PSYCHIATRIC INTERVIEW OF THE MEDICALLY ILL
Doc Wamcie Chua
GENERAL PSYCHIATRIC EVALUATION
 A general psychiatric evaluation has as its central
component an interview with the patient
 The interview-based data are integrated with
information obtained through other components of the
evaluation - review of medical records, a physical
examination, diagnostic tests, and history from collateral
sources
 In the course of any evaluation, it may be necessary to
obtain history from other individuals
o Particularly psychiatric patients, they might be very
difficult to interview and some of them might not be
able to give you reliable information
 The aims of a general psychiatric evaluation are:
o To establish whether a mental disorder or other
condition requiring the attention of a psychiatrist
(i.e. psychiatric care and management) is present
o To collect data sufficient to support differential
diagnosis and a comprehensive clinical formulation
o To collaborate with the patient to develop an initial
treatment plan that will foster treatment adherence,
with particular consideration of any immediate
interventions that may be needed to address the
safety of the patient and others—or, if the
evaluation is a reassessment of a patient in long-
term treatment, to revise the plan of treatment in
accordance with new perspectives gained from the
evaluation
o To identify longer-term issues (e.g., premorbid
personality) that need to be considered in follow-up
care
 One thing you need to remember with regards to a
medical psychiatric consult is evaluations are usually
requested by other physicians & healthcare professionals
 Purpose: to assist in the diagnosis, treatment, and
management of an individual with a suspected mental or
behavioral problem on top of or along with a medical
illness
 Psychiatric evaluations for consultative purposes use the
same data sources as general evaluations
 Information about illness, treatment, and prognosis are
always relevant
MEDICAL-PSYCHIATRIC CONSULT
The aim of the consultative psychiatric evaluation is to
provide clear and specific answers to the questions posed by
the party requesting the consultation
SCOPE:
 Understand impact of medical illness & how this affects
the presentation, experience & impact of psychiatric &
psychosocial morbidity
 Conduct biopsychosociocultural assessment, create
formulation & implement appropriate treatment
 Assess reactions to illness
 Understand combined trajectories of illness &
developmental issues of the person with mental health
problems & mental illness
o E.g. 20y/o vs. 50y.o patient with head & neck tumor
o They are at different stages of development
according to Erik Erikson
o How would that tumor and issues of disfigurement
affect them considering at what particular stage they
are in psychosocial development
 Assess & treat somatization & somatoform disorders
 Assess & manage common neuropsychiatric disorders
o E.g. patient with SLE would develop cerebritis and
would also present with behavioral changes
 Understand needs of special populations with psychiatric
& psychosocial morbidity in medical settings
o Special populations: pregnant women, children,
geriatric patients
 Assess and manage acute & emergency presentations of
psychiatric morbidity in the general medical setting
PSYCHIATRY IN THE GENERAL HOSPITAL
CATEGORIES OF PSYCHIATRIC DIFFERENTIAL DIAGNOSIS
 Psychiatric Presentations of Medical Conditions
 Psychiatric Complications of Medical Conditions or
Treatment
 Psychological Reactions to Medical Conditions or
Treatments
 Medical Presentation of Psychiatric Conditions
 Medical Complications of Psychiatric Conditions or
Treatments
 Co-morbid Medical and Psychiatric Conditions
THE ART OF PSYCHIATRIC CONSULTATION
 Determining where on the vast border between
psychiatry and medicine a patient’s pathologic condition
is located is the psychiatric consultant’s fundamental task
 As for any physician, his or her chief responsibility is
diagnosis
o Diagnosis should be justified by a really good history
of psychiatric illness
 4 key differences between general hospital psychiatry
and practice in other venues (e.g. OPD)
o clinical approach
o environment
o style of interaction
o use of language
CLINICAL APPROACH
ENVIRONMENT
 Must be prepared to work in an atmosphere less formal,
rigid, and predictable than one typically found in an
office or a clinic
 Flexibility and adaptability are crucial.
STYLE OF INTERACTION
 Permit themselves to crouch at the bedside
 Lowering themselves to the recumbent patient’s level
can diminish apprehension and can minimize the
inherent power differential between doctor and patient
 Shaking hands or otherwise laying on of hands may
achieve the same end.
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LANGUAGE
 Allowance for flexibility also extends to the use of
language
 They can feel freer than they might in other practice
settings to use humor, slang expressions, and perhaps
even foul language.
o As the doctor, take your cue from the patient,
particularly those with space-occupying lesions. If
they are not yet aware of what that mass is, use
whatever term they use. Do not approach the patient
and say “cancer” outright, especially if they do not
know their diagnosis yet.
o E.g. ask the patient “Ano po ‘yang bukol na ‘yan na
nasa leeg niyo?” if the patient says “Ah, cancer daw
ito.” Ask about what know about “cancer” because
there’s a possibility that their understanding of that
term isn’t the proper definition of their term. It could
be an opportunity to correct misconceptions.
PROCEDURAL APPROACH TO PSYCHIATRIC
CONSULTATION
1. Speak directly with the referring clinician
2. Review the current and pertinent past records
3. Review the patient’s medications
4. Gather collateral data
5. Interview and examine the patient
6. Formulate a diagnosis and management plan
7. Write a note
8. Speak directly with the referring clinician
9. Provide periodic follow-up
MEDICAL-PSYCHIATRIC CONSULTATION AND
INTERVIEW
 The purpose of the initial psychiatric interview is to build
a relationship and a therapeutic alliance with an
individual or a family, to collect, organize, and synthesize
information about present and past thoughts, feelings,
and behaviors.
o Therapeutic alliance: when we appeal to that side of
the patient that wants to get well
 The relevant data derived from several sources
o Observing the patient’s behavior with the examiner
and with others present
o Attending to the emotional responses of the
examiner
o Obtaining pertinent medical, psychiatric, social,
cultural, and spiritual history (using collateral
resources if possible)
o Performing a mental status examination.
