Psychiatry & Psychotherapy Podcast - The Basics of the Psychiatric Interview Part 1

Episode Date: January 16, 2018

In this first episode, I talk about my approach to seeing a new patient for the first time.  I go over the importance of empathy and psychological safety in the first interview.  I then go into how to do some of the components of a psychiatric history.  I go into details on what parts are important and why.  Please see my resource page for a full PDF of my notes and also the PDF of the document I give to patients prior to their first appointment with me.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video. Join David and post your comments for this episode on Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder Editor: Arvy Wuysang *This podcast is for informational purposes only and is the opinions of the people on this episode.  For full disclaimer go here.  

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Okay, so in this first episode, I am going to go through a basic lecture I give to third-year medical students on how to do a psych HMP. Now, the goal of the psych HMP is first and foremost to connect with the person in front of you as a human being, as a fellow life traveler, as someone who is

flawed like you are, flawed like I am, as someone who struggles like you are, struggles like I do, as someone who needs help. And the first thing you can almost always assume is that there's an aspect of shame that walks into a room. When you go visit a psychiatrist for the first time or for the maybe 50th time, there's still this aspect of there's something wrong with me, I'm defective, and what's up with that?

So if they look a little downcast, if they're looking down, if they're having a hard time, getting words out, just assume it's because the very nature of what it means to see a mental health professional. It's hard. It's gut wrenching. It takes time to get over that. So first and foremost, you really want to try to connect with this person in front of you. And I really think it's helpful to see them as someone who could be you. And specifically, like, even if they're schizophrenic, hearing things, been homeless for years. And that's not your story. That's not

something you struggled with. If you were to go through a biological schizophrenia like they have, you could end up in that position. And so I think it's really important to put yourself in their shoes and to meet them in the place that they're at and feel some of what they're feeling. And to feel that yourself and to put yourself in their shoes. So empathy is number one. The second thing I think is psychological safety is imperative. Psychological safety is the ability for someone to tell you that you've made mistakes or tell you that they don't agree with you.

And for you to be open to that, for you to take that as information, for you to find their information of value because it's their experience. and to consider honestly and look for truth in an honest fashion without getting defensive. So there's got to be this aspect of psychological safety. And that's very important, especially when you're trying to navigate mental health issues. They're concerns, their fears. I would have concerns. I have had concerns.

I have had fears when I've been in mental health as the patient. And so I think it's very valuable to live. listen to those concerns. And so I think that's the second thing. So first thing, put yourself in their shoes, empathy. Second thing, psychological safety. The third thing is therapeutic alliance. And I'm going to probably spend 10 lectures going into the details of therapeutic alliance, but suffice to say, from the first encounter, from the first time you are meeting someone, for the first time you are shaking their hands, you are trying to build a real relationship, a relationship that has a structure.

You know, they are the patient. You are the person there trying to help them. To some degree, you are not. The expert, you are listening to their goals. So therapeutic alliance has two aspects. One is aligning goals together. So you both have in mind the patient's goals, and you're trying to accomplish those.

And the second aspect is a bond, an attachment. And that takes time. it can really be something that can grow in the first encounter. And so a lot of how I phrase and listen and respond is going to be trying to build a therapeutic alliance for the sake of the joy and the pleasure and the effectiveness in and of the therapeutic alliance. So I'm not trying to build a therapeutic alliance or give empathy or be psychologically safe in order to obtain my goals but to help the patient obtain their goals.

and that's very important. I mean, you know, I think when our goals align with the patient's goals, align with society's goals, it becomes very meaningful what we're doing. And what that could look like is, you know, our goals is them getting better, their goals is them getting better. And through that, they're able to go out into society. And, you know, I've had patients who do incredible things, incredible things, volunteer, work in the inner city, you know, whatever it is, whatever their passion is, whatever that one bit spark of life that comes into them, that needs to be embodied, that needs to be transcended into actuality, whatever that is, to get that into space and time and to help society, it's really beautiful. And so when your goals and the patient's goals and society's goals and

your families, their families, all of those goals align, it's just a beautiful thing. So that being said, here's how I think of the psychiatric interview. First of all, I tend to want to find out why the patient is coming in today. And so, you know, I'll say something like, you know, my introduction or whatnot and that'll say, help me understand what brings you in today. You know, and some people will say, I'm feeling suicidal and you may, you know, fall it up by, well, how long have you been feeling this? And they'll go, you know, I've been feeling this for 20 years, 30 years, you know, on and off. And then you may ask, well, what is it about today? What is it

about recently? What is it that led to you coming in? And then maybe it was one of their loved ones kind of pushing them. Or maybe it was, you know, some acute stressor, loss of a friend to suicide, or maybe it was the realization that they couldn't do this by themselves. They couldn't make these changes by themselves. So once you find out what that is, I would call that the chief complaint. And really it kind of guides you. It's not, sometimes people don't know why they're coming in. They don't, they're not quite sure, but they're there.

