Psychiatric Clinical Skills

376 Pages·2006·3.338 MB·English

by  David S. Goldbloom, MD, FRCPC (Eds.)

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PSYCHIATRICCLINICALSKILLS ISBN 13:978-0-323-03123-3
ISBN 10:0-323-03123-4
Copyright © 2006,Mosby,Inc.All rights reserved.
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Notice
Knowledge and best practice in this field are constantly changing.As new research and experience broaden our
knowledge,changes in practice,treatment and drug therapy may become necessary or appropriate.Readers are
advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of
each product to be administered,to verify the recommended dose or formula,the method and duration
ofadministration,and contraindications.It is the responsibility of the practitioner,relying on their own experience
and knowledge of the patient,to make diagnoses,to determine dosages and the best treatment for each individual
patient,and to take all appropriate safety precautions.To the fullest extent of the law,neither the Publisher nor the
Editors assume any liability for any injury and/or damage to persons or property arising out or related to any use
of the material contained in this book.
Library of Congress Cataloging-in-Publication Data
Psychiatric clinical skills / [edited by] David S. Goldbloom.
p. ; cm.
Includes index.
ISBN 0-323-03123-4
1. Psychiatry. 2. Clinical competence. I. Goldbloom, David S.
[DNLM: 1. Mental Disorders–diagnosis. 2. Mental Disorders–therapy. 3. Psychology,
Clinical–methods. WM 141 P9733 2006]
RC454.4.P759 2006
616.89–dc22 2005052276
Editor: Susan F. Pioli
Editorial Assistant: Joan Ryan
Project Manager: David Saltzberg
Printed in the United States of America.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
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For Will, Daniel, and Nancy
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Contributing Authors
SUSANE. ABBEY, MD, FRCPC ELSPETHA. BRADLEY, BSC, PHD, MBBS, FRCPC,
Associate Professor of Psychiatry, University of Toronto; FRCPSYCH
Director of Program in Medical Psychiatry, University Associate Professor of Psychiatry, University of Toronto;
Health Network, Toronto, Canada Psychiatrist-in-Chief, Biomedical Services and Research
Division, Surrey Place Center, Toronto, Canada; Staff,
LISAFRANCESCAANDERMANN, MPHIL, MDCM, Department of Psychiatry, Hamilton Health Sciences,
FRCPC Hamilton, Canada; Consultant Psychiatrist in Learning
Assistant Professor of Psychiatry, Culture, Community and Disabilities, Learning Disabilities Service, West Resource
Health Studies, University of Toronto; Staff Psychiatrist, Centre, Cornwall Partnership Trust, Cornwall, United
Mount Sinai Hospital, Toronto, Canada Kingdom
PAULD. ARNOLD, MD, FRCPC PIERBRYDEN, MD, MPHIL, FRCPC
Fellow in Psychiatry, University of Toronto; Staff Assistant Professor of Psychiatry, University of Toronto;
Psychiatrist, Child, Youth, and Family Program, Centre for Staff Psychiatrist, Child and Adolescent Psychiatry,
Addiction and Mental Health, Toronto, Canada TheHospital for Sick Children, Toronto, Canada
R. MICHAELBAGBY, PHD, CPSYCH CORINEE. CARLISLE, MD, FRCPC
Professor of Psychiatry, University of Toronto; Director of Clinical Fellow in Child and Adolescent Psychiatry,
Clinical Research, Centre for Addiction and Mental University of Toronto; The Hospital for Sick Children,
Health, Toronto, Canada Toronto, Canada
JOSEPHH. BEITCHMAN, MD BARBARAJ.DORIAN, MD, FRCPC
Professor and Head of the Division of Child and Assistant Professor of Psychiatry, University of Toronto;
Adolescent Psychiatry, University of Toronto; Clinical Staff Psychiatrist, Mood and Anxiety Program, Centre for
Director of Child, Youth, and Family Program, Centre for Addiction and Mental Health, Toronto, Canada
Addiction and Mental Health; TD Bank Financial Group
Chair in Child and Adolescent Psychiatry, The Hospital for NATHANB. EPSTEIN, MD, FRCPC
Sick Children, Toronto, Canada Professor Emeritus of Psychiatry, Brown University
School of Medicine, Providence, Rhode Island;
ASHBENDER, MD, FRCPC Psychiatrist-in-Chief Emeritus, St. Luke’s Hospital,
