Psychiatric Interview Skills Guide

Supplied by the University of Sheffield

Introduction

Good doctor-patient communication is essential for a good doctor-patient relationship. The interview is particularly important in psychiatry, as this discipline relies less on physical examination and investigations and more on history and behavioural assessment.

The aim of this resource is to provide you with a basic framework to be used as a guide when interviewing different types of psychiatric patients. It also provides some useful links for additional information.

The focus is on the common psychiatric presentations you should be familiar with and will encounter during your placement in psychiatry. It is not an exhaustive list, but hopefully it will help you develop your psychiatric assessment skills and also serve as a resource to be drawn upon when preparing for observed cases and examinations.

We really hope you enjoy your psychiatry placement!

Contents

1. General Interview skills

2. The self harm / suicidal patient

3. The psychotic patient

4. The anxious patient

5. The cognitively impaired patient

6. The patient with an alcohol problem

Useful Resources

The Royal college of psychiatrists website has lots of useful resources to offer students. There is a ‘Clinical Skills Series’ with videos showing common psychiatric scenarios which you may find beneficial.

It is free and you can register as a ‘student associate’ by following this link:

http://www.rcpsych.ac.uk/discoverpsychiatry/studentassociates/resources/psychiatryinpractice.aspx

Another excellent resource is the CETL learning centre. There are numerous videos and interactive scenarios which can help you learn about common psychiatric scenarios. 

http://www.cetl.org.uk/learning/index.html

(Click on Tutorial link, scroll down to communication in mental health assessment)

http://www.cetl.org.uk/learning/tutorials.html

General Interview Skills

The following are general communication skills that can be applied to any doctor-patient interview:

Beginning the interview

Introduce yourself

Good afternoon Mr Jones. My name is Tom Brown….I’m a student doctor working with Dr X.

Check the patient’s name

Explain the purpose of the interview

    I would like to talk to you today to find out a bit more about your mood.

Put the patient at ease

     Is that OK with you?…..If at any time you do feel uncomfortable, please tell

    me…

Information Gathering

Use appropriate body language

Look relaxed and interested. Make good eye contact.

Ask open questions

Particularly useful in the early stages of the interview:

How have you been feeling lately?

            What can I do for you?

Clarify terms that you do not understand, are vague or ambiguous

You said a moment ago that you were feeling ‘out of sorts’. What exactly do you mean by that?

Express empathy

You must have been devastated when your wife died so suddenly.

That must have been a terrible time for you…

Facilitate communication

Facilitation conveys to the patient that you are listening to what they are saying and may be:

Verbal: Yes, I see,  OK…right….     Go on 

Non-verbal: Nodding one’s head

Mirror the patient’s feelings

The patient is usually helped to put feelings into words if the doctor acts as a sort of mirror in which the patient’s feelings are revealed. The following comments are examples of mirroring:

Your eyes began to water when you spoke about that.

            You looked upset when you mentioned your son

Use pauses appropriately

Sometimes when patients are expressing very painful feelings, they may need to be given the space to do this. Resist the temptation to always interrupt a silence with a new question and suppress what the patient may be struggling to say.

Rounding off the interview

Summarise

So let me summarise, you’ve told me that you have been feeling low and been unable to sleep for the last three weeks since you were diagnosed with breast cancer. Your mood has got progressively worse and two days go you took an overdose because you were feeling suicidal. Is that right?

Ask if there are any questions

Is there anything you would like to ask? Do you have any questions?

Thank the patient

The Self Harm / Suicidal Patient

One is often asked to see patients who have harmed themselves (eg. by self cutting or overdose). In this situation, one has to get a detailed HISTORY of the self-harm attempt and also assess the current SUICIDE RISK.

When taking a history of, for example, an overdose, the following details are important:

Objective (observed)

1. Exactly what was taken?

2. Where and when was it taken?

3. Was anyone else present?

4. Were any precautions taken to avoid discovery?

5. Was there a suicide note?

6. Was there any other act in anticipation of death? (eg. making a will)

7. Was action taken to alert possible helpers after taking the overdose?

Subjective  (patients perception)

1. What was the patient’s stated intent?

• What was the patient’s estimate of lethality of the substances taken?

• Evidence of recent / psychiatric illness, notably symptoms of depression or psychosis.

• Is there a past history of psychiatric illness or self harm?

• Is there any evidence of drug or alcohol abuse?

• Recent precipitating life event?

• Any family history of mental illness

• Social support at home?

