Psychiatry II: Patient Interviewing, Psychiatric Signs, and Psychoanalytic Theory

Flashcards cover key concepts from the patient-physician relationship, interview techniques, psychiatric signs and symptoms, and Freud/psychoanalytic theory, including transference, countertransference, defense mechanisms, dream analysis, and psychosexual development.

What are the two essential ingredients in a helpful patient-physician relationship?

1) The physician demonstrates understanding of what the patient is stating and emoting. 2) The patient recognizes that the physician cares; together these foster trust and a strong therapeutic alliance.

How is rapport defined in the clinical interview?

The spontaneous, conscious feeling of harmonious responsiveness that promotes a constructive therapeutic alliance and implies understanding and trust between doctor and patient.

What is clinical empathy and how is it demonstrated in interviewing?

Empathy is the ability to understand another’s feelings; it is demonstrated through empathic statements (e.g., 'That must have been very difficult for you') and nonverbal cues such as facial expressions and body language.

Name the four models of interaction between a patient and physician.

Paternalistic model, Informative model, Interpretive model, and Deliberative model.

What is transference in the patient-physician relationship?

A patient’s unconscious redirection of feelings, expectations, and patterns from past significant relationships onto the physician.

What is countertransference?

The physician’s emotional reaction to the patient, which can help or hinder the encounter and requires self-monitoring and management.

Differentiate intrapsychic from clinical reactions to illness.

Intrapsychic reactions are internal emotional processes in the patient; clinical reactions are observable external manifestations and behaviors related to illness.

What interview sequence helps develop a provisional differential diagnosis?

Begin with establishing rapport and determining the patient’s chief complaints, then use those complaints to develop a provisional differential diagnosis.

How should vague or obscure replies be handled in an interview?

Follow up with persistence and targeted questions to accurately determine the answer.

Why should you let the patient talk freely during the interview?

To observe how tightly thoughts are connected and to assess the organization and coherence of their thinking.

Why mix open-ended and closed-ended questions in an interview?

Open-ended questions elicit elaboration; closed-ended questions obtain specific information; a mix helps observe thought connections and gather detail.

What is the recommended approach to asking about suicidal thoughts?

Ask directly and non-judgmentally about suicidal thoughts to assess safety and risk.

When is confidentiality breached in psychiatric practice?

Confidentiality is breached when there is a clear, credible threat of harm to an identifiable person (duty to warn/protect).

How should the initial interview be concluded?

Conclude by conveying a sense of confidence and, if possible, hope for the patient.

What is the difference between mood and affect?

Mood is the sustained internal emotional state as reported by the patient; affect is the clinician’s observation of the patient’s external emotional expression.

What are the key components of thought process in the mental status exam?

Coherence and stream of thought (logical/goal-directed, circumstantiality, tangentiality, flight of ideas, loose associations, word salad, thought blocking, Perseveration, clang associations).

Define the terms: circumspect vs tangential vs flight of ideas vs loose associations vs word salad.

Circumstantiality: excessive detail before the point but eventually reaches it; Tangentiality: digresses and never returns to the point; Flight of ideas: rapid, loosely connected ideas; Loose associations: disorganized thinking with non-sequitur connections; Word salad: severely incoherent speech.

What is the difference between delusions and hallucinations?

Delusions are fixed false beliefs; hallucinations are sensory perceptions without external stimuli.

List some common delusions discussed (examples).

Persecutory, grandiose, erotomanic, nihilistic, jealousy (erotomanic), control, guilt, paranoid, poverty, somatic delusions.

What is clang association?

A thought process where ideas are linked by the sound of words (rhyming or punning) rather than by meaning; common in mania and schizophrenia.

How are obsessions and compulsions characterized in OCD?

Obsessions are intrusive, distressing thoughts; compulsions are repetitive behaviors performed to alleviate distress or prevent a feared outcome.

Differentiate depersonalization and derealization.

Depersonalization is a feeling of unreality or detachment from oneself; derealization is a sense that the external world is unreal or dreamlike.

What are the levels of consciousness and common orientations assessed in the mental status exam?