Lecturer, Department of Psychiatry, University of NewBedford, Massachusetts
Toronto; Medical Director, Psychological Trauma
Program, Centre for Addiction and Mental Health, ANTHONYFEINSTEIN, MPHIL, PHD, FRCPC
Toronto, Canada Professor of Psychiatry, University of Toronto; Staff
Psychiatrist, Sunnybrook and Women’s College Health
Sciences Centre, Toronto, Canada
ix
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x Contributing Authors
DAVIDS. GOLDBLOOM, MD, FRCPC ANTHONYJ. LEVITT, MD, FRCPC
Professor of Psychiatry, University of Toronto; Professor of Psychiatry, University of Toronto;
SeniorMedical Advisor, Education and Public Affairs, Psychiatrist-in-Chief, Sunnybrook and Women’s College
Centre for Addiction and Mental Health, Toronto, Canada Health Centre, Toronto, Canada
BENJAMINI. GOLDSTEIN, MD, PHD PAULS. LINKS, MD, FRCPC
Resident, Department of Psychiatry, University of Arthur Sommer Rotenberg Chair in Suicide Studies,
Toronto; Sunnybrook and Women’s College Health Department of Psychiatry, University of Toronto; Deputy
Sciences Centre, Toronto, Canada Chief of Mental Health Services, St. Michael’s Hospital,
Toronto, Canada
CURTISHANDFORD, BSC, MD, CCFP
Staff Physician, Nicotine Dependence Clinic, Centre for HUNG-TAT(TED) LO, MBBS, MRCPSYCH, FRCPC
Addiction and Mental Health; Staff Physician, Assistant Professor of Psychiatry, University of Toronto;
Department of Family and Community Medicine, Inner Staff Psychiatrist, Culture, Community, and Health
City Health Program, St. Michael’s Hospital, Toronto, Studies, Centre for Addiction and Mental Health; Mt. Sinai
Canada Hospital, Toronto, Canada
SHEILAHOLLINS, MBBS, FRCPSYCH, FRCPCH JODILOFCHY, MD, FRCPC
Professor of Psychiatry of Intellectual Disability, Associate Professor of Psychiatry and Director of
University of London; Consultant Psychiatrist, Joan Undergraduate Medical Education, University of Toronto;
Bicknell Centre, South West London and St. George’s Director of Emergency Services, Department of
Mental Health NHS Trust; President, Royal College of Psychiatry, University Health Network, Toronto, Canada
Psychiatrists, London, United Kingdom
NATASJAMENEZES, MDCM, FRCPC
ALLANS. KAPLAN, MD, FRCPC Clinical Research Fellow in Psychiatry, University of
Director of Postgraduate Education and Professor of Toronto; Staff Psychiatrist, Schizophrenia Program,
Psychiatry, University of Toronto; Loretta Anne Rogers Centre for Addiction and Mental Health, Toronto, Canada
Chair in Eating Disorders and Head of Program for Eating
Disorders, University Health Network/Toronto General JARRETD. MORROW, MD
Hospital, Toronto, Canada Resident in Psychiatry, University of Alberta, Edmonton,
Canada
MARKR. KATZ, MD, FRCPC
Assistant Professor of Psychiatry, University of Toronto; JULIANUNES
Staff Consultant-Liaison Psychiatrist, Toronto General Journalist and Author, Toronto, Canada
Hospital, University Health Network; Coordinator of
Psychiatric Services, Psychosocial Oncology and Palliative LARAJ.OSTOLOSKY, MD, FRCPC
Care, Princess Margaret Hospital, University Health Staff Psychiatrist, Eating Disorders Program, University of
Network, Toronto, Canada Alberta Hospital; Department of Psychiatry,University of
Alberta, Edmonton, Canada
GABORI. KEITNER, MD, FRCPC
Professor of Psychiatry, Brown University School of NEILA. RECTOR, PHD, CPSYCH
Medicine; Director of Adult Psychiatry and Mood Associate Professor of Psychiatry, University of Toronto;
Disorders Program, Rhode Island Hospital, Providence, Psychologist and Head of Anxiety Disorders Clinic, Centre
Rhode Island for Addiction and Mental Health, Toronto, Canada
PHILIPKLASSEN, MD, FRCPC GARYRODIN, MD, FRCPC
Assistant Professor, Departments of Psychiatry and Professor of Psychiatry, University of Toronto;
Medicine, University of Toronto; Deputy Clinical Department Head and Joint University of
Director, Law and Mental Health Program, Centre for Toronto/University Health Network Harold and Shirley
Addiction and Mental Health, Toronto, Canada Lederman Chair in Psychosocial Oncology and Palliative