When assessing the current suicide risk the following things are important things to ask about:

Assessment of history

Seriousness of attempt

Previous self harm

Presence of mental illness (eg., depression)

Use of drugs / alcohol

Identification of support person

Assessment of patient’s thoughts / mental state

Anything changed?

Regrets about attempt

Current intent (ie, any suicidal thoughts / plans)

Any reasons for stopping repeat

Feelings re future

Screening questions for depression

How have you been feeling in your spirits / mood?                   

Have you been rather weepy / crying a lot recently?

Have you been sleeping?

What is your energy like?

What is your interest in things like?

Can you concentrate OK?

What is your appetite like?

How is your weight doing?

Do you find your mood changes throughout the day?

Do you find yourself waking up earlier than normal?

Have you noticed any change in your sex drive recently?

If evidence of low mood, try to establish how low?

Have you been feeling hopeless/guilty/worthless?

Sometimes when people feel so low they do not want to go on any more. Have you felt like that?

Any thoughts of harming yourself?

Any thoughts of ending your life?

How does the future look?

The Psychotic Patient

Assessing a patient who has lost touch with reality can be difficult and daunting at first. It is useful to have some screening questions for common psychotic symptoms to utilise particularly when a patient may be guarded or lacking insight.

Screening questions for psychotic symptoms

General

Have you been having any strange experiences recently?

Auditory hallucinations

Do you ever seem to hear noises or voices even when there is nobody about?

Have you been hearing voices? What are they like?

Visual hallucinations

Do you ever seem to see things other people cannot?

Have you had any visions or seen things other people could not see?

Thought insertion

Do you ever have the feeling that thoughts are being put into your mind that are not your own?

Thought withdrawal

Do you ever feel that your thoughts are being taken out of your mind?

Thought broadcast

Do you ever feel that your thoughts are not private to yourself; as though they are being broadcast so others can know what you are thinking?

Thought echo

Does a thought in your mind ever seem to be repeated over again, like an echo?

Do you ever hear your thoughts echoed out aloud?

Passivity phenomena

Sometimes when people are unwell, they feel that they are no longer in control of their actions; it is as though they are being made to do things by someone else / an external force. Have you ever had this feeling?

Have you ever felt that your emotions / feelings are being controlled by an external force?

Delusions of persecution

Do you feel that your life is in danger or somebody is after you / wants to kill you?

Does anyone seem to be trying to harm you?

How sure are you about this?

Does there seem to be a plot or conspiracy behind this?

The Anxious Patient

An anxiety disorder is characterised by an intense, excessive state of apprehension and fear.

There are two common types of anxiety disorder:

• Generalised anxiety disorder – anxiety symptoms are pervasive and persistent

• Panic disorder – anxiety symptoms are episodic, occurring out of the blue

Screening questions for anxiety

Have you been worrying a lot recently?

Have you felt tense, keyed-up, and on edge?

Are you able to relax?

Have you been irritable?

How is your sleep?

Any difficulty falling asleep?

Any difficulty concentrating?

Any headaches, neckaches or back ache? 

Any dizziness, sweating?   (AUTONOMIC ANXIETY)

Any palpitations?

Any breathlessness?

Any tingling / pins and needles anywhere?

Any nausea, diarrheoa or vomiting?

Any problems passing water?

Are these symptoms there all the time or do they come as attacks with periods of feeling well in between?

The Patient with Cognitive Impairment

It is important to be able to assess a patient’s cognitive state confidently.

The Mini Mental State Examination (MMSE) is a widely used screening tool for cognitive function (see below). You should practice using it with patients you see. However, if time is very limited, the cognitive state examination needs to be more focused on the essentials – orientation, attention, concentration, memory (see later).

Mini Mental State Examination

Orientation What is the (year) (season) (date) (day) (month)? 5 Where are we: (country) (city) (part of city) (number of flat/house) (name of street)? 5 Registration Name three objects: one second to say each. Then ask the patient to name all three after you have said them. Give one point for each correct answer. Then repeat them until he learns all three. Count trials and record. 3 TRIALS Attention and calculation Serial 7s: one point for each correct. Stop after five answers. Alternatively spell ‘world’ backwards. 5 Recall Ask for the three objects repeated above. Give one point for each correct. 3 Language Name a pencil and watch (two points). Repeat the following: ‘No ifs, ands or buts’ (one point). Follow a three-stage command: ‘Take a paper in your right hand, fold it in half and put it on the floor’ (three points). Read and obey the following: Close your eyes (one point). Write a sentence (one point). Copy a design (one point). 9 Total score

Instructions for Administration of Mini Mental State Examination

Orientation

Ask the date. Then ask specifically for parts omitted, for example, ‘Can you also tell me what season it is?’ Score 1 point for each correct.

