Ovid - Kaplan & Sadock Psychiatric Interview

1/3/2020 Ovid: Kaplan & Sadock's Comprehensive Textbook of Psychiatry
Editors: Sadock, Benjamin J.; Sadock, Virginia A.; Ruiz, Pedro

Title: Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th Edition
Copyright ©2017 Lippincott Williams & Wilkins
> Table of Contents > Volume I > 7 - Diagnosis and Psychiatry: Examination of the Psychiatric Patient > 7.1 - Psychiatric Interview, History,
and Mental Status Examination of the Adult Patient
7.1
Psychiatric Interview, History, and Mental Status Examination
of the Adult Patient
Rory P. Houghtalen, M.D.

John S. McIntyre, M.D.
Introduction
George Engel said that the clinical interview in medicine is “Virtually indispensable for the physician–patient
interaction, the well-constructed interview truly may be regarded as the most powerful, the most sensitive and the
most versatile instrument available to the physician.” Despite advances in science and technology, this statement
remains true today and perhaps nowhere in medicine is it more salient than in psychiatric practice, a specialty that
relies almost entirely on a careful history and examination to develop a diagnosis.
Two primary aims shape the initial psychiatric interview. One is to develop a biopsychosocial database that informs
diagnosis, risk assessment and person (patient)-centered treatment planning. The other is to form a positive alliance
that sets the stage for effective treatment that may follow the initial encounter. This chapter will focus on the initial
psychiatric interview, but much of the commentary here is relevant to patient contacts in the course of treatment as
well.
Among the settings in which psychiatric interviews take place are psychiatric inpatient units, medical-surgical
inpatient units, partial hospital programs, emergency rooms, outpatient offices, recovery services, nursing homes,
other group homes, and correctional facilities. Emerging technologies like telemedicine are making virtual “contacts”
with patients possible.
The sections that follow will cover general principles and the processes of the diagnostic psychiatric interview from
the initial request for consultation to the closing of the contact. Content includes commentary about documentation
practices, addresses factors that influence the dynamics and quality of communication and provides commentary on
interviewing techniques. The chapter closes with a review of difficult patient scenarios and special topics related to
the psychiatric interview.
General Principles
Pre-Interview Contacts and Interactions

Referrals for psychiatric evaluation come from many sources including patients seeking help, concerned family, other
medical providers, schools, workplaces and other agencies interested the person's well-being. Some referrals are for
reasons other than clinical treatment, for example, forensic evaluations. These types of referrals require special
considerations that this chapter's section Forensic Interviews briefly reviews.
The first contact in ambulatory settings usually begins with a phone call during which demographic, insurance
information is obtained, and the patient (or other caller) is briefed on what to expect in the initial encounter including
the length of the initial interview, fees and other particulars of the office or service setting. Staff interacting with
callers should be adept at differentiating urgent from routine referrals. Psychiatrists may speak personally to a newly
ovidsp.dc2.ovid.com/sp-4.03.0b/ovidweb.cgi 1/39
referred patient before the first interview to determine the urgency of the problem, triage to the appropriate level of
care and to determine if the problem is something within the scope of their expertise and capability to manage.
Most offices ask new patients to bring to the first encounter a list of current medical providers and medications, and
may ask the patient to begin the process of securing records from previous providers of mental health care. Some
offices send out a packet to gather information prior to the first interview containing questionnaires for the patient to
return by mail, submit via a website link, or to bring in person to the first appointment.
A note confirming the reason for the referral and offering background information often accompanies referrals from
other medical or mental health providers. A personal discussion with the referral source prior to the first interview is
helpful to add additional clarity to the purpose of the referral and to obtain nuanced background information that may
not appear in the documentary history. In consultation/liaison settings, clarifying the nature and scope of referral
questions allows the consultant to tailor an evaluation that is responsive to these questions.
The patient's first impressions influence attitudes and expectations. Training office staff that interact with patients
before the initial interview to appreciate and recognize the anxieties that patients bring to the first encounter and
offering them strategies to help patients feel as much at ease as possible is important to successful engagement.
Self-report tools may be introduced during the pre-encounter waiting time to aid in gathering history and make the
subsequent interview more efficient. Patients are increasingly familiar with the use of such forms in medical settings.
Broadband screening tools, like the Brief Patient Health Questionnaire, gather information about depressive and
anxiety symptoms, social distress, traumatic exposure and for female patients, screen for the possibility of pregnancy
and other reproductive health issues. Disorder-based screening tools, like the Patient Health Questionnaire-9 (PHQ-9),
aid in identifying
P.945
patients likely to have a specific diagnosis, in this case major depressive disorder. Others, such as the Quality of Life
Enjoyment and Satisfaction Questionnaire (Q-LES-Q), are designed to survey social and emotional functioning.
While this method of data gathering has many advantages, there are potential unintended consequences to consider
when offering screening and rating tools prior to the first encounter with the clinician. The patient may inadvertently
develop the impression that short, closed-ended responses are desired, that the use of a particular tool means the
clinician already has a preconceived notion of the diagnosis and that treatment will have a formulaic outline. In
addition, any screening tool will produce false-positive and false-negative identifications depending on its sensitivity
and specificity. The clinician who uses screening tools must be prepared to take steps to define the true significance of
the screening result.
Setting the Stage for the First Encounter

In contemporary behavioral health practice, the psychiatrist interacts with patients in diverse settings that may be
variably suited to the psychiatric interview. With the advent of telemedicine, the doctor and patient may not even be
in the same location. No matter the setting certain principles for staging a successful first interview apply including
attention to optimizing comfort, safety, and privacy. Most patients come to their first encounter with a mental health
professional experiencing some level of trepidation. Some arrive cajoled or forced by others to have come at all.
Anxieties are reduced by early clarification of the nature and purpose of the encounter and defining a mutual agenda
before embarking on the interview. To the extent feasible, the patient should experience the clinician focused on him
or her for the time they have together. Toward this end, unnecessary distractions such as beeper and text alerts and
phone calls ought to be minimized. Potential distractions related to note taking and the electronic medical record are
discussed in the Special Topics section of this chapter.
Comfort and Safety

For most patients adding to the emotional distress that brings a person to the initial interview is considerable
apprehension about seeing a mental health professional. Often, inadequate knowledge about mental health care and
misconceptions about psychiatric treatment arising from stigma, misinformation, and misconceptions fuel these
anxieties. The skilled clinician is aware of these potential issues and interacts in a manner to decrease, or at least not
increase, the distress. Maya Angelou said, “I've learned that people will forget what you said, people will forget what
you did, but people will never forget how you made them feel.” The psychiatrist is advised to remember this adage
when setting the stage for the initial interview. The patient's experience of the first encounter is bound to affect
engagement and set the tone for subsequent interviews or treatment that may follow and may affect treatment
attitudes far into the future.
Not much is accomplished in any human interaction when the participants are physically uncomfortable and/or
excessively anxious about personal and emotional safety. The psychiatrist is in control of the environment in some
settings, like a private office, but not so much in others, like the lock-up of a county jail. Regardless of where the
initial contact occurs, interviewers should do what is within their power to adjust the environment to provide a
reasonable level of comfort and assure the safety of both the patient and the clinician.
Engaging with patients known or found to have active psychosis, acute intoxication, or a history of aggression requires
prudence and planning. Areas used for interviewing optimally have adequate interpersonal space and arrangements
that allow both patient and interviewer an easy exit without “going through” one another's space. It is wise not to
interview patients like this in isolated areas. Tenuous situations may require modifications to usual interview
techniques including having another staff member present in the room during an encounter or standing by outside the
door.
Explicitly discussing safety can reduce uncertainty, tension, and risk. The overtly disturbed patient is often calmed by
acknowledgement of their discomfort and reassurance that the first goal is for both the patient and staff to remain
safe. Sometimes pointing out the clinician's own anxieties about safety can level tension. A statement like this may
help: “When you swear and speak in such a loud voice it makes me anxious too. When I am very anxious, it is hard for
me to pay attention to what you are saying and interferes with my ability to help you. Do you think you can tone the
language down a bit so that I listen better?” “Is there anything that I can do to help you feel calmer?” Even in a
properly staged and managed interview, it may be necessary to shorten or quickly terminate the encounter if the
patient escalates or becomes explicitly threatening. Judicious use of a therapeutic “show of force” can actually
reduce the patient's fears of loss of control by demonstrating that there are adequate staff present and a commitment
to keep everyone safe.
Privacy and Confidentiality

Privacy and confidentiality are essential components of therapeutic relationships. Staging the interview to ensure that
others do not overhear the content is an important consideration. In some settings, for example, a shared inpatient
room or a cellblock in a jail, privacy may be difficult to establish. In less than optimal environments, judiciously
steering the interview away from material that may over expose the patient is wise.
The level of confidentiality afforded the patient varies depending on the nature of the encounter making it important
to define the boundaries of confidentiality at the onset so that patients can make informed decisions about the nature
and extent of material they are comfortable sharing. The clinician should consider reviewing with the patient
situations that may lead one to share information without expressed consent. Examples include contacting informants
to evaluate concern about imminent suicide or violence risk, transfer of information in medical or psychiatric
emergencies and mandated reporting of child abuse or neglect. Insurance claims and communications with pharmacies
routinely require sharing of information. Minor children need to understand that a parent or guardian must be
informed about diagnosis and treatment options to provide surrogate consent. Detailing the boundaries of
confidentiality and exceptions to it in writing may strengthen trust and confidence in the clinical engagement.
Specific consent is first obtained (best in writing or at least carefully documented in the medical record) when
information is shared outside of a genuine emergency or a mandated report. In the United States, the federal Health
Insurance Portability and Accountability Act (HIPAA) rules define standards for proper release of protected health
information and state-by-state regulations provide additional guidance for the management of protected health
information. The details of this are beyond the scope of this chapter, but the clinician should understand and carefully
follow appropriate procedure for release of information, understanding that HIPAA usually defers to the state
regulation if it is more restrictive.
When it is necessary to share information without specific consent, the nature and extent of disclosure should be
limited to that
P.946
information essential to the task. This discretion conserves confidences to the extent possible even in situations when
the clinician has a responsibility that may conflict with the patient's privacy.
Involvement of Third Parties

Often members of the patient's family, or other supports, attend a first encounter and may expect to be involved in
the interview. These persons can be important sources of collateral information and ultimately everyone may agree
they should be involved in treatment decisions and management. The patient and psychiatrist should discuss whether
and how to involve significant others in clinical interviews and the nature and extent of information the patient wishes
shared, assuming the patient is competent to assert confidentiality and an overriding factor, such as suicide or
violence risk, does not trump the patient's choice. Patients typically appreciate a principle of “no meeting about me
without me.” It is usually best to sequence the involvement of family or important others by first meeting privately
with the patient and then, with the patient's agreement, bringing others into the encounter with the patient present.
Engagement and Relationship Building

The term “doctor–patient relationship” is a phrase used to describe that remarkable interpersonal connection that sets
the stage for healing interventions and on which current culture confers special status and obligations. Recently, the
term “patient–doctor relationship” was coined reversing the order of the parties to reinforce that the treatment
should always be patient centered. Projecting a demeanor that is friendly and open, maintaining a respectful and
nonjudgmental posture and demonstrating genuine interest in developing an empathic understanding of the patient's
predicament are physician behaviors that build the type of rapport from which the patient–doctor relationship is
forged. In the initial interview, successful development of a trusting relationship is what allows the patient to feel
comfortable enough to share information that is often sensitive and quite private.
While the relationship between any one patient and their physician will vary depending on each of the respective
personalities and experiences, as well as the setting and purpose of the encounter, there are general principles that,
when followed, help to ensure that the relationship established is one from which successful treatment can occur.
Jerome Frank (1974) examined therapeutic relationships from an anthropological perspective discovering common
characteristics, regardless of culture, that confer on an individual the status of healer. In Western cultures, specialized
training and experience are factors. In addition to training and expertise, physicians are expected to behave in ways
that project caring, instill hope, and maintain focus on the patient's best interest.
In the clinical setting, rapport can be defined as the harmonious responsiveness of the physician and patient to one
another. It is important that the patient experiences the evaluation as a joint effort and that the psychiatrist is truly
interested in their story. Appreciating how and why the patient thinks and feels as she does requires an understanding
of the patient's life experience and perspectives in some detail and depth. Early in an initial interview, the clinician is
forming hypotheses about the patient's experience through what the patient says, what affects accompany the story
and just as importantly, what is not said. As the interview progresses, the details of the patient's symptoms and story
unfold, and patterns of thinking and behavior become evident, resulting in greater clarity about the patient's actual
lived experience.
Empathy is the capacity to appreciate and understand the experience of the patient at an emotional level, achieved
when the interviewer is able to imagine himself in the patient's position while at the same time maintaining
objectivity. Objectivity differentiates empathy from sympathy. Sympathetic identification with the patient may distort
and stunt the development of a mature therapeutic relationship. Consider the experience of interviewing a patient
with borderline personality disorder. Sean Shea has noted, “One feels compelled to say a silent prayer for the poor
patient with borderline features who meets a clinician who boldly proclaims, ‘I can feel your pain.’” An awareness and
understanding of the dynamics of the patient–physician relationship are important in helping the physician maintain
objectivity while still transmitting concerned understanding and extending a helping hand. Empathic expressions
(“that must have been very difficult for you” or “I'm beginning to understand how awful that felt”) serve to increase
rapport. Frequently a nonverbal response (raised eyebrows or leaning toward the patient) or a very brief response
(“wow”) will be similarly effective.
Ultimately, it must become clear to the patient that the doctor both understands and cares about his experience for
effective treatment to proceed. In 1927, Francis Peabody wrote, “The secret of care of the patient is caring for the
patient.” Caring for the patient is not automatic and at times, it is frankly difficult. James Groves, in 1978, published
a classic paper entitled, “Taking Care of the Hateful Patient.” Rael Strous and colleagues updated the paper for
contemporary practice. Groves described patterns of patient behaviors that made them unlikeable to physicians and
warned how this disdain could interfere with optimal medical care, noting that if physicians become more aware of
their own feelings and reactions, they have increased opportunities to interact in a manner that can be helpful even in
difficult situations.
The development of a healthy patient–physician relationship is reinforced when the physician is perceived as genuine.
Being comfortable enough to laugh in response to a humorous comment, admit a mistake, or apologize for an error
that inconvenienced the patient, like being late for or missing an appointment, strengthens the therapeutic alliance. It
is also important to be flexible in the interview and responsive to patient initiatives in relationship building. If the
patient brings in an item, for example, a photo she wants to show the psychiatrist, it is good to look at it, ask
questions, and thank the patient for sharing it. Much can be learned about the family history and dynamics from such a
seemingly sidebar moment. The psychiatrist should be mindful of the reality that there are no irrelevant moments in
the interview room.
At times patients will ask questions about the psychiatrist that range from inquires about training and experience to
more personal matters such as marital status, sexual orientation, or religious beliefs. Depending on the reason for the
interview, the nature of the question and the particular characteristics of the setting and patient, these questions may
properly be answered directly or reflected back to the patient to gain insight into the motive for the inquiry. Avoiding
excessive sharing of personal information is a good general principle to adhere to, especially if the interview is likely
to proceed into a psychotherapeutic treatment that relies on the relative anonymity of the therapist as central tenet,
such as in the case of psychodynamic therapy. On the other hand, the psychiatrist should not be excessively stingy with
information for reasons that are more self-serving than patient-centered at risk of appearing aloof or callous.
A clinical example may help to illustrate these principles. The inpatient psychiatrist is rounding on a newly admitted
patient with major depressive disorder for the first time and the following conversation initiated their contact:
P.947
Psychiatrist: Good morning, Mr. Smith. I'm Dr. Jones.