Care, Princess Margaret Hospital, University Health
ANDREAJ.LEVINSON, MD, FRCPC Network, Toronto, Canada
Clinical and Research Fellow in Psychiatry, University of
Toronto; Mood and Anxiety Program, Centre for
Addiction and Mental Health, Toronto, Canada
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Contributing Authors xi
CHRISTINEE. RYAN, PHD KENNETHI. SHULMAN, MD, SM, FRCPC
Assistant Professor of Psychiatry and Human Behavior, Professor of Psychiatry, University of Toronto; Staff
Brown University School of Medicine; Director of Family Psychiatrist, Sunnybrook and Women’s College Health
Research Program, Department of Psychiatry; Assistant Sciences Centre, Toronto, Canada
Director of Mood Disorders Program, Rhode Island
Hospital, Providence, Rhode Island IVANL. SILVER, MD, MED, FRCPC
Professor of Psychiatry and Associate Dean of Continuing
ISAACSAKINOFSKY, MD, FRCPC, FRCPSYCH Education, University of Toronto; Director, Centre for
Professor Emeritus of Psychiatry and Public Health Faculty Development, St. Michael’s Hospital, Toronto,
Sciences, University of Toronto; High Risk Consultation Canada
Clinic, Centre for Addiction and Mental Health, Toronto,
Canada SCOTTSIMMIE
Journalist and Author, Toronto, Canada
MARKSANFORD, MBCHB, FRCPC
Associate Professor of Psychiatry (Division of Child PERCYWRIGHT, PHD, CPSYCH
Psychiatry), University of Toronto; Head of Child Mood Psychologist, Forensic Assessment Program, Mental
Disorders Service, Child, Youth, and Family Program, Health Centre Penetanguishene, Penetanguishene,
Centre for Addiction and Mental Health, Toronto, Canada Canada
FIONAS. M. SCHULTE, MA L. TREVORYOUNG, MD, PHD, FRCPC
Department of Public Health Science, University of Professor and Cameron Wilson Chair in Depression
Toronto; Clinical Research, Centre for Addiction and Studies, University of Toronto; Physician-in-Chief, Centre
Mental Health, Toronto, Canada for Addiction and Mental Health, Toronto, Canada
PETERSELBY, MBBS, CCFP, MHSC, ASAM ROBERTZIPURSKY, MD, FRCPC
Assistant Professor, Family and Community Medicine, Professor of Psychiatry and Tapscott Chair in
Psychiatry, and Public Health Sciences, University of Schizophrenia Studies, University of Toronto; Clinical
Toronto; Clinical Director, Addictions Program, Head, Director, Schizophrenia Program, Centre for Addiction
Nicotine Dependence Clinic, and Principal Investigator, and Mental Health, Toronto, Canada
Ontario Tobacco Research Unit, Centre for Addiction and
Mental Health, Toronto, Canada
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Preface
“Go interview that new patient.” This instruction from a helps confer legitimacy to the associated distress; under-
clinical teacher or supervisor may be the immediate prel- standing the person helps cement the therapeutic alliance
ude to a first clinical encounter in a clinic, an inpatient unit, necessary for trust and hope to be buttressed by help.
an emergency room, or a home visit. For the student in any Psychiatry is all about the reconciliation of the unique
of the mental health professions—psychiatry, psychology, nature of human experience and individuality with the
social work, nursing, and counseling—there may be a sense highly reproducible patterns of human behavior and psy-
of dread related to not knowing what to ask or how to ask it. chiatric illness across centuries and cultures. Pattern recog-
Lectures and readings on the theoretical causes of psychi- nition is the foundation of all expertise in medical
atric disorders, memorized mnemonics of diagnostic crite- diagnosis, and no less so in psychiatry, but the reduction of
ria, and laminated cards of algorithmic treatment assessment to diagnostic checklists robs the field of its rich-
approaches provide little help for that ultimately human ness as a human encounter and deprives people with men-
encounter of two individuals. tal illness of the hope that can emerge from a sense of
Psychiatric assessment and engagement are not entirely connection with a professional who knows and under-
separable concepts. The art of asking the right questions in stands.