 The initial evaluation should enable the practitioner to
develop a clinical formulation that integrates biological,
psychological, and social dimensions of a patient’s life
and establish provisional clinical hypotheses.
 Finally, the interview must generate a relationship both
with the patient and with the primary medical or surgical
team as the basis of future collaboration for treatment.
 The medical literature clearly indicates that good
outcomes and patient satisfaction involve physician
relationship techniques that center on reflection,
empathy, understanding, legitimization, and support
 Patients reveal more about themselves when they trust
their doctors, and trust has been found to relate
primarily to behavior during clinical interviews rather
than to any preconceived notion of competence of the
doctor or behavior outside the office.
 Particularly important in the psychiatric interview is the
facilitation of a patient’s narrative
 The practice of narrative medicine involves an ability to
acknowledge, absorb, interpret, and act on the stories
and struggles of others
 The process of listening to patients’ stories is a process of
following the biological, familial, cultural, and existential
thread of the situation
 It encompasses recognizing the multiple meanings and
contradictions in words and events; attending to the
silences, pauses, gestures, and nonverbal cues; and
entering the world of the patient, while simultaneously
arousing the doctor’s own memories, associations,
creativity, and emotional responses
 Narratives, like all stories, are co-created by the teller
and the listener
 Storytelling is an age-old part of social discourse that
involves sustained attention, memory, emotional
responsiveness, nonverbal responses and cues,
collaborative meaning-making, and attunement to the
listener’s expectations
 If a physician can assist the patient in telling his or her
story effectively, reliable and valid data will be collected
and the relationship solidified
 Narratives are facilitated by authentic, compassionate,
and genuine engagement.
FACTORS INFLUENCING THE FORM AND CONTENT
OF THE INTERVIEW
SETTING
 The setting must be comfortable for the patient and the
physician
SITUATION
 Transcriber’s note: Please see sample situations at the
end of the trans
 In the general hospital, a physician is commonly asked to
perform a psychiatric evaluation on a patient who is
hospitalized on a medical or surgical service with
symptoms arising during medical or surgical treatment
 In each of these situations, the physician needs to
understand the nature of the situation and to take this
into account when planning the interview and
evaluation.
 It is always helpful to find out as much ancillary
information as possible before the interview.
 This may be done by talking with the medical team and
primary care physicians, by looking in an electronic
medical record or patient chart, and by talking with
family, friends, or professionals (such as police or
emergency medical technicians).
SUBJECT
 Confidentiality is a core part of the evaluation, and it will
be honored for the adolescent; it is essential that this be
communicated to them so they may feel safe in divulging
very sensitive and private information without fears of
repercussion
 One major exception is that if the patient or another is in
danger by virtue of an adolescent’s behavior,
confidentiality is waived
 Establishing a therapeutic alliance
 Building a relationship
o Elicit the patient’s story while guiding the interview
by diagnostic reasoning.
o Maintain an awareness that feelings, ideas, and
values of both the patient and the doctor influence
the relationship.
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 o Develop a partnership with the patient and form an
alliance in which the patient participates in decision-
making.
 One of the psychological reactions to illness of
patients, particularly those who have to be
admitted in the hospital to undergo treatment is
loss of control.
 So, letting them take an active part in decision
making with regards to their treatment
somehow gives them a semblance of control
o Work with patients’ families and support networks.
o Open the discussion
o Allow the patient to express his or her opening
statement without interruption.
o Encourage the patient to describe a full set of
concerns.
 Begin with more open-ended questions during
the start of the interview to encourage them to
expound
o Maintain a personal connection during the
interview.
o Gather information
o Use both open- and closed-ended questions.
o Provide structure, clarification, and a summary of
the information collected.
 Listen actively, using verbal and nonverbal methods (e.g.,
eye contact).
 Understand the patient’s perspective
o Explore contextual issues (e.g., familial, cultural,
spiritual, age, gender, and socioeconomic status).
o Elicit beliefs, concerns, and expectations about
health and illness.
o Validate and respond appropriately to the patient’s
ideas, feelings, and values.
 Share information
o Avoid technical language and medical jargon.
o Determine if the patient understands your
explanations.
o Encourage questions.
 Reach agreement on problems and plans
o Welcome participation in decision-making.
o Determine patient’s amenability to following a plan.
o Identify and enlist resources and supports.
o Provide closure
o Ask if the patient has questions or other concerns.
o Summarize and solidify the agreement with a plan of
action.
o Review the follow-up plans.
 Data Collection
 Psychiatric database
IN-PATIENT SETTING
 Evaluation should include assessment of the patient’s
access to appropriate treatment following
hospitalization.
