The Complete Clinical Assessment in Psychiatry - HETI Complete Clinical Assessment in Psychiatry -...

The Complete Clinical Assessment in Psychiatry

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

HETI | RESOURCE

Authors

Dr. Margot PhillipsConsultant Psychiatrist

NSW Institute of Psychiatry Special Fellow, Royal North Shore Hospital, Sydney

Staff Specialist South Eastern Sydney and Illawarra Area Health Service

Site Coordinator of Training, St George and Sutherland Hospitals, Sydney

Joanne ShawHETI Project Manager

Research Psychologist, Discipline of Psychological Medicine, University of Sydney

Dr. Jeffrey StreimerConsultant Psychiatrist & Psychotherapist

RANZCP NSW Director of Advanced Training in Psychotherapy

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

Acknowledgements

Dr. Agnes ChanConsultant Psychiatrist

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

Site Coordinator of Training, Royal North Shore Hospital, Sydney

Dr. Ralf IlchefConsultant Psychiatrist


Clinical Senior Lecturer, Discipline of Psychological Medicine, University of Sydney

Dr. Lisa LampeConsultant Psychiatrist

Staff Specialist Northern Sydney Central Coast Health Service

Senior Lecturer, Discipline of Psychological Medicine, University of Sydney

Dr. Loyola McLeanConsultant Psychiatrist & Psychotherapist

CADE clinic and Amaranth Centre, Sydney

Lecturer, Discipline of Psychological Medicine, University of Sydney

Dr. Jeanette MartinConsultant Psychiatrist & Psychotherapist

Psychotherapy Educator Northern Sydney Central Coast Health Service

Member of the Committee for Advanced Training in the Psychotherapies

Dr. Robert RussellConsultant Psychiatrist & Psychogeriatrician

Senior Staff Specialist, Northern Sydney Central Coast Health Service

Dr. Steven SpielmanConsultant Psychiatrist & Psychotherapist

Senior Staff Specialist, Child and Adolescent Psychiatry, Northern Sydney Central Coast Health Service

Dr. James TelferConsultant Psychiatrist & Psychotherapist


Clinical Lecturer, Discipline of Psychological Medicine, University of Sydney

Clinical Director C. J. Cummins Unit, Royal North Shore Hospital

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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

HETI THE COMPLETE CLINICAL ASSESSMENT IN PSYCHIATRY

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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?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.


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An area of unmet needA 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

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.

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Our visionThis 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.

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.

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Learning goalsOverall learning goalTo 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: º 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 º 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: º To be aware of some of the challenges that may arise when applying theoretical

knowledge to clinical practice º To understand different interviewing techniques and how these vary according to

the situation º To enable the practice of interview skills through role plays and observed interviews º To enable the development of cognitive assessment skills º To encourage reflection on clinical assessment skills and the clinical assessment process º 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 º To begin to use clinical reasoning skills during the assessment process

• Formulation

Content knowledge º To understand the elements of a formulation º To know the various schema used in formulation º To understand how a formulation will vary depending on its function,

for example: – Diagnostic formulation – Cognitive-behavioural formulation – Psychodynamic formulation

Process knowledge º To become familiar with using data from the clinical assessment to understand

the patient’s predicament º To synthesise the data into a coherent formulation º To learn to begin to formulate from early in the assessment process


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About this materialThere 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

The manualFor 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 USBEnclosed 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 materialThe 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 manual’s 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.

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What is required of you as facilitatorYou 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 individual’s 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 individual’s skills and techniques.

Facilitator notesFacilitator 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 sizeWe 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.

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.

ConsentsWhen 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.

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Session 1: The Psychiatric Assessment: An Overview

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Session SummaryThis 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 Session1. 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 SessionOption 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

Session 1The Psychiatric Assessment: An Overview

OPTION AOrganise your own

interview

OPTION BWatch the interview on the accompanying USB

OBSERVATION OF INTERVIEW AND GROUP DISCUSSION

OR

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OPTION A: Organise your own interview

Preparation for SessionPlease 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

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:

º through a one-way screen º via a monitor in another room º 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

1The Psychiatric Assessment: An Overview

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


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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

OPTION B: Use the recorded interview on the accompanying USB

Preparation for Session1. 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)


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 traineesAppendix 1.2.2 – Facilitator notes


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AppendicesAppendix 1.1.1 – Discussion prompts for traineesFor 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 patient’s affect

10. Comment on the patient’s 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 traineesFor 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




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


Now think back to the full-length interview




16. What is your provisional diagnosis?

17. What are your differential diagnoses? Discuss these



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 1.2.2 – 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.


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.


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


• 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.”

Excerpt Two


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 patient’s 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 patient’s 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 that’s hard for you to talk about.”

“That seems to be a sensitive area.”

“It sounds like you don’t want to talk about that topic right now.”

Excerpt Three


Involuntary mouth movements – pouting: this is an example of “rabbit syndrome”, a form of tardive dyskinesia that has been commonly reported with risperidone.

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Now think back to the full-length interview


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: º Age-related restriction of affect º Personality-style (e.g. reserved personality, schizoid, avoidant, anxious) º Depressive disorder º Residual paranoia (guarded and suspicious) º Negative feature of a schizophrenia-spectrum disorder º 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.


Thought-form is coherent. There is no formal thought-disorder.


Immediate suicide risk

• Low • Engaged 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 • Treatment under the Mental Health Act 2007 – involuntary admissions, multiple renewals

of Community Treatment Orders – suggests past risk and associated impaired insight • The patient’s 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.


• The temporal relationship of mood and psychotic symptoms:

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

º 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


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 “I’m 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.