the right way leads to a sense in the person being inter- Through the contributions of numerous senior academic
viewed that the interviewer knows what he or she is doing clinicians, this book provides a guide to psychiatric assess-
and understands the problem at hand. This combination of ment and engagement across a number of clinical prob-
expertise and empathy can result in the provision of hope lems and settings. While this book is targeted toward
and trust, which serve as foundations for engagement. students in the mental health professions, all of us benefit
Psychiatry is virtually alone in medicine in lacking any from the clinical pearls of our colleagues, whose years of
diagnostic laboratory or imaging tests. The absence of such dedication and experience are reflected in these pages.
external markers of validity that make both the patient and
the mental health professional know that the problem is David S. Goldbloom
“real” dramatically heightens the need for clinical skills of
assessment and engagement. Understanding the problem
xiii
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Acknowledgments
This book was unabashedly inspired by the work of myfather, counsel of Susan Pioli, Editor, and Joan Ryan, Senior
Richard Goldbloom, whose similarly conceptualized text- Editorial Assistant, at Elsevier. The commitment and
book Pediatric Clinical Skills(Saunders, 2003) is now in its enthusiasm of the contributors, largely from the University
3rd successful edition. He continues to emphasize the of Toronto, as well as the response from students to early
importance of clinical interviewing as the most sophisti- drafts, reassured us that the project was worthwhile.
cated form of diagnostic technology in his field. At the Finally, all the authors are grateful to the patients, families,
same time, my father-in-law, Nathan Epstein (one of students, and colleagues who helped us to hone our psychi-
thecontributors to this book), has profoundly shaped my atric clinical skills and to share them with our readers.
own views of the primacy of clinical skills in psychiatry.
The planning for and production of this book was made David S. Goldbloom
immeasurably easier by the friendly support and wise
xv
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1
General Principles of Interviewing
DAVID S. GOLDBLOOM
INTRODUCTION The room should be a setting where both you and the
patient feel safe (see Chapter 14, Emergency Assessment)
Your initial encounter with a patient—whether it is a and comfortable, free from distracting noises (e.g., your
brief meeting in a hallway or an extended interview in an cell phone, pager, or the jackhammer used in the ongoing
office—represents an opportunity to begin to understand renovation of the adjacent room). Given that many patients
the patient’s difficulties and to begin to establish a thera- will be in some sort of distress, a box of facial tissues avail-
peutic relationship. These processes are simultaneous and able at the outset is a thoughtful gesture, and it is prefer-
interdependent rather than sequential and autonomous. able to a frantic look by both of you around the room at an
In the chapters that follow, you will learn about some of emotional moment for something other than a sleeve to
the specific contexts of diagnostic interviewing and how absorb the tears.
they affect the types of questions you will ask and the ways Are the chairs at roughly the same height, or are you tow-
you will try to engage the patient. However, they also ering over the patient? Are you sitting behind a desk? Why?
appropriately reflect some current commonalities of For some patients, the desk will be a symbolic barrier
approach in psychiatry where diagnostic methodologies are between them and you.
largely limited to listening, asking, and talking. As a general rule, never stand during an interview when
the patient is either sitting or lying on a bed. Meet
patients at their level in terms of eye contact. Patients
THE PRELIMINARIES
who are in bed should remain there for an interview only
if they are too debilitated (or are restrained) to sit up.