 The patient’s living arrangements should also be
assessed to determine whether they will continue to be
suitable after discharge
 If the post-hospitalization disposition is not apparent, the
evaluation should identify both patient factors and
community resources that would be relevant to a viable
disposition plan and should identify the problems that
could impede a suitable disposition
 Family involvement, when appropriate, can also be
initiated
 Developing an ongoing relationship with staff on medical
inpatient units will increase the likelihood of obtaining
accurate behavioral data as well as of ensuring that staff
implement recommendations
 If the patient has an unclear sensorium or other cognitive
impairments, it is critical to interview people in the
patient’s relational network to see if these symptoms
were present before hospitalization or have developed
since treatment was begun
 In interviewing family members, it is very useful to
discuss their beliefs about the patient’s illness and prior
treatment, the patient’s record of adherence to
medication treatment, and concerns about discharge
planning
 Information written in general medical charts should be
confined to that necessary for the general medical team
and should be conveyed with a level of detail and
specificity that will be most helpful to the overall
management of the patient
 It is also important that documentation be of sufficient
detail to establish a diagnosis and treatment plan
 Information written in general medical charts should be
confined to that necessary for the general medical team
and should be conveyed with a level of detail and
specificity that will be most helpful to the overall
management of the patient
 It is also important that documentation be of sufficient
detail to establish a diagnosis and treatment plan
DOMAINS OF CLINICAL EVALUATION
REASON FOR THE EVALUATION
 What is the patient’s chief complaint and its duration?
 What reason does the patient give for seeking evaluation
at this specific time?
 What reasons are given by other involved parties (e.g.,
family, other health professionals) for seeking evaluation
at this specific time?
HISTORY OF PRESENT ILLNESS
 What symptoms is the patient experiencing (e.g.,
worries; preoccupations; changes in mood; delusions or
hallucinatory experiences; recent changes in sleep,
appetite, concentration, memory, including suicidal or
aggressive behaviors)?
 What is the severity of the patient’s symptoms?
 Over what time course have these symptoms developed
or fluctuated?
 Are associated features of specific psychiatric syndromes
(i.e., pertinent positive or negative factors) present or
absent during the present illness?
 What factors does the patient believe are precipitating,
aggravating, or otherwise modifying the illness or are
temporally related to its course?
 Did the patient receive prior treatment for this episode
of illness?
 Are other clinicians who care for the patient available to
comment?
INFORMATION DERIVED FROM THE INTERVIEW PROCESS
 Are symptoms minimized or exaggerated by the patient
or others?
 Does the patient appear to provide accurate
information?
 Do particular questions evoke hesitation or signs of
discomfort?
 Is the patient able to communicate about emotional
issues?
 How does the patient respond to the psychiatrist’s
comments and behaviors?
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FUNCTIONAL ASSESSMENT
 What are the patient’s functional strengths, and what is
the disease severity?
 To what degree can the patient perform physical
activities of daily living (e.g., eating, toileting,
transferring, bathing, dressing)?
 To what degree can the patient perform instrumental
activities of daily living (e.g., driving, using public
transportation, taking medications as prescribed,
shopping, managing finances, keeping house,
communicating by mail or telephone, caring for
dependents)?
PAST PSYCHIATRIC HISTORY
 What is the chronology of past episodes of mental illness,
regardless of whether such episodes were diagnosed or
treated?
 What are the patient’s previous sources of treatment,
and what diagnoses were given?
 With respect to somatic therapies (e.g., medications,
electroconvulsive therapy), what were the dose or
treatment parameters, efficacy, side effects, treatment
duration, and adherence?
 With respect to psychotherapy, what were the type,
frequency, duration, adherence, and patient’s perception
of the therapeutic alliance and helpfulness of the
psychotherapy?
 Is there a history of psychiatric hospitalization?
 Is there a history of suicide attempts or aggressive
behaviors?
 Are past medical records available to consult?
GIVEN MEDICAL HISTORY/PAST MEDICAL HISTORY
 What general medical illnesses are known, including
hospitalizations, procedures, treatments, and
medications?
 Are undiagnosed illnesses causing major distress or
functional impairment?
 Does the patient engage in high-risk behaviors that
would predispose him or her to a medical illness?
 Is the patient taking any prescribed or over-the-counter
medications, herbal products, supplements, and/or
vitamins?
 Has the patient experienced allergic reactions to or
severe adverse effects of medications?
FAMILY HISTORY
 What information is available about general medical and
psychiatric illnesses, including substance use disorders, in
close relatives?
 Is there a family history of suicide or violent behavior?
 Are heritable illnesses present in family members that
relate to the patient’s presenting symptoms?
DEVELOPMENTAL, PSYCHOSOCIAL, AND SOCIOCULTURAL
HISTORY (ANAMNESIS)
 What have been the most important events in the
patient’s life, and
 What were the patient’s responses to them?
 What is the patient’s history of formal education?
 What are the patient’s cultural, religious, and spiritual
beliefs, and how have these developed or changed over
time?
 Is there a history of parental loss or divorce; physical,
emotional, or sexual abuse; or exposure to other
traumatic experiences?
 What strategies for coping has the patient used
successfully during times of stress or adversity?
 During childhood or adolescence, did the patient have
risk factors for any mental disorders?
 What has been the patient’s capacity to maintain
interpersonal relationships, and what is the patient’s
history of marital and other significant relationships?
 What is the patient’s sexual history, including sexual
orientation, beliefs, and practices?
 Does the patient have children?
 What past or current psychosocial stressors have
affected the patient (including primary support group,
social environment, education, occupation, housing,
economic status, and access to health care)?
 What is the patient’s capacity for self-care?
 What are the patient’s sociocultural supports (e.g.,
family, friends, work, religious, community groups)?
 What are the patient’s own interests, preferences, and
values with respect to health care?
