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Editors: Carlat, Daniel J.

Title: Psychiatric Interview , The: Practical Guides in


Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> F ro nt o f Bo o k > Edit o rs

Editors
Daniel J. Carlat M.D.
Pr ivate Pr actice of Psychiatr y, Editor , The Car lat Repor t on
Psychiatr ic Tr eatment, Newbur ypor t, Massachusetts

Secondary Edi tors


Charles W . Mitchell
Acqui si ti ons Edi tor
Lisa R. Kairis
Devel opmental Edi tor
Bridgett Dougherty
Pr oject Manager
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Manufactur i ng Manager
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Pr oducti on Edi tor
Silver chair Science + Communications
Compositor : Silver chair Science + Communications

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Desi gn Coor di nator
Marie Clifton
Cover Desi gner
Printer: R. R. Donnelley, Craw fordsville
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> F ro nt o f Bo o k > De dic a t io n

Dedication

To Tammy, Ar i, and Sophia: You ar e my wor ld.


Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> F ro nt o f Bo o k > F o re w o rd

Foreword

The Psychiatr ic Inter view i s strai ghtfor war d, practi cal , and wi se, yet
often l i ght-hear ted and funny, a br eath of fr esh ai r wher e
comparabl e r efer ences have often been bor i ng and ponder ous. It
br i ms wi th extraor di nar y gi fts for i ts r eader s. It i s a schol ar l y
r evi ew of the r esear ch l i teratur e, yet i t moves swi ftl y and has a
l i ght, even jaunty, tone. It i s ver y much up-to-date and ser ves as a
useful i ntr oducti on to many i deas, such as those fr om
psychodynami cs, that ar e not wi del y avai l abl e to contemporar y
students.
Best of al l , the book i s al i ve, an extraor di nar y achi evement i n vi ew
of the amount of detai l ed mater i al pr esented. It emphasi zes the
per son within the patient and the need to for m an alliance wi th that
per son to secur e r el i abl e i nfor mati on and cooperati on i n tr eatment.
We feel the pati ents pr esented by Dr. Car l at; they ar e not si mpl y
di agnoses. Dr. Car l at offsets the pr ofessi on's r eputati on for bei ng
cheer l ess and pathol ogy-mi nded; he i l l ustrates many ways by whi ch
effecti ve r el ati onshi ps can be for med and shows how r el ati onshi ps
that ar e endanger ed can be r epai r ed, per haps especi al l y at the cl ose
of an i nter vi ew.
The Psychiatr ic Inter view i s desi gned i n an easi l y accessi bl e for mat,
wi th ai ds for memor y, appendi xes for or gani z i ng i nfor mati on, and
sensi bl e gui des for r ecor dkeepi ng. Thi s i s teachi ng by exampl e at i ts
best, wi th the exampl es both vi vi d and poi nted, so that they sti ck i n
the r eader 's mi nd.
Tr ul y under standi ng another human bei ng i s a daunti ng chal l enge,
yet nothi ng i s mor e i mpor tant i f we ar e to soothe the suffer i ng of a
ravaged soul . Use thi s book as a gui de to r each for that
under standi ng.
Leston Havens M.D.
Pr ofessor of Psychi atr y
Har var d Medi cal School , The Cambr i dge Heal th Al l i ance, Cambr i dge,
Massachusetts
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> F ro nt o f Bo o k > P re fa c e

Preface

Over the cour se of a 40-year pr ofessi onal car eer, you wi l l do


appr oxi matel y 100,000 di agnosti c i nter vi ews. The di agnosti c
i nter vi ew i s by far the most i mpor tant tool i n the ar senal of any
cl i ni ci an, and yet the average trai ni ng pr ogram di r ects r el ati vel y
few r esour ces to speci fi c trai ni ng i n the ski l l s r equi r ed for i t. The
general assumpti on seems to be that i f you do enough i nter vi ews
wi th di ffer ent ki nds of pati ents, you'l l natural l y pi ck up the r equi r ed
ski l l s. That may be tr ue, but i t can take a l ong ti me, and the
l ear ni ng pr ocess can be pai nful .
I hatched the i dea for thi s manual one ni ght dur i ng my fi r st year of
psychi atr i c r esi dency. Star ti ng my shi ft i n the acute psychi atr y
ser vi ce (APS), I noti ced fi ve pati ents i n the wai ti ng r oom; the
r esi dent who handed me the emer gency r oom beeper sai d ther e
wer e two mor e pati ents i n the emer gency r oom, both i n r estrai nts.
At that moment the beeper sounded, and I cal l ed the number.
Psychi atr y? Thi s i s El l i son 6. We have a pati ent up her e who says
he's depr essed and sui ci dal . Pl ease come and eval uate, STAT. That
meant that I had a total of ei ght di agnosti c assessments to do.
As the ni ght str etched on, my i nter vi ews got br i efer. The
devel opmental hi stor y was the fi r st to go, fol l owed qui ckl y by the
for mal mental status exami nati on. Thi s tr i mmi ng pr ocess conti nued
unti l , at 5 a.m., i t r eached i ts absur d, but i nevi tabl e, concl usi on. My
enti r e i nter vi ew consi sted of l i ttl e mor e than the fol l owi ng questi on:
Ar e you sui ci dal ?
As I handed the beeper off to my col l eague at 8 a.m. (I had sl ept for
50 mi nutes, about the l ength of a psychotherapeuti c hour ), I began
to thi nk about those i nter vi ews. Wer e they too shor t? (I was sur e
they wer e.) Wer e they effi ci ent? (I doubted i t.) Had anyone come up
wi th a system for conducti ng di agnosti c assessments that wer e rapi d
but at the same ti me thor ough enough to do justi ce to the pati ent?
Looki ng for such a system became my l i ttl e pr oject over the r est of
my r esi dency. I l abel ed a mani l a fi l e fol der inter viewing pear ls and
star ted thr owi ng i n bi ts and pi eces of i nfor mati on fr om var i ous
sour ces, i ncl udi ng i nter vi ewi ng textbooks, l ectur es i n our
Wednesday semi nar s, and conver sati ons wi th my super vi sor s and
wi th other r esi dents. When I became chi ef r esi dent of the i npati ent
uni t, I vi deotaped case confer ences and took notes on effecti ve
i nter vi ewi ng techni ques. Later, dur i ng my fi r st job as an attendi ng
psychi atr i st, I practi ced and fi ne-tuned these techni ques wi th
i npati ents at Anna Jaques Hospi tal and outpati ents at Har r i s Str eet
Associ ates.
What I ended up wi th was a compendi um of ti ps and pear l s that wi l l
hel p make your di agnosti c i nter vi ews mor e effi ci ent and, I hope,
mor e fun. Mnemoni cs wi l l make i t easi er for you to qui ckl y
r emember needed i nfor mati on. Inter vi ewi ng techni ques wi l l hel p
you move the i nter vi ew al ong qui ckl y wi thout al i enati ng your
pati ents. Ever y chapter begi ns wi th an Essenti al Concepts box that
l i sts the tr ul y take-home i tems of i nfor mati on ther ei n. The
appendi ces contai n useful l i ttl e stocki ng stuffer s, such as pocket
car ds wi th vi tal i nfor mati on to be photocopi ed and for ms that you
can use dur i ng your i nter vi ews to ensur e that you'r e not for getti ng
anythi ng i mpor tant.
However, i f you'r e l ooki ng for theor eti cal justi fi cati ons and poi nt-
by-poi nt evi dence for the effi cacy of these techni ques, you won't
fi nd i t her e. G o to one of the many textbooks of psychi atr i c
i nter vi ewi ng for that. Ever y pi ece of i nfor mati on i n thi s manual had
to meet the fol l owi ng str i ngent standar d: It had to be i mmedi atel y
useful knowl edge for the trai nee about to step i nto the r oom wi th a
new pati ent.

WHAT THIS MANUAL IS


F i r st, thi s i s only a manual . It's not a r esi dency or an i nter nshi p.
The way to l ear n how to i nter vi ew pati ents i s by i nter vi ewi ng them
under good super vi si on. Onl y ther e can you l ear n the subtl eti es of
the i nter vi ew, the ski l l s of under standi ng the i nteracti ons between
you and your pati ents.
It i s a tool that l ends you a gui di ng hand i n your i ni ti al effor ts to
i nter vi ew pati ents. It's confusi ng ter r i tor y. Ther e ar e l ots of
mi stakes to be made and many embar rassi ng and awkwar d moments
ahead. Thi s book won't pr event al l of that, but i t wi l l catal yze the
devel opment of your i nter vi ewi ng ski l l s.
It i s a handbook for any begi nni ng cl i ni ci an who does psychi atr i c
assessments as par t of hi s or her trai ni ng. Thi s i ncl udes psychi atr i c
r esi dents, medi cal students, psychol ogy i nter ns, soci al wor k i nter ns,
mental heal th wor ker s, nur si ng students, and r esi dents i n other
medi cal fi el ds who may need to do an on-the-spot di agnosti c
assessment whi l e wai ti ng for a consul tant.

WHAT THIS MANUAL IS NOT


It i s not a textbook of psychi atr i c i nter vi ewi ng. Ther e ar e a number
of i nter vi ewi ng textbooks al r eady avai l abl e (Shea 1988; Othmer
1994; Mor r i son 1995), my favor i te bei ng Shea's Psychiatr ic
Inter viewing: The Ar t of Under standing. Al though textbooks ar e
mor e thor ough and encycl opedi c, the drawback i s that they do not
gui de the begi nner to the essence of what he or she needs to know.
Al so, textbooks ar en't por tabl e, and I wanted to wr i te somethi ng
that you can car r y ar ound to your var i ous cl i ni cal setti ngs. That
sai d, pl ease buy a textbook, and have i t ar ound for those ti mes
when you want to r ead i n mor e depth.
Thi s i s al so not a handbook of psychi atr i c disor der s. Ther e ar e
pl enty of good ones al r eady publ i shed, and I wr ote thi s manual to
fi l l the need for a br i ef, how-to gui de to di agnosi ng those di sor der s.
F i nal l y, i t i s not a psychother apy manual . Doi ng a rapi d di agnosti c
assessment i sn't psychotherapy, al though you can extend many of
the ski l l s used i n the fi r st i nter vi ew to psychotherapy.
I hope that you wi l l enjoy thi s book and that i t wi l l hel p you to
devel op confi dence i n i nter vi ewi ng. As you embar k, r emember these
wor ds of Theodor e Roosevel t: The onl y man who never makes a
mi stake i s the man who never does anythi ng. G ood l uck!
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> F ro nt o f Bo o k > Int ro duc t io n t o t he Se c o nd Edit io n

Introduction to the Second Edition

Don't wor r y, I di dn't wr i te thi s r evi si on just to boost sal es of the


book. Nor (even wor se) di d I wr i te thi s r evi si on to keep up to date
wi th the l atest edi ti on of the DSM (DSM-IV, text r evi si on), whi ch
adds l i ttl e of val ue to psychi atr i c di agnosi s, al though i t does hel p
the coffer s of the Amer i can Psychi atr i c Associ ati on.
I wr ote thi s r evi si on because, dur i ng the 5 year s si nce the fi r st
edi ti on of The Psychiatr ic Inter view was publ i shed, I've seen many
thousands of pati ents and have had a chance to r efi ne my own
i nter vi ewi ng ski l l s. And I'd l i ke to pass on some thi ngs that I've
l ear ned over that ti me. Accor di ngl y, I have made changes to most
chapter s, general l y r efl ecti ng r esear ch on psychi atr i c di agnosi s
publ i shed si nce 1999.
I al so thought i t was i mpor tant to hi ghl i ght cer tai n content ar eas of
the i nter vi ew that I have found have become par ti cul ar l y i mpor tant
over ti me. Thus, I have wr i tten new chapter s pr ovi di ng mor e detai l
on the eval uati on of ADHD (attenti on-defi ci t hyperacti vi ty di sor der )
and on deter mi ni ng whether someone i s mal i nger i ng.
Pl ease l et me know what you thi nk of The Psychiatr ic Inter view, and
how you thi nk i t can be i mpr oved. My gui di ng pr i nci pl e has been, If
i t i sn't i mmedi atel y useful to someone i n the tr enches, i t shoul dn't
be i n the book. Let me know i f I've succeeded!
Dani el J. Car l at M.D.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> F ro nt o f Bo o k > Ac k no w le dgm e nt s

Acknowledgments

For thi s second edi ti on, I agai n want to fi r st thank Dr. Shawn Shea,
wi thout whose cl assi c textbook, Psychiatr ic Inter viewing: The Ar t of
Under standing, and per sonal mentor i ng I woul d never have
conceptual i zed thi s pr oject.
My father, Paul Car l at, who i s al so a psychi atr i st, has bestowed upon
me whatever per sonal qual i ti es have been hel pful as I wor k wi th
pati ents. Hi s suppor t and gui dance thr ough a ser i es of potenti al l y
hai r-brai ned ventur es have been a per petual G od-send.
Many member s of the facul ty of Massachusetts G eneral Hospi tal
(MG H), wher e I di d my psychi atr i c r esi dency, wer e extr emel y hel pful
i n the shapi ng of the manuscr i pt. In par ti cul ar, I thank Dr. Ed
Messner, whose ver y practi cal appr oach to pati ent car e was
r efr eshi ng; Dr. Paul Hambur g, who taught empathy and i nnumerabl e
other aspects of connecti ng wi th pati ents; Dr. Paul Summer grad, a
consummate cl i ni ci an and the di r ector of the i npati ent uni t dur i ng
my chi ef r esi dency, who suppor ted me i n my effor ts to cr eate an
i nter vi ewi ng cour se for r esi dents; Dr. Car ey G r oss, whose
astoni shi ng abi l i ty to rapi dl y make the r i ght di agnosi s for the most
di ffi cul t pati ents i s a conti nui ng sour ce of i nspi rati on; and Dr.
Anthony Er dmann, who gener ousl y contr i buted several scr eeni ng
questi ons. In addi ti on, speci al thanks go to Dr. Leston Havens, at
the Cambr i dge Hospi tal , who was ver y encouragi ng thr oughout thi s
pr oject.
I al so thank the psychi atr y r esi dents at MG H. The PG Y-2 r esi dents
of the 1994 to 1995 academi c year wer e extr emel y accommodati ng
as I devel oped my i nter vi ewi ng cur r i cul um whi l e teachi ng i t; the
r esi dents and psychol ogy fel l ows i n my own cl ass constantl y cheer ed
me on, par ti cul ar l y Dr s. Cl audi a Bal dassano, Chr i sti na Demopul os,
and Al an Lyman, co-member s of the Har var d G ar dens Cl ub, and Dr.
Rober t Mul l er, psychol ogi st supr eme.
F i nal l y, thanks ar e due to the staff of the Anna Jaques Hospi tal
i npati ent psychi atr y uni t, wher e I have r oad tested the many
techni ques descr i bed i n thi s book. I especi al l y thank Dr. Rowen
Hochstedl er, my medi cal di r ector and fr i end, who i s l i vi ng pr oof that
excel l ent mentor i ng can conti nue far beyond the r eaches of
academi a.
TABLE OF CONTENTS
[-]
Section I - General Principles of Effective Interviewing
[+] 1 - The Initial Interview: A Preview
[+] 2 - Logistic Preparations: What to Do before the Interview
[+] 3 - The Therapeutic Alliance: What It Is, Why It's Important, and How
to Establish It
[+] 4 - Asking Questions I: How to Approach Threatening Topics
[+] 5 - Asking Questions II: Tricks for Improving Patient Recall
[+] 6 - Asking Questions III: How to Change Topics with Style
[+] 7 - Techniques for the Reluctant Patient
[+] 8 - Techniques for the Overly Talkative Patient
[+] 9 - Techniques for the Malingering Patient
[+] 10 - Techniques for the Adolescent Patient
[+] 11 - Techniques for Other Challenging Situations
[+] 12 - Practical Psychodynamics in the Diagnostic Interview
[-]
Section II - The Psychiatric History
[+] 13 - Obtaining the History of Present Illness
[+] 14 - Obtaining the Psychiatric History
[+] 15 - Screening for General Medical Conditions
[+] 16 - Family Psychiatric History
[+] 17 - Obtaining the Social and Developmental History
[-]
Section III - Interviewing for Diagnosis: The Psychiatric Review of Symptoms
[+] 18 - How to Memorize the DSM-IV-TR Criteria
[+] 19 - Interviewing for Diagnosis: The Art of Hypothesis Testing
[+] 20 - Mental Status Examination
[+] 21 - Assessing Suicidal and Homicidal Ideation
[+] 22 - Assessing Mood Disorders I: Depressive Disorders
[+] 23 - Assessing Mood Disorders II: Bipolar Disorder
[+] 24 - Assessing Anxiety Disorders
[+] 25 - Assessing Alcohol Dependence and Drug Abuse
[+] 26 - Assessing Psychotic Disorders
[+] 27 - Assessing Dementia and Delirium
[+] 28 - Assessing Eating Disorders and Somatization Disorder
[+] 29 - Assessing Attention-Deficit Hyperactivity Disorder
[+] 30 - Assessing Personality Disorders
[-]
Section IV - Interviewing for Treatment
[+] 31 - How to Educate Your Patient
[+] 32 - Negotiating a Treatment Plan
[+] 33 - Writing Up the Results of the Interview
BACK OF BOOK

[-] Resources
[+] A - Pocket Cards
[+] B - Data Forms for the Interview
[+] C - Patient Education Handouts
- References
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 1 - The
Init ia l Int e rv ie w : A P re v ie w

1
The Initial Interview: A Preview

The Four Tasks

Bui l d a therapeuti c al l i ance.


Obtai n the psychi atr i c database.
Inter vi ew for di agnosi s.
Negoti ate a tr eatment pl an wi th your pati ent.

The Three Phases

Openi ng phase.
Body of the i nter vi ew.
Cl osi ng phase.

FOUR TASKS OF THE DIAGNOSTIC INTERVIEW


The di agnosti c i nter vi ew i s r eal l y about tr eatment, not di agnosi s.
It's i mpor tant to keep thi s l ar ger goal i n mi nd dur i ng the i nter vi ew,
because i f you don't, your pati ent may never r etur n for a second
vi si t, and your fi nel y wr ought Di agnosti c and Stati sti cal Manual of
Mental Di sor der s, Four th Edi ti on (text r evi si on) (DSM-IV-TR)
di agnosi s wi l l end up l angui shi ng i n a char t i n a fi l e r oom.
Studi es show that up to 50% of pati ents dr op out befor e the four th
sessi on of tr eatment, and many never r etur n after the fi r st
appoi ntment (Baekel and and Lundwal l 1975). The r easons for
tr eatment dr opout ar e many. Some pati ents do not r etur n because
they for med poor al l i ances wi th thei r cl i ni ci ans, some because they
wer en't r eal l y i nter ested i n tr eatment i n the fi r st pl ace, and other s
because the i ni ti al i nter vi ews al one boosted thei r moral e enough to
get them thr ough thei r str essor s (Pekar i k 1993). The upshot i s that
much mor e than di agnosi s shoul d occur dur i ng the i ni ti al i nter vi ew:
Al l i ance bui l di ng, moral e boosti ng, and tr eatment negoti ati ng ar e
al so vi tal .
The four tasks of the i ni ti al i nter vi ew bl end wi th one another. You
establ i sh a therapeuti c al l i ance as you l ear n about your pati ent. The
ver y act of i nqui r y i s an al l i ance bui l der ; we tend to l i ke peopl e who
ar e war ml y cur i ous about us. As you ask questi ons, you for mul ate
possi bl e di agnoses, and thi nki ng thr ough di agnoses l eads natural l y
to the pr ocess of negoti ati ng a tr eatment pl an.

Build a Therapeutic Alliance


A therapeuti c al l i ance for ms the gr oundwor k of any psychol ogi cal
tr eatment. Chapter 3, The Therapeuti c Al l i ance, focuses on the
al l i ance di r ectl y, and Chapter s 4, 5, 6, 7, 8, 9 and 10 pr ovi de
var i ous i nter vi ewi ng ti ps that wi l l hel p you i ncr ease rappor t wi th
your pati ent.

Obtain the Psychiatric Database


Al so known as the psychi atr i c hi stor y, the psychi atr i c database
i ncl udes hi stor i cal i nfor mati on r el evant to the cur r ent cl i ni cal
pr esentati on. These topi cs ar e cover ed i n Secti on II, The Psychi atr i c
Hi stor y, and i ncl ude hi stor y of pr esent i l l ness (HPI), psychi atr i c
hi stor y, medi cal hi stor y, fami l y psychi atr i c hi stor y, and aspects of
the soci al and devel opmental hi stor y. G l eani ng thi s i nfor mati on i s
the substance of the i nter vi ew, and thr oughout thi s step, you wi l l
have to wor k on bui l di ng and mai ntai ni ng the al l i ance. You wi l l al so
make fr equent forays i nto the next task, i nter vi ewi ng for di agnosi s.

Interview for Diagnosis


The abi l i ty to i nter vi ew for di agnosi swi thout soundi ng as i f you'r e
r eadi ng off a checkl i st of symptoms and wi thout getti ng si detracked
by l ess r el evant i nfor mati oni s one of the supr eme ski l l s of a
cl i ni ci an, and one that you wi l l hone and devel op over the cour se of
your pr ofessi onal l i fe. Secti on III, Inter vi ewi ng for Di agnosi s, i s
devoted to thi s ski l l ; i t contai ns chapter s on how to memor i ze DSM-
IV-TR cr i ter i a (Chapter 18) and on the ar t of di agnosti c hypothesi s
testi ng (Chapter 19) and several di sor der-speci fi c chapter s that
focus on how to use scr eeni ng and pr obi ng questi ons for each of the
major DSM-IV-TR di sor der s (Chapter s 21, 22, 23, 24, 25, 26, 27,
28, 29 and 30).

Negotiate a Treatment Plan and Communicate


It to Your Patient
How to negoti ate and communi cate a tr eatment pl an i s rar el y taught
i n r esi dency or graduate school , and yet i t i s pr obabl y the most
i mpor tant thi ng you can do to ensur e that your pati ent adher es to
whatever tr eatment you r ecommend. If your pati ent doesn't
under stand your for mul ati on, doesn't

agr ee wi th your advi ce, and doesn't feel comfor tabl e tel l i ng you so,
the i nter vi ew may as wel l never have taken pl ace. See Secti on IV,
Inter vi ewi ng for Tr eatment, for ti ps on the ar t of pati ent educati on
and cl i ni cal negoti ati on.

THREE PHASES OF THE DIAGNOSTIC


INTERVIEW
The di agnosti c i nter vi ew, l i ke most tasks i n l i fe, has a begi nni ng, a
mi ddl e, and an end. Al though thi s may seem obvi ous enough, novi ce
i nter vi ewer s often l ose si ght of i t and ther efor e fai l to acti vel y
str uctur e the i nter vi ew and contr ol i ts paci ng. The r esul t i s usual l y
a pani c-fi l l ed endi ng, i n whi ch 50 questi ons ar e wedged i nto the l ast
5 mi nutes.
It's tr ue that ther e's a huge amount of i nfor mati on to obtai n dur i ng
the fi r st i nter vi ew, and ti me may feel l i ke the enemy. Excel l ent
i nter vi ewer s, however, rar el y feel r ushed. They have the abi l i ty to
obtai n l ar ge amounts of i nfor mati on i n a br i ef per i od, wi thout gi vi ng
pati ents the sense that they ar e bei ng hur r i ed al ong or made to fi t
i nto a pr eor dai ned str uctur e. One of the secr ets of a good
i nter vi ewer i s the abi l i ty to acti vel y str uctur e the i nter vi ew i n i ts
thr ee phases.

Opening Phase (5 to 10 Minutes)


The openi ng phase i ncl udes meeti ng your pati ent, l ear ni ng a bi t
about her l i fe si tuati on, and then shutti ng up and gi vi ng her a few
uni nter r upted mi nutes to tel l you why she came. Thi s i s di scussed i n
mor e detai l i n Chapter 3, because the openi ng phase i s a cr uci al
per i od for al l i ance bui l di ng; the pati ent i s maki ng an i ni ti al deci si on
as to your tr ustwor thi ness. The openi ng phase i s based on car eful ,
pr ei nter vi ew pr eparati on, cover ed i n Chapter 2, Logi sti c
Pr eparati ons: What to Do befor e the Inter vi ew. Attenti on to l ogi sti cs
ensur es that you wi l l be compl etel y attuned to the r el ati onshi p wi th
your pati ent dur i ng the fi r st 5 mi nutes.

Body of the Interview (30 to 40 Minutes)


Over the cour se of the openi ng phase, you wi l l come up wi th some
i ni ti al di agnosti c hypotheses (Chapter 19), and you wi l l deci de on
some i nter vi ewi ng pr i or i ti es to expl or e dur i ng the body of the
i nter vi ew. For exampl e, you may deci de that

depr essi on, anxi ety, and substance abuse ar e l i kel y pr obl ems for a
par ti cul ar pati ent. You wi l l map out an i nter vi ewi ng strategy for
expl or i ng these topi cs, whi ch wi l l i ncl ude aski ng about the hi stor y
of the pr esent i l l ness (Chapter 13); hi stor y of depr essi on, sui ci dal
i deati on (SI), and substance abuse (Chapter s 21, 22, and 25);
fami l y hi stor y of these di sor der s (Chapter 16); and a detai l ed
assessment of whether the pati ent actual l y meets DSM-IV-TR
cr i ter i a (Chapter s 21, 22, and 25) for each di sor der. Once you've
accompl i shed these pr i or i ty tasks, you can move on to other topi cs,
such as the soci al /devel opmental hi stor y (Chapter 17), medi cal
hi stor y (Chapter 15), and psychi atr i c r evi ew of symptoms (PROS)
(Secti on III).

Closing Phase (5 to 10 Minutes)


Al though you may be tempted to conti nue aski ng di agnosti c
questi ons r i ght up to the end of the hour, i t's essenti al to r eser ve at
l east 5 mi nutes for the cl osi ng phase of the i nter vi ew. The cl osi ng
phase shoul d i ncl ude two components: (a) a di scussi on of your
assessment, usi ng the pati ent educati on techni ques outl i ned i n
Chapter 31 and (b) an effor t to come to a negoti ated agr eement
about tr eatment or fol l ow-up pl ans (Chapter 32). Of cour se, ear l y i n
your car eer, i t wi l l be di ffi cul t to come up wi th a coher ent
assessment on the spot, wi thout the benefi t of hour s of
posti nter vi ew super vi si on and r eadi ng. Thi s ski l l wi l l i mpr ove wi th
practi ce.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 2 -
Lo gis t ic P re pa ra t io ns : W ha t t o Do be fo re t he Int e rv ie w

2
Logistic Preparations: What to Do
before the Interview

Essential Concepts

Pr epar e the r i ght space and ti me.


Use paper tool s effecti vel y.
Devel op your pol i ci es.

The wor k of psychol ogi cal heal i ng begi ns i n a safe


pl ace, to be compar ed wi th the best of hospi tal
exper i ence or, fr om an ear l i er ti me, chur ch
sanctuar y. The psychol ogi cal safe pl ace per mi ts the
i ndi vi dual to make spontaneous, for ceful gestur es
and, at the same ti me, r epr esents a communi ty
that both al l ows the gestur es and i s val ued for i ts
own sake.
--Leston Havens, M.D. A Safe Pl ace

Logi sti c pr eparati on for an i nter vi ew i s i mpor tant because i t sets up


a mel l ower and l ess str essful exper i ence for both you and your
pati ent. Often, trai nees ar e thr own i nto the cl i ni c wi thout trai ni ng
i n how to fi nd and secur e a r oom, how to deal wi th schedul i ng, or
how to document effecti vel y. You'l l eventual l y ar r i ve at a system
that wor ks wel l for you; thi s chapter wi l l hel p speed up that
pr ocess.

PREPARE THE RIGHT SPACE AND TIME


Secure a Space
A space war i s ragi ng i n most cl i ni cs and trai ni ng pr ograms, and you
must fi ght to secur e ter r i tor y. Once secur ed, di g tr enches, cal l for
the caval r y, do whatever you need to do.
I r emember one ear l y l esson i n thi s r eal i ty: I was 2 months i nto my
trai ni ng and just fi ni shi ng super vi si on i n the War r en Bui l di ng of the
Massachusetts G eneral Hospi tal (MG H) campus.

It was 12:55 p.m., and I had a therapy pati ent schedul ed for 1:00
p.m. i n the Ambul ator y Car e Cl i ni c, a bui l di ng so far fr om War r en
that i t practi cal l y had i ts own ti me zone. I z i gged and z agged
ar ound staff and pati ents i n the hal l ways on thei r way to the
cafeter i a and r ushed i nto the cl i ni c by 1:05. My pati ent was i n the
wai ti ng r oom and got a good vi ew of sweat tr i ckl i ng down my
for ehead. I scanned the r oom schedul e and found that no r ooms
wer e fr ee. Pani c set i n, unti l the secr etar y poi nted out that the
r esi dent who had r oom 825 for that hour had not yet shown up. So I
l ed my pati ent to 825, and we star ted, 10 mi nutes l ate. F i ve
mi nutes l ater, ther e was a knock on the door. I opened i t, and ther e
stood the r esi dent and hi s pati ent. I r edeposi ted my pati ent i n the
wai ti ng r oom and scour ed the l i st for another r oom.
I won't tor tur e you wi th the r est of thi s saga. Suffi ce i t to say we
wer e evi cted fr om the next r oom as wel l , and the therapy sessi on
was, i n the end, onl y 15 mi nutes l ong, wi th much humi l i ati on on my
par t and good-natur ed amusement on my pati ent's.
Her e ar e some ti me-honor ed ti ps on how to secur e a r oom and what
to do wi th i t once you have i t:

Schedule the same time every w eek. Tr y to secur e your r oom


for the same ti me ever y week. That way you'l l be abl e to fi t
i nter vi ews i nto your weekl y schedul e r outi nel y. When i t comes to
psychi atr i c i nter vi ewi ng, r outi ne i s your fr i end. Psychodynami c
psychotherapi sts cal l thi s r outi nethe same ti me, the same
r oom, the same gr eeti ngthe frame. Maki ng i t i nvar i abl e
r educes di stracti ons fr om the wor k of psychol ogi cal expl orati on.
Make your room your ow n in some w ay. Thi s i sn't easy when
you onl y i nhabi t i t for a few hour s a week. Cl i ni c pol i cy may
for bi d thi s, or i t may be i mpol i te (e.g., i f you'r e usi ng an offi ce
that bel ongs to a r egul ar staff member ). If possi bl e, put a
pi ctur e on the desk or the wal l , br i ng a pl ant i n, pl ace some
r efer ence books on a shel f, hang some fi l es. The r oom wi l l feel
mor e l i ke your space, and i t wi l l seem homi er to your pati ent.
By the way, i f you do put up a pi ctur e, thi nk twi ce befor e you
di spl ay your fr i ends or fami l y; i t may l ead to transfer ence
pr obl ems wi th some pati ents.
A rrange the seating so that you can see a clock wi thout
shi fti ng your gaze too much. A wal l cl ock posi ti oned just behi nd
your pati ent wor ks wel l . A desk cl ock or a wr i stwatch pl aced
between the two of you i s al so acceptabl e. The object i s to al l ow
you to keep track of the passage of ti me wi thout thi s bei ng
obvi ous to your pati ent. It i s al i enati ng for a pati ent to noti ce a
cl i ni ci an fr equentl y l ooki ng at a cl ock; the per cei ved

message i s I can't wai t for the end of thi s i nter vi ew. You do
need to moni tor the ti me, though, to ensur e that you obtai n a
tr emendous amount of i nfor mati on i n a br i ef per i od. Actual l y,
keepi ng track of ti me wi l l paradoxi cal l y make you l ess di stracted
and mor e pr esent for your pati ent, as you'l l al ways know that
you'r e managi ng your ti me adequatel y.

Protect Your Time


Ti me i s but the str eam I go a-fi shi ng i n.
--Henr y Davi d Thor eau

Thi s i s not to say that you shoul d go fl y-casti ng wi th your pati ents
(though you'r e usual l y fi shi ng for somethi ng or other dur i ng an
i nter vi ew). Rather, you shoul d pr otect the ti me you schedul e for
i nter vi ews so that i t has that same peaceful , al most sacr ed qual i ty.
How to do i t?

A rrive earlier than the patient. You need ti me to pr epar e


your sel f emoti onal l y and l ogi sti cal l y for the i nter vi ew. Compose
your sel f. Lay out whatever for ms or handouts you'l l need.
Answer any ur gent messages that you just pi cked up at your
message box. Br eathe, medi tate, or do a cr osswor d puz z l e or
whatever you do to r el ax.
I once obser ved an i nter vi ewer who was vi si bl y anxi ous. He
cr ossed and uncr ossed hi s l egs and constantl y kneaded hi s l eft
pal m wi th hi s r i ght thumb. Eventual l y, the pati ent i nter r upted
the i nter vi ew and asked, Doctor ? Ar e you al l r i ght? You l ook
ner vous. He l aughed. Oh, I'm fi ne, he sai d. And no, thi s was
not a r esi dent, but one of my pr ofessor s.
Prevent interruptions. Ther e ar e var i ous ways to pr event
i nter r upti ons:

Ask the cl i ni c secr etar y to take messages for you.


Ask the page operator to hol d al l but ur gent pages.
Put your pager on vi brate mode and onl y answer ur gent pages.
Si gn your pages out to a col l eague.

Don't overbook patients. Know your l i mi ts. At the begi nni ng,
i t may take you an hour and a hal f to compl ete an eval uati on,
not i ncl udi ng the wr i te-up. If so, book onl y one pati ent per 2-
hour sl ot. Obvi ousl y, your trai ni ng pr ogram won't al l ow you to
mai ntai n such a l ei sur el y schedul e for l ong, but you wi l l i mpr ove
and become mor e effi ci ent. Eventual l y, you shoul d ai m towar d
compl eti ng the eval uati on and wr i te-up (or di ctati on) i n 1 hour.

Leave plenty of time for notes and paperw ork. The ti me


r equi r ed for paper wor k wi l l var y, dependi ng on both the setti ng
and the cl i ni ci an. The key i s to fi gur e out how l ong i t takes you
and then to make r oom for i t i n your schedul e. Don't fal l i nto
deni al . If you happen to be ver y sl ow at paper wor k, admi t i t and
pl an accor di ngl y.
I know an excel l ent psychi atr i st who has l ear ned fr om
exper i ence that he has to spend 30 mi nutes on char ti ng,
tel ephoni ng, and mi scel l aneous paper wor k r el ated to pati ents for
ever y hour of cl i ni cal wor k he does. If he spends 6 hour s seei ng
pati ents, he schedul es 3 hour s i n the eveni ng to take car e of the
col l ateral wor k. Al though hi s hour l y wage decr eases, he gai ns
the sati sfacti on of knowi ng that he's doi ng the ki nd of job he
wants to do.
Now, that woul dn't wor k for me. I schedul e sl i ghtl y l ess ti me
wi th pati ents so that I can fi ni sh al l col l ateral wor k befor e I see
my next appoi ntment. The poi nt, as Pol oni us sai d i n Haml et, i s
to Know thysel f, and to thi ne own sel f be tr ue.
USE PAPER TOOLS EFFECTIVELY
By paper tool s, I mean the whol e ar ray of i nter vi ew for ms, cheat-
sheets, pati ent handouts, and pati ent questi onnai r es. Ther e's l i ttl e
for mal trai ni ng i n how to use these, but they ar e i ndi spensabl e
when you see a l ot of pati ents ever y day. Al l of the paper tool s I
di scuss bel ow ar e i n the appendi ces of thi s manual , and you ar e
wel come to copy and use what you want. You mi ght fi nd al l , some,
or none of them useful , or you may want to adapt them to better
sui t your needs.

Psychiatric Interview Long Form


Thi s psychi atr i c i nter vi ew l ong for m (i n Appendi x B) i s adapted fr om
the one used by Anthony Er dmann, an attendi ng psychi atr i st at
MG H. He takes notes on i t whi l e tal ki ng to pati ents and puts i t i n
hi s char t.

Advantages
Use of thi s for m ensur es a thor ough data eval uati on and saves ti me,
because notes can be pl aced di r ectl y i nto the char t.

Disadvantages
Some pati ents may be al i enated i f you seem mor e i nter ested i n
compl eti ng a for m than i n getti ng to know them.

Psychiatric Interview Short Form


The shor t for m (i n Appendi x B) can be used for r ough notes when
you ar e goi ng to di ctate the eval uati on or wr i te i t up i n a l onger
ver si on l ater.

Advantages
Thi s for m pr esents l ess of a bar r i er between cl i ni ci an and pati ent
than the l ong for m and i s easy to r efer to whi l e di ctati ng.

Disadvantages
Use of the shor t for m may l ead to a l ess thor ough eval uati on.

Psychiatric Interview Pocket Card


The pocket car d (i n Appendi x A) i s used to r emi nd you of al l the
topi cs to cover. You can jot r ough notes on a bl ank pi ece of paper or
not take notes at al l , i f you'r e abl e to r emember most i nfor mati on.

Advantages
The car d al l ows maxi mum i nteracti on between cl i ni ci an and pati ent,
si nce ther e i s no for m to fi l l out.

Disadvantages
Requi r ed i nfor mati on i s not ful l y spel l ed out on the pocket car d, so
mor e use of memor y i s r equi r ed.

Patient Questionnaire*
Some cl i ni ci ans gi ve thei r pati ents a questi onnai r e (i n Appendi x B)
such as thi s one befor e the fi r st meeti ng, to decr ease the ti me
needed to acqui r e basi c i nfor mati on.

Advantages
The pati ent questi onnai r e al l ows mor e ti me dur i ng the fi r st sessi on
to focus on i ssues of i mmedi ate concer n to the pati ent. It may
hei ghten the pati ent's sense that he i s acti vel y par ti ci pati ng i n hi s
car e.

Disadvantages
If al l of the pati ent's answer s on the questi onnai r e ar e accepted at
face val ue, i nval i d i nfor mati on may be col l ected. Some pati ents may
vi ew fi l l i ng out the questi onnai r e as a bur den.

Patient Handouts
Pati ents usual l y appr eci ate r ecei vi ng some wr i tten i nfor mati on (i n
Appendi x C) about thei r di sor der, and i t pr obabl y i ncr eases
tr eatment compl i ance.

Advantages
Pati ent handouts i ncr ease pati ents' under standi ng of thei r di agnosi s
and gi ve them a sense that they ar e col l aborati ng i n thei r
tr eatment.
Disadvantages
The handouts may pr esent mor e i nfor mati on than some pati ents can
handl e ear l y i n thei r tr eatment. Infor mati on may al so be
mi si nter pr eted.

DEVELOP YOUR POLICIES


F r om the fi r st appoi ntment wi th a par ti cul ar pati ent, you ar e
enter i ng i nto a r el ati onshi p. You need to deter mi ne the parameter s
of thi s r el ati onshi p, i ncl udi ng i ssues such as how and when you can
be contacted, what the pati ent shoul d do i n case of an emer gency,
who you can tal k to about the pati ent, and how to deal wi th mi ssed
appoi ntments. As you face thi s ar ray of deci si ons, the fol l owi ng ti ps
and i deas shoul d hel p you devi se pol i ci es that fi t your per sonal i ty
and cl i ni cal setti ng.

Contacting You
You defi ne the boundar i es of the cl i ni cal r el ati onshi p by setti ng
l i mi ts on wher e and when pati ents can r each you. Do thi s ear l y on;
i f you don't, you'l l eventual l y suffer for i t.
I found thi s out the har d way wi th my ver y fi r st therapy pati ent
dur i ng r esi dency. She was a 40-year-ol d woman I'l l cal l Sal l y who
had pani c di sor der and depr essi on. I fi r st met her i n the cr i si s
cl i ni c, wher e she came after an upsetti ng conver sati on wi th her
father. I spoke to her for hal f an hour, and I gave her a

fol l ow-up appoi ntment for the next weekand I gave her my pager
number and tol d her that thi s was a way to r each me, anyti me.
The next Satur day mor ni ng, over br eakfast and the paper, I got my
fi r st page: Cal l Sal l y. She was i n the mi ddl e of a pani c attack,
whi ch subsi ded after a 10-mi nute conver sati on. Later that day, as I
was r i di ng my bi ke, I got another page. Cal l Sal l y. I was
somewher e on a countr y r oad i n Concor d, Massachusetts, and far
fr om a phone. Ten mi nutes l ater : Cal l Sal l y. Ur gent. Over the next
hour, I r ecei ved si x pages, each soundi ng mor e ur gent as the
al ar med hospi tal operator added mor e and mor e punctuati on. The
l ast page r ead, Cal l Sal l y!!! Emer gency!!!!!! When I fi nal l y found
a pay phone, my hear t poundi ng, Sal l y sai d, Doctor ! I just had
another pani c attack.
I fel t the fi r st hi nt of what I l ater l ear ned was
counter transfer ence. At the ti me, I cal l ed i t bei ng pi ssed off. I
tr i ed to keep the i r r i tati on out of my voi ce as I tol d her she di dn't
have to cal l me ever y ti me she had a pani c attack. At our next
appoi ntment, after some good super vi si on, I l ai d out some gr ound
r ul es. Sal l y coul d page me onl y dur i ng the week between 8 a.m. and
5 p.m. Other wi se, she was i nstr ucted to go to the cr i si s cl i ni c. Thi s
i n i tsel f hel ped decr ease the fr equency of her pani c attacks, because
i t took away the r ei nfor cement of a phone conver sati on wi th her
therapi st ever y ti me she pani cked.

Suggestions
Never gi ve your home tel ephone number to pati ents and
consi der keepi ng an unl i sted phone number.
You may gi ve out your pagi ng number, but speci fy the ti mes
when you'r e avai l abl e to be paged. Don't l et your l i fe r evol ve
ar ound your pager. Tel l your pati ent what to do i f ther e i s an
emer gency at a ti me when you ar e not avai l abl e for pagi ng. For
exampl e, he can cal l the cr i si s cl i ni c, and you can gi ve the cl i ni c
i nstr ucti ons to page you after hour s i f the on-cal l cl i ni ci an
judges that the si tuati on war rants your i mmedi ate i nvol vement.
If you have a voi ce-mai l system, have pati ents r each you ther e.
Your voi ce mai l i s accessi bl e 24 hour s a day, and you can check
i t whenever you want and deci de who to cal l back and when.
Some pati ents wi l l cal l your voi ce mai l just to be soothed by
your r ecor ded voi ce.
When you'r e on vacati on, I suggest you si gn your pati ents out to
a cl i ni ci an you know and tr ust, rather than have them cal l the
cr i si s cl i ni c dur i ng r egul ar hour s. That way, you can ensur e that
someone i s pr epar ed to deal wi th any i mpendi ng cr i ses. For
exampl e, you may have pati ents

who ar e chr oni cal l y sui ci dal but rar el y r equi r e hospi tal i z ati on
and can be managed thr ough cr i ses wi th fr equent outpati ent
suppor t. Letti ng your col l eague know about these pati ents may
pr event i nappr opr i ate hospi tal i z ati on.
Many cl i ni ci ans use e-mai l as a way of contacti ng pati ents. Thi s
can be a ti me-saver, because you can answer qui ck questi ons
wi thout bei ng at the mer cy of the avai l abi l i ty of your pati ent's
cel l phone or voi ce mai l . But agai n, wi thout cer tai n gr ound
r ul es, thi s can (and wi l l ) get out of hand. Make sur e your
pati ents know that e-mai l communi cati on i s not a for m of
tr eatment. Speci fy what you ar e wi l l i ng to use e-mai l for.
Typi cal l y, thi s wi l l be l i mi ted to schedul i ng changes and r equests
for pr escr i pti on r efi l l s. If you star t answer i ng mor e i nvol ved
cl i ni cal questi ons over e-mai l , be awar e that thi s i s par t of the
medi cal r ecor d, and you shoul d pr i nt out a copy of any
cor r espondence and put i t i n the char t.

Contacting the Patient


Be sur e to obtai n your pati ent's var i ous phone number s (e.g., home,
wor k, day tr eatment pr ogram). Ask whether i t's okay for you to
i denti fy your sel f when you cal l , because some pati ents don't want
empl oyer s or fami l y member s to know that they'r e i n tr eatment.
Obtai n number s of fami l y member s or cl ose fr i ends so that you can
contact them ei ther to gather cl i ni cal i nfor mati on or i n emer gency
si tuati ons. You'l l need to obtai n your pati ent's consent for thi s
ahead of ti me.

Missed Appointments
The usual practi ce i s to tel l pati ents that they must i nfor m you at
l east 24 hour s i n advance of any mi ssed appoi ntments or they wi l l
be char ged, except i n emer gency si tuati ons. As a sal ar i ed trai nee,
the fi nanci al aspects of thi s pol i cy ar en't r el evant, but ther e ar e
i mpor tant cl i ni cal benefi ts. Pati ents who make the effor t to show up
for sessi ons show a l evel of commi tment that bodes wel l for
therapeuti c success. Thi s pol i cy encourages that commi tment.
What i f a pati ent r epeatedl y cancel s sessi ons (al bei t i n ti me to
avoi d payi ng)? F i r st, fi gur e out why she i s cancel i ng. Is i t for a
l egi ti mate r eason, or i s she acti ng out some feel i ngs of anxi ety or
hosti l i ty? Di d you just r etur n fr om vacati on? If so,

thi s i s a common ti me for pati ents to act out a sense of havi ng been
abandoned by you.
One way to appr oach thi s i ssue i s head-on:

I notice that since I r etur ned fr om vacation, you've


canceled thr ee sessions in a r ow. What's going on?
Sometimes people get angr y at their ther apists.

I've noticed that since we star ted talking about the


causes of your bulimia, you've missed a lot of
sessions. Should we be going a bit mor e slowly with
these issues?

Footnotes
*Adapted fr om the questi onnai r e of Edwar d Messner, M.D.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 3 - The
The ra pe ut ic Allia nc e : W ha t It Is , W hy It ' s Im po rt a nt , a nd Ho w t o Es t a blis h It

3
The Therapeutic Alliance: What It Is,
Why It's Important, and How to
Establish It

Essential Concepts

Be war m, cour teous, and emoti onal l y sensi ti ve.


Acti vel y defuse the strangeness of the cl i ni cal si tuati on.
G i ve your pati ent the openi ng wor d.
G ai n your pati ent's tr ust by pr ojecti ng competence.

The therapeuti c al l i ance i s a feel i ng that you shoul d cr eate over the
cour se of the di agnosti c i nter vi ewa sense of rappor t, tr ust, and
war mth. Most r esear ch on the therapeuti c al l i ance has been done i n
the context of psychotherapy, rather than the di agnosti c i nter vi ew.
Jer ome F rank, author of Per suasi on and Heal i ng (F rank 1991) and
the father of the comparati ve study of psychotherapy, found that a
therapeuti c al l i ance i s the most i mpor tant i ngr edi ent i n al l effecti ve
psychotherapi es. Cr eati ng rappor t i s tr ul y an ar t and ther efor e
di ffi cul t to teach, but her e ar e some ti ps that shoul d i ncr ease your
success.

BE YOURSELF
Al though ther e i s much to be l ear ned fr om books and r esear ch
about how to be a good i nter vi ewer, you'l l never enjoy thi s
psychi atr y racket ver y much unl ess you can fi nd some way to i nject
your own per sonal i ty and styl e i nto your wor k. If you can't do thi s,
you'l l al ways be wor ki ng at odds wi th who you ar e, and thi s wor k
wi l l exhaust you.

CLINICAL VIGNETTE
My fr i end and col l eague, Leo Shapi r o, does both i npati ent and
outpati ent wor k. He's a character, no questi on about i t.
P.
As a pati ent, you'l l mor e l i kel y l ove hi m than hate hi m, but ei ther
way, what you see i s what you get.
Two exampl es of Dr. Shapi r o's unor thodox styl e:

1. Wal ki ng down the hal l way of the i npati ent uni t, Dr. Shapi r o
spotted the pati ent he needed to i nter vi ew next.

Dr. Hey, what's wrong, does your


Shapiro: face hurt?

Patient: No, my face doesn't hurt.

Dr.
Well, it's killing me!
Shapiro:

The pati ent chuckl ed, and the rappor t was sol i di fi ed.
2. The Shapi r o thumbwr estl i ng pl oy:
An angr y, depr essed man was demandi ng to be di schar ged,
pr ematur el y accor di ng to staff r epor ts. Dr. Shapi r o agr eed that
di schar ge woul d be r i sky, par tl y because the pati ent had
devel oped l i ttl e i n the way of rappor t wi th anyone.

Dr. I understand you want to be


Shapiro: discharged?

Of course, this place is stupid,


Patient:
no one's helping me.
Dr. If you can beat me at
Shapiro: thumbwrestling, I'll let you
leave.

Patient: What?!!!

(Putting out his hand)


Dr.
Seriously. Or are you afraid of
Shapiro:
the challenge?

(Reluctantly joining hands with


Patient:
Shapiro) This is crazy.

Dr.
One, two, three, go.
Shapiro:

Dr. Shapi r o qui ckl y wi ns, as he al ways does. Wel l , I guess you
have to stay another day. See you tomor r ow.

(Smiling, despite himself)


Patient:
That's it?

Dr. What? You wanna talk, OK,


Shapiro: let's talk.

A si gni fi cant exchange ensued, and the pati ent was i n fact
di schar ged that after noon wi th appr opr i ate fol l ow up.
No, I'm not necessar i l y endor si ng the Shapi r o techni que. It wor ks
gr eat, because that's hi s Br ookl yn per sonal i ty, but i t woul d be a
di saster for me, a mel l ow Cal i for ni an at hear t. The key i s to be
abl e to adapt your own per sonal i ty to the task at handhel pi ng
pati ents feel better.

BE WARM, COURTEOUS, AND EMOTIONALLY


SENSITIVE
Ar e ther e any speci fi c i nter vi ewi ng techni ques that l ead to good
rappor t? Sur pr i si ngl y, the answer appear s to be no, and that i s
good news. A gr oup of r esear cher s fr om London have studi ed thi s
questi on i n depth and publ i shed thei r r esul ts i n seven paper s i n the
Br i ti sh Jour nal of Psychi atr y (Cox et al . 1981a, 1981b, 1988). Thei r
bottom l i ne was that several i nter vi ewi ng styl es wer e equal l y
effecti ve i n el i ci ti ng emoti ons. As l ong as the trai nees whom they
obser ved behaved wi th a basi c sense of war mth, cour tesy, and
sensi ti vi ty, i t di dn't par ti cul ar l y matter whi ch techni ques they used;
al l techni ques wor ked wel l .
No book can teach you war mth, cour tesy, or sensi ti vi ty. These ar e
attr i butes that you pr obabl y al r eady have i f you ar e i n one of the
hel pi ng pr ofessi ons. Just be sur e to consci ousl y acti vate these
qual i ti es dur i ng your i ni ti al i nter vi ew.
Ther e ar e, however, some speci fi c rappor t-bui l di ng techni ques that
you shoul d be awar e of:

Empathic or sympathetic statements, such as you must have


fel t ter r i bl e when she l eft you, communi cate your acceptance
and under standi ng of pai nful emoti ons. Be car eful not to over use
empathi c statements, because they can sound wooden and
i nsi ncer e i f for ced.
Direct feeling questions, such as How di d you feel when she
l eft you? ar e al so effecti ve.
Reflective statements, such as You sound sad when you tal k
about her, ar e effecti ve but al so shoul d not be over used,
because i t can seem as though you ar e stati ng the obvi ous.

What do you do i f you don't l i ke your pati ent? Cer tai nl y, some
pati ents i mmedi atel y seem unl i keabl e, per haps because of thei r
anger, passi vi ty, or dependence. If you ar e bother ed by such
qual i ti es, i t's often hel pful to see them as expr essi ons of
psychopathol ogy and awaken your compassi on for the pati ent on
that basi s. It may al so be that your negati ve feel i ngs ar e
expr essi ons of counter transfer ence, whi ch i s di scussed i n Chapter
12.

ACTIVELY DEFUSE THE STRANGENESS OF THE


CLINICAL SITUATION
It's easy to l ose si ght of the fact that an hour-l ong psychi atr i c
i nter vi ew i s a strange and anxi ety-pr ovoki ng exper i ence.

Your pati ent i s expected to r eveal hi s deepest and most shameful


secr ets to a per fect stranger. Ther e ar e several ways to qui ckl y
defuse that strangeness.

Greet your patient naturally. Al though ther e ar e many


per fectl y acceptabl e ways to gr eet pati ents, a general r ul e of
thumb i s to act natural l y, whi ch usual l y means i ntr oduci ng
your sel f and shaki ng hands. I often engage i n some smal l tal k
for the fi r st few seconds, because many pati ents have a
di stor ted vi ew of psychi atr i sts as myster i ous, si l ent types who
busi l y scr uti ni ze a pati ent's smal l est gestur es. Smal l tal k
under mi nes thi s pr ojecti on and puts the pati ent at ease.
Acceptabl e topi cs i ncl ude the weather and di ffi cul ti es ar r i vi ng at
the offi ce.

Hi, I'm Dr . Car lat. Nice to meet you. I hope you


wer e able to make your way thr ough the maz e
of the hospital without too much tr ouble.

Ask the pati ent what he wants to be cal l ed, and make sur e to
use that name a few ti mes dur i ng the i nter vi ew.

Do you pr efer that I call you Mr . Whalen, or


Michael, or something else?

Usi ng the pati ent's name, especi al l y the fi r st name, i s a gr eat


way of i ncr easi ng a sense of fami l i ar i ty.
Get to know the patient as a person first. Some pati ents fi nd
i t awkwar d to r eveal sensi ti ve i nfor mati on to a stranger. If you
sense that thi s i s the case, you mi ght want to begi n by l ear ni ng
somethi ng about them as peopl e.
Befor e we get into the issues that br ought you
her e, I'd like to know a little bit about you as a
per sonwher e you live, what you do, that sor t
of thing.

Caveat
Some pati ents (as wel l as some cl i ni ci ans) vi ew smal l tal k as
unpr ofessi onal . I tr y to si ze up my pati ent vi sual l y befor e
deci di ng how to gr eet hi m. For exampl e, smal l tal k i s rar el y
appr opr i ate for pati ents who ar e i n obvi ous emoti onal pai n or for
gr ossl y psychoti c pati ents, par ti cul ar l y i f they ar e paranoi d.

Lear ni ng a bi t about your pati ent's demographi cs at the outset has


the added advantage of hel pi ng you star t your di agnosti c
hypothesi z i ng. Ther e's a r eason why the standar d

openi ng l i ne of a wr i tten or oral case pr esentati on i s a descr i pti on


of demographi cs: Thi s i s a 75-year-ol d whi te wi dower who i s a
r eti r ed pol i ce offi cer and l i ves al one i n a smal l apar tment
downtown. You can al r eady begi n to make di agnosti c hypotheses:
He's a wi dower and thus at hi gh r i sk for depr essi on. He's el der l y,
so at hi gher r i sk for dementi a. He appar entl y had a car eer as a
pol i ce offi cer, so pr obabl y i s not schi zophr eni c, and so on. Knowi ng
basi c demographi cs at the outset doesn't excuse you fr om aski ng al l
the questi ons r equi r ed for a di agnosti c eval uati on, but i t cer tai nl y
hel ps set pr i or i ti es i n the di r ecti on of i nqui r y.

Educate the patient about the nature of the interview . Not


ever y pati ent under stands the natur e of an eval uati on i nter vi ew.
Some may thi nk that thi s i s the fi r st sessi on i n a l ong-ter m
psychotherapy. They may come i nto the i nter vi ew wi th the
negati ve, medi a-fed expectati on of a cl i ni ci an who si ts qui etl y
and i nscr utabl y whi l e the pati ent pour s out hi s soul . Other s may
have no i dea why they ar e tal ki ng to you, havi ng been r efer r ed
to a doctor by an i nter ni st who bel i eves psychol ogi cal factor s
ar e i nter fer i ng wi th thei r medi cal tr eatment. Thus, i t's hel pful to
begi n by aski ng the pati ent i f he under stands the pur pose of the
i nter vi ew and then to gi ve hi m your expl anati on, i ncl udi ng the
expected l ength of ti me of the i nter vi ew, what sor ts of
i nfor mati on you'l l be aski ng about, and whether you wi l l fol l ow
hi m for fur ther tr eatment i f needed.
So, Mr. Johnson, did your
Interviewer: doctor explain the purpose of
this interview?

She said you might be able to


Patient:
help me with my nerves.

I certainly hope I can do that.


This is what we call an
evaluation interview. We'll be
meeting for about 50 minutes
today, and I'll be asking you
all sorts of questions, some
about your nerves, some
about your family and other
things, all so I can best
understand what might be
causing you the troubles
Interviewer:
you've been having.
Depending on your problem,
we may need to meet twice to
complete this evaluation, but
the way our clinic works is
that I won't necessarily be the
one who will treat you over
the long term; depending on
what I think is going on, I
may refer you to someone
else for treatment.
A ddress your patient's projections. Keep i n mi nd that a l ot of
shame i s associ ated wi th psychi atr i c di sor der s. Pati ents
commonl y pr oject aspects of thei r own negati ve sel f-i mages onto
you. They may see you as cr i ti cal or judgmental . Havens (1986)
r ecogni zed thi s and encouraged the use of counter pr ojecti ve
statements to i ncr ease the pati ent's sense of safety:

It may be embar r assing for you to r eveal all


these things to a str anger . Who knows how I'd
r eact? In fact, I'm her e to under stand you and
to help you.

CLINICAL VIGNETTE
Paranoi d pati ents often pr oject mal evol ent i ntenti ons onto the
i nter vi ewer. In thi s exampl e, the i nter vi ewer addr esses these
pr ojecti ons di r ectl y:

Are you concerned about why


Interviewer:
I'm asking all these questions?

Sure. You've got to wonder


What's in it for you? How are
Patient:
you going to use all this
information?

I'm going to use it to


understand you better and to
Interviewer:
help you. It won't go any
further than this room.

(Smirking) I've heard that


Patient:
before.

Did someone turn it against


Interviewer: you?

Patient: You bet.

Then I can understand that


you'd be careful about talking
Interviewer:
to meyou probably think I'd
do the same thing.

Patient: You never know.

Wi th the di str ust i ssue br ought out i nto the open, the pati ent was
mor e for thcomi ng thr oughout the r est of the i nter vi ew.

GIVE YOUR PATIENT THE OPENING WORD


In one study of physi ci ans, pati ents wer e al l owed to compl ete thei r
openi ng statements of concer n i n onl y 23% of cases

(Beckman and F ranckel 1984). An average of 18 seconds el apsed


befor e these pati ents wer e i nter r upted. The consequence of thi s
hi ghl y contr ol l i ng i nter vi ewi ng styl e i s that i mpor tant cl i ni cal
i nfor mati on may never make i t out of the pati ent's mouth (Pl att and
McMath 1979).
You shoul d al l ow your pati ents about 5 mi nutes of fr ee speech
(Mor r i son 1995) befor e you ask speci fi c questi ons. Thi s
accompl i shes two goal s: F i r st, i t gi ves your pati ent the sense that
you ar e i nter ested i n l i steni ng, ther eby establ i shi ng rappor t, and
second, i t i ncr eases the l i kel i hood that you wi l l under stand the
i ssues that ar e most tr oubl i ng to the pati ent and ther eby make a
cor r ect di agnosi s. Shea (1988) has cal l ed thi s i ni ti al l i steni ng phase
the scouti ng per i od, because you can use i t to scout for cl ues to
psychopathol ogy that you wi l l want to fol l ow up on l ater i n the
i nter vi ew. It has al so been cal l ed the war m up per i od by Othmer
and Othmer (1994), because one of i ts pur poses i s to cr eate a
comfor t l evel between you and the pati ent so that the pati ent i s not
put off by the l ar ge number of di agnosti c questi ons to come.
Of cour se, you have to be fl exi bl e. Some pati ents begi n i n such a
vague or di sor gani zed fashi on that you wi l l have to ask your
questi ons r i ght away, wher eas other s ar e so ar ti cul ate that i f you
l et them tal k for 10 or 20 mi nutes, they wi l l tel l you al most
ever ythi ng you need to know.
Each cl i ni ci an devel ops hi s or her own fi r st questi on, but al l fi r st
questi ons shoul d be open-ended and shoul d i nvi te the pati ent's
stor y. Her e ar e several exampl es of fi r st questi ons:

What was it that br ought you to the clinic today?


What br ings you to see me today?
What sor ts of things have been tr oubling you?
How can I be of help to you?
What can I do for you?

GAIN YOUR PATIENT'S TRUST BY PROJECTING


COMPETENCE
Thi s i s al ways a tr i cky i ssue for novi ce i nter vi ewer s, who often feel
anythi ng but competent. In fact, your pati ent usual l y gi ves you the
benefi t of the doubt her e, because of somethi ng cal l ed ascr i bed
competence. Thi s i s the competence your pati ent attr i butes to you
pur el y because of your i nsti tuti onal

ti es. You wor k for Hospi tal X or Uni ver si ty Y, so you must be
competent. Ascr i bed confi dence wi l l get you thr ough the fi r st
several mi nutes of the i nter vi ew, but after that, you have to ear n
your pati ent's r espect.
G ai ni ng a pati ent's tr ust i s easi er than you mi ght thi nk. Even as a
novi ce, you know much mor e about mental i l l ness than your
pati ent, and thi s knowl edge i s communi cated by the ki nds of
questi ons you ask. For exampl e, your pati ent tel l s you she i s
depr essed. You i mmedi atel y ask questi ons about sl eep and appeti te.
Most pati ents wi l l be i mpr essed by your abi l i ty to el i ci t r el evant
data i n thi s way.
Other, mor e pr osai c ways of pr ojecti ng competence i ncl ude dr essi ng
pr ofessi onal l y and adopti ng a general atti tude of confi dence. At the
end of the i nter vi ew, your abi l i ty to pr ovi de meani ngful feedback
wi l l fur ther cement your pati ent's r espect.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 4 -
As k ing Q ue s t io ns I: Ho w t o Appro a c h Thre a t e ning To pic s

4
Asking Questions I: How to Approach
Threatening Topics

Essential Concepts

Use normalizing questions to decr ease a pati ent's sense of


embar rassment about a feel i ng or behavi or.
Use symptom expectation and reduction of guilt to defuse
the admi ssi on of embar rassi ng behavi or.
Use symptom exaggeration to deter mi ne the actual
fr equency of a sensi ti ve or shameful behavi or.
Use familiar language when aski ng about behavi or s.

