The Clinical Interview - Psychology



The Clinical Interview

Carolyn R. Fallahi, Ph. D.

Introduction to Clinical Psychology

The Clinical Interview

Assessment important for psychologists

Competency of a defendant

How? Tests, interviews, observations.

Neurological disorder vs. mental disorder?

Unique contribution of psychologists.

What does the clinical interview involve?

Evaluation of strengths & weaknesses

Conceptualization of problem

Thoughts about etiology?

Thoughts about alleviating the problem?

A one time shot? No…ongoing.

Example case.

The Referral

Who?

Parent

Teacher

Psychiatrist

Judge

Psychologist

Poses a question

The Referral Question

Sometimes needs rephrasing.

Is this patient capable of murder?

Why is the patient having trouble in school?

Assessment

Not completely standardized set of procedures.

Describe the client in a useful way.

General Characteristics of the interview

The Interaction

Introduce yourself & make an assessment of any potential communication problems.

Talk about what the session will involve.

Obtained informed consent.

Get an understanding of the chief complaint or issue.

What is your understanding of the problem?

Case History Outline

Identifying data.

Reason for coming to the agency & expectations for service.

Present situation.

Family constellation.

Early recollections.

Birth & development.

Case History Outline

Health.

Education & training.

Work Record.

Recreation & Interests.

Sexual development.

Marital & family data.

Self-description.

Choices & turning points in life.

Case History Outline

View of the future.

Anything else?

Mental Status Examination

General presentation.

State of consciousness.

Attention & concentration.

Speech: clarity, goal-directedness, language deficits.

Orientation: person, place, time

Mood & Affect

Form of thought; formal thought disorder

Mental Status Examination

Thought content: preoccupations, obsessions, delusions.

Ability to think abstractly.

Perceptions: Hallucinations.

Memory: immediate, recent, remote

Intellectual functioning

Insight & judgment

Appearance & Behavior

Look at appearance, manners & behavior.

Keep socioeconomic group in mind.

Remember individuality.

Appearance & Personality:

High degree of attention to tidiness.

High degree of attention to fashion.

High degree of attention to flamboyant or seductive behavior.

Appearance & mental disorders

Omega sign = depression?

Long face.

Bizarre appearance is quite rare. Psychosis?

Self-neglect. Dementia? Retarded depression?

Neurological disturbance? Chronic schizophrenia?

Colorful dressing. Mania?

Somber dressing. Depression?

Behavior

Marked agitation. Anxiety? Agitated depression? Psychosis? Mania?

Irritability. Mania? ADHD? Delirium? Stimulant abuse?

Decreased activity. Acute depression, chronic schizophrenia, mental retardation, Parkinson’s, Hypothyroidism?

Repetitive movements. Tics? Vocal productions? Tourette’s? OCD? ADHD? Intellectual disability?

Movements

Echopraxia – movements that are replicated, e.g. crossing the legs, touching the face.

Drug intoxication? Psychosis? Schizophrenia?

Catatonic stupor.

Catatonic posturing.

Catatonic rigidity.

Waxy flexibility.

Suicidal Behavior

Self-cutting or slashing. Depression? Psychosis? Personality disorder? Hallucinations? Delusions?

Other suicidal behavior. Depression? Factitious disorder? Malingering? Desire for death?

Speech or talk

Articulation –

Dysarthria or mumbling. Mechanical problems?

Neurological disorders?

Chronic Schizophrenia?

Fatigue, sedation, medication, intoxication?

Speech

Volume –

Loud talk. Mania? Personality traits?

Quiet talk. Depression? Unassertive individual.

Speed –

Rapid talk. Mania? Anxiety? Stimulants?

Slow talk. Depression? Sedation? Intoxication?

Pressure of speech/thought/talk –

Increase in the speed of talk. Talk over. Mania? Stimulant intoxication?

Pitch

High pitched talk. Anxiety? Fear? Arousal?

Constant low-pitched talk. Depression? Hypothyroidism?

Dysprosody. Depression? Schizophrenia? Brain damange? Associated with disorders of affect.

Mood

Definitional issues.

Sustained for months

Pervasive character

Subjectively experienced

Observable by interviewer

Is the subjective response congruent with interviewer’s findings?

Subjective experience

Patient experience

Objective findings

Elation, Irritability, Anxiety,

Subjective experience

Objective findings

Affect

• Difference of opinion, e.g. affective versus mood

• Internal feeling state.

• Observation of feeling.

• Subtle changes expected.

• Mood & affect in depression.

• Loss of emotions in Schizophrenia.

• Affect assessed during the entire examination.

• Appropriate affect.

• Restricted and blunted affect? Flat affect?

Thought

• Examined through speech.