QUESTIONS IN THE ANAMNESIS FOR WHICH AN
AFFIRMATIVE ANSWER MAY INCREASE THE LIKELIHOOD OF
A PSYCHIATRIC ILLNESS
 Did the patient lose a parent at an early age?
 Was there unusual or excessive separation anxiety during
childhood or adolescence?
 Were there significant problems with sleep?
 Were there eating disturbances?
 Were there problems making or keeping friends?
 Was severe shyness a problem, including when
interacting in peer groups?
 Were there problems with being bullied or bullying?
 Were there frequent disciplinary problems in school?
 Were there serious difficulties with temper?
 Were there many school absences for medical problems
or any other problems?
 Were there delays in learning to read, write, or do math?
 Were there serious problems paying attention, finishing
school work, or completing homework?
 Did the above problems lead to grade retention or
special education intervention?
HISTORY OF ALCOHOL AND OTHER SUBSTANCE USE
 What licit and illicit substances have been used, in what
quantity, how frequently, and with what pattern and
route of use?
 What functional, social, occupational, or legal
consequences or self-perceived benefits of use have
occurred?
 Has tolerance or withdrawal symptoms been noted?
 Has substance use been associated with psychiatric
symptoms?
 Are family members available who could provide
corroborating information about the patient’s substance
use and its consequences?
OCCUPATIONAL AND MILITARY HISTORY
 What is the patient’s occupation, and what jobs has the
patient held?
 What is the quality of the patient’s work relationships?
 What work skills and strengths does the patient have?
 Is the patient unable to work due to disability?
 Regarding military service, what was the patient’s status
(volunteer, recruit, or draftee), did the patient
experience combat, and did the patient suffer injury or
trauma?
 Is the patient preparing for or adjusting to retirement?
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LEGAL HISTORY
 Does the patient have any past or current involvement
with the legal system (e.g., warrants, arrests, detentions,
convictions, probation, parole)?
 Do past or current legal problems relate to aggressive
behaviors or substance intoxication?
 Has the patient had other significant interactions with
the court system (e.g., family court, workers’
compensation dispute, civil litigation, court-ordered
psychiatric treatment)?
 Is past or current legal involvement a significant social
stressor for the patient?
REVIEW OF SYSTEMS
 Is the patient having difficulty with sleep, appetite, eating
patterns, or other vegetative symptoms, or with pain,
neurological symptoms, or other systemic symptoms?
 Does the patient have symptoms that suggest an
undiagnosed medical illness that may be causing or
contributing to psychiatric symptoms?
 Is the patient experiencing side effects from medications
or other treatments?
PHYSICAL EXAMINATION
 What is the appropriate timing, scope, and intensity of
the exam for this patient, and who is the most
appropriate examiner?
 Upon examination, are there abnormalities in the
patient’s general appearance, vital signs, neurological
status, skin, or organ systems?
 Is more detailed physical examination necessary to
assess the patient for specific diseases?
MENTAL STATUS EXAMINATION
 What symptoms and signs of a mental disorder is the
patient currently exhibiting?
 What are the patient’s general appearance and
behavior?
 What are the characteristics of the patient’s speech?
 What are the patient’s mood and affect, including the
stability, range, congruence, and appropriateness of
affect?
 Are the patient’s thought processes coherent?
 Are there recurrent or persistent themes in the patient’s
thought processes?
 Are there any abnormalities of the patient’s thought
content (e.g., delusions, ideas of reference, overvalued
ideas, ruminations, obsessions, compulsions, phobias)?
 Is the patient having thoughts, plans, or intentions of
harming self or others?
 Is the patient experiencing perceptual disturbances (e.g.
hallucinations, illusions, derealization,
depersonalization)?
 What are the patient’s sensorium and level of cognitive
function (e.g., orientation, attention, concentration,
registration, short- and long-term memory, fund of
knowledge, level of intelligence, drawing, abstract
reasoning, language, and executive functions)?
 What are the patient’s level of insight, judgment, and
capacity for abstract reasoning?
 What is the patient’s motivation to change his or her
health risk behaviors?
 The purpose of the mental status examination for the
medically ill is to elicit the patient's capacity to
understand and cope with the illness and to make
decisions about care
 The level of detail for assessment of cognitive function
varies depending upon the patient's combined medical
and psychiatric condition
 The mental status examination can be tailored to the
patient's clinical presentation, which may include
judgment about the patient's capacity to participate in
exams with formal rating scales
DIAGNOSTIC TESTS
 What diagnostic tests are necessary to establish or
exclude a diagnosis, aid in the choice of treatment, or
monitor treatment effects or side effects?
MEDICAL-PSYCHIATRIC HISTORY
 Contrary to the usual medical or psychiatric examination,
the medically ill patient seldom initiates or requests a
psychiatric consultation
 To obtain a psychiatric history that is more than
superficial, the consultant must be skilled at rapidly
establishing the context of the psychiatric disorder in the
medical setting
 Make inquiries that go beyond the usual domains of a
standard psychiatric evaluation
CLARIFICATION OF THE CONSULTEE-STATED VS.
