Some OCI bits and pieces

This is still a work in progress and the notes here reflect how I tried to
increase interview efficiency specifically for this game. They are not very
detailed but I hope it makes some sense.

General points:
- Start thinking about the management plan from the start of the interview
i.e.: even with demographics. i.e.: how will you manage a frail and lonely
elderly man on a sickness benefit in the community? This will help you
prioritise what is important and affect how you formulate the patient and
what questions you ask during the interview. Practice this now rather than
later – you will begin to see changes in your style fairly soon. It also makes
everyday clinical work a lot more enjoyable.

- Use Video recordings and bring recorded patient interviews into

supervision. Get your supervisor to be brutally honest about every minute of
the interview. It is excruciating. It is worth it.

- Although you have an agenda the examiners want to see that you are human
so if the patient is emotionally distraught – explore the feeling and make an
attempt at understanding it. Don’t overdo it – move on if getting nowhere.
E.g.: “I can see that x still affects you” … are you okay if we continue?” Over
time you will get this balance.

- Try to understand the big picture first the details will follow. Once
you begin working on the management plan as a priority you will see
what I mean.

Questions:
These are some of the questions that I have found to be ‘high yield’.
They also triggered thoughts in my mind pertaining to management.

Demographics: “Tell me a bit about yourself” – the information WILL come.

HPC: “What are the issues/problems that bring you here?”

 “When did this start?” – this will split either into an acute or chronic
picture

e.g.: the patient might say “oh a couple of weeks ago” therefore ask
questions under acute/current heading. If patient says something like “jeez
its always been like this” or something vague like “ages” – go to questions
under the chronic heading – the questions here will help when you are dealing
with a concrete person with schizophrenia that doesn’t say anything. Or
someone that says too much.

Acute/Current picture:

Onset “how did it start?” “What triggered it?”

Aggravating/relieving factors “What makes it worse/better?”
Quality/Associated features – tease out the symptom. “I’m just going to ask
some questions just to get an understanding of what it’s like for you now” –
e.g.: SIGECAPS, DIGFAST, Anxiety stuff, psyhosis and first rank symptoms
Severity – “How has it affected your functioning?”
Timing – if you get lost and are unsure when the episode started exactly –
ask “is this getting worse/better/staying the same?” – followed by “when did
it start getting worse/better?” “how long has it been staying the same like
this?”

Chronic picture:

“How old were you when this first started?”

“Did you go to hospital” – “what was the diagnosis and has it changed?”
“How many episodes/hospital admissions have you had in total?” (i.e.: always
big picture stuff)
“what usually leads to hospital?”
“When was the last time?”

“tell me about all the treatment you have had”

“what was most helpful?”
- ever had antidepressants? Lithium? ECT? Antipsychotics?
- What are you on now?
- ever had talking therapy?
o Ever had a counsellor/therapist?
 o How often did you see them?
o How long?
o What treatment did you have?
o Did it help? And how?
o How did you leave treatment? (this will give you some insights
into their coping/personality style – e.g.: avoidant, passive
aggressive etc and will affect your management of them in the
community e.g.: insist on intensive case management to engage
them etc.

Current care – “how often do you see your psychiatrist? Case manager?
“how often do you see your GP?”
“are you undergoing any other sorts of treatment?”

Once you’ve covered the above questions – you might then want to know
about specific symptoms/signs if not already mentioned. You might also want
to know the nature and pattern of specific symptoms like depressed mood –
i.e.: does it fluctuate? Is it pervasive? etc

If you want to find out about past episodes - “I just want to check…when
you were having an episode of x. Did you have..x symptoms” (here you are
going to ask about symptoms that will help make a DSMIV diagnosis).

If you want to know about what’s happening now - you might ask ”do you have
any of those symptoms now?“ and if they don’t endorse any symptoms now –
ask if they ever have. You want to also tick the boxed in DSMIV so you can
justify your diagnosis to the examiners.

MDE (SIGECAPS)
Ask them to rate mood – out of 10 ( 1 to 10 ). They will give you a number.
Ask if it goes up and down throughout the day or if it stays the same. How
long has it been up and down?or staying the same.
Is it improving? Is it getting worse? Why? And over what period?
Sleep – time to get to sleep, do you wake in the middle of the night, what
time do you wake up? – establish initial/middle insomnia
Interest – “have you lost interest in any of your usual activities?”
Guilt – “do you feel guilty about anything?” – and “do you think you deserve
punishment?”
Energy – “how are your energy levels?”
Concentration –
Appetite + weight gained/lost
Psychomotor agitation/retardation
Suicide – thoughts of ending your life?
- have you ever?
- How old were you the first time/how many times/last time/pattern
(ABC – antecedents, behaviour, consequence)
Violence – “have you ever been violent with people” – “when” – “what triggers
that?” – “ever serve time?” – “community service?” – “involve weapons?
Drugs?”

