Clinical Evaluation of Clinical Evaluation of Psychiatric PatientPsychiatric Patient

INTRODUCTIONINTRODUCTIONPsychiatric evaluations vary according to their Psychiatric evaluations vary according to their purpose. purpose. The purpose depends on: The purpose depends on:

1- Who requests the evaluation. 1- Who requests the evaluation. 2- Why it is requested. 2- Why it is requested. 3- The expected role of the psychiatrist in the 3- The expected role of the psychiatrist in the patient's care. patient's care.

Three main types: Three main types: 1) General psychiatric evaluation. 1) General psychiatric evaluation. 2) Emergency evaluation. 2) Emergency evaluation. 3) Clinical consultation.3) Clinical consultation.

Other types such as forensic evaluation. Other types such as forensic evaluation.

Clinical ExaminationClinical Examination

Mental Status Examination.Mental Status Examination.

Psychiatric History.Psychiatric History.

Laboratory Tests in Psychiatry.Laboratory Tests in Psychiatry.

Physical Examination in Psychiatry.Physical Examination in Psychiatry.

Psychological Factors.Psychological Factors.

Interview of A Interview of A Psychiatric PatientPsychiatric Patient

Interviews explore the following Interviews explore the following factors: factors: Genetic, Temperamental, Biological, Genetic, Temperamental, Biological,

Developmental, Social & Psychological.Developmental, Social & Psychological.

Successful Interview creates:Successful Interview creates:* Empathy, Respect, Competence & Interest.* Empathy, Respect, Competence & Interest.* An atmosphere of trust that encourages the * An atmosphere of trust that encourages the patient to talk honestly about his or her patient to talk honestly about his or her innermost feelings & thoughts.innermost feelings & thoughts.

The Aims of Psychiatric EvaluationThe Aims of Psychiatric Evaluation

To establish To establish a provisional diagnosis.a provisional diagnosis.To identify To identify other diagnostic possibilities. other diagnostic possibilities. To identify To identify social, environmental & cultural social, environmental & cultural factors relevant to immediate treatment factors relevant to immediate treatment decisions. decisions. What precautions What precautions are needed if there is a risk of are needed if there is a risk of harm to self or others & whether involuntary harm to self or others & whether involuntary treatment is necessary. treatment is necessary. To develop To develop a plan for immediate treatment with a plan for immediate treatment with determination of whether the patient requires determination of whether the patient requires treatment in a hospital or other supervised treatment in a hospital or other supervised setting. setting. What follow-up What follow-up will be required. will be required.

1. General Psychiatric Evaluation1. General Psychiatric Evaluation

A general psychiatric evaluation is a face-A general psychiatric evaluation is a face-to-face interview with the patient. to-face interview with the patient.

The interview-based data are integrated The interview-based data are integrated with a review of medical records, a with a review of medical records, a physical examination & diagnostic tests. physical examination & diagnostic tests.

Several meetings with the patient may be Several meetings with the patient may be necessary. necessary.

2. Emergency Evaluation2. Emergency EvaluationThe emergency psychiatric evaluation occurs The emergency psychiatric evaluation occurs in response to the occurrence of:in response to the occurrence of:

1) Thoughts or feelings that are intolerable 1) Thoughts or feelings that are intolerable to the patient. to the patient. 2) 2) Behavior that prompts urgent action by Behavior that prompts urgent action by others, such as violent or self-injurious others, such as violent or self-injurious behavior, threats of harm to self or others, behavior, threats of harm to self or others, failure to care for oneself, deterioration of failure to care for oneself, deterioration of mental status, bizarre or confused mental status, bizarre or confused behavior, or intense expressions of distress. behavior, or intense expressions of distress.

A. Identification DataA. Identification DataName.Name.Age.Age.Gender.Gender.Marital Status.Marital Status.Educational Level.Educational Level.Occupation.Occupation.Religion.Religion.Residence.Residence.

B. Referral, Informant & ComplaintB. Referral, Informant & Complaint

Source of referral.Source of referral.

Cause of referral.Cause of referral.

