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Psychiatric Interview

  • Author: Lorin M Scher, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: Mar 05, 2014
 

Overview

The following text provides an overview of the basic components and key concepts of the psychiatric interview. It is the authors' intention to also provide additional hints in how to effectively obtain information during that interview. This format is most appropriate for new patient interviews but can also be of value for existing patients whose psychiatric history has never been fully explored.

Each interview will be unique; for example, the length and depth of the interview with an acutely psychotic inpatient varies considerably from that of an outpatient struggling with many years of anxiety. Regardless, the essential goals for data collection within a psychiatric interview remain similar, and a consistently applied format is valuable. The clinician and patient benefit from the improved relationship and diagnostic accuracy that a thorough assessment provides.

Documentation is as important as the information collected. An example template for recording information that also serves as an interview template is demonstrated in Table 1, below.

Table 1. SIGECAPS Mnemonic (Open Table in a new window)

S Sleep
I Interest (reduced)
G Guilt
E Energy (low)
C Concentration (poor)
A Appetite (increased or decreased)
P Psychomotor agitation or retardation
S Suicidality

 

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Identification and Chief Symptom

An open-ended question provides the patient with flexibility in opening the interview, balanced against the clinician’s practical need to obtain relevant information. “What brings you to (see me/the hospital) today?” can have a wide variety of answers. Occasionally, a patient is unable to state clearly why he or she has actually come to visit. This frequently occurs in psychosis and cognitive impairment but may also be seen with intellectual disabilities or even depression with severe vegetative symptoms. A passive-aggressive or outright hostile chief symptom is an early sign of resistance to the interview, which can later be explored.

Exploring and expanding on the chief symptom is a reliable, patient-centered way to build rapport and begin gathering information. Recording a direct quote from the patient is best. Although recording “depression” is certainly acceptable, more descriptive phrases, such as “unable to stop crying for the past 3 days,” is more memorable to a reader.

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History of Present Illness

The history of present illness is the most important component of a modern diagnostic interview, yet it is approached differently depending on how the illness is defined. A longitudinal view of illness emphasizes obtaining a history of the course of the illness. Another approach involves looking only at the immediate events preceding the patient’s arrival for treatment; ie, a history of the patient's present illness episode.

Obtaining both is ideal; however, certain patient presentations make this a challenging task. If a patient is too disorganized (thought disordered) or otherwise impaired to participate fully, more emphasis should be placed on the current episode. If someone is presenting as a stable outpatient with an unclear diagnosis, the course of illness helps to clarify future treatment.

Although the depth may vary, every history of present illness should attempt to elicit information on certain topics. How the patient was functioning prior to his or her illness, current symptoms, if and when prior episodes occurred, and precipitating factors are a few that are particularly high yield. Remember that nearly every diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), requires the impairment of social, occupational, or academic functioning.[1] Without a firm knowledge of where the patient was with regard to these domains, assessing the impact of the symptoms on his or her life is more difficult.

Briefly looking at the recent or chronic stresses that the patient may be experiencing is also important; these may contribute to the illness or its severity. Any sort of transition, such as medical illness, a new relationship, a new job, or a recent loss, can be a stressor that precipitates or exacerbates a mental illness.

However, not all patients are necessarily able to elaborate on precipitating factors. Moreover, illnesses may occur spontaneously, so not "willing" a cause on every aspect of a patient’s suffering is important. Even so, helping the patient to relate the stressors in his or her life to the symptoms of mental illness can be informational and therapeutic.

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Psychiatric Review of Symptoms

The psychiatric review of symptoms seeks to reveal issues that the patient may have not brought up when describing the history of his or her present illness.

As in the rest of medicine, patients likely do not share an identical view with their physician of what constitutes an illness. Experiences that a practitioner would call pathologic may be experienced by the patient as "ego-syntonic." That is, they are not recognized as intrinsically different from how the patient would expect to act or feel. A person with bipolar disorder may not, for example, feel that the euphoric symptoms of mania represent anything wrong. If a significant positive response does occur during the review, it can be moved to the history of present illness when the practitioner is documenting his or her findings. The questions described below are also appropriate for delving deeper into a patient’s initial complaint.

Depression

Many practitioners are familiar with the SIGECAPS mnemonic. Depressive disorders can also be easily assessed with 2 questions, one regarding depressed or irritable mood and another regarding anhedonia.[2] When asked "What sort of things do you like to do for fun?" the anhedonic patient often answers "nothing" or discusses activities that he or she used to do for pleasure.

Follow-up questions regarding guilt, decreases in energy level, concentration, and appetite are assessed if needed and are important to assess longitudinally. Psychomotor retardation or agitation can be screened for by asking "Have you or someone else noticed anything different about how you move?" Suicidality should also be addressed with all patients, but especially those with a positive depression screen.

Mania

A discussion of depression should be followed with one of mania. Given that manic episodes often do not feel pathologic to a patient, it can be challenging to collect this history. DIGFAST is a common mnemonic used in mania screening. (See Table 2, below).

Table 2. DIGFAST Mnemonic (Open Table in a new window)

D Distractible
I Irritability
G Grandiosity
F Flight of ideas
A Activity (increase)
S Sleep (decrease)
T Talkative

Distractibility can be witnessed by the interviewer, by friends or family, or by the patients themselves. Increased risk taking can have many forms, but sex, spending, and substance use are common and are thus high-yield areas to explore.