Al ways the beauti ful answer who asks a mor e


beauti ful questi on.
--e. e. cummi ngs

Over the cour se of the di agnosti c i nter vi ew, many of your questi ons
wi l l be thr eateni ng to your pati ent. The si mpl e admi ssi on of
psychi atr i c symptoms i s humi l i ati ng for many peopl e, as i s the
admi ssi on of behavi or s consi der ed by soci ety to be ei ther
undesi rabl e or abnor mal . Such behavi or s i ncl ude dr ug and al cohol
abuse, vi ol ence, and homosexual i ty. Beyond thi s, ther e ar e other
behavi or s that your pati ents may not want to admi t, because they
may thi nk you wi l l di sappr ove of them per sonal l y. These mi ght
i ncl ude a hi stor y of noncompl i ance wi th mental heal th tr eatment, a
checker ed wor k hi stor y, or a defi ci ent soci al l i fe.
To mai ntai n a heal thy sel f-i mage, pati ents may l i e when asked what
they per cei ve to be thr eateni ng questi ons. Thi s has been a
si gni fi cant pr obl em among both cl i ni ci ans and pr ofessi onal
sur veyor s for year s, and a r eper toi r e of i nter vi ewi ng techni ques has
been devel oped to i ncr ease the val i di ty of r esponses to thr eateni ng
questi ons (Payne 1951; Shea 1988; Sudman and Bradbur n 1987).
G ood cl i ni ci ans i nsti ncti vel y use many of these techni ques, havi ng
found thr ough tr i al and er r or that they i mpr ove the val i di ty of the
i nter vi ew.

NORMALIZATION
Nor mal i z ati on i s the most common and useful techni que for el i ci ti ng
sensi ti ve or embar rassi ng mater i al . The techni que i nvol ves
i ntr oduci ng your questi on wi th some type of nor mal i z i ng statement.
Ther e ar e two pr i nci pal ways to do thi s:

1. Star t the question by implying that the behavior is a nor mal or


under standable r esponse to a mood or situation:

With all the str ess you've been under , I wonder


if you've been dr inking mor e lately?
Sometimes when people ar e ver y depr essed,
they think of hur ting themselves. Has this been
tr ue for you?
Sometimes when people ar e under str ess or ar e
feeling lonely, they binge on lar ge amounts of
food to make themselves feel better . Is this
tr ue for you?

2. Begi n by descr i bi ng another pati ent (or pati ents) who has
engaged i n the behavi or, showi ng your pati ent that she i s not
al one:

I've seen a number of patients who've told me


that their anxiety causes them to avoid doing
things, like dr iving on the highway or going to
the gr ocer y stor e. Has that been tr ue for you?
I've talked to sever al patients who've said that
their depr ession causes them to have str ange
exper iences, like hear ing voices or thinking that
str anger s ar e laughing at them. Has that been
happening to you?

It's possi bl e to go too far wi th nor mal i z ati on. Some behavi or s ar e
i mpossi bl e to consi der nor mal or under standabl e, such as acts of
extr eme vi ol ence or sexual abuse, so don't use nor mal i z ati on to ask
about these.

SYMPTOM EXPECTATION
Symptom expectati on, al so known as the gentl e assumpti on (Shea
1988), i s si mi l ar to nor mal i z ati on: You communi cate that a behavi or
i s i n some way nor mal or expected. Phrase your questi ons to i mpl y
that you al r eady assume the pati ent has engaged i n some behavi or
and that you wi l l not be offended by a posi ti ve r esponse. Thi s
techni que i s most

useful when you have a hi gh i ndex of suspi ci on of some sel f-


destr ucti ve acti vi ty. A few exampl es fol l ow:

Drug use. Your pati ent has r el uctantl y admi tted to excessi ve
al cohol use, and you str ongl y suspect abuse of i l l i ci t dr ugs.
Symptom expectati on may encourage a strai ghtfor war d, honest
r esponse.

What sor ts of dr ugs do you usual l y use when


you'r e dr i nki ng?

Suicidality. Your pati ent i s pr ofoundl y depr essed and has


expr essed feel i ngs of hopel essness. You suspect SI, but you
sense that the pati ent may be too ashamed to admi t i t. Rather
than gi nger l y aski ng, Have you had any thoughts that you'd be
better off dead? you mi ght deci de to use symptom expectati on.

What ki nds of ways to hur t your sel f have you


thought about?

Remember to use thi s techni que onl y when you suspect that the
pati ent has engaged i n the behavi or. For exampl e, the questi on
What ki nds of r ecr eati onal dr ugs do you use? may be appr opr i ate
when i nter vi ewi ng a young mal e admi tted for a sui ci dal gestur e
whi l e i ntoxi cated, but wi l dl y i nappr opr i ate for a 70-year-ol d woman
bei ng assessed for dementi a.
SYMPTOM EXAGGERATION
F r equentl y, a pati ent mi ni mi zes the degr ee of hi s pathol ogy, ei ther
to fool you or hi msel f. Symptom exaggerati on or ampl i fi cati on (Shea
1988), often used wi th symptom expectati on, i s hel pful i n cl ar i fyi ng
the sever i ty of symptoms. The techni que i nvol ves suggesti ng a
fr equency of a pr obl emati c behavi or that i s hi gher than your
expectati on, so that the pati ent feel s that hi s actual , l ower
fr equency of the behavi or wi l l not be per cei ved by you as bei ng
bad.

How much vodka do you dr ink each day? Two fifths? Thr ee?
Mor e?
How many times do you binge and pur ge each day? F ive times?
Ten times?
How many suicide attempts have you had since your last
hospitaliz ation? F our ? F ive?

As i s tr ue for symptom expectati on, you must r eser ve thi s techni que
for si tuati ons i n whi ch i t seems appr opr i ate. For exampl e,

i f you have no r eason to suspect that a pati ent has a dr i nki ng


pr obl em, aski ng how many cases of beer he dr i nks each day wi l l
sound qui te i nsul ti ng!

REDUCTION OF GUILT
Al though i t i s tr ue that al l the techni ques i n thi s chapter boi l down
to r educi ng a pati ent's sense of shame and gui l t, the r educti on-of-
gui l t techni que seeks to di r ectl y r educe a pati ent's gui l t about a
speci fi c behavi or to di scover what he has been doi ng. Thi s techni que
i s especi al l y useful i n obtai ni ng a hi stor y of domesti c vi ol ence and
other anti soci al behavi or.

Domestic Violence

When you argue with your wife,


Interviewer: does she ever throw things at
you or hit you?
She sure does. See this scar?
Patient: She threw a vase at me 2 years
ago.

Interviewer: Do you fight back?

Well, yes. I've bruised her a few


Patient: times. Nothing compared to
what she did to me.

Another ver si on of thi s techni que i s to begi n by aski ng about other


peopl e:

Do you have any friends who


push around their wives or
Interviewer:
girlfriends when they have an
argument?

Sure. They get pushed back,


Patient:
too.

Have you done that yourself,


Interviewer:
pushed or hit your wife?

Yeah. I'm not proud of it, but


Patient: I've done it when she's gotten
out of hand.

Antisocial Behavior
P.2

Have you ever had any legal


Interviewer:
problems?

Oh, here and there. A little


Patient:
shoplifting. Normal stuff.

Really? What was the best thing


Interviewer:
you ever stole?

The best thing? Well, I was into


cars for a while. I spent a week
cruising around in a Porsche
Patient:
924, but I returned it. I was just
into joyrides. Everyone was
doing it back then.

In thi s exampl e, the i nter vi ewer used i nducti on to braggi ng to


r educe the pati ent's sense of gui l t and l ead to an admi ssi on of
somethi ng mor e si gni fi cant than shopl i fti ng.

USE FAMILIAR LANGUAGE WHEN ASKING


ABOUT BEHAVIORS
Sudman and Bradbur n (1987) compar ed two methods of aski ng
about al cohol use and sexual i ty. In the fi r st method, they used
standar d l anguagewor ds and phrases such as i ntoxi cated and
sexual i nter cour se. In the second method, they used fami l i ar or
poeti c l anguagethe l anguage thei r r espondents used for the
same behavi or, l i ke getti ng l oaded and maki ng l ove. They found that
the use of fami l i ar l anguage i ncr eased r epor ts of these behavi or s by
15% .
Appar entl y, pati ents feel mor e comfor tabl e admi tti ng to soci al l y
undesi rabl e behavi or s i f they feel the i nter vi ewer speaks thei r
l anguage. Tabl e 4.1 suggests var i ous col l oqui al expr essi ons to use
i n pl ace of mor e for mal l anguage.

TABLE 4.1. Using familiar language

Instead of: Say:

Do you have a history of Have you ever shot


intravenous drug use? up?

Do you get high?


Do you smoke
Do you smoke
marijuana?
dope?

Do you snort coke?


Do you use cocaine?
Smoke crack?
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 5 -
As k ing Q ue s t io ns II: Tric k s fo r Im pro v ing Pa t ie nt Re c a ll

5
Asking Questions II: Tricks for
Improving Patient Recall

Essential Concepts

Anchor questi ons to memorabl e events.


Tag questi ons wi th speci fi c exampl es.
Descr i be syndr omes i n your pati ent's ter ms.

Utter i ng a wor d i s l i ke str i ki ng a note on the


keyboar d of the i magi nati on.
--Ludwi g Wi ttgenstei n

Thr oughout the di agnosti c i nter vi ew, your pati ent's memor y wi l l be
both your al l y and your enemy. Even when the desi r ed i nfor mati on
i s not thr eateni ng i n any way, be pr epar ed for major i naccuraci es
and fr ustrati on i f the events descr i bed occur r ed mor e than a few
months ago. Nonethel ess, we've al l had the i n-trai ni ng exper i ence
of watchi ng an excel l ent teacher el i ci t l ar ge quanti ti es of hi stor i cal
i nfor mati on fr om a pati ent for whom we coul d bar el y deter mi ne age
and sex. How do they do i t? Her e ar e some tr i cks of the trade.

ANCHOR QUESTIONS TO MEMORABLE EVENTS


Resear cher s have found that most peopl e for get dates of events that
occur r ed mor e than 10 days i n the past (Az ar 1997). Instead, we
r emember the di stant past i n r el ati on to memorabl e events or
per i ods (Sudman and Bradbur n 1987), such as major transi ti ons
(graduati ons and bi r thdays), hol i days, acci dents or i l l nesses, major
pur chases (a house or a car ), seasonal events (the gr eat bl i z z ar d
of '78), or publ i c events (such as the O. J. Si mpson tr i al or
Pr i ncess Di ana's death).
As an exampl e, suppose you ar e i nter vi ewi ng a young woman wi th
depr essi on. You fi nd out over the cour se of the i nter vi ew that she
has a heavy dr i nki ng hi stor y, and you want to deter mi ne

whi ch came fi r st, the al cohol i sm or the depr essi on. You coul d ask,
How many year s ago di d you begi n dr i nki ng? fol l owed by How
many year s ago di d you become depr essed? but chances ar e you
won't get an accurate answer to ei ther questi on. Instead, use the
anchor i ng techni que:

Did you drink when you


Interviewer:
graduated from high school?

I was drinking a lot back then,


every weekend at least.
Patient:
Graduation week was one big
party.

Interviewer: Were you depressed then, too?

Patient: I think so.

How about when you first


Interviewer: started high school? Were you
drinking then?

Oh no, I didn't really start


drinking until I hooked up with
Patient:
my best friend toward the end of
my freshman year.
Were you depressed when you
Interviewer:
started school?

Oh yeah, I could barely get up in


Patient: time to make it to classes, I was
so down.

You've succeeded i n establ i shi ng that her depr essi on pr edated her
al cohol i sm, whi ch may have i mpor tant i mpl i cati ons for tr eatment.

TAG QUESTIONS WITH SPECIFIC EXAMPLES


In Chapter 8, you'l l l ear n about the val ue of mul ti pl e-choi ce
questi ons i n l i mi ti ng over l y tal kati ve pati ents. Taggi ng wi th
exampl es i s si mi l ar to posi ng mul ti pl e-choi ce questi ons, but i t i s
used speci fi cal l y for ar eas i n whi ch your pati ent i s havi ng tr oubl e
wi th r ecal l . You si mpl y tag a l i st of exampl es onto the end of your
questi on.
To ascer tai n what medi cati ons your pati ent has taken i n the past for
depr essi on, for exampl e:

P.2

What were the names of the


Interviewer:
medications you took back then?

Who knows? I really don't


Patient:
remember.

Was it Prozac, Paxil, Zoloft,


Interviewer:
Elavil, Pamelor?

Pamelor, I think. It gave me a


Patient:
really dry mouth.
DEFINE TECHNICAL TERMS
Someti mes what appear s to be a pati ent's vague r ecal l i s actual l y a
l ack of under standi ng of ter ms. For exampl e, suppose you ar e
i nter vi ewi ng a 40-year-ol d man wi th depr essi on, and you want to
deter mi ne when he had hi s fi r st epi sode:

How old were you when you first


Interviewer:
remember feeling depressed?

I don't know. I've always been


Patient:
depressed.

You suspect that you and the pati ent have di ffer ent meani ngs of
depr essi on, and you al ter your appr oach:

Just to clarify: I'm not talking


about the kind of sadness that
we all experience from time to
time. I'm trying to understand
when you first felt what we call
a clinical depression, and by that
I mean that you were so down
Interviewer: that it seriously affected your
functioning, so that, for
example, it might have
interfered with your sleep, your
appetite, and your ability to
concentrate. When do you
remember first experiencing
something that severe?
Oh, that just started a month
Patient:
ago.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 6 -
As k ing Q ue s t io ns III: Ho w t o C ha nge To pic s w it h St y le

6
Asking Questions III: How to Change
Topics with Style

Essential Concepts

Use smooth transitions to cue off somethi ng the pati ent just
sai d.
Use referred transitions to cue off somethi ng sai d ear l i er i n
the i nter vi ew.
Use introduced transitions to pul l a new topi c fr om thi n ai r.

Inter vi ewi ng a pati ent for the fi r st ti me r equi r es touchi ng on many


di ffer ent topi cs wi thi n a br i ef per i od. You'l l need to constantl y
change the subject, whi ch can be jar r i ng and off-putti ng to a
pati ent, especi al l y when she i s i nvol ved i n an i mpor tant and
emoti onal topi c. Ski l l ed i nter vi ewer s ar e abl e to change topi cs
wi thout al i enati ng thei r pati ents and use var i ous transi ti ons to tur n
the i nter vi ew i nto what Har r y Stack Sul l i van (1970) cal l ed a
col l aborati ve i nqui r y.

SMOOTH TRANSITION
In the smooth transi ti on (Sul l i van 1970), you cue off somethi ng the
pati ent just sai d to i ntr oduce a new topi c. For exampl e, a depr essed
pati ent i s per severati ng on confl i cts wi th her husband and
stepchi l dr en; the i nter vi ewer wants to obtai n i nfor mati on on fami l y
psychi atr i c hi stor y:
John has been good to me, but I
can't stand the way his
Patient: daughters expect me to go out
of my way to make their lives
easy; after all, they're adults!

Speaking of family, has anyone


else in your family been through
Interviewer:
the kind of depression that
you've been going through?

REFERRED TRANSITION
In the r efer r ed transi ti on (Shea 1988), you r efer to somethi ng the
pati ent sai d ear l i er i n the i nter vi ew to move to a new topi c. For
exampl e, at the begi nni ng of an i nter vi ew, a depr essed pati ent had
br i efl y menti oned that he di dn't know i f he coul d take thi s
si tuati on any mor e. Now, wel l i nto the eval uati on, the i nter vi ewer
wants to ful l y assess sui ci dal i ty:

My doctor tried me on some


Patient: medication for a while, but it
didn't do much good.

Earlier, you mentioned that you


didn't know how much more of
Interviewer: this you could take. Have you
had the thought that you'd be
better off dead?

INTRODUCED TRANSITION
In the i ntr oduced transi ti on, you i ntr oduce the next topi c or ser i es
of topi cs befor e actual l y l aunchi ng i nto i t. Thi s transi ti on i s often
begun by a statement such as, Now I'd l i ke to swi tch gear s. or
I'd l i ke to ask some di ffer ent ki nds of questi ons now. For exampl e,
you need to qui ckl y r un thr ough the PROS, but you don't want the
pati ent to thi nk that you ar e aski ng these questi ons because you
expect that he actual l y exper i ences al l of these symptoms:

Now I'd like to switch gears a


little and ask you about a bunch
of different psychological
symptoms that people
Interviewer:
sometimes have. Many of these
may not apply to you at all, and
that is a useful thing to know in
itself.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 7 -
Te c hnique s fo r t he Re luc t a nt Pa t ie nt

7
Techniques for the Reluctant Patient

Essential Concepts

Use open-ended questions and commands to i ncr ease the


fl ow of i nfor mati on.
Use continuation techni ques to keep the fl ow comi ng.
Shift to neutral ground when necessar y.
Schedule a second interview when al l el se fai l s.

Occasi onal l y, you r un i nto the i deal pati ent. She's tr oubl ed and
eager to tal k. She br i efl y outl i nes the pr obl ems that l ed to her vi si t
and then answer s each of your questi ons i n ful l , stoppi ng i n
pr eparati on for your next quer y. You fi nd that you've gather ed al l
the vi tal i nfor mati on i n 30 mi nutes, and you have the l uxur y of
expl or i ng her soci al and devel opmental hi stor y deepl y. You feel l i ke
a r eal therapi st. Your mi nd i s whi r r i ng, and you can't wai t to dust
off that copy of F r eud you bought the day you got i nto your trai ni ng
pr ogram but haven't had ti me to l ook at si nce.
Usual l y, however, your pati ent wi l l fal l somewher e on ei ther si de of
a spectr um of i nfor mati on fl ow. Ei ther he's not sayi ng enough or
he's sayi ng too much, and i t's not hi s faul t. The average pati ent has
no way of knowi ng what i nfor mati on i s and i s not i mpor tant for a
psychi atr i c di agnosi s. It's up to you to educate the pati ent and to
steer the i nter vi ew appr opr i atel y.

OPEN-ENDED QUESTIONS AND COMMANDS


You can use open-ended questi ons and commands to i ncr ease the
fl ow of i nfor mati on. Open-ended questi ons can't be answer ed wi th a
si mpl e yes or no.

What ki nds of symptoms has your depr essi on caused?


What sor ts of thi ngs have you done when you fel t mani c?

Open-ended commands ar e questi ons al ter ed sl i ghtl y to sound mor e


di r ecti ve.

Tel l me what ki nds of symptoms you've had.


Descr i be for me some of the thi ngs you've done whi l e you wer e
mani c.

CLINICAL VIGNETTE
The pati ent was a woman i n her 30s who had been admi tted to
the hospi tal after an over dose. She was unhappy wi th the
i nvol untar y admi ssi on and i ni ti al l y r esi stant to answer i ng
questi ons.

I understand that you took an


Interviewer: overdose of your medicine last
week.

Patient: Uh huh.

What do you think was going


Interviewer:
on? (An open-ended question.)

I don't know. (Which doesn't


Patient:
get anywhere.)

Interviewer: Were you feeling depressed?

Patient: Maybe.
Tell me a little about how you
Interviewer: were feeling. (An open-ended
command.)

There's not much to tell. I took


Patient: the pills, that's all. (Still no
results.)

I really want to help you, but


the only way I can do that is to
understand what was going
through your head when you
Interviewer:
took the pills. (Some
education, combined with
another, more specific,
command.)

I guess I thought it would be a


good idea to take 'em. My
Patient: husband was driving me crazy.
(Now we're getting
somewhere.)

CONTINUATION TECHNIQUES
Conti nuati on techni ques can be used to keep the fl ow comi ng. These
expr essi ons encourage a pati ent to conti nue r eveal i ng sensi ti ve
i nfor mati on:

G o on.
Uh huh.
Conti nue wi th what you wer e sayi ng about
Real l y?
Wow.

They ar e often combi ned wi th faci l i tati ve body l anguage, such as


head nods, per si stent eye contact, hol di ng the chi n between thumb
and i ndex fi nger, and faci al emoti onal r esponse to the mater i al .
G eneral l y, the mor e spontaneous and genui ne your r esponses to
r el uctant pati ents, the mor e l i kel y you ar e to di sar m them.

NEUTRAL GROUND
Some i nter vi ews begi n badl y and qui ckl y deter i orate. For exampl e,
you may have had the exper i ence of i nter vi ewi ng a pati ent who
becomes i ncr easi ngl y al i enated as your questi ons become mor e
psychi atr i c. If thi s happens, tr y changi ng the subject to somethi ng
nonpsychi atr i c, wi th the i ntenti on of si dl i ng back i nto your ter r i tor y
once you've gai ned the pati ent's tr ust.
I i nter vi ewed a col l ege student who was r efer r ed by hi s dean for
psychol ogi cal eval uati on after havi ng sai d he woul d ki l l hi msel f i f he
was not gi ven a better grade i n a cour se. He was an unwi l l i ng
par ti ci pant and had shown up onl y because he was thr eatened wi th
suspensi on i f he di d not.
After the fi r st 5 mi nutes of the i nter vi ew, i t was cl ear that he was
not i nter ested i n tal ki ng about what was goi ng thr ough hi s mi nd, so
I shi fted to r el ati vel y neutral gr ound.

P.3

Interviewer: So how do you like college X?

It's fine. There's a good English


Patient:
department.

Really? Any particularly


Interviewer:
interesting classes?
Patient: King Lear and the Modern World.

It's been a while since I read


Interviewer: that. How is King Lear related to
the modern world?

It's all about money and power.


Everyone sucks up to King Lear
because he has all this land to
Patient:
give away. It's the same way
with lobbyists in Washington. Or
professors at a university.

Is that the way it is at your


Interviewer:
college?

Of course. Professors sit in their


offices, fat and happy, and
Patient: students mean nothing to them.
Unless they can get you to be
their slave.

Thi s l ed to a di scussi on of hi s fr ustrati ons wi th school , whi ch i n tur n


l ed to hi s r eveal i ng the extent of hi s depr essi ve symptoms.

SECOND INTERVIEW
When al l el se fai l s, you may need to schedul e a second i nter vi ew. If
you'r e not getti ng anywher e wi th the pati ent, no matter how many
i nter vi ewi ng tr i cks you use, you may need to cut the i nter vi ew shor t
wi th a comment such as

Why don't we stop for now and meet again next


week [or tomor r ow, for inpatient wor k]. That will
give you a chance to think mor e about the sor ts of
things that ar e bother ing you, and we can take it
fr om ther e.

I've done thi s several ti mes, and the pati ent i s usual l y mor e
for thcomi ng at the next i nter vi ew. I'm not sur e why thi s wor ks.
Maybe gi vi ng the message that I accept thei r r el uctance
paradoxi cal l y encourages them to open up, or per haps they feel
awkwar d about not answer i ng questi ons two i nter vi ews i n a r ow.
Of cour se, befor e you end the i nter vi ew, you must feel comfor tabl e
that the pati ent i s not at i mmi nent r i sk of sui ci de or other
danger ous behavi or s.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 8 -
Te c hnique s fo r t he O v e rly Ta lk a t iv e Pa t ie nt

8
Techniques for the Overly Talkative
Patient

Essential Concepts

Use closed-ended and multiple-choice questions to l i mi t


the fl ow.
Per fect the ar t of the gentle interruption.
Educate the pati ent about the need to move al ong i n the
i nter vi ew.

A man does not seek to see hi msel f i n r unni ng


water, but i n sti l l water. For onl y what i s i tsel f sti l l
can i mpar t sti l l ness i nto other s.
--Chuang-tz u

It was the end of a l ong day i n the cr i si s cl i ni c, and I pi cked up the


l ast char t. I usher ed the pati ent, a mi ddl e-aged woman, i nto the
i nter vi ew r oom. She was wel l -gr oomed and soci al l y appr opr i ate, and
she smi l ed war ml y as she sat down. A good si gn, I thought. She di d
not l ook l i ke the sor t of per son who woul d need to be hospi tal i zed,
whi ch i s a ti me-consumi ng and exhausti ng pr ocess.
How can I be of hel p today? I asked.
I am so gl ad I came her e today, she r esponded. I cannot tel l you
how ter r i bl e my l i fe i s. Someti mes I just don't thi nk i t's wor thwhi l e
goi ng on. It began 21 year s ago, when my fi r st husbanda har d-
dr i nki ng bastar d, a r eal womani zer, someone I r eal l y shoul d never
have hooked up wi th and I woul dn't have i f my par ents hadn't ni xed
ever y other guy they metand I can tel l you, i t was no pi cni c
gr owi ng up i n Westchester, because even though the average
i ncome i s hal f a mi l l i on, they tr eat thei r ki ds r otten.
A vi r tual tor r ent of i nfor mati on fol l owed. For the next hour, I
str uggl ed to r ei n i n her ci r cumstanti al and wander i ng stor i es and to
get at the ker nel of her compl ai nt.
The pr obl em wi th over l y tal kati ve pati ents i s how to l i mi t the fl ow
of i nfor mati on wi thout seemi ng i nsensi ti ve and i mpati ent. Cox et al .
(1988), i n an exper i mental study of i nter vi ewi ng

techni ques, found the fol l owi ng techni ques useful for over l y
expr essi ve pati ents:

Cl osed-ended and mul ti pl e-choi ce questi ons


Redi r ecti ng questi ons to another topi c
Str uctur i ng statements r egar di ng i nfor mati on r equi r ed and/or
cl i ni cal pr ocedur es

In general , they found that a br i sk, hi ghl y contr ol l i ng styl e was


hel pful i n l i mi ti ng over l y expr essi ve pati ents, wi thout al i enati ng
them.

USE CLOSED-ENDED AND MULTIPLE-CHOICE


QUESTIONS
Al though open-ended questi ons shoul d be used wi th most pati ents,
they wi l l tend to i ncr ease the tal kati veness of ci r cumstanti al
pati ents. Wi th such pati ents, the open-ended appr oach mi ght r esul t
i n somethi ng l i ke the fol l owi ng:

Interviewer: How have you been sleeping?

Not great. Who knows, though?


Do you think I've been keeping
track, with each one of my kids
Patient: coming at me with a different
problem, one kid a day, and with
work calling to ask when I'm
coming back, and

Closed-ended questions seek br i ef, yes or no r epl i es or r efer


to a l i mi ted range of possi bl e answer s. Thus,

Have you been sleeping nor mally over the past


week?

i s a cl osed-ended questi on, because i t can be answer ed wi th a yes


or no. The fol l owi ng sl eep questi on i s al so cl osed ended:

How many hour s of sleep did you get last night?

Al though thi s one can't be answer ed wi th a yes or no, i t does


r efer to a l i mi ted number of possi bl e r esponses, somewher e fr om
none to 12 hour s.
Multiple-choice questions l i mi t answer s to a gr eater extent than
do cl osed-ended questi ons. They i ncl ude a l i st of opti ons for
possi bl e answer s to the questi on, gi vi ng your pati ent gui dance as to
the l evel of pr eci si on expected. They ar e often useful i n aski ng
about the neur ovegetati ve symptoms of depr essi on:

How has your appeti te been over the past few weeks: better
than nor mal , wor se than nor mal , or nor mal ?
What sor t of sl eep pr obl em do you have? Pr obl ems fal l i ng
asl eep? Waki ng up thr oughout the ni ght? Waki ng up too ear l y i n
the mor ni ng?

A common cr i ti ci sm of mul ti pl e-choi ce questi ons i s that they may


bi as the pati ent towar d one of your pr epackaged answer s. Cox et al .
(1981b) exami ned thi s i ssue and found that pati ents wer e not
bi ased i n thei r r epl i es, and that mul ti pl e-choi ce questi ons
fr equentl y yi el ded cl ear, on-topi c answer s.
G eneral l y, you shoul d spr i nkl e the i nter vi ew wi th cl osed-ended and
mul ti pl e-choi ce questi ons to r ei n i n an over l y tal kati ve pati ent or
wi th any pati ent wi th whom you have a l ot of gr ound to cover i n a
ver y shor t ti me, such as i n an emer gency r oom eval uati on. Be
judi ci ous i n usi ng these ki nds of questi ons because some pati ents
ar e al i enated by them, and you r i sk tur ni ng a tal kati ve pati ent i nto
a ter mi nal l y r el uctant pati ent.

THE ART OF THE GENTLE INTERRUPTION


Al though i t may feel i mpol i te to i nter r upt your pati ent, you'r e doi ng
hi m no favor by l etti ng hi m rambl e for so l ong that you have
i nsuffi ci ent ti me to do a pr oper eval uati on. In some cases, you need
to take char ge of the i nter vi ew acti vel y. If you can accompl i sh thi s
wi th sensi ti vi ty, you wi l l not al i enate your pati ent. In my
exper i ence, pati ents wi th a rambl i ng, ci r cumstanti al styl e ar e so
used to bei ng i nter r upted that they bar el y fl i nch when you cut i n; i n
fact, they often appear grateful , especi al l y i f they ar e wor ki ng
themsel ves i nto a state of anxi ety or anger wi th thei r trai n of
thought.
The gentl e i nter r upti on i s al so known as a r edi r ecti ng statement
(Cox et al . 1988), and i t comes i n var i ous gui ses.
In the empathic interruption, you add an empathi c statement to
soften the bl ow:

I can tell that this situation's been r eally har d for


you to deal with. Have you been dr inking lately, to
cope with it?

In the delaying interruption, you assur e the pati ent that her topi c
i s i mpor tant and that you'd l i ke to come back to i t l ater :

I can see you feel str ongly about your daughter 's
school tr oubles, and that's something we can talk
about later ,
P.39
but r ight now I need to ask you about some of
those signs of depr ession you wer e exper iencing.
Was your appetite nor mal thr ough all this?

Of cour se, ther e's al so a note of empathy i n that del ayi ng


statement.
The educating interruption i ncor porates a str uctur i ng statement
i n whi ch you educate the pati ent about the sor ts of questi ons you
have yet to ask and the ti me constrai nts you'r e both wor ki ng under.
Usual l y, thi s i s done onl y after you've used the other two
i nter r upti ons several ti mes wi th no r esul ts.

I'm sor r y, but I need to inter r upt you again. We


have about 20 minutes left and a lot of gr ound to
cover , including your tr eatment histor y, your
family backgr ound, and your medical histor y, and I
want to make sur e we have time at the end to talk
about some medication changes. You can help by
tr ying to answer the questions dir ectly and not
getting too sidetr acked. How does that sound?

or,

It's impor tant that I lear n mor e about how you've


been eating and sleeping so that I can tell whether
you'r e suffer ing fr om a clinical depr ession, so I may
continue to inter r upt you to get that impor tant
infor mation.

or, mor e si mpl y,

We r eally have a lot of gr ound to cover over the


next half hour , so I'm going to have to ask you a
lot of questions. This may mean some
inter r uptions, okay?
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 9 -
Te c hnique s fo r t he M a linge ring Pa t ie nt

9
Techniques for the Malingering Patient

Essential Concepts

Rul e out mal i nger i ng i n:


Pati ents on di sabi l i ty.
Pati ents i nvol ved i n l i ti gati on r el ated to a psychi atr i c
condi ti on.
Pati ents seeki ng a pr escr i pti on for a contr ol l ed substance
dur i ng the i ni ti al i nter vi ew.

As you begi n to put mor e and mor e year s of practi ce under your
bel t, you wi l l i ncr easi ngl y begi n to r ecogni ze that some of your
pati ents ar e faki ng thei r symptoms for secondar y gai n. Nobody
knows how common thi s i s, and i t pr obabl y i s pr etty uncommon, but
you wi l l need to know how to r ecogni ze such pati ents and to smoke
them out. Thi s chapter pr ovi des you wi th some hel pful techni ques.
But befor e pr oceedi ng, make sur e not to confuse mal i nger i ng wi th
facti ti ous di sor der, or Mnchausen's syndr ome. Mnchausen's
i nvol ves the sel f-i nfl i cti on of actual pai n or i njur y wi th no cl ear
secondar y gai n bei ng ser ved. Such pati ents may be moti vated by
unconsci ous psychodynami c moti vati ons, and whi l e they, l i ke
mal i nger er s, l i e about thei r symptoms, the ul ti mate tr eatment
appr oach i s di ffer ent, because Mnchausen's r epr esents a
r ecogni zed psychi atr i c syndr ome unto i tsel f, wher eas mal i nger i ng i s
just l yi ng, pl ai n and si mpl e.

CLINICAL VIGNETTE
A 34-year-ol d, si ngl e man pr esented to me after havi ng been
r efer r ed by empl oyee heal th at hi s manufactur i ng company. He
appear ed somewhat di shevel ed and l aunched i nto a nar rati ve
about a wor k si tuati on, sayi ng that It al l star ted on June 6, when
thi s for eman cal l ed me i nto hi s offi ce. As he began descr i bi ng the
epi sode, I r eached over for my pen and cl i pboar d. He r esponded
to my movement wi th a dramati c star tl e r esponse and then
expl ai ned, I don't know what that i s, i t's been happeni ng ever
si nce that day i n June. On my pr ompti ng, he descr i bed i n gr eat
detai l a ser i es of events l eadi ng to hi s cur r ent shor t-ter m medi cal
di sabi l i ty, i ncl udi ng pr eci se dates and names of al l par ti es
i nvol ved. Dur i ng the r evi ew of psychi atr i c symptoms, when asked
about hi s memor y and concentrati on, he sai d, I can't r emember a
si ngl e thi ng si nce June, I can't even r ead.
Obvi ousl y, ther e ar e a number of cl ues to mal i nger i ng her e. The
star tl e r esponse was exaggerated to the poi nt of l ooki ng l i ke a
convul si on, and hi s sel f-descr i bed concentrati on pr obl ems wer e
under mi ned by hi s master ful abi l i ty to descr i be the traumati c
event at wor k. Over ti me, he fai l ed to r espond to any of the
medi cati ons usual l y hel pful for posttraumati c str ess di sor der
(PTSD), and once he was appr oved for l ong-ter m di sabi l i ty, he
stopped comi ng to appoi ntments. The coup de grace was fai l ur e to
pay hi s bi l l because of bankr uptcy!

The fi r st step i n cor r ectl y di agnosi ng mal i nger i ng i s to have a hi gh


i ndex of suspi ci on that i t exi sts. Al l of the fol l owi ng pati ent
categor i es ar e r ed fl ags for possi bl e mal i nger i ng:

Any pati ent on any for m of di sabi l i ty, whether thr ough wor k or
publ i c i nsurance.
Any pati ent i nvol ved i n l i ti gati on havi ng to do wi th the
psychi atr i c i l l ness.
Any pati ent who, ear l y i n the appoi ntment, i ndi cates that he i s
hopi ng to l eave the appoi ntment wi th a pr escr i pti on for a
contr ol l ed medi cati on.

I don't mean to sound hear tl ess; i n my exper i ence, the major i ty of


pati ents on di sabi l i ty ar e genui nel y di sabl ed, and l i ti gati on i s often
l egi ti mate. But i f you rai se your mal i nger i ng antennae wi th these
types of pati ents, you'l l rar el y fi nd your sel f duped.

INTERVIEWING CLUES TO MALINGERING


(AND STRATEGIES FOR RESPONDING)
The Tale Is Just Too Perfect
Al l of the symptoms ar e r eveal ed i n near-per fect DSM-IV-TR or der.
The qual i ty of the symptoms i s textbook, i n the sense that they ar e
pr esented i n the way you mi ght i f you had r ead thei r descr i pti ons
but hadn't actual l y exper i enced them.

Suggested Strategies
Be extra car eful not to l ead these pati ents thr ough symptoms as
you mi ght wi th other new pati ents i n the i nter est of ti me. Keep
questi ons open ended. If you suspect that they ar e tr yi ng to sel l
you on a di agnosi s, thr ow them a l i ttl e off-bal ance by aski ng
somethi ng that they ar e unl i kel y to have r ead much about, e.g.,
Di d ei ther of your par ents have these PTSD symptoms? Dependi ng
on what the answer i s, act mi l dl y sur pr i sed, sayi ng, That's odd, i n
my exper i ence i t's ver y unusual for the par ents of someone wi th
PTSD to have had i t as wel l ; ar e you sur e? The mal i nger er wi l l tend
to al ter her answer s as she feel s i t sui ts your expectati ons: Wel l ,
that's onl y what my br other sai d, I al ways thought they wer e pr etty
nor mal , and I don't thi nk they ever saw a psychi atr i st.

The Tale Is Too Vague


If you come acr oss as pr etty savvy i n your questi oni ng (whi ch you
hopeful l y wi l l after r eadi ng thi s chapter !), many mal i nger i ng
pati ents wi l l wor r y that they wi l l i mmi nentl y sl i p up and r eveal
thei r r use. Such pati ents may r esor t to answer i ng questi ons so
vaguel y that they can't be wr ong, e.g., It's har d to say how I've
been sl eepi ng, i t's been r eal l y l oud outsi de my wi ndow l atel y, and
someti mes when I wake up I can't tel l how l ong I sl ept.

Suggested Strategies
Use extr emel y cl osed-ended questi ons to nai l them down (see
Chapter 8 for exampl es). If that doesn't wor k, pr ecede questi ons
wi th obvi ous l eads, such as, In my exper i ence, pati ents wi th pani c
attacks have ti ngl i ng i n thei r l i ps, has that been tr ue for you? If
pr evi ousl y vague answer s become pr eci se wi th such l eadi ng, you
have a pr etty bi g cl ue to mal i nger i ng.
Nothing Works, Doc
If you have establ i shed that a ser i es of standar d tr eatments have
been tr i ed and that they have al l fai l ed, thi s may si mpl y mean that
the pati ent has a tr eatment-r esi stant condi ti on (whi ch cer tai nl y
happens l egi ti matel y), but i t may r epr esent an ongoi ng effor t to
keep the di sabi l i ty payments comi ng.

Suggested Strategies
Aski ng i n-depth questi ons about medi cati on and psychotherapy
tr i al s wi l l gi ve you a better sense of whether your pati ent was
actual l y compl i ant wi th anythi ng (e.g., as a r ul e of thumb, you
shoul d establ i sh at l east a 4- to 6-week durati on of anti depr essant
tr eatment or at l east 8 sessi ons of therapy). If they have tr i ed the
usual tr eatments and haven't gotten better, make sur e to offer mor e
aggr essi ve tr eatment. Such offer s can be ver y i nfor mati ve, as wi th
one of my pati ents who decl i ned tr i al s of several al ter nati ve
anti depr essants, ci ti ng vague r easons. I expl ai ned that i t woul d be
di ffi cul t for me to conti nue fi l l i ng out hi s di sabi l i ty for ms i f he di dn't
accept needed tr eatment; thi s tur ned out to be hi s l ast vi si t wi th
me.

I Heard about This Thing Called Klonopin


from a Friend Who Has What I Have
Pr escr i pti on substance abuser s (or pusher s) have to get thei r suppl y
somehow, and a favor i te method i s to go doctor-hoppi ng unti l they
fi nd someone who wr i tes the desi r ed pr escr i pti on. Red fl ags her e
i ncl ude

The pati ent asks for the contr ol l ed medi cati on ver y ear l y i n the
eval uati on.
The pati ent qui ckl y i nsi sts that he has tr i ed ever y other
potenti al nonaddi cti ve tr eatment opti on and that they have
ei ther not wor ked or have caused i ntol erabl e si de effects.
The pati ent says he has tr i ed a fr i end's or r el ati ve's medi cati on.
The pati ent has a hi stor y of al cohol or dr ug abuse.
Suggested Strategies
Say, Ar e you awar e that (Dr ug X) i s a ver y danger ous and addi cti ve
medi cati on?s A dr ug-seeker may r espond i n several di ffer ent ways.
He may make a bi g show of bei ng sur pr i sed and say, Real l y? He
may appear unfazed and smoothl y r espond, I know peopl e say i t's
addi cti ve, but I've never had a pr obl em wi th i t. No par ti cul ar
r esponse i s di agnosti c of mal i nger i ng, but i t may hel p sway you i n
one di r ecti on or another. Another hel pful techni que i s to ask to
speak to pr i or pr escr i ber s, be they pr i mar y car e doctor s, nur se
practi ti oner s, or psychi atr i sts. Any hedgi ng or hesi tati on i n
r esponse to thi s enti r el y r easonabl e r equest i s cause for suspi ci on.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 1 0 -
Te c hnique s fo r t he Ado le s c e nt Pa t ie nt

10
Techniques for the Adolescent Patient*

Essential Concepts

Invol ve the fami l y.


Over come the I don't know syndr ome.
Devel op strategi es for aski ng about dr ugs, sex, and conduct
pr obl ems.

Don't l augh at a youth for hi s affectati ons; he i s


onl y tr yi ng on one face after another to fi nd hi s
own.
--Logan Pear sal l Smi th

Ther e ar e thr ee r easons to i ncl ude a chapter on adol escents i n a


book other wi se devoted to adul t psychopathol ogy: (a) Chi l d and
adol escent tr eatment i s a par t of most general trai ni ng pr ograms;
(b) many pr i mar i l y adul t cl i ni ci ans ar e cal l ed on to eval uate
adol escents; and (c) many adul t pati ents ar e sti l l str uggl i ng
thr ough l ate adol escence, whi ch begi ns dur i ng the l ater teen year s
and extends to the ear l y 20s. If you can master the techni ques of
eval uati ng adol escents, you wi l l fi nd your sel f usi ng these same
techni ques for many of your adul t pati ents, of any age.

THE FAMILY INTERVIEW


Your i ni ti al i nter vi ew wi th an adol escent wi l l usual l y i ncl ude fami l y
member s for at l east par t of, and someti mes al l of, the sessi on.
Adol escents ar e gr eat mi ni mi zer s and deni er s, and you often wi l l
need to i nter vi ew the fami l y separatel y to ascer tai n the pr esence of
any pr obl em at al l . In addi ti on, many psychi atr i c di sor der s i n
adol escents ar e str ongl y r el ated to fami l y i ssues, wi th fami l y
dynami cs someti mes contr i buti ng si gni fi cantl y to them (e.g.,
opposi ti onal defi ant di sor der, depr essi on) and at other ti mes bei ng
the cause of fami l y str i fe [e.g., attenti on-defi ci t hyperacti vi ty
di sor der ________

(ADHD)]. F i nal l y, tr eatment can rar el y happen wi thout the consent


and cooperati on of fami l y member s.
Thus, for the fi r st appoi ntment, pl an to i nvi te the enti r e fami l y i nto
your offi ce. Usual l y, I wal k out to the wai ti ng r oom and gr eet the
pati ent wi th an i ntr oducti on and handshake, then face the fami l y,
sayi ng, Why don't we al l go i n for the fi r st par t of the hour, then
maybe I can have some ti me to chat wi th ________ after war d.
Once i n the offi ce, al l ow the fami l y to deci de wher e to si t, and then
shut up and l i sten for a whi l e, just as you woul d wi th your adul t
pati ents. If ther e i s some i ni ti al si l ence, you can get thi ngs goi ng
wi th questi ons such as

What br ings us all together today?

What sor t of issues have been coming up?

or, mor e si mpl y,

Okay, who wants to do the talking?

A par ent usual l y begi ns, and i t i s i mpor tant that you l i sten cl osel y,
because a fami l y's desi r es may be qui te di ffer ent fr om what you
suspected or fr om what you can pr ovi de.

CLINICAL VIGNETTE
Two par ents br ought i n thei r 17-year-ol d son for an eval uati on.
Once i n the offi ce, the mother 's fi r st wor ds wer e, I want you to
commi t my son for hi s dr ug addi cti on.
The son, taken aback, tur ned to her and sai d, Ar e you craz y?
What devel oped was that the par ents had suspected the son of
dr ug use but had tol d hi m that thi s was a fami l y therapy meeti ng
to wor k out some fami l y i ssues. The mother 's expectati on was
that the cl i ni ci an woul d i mmedi atel y have a pol i ce offi cer escor t
the pati ent fr om the offi ce to a substance abuse tr eatment
faci l i ty. The cl i ni ci an expl ai ned that thi s was not possi bl e and
went on to expl ai n the state's l egal cr i ter i a for i nvol untar y
commi tment. Eventual l y, the adol escent agr eed to outpati ent
tr eatment of substance abuse and depr essi on.

Al l ow at l east 5 mi nutes of fr ee speech, i n whi ch you si mpl y l i sten


to fami l y member s di scussi ng the per cei ved pr obl em. Asi de fr om
cl uei ng you i nto di agnosti c possi bi l i ti es, thi s

wi l l al l ow you to under stand the communi cati on styl e and fami l y


dynami cs. After l i steni ng for a few mi nutes, you wi l l want to jump
i n wi th var i ous questi ons to ascer tai n el ements of the psychi atr i c
and soci al hi stor y. It i s i mpor tant to adopt a neutral atti tude so as
not to appear that you ar e taki ng the par ents' si de. If the par ents
constantl y speak over the pati ent (or vi ce ver sa), make a cor r ecti ve
comment, such as

Ever yone obviously has a lot of feelings about this


issue, but it is impor tant that I get a chance to
hear ever yone's viewpoint without too much
inter r upting.

After a per i od of ti me, you wi l l want to tal k to the adol escent al one.

I enjoyed meeting you, and now I'd like to talk


about some things with Matthew. After war d we'll
get back together and discuss what we've talked
about.

THE INDIVIDUAL INTERVIEW


Initial Questions and Strategies
How much ti me shoul d you devote to the i ndi vi dual i nter vi ew? Ther e
ar e no har d-and-fast r ul es. A ful l hour of i ndi vi dual di scussi on may
be appr opr i ate for a sensi ti ve and sophi sti cated 14-year-ol d
adol escent wi th depr essi on, wher eas an angr y and i nvol untar y 17-
year-ol d adol escent wi th conduct di sor der may be abl e to tol erate
no mor e than 5 mi nutes al one wi th you. The mor e ver bal and
engaged the pati ent seems, the mor e ti me you wi l l want to al l ot for
your i ndi vi dual i nter vi ew wi th her.
So ther e you ar e, i n the r oom al one wi th your adol escent pati ent.
Cl i ni ci ans who spend most of thei r ti me wi th adul ts often fr eeze at
thi s poi nt. What do you say to a 15-year-ol d, who may feel qui te
awkwar d and embar rassed, especi al l y now that hi s par ents have l eft
the r oom?
You want to avoi d awkwar d gaps i n the conver sati on as much as
possi bl e, whi ch may i nvol ve doi ng mor e tal ki ng than you nor mal l y
do. Some degr ee of sel f-di scl osur e may be acceptabl e too, to bui l d
rappor t. You can star t wi th some tensi on-r el i evi ng statements such
as

Okay. Now I get to hear your side of the stor y.


We have a half hour or so to talk confidentially
now. I hope you'll feel comfor table telling me your
side of what's been going on at home.

If the fami l y di scussi on was heated, r eact to that i n some way:

Whew, things got pr etty hot ther e, what do you


think?

Remember that adol escents may have had no pr i or exper i ence wi th


a pr ofessi onal who asks ver y per sonal questi ons. Thus, i t may be
hel pful to begi n wi th a comment such as

Do you mind if I ask you some per sonal questions?


I may ask some questions that you'r e
uncomfor table answer ing, and you don't have to
answer if you don't want to.

At some poi nt dur i ng the i nter vi ew, say somethi ng about the l i mi ts
of confi denti al i ty. Rel ay the statement wi th ter ms such as wor r y:

I won't tell your par ents about anything you say


unless I'm r eally wor r ied that your life might be in
danger .
Later, befor e you br i ng the fami l y back i n, ask

Is ther e anything you don't want me to tell your


par ents?
Is it okay if I tell your par ents about these things?

If they say yes, fol l ow up wi th

Do you want to tell them or do you want me to?

Thi s way, you'r e maxi mi z i ng your pati ent's sense of contr ol .

I Don't Know Syndrome


Adol escents tend to have di ffi cul ty descr i bi ng thei r i nter nal
emoti onal state. Someti mes thi s i s because they don't want to seem
vul nerabl e; other ti mes i t's because thei r emoti onal vocabul ar y i s
under devel oped. Thus, aski ng di r ect questi ons about feel i ngs i s
l i kel y to l ead to the fol l owi ng type of exchange:

Have you been feeling


Interviewer:
depressed?

Patient: I don't know.

Interviewer: Have you been feeling angry?

Patient: I don't know.

Interviewer: How have you been feeling?

Patient: Okay, I guess.

How does one get beyond the I don't know syndr ome? One way i s
to gi ve the pati ent per mi ssi on to pl ead the fi fth:
Look, if you r eally don't know something, that's
fine. But if you don't want to tell me something,
that's okay too. Just say, I don't want to say.

Another strategy i s to ask the fl y on the wal l questi on:

If I wer e a fly on the wall when you get into one of


your moods, what would I see?

or, a sl i ght var i ati on,

What would your fr iend look like if he looked like


you in one of your moods?

These questi ons i nvi te the pati ent to descr i be hi s behavi or, a l ess
thr eateni ng pr oposi ti on than descr i bi ng a subjecti ve state.
A thi r d strategy i s to r el y on the defense mechani sm of
di spl acement. Ask your pati ent i f he has any fr i ends wi th pr obl ems:

Do you have any fr i ends who ar e i n tr oubl e?


What's goi ng on wi th them?

Thi s mi ght l ead i nto an el aborate di scussi on of a fr i end's anti soci al


or sui ci dal behavi or, whi ch may actual l y be autobi ographi cal .

Topics to Cover
Often, the tr i ck wi th adol escents i s to get them tal ki ng, much l ess
getti ng them to r eveal per sonal i nfor mati on. The best strategy i s to
adopt an atti tude of cur i osi ty and r espect; a sense of humor i s
al ways a pl us.
Most adol escents ar e i nter ested i n musi c, so thi s i s as good a pl ace
to star t as any.

Do you l i ke musi c? Who do you l i ke?

Chances ar e that you wi l l have never hear d of thei r favor i te gr oup.


You coul d r espond wi th
I have no i dea what ki nd of musi c that i s. Me, I
l i ke jaz z and, I'm ashamed to admi t, Bar r y
Mani l ow.

If you'r e squar e and goofy, and most of us over 30 ar e, admi t i t.


Thi s i s di sar mi ng to most adol escents and i s better than tr yi ng to
pose as cool .

Asking about School and Other Activities


Other questi ons that hel p open up a shut-down adol escent i ncl ude
questi ons about school , fr i ends, and i nter ests. Each

l i ne of i nqui r y can al so ser ve as a jumpi ng-off poi nt for di agnosti c


questi ons.

Wher e do you go to school?


What's that school like?
Is it fun?
Is it easy?
What ar e the other kids like ther e?
Who do you hang out with?

After aski ng these nonthr eateni ng questi ons, ask about grades. If
hi s grades ar e l ow or i f he l ooks di sappoi nted i n hi s grades, fol l ow
up wi th

Is that the same as you've always done, or have


your gr ades changed r ecently?

A change i n grades may si gnal the onset of depr essi on or


i nvol vement wi th substance abuse. You mi ght al so ask

Ar e ther e any par ticular subjects that ar e har d?

The DSM-IV-TR cl assi fi es l ear ni ng di sor der s under the tradi ti onal
categor i es of r eadi ng, wr i ti ng, and ar i thmeti c, and you can pi ck up a
hi nt of a l ear ni ng di sor der by aski ng thi s questi on. However,
chi l dr en ar e usual l y di agnosed wi th a l ear ni ng di sabi l i ty l ong befor e
thei r teenage year s.

What do you do with your time after school?


Ar e you involved in any extr acur r icular activities,
like spor ts or clubs?
What do you enjoy doing the most?

Besi des bei ng good questi ons for openi ng up your pati ent and
establ i shi ng rappor t, these ar e good scr eeni ng questi ons for
depr essi on. Wi thdrawal fr om soci al acti vi ti es i s a common featur e of
teenage depr essi on. Conver sel y, the pati ent who expr esses cl ear
i nter est and exci tement i n any acti vi ty i s l ess l i kel y to be
depr essed.

How many hour s of TV do you watch on the


average school ni ght?
How many hour s do you spend on the computer ?

Thi s gi ves another i ndi cati on of how soci al l y i nvol ved your pati ent
i s.

Asking about Drugs and Alcohol


Usi ng the techni ques di scussed i n Chapter 4 i s hel pful i n
communi cati ng a nonjudgmental atti tude when aski ng about dr ug
use. Thus, you can use nor mal i z ati on:

I hear ther e's a lot of dr inking and dr ug use at


your school. Do you know anyone who uses dr ugs?
You r ead in the paper that 90% of kids use dr ugs
these days. Do you ever use dr ugs?

or symptom expectati on:

How often do you have a dr ink?


What dr ugs do you use?

Other pati ents r espond qui te wel l to a di r ect quer y:


Do you dr ink or use dr ugs?

Asking about Sex


Al though aski ng about sex i s i mpor tant when i nter vi ewi ng
adol escents, use judgment and common sense i n deter mi ni ng when
such questi ons ar e appr opr i ate. If your rappor t i s shaky, you may
want to del ay such questi ons for fol l ow-up vi si ts, or you may deci de
not to rai se the questi ons at al l . It's vi tal l y i mpor tant that any
questi ons about sex not be seen by your pati ent as i dl e or l ur i d
i nter est, but rather that they ar e seen as an essenti al component of
your psychi atr i c eval uati on. A sexual hi stor y i s i mpor tant for a
var i ety of psychi atr i c and medi cal i ssues, i ncl udi ng assessi ng r i sk
for AIDS; di scover i ng a hi stor y of sexual abuse; and assessi ng the
pr esence of sexual acti ng-out as a symptom of depr essi on, mani a,
substance abuse, or other di sor der.
A good way to appr oach thi s uncomfor tabl e topi c i s to begi n tal ki ng
about r omance rather than sex.

Do you have any r omantic r elationships?


How long have you been seeing this per son?
What's his/her name?
What do you like about ________?

Now that you've gi ven a human face to the r el ati onshi p, you can
i ntr oduce the topi c of sex:

Would you feel comfor table if we talked about your


sex life?
Ar e you sexually active?
Ar e you using pr otection?
Do you know about AIDS?
Do you ever do things sexually that you later
r egr et, like not using pr otection or having sex with
people you don't know ver y well?

You can al so appr oach sexual i ty by embeddi ng i t i n a l i st of heal th-


r el ated questi ons:

I want to ask a few questions about your health:


Do you get headaches?
Stomachaches?
Do you have sexual pr oblems?
Ar e you sexually active?
Do you smoke?
Do you use dr ugs or alcohol?

If i t seems appr opr i ate, ask about sexual or i entati on:

Have you ever wonder ed whether your sexual


feelings ar e nor mal?
Do you ever think that your feelings about sex ar e
differ ent fr om other kids' feelings?

Note that nei ther of these questi ons uses ter ms such as sexual
or i entati on and sexual i denti ty, ei ther of whi ch may confuse or
al i enate adol escents.

Asking about Conduct Problems


Conduct di sor der and opposi ti onal defi ant di sor der ar e common
r easons for r efer ral , and you'l l often be faced wi th the task of
getti ng pati ents to admi t to i l l egal behavi or. Usual l y, the par ents
wi l l have di scl osed such behavi or dur i ng the fami l y meeti ng. A good
way to begi n a pr i vate i nter vi ew i n such ci r cumstances i s as fol l ows:

It looks like your mom feels ther e's been a lot of


stealing (or whatever alleged behavior ), and I have
no way of knowing if it's tr ue, but if you wer e
stealing, I'm sur e ther e
P.52
was a good r eason for it. Maybe it was the only
way you could get something? Or maybe your
fr iends challenged you to do it?

or, mor e si mpl y,


Do you know what your par ents ar e saying about
what you've been doing?

If the rappor t i s good, and you don't mi nd usi ng some humor, use
the i nduci ng to brag appr oach:

So, I hear you'r e an excellent thief. What's the


best thing you've stolen?

Remember that you ar en't aski ng these questi ons just to get your
pati ent to confess to bad behavi or s; rather, you'r e pr i mar i l y
i nter ested i n fi ndi ng out why he does these thi ngs. Is i t peer
pr essur e? A way of expr essi ng anger towar d hi s par ents? A symptom
of a mani c epi sode? Fol l ow up on an admi ssi on of anti soci al
behavi or s wi th questi ons desi gned to addr ess these topi cs.

Footnotes
*Wi th contr i buti ons fr om Davi d Sor enson, M.D., and Al an Lyman,
M.D.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 1 1 -
Te c hnique s fo r O t he r C ha lle nging Sit ua t io ns

11
Techniques for Other Challenging
Situations

Essential Concepts

The hosti l e pati ent.


The seducti ve pati ent.
The tear ful pati ent.

Be fir m, fair , and under standing. Hold the r eins in


one hand and a lump of sugar in the other .
--El vi n Semrad The Hear t of a Ther apist

THE HOSTILE PATIENT


When a pati ent becomes hosti l e dur i ng an i ni ti al i nter vi ew,
r emember that i t's not your faul t. Unl ess you'r e l aughabl y
i ncompetent or a r eal cr eep, a hosti l e attack i s a pr oduct of the
pati ent's pathol ogy. Common causes of pati ent anger dur i ng the
fi r st meeti ng i ncl ude paranoi d psychosi s, i r r i tabi l i ty due to
depr essi on or mani a, and bor der l i ne per sonal i ty di sor der. The best
way to defuse hosti l i ty i s to di agnose i ts cause and then tar get your
i nter venti on accor di ngl y.

The Hostile, Paranoid Patient


The hosti l e, paranoi d pati ent i s angr y at you because he per cei ves
you as a di r ect thr eat or per haps as par t of an el aborate conspi racy.
A good way to counteract thi s fal se pr ojecti on i s to use sel f-effaci ng
humor or general goofi ness, whi ch i s easi er to pul l off. The pati ent
usual l y per cei ves thi s atti tude as i nconsi stent wi th evi l i ntenti ons.

CLINICAL VIGNETTE
A pati ent wi th the di agnosi s of bi pol ar di sor der was admi tted
i nvol untar i l y to the i npati ent uni t because of paranoi a concer ni ng
her husband, who she bel i eved was tr yi ng to have her ki l l ed. It
was cl ear fr om the outset of the i nter vi ew that she thought that
she had been wr ongl y commi tted and wanted to l eave
i mmedi atel y.

How can you keep me here?


Patient: You have no right. I can call a
lawyer.

You can certainly call a lawyer.


Interviewer:
The reason we

(Interrupting) I can call a


lawyer, but it's not going to do
any good, is it? All the lawyers
Patient:
are part of a big game, and
they're going to say just what
you want them to say.

What kind of game do you


think this is? Last I checked,
Interviewer:
this was just a psychiatric
hospital.

You know exactly what's going


Patient: on here, and wipe that
innocent look off your face.
I'm not innocent. I plead guilty
to being a psychiatrist. I'm
trying to help you. And if you
Interviewer:
believe that, I have a bridge in
Brooklyn you might be
interested in.

Patient: What bridge?

Oh that's just an old joke, and


a bad one. I find that I have to
use humor to keep me sane
Interviewer:
here, you know? But enough
about me. What were we
talking about?

The people who are trying to


Patient:
have me killed.

At thi s poi nt, the pati ent opened up si gni fi cantl y, and a
pr oducti ve conver sati on ensued. The attempt at humor was
unexpected enough to derai l an i ncr easi ngl y hosti l e trai n of
thought.

The Irritable, Depressed Patient


Depr essed pati ents can come acr oss as hosti l e, but i t i s a hosti l i ty
that cl oaks a r eser voi r of pai n. A good techni que i s to make a fai r l y
di r ect i nter pr etati on, such as

You sound angr y, but I think ther e's some sadness


under neath that anger .

I can under stand how you would be angr y with me,


but I wonder if ther e isn't something beneath the
anger that's eating at you?

The Patient with Borderline Personality


Disorder
Li ke the i r r i tabl e, depr essed pati ent, the bor der l i ne pati ent's anger
over l i es pai n. Because of i mmatur e copi ng ski l l s, the pati ent cannot
si t wi th her pai n and rati onal l y pr obl em-sol ve. Instead, she tends
to pr oject and exter nal i ze, r esul ti ng i n l ashi ng out that can be qui te
uncomfor tabl e for you. It i sn't easy to mai ntai n your composur e
dur i ng these ti mes, but i t hel ps i f you can see the anger as a cr i si s
of al oneness. Be compassi onate, and fi ght agai nst the natural
tendency to ei ther fi ght back or to wi thdraw i nto a pr otecti ve shel l
of al oofness. Defensi veness wi l l onl y r i l e your pati ent fur ther, and
al oofness wi l l deepen her sense of abandonment.
Instead, be cur i ous, i nter ested, and car i ng. Effecti ve statements for
pati ents wi th bor der l i ne per sonal i ty di sor der often i ncl ude the
fol l owi ng:

F or the sake of our discussion, what do you think


just happened? You'r e ver y angr y at me, and I'm
wonder ing what that anger is about.

I've done (or said) something that upset you, and I


hope to under stand what that is so that we can put
it behind us and move on with the impor tant wor k
we have to do to help you feel better .

THE SEDUCTIVE PATIENT


Al though seducti ve behavi or often does not become appar ent unti l
fol l ow-up sessi ons, i t i s hel pful to have some i dea of how best to
r espond to over tl y seducti ve behavi or. To begi n wi th, r enew your
own absol ute commi tment never to become sexual l y i nvol ved wi th
your pati ents. Asi de fr om br eaki ng pr ofessi onal ethi cal codes, i t i s
al ways destr ucti ve, to both your pati ent and your sel f. Any
practi ti oner who often fi nds hi msel f tempted to br each thi s
boundar y shoul d obtai n therapy or super vi si on or fi nd another
car eer.
Thi s i s not to say that you wi l l never have sexual feel i ngs towar d
your pati ents. Of cour se you wi l l , but i f your commi tment never to
act on such feel i ngs i s absol ute, you can manage these feel i ngs
whi l e conti nui ng to del i ver excel l ent car e.
Seducti ve behavi or comes i n two gui ses, subtl e and bl atant. Subtl e
behavi or i ncl udes si gni fi cant gl ances, r eveal i ng cl othes, and
excessi ve cur i osi ty about the i nter vi ewer 's per sonal l i fe. Such
subtl e behavi or can be managed i n several ways:

Keep the trappi ngs of the therapeuti c r el ati onshi p r el ati vel y
for mal .
Use the pati ent's ti tl e and l ast name.
Keep the i nter vi ew focused on the pr esenti ng symptoms.
Avoi d smal l tal k.

Defl ect r equests for per sonal i nfor mati on wi th statements such as
The pur pose of thi s i nter vi ew i s for us to get a better
under standi ng of what's been tr oubl i ng you, and I r eal l y thi nk that
shoul d be the focus.
Bl atant seducti ve behavi or i nvol ves mor e di r ect questi ons about the
i nter vi ewer 's avai l abi l i ty and r equests to be touched or hugged by
the therapi st or to spend some ti me outsi de of the tr eatment
sessi on wi th her. These behavi or s r equi r e a di r ect and unambi guous
r esponse that makes i t cl ear that such contact i s i nappr opr i ate and
i mpossi bl e and expl ai ns why. The fol l owi ng vi gnette i l l ustrates thi s
type of si tuati on.

CLINICAL VIGNETTE
The pati ent i s a woman i n her 30s who i s i n the pr ocess of
di vor ci ng her husband. She has schedul ed a di agnosti c i nter vi ew
to eval uate her depr essi on. The i nter vi ewer i s a mar r i ed man al so
i n hi s 30s. The vi gnette begi ns towar d the end of the i nter vi ew,
and the cl i ni ci an has al r eady r ecommended an anti depr essant.

