The Psychiatric Interview
From Course Objectives
Objectives
List basic principles of interviewing as described in “Introduction to Interviewing”
- Getting Started:
- Orient & direct patient where to sit based on comfort needs
- Open-ended questions
- Free Speech:
- Open-ended questions: allow patient to speak freely.
- Purpose: gives hints to Mood, Anxiety, Cognitive, or Social/Personality Disorders; Psychosis; Somatic complaints; and Substance abuse issues
- Rapport: “Building ‘goodwill’ and ‘mutual trust’”
- Respond to patient demeanor (If depressed: supportive role; If angry: give personal space)
- Speak plainly & compassionately (avoid jargon/excess)
- Follow-up on important, difficult to understand topics
- Focus on patient feelings rather than words or behavior (to avoid own negative feelings toward patient)
- Offer praise for positive reinforcement
- Boundaries:
- Use patient’s title & last name (“Ms. Jackson”)
- Don’t reveal too much about yourself!
- Answer personal questions only when you feel comfortable with patients’ reasons for asking.
- Managing the Early Interview:
- Non-verbal encouragement (eye contact; nodding)
- Verbal encouragement: subtle “yes”, “mm-hmm”, or “please explain what you mean”
- Rephrase patients’ last word as a question (Patient: “…last week, I’ve thought a lot more about death.”; Interviewer: “Death?”)
- Request the information, again.
- Make transitions between topics graceful & logical
- Avoid leading questions
- Limit “why” questions to patient’s own experience (“why did you leave your wife?”)
- Offer Reassurance:
- Must be sincere, factual, and specific to situation
- Avoid false generalizations: “I wouldn’t’ worry about that”
List the important subject headings of a comprehensive psychiatric interview
- Identifying Info:
- Socio-demographic summary and referral source
- Chief Complaint
- HPI:
- Extended Information about Chief Complaint
- Vegetative Symptoms (Sleep, Appetite, Energy level)
- OPQRST (Stressors, Consequence of Illness)
- Psychiatric ROS:
- Mood, Anxiety disorders, psychosis, substance use, somatization, suicide behaviors, risk factors for AIDS, head trauma, loss of consciousness
- Review of major DSM-IV Psychiatric Diagnostic Symptoms
- Psychiatric disorders (Axis I)
- Personality disorders (Axis II)
- Medical disorders (Axis III)
- Identification of major psychosocial stressors (Axis IV)
- Global Assessment of Functioning (Axis V)
- Medical History
- Suicide & Other violent behaviors (be aware of personal safety measures in case patient is violent)
- Substance Use (loss of control, legal issues, financial, job)
- Family or Past Psychiatric History & Treatment
- Personal & Social History:
- Prenatal/Birth history (# trips to doctor, phobias)
- Childhood & Adolescence (education level, absences from school, obesity, stuttering, abuse, romantic/sexual relationships)
- Adulthood (education level, work history, living alone or with someone, periods of homelessness, financial stability, romantic/sexual relationships, legal difficulties, self-assessment of personality)
List and describe the major elements of the mental status examination
- General Appearance:
- Description of appearance, hygiene (Bizarre = psychosis; Unkempt = dementia)
- Attitude toward examiner
- Psychomotor activity
- Speech
- Prosody: monotonous or normal lilt
- Pathology: lisp, stutter, or impediment
- Rate & Rhythm: increased = mania; long pauses = psychomotor retardation
- Mood & Affect:
- Subjective and objective mood
- Affect variability (lability) and appropriateness
- Intensity (mild, moderate, severe, apathetic)
- Assessment of suicidality
- Thought & Language:
- Production (spontaneous? Responsive?)
- Form
- Content (Obsessions/Delusions)
- Perceptions:
- Hallucinations
- Illusions
- Dissociation (Depersonalization/De-realization)
- Cognitive Function:
- Level of Consciousness
- Orientation
- Concentration
- Memory
- Intelligence
- Insight & Judgment
Differentiate: delusions, hallucinations, disorganized behavior and speech, problems with affect, and mood symptoms.
- Delusions
- A fixed (unshakeable), false belief not explained by the patient’s culture. It is not a delusion if patient agrees/doubts the alternate explanation (“Not aliens, just airplanes”). Overvalued ideas: held despite lack of proof of their worth (not dislodged by logic; racial supremacy/inferiority)
- Hallucinations
- False sensory perceptions. Can involve all five senses. These are different from an internal monologue which is not as clear as interviewer’s voice and illusions which are misinterpretation of actual sensory stimulus
- Disorganized Behavior & Speech
- Clustered Speech: rapid, tongue-tied and disorganized. Associated with Cerebellar lesions (unnaturally uniform pace), or Muscular Dystrophy (speech clusters, difficulty uttering syllables)
- Mood
- the way a patient feels. Lability is a wide swings of mood (ecstasy to tears within moments)
- Affect
- - external presentation of a patient’s feelings. A blunted affect can be seen in Schizophrenia, Parkinson’s
- - Marked incongruity between mood and affect is observed in disorganized Schizophrenia. (inappropriate crying or laughing) can be seen with organic brain lesions like multiple Sclerosis, Strokes
Describe how attention to the process of the psychiatric interview can improve the accuracy of differential diagnosis and case formulation.
- Following this process helps to elicit a faithful and detailed picture of patient’s psychiatric status. An accurate picture will in turn help to construct a useful differential diagnosis geared toward appropriate treatment. For example, the psychiatric interview considers medical disorders that need to be
- As a bonus, the process also helps build rapport between interviewer and the patient.