Grandiosity can vary from just feeling superior to a true psychosis; a sensitive screen asks the patient if he or she has or has had any special abilities. Flight of ideas can be approached as a sort of internal distractibility.

Inquiring about sleep is one of the easiest ways to pick up a manic episode in the absence of substance abuse. If the answer to "What’s the longest period of time you’ve gone without sleeping but not feeling tired the next day?" is anything longer than 2 days, further assessment is warranted. Pressured speech should be immediately apparent in a person currently in a manic episode and easily recallable by friends or family members.

Psychosis

Frank psychosis is not often missed during a psychiatric interview, but an in-depth screen may be necessary to pick up prodromal symptoms or uncommon presentations. Asking all patients if they "ever see or hear things that other people don’t" is appropriate. This should be asked in the most normalizing manner possible. Terms such as hallucinations or delusions can have either very little or an extremely stigmatized meaning attached to them and should be avoided. Delusions can be difficult to elicit from a patient if ego-syntonic and not spontaneously offered.

Persecutory delusions are common,[3] and asking "are you ever concerned that other people may want to harm you?" is unlikely to offend a patient. Positive responses may be completely rational in clients suffering real abuse or engaged in criminal behavior, and sensitive follow-up questions are key to not misclassifying their symptoms.

Blunting of affect and disorganization of thought are not likely to be volunteered by a patient. Friends and family members of the patient can provide helpful details here as well.

Anxiety

The presence of anxiety suggests many diagnoses to consider. A concrete place to start is in the concept of panic. If the patient identifies panic attacks, determine what a "panic attack" means to this particular patient. Open questions such as "what does your body feel like when you are having one of these panic attacks?" may lead to expected cardiac, pulmonary, gastrointestinal (GI), or neurologic symptoms and give the interviewer more confidence in a diagnosis of panic disorder.

Similarly, the question "What are you thinking or feeling during these episodes?" can elicit diagnostic symptoms without suggesting them. Questions such as "Do you ever feel the need to count the number of certain objects in a room?," "How often do you find yourself checking and then repeatedly rechecking locks or switches?," and "Do you spend excessive time cleaning or organizing?" can identify some of the more common presentations of obsessive-compulsive disorder.

Cleaning and organization can also be assessed. Obsessive-compulsive disorder is often more ego-dystonic than obsessive compulsive personality disorder, and this is a helpful point to assess for diagnostic accuracy.

Trauma-related anxiety can be discussed without stressfully detailing the entire event. First, determine if the patient has ever been involved in an event in which either the patient or someone else was facing potential death or serious injury. If this first question has a positive response, then asking "Do you often have thoughts, feelings, or dreams about this event?" and "How have these thoughts or feelings affected your life?" is appropriate.

This is usually enough to begin a discussion of avoidant or hyperarousal symptoms of posttraumatic stress disorder (PTSD). The emotionally numbing aspect of PTSD may require a somewhat subtle approach to elicit; eg, the practitioner may address it by asking a question such as "How do you think your feelings are different from those of other people?"

Cognition

Cognitive symptoms should also be addressed. Many patients by middle age will endorse some memory problems, but this most often represents a normal decline in cognitive function.[4] A positive answer to "Do you find that you’ve become more forgetful recently?" is followed by a specific assessment of attention, memory, and executive functioning if needed. Family members are often considerably more useful at providing information in this realm than the patient. If any concerns are noted, cognition can be formally assessed.

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Psychiatric History

The psychiatric history provides perspective regarding the history of a patient's present illness and current symptoms by contrasting these findings with past treatment and illness episodes. "Have you ever been diagnosed with a mental illness in the past?" is an appropriately broad place to start, but a negative answer should not end this section of the interview. Stigma may be significant regarding mental illness,[5] and this may play a role in the patient’s acceptance of a diagnosis, as well as the depth in which previous practitioners discussed the diagnosis.

A good follow-up question regardless of the answer to the first is "Have you ever seen a mental health provider such as a psychiatrist, psychologist, or social worker before?" If so, ask about the past providers. "What sort of things have these providers done for you?" gives an open-ended opportunity to question the patient about his or her medication and psychotherapeutic history.

The adequacy, efficacy, and timing of treatment must be examined in depth. The timing of past trials is crucial to assess if treatments were individual or adjuvant to one another and help to appropriately assign intended or adverse effects. Neither therapy nor medications are likely to be effective with only brief trials, and failing to assess this can block a patient’s access to a beneficial therapy.

Psychiatric hospitalizations are discrete events that should also be assessed in detail. Most patients remember these emotionally charged events in detail.[6] Evaluate how severe the patient’s illness was, potential stressors, and the location and duration of past hospitalizations. Collateral information regarding all past psychiatric history is valuable, including hospital summaries, clinic records, and family reports.

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Suicide and Violence Risk Assessment

A suicide and violence risk assessment is an important part of any psychiatric interview, but it is often forgotten if the patient does not endorse or appear depressed. Not only does it provide immediately apparent information on the severity of the patient’s illness, it also has the benefit of protecting the patient and the community. Because no empirically validated and reliable suicide assessment instruments exist, a clinical interview focusing on current presentation, psychiatric illness, history of homicidal/suicidal behavior, psychosocial stressors/strengths, and individual strengths/vulnerabilities is the current criterion standard of assessment.[7]

If the patient appears overly anxious or withholding, asking if he or she has had serious thoughts of death and dying can start a stepwise approach toward exploring suicidality. Many patients welcome the chance to get "right to the point" and seek relief from these distressing thoughts.