I also think it would be helpful


Interviewer:
for you to see a therapist.
Patient: Can't you be my therapist?

No, I'm a
psychopharmacologist, and I
Interviewer: schedule brief follow-up visits
to check on how well the
medication is working.

Patient: But I like you.

(Beginning to sense a hint of


seductiveness) That's good,
because I'll continue to
Interviewer: monitor your medication, but I
think you'd benefit from seeing
a therapist for more frequent
sessions.

(Smiling seductively) What I'd


really like is to meet someone
Patient:
who could be both my
therapist and my lover.

Wait a minute. Let's back up a


little. It's very destructive for
therapists or psychiatrists to
have anything other than a
professional relationship with
their patients. That will never
happen during our treatment,
nor will it happen with any
Interviewer: therapist you might see. From
what you've told me today, I
can see you've been feeling
lonely, and I think it would be
good for you to work on
building up friendships, but
that will have to happen
outside of treatment sessions.

P.
The pati ent eventual l y accepted a therapy r efer ral and conti nued
i n tr eatment wi thout over t seducti veness.

THE TEARFUL PATIENT


Many pati ents cr y dur i ng the i ni ti al appoi ntment, and as a
begi nni ng cl i ni ci an, you may feel at a l oss when thi s happens. You
wi l l typi cal l y feel your own shar e of emoti ons i n such si tuati ons,
whi ch may range fr om poi gnant empathy to anxi ous di scomfor t. You
wi l l pr obabl y i nsti ncti vel y want to behave as you woul d when a
cl ose fr i end or fami l y member cr i es i n fr ont of you, whi ch may
i ncl ude a pat or a hug and comfor ti ng wor ds. That i s usual l y a
mi stake i n a pr ofessi onal r el ati onshi p. So what shoul d you do?
The pr oper appr oach wi l l var y fr om pati ent to pati ent. When a
pati ent cr i es, tr y to under stand the meani ng of the tear s, whi ch i s
not al ways obvi ous. For exampl e, the pati ent who cr i es whi l e
descr i bi ng a r ecent mar i tal separati on may be cr yi ng for several
r easons, i ncl udi ng a feel i ng of abandonment,

a fear of futur e fi nanci al har dshi p, a sense of per sonal fai l ur e, and
a r el i ef that the r el ati onshi p i s over.
When a pati ent becomes tear ful , I r ecommend offer i ng some
ti ssues, whi ch shoul d al ways be i n your offi ce, wai ti ng
empatheti cal l y for a few seconds, and then aski ng any of the
fol l owi ng questi ons:

What is it about what you ar e saying that is so


painful?
I can see you'r e feeling emotional now; what ar e
your tear s about?

What's on your mind now as you'r e cr ying?

It's al so hel pful to ask about the fr equency of cr yi ng:

Have you been cr ying a lot about this?

It's qui te common for pati ents to say they have not cr i ed unti l that
ver y moment, whi ch i s usual l y a val i dati on of your i nter vi ewi ng
ski l l s.
If a pati ent expr esses some shame or embar rassment about cr yi ng,
make a val i dati ng statement such as

Cr ying can be a good r elease.

G o ahead and cr y as much as you need to. It's


good that you feel comfor table enough her e that
you'r e allowing your self to cr y.

Cr ying is a big par t of the healing pr ocess.

Of cour se, l est I l eave you wi th the i mpr essi on that cr yi ng i s a


wonder ful thi ng, I shoul d r emi nd you that tear s i ndi cate i ntense
emoti onal pai n and shoul d pr ompt you to be especi al l y vi gi l ant for
SI (see Chapter 21).
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n I - G e ne ra l P rinc iple s o f Effe c t iv e Int e rv ie w ing > 1 2 -
P ra c t ic a l P s y c ho dy na m ic s in t he Dia gno s t ic Int e rv ie w

12
Practical Psychodynamics in the
Diagnostic Interview

Essential Concepts

Assess your pati ent's degr ee of r eal i ty di stor ti on.


Detect negati ve transfer ence and move beyond i t.
Identi fy defense mechani sms and copi ng r esponses.
Use your counter transfer ence di agnosti cal l y.

It might be said of psychoanalysis that if you give


it your little finger it will soon have your whole
hand.
--Si gmund F r eud

Keepi ng an ear open for psychodynami c mater i al can hel p you i n a


number of ways as you conduct your di agnosti c i nter vi ews. F i r st,
you can i ncr ease the accuracy of your di agnosi s, because symptoms
ar e often the pr oduct of l i fe ci r cumstances and dysfuncti onal ways
of r espondi ng to them. Psychodynami cs pr ovi des the pr eemi nent
l anguage for descr i bi ng defense mechanisms, and i t al so hel ps you
under stand how to use counter transfer ence towar d pati ents
pr oducti vel y. Second, under standi ng psychodynami c pr i nci pl es wi l l
hel p you manage the i nter vi ew i tsel f, especi al l y i f your pati ent has
negati ve transfer ence towar d you. F i nal l y, under standi ng defense
mechani sms wi l l hel p you to di agnose per sonal i ty di sor der s, whi ch
ar e cover ed i n mor e detai l i n Chapter 30.
REALITY DISTORTION
Real i ty di stor ti on i s often the fi r st cl ue that si gni fi cant
psychodynami c factor s may be at wor k i n your pati ent's psychol ogy.
Psychosi s i s the extr eme of r eal i ty di stor ti on, but many
nonpsychoti c pati ents di stor t r eal i ty as wel l . Exampl es i ncl ude the

depr essed woman who unfai r l y casti gates her sel f for bei ng the
cause of al l mi sfor tune i n her fami l y, the nar ci ssi st who tel l s you
that al l hi s past therapi sts have been substandar d and ther efor e
unhel pful , and the al cohol i c who says her husband i s bei ng
r i di cul ous i n cr i ti ci z i ng her dr i nki ng habi ts.
Often, r eal i ty di stor ti ons wi l l jump out at you over the cour se of the
i nter vi ew. Occasi onal l y, you'l l need to di g for them. In Chapter 26, I
suggest some scr eeni ng questi ons to el i ci t the pr esence of the
del usi ons. In these pati ents, however, we'r e not tal ki ng about frank
del usi ons; we'r e tal ki ng about mi l der di stor ti ons. The way to el i ci t
di stor ti ons i s to be cur i ous about how your pati ents i nter pr et the
moti vati ons of other s or how they make sense of events overal l .

CLINICAL VIGNETTE
The pati ent i s a 25-year-ol d woman wi th a hi stor y of pani c
di sor der wi th agoraphobi a and comor bi d al cohol abuse. She
r ecentl y ter mi nated vi si ts to her l ast psychi atr i st because he
r efused to pr escr i be benzodi azepi nes for her anxi ety di sor der.

Dr. X said, Absolutely not. I


Patient:
won't give you any Xanax.

What do you think was on his


mind when he said that? (You
Interviewer:
are probing for her world
view.)

To tell you the truth, I have no


Patient:
idea. Maybe that's his rule.
Interviewer: What sort of rule do you
mean?

Maybe he never prescribes


Patient: those kinds of drugs for people
like me.

Interviewer: People like you?

People with anxiety, people


Patient:
who really need them.

Why wouldn't he prescribe


Interviewer: meds to people who need
them?

Who knows. He's probably


Patient:
burned out. Most shrinks are.

The pati ent pr esents a jaded vi ew of psychi atr i sts, possi bl y


r efl ecti ng a mor e general vi ew of the wor l d as uncar i ng.
Al ter nati vel y, her statements may r efl ect the defense mechani sm
of pr ojecti on, i n whi ch the pati ent di savows her own anger at
bei ng depr i ved of an addi cti ve dr ug and pr ojects i t onto her
psychi atr i st, who then appear s sadi sti c to her because he doesn't
pr escr i be medi cati ons to peopl e who need them. Whatever the
natur e of her di stor ti ons, you can be cer tai n that you wi l l not be
exempt fr om them, and you can begi n to pr epar e your own
strategy to pr event futur e str uggl es. Thi s mi ght i ncl ude maki ng
statements that demonstrate an under standi ng of her wor l d vi ew:

As I listen to you, it sounds like you've gotten


the shor t end of the stick over and over again in
life. I wouldn't be sur pr ised if you'r e assuming
that it's going to be the same way her e, too.
Once you detect a r eal i ty di stor ti on, deter mi ne whether defense
mechani sms or transfer ence i s at wor k.

NEGATIVE TRANSFERENCE
Whenever two people meet ther e ar e r eally six
people pr esent. Ther e is each man as he sees
himself, each man as the other per son sees him,
and each man as he r eally is.
--Wi l l i am James

In transfer ence, your pati ent unconsci ousl y r eenacts a past


r el ati onshi p and transfer s i t to a pr esent r el ati onshi p; thi s doesn't
necessar i l y pose a pr obl em i n the i ni ti al i nter vi ew. Your pati ent may
have a posi ti ve transfer ence towar d you, i n whi ch you r emi nd hi m
of someone he admi r ed, l i ke hi s mother, causi ng hi m to
automati cal l y ascr i be to you al l ki nds of wonder ful qual i ti es. Si t
back and enjoy i t.
Negati ve transfer ence, however, can be pr obl emati c, especi al l y
when i t i nvol ves anger. Your pati ent may have been poor l y tr eated
by peopl e thr oughout hi s l i fe, and he expects you to be no di ffer ent.
Look for negati ve transfer ence when ther e i s a sense of tensi on.
Per haps your pati ent i s maki ng angr y comments or aski ng
pr ovocati ve questi ons. Per haps he i s gi vi ng monosyl l abi c answer s to
your questi ons.
In psychoanal yti c psychotherapy, negati ve transfer ence i s actual l y
el i ci ted, because i ts i nter pr etati on i s the backbone of tr eatment. In
the di agnosti c i nter vi ew, however, negati ve transfer ence

i s usual l y counter pr oducti ve, and the best way to deal wi th i t i s to


r ecogni ze i t and make an empathi c comment that neutral i zes i t.
Al though ther e's no easy way of l ear ni ng how to make these
commentsother than practi ce, practi ce, and mor e practi cethe
fol l owi ng l i st contai ns some common statements (i n i tal i cs) made by
pati ents dur i ng di agnosti c i nter vi ews. Most of these statements
r efl ect negati ve transfer ence or a defense mechani sm of some sor t.
Al l of these statements tend to thr ow novi ce i nter vi ewer s for a l oop.
Possi bl e hi dden meani ngs ar e l i sted after each pati ent statement;
the emphasi s i s on possible. Someti mes, such statements have no
hi dden meani ng and ar e a statement of fact. For exampl e, you may
l ook bor ed dur i ng an i nter vi ew and, i n fact, feel bor ed. If the
pati ent i s maki ng an accurate obser vati on, don't tr y to i nter pr et the
comment. That i s di shonest and unfai r to your pati ent. In addi ti on,
the hi dden meani ngs I've l i sted ar e i l l ustrati ve onl y. They don't
i mpl y that al l pati ents maki ng such a statement actual l y mean what
I suggest. You shoul d i nter pr et each statement i ndi vi dual l y, based
on your knowl edge of the par ti cul ar pati ent.
In general , the possi bl e r esponses ar e ways of movi ng beyond the
negati ve statement, so that the wor k of the di agnosti c i nter vi ew can
pr oceed. Note that thi s i s a ver y di ffer ent appr oach fr om what you
woul d do i f you wer e engaged i n psychodynami c therapy.

You'r e not a ver y helpful doctor .

Possible hidden meaning: No one has ever car ed for me, and
you'r e no excepti on.
Possible response (whi l e noddi ng empathi cal l y): You know, that's
not the fi r st ti me I've hear d that, and when I'm not bei ng hel pful to
a pati ent I al ways ask, How can I be mor e hel pful ? Because I r eal l y
do want to hel p. (Thi s communi cates that you r eal l y do car e and
i mpl i es that the therapeuti c al l i ance won't be damaged by your
pati ent's comment, but may actual l y be str engthened by i t.)
Possible hidden meaning: I'm a ver y speci al pati ent, and you
shoul d tr eat me unusual l y wel l .
Possible response: I bet i t feel s di sappoi nti ng to have a doctor
who doesn't come up to snuff. Is i t possi bl e, though, that you'r e
judgi ng pr ematur el y? (Empathi ze wi th the pati ent's i njur ed sense
of speci al ness, whi l e gi vi ng hi m an out to r epai r the r el ati onshi p.)

You look bor ed.

Possible hidden meaning: Of cour se you ar e bor ed, I'm such a


bor i ng per son.
Possible response: I'm actual l y not at al l bor ed, but do you thi nk
that the thi ngs you'r e sayi ng ar e bor i ng?
Possible hidden meaning: I expect you to r espond l ovi ngl y and
i mmedi atel y to ever ythi ng I say; i f you ar e si l ent, I have to assume
that you'r e feel i ng somethi ng negati ve towar d me.
Possible response: In my pr ofessi on, si l ence rar el y means
bor edom. It usual l y means concentrati on and i nter est.

Is that all you'r e going to do, just sit ther e silently


and nod?

Possible hidden meaning: You'r e just l i ke my par ents, who never


expr essed any ki nd of i nter est i n me, who never r esponded to
anythi ng I sai d.
Possible response: Does that seem unhel pful ? I actual l y have a
l ot to say, but I al ways tr y to bi te my tongue so that my pati ents
get a chance to tel l thei r whol e stor y. I usual l y fi nd that I'm most
hel pful to pati ents onl y after I've r eal l y l i stened to them and
under stood them wel l .

What kind of cr edentials do you have?

Possible hidden meaning: I'm i n a l ot of pai n, and I'm not cer tai n
whether you or anybody el se can hel p me.
Possible response: (Begi n by stati ng your cr edenti al s qui ckl y.)
I'm ________ (e.g., an i nter n, a r esi dent) at ________ (i .e., name
of school or hospi tal ). Ar e you concer ned about my abi l i ty to hel p
you?
Possible hidden meaning: I've been made to feel i neffectual al l
my l i fe, and I want you to get a taste of what that feel s l i ke. (Thi s
i s an exampl e of an i mmatur e defense mechani sm known as
pr ojective identification.)
Possible response: (State your cr edenti al s.) But my mai n
cr edenti al i s that I'm her e wi th you; I want to under stand you and
to hel p you as best I can. (By thi s, you demonstrate that sel f-
esteem does not depend on getti ng someone el se to say you ar e
effectual .)

You don't show much under standing of what I'm


saying.

Possible hidden meaning: I'm angr y at you for not under standi ng
me i mpl i ci tl y and ful l y wi thout my havi ng to be expl i ci t. I want you
to be the per fectl y empathi c par ent I never had.
Possible response: You know, I coul dn't agr ee mor e. It i s so har d
for one per son to r eal l y under stand another per son. But why don't
we tal k some mor e, and I'l l gi ve i t my best shot.

Ar e you mar r ied?

Possible hidden meaning: I wi sh I wer e mar r i ed to you.


A nother possible hidden meaning: I'l l bet you ar e mar r i ed, and
that you have a wonder ful spouse, pr ovi ng how much better you ar e
than I am and what a l oser I am.
Possible response (wi th a smi l e): Wai t a mi nute! I thought I was
the one who's supposed to be aski ng the questi ons her e.
A nother possible response: You know what? I've found that when
I star t answer i ng questi ons about my per sonal l i fe, i t can get i n the
way of my under standi ng you better, and i sn't that the whol e poi nt
of our hour together ?

DEFENSE MECHANISMS AND COPING


RESPONSES
When uncomfor tabl e and unpl easant emoti ons ar i se, we al l have
ways of l esseni ng the br unt of them. We use defense mechani sms.
The cl assi fi cati ons i n Tabl e 12.1 ar e adapted fr om Vai l l ant's (1988)
hi erar chy of defense mechani sms.

Table 12.1. Classification of defense


mechanisms

Mature defenses
Suppression
Altruism
Sublimation
Humor
Neurotic defenses
Denial
Repression
Reaction formation
Displacement
Rationalization
Immature defenses
Passive aggression
Acting out
Dissociation
Projection
Splitting (idealization/devaluation)
Psychotic defenses
Denial of external reality
Distortion of external reality

Adapted from Vaillant, G. E. (1988). Defense


mechanisms. In A. M. Nicholi, Jr. (Ed.), The
New Harvard Guide to Psychiatry. Cambridge,
MA: Harvard University Press, 81.

Main Defense Mechanisms


Fol l owi ng ar e br i ef defi ni ti ons and exampl es of the di ffer ent defense
mechani sms. The exampl es i ncl uded her e ar e var i ous ways that a
pati ent mi ght r eact i f, i n thi s i nstance, her husband l eft her.

Mature Defenses
Matur e defenses usual l y ar i se fr om, and l ead to, psychol ogi cal
heal th rather than fr om dysfuncti on.

SUPPRESSION
Defi ni ti on: Emoti on r emai ns consci ous but i s suppr essed.
Exampl e: I'm di sappoi nted and sad, but I won't l et these
emoti ons i nter fer e si gni fi cantl y wi th my l i fe.

ALTRUISM
Defi ni ti on: Suppr essi ng the emoti on by doi ng somethi ng ni ce for
other s.
Exampl e: I'l l vol unteer at a women's shel ter.

SUBLIMATION
Defi ni ti on: Transmuti ng the emoti on i nto a pr oducti ve and
soci al l y r edeemi ng endeavor.
Exampl e: I'l l star t i mmedi atel y on a book about how to cope wi th
r ejecti on.

HUMOR
Defi ni ti on: Expr essi ng the emoti on i n an i ndi r ect and humor ous
way.
Exampl e: Thi s i s gr eat! I've been tr yi ng for year s to get r i d of
180 pounds of ugl y fat.

Neurotic (Transitional) Defenses


Neur oti c defenses ar e l ess heal thy than matur e defenses because
they tend to cause psychol ogi cal di str ess ei ther i mmedi atel y, as
wi th r epr essi on or di spl acement, or i n the futur e, when the actual
pai n eventual l y sur faces.

DENIAL
Defi ni ti on: Denyi ng that the emoti on exi sts.
Exampl e: The r ejecti on doesn't bother me at al l .
REPRESSION
Defi ni ti on: Stuffi ng the emoti on out of consci ous awar eness.
(Unfor tunatel y, the emoti on typi cal l y r etur ns to haunt the
r epr essor i n unpr edi ctabl e ways.)
Exampl e: I di dn't feel at al l bad about hi s l eavi ng me, but for
the past few weeks I've had thi s spl i tti ng headache, and I don't
know why.

REACTION FORMATION
Defi ni ti on: For getti ng the negati ve emoti on by transfor mi ng i t
i nto i ts opposi te.
Exampl e: We've become such cl ose fr i ends si nce thi s happened.
He i s r eal l y a wonder ful per son.

DISPLACEMENT
Defi ni ti on: Di spl aci ng the emoti on fr om i ts or i gi nal object to
somethi ng or someone el se.
Exampl e: My boss has r eal l y been getti ng under my ski n l atel y.

RATIONALIZATION
Defi ni ti on: Inventi ng a convi nci ng, but usual l y fal se, r eason why
you ar e not bother ed.
Exampl e: I've been wanti ng to make some major l i fe changes
anyway. Thi s fi nal l y gave me the boost I needed to do al l the
thi ngs I've been wanti ng to do.

Immature Defenses
Immatur e defenses l ead to mor e sever e di str ess and often have a
negati ve i mpact on other peopl e.

PASSIVE AGGRESSION
Defi ni ti on: Expr essi ng anger i ndi r ectl y and passi vel y.
Exampl e: Oh, I'm sor r y, dear. I gave al l your cl othes to the
Sal vati on Ar my l ast week. I di dn't r eal i ze you wanted them.

ACTING OUT
Defi ni ti on: Expr essi ng the emoti on i n acti ons rather than
keepi ng i t i n awar eness.
Exampl e: (The pati ent makes harassi ng, l ate-ni ght phone cal l s.)

DISSOCIATION
Defi ni ti on: Di ssoci ati ng i nstead of feel i ng the pai n.
Exampl e: I was r eal l y spaced out al l of l ast week; my memor y of
hi m l eavi ng me i s ver y haz y.

PROJECTION
Defi ni ti on: Di savowi ng the anger and ascr i bi ng i t to the object of
the anger.
Exampl e: I'm convi nced that ever si nce he l eft me he's been
bad-mouthi ng me to al l our fr i ends.

SPLITTING (IDEALIZATION/DEVALUATION)
Defi ni ti on: Defi ni ng the r ejecti ng per son as bei ng al l bad, ver sus
havi ng seen hi m as al l good befor e the r ejecti on, ther eby
transfor mi ng pai n i nto anger and accusati on.
Exampl e: I al ways knew he was a hor r i bl e per son, and thi s
pr oves i t. May he r ot i n hel l .

Psychotic Defenses
Psychoti c defenses so compl etel y fl aunt exter nal r eal i ty that they
si gnal a psychoti c thought pr ocess (TP).

DENIAL OF EXTERNAL REALITY


Defi ni ti on i s sel f-expl anator y.
Exampl e: He never l eft me.

DISTORTION OF EXTERNAL REALITY


Defi ni ti on i s sel f-expl anator y.
Exampl e: He di dn't l eave me! He went off on a busi ness tr i p.
He'l l be back next week.

In the di agnosti c i nter vi ew, i denti fyi ng defense mechani sms i s


useful to qui ckl y sense whether your pati ent may have a per sonal i ty
di sor der (such pati ents typi cal l y use i mmatur e defenses) and to gi ve
you a sense of pr ognosi s (pati ents who use hi gher l evel defenses
tend to do better than other s).
As you l i sten to your pati ent wi th a psychodynami c ear, ask your sel f
the fol l owi ng questi ons:

How does the pati ent seem to shel ter hi msel f fr om the
psychol ogi cal pai n that he i s shar i ng wi th you?
Does he tend to use matur e or i mmatur e defenses?

Do hi s defenses tend to br i ng hi m out of hi s mi ser y (matur e


defenses) or steep hi m mor e deepl y i n i t (neur oti c and i mmatur e
defenses)?
If you wer e hi s therapi st, whi ch of hi s defenses woul d you
encourage and whi ch woul d you poi nt out to hi m as
unpr oducti ve?

At the end of the i nter vi ew, befor e you wr i te up the eval uati on,
you'l l fi nd i t hel pful to r evi ew the defenses (see the pocket car ds i n
Appendi x A) and deter mi ne whi ch one(s) the pati ent seems to use.
Make a habi t of spendi ng at l east a few moments thi nki ng about the
defenses your pati ents use. Thi s wi l l hel p you to better r ecogni ze
defenses i n the futur e.

Coping Styles
Copi ng styl es and defense mechani sms ar e si mi l ar concepts. Vai l l ant
(1988) di sti ngui shes copi ng r esponses fr om defense mechani sms:
Copi ng, he says, i nvol ves el i ci ti ng hel p fr om appr opr i ate other s
and vol untar y cogni ti ve effor ts l i ke i nfor mati on gather i ng,
anti ci pati ng danger, and r ehear si ng r esponses to danger (Vai l l ant
1988, p. 200). Defense mechani sms, on the other hand, ar e
i nvol untar y cogni ti ve r esponses to str essor s that usual l y fi t i nto one
of the categor i es l i sted i n the pr i or secti on.
Thi nk of copi ng as a ser i es of acti ve behavi oral and cogni ti ve
r esponses desi gned to over come a str essful event. You wi l l typi cal l y
be abl e to eval uate your pati ent's copi ng styl es by l i steni ng to her
HPI and hear i ng how she deal t wi th the di str ess. It i s not sur pr i si ng
that the copi ng r esponses of many psychi atr i c pati ents ar e not ver y
effecti ve.
How di d your pati ent r espond to the mai n pr obl ems descr i bed i n the
HPI? If depr essi on i s the pr obl em, di d he cope adapti vel y, by (for
exampl e) contacti ng fr i ends or fami l y for suppor t; decr easi ng hi s
r esponsi bi l i ti es for a whi l e; or doi ng somethi ng that he knew woul d
gi ve hi m pl easur e, such as seei ng a movi e or goi ng on a vacati on?
Or di d he cope mal adapti vel y, by i sol ati ng hi msel f, by l ashi ng out at
peopl e cl ose to hi m, or thr ough sel f-muti l ati ng behavi or ?
If anxi ety i s a major pr obl em, di d he use posi ti ve copi ng strategi es,
such as tel l i ng hi msel f the anxi ety wi l l pass, taki ng deep br eaths,
taki ng a wal k? Or di d he use mor e negati ve strategi es, such as
vi si ti ng hospi tal emer gency r ooms excessi vel y, usi ng al cohol or
other dr ugs, or bi ngei ng on sweets?

As wi th defense mechani sms, seek to encourage posi ti ve copi ng


r esponses and to di scourage negati ve ones.

USING COUNTERTRANSFERENCE
DIAGNOSTICALLY
Counter tr ansfer ence r efer s to the whol e range of emoti ons that you
may feel towar d your pati ent, whether posi ti ve or negati ve. Novi ce
i nter vi ewer s have a tendency to tr y to suppr ess or i gnor e such
feel i ngs, especi al l y when they ar e negati ve. Don't. These
counter transfer ence feel i ngs r epr esent some of the most cl i ni cal l y
val uabl e mater i al avai l abl e to you. Whatever feel i ngs your pati ent
el i ci ts i n you ar e feel i ngs she pr obabl y el i ci ts i n most other peopl e
she encounter s i n her l i fe. Knowi ng thi s can gi ve you power ful
i nsi ght i nto the natur e of her pr obl ems.

CLINICAL VIGNETTE
A 45-year-ol d man was admi tted to the psychi atr i c uni t for
depr essi on and SI. He had r ecentl y been fi r ed fr om hi s job, and
he compl ai ned of l onel i ness, as he had l ost most of hi s fr i ends
over the year s. I di d the admi ssi on i nter vi ew, and the fol l owi ng
exchange occur r ed 5 mi nutes i nto i t.

How long had you been feeling


Interviewer:
depressed?

Quite a while. But tell me,


Patient:
aren't you just a resident?

(Immediately feeling
Interviewer: defensive.) Well, yes, I'm the
chief resident of the unit.

(He narrows his eyes.) Chief


Patient: resident. I see. That's a pretty
political position, isn't it?

(Increasingly uncomfortable
and caught off guard.) No, I
Interviewer: wouldn't say it's a particularly
political position. I supervise
the other residents.

Yes, but there's always


someone watching over you,
isn't there? If you do well,
maybe you'll get a nice job in
Patient: the department. I know how it
works. I'd prefer to talk to a
full attending, someone who
isn't always looking over his
shoulder.

(Feeling enraged and


suppressing the urge to
scream at him and kick him
out of the office.) In fact, you
Interviewer:
will be talking to an attending
in the morning, but I do need
to talk to you briefly this
afternoon.

The pati ent agr eed to pr oceed wi th the i nter vi ew and answer ed
questi ons br i efl y and di sdai nful l y. On fur ther assessment, a
pi ctur e of sever e nar ci ssi sti c per sonal i ty di sor der emer ged, and
my counter transfer ence r eacti on made i t graphi cal l y
under standabl e how he had managed to al i enate al l the i mpor tant
peopl e i n hi s l i fe, l eadi ng to hi s cur r ent depr essi on.

The bottom l i ne i s that when you feel a negati ve emoti on towar d


your pati ent, don't act on i t. Instead, anal yze i ts possi bl e
connecti on to your pati ent's psychopathol ogy.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n II - The P s y c hia t ric His t o ry > 1 3 - O bt a ining t he His t o ry
o f P re s e nt Illne s s

13
Obtaining the History of Present Illness

Essential Questions

What has been happening over the past week or


two that has br ought you into the clinic?
Have ther e been any events that you think have
caused your pr oblem or made it wor se?
Have you sought any tr eatment for this pr oblem?

Recommended ti me: 10 mi nutes

WHAT IS THE HISTORY OF PRESENT ILLNESS?


The HPI i s pr obabl y the most i mpor tant par t of the psychi atr i c
i nter vi ew, and yet ther e i s di sagr eement on exactl y what i t shoul d
entai l . Even exper i enced cl i ni ci ans di ffer i n how they appr oach the
HPI. Some thi nk of i t as the hi stor y of pr esent cr i si s and focus on
the pr ecedi ng few weeks. Such cl i ni ci ans begi n thei r i nter vi ews wi th
questi ons such as, What has been goi ng on r ecentl y that br i ngs you
i nto the cl i ni c today? Other s begi n by el i ci ti ng the enti r e hi stor y of
the pati ent's pr i mar y syndr ome: Tel l me about your depr essi on.
How ol d wer e you when you fi r st fel t depr essed? These cl i ni ci ans
wor k for war d to the pr esent epi sode.
Each of these appr oaches may be useful , dependi ng on the cl i ni cal
si tuati on. If a pati ent has a r el ati vel y uncompl i cated and br i ef
psychi atr i c hi stor y, i t mi ght make sense to expl or e that fi r st and
then move to the HPI. If the psychi atr i c hi stor y i s l ong, wi th many
hospi tal i z ati ons and car egi ver s, star ti ng at the begi nni ng may br i ng
you too far fr om the pr esent pr obl em.
The most common pi tfal l for begi nner s i s spendi ng too much ti me on
the HPI. It's easy to do, because thi s i s the ti me for your pati ent to
shar e the most di ffi cul t and pai nful par t of hi s stor y, and cutti ng
your pati ent off as ti me begi ns to pass may seem unempathi c. Thus,
i t i s vi tal that you keep i n mi nd the advi ce offer ed i n Secti on I
about aski ng questi ons and changi ng topi cs sensi ti vel y. Use these
techni ques to gentl y but per si stentl y br i ng the pati ent back to the
HPI.
In the fol l owi ng secti ons, I descr i be techni ques for the two major
appr oaches to the HPI; you shoul d deci de whi ch to use for a gi ven
pati ent.

The History of Present Crisis Approach


The Amer i can Her i tage Di cti onar y defi nes cr i si s as A cr uci al poi nt
or si tuati on i n the cour se of anythi ng; a tur ni ng poi nt. As you
begi n the i nter vi ew, ask your sel f, Why now? Why i s thi s a cr uci al
poi nt i n thi s per son's l i fe? What has been happeni ng r ecentl y to
br i ng her i nto my offi ce? Often, psychi atr i c cr i ses occur over a 1-
to 4-week per i od, so focus your i ni ti al questi ons on thi s per i od.

What has been happening over the past week or


two that has br ought you into the clinic?
Tell me about some of the str essor s you've dealt
with over the past couple of weeks.

History of the Syndrome Approach


Al ter nati vel y, you can begi n your questi oni ng by ascer tai ni ng when
the pati ent fi r st r emember s si gns of the i l l ness.

When did you fir st begin having these kinds of


pr oblems?
When was the last time you r emember feeling
per fectly well?

Ensui ng questi ons track the cour se of the i l l ness thr ough months or
year s, ar r i vi ng eventual l y at the pr esent.

Now let's talk about this cur r ent episode. When did
it star t?
One ni ce thi ng about thi s appr oach to the HPI i s that most case
wr i te-ups ar e or gani zed i n thi s for matthey often begi n, The
pati ent was wi thout any psychi atr i c pr obl ems unti l age 18, when she
became depr essed

TIP: MAKING THE INTERVIEW ELEGANT, OR, THE


BARBARA WALTERS APPROACH
At i ts best, a wel l -conducted i nter vi ew r esembl es a dance i n whi ch
the gi ve and take between cl i ni ci an and pati ent fl ow effor tl essl y
thr oughout the hour, gi vi ng the pati ent the sense that he just
par ti ci pated i n a fasci nati ng conver sati on about hi s l i fe rather
than a psychi atr i c i nter vi ew. One way to set the stage for thi s
type of exper i ence i s to begi n the i nter vi ew by showi ng genui ne
i nter est and cur i osi ty about the pati ent's job, hobbi es, or l i fe
si tuati on, and to al l ow the pati ent to steer the di scussi on towar d
cl i ni cal topi cs. Imagi ne that you ar e Bar bara Wal ter s i nter vi ewi ng
a cel ebr i ty, br i ngi ng that same i ntense cur i osi ty to your pati ent:

I see from your intake sheet


Interviewer: that you work for the IRS.
What do you do with them?

I'm in their call center, but it's


Patient:
only seasonal.

So when I call the IRS to ask


Interviewer:
for a form, you might answer?

Yes, but I do a lot more. I can


Patient: answer questions about a
customer's return.

Wait, you're kidding. If I were


to call you and ask how much I
Interviewer: owed, you'd be able to pull
that information up while I was
on the phone?

Oh yes, we have the whole


database available, at least
when the computers aren't
down! It's really a great job,
Patient:
my first good job, but during
the summer I'm usually laid
off, and I don't know why
(patient appears dejected).

That's too bad, why do they


lay you off? (The patient
Interviewer: begins to describe difficulties
leading up to her current
depression.)

ELICIT A CHRONOLOGIC NARRATIVE,


EMPHASIZING PRECIPITANTS
Many pati ents automati cal l y jump i nto a chr onol ogi c nar rati ve of
thei r pr obl ems when pr ompted by one of the pr ecedi ng questi ons. If
thi s happens, i t i s a ti me to fal l si l ent for a whi l e and l i sten.
Remember, thi s i s your scouti ng per i od (see Chapter 3), dur i ng
whi ch you ar e obser vi ng, l i steni ng, and hypothesi z i ng. However, i f
your pati ent begi ns to jump ar ound i nto other i ssues or ti me
frames, you may want to r efocus hi m.

I felt so angry when my wife


yelled at me. But she's always
been that way. Back when I was
Patient: in law school, she nagged at me
constantly. I'd have to spend
late nights at the law library,
and she refused to understand.

I'd like to hear more about that


period later, but right now let's
focus on what's been happening
Interviewer:
over the last 2 weeks or so. You
said you got angry at her. What
happened then?

Ask the pati ent speci fi cal l y about potenti al pr eci pi tants for her
suffer i ng:

Have ther e been any events that have caused your


pr oblem or made it wor se?

Occasi onal l y, the pati ent wi l l deny any pr eci pi tants. Thi s i s
par ti cul ar l y tr ue of pati ents who vi ew thei r psychi atr i c i l l ness fr om
a medi cal model . Such a pati ent mi ght answer the questi on above
wi th

No, I can't think of anything that's causing it. My


life is going pr etty well; I just keep getting these
depr essions.

Cer tai nl y, some psychi atr i c i l l nesses, such as bi pol ar di sor der, can
have l i ves of thei r own, but i t's unusual for pati ents to
decompensate wi thout some pr eci pi tant. Often, pati ents haven't
associ ated par ti cul ar events wi th thei r pai n and si mpl y need thei r
memor i es jogged. Make i t a practi ce to di g by aski ng about speci fi c
events that commonl y destabi l i ze pati ents (Tabl e 13.1). You won't
necessar i l y ask about ever y i tem on thi s l i st, of cour se. You may
al r eady have some cl ues fr om an ear l i er par t of the i nter vi ew that
one of these events i s par ti cul ar l y l i kel y. As you ask these
questi ons, r emember that cor r el ati on does not equal causal i ty. A
str essful psychosoci al event may have occur r ed ar ound the ti me of a
psychi atr i c pr obl em and yet be unr el ated to i t.

TABLE 13-1 Common precipitants of


psychiatric syndromes

Arguments with friends or relatives

Rejection or abandonment

Death or major illness of loved one

Anniversary of a negative event, such as a


death or divorce

Major medical illness or age-related


deterioration in functioning

Stressful events at work or school

Mental health clinician going on vacation

Medication noncompliance

Substance abuse

Wi thi n the DSM-IV-TR system, pr eci pi tants woul d be noted i n axi s


IV, psychosoci al and envi r onmental pr obl ems.
LAUNCH INTO THE DIAGNOSTIC QUESTIONS
RIGHT AWAY
One of the secr ets of effi ci ent and rapi d di agnosti c i nter vi ewi ng i s a
gentl e tenaci ty; when the pati ent menti ons a depr essed mood,
i mmedi atel y assess for the pr esence of the di agnosti c cr i ter i a for
depr essi on.

I think the worst problem over


Patient: the past couple of weeks is that
I've felt so down about myself.

Has that down feeling been


Interviewer:
affecting your sleep?

I haven't slept more than 2 or 3


hours a night, and the next day
Patient: I can barely drag myself to
work. I should probably quit
anyway; it's a boring job.

Have you had problems focusing


Interviewer: on your work because of your
depression?

Her e, the i nter vi ewer stays on the depr essi on topi c by cuei ng off
what the pati ent has sai d about wor k (see the di scussi on of the
smooth transi ti on i n Chapter 6). If the i nter vi ewer had not acti vel y
str uctur ed the i nter vi ew thi s way, the pati ent mi ght have di scussed
detai l s of hi s wor k envi r onment that woul d be l ess r el evant to the
di agnosi s of major depr essi on. Later, when ascer tai ni ng the soci al
hi stor y, the i nter vi ewer can r efer to what the pati ent sai d about
wor k:
Earlier, you mentioned that your
work is boring. How did you get
Interviewer:
into that line of work? (Note the
use of the referred transition.)

CURRENT AND PREMORBID LEVEL OF


FUNCTIONING
Axi s V of the DSM-IV-TR di agnosti c scheme r equests that you note
the pati ent's G AF, or gl obal assessment of functi oni ng,

on a scal e of 0 to 100. (See Chapter 33 for mor e i nfor mati on.)


Al though I have not found i t useful to assi gn a speci fi c number to
functi oni ng, I do thi nk that axi s V i s an i mpor tant r emi nder to the
i nter vi ewer to ask about both cur r ent and basel i ne functi oni ng. You
want to know to what degr ee your pati ent's psychi atr i c i l l ness i s
i mpai r i ng her functi oni ng.
To assess overal l functi oni ng, ask about the thr ee basi c aspects of
l i fe: l ove, wor k, and fun. Love i ncl udes al l i mpor tant r el ati onshi ps:
fami l y, spouse, and cl ose fr i ends. In addi ti on to pai d empl oyment,
wor k i ncl udes school , vol unteer acti vi ti es, and the str uctur ed day
acti vi ti es i n whi ch many chr oni cal l y mental l y i l l pati ents par ti ci pate.
F un r efer s to hobbi es and r ecr eati onal pur sui ts.

How has your illness been affecting your wor k,


r elationships, and leisur e pur suits?

The phrasi ng of thi s questi on automati cal l y tar gets the pati ent's
pr emor bi d functi oni ng. Some pati ents have a har d ti me
di sti ngui shi ng a psychi atr i c i l l ness fr om the r est of thei r l i ves. If so,
you wi l l have to fol l ow up wi th another questi on to assess thei r
basel i ne functi oni ng.

Befor e you star ted to have these anxiety spells (or


other symptoms), how was wor k going?
How wer e you getting along with your family and
your wife?
What kinds of things wer e you doing for fun?

For pati ents who have mor e chr oni c i l l nesses wi th mul ti pl e
exacer bati ons and r emi ssi ons, ask the same types of questi ons
about per i ods between exacer bati ons:

Think about the last time that you wer e feeling


your best, when you wer en't hear ing any voices
and you didn't feel suicidal. How was your life going
then? (F ollow up with questions about love, wor k,
and fun.)

Aski ng about cur r ent ver sus basel i ne functi oni ng i s i mpor tant
di agnosti cal l y. The cl assi c exampl e i s the di ffer ence between
schi zophr eni a and bi pol ar di sor der. In schi zophr eni a, the pati ent's
l evel of functi oni ng gradual l y decr eases over months or year s,
wher eas i n bi pol ar di sor der, the pati ent may have been functi oni ng
dramati cal l y better wi thi n the past few weeks. Deter mi ni ng basel i ne
functi oni ng i s al so i mpor tant i n setti ng tr eatment goal s. You mi ght
ai m to hel p the pati ent

achi eve hi s best l evel of functi oni ng over the past year, for
exampl e.

CLINICAL VIGNETTE
A r esi dent was wor ki ng i n a busy psychi atr i c cr i si s cl i ni c and
i nter vi ewed a pati ent who was br ought by ambul ance for
psychoti c and di sor gani zed behavi or. The pati ent was a 32-year-
ol d woman and car r i ed the di agnosi s of schi zoaffecti ve di sor der
i n her pr evi ous emer gency depar tment r ecor ds. The phrase
hi stor y of mul ti pl e psychi atr i c hospi tal i z ati ons i n the ol d char t
caused the r esi dent to assume that the pati ent was a chr oni cal l y
poor l y functi oni ng woman who coul d rar el y stay out of a hospi tal .
In assessi ng her psychosoci al functi oni ng, the r esi dent was
sur pr i sed to l ear n that the pati ent had been wor ki ng as a
secr etar y for a r esear ch depar tment of a l ocal hospi tal unti l 1
year ago, when she had the fi r st of a ser i es of r ecent
hospi tal i z ati ons. Thi s i nfor mati on caused the r esi dent to pay
cl oser attenti on to the pati ent's hi stor y and to enter tai n the
possi bi l i ty of a di ffer ent di agnosi s, such as bor der l i ne per sonal i ty
di sor der or PTSD, both of whi ch woul d be mor e consi stent wi th
her good pr emor bi d functi oni ng.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n II - The P s y c hia t ric His t o ry > 1 4 - O bt a ining t he
P s y c hia t ric His t o ry

14
Obtaining the Psychiatric History

Essential Questions
Syndr omal hi stor y:

How ol d wer e you when you fi r st had these symptoms?


How many epi sodes have you had?
When was the l ast epi sode?

Mnemoni c for tr eatment hi stor y: Go CHaMP

General questi ons.


Who i s your cur r ent Car egi ver ?
Have you been psychi atr i cal l y Hospi tal i zed?
Have you taken Medi cati ons for these symptoms?
Have you had Psychotherapy?
Recommended ti me: 10 mi nutes

The past psychi atr i c hi stor y (PPH) r i sks becomi ng a tedi ous exer ci se
i n documentati on. You can avoi d thi s by r eal i z i ng how vi tal the PPH
i s to your twi n goal s of establ i shi ng a di agnosi s and for mul ati ng a
tr eatment pl an.
Speci fi c psychi atr i c di sor der s have speci fi c natural hi stor i es, wi th
character i sti c r i sk factor s, pr odr omal si gns, ages at onset, and
pr ognoses. Obtai ni ng a detai l ed PPH for a par ti cul ar pati ent al l ows
you to compar e the cour se of her i l l ness wi th the textbook's ver si on
of the cour se of i l l ness, i ncr easi ng the l i kel i hood that you wi l l make
a cor r ect di agnosi s.
Often, pati ents wi l l come to you after havi ng been tr eated for many
year s. One r eason such pati ents ar e eventual l y r efer r ed to an
exper t consul tant i s that exper ts ar e gr eat at el i ci ti ng a detai l ed
hi stor y of pr i or tr eatments. They can deter mi ne exactl y what has
been tr i ed i n the past and whether past tr eatment tr i al s have been
adequate. F r om thi s i nfor mati on, they can pr esent i nfor med
r ecommendati ons about what shoul d be tr i ed next. And they can do
al l thi s i n one or two 50-mi nute sessi ons.
Potenti al pi tfal l s i n obtai ni ng the PPH ar e si mi l ar to those l ur ki ng
dur i ng the HPI. At one end of the conti nuum, some i nter vi ewer s
become so caught up i n the i ntr i caci es of the PPH

that they spend most of the eval uati on ti me on i t, to the detr i ment
of, for exampl e, the PROS. At the other end, the PPH can become a
r ote exer ci se and may be obtai ned too super fi ci al l y, depr i vi ng the
i nter vi ewer of i nfor mati on necessar y to make a fi r m di agnosi s.

OBTAIN THE SYNDROMAL HISTORY


G eneral l y speaki ng, the HPI wi l l take between 5 and 10 mi nutes, at
the end of whi ch you shoul d have a few pr ovi si onal di agnoses i n
mi nd. Your next job i s to obtai n the hi stor y of these syndr omes.
Speci fi cal l y, you want to l ear n age at onset, pr emor bi d functi oni ng,
and hi stor y of subsequent epi sodes up to the pr esent.

Age at Onset
How old wer e you when you fir st had your symptoms?

Knowi ng the age at onset may hel p you to deci de between potenti al
di agnoses, al though the most r ecent epi demi ol ogi c data i ndi cate
that ages of onset for di sor der s ar e l ess di sti nct than pr evi ousl y
thought (Tabl e 14.1).

Premorbid Functioning or Baseline


Functioning
See Chapter 13 for a di scussi on of pr emor bi d functi oni ng/basel i ne
functi oni ng.

History and Precipitants of Subsequent


Episodes up to Present
Incl ude questi ons about the sever i ty of epi sodes and exacer bati ons,
as wel l as the durati on of epi sodes. Often, thi s i nfor mati on comes
out when you ar e obtai ni ng the tr eatment hi stor y. For exampl e,
epi sodes of mani a or exacer bati ons of schi zophr eni a often
cor r espond wi th hospi tal i z ati ons.
As wi th hospi tal i z ati ons, a ti me-effi ci ent method of aski ng about
epi sodes i s to ask about the fi r st one, the l atest one, and the total
number of epi sodes.

When di d you have your fi r st br eakdown?

TABLE 14.1. Median age at onset of major


psychiatric disorders

Disorder Age (yr)

21 (men), 27
Schizophrenia
(women)

Major depression 25

Bipolar disorder 19

Panic disorder 24

Obsessive-compulsive
23
disorder

Drug abuse/dependence 18

Alcohol
abuse/dependence 21

Adapted from Burke, J. D., and Regier, D. A.


(1994). Epidemiology of mental disorders. In
R. E. Hales, S. C. Yudofsky, and J. A. Talbott
(Eds.), American Psychiatric Press Textbook
of Psychiatry. Washington, DC: American
Psychiatric Press, 19.

How many have you had total ?


When was your l ast one?

OBTAIN THE TREATMENT HISTORY


You ask about pr i or tr eatments mostl y to hel p wi th futur e tr eatment
deci si ons but al so to hel p nai l down a di agnosi s. For exampl e, i f
l i thi um was hel pful for an affecti ve epi sode, bi pol ar di sor der woul d
be hi gh on your l i st. You want to know what has been tr i ed i n the
past and whether i t has wor ked. Accuracy and detai l ar e i mpor tant
her e, because a sl oppy tr eatment hi stor y can l ead to poor futur e
tr eatment deci si ons. For exampl e, pati ents may be fal sel y l abel ed
tr eatment r esi stant on the basi s of ol d r ecor ds i ndi cati ng that
numer ous medi cati ons wer e tr i ed but wer e unsuccessful . On cl oser
questi oni ng, such pati ents may i n fact have had few adequate tr i al s
of medi cati on.
I suggest the fol l owi ng for mat for obtai ni ng the tr eatment hi stor y:

General questi ons


Cur r ent car egi ver s
Hospi tal i z ati on hi stor y
Medi cati on hi stor y
Psychotherapy hi stor y
Use the mnemoni c Go CHaMP so that you don't mi ss any categor y.
You won't necessar i l y ask your questi ons i n the above or deri n
fact, you wi l l obtai n much of thi s i nfor mati on dur i ng

the HPIbut i t's hel pful to thi nk about these fi ve aspects of the
tr eatment hi stor y to make sur e that you haven't negl ected to ask
i mpor tant questi ons. At some poi nt dur i ng the i nter vi ew, mental l y
r evi ew whether you have obtai ned enough i nfor mati on about each
of these categor i es.

General Questions
What sor t of tr eatment have you had for your
depr ession?
What was the most helpful?

Mor e sophi sti cated and for thcomi ng pati ents wi l l tel l you al most
ever ythi ng you need to know about the tr eatment hi stor y i n
r esponse to a general questi on. Other pati ents wi l l r equi r e mor e
speci fi c questi oni ng.

What was going on in your life dur ing the per iod
when you wer e depr ession-fr ee?

In some cases, the best tr eatment for a par ti cul ar pati ent was a
cl ose r el ati onshi p wi th someone or thei r escape fr om a
dysfuncti onal r el ati onshi p. You can l ear n thi s fr om a car eful hi stor y,
and i t may become a par t of your tr eatment r ecommendati ons.

Current Caregivers
You wi l l need to know who your pati ent i s seei ng cur r entl y. If he i s
a new pati ent, you may be the onl y car egi ver. If you ar e
i nter vi ewi ng a pati ent wi th a chr oni c mental i l l ness, he wi l l l i kel y
have both a therapi st and a psychophar macol ogi st, and he may al so
have a case wor ker (usual l y a soci al wor ker ), a gr oup therapi st, and
a pr i mar y car e doctor (a fami l y practi ti oner or an i nter ni st) and
may be i nvol ved i n day tr eatment or r esi denti al tr eatment.

Hospitalization History
Have you ever been hospitaliz ed for a psychiatr ic
pr oblem?

For pati ents who have had mul ti pl e hospi tal i z ati ons, do not spend
your ti me ascer tai ni ng the names of the hospi tal s and dates of each
admi ssi on; thi s coul d take the enti r e 50 mi nutes. Instead, fi nd out
when they wer e fi r st and l ast hospi tal i zed and about how many
hospi tal i z ati ons they've had over thei r l i feti me.

If a pati ent has had many hospi tal i z ati ons, tr y to fi nd out i f they
ar e cl uster ed ar ound a speci fi c few year s. Some pati ents wi l l have
had several hospi tal i z ati ons ear l i er i n the cour se of thei r di sor der
because they had l i ttl e i nsi ght i nto thei r pr obl em and wer e
noncompl i ant wi th thei r medi cati ons. Later i n l i fe, thei r
hospi tal i z ati ons may be spaced much far ther apar t. Al ter nati vel y,
the opposi te patter n may appear, i n whi ch an affecti ve di sor der
wor sens wi th age. Thi nk of hospi tal i z ati ons as mar ker s of di sease
sever i ty.

When wer e you fir st hospitaliz ed?


How many hospitaliz ations have you had in your
life?
How many have you had in the past year ?
When was your last hospitaliz ation?

In addi ti on to aski ng these questi ons, i t i s often useful to ask why


your pati ent was hospi tal i zed:

In gener al, what sor ts of things have caused you to


need to be in the hospital?

Your assumpti ons about r eason for hospi tal i z ati on may be wr ong, as
i l l ustrated by the fol l owi ng exampl e.

CLINICAL VIGNETTE
A pati ent wi th chr oni c schi zophr eni a stated that he'd been
hospi tal i zed several ti mes over the past 2 year s. The r esi dent
i ni ti al l y assumed that these hospi tal i z ati ons wer e for psychoti c
decompensati ons, but when asked, the pati ent sai d that most
wer e al cohol detoxi fi cati on admi ssi ons. Thi s pr ompted the
r esi dent to obtai n a much mor e thor ough substance abuse hi stor y
than he had pl anned.

Medication History
The most i mpor tant l i mi t on the bi oavai l abi l i ty of
medi cati on has nothi ng to do wi th
phar macodynami cs or phar macoki neti cs; rather, i t
i s pati ent non-compl i ance.
--Dr. Ross Bal dessar i ni Chi ef of
Psychophar macol ogy McLean Hospi tal

Have you been on medications for your depr ession?

To the extent possi bl e, document al l the medi cati ons the pati ent has
tr i ed. Many pati ents wi l l not r emember gener i c names or may onl y
r emember what the pi l l l ooked l i ke or the si de effect i t caused.
Obvi ousl y, the mor e you know about al ter nati ve names, shapes, and
si de effects of medi cati on, the mor e effi ci entl y you wi l l be abl e to
obtai n thi s hi stor y. I fi nd i t hel pful to have a Physi ci ans' Desk
Refer ence (PDR) at my si de, because i t has photographs of many
medi cati ons, to hel p pati ents i denti fy them. For psychol ogi sts and
soci al wor ker s, a number of books have been publ i shed that teach
the basi cs of psychophar macol ogy to non-MDs, and I r ecommend
that you become fami l i ar wi th thi s i nfor mati on.

F or how many weeks did you take your


medications?

Many psychi atr i c medi cati ons take several weeks to have a
therapeuti c effect. Anti depr essants take 4 to 6 weeks.
Anti psychoti cs may take 1 to 2 weeks or l onger, dependi ng on the
cl i ni cal si tuati on. Thus, mer el y documenti ng that a pati ent has tr i ed
a par ti cul ar medi cati on does not mean that he's had an adequate
tr i al .
At thi s poi nt, a nor mal i z i ng questi on may be hel pful :

Often, people do not necessar ily take their


medications ever y day, but will take them ever y so
often, depending on how they feel. Was that tr ue
for you?

TIP: HOW ACCURATE ARE PATIENTS WHEN


RECALLING PRIOR TREATMENTS?
A fasci nati ng study r ecentl y exami ned thi s cl i ni cal l y r el evant but
under-expl or ed questi on (Poster nak and Zi mmer man 2003). An
i ndependent eval uator i nter vi ewed 73 pati ents who had been
tr eated i n an academi c psychi atr i c cl i ni c for an average of 3.5
year s. After the i nter vi ew, r esear cher s r evi ewed cl i ni c char ts to
deter mi ne how accuratel y the pati ents r ecal l ed thei r
anti depr essant tr i al s. The r esul ts? They di d pr etty wel l , overal l ,
r ecal l i ng 80% of the monotherapy (si ngl e medi cati on) tr i al s over
the pr i or 5 year s. However, they onl y r emember ed 26% of
augmentati on tr i al s (i .e., when a second medi cati on i s added to
the fi r st to boost the r esponse). And augmentati on tr i al s that
wer e over 2 year s ol d wer e not r emember ed by anybody. The
bottom l i ne i s that your pati ent wi l l accuratel y r ecal l medi cati ons
tr i ed i f the r egi men has al ways been si mpl e, but those who have
taken combi nati ons of medi cati ons wi l l be much l ess r el i abl e.

CLINICAL VIGNETTE
A r esi dent was doi ng a psychophar macol ogi c eval uati on of a 46-
year-ol d mar r i ed Lati no woman wi th a several -year hi stor y of
depr essi on and anxi ety. Dur i ng the tr eatment hi stor y, the pati ent
stated that she had taken a number of di ffer ent anti depr essants
fr om di ffer ent cl asses wi th onl y mi ni mal effecti veness. The
r esi dent asked a nor mal i z i ng questi on about whether the pati ent
had taken her medi cati ons consi stentl y; she r esponded that she
onl y took them when she fel t anxi ous, whi ch var i ed fr om dai l y to
once ever y 2 weeks. In fact, the r esi dent was unabl e to document
an adequate tr i al of any anti depr essant and subsequentl y focused
on educati ng the pati ent on the necessi ty of consi stentl y taki ng
medi cati ons.

Psychotherapy History
In r ecent year s, psychotherapi es have become i ncr easi ngl y tai l or ed
to speci fi c di sor der s, and evi dence of effecti veness has become
i r r efutabl e (Bar l ow 1993). In addi ti on, i t has become cl ear that
therapy can have negati ve si de effects, as can medi cati on. Thus,
obtai ni ng a hi stor y of psychotherapeuti c tr eatments i s i mpor tant.

Have you ever had counseling or ther apy for your


pr oblem?
How often did you see your ther apist?
How long did you see him/her ?

These basi c parameter s of sessi on fr equency and l ength of


tr eatment ar e usual l y nonthr eateni ng and easy to el i ci t.

What sor t of ther apy did you have?


Did it have a name, like cognitive ther apy,
behavior ther apy, or psychodynamic ther apy?

Mor e often than not, your pati ent wi l l not know the techni cal name
of the therapy he r ecei ved. You can compensate for thi s by
descr i bi ng the therapy.

Did your ther apist focus on automatic thoughts


that make you mor e anxious or depr essed?
Did she give you homewor k assignments between
sessions?
Did she have you pr actice doing things that caused
you anxiety? (F or cognitive-behavior al ther apy.)
Did your ther apist focus on your childhood
exper iences and how those affect your cur r ent life?
(F or psychodynamic ther apy.)

You can al so ask a mor e open-ended questi on:

Without going into too much detail, what sor ts of


things did you focus on in ther apy?
Was your ther apist a psychologist, a psychiatr ist,
or a social wor ker ?
Knowi ng thi s may or may not be useful . For exampl e, a pati ent may
say she had a therapi st, when i n fact she was seen by a psychi atr i st
once a month for br i ef vi si ts. Thi s was mor e l i kel y
psychophar macol ogi c management than psychotherapy.

How did you like wor king with your ther apist?
Was the ther apy helpful?
In what ways was it helpful?

Thi s i nfor mati on wi l l be par ti cul ar l y val uabl e i n assessi ng the


pati ent's sui tabi l i ty for fur ther therapy.

How did you leave tr eatment?

The way a pati ent ended tr eatment may tel l you much about how he
vi ewed tr eatment and may hel p you pl an how to pr oceed wi th your
own tr eatment of the pati ent. Some pati ents, for i nstance, have a
hi stor y of endi ng therapy by si mpl y not showi ng up for the next
sessi on. Other s may have had a stor my ter mi nati on. Other s may
have ter mi nated by the book but conti nue to feel unexpr essed sad
or angr y feel i ngs towar d the therapi st.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n II - The P s y c hia t ric His t o ry > 1 5 - Sc re e ning fo r G e ne ra l
M e dic a l C o ndit io ns

15
Screening for General Medical
Conditions

Screening Questions
Mnemoni c: MIDA S

Do you take any Medi cati ons now?


Do you have any medi cal Il l nesses?
Do you have a pr i mar y car e Doctor ?
Have you ever had A l l er gi es, r eacti ons, or si de effects fr om
any medi cati ons?
Have you ever had any Sur ger y?

Medi cal r evi ew of systems.


Recommended ti me: 3 mi nutes

Ther e ar e two major r easons for aski ng about the medi cal hi stor y i n
psychi atr i c pati ents:

To screen for medical illnesses. Many psychi atr i c pati ents,


par ti cul ar l y pati ents wi th chr oni c schi zophr eni a i n publ i c car e
systems, have ver y poor medi cal fol l ow up, both because they
ar e i ndi gent and because thei r psychi atr i c di sor der l eads to poor
compl i ance wi th appoi ntments (Hal l et al . 1980). Thus, they may
have a hi gh pr eval ence of undi agnosed medi cal condi ti ons.
Whether these condi ti ons affect thei r psychi atr i c status or not,
you wi l l do them a l ar ge ser vi ce by scr eeni ng for medi cal
condi ti ons for whi ch they may not be r ecei vi ng tr eatment.
To uncover general medical causes of psychiatric illness. A
number of medi cal i l l nesses and medi cati ons can cause
psychi atr i c syndr omes and aggravate pr eexi sti ng ones (Li shman
1987). Thi s i s a conveni ent secti on of the i nter vi ew for aski ng
about such i l l nesses.

MIDAS
If you can devel op the MIDA S touch, you'l l never for get to ask
about the medi cal hi stor y:

Medi cati ons


Il l ness hi stor y
Pr i mar y car e Doctor
A l l er gi es
Sur gi cal hi stor y

Medications
Obtai n a l i st of al l medi cati ons, i ncl udi ng those for general medi cal
condi ti ons. Ascer tai n whether the pati ent has been taki ng them as
pr escr i bed.

History of Medical Illnesses


You can begi n wi th a scr eeni ng questi on such as

Do you have any medical pr oblems?


Have you ever had a medical illness?

However, a common pr obl em wi th thi s appr oach occur s when the


pati ent says no wi thout thi nki ng car eful l y, as the fol l owi ng
vi gnette i l l ustrates.

CLINICAL VIGNETTE
A 36-year-ol d woman wi th several past hospi tal i z ati ons for
depr essi on was asked i f she had any medi cal pr obl ems, to whi ch
she r epl i ed, No. Later, when the r esi dent asked what
medi cati ons she took, she l i sted a number of psychotr opi cs and
then sai d, and I al so take Synthr oi d. The r esi dent sai d, I
thought you had no medi cal pr obl ems, to whi ch the pati ent
r epl i ed, I don't. I used to have hypothyr oi di sm, but that was
cor r ected wi th the Synthr oi d.

Primary Care Doctor


In the pr ecedi ng vi gnette, aski ng about i l l ness el i ci ted i nval i d
i nfor mati on. One way to i ncr ease the val i di ty of your medi cal
hi stor y questi ons i s to fi r st ask i f the pati ent i s bei ng seen by a
doctor.

Do you see a doctor r egular ly?


P.88
What does he/she tr eat you for ?

By r efer r i ng to a r el ati onshi p wi th a car egi ver, you wi l l typi cal l y jog
the pati ent's memor y for past di agnoses and tr eatments. You can
al so l ear n i nfor mati on about the pati ent's character :

Interviewer: Do you see a doctor regularly?

Yeah, I see someone at the


Patient: clinic. Not that he gives a damn
about me.

Such a statement coul d be expl or ed fur ther and mi ght be a cl ue to


character trai ts that may i nter fer e wi th tr eatment, such as passi ve-
aggr essi ve or sel f-defeati ng trai ts.
Whi l e you'r e at i t, ask the pati ent i f you may contact hi s doctor to
shar e i nfor mati on. Di scussi ng the pati ent wi th the pr i mar y car e
physi ci an wi l l hel p r ound out your eval uati on, as wel l as pr ovi de
useful i nfor mati on to the car egi ver who r efer r ed the pati ent to you.

Allergies
The usual scr eeni ng questi on i s
Do you have aller gies to any medications?

Thi s may wor k, but agai n ther e ar e potenti al pi tfal l s. Some pati ents
have i di osyncrati c under standi ngs of what consti tutes an al l er gy.
They may thi nk you'r e aski ng about ser i ous al l er gi c r eacti ons, such
as br onchospasm, and ther efor e may answer i n the negati ve even i f
they've had mi l der al l er gi c r eacti ons. They al so may not r eal i ze that
you'r e i nter ested i n hear i ng about any negati ve r eacti ons to
medi cati ons, and not just al l er gi es per se. Better to ask

Have you ever had any aller gies, r eactions, or side


effects to any medication?

A pati ent may say that he i s al l er gi c to a number of medi cati ons


that onl y uncommonl y pr oduce tr ue al l er gi c r eacti ons, such as
neur ol epti cs and anti depr essants. If so, pur sue the natur e of the
al l er gy.

What kinds of r eactions did you have to that


medicine?

If the pati ent's r esponse i s vague, make some suggesti ons based on
your knowl edge of dr ug effects:

Did the Haldol give you muscle spasms? Did it make


your hands shake or your body move slowly?

When you document al l er gi es i n your wr i te-up, speci fy the natur e of


the r eacti on. For exampl e, wr i ti ng that a pati ent i s al l er gi c to
neur ol epti cs i s pr obabl y i naccurate and mi ght mean that the
pati ent wi l l never agai n be offer ed a neur ol epti c, even i f she coul d
benefi t fr om i t. A mor e accurate statement woul d be, Hal dol causes
dystoni a. Thi s l eaves the door open to tr i al s of other neur ol epti cs.