And so sometimes you kind of have to pull it out through the course of the interview. But I think it's helpful to kind of understand from the get-go what they're hoping. to accomplish so that you're not, you know, sort of focused on things that are important for you, but maybe not as important for the patient. Okay. Then thinking about the HPI, the history of present illness, I'm thinking about the circumstances that brought them in. So like how they actually got here. So if they're coming to a psychiatric hospital, did they come on a 5150, you know, which is a 72-hour hold? Did they come from an ER? Did they, did their mom or dad drop the off? Did they come voluntarily? Were they forced to come? Where they pressured to come? You know,

what are the circumstances that brought them in? And then what are the, the second thing would be, what are the stressors? So those unique sort of, you know, stressors in their life in the last few weeks or months that have led them to be more anxious or be more depressed or be more, you know, psychotic or be more manic. Like, what are those stressors that sort of, have been there that are acute and new. And I think one thing is that you could spend an hour, you could even spend two hours sometimes listening to all the details. And in the first encounter, I want some idea of the stressors, but I really want to know about the symptoms as well. And so I may launch from the stressors into the symptoms. Now, I go through, like,

Sicky caps, kind of in my mind, you know, sleep, interest, guilt, energy, concentration, appetite, psychomotor agitation, retardation, and then suicidality. So I'm going to go through each one of those with you right now and kind of how I ask it and why I ask it and why it's important. So sleep. So I want to know how they're falling asleep, how they're able to maintain sleep, and are they waking up early? How long does it take to fall asleep? How often are they waking up at night? What are they doing when they do wake up at night? You know, if they're getting up and jumping

on Facebook for an hour and then, you know, maybe it's more of a behavioral thing that's keeping them from sleeping. What are they doing when they're not sleeping? Are they cooking? Are they doing some goal-oriented activity? That would be more, you know, classic mania type stuff. Are they just watching TV. Are they just tossing and turning? Are they waking up in pain from back pain? You know, normally people with back pain wake up several times a night and kind of readjust, kind of move about. So is that what's going on? And are they waking up early? If they're waking up early, I want to know how early. Are they waking up at 3, 4 a.m.? And are they waking up with anxiety? That is an interesting sign of depression that I like to kind of, kind of, you know,

of take note of and treat accordingly. If they're having a hard time just falling asleep, I want to know what are the things that they're doing before sleep. What is their sort of sleep pattern? Are they watching horror movies before they sleep? Are they, you know, doing a lot of stressful activities? Are they arguing with their spouse? If they're having a hard time waking up throughout the night, I want to know are they having nightmares. What do they think is waking them up? I want to think about are they that they are they having obstructive sleep apnea events? Do they snore at night?

Do they wake up early with headaches? That would be more like the obstructive sleep apnea concern. And then the next thing is interests. So when I think about interests, I think about a teenager. And sometimes it's hard to ascertain if their interests have actually decreased. And one way that I might ask this is, what did you use to, or what do you enjoy doing for fun. And if they say, I don't enjoy doing anything for fun, and you say, well, what did you used to enjoy doing for fun? And they may say, oh, hanging out with friends. And I'd say, okay, yeah, like,

how often did you used to enjoy hanging out with friends? Oh, you know, once a week. And then I might say, well, how often do you enjoy hanging out with friends now? And, oh, I just, I just don't hang out with friends anymore. It's been about six months since I hung out with any friends. Okay, so you kind of got the pattern before and now you have the pattern that's new, the pattern with the depression. With interest, I'm also looking at do they have a complete total lack of pleasure and hedonia? Do they not enjoy things at all like they used to? So sleep, interest, the third thing is guilt. So if I ask, you know, are there things that you think about, that you feel guilty about?

Is it more diffuse in general? Because that's more like depression. In depression, you just feel this kind of diffuse guilt. Or there's specific things that you feel guilty about. You know, like, and you may at this point hear about some other stressors, you know, like an affair or something like that, where they feel acutely guilty for that. And, you know, that in my mind is not necessarily depression.

Depression is more of the diffuse guilt. The next thing is energy. So I want to know kind of like their baseline energy, are you know, normally, you know, compared to normal, how is your energy level? And they may say, you know, my energy has been really low or my energy has been really high. I have a ton of energy. I have a lot of anxious energy is another common one. So that's S-I-G-C, concentration. Now for concentration, I want to know kind of like what is their baseline things that they do.