Patient: (Interrupting) Before you get started I have one question for you. Are you Catholic?
Psychiatrist: Wow. That's quite a start. May I sit down?
Patient: You can sit down but I'm not going to answer any questions until you tell me if you are Catholic.
Psychiatrist: I can see that's very important to you. Can you tell me why that is important?
Patient: I'm not going to say anything till you tell me.
Psychiatrist: I can tell you something about who I am and why I'm seeing you this morning.
Patient: Never mind about that stuff. I want to know if you're Catholic.
The psychiatrist presses on attempting to understand the reason for the question. Was there a prior unsatisfying
experience with a Catholic or non-Catholic psychiatrist? Does the patient worry that his religious concerns will not be
understood or incorporated into care? The same resistant responses occur with each attempt to reflect on or address
Mr. Smith's feelings.
Psychiatrist: I'd answer the question but I anticipate answering will lead to be more questions about me and we won't
talk about you and why you were hospitalized, or how you feel about being here.
Patient: No that's the only question I have, if you answer that question I'll answer whatever questions you have.
Psychiatrist: Okay. I'm Catholic.
Patient: Do you go to mass every week?
There are occasions when, depending on the nature of the planned or ongoing treatment, it can be helpful for the
psychiatrist to share some personal information even if the patient does not inquire directly. In all cases, the motive
for self-revelation should be to strengthen the therapeutic alliance in the service of the patient not to meet needs of
the doctor.
Meaning and Communication

An understanding of the process and content of the psychiatric interview would be incomplete without considering the
role of the unconscious. From psychodynamic and neurobiological perspectives, the reality is that the majority of
mental activity remains outside of conscious awareness. The psychiatrist and the patient both operate on conscious
and unconscious levels and bring to the encounter their respective personalities, personal histories, and idiosyncrasies.
The psychiatrist should remain alert for manifestations of unconscious process in communication and in relationship
dynamics on the part of both herself and the patient.
Unconscious process in the patient–doctor relationship reveals itself through transference and countertransference
manifestations and various psychological defense mechanisms. Transference is the process by which the patient
unconsciously and often habitually displaces/transfers onto individuals in his current life those patterns of behavior
and emotional reactions that originated with significant figures from earlier in life, often from childhood, like those
attached to a parent or authority figure. Similarly, countertransference is the process whereby the physician
unconsciously and reciprocally is involved in displacement to the patient. Remaining mindful that such distortions
drive affects and behaviors of the patient and the psychiatrist alike reduces the burden of unnecessary emotional
distress, unhelpful behaviors, and missed therapeutic opportunities that may occur when these processes are not
recognized. An example may help to illustrate these concepts:
The primary care physician (PCP) offered considerable detail about an elderly woman's background and symptoms in a
letter sent to initiate a referral for psychiatric evaluation. Early in the psychiatrist's first interview it became apparent
that the patient's major concern was the sexual relationship with her husband which the psychiatrist found puzzling
because the PCP was psychologically minded and had mentioned nothing about this in the letter. When asked if she
had discussed this issue with her PCP the patient responded, “Well, it took me awhile to even broach the topic with
him because he is young enough to be my son. I tried to bring it up a couple of times, but he looked uncomfortable,
and he changed the subject. I didn't bring it up again; I didn't want to bother him.” Subsequently, in a conversation
about this patient, the PCP spontaneously commented, “She's a very nice lady; she reminds me a lot of my mother.”
Other conscious and unconscious processes represented in the so-called “defense mechanisms” of psychodynamic
theory shape and sometimes interfere with interviewing. The patient is generally unaware of the impact of these
feelings and behaviors, which take many different forms including tangential references to an issue, slips of the
tongue, mannerisms of speech, avoidance of topics, exaggerated emotional responses, intellectualization,
generalization, missed appointments, or other acting out behaviors; each of these may be examples of the unconscious
at work. For example, phrases such as “to be honest with you” or “to speak frankly” suggest that the speaker is
perhaps not actually being honest or speaking frankly. Interpreting the meaning of statements like these when they
occur in initial interviews is tempting but generally ill advised. It is better to note such manifestations while refraining
from premature exploration of defenses until the relationship is secure enough to tolerate this manner of intervention
and the patient seems ready to receive it as helpful, though a reflection such as “I would hope you will always be
honest with me,” may be appropriate and constructive.
Open- versus Closed-Ended Questions

An open-ended question identifies and introduces an area of inquiry, but provides minimal structure about how to
respond to the question or the desirable response. This style of questioning, in theory, allows the subject to respond
spontaneously with as much detail as the subject chooses and minimizes the potential for influence of the questioner
on the answer. An example of an open-ended question is, “What can you tell me about this nervousness you mentioned
earlier?” Closed-ended questions invite brief, “Yes” and “No” types of responses and may telegraph the desirable
response. An example of a closed-ended question: “You are not nervous all the time are you?”
The flow of a typical interview moves from open-ended questions that probe a particular topic to closed-ended
questions that provide definition and detail when that is required. Both types of questioning prove important to full
exploration of topics and each approach has its relative strengths and weaknesses. The balance of open- versus closed-
ended questions will vary depending on the patient's capacity to grasp the invitation of open-ended questions, the
nature of the material explored, the patient's response style (e.g., patient's prone to circumstantial responses may
have to be structured more than others) the person's openness to disclosure and the purpose and time available for the
interview. No prescription defines the proper balance.
Person-Centered and Disorder-Based

The initial psychiatric interview has at least three important goals: establish a traditional bio-medical diagnosis,
understand the biopsychosocial dimensions of the person and build rapport. Clarifying the agendas of the clinician and
the patient early in the encounter helps
P.948
to define the boundaries of the interview and plan the best use of time. Starting an interview with a statement like
this can help initiate agenda setting: “We have all or part of an hour together today. My agenda is to understand the
problem or problems that bring you to this visit. I also want to learn background about your life story to understand
you as a person. Before we begin, I would like to know what you hope to get out of our meeting today and what
questions you have so that we also address your expectations.”
The individuality of the patient's experience is a central theme. The interviewer elicits the patient's life history in
more or less detail subject to the constraints of time and the patient's willingness to share details of experiences and
their private mental life. Adolf Meyer's “life-charts” were graphic representations of the material collected in this
endeavor and were a core component of the “psychobiological” understanding of illness. The patient's early life
experiences, cultural background, family dynamics, education, work history, religious beliefs and practices, hobbies,
talents, relationships, traumatic events, and losses are each areas that, in concert with genetic and biological factors,
represent the field in which distress arose. An appreciation of the richness of life experiences and their impact on the
person is necessary to develop a complex understanding of the patient. Gleaning all of this information in a first
encounter may not be practical, but gathering enough of it to grasp the essence of both the problem and the person is
an important goal.
Traditionally, medicine has focused on illness and deficits rather than strengths and assets. A person-centered
approach focuses on strengths and assets as well as deficits. During the assessment, it can be helpful to ask the
patient, “Tell me about some of the things you do best,” or, “What do you consider your greatest asset?” A more
open-ended question such as, “Tell me about yourself,” may elicit information that focuses more on either strengths
or deficits depending on a number of factors including the patient's mood and self-image.
In addition to being person-centered, it is also important that the psychiatric interview be disorder-based. Great
advances in medicine have occurred over the past two centuries as psychiatrists began to recognize clusters of signs
and symptoms were characteristic of disorders that have common epidemiology, features, presentations, course, and
response to treatment. Developing a criteria-based nomenclature, as catalogued in the Diagnostic and Statistical
Manual of Mental Disorders, now in its fifth edition (DSM-5), has furthered psychiatric diagnosis and effective
treatment. The DSM has some limitations of course, but it transformed the esoteric methods of diagnosis that
preceded it into a standardized method that improved the reliability of diagnosis and aided research as well as clinical
work. Evidence-based psychiatric practice has flourished in part because of the increased reliability of diagnoses.
A best practice interview integrates the person-centered and the disorder-based approaches, and the process of the
interview weaves back and forth between the two ending in a working diagnosis, differential diagnosis and treatment
plan. It is essential to incorporate the patient's needs and goals in the resulting treatment plan. Numerous studies have
demonstrated that too often the patient's goals for treatment (e.g., safe housing) are not the same as the
psychiatrist's (e.g., decrease in hallucinations). This dichotomy may have its origin in an initial interview wherein the
focus was not sufficiently person-centered but rather was exclusively or largely symptom-based. Even when the
interviewer specifically asks about the patient's goals and aspirations, the patient, likely exposed on numerous
occasions to what a medical professional is interested in hearing about, may attempt to focus on “acceptable” or
“expected” goals rather than her own. Clinicians should explicitly encourage patients to assert their goals and
aspirations and to express them in their own words.
Time and Number of Sessions

The time devoted to the initial interview will vary considerably by the goal of the encounter and the setting. In a
typical outpatient treatment environment, about an hour is generally allotted. In settings like emergency and hospital
inpatient units where patients are often distressed, confused, actively psychotic or agitated, the time may be
foreshortened and assessment may by default occur over multiple, brief encounters, or rely heavily on collateral
historians.
The clinician must accept the reality that any history obtained is never complete or fully accurate because of the
nature of human memory and the distortions of perception that each person involved in an experience makes when
recounting it and variations that occur with each retelling. An interview is dynamic and some aspects of the evaluation
are ongoing—new facts emerge so that the history often morphs in lesser or greater ways depending on various factors
including the patient's gradual comfort with revealing and the dynamics of the relationship between the patient and
doctor.
History and Examination
Process of the Interview

The key elements of the psychiatric interview are the patient's histories and the mental status examination (MSE). The
histories are based primarily on the subjective report of the patient but importantly should be enriched by and
compared to available records and the reports of collateral historians. It is important to document the sources of
information contributing to the evaluation with commentary on the quality and reliability of the sources. Table 7.1–1
lists the traditional elements of the psychiatric history and examination in the conventional sequence that findings are
typically documented. The following sections will further define and discuss these elements.
The MSE is in essence the “physical examination” of psychiatry; a series of observations of signs and symptoms that are
gathered and documented systematically. This chapter's section, Physical Assessment, provides an overview of physical
assessment in the context of psychiatric evaluation. Together the histories, MSE and physical assessment contribute to
defining a working diagnosis.
Opening the Interview

After introductions (including clarifying how the patient prefers to be addressed), explaining the practice's processes,
answering initial questions and agenda setting, the interview itself begins.
Table 7.1–1. Sections of the Psychiatric History and Examination
Identifying data
Sources of information and reliability
Chief complaint
History of present illness
Past psychiatric history (including suicide and violence risk)
Substance use/abuse/addictive behaviors
Past medical history
Family history
Developmental and social history
Review of systems
Mental status examination
Physical assessment
Formulation
DSM-5 diagnosis
Treatment plan
P.949
The psychiatrist can begin with an open-ended inquiry, “Why don't we start by you telling me your understanding of
what has led to your being here today.” Often, the patient is uncertain as to why referral to a psychiatrist was
necessary or may feel frustrated or angered by the need to see a psychiatrist. The following kind of conversation is not
uncommon:
Mr. Smith: Dr. Jones said I should see you.
Doctor: What's your understanding of why Dr. Jones recommended you see me?
Mr. Smith: Well, you're a psychiatrist, right?
Doctor: Yes I am.
Mr. Smith: Well, after my tests all came back negative, he kind of implied this nervousness—that it's all in my head
and I should see you. I think he's pretty frustrated with me.
The patient should have an opportunity to express his feelings about the need for the encounter, and his anxieties
about it. The psychiatrist has an opportunity to inform about the role of the psychiatrist as a medical specialist and
the nature and importance of collaborative relationships, such as those with primary care providers or other mental
health clinicians in the care of the patient.
Chief Complaint
Traditionally, the chief complaint is recorded in the patient's own words, for example, “I have been depressed for
months” or, “I have a lot of anxiety in public speaking.” The following example illustrates the importance of recording
the chief complaint as the patient offered it:
An elderly man presented in a psychiatric emergency room with the chief complaint, “I'm melting away like a
snowball.” He had become increasingly depressed over the prior 3 months. Four weeks before this emergency visit,
the PCP increased imipramine (an antidepressant) from 25 to 75 mg, and added hydrochlorothiazide (a diuretic) 50 mg
because of mild hypertension and slight pedal edema. Over the ensuing month, the patient's condition deteriorated. In
the emergency room, he was noted to have depressed mood, a hopelessness attitude, weakness, significant weight
loss, psychomotor retardation, and was described as appearing “depleted.” He also appeared dehydrated. Blood work
found elevated BUN and creatinine levels and hypokalemia. Examination of his medication supplies revealed that the
medications were dispensed in the wrong bottles such that the patient was actually taking 25 mg of imipramine,
generally a nontherapeutic dose for depression, and 150 mg of hydrochlorothiazide, generally a supratherapeutic dose
for diuresis. He was indeed “melting away like a snowball” from dehydration. Fluid and potassium replacement
resulted in immediate improvement in his general medical status and allowed the antidepressant to be safely titrated
toward a therapeutic dose to treat his depression.
Having establishing the chief complaint, the interview proceeds on into the history of present illness.
History of Present Illness

