Stages of the Psychiatric Interview
If the interviewer works in a clinic, at the opening of the psychiatric interview he or she goes to the waiting room, introduces himself or herself to the patient, accompanies the patient to the interview room, and shows him or her to a seat. After taking identifying data from the patient, the interviewer can tell the patient what he or she already knows. This approach avoids unnecessary mysteries and clears the way for action. Consider the following example:
Psychiatrist: Your parents came to see me yesterday. They told me they’re worried because your schoolwork has fallen off, although you’ve always been a good student; you’ve dropped most of your friends; and you seem to have become depressed. Last week they found one of your assignments in which you spoke about suicide. They think you may need help for an emotional problem.
Patient (a 16-year-old boy): So?
Psychiatrist: So they asked you to see a psychiatrist. I get the impression you’re not too happy about that.
Psychiatrist: Maybe we can start by you telling me how you feel about it.
Interviews are not always conducted in an office; they may be transacted beside a patient’s bed, or between pieces of equipment in the examination room of an emergency clinic, or even while driving a car. Wherever they occur they include a pattern to the beginning, a certain formality. The interviewer introduces himself or herself, says why he or she is there, and invites the patient to respond by telling his or her story. If the patient doesn’t want to do so, the interviewer helps the patient to explain why.
The interviewer helps the patient tell his or her story as spontaneously as possible. He or she listens and does not interrupt any more than is necessary to keep the story flowing. The interviewer does not rush the reconnaissance nor try to direct it prematurely. If all the interviewer does is ask questions, all he or she will get is answers. Open-ended probes should be used as much as possible. The more leading the probe, the less valid the response, unless the issue in question is a simple, unequivocal one. The facilitating techniques we describe later in this chapter are particularly appropriate for the reconnaissance stage.
After the patient has finished his or her story, the interviewer seeks further information about the present illness, past illness, medical history, early environment, education, and other relevant matters from the psychiatric history. A full detailed inquiry will take several interviews, but a scanning of the features most important for a provisional diagnosis can be completed within an hour.
Table 8-2 lists the content of the psychiatric history. The order suggested in the table should not be followed blindly. The interviewer should be prepared to deal with topics in whatever sequence is natural. Some areas will be emphasized and others pursued in less detail, as different cases demand.
Detailed inquiry involves questioning, but the questions are kept as open ended as possible at the outset. They move from general to specific as more detail is required. Compare the following questions:
- How are things in your marriage?
- How are things between you and your wife?
- How do you and your wife get on?
- Is your marriage a happy one?
- Do you love your wife?
This approach is similar to the way a surgeon approaches a guarded section of a painful abdomen: from the outside in. Direct questions provoke circumscribed responses and are most appropriate to issues of fact (eg, What year were you married?).
Some issues are left to a later time after a therapeutic alliance has developed. Unless the patient presents his or her sexual life as a problem at the outset, an exploration of this area is usually postponed.
The interviewer never moves abruptly from one topic to another. Change should be signaled. For example, the psychiatrist could say, “Okay. I’d like to go on from there to something else. Could you tell me about the jobs you’ve had? What did you do after you left school?”
Routine versus Discretionary Inquiry
Part of the detailed inquiry is routine, including questions obligatory for patients of a given age, in a specific clinical situation, or as part of a minimum database. The components of a routine inquiry should be defined in each clinical setting. The rest of the detailed inquiry is largely discretionary and involves the eliciting of evidence supporting or refuting the diagnostic hypotheses generated after reconnaissance.
Elements of the Psychiatric History
We now discuss the components of the psychiatric history, which are shown in Table 8-1. Each issue addressed in Table 8-1 must be addressed and the information related to one of the categories shown in Table 8-2.
The Present Illness
It is important to delineate the present illness, the episode for which the patient is seeking help. In some patients it is difficult to draw the line between the present episode and a much longer pattern of pathologic behavior or chronic illness resulting from external circumstances. A successful psychiatric history serves as a guide for diagnosis, intervention, and treatment. To this end, it is useful to define the present episode with its precipitants and then determine whether the present episode constitutes a discrete psychiatric illness or is an episode of a more chronic psychiatric illness that can then be documented chronologically.
Some patients may present a variety of subjective concerns. Others may have a more focused complaint and identify specific issues as problems. Whatever the problem(s) for which the patient or his or her associates seek help, the clinician attempts to delineate them; to understand how the patient experiences them; and to ascertain their duration, onset, development, and persistence.
Precipitation of Illness & Relevant Stressors
If the problems had an onset, the interviewer attempts to determine whether the patient experienced physical or psychosocial stress at that time. The mere coincidence of stress and the onset of pathologic behavior does not substantiate a causal association; causation may remain speculative in some cases. It is supported, however, if the patient previously had a breakdown when exposed to a similar stress or if the patient’s account of the stress indicates its personal significance.
Some stressors have universal impact. Others are highly idiosyncratic, and painstaking work may be required before they are unraveled in psychotherapy. In some cases it is an open question whether an event was a precipitant, the result of a disorder in its early stages, or mere coincidence.