We have to choose the informant We have to choose the informant particularly in psychotic & forensic particularly in psychotic & forensic patients.patients.

Complaint of the patient & that of the Complaint of the patient & that of the informant.informant.

(Can you tell me why you are here?)(Can you tell me why you are here?)

C. History of The Present IllnessC. History of The Present Illness

It is a chronologically organized history of It is a chronologically organized history of 1) Current symptoms or syndromes. 1) Current symptoms or syndromes. 2) 2) Onset, Course & Duration.Onset, Course & Duration. 3) Recent exacerbations or remissions. 3) Recent exacerbations or remissions. 4) Available details of previous treatments 4) Available details of previous treatments & the patient's response to those treatment. & the patient's response to those treatment. 5) Factors that the patient believes to be 5) Factors that the patient believes to be precipitating, aggravating, or otherwise precipitating, aggravating, or otherwise modifying the illness.modifying the illness. 6) 6) Sleep, Eating & Sexual activities.Sleep, Eating & Sexual activities.

D. Past Psychiatric HistoryD. Past Psychiatric HistoryA chronological summary of all past episodes of A chronological summary of all past episodes of mental illness & treatment: mental illness & treatment:

1) Psychiatric syndromes not formally 1) Psychiatric syndromes not formally diagnosed. diagnosed. 2) Previously established diagnoses, treatments 2) Previously established diagnoses, treatments

& responses to treatment (& responses to treatment (Psychiatric, Mental, Psychiatric, Mental,

Psychosomatics & Medical Diseases.Psychosomatics & Medical Diseases. 3) The dose, duration of treatment, efficacy, side 3) The dose, duration of treatment, efficacy, side effects & patient's adherence to previously effects & patient's adherence to previously prescribed medications.prescribed medications.

E. General Medical HistoryE. General Medical HistoryGeneral medical illnesses (e.g., hospitalizations, General medical illnesses (e.g., hospitalizations, procedures, treatments & medications). procedures, treatments & medications). Undiagnosed health problems that have caused Undiagnosed health problems that have caused the patient major distress or functional the patient major distress or functional impairment. impairment. History of any episodes of important physical History of any episodes of important physical injury or trauma; sexual & reproductive history injury or trauma; sexual & reproductive history & any history of neurological disorders, & any history of neurological disorders, allergies & drug sensitivities. allergies & drug sensitivities. High prevalence diseases, e.g., infectious High prevalence diseases, e.g., infectious diseases in users of intravenous drugs or diseases in users of intravenous drugs or pulmonary & cardiovascular disease in people pulmonary & cardiovascular disease in people who smoke. who smoke. Information regarding all recent medications. Information regarding all recent medications.

F. History of Substance UseF. History of Substance Use

The psychoactive substance use history The psychoactive substance use history includes past & present use including: includes past & present use including: alcohol, alcohol, caffeine, nicotine, marijuana, cocaine, opiates, caffeine, nicotine, marijuana, cocaine, opiates, sedative-hypnotic agents, stimulants, solvents sedative-hypnotic agents, stimulants, solvents & hallucinogens. & hallucinogens. Relevant information includes the quantity and Relevant information includes the quantity and frequency of use & route of administration: frequency of use & route of administration: The The pattern of use (e.g., episodic versus continual; pattern of use (e.g., episodic versus continual; solitary versus social); functional, interpersonal solitary versus social); functional, interpersonal or legal consequences of use; tolerance & or legal consequences of use; tolerance & withdrawal phenomena. withdrawal phenomena. Any temporal association Any temporal association between substance between substance use & present psychiatric illness.use & present psychiatric illness.

G. Personal History: G. Personal History: Psycho-Social & Developmental.Psycho-Social & Developmental.

Perinatal: Perinatal: Pre-natal, Natal & Post-natal.Pre-natal, Natal & Post-natal.

Early Childhood: Early Childhood: Through age 3 years.Through age 3 years.

Middle Childhood: Middle Childhood: Ages 3-11 years.Ages 3-11 years.