CONSULTANT-ASSESSED REASONS FOR REFERRAL
 The overt reason expressed for the need for consultation
may be incomplete, or a request may be made for the
assessment of one problem when another more serious
problem is unrecognized
 Direct contact with the individual who initiated the
request is beneficial for obtaining exact information
about the patient's behavior, which may not appear in
the record
ASSESSMENT FOR THE EXTENT THE PATIENT’S PSYCHIATRIC
DISTRUBANCE IS CAUSED BY THE MEDICAL/SURGICAL
ILLNESS
 The medical chart must be reviewed for pertinent
medical factors that could contribute to the patient's
current state
 Attention must be given to the description of the mental
status and the behavior noted by the medical staff
 Assessment for the Adequacy of Pain Management
o Seemingly exaggerated complaints and/or abnormal
behaviors are often associated with insufficiently
treated pain
o Fears of unremitting pain, as well as feelings of
unattended suffering and helplessness, need to be
addressed
o General principles of pain assessment and
management:
 Obtaining information about the pain complaint
 Awareness of how pain contributes to specific
illnesses (e.g., cancer, sickle cell disease, arthritis
 Awareness of how psychiatric disorders and
symptoms contribute to pain complaints and
vice versa (e.g., anxiety in acute pain,
depression in chronic pain)
 Detailed assessment of all analgesics and
adjuvant medications
 It is crucial to have an understanding of the
factors that contribute to undertreatment of
pain, the appropriate diagnostic workup for pain
complaints, and the elements of integrated,
multimodal assessment and management of
patients in pain
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ASSESSMENT FOR THE EXTENT THE PSYCHIATRIC
DISTURBANCE IS CAUSED BY MEDICATION OR SUBSTANCE
ABUSE
 The patient's medication list and recent changes in
medication are critically important to review
 Psychiatric symptoms are frequently produced by
medications (e.g., corticosteroids) prescribed for medical
disorders
 Analgesics, sedatives, anticonvulsants, anesthetics,
psychotropics, and anticholinergics are groups of
medications commonly associated with psychiatric
disturbances.
 The type, quantity, and frequency of prescription drug
use as well as illicit drug and alcohol use should be
assessed
 Previous episodes of structured outpatient or inpatient
treatment should be inquired about, as well as prior
experiences associated with drug withdrawal
ASESSMENT FOR DISTURBANCES IN COGNITION
 The search for even subtle disturbances in cognition is
crucial to every psychiatric evaluation of the medically ill
patient
 If a disturbance in cognition is identified, determine if the
change in mental status is chronic and due primarily to
the consequences of an underlying disorder OR acute
and arising secondary to the effects of illness,
medication, or a combination of factors
o E.g. patient with dementia, who, prior to admission,
was already exhibiting cognitive symptoms vs. a
patient undergoing a delirious process as effect of
the medical condition or medical treatment
ASSESSMENT OF PSYCHIATRIC SYMPTOMOLOGY AND
BEHAVIOR
 "Is the patient's behavior a normal response to the stress
of illness and/or hospitalization and, therefore, likely to
resolve with improvement in physical health?”
o E.g. is the sadness/depressed mood being
experienced by the patient a reaction to the current
medical situation or is it a separate diagnosis (i.e.
already experiencing major depressive disorder
instead of a depressive reaction to the illness)
 The patient's perspective of possible precipitating,
exacerbating, or resolving factors is most pertinent
 Review of prior response to illness or psychiatric
treatment can facilitate proper diagnosis and treatment
 Assess how well the patient is coping and whether
he/she will be able to endure the course of illness
EVALUATION OF THE PATIENT’S CHARACTER STYLE
 “What kind of patient has the illness?”
 Information from several domains (e.g., developmental
history, social history, occupational history) must be
integrated to form a dynamic life narrative leading up to
the current illness
 Medical illness, surgery, and the many stresses of
hospitalization are managed differently by individuals
with different character styles or DSM-IV Axis II
personality disorders
 Understanding how character influences the experience
of physical illness is critical for explaining abnormal
patient behaviors, emotions, and demands
EVALUATION OF THE PATIENT’S COPING STYLE
 Illness is a stress that requires both the afflicted patients
and the systems that surround them them to adapt via
improvements in coping strategies and interpersonal
relationships
 Coping is best defined as problem-solving behavior that
is intended to bring about relief, reward, quiescence, and
equilibrium.
 Implies a combination of knowing what the problems are
and how to go about reaching a correct direction that
will help resolution.
 Coping is not a simple judgment about how some
difficulty worked out. It is an extensive, recursive process
of self-exploration, self-instruction, self-correction, self-
rehearsal, and guidance gathered from outside sources.
 At virtually every step of patient care, physicians and
patients actively assess coping ability.
 The conclusions drawn about how a patient is processing
his or her illness has a tremendous impact on therapeutic
decisions, on psychological well- being, and indeed on
the overall course of illness.
 Coping with illness and its ramifications cannot help but
be an inescapable part of medical practice.
 Therefore the overall purpose of any intervention,
physical or psychosocial, is to improve coping with
potential problems beyond the limits of illness itself.
 Such interventions must take into account both the
problems to be solved and the individuals most closely
affected by the difficulties.
 How anyone copes depends on the nature of a problem
as well as on the mental, emotional, physical, and social
resources one has available for the coping process.
 Characteristics of good copers:
o They are optimistic about mastering problems and,
despite setbacks, generally maintain a high level of
morale.
o They tend to be practical and to emphasize
immediate problems, issues, and obstacles that must
be conquered, even before visualizing a remote or
ideal resolution.
o They select from a wide range of potential strategies
and tactics, and their policy is not to be at a loss for
fallback methods. In this respect, they are
resourceful.
o They heed various possible outcomes and improve
coping by being aware of consequences.
o They are able to mobilize mature defense
mechanisms (e.g. anticipation)
o They are generally flexible and open to suggestions,
but they do not give up the final say in decisions.
o They are composed, although vigilant, in avoiding
emotional extremes that could impair judgment.