The history of present illness (HPI) is a chronological description of the evolution of the symptoms of the current
episode. As with any well-developed HPI in medicine, the psychiatric history includes details about the nature,
frequency, severity, and pattern of symptoms including exacerbating and alleviating factors. Stressful life events,
physical symptoms, medication changes, and substance use patterns may provide clues to the context of the
presentation, the primary diagnosis and comorbid conditions that can influence treatment choices.
The exploration begins, ideally, with an open-ended invitation like, “Please tell me how this problem began, what the
experience has been like and how it has played out over time.” The interviewer may have to structure the patient
through parts of the story. It is important to try to answer to the question, “Why is the patient presenting now?” (e.g.,
“I'm here now because my girlfriend told me if I don't get help with this nervousness, she will leave me.”)
Treatments the patient utilized during the current episode are reviewed with attention to response, adherence, and
attitudes about the treatment. The common use of alternative and over-the-counter treatments makes it important to
inquire specifically about the use of these products.
Suicide and violence risk assessment (sometimes termed “lethality” assessment) is a standard element of the HPI and
any complete psychiatric evaluation. Patients may not spontaneously announce dangerous ideation or acts for a host of
reasons including shame and fear that revealing may lead to undesirable consequences including reporting and
confinement. The Suicide and Violence Risk History section of this chapter provides additional information about risk
assessment.
Rounding out a comprehensive HPI is a review of psychiatric and physical symptoms to ensure that important
symptoms of the primary problem or comorbid disorders relevant to comprehensive diagnosis, treatment planning, and
prognosis are not missed. Two examples may illustrate the importance of a review of symptoms. Failing to conduct a
review of psychotic symptoms with the depressed patient could lead to a missed diagnosis of psychotic depression, the
treatment of which varies importantly from nonpsychotic depression. Failing to conduct a medical review of
symptoms, the clinician could easily miss the fact that a patient with depression and congestive heart failure (CHF)
developed shortness of breath after the PCP initiated a tricyclic antidepressant (TCA). Not recognizing that the TCA
was exacerbating the CHF, the psychiatrist missed the opportunity to recommend a therapeutic alternative for
depression that would steer way from inotropic side effects. Table 7.1–2 offers an outline of major categories of
psychiatric symptoms, including mood, anxiety, psychotic symptoms, that are part of a psychiatric review of systems.
The Review of Systems section of this chapter and figures that accompany it offer more information about the physical
review of symptoms.
Past Psychiatric History

The past psychiatric history explores psychiatric illness prior to the current presentation including the nature of
symptoms, course, and treatment. Table 7.1–3 summarizes the items generally covered in a complete past history
review. Details of past episodes including age of onset, context, nature and duration of episodes, the diagnosis
offered, treatment applied and its setting, degree of response, treatment adherence, and attitudes toward treatment,
are all important facts to gather. Understanding the details of past treatment will lead to a better understanding of
which treatments are viable alternatives and which to avoid.
Most psychiatric disorders have a pattern of recurrence, and comorbidity is the rule rather than the exception. Some
episodes of illness may have gone undiagnosed, especially milder forms of illness. Establishing the patient's best
functional baseline and the extent of recovery between episodes provides a perspective on the impact of the
problem(s) on the trajectory of the patient's life and helps to identify elements of a comprehensive treatment plan
that optimizes fullest possible recovery.
P.950
Table 7.1–2. Psychiatric Review of Systems
Sleep
Sleep phase problems (initial, middle, terminal insomnia), total sleep time, abnormal sleep events
Mood
Depression: persistent sadness, reduced interest or pleasure in usual activities, tearfulness, reduced or
excessive sleep, reduced or increased appetite, weight loss or gain, low energy, reduced concentration,
low libido, excessive or inappropriate guilt, psychomotor change (slowing or agitation), negative self-
appraisal, helpless and hopeless thinking thoughts of death or suicide. A common mnemonic used to
remember the symptoms of major depression is SIGECAPS (Sleep, Interest, Guilt, Energy, Concentration,
Appetite, Psychomotor agitation or slowing, Suicidality).
Hypomania/Mania: elevated, expansive or irritable mood, decreased need for or inability to sleep,
excessive energy, marked increase in goal and pleasure directed activity, increase amount and pace of
speech and thought, grandiosity, heightened libido, impulsivity and/or recklessness in behaviors such as
spending and sex
Anxiety
Experience of panic attacks, somatic symptoms of anxiety, phobic, or social avoidance
Psychosis
Experience of hallucinations, delusions, disorganized behavior, speech or thought, negative symptoms
Obsessive-Compulsive
Repetitive intrusive and unwanted thoughts, compulsive behaviors to neutralize anxiety, hoarding
behaviors
Trauma
Traumatic exposure; intrusive and avoidance symptoms, negative alterations in cognitions and mood,
excessive arousal and reactivity
Behavioral
Substance use, gambling, impulse control problems, disordered eating, repetitive self-harm
Fastidious review of prior medication trials provides valuable information to define reasonable treatment medication
options and to rule out others. Important elements of this review include the dose and duration of trials, the degree of
nature and degree of effect and side effects and whether the medication was used alone or in combination with other
psychotropics or psychotherapies. Exploring adherence may lead to discovery of obstacles such as negative attitudes,
side effects, dosing complexities, stigma, social pressures, and financial burdens that affected prior medication trials.
Normalizing problems with medication adherence helps to obtain frank responses. Consider these types of questions to
invite the patient to acknowledge challenges with adherence: “Most people miss some doses of medication. How many
times a week do you miss your medication doses?” “What gets in the way of taking the medication regularly?”
It is similarly important to gather details about psychotherapy trials including the type of psychotherapy (individual,
group, couple, or family), the model of psychotherapy (Was it evidence-based for the diagnosis?) and the frequency
and duration of the treatment (Was it delivered in a manner that one expects to be effective?).
Table 7.1–3. Past Psychiatric History
1. Details of prior mental health contacts
Sites/Levels of care: school-based, primary care-based, outpatient, emergency, inpatient, partial

hospital, recovery programs
Nature of prior treatment: psychotherapy, medications, technologies (e.g., ECT), recovery-based,
alternative and complimentary
Adherence and response to treatment
2. Prior acts of self-harm, suicide, aggression, and violence
To ensure the history is complete, the clinician should inquire about less common technological modalities that the
patient may have used including light therapy, biofeedback, electroconvulsive therapy, and vagal nerve and
transcranial magnetic stimulation.
Suicide and Violence Risk History

Developing the risk history is a critical component of a complete past psychiatric history. The field of suicide and
violence risk assessment has matured to offer an understanding that risk is a dynamic process influenced importantly
by risk-enhancing and risk-reducing factors with origins in genetics, social learning, current environments, and the
particular nature of present signs and symptoms. A full discussion of risk assessment is beyond the scope of this
chapter, but it is important to point out key elements of a risk assessment history. These include details of past events
of intentional self-harm and aggression including the number of events, details of the context of prior dangerous
behaviors, the level of intent and seriousness of behaviors, harmful outcomes, and the means used to harm self or
others. A full exploration includes nonlethal behaviors that increase the risk of future lethality including intentional
self-injury. In addition to behavior itself, feelings and attitudes about the behavior and emotional states that
accompany or follow the behavior should also be explored, as well as the degree to which the patient has tried to
conceal evidence of these behaviors. The degree of family and/or community support and religious beliefs that
admonish against suicide are potential risk-reducing factors that should be assessed. Given the fact that firearms are
the leading method of suicide in men and the second leading method for women, screening for firearms access has
become a routine in psychiatric evaluation practice.
Additional information about risk assessment is found in other sections of this chapter: the Mental Status Examination
section under Risk Assessment, and in the Selected Challenging Interview Scenarios under the headings The Patient
with Depression, The Potentially Suicidal Patient and The Potentially Violent Patient.
Substance Use, Abuse, and Addictive Behaviors

Substance use may be the primary reason for a referral, and often is an important secondary problem. Substance use
disorders can mimic or induce psychiatric syndromes, elevate risk of suicide and violence, and have important impact
on safe medication prescribing. These facts highlight the importance of understanding the patient's current and past
patterns of substance use.
Starting the inquiry about substance use with a normalizing statement can help to reduce defensiveness and elicit a
fuller history: “Most people drink alcohol at times and many have also used a recreational drug at some point in their
life. I want to ask you some questions about your past and current use of alcohol and recreational drugs.”
Various tools can be used to aid in gathering the substance use history. Examples include the commonly used CAGE
questionnaire which has been modified to include other drugs (and now called CAGE-AID) though studies have found
the operating characteristics of this tool wanting in primary care settings, Caucasian females, pregnant women,
college students, and less severe levels of drinking. The National Institute on Alcohol Abuse and Alcoholism (NIAAA)
recommends a procedure for alcohol use inquiry (available at http://www.niaaa.nih.gov/guide) that offers opportunity
for education about
P.951
safe levels of drinking for those patients at risk in addition to screening for current alcohol use problems using the
Alcohol Use Disorders Identification Test (AUDIT).
For each substance the patient acknowledges using, the interviewer gathers basic information about age of onset,
pattern of use over time, current frequency, and level of use and consequences of use (physical, mental, social, and
legal). These facts help to identify problematic current or past patterns of use. Inquiry about tobacco use and problem
gambling should be a part of the addictive behavior inventory.
The interviewer should identify periods of abstinence and determine what helped the patient achieve control of use
including any specialized treatment for substance use with details about the setting, nature of and response to
treatment, as well as engagements with peer support engagement such as Alcoholics and Narcotics Anonymous.
Past Medical History

Past medical history is a bit of a misnomer given that this section of history taking and documentation is used to
review both past and present medical history. The interviewer is interested in obtaining an accounting of major
medical disorders both to develop a complete history and to identify illness that could mimic a psychiatric disorder,
contribute to the context of the presentation or factor into treatment planning.
Medical disorders can precipitate a psychiatric disorder (e.g., anxiety disorder in an individual recently diagnosed with
cancer), mimic a psychiatric disorder (e.g., hypothyroidism presenting “as if” major depression), be precipitated by
treatment of a psychiatric disorder (e.g., metabolic syndrome emerging during exposure to a second-generation
antipsychotic medication), or influence the choice of treatment of a psychiatric disorder (e.g., renal insufficiency and
the use of lithium carbonate).
A well-developed past medical history archives both current and past major medical disorders, surgeries,
hospitalizations and significant physical trauma, such as head injuries. In psychiatry, neurological and endocrine
disorders are of particular interest because of the significant overlap in symptoms and signs with psychiatric
syndromes. For female patients, obtaining a reproductive and menstrual history is important, as well as a careful
assessment of potential for current pregnancy and plans for future pregnancy.
A thorough review of all current medications is essential because some medications used in other fields in medicine
can create side effects that mimic psychiatric disorders and to identify potential drug–drug interactions before
prescribing. Patients have access to all variety of over-the-counter, herbal and alternative medications. They may not
mention the use of these products unless specifically asked. Many over-the-counter and herbal/alternative products
can produce psychiatric symptoms or interact with psychotropic medications in ways that range from nuisance side
effects to outright hazards. Frank Ayd published results of the so-called “Brown Bag Study” that illustrated just how
revealing an inspection of all the medications and products that a patient takes can be, and that serves as a reminder
of the value of having the patient actually bring to the appointment their “brown bag” of bottles for inspection.
Allergies to medications must be identified including the nature of the allergic response.
Family History
Because many psychiatric illnesses have a genetic predisposition, if not cause, a careful review of family history is
important to the assessment and can aid in diagnosis and establishing expected prognosis. This area of history
identifies family members with histories of known or suspected mental illness, substance use problems, and other
behavioral problems, for example, criminality. Patients may not know the diagnosis of a family member, but may be
able to give an accounting of the relative's signs and symptoms from which reasonable hypotheses regarding diagnosis
can be made. When the patient offers a diagnosis of a family member without much information to assess the
reliability of the claim, the alleged diagnosis should be held skeptically or some attempt made to clarify it. Specific
inquiry about family history of completed suicide is important to suicide risk assessment because this finding elevates
the index patient's future risk. Family history of medical disorders may offer clues to the patient's risk factors. For
example, diabetes in first-degree relatives ought to raise concern about the potential for metabolic syndrome with
exposure to second-generation antipsychotics.
Developmental and Social History
Factors such as the reason for the interview and the amount of time available for it will determine how broad and
deep the inquiries about developmental and social history can be, though it is important in first encounters for the
clinician to give patients a sense that one is interested in their personhood and the contexts of their distress, not just
their symptoms. Often in the first interview an outline is obtained that is further developed in subsequent encounters.
Table 7.1–4 provides an outline of topics for the developmental and social history.
The developmental and social history reviews the stages of the patient's life from gestation to the present with an eye
toward understanding the important exposures, relationships, and events that shaped the person's life story. One is
interested in understanding the nature of the person's temperament and character and the degree to which the person
has achieved developmentally appropriate role functions such as academic progress, work, peer and romantic
relationships, and parenting capacity. Gestational and birth history, developmental milestones and early childhood
development, family of origin, cultural identifications, educational, occupational, legal and military histories are all
areas to be explored. Histories of abuse (emotional, physical, and sexual), neglect (emotional and physical) and
specific traumatic exposures are important areas for specific inquiry. The nature of the patient's current social
environment is defined including financial status, housing, and current relationships.
It is often helpful to review the social history chronologically; doing so provides a natural flow to the questions and
ensures a complete history. Depending on the interviewer's assessment of how important missing information is and the
assessment of credibility of the patient's account, it may be necessary to consult collateral historians to obtain a clear
developmental and social history.
Table 7.1–4. Social and Developmental History
1. Pregnancy and delivery

