Professional Documents
Culture Documents
MADE EASY
DR NADER KORHANI PhD
Goals, Purposes, and Types of Assessment
Interviewing
Types of Interviews
Potential Threats to Effective Interviewing
Behavioral Observations
Checklists and Inventories
Physiological Testing
Lecture Preview
Since the foundation of psychology, assessment
and testing have been important activities.
depends on
Introduce yourself, and anyone accompanying you; greet pt. by name, and tell
reason of i/v.
Questions: Open-ended Q?- for neurotic, verbal, intelligent pt. “tell me more
about that.”
Closed-ended Q?- (yes or no) for psychotic, delirium, dementia, limited-time i/v.
avoid suggesting answers (you feel depressed, don’t - you?).
Five type of interview questions
Clarification
You ask a man to give you an example of what he means when he says he has suffered a panic attack.
You summarize the person's complaints, their time course and the events happening at the time.
Asking open-ended questions
At the beginning of the interview, you ask, 'How are you feeling?
Directive psychological questions
You ask a man who presents with fatigue and insomnia if he has been feeling down or depressed. Later, you
ask him about anhedonia, vegetative function change and suicidality.
Response to a verbal cue
A 47-year-old man complains of a number of vague physical symptoms including fatigue, abdominal
discomfort and headaches. He says that he cannot even be bothered playing football any more. You ask,
'When did you last do something that you really did enjoy? He takes some time responding, and then says,
'It seems ages. I suppose I enjoyed the trip to sharm last winter. Then you ask if he has been feeling
depressed. You pick up the man's cue about anhedonia and follow it up with direct questions about
depression.
Principals of psychiatric interview:
Examples of effective interview techniques:
Response to a non-verbal cue
A woman who has been attending your practice over the past five years is not herself. She looks tired and
depressed and sits slumped in the chair. Usually well groomed, today her hair is untidy and her clothes
rumpled. Her affect is flat and she speaks in a soft voice giving unelaborated responses to your questions.
You say, 'You look tired today. How are you feeling?' Later you ask if she has been feeling depressed.
Empathic style
A middle-aged man becomes depressed after being overlooked for a promotion at work. You ask about his
prospects for promotion in the future. This uncovers his fear that, at 52, he is unlikely ever to be promoted.
The question that you ask leads the man to elaborate his concerns. Further questions may address the other
developmental challenges of middle age that he is presently facing.
Maintaining control
An elderly man speaks at length about how unjustly he is treated by his neighbours. You say, 'I am sorry to
hear that you are so upset by your neighbours, but could I take you back to what you were saying about
feeling depressed'.
Types of Interviews
different types of interviews
Questions that begin with why are less useful as they tend to provoke defensiveness. How
can also be problematic in that it provokes analysis rather than awareness/autonomy
(compare how are you going to give up drinking? with what steps might you take to give
up drinking?).
They also encourage the use of descriptive rather than judgemental terminology
(preventing defensiveness and unhelpful self criticism that may distort perception).
It follows that good questions follow the line of interest of the patient, not the doctor:
the aim is to raise his or her awareness, so questions must follow this lead.
R/O:
• Depression
• Mania
• Anxiety/ PTSD/ OCD
• Psychosis
• Substance Abuse
• Suicidal/ Homicidal Ideations
HPI cont.
• Sleep
• Interest
• Guilt
• Energy
• Concentration
• Appetite
• Psychomotor activity
• Suicidal Ideation
HPI cont.
• Anxiety Disorders
• Panic, Specific Phobia, Social Phobia, GAD etc.
• O-C, Stereotypic & Related Disorders
• OCD, Body Dysmorphic, Hoarding, Hair Pulling, Skin
• Picking, etc.
• Trauma- and Stressor-Related Disorders
• PTSD, Reactive Attachment Disorder, etc.
• Dissociative Disorders
HPI cont.
Psychosis:
Delusion (fixed false beliefs):
• Paranoid Delusion
• Ideas of reference
• Delusion of Control
• Delusion of Grandeur
• Delusion of Guilt
Illusiions (misinterpretation
of the sensory stimulus):
• Auditory/ Visual/ Olfactory/
Tactile
HPI cont.
Substance Abuse:
Nicotine, Alcohol, Amphetamine (Ice, Speed, Crystal, Ecstasy), PCP (Ketamine, K2) Sedatives
(BDZ, Barbiturates), Hallucinogens (Mushrum, LSD), Opiods, Cannabis, Inhalants, Pills, etc.