Late Childhood: Late Childhood: Puberty & Adolescence.Puberty & Adolescence.

Adulthood: Adulthood: Occupational History, Military Occupational History, Military History, Educational History, Social History, Educational History, Social Activities, Legal History, Marital History, Activities, Legal History, Marital History, Sexual History, Fantasies & Dreams.Sexual History, Fantasies & Dreams.

H. Occupational HistoryH. Occupational History

The sequence of jobs held by the The sequence of jobs held by the patient. patient. Reasons for job changes. Reasons for job changes. The patient's current or most The patient's current or most recent employment, including recent employment, including whether current or recent jobs whether current or recent jobs have involved unusual physical have involved unusual physical or psychological stress, toxic or psychological stress, toxic materials or shift work. materials or shift work.

I. Military HistoryI. Military HistoryRelevant data about military experience Relevant data about military experience would include:would include:

- Volunteer versus draftee status. - Volunteer versus draftee status.

- Whether the patient experienced combat.- Whether the patient experienced combat.

- Discharge status, awards, disciplinary - Discharge status, awards, disciplinary

actions.actions.

- Whether the patient suffered injury or - Whether the patient suffered injury or

trauma while in service.trauma while in service.

K. Social HistoryK. Social HistoryThe patient's living arrangements & The patient's living arrangements & currently important relationships. currently important relationships. Relationships, both familial & non-Relationships, both familial & non-familial, that are relevant to the familial, that are relevant to the present illness, act as stressors. present illness, act as stressors. Any formal involvement with social Any formal involvement with social agencies or the courts, as well as, agencies or the courts, as well as, details of any current litigation or details of any current litigation or criminal proceedings. criminal proceedings.

J. Sexual HistoryJ. Sexual History

A sexual history: A sexual history: Premarital, Premarital,

marital & extramarital.marital & extramarital.

Sexual orientation & practice.Sexual orientation & practice.

AAny history of physical, ny history of physical,

emotional, sexual or other emotional, sexual or other

abuse or trauma. abuse or trauma.

L. Other Personal History L. Other Personal History Review of stages of patient's life, with special Review of stages of patient's life, with special attention to developmental milestones & to attention to developmental milestones & to patterns of response to normative life transitions patterns of response to normative life transitions & major life events. & major life events. Important cultural & religious influences on Important cultural & religious influences on patient's life.patient's life.Any involvement with the juvenile or criminal Any involvement with the juvenile or criminal justice system. justice system. Any experiences related to political repression, Any experiences related to political repression, war or a natural disaster. war or a natural disaster. Past & present levels of functioning in family & Past & present levels of functioning in family & social roles (e.g., marriage, parenting, work, social roles (e.g., marriage, parenting, work, school). school).

M. Family HistoryM. Family HistoryFather & Mother: Father & Mother: Mental & physical problems, Mental & physical problems, Death & cause of death, relationship to the Death & cause of death, relationship to the patient, attitude towards the patient illness.patient, attitude towards the patient illness.Siblings & patient order.Siblings & patient order.Consanguinity.Consanguinity.Family history of Family history of NS disease, Tumors, MR, NS disease, Tumors, MR, Psychotic disorders, Psychiatric disorders, Psychotic disorders, Psychiatric disorders, Suicide & Substance abuse.Suicide & Substance abuse.History of History of any treatment received & response to any treatment received & response to treatment. treatment. Current Current family health status that are of family health status that are of emotional importance to the patient. emotional importance to the patient. AttitudeAttitude of the family members towards his or of the family members towards his or her illness (Supportive, denial or criticizing). her illness (Supportive, denial or criticizing).

N. Pre-Morbid PersonalityN. Pre-Morbid Personality

Introversion-Extroversion.Introversion-Extroversion.

Temperament.Temperament.

Characters.Characters.

Religious Standard.Religious Standard.

Hobbies & Interests.Hobbies & Interests.

Special Habits.Special Habits.

O. Review of SystemsO. Review of SystemsCurrent symptoms not already identified in the Current symptoms not already identified in the present illness. present illness.