Previous Psychiatric Illness & Behavioral Problems
The interviewer considers the following questions in evaluating the patient for previous psychiatric illness and behavioral problems: Has the patient had any problems of a similar nature in the past? What precipitated them, if anything? Has the patient had any other emotional disorders or physical symptoms related to tension? Has the patient had, or does he or she have, physical or neurologic disease that could contribute to the present problem? Does the patient have, or has he or she had, personal habits (eg, substance abuse) that could cause, precipitate, or complicate the present problem?
Previous Psychiatric Treatment & Mental Health Intervention
The interviewer should be aware of any therapeutic interventions that occurred before the current evaluation. This includes formal psychiatric treatment (or treatment by another mental health professional), emergency evaluations, hospitalizations, or mental health treatment rendered by a primary care physician. The clinician who carried out the treatment and the treating facility should be identified, as should the approximate date(s) and duration of treatment. The patient’s response to each pharmacologic agent and associated side effects should be documented. Type, duration, and results of psychotherapy should be identified. The interviewer will need to amplify and verify some of this information by requesting records from previous treating professionals and facilities, with appropriate written consent from the patient.
Predisposition & Potentials
The interviewer considers the following questions in evaluating the patient for predisposition to and family history of psychiatric illness: What kind of person was the patient before he or she became ill? What biopsychosocial strengths and weaknesses predisposed the patient to breakdown? These questions require a comprehensive evaluation, and it is unrealistic to expect all of this information to be elaborated in a single interview. Important pieces of the jigsaw puzzle are usually lying around, if the interviewer keeps his or her eyes and ears open. The interviewer can ask the following additional questions: What personal and environmental strengths, resources, and liabilities are apparent at the present time? What has the patient got going for him or her now? What holds the patient back? What hurdles does he or she face? This too requires a full inventory of the patient’s physical, intellectual, emotional, and social assets and deficiencies. This inventory is crucial to the design of an individualized plan of management.
The interviewer considers the following questions in evaluating the patient’s current presentation for treatment: Why does the patient seek help now? Is the patient being seen at the onset of a disorder or later, either when a relatively defined pattern of symptoms has developed or after the patient has recovered partially but remains troubled by residual difficulties? Did the patient come of his or her own accord, or was he or she persuaded to do so? Did others bring in the patient for treatment? Why?
Insight, Judgment, & Motivation for Treatment
The interviewer considers the following questions in evaluating the patient’s insight, judgment, and motivation for treatment: Does the patient think he or she is unwell? Does the patient think he or she has been referred inappropriately? The patient may be correct. If the patient recognizes his or her own disturbance, does he or she have any idea of its nature or cause? How realistic are these notions?
What kind of help does the patient seek, if any? Is this in line with what is advisable, appropriate, or feasible? Is the patient troubled by doubts concerning his or her problem and the kind of treatment he or she will receive? Fears of craziness or of exotic psychiatric treatments are likely to be inflamed by deep-seated anxieties about helplessness and victimization. These fears are often aggravated by images derived from family or cultural values, including those depicted in the media. It is better that such concerns be expressed as soon as possible and corrected when they are the result of misinformation.
Mental Status Examination: Context, Purpose, & Format
The MSE is a set of systematic observations and assessments undertaken by a diagnostician during the clinical interview. Properly conducted, the MSE provides a detailed and systematic description of the patient at that time, information essential to the consolidation of those patterns of clues and inferences that are required for the generation of diagnostic hypotheses. The MSE, guided by the hypothetico-deductive approach to diagnosis, is an essential part of the subsequent inquiry plan. In this section we offer a comprehensive description of the components of the MSE. In regard to a particular patient—and in accordance with the clinical context, background information, and psychiatric history—the interviewer will apply the MSE tactically, pursuing brief, comprehensive, or discretionary lines of inquiry, as warranted.
The Need for Standardization
Because the MSE, like the psychiatric history, should involve routine and discretionary lines of inquiry according to the diagnostic hypotheses being entertained, it should not be standardized as a whole. Instead the separate observations and assessments that compose the MSE should be standardized. The techniques of eliciting data should be formalized, the phenomena in question clearly defined, and the weight to be placed on each phenomenon clarified.
The reliability of a test refers to the likelihood (usually expressed as a correlation) that similar results will be obtained on retesting (test-retest reliability) or that similar results will be obtained by different observers (interrater reliability). Test-retest reliability applies to relatively stable characteristics such as the use of language; it is not to be expected in characteristics (eg, mood) that are changeable and often linked to a current situation.
When psychiatrists test for the patient’s abstracting ability, for example, by asking the patient to explain proverbs in his or her own words, how certain can the psychiatrist be that the clinical test is a true measure of the ability in question? In other words, what is the validity of the test? Over the years a set of informal mental state assessments has accumulated, but in some instances their validity is questionable. When we describe any clinical test in this chapter, we will consider its validity along with the mental faculties required for adequate performance on the test.