Surgical History
It i s i mpor tant to ask speci fi cal l y about pr evi ous sur ger y; many
pati ents do not vol unteer thi s i nfor mati on when asked about
medi cal pr obl ems, ei ther because i t was too l ong ago or because
they do not consi der an operati on to have i ndi cated a medi cal
pr obl em per se.

CLINICAL VIGNETTE
A 54-year-ol d man wi th major depr essi on had menti oned gastr i ti s
as hi s onl y medi cal pr obl em. Mi dway thr ough the i nter vi ew, he
menti oned i n passi ng, I di vor ced my wi fe back i n '84 or so, just
after they took out par t of my pancr eas. On fur ther expl orati on,
the pati ent consi der ed that operati on to be a tur ni ng poi nt i n hi s
l i fe, because he made the deci si on to stop dr i nki ng then and had
been sober si nce.

MEDICAL REVIEW OF SYSTEMS


The pur pose of the r evi ew of symptoms i s to note medi cal pr obl ems
that the pati ent may have for gotten to descr i be i n r esponse to the
MIDAS questi ons. Whether i t's necessar y to do a r evi ew of
symptoms for ever y pati ent i s a matter of contr over sy. The MIDAS
questi ons may mi ss seemi ngl y mi nor symptoms that may be the fi r st
cl ues to a bi g pr obl em, such as the occasi onal cough that si gnal s
l ung cancer. But the r evi ew of symptoms takes a l ot of ti me, and
most mental heal th cl i ni ci ans r efer thei r pati ents to an i nter ni st for
physi cal exami nati ons anyway.
Her e's a compr omi se. I'l l outl i ne two appr oaches to the r evi ew of
symptoms, a br i ef r evi ew of symptoms (1 mi nute) and a mor e
extended one (5 mi nutes) (Tabl e 15.1). Whi ch appr oach i s better
depends on the pati ent and the cl i ni cal setti ng.

TABLE 15.1. Brief versus full review of


symptoms

Review of
Patient Rationale
symptoms

Young, Statistically, fewer


middle or medical problems;
Brief upper good follow up with
class doctors

Elderly; Statistically, more


chronically medical problems;
Full
mentally poor follow up with
ill doctors

Both the br i ef and extended r evi ews of symptoms begi n wi th


systemi c questi ons and pr ogr ess i n head-to-toe or der, whi ch i s an
easy way to r emember them and to ensur e that you do not for get to
ask i mpor tant questi ons.

Brief Review of Systems


I'm going to ask whether you'r e having pr oblems
with var ious par ts of your body, moving fr om your
head to your toes. Any pr oblems with headaches or
seiz ur es? Vision or hear ing pr oblems? Smelling,
taste, or thr oat pr oblems? Thyr oid pr oblems?
Pr oblems with your lungs like pneumonia or
coughing? Hear t pr oblems? Stomach pr oblems like
ulcer s or constipation? Pr oblems with ur ination?
Joint pr oblems? Pr oblems walking?

Extended Review of Systems


General
Over all, do you feel healthy?
Do you have joint pr oblems or skin pr oblems? (May
indicate systemic lupus.)
Do you have excessive bleeding or anemia?
(Anemia can cause depr ession.)
Do you have diabetes or thyr oid pr oblems?
(Diabetes can cause lethar gy; thyr oid pr oblems can
cause depr ession or mania.)
Have you ever had cancer ?
P.91
Do you have any infections, such as HIV or
tuber culosis (TB)? (HIV can mimic many psychiatr ic
disor der s; TB can mimic depr ession.)

HEENT (Head, Eyes, Ears, Nose, and Throat)


Do you get headaches? (Can be caused by br ain
tumor .)
Have you ever had a head injur y? (Can lead to
neur opsychiatr ic conditions.)
Any pr oblems with your vision or your hear ing?
Do you ever see or hear things that other people
don't notice? (Pr ovides a convenient place to ask
about psychotic phenomena in a nonthr eatening
way.)
Do you get nosebleeds?
Do you smell things that other people don't? (Often
a sign of tempor al lobe epilepsy.)
How ar e your teeth?
Do you often get sor e thr oats?

Cardiovascular and Respiratory


Do you have any hear t pr oblems?
Do you have chest pains; do you have palpitations
of your hear t?
Do you have high blood pr essur e?
Do you exper ience shor tness of br eath
(emphysema, cor onar y ar ter y disease)?
Do you cough excessively (lung cancer )?
Do you wheez e (asthma)?
NOTES
Di ffer enti ate pani c attack fr om car di ac di sease; r ul e out
congesti ve hear t fai l ur e as a cause of l ethar gy and fati gue that
mi ght be mi stakenl y di agnosed as depr essi on. Look for di agnosti c
cl ues to the pr esence of l ung cancer, whi ch can mi mi c the
anor exi a and wei ght l oss of depr essi on.

Gastrointestinal
Do you have pr oblems with nausea or vomiting?
Do you ever make your self vomit? (A scr een for
bulimic behavior .)
Do you have pr oblems swallowing?
Do you have constipation or diar r hea?
Have you noticed any change in your stool?

NOTES
Rul e out hi dden col on or stomach cancer ; di agnose i r r i tabl e bowel
syndr ome, whi ch often accompani es psychi atr i c compl ai nts.
Answer s to these questi ons may pr ovi de di r ecti on i n the choi ce of
medi cati ons (e.g., you'd want to avoi d a tr i cycl i c anti depr essant
i n a pati ent wi th pr eexi sti ng consti pati on).

Genitourinary and Gynecologic


Do you have pr oblems with ur ination, such as
bur ning or excessive ur ination?
Do you have r etention of ur ine or incontinence?
Do you have any pr oblems with sexual functioning
or sexual dr ive?
Have you ever had a vener eal disease (HIV,
syphilis)?
When wer e your last pap smear and mammogr am?
Do you have any pr oblems with menstr uation?
When was your last menstr ual per iod?
Might you be pr egnant?

NOTES
Rul e out bl adder cancer ; pr ostate cancer i n men; and uter i ne,
ovar i an, or br east cancer i n women. Establ i sh amenor r hea of
anor exi a ner vosa. Deter mi ne contrai ndi cati ons to the use of
anti chol i ner gi c medi cati ons, such as an enl ar ged pr ostate.

Neurologic
Have you had seiz ur es?
Have you ever passed out?
Have you ever had a str oke?
Any tingling in your ar ms or legs?
Any pr oblems with walking, coor dination, and
balance?
Any pr oblems talking or thinking?
Any changes in your handwr iting?

NOTES
Detect brai n tumor, epi l epsy, str oke. Scr een for mul ti pl e scl er osi s,
Par ki nson's di sease, and dementi a.

Assessing HIV Risk*


I've set up a separate categor y for HIV r i sk because i t's par ti cul ar l y
i mpor tant, and i t can be an awkwar d subject to br i ng up. Later i n
the i nter vi ew, dur i ng the soci al hi stor y, you'l l ask some questi ons
about i nti mate r el ati onshi ps to assess your pati ent's capaci ty for
r el atedness. Her e, you focus on sexual functi oni ng as i t r el ates to
r i sk of HIV, but thi s may l ead to a di scussi on of other concer ns.
Begi n wi th an i ntr oductor y statement such as

Her e ar e some questions I r outinely ask. Some may


be uncomfor table; let me know if they ar e.
If I may, I'd like to ask you some sexual histor y
questions, because many people ar e concer ned
about AIDS.

Then, go on to the scr eeni ng questi ons for HIV:

Ar e you sexually active, or have you ever injected


dr ugs, even once?
Do you have any r eason to believe you ar e at r isk
for HIV?

Fol l ow the pr ecedi ng questi ons, dependi ng on whether you ar e


tal ki ng to a man or woman, wi th these:

(F or men): Have you had sex with a man in the


past 15 year s? (If yes): Can I ask what kind of sex
that was? Was it or al sex or anal sex? Did you use
a condom?
(F or women): Have you had sex with a man who
sleeps with other men or who injects dr ugs?
(F or both men and women): How many sexual
par tner s have you had over the past year ?

At thi s poi nt, you've done an adequate assessment for HIV r i sk. You
may want to fol l ow up wi th some general questi ons about sexual
functi oni ng, whi ch i s often affected by psychi atr i c di sor der s and by
the medi cati ons used to tr eat them.

Ar e you satisfied with your sexual functioning?


Do you find that your sexual functioning changes
when you get depr essed (or substitute other
r elevant psychiatr ic symptom)?

If you ar e i nter vi ewi ng someone who you suspect has been sexual l y
abused or raped, thi s i s a good ti me to ask about i t.

Sometimes people have sex against their will. Has


that ever happened to you?
Have you ever been coer ced into having sex?

NOTES
These questi ons avoi d the l oaded ter ms rape, mol est, and abuse.
Thi s i s useful for pati ents who have been sexual l y coer ced by a
spouse or a r el ati ve and who may not want to thi nk of thei r
exper i ences i n such ter ms.

Footnotes
*I thank Stephen Brady, Ph.D., for suggesti ng many of these
questi ons.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n II - The P s y c hia t ric His t o ry > 1 6 - Fa m ily P s y c hia t ric
His t o ry

16
Family Psychiatric History

Screening Questions

Has any bl ood r el ati ve ever had ner vousness, a ner vous
br eakdown, depr essi on, mani a, psychosi s or schi zophr eni a,
al cohol or dr ug abuse, sui ci de attempts, or hospi tal i z ati on for
ner vousness?
Has any bl ood r el ati ve ever had a medi cal or neur ol ogi c
i l l ness, such as hear t di sease, di abetes, cancer, sei z ur es, or
seni l i ty?

Recommended ti me: 2 mi nutes for bar e bones; 5 mi nutes for


genogram.

The fami l y hi stor y may be appr oached i n one of two ways. One i s
the bar e-bones appr oach, whi ch ai ms to ascer tai n the pati ent's
i nher i ted r i sk of devel opi ng a psychi atr i c or medi cal di sor der. The
second appr oach i s mor e extensi ve and i s a way of begi nni ng the
soci al hi stor y par t of the i nter vi ew. I descr i be both appr oaches her e
and l et you deci de whi ch wor ks best for you.

BARE-BONES APPROACH
Ask the fol l owi ng l ong, hi gh-yi el d questi on, whi ch i s adapted fr om a
questi on suggested by Mor r i son and Munoz (1991, p. 102):

Has any blood r elative ever had ner vousness,


ner vous br eakdown, depr ession, mania, psychosis
or schiz ophr enia, alcohol or dr ug abuse, suicide
attempts, or hospitaliz ation for ner vousness?
Because the questi on i s so l ong, you have to ask i t ver y sl owl y,
pausi ng after each di sor der so that the pati ent has ti me to thi nk
about i t. You shoul d al so defi ne bl ood r el ati ve.

By blood r elative, I mean par ents, br other s,


sister s, uncles, aunts, gr andpar ents, and cousins.

TIP
If the pati ent answer s wi th a defi ni ti ve no, you can move on. If
ther e was a yes, you shoul d tr y to deter mi ne exactl y what the
di agnosi s was. Unl ess your pati ent i s i n the mental heal th fi el d
and i s fami l i ar wi th i ts jar gon, thi s may not be easy. It's hel pful
to ask about speci fi c tr eatments the r el ati ve may have r ecei ved,
such as l i thi um, car bamazepi ne (Tegr etol ), di val pr oex sodi um
(Depakote) (cl ues to bi pol ar di sor der ), anti psychoti cs [ol der
exampl es ar e hal oper i dol (Hal dol ) and chl or pr omaz i ne
(Thoraz i ne); newer ones ar e r i sper i done (Ri sper dal ), ol anz api ne
(Zypr exa), queti api ne (Ser oquel ), z i prasi done (G eodon), and
ar i pi prazol e (Abi l i fy)], el ectr oconvul si ve therapy (cl ue to
depr essi on, bi pol ar di sor der, or schi zophr eni a, dependi ng on when
the tr eatment was admi ni ster ed), anti depr essants, and
anti anxi ety agents. Remember that medi cati ons wer e used
di ffer entl y 20 year s ago. For exampl e, i n i ts heyday, di azepam
(Val i um) was gi ven to many pati ents for depr essi on, wher eas now
a hi stor y of benzodi azepi ne tr eatment i s a cl ue for the pr esence
of an anxi ety di sor der.

To deter mi ne a fami l y hi stor y of transmi ssi bl e medi cal and


neur ol ogi c pr obl ems, ask

Has any blood r elative ever had a medical or


neur ologic illness, such as hear t disease, diabetes,
cancer , seiz ur es, or senility?

How does i t hel p di agnosti cal l y to know that a pati ent has a fi r st-
degr ee r el ati ve wi th a psychi atr i c di sor der ? Tabl e 16.1 l i sts those
psychi atr i c di sor der s for whi ch ther e i s si gni fi cant evi dence of
fami l i al transmi ssi on. The r el ati ve r i sk compar es the r i sk for peopl e
wi th such a fami l y hi stor y agai nst the r i sk of peopl e i n the general
popul ati on, who ar e assi gned a r el ati ve r i sk of 1.0. For exampl e,
the r el ati ve r i sk of devel opi ng bi pol ar di sor der i s 25; thi s means
that i f your pati ent's father i s bi pol ar, she i s 25 ti mes mor e l i kel y to
devel op bi pol ar di sor der

than the average per son. The basel i ne l i feti me pr eval ence of each
di sor der i s al so l i sted i n the tabl e.

TABLE 16.1. Psychiatric disorders with sign


evidence of familial transmission

Lifetime
relative
risk if Lifetime
DSM-IV-TR first- prevalence
disorder degree in general
relative population b
has
disorder a

Bipolar
25 1
disorder

Schizophrenia 19 1

Bulimia
10 2c
nervosa

Panic
10 4
disorder

Alcoholism 7 14
Generalized
anxiety 6 5
disorder

Anorexia
5 1c
nervosa

Specific
3 11
phobia

Social phobia 3 13

Somatization
3 2d
disorder

Major
3 17
depression

Obsessive-
compulsive ? 3e Agorapho
disorder

aRelative risk figures from Reider, R.


O., Kaufmann, C. A., et al. (1994).
Genetics. In R. E. Hales, S. C.
Yudofsky, and J. A. Talbott (Eds.),
American Psychiatric Press Textbook of
Psychiatry. Washington, DC: American
Psychiatric Press. See text for
explanation.
b Lifetime prevalence figures from
Kessler, R. C., McGonagle, K. A., Zhao,
S., et al. (1994). Lifetime and 12-
month prevalence of DSM-III-R
psychiatric disorders in the United
States. Archives of General Psychiatry,
51, 819; and Regier, D. A., Farmer,
M. E., et al. (1990). Comorbidity of
mental disorders with alcohol and
other drug abuse. Journal of the
American Medical Association, 264,
25112518.

c Data from Halmi, K. A. (1994). Eating


disorders: Anorexia nervosa, bulimia
nervosa, and obesity. In R. E. Hales, S.
C. Yudofsky, and J. A. Talbott (Eds.),
American Psychiatric Press Textbook of
Psychiatry. Washington, DC: American
Psychiatric Press.

d Data from Martin, R. L., and Yutzy, S.


H. (1994). Somatoform disorders. In
R. E. Hales, S. C. Yudofsky, and J. A.
Talbott (Eds.), American Psychiatric
Press Textbook of Psychiatry.
Washington, DC: American Psychiatric
Press.

e Data from Hollander, E., Simeon, D.,


et al. (1994). Anxiety disorders. In R.
E. Hales, S. C. Yudofsky, and J. A.
Talbott (Eds.), American Psychiatric
Press Textbook of Psychiatry.
Washington, DC: American Psychiatric
Press.

Typi cal l y, fami l y i nfor mati on i s used i n conjuncti on wi th other


cl i ni cal i nfor mati on. For exampl e, fami l y hi stor y i s cr uci al i n
deci di ng whether a pati ent wi th new-onset psychosi s has
schi zophr eni a or i s i n the mani c phase of bi pol ar di sor der.

THE GENOGRAM: FAMILY HISTORY AS SOCIAL


HISTORY
Doi ng a genogram takes a whi l e, whi ch pr obabl y expl ai ns i ts l ack of
popul ar i ty i n most cl i ni cal setti ngs. But i t doesn't take that l ong,
and the ti me i nvestment usual l y pays off i n ter ms of r i chness of
i nfor mati on. The genogram ser ves the addi ti onal functi on of
i ntr oduci ng you to the pati ent's devel opmental hi stor y.
The techni que i s si mpl e. Begi n by tel l i ng your pati ent that you'd
l i ke to draw a fami l y di agram to better under stand her fami l y. Draw
smal l squar es for mal es and ci r cl es for femal es. Obtai n the fol l owi ng
i nfor mati on about each r el ati ve:

Age
If dead, year, age, and cause of death (put sl ash mar k thr ough
squar e or ci r cl e i f dead)
Pr esence of psychi atr i c pr obl em, substance abuse, or major
medi cal pr obl em
Status of the pati ent's r el ati onshi p wi th r el ati ve (e.g., cl ose,
estranged, a per petrator or vi cti m of sexual or physi cal abuse)

Begi n by di agrammi ng the fi r st-degr ee r el ati ves, wi th the ol dest


si bl i ng on the r i ght (F i g. 16.1).
FIG. 16.1. Basi c genogram.

Once you have the skel eton of the char t, ask about each fami l y
member and embel l i sh the char t wi th the i nfor mati on obtai ned.
Al though you wi l l l i kel y devel op your own pr efer ences,

i t i s standar d to wr i te the age wi thi n the ci r cl e or squar e, to use


sl ashes to r epr esent the deceased, and to use doubl e sl ashes to
r epr esent a di vor ce. In the exampl e i n F i gur e 16.2, the pati ent i s a
di vor ced 34-year-ol d man wi th two chi l dr en who has a fami l y
psychi atr i c hi stor y si gni fi cant for al cohol i sm and depr essi on.

FIG. 16.2. El aborated genogram.

Once you have compl eted a genogram, you have accompl i shed thr ee
tasks: You have obtai ned (a) the fami l y psychi atr i c hi stor y, (b) the
fami l y medi cal hi stor y, and (c) the bar e bones of the soci al and
devel opmental hi stor y. Al so, the physi cal l ayout of the genogram
makes i t a qui ck way to r emi nd your sel f of the pati ent's soci al
si tuati on, a par ti cul ar l y ni ce featur e i f you rar el y see the pati ent.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n II - The P s y c hia t ric His t o ry > 1 7 - O bt a ining t he So c ia l
a nd De v e lo pm e nt a l His t o ry

17
Obtaining the Social and Developmental
History

Essential Questions

Can you tel l me a bi t about your backgr ound, wher e you gr ew


up, and how you gr ew up?
Expl or e the fol l owi ng topi cs chr onol ogi cal l y:
Ear l y fami l y l i fe
School exper i ences, emphasi z i ng fr i endshi ps
Wor k exper i ences
Inti mate r el ati onshi ps and sexual hi stor y
Cur r ent soci al suppor t networ k
G oal s and aspi rati ons

Recommended ti me: 5 mi nutes

In the days when psychoanal ysi s was ki ng, the soci al and
devel opmental hi stor y was the psychi atr i c i nter vi ew. Resi dents wer e
i nstr ucted to cover ever ythi ng fr om br east-feedi ng to a pati ent's
fi r st sexual fantasi es, a pr ocess that coul d wel l take several hour s.
The r esul ts wer e wr i tten up and used to devel op a psychoanal yti c
for mul ati on, focusi ng on F r eudi an noti ons of psychosexual confl i ct.
In our age of psychophar macol ogy, i nter vi ewer s someti mes r each
the other extr eme, aski ng about l i ttl e mor e than thei r pati ent's job
and mar i tal status befor e movi ng on to the DSM-IV-TR di agnosti c
questi ons.
What i s the pur pose of the soci al and devel opmental hi stor y i n a
br i ef di agnosti c i nter vi ew? How extensi ve shoul d i t be? The soci al
hi stor y i s useful i n two cl osel y r el ated ways: (a) It al l ows you to get
to know the pati ent as a per son rather than as a di agnosi s, and (b)
you can appr oach the di agnosi s of a per sonal i ty di sor der thr ough
the soci al hi stor y (see Chapter 30).
The essenti al questi ons take 5 mi nutes to ask, wher eas the
extended ver si on takes 10 to 20 mi nutes and shoul d be r eser ved for
occasi ons on whi ch you can take two sessi ons to do the eval uati on.

EARLY FAMILY LIFE


Begi n wi th the fol l owi ng i ntr oductor y questi on:

Can you tell me a bit about your backgr ound,


wher e you gr ew up, and how you gr ew up?

Pr oceed to mor e speci fi c questi ons, movi ng chr onol ogi cal l y thr ough
the stages of l i fe.

How many siblings did you have, and wher e wer e


you in the bir th or der ?

Each fami l y confi gurati on has a uni que i mpact on psychol ogi cal
devel opment. Typi cal scenar i os i ncl ude the l onel i ness of the onl y
chi l d, the el dest chi l d of a l ar ge fami l y who was for ced i nto the r ol e
of a par ent, the i gnor ed mi ddl e chi l d, and the youngest chi l d who
gr ew up as the r esented appl e of hi s mother 's eye.

What did your par ents do for a living?

Par ental empl oyment may have affected the pati ent's r el ati onshi p
wi th her par ents. For exampl e, a father who wor ked as a travel i ng
sal esman may not have been home much. Thi s questi on al so gi ves
you a sense of soci oeconomi c si tuati on: Di d the pati ent gr ow up
ami d pover ty or affl uence?

How did you get along with your par ents?

Al though ther e's not enough ti me to do thi s topi c justi ce i n the


di agnosti c i nter vi ew, these questi ons wi l l gi ve you an i dea of the
general fl avor of the home. Was i t a peaceful , l ovi ng envi r onment,
or was i t angr y and chaoti c?

What did they do when you disobeyed?

Thi s questi on can gentl y i ntr oduce the topi c of physi cal or sexual
abuse. Dependi ng on the answer, you can fol l ow up wi th a mor e
expl i ci t questi on, such as

Wer e you abused physically or sexually as you gr ew


up?
Wer e ther e any other impor tant adults in the
home?

Often, another r el ati ve was a major factor i n the pati ent's ear l y l i fe,
wi th ei ther a posi ti ve or a negati ve effect.

How did you get along with your siblings?

A cl ose r el ati onshi p wi th si bl i ngs can often compensate for a


ter r i bl e r el ati onshi p wi th par ents.

Who wer e you closest to, gr owing up?

EDUCATION AND WORK


Did you enjoy school?

Thi s questi on wi l l gi ve you a sense of how the pati ent managed her
fi r st encounter wi th the soci al fi el d outsi de of the fami l y.

Did you have many fr iends, or did you keep to


your self?
Did you have a best fr iend?

The pati ent's l i fel ong patter n of r el ati ng i s often appar ent i n the
fi r st few year s of school .
What kinds of gr ades did you get?

G rades ar e a r ough measur e of i ntel l i gence and per severance.

What did you do after you gr aduated (or dr opped


out)?

Di d she take the strai ght and nar r ow cour se to col l ege or i nto the
job wor l d? Or di d she wander for a whi l e, not cer tai n what to do
wi th her l i fe?

Did you like your wor k?


How well did you get along with employer s and
colleagues?

Di d the pati ent's patter n of r el ati ng conti nue unal ter ed as she
enter ed the wor k envi r onment? Di d she have any di ffi cul ti es deal i ng
wi th author i ty fi gur es?

INTIMATE RELATIONSHIPS (SEXUAL


HISTORY)
How does one ask about sexual i ty? It's al ways an awkwar d topi c,
and pati ents ar e usual l y guar ded about r eveal i ng sexual
i nfor mati on, especi al l y when i t per tai ns to sexual or i entati on. One
study showed that adol escents ar e four ti mes mor e l i kel y to r eveal
a hi stor y of homosexual contact to a computer than to a per son, but
even the r esponses r eveal ed to the computer wer e wel l bel ow
esti mates of the actual pr eval ence of homosexual i ty i n adol escents
(Tur ner et al . 1996). Thus, aski ng about sexual hi stor y r equi r es
extra sensi ti vi ty.
Recal l that i n Chapter 13, I suggested some sexual hi stor y
questi ons i n the context of the medi cal hi stor y and the assessment
of the r i sk for HIV. An al ter nati ve tacti c i s to appr oach these i ssues
fr om wi thi n the soci al hi stor y. Her e,

the rati onal e for obtai ni ng a sexual hi stor y i s not so much to assess
HIV r i sk as i t i s to assess the qual i ty of the pati ent's i nti mate
r el ati onshi ps. Is she capabl e of r el ati ng i nti matel y wi th another ?
Ar e her i nti mate r el ati onshi ps stabl e or transi ent and chaoti c, as i n
the case of pati ents wi th bor der l i ne per sonal i ty di sor der ?
As wi th the r est of the soci al hi stor y, pr oceed chr onol ogi cal l y:

When did you fir st begin dating?

Eventual l y, you'l l deci de on a way of aski ng about sexual


or i entati on that i s comfor tabl e for you. The tr i ck i s to be
nonjudgmental .

Wer e you attr acted to men, women, or both?

The above questi on shoul d be asked i n a ver y matter-of-fact way,


wi th the unspoken message that i t wi l l not faze you i f the pati ent
says that he i s attracted to the same sex.
Other opti ons ar e as fol l ows:

Pr ecede your questi on wi th a nor mal i z i ng statement, such as:


Adol escents often exper i ment wi th di ffer ent sexual l i festyl es;
was that tr ue for you? What's your cur r ent sexual pr efer ence?
At the begi nni ng of the i nter vi ew, sl i p your questi on i nto a
checkl i st of r outi ne questi ons: How ol d ar e you? What's your
mar i tal status? And your sexual pr efer ence?
Ask dur i ng the medi cal hi stor y when you ask about r i sk factor s
for HIV: Do you have any r i sk factor s for HIV? Have you had
homosexual sex?

Ar e you satisfied with your sex life?


Ar e ther e things about your sex life or your sexual
desir es that make you uncomfor table?
When did you have your fir st impor tant
r elationship?
What attr acted you to that per son?

Is the pati ent capabl e of establ i shi ng an i nti mate r el ati onshi p? Can
he descr i be other peopl e i n thr ee-di mensi onal ter ms?

CLINICAL VIGNETTE
An attendi ng cl i ni ci an was i nter vi ewi ng a 40-year-ol d di vor ced
man i n the hospi tal for depr essi on. Hi s wi fe and daughter had l eft
hi m 2 year s ear l i er. He had a l i fel ong patter n of br i ef and shal l ow
r el ati onshi ps. The fol l owi ng exchange took pl ace as the attendi ng
cl i ni ci an was expl or i ng the r el ati onshi p hi stor y:

Interviewer: Tell me about your girlfriends.

Patient: They were animals.

Pick one, and tell me about


Interviewer:
her.

I met a woman last year; she


Patient:
was a stray cat.

Why do you say she was a


Interviewer:
stray cat?

Patient: She had no connections.

What was it that you were


Interviewer:
attracted to?

Patient: Her body.

Okay. What kicked in about


Interviewer:
her personality later?

Patient: What do you mean?

If I met her, what would I


Interviewer:
notice about her?
It's tough to answer. Her
Patient:
attitude.

Interviewer: How was that?

Patient: It was good.

The pati ent was unabl e to di scuss any i mpor tant per son i n hi s l i fe
i n mor e than a super fi ci al way, whi ch mi r r or ed hi s fear s of
i nti macy.

CURRENT ACTIVITIES AND RELATIONSHIPS


What attr acted you to your cur r ent significant
other ?
How has your mar r iage (r elationship) gone?
Do you have any close fr iends (aside fr om your
spouse)?
Ar e you in touch with your family?

Does the pati ent have a soci al suppor t system i n pl ace? Who woul d
she cal l i f she wer e i n tr oubl e?

What do you do dur ing your leisur e time?

Does she enjoy spor ts, hobbi es, r eadi ng, goi ng to movi es, and other
acti vi ti es, or does she onl y wor k?

What do you think you'll be doing 5 year s fr om


now, and what would you like to be doing?

Thi s questi on pr ovi des a wi ndow i nto the pati ent's vi ew of her
futur e and her dr eams and aspi rati ons.
CLINICAL VIGNETTE
An attendi ng cl i ni ci an was i nter vi ewi ng a 32-year-ol d si ngl e
woman who had wor ked as an extr emel y successful attor ney unti l
a year ago, when she was fi r ed whi l e i n the mi ddl e of a major
depr essi on. Dur i ng the soci al hi stor y, she r el ated that she di sl i ked
physi ci ans i n general , because her abusi ve father was a
physi ci an.
Towar d the end of the i nter vi ew, the attendi ng cl i ni ci an asked

What do you think you'll be


Interviewer: doing in 5 years, and what
would you like to be doing?

I'll probably be dead. I'd like


Patient:
to be a physician.

The attendi ng cl i ni ci an then pr oducti vel y expl or ed the meani ng of


her seemi ngl y paradoxi cal desi r e to become a physi ci an.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 1 8 - Ho w t o M e m o riz e t he DSM - IV-TR C rit e ria

18
How to Memorize the DSM-IV-TR
Criteria

Essential Concepts

DSM-IV-TR Mnemoni c:
Depr essed Pati ents Sound A nxi ous, So Cl ai m Psychi atr i sts
Depr essi on and other mood di sor der s
Psychoti c di sor der s
Substance abuse di sor der s
A nxi ety di sor der s
Somatofor m di sor der s
Cogni ti ve di sor der s
Per sonal i ty di sor der s

Ever ything should be as simple as it is, but not


simpler .
--Al ber t Ei nstei n

In thi s chapter, I descr i be an appr oach to memor i z i ng the cr i ter i a


for the major DSM-IV-TR di sor der s. These mnemoni cs ar e a way of
sor ti ng i nfor mati on i nto manageabl e chunks. Those who have
r esear ched the way exper t cl i ni ci ans thi nk have found that thi s
chunki ng pr ocess i s qui te common (Kapl an 1995). The father of
chunki ng, Mi l l er (1957), showed that humans can onl y pr ocess
about 7 (2) bi ts of i nfor mati on at a ti me, whi ch i s, pr esumabl y,
why phone number s have seven di gi ts. You have to be abl e to
pr ocess mor e than seven i tems to master the DSM-IV-TR, but
mnemoni cs hel p by gr oupi ng i tems i nto i nfor mati on-packed chunks.

MEMORIZE THE SEVEN MAJOR DIAGNOSTIC


CATEGORIES
Begi n by master i ng the fol l owi ng mnemoni c for the seven major
adul t di agnosti c categor i es i n the DSM-IV-TR:

Depr essed Pati ents Sound A nxi ous, So Cl ai m Psychi atr i sts.
Depr essi on and other mood di sor der s (major depr essi on, bi pol ar
di sor der, dysthymi a)
Psychoti c di sor der s (schi zophr eni a, schi zoaffecti ve di sor der,
del usi onal di sor der )
Substance abuse di sor der s (al cohol and dr ug abuse, psychi atr i c
syndr omes i nduced by dr ug and al cohol use)
A nxi ety di sor der s [pani c di sor der, agoraphobi a, general i zed
anxi ety di sor der (G AD), obsessi ve-compul si ve di sor der (OCD)]
Somatofor m di sor der s (somati z ati on di sor der, eati ng di sor der s)
Cogni ti ve di sor der s (dementi a, mental r etar dati on, ADHD)
Per sonal i ty di sor der s

Noti ce that these categor i es devi ate somewhat fr om DSM-IV-TR


dogma. For exampl e, I cal l ADHD a cogni ti ve di sor der, wher eas the
DSM-IV-TR cl assi fi es i t as a di sor der of i nfancy, chi l dhood, and
adol escence. Al so, I cl assi fy eati ng di sor der s under somatofor m
di sor der s, wher eas the DSM-IV-TR puts them i n a separate chapter.
My pur pose her e i s not to cr eate a new cl assi fi cati on of psychi atr i c
di sor der s but si mpl y to r ear range them i nto seven categor i es for
ease of memor i z ati on.

FOCUS ON POSITIVE CRITERIA


Now that you've memor i zed the major di sor der s, you need to
memor i ze the di agnosti c cr i ter i a. Begi n by di sr egar di ng the
vol umi nous excl usi ons and modi fi er s l i sted by the DSM-IV-TR and
i nstead focus on the actual behavi or s and affects needed to make
the di agnosi s.
For exampl e, under schi zophr eni a i n the DSM-IV-TR ar e si x
categor i es of cr i ter i a, l abel ed A thr ough F. B i s the usual pr ovi so
that the di sor der must cause si gni fi cant dysfuncti on, whi ch i s tr ue
for al l the di sor der s, so you don't need to memor i ze i t. D tel l s you
to r ul e out schi zoaffecti ve and mood di sor der befor e you di agnose
schi zophr eni aanother obvi ous pi ece of i nfor mati on; don't use up
val uabl e neur ons memor i z i ng i t. E r emi nds you to r ul e out
substance abuse or a medi cal condi ti on, whi ch you shoul d do befor e
maki ng any di agnosi s, and F deal s wi th the ar cane i ssue of
di agnosi ng schi zophr eni a i n someone who's auti sti c. So, onl y two
essenti al cr i ter i a ar e l eft: A (symptoms) and C (durati on).

Thi s secti on l i sts mnemoni cs for most of the major di sor der s, but i t
does not cover how to ascer tai n the di agnoses, whi ch i nvol ves the
ski l l ful use of pr obi ng questi ons and speci fi c fol l ow-up questi ons.
These ar e cover ed i n detai l i n Chapter s 22, 23, 24, 25, 26, 27, 28,
29 and 30, wher e the ful l DSM-IV-TR cr i ter i a ar e spel l ed out.

KEY POINT
How shoul d you use these mnemoni cs? They ar e pr i mar i l y an ai d
to ensur e that you r emember to ask about major di agnosti c
cr i ter i a. Do not ask the questi ons i n the same or der as the
mnemoni cs; doi ng so woul d l ead to a ver y sti l ted i nter vi ew. Tr y to
ask di agnosti c questi ons when they seem to fi t natural l y i nto the
context of the i nter vi ew, usi ng some of the techni ques for maki ng
transi ti ons al r eady di scussed i n Chapter s 4 and 6.
Unl ess stated other wi se, these mnemoni cs ar e the pr oducts of my
own di sor der ed brai n.

Mood Disorders
Major Depression: SIGECAPS
Four out of these ei ght, wi th depr essed mood or anhedoni a, for 2
weeks si gni fy major depr essi on:

Sl eep di sor der (ei ther i ncr eased or decr eased sl eep)
Inter est defi ci t (anhedoni a)
Gui l t (wor thl essness, hopel essness, r egr et)
Ener gy defi ci t
Concentrati on defi ci t
A ppeti te di sor der (ei ther decr eased or i ncr eased appeti te)
Psychomotor r etar dati on or agi tati on
Sui ci dal i ty

Thi s mnemoni c, devi sed by Dr. Car y G r oss of the MG H Depar tment
of Psychi atr y, r efer s to what mi ght be wr i tten on a pr escr i pti on
sheet for a depr essed, aner gi c pati ent: SIG : Ener gy CAPSul es. Each
l etter r efer s to one of the major di agnosti c cr i ter i a for a major
depr essi ve di sor der. To meet the cr i ter i a for an epi sode of major
depr essi on, your pati ent must have had four of the pr ecedi ng
symptoms and depr essed mood or anhedoni a for at l east 2 weeks.

Dysthymia: ACHEWS
Two out of these si x, wi th depr essed mood, for 2 year s si gni fy
dysthymi a:

A ppeti te di sor der (ei ther decr eased or i ncr eased)


Concentrati on defi ci t
Hopel essness
Ener gy defi ci t
W or thl essness
Sl eep di sor der (ei ther i ncr eased or decr eased)

The dysthymi c pati ent i s al l er gi c to happi ness; hence, the


mnemoni c r efer s to a dysthymi c pati ent's (mi sspel l ed) sneezes
(achoos) on exposur e to happi ness. To meet the cr i ter i a, the pati ent
must have had 2 year s of depr essed mood wi th two of the si x
symptoms i n the mnemoni c.

Manic Episode: DIGFAST


El evated mood wi th thr ee of these seven, or i r r i tabl e mood wi th
four of these seven, for 1 week si gni fy a mani c epi sode:

Di stracti bi l i ty
Indi scr eti on (DSM-IV-TR's excessi ve i nvol vement i n pl easurabl e
acti vi ti es)
Grandi osi ty
Fl i ght of i deas
A cti vi ty i ncr ease
Sl eep defi ci t (decr eased need for sl eep)
Tal kati veness (pr essur ed speech)

I don't know who came up wi th thi s jewel , but I use i t al l the ti me.
DIG FAST appar entl y r efer s to the speed wi th whi ch a mani c pati ent
woul d di g a hol e i f put to the task. A compl i cati on i n the di agnosi s
i s that i f the mood i s pr i mar i l y i r r i tabl e, four of seven cr i ter i a must
be met to qual i fy.

Psychotic Disorders
Schizophrenia: Delusions Herald
Schizophrenic's Bad News
Two of these fi ve for 1 month, wi th 5 months pr odr omal or r esi dual
symptoms, si gni fy schi zophr eni a:

Del usi ons


Hal l uci nati ons
Speech di sor gani z ati on
Behavi or di sor gani z ati on
Negati ve symptoms

To meet the cr i ter i a for schi zophr eni a, pati ents must have had some
di stur bance for 6 months. Dur i ng at l east 1 month of thi s per i od,
they must have two of the symptoms l i sted i n the mnemoni c; the
other 5 months may i ncl ude si mi l ar symptoms i n attenuated for m
(i .e., pr odr omal or r esi dual symptoms).

Substance Abuse
The same mnemoni c, Tempted W i th Cognac, i s used for cr i ter i a for
any dr ug or al cohol dependence:

Tol erance (i .e., a need for i ncr easi ng amounts of al cohol to


achi eve i ntoxi cati on)
W i thdrawal syndr ome has occur r ed
Loss of Contr ol of al cohol use (encompasses the fol l owi ng fi ve
cr i ter i a):
Al cohol i s often i ngested i n l ar ger amounts than the pati ent
i ntended.
The pati ent has tr i ed, unsuccessful l y, to cut down.
A gr eat deal of ti me i s spent i n acti vi ti es r el ated to obtai ni ng
or r ecover i ng fr om the effects of al cohol .
Impor tant soci al , occupati onal , or r ecr eati onal acti vi ti es ar e
gi ven up or r educed because of al cohol use.
Al cohol use i s conti nued despi te the pati ent's knowl edge of
si gni fi cant physi cal or psychol ogi cal pr obl ems caused by i ts
use.

Thr ee of the seven cr i ter i a l i sted above ar e r equi r ed for di agnosi s.


For al cohol dependence, the CA GE questi onnai r e i s often used:

Have you felt you should Cut back on your


dr inking?
Has anybody A nnoyed you with comments on your
dr inking?
Have you felt Guilty about your dr inking?
Have you ever had an Eye-opener in the mor ning
to get r id of a hangover ?

Two or mor e affi r mati ve answer s i ndi cate a hi gh pr obabi l i ty of


al cohol dependence (Ewi ng 1984).

Anxiety Disorders
Panic Attack (4 of 13)
Wi th so many separate cr i ter i a to r emember (13 total ), tr yi ng to
r ecal l them wi th an acr onym or phrase i s not practi cal . My tr i ck
i nstead i s to br eak the symptoms down i nto thr ee cl uster s: (a) the
hear t, (b) br eathl essness, and (c) fear. To r emember them, I
vi sual i ze a pani cki ng pati ent cl utchi ng hi s chest (hear t cl uster ),
hyper venti l ati ng (br eathl essness cl uster ), and shaki ng wi th fear
(fear cl uster ). F i nal l y, I i magi ne hi m scr eami ng out, Thr ee-fi ve-
fi ve! Thr ee-fi ve-fi ve!pr esumabl y as a way of di stracti ng hi msel f
fr om the pani c attack. The number s r efer to the number of cr i ter i a
i n each cl uster : The hear t cl uster has thr ee cr i ter i a, and the other
two cl uster s have fi ve each.
I admi t that thi s al l sounds hokey, but bel i eve me, you'l l never
for get the cr i ter i a i f you do i t!

Heart Cluster: Three


I thi nk of symptoms that often accompany a hear t attack:

Pal pi tati ons


Chest pai n
Nausea

Breathlessness Cluster: Five


I thi nk of symptoms associ ated wi th hyper venti l ati on, whi ch i ncl ude
di z z i ness, l i ghtheadedness, ti ngl i ng of the extr emi ti es or l i ps
(par esthesi as), and chi l l s or hot fl ashes.

Shor tness of br eath


Choki ng sensati on
Di z z i ness
Par esthesi as
Chi l l s or hot fl ashes

Fear Cluster: Five


I associ ate shaki ng and sweati ng wi th fear. To r emember
der eal i z ati on, thi nk of i t as a way of psychol ogi cal l y escapi ng pani c.

Fear of dyi ng
Fear of goi ng craz y
Shaki ng
Sweati ng
Der eal i z ati on or deper sonal i z ati on

Asi de fr om r emember i ng the cl uster names, r emember the patter n


3-5-5 to keep fr om mi ssi ng any of the 13 cr i ter i a. Your pati ent must
have exper i enced four symptoms to meet the cr i ter i a for a ful l -scal e
pani c attack.

Agoraphobia
I have no mnemoni c for agoraphobi a, because ther e ar e r eal l y onl y
two cr i ter i a: a fear of bei ng i n pl aces wher e escape mi ght be
di ffi cul t and effor ts to avoi d such pl aces. See Chapter 24 for detai l s.

Obsessive-Compulsive Disorder
The r equi r ement for the di agnosi s of OCD i s the pr esence of
obsessi ons, compul si ons, or both to a degr ee that causes si gni fi cant
dysfuncti on. The defi ni ti ons of obsessi ons and compul si ons ar e
easi l y l ear ned and r emember ed (see Chapter 24), so a mnemoni c i s
not necessar y. Instead, I have chosen some of the most common
symptoms seen i n cl i ni cal practi ce; none of them i s speci fi cal l y
r equi r ed to be pr esent by DSM-IV-TR.

W ashi ng and Strai ghteni ng Make Cl ean Houses:


W ashi ng
Strai ghteni ng (or der i ng r i tual s)
Mental r i tual s (e.g., magi cal wor ds, number s)
Checki ng
Hoar di ng

Posttraumatic Stress Disorder


The PTSD pati ent Remember s A tr oci ous Nucl ear A ttacks.

Reexper i enci ng the trauma vi a i ntr usi ve memor i es, fl ashbacks,


or ni ghtmar es (one of w hich is required for diagnosis)
A voi dance of sti mul i associ ated wi th trauma and Numbi ng of
general r esponsi veness (e.g., avoi di ng thi ngs associ ated wi th the
trauma, amnesi a for the trauma, r estr i cted affect and acti vi ti es,
detachment, and for eshor tened futur e; one required for
diagnosis)
Symptoms of i ncr eased A r ousal , such as i nsomni a, i r r i tabi l i ty,
hyper vi gi l ance, star tl e r esponse, and poor concentrati on (tw o
required for diagnosis)

Generalized Anxiety Disorder (Three of Six)


The fi r st par t of the di agnosi s of G AD i s easy: The pati ent has
wor r i ed excessi vel y about somethi ng for 6 months. The har d par t i s
r emember i ng the si x anxi ety symptoms, thr ee of whi ch must be
pr esent. The fol l owi ng mnemoni c i s based on the i dea that Macbeth
had G AD befor e and after ki l l i ng Ki ng Duncan:

Macbeth Fr ets Constantl y Regar di ng Il l i ci t Si ns:


Muscl e tensi on
Fati gue
Concentrati on pr obl ems
Restl essness, feel i ng on edge
Ir r i tabi l i ty
Sl eep pr obl ems

If thi s el aborate acr onym i sn't to your l i ki ng, an al ter nati ve i s


i magi ni ng what you woul d exper i ence i f you wer e constantl y
wor r yi ng about somethi ng or other. You'd have insomnia, l eadi ng to
dayti me fatigue. Fati gue i n tur n woul d cause irritability and
problems concentrating, and constant wor r y woul d cause muscle
tension and restlessness.

Somatoform Disorders*
Somatization Disorder
Reci pe 4 pain: convert 2 stomachs to 1 sex (ei ght of ei ght
symptoms, onset befor e age 30 year s).
The di agnosi s of somati z ati on di sor der r equi r es a number of
medi cal l y unexpl ai ned symptoms wi th onset befor e age 30 year s.
Ther e must be four pai n symptoms (4 pai n), one conver si on
symptom (conver t), two gastr oi ntesti nal symptoms (2 stomachs),
and one sexual symptom (1 sex). Thi s nonsensi cal mnemoni c wi l l
l odge these cr i ter i a i n your brai n for ever.

Bulimia Nervosa
Bul i mi cs Over Consume Pastr i es (four of these):
Bi ngei ng

Out-of-contr ol feel i ng whi l e eati ng


Concer n wi th body shape
Pur gi ng

Anorexia Nervosa
W ei ght Fear Bother s A nor exi cs (four of these):
W ei ght bel ow 85% of i deal body wei ght
Fear of fat
Body i mage di stor ti on
A menor r hea

For both bul i mi a and anor exi a, the pati ent must have al l four
cr i ter i a to mer i t the di agnosi s.

Cognitive Disorders
Dementia
A memor y i mpai r ment pl us one of four BREW symptoms:

Memor y BREW :
Memor y i mpai r ment
Behavi or di sor gani z ati on (apraxi a)
Recogni ti on i mpai r ment (agnosi a)
Executi ve functi oni ng i mpai r ment
W or d pr obl ems (aphasi a)

Somethi ng i s wr ong wi th the memor y br ew of the pati ent wi th


dementi a. A gradual onset of a memor y pr obl em i s r equi r ed, but
onl y one of the commonl y associ ated symptoms (BREW) must be
pr esent. See Chapter s 20 and 27 for fur ther i nfor mati on on
assessi ng these symptoms.

Delirium
Medi cal FRA T (al l fi ve of these):
Medi cal cause of cogni ti ve i mpai r ment
Fl uctuati ng cour se
Recent onset
A ttenti on i mpai r ment
Thi nki ng (cogni ti ve) di stur bance

Because del i r i um i s caused by a medi cal i l l ness, bei ng par t of the


medi cal frater ni ty hel ps to di agnose i t. To mer i t the di agnosi s, al l
fi ve cr i ter i a must be pr esent. See Chapter 27 for detai l s.

Attention-Deficit Hyperactivity Disorder


Ther e ar e 18 separate, though often r edundant, cr i ter i a for ADHD,
maki ng memor i z ati on i mpossi bl e for anyone wi thout a photographi c
memor y (Tabl e 18.1). As wi th pani c di sor der, I suggest br eaki ng the
symptoms i nto four br oad categor i es, whi ch can be r emember ed by
the mnemoni c MOA T (you'l l need a MOAT ar ound the cl assr oom for
the hyperacti ve chi l d):

Movement excess (hyperacti vi ty)


Or gani z ati on pr obl ems (di ffi cul ty fi ni shi ng tasks)

TABLE 18.1. DSM-IV-TR criteria for ADHD


A. Six of nine disorganization/inattention
symptoms or six of nine
impulsivity/hyperactivity symptoms must be
present.
Disorganization/inattention symptoms
Organization problems
Can't organize tasks
Loses things needed for tasks
Problems finishing tasks
Attention problems
Poor focus
Easily distracted
Doesn't listen
Forgets easily
Makes careless mistakes
Avoids tasks requiring concentration
Impulsivity/hyperactivity symptoms
Talking impulsively
Talks too much
Blurts out answers
Interrupts others
Can't play quietly
Movement excess
Fidgets and squirms
Leaves seat
Displays restlessness
On the go
Can't wait for his turn

B. Some symptoms must have been present


before age 7 years.
C. Symptoms occur in two or more settings,
such as school (or work) and home.

Adapted from American Psychiatric


Association. (2000). Diagnostic and
Statistical Manual of Mental Disorders, 4th
ed. Text revision. Washington, DC: American
Psychiatric Association.

A ttenti on pr obl ems


Tal ki ng i mpul si vel y

Personality Disorders
Chapter 30 outl i nes a system for di agnosi ng per sonal i ty di sor der s i n
general , i ncl udi ng mnemoni cs for al l ten of the per sonal i ty
di sor der s, whi ch ar e not r epeated her e.

Footnotes
*I use quotati on mar ks because the eati ng di sor der s ar e not
consi der ed somatofor m di sor der s by the DSM-IV-TR. They ar e
cl assi fi ed as such her e for ease of memor i z ati on.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 1 9 - Int e rv ie w ing fo r Dia gno s is : The Art o f Hy po t he s is Te s t ing

19
Interviewing for Diagnosis: The Art of
Hypothesis Testing

Essential Concepts

Use the fr ee speech per i od for generati ng hypotheses.


Investi gate each hypothesi s wi th scr eeni ng and pr obi ng
questi ons.
Make graceful transi ti ons to di agnosti c questi ons thr oughout
the i nter vi ew.
Use the PROS for cl ean-up.

The pr obl em i s how to come up wi th a compl ete and accurate


di agnosi s i n a ver y l i mi ted amount of ti me. Ear l y i n trai ni ng, thi s i s
l ess of an i ssue, when you ar e encouraged to spend what you wi l l
l ater consi der to be i nor di nate amounts of ti me i nter vi ewi ng your
pati ents. But after trai ni ng, you wi l l qui ckl y r eal i ze that ther e i s a
cor r el ati on between the number of pati ents that you see per day
and your abi l i ty to affor d a mor tgage on that new home. You wi l l be
tor n between the need to do thi ngs qui ckl y and the need to do
thi ngs r i ght.
The way thi ngs ar e done i n most busy communi ty cl i ni cs i s pr obabl y
not so r i ght. One r ecent study compar ed r outi ne di agnoses as
found i n the medi cal char t wi th a gol d standar d di agnosi s
generated usi ng the SCID [Str uctur ed Cl i ni cal Inter vi ew for
Di agnosti c and Stati sti cal Manual of Mental Di sor der s, Revi sed Thi r d
Edi ti on (DSM-III-R)] pl us char t r evi ew as wel l as an addi ti onal
i nter vi ew wi th a hi ghl y qual i fi ed psychi atr i st or psychol ogi st. Ther e
was onl y about a 50% rate of agr eement between r outi ne and gol d
standar d di agnosi s, and i n one-hal f of al l cases of di sagr eement,
feedback to the or i gi nal cl i ni ci ans r esul ted i n si gni fi cant changes i n
pati ent car e.
Does thi s mean that you shoul d gi ve the SCID to al l of your pati ents
befor e the i nter vi ew? Thankful l y not, because the techni ques
di scussed i n thi s secti on, i nvol vi ng scr eeni ng and pr obi ng questi ons,
mi r r or the SCID gol d standar d, adapti ng i t to the r eal i ti es of cl i ni cal
practi ce.
One mi ght assume that the best way to r each a di agnosi s i s to
fol l ow a two-step pr ocess:

1. Obtai n al l potenti al l y r el evant data about the pati ent.


2. Exami ne the data to deter mi ne whi ch di agnosi s fi ts best.

Thi s strategy woul d wor k wel l i f ti me wer e l i mi tl ess. Because i t


i sn't, cl i ni ci ans have devel oped ways of deter mi ni ng i n advance
what i s l i kel y to be r el evant data for a par ti cul ar pati ent, ther eby
vastl y i ncr easi ng the effi ci ency of the di agnosti c i nter vi ew.
How do exper t cl i ni ci ans make di agnoses? A number of r esear cher s
have done obser vati onal studi es to answer thi s questi on (El stei n et
al . 1978; Kapl an 1995). They have found that exper i enced cl i ni ci ans
begi n by car eful l y l i steni ng to the pati ent's i ni ti al compl ai nt and
aski ng open-ended questi ons. Based on thi s pr el i mi nar y
i nfor mati on, they generate a l i mi ted number of di agnosti c
hypotheses (the average bei ng four ) ear l y i n the i nter vi ew, usual l y
wi thi n the fi r st 5 mi nutes. They then ask a number of cl osed-ended
questi ons to test whether each hypothesi s i s tr ue. Thi s pr ocess i s
known as patter n-matchi ng, i n whi ch the pati ent's patter n of
symptoms i s compar ed wi th the symptom patter n r equi r ed for a
di agnosi s.
Another way to vi ew thi s appr oach i s to thi nk of a cl osed cone of
questi ons (Li pki n 1987). The i ni ti al questi ons ar e open ended and
expl orator y; they become mor e cl osed ended to pur sue a speci fi c
di agnosi s to an endpoi nt of ver i fi cati on or excl usi on.
In accor dance wi th these r esear ch-based concepti ons, I suggest the
fol l owi ng four stages for rapi dl y establ i shi ng di agnoses dur i ng the
psychi atr i c i nter vi ew.

FREE SPEECH PERIOD


In Chapter 3, I emphasi ze the val ue of gi vi ng the pati ent the
openi ng wor d as a way of hel pi ng to cr eate a therapeuti c al l i ance,
but i t's al so val uabl e for begi nni ng the pr ocess of generati ng
hypotheses. G enerati ng di agnoses begi ns the moment you fi r st see
your pati ent and conti nues thr oughout the i nter vi ew. It's i mpor tant
that your mi nd shoul d be especi al l y acti ve dur i ng the fi r st few
mi nutes.
Keep the mnemoni c Depr essed Pati ents Sound A nxi ous, So Cl ai m
Psychi atr i sts i n mi nd as you l i sten to your pati ent. Does she
appear depr essed or mani c? Is she speaki ng coher entl y, and i s her
r eal i ty testi ng good? Does she seem anxi ous? Does she

seem shar p or cogni ti vel y i mpai r ed? Is she begi nni ng the i nter vi ew
compl ai ni ng of numer ous somati c symptoms? Does she have al cohol
on her br eath? Does she seem i nappr opr i atel y angr y or enti tl ed?
You wi l l qui ckl y be abl e to generate a mental l i st of l i kel y
di agnoses, whi ch you shoul d fol l ow up on l ater i n the i nter vi ew wi th
appr opr i ate scr eeni ng and pr obi ng questi ons.

SCREENING AND PROBING QUESTIONS


Once you've generated your shor t l i st of l i kel y di agnoses, go on to
test your hypotheses. Begi n by aski ng a scr eeni ng questi on that
gets at the cor e featur e of the di sor der. Each di sor der-speci fi c
chapter i n Secti on III suggests one or mor e scr eeni ng questi ons. For
i nstance, a scr eeni ng questi on for bi pol ar di sor der (see Chapter 23)
is

Have you ever had a per iod of a week or so when


you felt so happy and ener getic that your fr iends
said that you wer e talking too fast or that you wer e
behaving differ ently and str angely?

If the pati ent answer s yes, go r i ght i nto the mnemoni c for mani c
epi sodes (DIG FAST) and ask pr i mar i l y cl osed-ended questi ons about
each cr i ter i on. If the pati ent answer s no and you ar e cer tai n that
he under stood the questi on, you shoul d concl ude that bi pol ar
di sor der i s unl i kel y and move onto another par t of the i nter vi ew.
Inter vi ewi ng for di agnosi s i s an acti ve, pr obi ng pr ocess i n whi ch you
wi l l often do as much tal ki ng as your pati ent. Is such an acti ve styl e
r eal l y mor e effecti ve i n el i ci ti ng di agnosti c i nfor mati on than a
qui eter, l i steni ng styl e? Common sense di ctates that i t i s, and the
Maudsl ey Hospi tal r esear cher s concl uded that i t i s as wel l . In one of
thei r paper s exami ni ng techni ques for el i ci ti ng factual i nfor mati on
(Cox et al . 1981b), they found that a focused and di r ecti ve styl e, i n
whi ch i nter vi ewer s used many pr obi ng questi ons and often
r equested detai l ed i nfor mati on, l ed to better data than a mor e
passi ve styl e. The best data wer e obtai ned when i nter vi ewer s used
at l east ni ne pr obi ng questi ons per symptom. Data wer e judged to
be better when, i n addi ti on to the mer e menti on of a symptom,
such as depr essi on, i nter vi ewer s coul d obtai n i nfor mati on about the
fr equency, durati on, sever i ty, context, and qual i ti es of the
symptom, al l of whi ch ar e extr emel y i mpor tant for di agnosti c
deci si on maki ng.

The concer n r emai ns that a di r ecti ve styl e may el i ci t gr eat factual


data at the expense of shutti ng the pati ent down emoti onal l y wi th
too much questi oni ng and not enough l i steni ng. Cox et al . (1981a)
exami ned thi s i ssue and found that mor e di r ecti ve i nter vi ewer s
actual l y el i ci ted sl i ghtl y mor e feel i ngs than di d i nter vi ewer s wi th a
l ess di r ecti ve styl e.

TRANSITION GRACEFULLY TO DIAGNOSTIC


QUESTIONS
KEY POINT
Don't tr y to tur n the di agnosti c i nter vi ew i nto a l ong checkl i st of
di agnosti c questi ons. Thi s gi ves the i nter vi ew a mechani cal
feel i ng and wi l l di mi ni sh pati ent rappor t. Instead, ask di agnosti c
questi ons at r el evant poi nts i n the i nter vi ew, usi ng the transi ti on
ski l l s you l ear ned i n Chapter 6. Much of Secti on III gi ves you ti ps
for accompl i shi ng such transi ti ons; her e ar e a few exampl es as a
pr evi ew.

Illustrative Transitions to Diagnostic Areas


Depr essi on
Wi th thi ngs so bad i n your mar r i age, I wonder how i t's been
affecti ng your mood.
OCD
You sai d you'r e often l ate. Ar e ther e r i tual s you do at home that
make you l ate, l i ke checki ng or cl eani ng thi ngs?
Substance abuse
G i ven al l the str ess you've been under, do you have a dr i nk now
and then to deal wi th i t?
Sui ci dal i ty
Wi th thi ngs goi ng so poor l y i n your l i fe, I wonder i f you've been
debati ng whether i t's wor th i t to go on?

Bor der l i ne per sonal i ty di sor der


Ear l i er you menti oned that your husband l eft you year s ago;
how do you nor mal l y deal wi th r ejecti on?
Psychosi s
You've been thr ough so much str ess l atel ydoes i t ever cause
your mi nd to pl ay tr i cks on you, so that you hear voi ces or have
strange i deas?

PSYCHIATRIC REVIEW OF SYMPTOMS


TIP
It's not uncommon to for get to ask i mpor tant questi ons dur i ng an
i nter vi ew, even i f you use al l the mnemoni cs i n Chapter 18. The
PROS i s a hel pful way to pr event thi s fr om happeni ng. At some
poi nt towar d the end of the i nter vi ew, mental l y r evi ew the DSM-
IV-TR mnemoni c (Depr essed Pati ents Sound A nxi ous, So Cl ai m
Psychi atr i sts) and ask scr eeni ng questi ons for any di sor der that
you haven't yet expl or ed. Thi s step r esembl es the sur vey
appr oach that I decr i ed ear l i er, but i t's usual l y qui te br i ef,
because by thi s ti me you al r eady wi l l have cover ed the pr i or i ty
topi cs.
The PROS i s usual l y best begun wi th an i ntr oduced transi ti onal
statement, such as

Now I'd like to switch gear s a little and ask you


about a bunch of differ ent psychological
symptoms some people have.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 0 - M e nt a l St a t us Ex a m ina t io n

20
Mental Status Examination

Essential Concepts

Mnemonic for Elements of the Mental Status Examination:


A l l Bor der l i ne Subjects A r e Tough, Tr oubl ed Character s
A ppearance
Behavi or
Speech
A ffect
Thought pr ocess
Thought content
Cogni ti ve exami nati on

Nothi ng i n the psychi atr i c assessment i s as mi sunder stood as the


mental status exami nati on (MSE). Two mi sconcepti ons ar e
ubi qui tous. The fi r st i s that the MSE takes pl ace at the par ti cul ar
poi nt i n the i nter vi ew when you test or i entati on and r ecal l . In fact,
the MSE occur s thr oughout the enti r e i nter vi ew, dur i ng whi ch you
ar e constantl y eval uati ng affect, concentrati on, memor y, and
i nsi ght. The second myth i s that the MSE i s i denti cal to the Fol stei n
Mi ni -Mental State Exami nati on (MMSE). In fact, the Fol stei n MMSE
i s a speci fi c scr een for dementi a. Incr easi ngl y, i ts use i n the r outi ne
psychi atr i c i nter vi ew i s bei ng questi oned, but we'l l tal k mor e about
that l ater.
The MSE i s your eval uati on of your pati ent's cur r ent state of
cogni ti ve and emoti onal functi oni ng. Al though most of the i ni ti al
i nter vi ew i s speci fi cal l y focused on your pati ent's past, doi ng an
excel l ent MSE r equi r es that you attend at the same ti me to hi s
pr esent. Her e your thi r d ear comes i nto pl ay. How i s your pati ent
pr esenti ng hi msel f ? What i s hi s TP l i ke? How i s he emoti ng? It wi l l
take you year s to hone your power s of obser vati on, and thi s i s
cer tai nl y the most i nter esti ng par t of the di agnosti c i nter vi ew.
An MSE accompl i shes two pur poses. F i r st, i t hel ps make a di agnosi s,
especi al l y i n those cases i n whi ch hi stor i cal data ar e unr el i abl e or
equi vocal . A pati ent coul d send you an e-mai l l i sti ng al l of hi s
depr essi ve symptoms, but i t r equi r es di r ect obser vati on

an MSEto assess the degr ee of hi s angui sh and hi s need for


tr eatment. Second, the MSE al l ows you to cr eate a vi vi d pati ent
descr i pti on for your r ecor ds. Usi ng thi s, you can mor e easi l y track
your pati ent's pr ogr ess fr om vi si t to vi si t, and you can gi ve
cl i ni ci ans to whom you r efer a mor e accurate sense of hi s condi ti on.

ELEMENTS OF THE MENTAL STATUS


EXAMINATION
The MSE has r oughl y seven components. Thi s mnemoni c wi l l hel p
you to r emember them:
A l l Bor der l i ne Subjects A r e Tough, Tr oubl ed Character s:

A ppearance
Behavi or
Speech
A ffect
Thought pr ocess
Thought content
Cogni ti ve exami nati on

Appearance
How does your pati ent's appearance hel p you i n your eval uati on? At
the extr emes, a speci fi c di agnosi s mi ght i mmedi atel y suggest i tsel f.
For exampl e, a di shevel ed man wear i ng bi z ar r el y mi smatched l ayer s
of cl othes i s schi zophr eni c unti l pr oven other wi se. Li kewi se, a
fl amboyant and seducti vel y dr essed woman wi th br i ght makeup who
bounces i nto your offi ce wi th ener gy to spar e str ongl y suggests
mani a.
In usual cl i ni cal practi ce, however, these pathognomoni c
pr esentati ons ar e rar e, and appearance pr ovi des mor e subtl e, but
no l ess useful , i nfor mati on. Qual i ti es to note i ncl ude

Sel f-esteem: Does the pati ent car e about hi s appearance?