You know, if you ask someone like, are you able to read or are you able to concentrate, they may not in a normal state, you know, read books. They may in a normal state watch TV, enjoy a movie, enjoy a two-hour movie. But at this point, they can't even watch, you know, 15 minutes of TV without getting distracted. You know, and of course, in our day and age, you have to know the baseline because are they on social media while they're watching a movie? That may be a baseline nowadays. but let's say you had a person who could watch a half an hour show and now it's just flipping through channels like never ending so their concentration may be poor

sometimes if I'm really curious if this is more of a concentration focus issue I may ask them if they can spell world for me if they can spell it backwards if they can spell it backwards I know that they can focus their frontal lobe is at least operating enough to be able to kind of move the letters around in their mind So that's concentration. The next one is appetite. For appetite, I want to know if they've gained any weight or if they've lost any weight. If they've gained weight, I want to know how much weight have they gained. And if they've lost weight, I want to know how much weight they've lost. And I want to know the time course. If they've lost 60 pounds over the last two months and they haven't been trying, I'm either thinking some sort of cancer or some sort of disease or I'm thinking this person has just, this person may be developing something like a catatonia or a pretty significant melancholic depression where they lose a lot of. of weight. I once had a patient who stopped drinking, who stopped eating, who lost about 30 pounds

over the course of a couple months just because they just didn't care anymore. And this person actually got dizzy. And it took me a while to realize it was because this person hadn't been drinking. And we actually had to schedule for this person to drink liquid and eat food. So, yeah, how much weight loss or weight gain? The next one is. psychomotor agitation and psychomotor retardation. So psychomotor agitation is just kind of like that never-ending feeling of needing to move. And psychomotor retardation is they're just slowed down, you know, and it may be a little psychomotor retarded like they feel like they're moving through a little jello. And that's good to note. And if they're psychomotor agitated, you know,

I want to differentiate that between aceshesia. Now, acesia is where usually you have some sort of dopamine blocker. And that could even be, let's see, chlamypramine, clomopramine. You know, like it could be an antipsychotic. It could be regaline. Reglin, yeah, that's what I was thinking. And one of these could block the dopamine. And whenever you have a dopamine blocker, you can get this sort of internal and external restlessness. And so you definitely want to note if the time course of their restlessness, if they have it. Like, did it start after they started an antipsychotic. Very important to catch. We don't want to be causing problems with our treatment. Okay. So there you go. Psychomotor agitation, psychomotor retardation. The last one being

suicide. And suicide is something that'll assess on different levels. One level is just simply, you know, does this person have a passive desire to die? So does this person say, to themselves over and over again, I wish I was dead, I wish it wasn't alive, I wish it didn't wake up. That's how I term sort of passive suicidality. And if they have that, I want to know the time course, you know, when did it start first? Did it start in early adolescence? Did it start just when the depression started, when the depressive episode started? The next thing is suicidal ideation. So do they actually have thoughts on how they would commit suicide. And some people are fairly guarded about this. So you have to kind of watch them

while you're asking and kind of probe in if you find it necessary. So do they have thoughts about how they would actually end their life? And then suicidal plan. So they actually move from the thoughts on how they might end their life to an actual plan. And that's a little bit from suicidal intent. So they move from just having a plan. I mean, they could have a plan or they just could have intent or they get up both. An intent would be like they're determined to do it and they have like a time course or whatnot. And then the next sort of level of suicidality would be they have intent, they have a plan and they're actually moving to execute it. So they've booked the place they're going to do it and they've set things in order, they've written letters, they've, you know,

kind of unimpulsively set things in order to do it. And the other type of suicidal ideation that's often there is more of the impulsive type. So they've impulsively, you know, done something that they didn't really think through and they're just impulsively doing it. The other sort of thing that I consider here is substances versus no substances. So do they have these sort of inclinations and the intensity of it is it higher when they are on substances. And do they have a plan to take substances in order to blunt their sort of inhibitions? And that's when it gets a little bit dangerous, is when someone has the inclination to do it and then they use substances.

It's a little bit more scary for me to have patients that use substances and have that suicidal ideation because, you know, you never know when they're going to use the substance, and although they wouldn't have killed themselves, because they're on the substance, they go through with it. So that's suicidality. And then I usually screen for like bipolar mania type of stuff by, you know, looking at their sleep patterns. What are they doing when they're not sleeping? That's one of the big things that I want to know. And I want to know if they're grandiose, in the midst of not sleeping. So here at sort of my institution where I practice,

we have a hesitancy to overdiagnose bipolar. And I think it's good to have a hesitancy. I think it's good to really sort of be careful about the diagnosis of bipolar because it really does put a person in a place where they have a disease that's not going to get better in a way that maybe other diseases would. They're going to have that for the rest of their life. And so we're fairly careful to give that diagnosis. And so what we're looking for is an episode of mania that usually lasts a couple weeks long.

And during that couple week episode, their mood is heightened. They're not sleeping as much. And they have grandiosity. So the common acronym is dig fast, distractibility, impulsivity, grandiosity, flight of ideas, agitation, sleeplessness, talkativeness. So all those things usually take place at once. And for patients who have bipolar, and I follow a couple of these patients, and I always get their spouses involved because I want their spouses to monitor when they're getting manic as well.