Setting the Stage
Even then, cranking up the head of the bed if tolerated
You should consider in advance where you are going to and then sitting adjacent to the bed will assist in normaliz-
conduct an interview. Is there a room that affords comfort ing the encounter. Assisting a patient out of bed and into a
and privacy? Emergency room waiting areas and shared chair is a physical act of helping that underscores your
inpatient accommodations are among the least conducive role nonverbally.
settings—and yet by default preliminary assessments are One of the commodities you offer is your time. Does the
often carried out there. Is there a room somewhere nearby interview environment you have selected allow you to
where you can interview the patient in private? It’s worth the know what time it is without checking your wristwatch
extra time to locate one—and patients appreciate the fact repeatedly? Many mental health professionals have strate-
that you have made the extra effort to do so; in other words, gically located clocks in various regions of their offices to
one brick for the foundation of a therapeutic alliance has allow tracking of time more subtly. They don’t need to be
already been laid, and you haven’t even started talking yet. hidden; patients also like to know what time it is.
1
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2 Psychiatric Clinical Skills
The more you build a structure into your interview and the
The Greeting
more you use the interview to test out hypotheses about the
Introducing yourself clearly and formally to a patient on person and the diagnosis, the less you will need to take
first meeting sets a tone. Formality need not imply a lack of notes. Some dates of events or doses of medication may
friendliness. Do you find it irritating when people you don’t require jotting down, but often these in-the-moment notes
know call you by your first name? Does it feel falsely are far too inclusive and defeat the task of synthesizing and
friendly? I prefer to begin with “Mr. or Ms.______” in filtering information.
addressing the patient while introducing myself as As an exercise, you should try interviewing a patient for
Dr. Goldbloom. Some patients may say, “Call me Bob” whom someone else has already done and documented an
(particularly so if that is their first name). However, there assessment that you haven’t seen. Don’t take any notes
may be an expectation of reciprocity that they should be while you conduct a diagnostic interview. Then sit down
able to address you by your first name. Although some immediately afterward and write it up. You will be sur-
mental health professionals will go along with that infor- prised, particularly if you take a semistructured approach,
mality, it can create a false level of mutual intimacy and dis- at how much relevant detail you recall. Compare it to the
closure. You will (and should) know far more about your previously documented assessment and you may begin to
patients’ lives than they know about yours. understand what, if anything, you left out—and why. It will
Shaking hands in many but not all cultures is a physical make you a better interviewer.
and normative form of greeting. Many patients have told
me that the memory of a firm handshake on first meeting
Explaining the Interview
was a tangible form of support at a time they were feeling
overwhelmed and alone. Think of the possible meanings There are two extremes in approach to explaining the inter-
for patients already feeling marginalized by their experi- view; one style assumes that the purpose is obvious—after all,
ences if you do not offer your hand in greeting. In my you’re a mental health professional—and any explanation is
experience, only extremely paranoid, angry, or obses- redundant. The other generates a 10-minute explanation that
sional patients have refused to offer theirs in return. It is starts to sound like a term life insurance policy.
the only sanctioned “laying on of hands” within mental Don’t assume that the patient knows who you are, why
health that has been such a comfort to patients in the rest this interview is happening, how long it will take, or what it
of medicine. will lead to. Remember that when people are feeling anx-
ious, they often have difficulty listening to long and elabo-
rate explanations.
To Write or Not To Write?
Have you ever had the experience, most commonly at a
All too often, I have witnessed students and psychiatry party, when someone tells you his name and as he says it you
residents taking notes furiously during interviews. Let’s forget it instantly? The same experience can happen in a
consider the advantages and disadvantages. The only advan- clinical encounter. After meeting a patient in a public area
tage is the immediate availability of an almost-literal tran- and introducing myself, I usually repeat my name once we
script of the encounter. The following are disadvantages: are seated for an interview and acknowledge that it is not an
easy name to remember (rather than putting the possible
1. The cognitive preoccupation that writing requires: It’s a blame for forgetting on an already anxious patient).
multi-tasking challenge to write down great quotes from As for explaining the purpose of the interview, I describe
patients while simultaneously processing what they say a process that has three goals.
and thinking about how to explore it further.
2. The lack of eye contact that writing demands: Unless 1. To find out who you are
you are blessed with an ability to write without looking 2. To find out what kind of problems you’re having
at what you are writing (I would veer eventually onto my 3. To find out how I can help
pant leg if I tried that), time looking at your penmanship
is time lost with the patient. This is a plain-language statement that reflects multiple
3. The fantasies that writing engenders: As patients watch tasks. First, it acknowledges that I am speaking with a
you write (they do exactly this), they may wonder why unique individual about whom I know little but need to
you write down only certain parts of what they say—and learn; second, it states that there will be a diagnostic focus
what that means. They may wonder who else is going to to the encounter; and third, it makes it clear that I am there
read your notes and what happens to those notes after to help. This message of help, which may seem incredibly
you are done. Patients don’t have to be paranoid to be obvious to you by virtue of your mere presence, benefits
morbidly curious. from overt statement and repetition.
