Wednesday, December 16, 2015

Psychiatric interviewing

I have mentioned Susan Lamb before (see eg. previous post). Her most recent article picks up Adolf Meyer's use of the term 'the new psychiatry' (although I don't think he used this phrase that often). Meyer emphasised the importance of history taking and mental state examination rather than neurobiology. To quote from the Meyer reference that Susan gives in the article, "Today it is far more necessary that a physician should learn to cope with the psychic data than even with the anatomy of the cortex." Meyer didn't always express himself that clearly, but what he meant should be apparent and it's still the same today. Psychiatrists need the skill of psychiatric interviewing even more than neurobiological understanding. This isn't always apparent from the way psychiatrists approach their work.

The best Notes on eliciting and recording clinical information were drawn up in a pamphlet by the Teaching Committee at the Institute of Psychiatry and published in 1973. They were used for ensuring a fairly uniform style and layout for recording clinical data throughout the Maudsley and Bethlem Royal Hospitals. These were disseminated throughout the country and I'm glad I was introduced to them in my first placement in psychiatry in Cambridge. It's difficult these days to obtain a copy of this guidance. The copy I currently have was withdrawn from the library of the Kings College School of Medicine and Dentistry, which includes the Institute, as too out of date to be kept on the shelves. But clinical interviewing hasn't really moved on and this edition is clear and concise.

As the pamphlet says, "A high standard of clinical recording is a hallmark of good medical practice and is nowhere more important than in psychiatry". More attention is paid to psychological and social phenomena than in a general medical examination. The interview itself serves as the psychiatrist's main tool of investigation.

Introduction of the anatomoclinical method in medicine in the nineteenth century led to the association of bedside observations of patients with autopsy findings of pathological lesions in organs and tissues. Pathology emerged as a distinct discipline. Microscopic studies established cellular abnormalities for disease and it was generally assumed there would be a histological basis for psychopathology. It was eventually established that dementia paralytica was a late consequence of syphilis. Senile dementia was also seen as having a physical cause such as Alzheimer's disease. 

However, most psychopathology is functional, in the sense that there are no structural abnormalities in the brain. Taking a pragmatic approach, as Susan says, Meyer still used the anatomoclinical method to study psychopathology "functionally in experiences and social interactions" and "not organically, at the level of tissues or cells". This new vision of the clinical skill of psychiatric interviewing made Meyer the dean of American psychiatry in the first half of the twentieth century. 

We need a new "new psychiatry" to help us move on from modern concepts of mental illness as chemical imbalance or some other abnormality in the brain (see previous post). Psychological formulation is a way forward (see previous post), although psychosocial assessment is more embedded in psychiatry than it may often appear in current practice.


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