And, you know, of course with consent, they allow the spouses to be able to contact me and if the patient is ramping up, I'll see them within that week and I'll usually add another medication. So this is something that once I get that diagnosis, I like to monitor these people very closely because one manic episode can really, really ruin their life. There's a saying that I heard that I think is important that all mania ends in three ways. A hospitalization, a jail episode, or death. And that's unfortunate. But in our society, that's kind of where the true episodes end. If they're untreated.

If they're treated, they're treated, they can end with, you know, maybe a week or two being out of it, keeping them outpatient, hopefully, and with a lot of family support. And usually it's going from, you know, one medication to three or four to get them to a place where they're able to not need to be hospitalized and keeping them from where they're not really, really ramping up. The other thing is something that really tells me that this exists is how they responded to medications when they were hospitalized. How many days did it take to get them to respond to medications once they were hospitalized?

And the people who have true, what I would call a true manic episode, we've noticed that it takes them three or four days to get their sleep decreased. So the first day they come in, you know, we actually have nurses record every 15 minutes what they're doing all night long. So we have a real idea of how many hours they actually slept. So the first day, we added a couple meds and they're still sleeping three hours. And then the next day, you know, they're on three or four meds and they're sleeping four hours. And then the next day, maybe it's five hours. And, you know, they're on medications that to a normal person would just knock them out for like days on end, right? And in contrast to that, people with more personality disorders, you give them medications the first night, they sleep, they're like a totally different person, possibly the next day. But someone who's a true mania, it may take them seven to ten days to get out of the psych hospital. So when I'm taking the psychiatric history, I'm looking at how many days they had a psych hospitalization. And if I have notes to it, I'm looking back through the notes. And in our notes in our system, we always detail how many hours of sleep that person got.

And we're fairly meticulous about the diagnosis of bipolar. The next things I'm concerned about are kind of like the schizophrenia, schizoaffective, psychotic symptoms. I'm looking at hallucinations, auditory hallucinations, visual hallucinations, paranoia, delusions. So those are the big kind of cluster of symptoms that I'm looking at next. and if they have auditory visual hallucinations, then I'm trying to decide, you know, how many voices, are the voices male or female? I'm asking some particulars about it, and then I may ask what the content of the voices is. If it's a male, the most common auditory hallucination of a male is you are gay, you know,

that's at this point, at this point in history, that is the most common one. for females, you're a slut, you're a whore, and the patient is not going to report this to you. They could also be things like you're a pedophile, you molest children, and these things are horrible, horrible thoughts to these people. You know, they hear this all day long, and they have this great fear that something is wrong with them. And so it's very important to sort of put some of these sort of things out there. Like, do you ever hear voices that tell you bad things, like blah, blah, blah, blah, blah. And they'll look at you like, oh, okay, this person kind of knows what they're talking about, and they'll say, yeah, I hear that. And they won't say much more than that. Like, they're not going to

elicit these really sort of negative internal voices. It's the same thing with OCD. People with OCD will tell you, yeah, I have issues with hand washing, but they're not going to tell you issues that are very taboo that they have sort of obsessive thoughts. Okay, so that's auditory visual hallucinations, which is, by the way, the most common sort of positive symptom of schizophrenia, visual hallucinations. You know, if they're only having like little men, if they're only seeing little men like kind of walk around, you know, you wonder, is that alcohol or some sort of delirium? The next one would be delusions. People honestly don't tell you much of. about delusions. People don't tell you much about delusions. Delusions are something you notice. You hear

from the family. If they tell you the delusions in kind of a very forward way, that's very odd. Someone with schizophrenia, they're usually fairly a little bit paranoid and a little bit guarded about their delusions. So usually the nurses are the ones to first notice it. You know, this patient doesn't eat from anything but, you know, food brought from their parents or this patient doesn't eat anything that isn't from a can or isn't from sealed containers. So maybe they have a delusion that everything is poison. So after delusions, I'm looking also at paranoia. So do they have a fear that people are after them chasing them? Do they have a fear that they aren't safe? And also ask, do you feel safe here? Is there anything I can do to make you feel more safe here if they're not

feeling safe here. If they are not feeling safe, I ask, you know, like, I, you know, tell them that they can, they can choose to end this conversation at any time and give them some sort of power back to the situation. Of note, you know, some people are paranoid, but for good reason. Maybe they actually are drug dealers and they're paranoid that, you know, the drug lord is coming after them, and they're hiding out in the psychiatric hospital. So sometimes you have to look at the context and the story to decipher, well, this is not really like a paranoia like schizophrenia, but this is something else. And sometimes collateral can be very helpful in that. So the next sort of category is anxiety disorders. And there's five basic ones to look for,

panic disorder, phobias, OCD, PTSD, and generalized anxiety disorder. So for panic disorder, I'm curious about panic episodes, and specifically when do they occur? What are the triggers? And do they occur spontaneously? Panic disorder usually starts in the 20s, and there isn't a lot of other stuff around it, unless the panic leads to other things. So they usually don't have a history of cutting, of binging, of purging with panic disorder. Now, someone who has those things can have panic attacks, that can be very scary, but that's different than panic disorder per se. Panic disorder tends to be their spontaneous episodes of panic and anxiety, and it's good to get a good diagnosis of panic disorder as an isolated sort of diagnosis because it informs

treatment. I don't mind so much giving benzodiazepines to someone with a true panic disorder, But to someone who has more of the lifelong passive suicidality type of stuff that also has panic attacks, the benzodiazepines are going to make them worse long term. So that's panic disorder. And then there's phobias. Are there specific things that they're afraid of? Are they afraid of certain things like social phobias or speaking in front of crowd phobias or test phobias? You know, some of these are called different things in phobias, like social anxiety disorder or, you know, I don't know.