Levels: Alert, clouding of consciousness, drowsiness, obtunded, stupor, comatose; Orientation to person, place, time, and situation (oriented x3/x4).

What memory domains are tested in the mental status exam?

Immediate (registration), Recent (short-term memory, 0-24 hours), and Remote (long-term memory, past months/years).

What is abstract thinking and how is it evaluated?

Abstract thinking involves understanding concepts and relationships (e.g., proverb interpretation, similarities); impaired abstract thinking shows concrete or literal responses.

What is insight and how does it relate to judgment in psychiatry?

Insight is the patient’s awareness and understanding of having a mental illness and need for treatment; judgment is the capacity to make safe, appropriate decisions and anticipate consequences.

Describe Freud’s topographical model of the mind.

Conscious, preconscious, and unconscious levels; unconscious contents must pass through the preconscious to become conscious.

What are Freud’s three structures of the psyche and their primary functions?

Id: primal drives; Ego: rational mediator and reality testing; Superego: moral conscience and internalized standards.

What are the Live Drive (Libido) and Death Drive (Thanatos)?

Libido is the life/sexual energy driving behavior; Thanatos is the death drive— aggression and self-destructive tendencies.

What are manifest and latent content in dreams?

Manifest content is the dream’s literal storyline; latent content is the hidden meaning; dream interpretation involves recognizing condensation, displacement, and symbolism.

What are transference mechanisms in psychoanalysis?

Displacement, Projection, and Projective Identification; transference can reflect or reveal unresolved conflicts from past relationships in the analytic setting.

Name a variant of transference in psychoanalysis.

Narcissistic transference (Heinz Kohut) is a variant where the analyst is experienced as an extension of the patient’s grandiose self or as a self-object.

What is countertransference in Freudian theory?

Originally viewed as an obstacle; now recognized as a source of information about the patient and a phenomenon that can be managed with analyst self-awareness.

What are the major psychosexual stages and their approximate ages?

Oral (birth-1 year), Anal (1-3 years), Phallic (3-6 years), Latency (6-puberty), Genital (puberty onward).

Which stage is associated with Oedipus complex and penis envy?

Phallic stage (3-6 years); involves identification with the same-sex parent and resolving castration anxiety/penis envy.

What is fixation and at which stage is it most commonly discussed?

Fixation is the persistence of particular behaviors/traits from a stage due to unresolved conflicts; commonly discussed in relation to the Anal stage (anal-retentive vs anal-expulsive traits) and other stages.

What is transference neurosis and how is it relevant in analysis?

A form of transference where the patient’s unresolved infantile conflicts are recreated and reenacted within the therapeutic relationship, potentially dominating the analytic process.

What are neurotic defenses? Give examples.

Unconscious strategies that reduce distress but can be problematic; examples include denial, repression, projection, displacement, dissociation, rationalization, isolation, intellectualization.

What are mature defenses? Give examples.

Adaptive defenses that are generally healthier and more flexible; examples include humor, sublimation, altruism, anticipation, suppression, asceticism, and self-discipline.

Explain sublimation with examples.

Channeling unacceptable impulses into socially valued activities (e.g., transforming aggressive energy into sports or artistic achievement).

Explain repression and its note in psychoanalytic theory.

Primary neurotic defense; unconscious blocking of unacceptable thoughts or wishes; often accompanied by symbolic behavior; can be difficult to access but shapes behavior.

What is projection and what is projective identification?

Projection attributes one’s own unacceptable thoughts/impulses to others; projective identification involves inducing the other to experience or act as if those projected feelings are present.

Which test assesses concentration via serial subtraction and what does it measure?

Serial 7s test; assesses concentration and attention; not memory or abstract thinking.

What clinical signs suggest a disorder of appearance and behavior (e.g., grooming, posture, motor activity)?

Appearance and behavior include apparent age, physical characteristics, attire, grooming/hygiene, nutrition status, attitude toward examiner, posture/gait, facial expressions, motor activity level, and speech characteristics.

Provide a concise definition of a 'proximate' ethical duty to protect when a patient expresses intent to harm others.

Duty to warn/protect: breach confidentiality when there is a credible threat to an identifiable victim; the clinician must take steps to protect potential victims.