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Session 2: Introduction to Psychiatric History-Taking

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Session 2Introduction to Psychiatric History-Taking

Session SummaryThis 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-playsOption B: Watch the role-plays on the accompanying USB

Focus of the Session1. 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 SessionPART 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.

Dr Agnes ChanThe Psychiatric Interview:

(History Taking)

Dr James TelferThe Diagnostic Interview

in Psychiatry

PART 1: LECTURES


role plays

OPTION BWatch role plays on

the accompanying USB

PART 2: ROLE PLAYS AND GROUP DISCUSSION

OR

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2Introduction to Psychiatric History-Taking

PART ONE: LecturesPreparation for Session1. 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)

Lecture Two: The Diagnostic Interview in Psychiatry Dr James Telfer (10 minutes)

3. Allow question and discussion time (10 minutes)

PART TWO: Role-playsOPTION A: Organise your own role-plays using provided vignettes Preparation for sessionPlease 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


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 interviewer’s performance

2. Select a trainee who is not participating in either role-play to be ‘the moderator’ of the role- plays 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)

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.

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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

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)


OPTION B: Watch the role-plays on the accompanying USBPreparation for Session1. 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)

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)

Note to Facilitator

It may be necessary to redirect discussions if the trainee’s individual technique is becoming a focus.


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.

23


2

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)


Appendices listing

For use with Part One (Lectures)Appendix 2.1.1 – Lecture slides for The Psychiatric Interview: (History Taking) by Dr Agnes ChanAppendix 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 BAppendix 2.3.5 – Interviewing Techniques

Introduction to Psychiatric History-Taking

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Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

Appendices Appendix 2.1.1 – Lecture slidesFor use with Part One (Lectures)

The Psychiatric Interview: (History Taking) by Dr Agnes Chan

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2

Slide 7

Slide 9

Slide 11

Slide 8

Slide 10

Slide 12


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Slide 15

Slide 17

Slide 16

Slide 13 Slide 14

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Page 1


Appendix 2.1.2For use with Part One (Lectures)

The Diagnostic Interview by Dr Telfer

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Page 2

29


Page 3


30

Page 4

31


Page 5


32

Page 6

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Page 7


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Page 8

35


Page 9


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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 roleYou 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.

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 roleYour 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 don’t know how you are going to get through it. You feel like you are wading in mud. You are heavy and slow and you can’t think straight. You seem to be forgetting things and not concentrating. The other day, you couldn’t 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 didn’t have to be anywhere special but it still made you feel hopeless and useless.

You haven’t been sleeping well. You lie awake at night worrying about the day that’s 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 something‘s woken you, but it’s all quiet and your girlfriend is fast asleep.

You are not sure if you’ve lost weight, but your appetite hasn’t 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 can’t make a single decision. Not even about what tie to wear with what shirt in the morning. That’s partly why you don’t go to work sometimes. You just go back to bed. If you go to work, you don’t 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 they’ve been looking at you strangely, wondering if something’s up, and also where you’ve 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 don’t want to make too much of it. You definitely haven’t heard anything they’ve said – no hallucinations, no secret conspiracies, nothing odd like that.

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2

You feel like you were always reliable. At least you had that. Maybe not the most exciting guy, but steady. Now, you’re not even that. You feel a bit guilty about work and about neglecting your girlfriend and about being so useless.

You haven’t spoken to anyone at work about what is happening. Your boss hasn’t said anything. He doesn’t seem like he’d “get it”. He’s a bit of a bloke. Not into the “touchy-feely” stuff. You aren’t into that either. So you can’t figure out what’s 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 you’ve stopped calling your friends back and you haven’t been to anything your girlfriend has organised.

You speak to your mum every couple of weeks but you don’t want to worry her or your dad. Your brother lives overseas.

Your girlfriend is really worried about you. She keeps asking what’s 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 GP’s been great. She’s seen you once a week since then. Started you on Cipramil three weeks ago. One tablet. You can’t remember the dose. But you don’t think it’s working. You haven’t 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 you’re not that concerned about it. It probably wouldn’t look good for the next promotion though if your boss knew you get down and can’t cope. That goes through your mind a bit.

It’s only been in the last week, when you are lying in bed at night thinking about things, that you’ve started to wonder what the point of all this is. Sometimes you think that if you had a gun you’d just blow your brains out. God no, you’d never do it. You don’t have a gun. They scare you. It’s just a thought. It’s gone as quickly as it comes. You sure haven’t made any plans or preparations, or thought about any other ways. You don’t think you’d ever actually do it. It’s not in your nature, you don’t think. And you’d hate to upset the people around you. It’d be awful.

You haven’t been paranoid about anything else (apart from the people at work maybe talking about you). There’s been nothing suspicious and you haven’t 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. She’d probably be better off with someone else. You think she’s too good for you. But you don’t want to let her down, either. You can’t really talk to her about this. You aren’t good at talking about stuff, and anyway it’d just upset her.

You got depressed at high-school once, but never got any treatment. It sure wasn’t this bad. It seemed like acne and teenage angst kicked in and you were on your own all the time. You weren’t 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 he’d 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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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,

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 HISTORYAppendicectomy 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

39


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 roleYou 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 don’t 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 don’t 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 aren’t 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 roleYour 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 it’s 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 wouldn’t go to sleep at all because you thought they’d come into your room and you don’t really know, kill you or something. You heard voices all the time. You can’t remember it, that well. The memory is blurred. But they put you on heaps of medication and you got all stiff and then couldn’t sit still. Eventually, they got it right and you went home with your parents.

Since then you’ve been in hospital about five times, every two years at first. Most times were on a schedule. But now you’ve been out of hospital for eight years. You think that’s pretty good.