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General Principles of Interviewing 3
Once this overview has been provided, I then explain the 2. It conveys your interest in the day-to-day realities he
process, which may include the following: “I’m going to be faces.
asking you lots of questions over the next hour, and I may 3. It helps you put solutions for him in a context of feasi-
need to interrupt you from time to time so I can understand bility.
things better, but at the end I’ll give you my sense of what is
4. It helps you gauge his financial competency.
going on and how I can help. You’ll have a chance to ask me
some questions as well.”
For someone who is unemployed, you should find out
when he last worked and what he did. Again, this helps
establish the identity of the person at the outset, rather
THE MAIN EVENT
than simply regarding the patient as someone who is cur-
rently receiving public assistance or lives on the streets.
Every interview has a structure—even those that seem on
Asking whether someone is “single, married, or in a rela-
the surface quite disjointed. Having a template in your mind
tionship”covers most of the ground. If the person is cur-
will assist you in progressing through the interview and does
rently single, then it is reasonable to ask, “What about in
not require a rigid or formulaic approach. However, many
the past?”Asking this way doesn’t presume sexual orienta-
novice interviewers display their template overtly by the
tion, and its openness may allow disclosure early in the
questions they ask, such as “Now I’d like to ask you about
interview.
your past personal and developmental history.” What you
Remember that single people have children. All too
actually want to know is about patients’ experiences growing
often, I see students forget to ask this of people who are not
up. Why not say so in plain language rather than using the
currently in a relationship or who are currently living alone.
actual section headings of your write-up?
Similarly, single people may be living in nonintimate rela-
As an exercise, write down the stock phrases you use in
tionships with a variety of friends and relatives.
introducing various sections of the interview. Try to imag-
Finally, in our multicultural and multiracial universe, it’s
ine how they sound to a patient. Get together with some
worth asking up front about the patient’s background.
colleagues and compare notes on this task.
Aname, an appearance, or an accent may all trigger your
curiosity, and the question is an opportunity at the outset of
Identifying Data the interview for the patient to teach you something about
himself and his community.
The advantage of beginning the interview with this section
is that, for most patients, it is less threatening and easier to
answer than questions related to their problems. It also
The Chief Complaint
begins what you have already described as the first task of the
interview—finding out who they are. And yet, far too many It’s somewhat archaic that this section heading persists
interviewers race through it as a pit stop en route to the diag- in medicine. Who likes a complainer? But the various
nostic finish line. Components include the following: meanings of the word “complaint” include dissatisfaction,
resentment, a bodily disorder or disease, and an expression
● Age of pain. It is that last category that probably comes closest
● Occupation to capturing what you are looking for. What is bothering
● Relationship status this person? What does he identify as a problem for which
● Living arrangements he is seeking help? The stock question of “What brought
● Ethnocultural and racial heritage you here today?” commonly evokes the concrete response
of “a taxi.” “What sort of problem or difficulty have you
In asking about occupation, remember that it is generally been having?”makes the question clearer.
no longer acceptable or accurate to ask homemakers (usu- Unless your patient has recently read a textbook of psy-
ally women), “Do you work or are you at home?” Rather, chiatry, he will answer with words that reflect his vocabu-
“Do you work outside the home?”conveys an appreciation lary, perspective, and priority. The labels he has come up
of the role within it. If someone is unemployed, you should with can serve as a common language and reference point
find out how financial support occurs. Is the person receiv- for further elaboration of the history. For instance, “My
ing public assistance? How much? What does he pay in head’s messed up” may be the anchor for your subsequent
rent? How much does that leave him to live on? This line of questions about chronology and other symptoms, such as
questioning helps for several reasons: “Since your head’s been messed up, have you noticed any
change in your sleeping?” Some patients will talk about
1. It gives you a picture of the financial realities the patient having had a “breakdown.” This is not the time to point out
faces and puts his problems in that context. to them that this term does not exist in the diagnostic