Suicidality or violence should be examined in detail. This includes obtaining a history of suicide attempts and of prior violent acts in general. The patient’s mental state at the time should be looked into, with some focus on past stresses in order to put the present into context. If no previous behaviors existed, but suicidal or violent thoughts occurred in the past or exist in the present, it may be appropriate to ask "What stopped you?" Similar questions should be asked of any current suicidal or violent ideation.

Suicidal and violent ideations are not simple "yes or no" concepts. Instead, both of these phenomena exist on continuums. The patient’s acute risk examines where he or she is at the time of the interview. It is increased by the extent of his or her ideation, clearly expressed intent (ie, moving from passive to active ideation), the development/practicality of any plans, and, finally, the extent of other current symptoms of mental illness.[8] .

The nature of the acute risk is such that it can fluctuate rapidly, even over the course of an interview. Conversely, the patient’s chronic risk is set largely before the interview has begun.

Large studies on the epidemiology of suicide and violence indicate that women are more likely to attempt suicide and that men are more likely to complete suicide. Persons in their teens and elderly are most likely amongst age groups. Anxiety, insomnia, agitation, previous suicide attempts, alcohol use, depression, anhedonia, and a lack of a social support system are all known to increase the risk of suicide.[9, 10]

Assessing the risk for violent behaviors toward others is less well studied, but having grown up around violence, a history of violence, current habitation in a violent neighborhood, and any sort of substance abuse problem raises the chronic risk.[11]

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Medical History

All mental illness is biologic, and the separation of mental and physical illness with regards to etiology (eg, "it's not organic, it's psychiatric") or legitimacy (eg, "it's all in the patient's head") is a false dichotomy. The designations of "medical" and "mental" illness have practical value only in that they allow a practitioner to subdivide illness for the sake of staying organized. A medical history obtained in psychiatry, while not structurally different from that obtained in other specialties, does have some important focuses.

Seizures,[12] head injuries,[13] human immunodeficiency virus (HIV),[14] and other medical illnesses predispose patients to mental illness. Some chronic mental illnesses, such as schizophrenia, are associated with reduced access to and use of medical care.[15] Pharmacologic treatment can cause such medical illnesses as metabolic abnormalities, movement disorders, and sexual dysfunction. Alternatively, a medical illness may in fact be the cause of a mental illness, such as is the case with delirium. Medical illnesses are likely to be an additional stressor in a person’s life. They should be examined in at least some detail to create as much of a comprehensive view of the patient as can be obtained in an initial evaluation.

"Do you have any medical problems?" is a straightforward question to begin this portion of the interview, but it is not likely to be sufficient. Medications, major surgeries, allergies, and the name of the patient's current primary care provider should be directly collected. The length of questioning beyond these topics can vary immensely by practitioner, time limitations, and setting. Consulting in the hospital setting, a complete medical history may already be available prior to seeing the patient. In a psychiatric office setting, a checkbox questionnaire before the interview may be more appropriate. Collateral information will again be helpful in providing additional details.

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Family History

The patient’s family history aids in the diagnosis of the patient, as well as providing a degree of context to his or her developmental history. Mental illnesses have variable degrees of hereditability, many quite strong. Having a parent with bipolar disorder, for example, raises the patient’s risk of developing the same disorder by at least 7-fold.[16]

Certain illnesses, such as those with psychotic features, may appear very similar on initial presentation, and a family history can help to guide accurate diagnosis and treatment, since the patient’s symptoms can be longitudinally observed. The second role that a family history plays is as a component of the social history. The transmissibility of mental illness is not entirely genetic, and the environmental factors can be identified. Having grown up with a severely depressed parent, for example, may have created distorted thinking or biases that effect functioning in the present.

The family history should cover topics similar to those of the psychiatric review of systems; namely, depression, mania, psychosis, and anxiety in first degree relatives. An assessment of seizures, metabolic disorders, early death and suicide, or violence is also likely to be useful. Of particular importance is the use and effectiveness of any medications, as this can be a guide in treatment of the patient. Severity, including hospitalizations, is also important to determine with regard to family members, as it may provide some information concerning prognosis.

Patients may not have the same level of knowledge about family members as they might about themselves, and definitive diagnoses or treatment history may be elusive. Of note, patients may not clearly recognize mental illness in family members, and a discussion of relevant symptoms in lay language may be more useful than asking about specific illnesses.

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Social History

The social history occasionally degrades into a simple inventory of vices. A harried physician may take the time to ask only about sex, drugs, and abuse, with a brief assessment of housing and finances. To say that this gives an incomplete view of the patient would be an understatement. The social history should provide a longitudinal view of the patient’s life, as do the psychiatric and medical histories, but with a more holistic view.

Pathologic and adaptive events are assessed. The depth of this portion of the interview may be limited by time and goals. Much more is to be gained from a thorough medical history review with a hospitalized, delirious patient, for instance. For some patients, a detailed history may need to occur over multiple, sequential outpatient visits. Some forms of psychotherapy may be able to be thought of as extended social histories, as disordered relationships and past traumas are examined and explored. Strong working relationships are built by patients knowing that their doctor is interested in them and not just in their pathology.