2. Developmental milestones
3. Educational (including history of special needs, in-school counseling, disciplinary problems)
4. Occupational history
5. Military
6. Legal
7. Relationships/committed relationships
8. Parenting
9. Leisure
10. Traumatic or potentially traumatic exposures (including neglect, physical and sexual abuse)
P.952
Review of Systems
As in a general medical interview, the review of systems is intended to capture any current physical signs and
symptoms not already identified in the HPI or past medical history (including Table 7.1–2 and is organized by asking
sentinel questions about the major systems of the body).
Mental Status Examination

The MSE is the functional equivalent of the physical examination in other areas of medicine. It is a systematic
collection of the observations (e.g., signs such as blunt affect or rapid speech) and reported mental experiences (e.g.,
symptoms such as depressed mood or hallucinations) that produce a picture of the patient's current mental state. The
interviewer makes these observations throughout an encounter and ultimately documents the findings together in the
MSE section of the evaluation document.
Table 7.1–5 lists the traditional elements of the MSE along with examples of potential abnormal findings. The sections
that follow offer commentary about each item of the MSE and model statements to illustrate how these findings might
be documented in a medical record.
Appearance and Behavior

This section of the examination archives findings related to the patient's levels of cooperativeness and behavioral
activation, manner of relatedness and interaction, and state of grooming and dress.
The patient appeared her stated age, was dressed eccentrically and was poorly groomed. She seemed tense, was
distracted and difficult to structure, but was otherwise cooperative with the interview.
Table 7.1–5. Elements of the Mental Status Examination with Examples of Abnormal Findings
Appearance and behavior: odd or eccentric dress, poorly groomed, disheveled, unkempt, difficult to
engage, evasive, indifferent, defensive, seductive, hostile
Eye contact: avoidant, excessively prolonged, intense
Motor activity: reduced activity, restlessness, agitation, posture and gait abnormalities, praxis problems,
mannerisms and other stereotyped behaviors, posturing, tics, tremor, choreic, athetoid, and dyskinetic
movements
Mood: sad, irritable, angry depressed, elevated, expansive, euphoric, elated, dysphoric, anxious,
incongruous with affect
Affect: restricted, constricted, blunt, flat, labile, inappropriate to mood
Speech: nonspontaneous, mute, rapid or slowed, low or high volume, abnormal pitch, tone or tempo,
monotonous, robotic, stilted, excessive or reduced production, paraphasia, word approximations, poverty
of content, dysarthria
Thought process/form: derailment, tangential, circumstantial, flight of ideas, incoherence, blocking,

perseveration, clanging
Thought content: obsession, delusion, magical thinking, overvalued ideas, ideas of reference or influence,
persecutory ideas
Perception: hallucination, misperceptions (e.g., illusion), depersonalization, derealization, jamais vu,

déjà vu
Risk assessment: suicidal or violent ideation, intent, plan
Cognition: impairments of orientation, attention, memory, language functions, calculation, visual spatial
capacity, following commands, impairment of intelligence, impairment of abstraction
Insight: impairment along a continuum
Judgment: impairment along a continuum
Eye Contact
Humans are keenly aware of eye contact and deduce a good deal of about another's state of mind from it. Eye contact
and its modulation in the psychiatric interview offer important clues to the subject's internal emotional state. For
example, a depressed patient may make little or no eye contact, an anxious patient's eye contact may be intermittent
whereas a patient with psychosis may stare and maintain intense eye contact. Eye contact is normally regulated to
modulate intensity and to prevent inadvertent dominance displays. If a patient is especially intense or overtly
paranoid, it is useful to avoid prolonged eye contact.
Eye contact was intermittent. When she made eye contact it was inappropriately prolonged and intense.
Motor Activity
This section of the examination offers observations about the patient's general level of motor activity, posture and
gait, and identifies the presence of abnormal movements such as tics, mannerisms, posturing, choreic, athetoid, and
dyskinetic movements. If screening neurological examination is conducted, for example, testing of muscle tone and
deep tendon reflexes, these findings are archived here. Many clinicians use this space to document the Abnormal
Involuntary Movement Scale (AIMS) examination for tardive dyskinesia.
Her gait was slowed and unsteady. When sitting, she was restless and rubbed the top of her head repetitively. On AIMS
examination, she had mild rolling movements of her tongue at rest that were accentuated when her tongue was
extended.
Mood
The terms mood and affect vary in their definition such that one term often merges with the other. A number of
authors have recommended combining the two elements into a new label “emotional expression.” Traditionally, mood
is defined as the patient's internal and sustained emotional state. Its experience is subjective, and hence it is best to
use the patient's own words when describing mood. Terms such as normal, calm, sad, happy, angry, irritable, and
anxious are examples of descriptors patients may offer.
She said her mood was “calm.”
Affect
Affect differs from mood in that it is the outward manifestation of a mood state visible to others. Mood is deduced to
some extent from the person's emotional display. Some terms used to describe the quality (or tone) of a patient's
affect include dysphoric, happy, excited, euthymic, irritable, angry, tearful, blunt, and flat. Speech provides affective
information as well through volume, tone, and word choices. Quantity of affect is a measure of its intensity. Two
patients both described as having depressed affect can vary greatly when one is mildly depressed and the other is
severely depressed. Terms such as restricted, constricted, normal, or labile describe the range of affect.
P.953
Affect that correlates with the patient's stated mood and expressed thoughts is said to be appropriate or congruent to
mood or thought content, whereas affect that contrasts sharply is said to be inappropriate with or incongruent to
mood or thought content.
Her affect was labile ranging from inconsolable tearfulness to wild displays of irritability accompanying hostile speech,
and was incongruent with her claim that her mood state was “calm.”
Speech
Speech has an expected range of rate and volume and elements of pitch, tone, and tempo that is recognized within a
normal range though there is cultural variation in these characteristics that must be accounted for. It normally flows in
a relatively linear manner conveying information efficiently. Strong emotions, such as intense anxiety, can lead to
speech abnormalities that are transient. Certain psychiatric conditions, such as mania and schizophrenia, often have
characteristic speech abnormalities that affect both the linear flow of speech and its effectiveness in communication.
The psychiatric interviewer should be alert for evidence of aphasic speech which can be mistaken for disordered
speech due to a psychiatric condition. Patients with speech disorders are often unaware that the communicative value
of their speech is failing and may not show reciprocity in speech that is characteristic of the interactive nature of
spoken communication.
At times, she was mute. When she did speak, her speech was excessive, difficult to interrupt and came in rapid, loud
bursts that made most of her communication ineffective.
Thought Process/Form
Thought process, also referred to as thought form, is the manner in which ideas are connected one to another in
conveying thoughts to a listener, or in the case of written speech, a reader. Normally, ideas string together in a
relatively linear pattern obeying conventions of grammar and syntax. Disordered thought takes many forms described
by terms such as circumstantial (an inordinately circuitous route from question to answer), tangential (an answer to a
question that veers off from the target of the question, but the connection may still be appreciated or inferred), and
derailment, also called “loose associations” (thoughts proceed from idea to idea in a manner so oblique that the
listener cannot follow the train of thought). Table 7.1–6 contains some examples of named thought disorders and their
typical characteristics.
Table 7.1–6. Examples of Disordered Thought Process/Form
Clanging: use of the sounds of words rather than their meaning or conventional application to determine
the connection between ideas
Circumstantial: circuitous and overly detailed responses
Derailment (loose associations): convoluted and random connections between ideas such that
communicative value is lost
Flight of ideas: derailment in the context of rapid speech
Incoherence (word salad): complete disregard for conventions of word usage, grammar, and syntax
resulting in incoherence
Neologism: a word created by the speaker with idiosyncratic meaning
Tangential: responses that have only partial or remote connection to the original idea
Thought blocking: loss of the goal of a communication and not being able to return to the topic
Occasionally, her speech was linear and conveyed information well, but for the most part she was quite disorganized
with tangential and circumstantial speech. She was hard to interrupt during periods of flight of ideas and became
frustrated when the interviewer tried to clarify what she was trying to say. At one point, she used an apparent
neologism. When asked how was transported to the hospital she said, “In a convestation, you fool!”
Thought Content
Thought content refers to the general themes of the patient's ideation and is an area of the examination that
identifies thought abnormalities such as obsessional thoughts and delusional ideation. The extent to which the
examiner gains access to the patient's private ideational life is determined by factors such as the patient's sense of
comfort with the examiner and interviewing techniques aimed at eliciting this content.
Some patients share a broad range of content spontaneously and may even require structure to restrain the field of
information they offer, while others perseverate or ruminate on specific thought content and require prodding to move
beyond a narrow focus. Some patients guard content carefully. Guarding of thought content has many roots including
embarrassment or shame about the ideation, as is often the case with obsessional thoughts and paranoia that spills
over into distrust of the interviewer.
Table 7.1–7. Examples of Delusional Thought
Bizarre: a delusional belief that members of one's culture consider impossible
Erotomanic: belief that another person is in love with one, usually someone perceived of as having higher
status
Grandiose: belief that one has special powers, influence, or a special relationship with a deity or famous
person
Identity: belief that the identity of oneself or another person (usually close to the individual has been
altered, replaced or replicated in some way, e.g., Capgras syndrome)
Influence: belief that someone of something outside one's self is influencing one to think, feel, or act in a
certain way
Persecution: belief that one is the subject of persecution, attack, harassment, or is being conspired
against
Reference: belief that an event, person, or object that is unconnected to the person has some special
meaning or significance to the person
Somatic: belief that a physical sensation or physical change is occurring to one's body caused by a source
other than a normal biological or pathophysiological process
Thought broadcasting: belief that the individual has thoughts that are produced by someone or something
outside oneself
Thought insertion: belief that the individual has thoughts that are produced by someone or something
outside oneself
A delusion is a firmly held, false belief based on an incorrect inference that is unshakeable despite
evidence to contradict it. It cannot be simply a cultural belief.
A patient may reveal abnormal thought content freely, for example, complaining vigorously about persecution as a
chief concern. At other times, gaining access to abnormal ideation is a delicate dance, especially when the patient is
anxious about the consequences of revealing such material. Identification and exploration of delusional ideation often
requires particular care and respectful inquiry. A delusion is a false belief that the patient holds firmly despite
evidence to the contrary and that is outside the normal range of beliefs of the patient's culture or subculture. Common
types of delusions are listed in Table 7.1–7. Delusions may be divided into two main groupings.
P.954
One grouping distinguishes whether the idea is bizarre or not and the other whether the idea is mood congruent or
incongruent. Bizarre delusions are those that no one in the culture would consider a valid belief whereas nonbizarre
delusions are plausible but unlikely to be true. Mood-congruent delusions have themes consistent with the patient's
dominate mood state, for example, a depressed patient's certainty that he has committed a mortal sin, whereas
mood-incongruent delusions have no referent to a mood state, for example, the belief that aliens have implanted a
device in one's tooth through which they are controlling thoughts.
Gentle exploration of the degree of conviction about a delusional belief can test the patient's capacity to consider the
possibility that their conviction is flawed. If one confronts the legitimacy of a delusional idea at all, this should only be
done when there is a firm enough relationship for the patient to tolerate challenge and with respect for the fact that
delusions often serve an explanatory role. It may be hard for the patient to consider the possibility that the idea
misrepresents reality for doing so may require confronting an intolerable alternative truth. Consider the example of a
young man with new onset of schizophrenia who is failing in his college coursework. He attributes academic problems
to a conspiracy among peers and faculties whom he is sure are modifying his work to ensure failure because they are
threatened by his intellect. To consider the possible truth that is there is something desperately wrong with his mind
now interfering with his cognitive capacities and derailing his academic progress may be too much to bear.
When I inquired about his concerns about fellow students and his professors he said, “Certainly you can see as well as I
do that the other students and faculty members are threatened by me. They are colluding to undo me to push me out
of the way. No, I do not think this could be a trick of my mind and the fact that you would even bring that up makes
me wonder if you too are a part of this effort to ruin my academic career.” This appeared to be a delusion with
persecutory and grandiose themes.
Perception
Perceptual abnormalities include phenomena like hallucinations, illusions, depersonalization, and derealization. Table
7.1–8 offers names and definitions for some of the more common types of perceptual disturbances.
Hallucinations are perceptions in the absence of external stimuli to account for them; they may occur in any of the
five senses (auditory, visual, gustatory, olfactory, and tactile) and seem as real in the person's experience as a true
perception. Auditory hallucinations are the most common type of hallucination in nonorganic psychiatric conditions. In
North American culture, the finding of nonauditory hallucinations should peak curiosity about an organic cause rather
than mental disorder. While visual hallucinations do present (usually accompanying auditory hallucinations) in North
American culture, some research in other cultures finds visual hallucinations to be the most common form of
hallucinations in schizophrenia. To avoid over diagnosis and over treatment the interviewer should be careful to
distinguish between a true hallucination and a misperception of actual sensory stimulus (i.e., an illusion) and other
phenomena, like hypnagogic and hypnopompic hallucinations, that are sleep–wake phenomena and a sign of a sleep
disorder not a psychotic illness. Most everyone can point to an example of a misperception or fleeting perception, for
example, hearing one's voice called when no one else is home. These phenomena should not be mistaken for a
hallucination, much less evidence of psychosis.
Table 7.1–8. Examples of Perceptual Abnormalities
Déjà vu: perception that a present circumstance is the duplicate of an experience that has occurred in
the past
Derealization: perception that one's surrounding and events are experienced as if the person is
detached from them, or that they are distorted, changed, or unreal
Depersonalization: perception that one is standing outside oneself as a detached observer to
surroundings, experiences, and events that occur
Hallucination: the experience of a perception that seems genuine yet occurs without an actual
external stimulus. The perception may occur in any of the five senses: auditory, gustatory, olfactory,
tactile/somatosensory, or visual
Illusion: inaccurate perception or interpretation of an actual perception
Jamais Vu: perception that a present experience in entirely foreign when it actually should be very
familiar
When documenting perceptual abnormalities the interviewer should provide some description of the patient's actual
experience, the context(s) in which the experience occurs, its frequency, and intensity, the degree of the patient's
conviction of the reality of the perception, and the degree of discomfort it causes, as well as any steps the patient
may have taken to alleviate adverse effects of the experience. In the case of auditory hallucinations, details of the
nature and character of the voices can be important to diagnosis: Does the patient hear one or several voices, simple
statements or complex sentences? Do the voices engage in a conversation or comment on the patient's thoughts?
Generally speaking, the more complex the hallucinations, the more likely they are due to a schizophrenic spectrum
condition. Whether the voices ever urge or command the patient to actions, including suicidal or violent behavior, is
important to risk assessment.
As with delusions, the character of hallucinations is often divided into those that are mood congruent (e.g., a
depressed patient hearing a voice chiding her for failure and urging her to suicide) and mood incongruent (e.g., a
patient with schizophrenia who despite being quite paranoid hears female voices making warm, sexual comments that
he finds arousing and soothing).
The patient is experiencing hallucinations. She said, “Yes, I do hear a voice that keeps repeating statements like ‘you
have failed as a mother, you will lose your family, you might as well be dead.’”
Risk Assessment
Suicidal, violent, and homicidal ideation fall under the category of thought content but many interviewers document
these findings in a separate section of the examination labeled risk assessment. Risk assessment is an important aspect
of any initial clinical psychiatric evaluation.
Developing depth of understanding about high-risk ideation requires something more than simply asking the subject
“Are you suicidal or homicidal?” Ideas about suicide and violence are among the most private of thoughts. Patients are
often hesitant to divulge ideation for fear of how the revelation will be received and what actions the clinician may
take. A useful approach is to begin with a normalizing statement followed by a question. For example, “In my
experience, people who are struggling with the kinds of emotions and life problems you have described to me are also
having ideas about death, dying, or taking their own life. Has this been the case for
P.955
you?” A complete inquiry into risk addresses not only the presence of ideation but also the level of intent and plans,
and preparations that the patient has considered. Questioning about suicidal and violent ideation generally flows best
by moving along the continuum from ideation to action.
Because many patients will withhold specific information about recent suicidal behaviors or suicidal ideation, Shawn
Shea recommends a technique called the Chronological Assessment of Suicidal Events (CASE) approach. This technique
uses a sequence of specific behavioral questions to determine how close the patient was to a lethal attempt. For
example, if a patient had suicidal ideation involving a gun, the psychiatrist might ask, “Is there a gun in the home?” If
the answer is “yes,” then the interviewer continues with a series of follow-up questions until a “no” response is
obtained: “Have you taken out the gun?” “Did you load the gun?” “Did you point the gun at yourself?” “How long did
you point the gun at yourself?” “What stopped you from completing the attempt?” Any developed planning for or
practicing means of suicide or violence should be viewed as a high-risk finding requiring immediate attention.
The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal
Behaviors is one source for more detailed information about best practices in suicide assessment. The interview
methods it recommends are analogous to the CASE approach reviewed earlier in this chapter. This approach leads the
patient through a full exploration of episodes of suicidal tension to develop a fuller understanding of the precipitants
and contexts of these occurrences, as well as the particular feelings, thoughts, and behaviors that define the degree
of intent, planning, and lethal potential of actual suicidal conduct. The guideline also highlights the importance of
inquiry into whether psychotic thought content or hallucinations is promoting suicidal ideation and behavior.
Insight
Insight is a frontal lobe/executive function represented by the capacity of the individual to appraise whether one's
thoughts, feelings, behaviors, perceptions, and planned actions are appropriate and realistic, and by the capacity to
reflect on how one's presentation may be perceived and interpreted by others. In everyday clinical practice, degree of
insight is typically rated on a continuum from absent to full; many patients have partial insight. The degree of insight
does not track neatly with severity of the illness. A person with dementia may be painfully aware of cognitive decline
while a person with a mild anxiety disorder may have little or no insight into their overreactions to a fear stimulus.
Her insight appeared to be partial. She had some sense that her behavior was being perceived as abnormal, but could
not consider the possibility that she is ill in some way that requires medical attention despite the evidence for overt
psychosis.
Judgment
Judgment is another executive function mediated by the frontal lobe that represents the capacity of the individual to
appraise a situation or problem, consider and decide among alternatives, plan and execute a course of action and
modify the course of action when necessary based on new inputs. At times, judgment is impaired despite adequate
insight. For example, a patient may recognize that he is confused about money management, including the funds in his
checking account, but decides to make a large purchase without clarifying his account balance.
Tests of judgment that do not require real-world decision making generally offer little value to an accurate assessment
of judgment. Take the example of a patient just arrested for dancing nude down the middle of a busy street while
yelling at passing cars in the throes of a manic episode. The patient may answer a question about what to do if one
found a stamped envelope on the sidewalk with a socially acceptable response such as, “mail it,” but the clinician
would not therefore assess judgment as good. For this reason, it is useful to distinguish between abstract application
of judgment and demonstrable judgment. Most examiners rate judgment on a continuum from very poor to good.
Her social judgment in the context of the interviewer was fair. For the most part, she behaved well in the
examination, but she did become loud at one point and called me a “fool.” Recent events in the community, for
example her disrobing in public, demonstrate very poor judgment. She stopped her medication weeks ago and is now
unwilling to consider any type of psychotropic medication.
Cognitive Assessment
During the course of the interview, the clinician will develop history and make observations that inform cognitive
assessment. In general, vocabulary level and abstract reasoning capacity are rough surrogates for intellectual capacity.
Use of cognitive screening tests can be quite helpful in defining areas of strength or deficit that may not be obvious in
a casual conversation without using more specific probes.
Domains of cognitive function important to the initial assessment include level of alertness, orientation,
attention/concentration, visual-spatial function, memory (registration and recall), calculation, receptive and
declarative language functions, fund of knowledge, capacity to abstract, and executive functions including insight and
judgment.
The amount of detail required in the assessment of cognitive function will depend on the purpose of the examination
and findings that raise concern about the possibility of cognitive problems, like a history of learning challenges or a
clear decline from a previous level of cognitive function.
Two bedside tests commonly used to screen for cognitive function are the Mini Mental State Examination (MMSE) and
the Montreal Cognitive Assessment (MOCA). Each requires about 5 to 10 minutes to administer and both are scored on
a 30-point scale providing cutoffs between normal range and levels of impairment. The MOCA is supplanting the
better-known MMSE in many settings because it tests a wider range of functional problems, performs better in
identifying mild cognitive impairment and provides administration instructions in many languages. The MOCA is
available as an open source product accessed at www.mocatest.org while the authors of MMSE have begun to assert
copyright protection.
Physical Assessment
The extent of physical assessment will depend on the nature of the referral, the setting and the findings of the history
and MSE. In the outpatient, setting, routine physical examination is not generally a part of the initial consultation
while it is often critical to emergency room or inpatient settings. Psychiatrists do not usually personally conduct
comprehensive physical examinations but may conduct
P.956
focused examinations such as neurological or thyroid examinations. In the outpatient setting, the psychiatrist generally
relies on the PCP to conduct the physical examination and it is useful in the initial evaluation to record the date of the
most recent physical examination and review of recent laboratories if results are available. All psychiatrists should be
prepared to measure vital signs and conduct other measurements, like waist circumference, that are indicated when
psychotropic medications are used. The Abnormal Involuntary Movement Scale (AIMS) is an example of a screening
physical examination conducted at baseline and serially during treatment with antipsychotic medication to monitor for
abnormal movements like tardive dyskinesia.
Review and interpretation of laboratory results and ordering of relevant laboratory tests or special studies, such as
neuroimaging, is an important aspect of many psychiatric evaluations. Psychiatrists lacking confidence in
interpretation of test results should consult with medical providers that can interpret them and offer opinions about
the significance of results in the context of other findings.
Closing the Interview