To be efficient – if you ask about suicide then always ask about homicide
stuff and vice versa. This will save you coming back to it later. Be tactful.

MANIC (DIGFAST)

Ever been the opposite of depressed?

Distractible – racing thoughts?
Indiscretions – has your interest in sex increased?, speeding? Spending large
sums of money?
Grandiosoity – are you on a special mission? How do you compare to others?
Fast – have your friends told you that you talk fast?
Activities – have you taken on any new activities?
Sleep – decreased need for it?
Thoughtlessness

PSYCHOSIS:
Ever hear things when no one is around?
- voices? Do people whisper about you? Radio waves?
Are people out to harm you – watching you?
People controlling your mind? Body?
?Special messages from radio/tv?

ANXIETY:
General – are you a worrier? Even if things are going well? Physical
symptoms? – butterflies in stomach, headaches, tension, on edge?
Panic – ever felt panicky? Sudden surge of fear where your heart pounds you
feel like something terrible is going to happen? What triggers it? How often
a week? Have you limited where you go because of it?
Social – do you embarrass easily in public?
Obsessions/Compulsions – do you have thoughts from your own mind that you
try to stop but they keep coming? Do you check / count / touch things
repetitively ? >1hr day
PTSD – have you had any traumas that haunt you still? – do you avoid thinking
about it/do you avoid situations that remind you of it? Do you startle easily?

EATING:
Whats your weight?/height/bmi?
Target weight?
How satisfied are you with your body weight?
- the way you look?
- Do people say you are thin?
Are you dieting? Or been on diets?
Tell me about your eating
What do you eat?snack?
Restrict?
Make self sick?
Laxatives/diuretics?
Menstrual irregularities?

Drug/Alcohol

- do you smoke/drink?
- Use any street drugs?
- When did you last use…
- How old were you when you first started?
- How has that progressed over the years?
- When was the heaviest period? – what was going on for you then?
- How many days a week during the heavies period (which could be now)
- Try to cut down? – control how much you use?
- Eye openener – calm nerves/shakes/fits/DT’s?
- Need more to get same effect?
- Affected – work? Relationships? Health? Trouble with law –
speeding/fights
 - Have you ever had treatment for it
- Longest period without substance x

Screen for:
Cigarretes
ETOH
Cannabis
Stimulatns
Opiates
Hallucinogens
Solvents
Benzos
Prescription meds
I/V stuff – if yes – AIDS? STDs etc

Medication/Medical history

Do you have any medical problems?

Ever had a medical illness?
Are you on any regular medications? Any allergiews/sensitivities
- heart/lung/stomach problems
- blood pressure, cholesterol. Glucose,
- surgery?

Could lead into “tell me about ALL the treatment you have had for…”

Family hx – suicide/hospital/addictions

Social / personal history:

Where were you born
Were there any problemw with your birth
Were there any childhood illnesses
Did you talk and walk at the right age
Tell me about your mum/dad
Were you close
Siblings? Who else was in the house growing up
How was discipline handled
Any domestic violence. Did any one ever touch you in a way you did not like –
sexually
What sorts of challenges did you face
How was school? What were you good at?
Friends? Bullies? Wagged?
Problems concentrating or sitting still?
Set fires/damage property/cruel to animals?
How far did you get at school?
Do you have any qualifications?

When was the last time you worked?

What was the longest job?
What’s the longest period without a job?

How many significant relationships hve you been in?

What sort of person are you in relationships?
Current relationship. Happy/conflictual

Any hobbies/interests?/goals?

How would you describe yourself?

How would …so and so…describe you?

THe following questions is a screening tool for a personality disorder – I

can’t remember which paper it comes from.

Schizoid/shizotypal - Are you someone who likes to have friends/be a loner?

Paranoid - Do you have problems trusting people?
Borderline/histrionic – do you get mood swings?Are you an angry or impulsive
person?
Avoidant/dependent/OCPD - Are you a worrier/do you depend on others to
make decisions for you/perfectionist

For borderline
- mood swings
- worry about being alone
 - how often do you think about suicide
- do you feel empty
- are you confident in yourself
- do you have trouble knowing who you are?
- Dissosiative experiences

If a person says they have never been happy – think PD

Other interest question:

“If I was to work with you. What are the 3 most important things you would
like me to help you with?”

END with a brief cognitive screen (my favourites)

- where are you? What’s the date?
- 3 things – brown car, black flag, green shoe
- Give me as many four legged animals as you can in one minute
- Luria’s hand sequence
- Recall 3 things
- Draw a clock

End nicely.
Thank the patient.
All the best for you treatment.
“I really hope that you and your doctor can work together to find some
solutions” – etc. or something like that.