You’ve tried a lot of different medications and you have had ECT (shock treatment) twice. You’ve 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. You’re on lithium (250mg morning and night) and Seroquel (600mg at night). You’ve been on them for ages.

You don’t 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 you’re sluggish in the day. Still, you know you need it because if you ever stop it you get sick again.

You’re 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 you’re in a routine. Mum is always checking up on you, too.


40

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 can’t remember how long ago this was.

The first time was the worst. Because no one knew what was going on. You’d 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 that’s all gone now and you don’t really want to talk about the past. You can’t remember it that well.

You have had times when you’ve been too high. All giggly and full of energy. You can’t 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 you’ve done is shout at your parents.

Most of the time you don’t have any symptoms. When you go out you sometimes get paranoid that people are talking and laughing about you, but you know it’s just the schizophrenia.

You’ve got some friends. One friend from school that you talk to every couple of months and a few friends you’ve 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. She’s 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 you’d get married and have a family but you don’t think that’s going to happen now. You have a cat called Mustard and she cheers you up. Mostly you’re okay and you are thinking of doing animal studies at TAFE next year.

41


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


42

Appendix 2.2.3 – Discussion prompts for trainees for Role-play 1 and Role-play 2For 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

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?

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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?




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


44

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?


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

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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

− Triggers/precipitants to the depression

− Presence or absence of psychotic symptoms

− Presence or absence of anxiety symptoms


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


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 patient’s responses

− Nodding

− Eye contact held but non-confrontational


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

º “You seem to be struggling with that”

º “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.


46

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

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”


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 reality- based, or may be an overvalued idea or a delusion.

Role-play how you could take up some of the missed leads.

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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


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 don’t want to talk about that” “That’s great you have been good for a long period of time”


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


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 “That’s okay, I can understand why you don’t 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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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 don’t want to talk about difficult topics, can’t 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.”

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Appendix 2.3.5 – Interviewing techniquesFor 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 patient’s experience

º “That must have been hard for you”

• Making observations and feeding them back to the patient

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

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

º 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

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

• Putting hypotheses to the patient

º “So, when you feel hurt you respond by getting angry?”

• Appropriate reassurances

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NOTES

Session 3: Cognitive Assessment I

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Session 3Cognitive Assessment I

Session Summary This session is the first of two sessions on the Cognitive Assessment in Psychiatry.


PART ONE: A lecture about bedside testing of cognitive function

PART TWO: A workshop in which trainees practice the cognitive assessment

Focus of the Session1. 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 SessionPART 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


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)

PART 1: LECTURE

PART 2: WORKSHOP

Dr Agnes ChanBedside Cognitive Testing

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3Cognitive Assessment I

PART TWO: WorkshopPreparation 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 Session1. 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


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 – Checklist 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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Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

Appendices Appendix 3.1 – Lecture NotesFor use with Part One (Lecture)

Bedside Cognitive Testing by Dr Agnes Chan

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Slide 7

Slide 9

Slide 11

Slide 8

Slide 10

Slide 12


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Slide 13

Slide 15

Slide 17

Slide 14

Slide 16

Slide 18

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Slide 19

Slide 21

Slide 23

Slide 20

Slide 22

Slide 24


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Slide 25

Slide 27

Slide 29

Slide 26

Slide 28

Slide 30

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Appendix 3.2For use with Part Two (Workshop)

Checklist for testing cogitive function: Testing Cognitive Function at the Bedside.

p113


60

p114-115

61


p116-117


62

p118-119

63


p120-121


64

p122-123

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p124-125


66

p126-127

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p128-129


68

p130-131

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p132-133


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p134-135

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p136-137


72

p138-138

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p140-141


74

p142-143

Session 4: Cognitive Assessment II

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Session 4Cognitive Assessment II

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 patient’s 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 Session1. 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 SessionComputer, with either a data projector or TV monitor, and external speakers


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 (Addenbrooke’s 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)

OBSERVATION OF A COGNITIVE ASSESSMENT AND GROUP DISCUSSION

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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

Appendices listing

Appendix 4.1 – Discussion prompts for traineesAppendix 4.2 – Facilitator notesAppendix 4.3 – Addenbrooke’s 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?

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 patient’s 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 patient’s 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 Alzeimer’s 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?

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Appendix 4.2 – Facilitator notes

The interviewing psychogeriatrician uses the Revised Version of the Addenbrooke’s 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?

º “Inherit this” and “Slip into this” [when talking about the onset of his memory disturbance]

º “Don’t have much of an intake” [regarding the reduction in his social and other activities]

º “When you’re 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 patient’s 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?

1. 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.


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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 patient’s 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?

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

º Although not shown in the video, the patient has a history of hypertension – a vascular risk factor for both Vascular Dementia and for Alzheimer’s 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 Alzheimer’s Dementia.

11. Comment on the patient’s 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.

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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 Alzeimer’s 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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No. 1

Appendix 4.3 – Addenbrooke’s Cognitive Examination (ACE-R) – Blank copy

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No. 2

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No. 3

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No. 4


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No. 5

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No. 6


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No. 7

Appendix 4.3 – Addenbrooke’s Cognitive Examination (ACE-R) – Completed assessment

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No. 8


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No. 9

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No. 10


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No. 11

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No. 12


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No. 1

Appendix 4.4 – Carers’ Assessment of Executive Function – Blank copy

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No. 2

Appendix 4.4 – Carers’ Assessment of Executive Function – Completed assessment

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NOTES

Session 5: Movement Disorders

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Session 5Movement Disorders

IMPORTANTThis 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.


