions in his
attire and general appearance?

145

5.  What feelings and responses are evoked in this segment? What could this tell us about aspects
of his personality?
Segment Two (10 minutes)
6.  What strikes you in this segment? What words, images and affective responses come to mind?
Keep in mind your initial speculations
7. Discuss any forming hypotheses
8.  In this segment, the patient talks about others exploding, breaking out and killing. What do you
think this is about? Is he talking about himself?
9.  When the interviewer asks the patient if he is talking about himself, the patient flatly denies it.
Why might this be? What defense mechanisms is he using?
10.  This man is simultaneously guarded and attacking. What personality style does this remind you of?
11.  What is the difference between the control exerted by an obsessional person and that exerted
by a paranoid person?
12.  Do you think there is an anti-social element here? What are key features of an antisocial
personality structure?
13. What is his affective state? What effect does this have on you?
14. Do you think he is able to use help?
15. Do you notice the dilemma that his persecutory world view presents you with?
16. He mentioned that he owns firearms. How does this make you feel?
17. Do you notice the grandiosity in his descriptions? Discuss where this might come from
18.  To what extent is the grandiosity an example of unhealthy narcissism and to what extent does
it reflect healthy aspirations?
19.  Despite a rough facade, this man is seeking to form attachment. If you engaged in a treatment
contract with him, what are the difficulties you might face? Reflect on his future prognosis,
particularly in regards to co-operative relationships, including a therapeutic alliance

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Appendix 10.3 Facilitator notes


For use with Part Two (Interactive exercise)
Segment One (1 minute)
1. What strikes you in this segment? What words, images and affective responses come to mind?
 void prematurely foreclosing on your impressions. Allow apparent contradictions to remain. Note
A
down the words, images and affects that arise. Use a white-board or butchers paper for this.
Spend at least five minutes on this section.

146

2.  With your observations and associations in mind, discuss tentative hypotheses about
personality style and traits.
Spend at least ten minutes on this section.
3. What do you notice about the mans appearance?
4.  What do you notice about his clothing? Do you notice any contrasts or contradictions
in his attire and general appearance?
He is wearing a police-shirt with casual shorts.
This man does not work, nor has he ever worked, for the police force.
The police-shirt contrasts with the long ponytail and shorts.
 he police-shirt is likely to be important, though we can only guess at its significance.
T
There are many possible explanations for this. It may be a deliberate statement. Perhaps it
reflects an anti-authoritarian attitude and/or a wish for power.
5.  What feelings and responses are evoked in this segment? What could this tell us about
aspects of his personality?
People feel wariness or fear. At the same time, they attack him, sometimes in a ridiculing manner.
This man might likely evoke a similar response in others.
 his is probably a direct reflection of how he responds to the world. He attacks others through
T
his own fear and defensiveness.
Segment Two (10 minutes)
6. What strikes you in this segment? What words, images and affective responses come to mind?
Keep in mind your initial speculations.
Note down the words, images and affects that arise. Use a white-board or butchers paper for this.
Spend at least five minutes on this section.
7. Discuss any forming hypotheses
Spend at least ten minutes on this section.
Notice that the paranoia is highlighted and reinforced.
8.  In this segment, the patient talks about others exploding, breaking out and killing.
What do you think this is about? Is he talking about himself?
9.  When the interviewer asks the patient if he is talking about himself, the patient
flatly denies it. Why might this be? What defense mechanisms is he using?
He is putting unwanted feelings into others, including his own children.
The defense mechanisms include denial, projection and displacement.

Personality Style I

10

10.  This man is simultaneously guarded and attacking. What personality style does
this remind you of?
Paranoid. When feeling under threat, a paranoid personality will respond with a counter-attack.
11.  What is the difference between the control exerted by an obsessional person and that
exerted by a paranoid person?
12.  Do you think there is an anti-social element here? What are key features of an antisocial
personality structure?
 hile there are many features of an antisocial personality disorder, many of which are listed
W
in DSM, perhaps the most important of these is a lack of empathy and concern for others.
13. What is his affective state? What effect does this have on you?

147

 e demonstrates marked ambivalence. This leaves him frustrated and helpless in dealing with
H
the world and its challenges. Those involved with him, including his carers, find themselves in
the same situation helpless and frustrated.
14. Do you think he is able to use help?
15. Do you notice the dilemma that his persecutory world view presents you with?
This man wants his persecutory world view confirmed.
 ou are forced to either join him in his persecutory position or to reject his viewpoint and
Y
thus threaten to reject him.
 ither of these two options reinforces his paranoid stance and leaves him isolated and lonely
E
in a persecutory world.
16. He mentioned that he owns firearms. How does this make you feel?
Afraid? Suspicious? Threatened? Cautious? Angry?
17. Do you notice the grandiosity in his descriptions? Discuss where this might come from.
18.  To what extent is the grandiosity an example of unhealthy narcissism and to what extent
does it reflect healthy aspirations?
19. Despite a rough facade, this man is seeking to form attachment.
If you engaged in a treatment contract with him, what are the difficulties you might face?
 eflect on his future prognosis particularly in regards to co-operative relationships including
R
a therapeutic alliance.
 he difficulty is that for this man, feeling vulnerable is likely to be intolerable. He will therefore
T
avoid affect states that make him feel vulnerable and needy.
If he is forced to confront these negative emotions he will respond with either:
depression, or
acting under threat, become aggressive and reassert control.

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NOTES

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Session 11: Personality Style II

149

Session 11
150

Personality Style II
OBSERVATION OF RECORDED SEGMENTS OF AN INTERVIEW
AND GROUP DISCUSSION

Summary of Session
This is the second of two sessions on Personality Style. It draws on the lecture and other material
discussed in the first of these two sessions and then goes more deeply into the interpersonal and
trans-generational impact of personality structure and personality disorder.
In this session, a pre-recorded interview between a consultant psychiatrist and a patient is used
as a launch pad for discussion.

Focus of the Session


1. To expand on what was learned in Personality Style I
2. To encourage attunement to a patients interpersonal style
3. To reflect on interview techniques in response to a patients style
4. To explore and understand the trans-generational impact of personality style in terms of:
the genesis of personality style and personality disorder in an individual
the impact of personality style on significant others, including ones children
the impact of trauma through generations

Materials Required for the Session


Computer, with either a data projector or TV monitor, and external speakers

Preparation for Session


Please note that there are no Facilitator Notes for this option

1.  Review the accompanying USB material containing six segments of an interview between a
consultant psychiatrist and a patient, and recorded group discussions
Ensure that you are able to discuss relevant aspects of the topic
2. Photocopy the discussion prompts (appendix 11.1) to distribute to trainees during the session

Personality Style II

11

Conducting the Session


1.  Hand out the discussion prompts (appendix 11.1) and allow reading time
2.  Watch the accompanying USB material containing interview segments and relevant recorded
group discussion. The USB contains about 30 minutes of interview material and 30 minutes of
recorded group discussions
3.  Follow the prompts on the USB, pausing for discussion when discussion prompts appear on
the screen
4.  Take 5-10 minutes at the end of the session to summarise session outcomes and to answer
any questions

151

Appendices listing
Appendix 11.1: Discussion prompts for trainees

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Appendices
Appendix 11.1: Discussion prompts for trainees
1. What do you notice about the interviewers approach to the patient?
Why do you think he approaches him in this way?
Consider
affects
patients somatic state
interviewers body language

152

2. What do you think of the young female registrar being sent out of the room?
3. Discuss what you noticed in Segment Three
4.  Discuss what you noticed in Segment Four. Why do you think he has raised his children in
this way?
5. What precipitated the suicide attempt?
How does it relate to his personality style?
How does it relate to his relationship with his wife and children?
6. What is the aetiology of his childrens narcissism and grandiosity in terms of their upbringing?
7. What is the aetiology of his (the patients) narcissism and grandiosity in terms of his upbringing?
8. What do you think of the hair-cutting episode?
9. Summarising discussion: Discuss the trans-generational transmission of personality issues

Session 12: Reflective Interview Skills I

153

154

Session 12
Reflective Interview Skills I
OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION
OPTION A
Organise your own
interview

OR

OPTION B
Watch the interview segments
on the accompanying USB

Summary of Session
This session is an introduction to the concept of reflective interviewing.
In this session the group watches and discusses several brief segments of a doctor-patient
interview. There are two options for this session:
Option A: Organise your own doctor-patient interview
Option B: Watch the interview material on the accompanying USB

Focus of the Session


1. To increase trainees awareness of the many layers of communication in any interaction
2.  To encourage trainees to reflect upon the many layers of communication and their meaning
Verbal communication
Non-verbal communication subtext, body language, affects, emotions, transference and
countertransference

Materials Required for the Session


Option A: Video camera if pre-recording your own interview
Equipment to watch the pre-recorded interview during the session
Option B: Computer, with either a data projector or TV monitor, and external speakers

Reflective Interview Skills I

12

OPTION A: Organise your own interview


Please note that there are no Facilitator Notes for this option

Preparation for Session


Please note that this option requires significant preparation time and requires video/DVD prerecording

1. Select a trainee to be interviewer


2. Select a patient to be interviewed by the trainee

NB. Patient selection is important


155

Can be an inpatient or an outpatient


Must be co-operative
Must have capacity to consent to the interview
Ideally non-psychotic but, if psychosis is present, please ensure there is minimal
blunting of affect and emotional reactivity.
3. Prior to the interview
Explain the interview to the patient and obtain written consent

Check with your relevant hospital authority about the procedures relating to confidentiality
and consent in your hospital

4. The interview
A fifty-minute assessment interview
The interview must be recorded prior to the session
NB. The interview needs to be done in sufficient time for the interviewer (trainee) to watch
the recording and to select segments from the interview for discussion during the session
see below
The trainee conducting the interview should not take notes while interviewing the patient
5. After the Interview
The interviewer should watch the recording of their interview and select three segments of
two-five minutes duration to be watched by the group during the session

Selected segments should include poignant moments, for example where transference/

countertransference was particularly strong, where there was a shift or change in rapport,
or other illustrative moments

The interviewer should prepare a very brief (ten second) introduction to their interview one
that does not include diagnosis or formulation, but one that orientates viewers to the interview.
e.g. This is an interview with a 39-year-old man who I saw on the day of his admission to the
psychiatric unit.
6. Watch the segments selected by the trainee to ensure you are familiar with the content
7.  Review the discussion prompts (appendix 12.1.1), and photocopy them to distribute to
trainees during the session

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Conducting the Session


1.  The interviewer should provide a brief introduction to the interview that they have prepared to
orientate the group
2. Hand out the discussion prompts (appendix 12.1.1) and allow reading time (5 minutes)
3.  Play the selected interview segments one at a time, with a discussion after each segment using
the discussion prompts provided (appendix 12.1.1). Allow 30 minutes for viewing each interview
segment and subsequent discussion

156

Note to Facilitator 1
It is important that the trainee who conducted the interview limit their input into the initial
part of the discussion. This is to ensure uncontaminated responses from the group in the
relative absence of background information.
Refrain from asking the interviewer for additional content or history not covered in that
segment. Instead the focus should remain on the information that can be gleaned from the
moment-to-moment interaction.