 Characteristics of poor copers:
o They tend to be excessive in self-expectation, rigid in
outlook, inflexible in standards, and reluctant to
compromise or to ask for help.
o Their opinion of how people should behave is
narrow and absolute; they allow little room for
tolerance.
o Although prone to firm adherence to
preconceptions, they may show unexpected
compliance or be suggestible on specious grounds,
with little cause.
o They are inclined to excessive denial and elaborate
rationalization; in addition, they are unable to focus
on salient problems.
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 o Because they find it difficult to weigh feasible
alternatives, they tend to be more passive than usual
and they fail to initiate action on their own behalf.
o Their rigidity occasionally lapses, and they subject
themselves to impulsive judgments or atypical
behavior that fails to be effective.
o They tend to be more passive than usual and fail to
initiate action on their own behalf
o They then to make impulsive decisions
 No one copes exceptionally well at all times, especially
with problems that are associated with risk and that
might well be overwhelming.
 However, effective copers appear able to choose the
kind of situation in which they are most likely to prosper.
 In addition, effective copers often maintain enough
confidence to feel resourceful enough to survive intact.
 Finally, it is our impression that those individuals who
cope effectively do not pretend to have knowledge that
they do not have; therefore they feel comfortable
turning to experts that they trust.
 The better we can pinpoint which traits a patient seems
to lack, the better we can help a patient cope.
THE MEDICAL PREDICAMENT – BRINGING IT ALL TOGETHER
 Coping refers to how a patient responds and deals with
problems within a complex of factors that relates to
disease, sickness, and vulnerability
 In approaching medically ill patients, it is helpful to
conceptualize disease as the categorical reason for being
sick, sickness as the individual style of illness and
patienthood, and vulnerability as the tendency to be
distressed and to develop emotional difficulties in the
course of trying to cope
 Given these definitions, the psychiatrist needs to first ask
why now?
 What has preceded the request for consultation?
 How does the patient show his or her sense of futility
and despair?
 How did the present trouble, both the medical and the
corresponding coping challenges, come about?
 Was there a time when such problems could have been
thwarted?
 It is also important to note that not infrequently the
treatment team is even more exasperated than the
patient.
 The clinician must also assess the motivation of staff and
patients when a psychiatric intervention is requested.
Additionally, clinicians need to be aware that the real
question is not always the problem for which one is
consulted.
PROBLEM
 In your opinion, what has been the most difficult for you
since your illness started? How has it troubled you?
STRATEGY: WHAT DID YOU DO (OR ARE DOING) ABOUT THE
PROBLEM?
 Get more information (rational/intellectual approach)
 Talk it over with others to relieve distress (share concern)
 Try to laugh it off; make light of it (reverse affect) Put it
out of mind; try to forget (suppression/denial)
 Distract myself by doing other things
(displacement/dissipation)
 Take a positive step based on a present understanding
(confrontation)
 Accept, but change the meaning to something easier to
deal with (redefinition)
 Submit, yield, and surrender to the inevitable
(passivity/fatalism)
 Do something, anything, reckless/impractical (acting out)
 Look for feasible alternatives to negotiate (if x, then y)
 Drink, eat, take drugs, and so on, to reduce tension
(tension reduction)
 Withdraw, get away, and seek isolation (stimulus
reduction)
 Blame someone or something (projection/
disowning/externalization)
 Go along with directives from authority figures
(compliance)
 Blame self for faults; sacrifice or atone (undoing self-pity)
RESOLUTION: HOW HAS IT WORKED OUT SO FAR?
 Not at all
 Doubtful relief
 Limited relief, but better
 Much better; actual resolution
INQUIRY ABOUT THOUGHTS OF DYING
 Many patients think about dying, especially when their
illness is protracted, exhausting, or critical
 Thoughts of dying related to life-threatening physical
illness and suicidal ideation related to depression need to
be distinguished
 Inquiry about the patient's understanding of the physical
illness—its course and prognosis—allows the consultant
a unique opportunity to correct cognitive distortions on
the part of the patient
 In some situations, it is necessary to assess the capacity
of the patient to refuse treatment and to help the
patient set reasonable limits on further treatment
 Must be familiar with the medical treatment and/or
hospital course to ascertain the patient's understanding
of his/her illness and its possible course, with or without
treatment
FACTORS INFLUENCING THE FORM AND CONTENT
OF THE INTERVIEW
SHARING INFORMATION AND PREPARING PATIENT FOR
TREATMENT
 The conclusion of the psychiatric interview requires
summarizing the symptoms and history and organizing
them into a coherent narrative that can be reviewed and
agreed on by the patient and the clinician
 This involves recapitulating the most important findings
and explaining the meaning of them to the patient
 This part of the interview should involve explaining one
or more diagnoses to the patient, as well as a
formulation of the patient’s strengths, weaknesses, and
style of managing stress
o Ethical consideration: you can explain psychiatric
diagnosis but if there are other medical conditions
that is not clear to the patient but is not within your
scope of expertise, refer to one with more expertise
o Disclosure of diagnosis such as CA should be done by
the attending physician
 The latter part of the summary is intended to help ensure
that the patient feels understood
 Education about treatment should include reviewing the
pros and cons of various options. This is a good time to
dispel myths about psychiatric treatments, either
pharmacotherapy or psychotherapy
 Letting the patient know that treatment decisions are
collaborative and patient-centered is absolutely essential
in a discussion of this order.