PART ONE: Discussion and role-play on the clinical assessment of movement disorders

PART TWO: (Optional) CD examples of movement disorders

Focus of the Session1. 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)


PART TWO: nil

PART 1: GROUP DISCUSSION AND ROLE-PLAY

PART 2: (OPTIONAL) CD EXAMPLES OF MOVEMENT DISORDERS

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5Movement Disorders

PART ONE: Group Discussion and Role-playPreparation 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


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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PART TWO: CD Examples of Movement DisordersPreparation 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

Appendices listing

For use with Part One (Group Discussion and Role Play) Appendix 5.1.1 – Extrapyramidal Syndrome SummaryAppendix 5.1.2 – AIMS Examination procedureAppendix 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

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5Movement Disorders

AppendicesAppendix 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

Acute syndromes

Akathisia

º Subjective feeling of inner restlessness, often associated with observed movements such as rocking, pacing, and shifting the weight from foot to foot

º Usually occurs within hours to days of treatment commencement or of increasing the dose

Postural tremor

º Fine tremor that develops when trying to maintain a postural stance

Parkinsonism

º Parkinsonian tremor, muscular rigidity and bradykinesia

º May be associated with mental symptoms such as apathy and mental slowing

º Occurs within 5-30 days of treatment commencement or of increasing the dose

Focal Dystonias

º Sustained abnormal posture secondary to involuntary muscle spasm

º May affect a single muscle or a group of muscles: head, neck, limbs or trunk

º Occurs within the first few days of treatment commencement or of increasing the dose

º E.g. oculogyric crisis, torticollis, the Pisa-syndrome

Acute dyskinesias

º Repetitive, involuntary, hyperkinetic movements

º Often in the face and mouth region

º More commonly occurs after more than three months of treatment commencement when it is called tardive dyskinesia (see below)

Neuroleptic Malignant Syndrome

º A medical emergency

º 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)

º May 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.

Tardive dyskinesia

º Choreiform, dystonic, athetoid or stereotypic movements

º Frequently affect the mouth and tongue, e.g. lip-smacking, sucking, puckering and facial grimacing

º Seriously disabling dyskinesia is uncommon but a small proportion may affect walking, talking, eating and breathing

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Appendix 5.1.2 – AIMS Examination ProcedureFor 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.

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 patient’s 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 patient’s 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

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

0 1 2 3 4

2. Lips and perioral area e.g. puckering, pouting, smacking 0 1 2 3 4

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

0 1 2 3 4

4. Tongue. Rate only increase in movement both in and out of mouth, not inability to sustain movement

0 1 2 3 4

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)

0 1 2 3 4

6. Lower (legs, knees, ankles, toes), e.g. lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot

0 1 2 3 4

Trunk Movements

7. Neck, shoulders, hips e.g. rocking, twisting, squirming, pelvic gyrations. Include diaphragmatic movements

0 1 2 3 4

Global Judgments

8. Severity of abnormal movements 0 1 2 3 4 (based on the highest single score on the above items)

9. Incapacitation due to abnormal movements 0 = none, normal 1 = minimal2 = mild3 = moderate4 = severe

10. Patient’s awareness of abnormal movements 0 = no awareness 1 = aware, no distress2 = aware, mild distress3 = aware, moderate distress4 = 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

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

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NOTES

Session 6: Phenomenology

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Session 6Phenomenology

Summary of Session

This session provides an overview of phenomenology.


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 Session1. 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 RequiredPART ONE: NIL

PART TWO: NIL

PART 1: INTERACTIVE DISCUSSION

PART 2: ROLE-PLAY

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PART ONE: Interactive DiscussionPreparation 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


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

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-playPreparation 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 interviewer’s role will be to take a history from the simulated patient during the session


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


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.

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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)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

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No. 1

AppendicesAppendix 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

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Appendix 6.2 – Discussion promptsFor 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 someone’s mind?

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

º How does this hold for Anorexia Nervosa?

º How does this hold for Body Dysmorphic Disorder?

• A hallucination and a pseudo-hallucination

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6Phenomenology

Appendix 6.3 – Facilitator notesFor 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?

Being unable to directly observe the mind, we are dependent on particular patterns of communication, such as speech.

5. When do we face difficulties assessing someone’s mind?

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

We can use other tools such as observing behaviours but because of the lack of objective tests and a relative lack of other objective signs we are limited.

6. What is the difference between signs and symptoms?

A symptom is any subjective evidence of disease. It is a phenomenon that is subjectively 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?

The lack of objective assessment tools makes psychiatry, more than many other medical specialties, heavily reliant on symptoms.

When a sign is present, such as psychomotor impairment, or catatonia, it usually indicates 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?

Jaspers 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.

Although delusions are diagnostically nonspecific, some types of delusions are more prevalent 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.

Schneiderian first-rank symptoms and primary delusions were once seen as pathognomonic 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:

º 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.

º 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:

•Adelusionandanovervaluedidea

•Howdoesthisholdforanorexianervosa?

•Howdoesthisholdforbodydysmorphicdisorder?

•Ahallucinationandapseudo-hallucination

Bring the groups together to discuss their ideas.

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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 can’t 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.

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

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Session 7: Mental State Examination I

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Session 7Mental State Examination I

Summary of SessionThis 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 patient’s mental state.

Focus of the Session1. 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



1. Review the accompanying USB material showing a registrar presenting their account of a patient interview followed by a group discussion of that patient’s 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


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)


Appendices listing

Appendix 7.1 – Mental State ExaminationAppendix 7.2 – Classification of Defense Mechanisms

OBSERVATION OF A RECORDED PRESENTATION AND A RECORDED GROUP DISCUSSION

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AppendicesAppendix 7.1 – Mental State Examination

AppearanceRelaxed, 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

BehaviourA 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

SpeechFluent 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) qualityStriking 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

MoodApprehensiveMildly dysphoric

AffectMildly 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 qualityPerformance mask

Thought-contentConcise 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 isn’t an overt sense of worthlessness, hopelessness or nihilism He reports some agency and control No frank delusions

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Thought formNo formal thought disorder.