Note to Facilitator 2
It is essential to ensure that the trainee who conducted the interview feels safe and
supported rather than exposed to the group. The purpose of the interview segments
is to generate discussion surrounding interview technique and NOT to critique the skill
of the trainee. Therefore the discussion should not involve feedback or criticism of the
interviewers technique and as session facilitator you must ensure that the discussion does
not head down this path.
4.  Ensure that there is sufficient time at the end of the session for summarising discussion refer
to discussion prompts and facilitator notes (15 minutes)

OPTION B: Watch the recorded interview segments on the accompanying USB


Preparation for Session
1.  Review the USB material. It contains four segments from an interview between a psychiatry
registrar and a patient
2. Photocopy the discussion prompts (appendix 12.2.1) to distribute to trainees during the session
3. Review the facilitator notes (appendix 12.2.2)

Note to Facilitator
The interview segments on the accompanying USB contain subject matter of a particularly
horrific and shocking nature.

Reflective Interview Skills I

12

Conducting the Session


1.  Give a brief introduction to the interview on the USB to orientate the group. Warn the group that
the interview segments contain subject matter of a particularly horrific and shocking nature
2.  Hand out the discussion prompts (appendix 12.2.1) and allow reading time (5 minutes)
3.  Play the USB, pausing for discussion where indicated in the USB. The USB contains four
interview segments each of 2-6 minutes duration. Play the first three segments allowing 30
minutes for each segment and its discussion. If there is time, watch segment four and discuss
following a similar format
4.  Lead a group discussion of each interview segment guided by the discussion prompts
(appendix 12.2.1) and facilitator notes (appendix 12.2.2)

157

5.  Ensure that there is sufficient time at the end of the session for a summarising discussion
refer to discussion prompts and facilitator notes (15 minutes)

Appendices listing
For use with Option A (Organising your own interview)
Appendix 12.1.1 Discussion prompts for trainees

For use with Option B (Watching the interview segments on the accompanying USB)
Appendix 12.2.1 Discussion prompts for trainees
Appendix 12.2.2 Facilitator notes

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Appendix 12.1.1 Discussion prompts for trainees


For use with Option A (Organising your own interview)
The following discussion prompts should be applied to each interview segment
Watch the segment
1.  Even with minimal stimulus material, your unconscious mind has begun to make links and associations
What strikes you in this segment? What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions to remain

158

Note all words, images and affective responses on a white board or butchers paper
2.  Begin to formulate tentative hypotheses about the patients diagnoses on various axes on the
basis of your observations and associations.
3. What do you notice about the patients general appearance?
4. What do you notice about the patients tone of speech?
5. What do you notice about the patients content of speech?
6. Discuss any incongruities
For example:
contradictions within the content of the segment parts of the narrative that dont quite fit together
incongruities between the tone of speech and the content
incongruities between the verbal and non-verbal communication
incongruities between the way the patient presents him/herself to you and what the content
of the narrative suggests (e.g. a patient reports that they are compliant but the history includes
police presentations, lengthy involuntary admissions and community treatment orders)
7. Discuss your affective responses to the patient
8. Do you feel empathy for the patient? Why, or why not?
9. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
10.  With your observations and associations in mind, discuss and elaborate on your early
tentative hypotheses
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others, including the
treating team, are likely to respond to that patient, and about their early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences

Reflective Interview Skills I

12

Appendix 12.2.1 Discussion prompts for trainees


For use with Option B (Watching the interview segments on the accompanying USB)
Segment One
1. Even in this short segment, your unconscious mind has begun to make links and associations.
What strikes you in this segment?
What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions
to remain
2.  The first few minutes of a psychiatric assessment are critical in forming early impressions
and diagnostic hypotheses1

159

Begin to formulate tentative hypotheses about the patients diagnoses on various axes on
the basis of your observations and associations
3. What do you notice about the patients general appearance?
4.  The patients face is blurred out of this recording. He specifically requested this. In view of this,
does it surprise you that he agreed to be recorded?
5. What do you notice about the patients tone of speech?
6. What do you notice about the patients content of speech?
7. What do you notice about the patients thought-form?
8. Discuss any incongruities
9. Discuss your affective responses to the patient
10. How do you feel when the patient mentions these traumatic and shocking things?

Do you feel disturbed?

11. Do you feel empathy for the patient? Why or why not?
12. What do you notice in the interaction between interviewer and interviewee?

Were there any changes or shifts in rapport in this segment? Discuss these
Discuss what the interviewers responses to the patient might reflect

Segment Two
13. What strikes you in this segment? What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions
to remain
Note all words, images and affective responses on a white board or butchers paper
14. With your observations and associations in mind, discuss tentative hypotheses
15. What do you notice about the patients tone of speech?
16. What do you notice about the patients content of speech?
17. Discuss any incongruities
18. In terms of diagnostic possibilities, what is the interviewer exploring in this segment?
19. What techniques is the interviewer using in this segment?
20. Discuss your affective responses to the patient
21. What is your response to the shocking content?
1

 ourgeois, M. (1994) The First Few Minutes: Original Contact and the Speed of Psychiatric Diagnosis. In The Clinical Approach
B
in Psychiatry. Pierre Pichot and Werner Rein (eds).

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22. Do you feel empathy for the patient? Why, or why not?
23. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
24. Does the patient feel empathy for the boys?
25.  Do you see a parallel between the patients lack of empathy and our difficulty in empathising
with him?

160

26.  With your observations and associations in mind, discuss and elaborate on your early tentative
hypotheses
Segment Three
27. What strikes you in this segment? What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions to
remain
Note all words, images and affective responses on a white board or butchers paper
28. With your observations and associations in mind, discuss tentative hypotheses
29. What do you notice about the patients tone of speech?
30. What do you notice about the patients content of speech?
31. Discuss any incongruities that are apparent
32. Discuss your affective responses to the patient
33. What do you notice about the patients understanding of actions and consequences?
34. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
35. Is this man trying to make a connection with others?
36. How do treating teams experience this man?
37. What does this tell us about his early life experiences?
38. What problems might treating teams face in the management of this patient?
39. If there is time, watch segment four and discuss following a similar format to above
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others (including
the treating team) are likely to respond to that patient, and their early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences

Reflective Interview Skills I

12

Appendix 12.2.2 Facilitator notes


For use with Option B (Using the interview segments on the accompanying USB)
Segment One
1. Even in this short segment, your unconscious mind has begun to make links and
associations. What strikes you in this segment? What words, images and affective
responses come to mind? Avoid prematurely editing or foreclosing on your impressions.
Allow apparent contradictions to remain
Note all words, images and affective responses on a white board or butchers paper.
2.  The first few minutes of a psychiatric assessment are critical in forming early
impressions and diagnostic hypotheses

161

Begin to formulate tentative hypotheses about the patients diagnoses on various axes
on the basis of your observations and associations
3. What do you notice about the patients general appearance?
4.  The patients face is blurred out of this recording in response to his request. In view
of this, does it surprise you that he agreed to be recorded?
This is an incongruity and should be kept in mind.
The blurring of the face creates a sense of anonymity.
We wonder about shame and embarrassment.
5. What do you notice about the patients tone of speech?
Speech is low key and toneless. It lacks affective range.
Each piece of information is given the same weight.
The patient sounds almost bored, or perhaps detached from himself.
6. What do you notice about the patients content of speech?
Initially, the topics are emotionally neutral, or convey a low-grade dysphoria and low
self-esteem.
He then mentions the mutilation, torture and murder of young boys.
7. What do you notice about the patients thought-form?
8. Discuss any incongruities
For example:
 contradictions within the content of the segment parts of the narrative that dont quite fit together
incongruities between the tone of speech and the content
incongruities between the verbal and non-verbal communication
incongruities between the way the patient presents him/herself to you and what the content
of the narrative suggests (e.g. a patient reports that they are compliant, but the history includes
police presentations, lengthy involuntary admissions and community treatment orders)
The shame communicated by the preservation of his anonymity contrasts with his willingness
to be recorded
The tone of speech is incongruous with the dramatic content it remains unchanged in a way
that is surprising and somewhat jarring.

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9. Discuss your affective responses to the patient


10.  How do you feel when the patient mentions these traumatic and shocking things?
Do you feel disturbed?
The patient drops the shocking content into the conversation in an affect-less way.
People might feel incredibly anxious in the face of this incongruity, or they might feel strangely
unaffected.
There are several reasons for not responding with anxiety to an alarming piece of information.
These include the defenses of detachment, dissociation, isolation of affect and deliberate
suppression.