Inexperienced interviewers often are naive to the importance of the last 5 to 10 minutes of the first encounter and
find closing of encounters challenging. It is important to alert the patient to the remaining time: “We have to stop in
about 10 minutes.” This signal gives the patient the opportunity to plan how to use the time, especially if she has
delayed or failed to address something that she wanted to. Directly asking the patient if there is anything else he
wanted to share before the end of the encounter is a useful technique to reduce the risk that the patient will bring up
an important issue “at the door” that cannot be adequately addressed. Sometimes late interview disclosures are too
complex to address in the remaining time. If so, this may be an indication for a second interview to complete the
evaluation. It is important to leave time to share opinions and recommendations and for questions.
Communication of Opinions and Recommendations
The Formulation
The psychiatric interview and examination culminates with a formulation of the case that pulls together the
biopsychosocial data into a working hypothesis about diagnosis and recommendations for treatment. The formulation
should include a brief summary of the relevant findings from the history and examination including the psychosocial
contexts in which the problem has developed and comments on the relevant contributions to the presentation of
personality function, medical problems, social stress, and other social and cultural factors.
Although the formulation typically comes at the end of an evaluation document, the hypothesis checking process is a
dynamic one that continues from the first contact with the patient to the summary of opinions. Since most psychiatric
diagnoses represent syndromes that often have overlapping features and presentations, a differential diagnosis of
possibilities other than the working diagnosis is usually found in the formulation, as well as plans to obtain other data
(history, tests, studies) to sharpen the diagnosis when this is indicated. The Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) is the standard to establish criteria-based diagnosis in the United States. Some
other areas of the world use ICD-10. The two systems cross walk in coding frameworks.
Finally, the formulation should include a summary of the risk assessment with estimates of acute and long-term risk of
suicidal or violent behavior and an opinion about the appropriate level of care that will lead to a safe and successful
outcome.
Treatment Recommendations
Consultations initiated by the patient and those requested by other professionals for input or care collaboration will
usually include treatment recommendations. Certain types of evaluations, for example, disability determination,
competency assessment, and other forensic-related assessments may not.
When evaluation produces treatment recommendations, these are typically shared with the patient at the conclusion
of the encounter in a manner consistent with the patient's capacity to receive and process the information and with
explicit discussion of matters relevant to informed consent for recommended treatment. Treatment discussions
typically involve a good deal of psychoeducation about diagnosis, the nature, risks, and benefits of recommended
treatments and information that addresses stigma and adherence. It is wise to involve significant others in these
conversations especially if there are concerns that the patient may need assistance in processing information and
making decisions to ensure that decisions are consistent with the patient's best interest. Recommendations may
include referral to other professionals or peer supports such as the National Alliance for Mental Illness (NAMI), the
Mental Health Association (MHA), or Alcoholics Anonymous (AA). Plans for crisis contacts and supports are typically
addressed. All of these counseling and coordination of care efforts should be documented in the medical record.
Techniques
General principles of the psychiatric interview, such as the patient–doctor relationship, open-ended interviewing, and
confidentiality have been reviewed in earlier sections of the chapter. This section of the chapter will review a number
of specific techniques that aid in facilitating and expanding information acquisition that are referred to here as
“facilitating” and “expanding” interventions. Also reviewed here are some interventions that may prove to be
counterproductive and interfere with patients telling their stories and that can interrupt development of the
therapeutic alliance.
Facilitating Interventions
Facilitating interventions are effective in enabling the patient to continue sharing their story and are helpful in
promoting a positive patient–doctor relationship (Table 7.1–9). At times, some of these techniques may be combined in
a single intervention.
Table 7.1–9. Facilitating Interventions
Reinforcement
Reflection
Summarizing
Education
Reassurance
Encouragement
Acknowledging emotion
Humor
Nonverbal communication
Silence
P.957
Reinforcement
Brief phrases such as, “I see,” “Go on,” “Yes,” “Tell me more,” “Hmm,” or “Uh-huh,” all convey the interviewer's
interest in the patient continuing. It is important that these phrases fit naturally into the dialogue.
Patient: For the past 2 months I've been waking up about 4 AM and I can't get back to sleep. I feel anxious like
something bad is going to happen. A lot of times I feel bad all day; it's only about 8 PM when I begin thinking of going
to bed that I feel a little bit better.
Psychiatrist: I see.
Patient: I used to be a good sleeper. This seemed to come out of nowhere. It's a miserable feeling; I can tell you that.
Reinforcement interventions, although seemingly simplistic, are very important in encourage the patient to continue
sharing material. Without these reinforcements the interview often becomes less productive.
Reflection
By using the patient's words, the psychiatrist indicates that she has heard what the patient is saying and conveys the
implicit message that he or she is interested in hearing more.
Patient: I don't know what's happening. I don't like going in to work anymore. The other guys at work are really
starting to bug me.
Psychiatrist: Really starting to bug you.
This response is not a question. A question, with a slight inflection at the end, calls for some clarification (see below).
The reflection is not stated with a tone that is challenging or disbelieving but rather as a statement of fact: the
patient's experience is what it is and the psychiatrist clearly hears it. Sometimes it is helpful to paraphrase the
patient's statement so it does not sound like it is coming from an automaton. However, in the example provided the
interviewer is not clear what the patient meant by “bug me” so changing the words (other than the pronoun) may
steer the patient in a different direction.
Summarizing
Periodically during the interview, it is helpful to summarize what the patient offered about a certain topic. This
provides the opportunity for the patient to clarify or modify the psychiatrist's understanding and possibly add new
material.
Psychiatrist: So, as I understand it, ever since you got a new boss this Spring things began to happen. You began to
feel more anxious, and some of the comments of your co-workers really bothered you.
Patient: Yeah, and now that I think about it, around that time my wife started complaining I wasn't fun anymore.
New material has been introduced. The psychiatrist may decide to continue with a further exploration of the previous
discussion and return to the issue concerning the patient's wife at a later point.
Psychiatrist: I want to hear about how things were between you and your wife but before we talk about that is there
anything else you can say about how you felt at work?
Education
At times in the interview, it is helpful for the psychiatrist to educate the patient about the interview process.
Patient: (after considerable hesitation) There are some problems at home, but I don't know if that's what I'm supposed
to be talking about.
Psychiatrist: It's helpful to talk about whatever has been bothering you. If I think we're getting off track I'll let you
know. Tell me about the problems at home.
If this is not the first session and the patient has generally been sharing information, then it might be useful to focus
on the hesitation.
Psychiatrist: It seems difficult for you to mention that. Why do you hesitate to talk about the problems at home?
This may lead to a discussion of confidentiality, loyalty to family members, or the nonjudgmental stance of the
psychiatrist.
Reassurance
It is often appropriate and helpful to provide reassurance to the patient. For example, accurate information about the
usual course of an illness can decrease anxiety, encourage the patient to continue to discuss their illness, and
strengthen their resolve to continue in treatment.
Patient: I don't think I'll ever feel better.