• Reflected in behavior.

o Form: arrangement of parts. Disturbances in the logical connections between ideas.

o Formal thought disorder.

o What is normal range? Need to let the patient speak freely – periods where there is little structure.

o Abstract questions.

o Proverbs.

o The use of silence.

o Record verbatim examples of a formal thought disorder in the patient’s file.

o Derailment: deviation in the train of thought. This has replaced the old term, “loosening of associations”.

o Tangentiality: inability to have goal-directed associations of thought.

o Derailment. Mania? Depression? Schizophrenia? Schizophreniform disorder? Schizotypal personality disorder?

o Flight of ideas. Mania? Schizophrenia? Intoxication with stimulants?

o Pressured speech.

o Incoherence. Why? Derailment? Neurological problem? Often not due to a psychiatric disorder.

o Why not schizophrenia?

o Neologism: words are invented by the speaker or distorted. Schizophrenia?

o Thought block or thought withdrawal. Rare phenomenon. Thoughts withdrawn from the head – only identified if it occurs in mid-thought and if the patient volunteers or admits on question that the thought was lost. Differential: Schizophrenia versus Mania.

o Perseveration & echolalia: Perseveration is the repetitive expression of a particular word or phrase. Echolalia: pathological repeating of words or phrases. Organic conditions? Mania? Schizophrenia?

o Poverty of thought (speech): speech decreased amount. Hyperthyroidism? Dementia? Brain damage? Depression? Chronic Schizophrenia?

o Poverty of content: little information given. Derailment?

o Illogicality: erroneous conclusions or internal contradictions in thinking. Psychotic? Intoxication?

o Content.

o Delusion: false beliefs that are sustained despite evidence to the contrary. Somatic, persecutory, guilt.

o Bizarre delusions.

o Grandiose delusions.

o Persecutory delusions.

o Delusions of reference.

o Delusions of control.

o Thought withdrawal.

o Thought insertion.

o Thought broadcasting.

o Nihilistic delusion.

o Somatic delusion.

o Delusions of guilt.

o Delusional jealousy.

o Erotomanic delusions.

o Mood-congruent delusion.

o Systematised delusions.

o Obsession & compulsions.

o Phobias.

o Agoraphobia.

o Social Phobia.

o Simple Phobia.

o Hypochondria.

o Suicidal thoughts.

o Homicidal thoughts.

Perception

• Perception: transferring physical stimulation into psychological information.

• Depersonalization and derealization.

• Delusional mood.

• Heightened perception.

• Changed perception.

• Hallucinations.

• Non-pathological hallucinations.

• Alcoholic hallucinosis.

• Illusions – misperceptions of stimuli. Usually transitory.

Intelligence

• The ability to think and act rationally and logically.

• Mental retardation.

• Cognition is the new term.

Cognition

• Thinking and mental processes of knowing and becoming aware.

• Cognitive testing.

• Memory, orientation, concentration, & language.

• Mini-mental status examination (MMSE, Folstein) – standardized & internationally accepted screening test of cognitive functions.

• Memory. Includes 3 basic mental processes. The ability to perceive, recognize, and establish information in the CNS, retention , and recall. Measurement includes Immediate memory, STM, LTM.

• Tests of memory.

o History & conversation. Can the patient give a clear account of their life from the remote to the recent past?

o Short-term memory: repeat sequences of digits. Reverse digits?

o Recent memory test. Have patient learn 3 or 4 unrelated words. Tell the patient that his/her memory will be tested. Ask them to repeat to make sure registered properly. Some minutes later, ask to recall the words.

o Remote memory test. Some issues with what to include. Highly learned material, like DOB can be problematic.

o Loss of memory.

▪ Organic origin.

▪ Dementia.

▪ Head injury.

▪ Amnestic Disorder.

▪ Loss of memory when there is a psychological explanation: psychogenic amnesia; psychogenic fugue; MPD; Paramnesia; Confabulation; depersonalization & derealization.

o Orientation.

▪ Time, person, place.

o Attention/Concentration.

o Attention: context of consciousness. A state of awareness of the self & environment.

▪ Disorders that show subtle attention problems.

▪ Severe disorders of attention: schizophrenia, depressive psychosis, delirium, dementia, brain damage, severe attention disorders.

▪ Tests of attention: History & conversation. Subtraction. Reversing components.

▪ Language:

• Aphasia – impairment.

• Dysphasia – dysfunction of speech.

• Broca’s aphasia – output sparse, effortful, short-phrased & agrammatical. Patient is aware of and frustrated by his/her expressive difficulties.

• Wernicke’s aphasia: word finding problems & problems with comprehension.

• Conduction aphasia – severe disturbance in repetition.

• Transcortical aphasia –preservation of repeating in the presence of marked language impairment.

• Nominal aphasia – word finding. Reading & writing disturbances.

• Dysarthria – mechanical problem.

• Testing aphasia – mechanics of speech; fluency, phrase length & paraphasic substitutions; comprehension; repetition; naming; writing ability; reading ability.

Rapport

Insight

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