162

11. Do you feel empathy for the patient? Why or why not?
Perhaps it is partly because of the blurring of the face the lack of facial features,
but it is hard to feel empathy at this stage.
12. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss these
Discuss what the interviewers responses to the patient might reflect
When the patient brings up the topic of the torture of young boys, neither he nor the
interviewer react the way you would expect someone to react to something so sensational.
When someone reacts in an unusual way it usually indicates something important.
The interviewer probably found this topic unthinkable at this point and was reacting in a
defensive manner. Alternative explanations include empathic mirroring or suppression to
maintain rapport.
Segment Two
13. What strikes you in this segment? What words, images and affective responses come
to mind? Avoid prematurely editing or foreclosing on your impressions. Allow apparent
contradictions to remain
Note all words, images and affective responses on a white board or butchers paper.
14. With your observations and associations in mind, discuss tentative hypotheses.
15. What do you notice about the patients tone of speech?
16. What do you notice about the patients content of speech?
The content is increasingly shocking and dramatic, and the story increasingly brutal.
17. Discuss any incongruities
18. In terms of diagnostic possibilities, what is the interviewer exploring in this segment?
The interviewer is attempting to determine whether the disturbing thoughts are:
1. Ego-dystonic: characteristic of obsessions, reflecting an obsessive-compulsive disorder, or
2. Ego-syntonic: characteristic of a paraphilia
19. What techniques is the interviewer using in this segment?
The patient initially appears to disown his symptoms but the interviewer brings him back to them.
The interviewer is clear and persistent. She asks first open-ended questions, then poses
alternatives, and then uses clarification to hone in on the specific psychopathology.
20. Discuss your affective responses to the patient
21. What is your response to the shocking content?
You may feel anxious and alarmed. You may feel repulsion.
You may feel paradoxically bored and/or detached.

Reflective Interview Skills I

12

22. Do you feel empathy for the patient? Why, or why not?
While you might feel some empathy for the patient, as he is very alone in this predicament,
it is very hard to genuinely relate to him, to imagine what it would be like to be in his shoes
23.  What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
The interviewer is not showing much reaction.
She appears to be trying to remain calm, non-judgemental and understanding.
24. Does the patient feel empathy for the boys?
No, he does not feel real empathy. Any attempt at empathy is very concrete.

163

 An extreme example of this is his explanation for electrocuting himself, that he did it in
order to see what it would feel like to a little boy.
 This man lacks the capacity for what Peter Fonagy refers to as mentalization the
fundamental capacity to understand mental states such as thoughts and feelings. He has no
ability to think about how things might feel to another. the capacity to make sense of ourselves
and others in terms of mental states.
25.  Do you see a parallel between the patients lack of empathy and our difficulty in
empathising with him?
26.  With your observations and associations in mind, discuss and elaborate on your early
tentative hypotheses
Segment Three
27. What strikes you in this segment? What words, images and affective responses come
to mind? Avoid prematurely editing or foreclosing on your impressions. Allow apparent
contradictions to remain
Note all words, images and affective responses on a white board or butchers paper.
28. With your observations and associations in mind, discuss tentative hypotheses
29. What do you notice about the patients tone of speech?
30. What do you notice about the patients content of speech?
31. Discuss any incongruities that are apparent
32. Discuss your affective responses to the patient
33. What do you notice about the patients understanding of actions and consequences?
He has a very primitive, concrete understanding of actions and their consequences.
34. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
There is a shift in rapport. Up to this point, the interviewer seems to be oscillating between
empathy and distaste but in this segment it is as though she has given up. She is no longer
trying to create a moral awareness in the patient.
She becomes less empathic and appears angry with him and while not quite punitive is
certainly challenging.
35. Is this man trying to make an emotional connection with others?
This man appears to want a connection with others, but is completely unable to create
this connection.

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36. How do treating teams experience this man?


Those who meet him possibly experience him as cruel and they respond with a lack of
empathy that mirrors his cruelty.
37. What does this tell us about his early life experiences?
Our response to a patient gives us useful information about:
1. the way others respond to them, and
2. their early life experiences
Therefore we can use our responses to form tentative hypotheses

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Our response to this man tells us that he has been very damaged from a very young age.
We can imagine that in his formative years he experienced others as confusing, punitive,
cruel and/or sadistic and lacking in empathy. It is likely that his only experience of emotional
connection was through pain and that he has learnt to experience pain as love.
38. What problems might treating teams face in the management of this patient?
Without on any level justifying what this man does, we can imagine that he is trying to make
emotional contact with others the only way he knows through perversity and horror.
Any successful treatment program would require that this man make a connection on a
level other than that of pain and sadism.
A difficulty faced in Victim Empathy Programs is that some sadistic patients, rather than
develop empathy, get gratification from seeing victims suffer. This is something that would
need to be monitored closely.
39. If there is time, watch segment four and discuss following a similar format to above.
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others (including
the treating team) are likely to respond to that patient, and their early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences.

Session 13: Reflective Interview Skills II

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Session 13
166

Reflective Interview Skills II


OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION
OPTION A
Organise your own
interview

OR

OPTION B
Watch the interview segments
on the accompanying USB

Summary of Session
This session is the second of two sessions on reflective interviewing. It follows a similar format
to the previous session on reflective interviewing.
During the session the group watches and discusses several brief segments of a doctor-patient
interview. There are two options for this session:
Option A: Organise your own doctor-patient interview
Option B: Watch the interview material on the accompanying USB

Focus of the Session


1.  To continue to increase trainees awareness of the layers of communication in any interaction
2. To encourage trainees to use this awareness in their day-to-day practice of psychiatry

Materials Required for the Session


Option A: Video camera to record the interview OR
Video camera if pre-recording your own interview
Equipment to watch the pre-recorded interview during the session
Option B: Computer, with either a data projector or TV monitor, and external speakers

OPTION A: Organise your own interview


Preparation for Session
Please note that
i) There are no Facilitator Notes for this option
ii) This option requires significant preparation time and requires a video/DVD prerecording

1. Select a trainee to be interviewer


2. Select a patient to be interviewed by the trainee

Reflective Interview Skills II

13

NB. Patient selection is important


Can be an inpatient or an outpatient
Must be co-operative
Must have capacity to consent to the interview
Ideally non-psychotic but, if psychosis is present, please ensure there is minimal
blunting of affect and emotional reactivity.
3. Prior to the interview
Explain the interview to the patient and obtain written consent

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Check with your relevant hospital authority about the procedures relating to confidentiality
and consent in your hospital

4. The interview
A fifty-minute assessment interview
The interview must be recorded prior to the session
NB. The interview needs to be done in sufficient time for the interviewer (trainee) to watch the
recording and to select segments from the interview for discussion during the session see below
The trainee conducting the interview should not take notes while interviewing the patient
5. After the Interview
The interviewer should watch the recording of their interview and select three segments
of two-five minutes duration to be watched by the group during the session

Selected segments should include poignant moments, for example where transference/

countertransference was particularly strong, where there was a shift or change in rapport,
or other illustrative moments.

The interviewer should prepare a very brief (ten second) introduction to their interview one
that does not include diagnosis or formulation, but one that orientates viewers to the interview.
e.g. This is an interview with a 39-year old man who I saw on the day of his admission to the
psychiatric unit.
6. Watch the segments selected by the trainee to ensure you are familiar with the content
7. R
 eview the discussion prompts (appendix 13.1), and photocopy them to distribute to trainees
during the session

Conducting the Session


1.  Ask the interviewer to present the brief (10 second) introduction that they pre-prepared to
orientate the group to the setting and context of the interview
2.  Hand out the discussion prompts (appendix 13.1) and allow reading time (5 minutes)
3.  Play the selected interview segments one at a time and lead a group discussion after each
segment guided by the discussion prompts. Allow 30 minutes for the viewing of each interview
segment and its discussion

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

Note to Facilitator
The trainee who conducted the interview is to remain silent for the initial part of each
discussion. This is to ensure uncontaminated responses from the rest of the group.
Refrain from asking the interviewer for additional content or history not covered in the
segment. Instead, the focus should be on the information that can be gleaned from the
segment itself and from the moment-to-moment interaction between the interviewer and
interviewee.

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Note to Facilitator
The trainee who conducted the interview must feel safe and supported rather than
exposed to the group. The purpose of the interview segments is to generate discussion.
It is NOT a critique of the skill of the trainee. As session facilitator you must ensure that the
group discussion does not head down this path.
4.  Ensure that there is sufficient time at the end of the session for a summarising discussion
refer to discussion prompts and facilitator notes (15 minutes).

OPTION B: Watch the recorded interview segments on the accompanying USB


Preparation for Session
1.  Review the accompanying USB material of the five segments of an interview between a
psychiatry registrar and a patient
2. Photocopy the discussion prompts (appendix 13.2.1) to distribute to trainees during the session
3. Review the facilitator notes (appendix 13.2.2)

Conducting the Session


1. Give a brief introduction to the interview on the USB to orientate the group
2. Hand out the discussion prompts (appendix 13.2.1) and allow reading time (5 minutes)
3.  Play the USB pausing for discussion where indicated in the USB. The USB contains five
interview segments each of 2-5 minutes duration. Play the first two segments allowing 30
minutes for each segment and its discussion. If there is time, watch segment three to five
and discuss following a similar format
4.  Lead a group discussion of each interview segment guided by the discussion prompts and
facilitator notes (appendix 13.2.2)
5.  Ensure that there is sufficient time at the end of the session for a summarising discussion
refer to discussion prompts and facilitator notes (15 minutes)

Appendices listing
For use with Option A (Organising your own interview)
Appendix 13.1 Discussion prompts for trainees

For use with Option B (Watching the interview segments on the accompanying USB)
Appendix 13.2.1 Discussion prompts for trainees
Appendix 13.2.2 Facilitator notes

Reflective Interview Skills II

13

Appendix 13.1 Discussion prompts for trainees


For use with Option A (Organising your own interview)
The following discussion prompts should be applied to each interview segment.
Watch the segment
1.  Even with minimal stimulus material, your unconscious mind has begun to make links and
associations
What strikes you in this segment?
What words, images and affective responses come to mind?