Sleep, appetite, pain & discomfort, systemic Sleep, appetite, pain & discomfort, systemic symptoms such as fever & fatigue & symptoms such as fever & fatigue & neurological symptoms. neurological symptoms.

Common symptoms of diseases for which the Common symptoms of diseases for which the patient is known to be at particular risk because patient is known to be at particular risk because of genetic, environmental, or demographic of genetic, environmental, or demographic factors. factors.

P. Physical ExaminationP. Physical ExaminationA physical examination is needed to evaluate A physical examination is needed to evaluate the patient's general medical condition (GMC), the patient's general medical condition (GMC), (including neurological). (including neurological). An understanding of patient's GMC is important An understanding of patient's GMC is important in order to:in order to:

1) 1) Properly assess the patient's psychiatric Properly assess the patient's psychiatric symptoms & their potential cause. symptoms & their potential cause. 2) 2) Determine the patient's need for general Determine the patient's need for general medical care. medical care. 3) 3) Choose among psychiatric treatments those Choose among psychiatric treatments those are suitable for the patient's GMC.are suitable for the patient's GMC.

The Physical Examination Includes The Physical Examination Includes Sections Concerning The Following:Sections Concerning The Following:

General appearance & nutritional status. General appearance & nutritional status. Vital signs. Vital signs. Head & neck, heart, lungs, abdomen & Head & neck, heart, lungs, abdomen & extremities. extremities. Neurological status, including cranial Neurological status, including cranial nerves, motor & sensory function, gait, nerves, motor & sensory function, gait, coordination, muscle tone, reflexes & coordination, muscle tone, reflexes & involuntary movements. involuntary movements. Skin, with special attention to any Skin, with special attention to any trauma, self-injury or drug use. trauma, self-injury or drug use. Any body area or organ system that is Any body area or organ system that is sp., mentioned in the patient’s history. sp., mentioned in the patient’s history.

Q. Mental Status Examination Q. Mental Status Examination (MSE)(MSE)

A systematic collection of data based on A systematic collection of data based on observation of the patient's behavior observation of the patient's behavior during the interview & before & after the during the interview & before & after the interview. interview. Responses to specific questions are an Responses to specific questions are an important part of the MSE, particularly in important part of the MSE, particularly in the assessment of cognition.the assessment of cognition.The purpose of MSE is to obtain evidence The purpose of MSE is to obtain evidence of current symptoms & signs of mental of current symptoms & signs of mental disorders from which the patient might be disorders from which the patient might be suffering.suffering.

Q. Mental State AssessmentQ. Mental State AssessmentAppearance: Appearance:

Simply describe the patient's physical Simply describe the patient's physical presentation: presentation: Body built, Gait, Clothing & Make Body built, Gait, Clothing & Make upup, hygiene & cultural appropriateness. , hygiene & cultural appropriateness.

Behavior:Behavior: Briefly describe the patient's behavioral style, Briefly describe the patient's behavioral style,

including agitation, retardation & any including agitation, retardation & any inappropriate, unusual behavior,inappropriate, unusual behavior, Involuntary Involuntary movement, Posture & Sittingmovement, Posture & Sitting. .

Conversation: Conversation: Describe both the content of conversation, as Describe both the content of conversation, as

well as the form, which includes the rate of well as the form, which includes the rate of conversation. conversation.

Q. Mental State AssessmentQ. Mental State AssessmentAffect & Mood: Affect & Mood:

Mood level, variability, range, intensity & Mood level, variability, range, intensity & appropriateness (appropriateness (MoodMood = = Feeling; Feeling; AffectAffect = Non = Non verbal expressions of mood).verbal expressions of mood). Characteristics of Speech: Characteristics of Speech:

Rate, rhythm, structure, flow of ideas & Rate, rhythm, structure, flow of ideas & pathologic features such as tangentially, pathologic features such as tangentially, vagueness, incoherence, or neologisms), Avagueness, incoherence, or neologisms), Also, lso, Aphonia & Aphasia (Receptive or expressive)Aphonia & Aphasia (Receptive or expressive). .