Defense mechanisms:• minimising• repression • some denial • humour• isolation of affect?

PerceptionNo perceptual abnormalities identified

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

InsightNot 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

JudgementJudgement 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

RiskThe 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

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7Mental 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

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NOTES

Session 8: Mental State Examination II

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Session 8Mental State Examination II

Summary of SessionThis 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 Session1. 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 SessionNil

Preparation for SessionPlease note that there are no Facilitator notes for this option



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

OBSERVED INTERVIEW FOLLOWED BY A PERIOD OF REFLECTION

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• Explain the interview to the patient, confirming that patient confidentiality will be maintained

• Obtain written consent from the patient

Conducting the Session1. 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

º through a one-way screen

º via a monitor in another room

º by having the group present in the room during the interview*

• 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

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AppendicesAppendix 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.

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 patient’s 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 John’s 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 observersIn 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.

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8Mental 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)

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2. The patient’s appearance

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3. Body language (both interviewer’s and patient’s)

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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

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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)

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7. Any striking use of words or phrases?

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8. Other observations

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Session 9: Mental State Examination III

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Session 9Mental State Examination III

Summary of SessionThis 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 Session1. 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 SessionWhiteboard or butcher’s 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

INTERACTIVE EXERCISE INVOLVING A PRESENTATION OR AN INTERVIEW

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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:

• 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 butcher’s paper


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NOTES

Session 10: Personality Style I

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Session 10Personality Style I

Summary of SessionThis 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 patient’s personal and interpersonal style

Focus of the Session1. 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


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

PART 1: LECTURE

PART 2: INTERACTIVE EXERCISES

Dr Jeffrey StreimerPersonality

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PART ONE: Lecture

Preparation for Session1. 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



2. Play the lecture on the accompanying USB: Personality – Dr Jeffrey Streimer (30 minutes)

3. Allow question and discussion time (10 minutes) PART TWO: Interactive ExercisePreparation for Session1. Review the accompanying USB material of the two interview segments


3. Review facilitator notes (appendix 10.3)


1. Hand out the discussion prompts (appendix 10.2) and allow reading time

2. Play segment one on the USB (2 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)


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 traineesAppendix 10.3 – Facilitator notes

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Appendices Appendix 10.1 – Lecture slidesFor use with Part One (Lecture) Personality by Dr Jeffrey Streimer

Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

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Slide 7

Slide 9

Slide 11

Slide 8 See larger version on next page

Slide 10

Slide 12

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Slide 13

Slide 8

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Appendix 10.2 – Discussion prompts for traineesFor 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 man’s appearance?

4. What do you notice about his clothing? Do you notice any contrasts or contradictions in his attire and general appearance?

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 notesFor use with Part Two (Interactive exercise)

Segment One (1 minute)


Avoid prematurely foreclosing on your impressions. Allow apparent contradictions to remain. Note down the words, images and affects that arise. Use a white-board or butcher’s paper for this.

Spend at least five minutes on this section.

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 man’s 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.

The police-shirt is likely to be important, though we can only guess at its significance. 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.

This is probably a direct reflection of how he responds to the world. He attacks others through his own fear and defensiveness.

Segment Two (10 minutes)


Keep in mind your initial speculations.

Note down the words, images and affects that arise. Use a white-board or butcher’s 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.

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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?

While there are many features of an antisocial personality disorder, many of which are listed 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?

He demonstrates marked ambivalence. This leaves him frustrated and helpless in dealing with 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.

You are forced to either join him in his persecutory position or to reject his viewpoint and thus threaten to reject him.

Either of these two options reinforces his paranoid stance and leaves him isolated and lonely 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?

Reflect on his future prognosis particularly in regards to co-operative relationships including a therapeutic alliance.

The difficulty is that for this man, feeling vulnerable is likely to be intolerable. He will therefore 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

Session 11: Personality Style II

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150

Session 11Personality Style II

Summary of SessionThis 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 Session1. To expand on what was learned in Personality Style I

2. To encourage attunement to a patient’s interpersonal style

3. To reflect on interview techniques in response to a patient’s 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 one’s children

• the impact of trauma through generations

Materials Required for the SessionComputer, 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


OBSERVATION OF RECORDED SEGMENTS OF AN INTERVIEW AND GROUP DISCUSSION

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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

Appendices listing

Appendix 11.1: Discussion prompts for trainees

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AppendicesAppendix 11.1: Discussion prompts for trainees

1. What do you notice about the interviewer’s approach to the patient?

Why do you think he approaches him in this way?

Consider

• affects

• patient’s somatic state

• interviewer’s body language

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 children’s narcissism and grandiosity in terms of their upbringing?

7. What is the aetiology of his (the patient’s) 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

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154 Session 12Reflective Interview Skills I

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 B: Watch the interview material on the accompanying USB

Focus of the Session1. 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





interview

OPTION BWatch the interview segments

on the accompanying USB

OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION

OR

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OPTION A: Organise your own interviewPlease note that there are no Facilitator Notes for this option

Preparation for SessionPlease note that this option requires significant preparation time and requires video/DVD prerecording




• Explain the interview to the patient and obtain written consent

º 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 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

º 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

12Reflective Interview Skills I





– Ideally non-psychotic but, if psychosis is present, please ensure there is minimal blunting of affect and emotional reactivity.

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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

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 Session1. Review the USB material. It contains four segments from an interview between a psychiatry

registrar and a patient



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 interviewer’s technique and as session facilitator you must ensure that the discussion does not head down this path.