Developmental history and parental relationships

A logical place to begin is the patient's developmental history. This could start with questions about drug exposures in utero and other prenatal history but will most often begin with birth. These questions and early childhood developmental milestones may not be well known to the patient. It is helpful to have additional information from family members to help determine if current symptoms may actually represent developmental disorder.

Discuss the relationship of the patient to his or her parents and their relative presence or absence in the patient’s life. Abuse is a complicated topic. Given that what a patient views as abuse may differ significantly from what a clinician considers to be abuse, asking "Were you ever physically, sexually, or emotionally abused growing up?" is a nonjudgmental and empathetic approach that will be accepted by most patients. A positive answer to any of these should be examined in detail. This is also a good time to inquire about any current abuse, especially in patients with a positive history.

Academic and occupational histories

Academic and occupational histories provide a smooth transition from early childhood to adolescent and adult life. Questions may involve what subjects the patient enjoyed in school and how well he or she got along with teachers and peers, queries that help to establish whether learning/conduct disorders are present and that aid in illuminating the patient's interpersonal skills and personality structure. At a minimum, assess for the patient's last competed grade level. The stresses that led to an early termination of education may relate directly to mental illness and could continue to impair the patient.[17]

Occupational history should ideally follow the patient from his or her first job to the present. Periods of disability and function, as well as of failure and triumph, are often remembered based on their relationships to school and work. Periods of incarceration and military service should also be detailed. Goals for future education, occupation, or other opportunities for growth should also be explored.

Adult relationships

Adult relationships are an important aspect of the patient's social history as well. A feel for the depth and length of multiple types of relationships should be obtained; eg, boss, coworker, and family. Sexual history is a challenging topic for the patient and the interviewer. More than many areas of the interview, this portion calls for questions that are neither judgmental nor overtly supportive, in order not to burden the patient with the clinician’s emotions in addition to his or her own.

The patient should be given the option to decline answering. Intimacy, sexual attraction, and sexual action are separate, although often related, topics. They should be explored equally with questions sensitive to the possibility that "men, women, or both" are involved, and this is a straightforward way of phrasing such queries. Asking directly about marriage, although common, can unfortunately indicate a bias toward heteronormativity and lead to a patient withholding otherwise pertinent information. Instead of using this interview shortcut, asking about "long-term relationships" can provide much more information.

Sources of emotional support

Other sources of support in the patient’s life should be explored in the context of a social history. This includes faith or religious tradition, as well as family or other communities. It is rarely sufficient to simply ask, "Do you belong to any particular religion?" Using a broader term such as "spirituality" or "faith tradition" gives a patient more flexibility in answering the question without concern for the clinician’s biases. If time permits, a religious or spiritual history from childhood onward is helpful to establish how a patient’s spiritual worldview developed.

Asking "Does your (religion/faith/community) help you with life?" may provide a wealth of information on the patient’s current support or lack thereof. Remember that not all experiences the patient has had are necessarily positive. As with the entirety of the interview, an open and nonjudgmental interview technique is crucial to collecting a full picture.

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Substance Use and Abuse

Acquiring a list of substances used, as well as determining the quantities used and the periods of time over which they were used, is important, but more important is the role that these substances play in the patient’s overall life. Use of vernacular may be appropriate for some patients and may yield more accurate information, but an interviewer should ask for clarification if the patient begins to use terminology that is unfamiliar.

In addition to illicit drugs, prescription medication usage should be examined with a simple "do you ever find yourself using more of a medication than your doctor prescribes or using other people’s prescriptions?" The route and amount consumed are important for illicit and prescribed medications.

For alcohol in particular, the CAGE questionnaire[18, 19] can be a quick screening tool (see Table 3, below). Two or more positive responses are likely to indicate some form of alcohol abuse. Beyond abuse, differentiating the presence of dependence is important. Tolerance, withdrawal, and loss of control in the amount or time of use can all be signs of dependence.

Table 3. CAGE Questions (Open Table in a new window)

C Have you ever felt you needed to C ut down on your drinking?
A Have people A nnoyed you by criticizing your drinking?
G Have you ever felt G uilty about drinking?
E Have you ever felt you needed a drink first thing in the morning ( E ye-opener) to steady your nerves or to get rid of a hangover?

 

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Mental Status Examination

Appearance

The mental status examination is often and accurately described as the physical examination of psychiatry. It is of particular importance given the lack of clinically relevant lab or imaging studies for many psychiatric diagnoses, which are in fact syndromes of historical data and objectively observed symptoms.

The mental status examination begins upon first seeing the patient and noting his or her appearance. Apparent race/ethnicity, age, and gender are usually noted first. Attire and overall hygiene are noted next. Tattoos, make-up, jewelry, and any physical abnormalities are included and may be topics of further inquiry. Make every attempt to be descriptive and not interpretive to minimize subjectivity. For instance, "punk rock hair" is a less objective description than "purple hair styled into 2-inch spikes."

Behavior

Behavior is the active component of the patient’s appearance and is described separately. A bare minimum includes describing any psychomotor agitation or retardation seen in the patient. Any abnormal movements should be noted. Examination and notation of facial movements are important for monitoring tardive dyskinesia. Compulsive movements, such as picking at the skin or rearranging items or clothing, can be helpful in a differential.

Specific behaviors are important to note because they can be side effects of psychiatric medications. These include muscle rigidity, an extrapyramidal symptom that, when severe and acute, may also point to the more serious neuroleptic malignant syndrome.