Compar e the fol l owi ng two pati ent descr i pti ons:

The patient was a mildly over weight man with


unr uly black cur ly hair , dr essed in ill-fitting
baggy jeans and a T-shir t so tight that his
stomach was visibly bulging above his belt.
The patient was a slim man who appear ed
younger than his 47 year s, with fashionably cut
shor t br own hair , an
P.124
ir oned button-down shir t, new jeans, and
polished penny loafer s.
Both patients wer e diagnosed with depr ession,
but they pr esented ver y differ ently and
r equir ed differ ent tr eatment plans.

Per sonal statement: Does the appearance say somethi ng speci fi c


about your pati ent's i nter ests, acti vi ti es, or atti tudes?

The patient came into the office dr essed in a


pr essed electr ician's unifor m, with his name
stitched over his br east pocket.
She wor e a T-shir t with the slogan, Ever y day
I'm for ced to add one mor e name to the list of
people who piss me off.

Memorabl e aspects: Descr i be whatever par ti cul ar l y str i kes you


about your pati ent. For exampl e, i f he i s par ti cul ar l y attracti ve,
note i t, si nce degr ee of attracti veness i s usual l y r el evant to sel f-
i mage. However, I have yet to see any r epor t descr i be a pati ent
as unattracti ve, and I woul dn't r ecommend i t, because i t
i mpl i es that you di sl i ked hi m. Instead, descr i be the unattracti ve
aspects.
This was a man of nor mal build who had a
r ound, acne-cover ed face and was essentially
bald, with the exception of small amounts of
oily black hair on either side.

Someti mes, a par ti cul ar featur e jumps out at you:

She had shor t cur ly br own hair , and her left


eye was congenitally deviated towar d the left,
giving her a somewhat unsettling appear ance.

TIP
The mor e vi vi d the notati on, the better. I fi nd i t hel pful to
actual l y jot down a few descr i ptor s at the begi nni ng of the
i nter vi ew, dur i ng the fr ee speech per i od.

Comment on hei ght and bui l d; hai r col or, styl e, and qual i ty,
i ncl udi ng faci al hai r, i f any; faci al featur es, i ncl udi ng

eyes; cl othes; movements; and any other pr omi nent featur es of


appearance, l i ke tattoos or scar s.

TABLE 20.1. Appearance terms

Aspect of
Descriptors
appearance

Bald, thinning, close-cropped,


short, long, shoulder-length,
crew-cut, straight, curly, wavy,
Hair frizzy, braided, pony tail, pig
tails, afro, relaxed, dreadlocks,
unevenly cut, stiff, greasy, dry,
matted
Clean-shaven, neatly trimmed
Facial hair beard, long and scraggly beard,
goatee, unshaven

Attractive, nice-looking, pleasant,


plain, pale, drawn, ruddy,
Face flushed, bony, thin, broad, moon-
shaped, red-nosed, thickly made-
up

Good or poor eye contact, shifty,


averted gaze, staring, fixated,
Eyes (gaze)
dilated, downcast, forceful,
intense, aggressive, piercing

Thin, cachectic, lean, frail,


underweight, normal build,
muscular, husky, stocky,
Body overweight, moderately obese,
obese, morbidly obese, short,
medium height, tall, tattooed
arms

No abnormal movements, fidgety,


bobbing knee, facial tic or twitch,
lip smacking, lip puckering,
Movements
tremulous, jittery, restless,
wringing hands, motionless,
rigid, limp, stiff, slumped

Casually dressed, neat,


appropriate, professional,
immaculate, fashionable, sloppy,
Clothes ill-fitting, outdated, flamboyant,
sexually provocative, soiled,
dirty, tight, loose, slogans on
clothes

Tabl e 20.1 (i ncl uded i n Appendi x A as a pocket car d) may appear to


r estate the obvi ous, but i t's useful to me when I l ack the r i ght
descr i pti ve wor ds.

Behavior and Attitude


How di d your pati ent behave towar d you when you fi r st met her ?
Was she fr i endl y and cooperati ve, or di d she seem i ndi ffer ent and
apatheti c? Di d she si t r i ght down and face you, or was she agi tated,
paci ng ar ound the r oom and tal ki ng rapi dl y wi thout r eal l y attendi ng
to your questi ons? The context of the i nter vi ew may al so be
i mpor tant to maki ng sense of the behavi or.

Was i t a schedul ed eval uati on i nter vi ew or di d i t take pl ace i n an


emer gency r oom?

Table 20.2. Affect terms

Affect Terms

Appropriate, calm, pleasant,


Normal relaxed, normal, friendly,
comfortable, unremarkable

Cheerful, bright, peppy, content,


self-satisfied, silly, giggly,
Happy
grandiose, euphoric, elated,
exalted
Sad, gloomy, sullen, depressed,
Sad pessimistic, morose, hopeless,
discouraged

Anxious, worried, tense, nervous,


Anxious apprehensive, frightened,
terrified, bewildered, paranoid

Angry, irritable, disdainful, bitter,


Angry arrogant, defensive, sarcastic,
annoyed, furious, enraged, hostile

Indifferent, shallow, superficial,


cool, distant, apathetic, aloof,
Indifferent
dull, vacant, affectless,
uninterested, cynical

Descr i ptor s of atti tude ar e si mi l ar to descr i ptor s of affect (Tabl e


20.2), but the emphasi s i s on wor ds that descr i be a r el ati onshi p
towar d someone. Often, a sentence of descr i pti on i s i mpor tant. Her e
ar e some exampl es:

He pr esented himself as someone who was ver y


anxious to tell his stor y and to gain r elief fr om his
symptoms. He had an attitude of submissive
r espect, saying things like, Do you think you can
help me, doctor ? What do you think I have?
She pr esented as indiffer ent and apathetic. Her
gener al attitude was that this was just the latest in
a long str ing of unhelpful inter views.
Often, your patient's attitude towar d you will
change over the cour se of the inter view.
He was initially r eluctant to answer questions and
seemed ir r itable. Over the cour se of the inter view,
he became mor e self-r evealing and tear ful.

Speech
Descr i pti on of speech has gr eat over l ap wi th descr i pti on of TP,
because we can onl y know our pati ents' thoughts thr ough speech.
Qual i ti es of speech to consi der i ncl ude

TABLE 20.3. Speech terms

Normal
Thoughtful
Articulate
Intelligent
Rapid
Staccato
Pressured
Rambling
Continuous
Loud
Soft
Barely audible
Slow
Halting

Rate: Does he speak rapi dl y or sl owl y? Rapi d or pr essur ed


speech i s usual l y a buz z wor d for mani c speech, but you need to
be car eful not to over pathol ogi ze. Rapi d speech can si gnal
anxi ety or even be the nor mal speech patter n. We al l know
peopl e who speak ver y rapi dl y but ar e not mani c.
Vol ume: Pati ents who speak l oudl y may be mani c, i r r i tabl e, or
anxi ous. Ver y l ow vol ume may si gnal depr essi on or shyness.
Agai n, l oud or qui et speech may al so be a nonpathol ogi c var i ant
of nor mal .
Latency of r esponse: Nor mal l y, when you ar e asked a questi on,
you'l l thi nk for a fracti on of a second befor e r espondi ng. Thi s i s
the nor mal l atency of r esponse. Mani c pati ents may r espond so
qui ckl y that they seem to jump onto the l ast few wor ds of your
questi ons. Depr essed or psychoti c pati ents may show an
i ncr eased l atency of r esponse, wai ti ng several seconds befor e
answer i ng si mpl e questi ons.
G eneral qual i ty: Does your pati ent speak thoughtful l y and i n an
ar ti cul ate manner, or does she rambl e i n a vague and
di sconnected way, maki ng her har d to fol l ow? The ter ms i n Tabl e
20.3 ar e di scussed i n mor e detai l i n Chapter 26, i n the secti on
on di sor der s of TP.

Affect and Mood


Tradi ti onal teachi ng di sti ngui shes mood fr om affect, wi th mood
defi ned as a pati ent's subjecti ve r epor t of how he feel s, and affect

defi ned as your own i mpr essi on of hi s emoti onal state. Al though
many cl i ni ci ans do not make thi s di sti ncti on i n cl i ni cal wor k, you
shoul d become fami l i ar wi th i t, because i t i s wi del y used.
Li ke obser vati on of appearance and behavi or, accurate obser vati on
of affect i s a ski l l that takes year s to master. Al though the overal l
emoti onal fl avor i s usual l y obvi ous, the gradati ons and subtl eti es
ar e not, and assessi ng degr ee of affect can be vi tal l y i mpor tant for
such thi ngs as deter mi ni ng i mmi nence of SI or pr edi cti ng the
l i kel i hood of aggr essi ve acti ng out.
Often, you won't have to expl i ci tl y ask your pati ent how he's been
feel i ng, because he'l l r epor t i t spontaneousl y. However, what do you
do when your pati ent i s vague about hi s emoti ons or i s r el uctant to
r eveal hi msel f ?
The obvi ous (and easi est) appr oach i s to come r i ght out and ask.

How do you feel r ight now? How has your mood


been over the past few days?

If the pati ent answer s wi th a vague ter m, fol l ow up wi th questi ons


ai med at gi vi ng a mor e r efi ned name to the affect, a name on whi ch
you both can agr ee but whi ch you have not fed the pati ent.

CLINICAL VIGNETTE

How have you been feeling


Interviewer:
over the past few days?

Patient: Not so great.

Hmmm. Not so great. Can you


Interviewer:
give that feeling a name?

Patient: Justreally lousy.

I mean an emotion word, like


Interviewer: sad, nervous, angry, and so
on.

Patient: Sad, I guess.

One par ti cul ar l y di ffi cul t si tuati on i s when your pati ent says he
feel s up and down or that he has mood swi ngs. Suddenl y you ar e
faced wi th a huge di agnosti c di ffer enti al . Does the pati ent have
bi pol ar di sor der ? Cycl othymi a? Does he have depr essi on wi th mood
r eacti vi ty? Does he have a per sonal i ty

di sor der ? An anxi ety di sor der ? A substance abuse di sor der ? Al l of
these ar e compati bl e wi th an up-and-down mood.
Your questi oni ng strategy shoul d be based on tr yi ng to l ocate an
endur i ng, per si stent mood beneath the var i ati ons. Or, i f ther e i s
tr ue mood i nstabi l i ty, you shoul d deter mi ne whether the l ows meet
cr i ter i a for major depr essi on and the hi ghs sati sfy cr i ter i a for
mani a. I'l l have mor e to say about these i ssues i n Chapter s 22 and
23, but her e's an exampl e of a strategy that usual l y wor ks wel l :
CLINICAL VIGNETTE

How have you been feeling


Interviewer:
over the past few days?

(Shaking head, looking at


Patient: interviewer intensely.) Totally
up and down.

Tell me about the downs first.


When you say down, do you
Interviewer:
mean sad or depressed, or
something else?

Patient: Really depressed.

Do you feel depressed nearly


Interviewer:
every day?

Patient: Sometimes I get really happy.

I want to talk about the happy


times, too, in a second. To
Interviewer: focus on the down times, do
you have depressed periods
nearly every day?

Patient: Yes.

Is your concentration affected


Interviewer: during those depressed
periods?

[The interviewer goes through the


neurovegetative symptoms (NVSs) of
depression and determines that the patient
meets criteria for a major depressive
episode.]

Now, tell me more about the


really happy times you've been
Interviewer:
having. What do you mean by
ups?

Feeling great, feeling on top of


Patient:
the world.

Okay. Do you really feel great


Interviewer:
nearly every day?

No, not every day, but


Patient:
sometimes I do.

Over the past 2 weeks, how


Interviewer: many days would you say you
felt really great?

Oh, a couple. My parents gave


Patient: me a car for graduation. I was
so happy.

How long did that happy mood


Interviewer:
last?
Patient: Couple of days.

Interviewer: Then how did you feel?

Patient: Down, as usual.

The eventual di agnosi s was major depr essi on, because the
pati ent's per vasi ve mood had been depr essi on, wi th a number of
the r equi r ed NVSs. The ups tur ned out to be br i ef r epr i eves
fr om the per si stent depr essed mood.

Tabl e 20.2 (i ncl uded as a pocket car d i n Appendi x A) i s a useful


r efer ence whi l e you'r e wr i ti ng up the MSE. Use i t to enr i ch your
emoti onal vocabul ar y, so that you don't get i n the habi t of usi ng a
si ngl e wor d to descr i be al l pati ents wi th a par ti cul ar ki nd of affect.

Qualities of Affect
Four qual i ti es of affect ar e commonl y taught, but, as wi th the
di sti ncti on between mood and affect, the useful ness of these
di sti ncti ons i s contr over si al . My opi ni on i s that ther e i s too much
hai r-spl i tti ng i n academi c psychi atr y, and that cl i ni cal wor k woul d
be si mpl er and just as effecti ve wi thout wor r yi ng about the
fol l owi ng di sti ncti ons. Nonethel ess, many woul d di sagr ee, and you
shoul d at l east become fami l i ar wi th the ter ms, whether or not you
use them.

1. Stabi l i ty of affect: Thi s r efer s to a conti nuum fr om stabl e affect


(general l y defi ned as nor mal ) to l abi l e affect (general l y
abnor mal ). Mar ked l abi l i ty of affect (e.g., when a pati ent
al ter nates between gi ggl i ng and uncontr ol l abl e sobbi ng) i s
usual l y a mar ker of ei ther mani a or acute psychosi s, but i t may
al so be seen i n dementi a and other neur opsychi atr i c syndr omes.
2. Appr opr i ateness: A pati ent who l aughs uncontr ol l abl y whi l e
tal ki ng about her mother 's death i s exhi bi ti ng i nappr opr i ate
affect, and thi s i s useful to r ecor d. Inappr opr i ate affect i s often
seen i n psychosi s or mani a. Don't over pathol ogi ze,
however ; many i ntact peopl e smi l e a bi t when tal ki ng about sad
thi ngs. Thi s may r efl ect a defense mechani sm such as deni al ,
rather than psychosi s.
3. Range of affect: Mental l y heal thy humans exhi bi t a ful l range of
affect. At some moments they feel happy, at other moments
annoyed, and at other s sad. Depr essed pati ents ar e sai d to
exhi bi t constr i cted affect, and pati ents wi th schi zophr eni a ar e
often sai d to exhi bi t fl at affect. The pr obl em, of cour se, i s that
many heal thy peopl e exhi bi t a nar r ow range of affect. Thi s may
be especi al l y tr ue dur i ng a psychi atr i c i nter vi ew, because
pati ents may not feel emoti onal l y safe exposi ng themsel ves to a
stranger. Thus, the di agnosti c speci fi ci ty of a l i mi ted range of
affect i s suspect and shoul d not be over i nter pr eted.
4. Intensi ty of affect: Intensi ty i s often har d to di sti ngui sh fr om
range of affect, and l i ke range, the di agnosti c speci fi ci ty i s
unknown. The usual jar gon descr i bes thr ee grades: i ntense, fl at,
and bl unted. F l at and bl unted ar e usual l y r eser ved for
descr i pti ons of sever el y depr essed pati ents or pati ents wi th
negati ve symptoms of schi zophr eni a. Intense i s often used for
mani c or hi str i oni c pati ents, but r emember that many compl etel y
heal thy peopl e come acr oss as passi onate or i ntense.

Thought Process
TP r efer s to the fl ow of thought (coher ent vs. i ncoher ent) and i s
cover ed i n detai l i n Chapter 26.

Thought Content
Thought content (TC) r efer s to unusual or danger ous i deas and
i ncl udes SI and homi ci dal i deati on (HI) (see Chapter 21); psychoti c
i deati on, such as del usi ons and hal l uci nati ons (see Chapter 26); and
any si gni fi cant themes that came up dur i ng the i nter vi ew and r el ate
to the psychi atr i c di agnosi s.

Cognitive Examination
What ar e the essenti al components of the scr eeni ng cogni ti ve
exami nati on? Ther e i s no general agr eement on thi s i ssue, and
many cl i ni ci ans ar gue that much of what i s commonl y taught as
essenti al to the cogni ti ve exami nati on i s of questi onabl e use (Rapp
1979). For exampl e, most trai ni ng pr ograms conti nue to

teach the ser i al sevens subtracti on test (SSST) of attenti on, even
though studi es have demonstrated that i t has l i ttl e val i di ty i n
separati ng demented pati ents fr om heal thy pati ents. (See the
secti on on Attenti on and Concentrati on for a mor e compl ete
di scussi on.) Many of the other commonl y taught el ements of the
cogni ti ve exami nati on ar e equal l y suspect, i ncl udi ng the di gi t span
test, abstracti ons, si mi l ar i ti es, pr over bs, and judgment questi ons
(Kel l er and Manschr eck 1989).
I focus her e on what i s tr ul y useful i n hel pi ng you to di ffer enti ate
between nor mal and i mpai r ed cogni ti on. You shoul d be awar e,
however, that thi s i s a scr eeni ng appr oach onl y. Speci al i zed tests of
cogni ti ve abi l i ti es, usual l y conducted by a neur opsychol ogi st, shoul d
be done i f your scr eeni ng i ndi cates a potenti al pr obl em.

Caveat
A number of studi es have shown that l ow educati onal attai nment
cor r el ates wi th poor per for mance on cogni ti ve testi ng i n the
absence of dementi a or other or gani c i mpai r ments (Ai nsl i e and
Mur den 1993; Anthony et al . 1982; Mur den et al . 1991). Most
studi es have defi ned poor l y educated as 8 or fewer year s of
educati onthat i s, no hi gh school . The i mpl i cati on for cl i ni ci ans i s
that you shoul d ask about educati onal l evel befor e testi ng and be
cauti ous about over i nter pr eti ng cogni ti ve abnor mal i ti es i n poor l y
educated pati ents.

The el ements of cogni ti on that you shoul d assess i ncl ude

Level of awar eness or wakeful ness


Attenti on and concentrati on
Memor y
Judgment
Insi ght

Per cepti on i s i mpor tant too, of cour se, but i ts assessment i s


di scussed i n Chapter 26.

Level of Awareness or Wakefulness


KEY POINT
The conti nuum of wakeful ness ranges fr om comatose to ful l y
al er t. Deter mi ni ng the l evel of wakeful ness i s i mpor tant for two
r easons. F i r st, i t wi l l cl ue you i n to cer tai n di agnoses, such as
benzodi azepi ne or al cohol abuse i n the dr owsy pati ent or mani a
or sti mul ant abuse i n the hyperal er t pati ent. Second, i t wi l l gi ve
you gui dance i n how to pr oceed wi th the r est of the cogni ti ve
exami nati on. For exampl e, a ful l cogni ti ve exami nati on i s not
val i d i n a pati ent who i s noddi ng off thr oughout the i nter vi ew.

The assessment of wakeful ness i s easy enough. Your fi r st 10


seconds of contact wi th a pati ent wi l l tel l you whether he i s al er t
enough to gr eet you appr opr i atel y and tel l you hi s name. If he
seems sl eepy, you have at your di sposal an enti r e l exi con for
descr i bi ng degr ees of sl eepi ness: sl eepy, dr owsy, l ethar gi c,
somnol ent, stupor ous, obtunded, and comatose. Because ther e ar e
no general l y agr eed-on defi ni ti ons of most of these ter ms, i t's best
to descr i be the degr ee of sl eepi ness i n pl ai n Engl i sh. Thus, i nstead
of stupor ous, say,

The patient was sleepy and could only be awakened


by my calling his name loudly and shaking his
shoulder .

Instead of dr owsy, say,

The patient yawned fr equently dur ing the inter view


but attended well to all questions.
The patient nodded off fr equently and had difficulty
r esuming his tr ain of thought.

These descr i pti ons hel p the r eader of your assessment to draw
concl usi ons r egar di ng the r el i abi l i ty of the r est of the MSE.

Attention and Concentration


You want to assess whether your pati ent can sustai n attenti on over
a per i od of ti me. The conti nuum of attenti on r uns fr om attenti ve
and focused at one end to confused and di stracti bl e at the other.
Most trai ni ng pr ograms teach two tests for assessi ng attenti on: the
di gi t span test and the SSST. In the di gi t span test, the pati ent i s
gi ven fi ve to seven number s and asked to r epeat them for war d and
backwar d; i n the SSST, the pati ent i s asked to subtract seven fr om
100 and to conti nue counti ng back by sevens unti l tol d to stop. Both
of these tasks i ntui ti vel y seem l i ke r easonabl e

tests of attenti on; however, r esear ch studi es have not endor sed
them.
In one study (Smi th 1967), the SSST was gi ven to 132 nor mal
adul ts aged 18 to 63, al l of whom wer e ful l y empl oyed and the
major i ty of whom had at l east 16 year s of educati on. The
pr ofessi ons r epr esented i ncl uded psychi atr y, psychol ogy, neur ol ogy,
and pedi atr i cs. Onl y 42% of these subjects had er r or l ess
per for mance on the SSST. F ul l y 31 of the subjects made between
thr ee and 12 er r or s, and 14 ei ther gave ster eotyped r esponses
(supposedl y consi stent wi th fr ontal l obe di sease) or total l y
abandoned the task. In another study (Mi l stei n et al . 1972), 325
hospi tal i zed psychi atr i c pati ents wer e gi ven the SSST. No di ffer ence
i n per for mance between pati ents and 50 heal thy contr ol subjects
appear ed, and ther e was no associ ati on between poor per for mance
on the test and the pr esence of or gani c cogni ti ve i mpai r ments. Wi th
r egar d to the di gi t span test, Cr ook et al . (1980) found no
di ffer ence i n seven-di gi t r ecal l among 60 el der l y pati ents who had
memor y i mpai r ment and 44 el der l y peopl e who wer e heal thy.

TIP
The best way to assess attenti on and concentrati on i s si mpl y to
tal k to your pati ent and obser ve how she thi nks. Is she abl e to
concentrate on your questi ons? Can she mai ntai n a trai n of
thought as she answer s you? If the answer to these questi ons i s
yes, your pati ent's attenti on i s i ntact.

Memory
You shoul d assess both shor t-ter m memor y (memor y of thi ngs
l ear ned a few mi nutes to a few days ago) and l ong-ter m memor y
(memor y of thi ngs l ear ned l onger than a few days ago). Studi es
have documented that the most cl i ni cal l y val i d tests of these ar e (a)
or i entati on, (b) thr ee-object r ecal l , (c) r ecal l of r emote per sonal
events, and (d) r ecal l of general cul tural i nfor mati on (Kel l er and
Manschr eck 1989).
Orientation
Or i entati on to per son, pl ace, and ti me i s often thought to be a
speci fi c test of del i r i um or confusi on, but i t i s actual l y a test of

memor y. One's name, one's l ocati on, and the date ar e al l pi eces of
i nfor mati on that must be l ear ned and r etai ned. Wher eas one's name
i s i nvar i ant and ther efor e i s encoded i n l ong-ter m memor y, both the
date and the pl ace change often, offer i ng i deal ways to test whether
peopl e ar e capabl e of r etai ni ng new i nfor mati on.
Because aski ng peopl e wher e they ar e and what the date i s can feel
awkwar d, her e ar e some ways to transi ti on i nto these questi ons
smoothl y. You can i ntr oduce al l your memor y questi ons wi th a
statement such as

I'd like to change gear s her e and ask you a few


questions to test your memor y.

Often, you can make a smooth transi ti on fr om some i nfor mati on you
just obtai ned:

(The patient just told you her father had


Alz heimer 's disease.) Speaking of that, how has
your memor y been? I'd like to ask you some
questions to test your memor y.
(The patient said his concentr ation has been poor
while he's been depr essed.) Speaking of
concentr ation, I'd like to ask a few questions to
test how your memor y and concentr ation ar e doing
now.

Once you've i ntr oduced the need to assess memor y, you can go i nto
your or i entati on questi ons wi th a questi on such as

Do you keep tr ack of time pr etty well?

Regar dl ess of the r esponse, you can fol l ow up wi th

F or example, would you be able to tell me today's


date?
TIP
If your pati ent i s taki ng a whi l e and str uggl i ng to r emember, a
ti me-savi ng ti p i s to ask about speci fi c components, goi ng fr om
easi est to har dest.

What year is it? What month? What day of the


week? And what's the date?

Caveat
Don't over i nter pr et an i naccurate date. Many cogni ti vel y i ntact
peopl e don't keep cl ose track of the date. To pr ove thi s to
your sel f, ask your sel f what the date i s today. If you'r e off by a
day, you'r e nor mal . Thus, i n r ecor di ng your MSE, rather than
wr i ti ng pati ent was not or i ented to date, r ecor d i nstead what
the pati ent sai d. Assumi ng, for exampl e, that the tr ue date i s
Monday, June 28, 2004, ther e i s a wor l d of di ffer ence between the
pati ent who says Monday, June 27, 2004, and the pati ent who
answer s, someti me i n '64.

Three-Object Recall
Recal l of thr ee objects after at l east 2 mi nutes has been shown to
be a useful test i n di agnosi ng cogni ti ve i mpai r ments (Hi nton and
Wi ther s 1971). Say to your pati ent,

Repeat the following thr ee wor ds: ball, chair ,


pur ple.

Make sur e your pati ent can r epeat them cor r ectl y befor e movi ng on.
You must be sati sfi ed that your pati ent has cor r ectl y r egi ster ed al l
thr ee of the wor ds, because other wi se your test of memor y wi l l not
be val i d. Some el der l y pati ents may have di ffi cul ty r epeati ng the
wor ds because of a hear i ng pr obl em. (One of my har d-of-hear i ng
pati ents r epeated the wor ds as pal l , shar e, gur gl e.) In such cases,
r epeat the wor ds mor e l oudl y unti l they have r egi ster ed. You may
encounter a si mi l ar pr obl em i f Engl i sh i s not your pati ent's fi r st
l anguage. Of cour se, i f your pati ent i s extr emel y demented or
confused, she wi l l not be abl e to r epeat the wor ds for that r eason.
However, pati ents wi th such sever e cogni ti ve i mpai r ment wi l l have
al r eady been di agnosed because of di ffi cul ti es i n answer i ng basi c
i nfor mati onal questi ons ear l y i n the i nter vi ew.
Once you ar e sati sfi ed that your pati ent has r egi ster ed al l thr ee
wor ds, say,

Now I want you to r emember those thr ee wor ds,


because I'm going to ask you to r epeat them in a
couple of minutes.

In the meanti me, ask your pati ent general knowl edge questi ons (see
bel ow) about general cul tural and per sonal i nfor mati on. Then ask
hi m to r epeat the thr ee wor ds.
If your pati ent has tr oubl e, use the fol l owi ng hi nts:

One of them is something you can play with.


One is a piece of fur nitur e.
One is a color.

Cogni ti vel y nor mal peopl e usual l y r emember al l thr ee wor ds, and i f
they for get one, they wi l l r emember i t after your hi nt. Per for mance
any wor se than that i ndi cates a possi bl e pr obl em i n shor t-ter m
memor y.

General Cultural Knowledge


Cer tai n i tems of cul tural and hi stor i cal i nfor mati on have been so
wi del y taught that you can assume any Amer i can wi th at l east a
hi gh school educati on has l ear ned them. Inabi l i ty to r ecal l at l east
hal f of these i tems i s pr esumpti ve evi dence of l ong-ter m memor y
i mpai r ment.

TIP
The tradi ti onal task i s to name the l ast fi ve pr esi dents, al though
ther e's no evi dence that ther e i s anythi ng magi cal about the
number fi ve. In practi ce, cogni ti vel y i ntact pati ents commonl y
have pr obl ems r emember i ng that Reagan came befor e Bush and
that Car ter came befor e Reagan. Ther efor e, I r ecommend aski ng
about the l ast thr ee pr esi dents.
Last thr ee pr esi dents: Begi n wi th

Who is the cur r ent pr esident?

Then

Who was pr esident befor e Bush?


Who was befor e Clinton?

Other famous fi gur es: I ask about peopl e who ar e so endur i ngl y
famous that the average per son can't get thr ough a typi cal
month wi thout hear i ng a r efer ence to them.

Who was ________? What was he/she famous


for ?

Her e ar e a few of these famous peopl e, al ong wi th what a


cogni ti vel y i ntact per son shoul d be abl e to tel l you about them:

G eor ge Washington, fir st pr esident


Abr aham Lincoln, fr eed the slaves
Mar tin Luther King, Jr ., civil r ights leader
P.138
Pr incess Diana, Br itish pr incess killed in car
accident
William Shakespear e, wr iter
Chr istopher Columbus, discover ed Amer ica

Famous dates: In aski ng these questi ons, you shoul d not expect
a pr eci sel y cor r ect r esponse, but rather a r esponse that names a
year i n the bal l par k.

When did Wor ld War II happen? (Any time in


the 1930s or 1940s is adequate.)
When was John F . Kennedy assassinated?
(Sometime in the 1960s.)

Li sts of i nfor mati on: A hi ghl y sensi ti ve appr oach to scr eeni ng for
dementi a i s the set test, fi r st descr i bed i n 1973 (Isaacs and
Kenni e 1973). The pr ocedur e i s to ask your pati ent to name as
many i tems (up to ten) as he can r ecal l i n each of four
categor i es: col or s, ani mal s, fr ui ts, and towns. Out of a maxi mum
of 40, a scor e of 25 or above excl uded the di agnosi s of dementi a
i n the or i gi nal study.

Personal Knowledge
Per sonal knowl edge i ncl udes aspects of cur r ent l i fe as wel l as
memor y of r emote per sonal events. Cogni ti vel y i ntact pati ents
shoul d be abl e to tel l you

Cur r ent addr ess and phone number


Names and ages of spouse, si bl i ngs, and chi l dr en
Spouse's bi r thday, weddi ng anni ver sar y, and date and pl ace of
mar r i age (i f mar r i ed)
Par ents' names and bi r thdays (pr i mar i l y for younger pati ents
who ar e not mar r i ed)

TIP
How do you know i f the pati ent's answer i s accurate? Addr ess,
phone number, and spouse's name ar e often on the char t's
r egi strati on sheet. You can check the other i nfor mati on by cal l i ng
a fami l y member. G eneral l y, however, pati ents do not bl atantl y
confabul ate, al cohol i c dementi a bei ng the major excepti on to thi s,
and you can often get a sense of cogni ti ve status wi thout
r esor ti ng to ti me-consumi ng phone cal l s.

TABLE 20.4. Wilson Rapid Approximate


Intelligence Test

Best IQ (rough
Intelligence
effort estimate)
Retarded 2 6 <70

Borderline 2 24 70-80

Dull normal 2 48 80-90

Average 2 384 90-110

Bright
2 1,536 110-120
normal

Superior 2 3,072 120-130

Intelligence
As wi th concentrati on, you can get a general i dea of l evel of
i ntel l i gence vi a the r est of the i nter vi ew. Thi nk of i ntel l i gence as
the abi l i ty to mani pul ate i nfor mati on. Hi gh l evel s of educati onal and
job attai nment usual l y cor r el ate wi th hi gh i ntel l i gence.

TIP
For a qui ck and di r ty measur e of i ntel l i gence quoti ent (IQ), you
can gi ve the easy-to-r emember Wi l son Rapi d Appr oxi mate
Intel l i gence Test (Wi l son 1967) (Tabl e 20.4). Star t wi th 2 48 as
a scr eeni ng test. If the pati ent can cal cul ate thi s, she's ver y
unl i kel y to be i n the bor der l i ne or r etar ded range, and you can
end the testi ng. Pati ents who can't cal cul ate 2 24 ar e l i kel y to
meet IQ cr i ter i a for mental r etar dati on and shoul d defi ni tel y be
r efer r ed for for mal neur opsychol ogi cal testi ng. The usual caveat
r egar di ng educati onal l evel appl i es: You shoul d onl y gi ve thi s test
to pati ents who have compl eted hi gh school .

Insight
KEY POINT
Al though the ter m i nsi ght has many l ayer s of meani ng, for the
pur poses of the eval uati on i nter vi ew you ar e most i nter ested i n
whether your pati ent knows that he has an i l l ness and has some
r eal i sti c concepti on of i ts causes and possi bl e tr eatments.

Someti mes a pati ent's l ack of i nsi ght i s bl atant. Such i s the case
wi th many pati ents wi th mani a and schi zophr eni a, who may be
absol utel y convi nced of the veraci ty of thei r del usi ons. Documenti ng
poor i nsi ght i n such cases i s easy, but i n many cases, you have to
pr obe for degr ee of i nsi ght by aski ng, often towar d the end of the
i nter vi ew,

So, why do you think you've been having these


pr oblems?
What do you think needs to happen for your life to
impr ove?
Insightful patients will be able to identify some
psychosocial str essor s r elated to their disor der
(either as cause or effect). Patients with poor
insight might r espond with phr ases such as
I don't know. You'r e the doctor.
People need to stop hassling me. (A par anoid
patient.)

Wher eas compl ete l ack of i nsi ght i s often seen i n psychoti c
di sor der s or dementi a, poor i nsi ght mi ght poi nt you at a di agnosi s
of a character di sor der or l ow i ntel l i gence.

Judgment
The standar d questi on for testi ng judgment i s by now wi del y
r ecogni zed as unhel pful i n assessi ng the sor t of judgment i n whi ch
cl i ni ci ans ar e i nter ested:

If you found a stamped and addr essed envelope


laying on the sidewalk, what would you do?

Instead, you shoul d assess judgment based on the mater i al


gather ed thr oughout the i nter vi ew. Di d your pati ent deci de to seek
hel p when she fel t depr essed? Di d she appl y for unempl oyment
benefi ts when she l ost her job? These show good judgment. Di d she
deci de that the best tr eatment for her depr essi on was to go on a
cocai ne bi nge? Thi s shows poor judgment.
Often, students l ump tests of abstracti on wi th tests of judgment.
These i ncl ude the i nter pr etati on of pr over bs and the r ecogni ti on of
si mi l ar i ti es. These tests show ver y l ow i nter-rater

r el i abi l i ty (Andr easen et al . 1974), they show no demonstrated


useful ness i n the di agnosi s of or gani c pr obl ems, and good
per for mance i s hi ghl y cor r el ated wi th i ntel l i gence (Kel l er and
Manschr eck 1989), whi ch i s general l y not what the tests ar e
supposed to be testi ng.

SHOULD YOU USE THE FOLSTEIN MINI-


MENTAL STATE EXAMINATION?
The Fol stei n MMSE (Fol stei n et al . 1975) contai ns 11 categor i es of
scor ed questi ons. The maxi mum possi bl e scor e i s 30, and scor es
bel ow 30 may i ndi cate cogni ti ve i mpai r ment, wi th the pr eci se cutoff
poi nt var yi ng by age and educati on. The sensi ti vi ty of the test i s
hi ghyou'r e unl i kel y to mi ss cases of dementi abut the speci fi ci ty
i s l ow, meani ng that many pati ents who ar e cogni ti vel y heal thy wi l l
be mi scl assi fi ed as demented. Thi s happened i n 17% of pati ents i n
one study (Anthony et al . 1982).
Whether the MMSE shoul d be used i n al l psychi atr i c eval uati ons i s a
matter of gr eat contr over sy. Opponents ar gue that the test's
posi ti ve pr edi cti ve val ue i s unacceptabl y l ow and that i t i s l ess
sensi ti ve and speci fi c than cl i ni cal judgment that i s based on the
r esul ts of the enti r e i nter vi ew (Har wood et al . 1997; Tangal os et al .
1996). Pr oponents ar gue that i ts hi gh sensi ti vi ty makes i t essenti al
and that a numer i cal measur e of cogni ti ve functi oni ng i s a gr eat
hel p i n tracki ng the cour se of dementi a. But even the useful ness of
the MMSE for tracki ng cogni ti ve decl i ne has come i nto questi on.
Resear cher s exami ned a l ar ge r egi str y of pati ents wi th Al z hei mer 's
di sease and fol l owed MMSE scor es over several year s. Al though they
found that ther e was a 3.4-poi nt average annual decl i ne, the
measur ement er r or of the test was al most as l ar ge (2.8), and even
after 4 year s of fol l ow up, 15.8% of pati ents had no cl i ni cal l y
meani ngful decl i ne i n the MMSE scor e.
The MMSE i s most useful for cl i ni ci ans wi th l i ttl e trai ni ng i n the
psychi atr i c i nter vi ew who need a standar di zed for mat for aski ng a
ser i es of questi ons. It i s l ess useful for mental heal th cl i ni ci ans,
because we can ski l l ful l y ascer tai n cogni ti ve functi oni ng fr om the
i nter vi ew as a whol e and can tar get par ti cul ar questi ons to assess
speci fi c ar eas of possi bl e i mpai r ment. In addi ti on, the MMSE
i ncl udes one test that has been found to be i nval i d for eval uati ng
cogni ti ve i mpai r ment (SSST) and does not i ncl ude other questi ons
that ar e ver y i mpor tant i n assessi ng for dementi a, such as
questi ons about per sonal and general knowl edge.

Notwi thstandi ng the many l i mi tati ons of the MMSE, i t i s used so


wi del y i n a var i ety of cl i ni cal setti ngs that you shoul d become
fami l i ar wi th i t.

MINI-COG
Recentl y, a str eaml i ned dementi a scr een has been val i dated, cal l ed
the Mi ni -Cog. Thi s combi nes two tests: the thr ee-i tem r ecal l (of
MMSE fame) and the cl ock-drawi ng task (CDT). Studi es compar i ng
the Mi ni -Cog wi th the MMSE have shown no r eal di ffer ences i n
sensi ti vi ty or speci fi ci ty, and because the Mi ni -Cog i s much faster to
admi ni ster and avoi ds most of the cul tural and l anguage pr obl ems
associ ated wi th the MMSE, you can bet that the Mi ni -Cog i s the
wave of the futur e.
The Mi ni -Cog i s admi ni ster ed i n two steps. F i r st, you ask your
pati ent i f you can test hi s memor y by aski ng hi m to r epeat and
memor i ze thr ee si mpl e wor ds (the speci fi c wor ds ar e up to you).
Then you gi ve hi m a paper and pen and ask hi m to draw a cl ock,
wi th the hands poi nti ng to 11:10 (or pi ck another ti me i n whi ch
ther e i s a hand on each si de of the cl ock). Once the cl ock i s drawn,
ask hi m to r epeat your thr ee wor ds.
How do you i nter pr et your pati ent's per for mance? Use the r esul ts of
the thr ee-i tem r ecal l as a scr een. Pati ents who r ecal l al l thr ee
wor ds ar e not demented, those who can r emember none of them ar e
demented, wher eas those who r emember one or two mi ght be
demented. For pati ents i n the mi ddl e, thei r per for mance on the CDT
pr ovi des cr uci al i nfor mati on that may or may not convi nce you to
seek neur opsychol ogi cal testi ng.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 1 - As s e s s ing Suic ida l a nd Ho m ic ida l Ide a t io n

21
Assessing Suicidal and Homicidal
Ideation

Essential Concepts

Sui ci dal Ideati on


Lear n the SA D PERSONS r i sk factor s for sui ci de.
Use the CASE appr oach for assessi ng sui ci de r i sk.
Assess passi ve sui ci dal i ty.
Assess acti ve sui ci dal i ty.
Assess i mmi nent pl an.
Homi ci dal Ideati on
Lear n the r i sk factor s for homi ci de.
Ask about HI.
Know your Tarasoff duti es.

We cannot tear out a single page fr om our life, but


we can thr ow the whole book into the fir e.
--G eor ge Sand

RISK FACTORS FOR SUICIDE


The r eason an assessment of sui ci dal i ty i s necessar y i n ever y
di agnosti c i nter vi ew i s obvi ous enough: We hope to pr event sui ci de.
However, the mental heal th fi el d has not yet devi sed tool s that
al l ow pr edi cti on of sui ci dal behavi or i n a par ti cul ar pati ent. On the
other hand, r esear cher s have di scover ed a number of factor s that
i ncr ease the stati sti cal r i sk for sui ci de. It i s i mpor tant to be awar e
of these r i sk factor s as you i nter vi ew any potenti al l y sui ci dal
pati ent.
In eval uati ng sui ci dal i ty dur i ng the i ni ti al i nter vi ew, you have two
goal s. The fi r st and most i mpor tant i s to assess whether an
i mmedi ate r i sk of a sui ci de attempt exi sts. Your second goal i s to
deter mi ne cur r ent or past sui ci dal i ty to hel p you for mul ate an
accurate DSM-IV-TR di agnosi s. You can achi eve both of these goal s
wi th the same l i ne of questi oni ng.
Befor e r evi ewi ng the types of questi ons to ask, you shoul d be
fami l i ar wi th the r i sk factor s for sui ci de. An excel l ent mnemoni c for
the major r i sk factor s i s SAD PERSONS, devi sed by Patter son et al .
(1983).
Mnemoni c: SA D PERSONS (r i sk factor s for sui ci de):

Sex: Women ar e mor e l i kel y to attempt sui ci de; men ar e mor e


l i kel y to succeed.
A ge: Age fal l s i nto a bi modal di str i buti on, wi th teenager s and
the el der l y at hi ghest r i sk.
Depr essi on: F i fteen per cent of depr essi ve pati ents di e by
sui ci de.
Pr evi ous attempt: Ten per cent of those who have pr evi ousl y
attempted sui ci de di e by sui ci de.
Ethanol abuse: F i fteen per cent of al cohol i cs commi t sui ci de.
Rati onal thi nki ng l oss: Psychosi s i s a r i sk factor, and 10% of
pati ents wi th chr oni c schi zophr eni a di e by sui ci de.
Soci al suppor ts ar e l acki ng.
Or gani zed pl an: A wel l -for mul ated sui ci de pl an i s a r ed fl ag.
No spouse: Bei ng di vor ced, separated, or wi dowed i s a r i sk
factor ; havi ng r esponsi bi l i ty for chi l dr en i s an i mpor tant
stati sti cal pr otector agai nst sui ci de.
Si ckness: Chr oni c i l l ness i s a r i sk factor.

Al though useful for deter mi ni ng a pati ent's l ong-ter m r i sk for


commi tti ng sui ci de, these r i sk factor s ar e l ess useful for assessi ng
i mmi nent r i sk, and i mmi nent r i sk i s the most i mpor tant factor to
assess dur i ng a di agnosti c i nter vi ew. One study hel pful i n
i denti fyi ng r i sk factor s for shor t-ter m r i sk i s the Nati onal Insti tute
of Mental Heal th Col l aborati ve Depr essi on Cl i ni cal Study (Cl ar k and
Fawcett 1992). Resear cher s fol l owed 954 pati ents wi th major
affecti ve di sor der s and found that cl i ni cal featur es associ ated wi th
ear l y sui ci de (i .e., wi thi n 1 year of assessment) i ncl uded

Anxi ety
Pani c attacks
Anhedoni a
Al cohol abuse
Cl i ni cal factor s associ ated wi th a l ater attempt (at 5 year s)
i ncl uded
Hi gh l evel s of hopel essness
SI
Hi stor y of sui ci de attempts

ASSESSING SUICIDAL IDEATION: INTERVIEW


STRATEGIES
KEY POINT
Sui ci dal i ty can be a di ffi cul t topi c to br oach, but you must ask
about i t i n ever y di agnosti c i nter vi ew. Pati ents ar e rar el y angr y
or embar rassed about sui ci dal i ty questi ons. A major i ty of
depr essed pati ents have at l east passi ng sui ci dal thoughts fr om
ti me to ti me (Wi nokur 1981), and many pati ents ar e r el i eved
when they ar e asked about sui ci dal i ty, because i t al l ows them to
r eveal the tr ue depth of thei r depr essi on. If they r eal l y have not
thought about sui ci de, they wi l l say somethi ng l i ke, Oh no, I
coul d never do anythi ng l i ke that, and wi l l tel l you why not.

Another common di si ncenti ve to aski ng about sui ci dal i ty i s the


i nter vi ewer 's fear of a posi ti ve r esponse. You may feel a sense of
pani c when fi r st confr onted wi th a sui ci dal pati ent, but wi th
exper i ence, you wi l l r eal i ze that ther e ar e degr ees of sui ci dal i ty,
and that not al l sui ci dal pati ents r equi r e ur gent hospi tal i z ati on.

The CASE Approach


By far the best method of assessi ng sui ci de r i sk i s the CASE
appr oach, whi ch was devi sed by one of my mentor s, Dr. Shawn
Shea, and publ i shed i n hi s book The Practi cal Ar t of Sui ci de
Assessment. I hi ghl y r ecommend that you r ead thi s book, as I have,
because i t pr ovi des much mor e detai l r egar di ng hi s techni que and
i ncl udes i nnumerabl e cl i ni cal exampl es.
CASE stands for Chr onol ogi cal Assessment of Sui ci dal Events and
wi l l hel p you to r emember to ask about ever ythi ng r el evant to a
par ti cul ar pati ent's sui ci dal r i sk. The techni que goes l i ke thi s:

1. Star t by assessi ng the pr esenti ng SI or event.


2. El i ci t i nfor mati on about any SI over the past 2 months.
3. Expl or e past SI.
4. Retur n to the pr esent and expl or e any i mmedi ate sui ci dal i ty.

The rati onal e her e i s that the pr ocess of expl or i ng the pr esenti ng
event and the past al l ows you to establ i sh rappor t wi th your

pati ent. Thi s rappor t wi l l make i t mor e l i kel y that he or she wi l l be


open wi th you about any i mmi nent sui ci dal pl ans, whi ch i s r eal l y
what you most need to assess dur i ng the i nter vi ew.
How does one go about aski ng the questi ons r equi r ed for the CASE
appr oach? Regar dl ess of the ti me per i od bei ng expl or ed, the i ssue of
sui ci dal i ty can be appr oached i n a number of ways. The di r ect
appr oach can be per fectl y acceptabl e. For exampl e, as par t of your
eval uati on of the SIG ECAPS of depr essi on, you can say,

Have you felt suicidal?


Have you had thoughts of wanting to hur t your self?

TIP
In some si tuati ons, however, thi s appr oach may feel jar r i ng to the
pati ent, and a smooth transi ti on may be better :

Someti mes when peopl e feel depr essed, they thi nk that they'd
be better off dead. Has that thought cr ossed your mi nd at al l ?
Consi der i ng al l the thi ngs you've tol d me, have you fel t so bad
that i t seems that l i fe i s not wor th l i vi ng?
These ar e both nor mal i z i ng questi ons that i nqui r e about passi ve
SI. If you get a yes, you shoul d ask about acti ve SI.

Have you thought about suicide?


What sor ts of ways have you thought about to
hur t your self? (Phr ased as a behavior
expectation.)

Many peopl e wi th mi l d to moderate depr essi on endor se passi ve SI


but deny havi ng thought of actual l y taki ng some acti on to har m
themsel ves. Thi s i s an i mpor tant cl i ni cal di sti ncti on, and you can
general l y br eathe easi er i f your pati ent's SI has never gotten
beyond the passi ve stage. If, however, your pati ent admi ts to acti ve
SI, you'l l need to ask an addi ti onal ser i es of questi ons. You want to
fi nd out how el aborate and how r eal i sti c the sui ci de pl an i s.

Have you thought about cutting your self?


Taking an over dose?
Jumping fr om the window?
P.147
Shooting your self?
Hanging your self?

Don't wor r y that you ar e putti ng i deas i nto thei r heads. By i nqui r i ng
speci fi cal l y about common sui ci dal behavi or s, you ar e gi vi ng
pati ents per mi ssi on to be tr uthful and communi cati ng that you'r e
fami l i ar wi th thi s di ffi cul t topi c and won't be put off by a posi ti ve
answer.

How close have you come to actually hur ting


your self?
Have you planned it out in your mind?
Have you acquir ed any of the things you would
need to do something?

Her e, you'r e aski ng about the pr esence of a pl an and getti ng a


sense of how cl ose the pati ent has come to car r yi ng out hi s pl an.
Have you actually had the pills in your hand with a
glass of water in fr ont of you?
Have you put the pills in your mouth?
What pr evented you fr om actually swallowing
them?

Thi s conti nues speci fi c questi oni ng. The same l i ne of questi oni ng
can be used wi th any other method of sui ci de the pati ent may have
been fantasi z i ng about.

Do you have a gun in the house?


Do you have access to a r ope?
Do you have pills at home?

You shoul d assess how r eal i sti c the pl an communi cated by your
pati ent i s. If a pati ent says he wants to shoot hi msel f, thi s sounds
qui te ser i ous, but does he own a gun? If not, does he have access to
a fr i end's or r el ati ve's gun? Has he l ocated a shop at whi ch he pl ans
to buy a gun?

Have you wr itten a suicide note?


Have you done anything to put your affair s in or der
in pr epar ation for your death?

Ar rangements such as these ar e par ti cul ar l y omi nous i ndi cator s of


an i mmi nent sui ci de attempt.

Ar e you feeling suicidal r ight now? Do you have


any specific plan to hur t your self?

Her e, you ar e aski ng about the i mmedi acy of the i ntenti on, so that
you can deter mi ne the necessi ty for hospi tal i z ati on or other ur gent
i nter venti on.

What has kept you fr om killing your self?

Thi s i s a ver y useful topi c to i ntr oduce. Many desperate pati ents
r emai n adamantl y opposed to sui ci de for speci fi c r easons, often
because they have dependent chi l dr en or on r el i gi ous gr ounds. If
you can i denti fy compel l i ng factor s that ar e keepi ng your pati ent i n
the l and of the l i vi ng, r ei nfor ce them.

If you wer e to feel mor e suicidal over the next few


days, do you think you could pr omise to pick up the
phone and talk to someone befor e actually hur ting
your self, or would you be in so much pain that you
wouldn't want to ask for help?

TIP
Her e, you ar e tr yi ng to di scover whether the pati ent i s abl e to
contract for safety. The whol e noti on of a safety contract i s
contr over si al , and such a contract can cer tai nl y pr ovi de a fal se
sense of r eassurance to the cl i ni ci an. My feel i ng i s that safety
contracts at l east do no har m, and that they pr obabl y have saved
l i ves, because they offer a concr ete pl an to someone who may be
exper i enci ng too much tur moi l to thi nk cl ear l y. A good safety
contract i ncl udes names and number s of peopl e the pati ent agr ees
to contact and a way for her to contact you or your coverage.

ASSESSING HOMICIDAL IDEATION


KEY POINT
Al though I have combi ned the assessment of HI wi th the
assessment of SI, the two ar e ver y di ffer ent cr eatur es. You shoul d
assess SI i n ever y pati ent you i nter vi ew, but you wi l l ask about
HI onl y i n pati ents you feel ar e at r i sk of becomi ng homi ci dal .
Thi s i ncl udes pati ents i n gr oups who have been i denti fi ed by
r esear cher s as at hi gh r i sk for homi ci de (Asni s et al . 1994; Tar di ff
1992), such as those who ar e paranoi d, anti soci al , or substance
abuser s or who tel l you they ar e angr y at someone i n par ti cul ar.

HI i s not the easi est topi c to br oach dur i ng the i nter vi ew. Inter vi ew
techni ques (see Chapter 4) such as nor mal i z ati on and r educti on of
gui l t ar e hel pful . Once you have i ntr oduced the topi c, your strategy
shoul d be to deter mi ne exactl y who i s the tar get of the HI and then
to assess the ser i ousness of the i deati on. Thi s pr ocess i s anal ogous
to the assessment of SI, i n whi ch you must l ocate the i deati on on a
conti nuum fr om passi ve to acti ve to a speci fi c and i mmi nent pl an.

CLINICAL VIGNETTE
A 35-year-ol d woman was admi tted to the hospi tal wi th the
del usi on that her mother had been r epl aced by an i mpostor who
was attempti ng to take possessi on of the fami l y home. Knowi ng
that paranoi a i s a r i sk factor for HI, the i nter vi ewer deci ded to
assess thi s possi bi l i ty.

How do you feel about this


Interviewer: woman? (Referring to the
impostor mother.)

How would you feel? She's


Patient:
taking away all that is mine.

Interviewer: I'd be very angry.

There you go. I'm being


Patient:
wronged.

I imagine someone in your


situation would go to great
Interviewer: lengths to prevent this from
happening. (Using
normalization.)

Patient: I'd say so.

Even to the extent of wanting


Interviewer:
to do away with that person?

She's raping my heritage.


Patient: Death would be too good for
her.

It sounds like you'd be happy


Interviewer:
if she were dead.

(Looking at interviewer
Patient: incredulously.) Of course I
would.

(At thi s poi nt, the i nter vi ewer has establ i shed passi ve HI; he
must now assess whether ther e i s acti ve HI.)

Have you thought about killing


Interviewer:
her yourself?

I wish I could. But there are


too many others just like her.
Patient: If I killed her, they would know
who did it, and they'd come
after me.

So you haven't come up with a


Interviewer:
plan for killing her?

Plenty of plans, but where will


Patient: that get me? I told you, I can't
do it.

Interviewer: What sorts of plans?


The best way would be to
Patient: cremate her in the house that
she wants so much.

You mean set fire to the


Interviewer:
house?

It would break my heart to


Patient: lose the house, but that may
be necessary.

The i nter vi ewer concl uded that the pati ent was at hi gh r i sk of
fol l owi ng thr ough on her pl an to tor ch her mother 's house as a
homi ci de attempt.

Thi s vi gnette br i ngs up the i mpor tant i ssue of what you shoul d do
when a pati ent expr esses HI. The Tarasoff deci si on of 1976 pr ovi des
gui del i nes for mental heal th pr ofessi onal s (Fel thous 1991). In
essence, you have a r esponsi bi l i ty to pr otect the potenti al vi cti m.
Thi s general l y entai l s i nfor mi ng both the potenti al vi cti m and the
pol i ce.
If you do deci de to i ssue a Tarasoff war ni ng, i nfor mi ng your pati ent
of your i ntenti ons i s a good i dea. In such cases, a strai ghtfor war d
appr oach wor ks best.

The law r equir es me to do what I can to keep this


per son safe. That means I'm going to tr y to call
him and also call the police.

You may wor r y that tel l i ng the pati ent about your i ntenti ons wi l l
har m the therapeuti c al l i ance. However, accor di ng to the onl y study
that actual l y l ooked at thi s i ssue, i n most cases, i ssui ng a war ni ng
had ei ther a mi ni mal negati ve or a posi ti ve effect on the al l i ance
(Bi nder and McNi el 1996).
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 2 - As s e s s ing M o o d Dis o rde rs I: De pre s s iv e Dis o rde rs

22
Assessing Mood Disorders I:
Depressive Disorders

Essential Concepts

Scr eeni ng Questi ons


Ar e you depr essed?
Have you ever gone thr ough a 2-year (for the di agnosi s of
dysthymi a) per i od of feel i ng sad most of the ti me?
Mnemoni c: SIGECA PS
Recommended ti me: 1 mi nute i f scr een i s negati ve; 5 mi nutes
i f scr een i s posi ti ve.

Di agnosi s of the di ffer ent types of depr essi ve di sor der s begi ns wi th
di agnosi s of a major depr essi ve epi sode (Tabl e 22.1). Once you
become exper t at assessi ng the pr esence of the NVSs of depr essi on,
you wi l l be abl e to di agnose qui ckl y major depr essi on, atypi cal
depr essi on, seasonal affecti ve di sor der (SAD), and dysthymi c
di sor der.

KEY POINT
It i s equal l y i mpor tant that you know when not to di agnose a
depr essi ve di sor der. Major depr essi on tends to r ecei ve a
di spr opor ti onate amount of attenti on i n mental heal th educati on,
par tl y because i t i s genui nel y common and par tl y because we ar e
so good at tr eati ng i t. Nonethel ess, you do a di sser vi ce to a
pati ent by di agnosi ng hi m wi th major depr essi on i f i nstead he has
an adjustment di sor der wi th depr essed mood and woul d benefi t
mor e fr om br i ef psychotherapy than fr om medi cati on.
TABLE 22.1. DSM-IV-TR criteria for major
depressive episode

Five or more of the following symptoms have


been present for at least 2 weeks; at least one
of the symptoms is either (a) depressed mood
or (b) loss of interest or pleasure.
Depressed mood most of the day, nearly
every day
Markedly diminished interest or pleasure in
all, or almost all, activities
Decrease in appetite or significant weight loss
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive or
inappropriate guilt
Diminished concentration or indecisiveness
Thoughts of death or SI

Mnemonic: SIGECAPS

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.
MAJOR DEPRESSIVE EPISODE
Mnemonic: SIGECAPS
A useful mnemoni c to gui de your questi oni ng of the NVSs of
depr essi on i s SIG ECAPS. It was devi sed by Dr. Car ey G r oss at MG H
and r efer s to what one mi ght wr i te on a pr escr i pti on sheet for a
depr essed, aner gi c pati ent: SIG: Ener gy CA PSul es. Each l etter
r efer s to one of the major di agnosti c cr i ter i a for major depr essi ve
di sor der :

Sl eep di sor der (ei ther i ncr eased or decr eased)*


Inter est defi ci t (anhedoni a)
Gui l t (wor thl essness,* hopel essness,* r egr et)
Ener gy defi ci t*
Concentrati on defi ci t*
A ppeti te di sor der (ei ther decr eased or i ncr eased)*
Psychomotor r etar dati on or agi tati on
Sui ci dal i ty

For dysthymi c di sor der, two of the si x star r ed symptoms must be


pr esent.

Asking about the Symptoms of Depression


The mai n di ffi cul ty for begi nni ng cl i ni ci ans i s i n transl ati ng the
DSM-IV-TR ter mi nol ogy i nto l anguage that i s meani ngful

for the pati ent. A r el ated di ffi cul ty i s di sti ngui shi ng tr ue-posi ti ve
fr om fal se-posi ti ve r esponses to questi ons about symptoms. Most
peopl e exper i ence some of the symptoms of major depr essi on to
some degr ee at some ti me. Establ i shi ng that your pati ent has
symptoms sever e enough to meet DSM-IV-TR cr i ter i a takes
cr eati vi ty, per si stence, and exper i ence.
In thi s chapter, I di scuss techni ques for assessi ng each of the NVSs
i n tur n. F i r st, her e ar e some general ti ps:

Establ i sh that the symptom i s tr ul y a change fr om basel i ne.


Many pati ents may have di ffi cul ti es wi th concentrati on, ener gy,
appeti te, and so for th that may be chr oni c and have l i ttl e to do
wi th depr essi on. If so, these symptoms cannot count towar d
your di agnosi s of a major depr essi ve epi sode.
Establ i sh that the symptom has occur r ed al most ever y day for 2
weeks. Many pati ents may r eact to upsetti ng events wi th a few
days of NVSs. Thi s does not consti tute a major depr essi ve
epi sode, al though i t may be an adjustment di sor der wi th
depr essed mood. It's useful to r emi nd pati ents that you ar e
aski ng about a speci fi c per i od.
Thi nk back car eful l y: Have you fel t depr essed pr etty much ever y
day over the past 2 weeks?
Tr y not to ask l eadi ng questi ons. An exampl e of a l eadi ng
questi on i s Has your depr essi on made i t har d for you to
concentrate? Thi s i mpl i es that decr eased concentrati on woul d
be expected, and a suggesti bl e or mal i nger i ng pati ent mi ght
answer wi th a fal se yes. An exampl e of a

nonl eadi ng questi on woul d be Do you thi nk your concentrati on


has been better or wor se than nor mal over the past 2 weeks?
Of cour se, you can substi tute any of the NVSs for
concentrati on i n thi s templ ate.

CLINICAL VIGNETTE
An i nter n was i nter vi ewi ng a 45-year-ol d ni ghtcl ub owner. When
asked, How have you been sl eepi ng for the past 2 weeks? the
pati ent r esponded, Ter r i bl y. I can't fal l asl eep befor e 4 a.m., and
then I get up at 10. I'm al ways ti r ed. The r esi dent consi der ed
thi s statement suffi ci ent to meet cr i ter i a for the i nsomni a of
depr essi on, unti l the pati ent menti oned that thi s had been hi s
sl eep patter n for the past 6 year s, and that i t had been
unchanged over the past 2 weeks. The pati ent was r efer r ed to a
sl eep cl i ni c and was eventual l y di agnosed wi th sl eep apnea.

Screening Questions
Ar e you depr essed?

One study showed that thi s si mpl e questi on had 100% sensi ti vi ty
and speci fi ci ty i n di agnosi ng major depr essi on i n the ter mi nal l y i l l ,
outper for mi ng el aborate scr eeni ng i nstr uments such as the Beck
Depr essi on Inventor y (Chochi nov et al . 1997).

How has your mood been r ecently?

Thi s i s a nonl eadi ng questi on, but note that i t i s mor e speci fi c than
aski ng, How have you been doi ng? or even, How have you been
feel i ng? If your pati ent star ts tal ki ng about hi s di str ess at thi s
poi nt, go to the NVSs of depr essi on. However, i f he says fi ne, you
shoul d move to the mor e speci fi c questi on:

Have you ever felt ver y down or depr essed, so


depr essed that your whole life was affected by it
for at least 2 weeks?

SIGECAPS Questions
Sl eep di sor der

Have you been sleeping nor mally? (A good


initial scr eening question for a sleep pr oblem.)
What has your sleep patter n been like lately?
(Depending on the adequacy of your patient's
r esponse to this question, you may or may not
need to follow up with the following questions.)
What time do you lie down to fall asleep?
What time do you actually fall asleep?
(To diagnose difficulty falling asleep.)
Do you sleep thr ough the night, or do you wake
up often dur ing the night?
P.155
(To diagnose fr equent awakenings.)
What time do you usually wake up in the
mor ning?
Do you gener ally feel r ested when you wake
up?
Do you feel mor e or less depr essed when you
wake up?
How does your mood change as the day goes
on?
(To diagnose ear ly mor ning awakening and
diur nal var iation in mood.)

Inter est defi ci t (anhedoni a): Anhedoni a i s a sur pr i si ngl y di ffi cul t
symptom to ascer tai n. Obvi ousl y, no pati ent i s goi ng to come
r i ght out and say, Doctor, I've been r eal l y anhedoni c l atel y. You
wi l l mor e l i kel y hear wor ds l i ke, I'm bor ed al l the ti me, I have
no moti vati on, or I don't car e about anythi ng. One pr obl em i s
that pati ents may not under stand what we mean i f we ask, Can
you descr i be your i nter est l evel ? or Have you been taki ng
pl easur e i n thi ngs? A pati ent may onl y associ ate pl easur e wi th
extraor di nar y exper i ences, such as goi ng on vacati on, or she
may say she has been taki ng an i nter est i n thi ngs when i n fact
her l evel of i nter est has decr eased mar kedl y si nce the onset of
depr essi on. Because of these potenti al pi tfal l s, i t's i mpor tant to
be speci fi c i n your questi oni ng.

Befor e you felt r eally sad, what sor ts of things


would you do for fun or for r elaxation?
What sor ts of hobbies did you have?
Did you r ead?
Did you play spor ts or follow the spor ts teams?
Did you go out to movies?
Did you go out with fr iends?

Thi s establ i shes a basel i ne agai nst whi ch to compar e the


depr essed per i od. You can then go on to ask about how the
depr essi on has affected the pati ent's acti vi ti es:

Since you have felt depr essed, have you noticed


that you've been any less inter ested in these
pur suits?
Have you found that you've been able to enjoy
the things that you used to be able to enjoy?
P.156
Have you given up doing anything that you
nor mally like to do?