1. How often you use?
2. How much money you spend on it?
3. When was the last time you were sober?
4. Have you experienced:
financial or legal problems,
health consequences of use (cirrhosis, blackouts, vomiting)
social consequences such as fights,
marital problems, and loss of friends,
loss of job or problems at work
HPI cont.
• Stress – pressure
• Hopelessness
• Self-Hate
Previous Admission:
Onset:
Duration:
Medication:
ECT:
PAST PSYCHIATRIC cont.
• Medical History
• Allergies
• Family History
• Social History
• Legal History
• Sexual History
Mental Status Interview
is conducted to screen the patient’s level of psychological functioning and
the presence or absence of abnormal mental situation such as delusions,
delirium, or dementia.
It might focus on
how the patient experienced the treatment,
what the patient found useful or not useful,
how he or she might best deal with problems in the future.
Potential Threats to
Effective Interviewing
Transference can be broadly defined as the feelings that the patient has for you. Some of these feelings are
reality-based, for example, respect for your expertise in medicine. Others have unconscious origins and
arise from the transference on to you of feelings that are held towards others who are significant in the
person’s past or present. For example, being perceived by a young man as an authority figure, you may elicit
transference feelings that he has towards his parents, teachers and other authority figures in his life.
Countertransference refers to the feelings that you have towards the patient. Again, these will, in part, be
reality-based. Some will arise in response to the transference. Some will be similar to feelings that are
elicited in other people who deal with that person, while others will reflect aspects of your own past and
present relationships transferred on to the patient. Most will be a combination of all of these. It is normal,
of course, that you should experience these feelings. The important thing is to be aware of them and to
acknowledge them to yourself, even if they seem unacceptable - for example, feeling angry or bored with a
person, feeling overly concerned about or even feeling attracted to him or her. By acknowledging these
feelings to yourself and making them conscious you are much less likely to act inappropriately upon them.
For example, it is quite normal to feel angry with certain people, but it is likely to be damaging and
unprofessional to act out this anger.
Principals of psychiatric interview:
5. Boundary issues:
Doctors are sanctioned to ask about private and intimate aspects of their patients' lives and to conduct physical examinations. There is a
clear power differential in the relationship between patient and doctor. In particular, people presenting for counseling or any type of
psychological therapy are often at their most vulnerable. The transference of flattering feelings and impulses onto the doctor -
respect for authority, attraction to power and success, desire for approval - may tempt the doctor into abusing his or her
power. To exploit such a position to fulfil ones own needs is unethical and potentially damaging to patients.
It is essential to be clear about your role as a professional. You are not a friend of the patient. Indeed, it is wise to avoid, if possible,
treating your friends. It is always unethical to have sexual relations with a patient. For professional therapists, it is prohibited to have
intimate relations even after therapy has finished.
Monitor your countertransference feelings and impulses and take care not to act out in ways that breach professional boundaries.
Transgressions of these boundaries typically occur in a stepwise progression. They may begin with the acceptance of expensive
gifts, financial advice. There may be a temptation to disclose and discuss one's own problems. Appointments may be made that
are longer than usual, or regularly scheduled at the end of the day when other staff members have left the practice. Fees may
be waived. Unnecessary home visits may be made. This may progress to the performance of unnecessary physical
examinations, meeting patients outside the consulting room, and to involvement in social situations and sexual relations.
Doctors who are vulnerable to boundary transgressions:
Include those experiencing life crises,
1. Those with problems in their own marriages or personal relationships.
2. Perfectionists who are excessively self-sacrificing and work unnecessarily long
hours may have difficulty setting limits on the demands of certain patients
and begin taking extraordinary measures in attempt to rescue them.
3. Patients with histories of sexual abuse may be particularly prone to evoke
such countertransference responses, especially when they express recurrent
suicidal ideation.
4. Doctors who deny their dependency needs and give the appearance of being
self-contained may be prone to seeking gratification for their needs for love
and nurturance through their patients: while denying their own dependency
needs, they may perceive others as being dependent on and needy of them.
5. A doctor suffering a psychosis might violate professional boundaries as a
consequence of the illness. Psychopathic doctors who willfully exploit patients
for the gratification of their own needs have no place in the medical
profession.
Dealing with countertransference:
By acknowledging to yourself your countertransference responses, you
lessen the likelihood of acting out upon them.