Language functions: Language functions: Naming, fluency, comprehension, repetition, Naming, fluency, comprehension, repetition, reading & writing.reading & writing.

Q. Mental State AssessmentQ. Mental State AssessmentThinking Abnormalities:Thinking Abnormalities:

Form, Stream, Control & Content (Form, Stream, Control & Content (delusions, delusions, obsessions, Compulsions, Phobia, Suicide, obsessions, Compulsions, Phobia, Suicide, Homicide, Self injurious thoughtsHomicide, Self injurious thoughts..

Abstract Reasoning Abstract Reasoning (e.g., explaining (e.g., explaining similarities or interpreting proverbs).similarities or interpreting proverbs).

Perceptual Abnormalities: Perceptual Abnormalities: Illusions & hallucinations (Five Modalities). Illusions & hallucinations (Five Modalities).

Q. Mental State AssessmentQ. Mental State AssessmentCognition:Cognition:

1- Consciousness.1- Consciousness. 2- Orientation.2- Orientation. 3- Attention.3- Attention. 4- Concentration.4- Concentration. 5- Memory.5- Memory. 6- Intelligence.6- Intelligence. 7- General Knowledge.7- General Knowledge. 8- Insight.8- Insight. 9- Judgment.9- Judgment.

1. Level of consciousness: 1. Level of consciousness: (Fully conscious, (Fully conscious, Semi conscious, Comatose Semi conscious, Comatose or Deep coma), the or Deep coma), the best evaluation is to use Glasgow coma scale best evaluation is to use Glasgow coma scale (eye opening, verbal & motor response)(eye opening, verbal & motor response)..2. Orientation: 2. Orientation: (To time, place and person)(To time, place and person)..3. Attention: 3. Attention: (Ask the patient to mention days (Ask the patient to mention days of the week in reverse order or of the week in reverse order or months of the months of the year), for illiterate, we use the digit test year), for illiterate, we use the digit test ..4. Concentration: 4. Concentration: (Subtraction test; 7s of 100 or (Subtraction test; 7s of 100 or 3s of 20 or others)3s of 20 or others). . 5. Memory: 5. Memory: (Immediate, Recent & Remote)(Immediate, Recent & Remote)..6. Intelligence: 6. Intelligence: (Clinical: Average or below)(Clinical: Average or below)..7. General knowledge: 7. General knowledge: (A(Ask the patient to name sk the patient to name 5 governorates, newspapers).5 governorates, newspapers).8. Insight: 8. Insight: Insight less, partial insight, Insight less, partial insight, intellectual insight or insightfulintellectual insight or insightful..9. Judgment: 9. Judgment: Short term & long term plans.Short term & long term plans.

R. Psychometrics & R. Psychometrics & Neuropsychological TestingNeuropsychological Testing

Types of TestsTypes of TestsPersonality:Personality:

Objective: Objective: MMPI 2 & EPQ.MMPI 2 & EPQ.Projective: Projective: Rorschach & TAT.Rorschach & TAT.

Neuropsychological Assessment:Neuropsychological Assessment:Cognitive Evaluation.Cognitive Evaluation.Memory & Executive Functions.Memory & Executive Functions.

Intelligence Testing:Intelligence Testing:– WAISIII.WAISIII.– Stanford Binet.Stanford Binet.

Measurement of Cognitive Disorders:Measurement of Cognitive Disorders:

* Delirium & Dementia: * Delirium & Dementia:

Folstein Mini Mental Status Exam..

Traumatic Brain Injury: Traumatic Brain Injury:

Galveston Orientation & Amnesia Test..

Mood scales:Mood scales:– Beck Depression Scale.Beck Depression Scale.

– State-Trait Anxiety Scale.State-Trait Anxiety Scale.

S. Biological TestsS. Biological Tests

Computerized Tomography (CT).Computerized Tomography (CT).

Positron Emission Tomography Positron Emission Tomography (PET).(PET).

Magnetic Resonance Imaging (MRI).Magnetic Resonance Imaging (MRI).

Electroencephalogram (EEG).Electroencephalogram (EEG).