Maybe you wouldn't consider that a phobia at all. It's different. But basically, are there more isolated events that lead to large amounts of fear and anxiety? That's kind of that category in my mind. And then there's OCD. So OCD, you know, a lot of people who say their OCD are actually OCPD, obsessive, compulsive personality disorder. where they're obsessive and meticulous and like to be organized and are maybe, you know, in the classic Freudian way, a little bit anal in how they describe themselves. But OCD is you have obsessions

that lead to compulsions. For example, you have an obsession to wash your hands and it leads to a compulsion to wash your hands. The obsession might be my hands are dirty, my hands are have feces on them. My hands are filthy. So anything they touch, they feel this great, great impulse to wash their hands. Now, obsessions can be something that it's hard to have a compulsion to get rid of. Like an obsession can be, you know, something like I am a pedophile. That that can be a really difficult obsession, especially in some cultures. Like if you were raised Islamic and you had that and you told your parents, they may not understand that you have OCD. And the same thing would be true for other taboos. And so when looking at sexual taboos that are obsessions, I want to know is this person

masturbating to this? Is this person watching porn related to this? And so, and you know, is this person watching porn related to this and if they are, that's probably a desire. And if not, it's probably more an obsession. And then you have to kind of consider what are their compulsions. They might have religious compulsions. They might have cleaning compulsions after these thoughts. The tricky thing about OCD is a lot of OCD people will not end up in treatment. They tend to not like to be seen in a sick role. they try to avoid treatment at all costs. And they're usually brought by family. And it's usually the first and the second visit is you're trying to connect with them enough

to have a relationship where they'll trust you to take medications. The problem is with medications that treat them is sometimes it'll make them a little bit more anxious before it helps them. You know, it takes like around six to eight weeks, sometimes even a couple months for these medications to kick in for OCD. So they're going to have to be willing to be willing to. to go along with it and trust you enough to go along with it. So that's OCD in a nutshell.

Oh, so yeah, in a nutshell, they don't want to tell you. And so I may ask someone a question like this, do you have obsessive thoughts that start when you wake up in the morning and don't end until you go to bed at night? And if they do, then that could be like an OCD type of thing. The next category is PTSD, post-traumatic stress. disorder. So you're asking about nightmares, about flashbacks, you're asking about if they have traumatic events in their past, things that they ruminate on. And one thing, one way of thinking

about PTSD is you have positive symptoms like the flashbacks, like the nightmares, and then you have negative symptoms like emotional blunting and kind of distancing themselves from other people. And the positive symptoms, you also have, like, anger and rage, and the negative symptoms, you have kind of like this, like, shutdown or isolation or negativism. Now, in schizophrenia, you have positive symptoms of, like, auditory visual hallucinations, but in PTSD, the positive symptoms can be seen as things that relate to the trauma. And in psychosis, you can have negative symptoms, such as emotional blunting, and sort of moving away from people isolating.

But in PTSD, it's more of a reaction against the triggers, and it's more of a way of coping with having to deal with the thoughts of the trauma. The last of the anxiety things is generalized anxiety disorder. So generalized anxiety disorder is kind of hard to catch by itself. Are they generally anxious all the time? you know, a lot of people fit into that. And so often it's like they have depression and generalized anxiety disorder or they have something else and generalizing anxiety disorder. It's kind of rare to find someone with just generalized anxiety disorder by themselves in my

practice and what I've seen. So a couple of other things in this sort of first box is confusion. And with confusion, I'm looking for are they acutely confused or is this sort of a pattern of confusion that started. And if it is a pattern that started and has a time course, what was the first thing they lost? What was the most, you know, the progression of things?

Did they first lose word-finding issues? Were there any changes in medications at the time? You know, and if they have sort of a waxing and waning or, you know, if they're better one day and worse another, you know, or if they're acutely sort of confused, then I'm thinking, you know, is this a censorium issue? Is this like a delirium type of picture? Delirium, waxing and waning, confusion.