Monitoring your countertransference responses can provide you with valuable
information about a person. For example, when seeing a young woman who
repeatedly self-harms, you may feel frustrated and angry and you may even
imagine being cruel to her. Recognising these feelings and impulses, you take
care not to act out upon them. Reflecting upon them, you recognise their origin
in the physical and sexual abuse that she suffered at the hands of her step father.
You gain a deeper understanding of her and the way people react towards her. By
containing the impulse to act out, you avoid repeating and reinforcing the
abusive patterns of her previous relationships. At the same time, you take care
not to act upon unrealistic fantasies of 'rescuing' her .
Monitoring the countertransference can improve your understanding of
the patient.
Principals of psychiatric interview:
6. Understanding versus explanation:
In formulating a person's problems, we seek to answer the question, 'Why
does this individual feel, think and act this way at this time?' The method
of understanding helps us find reasons for his or her experience; the
method of explanation seeks causes.
We understand a person's experience when, through listening to his or
her story and clarifying the experience, we are able to empathise with him
or her and to imagine how we might feel under similar circumstances. We
can understand experiences in the mind of another. For example, we
understand the grief of the bereaved, the anger of someone who is
frustrated, the guilt of the person who has hurt another and the shame of
someone who has done something foolish. We can also understand the
meaning of an event for that person, and we can look for reasons why he
or she feels that way.
Principals of psychiatric interview:
7.The dialectical principle:
In the philosophy of Hegel, dialectics is a process in which a proposition is
made (thesis), then negated (antithesis), and finally replaced by a new
proposition that resolves the conflict between the two (synthesis)4.
Although this may seem a little obscure, this way of thinking is common
in making decisions about mental health problems. You will often have to
make choices between apparently contradictory propositions. Always
consider the possibility that the best course of action lies in a synthesis of
the two. There are very few propositions in psychiatry that hold true in
every case.
Some dialectical dilemmas:
Since she has a terminal illness, it is understandable that she is depressed, so I should not prescribe medication.
Wrong: although her depression is understandable, if her symptoms persist and include feelings of worthlessness and guilt, suicidality or
psychotic symptoms, she should be treated with an antidepressant (and possibly an antipsychotic or ECT) in addition to some form of
psychotherapy to deal with her grief.
Should I make a formulation specific to this woman’s problems or should I make a diagnosis and treat the condition from which she suffers?
Do both.
Is substance abuse or an underlying psychosis causing his psychotic symptoms?
It could be a combination of the two.
Are his cognitive deficits due to dementia or major depression?
A third possibility is that he suffers both conditions.
Her panic attacks are probably just secondary to her depression so if I treat the depression they should also improve.
Isolated panic attacks can occur in major depression, but if they are recurrent and accompanied by persistent concern about having more
attacks, worry about the implications of the attacks, or significant behaviour change, then both diagnoses should be made. In general
practice settings, mixed anxiety/depression is more common that either one alone. Treat both.
I should strive to be decisive and make the final diagnosis in the first session.
Make a working diagnosis in the first session, but be prepared to tolerate some uncertainty about the final diagnosis. The formulation will
continue to evolve and deepen so long as you continue to see the person.
I must never breach a patient's confidentiality.
There are exceptions. For example, if the person makes a direct threat against someone else, you may be obliged to contact the police or to
warn the intended victim. With most mental health treatment now being delivered in the community, a larger responsibility for care now
falls on the family or other carers. Unless expressly forbidden to do so by the individual, carers should, whenever possible, be involved in
treatment. Ask the person if you can meet his or her spouse and family at the next consultation.
Some dialectical dilemmas:
During an exacerbation of his psychosis, a man with schizophrenia develops obsessive -
compulsive symptoms.
Should I diagnose obsessive–compulsive disorder? Here, the hierarchical principle of
diagnosis applies. The anxiety symptoms are subsumed under the diagnosis of a
psychotic disorder.
A man subjected to severe road accident presents with a number of anxiety and
depressive symptoms in addition to re-experiencing the traumatic accident scene. Should
I diagnose depression, generalized anxiety and agoraphobia?
The most parsimonious explanation is post-traumatic stress disorder, though this
disorder may be complicated by major depression or an anxiety disorder.
Principals of psychiatric interview:
8.Impairment, disability and handicap:
When assessing people with mental health problems, it is useful to classify their complaints as
impairments, disabilities or handicaps. Mental impairment is any loss or abnormality in
psychological functioning. It includes the signs and symptoms of mental illness. Disability is any
restriction or lack in ability to perform an activity normal for a human being. Handicap is a
disadvantage, resulting from impairment or disability, that limits or prevents the fulfilment of a
social role that is normal for that individual, given his or her age, sex and cultural expectations.