TIP
If the per son you ar e eval uati ng i s al r eady on an anti depr essant,
par ti cul ar l y i f thi s i s a sel ecti ve ser otoni n r euptake i nhi bi tor
(SSRI), he may seem to have anhedoni a, wher eas he may actual l y
have apathy syndr ome secondar y to the anti depr essant. Thi s
occur s i n up to 20 to 30% of pati ents on newer anti depr essants
and may be caused by l ower ed l evel s of brai n dopami ne.

Gui l t, wor thl essness, hopel essness: Her e, you want to obtai n a
sense of how negati vel y the pati ent feel s about hi msel f. Star ti ng
wi th questi ons that assess the pati ent's sel f-wor th often wor ks
wel l :

How have you been feeling about your self, in


ter ms of self-esteem, since you've been
depr essed?
Do you feel that you ar e essentially a good
per son, or do you have your doubts?
Have you felt especially cr itical of your self
lately?
These questions touch specifically on the theme
of hopelessness:
How do you see your futur e?
Do you have hope that things will get better , or
does it look pr etty bleak?
Do you feel helpless to change your situation?

TIP
In assessi ng gui l t, si mpl y aski ng, Do you feel gui l ty? may not be
enough, because the pati ent may not be feel i ng gui l ty at that
moment, even i f she's been feel i ng gui l ty fr equentl y over the l ast
few weeks. For thi s r eason, i t i s hel pful to ask about some speci fi c
aspects of l i vi ng that depr essed peopl e often feel gui l ty about.
Have you been feeling guilty or r egr etful about
things that you've done or haven't done? Like
not being pr oductive, not r eaching your
potential, being a bur den?

Ener gy defi ci t: Begi n wi th a scr eeni ng questi on.

How has your ener gy level been over the past


couple of weeks?
If the patient answer s Lousy, make sur e that
the low ener gy coincides with the onset of the
depr ession, r ather than being a constant
featur e of her physical state.
Is this a change for you? Did you feel
significantly mor e ener getic befor e your
depr ession?

Because medi cal i l l ness can cause aner gi a i n the absence of


depr essi on, you may be mi sl ed about the sour ce of the l oss of
ener gy, par ti cul ar l y when deal i ng wi th pati ents wi th chr oni c
medi cal i l l nesses or ger i atr i c pati ents. In such cases, aski ng
about the patter n of ener gy thr oughout the day i s hel pful .
Pati ents wi th medi cal i l l nesses ar e at thei r most ener geti c when
they wake up and then feel wor se as the day pr ogr esses,
wher eas depr essed pati ents often wake up feel i ng l ow and
aner gi c and feel better l ater i n the day.
Concentrati on defi ci t

Have you been able to focus on things well?


How has your concentr ation been?
(These gener al questions ar e sometimes
sufficient for scr eening pur poses.)
Have you felt mor e absentminded than usual?
Have you noticed any changes in your memor y?
(These get at the pseudodementia sometimes
seen in depr ession.)
Have you had pr oblems making decisions?
Sometimes, the fir st sign of concentr ation
pr oblems is difficulty in making basic decisions
such as What should I make for dinner ? or
Should I go out tonight or not?
P.158
If you wer e to sit down with a newspaper in
fr ont of you, would you be able to r ead an
entir e ar ticle fr om star t to finish without losing
your concentr ation, or do you have to r ead the
same sentence over and over again?
Can you watch a half-hour television show fr om
star t to finish without losing your focus?
Have you noticed that you haven't been able to
get quite as much done at wor k as befor e?
Concentr ation questions such as these can be
tailor ed to the patient, depending on what sor ts
of activities he nor mally engages in. One study
of 31 depr essed patients found that the
activities most commonly r epor ted to be
impair ed wer e television watching (71% ),
r eading (68% ), and household jobs (65% )
(Pi l owsky and Boul ton 1970).

KEY POINT
We ar e often taught to l ook mai nl y for l oss of appeti te and
consequent wei ght l oss i n depr essi on, wi th the excepti ons of
atypi cal depr essi on and SAD. However, studi es show that wei ght
gai n i s qui te common i n typi cal major depr essi on as wel l
(Stunkar d et al . 1990; Wei ssenbur ger et al . 1986). In one study
of 93 pati ents wi th typi cal depr essi on, 37% gai ned wei ght, 32%
l ost wei ght, and 31% showed no change i n wei ght (Wei ssenbur ger
et al . 1986), so you'l l want to make sur e to phrase your appeti te
questi on i n a nonl eadi ng way.

A ppeti te

Since you've been depr essed, have you noticed


that your appetite has incr eased, decr eased, or
stayed about the same?
Have you lost or gained weight since you've
been depr essed?
Do your clothes fit you differ ently?
How many meals a day do you eat?
These questions often lead to mor e accur ate
infor mation; you can quantitate how much the
patient is actually
P.159
eating, and the patient may in fact be sur pr ised
to r ealiz e that he has been eating less or mor e
than usual.
Does food taste good to you?
Depr essed patients sometimes identify their
eating pr oblem not so much as a decr ease in
appetite, but as a sense that food has become
tasteless and unenjoyable, like car dboar d, as
one patient told me.

TIP
Thi s par t of the i nter vi ew pr ovi des a natural transi ti on for aski ng
about symptoms of eati ng di sor der s. For exampl e, i f a pati ent
tel l s you that she over eats when depr essed, ask i f she bi nges and
pur ges as wel l (see Chapter 28).

Psychomotor agi tati on and r etar dati on: Al though the DSM-IV-TR
speci fi es that psychomotor agi tati on and r etar dati on shoul d be
di agnosed based on what you obser ve i n the pati ent dur i ng the
eval uati on, the fol l owi ng questi ons may al so be hel pful :

Sometimes when people get depr essed, they


notice that their movements r eally slow down,
almost as though their limbs ar e made of lead.
Has that happened to you? (F or psychomotor
r etar dation.)
Have you been mor e r estless than usual? Have
you been pacing, wr inging your hands, unable
to sit down for long? (F or psychomotor
agitation.)

Sui ci dal i ty (see Chapter 21)

OTHER DEPRESSIVE SYNDROMES


Dysthymia
Mnemoni c: ACHEWS. Two of these si x, wi th depr essed mood, for 2
year s ar e i ndi cati ve of dysthymi a.

A ppeti te di sor der (ei ther decr eased or i ncr eased appeti te)
Concentrati on defi ci t

Hopel essness
Ener gy defi ci t
W or thl essness
Sl eep di sor der (ei ther i ncr eased or decr eased sl eep)

The dysthymi c pati ent i s al l er gi c to happi ness; hence, the


mnemoni c r efer s to a dysthymi c pati ent's (mi sspel l ed) sneezes
(achoos), br ought on by exposur e to happi ness. To meet the
cr i ter i a, the pati ent must have 2 year s of depr essed mood, al ong
wi th two of the si x symptoms i n the l i st.
Dysthymi a i s often di agnosed ear l y i n the i nter vi ew i n the context
of the chi ef compl ai nt. When a pati ent pr esents wi th symptoms of
depr essi on, a good scr eeni ng questi on for dysthymi a i s

When was the last time you r emember not feeling


depr essed?

The typi cal dysthymi c pati ent wi l l answer many year s. In fact, the
average durati on of the di sor der i s 16 year s (Kl ei n et al . 1993).
Al ong wi th depr essed mood, you al so have to establ i sh the
conti nuous pr esence of at l east two of the ACHEWS symptoms for 2
year s or mor e. The most effi ci ent way to do thi s i s to star t wi th
depr essi ve symptoms that your pati ent has al r eady menti oned,
rather than goi ng thr ough your l i st. Thus, i f you have al r eady hear d
about her l ethar gy, ask about that:

Over these last 2 year s, in which you say you've


been depr essed, has your ener gy been low most of
the time?

Atypical Depression
Atypi cal depr essi on i s a depr essi ve subtype character i zed by
r ever se NVSs (e.g., i ncr eased appeti te rather than anor exi a and
i ncr eased need for sl eep rather than i nsomni a), mood r eacti vi ty
(the abi l i ty to be cheer ed up by posi ti ve events), a patter n of
r ejecti on sensi ti vi ty thr oughout one's adul t l i fe, and a feel i ng of
bei ng wei ghed down (l eaden paral ysi s).
Recent r esear ch has cast str ong doubt on the val i di ty of thi s
di agnosi s, so I do not r ecommend spendi ng much ti me assessi ng for
i t dur i ng the i ni ti al i nter vi ew.

Seasonal Affective Disorder


Once you have establ i shed that the pati ent has epi sodes of major
depr essi on, ask i f these epi sodes fol l ow any seasonal

patter n. The most common patter n i s depr essi on i n the wi nter and
euthymi a i n the summer.

Have you noticed that your depr essions


consistently come on or get wor se in the winter
and then go away when the weather impr oves?

SAD i s si mi l ar to atypi cal depr essi on i n that r ever se NVSs ar e


usual l y pr esent, such as car bohydrate cravi ng (wi th consequent
wei ght gai n) and hyper somni a.
If your pati ent i s havi ng a har d ti me r emember i ng a seasonal aspect
to the depr essi on, you can jog hi s memor y by aski ng

Do you gener ally go on vacation to a sunny place


dur ing the winter ? Do you find that your mood
dr amatically impr oves dur ing the vacation?

Obvi ousl y, anybody's mood i mpr oves to some extent dur i ng


vacati on, but the pati ent wi th SAD wi l l r epor t a mor e extr eme mood
shi ft that often l asts for several weeks after hi s r etur n, wi th a
gradual l apsi ng back i nto depr essi on ther eafter. Thi s mi mi cs the
r esponse to l i ght therapy.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 3 - As s e s s ing M o o d Dis o rde rs II: Bipo la r Dis o rde r

23
Assessing Mood Disorders II: Bipolar
Disorder

Essential Concepts

Scr eeni ng Questi ons


Have you ever had a per i od of a week or so when you fel t
so happy and ener geti c that your fr i ends tol d you that you
wer e tal ki ng too fast or that you wer e behavi ng di ffer entl y
and strangel y?
Has ther e been a per i od when you wer e so hyper and
i r r i tabl e that you got i nto ar guments wi th peopl e?
Mnemoni c: DIGFA ST
Recommended ti me: 1 mi nute i f negati ve scr een; 5 mi nutes i f
posi ti ve scr een.

MANIC EPISODE
Bi pol ar di sor der tends to be under di agnosed by begi nni ng cl i ni ci ans.
Most pati ents who pr esent for psychi atr i c i nter vi ews appear
demoral i zed, depr essed, or anxi ous, and one i sn't i ntui ti vel y moved
to ask about per i ods of extr eme happi ness. It's hel pful to r eal i ze
that bi pol ar di sor der usual l y pr esents fi r st as a major depr essi on,
and that up to 20% of pati ents wi th depr essi on go on to devel op
bi pol ar di sor der (Bl acker and Tsuang 1992).
Even when you do r emember to ask about mani a, ther e i s another
r oadbl ock: a hi gh rate of fal se-posi ti ve r esponses. Many pati ents
r epor t per i ods of euphor i a and hi gh ener gy that r epr esent nor mal
var i ati ons i n mood rather than mani a. Thus, the most effecti ve
scr eeni ng questi ons for mani a ask about other peopl e's per cepti ons
as wel l as the pati ent's sel f-per cepti on.
In general , you shoul d keep r efer r i ng to a par ti cul ar per i od as you
ask your questi ons, because many peopl e exper i ence the separate
di agnosti c cr i ter i a of mani a at var i ous poi nts i n

thei r l i ves (e.g., spendi ng fool i shl y, tal ki ng unusual l y fast, bei ng
unusual l y di stracti bl e), but unl ess a number of these symptoms
have co-occur r ed dur i ng a di scr ete per i od (at l east 1 week, or 4
days for hypomani a), a mani c epi sode cannot be di agnosed (Tabl e
23.1).

Screening Questions
Have you ever had a per iod of a week or so in
which you felt so happy and ener getic that your
fr iends told you that you wer e talking too fast or
that you wer e behaving differ ently and str angely?

If you get a yes her e, fi nd out when that per i od was and how l ong
i t l asted, and then conti nual l y r efer to that per i od when you ask
about the di agnosti c cr i ter i a for mani a. If the pati ent cannot
r emember such a per i od l asti ng an enti r e week, you shoul d suspect
that mani a i s not the di agnosi s. Deter mi ne the ci r cumstances of the
el evated mood. Bei ng r eal l y happy for a coupl e of days after col l ege
graduati on, for exampl e, i s not mani a.

Has ther e been a time when you felt just the


opposite of depr essed, so that for a week or so you
felt as if you wer e on an adr enaline high and could
conquer the wor ld?

TABLE 23.1. DSM-IV-TR criteria for manic


episode

A distinct period of abnormally and


persistently elevated, expansive, or
1. irritable mood, lasting at least 1 week, or
such a mood of any duration if
hospitalization is necessary.

Persistence of three or more of the


following symptoms (four if the mood is
only irritable) during the period of mood
disturbance:
Mnemonic: DIGFAST
Distractibility
Indiscretion (excessive involvement in
2. pleasurable activities that have a high
potential for painful consequences)
Grandiosity or inflated self-esteem
Flight of ideas or racing thoughts
Activity increase (increase in goal-
directed activity or psychomotor agitation)
Sleep deficit
Talkativeness (pressured speech)

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

The pr ecedi ng questi on about mani a i s handy i f you have just


fi ni shed aski ng about symptoms of depr essi on.

Do you exper ience wild mood swings in which you


feel incr edibly good for a week or mor e and then
cr ash down into a depr ession?

Inter pr et r esponses to thi s questi on cauti ousl y, because some


pati ents who r espond wi th an emphati c yes ar e r efer r i ng to
r ecur r ent epi sodes of depr essi on wi thout mani a or hypomani a.

Has ther e been a time when you wer e so hyper and


ir r itable that you got into ar guments with people?

Thi s gets at the di agnosi s of i r r i tabl e, mi xed, or dysphor i c mani a.


Obvi ousl y, fal se-posi ti ve r esponses abound her e, and fol l owi ng up
wi th questi ons establ i shi ng that thi s per i od of i r r i tabi l i ty
r epr esented a mani c epi sode, rather than a depr essi on or si mpl y a
transi ent foul mood, wi l l be no smal l task.

Has anyone ever called you manic?

If someone answer s yes to thi s, pay cl ose attenti on. It's not
common for heal thy peopl e to have been cal l ed mani c by someone.

Use DIGFAST to Elicit Diagnostic Criteria


The author of the DIG FAST jewel i s unknown, but i t's ver y useful i n
r emember i ng the di agnosti c cr i ter i a for a mani c epi sode. The ter m
appar entl y r efer s to the speed wi th whi ch a mani c pati ent woul d di g
a hol e i f put to the task.
Mnemoni c: DIGFA ST

Di stracti bi l i ty
Indi scr eti on (DSM-IV-TR's excessi ve i nvol vement i n pl easurabl e
acti vi ti es)
Grandi osi ty
Fl i ght of i deas
A cti vi ty i ncr ease
Sl eep defi ci t (decr eased need for sl eep)
Tal kati veness (pr essur ed speech)

In addi ti on to expansi ve mood, the pati ent must qual i fy for thr ee of
the seven DIG FAST symptoms, or four of seven i f the pr i mar y mood
i s i r r i tabl e.

When you ask about the symptoms of mani a, pr ecede your questi ons
wi th somethi ng such as, Dur i ng the per i od l ast year when you fel t
hi gh, wer e you? Thi s way, you can ensur e that al l the symptoms
have occur r ed wi thi n the same ti me frame.

TIP
Be sur e to ask whether these behavi or s occur r ed i n the context of
al cohol or dr ug abuse. If so, you'l l have to judge whether the
mani c behavi or i s actual l y secondar y to a substance abuse
pr obl em or whether the substance abuse i s secondar y to mani a.
Thi s i s often a di ffi cul t questi on to sor t out.

Distractibility
Wer e you having tr ouble thinking? Was this
because things ar ound you would get you off tr ack?

KEY POINT
Remember that the di stracti bi l i ty of a pati ent wi th mani a i s
di ffer ent fr om the decr eased concentrati on of a depr essed per son.
A per son wi th mani a i s di stracti bl e not because hi s thi nki ng i s
sl owed down, but because hi s mi nd i s wor ki ng so qui ckl y and
fur i ousl y that any mental sti mul us, i nter nal or exter nal , knocks
hi m off track.

Indiscretion
Dur ing the per iod we've been talking about, how
did you spend your time?
Wer e you doing things that wer e out of char acter
or unusual for you?

These ar e ni ce questi ons to star t wi th, because they ar e r el ati vel y


unbi ased and unl i kel y to l ead the pati ent to i nval i d r esponses.
Wer e you doing things that caused tr ouble for you
or your family?

Thi s i s a good questi on because i t doesn't i mpl y a judgment of the


moral i ty of any par ti cul ar behavi ori t mer el y asks i f a behavi or has
caused tr oubl e for anyone.

Wer e you doing things that showed a lack of


judgment, such as dr iving too quickly, r unning r ed
lights, or spending too much money?
Did you do anything sexual dur ing this per iod that
was unusual for you?

KEY POINT
Al though you r i sk pushi ng a pati ent's bei ng judged button wi th
these questi ons, most pati ents r espond strai ghtfor war dl y,
especi al l y i f the rappor t i s good. One potenti al pi tfal l i s assumi ng
that any per i od of i ncr eased spendi ng i s di agnosti c of a mani c
epi sode. In fact, some pati ents have per i ods of compul si ve buyi ng
wi thout mani a; such buyi ng may be moti vated by a need to
r educe feel i ngs of depr essi on or anxi ety (Lejoyeux et al . 1997).

Grandiosity
Dur ing this per iod, did you feel especially self-
confident, as if you could conquer the wor ld?
Did you have par ticular ly good ideas?
Did you feel that you wer e r ight and that
ever ybody else was wr ong?

Often, thi s i s a good oppor tuni ty to el i ci t the grandi ose del usi ons
that ar e so common i n mani a:

Did you feel like you had any special power s?


Did you feel mor e r eligious than nor mal?

Flight of Ideas
Did you have so many ideas that you could bar ely
keep up with them?
P.167
Wer e thoughts r acing thr ough your head?
Wer e other people having a har d time
under standing your ideas?

When assessi ng fl i ght of i deas, be awar e that raci ng thoughts per


se ar e not speci fi c to bi pol ar di sor der. Pati ents wi th anxi ety
di sor der s, ADHD, or depr essi on wi th anxi ous r umi nati ons commonl y
descr i be thei r thoughts as raci ng. A good way to di sti ngui sh mani c
raci ng fr om anxi ous raci ng i s to ask:

Wer e your thoughts r acing in a good way or in an


unpleasant, wor r ied, or depr essed way?

Pati ents exper i enci ng mani c epi sodes often have a sense of an
accel erated thought pr ocess that i s l i ke a joy r i de i n a stol en car.
Pati ents wi th anxi ety or depr essi on wi l l feel ver y di ffer entl y.

Activity Increase
The acti vi ty i ncr ease cr i ter i on i s si mi l ar to i ndi scr eti on but focuses
speci fi cal l y on the fr eneti c natur e of the acti vi ty.

Wer e you mor e active than usual?


Wer e you constantly star ting new pr ojects or
hobbies?
Did you have so much ener gy that you felt it was
har d to calm down?

Sleep Deficit
Did you need less sleep than usual?
Did you ever stay up all night doing all kinds of
things, such as wor king on pr ojects or calling
people?
TIP
Be car eful not to confuse the sl eepl essness of depr essi on or
anxi ety wi th mani a. Pati ents wi th mani a stay awake because they
have so much to thi nk about and do, wher eas depr essed pati ents
stay awake because they feel tor tur ed by thei r feel i ngs.
Ther efor e, be sur e to ask pati ents what sor ts of thi ngs they do
when they can't sl eep. Pati ents wi th mani a wi l l r epor t pr oducti ve
acti vi ti es, wher eas depr essed pati ents wi l l r ead or watch
tel evi si on as they wai t for the sol ace of sl eep.

Talkativeness
Did you find it har d to stop talking?
Did other people tell you that they had tr ouble
under standing you?
Did fr iends have to inter r upt you to get a wor d in
edgewise?
Wer e you using the phone mor e than usual?

Other Tips for Diagnosing Mania


History of hospitalization: If a pati ent was hospi tal i zed dur i ng
a hyper per i od, chances ar e good that thi s was i ndeed a mani c
epi sode.
Interview w ith relatives and friends: One of the hal l mar ks of
mani a i s a l ack of i nsi ght, maki ng ver i fi cati on of hi stor i cal
i nfor mati on par ti cul ar l y i mpor tant.
Family history of bipolar disorder: Bi pol ar di sor der i s one of
the most i nher i tabl e of al l psychi atr i c di sor der s (see Chapter
16).

BIPOLAR DISORDER, TYPE II: THE


HYPOMANIC EPISODE
Si nce the fi r st edi ti on of The Psychi atr i c Inter vi ew, we have become
i ncr easi ngl y awar e of bi pol ar di sor der, type II, i n whi ch
depr essi ve and hypomani c epi sodes occur. Hypomani a can be har d
and pr etty unsati sfyi ng to di agnose (Tabl e 23.2). Essenti al l y, i t
amounts to a psychi atr i c di agnosi s for exuberant and often ver y
pr oducti ve happi ness. However, pati ents wi th bi pol ar II spend much
of thei r non-hypomani c ti me i n depr essi on, whi ch i s why bi pol ar II
i s i mpor tant not to mi ss. Use the same DIG FAST questi ons to
di agnose hypomani a that ar e used to di agnose mani a. The pati ent
wi th hypomani a wi l l descr i be defi ni te hi gh per i ods that have not
caused r eal pr obl ems i n her l i fe. When hypomani c per i ods al ter nate
wi th depr essed per i ods, the pr oper di agnosi s i s bi pol ar, type II
di sor der.

TABLE 23.2. DSM-IV-TR criteria for


hypomanic episode

Same as the criteria for manic episode except


that

The period of expansive or irritable mood


1. need last only 4 days rather than a full
week.

The episode is not severe enough to cause


2. marked impairment in social or
occupational functioning.

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 4 - As s e s s ing Anx ie t y Dis o rde rs

24
Assessing Anxiety Disorders

Screening Questions

Ar e you a wor r i er ?
Have you ever had a pani c or anxi ety attack?
Ar e you uncomfor tabl e i n soci al si tuati ons?
Do you have any speci al fear s, such as fear of i nsects or of
fl yi ng?
Do you have symptoms of OCD, such as needi ng to wash your
hands al l the ti me because you feel di r ty, constantl y checki ng
thi ngs, or havi ng annoyi ng thoughts pop i nto your head
r epeatedl y?
Do you have PTSD, whi ch means havi ng pai nful memor i es or
dr eams of a ter r i bl e exper i ence, such as bei ng attacked by
someone or sur vi vi ng a natural di saster ?

Recommended time: 3 mi nutes

Anxi ety i s a common symptom and can be a fr ustrati ng di agnosti c


i ssue for begi nni ng i nter vi ewer s because of the enor mous number of
di sor der s that can pr esent wi th anxi ety. For exampl e, many pati ents
wi th major depr essi on, mani a, and schi zophr eni a al so r epor t
si gni fi cant anxi ety, even i n the absence of a speci fi c anxi ety
di sor der (Boyd 1986).
Nonethel ess, i t i s i mpor tant to be systemati c about di agnosi ng
anxi ety di sor der s, par ti cul ar l y because many di sor der-speci fi c
psychotherapi es have been devel oped. For exampl e, the cogni ti ve-
behavi oral appr oach to the tr eatment of pani c di sor der i s ver y
di ffer ent fr om the cogni ti ve-behavi oral appr oach to soci al phobi a
(Bar l ow 1993).
You shoul d devel op a systemati c appr oach to aski ng about the seven
major DSM-IV-TR anxi ety di sor der s:

1. Pani c di sor der


2. Agoraphobi a
3. G AD
4. Soci al phobi a
5. Speci fi c phobi a
6. OCD
7. PTSD

Even i f you ask al l the r i ght questi ons, di sti ngui shi ng among these
anxi ety di sor der s, especi al l y the fi r st four, can be tr i cky. A useful
ai d i s the DSM-IV Handbook of Differ ential Diagnosis ( F i r st et al .
1995), whi ch contai ns excel l ent tabl es to gui de you i n
di ffer enti ati ng one di sor der fr om another.
Fol l owi ng ar e suggested questi ons for di agnosi ng the anxi ety
di sor der s, al ong wi th br i ef r emi nder s of the di agnosti c cr i ter i a for
each di sor der.

PANIC DISORDER
The fi r st step i n di agnosi ng pani c di sor der i s establ i shi ng that your
pati ent has had pani c attacks. Remember, however, that a pani c
attack does not i mpl y pani c di sor der. In fact, appr oxi matel y 35% of
heal thy peopl e r epor t havi ng had a pani c attack wi thi n the past year
(Nor ton et al . 1986), wher eas onl y 3% of the popul ati on wi l l ever
devel op ful l -bl own pani c di sor der (Kessl er et al . 1994). Pani c
attacks ar e often r esponses to speci fi c si tuati ons that peopl e can
successful l y avoi d (e.g., cl austr ophobi a, speci fi c phobi as). Pani c may
si gnal a di sor der other than pani c di sor der, such as soci al phobi a or
PTSD. F i nal l y, many peopl e exper i ence pani c and anxi ety that ar e
not qui te sever e enough to meet cr i ter i a for a DSM-IV-TR di sor der
(Tabl e 24.1).

TABLE 24.1. DSM-IV-TR criteria for panic


disorder

1. Recurrent unexpected panic attacks (must


have 4 of 13 symptoms)
Mnemonic for panic attack: Heart,
Breathlessness, Fear
Heart cluster: palpitations, chest pain,
nausea
Breathlessness cluster: shortness of breath,
choking sensation, dizziness, paresthesias,
hot/cold waves
Fear cluster: fear of dying, fear of going
crazy, sweating, shaking,
derealization/depersonalization
2. At least one of the attacks has been followed
by 1 month (or more) of at least one of the
following three:
Fear of another attack occurring
Persistent worry about the implications or
consequences of the attack
A significant change in behavior because of
the attacks

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.
The i ni ti al scr eeni ng questi on for pani c i s strai ghtfor war d:

Have you ever had a panic or anxiety attack?

Most peopl e have hear d the ter m panic attack. However, a posi ti ve
r esponse to thi s questi on r equi r es ver i fi cati on, because many
peopl e defi ne a subpani c l evel of anxi ety as a pani c attack. Thi s
seems especi al l y tr ue of pati ents wi th G AD. Such pati ents may
r espond, I'm al ways havi ng a pani c attack. I'm havi ng one r i ght
now. Other pati ents wi l l ask you what you mean by a pani c attack.
You need to pr ovi de a good defi ni ti on i n l ay ter ms to effecti vel y
di agnose pani c attack:

A panic attack is a sudden r ush of fear and


ner vousness in which your hear t pounds, you get
shor t of br eath, and you'r e afr aid you'r e going to
lose contr ol or even die. Has that ever happened to
you?

In my exper i ence, thi s questi on i s hi ghl y sensi ti ve and speci fi c for


di agnosi ng tr ue pani c attack. Pati ents who hear thi s defi ni ti on and
say unequi vocal l y, Oh no, I've been ner vous befor e, but I've never
had anythi ng l i ke that, ar e unl i kel y to have ever had a pani c
attack. For pati ents who answer yes, ask them to descr i be the
exper i ence:

When did you last have one of these attacks? Can


you descr ibe that attack for me? What wer e you
doing when it star ted? How did it make you feel,
and how long did it last?

The best way to assess the cl i ni cal si gni fi cance of a pani c attack i s
to l i sten to your pati ent descr i be one. You wi l l fi nd out whi ch
anxi ety symptoms ar e pr esent and whether the attacks have a
speci fi c pr eci pi tant.

When you have these attacks, do you notice any of


the following symptoms: sweating, shaking, tingling
in your hands or lips, shor tness of br eath, choking,
your hear t pounding, chest pain, nausea, or a
feeling that you'r e about to die or go cr az y?
Al though I've l i sted al l these symptoms i n one paragraph for
conveni ence, you shoul d ask about them one by one to gi ve your
pati ent ti me to thi nk about each. Use the symptom cl uster
techni que (hear t, br eathl essness, fear ) to r emember each of the
symptoms.

When you have a panic attack, does it come out of


the blue, or do you pr etty much know what's going
to cause it?

Remember that to meet cr i ter i a for pani c di sor der, the pani c attacks
have to be unexpected (i .e., out of the bl ue). Other wi se, pani c
attacks may si gni fy soci al phobi a, i f the tr i gger i s a soci al si tuati on;
PTSD, i f the tr i gger i s a fl ashback; agoraphobi a, i f the tr i gger i s a
har d-to-escape pl ace; or a speci fi c phobi a wi th a var i ety of possi bl e
tr i gger s.

Has one of these attacks ever woken you up at


night?
Do you r emember when you had your fir st panic
attack?

These two questi ons wi l l i ncr ease the speci fi ci ty of your expl orati on.
If a pati ent i s awakened at ni ght by pani c, i t's ver y l i kel y a tr ue,
unexpected pani c attack. (Some cl i ni ci ans woul d al so wonder about
a hi stor y of sexual abuse.) In addi ti on, peopl e wi th tr ue pani c
di sor der s often di sti nctl y r emember thei r fi r st pani c attack.
Beyond si mpl y establ i shi ng the bar e bones of the di agnosi s, you
shoul d make some attempt to assess whether the pati ent mi ght be a
good candi date for cogni ti ve-behavi oral therapy (CBT). In many
cases, CBT wor ks better than medi cati on for pani c di sor der,
par ti cul ar over the l ong haul (Bar l ow 2000). Pati ents who wi l l
r espond wel l to CBT ar e those who can i denti fy catastr ophi c
cogni ti on i n r esponse to the pani c sensati ons. A typi cal i nter change
fol l ows:

When you have panic attacks,


Interviewer: what exactly goes through your
mind?

I think I'm going to pass out, or


Patient:
worse.

Do you think you're going to


Interviewer:
die?

Yes, that's when I really get


Patient:
scared.

You mean the panic sensations


Interviewer: become more intense when you
have those thoughts?

Patient: Definitely.

But have you ever actually


Interviewer:
passed out?

Patient: No.

Do you think it's possible that


your thought process makes you
Interviewer:
feel even more anxious than
you'd otherwise feel?

I never thought about it that


Patient:
way, but I guess you're right.
TABLE 24.2. DSM-IV-TR criteria for
agoraphobia

1. Anxiety about being in places or situations


from which escape might be difficult or
embarrassing
2. Situations are avoided or are endured with
marked distress

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

Such a pati ent woul d l i kel y be a good pr ospect for r efer ral to a
cogni ti ve-behavi oral therapi st after you have fi ni shed your
di agnosti c i nter vi ew.

AGORAPHOBIA
Agoraphobi a (Tabl e 24.2) usual l y devel ops as a compl i cati on of
pani c di sor der (Amer i can Psychi atr i c Associ ati on 2000). Usual l y, the
pati ent has a few pani c attacks and gradual l y begi ns to avoi d
si tuati ons that he associ ates wi th those attacks, a pr ocess ter med
phobic avoidance. The agoraphobi c avoi ds si tuati ons i n whi ch a
qui ck escape woul d be di ffi cul t. Typi cal exampl es i ncl ude cr owded
pl aces (e.g., r estaurants, stor es, trai ns, buses) and dr i vi ng a car,
especi al l y i n heavy traffi c or far fr om home.

Have you star ted to avoid things because of your


panic attacks?
Ask thi s questi on of ever y pati ent wi th pani c di sor der. Agoraphobi a
accompani es pani c di sor der so commonl y that the DSM-III-R
descr i bes no di agnosi s of agoraphobi a wi thout pani c di sor der.

Do you have pr oblems with cr owds? Buses or


subways? Restaur ants? Br idges? Dr iving places?

Be sur e not to confuse agoraphobi a, a general i zed fear of a var i ety


of si tuati ons i n whi ch escape mi ght be di ffi cul t, wi th a speci fi c
phobi a of br i dges or buses or wi th PTSD, i n whi ch a speci fi c
si tuati on r emi ni scent of a past trauma may pr ovoke a fear r esponse.

Do you get anxious when you leave home?

At i ts wor st, the agoraphobi c's wor l d constr i cts so much that l eavi ng
the home i s a ter r i fyi ng pr ospect.

GENERALIZED ANXIETY DISORDER


The pati ent wi th G AD i s the pr ototypi cal wor r i er, who wor r i es about
several thi ngs for months on end and i s i ncapabl e of r el axi ng.

Begi n wi th thi s scr eeni ng questi on:

Ar e you a wor r ier ?

Li ke the scr eeni ng questi on for pani c di sor der, thi s questi on i s
exceedi ngl y unl i kel y to el i ci t a no answer fr om someone who tr ul y
has G AD.

What do you wor r y about?

Common topi cs of general i zed anxi ety i ncl ude the heal th of
r el ati ves (especi al l y chi l dr en), the qual i ty of a r omanti c
r el ati onshi p, job or school per for mance, and the possi bi l i ty that
possessi ons wi l l br eak down or be stol en. However, cer tai n topi cs of
wor r y suggest other di agnoses. For exampl e, excessi ve wor r y about
per for mance i n soci al si tuati ons may i ndi cate soci al phobi a, wor r y
about havi ng a pani c attack suggests pani c di sor der, and excessi ve
wor r y about bodi l y sensati ons poi nts to somati z ati on di sor der. Don't
make the mi stake of over di agnosi ng G AD when the actual di agnosi s
i s somethi ng mor e speci fi c.
On the other hand, some pati ents exper i ence fr ee-fl oati ng anxi ety
wi thout havi ng a par ti cul ar focus for thei r wor r i es. Such pati ents do
not meet cr i ter i a for G AD or any other anxi ety di sor der ; di agnosti c
possi bi l i ti es to consi der i ncl ude major depr essi on, schi zophr eni a, or
a medi cati on si de effect such as akathi si a (i .e., a feel i ng of
r estl essness caused by anti psychoti c medi cati on).

Over these past few months of wor r ying, have you


noticed that you've been feeling jitter y? Ir r itable?
Do you feel tension in your muscles? Do you tir e
easily? Do you have insomnia? Do you have
pr oblems concentr ating?

The DSM-IV-TR r equi r es that G AD pati ents exper i ence at l east thr ee
of the pr ecedi ng si x NVSs (Tabl e 24.3). Other wi se, too many qui te
happy and functi onal wor r i er s woul d be r ecei vi ng psychi atr i c
di agnoses.

SOCIAL PHOBIA
The per son wi th soci al phobi a fear s embar rassment and humi l i ati on
i n a range of di ffer ent publ i c si tuati ons, such as publ i c speaki ng,
meeti ng someone new, or eati ng i n fr ont of other s. Al l of us fear
some of these thi ngs to some extent, but the soci al phobi c's fear i s
unusual l y i ntense, to the poi nt of havi ng a pani c attack (Tabl e
24.4). Soci al phobi cs wi l l often gi ve you a cl ue to thei r condi ti on by
bei ng shy and awkwar d dur i ng the i nter vi ew, avoi di ng eye contact,
and l aughi ng ner vousl y.

TABLE 24.3. DSM-IV-TR criteria for GAD

1. Excessive anxiety and worry, occurring more


days than not for at least 6 months, about a
number of events or activities
2. Difficulty controlling the worry
3. Anxiety associated with at least three of the
following six symptoms:
Mnemonic: Macbeth Frets Constantly
Regarding Illicit Sins
Muscle tension
Fatigue
Concentration difficulty
Restlessness or feeling on edge
Irritability
Sleep disturbance

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

The scr eeni ng questi on i s

Ar e you uncomfor table in social situations?

You may need to speci fy the si tuati ons you have i n mi nd:

I mean situations such as public speaking, asking


questions in fr ont of a class, or being at a par ty or
in a meeting.

If you get a yes to the scr eeni ng questi on, ask

How uncomfor table do you get? Do you get to the


point of having a panic attack?
Is this anxiety so intoler able that you would go out
of your way to avoid any social situations?
SPECIFIC PHOBIA
A speci fi c phobi a i s easi l y di agnosed wi th the questi ons

Do you have any special fear s, such as a fear of


insects or a fear of flying?
Have you ever had a panic attack when you've
been ar ound this thing that you fear ?

TABLE 24.4. DSM-IV-TR criteria for social


phobia

1. A fear of social performance situations in


which the person is exposed to unfamiliar
people or to possible scrutiny by others
2. Exposure to the feared situation almost
invariably provokes anxiety, which may take
the form of a panic attack

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

TABLE 24.5. DSM-IV-TR criteria for specific


phobia
1. Excessive and unreasonable fear of a
specific object or situation
2. Exposure to the phobic stimulus causes
intense anxiety

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

If you get posi ti ve r esponses to these questi ons, you must fur ther
establ i sh that the speci fi c phobi a i nter fer es si gni fi cantl y wi th
psychosoci al functi oni ng (Tabl e 24.5).

OBSESSIVE-COMPULSIVE DISORDER
OCD i s a commonl y over l ooked di agnosi s because pati ents rar el y
vol unteer such embar rassi ng symptoms wi thout bei ng asked. Thus,
i ncl udi ng OCD questi ons as par t of your r outi ne PROS i s par ti cul ar l y
i mpor tant.
Begi n wi th the fol l owi ng hi gh-yi el d scr eeni ng questi on:

Do you have symptoms of an obsessive-compulsive


disor der , such as needing to wash your hands all
the time because you feel dir ty, constantly
checking things, or having annoying thoughts pop
into your head over and over ?

Al though thi s may sound l i ke an excessi vel y l ong questi on, so much
i nfor mati on i s packed i nto i t that i f you get a fl atl y confi dent no i n
r esponse, you ar e unl i kel y to fi nd OCD by di ggi ng fur ther. A yes
r equi r es fur ther pr obi ng, because pati ents wi l l often say that they
check or wash, but on detai l ed questi oni ng they may not meet
cr i ter i a for OCD (Tabl e 24.6).
For exampl e, i f a pati ent says that he checks thi ngs, you must
establ i sh that he i s uncomfor tabl y dr i ven to do so:

When you check to make sur e the door is locked,


do you feel like you r eally have to check it, and
that if you didn't you'd feel ver y uncomfor table?

You must establ i sh that the checki ng takes up enough of a per son's
ti me to si gni fi cantl y i nter fer e wi th day-to-day acti vi ti es:

How many times do you check the door usually? Is


it just once or twice or do you have to check it 10
or 20 times to be satisfied that it's locked?

Pati ents may pr esent wi th a number of di ffer ent types of obsessi ons
and compul si ons. You can often ask about obsessi ons and
compul si ons i n the same questi on:

Do you wash your hands excessively because of


wor r ies about dir t or ger ms?

TABLE 24.6. DSM-IV-TR criteria for OCD

Mnemonic: Washing and Straightening Make


Clean Houses
Washing
Straightening
Mental rituals (e.g., magical words,
numbers)
Checking
Hoarding
Must have either obsessions or compulsions
Obsessions
Recurrent intrusive thoughts
Impulses
Images that cause anxiety and that the
person tries to ignore or suppress
Compulsions
Repeated behaviors or mental acts that the
person feels driven to perform in response to
an obsession
Behaviors or acts aimed at preventing or
reducing distress

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

Do you feel the need to check things ar ound the


house because of a fear that bad things might
happen if you don't?
Do you feel the need to save ever y little scr ap of
paper because of a fear that you'll need them all
sometime?

For mental r i tual s, ask

Do you often find your self counting things or


naming things for no par ticular r eason?

To deter mi ne the degr ee of functi onal i mpai r ment caused by the


symptoms, you can ask

How much time do you usually need to get r eady to


leave the house in the mor ning?
A pati ent wi th many cl eani ng and dr essi ng r i tual s may take 2 to 3
hour s or mor e to get shower ed and dr essed.

POSTTRAUMATIC STRESS DISORDER


Because most peopl e have hear d of PTSD, the scr eeni ng questi on
can i ncl ude the ter m, al ong wi th a br i ef defi ni ti on.

TABLE 24.7. DSM-IV-TR criteria for


posttraumatic stress disorder

Mnemonic: Remembers Atrocious Nuclear


Attacks

1. The person has experienced a traumatic


event that involved actual or threatened
death or a threat to the physical integrity of
self or others.
2. The traumatic event is persistently
Reexperienced via memories, dreams,
flashbacks, or intense distress when the
person is exposed to events that are
symbolic of the original event.
3. Stimuli associated with the event are
persistently Avoided, for example, avoiding
certain activities or thoughts, amnesia for
the event.
4. The person experiences Numbing of general
responsiveness, as in a sense of detachment
from others, a restricted range of affect,
diminished interest in various activities, or a
sense of foreshortened future.
5. Increased Arousal occurs: sleep disturbance,
irritability, difficulty concentrating,
hypervigilance, exaggerated startle
response.
6. The disturbance lasts at least 1 month.

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

Do you have posttr aumatic str ess disor der , which


means having memor ies or dr eams of a ter r ible
exper ience, like being attacked by someone or
sur viving a natur al disaster ?

Resear cher s have found that l i sti ng exampl es of traumati c events


i ncr eases pati ent r ecal l i n PTSD (Sol omon and Davi dson 1997). If
your pati ent answer s no to such questi ons, PTSD i s unl i kel y. A
posi ti ve r esponse r equi r es that you establ i sh the pr esence of the
DSM-IV-TR cr i ter i a (Tabl e 24.7).

What sor t of exper ience was it?

Aski ng i n thi s general manner, rather than i nqui r i ng di r ectl y about


the exper i ence, gi ves your pati ent per mi ssi on to answer vaguel y,
whi ch may be al l she can tol erate. Remember that a hal l mar k of
PTSD i s the need to avoi d the memor y of the trauma; al l ow your
pati ent to do thi s i f she needs to.
Once you have establ i shed that a traumati c exper i ence occur r ed,
ask about each of the cr i ter i a.

Reexper i ence (Remember s)


Does the exper ience come back to haunt you
fr om time to time?
Have you had nightmar es or flashbacks of this
exper ience?

If your pati ent doesn't under stand what you mean by flashbacks,
you can el aborate:

Do you find that you'r e r emember ing the event


and you tr uly feel like you'r e back ther e again?

Avoi dance (A tr oci ous)

Do you find your self avoiding things that you


associate with the memor y?

Inqui r i ng about speci fi c acti vi ti es or si tuati ons r el ated to the


actual trauma i s better than usi ng thi s general questi on. For
exampl e, i f the trauma was a rape, you mi ght ask

Do you find your self avoiding going out with


men to avoid r emember ing what happened?

If the exper i ence was an automobi l e acci dent, you mi ght ask

Do you avoid dr iving or even getting into car s


because of that exper ience?

Numbi ng (Nucl ear ): The symptoms of numbi ng ar e si mi l ar to


some of the symptoms of depr essi on, especi al l y anhedoni a and
decr eased ener gy. You may have asked about them ear l i er i n the
i nter vi ew.

Since the tr auma, has your inter est in life gone


downhill?

Your pati ent may descr i be a di mi ni shed range of acti vi ti es.

Have fr iendships suffer ed? Has it been har der


to have feelings for loved ones?
Has your sense of the futur e changed?

A PTSD pati ent may r espond wi th I don't see any futur e or I


don't even thi nk about the futur e.
Ar ousal (A ttacks): As i n numbi ng, many symptoms of
hyperar ousal ar e al so typi cal symptoms of major depr essi on,
such as i nsomni a, di ffi cul ty concentrati ng, and i r r i tabi l i ty.
Hyper vi gi l ance and a star tl e r esponse ar e mor e speci fi c to PTSD.

Since the tr auma, have you felt hyper and on


edge much of the time?
Do you star tle easily?
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 5 - As s e s s ing Alc o ho l De pe nde nc e a nd Drug Abus e

25
Assessing Alcohol Dependence and
Drug Abuse

Screening Questions

Do you enjoy a dr i nk now and then?


Ask CAG E questi ons.
Do you use any r ecr eati onal dr ugs, such as mar i juana, LSD, or
cocai ne?

Recommended time: 2 mi nutes for scr eeni ng; 5 to 10 mi nutes for


pr obi ng, i f scr een i s posi ti ve.

F i r st you take a dr i nk, then the dr i nk takes a


dr i nk, then the dr i nk takes you.
--F. Scott F i tzgeral d

NOTES
In thi s chapter, I focus on al cohol dependence; most of the poi nts
ar e appl i cabl e to dr ug abuse as wel l .

In an i ni ti al di agnosti c i nter vi ew, you wi l l pr obabl y not have ti me to


do a compl ete assessment of the hi stor y, extent, and consequences
of a pati ent's substance abuse pr obl em. Such an assessment
r equi r es a ful l sessi on i n i tsel f. What, then, ar e your mor e l i mi ted
goal s? Ther e ar e thr ee:

1. Deter mi ne whether your pati ent meets DSM-IV-TR cr i ter i a for


al cohol /dr ug dependence or abuse.
2. G et a sense of the sever i ty of the pr obl em.
3. Deter mi ne how the al cohol use i nteracts wi th any comor bi d
psychi atr i c di sor der s pr esent.

The most i mpor tant ti p for begi nner s i s to be nonjudgmental. Thi s


r equi r es some soul -sear chi ng because most of us have negati ve
pr ejudi ces about substance abuser s, and we tend to see them as
bei ng moral l y suspect. Be awar e of the extent to whi ch you hol d
such atti tudes and eval uate whether they ar e accurate. Tr y to meet
wi th r ecover ed al cohol i cs. Thei r stor i es ar e often poi gnant and wi l l
hel p you to devel op a mor e sympatheti c and compassi onate atti tude.
Lear n about the di sease model of al cohol i sm (Cl ar k 1981). The mor e
you can vi ew al cohol i sm as si mi l ar to the other psychi atr i c di sor der s
you tr eat, the fewer pr ejudi ces you wi l l r etai n.

ASSESSMENT TECHNIQUES
Screening Questions
TIP
The best qui ck scr een for al cohol i sm r emai ns the tr i ed-and-tr ue
CAG E questi onnai r e (see bel ow; Ewi ng 1984), i n whi ch a posi ti ve
r esponse to two or mor e of the i tems i mpl i es a 95% chance of
al cohol abuse or dependence. However, one study (Stei nweg
1993) suggests that the way i nter vi ewer s transi ti on to the CAG E
questi ons pr ofoundl y affects the questi onnai r e's sensi ti vi ty.
Resear cher s di vi ded 43 confi r med al cohol i cs i nto two gr oups. In
gr oup I, the CAG E was i ntr oduced wi th an open-ended questi on,
such as Do you have a dr i nk now and then? In gr oup II, pati ents
wer e fi r st asked to quanti tate thei r al cohol i ntake wi th the
questi on, How much do you dr i nk? Sensi ti vi ty towar d the CAG E
questi ons was dramati cal l y hi gher i n gr oup I (95% ) than i n gr oup
II (32% ), demonstrati ng the i mpor tance of begi nni ng the
scr eeni ng i n a nonjudgmental way.

CAG E Questi onnai r e:

Cut down: Have you fel t you shoul d cut down on your
dr i nki ng?
A nnoyed: Have peopl e annoyed you by getti ng on your case
about your dr i nki ng?
Gui l ty: Have you ever fel t bad or gui l ty about your dr i nki ng?

Eye-opener : Have you ever needed to take a dr i nk fi r st thi ng i n


the mor ni ng to steady your ner ves or get r i d of a hangover ?
Begi n your scr een wi th the nonthr eateni ng questi on

Do you enjoy a dr ink now and then?

If a pati ent answer s, I never dr i nk, you shoul d ask, Why not?
Most peopl e of the Amer i can cul tur e have a dr i nk occasi onal l y;
peopl e who make a poi nt of not dr i nki ng ar e uncommon. They may
avoi d dr i nki ng because they ar e r ecover ed al cohol i cs, because they
have a fami l y member wi th a ser i ous dr i nki ng pr obl em, or for
r el i gi ous or ethi cal r easons. Most peopl e wi l l answer wi th somethi ng
l i ke, Oh, I have gl ass of wi ne wi th di nner, or I have a beer when I
bar becue. Jump r i ght i nto the CAG E questi ons:

Cut down: Have you ever tr ied to cut down on your


dr inking?

A car di nal featur e of al cohol i sm i s the l oss of contr ol over dr i nki ng,
and thi s questi on gets at that i ssue. If the pati ent answer s yes,
fol l ow up wi th

What made you decide to cut down?

The answer to thi s questi on wi l l l i kel y move you i nto an expl orati on
of the adver se consequences of dr i nki ng that the pati ent
exper i enced. (See next secti on.)

A nnoyed: Have you ever been annoyed about


fr iends' or family's cr iticism of your dr inking?

The sever e al cohol i c wi l l not onl y have been cr i ti ci zed by l oved ones
for hi s dr i nki ng, but may have compl etel y al i enated most i mpor tant
peopl e i n hi s l i fe.
Guilty: Have you ever felt a little guilty about your
dr inking?

Agai n, a posi ti ve r esponse i s an i nvi tati on to fur ther expl orati on.

Eye-opener : Have you ever felt hungover or shaky


in the mor ning and taken a dr ink to get r id of that
feeling?

Thi s behavi or i s a good i ndi cator of out-of-contr ol dr i nki ng.


As your fi nal scr eeni ng questi on, ask matter-of-factl y:

Do you think that you have a dr inking pr oblem?

I have been amazed at how many pati ents answer no to al l the


CAG E questi ons and then answer yes to thi s one.
If the pati ent has answer ed no to the CAG E questi ons and the
dr i nki ng pr obl em questi on, and i f ther e wer e no cl ues to a dr i nki ng
pr obl em (e.g., the odor of al cohol on the br eath), the pati ent has no
dr i nki ng pr obl em, and you can ask the general questi on:

Do you use any r ecr eational dr ugs, like mar ijuana,


LSD, or cocaine?

If the pati ent gi ves a negati ve answer to thi s questi on, you can
move out of the substance abuse ar ea.

TIP
If a pati ent has admi tted to a dr i nki ng pr obl em, I have found i t
useful to ask about other types of substance abuse by usi ng the
i nter vi ewi ng techni que of symptom expectati on:

Aside fr om dr inking, what sor ts of r ecr eational dr ugs do you


use r egular ly? Cocaine? Mar ijuana? Speed? Her oin?

The phrasi ng her e not onl y communi cates the assumpti on that
your pati ent has used these dr ugs, but that he uses them on a
r egul ar basi s; thi s i s an exampl e of symptom exaggerati on. The
r esul t i s that the pati ent who abuses these dr ugs occasi onal l y wi l l
feel l ess ashamed to admi t such use (e.g., I don't use them al l
the ti meI've gone on a few coke bi nges, and I've shot dope a
few ti mes, but I keep i t under contr ol ).

Probing Questions
Once your scr eeni ng questi ons have establ i shed that your pati ent
has a substance abuse pr obl em, your next step i s to use pr obi ng
questi ons to defi ni ti vel y establ i sh the DSM-IV-TR substance
dependence (Tabl e 25.1) or abuse (Tabl e 25.2) di agnosi s, and to
assess sever i ty. One way to appr oach establ i shi ng the di agnosi s
woul d be to go down the l i st of cr i ter i a, begi nni ng wi th tol erance,
and to si mpl y ask about each one. Al though thi s may be ti me-
effi ci ent, i t tends to pr oduce unr el i abl e i nfor mati on, par ti cul ar l y i n
the pati ent who i s ashamed of her addi cti on or i s tr yi ng to hi de the
extent of i t for other r easons.

TABLE 25.1. DSM-IV-TR criteria for alcohol


dependence

The following list refers to the mnemonic


Tempted With Cognac. To be considered
alcohol dependent, the patient must meet at
least three of the following seven criteria:
Tolerance, that is, a need for increasing
amounts of alcohol to achieve intoxication
Withdrawal syndrome
Loss of Control of alcohol use (five criteria
follow):
More alcohol ingested than the patient
intended
Unsuccessful attempts to cut down
Much time spent in activities related to
obtaining or recovering from the effects of
alcohol
Important social, occupational, or
recreational activities given up or reduced
because of alcohol use
Alcohol use continued despite the patient's
knowledge of significant physical or
psychological problems caused by its use

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

The better appr oach i s to ask open-ended questi ons about your
pati ent's dr i nki ng hi stor y and transi ti on to speci fi c questi ons about
DSM-IV-TR cr i ter i a as you go al ong.

Do you r emember your fir st dr ink?

Al cohol i cs often r emember thei r fi r st dr i nk vi vi dl y and get a twi nkl e


i n thei r eye. For some, thi s was the fi r st ti me they ever fel t at
peace wi th themsel ves.

When did you star t dr inking fr equently?

TABLE 25.2. DSM-IV-TR criteria for alcohol


abuse

A maladaptive pattern of alcohol use leading to


clinically significant impairment or distress, as
manifested by at least one of the following:

1. Failure to fulfill major role obligations at


work, school, or home
2. Recurrent alcohol use in situations in which
it is physically hazardous
3. Recurrent alcohol-related legal problems
4. Continued alcohol use despite persistent
problems caused by its use

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

KEY POINT
The ear l i er al cohol i sm began, the mor e sever e and r efractor y the
pr obl em i s l i kel y to have become. Recent fi ndi ngs i ndi cate that
25% of mal e dr i nker s have an ear l y-onset for m of al cohol i sm
cal l ed type II al cohol i sm. Thi s i s usual l y i nher i ted fr om the father
and i s a par ti cul ar l y sever e for m of the di sor der, wi th a hi gh
pr eval ence of vi ol ence and comor bi d depr essi on and sui ci dal i ty.

When wer e you dr inking most heavily?

Thi s questi on al l ows you to ascer tai n the sor ts of l i fe si tuati ons that
have been most associ ated wi th heavy dr i nki ng, and i t al so ser ves
as a good jumpi ng-off poi nt for a ser i es of questi ons r el ati ng to
tol erance, wi thdrawal , and adver se consequences.

Have you found that you've needed mor e dr inks to


get the same high?
F r equent dr i nker s devel op tol erance to the effects of al cohol . A
general r ul e of thumb i s that a nonal cohol i c per son wi l l feel dr unk
after consumi ng thr ee to four average dr i nks on an empty stomach
over the cour se of an hour (Cl ar k 1981). An al cohol i c may r equi r e
two or thr ee ti mes that amount.

When you've cut down or stopped dr inking for a


few days, have you developed pr oblems such as
insomnia, the shakes, or convulsions?

You shoul d become fami l i ar wi th the usual ti me cour se and the


symptoms of al cohol wi thdrawal . Pati ents general l y r epeat patter ns
of wi thdrawal that they have exper i enced i n the past. Thi s i s
i mpor tant for you to know so that you can deci de whether to
r ecommend i npati ent detoxi fi cati on to a pati ent who just stopped
dr i nki ng.

Have you found over the year s that you've had


tr ouble contr olling your intake of alcohol?

Thi s i s essenti al l y a r ephrasi ng of the cut down questi on of the


CAG E, and i t gets at the cr uci al i ssue of l ack of contr ol of al cohol
i ntake, as expr essed i n cr i ter i a 3 and 4 of the DSM-IV-TR.
The next few questi ons ar e di r ected towar d fi ndi ng out whether
al cohol use has had a negati ve effect on the pati ent's

l i fe i n some objecti ve way. I str ess objective because many


al cohol i cs wi l l deny that they have a subjective pr obl em; vi a ski l l ful
i nter vi ewi ng, you can demonstrate that al cohol has caused
pr obl ems. In thi s way, your assessment can, i n i tsel f, contr i bute
towar d the ear l i est stage of al cohol i sm tr eatment, i n whi ch the
al cohol i c accepts that he has a pr obl em.
In an i nsi ghtful and cooperati ve pati ent, you can obtai n r el i abl e
i nfor mati on about adver se effects by aski ng strai ghtfor war d
questi ons:

How has your alcoholism affected your


r elationships? Your wor k? Other aspects of your
life? Have you gotten into fights or been ar r ested
because of your dr inking?
TIP
When i nter vi ewi ng a pati ent i n deni al , however, you wi l l have to
obtai n thi s i nfor mati on i ndi r ectl y, vi a the soci al hi stor y and
medi cal hi stor y. A sever e al cohol i c's soci al hi stor y wi l l be r epl ete
wi th fai l ed r el ati onshi ps, job changes, and l egal di ffi cul ti es, and
hi s medi cal hi stor y wi l l be si gni fi cant for emer gency r oom vi si ts
or hospi tal i z ati ons for al cohol -r el ated i njur i es. As you gl ean such
i nfor mati on, gi nger l y i ntr oduce the i ssue of al cohol use:

You must have felt pr etty down when your wife


left you. Was dr inking any solace for you then?

Note that thi s i s a nor mal i z i ng questi on, wi th the i mpl i ci t


message: Anyone i n a si mi l ar si tuati on mi ght have r eached for
the bottl e; that's not somethi ng to be ashamed of. If your pati ent
admi ts to dr i nki ng, fol l ow up wi th

Was your dr inking an issue with your wife? Did


she leave you because of it?

You can use the same techni que wi th other aspects of the soci al
hi stor y. When you hear some cl ue of al cohol i sm-r el ated adver se
consequences, ask i f al cohol was i nvol ved.

F i nal l y, once you've fi ni shed getti ng the r emote al cohol i sm hi stor y,


you shoul d ask about r ecent use. Thi s wi l l hel p you to deter mi ne
the need for detoxi fi cati on hospi tal i z ati on and the

extent to whi ch r ecent al cohol use may be affecti ng the pati ent's
mental status. For these questi ons, you shoul d tr y to ascer tai n
quanti ty of both the amount consumed and the fr equency.

I need to know about how much you've been


dr inking over the past 2 weeks so that I can come
up with some good tr eatment ideas for you. How
many fifths have you been able to put away per
dayone? two? mor e?

Thi s questi on combi nes a number of defusi ng strategi es. F i r st, you
i ntr oduce the questi on by sayi ng why you'r e aski ng i t, not to
condemn the pati ent, but to hel p hi m. Second, you appeal to hi s
nar ci ssi sm by sayi ng How many fi fths have you been abl e to put
away? F i nal l y, you use symptom exaggerati on by suggesti ng a
degr ee of use hi gher than you expect: one, two, or mor e fi fths per
day.

SPECIAL TECHNIQUES IN DUAL DIAGNOSIS


If your pati ent has a substance abuse pr obl em, chances ar e hi gh
that he has another psychi atr i c di sor der, as wel l . Accor di ng to the
l ar gest Amer i can epi demi ol ogi c study to l ook at thi s questi on, 37%
of al cohol i cs and 53% of dr ug abuser s have had another psychi atr i c
di sor der at some poi nt i n thei r l i ves (Regi er et al . 1990). Usi ng a
par ti cul ar l y common exampl e, that of depr essi on combi ned wi th
al cohol i sm, two di sor der s can i nteract wi th each other i n two ways:
Depr essi on can dr i ve a per son to dr i nk, or dr i nki ng can cause
depr essi on, ei ther di r ectl y vi a a depr essant effect on the ner ve cel l s
or i ndi r ectl y, vi a the psychosoci al chaos that al cohol i sm causes.
Pati ents wi th dual di agnoses ar e compl i cated, and you may need to
schedul e two sessi ons to compl ete your di agnosti c assessment. Her e
ar e some suggesti ons for maki ng these assessments easi er. For ease
of pr esentati on, I use the exampl e of depr essi on and al cohol i sm, but
any other dual di agnosi s can be appr oached si mi l ar l y.

When was your longest per iod of sobr iety?

You want to i denti fy a per i od of sobr i ety l asti ng at l east 2 months,


pr eferabl y l onger. Refer to that per i od i n fur ther questi ons.

How was your life going dur ing that per iod? Wer e
you suffer ing fr om depr ession or anxiety?

Tr y to deter mi ne i f the pati ent met DSM-IV-TR cr i ter i a for a major


depr essi ve epi sode dur i ng her sobr i ety. It doesn't count i f she was
depr essed for onl y a few weeks after she stopped dr i nki ng, and the
depr essi on r esol ved on i ts own. That's the typi cal cour se of al cohol -
i nduced depr essi on. Look for depr essi on that was separated fr om
the al cohol use by at l east 1 month.

Why did you begin dr inking again?


Was it because of depr ession, or just because the
temptation to dr ink was too gr eat?
Which do you think is a bigger pr oblem for you,
alcohol dependence or depr ession?
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 6 - As s e s s ing P s y c ho t ic Dis o rde rs

26
Assessing Psychotic Disorders

Screening Questions

Have you had any exper i ences l i ke dr eami ng when you'r e


awake?
Have you had any strange or odd exper i ences l atel y that you
can't expl ai n?
Do you ever hear or see thi ngs that other peopl e can't hear or
see?
Do you ever feel that peopl e ar e bother i ng you or tr yi ng to
har m you?
Does i t seem that stranger s l ook at you a l ot or make
comments about you?

Recommended time: 2 mi nutes for scr eeni ng; 5 to 10 mi nutes for


pr obi ng i f scr een i s posi ti ve.

A body ser i ousl y out of equi l i br i um, ei ther wi th


i tsel f or wi th i ts envi r onment, per i shes outr i ght.
Not so a mi nd. Madness and suffer i ng can set
themsel ves no l i mi t.
--G eor ge Santayana

The fi r st i mpor tant poi nt for novi ce i nter vi ewer s i s that psychosi s
and schi zophr eni a ar e not i nter changeabl e. Psychosis i s a general
ter m r efer r i ng to di sor der ed pr ocessi ng of thought and i mpai r ed
grasp of r eal i ty. As such, psychosi s can occur as a par t of many
psychi atr i c syndr omes other than schi zophr eni a, i ncl udi ng
Depr essi on
Mani a
Over whel mi ng str ess (br ief r eactive psychosis)
Di ssoci ati ve di sor der s
Dementi a and del i r i um
Substance i ntoxi cati on or wi thdrawal
Per sonal i ty di sor der s (PDs)

In ter ms of the rapi d di agnosti c eval uati on, thi s means that you
must ask ever y pati ent you i nter vi ew, not onl y those

whom you suspect of havi ng schi zophr eni a, scr eeni ng questi ons
about psychoti c i deati on.
The second useful poi nt, r el ated to the fi r st, i s that ther e ar e two
types of psychoti c pati ents: (a) those who ar e obvi ousl y psychoti c
and (b) those whose psychoses ar e not obvi ous. In most outpati ent
setti ngs, the typi cal pati ent wi l l not appear psychoti c at fi r st gl ance.
He wi l l speak coher entl y, wi l l not vol unteer any del usi onal mater i al ,
and wi l l not appear to be hal l uci nati ng. However, many of these
pati ents wi l l have a subtl e or hi dden psychosi s that wi l l r equi r e a
number of scr eeni ng questi ons to uncover. These scr eeni ng
questi ons and techni ques ar e descr i bed i n the fi r st par t of thi s
chapter.
On the other hand, pati ents who ar e obvi ousl y psychoti c don't
r equi r e subtl e scr eeni ng questi ons. Instead, you wi l l ask pr obi ng
questi ons to better under stand the pr eci se type of psychosi s wi th
whi ch you ar e deal i ng. In the second par t of thi s chapter, I defi ne
the mor e common thought di sor der s and then descr i be strategi es for
ascer tai ni ng whi ch ar e pr esent i n a par ti cul ar pati ent.