Note to Facilitator

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

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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


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)

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 traineesAppendix 12.2.2 – Facilitator notes


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Appendix 12.1.1 – Discussion prompts for traineesFor 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?


Note all words, images and affective responses on a white board or butcher’s paper

2. Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations.

3. What do you notice about the patient’s general appearance?

4. What do you notice about the patient’s tone of speech?

5. What do you notice about the patient’s content of speech?

6. Discuss any incongruities

For example:

• contradictions within the content of the segment – parts of the narrative that don’t 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 interviewer’s 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

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Appendix 12.2.1 – Discussion prompts for traineesFor 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?


2. “The first few minutes” of a psychiatric assessment are critical in forming early impressions and diagnostic hypotheses1

Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations


4. The patient’s 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?



7. What do you notice about the patient’s thought-form?



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?


Were there any changes or shifts in rapport in this segment? Discuss these


Segment Two




14. With your observations and associations in mind, discuss tentative hypotheses




18. In terms of diagnostic possibilities, what is the interviewer exploring in this segment?

19. What techniques is the interviewer using in this segment?


21. What is your response to the shocking content?

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


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24. Does the patient feel empathy for the boys?

25. Do you see a parallel between the patient’s lack of empathy and our difficulty in empathising with him?


Segment Three







31. Discuss any incongruities that are apparent


33. What do you notice about the patient’s understanding of actions and consequences?




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



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:




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Appendix 12.2.2 – Facilitator notesFor 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 butcher’s paper.

2. “The first few minutes” of a psychiatric assessment are critical in forming early impressions and diagnostic hypotheses



4. The patient’s 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.


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.


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”.



For example:




• 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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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.

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.


Were there any changes or shifts in rapport in this segment? Discuss these


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


14. With your observations and associations in mind, discuss tentative hypotheses.



The content is increasingly shocking and dramatic, and the story increasingly brutal.


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.


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.

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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




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.

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 patient’s lack of empathy and our difficulty in empathising with him?


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





31. Discuss any incongruities that are apparent


33. What do you notice about the patient’s understanding of actions and consequences?

He has a very primitive, concrete understanding of actions and their consequences.




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

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.



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:



• what this might tell us about their early life experiences.

Session 13: Reflective Interview Skills II

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Session 13Reflective Interview Skills II

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 B: Watch the interview material on the accompanying USB

Focus of the Session1. 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 SessionOption A: Video camera to record the interview OR

Video camera if pre-recording your own interview


Option B: Computer, with either a data projector or TV monitor, and external speakers OPTION A: Organise your own interviewPreparation for SessionPlease note that i) There are no Facilitator Notes for this option ii) This option requires significant preparation time and requires a video/DVD prerecording




interview

OPTION BWatch the interview segments

on the accompanying USB

OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION

OR

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º 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 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

º 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 13.1), and photocopy them to distribute to trainees during 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


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

13Reflective Interview Skills II





– Ideally non-psychotic but, if psychosis is present, please ensure there is minimal blunting of affect and emotional reactivity.

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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


1. Review the accompanying USB material of the five segments of an interview between a psychiatry registrar and a patient




1. Give a brief introduction to the interview on the USB to orientate the group


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 traineesAppendix 13.2.2 – Facilitator notes

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.

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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Appendix 13.1 – Discussion prompts for traineesFor 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




2. Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations




6. Discuss any incongruities apparent in this segment

For example:




• 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 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:





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Appendix 13.2.1 – Discussion prompts for traineesFor use with Option B (Watching the interview segments on the accompanying USB)

Segment One


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












11. What do you think this segment tells us about the patient’s 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?



14. With your observations and associations in mind, discuss tentative hypotheses.






20. How might you see a punitive reaction in the hospital setting?

21. Does anyone feel sad?

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Does the interviewer direct the patient much, or does the patient take control of the interview herself?


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?

28. If there is time, watch segments three, four and five and discuss following a similar format to above



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:





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Appendix 13.2.2 – Facilitator notesFor use with Option B (Watching the interview segments on the accompanying USB)

Segment One



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. Begin to formulate tentative hypotheses about the patient’s diagnoses on various axes on the basis of your observations and associations


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.


Low, monotonous and lacking inflection.


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. I’ve never had a boyfriend, never had sex, have no interest in sex. I’ve 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.


Circumstantial/over-inclusive – long and detailed response to a single question.


For example: • contradictions within the content of the segment – parts of the narrative that don’t 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.

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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.




In this segment, the patient is largely in control of the direction of the interview, and the interviewer is passive.

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 patient’s 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


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.








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 aren’t 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 don’t. 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 interviewer’s 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.

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. I n 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.



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:



• what this might tell us about their early life experiences.

Session 14: The Therapeutic Alliance

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176Session 14The 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 Session1. 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.