It is helpful to make this distinction when planning management. In general, the alleviation of
impairments is the focus of treatment, while the prevention and minimization of disabilities and
handicaps constitutes disability support and rehabilitation. As a general practitioner, you will
mainly be involved in the delivery of treatment. However, you need to be familiar with the
rehabilitation services in your area, to know the appropriate referral procedures and to be able to
work in partnership with them.
Examples of impairment, disability and handicap:
A woman with schizophrenia hears her thoughts spoken out loud (thought broadcast, an
impairment). As a consequence, she withdraws, spending much of her time at home, and she no
longer goes shopping (agoraphobia, a disability). She has not managed to work since the onset of
her illness five years before, she has no social contacts outside her immediate family and she
depends on her husband to do all of her shopping (handicap).
A man has developed agoraphobia (disability) after having a panic attack (impairment) in a
bank three months before. He remains on sickness allowance and sees little of his friends. His
wife is becoming increasingly angry by his dependence on her (handicap).
A man with early dementia suffers memory deficits, disorientation in place and mild agnosia
(impairments). He has left the gas on twice after heating the kettle, he got lost on the way back
from the shops and his wife has to remind him to attend to his personal hygiene (disabilities).
He had to give up his job as an architect a year ago and is now becoming increasingly dependent
on his wife for care and supervision (handicap).
Interviewing a paranoid patient:
Don’t try to argue or rationally persuade the patient out of a delusion.
This may lead to more assertion of delusional ideas.
Don’t automatically laugh at a patient when something is said that seems
funny. Laughing at a patient can convey disrespect and lack of
understanding of the underlying terror and despair that many patient’s
feel.
Interviewing a paranoid patient:
Do listen. Listen to how patients experience the world. They may
experience it as dangerous, bizarre , overwhelming and invasive.
Try to understand what is their image of themselves.
DO acknowledge these feelings to the patient simply and clearly. For
example if the patient respond that “When I walk into a room people can
see inside my head and read my thoughts”. The clinician might respond to
it as “ What are your feelings then” or “How do you feel then”.
Be straightforward with a patient. Do not pretend that a delusion is
actually true, but convey that delusion is actually true for the patient. If a
paranoid schizophrenic says that “people are watching me all the time and
they could know what I am thinking and see what I am doing” the doctor
should say that “I can understand what you are feeling but I could not see
anyone here who is keeping an eye on you”.
Interviewing a paranoid patient:
Do respect a paranoid’s patient’s need for maintaining distance and
control. Sometimes the paranoid patients are more comfortable when
they are aloof as opposed to the expressions of warmth and empathy.
Allow, the patient to speak. This helps the patient to feel that he is
somebody important and has something important to say.
Be flexible about interview times. If the patient can tolerate only 10
minutes , tell him that the interview will resume later.
DO pay attention, how the patient make you feel. Work over and analyze
your feelings. Feel empathetic but do not get carried over by the feelings.
If you feel annoyed find the reason for it.
Interviewing a patient with somatization:
Encourage the development of trusting relationship.
Don’t argue about the reality.
Respectfully and systematically evaluate physical symptoms.
Establish appropriate therapeutic goals.
Regular follow-up independent of symptoms.
Appropriate treatment of psychiatric condition.
Only appropriate referrals, but maintain involvement.
Minimize medicalization.
Focus on positive aspects of patient’s personality and behavior.
Suicide assessment:
Current presentation of suicidality:
Suicidal or self-harming thoughts, plans, behavior, and intent.
Specific methods for suicide, including their lethality and whether firearms are accessible.
Evidence of hopelessness, impulsivity, anhedonia, panic attacks, or anxiety.
Alcohol or substance abuse.
Thoughts, plans, or intentions of violence toward others.
Psychiatric illness:
Current evidence of psychiatric disorder , mood(MDE or mixed episodes), schizophrenia,
substance abuse, anxiety disorders, BPD.
History: previous suicidal attempts, or other self-harming behavior.
Family history of suicide.
Previous and current medical diagnosis ,medications ,surgeries, hospitalizations.
Suicide assessment:
Psychosocial situation:
Acute and chronic psychosocial crises, interpersonal loss, financial difficulties, or change in
socioeconomic status , family discord, domestic violence, past or current sexual or physical
abuse or neglect.