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DISAGREEMENTS ABOUT ASSESSMENT AND TREATMENT
 There are times when a patient disagrees with a
clinician’s formulation, diagnosis, and treatment
recommendations.
 Or the disagreement may be between the patient and
the medical staff, with the psychiatrist in the challenging
position of the intermediary.
 In either case, it is wise to listen to the patient and hear
where there is conflict.
 This can serve to reestablish the alliance.
 It may also diffuse the patient’s need to defend himself
or herself against what he or she may perceive as doctors
“ganging up” on him or her.
 Evaluator should systematically review what was said
and how he or she interpreted the clinical findings.
 The patient should be encouraged to correct
misrepresentations
 At other times, the patient may deny or minimize a
problem. In this case additional interviews may be
necessary.
 It is sometimes useful to involve a close relative or friend
 If the patient is a danger to self or others, protective
measures will be needed, short of any agreement.
 If there is no imminent danger, explaining one’s clinical
opinion and respecting the right of the patient to choose
treatment must be observed
 It may also be necessary to work with the medical team
to reach a compromise that takes into consideration the
patient’s goals and wishes when they differ from that of
the medical team.
o We encourage the patient to take a more
collaborative role in their treatment
ERRORS IN PSYCHIATRIC INTERVIEWING
 Premature closure and false assumptions about
symptoms
 False reassurance about the patient’s condition or
prognosis
 Defensiveness around psychiatric diagnoses and
treatment, with arrogant responses to myths and
complaints about psychiatry
 Omission of significant parts of the interview
 Recommendations for treatment when diagnostic
formulation is incomplete
 Inadequate explanation of psychiatric disorders and their
treatment, particularly not giving the patient multiple
options for treatment
 Minimization or denial of the severity of symptoms, due
to overidentification with the patient;
countertransference phenomenon
 Failure to establish a genuine, empathic rapport (e.g., by
using brusque language, tone, or body posture)
 Use of an angry or dismissive style in response to a
patient who is guarded or hostile
 Inadvertently shaming or embarrassing a patient, and not
offering an apology
“The good physician treats the disease
The great physician treats the patient who has the disease”
- Doctor William Osler
END OF TRANSCRIPTION
Life before death.
Strength before weakness.
Journey before destination.
-The First Ideal, Oathbringer by Brandon Sanderson
Transcription Team 2019
Transcribed by: Sharmaine Tablada
Edited by:
References: Lecture handout,
recordings
Remarks: Underlined text were
underlined by Doc in
the handout and ppt.
Must be must knows
Factors influencing the form and content of the interview:
situation (sample situations)
“Hi, Ms. Jones. I know you really don’t want to be here. I
understand that your doctor and family are concerned about
your weight. I assure you that my job is first and foremost to
understand your point of view. Can you tell me why you think
they wanted you to see me?”
“Good morning, Mr. Jones. I heard from your wife that she is
really concerned about your drinking, and your safety,
especially when driving. First, let me tell you that neither I nor
anyone else can stop you from drinking. That is not my
mission today. I do want to know what your drinking pattern
is, but more than that, I want to get the picture of your entire
life to understand your current situation.”
“Hi, Ms. Carter, my name is Dr. Beresin. I am terribly sorry
you are strapped down, but the police and your family were
very upset when you locked yourself in the car and turned on
the ignition. They found a suicide note on the kitchen table.
Everyone was really concerned about your safety. I would like
to discuss what is going on, and see what we can do together
to figure things out.”
“Good morning, Mr. Harris. My name is Dr. Beresin. I heard
about your surgery from Dr. Rand and understand you have
been having some experiences that may seem kind of strange
or frightening to you. Sometimes after surgery, people have a
reaction to the procedure or the medications used that
causes difficulties with sleep, agitation, and mental confusion.
This is not unusual, and it is generally temporary. I would like
to help you and your team figure out what is going on and
what we can do about this.”