Psychiatrist: I understand how hopeless it feels for you right now. Feelings like that are common in depression, but
most people with this type of depression do get better and I think it's very likely you will also.
It is generally inappropriate to reassure the patient when the psychiatrist cannot predict with some confidence what
the outcome will be. In these cases the psychiatrist can assure the patient that he or she will continue to be available
and will help in whatever way he or she can.
Encouragement
It is difficult for many patients to come for a psychiatric evaluation. Often they are uncertain about what will happen,
and receiving encouragement can facilitate their engagement.
Patient: I'm not doing very well describing this nervousness. I've never done this before.
Psychiatrist: I think you are doing well in describing the nervousness. As you talk I'm getting a clearer picture of what
it's been like for you.
The psychiatrist is careful not to overstate the progress in the interview. The patient is given positive feedback about
their efforts, but the secondary message is that although the “picture” is getting “clearer” there is more work to be
done.
Acknowledgment of Emotion
It is important for the interviewer to acknowledge the expression of emotion by the patient. This frequently leads to
the patient sharing more feelings and being relieved that they can do so. Sometimes a nonverbal action, such
P.958
as moving a tissue box closer can suffice, or be used as an adjunct behavior to an empathic comment.
Patient: He was a good friend.

Psychiatrist: As you talk about him you look very sad.
If the display of the emotion is clear (e.g., patient openly crying), then it is not helpful to comment directly on the
expression of the emotion.
Patient: (sobbing) I really miss him.

Psychiatrist: I see that you are crying.
Patient: No shit. You're very observant.
It is better to comment on the associated feelings.
Psychiatrist: You feel awful without him.
Humor
At times, patients make humorous comments or tell a joke. It can be very helpful if the psychiatrist smiles, laughs, or
even, when appropriate, adds another punch line. This sharing of humor can decrease tension and anxiety and
reinforce the interviewer's genuineness. It is important to be certain that the patient's comment was indeed meant to
be humorous and that the psychiatrist clearly conveys that she is laughing with the patient not at the patient.
Silence
Careful use of silence can facilitate the progression of the interview. The patient may need time to think about what
has been said or to experience a feeling that has arisen in the interview. The psychiatrist who cannot bear the anxiety
of silence may terminate it prematurely retarding the development of insight or the expression of feeling by the
patient. As George Engel encouraged new trainee, “Don't just do something, sit there.” On the other hand, extended
or repeated silences can deaden an interview and lead to a struggle as to which party can out wait the other. If the
patient is looking at his watch or looking about the room, then it might be helpful to comment, “It looks like there are
other things on your mind.” If the patient has become silent and looks like he is thinking about the subject, then the
psychiatrist might ask, “What thoughts do you have about that?”
Nonverbal Communication
In many good interviews, the most common facilitating interventions are nonverbal. Nodding of the head, body
posture including leaning toward the patient, body positioning becoming more open, moving the chair closer to the
patient, putting down pen and folder, and facial expressions including arching of eyebrows all indicate that the
psychiatrist is concerned, listening attentively, and engaged in the interview. Excessive repetition or exaggeration of
nonverbal techniques risks one being perceived in the vein of popular caricatures of the psychiatrist that nods his head
repeatedly regardless of the content of what is being said or the emotion being expressed.
Expanding Interventions
There are a number of interventions that can be used to expand the focus of the interview. These techniques (Table
7.1–10) are helpful when the line of discussion has been sufficiently mined, at least for the time being, and the
interviewer wants to encourage the patient to talk about other issues. These interventions are most successful when a
degree of trust has been established in the interview and the patient feels that the psychiatrist is nonjudgmental
about what is being shared.
Table 7.1–10. Expanding Interventions
Clarifying
Associations
Leading
Probing
Transitions
Redirecting
Clarifying
At times carefully clarifying what the patient has said can lead to unrecognized issues or psychopathology.
A 62-year-old widow describing how it feels since her husband died 14 months ago repeatedly comments, “Everything
is empty inside.” The resident interprets this to mean that her world feels empty without her spouse and makes this
interpretation on a few occasions. The patient's nonverbal cues suggest that she is not agreeing with this view. The
supervisor asks the patient to clarify what she means by “empty inside.” After some avoidance, the patient states that
she is indeed empty inside; all her organs are missing; they have “disappeared.”
The resident's interpretation may actually have been psychodynamically accurate, but the interpretation interfered
with the opportunity to discover a somatic delusion. The correct identification of what the patient was actually saying
led to an exploration of other thoughts, and delusions were uncovered. This vignette of “missing” the delusion is an
example of the interviewer “normalizing” what the patient is saying. The interviewer was using secondary process
thinking in understanding the words of the patient while the patient was using primary process thinking.
Associations
As the patient describes symptoms, other areas that may accompany or relate to a symptom should be explored. For
example, the symptom of nausea leads to questions about appetite, bowel habits, weight loss, and eating habits. In
addition, experiences that are temporally related may be investigated. When a patient is talking about their sleeping
pattern, it can be a good opportunity to ask about dreams.
Leading
Often, encouraging the patient to continue their story can be facilitated by asking a “what,” “when,” “where,” or
“who” questions. “Why” questions are generally not helpful early in an interview.
Patient: And I said, “That's enough.” (pause)

Psychiatrist: What happened then?
Sometimes the psychiatrist may suggest or ask about something not yet introduced by the patient because the
psychiatrist surmises it may be relevant. In the courtroom, leading the witness is certain to raise an objection, but in
clinical work it can be helpful as long as
P.959
the interviewer is not making too far an intuitive leap and is open to reframing the question pending a response by the
patient.
Patient: “…feels like my husband is always telling me what to do, criticizing my driving.”
Psychiatrist: You mentioned that earlier. Have there been other relationships where you have also experienced that?
Patient: Well … (pause) actually my father used to do that to my mother all the time. I really hated that.
Probing
The interview may point toward an area of conflict, but the patient may minimize or deny any difficulties. Gently
encouraging the patient to talk more about this issue may be quite productive.
Psychiatrist: Tell me more about how things are at home.

Patient: Not really a whole lot to tell; everything is cool.
Psychiatrist: You mentioned that weekends are difficult.
Patient: I didn't mean that difficult.
Psychiatrist: OK. How are they different from before?
Patient: I don't know what you mean. (pause) Well, I guess it's a little different. Now my wife does her things and I'm
doing mine.
Transitions
Sometimes transitions occur very smoothly. The patient is talking about her primary education major in college and
the psychiatrist asks, “Did that lead to your work after college?” On other occasions, the transition means moving to a
different area of the interview and a bridge statement is useful.
Psychiatrist: That gives me a good idea about your nervousness, perhaps now you can tell me about your health in
general.
Redirecting
A difficult technique for unseasoned interviewers is redirecting the focus of the patient. It can be difficult to move the
interview in a different direction when one is concentrating on reinforcing the patient telling his or her story.
However, the reality is that time constraints and the goal of obtaining a broad overview of the patient's life as well as
the current problems makes redirection necessary at times. Redirection is also used when the patient changes topics
too quickly or persists in offering excessive information about a nonproductive or already well-covered area. For both
conscious and often unconscious reasons, the patient may avoid certain important areas and need guidance in
approaching these subjects.
Patient: (After beginning to describe some significant issues with her mother) But enough of that, let me tell you
about my job.
Psychiatrist: Before we move on to your job perhaps you can say more about your struggles with your mother. It
sounds like that has been very upsetting to you.
Patient: (After much discussion about her arthritis) and then six months ago I saw a new rheumatologist…
Psychiatrist: I know your arthritic pains have been a big burden to you, and we can come back to that, but I would
also like to hear more about the issues you mentioned with your daughter.
Sometimes if the patient is wandering and does not respond to an attempt at transitioning, then it is necessary to be
more directive.
Psychiatrist: I'm going to interrupt at this point because I am aware of the time we have left and there are several
other areas it would be good to talk about.
Obstructive Interventions
While supportive and expanding techniques facilitate the gathering of information and the development of a positive
patient–doctor relationship, some other interventions are not helpful for either task (Table 7.1–11). Sometimes these
interventions are technically correct, but if introduced in an unclear manner, unconnected to content, or poorly timed
they may be experienced as unresponsive to the patient's concerns or feelings.
Closed-Ended Questions
A series of closed-ended questions early in the interview can retard the natural flow of the patient's story and
reinforces the patient providing one-word responses or brief answers with little or no elaboration.
Psychiatrist: Did you have a happy childhood?

Patient: (Pause) Yes, I guess so.
Psychiatrist: Did you have friends?
Patient: (Intuitively trying to get the interview pointed in a more productive direction) Well, I guess it depends on
what you mean by a friend.
Psychiatrist: (Not joining the patient's attempt to enrich the discussion) Kids you did things with. How many?
This example illustrates that the patient can be a partner in the interview, unless blocked by the psychiatrist. Many
patients, some of whom have previous experiences in therapy, come prepared to talk about even painful matters. Over
the course of time, psychiatrists, especially if they have had the benefit of supervision, learn from patients and refine
their interviewing skills.
Compound Questions
Some questions are difficult for patients to respond to because more than one answer is being sought.
Psychiatrist: How did you feel? What did you do?

Patient: I'm not sure what happened.
Table 7.1–11. Obstructive Interventions
Excessive use of closed-ended questions
Compound questions
Excessive “Why?” questions
Judgmental questions
Minimizing patient concerns
Premature advice
Premature interpretations
Abrupt transitions
Ambiguous nonverbal communication
P.960
Why Questions
Especially early in the psychiatric interview, “why” questions are often nonproductive. Very often seeking an answer to
a “why” question is one of the reasons that the patient has sought help.
Patient: I felt very depressed. I just couldn't go on.

Psychiatrist: Why were you so depressed?
Patient: I don't know. I thought you might know.
Judgmental Questions or Statements

Judgmental interventions are generally nonproductive for the issue at hand and also inhibit the patient from sharing
even more private or sensitive material.
Patient: I felt she wasn't paying attention so I yelled at her.

Psychiatrist: Don't you know that yelling only makes matters worse?
It would be better for the psychiatrist to help the patient reflect on how successful that behavior was.
Psychiatrist: How did that go?

Patient: Not good. Then she got upset about the yelling.
Minimizing Patient's Concerns

In an attempt to reassure a patient the psychiatrist makes the error of minimizing a concern.
Patient: I worry I'm going to have a heart attack. My doctor says I have to lose weight.
Psychiatrist: I don't think you need to worry. You look pretty healthy and your father is still alive.
Rather than being reassured, the patient may feel that the psychiatrist does not understand what he is trying to
express and is trivializing the experience. Furthermore, the advice is counter to what the PCP has said and is confusing
to the patient. It is much more productive to explore the concern; there is likely much more material not yet shared.
Premature Advice
Advice given too early is often bad advice because the interviewer does not yet know all of the variables. In addition,
it can preempt the patient arriving at a plan for himself or herself.
Patient: My boss is so demanding.