Event-Related Potential (ERP).Event-Related Potential (ERP).

T. Diagnostic TestsT. Diagnostic TestsLaboratory tests are included in a Laboratory tests are included in a psychiatric evaluation: psychiatric evaluation:

1) When they are necessary to establish or 1) When they are necessary to establish or

exclude a diagnosis. exclude a diagnosis.

2) To aid in the choice of treatment. 2) To aid in the choice of treatment.

3) To monitor treatment effects or side 3) To monitor treatment effects or side

effects. effects.

U. Functional AssessmentU. Functional AssessmentFunctional assessment means Functional assessment means assessing disease assessing disease severity & treatment outcome. severity & treatment outcome.

Functional assessment includes Functional assessment includes assessment of assessment of Physical Physical ActivitiesActivities of daily living (e.g., eating, using the toilet, of daily living (e.g., eating, using the toilet, transferring, bathing & dressing) & transferring, bathing & dressing) & Instrumental Instrumental ActivitiesActivities of daily living (e.g., driving or using public of daily living (e.g., driving or using public transportation, taking medication as prescribed, transportation, taking medication as prescribed, shopping, managing one's own money, keeping house, shopping, managing one's own money, keeping house, communicating by mail or telephone & caring for a child communicating by mail or telephone & caring for a child or other dependent). or other dependent).

Impairments in these activities Impairments in these activities can be due to physical or can be due to physical or cognitive impairment or to the disruption of purposeful cognitive impairment or to the disruption of purposeful activity by the symptoms of mental illness. activity by the symptoms of mental illness.

V. Psychiatric ClassificationsV. Psychiatric ClassificationsIllness, Disease, Syndrome or Disorder.Illness, Disease, Syndrome or Disorder.The most important classifications The most important classifications are the DSM-IV and are the DSM-IV and the ICD-10.the ICD-10.

The DSM-IV:The DSM-IV:

Axis I: Clinical psychiatric diagnoses.Axis I: Clinical psychiatric diagnoses. Axis II: Developmental and Personality.Axis II: Developmental and Personality. Axis III: General medical condition.Axis III: General medical condition. Axis IV: Psycho-social stresses.Axis IV: Psycho-social stresses. Axis V: Adaptation to role function.Axis V: Adaptation to role function.

The ICD-10:The ICD-10: Axis I: Psychiatric and physical diagnoses.Axis I: Psychiatric and physical diagnoses. Axis II: Developmental, personality and stresses.Axis II: Developmental, personality and stresses. Axis III: Adaptation to role function.Axis III: Adaptation to role function.

W. Difficult InterviewW. Difficult Interview

1. Depressed Patients1. Depressed PatientsDepressed patients are often unable to Depressed patients are often unable to provide an adequate account of their provide an adequate account of their illness spontaneously because of such illness spontaneously because of such factors as factors as psychomotor retardation & psychomotor retardation & hopelessnesshopelessness..Need to ask history & symptoms related Need to ask history & symptoms related to depression including to depression including Suicidal IdeationSuicidal Ideation..Typical Symptoms Include: Typical Symptoms Include: feelings of feelings of hopelessness, sleep disturbance, appetite hopelessness, sleep disturbance, appetite change, concentration problems, lack of change, concentration problems, lack of energy or problem solving.energy or problem solving.

2. Suicidal Patients2. Suicidal PatientsEvaluating Suicide Potential is Evaluating Suicide Potential is ImperativeImperative..

Inquire about suicidal thoughts… Inquire about suicidal thoughts… ““Are Are you suicidal now, or do you have plans to you suicidal now, or do you have plans to take your own life?”take your own life?”

Other Risk Factors for Suicide: Other Risk Factors for Suicide: suicide suicide note, family history of suicide or note, family history of suicide or previous suicidal behavior, evidence of previous suicidal behavior, evidence of impulsivity or of pervasive pessimism impulsivity or of pervasive pessimism about the future.about the future.