Ask in turn, ‘Can you tell me the name of this place?’ (town, country, etc). Score 1 point for each correct.

Registration

Ask the patient if you may test his or her memory. Then say the names of three unrelated objects, clearly and slowly, about one second for each. After you have said all three, ask him or her to repeat them.

This first repetition determines the score (0-3) but keep saying them until he or she can repeat all three, up to six trials. If he or she does not eventually learn all three, recall cannot be meaningfully tested.

Attention and calculation

Ask the patient to begin with 100 and count backwards by 7. Stop after five subtractions (93, 86, 79, 72, 65). Score the total number of correct answers. If the patient cannot or will not perform this task, ask him or her to spell the word ‘world’ backwards. The score is the number of letters in correct order, eg dlrow 5, dlowr 3.

Recall

Ask the patient if he or she can recall the three words you previously asked him or her to remember. Score 0-3.

Language

Naming: Show the patient a wrist-watch and ask him or her what it is. Repeat for pencil. Score 0-2.

Repetition: Ask the patient to repeat the sentence after you. Allow only one trial. Score 0 or 1.

Three-stage command: Give the patient a piece of plain blank paper and repeat the command. Score 1 point for each part correctly executed.

Reading: On a blank piece of paper, print the sentence ‘Close your eyes’ in letters large enough for the patient to see clearly. Ask him or her to read it and do what it says. Score 1 point only if he or she actually closes his eyes.

Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do not dictate a sentence, it is to be written spontaneously. It must contain a subject and verb and be sensible. Correct grammar and punctuation are not necessary.

Copying: On a clean piece of paper, draw intersecting pentagons (as below), each side about one inch and ask him or her to copy it exactly as it is. All ten angles must be present and two must intersect to score 1 point. Tremor and rotation are ignored.

Essential Cognitive State Examination

Orientation

Time                What day/time is it? (without looking at clock)

Person             Do you remember what I said my job is?

Place                 Do you know where you are?

Registration

3 items  (eg. ball, flag, tree)

OR

Name and address (eg. John Brown, 15 Regent St, Glasgow)

Attention & Concentration

Serial 7’s

 OR

Spell WORLD backwards

Memory

Recent

ie. Recall of three items or Name and address at 5 minutes 

Remote

eg. Past personal events, major public events in lifetime (eg. dates of World War II)

General

eg. News, name of Prime Minister

The Patient with an Alcohol Problem

Problems with alcohol such as MISUSE or DEPENDENCE may exist in isolation or co-exist with other psychiatric or physical disorders. It is important not only to be able to clarify whether a problem exists but also what type of problem it is.

CAGE may help in initial screening:

C     Have you ever felt you ought to CUT down on your drinking?

A     Have people ANNOYED you by criticising your drinking?

G     Have you ever felt bad or GUILTY about your drinking?

E     Have you had a drink first thing in the morning to steady your nerves or

        Get rid of a hangover (EYE OPENER)?

If you get positive replies to any TWO of these questions, it is worth taking a proper ‘drinking history’.

Taking a Drinking History

Start by asking the patient to describe a typical drinking day (Begin with the morning and proceed through the day) establishing what is drunk and when:

• Establish if the first drink of the day is taken to combat withdrawal symptoms
• Does the patient drink without getting drunk, or in bouts – usually at lunchtime and the evening?
• How much is drunk at each session?
• Does a single drink always lead to many more, and the person generally become drunk? If so, has this led to blackouts or falls?
• Establish whether drinking takes place alone, and whether the person drinks only in response to certain moods or situations.

Screening for alcohol dependence syndrome

PRIMACY

Has alcohol become the most important thing in your life?

Would you say you devote more time to drinking than to other things in your life?

TOLERANCE

Do you find that you have to drink more alcohol now to get the same level of satisfaction that you used to get with fewer drinks?

Have you noticed any change in the effect that alcohol has?

WITHDRAWAL

What happens if you don’t have a drink?

Sometimes, if people don’t drink for a while, they start feeling shaky, sweaty and anxious. Does this ever happen to you?

RELIEF DRINKING

If this does happen, do you find a drink will calm you down?

CRAVING

Do you ever find yourself craving alcohol?

NARROWING OF REPERTOIRE

What do you drink?

Do you find that you always drink the same things?

STEREOTYPED DRINKING PATTERN

Do you tend to drink at a set time / place / alone or with others? Does it vary?

REINSTATEMENT AFTER ABSTINENCE

Have you ever managed to stay off alcohol?

What has been your longest period of abstinence?