You know, they can't spell world backwards. They can't count down from 21 by threes or, you know, 73 by sevens. They will have a really hard time drawing a clock. And so I tell the people who train under me when they're in a medical, setting, to always get the patients to draw a clock, always get them to spell world backwards, always count down from 21 by 3s with every patient they're consulted on. Because it turns out at Mayo, it was something like 70% of the patients that were consulted by internal medicine to psychiatry for depression had delirium, which is this sort of waxing and waning confusion.

and it's caused by a multitude of factors, the hospital itself, the lights, the people coming into the rooms, all of that can make you confused. I'm going to talk about Sensorium more in detail later, but I think it's important to know that we also have changes in our Sensorum. So, you know, if we're tired, if we're hungry, if we're, you know, without rest, without love, without community, you know, we're on call,

lots of patients that we've seen, we can be more confused and we can be in a lower sensorium state compared to if we're rested, if we're getting adequate amounts of exercise, good nutrition, you know, we're seeing just not too many patients, but, you know, we have some breaks in the day. You know, our sensorium will be better. And so I really recommend getting those things, taking care of yourself so that your sensorium can be well because sometimes if our sensorium is down, we seem burned out or we feel burned out. And so we need to take care of ourselves first and foremost and not feel bad about taking care of ourselves.

The next thing I consider is like the personality type of stuff. Like is there a history of cutting patterns of suicidality? So is there passive suicidality starting in adolescence? Do they have binging and purging legal issues? You know, kind of like this cluster B type of personality. issues. You know, if they have passive suicidality, some self-harm starting in adolescence, you know, the suspicion is there for borderline personality disorder, which I think it's actually good to get that diagnosis. And if you're, I think there's, there's some stigma around it.

But now with the treatments that there are, both dialectal behavioral therapy and mentalization-based therapy and some of the schema-based cognitive behavioral therapies, but mostly, you know, DBT and mentalization, there's really good outcomes for those patients. And so identifying those patients, separating them from, you know, bipolar and getting them adequate treatment for themselves with the therapy can be really, really, really important for their progress and sort of life course. Okay. So the next thing is past psychiatric history, you know, and I'm going to go through the different components of that. And one component is hospitalizations. So how many hospitalizations? What were they hospitalized for? Was it a suicide

attempt? If so, how do they try to kill themselves? What medications do they start? What was that experience like this this can take a while with some patients but it's really important because if they've had negative experiences with certain medications you want to know about it a lot of the times they won't remember all the details but sometimes it's helpful if they have if they have records to look through them and see what they were on and ask them further questions um you know what kind of meds did they use in the past what side effects what worked how long do they use it? Were there issues of non-compliance? I often have patients who have taken antidepressants and they say none of them worked and I asked them how long they took it and they all say, you know,

one week or two weeks. And then I, you know, I missed a bunch of doses and then I just stopped it because it was causing this and the side effect. And so they've never really tried, you know, an antidepressant in my mind for the time that it takes for it to actually work, which is, you know, three to four weeks and you have to take it every day and you have to, you know, not be on a huge amount of drugs while you're taking it, like, you know, like illegal drugs. The next thing is suicide attempts. So I like to know, like, what was the method? How much planning did they go into it?

Was it impulsive? Were they under the influence? I want to know about past diagnoses. You know, were they diagnosed with MDD? major depression disorder, PTSD, bipolar, and I'll just write down whatever they say. And sometimes they have a list of like six or ten different things they've been diagnosed with. You know, I'm going to come to my own conclusions, but it's interesting to know that at some point they were diagnosed with different things. And if they were diagnosed with those things,

then we can kind of be curious about, well, what was happening around that time? Or do I need to get more collateral to make a clear diagnosis on what's, going on. So the last thing in past psych history is I want to know about the past psychiatrists and psychotherapists. I'm really curious about negative experiences they've had with them. You know, I didn't like this therapist because they tried to do this weird thing where they put their finger back and forth. Okay, this person had an aversion to EMDR or they didn't you know know what was happening or wasn't helpful. You know, I didn't like this therapist because they gave me too much advice.

Okay, that's a clue. Don't give them too much advice. Now, if you work in a community and you do this for a while, you realize that some patients are going to have bad experiences with pretty much everyone. So I don't take it sort of personal if I find out that a patient had a bad experience with me. It doesn't happen very often, but when it does happen, you know, I try to learn from it. but that's not the point of why I'm asking them. I'm asking them because a lot of the stuff like transference and countertransference,

you can start to kind of get an idea for what might be there in the future if you ask about the therapists. If they hate every psychiatrist, but it seems like they absolutely love you, like you are the best thing that's ever happened. You are the first one that's ever listened to me. Maybe they're going all good on you for now, but they've gone all bad on all the other past treatment providers. So you kind of have to walk the line and I even had some of my mentors say they would say things like, well, you know, I'm not perfect and I just try my best to kind of, you know, downplay this sort of idealizing of them that may be going on. The last sort of set of questions

that I'll go into is the family psychiatric history. And I'm curious about, you know, suicide attempt, substance abuse, diagnoses, treatment in their family members, their blood relatives, the people that raised them. I'm interested in the people that raised them, even if they were adopted because this influences them on an environmental level. But I'm also interested if they have blood relatives in those different diseases, different diagnoses. And just to give you an idea of how that sort of influences things, if your first degree relative has bipolar, your lifetime risk will be 25%.