Employment, living situation, and presence or absent of external support.
Family constellation and quality of family relationships.
Cultural and religious beliefs about death or suicide.
Individual strengths and vulnerabilities:
coping skills.
Personality traits.
Past responses to stress.
Capacity for reality testing.
Ability to tolerate psychological pain and satisfy psychological needs.
Risk factors for violence and assessment of dangerousness:
Must be conducted in a safe environment, safe for patient and psychiatrist.
Determine substance of abuse, alcohol, amphetamines.
Severe akathisia (Akathisia is a movement disorder characterized by a feeling of inner restlessness and a
compelling need to be in constant motion, as well as by actions such as rocking while standing or sitting, lifting the feet
as if marching on the spot, and crossing and uncrossing the legs while sitting. People with akathisia are unable to sit or
keep still, complain of restlessness, fidget, rock from foot to foot, and pace.) may contribute to aggressive
behavior.
Inquire about thoughts of violence and determine the person to whom this is
directed.
When patient pose serious threat to others (having homicidal ideation with
imminent plans , the psychiatrist must consider hospitalization.
The psychiatrist must exercise his own best judgment in accord with the legal
requirements and system.
How to deal with a violent patient:
If the patient is acutely aggressive, the psychiatrist can try to calm the patient
by “ de-escalation” technique.
If restraint or seclusion is required it should be done with adequate numbers of
well trained professional staff.
When sedation is indicated and the patient refuse oral medication,
intramuscular injection of antipsychotic (haloperidol 5mg) can be given with or
without 1-2 mg of oral or intramuscular lorazepam.
After seclusion, restraint or sedation, the mental status and vital signs of the
patient should be monitored regularly.
Release from seclusion or restraint can proceed in a graded fashion, as risk of
harm to self or others diminishes.
De-escalation technique
Appear confident
· Displaying calmness
· Create some space
· Speak slowly, gently and clearly
· Lower your voice
· Avoid staring
· Avoid arguing and confrontation
· Show that they are listening
· Calm the patient before trying to solve the problem
Staff should adopt a non-threatening body posture:
· Use a calm, open posture (sitting or standing)
· Reduce direct eye contact (as it may be taken as a confrontation)
· Allow the patient adequate personal space
· Keep both hands visible
· Avoid sudden movements that may startle or be perceived as an attack
· Avoid audiences – as an audience may escalate the situation
Thank You
Behavioral Observations
are an attempt by the psychologist to watch the problems and behaviors in
the real world.
The clinical interview relies on self-report information that may or may not
be accurate. Information obtained through an interview may be biased.
naturalistic,
self-monitoring, and
controlled
Behavioral Observations
Functional analysis refers to a behavioral analysis of the antecedents, or what
led up to the behavior, as well as the consequences of the behavior.
Target behaviors are specific behaviors that are examined, evaluated, and
altered by interventions. Many people have vague complaints. To isolate target
behavior is difficult.
Disadvantages:
It can be time consuming and expensive.
Confidentiality can be problem, when teachers, coworkers, peers, and others know
that there is a psychologist.
Most people behave differently when they know they are being watched. This is
referred to as reactivity.
The problematic behavior may or may not occur during the observation.
The observation may be biased. The psychologist may expect to see certain behavior.
Self-Monitoring
is conducted by the patient. The patient is instructed in how to observe and
record his or her own behavior in an objective manner. Self-monitoring has
become a very commonly used tool not only for assessing problems but also
as an intervention.
Patients are instructed to record the problematic behaviors when they occur
each time as well as other important information such as feelings and
thoughts.
If patients know that they must write down everything they eat, they may
think twice before impulsively eating. Thus, self-monitoring is used as both
an intervention and an assessment technique.
Self-Monitoring
Disadvantages:
Few people are willing to self-monitor for a long period of time.
Some people may not record honestly because of embarrassment and /or
denial.
Controlled Observations
Rather than waiting for target behaviors in the natural environment or for
the patient to report using self-monitoring, controlled observations force
the behavior to occur in a simulated way.
The most commonly used type of controlled observation is the role play.
Role plays require people to act as if they were in a particular situation that
causes them concern. Role plays can be used both for the assessment of a
problem and for treatment interventions.
Checklists and Inventories
Interviews and observations can provide a great deal of helpful information,
but both methods take a lot of time to complete and tend to be expensive.
When many people’s assessment are needed at one time, they are
impractical.