Movement disorder descriptions are as follows:

  • Choreiform - Jerky, irregular, not specifically repeated, and semi-purposeful
  • Athetoid - Writhing, more repetitive
  • Ballismus - Involuntary, rapid movement in one direction; often a punch or throw movement

Speech

Speech and thought can be difficult to separate objectively; after all, we only know what our patients are thinking based on what they tell us. For the purposes of a mental status examination, speech covers the motor and neurologic aspects of producing words, although process and content, discussed later, will refer to the informational and organizational components.

The relative or total absence of speech may be notable and indicate depression or severe psychotic disorders. Accents provide some information to be further examined in the social history. In mania, rapid or pressured speech may be noted. Mania may also present with increased tone or volume.

Poor articulation of words could point towards substance intoxication. Rhythm abnormalities may be most pronounced in Tourette syndrome, in which speech can be cluttered with repeated sounds or noises. Alterations in prosody can suggest affective disorders. Some commonly used terms to describe speech are defined as follows:

  • Rapid - Increased rate of speech
  • Pressure - A flow of speech that is difficult to interrupt; often related to, but not dependent on, an increased rate of speech
  • Prosody - The rhythm, stress, and intonation of speech
  • Speech latency - The delay between the question/statement of an interviewer and the response of the patient
  • Aphasia - Inability to speak

Mood and affect

Mood and affect are separated in the mental status examination. The mood is the internal, subjective aspect of the patient's emotional state and the affect is the external, objective aspect of the patient's emotional state. Many terms have been used to try to capture and convey these states. For example, mood is defined as follows:

  • Depressed - Low or sad mood
  • Anxious - Distress or unease, fears of misfortune or harm
  • Euphoric - Elevated, distorted levels of happiness

Affect is defined as follows:

  • Labile - More affective states evident than expected during the interview, with the changes occurring rapidly
  • Appropriate - Affect matches the individual's described mood
  • Inappropriate - Affect does not match the person's described mood
  • Euthymic - Emotional range is evident
  • Restricted/constricted - Emotional range is limited but not completely absent
  • Flat - No emotional range evident

The mood is most often obtained by asking the patient, "How are you feeling?" Use a direct quote from the patient when recording your finding. A thorough examination of mood includes questions regarding how long the patient has felt the way he or she does, how often his or her mood changes, and the patient’s view of the relative strength of the emotion, to determine the pervasive and most sustained emotion that the patient has been experiencing as opposed to each and every momentary feeling.

The examination of affect looks at stability and range (or constriction) of displayed emotion across the interview. An affect is compared to the stated mood and congruence (or lack thereof) noted. The appropriateness of a patient’s emotional appearance to the topics being discussed is also a part of the affective examination. A patient with limited affect or no affect may be described as blunted or flat, respectively.

Thought process

Thought process, defined as how a patient organizes his or her thoughts, becomes apparent over the course of the interview through dialog. Some examples of thought processes are as follows:

  • Loose associations - Ideas from the patient only indirectly related to what the interviewer was actually asking
  • Tangential - If responses begin to relate to a question but veer off into unrelated topics
  • Circumstantial - The response eventually does answer the question posed, but extensive and only vaguely related information is also included
  • Thought blocking/derailment - Thoughts are suddenly stopped (blocking), with speech then resuming after several seconds on a new topic (derailment)

Associations are a part of the thought process wherein a patient connects meaning to words and sentences. Loose associations such as "I’ve read that driving a car is more dangerous than flying in an airplane. The birds outside my window were loud this morning," are often associated with mania. Often, very loose associations have connections understood only by the patient.

Normal associations are referred to as tight. The overall thought process could be described as tangential, circumstantial, or goal directed. Flight of ideas is an extreme form of tangential thought process, in which not only the question posed, but also the patient’s own words, lead the patient onto separate topics, usually in quick succession. Thought blocking and derailment are thought-process disorders classically seen in schizophrenia.

Thought content

Thought content describes what the patient’s focus is during the interview. In a tightly structured interview with closed-ended questions, the content of the patient’s thoughts may be "question focused," with the patient having little opportunity or desire for spontaneity and discussing only what the interviewer brings up.

However, a more accurate view of the topics that are crossing the patient’s mind can be ascertained by simply letting the patient talk. Using the first 5 minutes of the interview in this way is of great benefit. Record any topics the patient identifies as significant or spends significant time on. Details of psychosis are defined as follows:

  • Delusions - Fixed, false beliefs
  • Hallucinations - Sensory perceptions of something that does not exist
  • Illusions - Sensory misrepresentations of real stimuli; eg, a hat across a dim room becomes an assassin

Any delusion should be detailed and categorized as bizarre and nonbizarre based on the possibility of it being accurate. Hallucinations are also included under thought content. Although a hallucination may not always be directly evident to a patient, many sufferers recognize some foreign aspect to the sensory experience and will reply affirmatively to the question "Do you ever see or hear things that other people don’t?" Ideally, hallucinations from all sensory domains should be queried. Finally, any active thoughts that the patient has about harming himself or herself or others should be directly investigated and noted in this section if such thoughts are currently present.

Insight and judgment

Insight and judgment can be assessed throughout the entirety of the interview. Insight in this context references the patient’s mental illness and the patient's awareness of it. If a patient presents with clear symptoms of a mental illness but rejects the diagnosis, he or she may be deemed to have poor insight. Judgment is narrowly defined as the active demonstration of insight, such as willingness to take medication or accept other treatments. A proxy measurement may be why or how the patient came to see the interviewer.