PAST-E 2018
35. Elements of the psychiatric interview of the medically ill:
a. Clarification of the reason for referral
b. Review of the medical chart for pertinent medical factors
c. Description of the behavior noted by the medical staff
d. All of the above
36. Pain assessment and management except:
a. Diagnostic workup for pain complaints
b. Awareness of how anxiety may contribute to acute pain
and depression to chronic pain
c. Exaggerated complaints and/or abnormal behaviors are
often associated with Pain Disorder
d. Understand how pain contributes to a specific illness
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37. True regarding evaluation of the medically ill patient’s
character style:
a. Based solely on information obtained from the history of
present illness
b. Reaction to illness Is influenced by an existing personality
disorder
c. Understanding of the factors that contribute to under
treatment of pain
d. All of the above
38. Included in the medical-psychiatric history of a medically
ill patient except:
a. Patient’s medication list and recent changes in medication
b. Subtle disturbances in cognition
c. Patient’s perpective of how he/she should be managed
d. None of the above
39. Purpose of the Mental Status Examination in the
medically ill patient:
a. To obtain information about how pain contributes to the
illness
b. To address feeling of unattended suffereing and
helplessness
c. To elicit the patient’s capacity to understand the illness
d. To form a dynamic life narrative leading up to the current
illness
40 Interpersonal transactions of all members of clinical team
are taken into account to understand patient’s behavior &
consultee’s (referring physician/non-psychiatrist) concern
about it:
a. Patient-centered consultation
b. Consultee-centered consultation
c. Situation-centered consultation
d. Hybrid model of consultation
PAST-E 2017
21. Elements of the psychiatric interview of the medically
ill:
a. Clarification of the reason for referral
b. Review of the medical chart for pertinent medical factors
c. Description of the behavior noted by the medical staff
d. All of the above
23. Pain assessment and management except:
a. Diagnostic workup for pain complaints
b. Awareness of how anxiety may contribute to acute pain
and depression to chronic pain
c. Exaggerated complaints and/or abnormal behaviors are
often associated with Pain Disorder
d. Understand how pain contributes to a specific illness
26. True regarding evaluation of the medically ill patient’s
character style:
a. Based solely on information obtained from the history of
present illness
b. Reaction to illness Is influenced by an existing personality
disorder
c. Understanding of the factors that contribute to under
treatment of pain
d. All of the above
27. Included in the medical-psychiatric history of a medically
ill patient except:
a. Patient’s medication list and recent changes in medication
b. Subtle disturbances in cognition
c. Patient’s perspective of how he/she should be managed
d. None of the above
29. Purpose of the Mental Status Examination in the
medically ill patient:
a. To obtain information about how pain contributes to the
illness
b. To address feeling of unattended suffereing and
helplessness
c. To elicit the patient’s capacity to understand the illness
d. To form a dynamic life narrative leading up to the current
illness
PAST-E 2016
51. Which part of the Mental Status Exam would be most
relevant when evaluating amedically ill patient whom you
suspect may have a chronic neurological condition?
A. Mood & Affect, Attitude toward the examiner, Reading &
Writing
B. Perceptual Disturbances, Continuity of Thought,
Concentration & Attention
C. Remote Memory, General Fund of Information, Calculation
D. Abstract Thinking, Visuospatial Capability, Social Judgment
52. When writing a psychiatric report about a medically ill
patient, what should be
included in the History of Present Illness?
A. Psychosocial stressor, Course in the ward, Progress of
symptoms that lead to consult
B. Family’s reactions to illness, Course in the ward, Past
psychiatric illness
C. Psychosocial impact of illness on family, Patient reactions
to illness
D. Psychosocial context of onset of physical symptoms,
Medications and Surgical procedures
53. JJ is easily stressed with minor problems but keeps his
feelings to himself. He tends to think he needs to ask his
parents’ approval before he engages in any endeavor and
very careful not to hurt their feelings even if he is already 30
years old professional. This would be included in
A. Chief Complaint
B. Premorbid Function
C. Premorbid personality
D. Mental Status Exam
Case: JB, 25 year old single Fil American male, left handed,
college graduate from Ilocos Norte who lives with his parents
and works as a librarian at La Salle University, was admitted
to the Emergency Room of Pilar Hospital for anxiety and
insomnia accompanied by his best friend last Jan 2012.
54. In the case of JB what else should be included in his
general data?
A. Full name, birthdate
B. Sibling order, language spoken
C. Religion, chief complaint
D. Nationality, residential address
55. How should the history of present illness begin and end
when conducting a psychiatric interview of a medically ill
patient?
A. Onset of physical symptoms up to hospital admission
B. Onset of physical symptoms up to hospital discharge
C. Onset of physical symptoms up to day of interview
D. Onset of physical symptoms up to day of psychiatric
referral
Page 9 of 10
56. As history of physical symptoms are described from their
onset and progress to the point of consult, the psychiatric
interview of a medically ill patient also takes into account the
ff
A. Psychosocial context in which symptoms started, patient’s
reactions to his symptoms
B. Past medications or factors that relieve or worsen patient’s
symptoms
C. Family relationships and economic status or capability to
pay for hospital bills
D. Psychosocial stressors that may have triggered physical
symptoms and diagnostic questions

57. While in the hospital the patient and family’s reactions to

the ff issues should also be included in the History of present
illness
A. How does illness affect patient’s work function and social
relations
B. Worries about the finances in paying the hospital bill, past
marital conflicts
C. Diagnosis & prognosis given by the doctor, alcohol and
drug use
D. How nurses and medical staff treat patient, fears al staff
treat patient, fears about injections and surgical procedures

Case: When JB was born, his father worked abroad until he

was 12 years old when his father suffered a stroke. After
which his mother had to work abroad and JB and his siblings
were left to the care of his father’s family. After graduating
from college, JB’s mother retired and soon after getting his
first job, his family was able to move out to their own home
near the paternal relatives.

58. The description of the above case of JB describes

A. Genogram
B. Family Time/Lifeline
C. Family Profile
D. Family History

59. Why is there a need to conduct a psychiatric interview of

a medically ill patient?
A. To check if he has a psychiatric illness and thus refer to
psychiatry service
B. To practice conducting a psychiatric interview on patients
C. To realize that all medically ill patients have emotional
reactions to the whole illness experience
D. To provide a thorough evaluation of their condition

60. What should be included in the description of a patient’s

family of origin profile?
A. Past medical and psychiatric illnesses in the family
B. Personality and role of all the family members in the family
& their current living situation
C. General data & vices of each member, relationship of all its
members with the patient,
D. Attitude and reactions to patient’s illness, genogram of
family of progeny

ANSWER KEY
2018 35 D 36 C 37 B 38 C 39 C 40 C
2017 21 D 23 C 26 B 27 C 29 C
2016 51 C 52 C 53 C 54 B 55 C
56 A 57 D 58 B 59 C 60 C

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