GENERAL SCREENING QUESTIONS


When you ar e i nter vi ewi ng a pati ent who speaks coher entl y and has
a good grasp of r eal i ty, i t i s tempti ng to ski p questi ons r egar di ng
psychosi s. Thi s i s a mi stake, because hi dden psychosi s i s common,
especi al l y i n major depr essi on, dementi a, and substance abuse. In
addi ti on, a nonpsychoti c pati ent may have a hi stor y of psychosi s,
whi ch i n tur n may i nfl uence your di agnosi s or tr eatment.
Two good i ni ti al questi ons ar e as fol l ows:
Have you had any exper iences like dr eaming when
you'r e awake?
Have you had any str ange or odd exper iences
lately that you can't explain?

Pati ents who answer no to both of these questi ons may sti l l be
psychoti c, and i f you suspect thi s, you shoul d fol l ow up wi th

Do you ever hear or see things that other people


can't hear or see?

Thi s asks di r ectl y about audi tor y and vi sual hal l uci nati ons but i s
mor e graceful than the ol d standby, Do you hear voi ces?

TIP
Not al l peopl e who hear voi ces have a psychi atr i c syndr ome.
Epi demi ol ogi cal r esear ch has documented that 3% to 4% of
peopl e i n the general popul ati on r epor t a hi stor y of audi tor y
hal l uci nati ons (AHs), and l ess than one-hal f of them meet cr i ter i a
for schi zophr eni a or di ssoci ati ve di sor der. In one study compar i ng
pati ent wi th nonpati ent voi ce hear er s, the nonpati ents often
r epor ted the onset of AHs befor e age 12, and 93% of them
thought that the voi ces wer e pr edomi nantl y posi ti ve (Honi g et al .
1998).

Have people been har assing you or tr ying to har m


you?

Thi s questi on scr eens for paranoi d i deati on i n a nonjudgmental way.


You ar e not aski ng your pati ent i f she i s paranoi d, but rather
whether she feel s other s ar e wr ongi ng her. A subtl y paranoi d
pati ent may wel come thi s chance to vent her compl ai nts about the
Federal Bur eau of Investi gati on's (F BI's) wi r e-tappi ng acti vi ti es.

Does it seem that str anger s look at you a lot or


make comments about you?

Thi s i s a scr een for i deas of r efer ence, a common psychoti c del usi on
i n whi ch the pati ent bel i eves that appar entl y neutral events have a
speci al si gni fi cance or communi cati on for her. Ideas of r efer ence can
be ver y subtl e and di ffi cul t to di agnose, as the fol l owi ng vi gnette
i l l ustrates.

CLINICAL VIGNETTE
An i nter n was admi tti ng a 63-year-ol d wi dowed woman wi th major
depr essi on. The pati ent had become i ncr easi ngl y depr essed si nce
her husband di ed 1 year ear l i er, and she had not r esponded to
anti depr essants thus far, pr ompti ng an admi ssi on for mor e
i ntensi ve di agnosti c eval uati on and tr eatment. After establ i shi ng
cr i ter i a for major depr essi on, the i nter n asked her scr eeni ng
questi ons for psychoti c i deati on:

Do you ever feel that people


you don't know are looking at
Interviewer:
you or making comments about
you?

Patient: No.

Do you ever hear voices or see


Interviewer: things that other people can't
see?

Patient: No.

Has anyone been bothering


Interviewer:
you or harassing you?

Just the kids in the


Patient:
neighborhood.

Interviewer: What have they been doing?


Patient: What kids do, yelling and
carrying on.

At thi s poi nt, the i nter n was tempted to dr op thi s topi c and move
on to another secti on of the i nter vi ew, but she had a vague sense
that ther e was somethi ng mor e to thi s stor y than the car r yi ng
on of nei ghbor hood ki ds.

What sorts of things have the


Interviewer:
kids been yelling?

Patient: Saying bad things about me.

Interviewer: What sorts of things?

Oh, that I'm a prostitute. That


Patient: I run a whorehouse. They're
yelling it day and night.

As i t tur ned out, the pati ent had major depr essi on wi th psychoti c
featur es (AHs and i deas of r efer ence) and r equi r ed combi nati on
therapy wi th an anti depr essant and a neur ol epti c befor e she
i mpr oved.

TIP
You can al so make any of these questi ons sound l ess thr eateni ng
by usi ng smooth transi ti ons and nor mal i z ati on techni ques,
cover ed i n Chapter s 4 and 6.
For exampl e, your pati ent has just tol d you how depr essed she
has been, and you fol l ow up:

Deep depr ession sometimes causes people to have str ange


exper iences, such as hear ing voices or feeling that other s ar e
tr ying to har m them. Has that happened to you?
Of cour se, you can use many other symptoms as spr i ngboar ds for
aski ng about psychosi s, i ncl udi ng the fol l owi ng:

Anxi ety: Has your anxi ety gotten to the poi nt wher e your
i magi nati on i s wor ki ng i n over dr i ve, so that you hear voi ces or
thi nk peopl e ar e tr yi ng to har m you?
Substance abuse: Have these dr ugs ever caused your mi nd to
pl ay tr i cks on you, such as?
Dementi a: When you mi spl ace thi ngs ar ound the house, do you
ever suspect that someone's been steal i ng them?

PROBING QUESTIONS: HOW TO DIAGNOSE


SCHIZOPHRENIA
Ther e i s both good news and bad news about di agnosi ng
schi zophr eni a. The good news i s that i t i s fai r l y easy; the bad news
i s that we have made i t seem compl i cated by cr eati ng a pl ethora of
col or ful , though confusi ng, ter ms for descr i bi ng psychosi s. To
i l l ustrate, her e i s a par ti al l i st of ter ms i n cur r ent use:

Tangenti al i ty
Ci r cumstanti al i ty
Di stracti bi l i ty
Derai l ment
Looseness of associ ati ons (LOAs)
Di sjoi nted speech
F l i ght of i deas
Pr essur e of speech
Raci ng thoughts
Wor d sal ad
Incoher ence
Loss of goal
Il l ogi cal thi nki ng
Rambl i ng
Thought bl ocki ng

Pover ty of speech
Pover ty of thought
Pover ty of content
Non sequi tur s
Per severati on
Cl angi ng
Neol ogi sm
Paraphasi as
Echol al i a
Sti l ted speech
Sel f-r efer ence
Per secutor y (paranoi d) del usi ons
Del usi on of jeal ousy
Er otomani a
Del usi on of contr ol
Del usi on of gui l t or si n
Del usi on of grandi osi ty
Del usi on of mi nd r eadi ng
Ideas of r efer ence
Del usi on of r epl acement
Ni hi l i sti c del usi on
Somati c del usi on
Thought br oadcasti ng
Thought i nser ti on
Thought wi thdrawal
Magi cal thi nki ng
Poor r eal i ty testi ng
Attendi ng to i nter nal sti mul i
To begi n to si mpl i fy thi s semanti c onsl aught, i t's hel pful to r evi ew
the basi c cr i ter i a for schi zophr eni a.

SCHIZOPHRENIA
The DSM-IV-TR cr i ter i a for schi zophr eni a ar e l i sted i n Tabl e 26.1.

Delusions (Disorders of Thought Content)


A common and useful di sti ncti on i s made between TC and TP. Both
TC and TP can be i mpai r ed i n psychosi s. Impair ed TP i s cover ed
under the speech di sor gani z ati on cr i ter i on for schi zophr eni a l ater i n
thi s chapter. Impai r ed TC r efer s to del usi onal thi nki ng. A delusion i s
a bel i ef about the wor l d that most peopl e

woul d agr ee i s i mpossi bl e. Most del usi ons fi t i nto two br oad
categor i es: paranoi d del usi ons and grandi ose del usi ons.

TABLE 26.1. DSM-IV-TR criteria for


schizophrenia

Requires two symptoms for 1 month, plus 5


months of prodromal or residual symptoms.
Mnemonic: Delusions Herald Schizophrenic's
Bad News
Delusions
Hallucinations
Speech disorganization
Behavior disorganization
Negative symptoms

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

Paranoid Delusions
Accor di ng to a Wor l d Heal th Or gani z ati on study of 811 i ndi vi dual s
wi th schi zophr eni a wor l dwi de (McKenna 1994), paranoi a was the
most common si ngl e del usi on, affecti ng 60% of pati ents. Paranoi d
pati ents bel i eve that peopl e ar e harassi ng them, chasi ng them,
spyi ng on them, spr eadi ng r umor s about them, or tr yi ng to ki l l
them. Lar ge or gani z ati ons ar e fr equentl y thought to be i nvol ved,
such as the F BI, the Central Intel l i gence Agency, or the Mafi a. For
exampl e, a young man bel i eved that hi s wi fe was an under cover F BI
agent deter mi ned to ki l l hi m for havi ng bl own her cover.
A number of subcategor i es of paranoi d del usi ons may or may not be
pr esent i n a par ti cul ar psychoti c pati ent.

Delusions (or Ideas) of Reference


The pati ent havi ng del usi ons of r efer ence bel i eves that casual
events have a speci al (and usual l y danger ous) si gni fi cance i n
r efer ence to her. Thus, stranger s wai ti ng at a subway stop may be
thought to be star i ng at or tal ki ng about her. In i ts mor e sever e
for m, the pati ent may bel i eve that peopl e on the radi o or TV ar e
di scussi ng hi m or speaki ng di r ectl y to hi m.

NOTES
Del usi ons of r efer ence can al so occur as a featur e of grandi ose
del usi ons but ar e most common i n paranoi a. For exampl e, a
woman thought she was bei ng pur sued by a hi t squad. At wor k,
she noted that cowor ker s appear ed to be whi sper i ng thi ngs about
the pl ot agai nst her. Whi l e she was dr i vi ng, she per cei ved an
el aborate system of communi cati on among other car s, i n whi ch
tur n si gnal s and headl i ghts wer e used to i ndi cate her pr eci se
l ocati on to the ki l l er s.

Fol l owi ng ar e questi ons for del usi ons of r efer ence:

Have you noticed that str anger s on the str eet have
been looking at you or talking about you?
Have you felt that people on the r adio or TV wer e
talking about you in their r epor ts, or giving you
special messages?
Do you get any messages fr om books or
newspaper s?

Delusions of Control or Influence


The pati ent wi th del usi ons of contr ol bel i eves he i s bei ng contr ol l ed
by some outsi de for ce. For exampl e, an i mmi grant fr om Lati n
Amer i ca bel i eved he was bei ng for ced to stay i n the Uni ted States
by the Pr esi dent, who he bel i eved was transmi tti ng ensnar i ng rays
thr ough hi s tel evi si on set.

Delusions of Replacement (Capgras


Syndrome)
A del usi on of r epl acement i s a bel i ef that i mpor tant peopl e i n one's
l i fe have been r epl aced by i mpostor s. For exampl e, a woman
bel i eved that her mother had been r epl aced by a stranger who was
i n l eague wi th a fr i nge r el i gi ous gr oup attempti ng to sei ze
possessi on of her home.

Delusions of Jealousy
A del usi on of jeal ousy i s a bel i ef that one's spouse i s unfai thful ,
despi te no suppor ti ng evi dence.

Somatic Delusions
The pati ent havi ng somati c del usi ons bel i eves that she has an
i l l ness or i s bei ng poi soned despi te the absence of medi cal

evi dence. If you suspect somati c del usi ons, you can el i ci t them wi th
these questi ons:

Ar e you wor r ied about your body?


Do you think you have cancer or another ser ious
disease?
Do you suspect that someone has poisoned you?
Has anyone been alter ing your medication?
Is a par ticular per son r esponsible for your physical
symptoms?

NOTES
Many of these questi ons ar e al so appr opr i ate for assessi ng
somati z ati on di sor der, whi ch i s not a psychoti c di sor der.

Somati c del usi ons fr equentl y occur as an associ ated featur e of


depr essi on.

CLINICAL VIGNETTE
A 38-year-ol d mar r i ed woman pr esented to the emer gency r oom
wi th symptoms of anxi ety and depr essi on. In the i nter vi ew, she
sai d she was afrai d that she had HIV i nfecti on and syphi l i s,
despi te several r ecent nor mal bl ood test r esul ts. These fear s
began after an extramar i tal affai r i n whi ch her par tner had not
used a condom. The pati ent began to r umi nate about the
possi bi l i ty that she had contracted a vener eal di sease. She
became convi nced that her enti r e nei ghbor hood knew about i t and
that, because of thi s, she had br ought doom on her fami l y.
These fear s l ed her to consi der over dosi ng on medi cati on as a
sui ci de attempt.

Grandiose Delusions
Often seen dur i ng a mani c epi sode, grandi ose del usi ons entai l the
bel i ef that one has speci al power s and i s accompl i shi ng (or

wi l l accompl i sh) extraor di nar y thi ngs. Two common types of


grandi osi ty exi st: r el i gi ous and technol ogi cal .

Religious Delusions
A r el i gi ous del usi on i s a ver y common type of grandi ose del usi on i n
whi ch the pati ent bel i eves she i s G od-l i ke. In an exampl e of thi s, a
40-year-ol d woman was eval uated i n the emer gency r oom after
havi ng been found standi ng i n the mi ddl e of traffi c hol di ng her
hands hi gh above her head, pal ms faci ng oncomi ng car s. She
expl ai ned thi s behavi or by sayi ng she was the Messi ah and was
heal i ng al l the peopl e i n thei r car s dur i ng r ush hour.
The fol l owi ng questi ons ar e for r el i gi ous del usi ons:
Do you consider your self to be a r eligious per son?
Do you have a special r elationship with G od?
Do you have any special r eligious power s or
abilities?

Technological Delusions
The pati ent wi th technol ogi cal del usi ons bel i eves that he i s
somehow connected to computer s or other el ectr i cal appl i ances,
al l owi ng hi m to exer t i mmense power. For exampl e, a 30-year-ol d
for mer taxi dr i ver descr i bed a busi ness i dea. He pr oposed to
coor di nate l ar ge fl eets of taxi s that woul d be i n busi ness wi th
r estaurants, theater s, and wor kpl aces i n a l ar ge ci ty. Because al l of
these setti ngs had fi nanci al stakes i n peopl e's ar r i vi ng and l eavi ng,
they woul d be happy to pay the pati ent for hi s ser vi ces. I woul dn't
need any staff, he conti nued. I coul d do i t al l mysel f, thr ough the
l i cense pl ates. Hi s i ntenti on was to have a transmi tter i nser ted i nto
hi s brai n that coul d send messages to each cabbi e vi a r ecei ver s i n
the l i cense pl ates. In an effor t to r eal i ty test, i t was poi nted out to
hi m that no such devi ce exi sted. He r esponded, I have i t al r eady,
poi nti ng to what l ooked l i ke a l ar ge pi mpl e on hi s for ehead.

General Interviewing Tips for Asking about


Delusions
Nonjudgmental Questions
The general strategy i n i nter vi ewi ng pati ents you suspect to be
paranoi d i s to por tray your sel f as nonjudgmental . If you come
acr oss as cr i ti cal , you ar e l i kel y to become par t of thei r del usi onal
system.

Has anyone tr eated you badly or annoyed you in


any way that was unusual?
Has anyone been paying par ticular attention to
you, watching you, or talking about you?

Both of these questi ons i mpl y that you want to become the pati ent's
al l y, rather than hi s enemy.
Counterprojective Statements
In some cases, your pati ent may be so paranoi d that he cl ear l y
di str usts you, i ncor porati ng you i nto hi s del usi onal system. A
counter pr ojecti ve statement can wor k wel l her e. In i t, you expl i ci tl y
acknowl edge and sympathi ze wi th your pati ent's pr ojecti on (Havens
1986; see al so Chapter 3).

CLINICAL VIGNETTE

What brought you into the


Interviewer:
hospital?

(Looking suspicious) You would


Patient:
know, wouldn't you?

I don't know. That's why I'm


Interviewer:
asking.

I was forced here for


surveillance. The Secret
Patient: Service is involved. That's all
I'm saying, because I know my
rights.

(Using counterprojective
statement) And then here I
come, looking all official in my
coat and tie, saying I'm a
Interviewer:
psychiatrist. You probably
think I'm part of the Secret
Service too, which would be
understandable.
Patient: Can anyone hear us?

Interviewer: Nope. The door's closed.

Okay, here's what happened.


Patient: (Patient opens up
significantly.)

Techniques for Reality Testing


Real i ty testi ng r efer s to your effor ts to see how str ongl y your
pati ent bel i eves i n hi s del usi on. It hel ps you to deter mi ne the

sever i ty of a psychoti c di sor der and al so wi l l hel p you moni tor the
pati ent's r esponse to tr eatment. Studi es of the natural cour se of
del usi ons have r eveal ed thr ee phases (Sacks 1974):

1. An i ni ti al phase i n whi ch the pati ent i s total l y convi nced of the


bel i ef
2. An i nter medi ate, doubl e-awar eness phase i n whi ch the pati ent
begi ns to questi on the del usi on
3. A nondel usi onal phase

Sensi ti ve questi oni ng wi l l hel p you deter mi ne just whi ch phase your
pati ent i s i n. Rather than l abel i ng her bel i ef as del usi onal , frame
the del usi on i n such a way that i t i s nor mal i zed.

TIP
F rame del usi ons i n ter ms of the pati ent's i magi nati on:

Do you think your imagination has been getting the best of


you?
Has your imagination been wor king in over dr ive?
Have you been imagining things?

Bl ame i t on the mi nd:


Has your mind been playing tr icks on you lately?
Do you think your mind pulled a fast one on you when you
thought that?

Ask about fantasy:

Do you think you might have been fantasiz ing any of this?

Hallucinations
Hal l uci nati ons occur i n appr oxi matel y one-hal f of al l pati ents wi th
schi zophr eni a (F l aum 1995), but they al so commonl y occur i n
depr essi on, bi pol ar di sor der, substance abuse di sor der s, di ssoci ati ve
di sor der s, and dementi a.

Have you had any unusual exper iences lately, such


as hear ing voices when ther e's no one else ar ound?

Once you've establ i shed the pr esence of AHs, ask i n mor e detai l
about the qual i ty and content of the voi ces. Adopti ng an i nter ested
and cur i ous atti tude often hel ps br eak the pati ent's guar d.

I've never hear d voices befor e, and I'm cur ious


what it's like for you. Tell me mor e about these
voices. Is ther e one voice or mor e than one? Is it
male or female? If I wer e to put a micr ophone to
the voices, what exactly would I hear ?

Ask speci fi cal l y i f the pati ent i s hear i ng command hal l uci nati ons.

Ar e the voices telling you to do anything?


Ar e they saying bad things about you, or telling
you to hur t your self or anyone else?

Another way to ask about hal l uci nati ons i s to ask i n the context of
your questi ons about depr essi on.

Sometimes when people get ver y depr essed, their


mind plays tr icks on them, and they think they
hear things that other s can't hear . Has that
happened to you?

Thi s di mi ni shes the embar rassi ng natur e of a posi ti ve r esponse by


nor mal i z i ng the exper i ence (see Chapter 4).

Have you hear d, seen, smelled, or felt things that


other people couldn't?

Her e, you ar e aski ng about al l the major types of hal l uci nati ons i n
one fel l swoop: audi tor y, vi sual , ol factor y, and tacti l e.

Disorganized Speech
What the DSM-IV-TR ter ms disor ganiz ed speech i s al so known as
disor der of thought pr ocess or for mal thought disor der, because
ther e i s a di sor der of the for m, rather than the content, of thought.
To under stand how to r ecogni ze a di sor der of TP, consi der your own
thi nki ng styl e. When you thi nk or tal k about somethi ng, you do so
i n a l i near and l ogi cal waythat i s, one thought l eads natural l y to
another. In addi ti on, you nor mal l y thi nk your thoughts at a
comfor tabl e speed, so that when you ar e speaki ng, other peopl e can
under stand you. Pati ents wi th a for mal thought di sor der do not
make sense, because thei r thi nki ng i s nei ther l i near nor l ogi cal , and
ther e i s often a di sor der i n the speed of thei r thoughts.

Al l of the jar gon concer ni ng di sor gani zed speech can be fi t i nto one
of two cl uster s: the LOA cl uster and the vel oci ty cl uster.

Looseness of Association Cluster


LOA r efer s to a veer i ng off fr om the subject at hand. Ther e i s a
range of sever i ty of LOA, fr om ci r cumstanti al i ty at one end to wor d
sal ad at the other. A pati ent who exhi bi ts any one of these qual i ti es
to a si gni fi cant degr ee ful fi l l s the di sor gani zed speech cr i ter i a for
schi zophr eni a.
Al though a number of ter ms descr i be di ffer ent degr ees of LOA, the
most useful thi ng to do cl i ni cal l y i s to document that the pati ent
exhi bi ts LOA; descr i be i t as mi l d, moderate, or sever e; and gi ve a
br i ef exampl e (ver bati m fr om the i nter vi ew) i n the wr i te-up. Thi s
al l ows you to track the pati ent's r esponse to tr eatment and enabl es
other cl i ni ci ans who r ead your notes to compar e thei r obser vati ons
wi th your s.

Circumstantiality
The pati ent wi th a ci r cumstanti al thi nki ng styl e makes many
di gr essi ons i n her speech and adds extraneous detai l s. These
di gr essi ons ar e usual l y r el ated, however di stantl y, to the subject
matter at hand, and after a whi l e, the speaker wi l l r etur n to that
subject matter. You'l l r ecogni ze a ci r cumstanti al styl e because you
wi l l feel i mpati ent and wi l l be for ced to i nter r upt often and r edi r ect
to fi ni sh the i nter vi ew wi thi n a r easonabl e per i od.
Ci r cumstanti al i ty i s not necessar i l y pathol ogi c. Nonpati ents who ar e
ci r cumstanti al ar e popul ar l y ter med long-winded. Col l ege l ectur er s
and gr eat stor ytel l er s ar e famous for ci r cumstanti al i ty. Wi thi n the
r eal m of the DSM-IV-TR, demented or anxi ous pati ents often
pr esent wi th ci r cumstanti al styl e.

Tangentiality
Wher eas ci r cumstanti al speech i s basi cal l y under standabl e, though
tedi ous, tangenti al speech begi ns to appr oach i ncoher ence.
Di gr essi ons ar e mor e abr upt and l ess obvi ousl y r el evant to the
subject at hand. Unl i ke the ci r cumstanti al pati ent, the tangenti al
pati ent wi l l never r etur n to the topi c of your questi on, no matter
how l ong you wai t. Thi s usual l y i ndi cates ei ther psychosi s or
dementi a.

Example

Have you ever been hospitalized


Interviewer:
before?

I went into the hospital in 1992


and again in 1993. I'm a
wanderer, and where people tell
me to go, there I will go. Last
night I wandered into the room
Patient: at the end of the hall here and
there were some flies buzzing
around. I told the nurse about it
but she didn't see that as her
job, so I swatted them. Do you
have any control over the
hygienic circumstances here?

Her e, the pati ent has veer ed fr om the subject of her PPH to that of
fl i es i n the uni t. However, she i s basi cal l y coher ent and wi th
fr equent r edi r ecti on wi l l be abl e to gi ve meani ngful hi stor i cal
i nfor mati on.

Related Term
Rambling: the same as tangenti al i ty, but i t i s cl assi cal l y r eser ved
for descr i bi ng demented pati ents.

Looseness of Association
LOA i s a mor e sever e ver si on of tangenti al i ty. The pati ent makes
statements that l ead to other statements i n a ver y l oose way, so
that the associ ati ve l eaps ar e uncl ear. Ther e ar e cl ear l y associ ati ons
goi ng on somewher e i n your pati ent's mi nd, but you can't make
them out.

Example

What brings you into the clinic


Interviewer:
today?

I don't know. I might be thrown


out. Benito Mussolini actually
came alive out in the waiting
room. I figured it out. There was
a picture in a book. If it's not
my mother, it could have been
Hitler. What if that was one of
Patient:
his armed guards. Mussolini was
hanging from a tree! Thank you
for letting me reason it out. Oh,
that's another thing that I
wanted to talk to you about
being brainwashed. I didn't buy
the Beatles tape, I never did.

The pati ent i s fol l owi ng some pr etty di sjoi nted associ ati ons i n hi s
brai n, and i t i s unl i kel y that you wi l l be abl e to obtai n a meani ngful
hi stor y. However, the sentences ar e grammati cal l y cor r ect and
i nter nal l y coher ent.

Related Terms

Der ailment: equi val ent ter m.

Disjointed speech: equi val ent ter m.


Loss of goal: r efer s to speech that doesn't l ead to any par ti cul ar
poi nt and that doesn't come cl ose to answer i ng your questi on;
the cause i s general l y LOA.
F light of ideas: r efer s to LOA when thoughts ar e movi ng rapi dl y.
Racing thoughts: r efer s to coher ent thoughts that ar e movi ng
rapi dl y.

Word Salad
Wor d sal ad i s an extr eme ver si on of LOA, i n whi ch the changes i n
topi c ar e so extr eme and the associ ati ons so l oose that the r esul ti ng
speech i s compl etel y i ncoher ent. It di ffer s fr om LOA i n that the
di gr essi ons occur wi thi n a par ti cul ar sentence, between wor ds, i n
addi ti on to between sentences.

Example
How did you end up at the
Interviewer:
hospital?

It was a section 8 day. I'm not


saying there's a utilitarian. I just
Patient:
had no patience with the curfew
system.

Why did you go to the halfway


Interviewer:
house?

I'm helpless as a savant idiot.


Patient: There was a circulation of their
publicity. Would you like it?

Interviewer: What kind of work did you do?

I worked in computer
electricities. It was a nondilated
Patient:
baccalaureate. I mean a
nondiluted baccalaureate.

In thi s case, i ndi vi dual sentences make no sense. You feel al most as
though your pati ent i s speaki ng a di ffer ent l anguage.

Related Terms

Incoher ence: the di r ect consequence of wor d sal ad.


Non sequitur s: out-of-context wor ds pl aced i nto sentences.
Neologisms: spontaneousl y made up wor ds that often accompany
wor d sal ad; nondi l uted baccal aur eate i s an exampl e.
Cl ang associ ati ons: associ ati ons based on the sounds of wor ds.
Velocity Cluster
In addi ti on to an i mpai r ed abi l i ty to associ ate one thought wi th
another, psychoti c pati ents often show an abnor mal i ty

i n the speed or rate of pr oducti on of thei r thoughts. Thi s ranges


fr om mutism at one end of the conti nuum to flight of ideas at the
other.

Mutism
A pati ent exhi bi ti ng mutism si mpl y wi l l not speak. Thi s may mean
that he i s havi ng few, i f any, thoughts, whi ch can occur as a
negati ve symptom of schi zophr eni a. It can occur i n the catatoni a of
affecti ve di sor der s. Muti sm may al so be a r esponse to a del usi onal
system.

Example
A young woman who was admi tted to a psychi atr i c uni t r emai ned
mute for several days unti l she began r espondi ng to anti psychoti c
medi cati on. She l ater r el ated that she had been tol d by G od that
her absol ute si l ence was the onl y thi ng pr eventi ng the col l i si on of
matter wi th anti matter and the consequent anni hi l ati on of the
wor l d.

Poverty of Thought
Your pati ent has pover ty of thought i f he offer s ver y l i ttl e
spontaneous speech and i f hi s answer s to questi ons ar e wi th the
mi ni mum number of wor ds r equi r ed. You have to di sti ngui sh thi s
type of psychoti c pati ent fr om the angr y and r esi stant pati ent who
i s admi tted i nvol untar i l y to a hospi tal uni t or who i s under cour t
or der to seek therapy. The psychoti c pati ent wi l l often show other
negati ve symptoms of schi zophr eni a, such as poor hygi ene, fl at
affect, or a hi stor y of soci al i sol ati on.

Example (from Andreasen 1979)

Were you working at all before


Interviewer:
you came to the hospital?
Patient: No.

What kinds of jobs have you had


Interviewer:
in the past?

Patient: Oh, some janitor jobs, painting.

Interviewer: What kind of work do you do?

I don't. I don't do any kind of


Patient:
work. That's silly.

Interviewer: How far did you go in school?

Patient: I'm still in eleventh grade.

Interviewer: How old are you?

Patient: Eighteen.

Related Terms

Pover ty of speech: equi val ent ter m.


Lack of spontaneous speech: equi val ent ter m.
Thought blocking: Your pati ent begi ns to say somethi ng, then
stops i n mi dthought and for gets what he was goi ng to say.

Interviewing Strategies
You wi l l r ecogni ze pover ty of thought easi l y. You wi l l fi nd your sel f
aski ng questi ons far mor e fr equentl y than usual , because the
pati ent pr ovi des no i nfor mati on beyond a mi ni mal r esponse to each
questi on. It i s often di ffi cul t i n these pati ents to di scover whether
ther e ar e any posi ti ve symptoms of schi zophr eni a, such as del usi ons
or hal l uci nati ons. One way to el i ci t a fl ow of spontaneous speech i s
to ask open-ended and pr ovocati ve questi ons about general topi cs:

Do you think O. J. Simpson was guilty or innocent?


Who was your favor ite teacher in high school?
What kind of per son ar e you?
Do you believe in G od?

Poverty of Content
Your pati ent may pr oduce a copi ous amount of speech but somehow
communi cate ver y l i ttl e i nfor mati on or di scer ni bl e meani ng. Thi s i s
usual l y because the speech i s over l y abstract.

Why do you think it would be


Interviewer: better for you to move out of
your mother's house?

It would be exactly because of


the things we were talking about
before, and which I was talking
to some of the other counselors
about. I think we were talking
about supervised housing and
that would be related to how I
might find another place to live,
away from my mother, and that
would change who I would
Patient: communicate with. Of course my
mother is a person and she
would like to communicate with
me, and I communicate with her
all the time. I think the
difference is that it would be a
different situation and in a
different place. I would have to
talk to my case worker about
moving. I'm sure my mother
wants it, too.

You fi nd your sel f scratchi ng your head. Your questi on hasn't been
answer ed, but not because the pati ent has veer ed away fr om the
topi c of movi ng, as i n LOA. Hi s r esponse has r emai ned on topi c, but
he hasn't sai d anythi ng meani ngful about i t.

Related Term
Per sever ation: Your pati ent tal ks but dwel l s on a si ngl e i dea or
pr eoccupati on over and over. Thi s can be seen i n both OCD and
dementi a, as wel l as i n psychosi s.

Racing Thoughts
Raci ng thoughts r efer s to the subjecti ve sense of one's thoughts
goi ng so fast that they'r e har d to keep track of, whi ch may or may
not be associ ated wi th pr essur ed speech. Some pati ents who ar e not
tal kati ve r epor t havi ng raci ng thoughts, often occur r i ng wi th
anxi ety. Raci ng thoughts al so occur commonl y i n substance-abusi ng
pati ents under goi ng detoxi fi cati on. To ascer tai n the pr esence of
raci ng thoughts, ask:

Ar e you having tr ouble keeping up with your


thoughts?
Ar e your thoughts moving so quickly that you can't
keep up with them?

Related Term
Pr essur ed speech: Thi s i s ver y rapi d speech that i s di ffi cul t to
i nter r upt and i s often l oud and i ntense. When raci ng thoughts ar e
conver ted di r ectl y i nto speech, the r esul t i s pr essur ed speech, and
the di agnosi s i s al most al ways mani a.

Example

How did you come into the


Interviewer:
hospital?

(While pacing back and forth in


her room) I could remember
taking care of business. I felt
like I was here, there, and
everywhere. I know I was not
sick, because a sick human
cannot remember everything
Patient:
there is to remember, like that
(she snaps her fingers), and I
could, and do you know why?
Ask the Master, the Master is
everywhere, the Master knows
everything, the Master is God,
and that's why I'm still here.

Flight of Ideas
F light of ideas i s a speci al case of LOA when the i ncoher ent
associ ati ons occur ver y rapi dl y. As such, i t i s not necessar i l y
equi val ent to ei ther pr essur ed speech, whi ch can r efer to qui te
coher ent but rapi d speech, or r acing thoughts, whi ch can al so be
coher ent.

Disorder of Behavior (Disorganized Behavior)


Di sor gani zed behavi or i s di agnosed pr i mar i l y by obser vati on dur i ng
the i nter vi ew, al though obtai ni ng i nfor mati on fr om outsi de sour ces
i s often hel pful . Obser vati onal cl ues i ncl ude poor gr oomi ng, body
odor, and bi z ar r e cl othi ng combi nati ons. Another cl ue can be
obtai ned by aski ng your pati ent to compl ete a si mpl e task. Thi s can
be done i n the context of the cogni ti ve exami nati on (see Chapter
20) or si mpl y by aski ng your pati ent for hi s i nsurance or
appoi ntment car d. A typi cal l y di sor gani zed pati ent wi l l pul l out a
tor n, bul gi ng pur se or wal l et and wi l l r ummage thr ough a seemi ngl y
random ar ray of mater i al befor e fi ndi ng anythi ng.

Paucity of Thought, Affect, and Behavior


(Negativism)
Symptoms of schi zophr eni a have been cl assi cal l y di vi ded i nto
positive symptoms (e.g., del usi ons, hal l uci nati ons) and negative
symptoms (e.g., fl at affect, apathy, asoci al i ty, pover ty of speech)
(Andr easen 1982). The pati ent wi th negati ve symptoms wi l l tend to
say ver y l i ttl e, speak sl owl y, show ver y l i ttl e affect, have few
spontaneous movements, and be poor l y gr oomed. Hi s soci al hi stor y
wi l l r efl ect l ack of moti vati on and i nabi l i ty to per si st i n school or
wor k acti vi ti es. Fami l y member s may r epor t that he spends most of
hi s ti me si tti ng ar ound, doi ng l i ttl e and that he has few, i f any,
fr i ends.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 7 - As s e s s ing De m e nt ia a nd De lirium

27
Assessing Dementia and Delirium

Screening Questions

Or i entati on
What's your ful l name?
Wher e ar e we r i ght now?
What's today's date?
Shor t-ter m memor y
Repeat these thr ee wor ds: bal l , chai r, pur pl e. Keep them i n
mi nd, because I'm goi ng to ask you to r epeat them i n a
coupl e of mi nutes.
Per sonal and general i nfor mati on
Name the l ast thr ee pr esi dents.
Who was G eor ge Washi ngton? Abraham Li ncol n? Mar ti n
Luther Ki ng, Jr.? Shakespear e?
When was Wor l d War II? When was John F. Kennedy
assassi nated?
What's your addr ess and phone number ?
What ar e your spouse's/chi l dr en's/si bl i ngs'/par ents' names
and bi r thdays?
When and wher e wer e you mar r i ed?

In Chapter 20, I outl i ne a rapi d cogni ti ve exami nati on wi th


components based on studi es showi ng them to be effecti ve i n
i denti fyi ng pati ents wi th cogni ti ve defi ci ts. In thi s chapter, I show
you how to tai l or your questi ons to the pati ent who may have ei ther
del i r i um or dementi a. In delir ium, attenti on i s i mpai r ed, and al l of
the cogni ti ve pr ocesses ar e ther efor e al so i mpai r ed. In dementia,
attenti on i s i ntact, but the cogni ti ve pr ocesses, par ti cul ar l y
memor y, ar e i mpai r ed.
Wi th thi s i n mi nd, l et's l ook at the DSM-IV-TR cr i ter i a for both
dementi a and del i r i um and then r evi ew i nter vi ew techni ques for
maki ng the di agnoses.

DELIRIUM
Impaired Attention
The key to di agnosi ng del i r i um i s establ i shi ng an i mpai r ment i n
your pati ent's attenti on, whi ch i s what the DSM-IV-TR means by
di stur bance of consci ousness (Tabl e 27.1). A del i r i ous pati ent has
di ffi cul ty sustai ni ng hi s attenti on for a si gni fi cant per i od. As i n
Chapter 20, I di scourage r el i ance on tradi ti onal and unpr oved tests
of attenti on, such as the SSST, and i nstead encourage you to r el y
on your pati ent's abi l i ty to r espond to r outi ne questi ons.
Most of your i nter vi ews wi th del i r i ous pati ents wi l l occur i n a
hospi tal setti ng, often when you have been asked to see the pati ent
by the pr i mar y car e physi ci an. In such setti ngs, ther e ar e two types
of del i r i ous pati ents: the l oud and the qui et. The l oud del i r i ous
pati ent wi l l typi cal l y be rambl i ng i ncoher entl y and may be
str uggl i ng agai nst r estrai nts i n an effor t to l eave the hospi tal bed or
to pul l out i ntravenous l i nes.
The qui et del i r i ous pati ent, on the other hand, r equi r es some ver bal
pr obi ng to make a di agnosi s. It's often hel pful to begi n by sayi ng
nothi ngthat i s, by wal ki ng i nto the r oom and obser vi ng your
pati ent's behavi or. A per son wi th nor mal cogni ti ve abi l i ti es wi l l
general l y l ook at you and

make some ki nd of gr eeti ng, then wai t for you to r espond. A


del i r i ous pati ent may gl ance at you br i efl y and then pay l i ttl e
attenti on to you. He may be tal ki ng softl y to hi msel f. He may be
l ooki ng al l ar ound the r oom, tracki ng a hal l uci nated bi r d or i nsect.

TABLE 27.1. DSM-IV-TR criteria for delirium

(Note: The DSM-IV-TR specifies a number of


different types of delirium, but the core
diagnostic criteria as listed below do not
change.)
Disturbance of consciousness (i.e., reduced
clarity of awareness of the environment) with
reduced ability to focus, sustain, or shift
attention
A change in cognition (e.g., memory deficit,
disorientation, language disturbance) or the
development of a perceptual disturbance that
is not better accounted for by a preexisting
dementia
A disturbance developing over a short period
(usually hours to days) and fluctuating during
the course of the day
Mnemonic: Medical FRAT
Medical cause
Fluctuating course
Recent onset
Attentional impairment
Thinking impairment

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

Hello, Mr . Br own. What br ings you into the


hospital?

The pati ent shoul d be abl e to answer coher entl y. If the pati ent
answer s i ncoher entl y, you have to assess the natur e of the
i ncoher ence. In many mental di sor der s, the pati ent's attenti on i s
nor mal , but the TP or TC i s di sor der ed i n some way.
Of the fol l owi ng thr ee cl i ni cal vi gnettes, for exampl e, onl y the thi r d
descr i bes tr ue del i r i um.

CLINICAL VIGNETTE 1
A hospi tal i zed psychoti c pati ent gave me thi s answer :

I got tr icked into this, but I won't complain,


because exactly at this moment ther e ar e
ster eoscopic beams coming into this r oom fr om
tr ansmitter s, and they ar e focused on my br ain
cells. Please stay still, because the beams ar e
coming ar ound you now.

On fur ther questi oni ng, i t was appar ent that the pati ent was
suffer i ng a fi xed, bi z ar r e, paranoi d del usi on, but hi s attenti on was
qui te i ntact.

CLINICAL VIGNETTE 2
Another pati ent r esponded wi th the fol l owi ng:

This is no hospital, this is my home, because I


can see my gr anddaughter out ther e. She was
just about to br ing me in some tea. Oh, I know
you. You'r e that man they sent in to help me.

The pati ent had a pr ofound i mpai r ment of shor t-ter m memor y,
secondar y to Al z hei mer 's dementi a. She coul d not r emember that
she was i n a hospi tal , but her attenti on was i ntact.

CLINICAL VIGNETTE 3
A tr ul y del i r i ous pati ent r esponded:

Hello! (He looked up at the ceiling.) Something


what is that? (He was quickly oblivious to my
pr esence. I asked again why he was in the
hospital.) I'm in the hospital for (He looked
confused.) Ther e's something her e in the
hospital, my son said(He looked at me again as
if scr utiniz ing me, then tur ned away, again
seeming to for get about my pr esence as he
looked at the ceiling.)

The pati ent seemed to under stand my wor ds, but he had no abi l i ty
to mai ntai n hi s attenti on to me or to conti nue a si ngl e trai n of
thought. As i t tur ned out, the pati ent was i n del i r i um tr emens
after havi ng abr uptl y stopped hi s pr escr i bed al prazol am (Xanax) 3
days ear l i er.

Change in Cognition
Al most al l del i r i ous pati ents wi l l have gr eat di ffi cul ty wi th the
thr ee-object r ecal l task, as thei r attenti on i s too i mpai r ed to
r egi ster the wor ds i n the fi r st pl ace. Vi sual or audi tor y
hal l uci nati ons ar e al so extr emel y common.

Recent Onset and Fluctuating Course


You have to r el y on gather i ng hi stor y fr om sour ces other than the
pati ent to ascer tai n that the onset of the cogni ti ve i mpai r ment has
been r el ati vel y r ecent (days to weeks), excl udi ng the di agnosi s of
dementi a. Wi th r egar d to fl uctuati ons i n attenti on, the best way for
you to deter mi ne thi s i s to exami ne the pati ent at l east twi ce dur i ng
the day. If you can't see the pati ent agai n, ask other car egi ver s to
r epor t whether she was abl e to coher entl y answer si mpl e questi ons
(e.g., Why ar e you her e?).

DEMENTIA
Interviewing Family Members
Inter vi ews wi th fami l y member s and other i nfor mants ar e vi tal l y
i mpor tant i n maki ng the di agnosi s of dementi a (Tabl e 27.2).

Thi s i s because the pati ent hi msel f wi l l often deny or mi ni mi ze hi s


memor y pr obl em and, at any rate, a demented pati ent's sel f-
r epor ted hi stor y wi l l be unr el i abl e. Ther efor e, the best way to
di agnose dementi a i s by combi ni ng the MSE wi th i nter vi ews of
i nfor mants. In fact, studi es that have compar ed the two appr oaches
(the MSE vs. i nfor mant questi onnai r es) have found i nfor mant
i nter vi ews to be the mor e sensi ti ve of the two (Har wood 1997).

TABLE 27.2. DSM-IV-TR criteria for


dementia

(Note: The DSM-IV-TR specifies a number of


different types of dementia, but the core
diagnostic criteria as listed below do not
change.)
Mnemonic: Memory BREW
Memory impairment (required)
Behavior disorganization (i.e., apraxia)
Recognition impairment (i.e., agnosia)
Executive functioning impairment
Word problems (i.e., aphasia)
At least one of the BREW criteria is required.

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

When you i nter vi ew fami l y member s, you shoul d begi n by aski ng


them to compar e the pati ent's cur r ent cogni ti ve abi l i ti es wi th the
pati ent's abi l i ti es of 10 year s ago. Thi s wi l l put the focus on a
gradual decl i ne i n functi oni ng, whi ch i s what di ffer enti ates dementi a
fr om del i r i um.
The general for m of your questi oni ng shoul d fol l ow the for mat of
the Infor mant Questi onnai r e on Cogni ti ve Decl i ne i n the El der l y
(IQCODE; Jor m 1991), fr om whi ch most of the fol l owi ng questi ons
ar e der i ved. Ask the fol l owi ng questi ons:
Compar ed with 10 year s ago, how is this per son at

Remember i ng thi ngs that have happened r ecentl y?


Remember i ng wher e thi ngs ar e usual l y kept?
Remember i ng thi ngs about fami l y and fr i ends, such as names,
occupati ons, bi r thdays, or addr esses?
Maki ng deci si ons on ever yday matter s?
Handl i ng fi nanci al matter s?
F i ndi ng the r i ght wor d when tal ki ng about thi ngs?
Knowi ng how to do ever yday thi ngs ar ound the house, such as
cooki ng and cl eani ng?

Interviewing the Patient


I suggested an appr oach to assessi ng memor y i n Chapter 20, whi ch
I won't r epeat her e. Remember that befor e you go too far i n your
exami nati on, do your basi c del i r i um scr een (see above). If the
pati ent i s del i r i ous, you won't be abl e to concl ude anythi ng about
dementi a based on the exami nati on; i f the pati ent i s awake and
attenti ve, pr oceed wi th the r est of the cogni ti ve exami nati on as
outl i ned i n Chapter 20.
In addi ti on to demonstrati ng a memor y i mpai r ment, the DSM-IV-TR
r equi r es that you di agnose at l east one of the fol l owi ng speci fi c
cogni ti ve i mpai r ments (r emember the BREW mnemoni c):

Behavi or di sor gani z ati on (apraxi a): Behavior disor ganiz ation i s
defi ned as di ffi cul ty accompl i shi ng si mpl e, ever yday acti vi ti es
despi te an i ntact ner vous system. Thi nk of i t as a ki nd of
behavi oral confusi on. Apraxi c pati ents may have di ffi cul ty
getti ng dr essed i n the mor ni ng because they have for gotten how
to button cl othes or ti e shoes. The best way to deter mi ne i f thi s
has been a pr obl em i s by aski ng fami l y member s questi ons such
as

Does your father have pr oblems getting dr essed


on his own?
Does he need any help with shaving or putting
on a tie?
Can he thr ow a sandwich together easily?

You can someti mes assess apraxi a dur i ng the i nter vi ew by


obser vi ng your pati ent doi ng somethi ng (e.g., pul l i ng her
hospi tal r egi strati on car d fr om her wal l et), or you can ask the
pati ent to wr i te down your offi ce phone number and obser ve her
abi l i ty to pr ocur e a pi ece of paper and pen and cor r ectl y wr i te
down the number.
The Fol stei n MMSE i ncl udes a standar d thr ee-step command for
assessi ng apraxi a:

Now I want to see how well you can follow


instr uctions. I'm going to give you a piece of
paper . Take it in your r ight hand, use both
hands to fold it in half, then put it on the floor .

Recogni ti on i mpai r ment (agnosi a): Thi s r efer s to the i nabi l i ty to


r ecogni ze fami l i ar objects or peopl e. Agnosi a for objects i s har d
to di sti ngui sh fr om wor d-fi ndi ng pr obl ems. If you have i denti fi ed
somethi ng that the pati ent

cannot name, you can ask hi m what the object i s used for. If
ther e i s no agnosi a, he wi l l be abl e to tel l you. (For exampl e, he
may not be abl e to name a pen but wi l l tel l you that i t's
somethi ng used for wr i ti ng.) Agnosi a for peopl e i s a si gn of
r el ati vel y sever e dementi a, and i t's best to get thi s i nfor mati on
fr om fami l y member s.
Executi ve functi oni ng i mpai r ment: Her e, you ar e testi ng a
compl ex abi l i tythe abi l i ty to pl an and thi nk abstractl y. A defi ci t
i n executi ve functi oni ng wi l l often come thr ough dur i ng the
hi stor y. Thi s i s especi al l y tr ue i f the pati ent was empl oyed as the
dementi a began. You wi l l hear about job di ffi cul ti es,
i neffi ci enci es accompl i shi ng tasks that wer e once easy, and the
l i ke. Occasi onal l y, i t may be di ffi cul t to di sti ngui sh thi s fr om the
per sonal i ty changes that occur i n dementi a. New-onset
i ndi ffer ence and i r r i tabi l i ty can pl ay havoc wi th job per for mance,
especi al l y i n ser vi ce-or i ented jobs.
To test executi ve functi oni ng, you can use the thr ee-step
command (descr i bed ear l i er ). However, the cl assi c scr eeni ng test
for thi s i s the clock-dr awing task, i n whi ch you gi ve the pati ent a
sheet of paper wi th a ci r cl e and a dot i n the center, and tel l her

I'd like you to wr ite in all the number s of a


clock and then to dr aw in the hands to
r epr esent 2:30.

Demented pati ents may exhi bi t a number of di ffer ent er r or s,


such as bunchi ng number s too cl osel y together, ski ppi ng or
r epeati ng number s, or drawi ng the hands i ncor r ectl y. One
potenti al pr obl em wi th thi s task i s that per for mance var i es by
educati on (Ai nsl i e 1993). Thus, you shoul d gi ve i t onl y to
pati ents wi th at l east some hi gh school educati on. Other wi se,
you may fal sel y i nter pr et a poor cl ock as meani ng that a pati ent
i s cogni ti vel y i mpai r ed, when i n fact he i s mer el y poor l y
educated.
In Chapter 20, I descr i bed a newl y val i dated scr een for dementi a
(the Mi ni -Cog) that uses the cl ock-drawi ng task as one of i ts
components; I suggest you r evi ew the use of thi s now, as i t wi l l
l i kel y become a ver y common test.
W or d pr obl ems (aphasi a): The most common l anguage pr obl em
i n dementi a i s a di ffi cul ty fi ndi ng the r i ght wor d for somethi ng.
If pr esent, wor d-fi ndi ng di ffi cul ty wi l l have become appar ent
over the cour se of the i nter vi ew. In mi l d cases, the r i ght wor d
seems to be on the ti p of the pati ent's tongue:

Interviewer: Who was George Washington?

Oh, he was that man, the uh


Patient:
top man of the whole thing.

What do you mean by the


Interviewer:
top man?

The whole country voted for


Patient: him.
Interviewer: Do you mean the president?

Patient: Right! The president!

Of cour se, i t may be har d to di sti ngui sh wor d-fi ndi ng di ffi cul ti es
fr om memor y i mpai r ment. A speci fi c scr eeni ng test for aphasi a i s
to poi nt out common objects i n the r oom and ask your pati ent to
name them (e.g., your pen, your watch, or a chai r ). However,
doi ng so wi l l onl y pi ck up sever e cases of aphasi a. Inter vi ewi ng
i nfor mants i s often an excel l ent way to pi ck up an ear l y aphasi a.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 8 - As s e s s ing Ea t ing Dis o rde rs a nd So m a t iz a t io n Dis o rde r

28
Assessing Eating Disorders and
Somatization Disorder

Screening Questions

Eati ng di sor der s: Have you ever thought you wer e over wei ght?
Somati z ati on di sor der : Have you had a l ot of unexpl ai ned
i l l nesses?

EATING DISORDERS
KEY POINT
Eati ng di sor der s ar e r el ati vel y easi l y di agnosed (Tabl es 28.1 and
28.2). The pr obl em i s that many cl i ni ci ans don't ask about them,
and many suffer er s don't vol unteer thei r symptoms, ei ther
because they ar en't bother ed by them, as i n anor exi a, or because
they'r e too ashamed of them, as i n bul i mi a. F ur ther mor e,
cl i ni ci ans rar el y ask men about eati ng di sor der s, even though
studi es have esti mated that 10% to 15% of al l pati ents wi th
eati ng di sor der s ar e men, wi th an especi al l y hi gh pr eval ence i n
gay men (Car l at et al . 1997). Ther efor e, scr eeni ng questi ons for
eati ng di sor der s shoul d al ways be i ncl uded i n your PROS.

When ti me i s tr ul y of the essence, you can begi n wi th a di r ect


questi on:

Have you ever had an eating disor der , such as


anor exia or bulimia?
However, i f you have the sense that your pati ent may be
par ti cul ar l y ashamed of a suspected eati ng di sor der, a too bl unt
appr oach mi ght endanger the therapeuti c al l i ance. In these cases,
you can appr oach the i ssue mor e i ndi r ectl y:

Have you ever thought you wer e over weight?

TABLE 28.1. DSM-IV-TR criteria for anorexia


nervosa

Mnemonic: Weight Fear Bothers Anorexics


Refusal to maintain body Weight above 85%
of expected weight
Intense Fear of gaining weight or becoming
fat
Distorted Body image
For women: Amenorrhea (the absence of at
least three menstrual cycles)

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

If the answer i s no, i t i s unl i kel y that your pati ent has an eati ng
di sor der. If the r epl y i s yes, conti nue.

Have you ever dieted?

Al most ever yone, and women i n par ti cul ar, has di eted at some
poi nt. You'r e pr obi ng her e for a par ti cul ar l y sever e di et, per haps a
star vati on di et (i .e., fasti ng) or a di et i n whi ch, for exampl e, the
pati ent ate onl y sal ad or fr ui t.

Have you ever weighed much less than people


thought you should weigh? What was your lowest
weight?

You want to deter mi ne whether i t i s l i kel y that your pati ent wei ghs
l ess than 85% of hi s i deal body wei ght (IBW). Refer to the wei ght
tabl es i n Appendi x A for gui del i nes.

Did you think you wer e over weight at your lowest


weight?

Anor exi c pati ents wi l l r epor t feel i ng over wei ght, even obese, at a
wei ght that i s far bel ow IBW. Often, the pati ent wi l l fi xate on a
par ti cul ar body par t, such as the thi ghs or the stomach.

Wer e you afr aid of gaining weight?


(F or women only.) Dur ing the time when you wer e
under weight, wer e you having r egular per iods?

TABLE 28.2. DSM-IV-TR criteria for bulimia


nervosa

Mnemonic: Bulimics Over-Consume Pastries


Recurrent episodes of Binge eating (at least
twice a week for 3 months) that feel Out of
control
Excessive Concern with body shape and
weight
Purging behaviors, such as self-induced
vomiting; misuse of laxatives, diuretics,
enemas, or other medications; fasting; or
excessive exercise

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

To meet a di agnosi s of amenor r hea, the pati ent must have mi ssed at
l east thr ee consecuti ve per i ods. Of cour se, amenor r hea has many
other causes, and you shoul d ensur e that the pati ent was eval uated
by a speci al i st to r ul e out pr egnancy or endocr i nol ogi c pr obl ems.
For bul i mi a, ask

Have you ever gone on eating binges, when you've


eaten an unusually lar ge amount of food within a
2-hour per iod and felt that you couldn't contr ol
your eating?

TIP
You have to be somewhat skepti cal of a yes answer, because
what the pati ent consi der s a bi nge may seem l i ke a nor mal meal
to someone el se. Ask your pati ent to descr i be the contents of a
typi cal bi nge and deci de whether i t seems l i ke an unusual l y l ar ge
meal .

If she bi nges, ask i f she has ever pur ged after war d.

After you've binged, have you ever gotten r id of


the food in some way, such as vomiting or taking
laxatives?

Establ i sh the fr equency of the behavi or wi th a symptom


exaggerati on questi on:
At the most, how often wer e you bingeing and
pur ging? Once a day? Twice a day? Mor e?

You have al r eady asked about body i mage i n the anor exi a questi ons.

SOMATIZATION DISORDER
An excel l ent scr eeni ng questi on for somati z ati on di sor der i s

Have you had a lot of unexplained illnesses?

If the pati ent says no, you can avoi d the pr obi ng questi ons. In
tr uth, a pati ent wi th somati z ati on di sor der wi l l have l i kel y hi nted at
the pr obl em when you el i ci ted the HPI, much of whi ch wi l l have
been devoted to somati c pr obl ems. If so, you

can bypass thi s scr eeni ng questi on and move on to a checkl i st of


symptoms. Remember to ask when the symptoms began, because
the DSM-IV-TR speci fi es that they must star t befor e age 30 (Tabl e
28.3).

TABLE 28.3. DSM-IV-TR criteria for


somatization disorder

Mnemonic: Recipe 4 Pain: Convert 2


stomachs to 1 sex.
There is a history of many physical complaints,
beginning before the age of 30.
Each of the following criteria must have been
met:
Four pain symptoms (4 Pain)
Two gastrointestinal symptoms (2 Stomachs)
One sexual symptom (1 Sex)
One pseudoneurologic symptom (Convert)
Each symptom cannot be fully explained by a
known medical condition, or, if there is a
demonstrated medical condition, the
impairment is in excess of what would be
expected.

Adapted from American Psychiatric Association.


(2000). Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. Text revision.
Washington, DC: American Psychiatric
Association.

To expedi te the pr ocess of aski ng about par ti cul ar symptoms, begi n


wi th the fol l owi ng focusi ng comment:

I'm going to ask you about a number of differ ent


physical symptoms. In the inter est of time, I'd like
to hear mainly whether you've exper ienced these
within the last few weeks, r ather than about the
long-ter m histor y of the pr oblem.

Wi thout some statement such as thi s, many pati ents wi l l l aunch i nto
a l engthy hi stor y of each symptom, compl ete wi th i nfor mati on on al l
the physi ci ans they have seen and the var i ous l aborator y tests that
have been conducted. You ar e unl i kel y to have ei ther the ti me or
the exper ti se to ful l y eval uate the adequacy of pr evi ous medi cal
wor kups.

1. Pai n symptoms (must have four )

Please give me a quick r un-down of all the pains


you've had in the differ ent par ts of your body.

2. G astr oi ntesti nal symptoms (must have two, other than pai n)

I want to ask about some stomach symptoms.


Have you had nausea? Vomiting? Bloating or
gas? Diar r hea? Do you get sick when you eat
cer tain foods?

3. Sexual /r epr oducti ve symptoms (must have one, other than pai n)

Have you had any pr oblems with your sexual


life, such as lack of desir e or inability to have
sex for some r eason?
(F or women only.) Have you had ir r egular
per iods or excessive bleeding with your per iods?

4. Pseudoneur ol ogi c (conver si on) symptoms (must have one)

Have you been having any neur ologic


symptoms, such as pr oblems with vision,
hear ing, or balance? Have you exper ienced
weakness or numbness or had seiz ur es?

Note that ther e ar e other somatofor m di sor der s i n the DSM-IV-TR,


and al though somati z ati on di sor der seems to get the most ai r pl ay
i n psychi atr i c jour nal s, other r el ated but l ess dramati c pr obl ems ar e
mor e commonl y seen i n a cl i ni cal practi ce. One of the most common
of these i s l abel ed pain disor der associated with both psychological
factor s and a gener al medical condition. Pati ents wi th thi s di sor der
have a chr oni c pai n pr obl em, usual l y due to a r ecogni zed or gani c
condi ti on, and ar e havi ng a har d ti me deal i ng wi th i t. They ar e
r efer r ed to you by the pr i mar y car e doctor (possi bl y mor e out of
desperati on than the bel i ef that you can r eal l y hel p) and pr esent
wi th a sense of demoral i z ati on caused by chr oni c pai n.
It's i mpor tant not to di smi ss these pati ents as somati ci zer s,
because the pai n i s i n fact or gani c, but at the same ti me, they ar e
suffer i ng fr om a heavy psychol ogi cal over l ay on top of thei r pai n.
Thei r mental angui sh may, i n fact, ratchet up the sever i ty of
per cei ved pai n. Accuratel y di agnosi ng such pati ents has i mpl i cati ons
for the type of tr eatment you wi l l choose.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 2 9 - As s e s s ing At t e nt io n- De fic it Hy pe ra c t iv it y Dis o rde r

29
Assessing Attention-Deficit
Hyperactivity Disorder

Screening Question

When you wer e young, di d you have pr obl ems wi th


hyperacti vi ty or wi th payi ng attenti on i n school ?

ATTENTION-DEFICIT HYPERACTIVITY
DISORDER
Pati ents must meet ei ther cr i ter i on 1 or cr i ter i on 2 (must have si x
of ni ne di sor gani z ati on/i nattenti on symptoms or si x of ni ne
i mpul si vi ty/hyperacti vi ty symptoms) pl us cr i ter i a 3 and 4 (Tabl e
29.1):

1. Or gani z ati on/i nattenti on


Or gani z ati on pr obl ems
Can't or gani ze tasks
Loses thi ngs needed for tasks
Has pr obl ems fi ni shi ng tasks
2. A ttenti on pr obl ems
Poor focus
Easi l y di stracted
Doesn't l i sten
For gets easi l y
Makes car el ess mi stakes
Avoi ds tasks r equi r i ng concentrati on
3. Impul si vi ty/hyperacti vi ty symptoms
Tal ks too much
Bl ur ts out answer s
Inter r upts other s
Can't pl ay qui etl y
Movement excess
F i dgets and squi r ms
Leaves seat
Is r estl ess

TABLE 29.1. DSM-IV-TR criteria for


attention-deficit hyperactivity disorder

Mnemonic: You'll need a MOAT around the


classroom for the hyperactive child.
Movement excess (hyperactivity).
Organization problems (difficulty
finishing tasks).
Attention problems.
Talking impulsively.

Adapted from American Psychiatric


Association. (2000). Diagnostic and
Statistical Manual of Mental Disorders, 4th
ed. Text revision. Washington, DC:
American Psychiatric Association.
Is on the go
Can't wai t for hi s tur n
4. Some symptoms must have been pr esent befor e age 7.
5. Symptoms occur i n two or mor e setti ngs, such as school (or
wor k) and at home.

ADHD i s one of those di sor der s, such as pani c di sor der, that i nvol ve
a l ong l i st of cr i ter i a, maki ng i t i mpracti cal to memor i ze each one.
To make matter s mor e confusi ng, many of the cr i ter i a ar e so si mi l ar
as to be r edundant (e.g., i s ther e r eal l y a di ffer ence between often
fai l s to pay cl ose attenti on and often has di ffi cul ty sustai ni ng
attenti on?). Ther efor e, as was tr ue for pani c di sor der, the most
rati onal appr oach i s to cl ump cr i ter i a i nto meani ngful cl uster s by
usi ng a mnemoni c, i n thi s case MOA T.
To meet the cr i ter i a, your pati ent must have si x of ni ne symptoms
of i nattenti on/di sor gani z ati on or si x of ni ne symptoms of
hyperacti vi ty/i mpul si vi ty.

ATTENTION-DEFICIT HYPERACTIVITY
DISORDER IN CHILDREN
Al though i t may seem counter i ntui ti ve, di agnosi ng ADHD i s
general l y easi er i n chi l dr en than i n adul ts. Thi s i s because chi l dr en
and adol escents come to the appoi ntment wi th an adul t who i s
(hopeful l y) a r el i abl e sour ce of behavi oral i nfor mati on. Al so, one of
the key di ffi cul ti es i n establ i shi ng the di agnosi s i n adul ts i s
documenti ng that symptoms occur r ed as a chi l d; thi s i s a non-i ssue
when you have a l i vi ng, br eathi ng chi l d i n fr ont of you!
For general hi nts on eval uati ng adol escent pati ents, r evi ew Chapter
10. G eneral l y, you'l l begi n your eval uati on wi th fami l y i n the r oom.
The par ents have br ought thei r chi l d to you for an ADHD eval uati on,
so get r i ght down to i t:

So what makes you think Johnny has ADHD?

Par ents wi l l often come bear i ng testi ng r epor ts fr om the school and
wi l l al so often have mi sconcepti ons about how easy (or har d) the
condi ti on i s to di agnose. (We'r e not sur e whether or not Johnny
has ADHD, and we wer e hopi ng you coul d test hi m for i t. Do you do
testi ng her e?)
Now i t's ti me for some basi c psychoeducati on about ADHD. The
di agnosi s i s based on a synthesi s of di ffer ent peopl e's r epor ts and
obser vati ons of the chi l d, and ther e i s no defi ni ti ve test apar t
fr om good i nter vi ewi ng and deducti on.