An incarcerated patient being brought in for treatment by the custody staff is less likely to have good judgment than an outpatient who scheduled his or her own appointment. Judgment more commonly is broadly defined by determining whether recent choices that patients have made were adaptive or maladaptive in maintaining or improving their level of functioning.

Cognition

Insight and judgment may be limited by cognitive ability, which is assessed separately. This section of the examination often begins with a statement on the patient’s level of alertness and orientation to his or her name, location, date, and reason for being where he or she is. Concentration can be assessed through simple arithmetic or by spelling words backwards. Memory should be assessed in the short term, often through recall of number or word sequences, and in the long term, possibly through the recalling of important dates in the patient’s life as verified by a family member.

The patient’s general fund of knowledge should be assessed through questions about major national events or figures. Of note, the patient’s fund of knowledge will be heavily based on his or her educational background. A patient’s ability to understand abstract concepts may be tested through comparisons such as "How are an orange and an apple the same?" or through the use of proverbs, such as asking what "You can’t judge a book by its cover" means. Concrete answers, such as "Both have skins" or "You can’t tell what is in a book by looking at it," respectively, should be documented.

Finally, executive functioning should be examined with a question such as "If you heard a fire alarm going off in your house, what would you do?" These domains of cognition are often examined in more structured tests, such as the Folstein Mini-Mental Status Exam[20] or the Montreal Cognitive Assessment,[21, 22] to provide an objective measure between interviewers and over time.

Please see the Medscape Reference topic History and Mental Status Examination for additional information on collecting the mental status examination.

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Assessment

The assessment is a summary of the entire interview, clearly combining history and examination into a differential diagnosis. Pertinent positives and negatives are included in order to support the listed diagnosis. If a specific diagnosis or specific diagnoses have not yet been reached, a list of possible diagnoses is discussed in brief, along with which diagnostic information is missing to finalize a diagnosis.

Do not hurry to a diagnosis if further investigation, information, or longitudinal assessment is needed; provisional diagnoses are common and accepted in the early stages of treatment. Including at least a few sentences on the current and historical stressors in the patient’s life that may be contributing to either the presence or the exacerbation of the current illness is also usually important.

The "biopsychosocial model,"[23] while not a strict outline, encourages the examination of biologic, psychological, and social factors in the patient’s diagnosis and how they support or impede recovery. It facilitates a broader approach to treatment than a purely biomedical focus. Since its formulation, its use has spread to diseases with a classically medical focus, such as diabetes,[24] but it is most commonly used with psychiatric illnesses.

Within psychiatry, substance abuse and dependence are particularly well suited to an assessment in the biopsychosocial format.[25] For example, alcohol abuse can have biologic predispositions in the form of the genetic loading and may have biologic implications, such as hepatic cirrhosis. Having had parents with substance abuse problems is likely to have impacted the patient’s social functioning and how the patient relates to people as adults. The psychological stress of dealing with the current and past stresses in the patient’s life is likely to be contributing to the continuation of the patient’s substance abuse. Actions by the patient while intoxicated may have reduced the social support available to him or her, impeding recovery.

All psychiatric assessments should end with the 5 axis diagnoses, which summarize findings in a very brief list format. Axis I includes the patient’s psychiatric disorders and can include the provisional diagnosis (ie, psychosis not otherwise specified [NOS]) followed by the diagnoses under consideration, such as "schizophrenia vs. schizoaffective disorder vs. substance induced psychosis."

Axis II includes personality disorders and mental retardation. Personality disorders are rarely diagnosed in the first psychiatric interview with a patient; thus, in this section, it is common to refrain from a formal diagnosis and to identify only prominent traits suggested by history and examination. If no clear traits manifest during the course of the interview, many clinicians "defer" Axis II.

Axis III includes any significant general medical conditions that may relate to the patient’s current presentation. Axis IV includes psychosocial stressors that contribute to the severity of a patient’s mental illness or its perpetuation. Some of particular note to include are levels of social support, financial resources, legal issues, and housing.

Axis V is numeric and rates the patient’s overall level of functioning, known as a Global Assessment of Functioning (GAF) score. (See Table 4, below.)

Table 4. Global Assessment of Functioning Quick Chart (Open Table in a new window)

>70 Mild or no symptoms/impairment
50-70 Moderate symptoms/impairment
30-50 Severe symptoms/impairment
< 30 Hospitalization likely needed
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Plan and Documentation

Plan

The plan addresses any intervention needed to improve a patient's symptoms or functioning, and considering the biopsychosocial assessment will help with its organization. Biologic consideration may include needed laboratory tests or imaging that will aid in accurate diagnosis or treatment monitoring. Any medications should also be described, noting dose, titration, potential length of treatment, and a description of what risks and benefits were discussed with the patient.

The psychological plan includes the nonpharmacologic treatment of psychiatric conditions. This may vary from something as simple as breathing exercises for anxiety to something as complex as long-term psychodynamic psychotherapy.

The social plan details how support networks, including friends and family, among others, will be used or shored up. Depending on the setting, legal filings may also be noted here, including any involuntary holds. Social planning further includes goals for the patient’s residence, work, education, or filing for disability, among many others.

Sources for additional information in any of the domains and how they may be reached should be described. Any remaining issues or questions that were not fully answered during the course of the psychiatric interview should be left in the plan as a reminder for either the interviewer or other clinicians at the patient’s next visit. The anticipated timing of this next visit can serve as an endpoint for the plan.