Preparation for Session1. 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

LECTURES

Dr Jeanette MartinThe Therapeutic Alliance

Dr Loyola McLeanWorking the Therapeutic

Alliance

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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)

Appendices listing

Appendix 14.1 – Lecture slides for The Therapeutic Alliance by Dr Jeanette MartinAppendix 14.2 – Lecture slides for Working the Therapeutic Alliance by Dr Loyola McLean

14The Therapeutic Alliance

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Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

AppendicesAppendix 14.1 – Lecture slides The Therapeutic Alliance by Dr Jeanette Martin

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Slide 7

Slide 9

Slide 11

Slide 8

Slide 10

Slide 12


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Slide 13

Slide 15

Slide 17

Slide 14

Slide 16

Slide 18

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Slide 19

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Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

Appendix 14.2 – Lecture slidesWorking the Therapeutic Alliance by Dr Loyola McLean

See larger version on page 180

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Slide 7

Slide 9

Slide 8

Slide 10

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NOTES

Session 15: Introductory Formulation I

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Session 15Introductory Formulation I

Summary of SessionThis 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 Session1. 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 patient’s 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



PART ONE: Lecture

Session Preparation1. 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

PART 2: OBSERVATION OF INTERVIEW SEGMENTS INTERACTIVE GROUP EXERCISE AND DISCUSSION

Dr James TelferFormulation

PART 1: LECTURE

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2. Play the lecture on the accompanying USB

Formulation – Dr James Telfer (10 minutes)


PART TWO: Interactive ExercisePreparation for Session

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)


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)


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 traineesAppendix 15.2.2 – Facilitator notesAppendix 15.2.3 – Example of a formulation Using the Three P ModelAppendix 15.2.4 – RANZCP Clinical Examinations Formulation Guidelines for Trainees

15Introductory Formulation I

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Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

Appendices Appendix 15.1 – Lecture slidesFor use with Part One (lecture)

Formulation by Dr James Telfer

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Slide 7

Slide 9

Slide 11

Slide 8

Slide 10

Slide 12


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Slide 13

Slide 15

Slide 17

Slide 14

Slide 16

Slide 18

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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?

3. Discuss the key issues raised in this interview

4. In this interview, what is the patient’s 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 patient’s behaviour during an interview also informs your formulation. Think about this man’s 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 trainee’s 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 NotesFor 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.

A collaborative style helps in coming to an understanding of the patient’s predicament. 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.


• 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 patient’s 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

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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 patient’s behaviour during an interview also informs your formulation. Think about this man’s behaviour during the interview and the information we may take from this

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


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 trainee’s 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 one’s individual lifespan.

This man’s 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

• coping mechanisms e.g. problem-solving skills

• defense mechanisms

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Appendix 15.2.3 – Example of a Formulation Using the Three P ModelFor 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.

We don’t know very much about Tom’s 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 Tom’s attachment to his primary caregiver. We might also hypothesise that his mother’s 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 Tom’s 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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No. 1

Appendix 15.2.4 – RANZCP Clinical Examinations Formulation Guidelines for Trainees

For use with Part Two (Interactive exercise)

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No. 2

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No. 3

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No. 4

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No. 5

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No. 6

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No. 7

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No. 8

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NOTES

Session 16: Introductory Formulation II

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206 Session 16Introductory Formulation II

Summary of SessionThis 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 Session1. 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 patient’s predicament from a number of angles





interview

OPTION BWatch the interview on the accompanying USB

OBSERVATION OF AN INTERVIEW FOLLOWED BY AN INTERACTIVE GROUP EXERCISE AND DISCUSSION

OR

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OPTION A: Organise your own interview






º 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:

º through a one-way screen

º via a monitor in another room

º by having the group present in the room during the interview*


* 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. 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

16Introductory Formulation II

N.B. Patient selection is important




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.

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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)


5. Lead a group discussion guided by the discussion prompts


OPTION B: Watch the interview segments on the accompanying USBPlease note that there are no Facilitator Notes for this option


1. Review the accompanying USB material of three interview segments. Note that these segments do not comprise a complete interview




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)


5. Lead a group discussion guided by the discussion prompts


Appendices listing

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

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AppendicesAppendix 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?


3. Discuss the key issues raised in this interview

4. In this interview, what is the patient’s primary predicament?

5. Why is the patient in this predicament – why is this happening at this particular time?

Consider:

• predisposing factors

• precipitating factors

• perpetuating factors

6. A patient’s behaviour during an interview also informs your formulation. How does the patient’s behaviour inform us?

7. Choose a member of the group to read out their formulation


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)?

16Introductory Formulation II

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NOTES

Session 17: Cognitive-Behavioural Approach and Formulation

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Session 17Cognitive-Behavioural Approach and Formulation

Summary of Session

This session is about a cognitive-behavioural approach to understanding a patient’s presentation.


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 Session1. 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



Whiteboard or butcher’s paper

PART ONE: LecturePreparation 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

PART 2: OBSERVATION OF INTERVIEW SEGMENTS AND GROUP DISCUSSION

PART 1: LECTURE

Dr Lisa LampeThe Cognitive Formulation

in Anxiety

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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


PART TWO: Interactive ExercisePreparation for Session1. 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)


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).


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 patient’s historyAppendix 17.2.2 – Discussion prompts for traineesAppendix 17.2.3 – Facilitator notesAppendix 17.2.4 – Cognitive-Behavioural Model for “Jenny”

17Cognitive-Behavioural Approach and Formulation

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Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

AppendicesAppendix 17.1.1 – Lecture slidesFor use with Part One (lecture)

The Cognitive Formulation in Anxiety by Dr Lisa Lampe

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Slide 7

Slide 9

Slide 11

Slide 8

Slide 10


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Appendix 17.2.1 – Summary of the patient’s historyFor 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

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

1. Not her real name.

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Appendix 17.2.2 – Discussion prompts for traineesFor 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?

4. Watch and discuss an excerpt of Segment One. In this excerpt the interviewer is posing a hypothesis to the patient.

What is Jenny’s response to the interviewer’s hypothesis? What does Jenny’s 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 Jenny’s 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 patient’s response to the hypothesis?

Segment Five

Watch the interviewer posing the following hypothesis in Segment Five



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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?

17. Why does avoidance (including safety behaviours) perpetuate the problem?

18. What are attributions? What is an attributional bias?

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Appendix 17.2.3 – Facilitator notesFor 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

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 patient’s response to these events, including their cognitive reactions

• How the patient’s 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?