Psychiatrist: Why don't you get in early in the morning before he does and give him a list of what will improve
everyone's performance.
Premature Interpretation
Even if it is accurate, a premature interpretation can be counterproductive as the patient may respond defensively
and feel misunderstood.
Patient: I was so angry at my neighbor when he said that and I'm not sure why.
Psychiatrist: He reminds you of your brother and the way he was always trying to control you.
Patient: (angrily) He doesn't remind me of my brother; he doesn't even look like him.
Transitions
Some transitions are too abrupt and may interrupt important issues that the patient is discussing.
Patient: Ever since my father died I've been feeling anxious.

Psychiatrist: Tell me more about your job.
Nonverbal Communication
The psychiatrist repeatedly looking at her watch, turning away from the patient, yawning, or refreshing the computer
screen all convey boredom, disinterest, distraction, or annoyance. Just as reinforcing nonverbal communications can
be powerful facilitators of a good interview; these obstructive actions can quickly shatter an interview and undermine
the patient–doctor relationship.
Selected Challenging Interview Scenarios
Patients with Psychosis

Patients with psychotic symptoms are often frightened, guarded, and suspicious about the purpose of the interview
and the intentions of the clinician. They may have difficulty with reasoning and clear thought and communication.
Hallucinations may cause inattention and distraction. These factors often require adaptations to match the capacity
and tolerance of the patient. Patients with psychosis may not perceive their behaviors, speech, delusions, or
hallucinations as abnormal in any way making it important to inquire in a manner that encourages the patient to share
their ideational and perceptual experience without seeming judgmental of it.
Toward this end, prefacing direct questioning about psychotic symptoms by making normalizing statements such as
“Many people have ideas that others find strange or different,” can increase the patient's comfort with sharing
delusional ideation and similarly for hallucinations by stating that, “Many people have had the experience of hearing a
voice or seeing a vision.” Such statement may help the patient talk more openly.
The psychiatrist should be alert for cues that psychotic processes may be part of the patient's productions during the
interview. It is usually best to ask directly about any such behaviors or comments as this example illustrates:
During an initial interview, a 28-year-old man suddenly stood up and turned 360 degrees, sat down, and after a brief
pause, resumed talking. When asked, “What just happened?” the patient responded that he “had to unwind.” While
exploring this example of concrete, primary process thinking, a number of other psychotic features were uncovered.
By definition, patients with delusions have fixed false beliefs. With delusions, as with hallucinations, it is important to
explore the symptoms in some detail. Patients are often reluctant to discuss their experience because of past
occurrences of being dismissed, ridiculed, or confined when they revealed their thoughts and perceptions. They
P.961
may ask directly if the clinician believes the delusion. Interviewers are advised not to endorse the false beliefs, but it
is rarely helpful to challenge the delusion directly particularly in the initial examination. It can be helpful to shift the
focus of attention back to the patient's beliefs while acknowledging the need for more information by responding like
this: “I believe that what you are experiencing is frightening and I would like to know more about your experiences so I
can form an opinion.”
With patients evidencing a high degree of suspiciousness, it is useful to maintain distance and modulate statements or
behaviors that patient may interpret as promoting excessive closeness, for example, excessive use of empathic
statements or prolonged eye contact. Harry Stack Sullivan recommended that rather than sitting face to face with the
patient who is paranoid, the psychiatrist might sit more side by side (but not too near), “looking out” with the patient.
While interviewing the psychotic patient, the interviewer should keep in mind that the patient might be incorporating
the clinician into the psychotic process. It can be helpful to ask about this directly, for example, “Are you concerned
that I am involved?”
Acute psychosis raises concern about the potential for violent behaviors that are further reviewed in this section under
the heading The Potentially Violent Patient.
The Patient with Depression

The depressed patient may have particular difficulty participating in the interview due to psychomotor slowing,
cognitive deficits, and lack of motivation to engage caused by the depression itself. Feelings of hopelessness may
contribute to a lack of engagement.
Patient: “What's the use [of talking]? It's not going to make any difference. Nothing is going to change.”
Psychiatrist: “I'm glad that you are able to share that. It sounds like you feel hopeless about getting better. Hopeless
feelings are common in patients who have depression. I think your condition will improve and you will feel more
hopeful.”
The depressed patient's responses to questions are often latent and may lack spontaneous elaboration. Depending on
the severity of symptoms, the interviewer may need to turn to more direct questioning and abandon an open-ended
format. The interview of severely depressed patients can be a laborious process and may require more time than
expected to gather even minimally necessary information, even then collateral historians may need to fill in gaps in
the patient's history.
The Potentially Suicidal Patient

There are times in initial interviews when it is obvious that one is encountering a patient on the brink of suicide, but
in many other instances, patients have suicidal ideation without betraying much, if anything, in the way of clues. For
this reason, it is important to conduct suicide risk assessment in any initial psychiatric interview. Certain diagnoses and
problems heighten suicide risk, among them major depression, borderline personality disorder, high levels of anxiety,
acute psychosis, acute intoxication, patients who have become hopeless about their substance use problems, acute
grief and loss reactions, and patients with grave or burdensome medical problems. Persons recently arrested and
patients who are homicidal may also be suicidal. As discussed in earlier sections of this chapter, normalizing the
potential for suicidal ideation is a good way to encourage patients to share their thoughts and feelings. An invitation
like this can help to initiate the conversation about suicide: “Many people who describe a life event or the feelings
that you have today are also having thoughts about death, dying, or even ending their own life. Has this been the case
for you?”
The science of suicide risk assessment is beyond the scope of this chapter, but there are important risk factors that
elevate suicide risk to survey as the history is developed. Some relate to demographics (e.g., age, gender, living alone,
race and ethnicity, sexual orientation) others to particular factors related to diagnosis and clinical features (see
above) and life experiences such as childhood physical and sexual abuse. Family history of suicide, prior attempts at
suicide, and acts of deliberate self-harm are important historical risk factors. Active substance use, acute psychosis,
and high levels of anxiety seem to fuel suicide risk. Protective factors include the level of social support, children in
the home, pregnancy, and religious beliefs that admonish against suicide.
The Potentially Violent Patient

Safety for the patient, interviewer, and others present is the main concern when engaging with hostile or agitated
patients. If one knows in advance that an encounter with a hostile or agitated patient is to occur, there is opportunity
to plan and marshal supports. As noted elsewhere in the chapter, thoughtful attention to managing personal space and
having an attendant during the encounter can be important to reducing risks in these situations. It is good practice to
alert other clinical staff in the area and security, if an officer is present.
Reducing excessive stimulation of already hostile or agitated patients is a priority. Interviewers should be aware of
their own body position and avoid postures, behaviors, eye contact tone of voice, and choice of words that could
perceived as threatening. Approach the interview in a calm, direct manner and take care not to make bargains or
promises to elicit cooperation in the interview, for example, implying that cooperation will avoid an admission. These
tactics will only likely escalate agitation and the potential for aggression when the patient discovers the examiner
cannot deliver.
Managing the interview requires thoughtful choices about areas to explore and those to leave alone, as well as the
phrasing and timing of questions to avoid stirring up unnecessary conflict. Taking breaks, agreeing to leave a topic that
causes tension for another time and attending to basic comforts like hunger and nicotine replacement before pressing
on with the interview may reduce tension and build rapport. Avoid unnecessary displays of dominance and give
patients choices where there are reasonable options so that the patient can maintain some semblance of control.
Despite best efforts, termination of some interviews must occur when the patient's agitation escalates. Generally,
preceding unpremeditated violence is a period of gradually escalating psychomotor agitation such as pacing, loud
speech, and threatening comments. As noted earlier in the chapter, some agitated patients will calm when the
interviewer shares that the patient's behavior is making the interviewer too anxious to be helpful. There is no virtue in
pressing on and taking unnecessary risk, especially when the interviewer is frightened. Consider terminating the
interview and seeking assistance if the patient's behaviors escalate and do not easily respond to structure and
feedback.
The hostile or agitated patient may be placing others in his community at risk. The most common victims of violence
by acutely ill psychiatric patients are those that live or work in close proximity to the patient, such as family,
residential staff, and coworkers. If the patient can tolerate it, explore feelings and attitudes about those
P.962
close to him to discover persons who may be at particular risk. If the patient makes specific threats and/or identifies
specific targets, take the threat seriously and carefully define the actual risk.
Like the assessment of suicide risk, a complete discussion of the violence risk assessment is beyond the scope of this
chapter. Certain facts are worth noting here. Research reveals more about risk factors for violence than protective
factors. Among the important risk factors are patient age (youth), lower intelligence, past acts of violence and general
suspiciousness as well as active psychosis; individuals physically or sexually abused as children are also at greater risk
of violence. Interviewing for violence risk follows much the same pattern as that used for suicide risk assessment. The
interview generally moves along the continuum of ideation to plan to action exploring the nature and extent of the
patient's ideation, planning, and intent. Similar to suicide assessment, the clinician seeks to define past instances of
violence, the particulars of these episodes and the outcomes to understand the level of risk at the time of the
interview and to identify patients who are at elevated risk over time.
The Patient Engaging in Deception

For the purpose of this discussion, deception is defined as the intentional production or exaggeration of symptoms.
Psychiatrists train to maintain vigilance for deception while eliciting information but they are not immune to being
deceived. Studies show that even experienced clinicians will fail to recognize malingered mental illness in some
settings. Patients engage in deceit for many different reasons. Some are motivated by secondary gain, like work
excuses, disability, or to secure desired medications. Others are seeking primary gains, like the psychological benefits
of assuming a sick role.
This example illustrates some points:
A soldier in basic training presents to the military base mental health service with a long list of symptoms. He
escalates the drama of his responses each time he perceives that the psychiatrist is not reacting to his productions as
he expected. Finally, after describing some elaborate visual hallucinations that do not comport to those typically
experienced by psychotic patients and that also failed to impress the psychiatrist, the soldier blurts out, “What's the
matter, you never heard of paranoid schizophrenia?” Later, the psychiatrist learned the soldier visited the base library
to read about psychiatric illnesses, and schizophrenia. The solider admitted he was feigning symptoms to avoid an
undesirable deployment.
There are no infallible means to detect deceit, but there are markers in interviews that raise suspicion including vague
and contradictory responses, symptom claims that are inconsistent with functional findings, claims that are far beyond
the variations of psychopathology seen in certain conditions or problems, or that are frankly preposterous. View
skeptically patients that draw excessive attention to symptoms and those that become irritated with attempts to
clarify the nature of complaints. This said it is important to remain cognizant of the fact that there are unusual
presentations and one should not assume that all that confuses or does not fit typical patterns is therefore evidence of
deceit. Collateral historians become critically important when there is concern about the credibility of patient
reports. Certain psychological tests are designed to detect deceit (e.g., the Word Memory Test) and others have
validity scales imbedded in their structure that measure the nature of response style to identify likely exaggeration or
suppression of symptoms in reporting (e.g., the Minnesota Multiphasic Personality Inventory [MMPI]).
It is important to be confident in one's opinion about deceit before confronting a patient with this conclusion. It is also
important to try to maintain an empathic approach to when discussing findings, ideally helping the patient to save
face while also accepting responsibility. For example, the following type of exchange can be helpful:
“Would you agree that it is important for you to be truthful with me about your history and symptoms and for me to be
truthful with you about my findings and recommendations? Okay then to be a good doctor to you, I must share that I
believe that you are exaggerating some of the symptoms you have described. These are the reasons why I believe this
to be so (clinician explains the reasons). I am concerned that you are trying to present yourself as ill in certain ways
that in the end could lead to bad outcomes, like applying treatments that could do more harm than good. If I am right
about this, let us start over and talk about what is really going on and why you might have tried to present yourself as
ill in this way. Then I can see if there are ways I can help you with your predicament that are reasonable and safe.”
Special Topics
Note Taking and the Electronic Medical Record

Many psychiatric interviewers take handwritten notes during the interview. With the advent of electronic medical
records, some advocate for a method called “contemporaneous documentation” during which the interviewer pauses
either periodically during the encounter or at the end of the encounter to create all or part of the consultation
document with the patient's participation. Advocates of this method point out that a patient increasingly has direct
access to all or parts of their medical record through patient portals. Writing the note with the patient, so to speak,
reduces the chances of documenting inaccurate information or writing statements in a manner that the patient might
find offensive.
This is an example of how contemporaneous documentation might proceed in real time:
Psychiatrist: “Now you have told me a lot about your current problem and I'd like to pause now and document what
you said to summarize it in the record. I will summarize what I am writing while I type it. You listen and tell me
whether I have heard you correctly.”
The process of contemporaneous documentation can result in synergistic efficiency that provides opportunity to
summarize, clarify, and correct information while completing documentation. For those that now offer an hour for the
consultation and then do documentation after the encounter, extending the time for the consultation to include time
for contemporaneous documentation an improved time economy may be realized.
Note taking and contemporaneous documentation in an electronic record during the interview are activities that
present some risks. These activities can interfere with the observation of nonverbal information, like affects and body
language, that are often as or more important than what the patient says. Failing to recognize these nonverbal cues
can result in both loss of important data and empathic failures affecting the development of rapport. The activities
can also introduce distractions for both the patient and the interviewer if they dominate the interview.
P.963
Cultural Variation
One definition of culture is a common heritage, a set of beliefs, and values that set expectations for behaviors,
thoughts, and even feelings. Culture influences the patient's attribution of illness, decisions about when and where to
seek help, how distress is articulated or demonstrated to others (including when speaking with medical providers) and
perceptions of necessary and acceptable forms of treatment. Often, individuals from a minority population are
reluctant to seek help from a physician who is from the majority group, especially for emotional difficulties.
Just as the array of cultural syndromes and variations are beyond the scope of this chapter, interviewers cannot be
aware of all culturally bound syndromes or idioms of distress but should make the effort to learn about variant
presentations and syndromes that affect cultural groups commonly encountered in the scope of their practice settings.
Reducing the risk of overdiagnosis (e.g., misreading a cultural belief for a delusion) and the possibility of over or
undertreatment that can issue from inaccurate diagnosis are among the reasons cultural awareness is important.
By remaining humble and curious about the patient's cultural identifications and beliefs, and being open and respectful
to them, the psychiatrist increases the likelihood of developing a trusting working relationship and a collaborative and
effective plan.
Interviewing with an Interpreter