Documentation

Documentation of the interview is at least as important as the process of the interview itself. It provides a reference during follow-up visits for the interviewing clinician, and at least parts of it will likely be seen by other medical providers, such as the patient's primary care provider. Further, the write-up will serve as evidence of the patient interaction for billing purposes, and it can be an important source for at least the minimum degree of information required by any involved insurance programs.

The write-up should provide a summary of the all of the information collected. Providing every detail is obviously not possible, and this should not be a goal in general, as time constraints will likely be present for most readers in the future. Wording in all documentation should also reflect the possibility of being read by the patient in the future and thus avoid any judgmental language. An example template is demonstrated as follows:

Name:

Date of Evaluation:

DOB:

Age:

Race:

Gender:

Height:

Weight:

Referred by:

Current Medication/s:

Allergies:

CC:

History of Present Illness:

Psychiatric Review of Symptoms:

Psychiatric History

Hospitalizations:

Medication Trials:

Suicide Attempts:

Family Psychiatric History:

Past Medical History:

Past Surgical History:

Social History

Relationship Status:

Employment:

Children:

Legal:

Abuse:

Education:

Finances:

Mental Status Examination

Appearance:

Behavior:

Attitude:

Speech:

Mood: " "

Affect:

Thought Process:

Thought Content:

Cognition:

Insight:

Judgment:

Diagnostic Assessment:

Axis I:

Axis II:

AXIS III.

Axis IV:

Axis V: Current GAF =

Highest GAF Past Year:

Initial Treatment Plan

Medications:

Therapy:

Time to Return to Clinic:

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Special Considerations

Adolescent interview

An interview involving adolescents is not likely to have been initiated by the patient and will likely involve interacting with the entire family. From the outset, confidentiality must be discussed with everyone and firm ground rules laid out. The adolescent should feel comfortable speaking openly with the interviewer.

Everyone should understand that outside of the adolescent posing harm to himself/herself or others, the clinician will share information only at the patient’s discretion. Information sharing among all other parties should be encouraged, and the patient should be given the option to share himself/herself or to allow the interviewer to summarize findings.

Topics such as sexual activity and drug use covered during a one-to-one interview provide significant opportunities for behavioral counseling but also pose a risk of the patient becoming more withdrawn. If possible, they may be best discussed at interviews subsequent to the first meeting. They should be initially broached in reference to peers. For example, "Drug use can start happening in kids your age; do any of your friends use drugs?" This sort of question gives the interviewer an opening to more directly discuss the patient's own experiences with drugs (or sexual activity).

Interviews with adolescents often have specific focuses beyond symptoms control. Academic functioning is a common concern. Family members may be comforted by the knowledge that such challenges are common. For example, between 5-10% of a given population may suffer from dyslexia.[26] Parents have been shown in some studies to underreport or otherwise minimize psychiatric symptoms;[27] thus, it can be useful to obtain information directly from the patient’s teachers or other care providers.

Specific learning disabilities may need formal neuropsychiatric testing. However, as with the entirety of the psychiatric interview, further studies should be guided by the past; the collection of information on learning disabilities from the patient and caretaker requires a longitudinal approach that looks for a consistent pattern of difficulty over time and space. A fresh and unique view of the patient may help to narrow down diagnoses, since anything from conduct disorder to attention deficit hyperactivity disorder can have the same end result — poor school performance — but require dramatically different treatments.

Consult interview

A consultation evaluation to a general medical hospital or clinic is usually focused on a specific question. A clear description of the problem from the patient’s primary provider is a significant piece of information needed in formulating this question. In addition to any physicians involved in the patient’s care, additional information should be obtained from nursing and other ancillary staff.

A very thorough chart review is often required because the patient may be unable to provide a complete history due to his or her medical illness. A chart review and discussions with staff can also help to illuminate underlying issues that may not have been clearly stated in the original consult question.[28]

If interpersonal conflicts have been frequent, significant therapeutic benefit can often be obtained simply by giving the provider a space to discuss his or her concerns. Challenges with communication between staff members should be looked for.

Begin the interview with an assessment of the patient’s understanding as to why a psychiatrist was consulted. If the patient has any concerns about being seen for a psychiatric assessment, these should be addressed before any history is collected.

This interaction may be the patient’s first with a mental health professional, one that the patient may not have sought; the patient may also be under duress due to his or her medical illness. Greater flexibility should be allowed in the style and language of the interaction than would occur in a "traditional" interview for these reasons.[29] The content of the interaction, while not structurally dissimilar from that of other psychiatric interviews, will be more focused on the underlying medical illness as either a source of the psychiatric complaint or an exacerbation.

Delirium affects between 10-30% of all hospitalized patients;[30] thus, the ability of a patient to remain alert throughout the interview and a full cognitive evaluation should be documented.

Translated interview

Nearly 1 in 5 Americans speak a language other than English at home.[31] This can present a particular challenge for psychiatry given the length and depth of the interview required. A patient who is conversationally fluent and is able to otherwise navigate the medical system, may have more difficulties with the details of a psychiatric interview. Similarly, whereas the use of a multilingual staff member (untrained in translation) or a family member of the patient could be appropriate in other settings, the dual role may create additional confusion in this setting. A medical interpreter with experience in mental health care should be obtained.