This is an extremely anxious and distressed patient, with outbursts of tears, coughing, and even retching

She says, “When I’m with someone like you, I don’t want to leave you”

The patient’s 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 Jenny’s response to the interviewer’s hypothesis? What does Jenny’s response tells us?

The patient doesn’t 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 patient’s 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 butcher’s 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

Perpetuating:

• Perhaps the stress of ongoing conflict with her husband’s 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 don’t 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 Jenny’s 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.

The ongoing fears – of others seeing her in a distressed state, of never getting better, and the 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?

As well as an anxiety disorder, it is important to have major depression high up on the list of differentials.

Supporting the diagnosis of depression is the extreme distress that the patient exhibits, the 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

221


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 can’t 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

Segment Four

Watch the interviewer posing the following hypothesis in Segment Four


While the patient doesn’t openly disagree with the interviewer, she doesn’t agree with her either.

Segment Five

Watch the interviewer posing the following hypothesis in Segment Five


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 butcher’s 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.


222

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?

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.

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Appendix 17.2.4 – Cognitive-Behavioural Model for “Jenny” For use with Part Two (Interactive exercise)

Cognitive Behavioural Model

Behaviours

• Withdrawal from usual duties and activities

• Seeing a number of different health professionals who give different advice

Strengths

• Supportive relationship with husband

• Good premorbid function

• Reasonable insight

• Feels loved by her own family

• Some other good relationships, e.g. sister-in-law

Cognitions

• I am worthless and a failure

• I am letting others down

• I don’t deserve to be happy

Predisposing

• Past psychiatric history

• Family history

• Early life experiences

• Anxious, sensitive temperament

Environmental

• Conflict with in-laws

• Own family unable to give emotional support

Precipitating

• The event in the car

• Other life stressors e.g. moving

• Issues raised with private psychologist

PERPETUATING

DEPRESSION/ANXIETY

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NOTES

Session 18: Psychodynamic Formulation I

225

226

Session 18Psychodynamic Formulation I

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 Session1. 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

Materials Required for the SessionComputer, 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

LECTURES

Dr Jeffrey StreimerPsychological Formulation in

the Assessment Interview

Dr Loyola McLeanPsychodynamic Formulation: Aspects of Attachment and

Development

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.

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18Psychodynamic Formulation I

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)


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: It’s 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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Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

AppendicesAppendix 18.1 – Lecture slides Psychological Formulation in the Assessment Interview by Dr Jeffrey Streimer

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Slide 7

Slide 9

Slide 8

Slide 10

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Slide 1

Slide 3

Slide 5

Slide 2

Slide 4

Slide 6

Appendix 18.2 – Lecture slides Psychodynamic Formulation: Attachment and Development by Dr Loyola McLean

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Slide 7

Slide 9

Slide 11

Slide 8

Slide 10

Slide 12

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Slide 13

Slide 15

Slide 17

Slide 14

Slide 16

Slide 18


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Slide 19

Slide 21

Slide 23

Slide 20

Slide 22

Slide 24

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Slide 25

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Slide 29

Slide 26

Slide 28

Slide 30

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Slide 31

Slide 33

Slide 35

Slide 32

Slide 34

Slide 36

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Slide 37

Slide 39

Slide 41

Slide 38

Slide 40

Slide 42


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Slide 43

Slide 45

Slide 44

Slide 46

238

Slides 13 & 37

Session 19: Psychodynamic Formulation II

239

240

Session 19Psychodynamic Formulation II

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 Session1. 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 SessionComputer, with either a data projector or TV monitor, and external speakers Preparation for Session1. 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 facilitator’s copy of the formulation summary sheet (appendix 19.3)

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

241


19Psychodynamic Formulation II


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


Appendices listing

Appendix 19.1 – Case summaryAppendix 19.2 – Tables: Attachment Style Summary and Level of MaturationAppendix 19.3 – Formulation summary sheet for traineesAppendix 19.4 – Formulation summary sheet for facilitators

242

Appendices Appendix 19.1 – Case summaryKylie: Introductory Case Outline

This information is a summary of the history revealed at interview

‘Kylie’1 – nineteen-year old, unemployed single woman

Presenting Problems

− 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 Kylie’s ‘best friend’ and confidant − Father alcohol & cannabis abuser – frequent mood swings − Mother abused by husband (Kylie’s 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

1. Not her real name.

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No. 1

Appendix 19.2 – Tables

244

No. 1

Appendix 19.3 – Formulation summary sheet for trainees

245


No. 2


246

No. 3

USB

USB

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No. 4


USB

USB

USB

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No. 5

USB

USB

USB

USB

USB

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No. 6


USB

USB

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Appendix 19.4 – Formulation summary sheet for facilitators

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No. 2


USB

USB

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No. 3

USB

USB

USB

USB

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No. 4


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USB

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No. 5

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USB

USB

USB

USB

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No. 6


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NOTES

Session 20: History and Formulation in Child and Adolescent Psychiatry

257

258

Session 20History and Formulation 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 Session1. 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 SessionComputer, with either a data projector or TV monitor, and external speakers Preparation for Session1. 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


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

LECTURE

Dr Steven SpielmanAssessment in Child and Adolescent Psychiatry

259


20History and Formulation in Child and Adolescent Psychiatry

AppendicesAppendix 20.1 – Lecture slidesAssessment in Child and Adolescent Psychiatry by Dr Steven Spielman

Slide 1

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Building 12Gladesville HospitalShea Close off Victoria RoadGladesville NSW 2111

Tel: (02) 9844 6551Fax: (02) 9844 6544email: [email protected]

www.heti.nsw.gov.au


Date post:	07-Apr-2018
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