But in the general population, it's like 1% will have this disorder. For schizophrenia, once again, 1% in the general population. But it'll be about 19% risk if your first degree relative has this disorder. Okay, so we are through the first box of psychiatry. So there's a lot there. And in the second box of psychiatry, we have the medical history, which I think can be of equal importance in a lot of ways to understanding the patient and what they're going through and their overall picture.

So in this box, you know, we have what are the medical problems that they've had in their past? So a brief question may be, do you have any medical problems? Are you currently having any medical problems? Have you had any surgeries in the past? Specifically, I want to screen for obstructive sleep apnea. So do you snore at night? Do you wake up with headaches? Do you feel fatigue during the day? How long has it been going on? Have you ever noticed that you've stopped breathing in the middle of the night? Or this box I also want to screen for traumatic brain injuries with every patient I have. So have you ever been hit in the head, loss of consciousness, concussions, heart accidents where you got hit in the head? And if they have, I'm curious, how long do they

lose consciousness? What kind of deficits do they have when they came to? You know, big difference if they were in the hospital for three months, learning how to walk, talk, read again after a injury compared to a couple concussions. But I want to document those things. I want to think about how their actual hardware is in their brain and how that might influence their overall picture. I also want to know about headaches, seizures, strokes, you know, thyroid issues, cardiac issues, autoimmune issues,

if they have any unique allergies, non-psychiatric medications. when they started on those non-psychiatric medications, if I think they might influence their mood issues. So I'm not going to ask that about every medication, but I'm curious. I want to ask if their illnesses are controlled or uncontrolled, like if they have diabetes, there's a lot of people who have uncontrolled diabetes.

That raises the risk for depression, like quite a bit. You know, if they're on steroids for autoimmune issues, I want to understand what the course of that has been, has been increased, when that was added, what the timing is on that, because the timing of that and the timing of their mental health issues may coincide. So their depression developed the moment that they stop their steroids or the moment they started their steroids. The next thing I'm curious about is if they've ever been through surgeries, you know, what parts of their body? were taken out, were their ovaries taken out, was part of their stomach taken out? Do they have a ruin why, you know, a gastric bypass? What type of gastric bypass did they have? And when I'm thinking

about that, I'm thinking about how the medications are going to be absorbed in their stomach, how vitamins are going to be absorbed in their stomach, and how that might influence their mood issues. and one simple thing that I've done for patients, for example, is if they've had a ruin why I just crush up their meds and all of a sudden their meds start working again or their meds work for the first time. Another consideration is does this person have illness that, you know, can be explained through medical sort of understanding like fibromyalgia, irritable bowel, but there's a psychiatric component. And there's a psychiatric component. And there's a psychiatric component in that there's psychological things that are going on that influence their

physical pain or the physical manifestations. For example, with psychogenic seizures, I've treated a number of these patients where, you know, there's different reasons why they're having the psychological seizure-like episodes, and once those psychological considerations are addressed, they stop having the episodes. So this can be very nuanced, and I'm going to probably have to go into this in more detail at a further time. The next box is the social history box. How far do they get in school? What is their spiritual heritage, marital status, interest, work, military, abuse history, legal issues.

you know, and I'm going to go into these in a little bit more detail here. And some of the questions that I might ask in how these details might influence the bigger picture. So starting with school, how far did they get in school? What was their major? What did they enjoy doing school-wise? You know, different people had mental illness hit at different points, and you get to see a little bit of their pre-morbid function or their, you know, functional, how, you know, sort of disciplined, you know, excited about different things they were before

their illness hit. Or, you know, how do they struggle through school in the midst of their illness? The next thing is that, you know, the work history, the types of work that they've had, the types of jobs, how many jobs, what was their first job, their second job, their third job, what were their bosses like? You get a picture of how they interact interpersonally. If they've had a multiplicity of jobs, you know, is it a lack of interest or ADHD or they just get bored or, you know, what's going on there? So just more curiosity than anything else. Spiritual history, I usually ask it by, you know, were you raised in a particular spiritual tradition? were your parents spiritual or grandparents?

Did they bring you up in that? And did you ever consider that spiritual tradition your own? Or did you kind of experiment with other spiritual worldviews? And where are you currently? And if they say they're Christian, you know, I usually follow that up by looking at their support structure or, you know, they're another faith as well. You know, do they attend mass or church or temple?

and if they're attenders, do they pray? Do they do any spiritual readings? Are they close to any sort of spiritual mentors? And the other sort of overarching questions I'll have here, and I don't always ask this, but I do when it's, I think it's indicated, is do they feel that God is a loving God, an angry God, or an absent God? And if they tell me they're an atheist,

I won't ask them this question, because, you know, they don't believe God exists. But if they're a spiritual person or if they, you know, have a faith, I might classify them in those three categories, which kind of gives me an idea for where they are at this point in their life. As far as their marital history, how many marriages have they had? What was their current marriage like? Was their current relationship like?