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Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions


to remain
2.  Begin to formulate tentative hypotheses about the patients diagnoses on various axes on
the basis of your observations and associations
3. What do you notice about the patients general appearance?
4. What do you notice about the patients tone of speech?
5. What do you notice about the patients content of speech?
6. Discuss any incongruities apparent in this segment
For example:
contradictions within the content of the segment parts of the narrative that dont quite fit
together
incongruities between the tone of speech and the content
incongruities between the verbal and non-verbal communication
incongruities between the way the patient presents him/herself to you and what the content
of the narrative suggests (e.g. a patient reports that they are compliant, but the history includes
police presentations, lengthy involuntary admissions and community treatment orders)
7. Discuss your affective responses to the patient
8. Do you feel empathy for the patient? Why, or why not?
9. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
10.  With your observations and associations in mind, discuss and elaborate on your early tentative
hypotheses
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others, including the
treating team, are likely to respond to that patient, and about their early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

Appendix 13.2.1 Discussion prompts for trainees


For use with Option B (Watching the interview segments on the accompanying USB)
Segment One
1.  Even with minimal stimulus material, your unconscious mind has begun to make links and
associations
What strikes you in this segment? What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions to remain
2. The first few minutes of a psychiatric assessment are critical in forming early impressions

170

Begin to formulate tentative hypotheses about the patients diagnoses on various axes on the
basis of your observations and associations
3. What do you notice about the patients general appearance?
4. What do you notice about the patients tone of speech?
5. What do you notice about the patients content of speech?
6. What do you notice about the patients thought-form?
7. Discuss any incongruities
8. Discuss your affective responses to the patient
9. Do you feel empathy for the patient? Why, or why not?
10. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
11. What do you think this segment tells us about the patients view of herself?
12.  With the above observations and associations in mind, discuss and elaborate on your early
tentative hypotheses
Segment Two
13. What strikes you in this segment?
What words, images and affective responses come to mind?
Avoid prematurely editing or foreclosing on your impressions. Allow apparent contradictions to remain
14. With your observations and associations in mind, discuss tentative hypotheses.
15. What do you notice about the patients tone of speech?
16. What do you notice about the patients content of speech?
17. Discuss any incongruities
18. Discuss your affective responses to the patient
19. Do you feel empathy for the patient? Why, or why not?
20. How might you see a punitive reaction in the hospital setting?
21. Does anyone feel sad?

Reflective Interview Skills II

13

22. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Does the interviewer direct the patient much, or does the patient take control of the interview herself?
Discuss what the interviewers responses to the patient might reflect
23.  In which personality type do we characteristically see the communication of vast amounts
of detail in the absence of emotional content?
24. In this segment, the patient describes many inadequate caregivers. What do you make of this?
25. How might treating teams respond to this woman?
26. What might this tell you about her early life?
27.  In view of this discussion, what do you think about her recurrent medical and psychiatric complaints?

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28.  If there is time, watch segments three, four and five and discuss following a similar format to above
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others, including the
treating team, are likely to respond to her and her early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences

HET I T H E C O M PLE T E C LIN IC AL AS S E S S M E N T I N P SY C H I AT RY

Appendix 13.2.2 Facilitator notes


For use with Option B (Watching the interview segments on the accompanying USB)
Segment One
1.  Even with minimal stimulus material, your unconscious mind has begun to make links
and associations
What strikes you in this segment?
What words, images and affective responses come to mind? Avoid prematurely editing
or foreclosing on your impressions. Allow apparent contradictions to remain

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Note all words, images and affective responses on a white board or butchers paper.
2. The first few minutes of a psychiatric assessment are critical in forming early impressions.
Begin to formulate tentative hypotheses about the patients diagnoses on various axes on
the basis of your observations and associations
3. What do you notice about the patients general appearance?
She is dressed as a patient would dress, wearing a nightgown rather than street clothes.She
has set herself up comfortably for the interview a blanket, lip cream, a bottle of water things
that may be comforting for her
There is something young about this appearance and set-up.
4. What do you notice about the patients tone of speech?
Low, monotonous and lacking inflection.
5. What do you notice about the patients content of speech?
She is versed in medical terminology
The content is dramatic, her account detailing seemingly endless traumatic events since birth,
events in which she was a victim, and was passive.
For example raped by an ex-best friend at the age of eight and a bit. Ive never had a
boyfriend, never had sex, have no interest in sex. Ive had thirty-nine general anaesthetics.
I had a total abdominal hysterectomy
There is little, if any, mention of the feelings associated with the above events.
6. What do you notice about the patients thought-form?
Circumstantial/over-inclusive long and detailed response to a single question.
7. Discuss any incongruities
For example:
c ontradictions within the content of the segment parts of the narrative that dont quite fit
together
incongruities between the tone of speech and the content
incongruities between the verbal and non-verbal communication
incongruities between the way the patient presents herself to you and what the content of the
narrative suggests
There is a marked incongruity between her monotonous tone of speech and the content of
speech. It appears as though she is uninterested in her own life story and has been through it
many times before.

Reflective Interview Skills II

13

8. Discuss your affective responses to the patient


9. Do you feel empathy for the patient? Why, or why not?
It can be difficult to sustain empathy for the patient. This is surprising in view of the tragic life
picture she paints.
The monotonous tone of speech, and the list-like recitation of ordeals, can induce a sense
of detachment or boredom despite what is, objectively, a traumatic life story.
10. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Discuss what the interviewers responses to the patient might reflect
In this segment, the patient is largely in control of the direction of the interview, and the
interviewer is passive.

173

The interviewer is perhaps overwhelmed by the quantity of content that is impassively related
to her. She allows the flow to continue for some time but towards the end of this segment
makes an attempt to direct the patient.
11. What do you think this segment tells us about the patients view of herself?
She seems to be demonstrating two things:
 worthlessness, low self-esteem and indifference about her experiences
 pride in what she has endured. This has become her primary identity as a patient
12. With your observations and associations in mind, discuss and elaborate on your early
tentative hypotheses
Segment Two
13. What strikes you in this segment?
What words, images and affective responses come to mind? Avoid prematurely editing
or foreclosing on your impressions. Allow apparent contradictions to remain.
Note all words, images and affective responses on a white board or butchers paper.
14. With your observations and associations in mind, discuss tentative hypotheses
15. What do you notice about the patients tone of speech?
16. What do you notice about the patients content of speech?
17. Discuss any incongruities
18. Discuss your affective responses to the patient
19. Do you feel empathy for the patient? Why, or why not?
It remains difficult to feel empathy for this patient.
 The sense that she may be responsible for her own incapacity or is using the system for
secondary gain, further disrupts empathy.
 Those directly involved in her care may have a similar response and could feel increasingly
helpless and frustrated.
As frustration builds, another common response may be to become moralistic and punitive.
20. How might you see a punitive reaction in the hospital setting?
 This may be acted out, for example, by treatments or operations that arent medically required,
or by refusing treatment such as pain medication even when medically-indicated.
21. Does anyone feel sad?
It is as though we should feel sad but dont. By the time she gets to the point of a story, we
are fatigued and overwhelmed by relentless detail.

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22. What do you notice in the interaction between interviewer and interviewee?
Were there any changes or shifts in rapport in this segment? Discuss
Does the interviewer direct the patient much, or does the patient take control of the
interview herself?
Discuss what the interviewers responses to the patient might reflect
The interviewer allows the patient to talk. The interviewer is relatively passive. She is tolerating
the patient without being actively engaged.
Meanwhile, the patient talks without requiring any direction from the interviewer. She appears to
enjoy the attention focussed on herself. She is demonstrating, albeit subtly, a controlling quality.

174

The patient would probably not tolerate any loss of this control. To interrupt her, for example to
insist on certain details, might feel threatening to her fragile sense of self.
In this segment the patient communicates times when she has lashed out against unhelpful
others and is communicating her potential to lash out again.
23.  In which personality type do we characteristically see the communication of vast amounts
of detail in the absence of emotional content?
This is typical of cluster C Obsessive Compulsive Personality Disorder.
24. In this segment, the patient describes many inadequate caregivers. What do you make of this?
There is a devaluation of those who fail her.
In this setting she is attempting to form a bond with the interviewer and does so by uniting
herself with the interviewer, both with superior knowledge and expertise.
This is an example of splitting. The patient is not aware of this process. It is unconscious.
25. How do treating teams respond to this woman?
We would anticipate that many who come in contact with this patient would respond in a
similar way. There would likely be frustration, weariness and helplessness in response to her
recurrent presentations.
26. What might this tell you about her early life?
Our response to a patient gives us useful information about:
the way others respond to them, and
their early life experiences.
Therefore we can use our responses to form tentative hypotheses.
For example, we may wonder if this is a communication of her early experiences of the world
as the youngest of six children, with an overloaded, fatigued and overwhelmed mother.
27. In view of this discussion, what do you think about her recurrent medical and psychiatric
complaints?
Perhaps it is only through illness that she is able to evoke a response from others.
28.  If there is time, watch segments three, four and five and discuss following a similar format
to above.
Summarising the discussion
After watching all segments, discuss the following (in the last fifteen minutes of the session):
The effect a patient has on us gives us useful information about the way others, including the
treating team, are likely to respond to her and her early life experiences.
Reflect on:
the effect the patient has on you
how this reflects the effect they would have on others
what this might tell us about their early life experiences.

Session 14: The Therapeutic Alliance

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176

Session 14
The Therapeutic Alliance
LECTURES
Dr Jeanette Martin
The Therapeutic Alliance

Dr Loyola McLean
Working the Therapeutic
Alliance

Summary of Session
This session is an overview of the therapeutic alliance. It includes definitions, theory
and clinical applications.
The session consists of two lectures that detail/discuss different aspects of the therapeutic alliance.

Focus of the Session


1. To provide an overview of the therapeutic alliance, including
definition
clinical relevance
the relationship between the therapeutic alliance and attachment styles
2.  To use real examples to demonstrate how our understanding of the therapeutic
alliance and of attachment styles can be applied to clinical work.