3. Aggressive Patients3. Aggressive Patients

Assure the patient you can assist Assure the patient you can assist them in managing their behavior them in managing their behavior through the interview.through the interview.Must establish whether effective Must establish whether effective verbal contact can be made with the verbal contact can be made with the patient or whether the patient’s patient or whether the patient’s sense of reality is so impaired that sense of reality is so impaired that effective interviewing is impossible.effective interviewing is impossible.

3. Aggressive Patients 3. Aggressive Patients ContinuedContinued

May have to medicate the patient before May have to medicate the patient before the interview begins.the interview begins.

Have to make the decision whether it is Have to make the decision whether it is safe to remove restraints.safe to remove restraints.

With or without restraints a violent patient With or without restraints a violent patient should not be interviewed alone.should not be interviewed alone.

Other precautions include leaving the Other precautions include leaving the door open & sitting between the patient & door open & sitting between the patient & the door.the door.

3. Aggressive Patients 3. Aggressive Patients ContinuedContinued

Must make it clear that the patient may Must make it clear that the patient may say or feel anything but is NOT free to say or feel anything but is NOT free to act in a violent way.act in a violent way.

Interviewer must remain calm & have Interviewer must remain calm & have additional staff able to maintain control additional staff able to maintain control by physical means if necessary.by physical means if necessary.

Confrontation is to be avoided.Confrontation is to be avoided.

3. Aggressive Patients 3. Aggressive Patients ContinuedContinued

The interviewer should respect as The interviewer should respect as much as possible the patient’s need for much as possible the patient’s need for space.space.

Questions need to be asked regarding Questions need to be asked regarding previous acts of violence, violence previous acts of violence, violence experienced as a child, under what experienced as a child, under what specific conditions the patient resorts specific conditions the patient resorts to violence, with corroboration from to violence, with corroboration from friends & family members.friends & family members.

4. Delusional Patients4. Delusional PatientsThe patients delusions should never be The patients delusions should never be directly challenged.directly challenged.

Challenging only increases a patient’s Challenging only increases a patient’s anxiety & often leads the threatened anxiety & often leads the threatened patient to defend the belief.patient to defend the belief.

It is also inadvisable to believe the It is also inadvisable to believe the patient’s delusion.patient’s delusion.

The interviewer can help by indicating that The interviewer can help by indicating that he understands that the patient believes he understands that the patient believes the delusion to be true but that the the delusion to be true but that the interviewer does not hold the same belief.interviewer does not hold the same belief.

4. Delusional Patients 4. Delusional Patients ContinuedContinued

Focus on the feelings, fears & hopes that Focus on the feelings, fears & hopes that underlie the delusional belief to underlie the delusional belief to understand the delusions particular understand the delusions particular function.function.Delusions may be excessively fixed & Delusions may be excessively fixed & chronic or they may be subject to chronic or they may be subject to question & doubt by a patient & may last question & doubt by a patient & may last only a relatively brief time. only a relatively brief time. A patient may or may not be influenced by A patient may or may not be influenced by the delusional beliefs & may be able to the delusional beliefs & may be able to recognize their effects.recognize their effects.

5. Other Difficult Patients to Interview5. Other Difficult Patients to Interview((Behavioral CharacteristicsBehavioral Characteristics))

Histrionic. Histrionic.

Obsessive. Obsessive.

Dependent. Dependent.

Malingering. Malingering.

Sociopath or Psychopath. Sociopath or Psychopath.

Others.Others.

X. Privacy & ConfidentialityX. Privacy & ConfidentialityPsychiatrists should follow WPA Psychiatrists should follow WPA standards for confidentiality in dealing standards for confidentiality in dealing with the results of psychiatric with the results of psychiatric evaluations. evaluations. Evaluations should be conducted in the Evaluations should be conducted in the most private setting compatible with the most private setting compatible with the safety of the patient & others. safety of the patient & others. Psychiatrists should not make audiotape Psychiatrists should not make audiotape or videotape recordings of patient or videotape recordings of patient interviews without the knowledge & interviews without the knowledge & consent of the patient or the patient's consent of the patient or the patient's legal guardian.legal guardian.