Prior to beginning the interview, it may be helpful to speak separately with the interpreter to discuss any potential concerns or issues that may arise. For example, if the interpreter is not experienced in mental health and if the patient is already known, it may put the interpreter more at ease if he or she is informed ahead of time of known symptoms and what specific areas of thought content, language, or disorganization the clinician is interested in. It also gives the interpreter some opportunity to educate the interviewer on any cross-cultural issues that may impact the interview.

The goal is to interpret what the patient is saying as closely as possible but to recognize the difficulty that the interpreter may have in conveying feelings and thoughts that may not easily be communicated in English. Given this difficulty, the patient and provider should limit themselves to no more than 2-3 sentences at a time before pausing for interpretation.

After the interview, the clinician and interpreter can discuss some of the translation difficulties they encountered, as well as discuss any cultural issues that may have arisen. This is more appropriate than talking about the patient in his or her presence, regardless of the language used.

Geriatric interview

The number of Americans over age 65 years is expected to double to over 70 million by 2050.[32] Interviews with elderly patients need to cover the same material that they do with younger patients, but certain areas are likely to require more depth and detail. Physical symptoms are likely to take a larger role, and adequate time should be devoted not just to detailing them, but also to examining the role they play as a stressor in the patient’s life. Moreover, simply by virtue of having been alive longer, a geriatric patient will have a longer history, and time should be allotted to accommodate this.

The interviewer should be vigilant for minimization/dismissal of symptoms as "normal" aging. For example, a decline in sexual interest may be viewed by some elderly patients as normal or even expected; thus, these patients may not bring this up as a symptom to their physician. Simply raising the question may be enough normalization for the patient to realize that something is wrong. This realization, in turn, may allow the interviewer to begin to probe more deeply into the root cause of these symptoms, such as depression.

Caregivers can play an important role in the geriatric patient’s life and should not be excluded from the interview. Concerns that the caregiver has are particularly important in relation to cognitive disorders, which may not be readily apparent to the patient. Caregivers may be able to provide a more complete longitudinal view of the patient’s functioning as well.

In addition, discussing matters with a caregiver gives the interviewer the opportunity to assess and address caregiver burnout and fatigue, helping the caregiver and patient to function better together. The patient should also be given an opportunity to discuss their perspective on care giving with a review of potential neglect or abuse.

Crisis interview

An emergency psychiatric evaluation is often performed when a patient poses an immediate harm to himself/herself or others or when such a threat is thought to exist. The potential for danger can raise the anxiety level during what would already be a stressful interview. The maintenance of a quiet, safe environment should be foremost in mind before beginning the interview, emphasized to the patient from the onset.[7]

A description by the interviewer of his or her role and how he or she will be interacting with the patient in the future becomes even more important than in most interviews. Some patients may even require a dose of antipsychotic or anxiolytic medications before proceeding with the interview. Concern for the safety of the interviewer is as valid as it is for that of the patient. Often, an interview with a potentially assaultive person may best be accomplished with multiple interviewers.

If the assaultive person is restrained in any way, an important way to begin the interview is with the steps that the patient needs to take to have the restraints removed. If the patient is not restrained, the interviewer should at no time block the patient’s exit from the interview space or be situated in the interview space in such a way that he or she could easily become trapped.

Once the patient is deemed stable enough, the interview should focus on the relatively recent past and what led to the specific problem now being addressed. Clearly, something significant has taken place, and "what changed?" should be high on the list of questions to ask.[7]

Acute stressors may be medication changes or substance use or may be social in nature and are reasonable to ask about if the patient is not immediately forthcoming. Substances are also able to rapidly escalate psychiatric problems to the level of crises, becoming a combined biologic and social stressor.

In addition to the diagnostic and treatment considerations that are part of any interview, special consideration should be placed on the appropriate location for treatment when doing an emergency assessment. Interventions can range from hospitalization to more frequent follow-up visits, but should be an explicit part of the treatment plan.

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Contributor Information and Disclosures
Author

Lorin M Scher, MD Director, Emergency Psychiatric ServicesHealth Sciences Assistant Clinical ProfessorDepartment of Psychiatry and Behavioral SciencesUniversity of California, Davis, School of Medicine

Lorin M Scher, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Alpha Omega Alpha, American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Coauthor(s)

Travis J Fisher, MD Assistant Professor, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin

Travis J Fisher, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Scott M Summers, MD, PhD Resident Physician, Department of Psychiatry, University of California, Davis, School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

References
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Table 1. SIGECAPS Mnemonic
S Sleep
I Interest (reduced)
G Guilt
E Energy (low)
C Concentration (poor)
A Appetite (increased or decreased)
P Psychomotor agitation or retardation
S Suicidality
Table 2. DIGFAST Mnemonic
D Distractible
I Irritability
G Grandiosity
F Flight of ideas
A Activity (increase)
S Sleep (decrease)
T Talkative
Table 3. CAGE Questions
C Have you ever felt you needed to C ut down on your drinking?
A Have people A nnoyed you by criticizing your drinking?
G Have you ever felt G uilty about drinking?
E Have you ever felt you needed a drink first thing in the morning ( E ye-opener) to steady your nerves or to get rid of a hangover?
Table 4. Global Assessment of Functioning Quick Chart
>70 Mild or no symptoms/impairment
50-70 Moderate symptoms/impairment
30-50 Severe symptoms/impairment
< 30 Hospitalization likely needed
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