Materials Required for the Session


Computer, with either a data projector or TV monitor, and external speakers

Preparation for Session


1.  Review the recorded lectures to ensure you are able to discuss relevant aspects of the topic
2.  Photocopy the lecture slides (appendices 14.1 and 14.2) to distribute to the trainees during
the session

The Therapeutic Alliance

14

Conducting the Session


1. Hand out copies of the lecture slides to trainees (appendices 14.1 and 14.2)
2. Play each lecture on the accompanying USB
Lecture One: The Therapeutic Alliance Dr Jeanette Martin (50 minutes)
Lecture Two: Working the Therapeutic Alliance Dr Loyola McLean (10 minutes)
3. At the end of each lecture allow question and discussion time (10 minutes)

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Appendices listing
Appendix 14.1 Lecture slides for The Therapeutic Alliance by Dr Jeanette Martin
Appendix 14.2 Lecture slides for Working the Therapeutic Alliance by Dr Loyola McLean

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Appendices
Appendix 14.1 Lecture slides
The Therapeutic Alliance by Dr Jeanette Martin

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Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

The Therapeutic Alliance

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Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

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Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

The Therapeutic Alliance

14

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Slide 19

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Appendix 14.2 Lecture slides


Working the Therapeutic Alliance by Dr Loyola McLean

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Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

See larger version on page 180

Slide 6

The Therapeutic Alliance

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Slide 7

Slide 8

Slide 9

Slide 10

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NOTES

Session 15: Introductory Formulation I

185

Session 15
Introductory Formulation I
186

PART 1: LECTURE
Dr James Telfer
Formulation

PART 2: OBSERVATION OF INTERVIEW SEGMENTS


INTERACTIVE GROUP EXERCISE AND DISCUSSION

Summary of Session
This is the first of two sessions on formulation. The session is divided into two parts:
PART ONE: A lecture an overview of formulation
PART TWO: An interactive component where the group discusses and practices formulation with a
real clinical example. This component is based on segments of a recorded doctor-patient interview
and relevant recorded group comments and discussion

Focus of the Session


1. To provide an introductory grounding in the essential skill of formulation
2.  To introduce formulation as something unique to the profession of psychiatry and as distinct
from a summary of clinical information
3.  To create an awareness of the importance of formulation in day-to-day practice, in
understanding the patients predicament and in communicating with other professionals
4. To introduce the various schema used in developing a formulation
5. To practise a formulation based on real clinical material

Materials Required for the Session


PART ONE: Computer, with either a data projector or TV monitor, and external speakers
PART TWO: Computer, with either a data projector or TV monitor, and external speakers

PART ONE: Lecture


Session Preparation
1.  Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic
2.  Photocopy the lecture slides (appendix 15.1) to distribute to trainees during the session

Introductory Formulation I

15

Conducting the Session


1. Hand out copies of the lecture slides to trainees (appendix 15.1)
2. Play the lecture on the accompanying USB
Formulation Dr James Telfer (10 minutes)
3. Allow question and discussion time (10 minutes)

PART TWO: Interactive Exercise


Preparation for Session

187

1.  Review the accompanying USB segments of an interview these segments do not comprise
a complete interview (25 minutes)
2.  Photocopy the discussion prompts (appendix 15.2.1), the example of a formulation using the
Three P Model (appendix 15.2.2) and the RANZCP Clinical Examinations Formulation Guidelines
for Trainees (appendix 15.2.3) to distribute to trainees during the session
3. Review facilitator notes (appendix 15.2.2)

Conducting the Session


1.  Hand out the discussion prompts (appendix 15.2.1) and the RANZCP Clinical Examinations
Formulation Guidelines for Trainees (appendix 15.2.4) and allow time for reading the discussion
prompts (5 minutes)
2.  Advise trainees to take notes while watching the USB material as they will be expected to write
their own formulations
3.  Play the interview segments sequentially without pausing for discussion between segments
(25 minutes)
4. Ask trainees to think about the questions (discussion prompts) in light of the interview
5. Allow 5-10 minutes after watching the USB for trainees to write their own formulations
6. Lead a group discussion guided by the USB and the discussion prompts
Note: For some of the discussion prompts a brief group discussion has also been included on the USB.
This extra footage is approximately 15 minutes in total.

7. Hand out the example formulation (appendix 15.2.3)


8.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions.

Appendices listing
For use with Part One (Lecture)
Appendix 15.1 Lecture slides for Formulation by Dr James Telfer

For use with Part Two (Interactive exercise)


Appendix 15.2.1 Discussion prompts for trainees
Appendix 15.2.2 Facilitator notes
Appendix 15.2.3 Example of a formulation Using the Three P Model
Appendix 15.2.4 RANZCP Clinical Examinations Formulation Guidelines for Trainees

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Appendices
Appendix 15.1 Lecture slides
For use with Part One (lecture)
Formulation by Dr James Telfer

188

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Introductory Formulation I

15

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Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

Slide 12

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Slide 13

Slide 14

Slide 15

Slide 16

Slide 17

Slide 18

Introductory Formulation I

15

Appendix 15.2.1 Discussion prompts for trainees


For use with Part Two (Interactive Exercise)
1. The process of formulation starts at the very moment that you begin interviewing a patient
sometimes even earlier than this
With this in mind, what interviewing techniques help you in your formulation (i.e. in coming to
an understanding of the patient and their predicament)?
What techniques does the interviewer use in this interview?
2. What are relevant gaps in the history?

191

3. Discuss the key issues raised in this interview


4. In this interview, what is the patients predicament?
5. Now, think about why he is in this predicament why is this happening at this particular time?
Specifically consider:
predisposing factors
precipitating factors
perpetuating factors
6.  A patients behaviour during an interview also informs your formulation. Think about this mans
behaviour during the interview and the information we may take from this
7.  Choose one of the trainees to read out their formulation to the group. This may follow a similar
format and contents to the issues just discussed or it may bring in different themes and ideas
8.  Discuss any pertinent themes that came up in the trainees formulation that have not yet been
raised
9.  There are a number of well-known schema or frameworks that can be used in formulation.
Most formulations utilise several frameworks. One particular model is the Three P Model.
Choose a trainee to read out a formulation that follows the Three P Model. Discuss the trainees
formulation
10. Can you think of any other schema for organising a formulation? Discuss these
11. What are the issues relevant to the developmental stage of this man? Discuss these
12. Discuss the risk issues in this man
13.  Consider how the formulation might differ in someone with a chronic mental illness, for example
chronic schizophrenia or chronic personality disorder. See the formulation from the RANZCP
Clinical Examinations Formulation Guidelines for Trainees (appendix 15.5) for an example of a
formulation in chronic illness
14.  Discuss elements of the case that have not been discussed so far that could be included in
your formulation

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Appendix 15.2.2 Facilitator Notes


For use with Part Two (Interactive exercise)
1. The process of formulation starts at the very moment that you begin interviewing a
patient sometimes even earlier than this. With this in mind, what interviewing techniques
help you in your formulation (i.e. in coming to an understanding of the patient and their
predicament)? What techniques does the interviewer use in this interview?
It is important to begin forming hypotheses from the moment that you sit down with a patient.
It is important not to rely entirely upon a question-and-answer approach to interviewing.

192

 collaborative style helps in coming to an understanding of the patients predicament.


A
This should include a combination of:
the patient being invited to put forward his/her own hypotheses (for example, on his
predisposition to mental illness, or the stresses he has been under), and
the interviewer posing hypotheses, putting these back to the patient, and noting the response.
In this interview, we see a few examples of the interviewer putting hypotheses to the patient.
For example, the interviewer poses the hypothesis that the patient has been thinking a lot
about the loss of his family and of his marriage. Although the patient denies this, he then
reveals important information regarding his feelings of guilt, and his doubt over whether he
should ever have married in the first place.
2. What are relevant gaps in the history?
medical history including changes in physical health
significant anniversaries and their significance to the patient
drug and alcohol history
3. Discuss the key issues raised in this interview?
The issues seen as key will vary somewhat from person to person. They may include:
depressed man
strong family history of bipolar disorder
risk suicide risk (always a key issue)
social isolation
4. In this interview, what is the patients predicament?
relapse of depression
socially-isolated
history of losses
suicidal ideas
5. Now, think about why he is in this predicament why is this happening at this particular time?
Specifically consider:
a) Predisposing factors
genetic loading
demographics (male sex, age-bracket)
social isolation
psychological vulnerability early life trauma/mother overdosing and likely insecure
attachment status
may mention here that we would want to know about alcohol and its role

Introductory Formulation I

15

b) Precipitating factors
recent loss of employment
eviction from his unit
relationship breakdown
we might hypothesise that his impending 50th birthday could have a role
c) Perpetuating factors
social isolation
ongoing stressors such as financial strain from his loss of employment
6.  A patients behaviour during an interview also informs your formulation. Think about
this mans behaviour during the interview and the information we may take from this

193

 e is somewhat difficult to engage, and cut-off emotionally. We may hypothesise that


H
this is consistent with his having left his wife and children, his mother having left him,
and an avoidant-dismissive attachment style.
7.  Choose one of the trainees to read out their formulation to the group. This may follow
a similar format and contents to the issues just discussed, or it may bring in different
themes and ideas
8.  Discuss any pertinent themes that came up in the trainees formulation that have not
yet been raised
9.  There are a number of well-known schema or frameworks that can be used in
formulation. Most formulations utilise several frameworks. One particular model is the
Three P Model. Choose a trainee to read out a formulation that follows the Three P
Model. Discuss the trainees formulation
An example of a formulation that follows the Three P Model is given in appendix 15.2.3.
Trainees can be provided with this example when they have finished their own formulations
10. Can you think of any other schema for organising a formulation? Discuss these
11. What are the issues relevant to the developmental stage of this man?
Eriksonian stage Generativity versus Stagnation:
The task of this stage is to create something independent of oneself that will live
on past ones individual lifespan.
This mans difficulty in negotiating the earlier life stages, for example, intimacy
versus isolation, has had an impact on his ability to now negotiate new
developmental stages.
12. Discuss the risk issues in this man
13.  Consider how the formulation might differ in someone with a chronic mental illness,
for example chronic schizophrenia, chronic personality disorder
Rehabilitation issues become paramount.
Consider:
strengths and how to optimise these
accommodation
occupation
social and living skills
morale

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See the formulation from the RANZCP Clinical Examinations Formulation Guidelines
for Trainees (appendix 15.2.4) for an example of a formulation in chronic illness.
14. Discuss elements of the case that have not been discussed so far that could be
included in your formulation
culture: Anglo-celtic male (sense of identity and worth focussed on family and
employment success)
spirituality
cognitive style

194

coping mechanisms e.g. problem-solving skills


defense mechanisms

Introductory Formulation I

15

Appendix 15.2.3 Example of a Formulation Using the Three P Model


For use with Part Two (Interactive Exercise)
Tom (not his real name) is a forty-nine-year-old divorced male who self-presented to hospital two
days ago with a one-month history of depressive symptoms. He describes a low mood, anhedonia,
a wish to die and social withdrawal. This resulted in significant functional impairment with Tom being
absent from work and spending all day in bed. This is his second episode this year.
The current episode is likely to have been precipitated by the recent relationship break-up with
his girlfriend of six years, his recent loss of accommodation and his loss of employment with a
subsequent financial burden.
Tom is likely to have a genetic predisposition to mood disorders as evidenced by a family history of
bipolar disorder and a number of attempted suicides among his relatives.