How many years has it been? How involved is their spouse in their sort of issues that? are ongoing. This portion can take, you know, a session in and of itself, usually. But we're trying to get a brief overview in the first session, just kind of get an idea and a framework. Next time I'd ask them about their parents, what their parents did for work. If they had an issue when they were a kid, which parent would they go to for help? What would the parent do? How the parent react to them needing help. Those are more like attachment, adult attachment interview questions, but I find them helpful at times. If they have brothers or sisters, I might quickly

find out, you know, how are their brothers and sisters doing? I have already probably got an idea if they have mental illness, so I might get like what job they currently have or if they don't have jobs. And I had a mentor who was very, very interested in this, who was a chemical dependency guy. And he wanted to know, you know, what is the function of the family unit and how do they fit into that function? And that was sort of a thing that was very helpful for him. As far as interests, you know, like what are the things they enjoy doing for fun? What kind of hobbies? what kind of goals do they have, things that they would like to accomplish in their sort of extracurricular life.

I'll look at military and specifically like if they've been overseas in combat, what type of training they had, you know, that sort of thing. And then for abuse, you know, there's always a question of how much do I really want to know the first time they come to the office. And usually the first time, we're just building a relationship, we're just getting to know each other. I don't want them to tell me everything they remember about the abuse that happened to them. So I tell them, you know, I just want to get like a general kind of idea. Did you grow up and have any physical, sexual, or emotional abuse occurred to you?

And if they want to tell me a little bit about it, you know, of course, I don't stop them, but I'm hesitant to elicit or to have them go down that road too much on the first time because at least as a psychiatrist, and if I'm doing more of a psychotherapy type of first time, it might be a little bit different. But, you know, I really want them to feel comfortable and to trust me before they start talking about traumatic things. And I want to also sort of make sure they know how to ground themselves

and to, you know, basically move out of a state of dissociation. I also want to know about domestic violence, you know, so adult abuse that they've experienced. I want to know about legal issues and if they have guns. And why do I ask about guns? Well, if they're suicidal or if they drink alcohol and they're suicidal and they have a gun at home, then I will be very passionate about getting them to let someone else have their gun.

You know, relative have their gun for a time period. Getting rid of their gun, I think, can be very, very important because you don't want someone who could drink and who could potentially be suicidal to have a gun. And, yeah, enough said. Developmental history, you know, did they have any trouble learning to read, walk, talk, those kind of things?

did they have a stable home? Did their parents get divorced early on? You know, would they consider a loving home or was it kind of an antagonistic or cold home? Like just kind of general vibe of that home. Okay, so that's kind of the social developmental history box. And with my longer term patients, you know, that I've seen for a while, that kind of grows and gets expanded.

and you can spend 20 sessions going over just some of those aspects and zooming in on them. But the first time you kind of want like an overview, kind of like a picture of how these sort of pieces fit together. And the fourth box is substances. Now this box gets its own because it's that important. We want to know when they started the different substances that they've used. like we're talking about alcohol, marijuana, drugs, you know, like cocaine, methamphetamines.

When they started, their length of use, the route, you know, like how they used it, the longest time sober, their heaviest use, you know, was it an everyday thing or a binge, and their last use? So we really want to get kind of like a picture of each substance and the course of it. And, you know, if they had any treatment for it, if they went through detox, if they, you know, were an AA, if they had a sponsor, if they were in AA, what step they got through if they went through AA, NAA. And all of those things kind of help us understand how these are playing a role. you know, the time course combined with the time course of their mental illness can kind of give you an idea how linked the two are. You know, is this person depressed because they've been drinking alcohol nonstop? I will also add that sometimes people do not tell the truth. And I've had a couple patients where it's like year two and then I learn this person's been on alcohol one bottle a day,

you know, or this person's been on two bottles a day or this person has used cocaine. And so one of my suspicions is when the person doesn't get better, you know, is there something that I'm missing? Is there some drug or some use of something that I'm missing that the patient hasn't completely reported to me? So food for thought. Okay, so we're going to leave it there for today, actually. And in the future, I will go over box five and then later, box six. box five will be on the mental status examination and box six will be on diagnosis so I hope you enjoyed that

thank you for listening to this podcast if you check out my show notes and website link you can get some of the notes and content discussed here I will post an example template of what I give to patients, new patients so you can see what I do in particular If you have any comments, please find my Instagram at Dr. David Puter. That's d.r.com. E-V-I-D-U-D-R also in my show notes.

And post your comments on the picture representing this episode. If you're grateful for this content, please leave a review on iTunes, Stitcher, wherever you're listening to this. Also, I would be grateful if you share this episode with a friend who might find it helpful. Thank you. And until next time.