Translated interviews require forethought and preparation. Whenever possible, the use of a professional translator is
favored over use of a person familiar to the patient. Professional translators have training and experience to interact
with patients and providers skillfully, the vocabulary skills to translate medical words and concepts, operate under a
code of ethics that highlights confidentiality, and understand the importance of verbatim translation and neutrality.
The use of nonprofessional interpreters risks a poor quality translation fraught with all the challenges of agency, skill,
and interpersonal dynamics that friends and family bring to the process of interpretation and too often lead to
incomplete or frankly inaccurate communication.
It is helpful to speak with the interpreter prior to the interview to clarify the goals of the examination and the
expectations. Most professional interpreters are attuned to the fact that their role is to facilitate not create
communication and so understand the importance of verbatim translation, and that the interpreter does not
intersperse ad-lib questions or edit the patient's responses. If the interpreter does not primarily work with psychiatric
patients, it may be useful to highlight the need for verbatim translation even if the responses are disorganized or
contain unusual content. During the course of the interview, the interpreter may slip into giving sparse interpretation
to longer speech productions. If this occurs, the interviewer should pause and ask the interpreter to offer everything
that the patient said and remind the interpreter of the request for verbatim interpretation.
To avoid the patient connecting more with the interpreter than the interviewer one should arrange the positions of the
parties to allow the patient to maintain gaze in the direction of both interviewer and interpreter during the encounter.
Interviewers need to be sensitive to the pace of questioning and parse out the questions and comments into smaller
segments to allow the interpreter time to facilitate communication. As a general rule, more than one or two sentences
or three complete thoughts is more than the anyone, including interpreters, can hold accurately in memory to
reproduce a verbatim translation once the interviewer stops speaking.
At the conclusion of the interview, the interpreter who is especially knowledgeable about the patient's cultural
background may be able to provide helpful insights and opinions about the nature of the patient's communication, for
example, if a formal thought disorder was present and whether ideas the patient expressed were outside the norm for
the cultural group.
Observed and Recorded Interviews

One-way mirror observation and/or recording of interviews occur in some settings for clinical, educational, or forensic
purposes. Before initiating an observation or recording, the patient's informed consent for these activities must be
specifically established. The patient should understand the purpose of observation and/or recording (e.g.,
psychotherapy, supervision), how it will be used and who may have access to it (e.g., an attorney or other third parties
in a forensic case). When recordings are made for clinical purposes it should be made clear how long the recording will
be archived before it is destroyed. If a recording is to be used for educational purposes, there are special informed
consent considerations, including the patient's right to withdraw the consent and others matters that are beyond the
scope of this chapter. In treatment settings, the clinician must ensure that the patient receives the same nature and
quality of care regardless of whether consent to observe or record is granted.
Observation and/or recording of an interview can perturb the clinical interaction in expected and unexpected ways.
The clinician should remain vigilant for untended negative effects on engagement and the free flow of information
when interviews are observed or recorded.
Forensic Interviews
For the purposes of this section, a forensic interview is defined as one taking place in a legal context for a purpose
other than clinical treatment. For example, the psychiatrist may be retained by an insurance company to conduct an
Independent Medical Examination (IME) to offer an opinion in a disputed disability case, or by an attorney representing
or prosecuting a defendant in a criminal case to offer opinions about competency to stand trial or criminal
responsibility. Even in forensic settings where psychiatrist is acting in a clinical role, for example, providing treatment
in a correctional facility, some of the issues to be discussed here will apply.
Forensic consultants, with the exception of those providing clinical care in a forensic setting, do not form patient–
doctor relationships with subjects, yet should still operate in these settings observing the ethical principles that apply
and aspire to maintain the subject's dignity.
The agency or duty of the psychiatrist in the forensic setting is typically owed to a third party, for example, the
attorney that retained the psychiatrist. Before proceeding with the interview, the subject should understand the
agency of the psychiatrist and the boundaries of confidentiality. For example, when the psychiatrist is retained by the
subject's defense attorney confidential material is protected by the attorney-client privilege unless and until the
attorney and client decide to use an opinion, at which point a report or testimony may be provided requiring a waiver
of confidentiality to produce it. If the examiner is retained by a prosecuting attorney, an insurance company in an
adversarial proceeding, or if a judicial order demands a report, the subject waives confidentiality by agreeing to the
examination.
The principles of forensic interview are built on the foundation of sound clinical practices though there are some
important differences. The level of detail required in a forensic setting is typically greater than that sought in a
general psychiatric interview. Forensic interviewing techniques require more detailed probing of the patient's story
and mental state that at times may necessitate more clarification
P.964
and even confrontation than typically utilized in a general psychiatric interview. Such interventions should be
conducted in an ethically sound and sensitive manner. Collateral sources of information are critical to forensic
examinations. These sources help to discover important elements of the history that the subject may not provide and
serve to externally verify information offered by the subject. Forensic interviews are much more likely to be recorded
than general psychiatric interviews and require special considerations for recording that are beyond the scope of this
chapter, but the subject must know when recording is occurring and understand who may have access to such
recordings as part of the consent process. Psychiatrists engaging in forensic interviewing should have a clear sense of
the boundaries of their own training and experience and recognize the implications of their activities and the opinions
they offer. Knowledge of the legal system (including the legal standards that apply to clinical questions), skills in
specialized interviewing techniques, the role and proper application of psychological testing, and the vicissitudes of
engaging with attorneys and courts are some examples of the specialized information and skills that forensic settings
demand.
Telepsychiatry
In response to concerns about access to expertise and with improvements in technology, interviewing and examining
patients through video conferencing is now emerging as a feasible alternative to live interviewing in selected
circumstances. Telepsychiatry is primarily utilized in underserved areas where geographic distance from or reliable
access to the provider makes it unrealistic for the patient to come to a live appointment. Typical applications are in
rural areas and in the care of homebound patients. One must be cognizant of the fact that technology is not pristine
enough to protect against some drop out of information normally gleaned in a live interview. Televised observation and
communication can degrade nuisances of speech, subtleties of the nature of eye contact, emotional display, body
language, and other forms of nonverbal communication. Causes of information degradation include the narrow
perspective of the camera, the quality of the audio-visual product and the unexplained effects that humans have on
one another in a live interaction that are not completely replicated in a distance medium.
The American Telemedicine Association and the American Medical Association are associations that work in
collaboration with other professional organizations to develop evidence-based guidelines promoting quality and safe
practices for various applications of telemedicine including telepsychiatry. Clinicians engaging in telemedicine are
advised to familiarize themselves with the special considerations that this medium introduces, including medical-legal
and reimbursement issues.
References
*American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal
behavior. Am J Psychiatry. 2003;(11 Suppl):1–60.
*American Psychiatric Association. Practice Guideline for the Psychiatric Evaluation of Adults. 2nd ed. Am J
Psychiatry. 2006;(Suppl):163.
Baliant M. The Doctor, His Patient and the Illness. 2nd ed. New York: International Universities Press; 1972.
Chiles JA, Strosahl KD. Clinical Manual for Assessment and Treatment of Suicidal Patients. Washington, DC:
American Psychiatric Publishing; 2005.
Cruz M, Roter DL, Cruz RF, et al. Appointment length, psychiatrists' communication behaviors, and medication
management appointment adherence. Psychiatr Serv. 2013;64(9):886.
Dhalla S, Kopec JA. The CAGE questionnaire for alcohol misuse: A review of reliability and validity studies. Clin
Invest Med. 2007;30(1):33.
Engel GL. The need for a new medical model: A challenge for biomedicine. Science. 1977;196:129.
*Epstein RM. Whole mind and shared mind in clinical decision-making: Patient Educ Couns. 2013;90(2):200–206.
Folstein MF, Folstein SW, McHugh PR. Mini Mental State: A practical method of grading the cognitive state of
patients for the clinician. J Psychiatry Res. 1975;12:189.
Gabbard GO. Psychodynamic Psychiatry in Clinical Practice. 4th ed. Washington, DC: American Psychiatric
Publishing; 2005.
Gaw AC. Cross Culture, Ethnicity, and Mental Illness. Washington, DC: American Psychiatric Press; 1993.
Greenfield SF, Hennessey G. Assessment of the patient. In: Galanter M, Kleber HD, eds. Assessment of the
patient. In Textbook of Substance Abuse Treatment. 5th ed. Washington, DC: American Psychiatric Publishing;
2008.
Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298:883.
Irani JS, Middleton JL, Marfatia R, Omana ET, D'Amico F. The use of electronic health records in the exam room
and patient satisfaction: A systematic review. J Am Board Fam Med. 2009;22(5):533.
Kashner TM, Rush AJ, Suris A, Biggs MM, Gajewski VL. Impact of structured clinical interview on physicians'
practices in community mental health settings. Psychiatr Serv. 2003;54:712.
Kendell RE. Five criteria for an improved taxonomy of mental disorders. In: Helzer JE, Hudziak JJ, eds. Defining
Psychopathology in the 21st Century. DSM-V and Beyond. Washington, DC: American Psychiatric Publishing;
2002:3.
Kraemer HC, Measelle JR, Ablow JC, Essex MJ, Boyce T. A new approach to integrating data from multiple
informants in psychiatric assessment and research: Mixing and matching contexts and perspectives. Am J
Psychiatry. 2003;160:1566.
*MacKinnon RA, Michels R, Buckley PJ. The Psychiatric Interview in Clinical Practice. 2nd ed. Arlington, VA.
American Psychiatric Publishing; 2005.
McCabe R, Priebe S. Communication and psychosis: It's good to talk, but how? Br J Psychiatry. 2008;192:404.
McLean M, Armstrong D. Eliciting patient's concerns: A randomized controlled trial of different approaches by the
doctor. Br J Gen Pract. 2004;54:663.
Rodgers R. Clinical Assessment of Malingering and Deception. New York: Guilford Press; 2008.
Sadock BJ, Sadock VA, eds. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2009.
*Shea SC. Psychiatric Interviewing; The Art of Understanding. 2nd ed. Philadelphia, PA: W.B. Saunders; 1998.
Shore JH. Telepsychiatry. Videoconferencing in the delivery of psychiatric care. Am J Psychiatry. 2013;170:256.
Strous RD, Ulman AM, Kotler M. The hateful patient revisited: relevance for 21st century medicine. Eur J Int Med.
2006;17:387.

Ovid - Kaplan & Sadock Psychiatric Interview

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ovid - Kaplan & Sadock Psychiatric Interview

Uploaded by

Copyright:

Available Formats

1/3/2020 Ovid: Kaplan & Sadock's Comprehensive Textbook of Psychiatry

Editors: Sadock, Benjamin J.; Sadock, Virginia A.; Ruiz, Pedro

Rory P. Houghtalen, M.D.

Pre-Interview Contacts and Interactions

Setting the Stage for the First Encounter

Comfort and Safety

Privacy and Confidentiality

Involvement of Third Parties

Engagement and Relationship Building

Psychiatrist: Good morning, Mr. Smith. I'm Dr. Jones.

Meaning and Communication

Open- versus Closed-Ended Questions

Person-Centered and Disorder-Based

Time and Number of Sessions

History and Examination

Process of the Interview

Opening the Interview

Table 7.1–1. Sections of the Psychiatric History and Examination

History of Present Illness

Past Psychiatric History

Table 7.1–2. Psychiatric Review of Systems

Experience of panic attacks, somatic symptoms of anxiety, phobic, or social avoidance

Experience of hallucinations, delusions, disorganized behavior, speech or thought, negative symptoms

Table 7.1–3. Past Psychiatric History

1. Details of prior mental health contacts

Sites/Levels of care: school-based, primary care-based, outpatient, emergency, inpatient, partial

Suicide and Violence Risk History

Substance Use, Abuse, and Addictive Behaviors

Alcohol Use Disorders Identification Test (AUDIT).

Past Medical History

Developmental and Social History

Table 7.1–4. Social and Developmental History

1. Pregnancy and delivery

Mental Status Examination

Appearance and Behavior

Eye contact: avoidant, excessively prolonged, intense

Affect: restricted, constricted, blunt, flat, labile, inappropriate to mood

Thought process/form: derailment, tangential, circumstantial, flight of ideas, incoherence, blocking,

Perception: hallucination, misperceptions (e.g., illusion), depersonalization, derealization, jamais vu,

Risk assessment: suicidal or violent ideation, intent, plan

Insight: impairment along a continuum

Judgment: impairment along a continuum

She said her mood was “calm.”

Table 7.1–6. Examples of Disordered Thought Process/Form

Circumstantial: circuitous and overly detailed responses

Flight of ideas: derailment in the context of rapid speech

Neologism: a word created by the speaker with idiosyncratic meaning

Table 7.1–7. Examples of Delusional Thought

Bizarre: a delusional belief that members of one's culture consider impossible

Table 7.1–8. Examples of Perceptual Abnormalities

of any initial clinical psychiatric evaluation.

Closing the Interview

Communication of Opinions and Recommendations

Table 7.1–9. Facilitating Interventions

Patient: I don't think I'll ever feel better.

Patient: He was a good friend.

Patient: (sobbing) I really miss him.

It is better to comment on the associated feelings.

Psychiatrist: You feel awful without him.

Table 7.1–10. Expanding Interventions

Patient: And I said, “That's enough.” (pause)

Psychiatrist: Tell me more about how things are at home.

Psychiatrist: Did you have a happy childhood?