195

We dont know very much about Toms earlier life but his mother attempting suicide when Tom was
a child is suggestive of significant major mental illness. In addition to the genetic factors, the loss of
his mother would have constituted a major disruption in Toms attachment to his primary caregiver.
We might also hypothesise that his mothers mental illness prior to her suicide would have resulted in
a lack of attunement to Tom, and this would have resulted in a lack of the validation required for him
to develop a healthy sense of self.
A marital breakdown ten years ago, and the ongoing strain in Toms relationship with his wife and
children since that time, suggest ongoing attachment issues possibly of an avoidant-dismissive style.
This would have further predisposed Tom to developing a major depressive disorder.
There are a number of perpetuants social withdrawal, reduced contact with his girlfriend, and
leaving his job exacerbating his financial stressors.
Tom does have strengths he is well-engaged with the community mental health team, and
makes reference to ongoing relationships with his siblings, showing the ability to form some helpful
attachments. He is also able to identify some strengths and talents that he has. These strengths
may have had a role in Tom seeking treatment, and are potentially good prognostic indicators.

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Appendix 15.2.4 RANZCP Clinical Examinations Formulation Guidelines for Trainees


For use with Part Two (Interactive exercise)

196

No. 1

Introductory Formulation I

15

197

No. 2
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No. 3

Introductory Formulation I

15

199

No. 4

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No. 5

Introductory Formulation I

15

201

No. 6

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No. 7

Introductory Formulation I

15

203

No. 8

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NOTES

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Session 16: Introductory Formulation II

205

206

Session 16
Introductory Formulation II
OBSERVATION OF AN INTERVIEW FOLLOWED BY
AN INTERACTIVE GROUP EXERCISE AND DISCUSSION
OPTION A
Organise your own
interview

OR

OPTION B
Watch the interview on
the accompanying USB

Summary of Session
This session is the second session on formulation. It draws on the knowledge and skills
introduced in the previous session.
In the session, the group watches clinical material and then discusses and develops a formulation.
There are two options for this session.
Option A: Organising your own doctor-patient interview
Option B: Watching the interview segments on the accompanying USB

Focus of the Session


1. To cement and applying the learning goals of the last session
2. To encourage trainees to be active in developing a formulation
3. To encourage trainees to practice the various formulation schemata
4. To encourage trainees to explore the patients predicament from a number of angles

Materials Required for the Session


Option A: Video camera if pre-recording your own interview
Equipment to watch the pre-recorded interview during the session
Option B: Computer, with either a data projector or TV monitor, and external speakers

Introductory Formulation II

16

OPTION A: Organise your own interview


Preparation for Session
Please note that there are no Facilitator Notes for this option

1. Select a trainee to be interviewer


2. Select a patient to be interviewed by the trainee

N.B. Patient selection is important


Can be an inpatient or an outpatient

207

Must be co-operative
Must have capacity to consent to the interview
3. Prior to the interview
Explain the interview to the patient and obtain written consent

check with your relevant hospital authority about the procedures relating to confidentiality
and consent in your hospital

4. The interview
A forty-minute assessment interview
The interview can either be pre-recorded and then watched by the group during the session,
or it can be observed live by the group:

through a one-way screen


via a monitor in another room
by having the group present in the room during the interview*

The trainee conducting the interview should not take notes while interviewing the patient
*If the group is present in the room during the interview, the number of observers should be limited.
Ensure that observers sit out of the direct line of sight of the patient and that they remain passive throughout
the interview

Note to Facilitator
The focus of this session is formulation rather than the interview itself. The interview is short
(i.e. 40 minutes), therefore it will not be possible to take a full history. There should however
be sufficient history to enable the group to formulate.

5.  If you selected that the interview be pre-recorded for viewing during the session, it is recommended
that you watch the interview prior to the session to familiarise yourself with the content
6.  Review the discussion prompts (appendix 16.1), and photocopy them to distribute to trainees
during the session

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Conducting the Session


1. Hand out the discussion prompts (appendix 16.1) and allow reading time (5 minutes)
2.  Advise trainees to take notes while watching the interview as they will be expected to write
their own formulations
3. Watch the interview either live or play it in full on a video/USB player (40 minutes)
4. Allow 5-10 minutes after watching the USB for trainees to write their own formulations
5. Lead a group discussion guided by the discussion prompts

208

6.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

OPTION B: Watch the interview segments on the accompanying USB


Please note that there are no Facilitator Notes for this option

Preparation for Session


1.  Review the accompanying USB material of three interview segments. Note that these segments
do not comprise a complete interview
2. Photocopy the discussion prompts (appendix 16.1) to distribute to trainees during the session

Conducting the Session


1. Hand out the discussion prompts (appendix 16.1) and allow reading time (5 minutes)
2.  Advise trainees to take notes while watching the interview as they will be expected
to write their own formulations
3.  Watch the interview play the three interview segments sequentially without pausing for
discussion between segments (30 minutes)
4.  Allow 5-10 minutes after watching the USB for trainees to write their own formulations
5.  Lead a group discussion guided by the discussion prompts
6.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

Appendices listing
For use with both Option A and Option B
Appendix 16.1 Discussion prompts for trainees

Introductory Formulation II

16

Appendices
Appendix 16.1 Discussion prompts for trainees
For use with both Options A and B
1. What techniques does the interviewer use in this interview? Are these helpful?
2. What are relevant gaps in the history?
3. Discuss the key issues raised in this interview
4. In this interview, what is the patients primary predicament?
5. Why is the patient in this predicament why is this happening at this particular time?

209

Consider:
predisposing factors
precipitating factors
perpetuating factors
6.  A patients behaviour during an interview also informs your formulation. How does the
patients behaviour inform us?
7. Choose a member of the group to read out their formulation
8.  Discuss any pertinent themes that came up in the trainees formulation that have not
yet been raised
9. Have you considered:
bio-psycho-social issues
cultural context
spiritual beliefs
cognitive style
developmental stages
coping/defense mechanisms
risk assessment
countertransference
prospects of rehabilitation (strengths, quality of life, morale)?

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NOTES

210

Session 17: Cognitive-Behavioural


Approach and Formulation

211

Session 17
Cognitive-Behavioural Approach and Formulation
212

PART 1: LECTURE
Dr Lisa Lampe
The Cognitive Formulation
in Anxiety

PART 2: OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION

Summary of Session
This session is about a cognitive-behavioural approach to understanding a patients presentation.
The session is divided into two parts:
PART ONE: A lecture: an overview of developing a cognitive-behavioural model or formulation
PART TWO: An interactive component using segments of a pre-recorded interview between a
consultant psychiatrist and a patient to integrate the concepts introduced in the lecture

Focus of the Session


1. To understand what constitutes a cognitive-behavioural model in psychiatry
2. To discuss a patient from a cognitive-behavioural perspective
3. To develop a cognitive-behavioural model for a patient
4. To discuss some cognitive-behavioural concepts, particularly in relation to anxiety disorders

Materials Required for the Session


PART ONE: Computer, with either a data projector or TV monitor, and external speakers
PART TWO: Computer, with either a data projector or TV monitor, and external speakers
Whiteboard or butchers paper

PART ONE: Lecture


Preparation for Session
1. Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic
2. Photocopy the lecture slides (appendix 17.1.1) to distribute to trainees during the session

Cognitive-Behavioural Approach and Formulation

17

Conducting the Session


1. Hand out copies of the lecture slides to trainees (appendix 17.1.1)
2. Play the lecture on the accompanying USB (15 minutes):
The Cognitive Formulation in Anxiety Dr Lisa Lampe
3. Allow question and discussion time (10 minutes)

PART TWO: Interactive Exercise


Preparation for Session

213

1.  Prior to the session, review the USB and discussion prompts to familiarise yourself with the
material
2.  Photocopy the session discussion prompts (appendix 17.2.2), the patient history (appendix
17.2.1) and the Cognitive-Behavioural Model for Jenny (appendix 17.2.4) to distribute to
trainees during the session
3. Review facilitator notes (appendix 17.2.3)

Conducting the Session


1.  Hand out the discussion prompts (appendix 17.2.2), the patient history (appendix 17.2.1) and
the Cognitive-Behavioural Model for Jenny (appendix 17.2.4). Allow reading time (5 minutes)
2.  Play the USB of the interview, pausing where indicated, and lead a group discussion guided by
the discussion prompts and facilitator notes (appendix 17.2.3)
 Note: For some of the discussion prompts, a brief group discussion has also been included on
the USB. Included on the USB are five interview segments (15 minutes in total) and additional
footage of discussion (12 minutes).
3.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

Appendices listing
For use with Part One (Lecture)
Appendix 17.1 Lecture slides for The Cognitive Formulation in Anxiety by Dr Lisa Lampe

For use with Part Two (Interactive exercise)


Appendix 17.2.1 Summary of the patients history
Appendix 17.2.2 Discussion prompts for trainees
Appendix 17.2.3 Facilitator notes
Appendix 17.2.4 Cognitive-Behavioural Model for Jenny

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Appendices
Appendix 17.1.1 Lecture slides
For use with Part One (lecture)
The Cognitive Formulation in Anxiety by Dr Lisa Lampe

214

Slide 1

Slide 2

Slide 3

Slide 4

Slide 5

Slide 6

Cognitive-Behavioural Approach and Formulation

17

215

Slide 7

Slide 8

Slide 9

Slide 10

Slide 11

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Appendix 17.2.1 Summary of the patients history


For use with Part Two (Interactive exercise)
Identifying data: Jenny1, thirty-nine-year-old married woman living with her husband and three children
Presenting Problems
Severe anxiety and distress
Triggering event a panic attack while driving
Inability to function in her role as a wife and mother

216

Currently
Married twenty-one years
Children aged fifteen years, thirteen years and nine years
Her husband is supportive and they have a good relationship
Many stressors recently including recent sale of her house and building a new one, and
assisting her parents with the sale of their property
Chronic, ongoing stressors with her in-laws
Close to her parents but they are emotionally dependent on Jenny and unable to be supportive of her
A few months ago Jenny gave up her one day per week job at a coffee-shop as she had too
much on her plate
Psychiatric treatment
Outpatient treatment has not given any relief to her symptoms. She has had very brief trials of
Alprazolam and Escitalopram
Continues to see her psychologist of one year regularly
Routine GP visits
Has also sought treatment during this episode from numerous other medical and alternative
health providers
Past history
She has a past history of post-natal depression/anxiety nine years ago full recovery
Commenced antidepressant medication approximately one to two years ago, and then ceased
these six months ago
Family history
Father: alcoholism
Mother: anxious
Premorbid Personality
An anxious temperament but usually functions well (social, occupational and family)
Developmental History
From early childhood Jenny felt she had to be an adult that she was responsible for her
parents safety and well-being

Not her real name.

1. 

Cognitive-Behavioural Approach and Formulation

17

Appendix 17.2.2 Discussion prompts for trainees


For use with Part Two (Interactive exercise)
Read the Patient History on the handout before proceeding
Segment One
Interviewing techniques
1. What do you notice about the interviewing style?
2. Why do you think the interviewer keeps returning to the precipitating incident?
3.  What are some of the difficulties the interviewer faces in this segment of the interview? How
does she manage these?

217

4.  Watch and discuss an excerpt of Segment One. In this excerpt the interviewer is posing a
hypothesis to the patient.
What is Jennys response to the interviewers hypothesis? What does Jennys response tells us?
5. Why does the interviewer put forward hypotheses to the patient?
Segment Two
Beginning to conceptualise the patient in terms of a cognitive model
6. Are you getting a picture of what is going on with this patient? What is the history so far?
Discuss in terms of predisposing, precipitating and perpetuating factors
7. What are Jennys cognitions around her fear i.e. what does she fear?
8. Are these cognitions typical of an anxiety disorder?
9.  Thinking about the history attained thus far and the mental state of the patient what are your
differential diagnoses?
Difficulties associated with anxious patients
10. Discuss how to manage each of the following difficulties associated with anxious patients:
high levels of distress during the interview
requesting or demanding reassurance from the interviewer
increased frequency of medication side-effects
a contagious sense of anxiety and urgency
a level of distress and urgency that propels patients into seeking treatment from a number
of different health care providers
Segment Three
11. Discuss the interview techniques that were used in this segment
Segment Four
Watch the interviewer posing the following hypothesis in Segment Four
12. What is the patients response to the hypothesis?
Segment Five
Watch the interviewer posing the following hypothesis in Segment Five
13. What is the patients response to the hypothesis?

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Continue to conceptualise the patient in terms of a cognitive-behavioural model


14.  Add to your initial formulation in terms of predisposing, precipitating and perpetuating factors,
and cognitive-behavioural factors. Think particularly about the perpetuating factors
15. What is your diagnosis?
Anxiety disorders in general
16.  Moving away from this particular patient: were Jenny to have typical panic disorder with
driving as the precipitant, what behaviours would we watch for as potential perpetuants?

218

17. Why does avoidance (including safety behaviours) perpetuate the problem?
18. What are attributions? What is an attributional bias?

Cognitive-Behavioural Approach and Formulation

17

Appendix 17.2.3 Facilitator notes


For use with Part Two (Interactive exercise)
Read the Patient History before proceeding
Segment One
Interviewing techniques
1. What do you notice about the interviewing style?
The interviewer has a directive style of interviewing
She asks clear and specific questions in order to piece together the precipitating incidents
We also see the interviewer begin to put forward hypotheses to the patient

219

2. Why do you think the interviewer keeps returning to the precipitating incident?
Your first assessment of a patient is often your best chance of gaining a clear understanding of:
The exact sequence of events
The patients response to these events, including their cognitive reactions
How the patients response to the precipitating event might have affected future outcomes
This understanding affects your cognitive model/formulation, and influences your management plan
3.  What are some of the difficulties the interviewer faces in this segment of the interview?
How does she manage these?
 his is an extremely anxious and distressed patient, with outbursts of tears, coughing, and
T
even retching
She says, When Im with someone like you, I dont want to leave you
The patients level of distress impacts on her ability to give a clear account of recent events
Her distress means she requires a lot of containment by the interviewer
4.  Watch and discuss an excerpt of Segment One. In this excerpt the interviewer is posing
a hypothesis to the patient. What is Jennys response to the interviewers hypothesis?
What does Jennys response tells us?
The patient doesnt respond to the hypothesis posed. This could either be because:
It does not ring true for her, or
She is too overwhelmed by distress and anxiety to take in what the interviewer has said
5. Why does the interviewer put forward hypotheses to the patient?
It is part of the collaborative approach of cognitive-behavioural therapy models that the patient
and the doctor work together to come to an understanding of the presenting problem, and its
causes
It is important that the doctor notices and listens to the patients responses and adjusts future
hypotheses accordingly
Segment Two
Beginning to conceptualise the patient in terms of a cognitive model
6. Are you getting a picture of what is going on with this patient? What is the history so far?
Discuss in terms of predisposing, precipitating and perpetuating factors

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Write the factors the group comes up with on a white-board or on butchers paper
Predisposing factors:
Past history of depression/anxiety
Family history suggests a biological predisposition
Early life experiences may make her psychologically vulnerable
Precipitating:
The event in the car
Other life-stressors e.g. moving house

220

Perpetuating:
Perhaps the stress of ongoing conflict with her husbands family plays a role though we
would need to explore this further
At this stage in the interview we are beginning to form hypotheses about the perpetuating
cognitions and perpetuating behaviour:
a. Behaviours, particularly avoidance behaviours, are common perpetuants of anxiety
disorders. At this point in the history we dont see that as a major factor. Jenny did try and
get in her car and drive again so she tried to face her fears, but the anxiety persisted.
b. It is typical of anxiety that the cognitions ensuing from the precipitating event perpetuate
the disorder. The cognitions are discussed in more detail below.
7. What are Jennys cognitions around her fear. That is, what does she fear?
Precipitating event: In the car Jenny feared loss of control
On an ongoing basis Jenny fears others seeing her anxious, and of letting others down
8. Are these cognitions typical of an anxiety disorder?
The initial fear of loss of control is typical of an anxiety disorder.
 he ongoing fears of others seeing her in a distressed state, of never getting better, and the
T
sense of failure, worthlessness and guilt at letting others down are not typical of an anxiety
disorder.
9.  Thinking about the history attained thus far and the mental state of the patient, what
are your differential diagnoses?
 s well as an anxiety disorder, it is important to have major depression high up on the list of
A
differentials.
 upporting the diagnosis of depression is the extreme distress that the patient exhibits, the
S
sense of failure, worthlessness and guilt at letting her family down, the reported diurnal
variation, and that her cognitions as above are not typical of those of an anxiety disorder.
Difficulties associated with anxious patients
10. Discuss how to manage each of the following difficulties associated with anxious
patients:
high levels of distress during the interview
requesting or demanding reassurance from the interviewer
increased frequency of medication side-effects
a contagious sense of anxiety and urgency
a level of distress and urgency that propels patients into seeking treatment from
a number of different health care providers

Cognitive-Behavioural Approach and Formulation

17

Segment Three
More on interviewing techniques
11. Discuss the interview techniques in this segment
There are appropriate reassurances
There are no false reassurances. For example, the interviewer is honest when she replies
I cant predict the future
Socratic dialogue, asking questions and involving Jenny
Grounds with firm and definite statements when possible and appropriate, for example she
tells Jenny with certainty that she will not end up in hospital for the rest of her life
Gives appropriate information and education

221

Segment Four
Watch the interviewer posing the following hypothesis in Segment Four
12. What is the patients response to the hypothesis?
While the patient doesnt openly disagree with the interviewer, she doesnt agree with her either.
Segment Five
Watch the interviewer posing the following hypothesis in Segment Five
13. What is the patients response to the hypothesis?
Jenny is listening and nodding.
Here we see interviewer and interviewee working collaboratively on a shared hypothesis.
Continue to conceptualise the patient in terms of a cognitive-behavioural model
14.  Add to your initial formulation in terms of predisposing, precipitating and perpetuating
factors, and cognitive-behavioural factors. Think particularly about the perpetuating factors.
Return to your white-board or your butchers paper and add to your initial formulation
See appendix 17.2.4 for an example of a cognitive-behavioural model for this patient.
15. What is your diagnosis?
Provisional Diagnosis:
The provisional diagnosis is a Major Depressive Episode. The history is of a non-psychotic
depression, though Jenny refers at one stage in the interview to critical voices that would
need to be explored further.
There is probably an underlying Generalised Anxiety Disorder (GAD). There is often a
significant overlap between GAD and depression.
Differential diagnoses:
Panic disorder is on the list of differentials but is less likely than depression.
Be cautious about the diagnosis of a primary anxiety disorder (even as a comorbidity) in
the context of significant depression.

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Anxiety disorders in general


16.  Moving away from this particular patient: were Jenny to have typical panic
disorder with driving as the precipitant, what behaviours would we watch for
as potential perpetuants?
We look for avoidance behaviours. A type of avoidance behaviours that are
easy to miss are safety behaviours. For example, a safety behaviour could be
making sure you always have someone with you in the car when you drive. Safety
behaviours are powerful perpetuants of panic disorder.
17. Why does avoidance (including safety behaviours) perpetuate the problem?

222

It perpetuates the panic because there is no disconfirmatory evidence of your


irrational beliefs.
18. What are attributions? What is an attributional bias?
Attribution means the ascribing of meaning to explain the cause of events.
An attributional bias is a form of faulty reasoning. It is a cognitive bias that leads
to faulty attribution of the cause of events. That is, an attributional bias means
an incorrect explanation of who or what was responsible for a particular event or
action. For example, in OCD someone may believe that washing their hands fifty
times each hour is the reason that they are safe from disease.

Cognitive-Behavioural Approach and Formulation

17

Appendix 17.2.4 Cognitive-Behavioural Model for Jenny


For use with Part Two (Interactive exercise)

Cognitive Behavioural Model


Precipitating

Predisposing

Strengths

The event in the car

Past psychiatric history

Supportive relationship with husband

Other life stressors


e.g. moving

Family history

Good premorbid function

Early life experiences

Reasonable insight

Issues raised with


private psychologist

Anxious, sensitive
temperament

Feels loved by her own family

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Some other good relationships, e.g.


sister-in-law

DEPRESSION/ANXIETY

PERPETUATING

Environmental

Cognitions

Behaviours

Conflict with in-laws

I am worthless and a
failure

Withdrawal from usual


duties and activities

I am letting others down

Seeing a number
of different health
professionals who give
different advice

Own family unable to


give emotional support

I dont deserve to be
happy

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Session 18: Psychodynamic Formulation I

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Session 18
Psychodynamic Formulation I
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LECTURES
Dr Jeffrey Streimer
Psychological Formulation in
the Assessment Interview

Dr Loyola McLean
Psychodynamic Formulation:
Aspects of Attachment and
Development

Summary of Session
This is the first of two sessions on psychodynamic formulation. It provides trainees with an
introduction on how to formulate from a psychodynamic perspective.
In this session there are two lectures, each on a different aspect of psychodynamic formulation.

Focus of the Session


1. To introduce trainees to the concept of psychological and psychodynamic formulation as
distinct from formulation in general psychiatry
2. To introduce key ideas and themes of psychodynamic formulation

Please Note
There are no generally agreed formats that all psychodynamic formulations should follow.
Therefore the following two sessions introduce and explore the various themes and
concepts of psychodynamic formulation but do not provide a prescriptive framework.
Use the concepts and ideas introduced herewith to practise and develop your own style,
appropriate to your level of experience, the particular patient and to the context.

Materials Required for the Session


Computer, with either a data projector or TV monitor, and external speakers

Preparation for Session


1.  Review the recorded lectures to ensure you are able to discuss relevant aspects of the topic
2.  Photocopy the lecture slides (appendices 18.1 and 18.2) to distribute to trainees during the
session

Psychodynamic Formulation I

18

Conducting the Session


1. Hand out copies of the lecture slides to trainees (appendices 18.1 and 18.2)
2. Play each lecture on the accompanying USB
Lecture One: Psychological Formulation in the Assessment Interview
Dr Jeffrey Streimer (40 minutes)
Lecture Two: Psychodynamic Formulation: Attachment and Development
Dr Loyola McLean (30 minutes)
3. At the end of each lecture allow question and discussion time (10 minutes)
4.  Take 5-10 minutes at the end of the session to summarise session outcomes and
answer any questions.

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Appendices listing
Appendix 18.1 Lecture slides for Psychological Formulation in the Assessment
Interview by Dr Jeffrey Streimer
Appendix 18.2 Lecture slides for Psychodynamic Formulation: Attachment and
Development by Dr Loyola McLean

Recommended reading:
Kassaw K, Gabbard G: Creating a Psychodynamic Formulation from a clinical examination.
Am.J.Psychiatry 159:5, May 2002
Perry S, Cooper A, Michaels R: The Psychodynamic Formulation: Its Purpose, Structure
& Clinical Application. Am J Psychiatry 144:5, May 1987
Summers R: The Psychodynamic Formulation Updated. Am J Psychotherapy 59:1, 2003
Mace C, Binyon S: Teaching Psychodynamic Formulation to psychiatry trainees: Part 1:
Basics of Formulation. Advances in Psychiatric Treatment 11:416-423, 2005

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Appendices
Appendix 18.1 Lecture slides
Psychological Formulation in the Assessment Interview by Dr Jeffrey Streimer

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Appendix 18.2 Lecture slides


Psychodynamic Formulation: Attachment and Development by Dr Loyola McLean

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Session 19: Psychodynamic Formulation II

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Session 19
240

Psychodynamic Formulation II
OBSERVATION OF A RECORDED INTERVIEW FOLLOWED
BY AN INTERACTIVE EXERCISE AND GROUP DISCUSSION

Summary of Session
This is the second session on psychodynamic formulation. It builds on the concepts introduced
in the previous session.
This session uses a recorded interview between a consultant psychiatrist and a patient to develop
a psychodynamic formulation.

Focus of the Session


1. To learn to apply the concepts, ideas and themes introduced in the last session
2. To practise developing a psychodynamic formulation based on real clinical material

Materials Required for the Session


Computer, with either a data projector or TV monitor, and external speakers

Preparation for Session


1.  Review the accompanying USB material. This USB contains an interview between a consultant
psychiatrist and a patient, as well as relevant comments and group discussion. Ensure that
you are able to discuss the material covered
2.  Photocopy the case summary (appendix 19.1) and the formulation summary sheet
(appendix 19.2) to distribute to trainees during the session
3. Review the facilitators copy of the formulation summary sheet (appendix 19.3)

Psychodynamic Formulation II

19

Conducting the Session


1.  Hand out the case summary (appendix 19.1) and allow reading time (5 minutes)
2. Hand out the formulation summary sheet for trainees (appendix 19.2) and allow reading time
(5 minutes)
3. Play the USB of the interview (50 minutes)
4.  Lead a group discussion about how to formulate the patient using the facilitator copy of the
formulation summary sheet (appendix 19.3) as a guide
Note: For some of the discussion prompts a group discussion has also been included on the
USB. Watching some or all of these group discussions is optional. This additional footage is
40 minutes in total

241

5.  Take 5-10 minutes at the end of the session to summarise session outcomes and answer
any questions

Appendices listing
Appendix 19.1 Case summary
Appendix 19.2 Tables: Attachment Style Summary and Level of Maturation
Appendix 19.3 Formulation summary sheet for trainees
Appendix 19.4 Formulation summary sheet for facilitators

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Appendices
Appendix 19.1 Case summary
Kylie: Introductory Case Outline
This information is a summary of the history revealed at interview
Kylie1 nineteen-year old, unemployed single woman
Presenting Problems

242

Recurrent suicidal ideation


Significant rapid mood swings: episodes of depression and brief episodes of elevated mood.
These mood swings are related to and reactive to environmental factors
Reports hearing voices
Seeks a definitive admission for expert assessment and improved management of the above
Currently
An inpatient: a voluntary admission to a General Teaching Hospital Mental Health Unit
Unemployed, unskilled worker
Has been living six months in a capital city, the last four months with a supportive boyfriend
Additional support from:
a. Her mother who still lives in the small rural town in which the patient was raised, and
b. Her brother who lives in Queensland
Past History
Oppositional defiant disorder fighting and drug & alcohol abuse ex-13yrs
Reported marked mood swings dating back to early childhood
Six rural hospitalisations for depression and associated deliberate self-harm since her mid-teens
Diagnosed by GPs with Bipolar Affective Disorder
Premorbid personality
Tomboy. Oppositional, rivalrous and moody
Overly sensitive to control, criticism, abandonment and loss
Developmental History
Family disharmony from early years
Mother always Kylies best friend and confidant
Father alcohol & cannabis abuser frequent mood swings
Mother abused by husband (Kylies father) who abandoned the family for another woman
when Kylie was young
Kylie has a highly ambivalent relationship with him and his new partner
An A student until father left with decline in grades and behaviour thereafter
Dropped out of school, left home aged seventeen years to live with thirty-year-old boyfriend
left him after 3 years and moved to another city

Not her real name.

1. 

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Appendix 19.2 Tables

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Session 20: History and Formulation


in Child and Adolescent Psychiatry

257

Session 20
History and Formulation in Child
and Adolescent Psychiatry
258

LECTURE
Dr Steven Spielman
Assessment in Child and
Adolescent Psychiatry

Summary of Session
This session is on assessment in child and adolescent psychiatry. It is a lecture and includes
some group discussion.

Focus of the Session


1. To provide an overview of the assessment of children in psychiatry
2. To provide an overview of the assessment of adolescents in psychiatry
3.  To highlight key differences between the assessment of children, adolescents and adults
in psychiatry

Materials Required for the Session


Computer, with either a data projector or TV monitor, and external speakers

Preparation for Session


1.  Review the recorded lecture to ensure you are able to discuss relevant aspects of the topic
2. Photocopy the lecture slides (appendices 20.1 ) to distribute to trainees during the session

Conducting the Session


1. Handout copies of the lecture slides to trainees (appendix 20.1)
2. Play the lecture on the accompanying USB
Assessment in Child and Adolescent Psychiatry Dr Steven Spielman (90 minutes)
3. Allow question and discussion time (10 minutes).

Appendices Listing
Appendix 20.1 Lecture slides for Assessment in Child and Adolescent Psychiatry
by Dr Steven Spielman

History and Formulation in Child and Adolescent Psychiatry

20

Appendices
Appendix 20.1 Lecture slides
Assessment in Child and Adolescent Psychiatry by Dr Steven Spielman

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H ETI THE COM PLE T E CLI NI CAL AS S E S S M E NT I N P SYC H I AT RY

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