What we'll do today is talk about Johnny's


behavior , both at home and at school, and based
on that, we'll come up with a good idea of whether
he has ADHD.

The essence of the di agnosi s i s aski ng about al l the DSM-IV-TR


cr i ter i a, and the appr oach that wor ks best for me i s to si mpl y
photocopy the DSM-IV-TR cr i ter i a for the par ents and pati ent to
l ook over, and to go down the l i st, aski ng about each one i n tur n.
You can r ead the cr i ter i a ver bati m, or you can paraphrase i t to
make i t mor e under standabl e, dependi ng on the sophi sti cati on of
your i nfor mants.
For exampl e, for or gani z ati on pr obl ems, you woul d say somethi ng
l i ke

Does Johnny not pay close attention to details, or


does he make car eless mistakes at school or at
home?

For each cr i ter i on, I tr y to establ i sh not onl y that i t happens, but
that i t happens i n two di ffer ent setti ngs, and I al so ask for a
speci fi c exampl e to assess how si gni fi cant the symptom i s. I
r ecommend wr i ti ng al l these exampl es down; l ater, after tr eatment
has begun, i t's ver y hel pful to go thr ough al l these exampl es to
assess how much better thi ngs ar e than befor e you wor ked your
tr eatment magi c!
Once you ar e done, you can say,

Well, it looks like Johnny definitely meets


diagnostic cr iter ia for ADHD, because as you can
see, he has almost all the symptoms listed her e.

Occasi onal l y, you'l l be abl e to obser ve bl atant hyperacti vi ty (12-


year-ol d tear i ng ar ound your offi ce, causi ng damage to the
cher i shed pai nted gi raffe you bought i n Oaxaca), but usual l y not.
Cer tai nl y, i f the pati ent has ADD wi thout the H, i t's ver y har d to
noti ce poor focus i n a hi ghl y char ged and focused setti ng l i ke a
psychi atr i c offi ce.

KEY POINT
As you ask the DSM-IV-TR questi ons, r emember that many
psychi atr i c di sor der s other than ADHD can cause pr obl ems of
i mpul si vi ty or concentrati on, i ncl udi ng substance abuse,
depr essi on, mani a, and anxi ety di sor der s (Bi eder man 1991). If a
chi l d meets onl y a few ADHD cr i ter i a but i s sti l l causi ng the
par ents conni pti on fi ts, move your questi oni ng to these other
di agnosti c categor i es.

ATTENTION-DEFICIT HYPERACTIVITY
DISORDER IN ADULTS
Adul t ADHD has become qui te the rage i n r ecent year s. Some days,
i t seems that ever y other pati ent enter i ng your offi ce ends up
wonder i ng i f they shoul d tr y methyl pheni date (Ri tal i n), whi ch seems
to wor k so wel l for thei r son or daughter.
As I al l uded to above, di agnosi ng ADHD i n adul ts entai l s the speci al
chal l enge of goi ng i nto a ti me machi ne and tr yi ng to establ i sh that
the symptoms began at an ear l y age. If you can't establ i sh
chi l dhood onset, you wi l l end up vastl y over-di agnosi ng ADHD i n
adul ts, wi th the r esul t that a l ot mor e sti mul ant pr escr i pti ons end
up fl oati ng ar ound out ther e than i s good for soci ety.
Begi n wi th some scr eeni ng questi ons:

When you wer e young, did you have pr oblems with


hyper activity or paying attention in school?

If the r esponse i s posi ti ve, ask

Do you still have those sor ts of pr oblems?

If the answer i s negati ve, i t's pr obabl y not wor th your ti me to


conti nue wi th pr obi ng questi ons to ver i fy an ol d di agnosi s of ADHD.
If the answer i s posi ti ve, move on to questi ons establ i shi ng the
di agnosi s. You can whi p out the DSM-IV-TR cr i ter i a as was
r ecommended above, or you can ask questi ons i n a l ess str uctur ed
fashi on, star ti ng fi r st wi th questi ons per tai ni ng to i nattenti veness,
and then movi ng on to questi ons about i mpul si vi ty.

Inattentiveness and Disorganization


Do you have a har d time paying attention to
things?
Do you have tr ouble concentr ating?

Some pati ents fi nd that they ar e abl e to concentrate on engagi ng


tasks, such as watchi ng a footbal l game or r eadi ng a tabl oi d, but not
on tasks that ar e l ess fun, such as wr i ti ng a r epor t at wor k or
studyi ng for school .

Ar e you distr actible?

Because many peopl e wi l l not know what thi s means, you mi ght
need to fol l ow up wi th

Do you know what that means? It means that you


can't listen to the teacher if the guy next to you is
talking or if something's happening outside the
window.
Do you have a har d time finishing things?

Some pati ents may not thi nk of thei r pr obl em as i nattenti veness,
but they do fi nd that they get di stracted i n the mi ddl e of a task and
don't fi ni sh pr ojects. If the pati ent's par ent i s pr esent, ask

Was he the type of kid who, if you said, G o to


your r oom and get your shoes, wouldn't come
back because he got inter ested in something else
and for got about the shoes?

Talking Impulsively and Hyperactivity


Wer e you the class clown?

The typi cal ADHD pati ent wi l l br eak i nto a smi l e and say, Oh yeah,
l et me tel l you and may descr i be some choi ce anti cs. A var i ati on
on thi s questi on i s

When you wer e in class, was the teacher always


having to say to you, Now, Johnny, you need to
stop doing this or that?

Some pati ents wi l l say that they ar e hyperacti ve when what they
mean i s over l y ener geti c, as i n a mani c epi sode, or anxi ous. Ask
your pati ent for hi s defi ni ti on:

What do you mean when you say that you'r e


hyper active?

Pr ovi de your own defi ni ti on, i f necessar y:

By hyper active, I mean a feeling that you can't sit


still, almost as though you had a little motor
r unning inside you all the time that you can't tur n
off.

Other speci fi c questi ons to ask i ncl ude

Do you have a har d time keeping still?


Do you tend to be fidgety?

Al though hyperacti vi ty i n chi l dr en may be obser vabl e dur i ng an


i ni ti al sessi on, i n adol escents and adul ts i t pr esents mor e subtl y.
You may obser ve constant foot-tappi ng or rapi d hand gestur es. The
per sonal i ty styl e wi l l often be character i sti coutgoi ng, chatty, and
l i vel yal though these ar e har dl y di agnosti c of ADHD and ar e
r emi ni scent of mani a.
To ask about i mpul si ve tal ki ng, a good questi on i s

Is it easy for you to sit quietly at meetings or in


class, or do you tend to blur t things out a lot?
Formal Rating Scales and Family Interviews
Inter vi ewi ng a pati ent's par ents (even when the pati ent i s an adul t)
wi l l al ways make an ADHD di agnosi s easi er. Often, the par ent wi l l
say, Oh yes, he was di agnosed wi th ADHD i n school , and wi l l
brandi sh psychol ogi cal test r epor ts.
The most common rati ng scal e i s the Conner s' Scal e, avai l abl e
thr ough school systems and i n most i nsti tuti onal chi l d psychi atr y
depar tments. If a par ent or spouse i s pr esent, compl ete the scal e
wi th hi m dur i ng the i ni ti al vi si t. In addi ti on, gi ve the pati ent a copy
to take home to be fi l l ed out by a teacher or empl oyer. Remember
that you have to establ i sh that your pati ent's symptoms occur i n at
l east two di ffer ent setti ngs to make the di agnosi s of ADHD.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n III - Int e rv ie w ing fo r Dia gno s is : The P s y c hia t ric Re v ie w
o f Sy m pt o m s > 3 0 - As s e s s ing Pe rs o na lit y Dis o rde rs

30
Assessing Personality Disorders

Essential Concepts

Use the gr ound-up techni que to assess for PDs fr om the soci al
hi stor y.
Use the symptom-wi ndow techni que to assess for PDs that
mi ght be l i nked to speci fi c symptoms.
Memor i ze sel f-statements, pr obi ng questi ons, and mnemoni cs
for each di sor der.

The DSM-IV-TR emphasi zes the medi cal model of psychi atr i c
di sor der s. Each di sor der i s pr esented as though i t wer e a di scr ete
syndr ome that a pati ent has, i n the same way that she mi ght
have di abetes or asthma. Most cl i ni ci ans r eal i ze that thi s i s a
si mpl i sti c vi ew, i ncl udi ng those cl i ni ci ans who wr ote the DSM-IV-TR,
whi ch i s why they di sti ngui shed axi s I fr om axi s II pathol ogy. Axi s
II, the PDs, for ces us to r ecogni ze that each pati ent has a
per sonal i ty that i nteracts and often contr i butes to the for mati on of
a psychi atr i c syndr ome. Tr eatment focused sol el y on axi s I
di sor der s, ther efor e, can go onl y so far, necessi tati ng an effor t to
di agnose per sonal i ty trai ts and di sor der s i n the i ni ti al i nter vi ew.
Al though the pr esence of a PD doesn't make an axi s I di sor der any
l ess genui ne, i t si gnal s to the cl i ni ci an that conventi onal tr eatment
appr oaches, such as medi cati on or symptom-focused psychotherapy,
may not be suffi ci ent.
PDs ar e notor i ousl y di ffi cul t to di agnose. It i s the rar e cl i ni ci an who
can confi dentl y concl ude after a si ngl e i nter vi ew that a pati ent has
a PD. Thus, thi s chapter does not assume that you wi l l be abl e to
di agnose a PD qui ckl y, but rather that you wi l l be abl e to for mul ate
some good hypotheses. Such hypotheses ar e usual l y noted on axi s
II as r ul e out ________ per sonal i ty di sor der.

TWO GENERAL APPROACHES


Two general strategi es ar e useful for assessi ng PDs i n the i nter vi ew.
They ar e not mutual l y excl usi ve, and cl i ni ci ans commonl y use both
over the cour se of the eval uati on.

Strategy 1: The Ground-Up Technique


In the gr ound-up techni que, you gradual l y fashi on a pi ctur e of your
pati ent's per sonal i ty by wor ki ng fr om the gr ound upthat i s, by
l ear ni ng about her l i fe hi stor y chr onol ogi cal l y i n the context of the
soci al and fami l y hi stor y. As outl i ned i n Chapter 14, the for mal
soci al hi stor y often begi ns wi th a general questi on about fami l y l i fe.

Tell me a bit about what gr owing up was like for


you.

As you ask chr onol ogi c questi ons about your pati ent's l i fe,
especi al l y those aspects of l i fe that i nvol ve i nter per sonal
r el ati onshi ps, tr y to i denti fy any dysfuncti onal patter ns of r el ati ng.
Recur r ent patter ns ar e the hal l mar k of PDs. Memor i ze one or two
pr obi ng questi ons for each PD (see the fol l owi ng exampl es) and ask
them at appr opr i ate ti mes.
A typi cal exampl e i s the pati ent who r el ates a patter n of havi ng had
few cl ose fr i endshi ps thr oughout the ear l y year s of hi s l i fe.
Dependi ng on the pati ent's behavi or towar d you dur i ng the
i nter vi ew (see the secti on on Behavi oral Cl ues), you may have some
hypotheses about whi ch PD i s most l i kel y. Per haps the pati ent
appear s anxi ous and shy dur i ng the i nter vi ew, l eadi ng you to
suspect avoi dant PD. You woul d then ask a pr obi ng questi on, such as

Have you tended to have few fr iends in your life


because you didn't want to have fr iends, or
because you wer e scar ed of getting close to
someone who might r eject you?

Usi ng the gr ound-up techni que, you wi l l usual l y be abl e to ar r i ve at


a good hypothesi s for a PD or per sonal i ty trai ts.
Consi der the fol l owi ng exampl e.

CLINICAL VIGNETTE
The i nter vi ewer i s aski ng a pati ent about hi s wor k hi stor y:

What sorts of jobs have you


Interviewer:
had?

I've had a whole bunch of


Patient: different jobs. I don't stick
with any one job for very long.

What usually happens with


Interviewer:
these jobs?

I usually quit, because the


Patient: people I work with end up
backstabbing me.

At thi s poi nt, the i nter vi ewer suspects paranoi d PD and asks the
pr obi ng questi ons.

Have you found in your life


that people have turned
Interviewer:
against you for no good
reason?

Yeah, beginning with my


Patient:
parents.

Do you tend to think of people


Interviewer: in general as being disloyal or
dishonest?

Well, I've found that you just


can't trust anyone, because
Patient:
they'll always try to do you in
if you let down your guard.

The i nter vi ewer, havi ng establ i shed two of the four cr i ter i a
r equi r ed to make the di agnosi s of paranoi d PD, wi l l then go on to
ask questi ons r egar di ng other cr i ter i a.

Strategy 2: The Symptom-Window Technique


The symptom-wi ndow techni que entai l s begi nni ng wi th your
pati ent's major symptoms and usi ng them as wi ndows for
expl or i ng possi bl e r oots i n PDs. Thi s i s general l y done towar d the
end of the PPH, by whi ch ti me you wi l l have i denti fi ed the major
symptoms and del i neated the syndr omal and tr eatment hi stor y. The
next step i s to ask questi ons about events that may have occur r ed
each ti me the symptoms ar ose. Wer e these i nter per sonal events?
Wer e they r el ated to l i fe transi ti ons? In your judgment, do the
symptoms seem to be r easonabl e r esponses to the events, or do
they seem exaggerated?
The natur e of the symptoms per se does l i ttl e to poi nt to a speci fi c
PD, but usi ng the symptoms as wi ndows to the per sonal i ty i s often
pr oducti ve. For exampl e, a major depr essi on can be a pr oduct of
vi r tual l y any of the PDs, but each pati ent wi l l ar r i ve at the
depr essi on by a di ffer ent r oute. Her e ar e some typi cal exampl es:

Nar ci ssi sti c PD: The pati ent fi nds that nobody meets hi s hi gh
standar ds, ther eby al i enati ng fr i ends and fami l y, l eadi ng to a
soci al i sol ati on that can cause depr essi on.
Avoi dant PD: The pati ent avoi ds fr i endshi ps for fear of r ejecti on,
l eadi ng to l onel i ness and depr essi on.
Dependent PD: Pati ent devel ops a sense of wor thl essness and
demoral i z ati on because of an i nabi l i ty to make l i fe deci si ons
wi thout r el yi ng on someone el se.

Bor der l i ne PD: A chr oni c sense of i nner empti ness may l ead to
depr essi on, sui ci dal i ty, and other pr obl ems, such as substance
abuse, bul i mi a, and i mpul se contr ol di sor der.

As an exampl e, assume you ar e i nter vi ewi ng a pati ent wi th major


depr essi on who r ecentl y consi der ed over dosi ng on some medi cati on
after bei ng r ejected by her boyfr i end. You suspect bor der l i ne PD.
You can br oach the i ssue wi th a r efer r ed transi ti on:

Ear lier , we wer e talking about your depr ession and


some of the suicidal thoughts you had after your
boyfr iend left you. Have you r eacted in this way to
r ejection at other times in your life?

After you've gotten the bal l r ol l i ng by usi ng the r efer r ed transi ti on,
you can r un thr ough the r est of the cr i ter i a, joggi ng your memor y
wi th the mnemoni c I DESPA IRR. You can i ntr oduce these questi ons
wi th a r emar k such as

I'd like to ask a few mor e questions about your


per sonality and the ways that you tend to r eact to
cer tain situations. I'm inter ested in lear ning about
what sor t of per son you've been since your teenage
year s, not only how you've been over the last few
weeks.

Thi s hel ps to ensur e that your pati ent answer s i n ter ms of endur i ng
per sonal i ty trai ts rather than r ecent symptoms.

KEY POINT
Thi s l ast poi nt deser ves r epeati ng: A PD r efer s to a per sisting
patter n of dysfuncti onal r el ati ng styl es over many year s, at l east
si nce adol escence or young adul thood. Thus, when you ask about
cr i ter i a for a PD, make cl ear to your pati ent that you'r e
i nter ested i n the l ong-ter m vi ew. Begi nner s often for get thi s and
may end up fal sel y di agnosi ng a PD when the pati ent actual l y has
an acute axi s I di sor der. For exampl e, depr essed pati ents
commonl y appear i r r i tabl e, needy, and sui ci dal , featur es that
coul d easi l y l ead to the di agnosi s of bor der l i ne PD. Once the
depr essi on cl ear s, such pati ents may magi cal l y shed thei r axi s II
pathol ogy.

SPECIFIC PERSONALITY DISORDERS: SELF-


STATEMENTS, PROBING QUESTIONS, AND
BEHAVIORAL CLUES
I have l i sted bel ow al l ten DSM-IV-TR PDs. For each, ther e i s a
pati ent sel f-statement, whi ch i s a hypotheti cal descr i pti on that a
pati ent wi th the gi ven di sor der woul d make about hi msel f. The
statements ar e si mpl i sti c and ster eotypi c and ar e onl y meant to be
used as memor y ai ds, so that you can dependabl y fi x the mai n
featur es of each PD i n your mi nd. Two suggested pr obi ng questi ons,
al ong wi th common behavi oral cl ues that mi ght i ncr ease your
suspi ci on of a par ti cul ar di sor der, ar e l i sted beneath each
statement. F i nal l y, a mnemoni c i s gi ven for each PD, al l of whi ch
(except the one for bor der l i ne PD) wer e wr i tten by Har ol d Pi nkofsky
(1997). If you obtai n posi ti ve r esponses to your pr obi ng questi ons,
fol l ow up wi th mor e questi ons r el ated to speci fi c di agnosti c cr i ter i a,
usi ng the mnemoni cs as ai ds. As an i l l ustrati on, I have i ncl uded
questi ons that can be used for each of the cr i ter i a for bor der l i ne PD.

Borderline Personality Disorder


Sel f-statement: I need peopl e desperatel y, and when peopl e
r eject me I fal l apar t compl etel y. I hate them, and I get
sui ci dal .
Pr obi ng questi ons:

Have people often disappointed you in your life?


When something has gone r eally wr ong in your
life, such as losing a job or getting r ejected,
have you often done something to hur t
your self, such as cutting your self or
over dosing?

Behavi oral cl ues: May al ter nati vel y i deal i ze and deval ue you
over the cour se of the i nter vi ew; may be unusual l y emoti onal l y
l abi l e.
Mnemoni c: I DESPA IRR
Identi ty di stur bance

Have you gener ally been pr etty clear about


what your goals ar e in life and what sor t of
per son you ar e, or do you have tr ouble
knowing who ________ is? (Say patient's
name.)

Di sor der ed, unstabl e affect owi ng to a mar ked r eacti vi ty of


mood

Ar e you a moody per son?

Chr oni c feel i ngs of Empti ness

Do you often feel empty inside?

Recur r ent Sui ci dal behavi or, gestur es, or thr eats, or sel f-
muti l ati ng behavi or

Looking back, when something has gone


r eally wr ong in your life, like losing a job or
getting r ejected, have you often done
something to hur t your self, such as cutting
or over dosing?

Transi ent, str ess-r el ated Paranoi d i deati on or sever e


di ssoci ati ve symptoms

When you'r e under str ess, do you feel you


lose touch with your envir onment or with
your self? Dur ing those times, do you feel as
if people ar e ganging up on you?

F ranti c effor ts to avoi d r eal or i magi ned A bandonment

When someone abandons or r ejects you,


how do you r eact?
Impul si vi ty i n at l east two ar eas that i s potenti al l y sel f-
damagi ng

Do you see your self as an over ly impulsive


per son?
Have you ever done things that can get you
into tr ouble, such as spending all your
money, dr iving like a maniac, using a lot of
dr ugs, having a lot of sex, and so for th?

Inappr opr i ate, i ntense Rage or di ffi cul ty contr ol l i ng anger

What do you do when you get angr y?


Do you hold it inside or let loose with it so
that ever ybody knows how you'r e feeling?

A patter n of unstabl e and i ntense i nter per sonal Rel ati onshi ps
character i zed by al ter nati ng extr emes of i deal i z ati on and
deval uati on

Do your r elationships tend to be calm and


stable or stor my and unstable, with lots of
ups and downs?

Cluster A (Odd)
Paranoid
Sel f-statement: Other s ar e untr ustwor thy, and they tr y to take
advantage of me.

Pr obi ng questi ons:

Have you often found that people in your life


have not been tr ustwor thy?
Have people tur ned against you for no good
r eason?
Behavi oral cl ues: Pati ent appear s guar ded and suspi ci ous;
pati ent answer s questi ons r el uctantl y and wi th an ai r of
suspi ci on.
Mnemoni c: SUSPECT (four of these seven)
Spousal i nfi del i ty suspected
Unfor gi vi ng (bear s gr udges)
Suspi ci ous of other s
Per cei ves attacks
Vi ews ever yone as ei ther an Enemy or a fr i end
Confi di ng i n other s fear ed
Thr eats per cei ved i n beni gn events

Schizoid
Sel f-statement: I pr efer to be al one; my wor l d i s compl etel y
empty.
Pr obi ng questi ons:

Ar e you a people per son, or ar e you someone


who pr efer s to be alone? (Pr efer s to be alone.)
Can you name some things that you r eally
enjoy doing? (Takes pleasur e in few, if any,
activities.)

Behavi oral cl ues: Pati ent appear s shy and al oof. Pati ent seems
to be pr eoccupi ed, i n her own wor l d.
Mnemoni c: DISTA NT (four of these seven)
Detached (or fl attened) affect
Indi ffer ent to cr i ti ci sm or prai se
Sexual exper i ences of l i ttl e i nter est
Tasks (acti vi ti es) per for med sol i tar i l y
A bsence of cl ose fr i ends
Nei ther desi r es nor enjoys cl ose r el ati ons
Takes pl easur e i n few acti vi ti es
Schizotypal
Sel f-statement: I'd l i ke to have fr i ends but i t's har d, because
peopl e fi nd me pr etty strange.
Pr obi ng questi ons:

Do you tend to feel pr etty uncomfor table


ar ound other people?
Do you sometimes have ideas that other people
don't r eally under stand or find unusual?

Behavi oral cl ues: Pati ent appear s odd i n any number of ways
for exampl e, she may be di shevel ed, wear i ng strange cl othes, or
have odd manner i sms. Pati ent descr i bes strange i deas that
bor der on psychoti c.
Mnemoni c: ME PECULIA R (fi ve of these ten)
Magi cal thi nki ng or odd bel i efs
Exper i ences unusual per cepti ons
Paranoi d i deati on
Eccentr i c behavi or or appearance
Constr i cted (or i nappr opr i ate) affect
Unusual (odd) thi nki ng and speech
Lacks cl ose fr i ends
Ideas of r efer ence
A nxi ety i n soci al si tuati ons
Rul e out psychoti c di sor der and per vasi ve devel opmental
di sor der

Cluster B (Dramatic)
Borderline
See the ear l i er Bor der l i ne secti on.
Antisocial
Sel f-statement: I l ove to take advantage of other peopl e, and I
never feel bad about i t.
Pr obi ng questi ons:

Do you admir e a good scam when you see it?


Have you ever done anything that could have
gotten you in tr ouble with the law?

Behavi oral cl ues: The pati ent i s excessi vel y cocky and ar r ogant.
The pati ent al ways por trays sel f as i nnocent and a vi cti m i n
vi ol ent or cr i mi nal ci r cumstances.
Mnemoni c: CORRUPT (thr ee of these seven)
Confor mi ty to l aw l acki ng
Obl i gati ons i gnor ed

Reckl ess di sr egar d for safety of sel f or other s


Remor se l acki ng
Under handed (decei tful , l i es, cons other s)
Pl anni ng i nsuffi ci ent (i mpul si ve)
Temper

Histrionic
Sel f-statement: I'm qui te an emoti onal and sexual l y char mi ng
per son, and I need to be the center of attenti on!
Pr obi ng questi ons:

Do you like to be the center of attention? (Yes.)


When you feel an emotion, do you keep it inside
or do you expr ess it? (Expr ess it.)

Behavi oral cl ues: The pati ent i s fl amboyantl y and seducti vel y
gr oomed or dr essed. The pati ent i s rapi dl y and dramati cal l y sel f-
r eveal i ng to the poi nt of i nappr opr i ateness, even i n the context
of a psychi atr i c eval uati on.
Mnemoni c: PRA ISE ME (fi ve of these ei ght)
Pr ovocati ve (or sexual l y seducti ve) behavi or
Rel ati onshi ps (consi der ed mor e i nti mate than they ar e)
A ttenti on (uncomfor tabl e when not the center of attenti on)
Infl uenced easi l y
Styl e of speech (i mpr essi oni sti c, l acks detai l )
Emoti ons (rapi dl y shi fti ng and shal l ow)
Made up (physi cal appearance used to draw attenti on to sel f )
Emoti ons exaggerated (theatr i cal )

Narcissistic
Sel f-statement: I'm an extr emel y tal ented and speci al per son,
better than most peopl e, and yet I get angr y and depr essed
because peopl e don't r ecogni ze how gr eat I am!
Pr obi ng questi ons:

Do you often find your self getting fr ustr ated


because other people don't meet your
standar ds? (Yes.)
What ar e your ambitions for your self? (Will be
unr ealistically high.)

Behavi oral cl ues: The pati ent may appear haughty and
excessi vel y cr i ti cal of your cr edenti al s or exper i ence. She

may begi n the i nter vi ew wi th a l i tany of angr y compl ai nts about


how unfai r l y other s have tr eated her.
Mnemoni c: SPEEECIA L (fi ve of these ni ne)
Speci al (bel i eves he i s speci al and uni que)
Pr eoccupi ed wi th fantasi es (e.g., of unl i mi ted success, power )
Envi ous
Enti tl ement
Excessi ve admi rati on r equi r ed
Concei ted
Inter per sonal expl oi tati on
A r r ogant
Lacks empathy

Cluster C (Anxious)
Avoidant
Sel f-statement: I'm r eal l y afrai d of what peopl e wi l l thi nk of
me, so I avoi d maki ng new fr i ends to pr event r ejecti on.
Pr obi ng questi ons:

Do you tend to avoid meeting people or getting


close to people? (Yes.)
Is that because you pr efer to be alone or
because you've been r ejected befor e and you
don't want it to happen again? (The latter .)

Behavi oral cl ues: The pati ent may appear shy and ner vous but
wi th a poi gnant eager ness to make contact. He may begi n the
i nter vi ew r el uctant to open up and wi l l typi cal l y become qui te
sel f-r eveal i ng once rappor t has been establ i shed.
Mnemoni c: CRINGES (four of these seven)
Cer tai nty of bei ng l i ked r equi r ed befor e wi l l i ng to r i sk
i nvol vement
Rejecti on possi bi l i ty pr eoccupi es hi s thoughts
Inti mate r el ati onshi ps avoi ded
New r el ati onshi ps avoi ded
Gets ar ound occupati onal acti vi ti es that i nvol ve i nter per sonal
contact
Embar rassment potenti al pr events new acti vi ti es
Sel f vi ewed as unappeal i ng, i nept, i nfer i or
Dependent
Sel f-statement: I'm pr etty passi ve and dependent on other s for
di r ecti on, and I go far out of my way not to di spl ease peopl e who
ar e i mpor tant to me.
Pr obi ng questi ons:

Do you consider your self a completely


independent per son, or have you tended to lean
on other s in your life for emotional suppor t and
guidance? (Lean on someone else.)
Who has made most major decisions in your life,
you or your ________ (spouse, par ents, or
other , depending on situation)? (Someone other
than the patient.)

Behavi oral cl ues: The pati ent wi l l seem to make extraor di nar y
attempts to i mmedi atel y gai n your affecti on.
Mnemoni c: RELIA NCE (fi ve of these ei ght)
Reassurance r equi r ed for deci si ons
Expr essi ng di sagr eement di ffi cul t (because of fear of l oss of
suppor t or appr oval )
Li fe r esponsi bi l i ti es assumed by other s
Ini ti ati ng pr ojects di ffi cul t
A l one (feel s hel pl ess and a sense of di scomfor t when al one)
Nur turance (goes to excessi ve l engths to obtai n nur turance
and suppor t)
Compani onshi p sought ur gentl y when cl ose r el ati onshi p ends
Exaggerated fear s of bei ng l eft to car e for sel f

Obsessive-Compulsive
Sel f-statement: I'm a per fecti oni st. I keep l i sts, I dr i ve mysel f
har d, and I'm ver y ser i ous about l i fe.
Pr obi ng questi ons:

Do you consider your self a per fectionist?


Do you dr ive your self so har d with your wor k
that you find you have no time for leisur e
activities?

Behavi oral cl ues: The pati ent i s meti cul ousl y gr oomed and
dr essed. He wi l l tend to gi ve an excessi vel y detai l ed and
accurate account of hi s symptoms.
Mnemoni c: LA W FIRMS (four of these ei ght)
Loses poi nt of acti vi ty
A bi l i ty to compl ete tasks compr omi sed by per fecti oni sm

W or thl ess objects (unabl e to di scar d)


Fr i endshi ps (and l ei sur e acti vi ti es) excl uded (owi ng to
pr eoccupati on wi th wor k)
Infl exi bl e, scr upul ous, over consci enti ous
Rel uctant to del egate
Mi ser l y
Stubbor n
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n IV - Int e rv ie w ing fo r Tre a t m e nt > 3 1 - Ho w t o Educ a t e
Yo ur Pa t ie nt

31
How to Educate Your Patient

Essential Concepts

Br i efl y state your di agnosi s.


F i nd out what your pati ent knows about the di sor der.
G i ve a mi ni -l ectur e about the di sor der, i f i ndi cated.
Ask i f ther e ar e any questi ons.
G i ve your pati ent wr i tten educati onal mater i al s.

Does this mean I'm cr az y?

Is this medication going to tur n me into a z ombie?

Am I going to be this way for the r est of my life?

These ar e the sor ts of questi ons that pati ents wi l l ask you, often
towar d the end of the di agnosti c i nter vi ew. Cl i ni ci ans eventual l y
devel op an effecti ve appr oach to answer i ng such questi ons i n l ay
ter ms. Al though pati ent educati on i s rar el y for mal l y taught i n
trai ni ng pr ograms, fr om the pati ent's per specti ve, i t i s often the
most i mpor tant par t of the i ni ti al eval uati on.
Educati ng your pati ent about hi s di sor der i s hel pful for var i ous
r easons. F i r st, educati on decr eases hi s anxi ety. As cl i ni ci ans, we
tend to take mental i l l ness for granted, but pati ents ar e often
ter r i fi ed by thei r di sor der s. By gi vi ng an i l l ness a name and showi ng
that i ts pr ognosi s and tr eatment ar e wel l under stood and that
mi l l i ons of other peopl e have exper i enced i t, we can si gni fi cantl y
decr ease the pati ent's anxi ety.
Second, pati ent educati on i mpr oves adher ence to tr eatment, both
for medi cati ons and therapy. Mi sconcepti ons about psychi atr i c
tr eatment abound i n our soci ety; most peopl e obtai n thei r
i nfor mati on about psychi atr y fr om car toons, tel evi si on si tcoms, and
news magaz i nes, whi ch l eads to a mi smatch between r eal i ty and
fantasy. For exampl e, many pati ents bel i eve that psychotherapy i s a
l ong-ter m pr ocess i n whi ch pai nful fami l y

dynami cs ar e r ehashed for year s on end. Such a mi sconcepti on


decr eases the l i kel i hood that pati ents wi l l commi t to therapy. When
educated about the fact that most pr esent-day therapy i s br i ef and
focuses on cur r ent pr obl ems, pati ents become mor e r ecepti ve to
r efer ral s.
Mi si nfor mati on about medi cati ons al so abounds. Pati ents often
bel i eve that anti depr essants ar e to be di sconti nued once they feel
better, as opposed to the 6 to 12 months of conti nuous therapy
r ecommended. Other pati ents consi der anti depr essants to be rapi d
mood booster s. One pati ent for whom I had pr escr i bed fl uoxeti ne
(Pr oz ac) for depr essi on came back i n a month r epor ti ng that she
had onl y needed to take the Pr oz ac four or fi ve ti mes. Her bel i ef
had been that the medi cati on was to be taken onl y on those
mor ni ngs that she awoke feel i ng ver y depr essed.
In thi s chapter, I gui de you thr ough a commonl y used strategy for
pr ovi di ng pati ent educati on that can be appl i ed to a wi de var i ety of
mental di sor der s.

BRIEFLY STATE YOUR DIAGNOSIS


Al though thi s i s sel f-expl anator y, I woul d add that you needn't
al ways phrase the di agnosi s i n DSM-IV-TR ter mi nol ogy. For exampl e,
I often tel l pati ents that they have a cl i ni cal depr essi on rather
than a major depr essi on, because I know fr om exper i ence that
mor e pati ents have hear d of the for mer than the l atter.

WHAT YOUR PATIENT KNOWS ABOUT THE


DISORDER
The way I general l y fi nd out what my pati ent knows about the
di sor der i s as an extensi on of pr ovi di ng a di agnosi s. Thus:

I think that you've been suffer ing fr om a clinical,


or major , depr ession. Do you know what that is?

If the pati ent says yes, I ask hi m to el aborate a bi t:

What is your definition of depr ession?

As a pr el ude to tr eatment negoti ati on, I often ask whether the


pati ent has any expectati ons about tr eatment.

Do you have any ideas about tr eatment?

Some pati ents may over tl y r equest a par ti cul ar for m of tr eatment,
such as psychotherapy or medi cati on, wher eas other s may tel l you
what they don't want.

MINI-LECTURE ABOUT THE DISORDERS


Not al l pati ents want to hear you wax poeti c about thei r di sor der s.
For exampl e, a wel l -i nfor med pati ent who has just del i neated each
of the DSM-IV-TR cr i ter i a of OCD mi ght be i nsul ted to hear you
r epeat them. Other pati ents may be qui te uni nfor med but, taki ng
the atti tude that you, and not they, ar e the doctor, mi ght feel
uncomfor tabl e wi th your effor ts to educate them and i nvol ve them
i n thei r tr eatment. Ther e's no fi r m r ul e about whi ch pati ents shoul d
get a mi ni -l ectur e. Accor di ngl y, you can ask the pati ent somethi ng
l i ke thi s:

Would you like me to give you some infor mation on


depr ession?

Al though i t i s the rar e pati ent who r esponds wi th a fl at no, even i f


he'd pr efer not to have the i nfor mati on, you can general l y gauge
the degr ee of i nter est based on the r esponse and adjust the l ength
of your mi ni -l ectur e accor di ngl y.
As a gui de for str uctur i ng your mi ni -l ectur e, I tur n to the
exper i ence of the r esear cher s at the Uni ver si ty of Pi ttsbur gh, who
used a psychoeducati onal pr ogram that hel ped them achi eve a
r emar kabl y hi gh (90% ) adher ence to tr eatment over 3 year s (F rank
et al . 1995; Jacobs et al . 1987). Thei r pr ogram was devi sed to teach
pati ents and thei r fami l i es about depr essi on. Its components
i ncl uded the fol l owi ng:

Defi ne the i l l ness. Ask your pati ent to i denti fy al l the symptoms
that he has exper i enced. A chal kboar d, or mor e r eal i sti cal l y, a
pi ece of paper on whi ch to wr i te, i s hel pful . Defi ne the di sor der
as an i l l ness that has many symptoms, i ncl udi ng the ones your
pati ent has i denti fi ed; tr y to por tray i t as an i l l ness si mi l ar to
the medi cal i l l nesses of di abetes or hyper tensi on. Thi s hel ps
decr ease the sti gma associ ated wi th mental i l l ness.
Di scuss the pr eval ence and cour se of the i l l ness. (Refer to
Appendi x A for a pocket car d l i sti ng the pr eval ence for the major
mental di sor der s.)
Di scuss the causes. Al though we don't know the causes of most
mental i l l nesses, you can di scuss some di ffer ent theor i es.

Di scuss the opti ons for tr eatment.


For medi cati ons, di scuss si de-effect pr ofi l es and emphasi ze the
fact that i ndi vi dual s exper i ence di ffer ent si de effects.

Her e i s an exampl e of a mi ni -l ectur e for major depr essi on:

A major depr ession is a br eakdown in a per son's


ability to cope with str ess. While we all get sad
fr om time to time when things go poor ly, a per son
with major depr ession feels so down that the basic
functions of living ar e affected. As with medical
illnesses, depr ession causes specific symptoms. In
your case, you haven't been able to sleep, you've
lost your appetite, you haven't been able to
concentr ate at wor k, and you've had some scar y
suicidal thoughts.

Depr ession is quite common; about 10% of people


develop it at some point in their lives. What causes
it isn't clear . F or some people, str essor s seem to
cause depr ession; this may be the case for you,
because you felt bad after your divor ce. In other
cases, depr ession seems to be a biological disor der .

The good news about depr ession is that it's ver y


tr eatable. Ther e ar e two main techniques,
medication or talk ther apy. A combination of the
two is often most effective. In your case, I'd
r ecommend the combined tr eatment. Do you have
any questions about all this?

I'l l al so gi ve you an exampl e of a mi ni -l ectur e for bor der l i ne PDs,


just to pr ove that you can di scuss PDs wi th pati ents wi thout
soundi ng cr i ti cal .

You're suffering from borderline


Interviewer: personality disorder. Do you
know what that is?

No, but it sounds bad, like being


Patient:
on the edge.

You're not far off. It is a bit like


being on the edge. People with
borderline personality disorder
tend to have poor self-esteem,
and this causes them to be very
moody, especially when it comes
Interviewer: to dealing with friends and
family. For instance, you told me
earlier that when people reject
you, you don't just get
depressed, you get suicidal. And
when you get angry at people,
you really lose control.

That's just the way I've always


Patient: been; I didn't know it was an
official disorder.

It is, and believe me, you're not


alone. Studies show that about
2% of all people have the same
problem. No one knows exactly
what causes it, but the early
Interviewer:
family environment usually plays
a role. The best treatment is
long-term therapy, with
medications from time to time to
treat depression.

You'l l devel op your own styl e of educati ng pati ents, and your
l ectur e wi l l i nevi tabl y var y dependi ng on the pati ent. As much as
possi bl e, you want to speak your pati ent's l anguage, whi ch wi l l var y
wi th l evel of i ntel l i gence and educati on, cul tural backgr ound, age,
and other factor s.

QUESTIONS
Even i f you ar e feel i ng the pr essur e of the end of the hour, gi ve
your pati ent pl enty of ti me to thi nk about questi ons.

WRITTEN EDUCATIONAL MATERIALS


G i vi ng wr i tten educati onal mater i al s to your pati ents al l ows them to
consi der the i nfor mati on i n pr i vacy and at gr eater l ength. You may
use the handouts i n Appendi x C, al l of whi ch ar e publ i c domai n
documents that can be r epr oduced wi th or wi thout
acknowl edgments.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n IV - Int e rv ie w ing fo r Tre a t m e nt > 3 2 - Ne go t ia t ing a
Tre a t m e nt P la n

32
Negotiating a Treatment Plan

Essential Concepts

El i ci t the pati ent's agenda.


Negoti ate a pl an that you and your pati ent can agr ee on.
Hel p the pati ent i mpl ement the agr eed-on pl an.

Once you've come up wi th a di agnosi s, you have to deter mi ne a


tr eatment pl an based on that di agnosi s. A tr eatment pl an i s
somethi ng you shoul d ar r i ve at wi th your pati ent, rather than
handi ng i t to her l i ke a pr escr i pti on. The mor e you i nvol ve your
pati ent i n pl anni ng tr eatment, the mor e l i kel y that she wi l l fol l ow
thr ough wi th the pl an.
Compliance was once a popul ar ter m for descr i bi ng good fol l ow up,
but now that ter m i s bei ng gradual l y r epl aced wi th adher ence, whi ch
i mpl i es l ess passi vi ty. A pati ent chooses to adher e, wher eas he i s
made to compl y. Resear cher s have found that when cl i ni ci ans and
pati ents negoti ate a tr eatment pl an together, both adher ence and
cl i ni cal outcome ar e i mpr oved (Ei senthal et al . 1979). Laz ar e et al .
(1975) have outl i ned an appr oach to negoti ati ng a tr eatment pl an
that makes good sense, fr om whi ch the fol l owi ng schema i s adapted.

ELICIT THE PATIENT'S AGENDA


Your pati ent's agenda may not be as obvi ous as i t fi r st appear s. You
can begi n to el i ci t i t wi th a si mpl e questi on, such as

How do you hope I can help you?


Note that thi s i s a l ess confr ontati onal way of aski ng about your
pati ent's agenda than aski ng

What do you want?

What do you expect?

At thi s poi nt, the pati ent may answer vaguel y or put the bal l back
i n your cour t:

I want to feel better .

I don't know. You'r e the doctor .

It's often i mpor tant to cl ar i fy what sor t of i nfor mati on you'r e


seeki ng:

How wer e you hoping that I could help you to feel


better ?

TIP
Often, pati ents come i nto an i nter vi ew wi th a few speci fi c
r equests, such as a desi r e for medi cati on, therapy, a communi ty
r efer ral , a l etter to thei r empl oyer, and so on. Some pati ents may
feel embar rassed about di vul gi ng thei r r equests so bl atantl y and
may need some encouragement fr om you:

Sometimes patients have a pr etty clear idea of what they'd


like, for instance medication, counseling, or a piece of advice
about something, a letter to someone. (A nor maliz ing
r esponse.)

However, many pati ents who come to see a cl i ni ci an r eal l y don't


have a speci fi c r equest or agenda. Thi s i s often the case wi th
pati ents who ar e new to the mental heal th car e system or who ar e
l ess fami l i ar wi th the moder n consumer model of heal th car e. Don't
for ce the i ssue wi th these pati ents; i f they say that they want to
hear what your r ecommendati on i s and they'l l fol l ow i t just because
you ar e the exper t, go al ong wi th i t.
NEGOTIATE A PLAN
Remember that eventual tr eatment adher ence i s enhanced when the
pati ent and practi ti oner agr ee on the natur e of the pr obl em. The
next phase of negoti ati on i nvol ves ar r i vi ng at thi s agr eement. If
you and your pati ent agr ee at the outset about a pl an, go di r ectl y to
the i mpl ementati on phase. However, often enough you'l l fi nd that
your pati ent's r equest i s ei ther unr eal i sti c or not cl i ni cal l y
i ndi cated. Thank your star s that you el i ci ted the r equest wi th ti me
to spar e, because now you must negoti ate a

mutual l y agr eed-on goal . Each negoti ati on wi l l be di ffer ent,


dependi ng on the natur e of the r equest. Cr eati vi ty i s a pl us.
Common pr obl emati c r equests, al ong wi th possi bl e negoti ati on
strategi es, ar e as fol l ows:
Request: Your pati ent asks you for medi cati on, but you cannot
pr escr i be.
Strategy: Deter mi ne how ur gent the need for medi cati on i s. If i t's
not ur gent, make a r efer ral to a psychi atr i st, and teach the pati ent
a psychol ogi cal method for symptom r el i ef, such as r el axati on
exer ci ses, hypnosi s, or cogni ti ve r estr uctur i ng. Now i s a good ti me
to r each i nto your fi l e of pati ent handouts. If the need i s ur gent,
r efer the pati ent to an emer gency r oom or cr i si s cl i ni c, l eavi ng
enough ti me for you to cal l the cl i ni c to i nfor m the psychi atr i st of
the pati ent's di agnosi s and medi cati on needs.
Request: Your pati ent asks for i nappr opr i ate medi cati on, such as
benzodi azepi nes for someone wi th a hi stor y of benzodi azepi ne
abuse or anti depr essants for mi l d or transi ent depr essi ve symptoms.
Strategy: Pr esent a mi ni -l ectur e about the pati ent's di sor der,
compl ete wi th handouts and r ecommendati ons of books.
Request: The pati ent seeks hospi tal i z ati on for a pr obl em that can
be tr eated i n an outpati ent setti ng.
Strategy: Thi s has become an i ncr easi ngl y pr obl emati c r equest i n
our era of managed car e, and pati ents may need some educati on
about thi s i ssue:

These days, insur ance companies r ar ely pay for


hospitaliz ations unless the patient is suicidal,
because we have a lot of outpatient tr eatments
that wor k well.
An i mpor tant thi ng to keep i n mi nd i s the possi bi l i ty that the
pati ent i s suffer i ng much mor e than she or i gi nal l y i ndi cated, and
that her r equest for hospi tal i z ati on i s her way of obl i quel y
di scl osi ng that. You may need to r eassess her for SI at thi s poi nt. If
you'r e sti l l sati sfi ed that hospi tal i z ati on i s not i ndi cated, di scuss
some other opti ons, such as

Day hospi tal i z ati on


Respi te car e
Stayi ng wi th a fr i end or r el ati ve for a whi l e i f the home si tuati on
i s i ntol erabl e
Taki ng a few days off fr om wor k
Havi ng the pati ent cal l you (or another cl i ni ci an) for dai l y check-
i ns dur i ng a cr i si s per i od
Setti ng up mor e fr equent appoi ntments
A shor t cour se of an anti anxi ety medi cati on

IMPLEMENTING THE AGREED-ON PLAN


Your agr eed-on pl an wi l l l i kel y fal l i nto one or both of the fol l owi ng
categor i es:

A fol l ow-up therapy appoi ntment wi th you or someone el se


Medi cati on tr i al

Follow-Up Appointments
Your job i s to i ncr ease the chances that your pati ent wi l l show up at
the fol l ow-up appoi ntment, r egar dl ess of wher e that i s. You've
al r eady contr i buted to thi s cause by i nvol vi ng the pati ent i n the
pr ocess of deci di ng on a pl an. What mor e can you do?
The r esear ch shows that the hi ghest fol l ow-up adher ence rates
occur r ed under the fol l owi ng ci r cumstances (Ei senthal et al . 1979):

The wai t for fol l ow-up appoi ntments i s shor t.


Refer ral s ar e made to speci fi c cl i ni ci ans rather than to a cl i ni c.
Speci fi c appoi ntments ar e made at the ti me of di sposi ti on.
The pati ent speaks di r ectl y to someone at the r efer ral cl i ni c
dur i ng the eval uati on sessi on.

The cl oser you can come to i mpl ementi ng these gui del i nes, the
better. Of cour se, thi s r equi r es pl enty of pr ei nter vi ew pr eparati on
(see Chapter 2 on l ogi sti cal pr eparati on), i ncl udi ng the fol l owi ng:

Have an effi ci ent system for booki ng your fol l ow-up


appoi ntments.
Have a l i st of speci fi c cl i ni ci ans who do not have excessi ve
wai ti ng per i ods for appoi ntments.
Have a l i st of r efer ral cl i ni cs wi th thei r phone number s so your
pati ent can cal l and make the appoi ntment fr om your offi ce.

Medication Trials
If you have tr ul y col l aborated wi th your pati ent i n deci di ng on a
medi cati on tr i al , you'r e wel l on your way towar d achi evi ng
adher ence to the r egi men. Her e ar e some practi cal i ssues r egar di ng
medi cati ons and suggesti ons for deal i ng wi th them:

1. Deter mi ne how your pati ent wi l l pay for medi cati on. Some
i nsurance compani es pay for pr escr i pti ons, and other s don't. If
the pati ent has to pay out of pocket, make sur e she knows how
much she's goi ng to be spendi ng. If she can't affor d to pur chase
medi cati ons, you may be abl e to pr ovi de sampl es, dependi ng on
thei r avai l abi l i ty at your cl i ni c. Many dr ug compani es now have
voucher pr ograms. Under these pr ograms, the dr ug company wi l l
send you a stack of voucher s, each of whi ch i s good for one
month's medi cati on. The pati ent gi ves the voucher to the
phar maci st and gets the medi cati on.
2. Make sur e your pati ent under stands the si de-effect pr ofi l e of the
medi cati on.
3. Si mpl i fi cati on i ncr eases r ecal l and compl i ance. Thus, i nstead of
Take 20 mg of Pr oz ac once a day and 50 mg of trazodone at
ni ght, as needed for i nsomni a, say, Take the gr een capsul e
ever y mor ni ng and the whi te pi l l at ni ght i f you can't sl eep.
4. Havi ng your pati ent r epeat what you say i ncr eases her r ecal l of
your i nstr ucti ons.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ta ble o f C o nt e nt s > Se c t io n IV - Int e rv ie w ing fo r Tre a t m e nt > 3 3 - Writ ing U p t he
Re s ult s o f t he Int e rv ie w

33
Writing Up the Results of the Interview

I've had a l ong and stor my r el ati onshi p wi th the dr eaded wr i te-up.
Dur i ng medi cal school , the r equi r ement of a novel -l ength wr i te-up
was a wel come r epr i eve fr om the str esses of r oundi ng on pati ents
and maki ng oral pr esentati ons. In r esi dency, I became annoyed wi th
the wr i te-up, whi ch seemed a pesky i ntr usi on i nto the l i mi ted ti me I
had to spend wi th pati ents. At the end of a l ong day, I woul d si t
down heavi l y at the Di ctaphone and tr y to gather my thoughts,
hopi ng that the r esul ti ng transcr i pti on woul d be coher ent.
It wasn't unti l I had been i n cl i ni cal practi ce for a few year s that I
came to ter ms wi th the wr i te-up. Havi ng come ful l ci r cl e, I'm back
to (sor t of ) l i ki ng i t, vi ewi ng i t as a wel come few mi nutes of qui et
thought and synthesi s between pati ent appoi ntments.
I hope thi s chapter hel ps you to wor k thr ough some of the mor e
pai nful moments i n your own r el ati onshi p wi th the wr i te-up. I
outl i ne some for mats for you to choose among, and I pr ovi de some
ti ps to hel p you str eaml i ne the pr ocess.
Ever y wr i te-up r epr esents a bal anci ng act among thr ee objecti ves:

1. Thor oughness
2. Ti me-effi ci ency
3. Readabi l i ty

The i deal wr i te-up i ncor porates al l thr ee objecti ves. It i s thor ough
enough to document the basi s for a di agnosi s and tr eatment pl an; i t
does not r equi r e so much ti me that i t woul d be unfeasi bl e for a busy
cl i ni ci an to pr oduce; and i t i s not so l engthy as to pr ovoke si ghs
fr om equal l y busy col l eagues who must r ead the wr i te-up because of
thei r i nvol vement i n the pati ent's tr eatment.
In general , a wr i te-up shoul d not take you mor e than 10 to 15
mi nutes to pr oduce, whether you di ctate i t or wr i te i t your sel f. It
shoul d not be l onger than two or thr ee typed pages i f you r eal l y
want col l eagues to r ead i t.

IDENTIFYING DATA
The i denti fyi ng data shoul d be a fai r l y l ong i ni ti al sentence that
sets the stage for the enti r e eval uati on. You want to not onl y
i denti fy who the pati ent i s, but al so to l ocate her wi thi n the context
of soci al and cul tural nor ms. Thi s i ncl udes age, sex, mar i tal status,
and sour ce of r efer ral at a mi ni mum and may i ncl ude other
i nfor mati on such as occupati on, l i vi ng si tuati on, and pr esence of
other fami l y.

This is a 45-year -old, twice-mar r ied woman with


two gr own childr en, who is an accountant for her
husband's car pet cleaning business, and who was
r efer r ed by her pr imar y car e doctor because of
incr easing anxiety and the possibility that she is
abusing anxiety and pain medication.

or

This is a 29-year -old, single, white man on


psychiatr ic disability, living in a gr oup home
downtown, with a long histor y of par anoid
schiz ophr enia, who was admitted to the hospital
after gr oup home staff member s found him in the
pr ocess of dr inking a bottle of methyl alcohol in an
appar ent suicide attempt.

CHIEF COMPLAINT
The chi ef compl ai nt shoul d be a ver bati m sentence of the pati ent's,
usual l y i n r esponse to your questi on as to the r eason he i s seeki ng
hel p.

My wife made me come her e. Ther e's nothing


wr ong with me.
My mother just died. I can't deal with it.

I just figur ed it was time to see a ther apist to wor k


out some issues.

Each of these statements r efl ects a di ffer ent sense of pur pose and
ur gency for tr eatment, and consequentl y, thi s i nfor mati on i s hel pful
i n setti ng the stage for the r epor t to fol l ow.

HISTORY OF PRESENT ILLNESS


In Chapter 13, I descr i be two di ffer ent defi ni ti ons of the HPI, one
r efer r i ng to the hi stor y of the i l l ness, whi ch may begi n

year s befor e the i nter vi ew (hi stor y of syndr ome appr oach), and the
other r efer r i ng mor e nar r owl y to events of the past few weeks
(hi stor y of pr esent cr i si s appr oach). Whi ch defi ni ti on to use i s a
matter of per sonal or i nsti tuti onal pr efer ence. Fol l owi ng ar e
exampl es of both appr oaches.

HISTORY OF SYNDROME
Mr . M has a long histor y of bipolar disor der ,
beginning in his junior year of college. He was
hospitaliz ed for manic behavior , which included
studying for days at a time to the point of
exhaustion. In addition, he exhibited gr andiose,
disor ganiz ed behavior when he occupied the
chancellor 's outer office and stated that he was the
chancellor of the univer sity. He was star ted on
lithium at that point and did well for sever al year s,
until he had a ser ies of hospitaliz ations in the ear ly
1990s for depr ession and alcohol use after a
divor ce fr om his wife.

His last hospitaliz ation was 2 year s ago for


depr ession, and he has done fair ly well since then,
taking medications [venlafaxine (Effexor ) and
valpr oic acid (Depakote)] and going to r egular
ther apy and medication appointments.
HISTORY OF PRESENT CRISIS
Mr . M has a long histor y of bipolar disor der with
sever al hospitaliz ations but had been doing fair ly
well for the past 2 year s until about 2 weeks ago,
when his gir lfr iend noticed a patter n of manic
behavior , which began after a pr omotion to a new
position at his company. He has slept an aver age of
3 hour s a night because of a need to pr epar e for
his day, he has been talking mor e r apidly than
usual, and he has been making unr ealistic plans to
become the pr esident of his company. He
consented to this admission on the advice of his
gir lfr iend and his outpatient car egiver s.

PAST PSYCHIATRIC HISTORY


The natur e of the PPH secti on of your wr i te-up depends on how
thor ough you have been i n the HPI. G eneral l y, the PPH i s a ti me to
go i nto some detai l on what sor t of psychi atr i c tr eatment your
pati ent has had i n the past. In Chapter 14, I r ecommend the
mnemoni c GoCHaMP as a way of or gani z i ng your questi oni ng, and
you can al so usethi s for your wr i te-up. You can begi n wi th a General
statement, such as

The patient feels that he has r eceived fair ly


intense, and over all successful, tr eatment for his
depr ession over the year s.

or

The patient has star ted tr eatment at var ious times


but by his own admission has been gener ally
noncompliant.

InCHaMP, the C i s for cur r ent Car egi ver s, i f any. Documenti ng
Hospi tal i z ati ons i s strai ghtfor war d, and usual l y the detai l i s l i mi ted
by your pati ent's memor y. Noti ng the date of the l ast hospi tal i z ati on
i s i mpor tant, because i t has i mpl i cati ons for the sever i ty of the
cur r ent pr obl em. Havi ng a separate headi ng for Medi cati on tr i al s
i s often ver y hel pful , both for other car egi ver s and for easy
r efer ence i f you have to make a medi cati on change several months
or year s after the fi r st vi si t. F i nal l y, documentati on about past
Psychotherapy shoul d i ncl ude a note about whether the pati ent
found i t hel pful and why or why not.

SUBSTANCE USE HISTORY


Wher e i n the eval uati on shoul d you document hi stor y of substance
use? Thi s var i es by practi ti oner, wi th some i ncl udi ng i t i n the PPH,
other s i n the soci al hi stor y, and sti l l other s i n the medi cal hi stor y,
usual l y under habi ts. My pr efer ence i s to use a mai n headi ng
devoted to the i ssue, because i t i s such an i mpor tant and often
over l ooked par t of the psychi atr i c hi stor y.
Under substance use, I i ncl ude tobacco and caffei ne use, as wel l as
the usual ar ray of mor e i nsi di ous substances, such as al cohol or
cocai ne.

REVIEW OF SYMPTOMS
The r evi ew of symptoms i s wher e you can r eal l y i mpr ess your
r eader s wi th your di agnosti c thor oughness. Si mpl y go thr ough the
major di agnosti c categor i es, i ndi cati ng whether the pati ent met any
of the cr i ter i a and excl udi ng those that you al r eady menti oned i n
the HPI and i n the substance abuse secti on, i f you have i ncl uded
one.

On r evi ew of psychi atr i c symptoms, the pati ent


deni ed any hi stor y of mani a or hypomani a. She
descr i bed a hi stor y of fr equent pani c attacks i n the
past, wi th some accompanyi ng agoraphobi c
avoi dance, but sai d that these events had abated
spontaneousl y 2 year s ago. Whi l e she
P.255
consi der s her sel f a per fecti oni st, she deni ed
frank obsessi ons or compul si ons. Ther e was no
hi stor y of eati ng di sor der s, ADHD, somati z ati on
di sor der, di ssoci ati ve di sor der s, or psychoti c
phenomena. Wi th r egar d to PDs, ther e was a hi nt
of dependent trai ts i n her descr i pti on of her
r el ati onshi ps wi th her husband and her best fr i end.
FAMILY HISTORY
If you draw a genogram di r ectl y on the eval uati on for m, thi s wi l l
suffi ce for the fami l y psychi atr i c hi stor y, al though you may want to
add a one-l i ne comment to hi ghl i ght some facet of the hi stor y, such
as

The patient has a str ong genetic loading for bipolar


disor der , as shown in the genogr am.

If you ar e di ctati ng the eval uati on, I suggest drawi ng a genogram


on a bl ank sheet that you can stapl e to the back of the
transcr i pti on, wi th the note see attached genogram i n the fami l y
hi stor y secti on.

SOCIAL HISTORY
The thor oughness and l ength of the soci al hi stor y depend on
cl i ni ci an pr efer ence and the pur pose of the eval uati on. Obvi ousl y, a
mor e l engthy soci al hi stor y i s necessar y i n a psychotherapeuti c
eval uati on than a psychophar macol ogi c eval uati on. In addi ti on,
some cl i ni cal pr obl ems ar e mor e i nfl uenced by psychosoci al i ssues
than other s. PTSD, for exampl e, wi l l al ways r equi r e a fai r l y
extensi ve soci al hi stor y, wher eas schi zophr eni a often devel ops
i ndependentl y of the soci al mi l i eu.
At a mi ni mum, your soci al hi stor y shoul d i ncl ude these pi eces of
i nfor mati on:

Wher e your pati ent was bor n and rai sed


Number of si bl i ngs
Bi r th or der of pati ent and si bl i ngs
Who was pr esent i n the househol d dur i ng the for mati ve year s
Educati onal l evel
Wor k hi stor y
Mar i tal and par enti ng hi stor y of pati ent
Typi cal dai l y acti vi ti es other than wor k
The patient was bor n and r aised in Lowell,
Massachusetts, and is the youngest of thr ee
childr en, with a br other aged 50 and a sister aged
53. He descr ibes his childhood as nor mal until his
father died in a car accident when the patient was
10 year s old, after which his mother was always
depr essed. His gr ades in high school wer e Bs and
Cs, and he went to technical school to study auto
mechanics for 2 year s. He eventually opened his
own auto body business, which he still r uns. He
mar r ied his cur r ent wife, Diane, when he was 24,
and they now have two childr en, both gir ls, ages
21 (Laur a) and 24 (Angie). He is close to both of
them. He wor ks 6 days a week, and when he is not
at wor k, he often watches television while dr inking
a beer and occasionally goes fishing with male
fr iends. He descr ibed his r elationship with his wife
with the comment, We get along.

MEDICAL HISTORY
You may use the mnemoni c MIDA S to or gani ze the medi cal hi stor y.
I usual l y begi n wi th a statement about the pati ent's general heal th,
such as:

The patient r epor ts that she is in good over all


health.

The patient has suffer ed a number of chr onic


medical pr oblems.

Li st any i l l nesses, sur ger i es, pr escr i bed medi cati ons, and medi cati on
al l er gi es. Note the name of the pr i mar y car e physi ci an. If you have
asked questi ons fr om the medi cal r evi ew of systems, note any
r el evant answer s. At a mi ni mum, note whether the pati ent has had
any sei z ur es or head i njur i es, both of whi ch ar e often ger mane to
psychi atr i c pr obl ems.

The patient is in good gener al health and denies


any histor y of major illnesses, sur ger ies, head
injur ies, or seiz ur es. She takes no medications
aside fr om bir th contr ol pills, and she r epor ts an
aller gy to penicillin. She has r egular gynecologic
examinations with Dr . L.

The pati ent has a si gni fi cant and compl i cated


medi cal hi stor y, i ncl udi ng hear t di sease, di abetes,
and neur ol ogi c pr obl ems stemmi ng fr om the
di abetes. She had cor onar y bypass sur ger y l ast
year. Cur r entl y, she has shor tness of br eath when
she wal ks a hal f bl ock, and she has constant pai n
i n her feet. She r ecal l s havi ng had a concussi on
after fal l i ng off a hor se when she was young, but
she deni es any sei z ur e hi stor y. Her pr i mar y car e
physi ci an i s Dr. R, and her medi cati ons i ncl ude
i nsul i n, captopr i l ,
P.257
fur osemi de (Lasi x), potassi um suppl ement,
hydr ocodone (Vi codi n) for pai n, and par oxeti ne
(Paxi l ) (20 mg a day). She once had an al l er gi c
r eacti on to bupr opi on (Wel l butr i n), i nvol vi ng a
total body rash.

MENTAL STATUS EXAMINATION


In wr i ti ng up or di ctati ng the mental status secti on of your
di agnosti c eval uati on, temporar i l y shed your cl i ni ci an's mantl e and
become a cr eati ve wr i ter. Descr i be your pati ent so wel l that a
r eader woul d be abl e to r ecogni ze hi m fr om your descr i pti on al one.
Compar e the fol l owi ng two descr i pti ons of the same pati ent:

The patient was a 32-year -old man who was tir ed


but cooper ative with the inter view. He was
disheveled. Eye contact was good. Mood and affect
wer e angr y and ir r itable.

The patient was inter viewed in a medical bay of the


emer gency r oom. He was lying on his back on a
gur ney in four -point r estr aints, wear ing a hospital
gown. He had r eceived 5 mg of haloper idol (Haldol)
intr amuscular ly shor tly befor e the inter view. As I
walked in, he lifted his head and looked at me
intensely, saying, Will you get me the hell out of
these shackles? I assur ed him that I would do so if
he posed no danger to himself or other s. He was
r esigned and cooper ative fr om that point on.

The second ver si on gi ves a mor e vi vi d sense of the pati ent's mental
status. Yes, he i s angr y and i r r i tabl e, but thi s i s i n r eacti on to
somethi ng i n hi s envi r onment. F ur ther mor e, he's abl e to modul ate
hi s affect i n r esponse to the i nter vi ewer 's statement, i ndi cati ng a
degr ee of contr ol over hi s emoti onal state not communi cated by the
fi r st summar y. The di shevel ed of the fi r st wr i te-up mi ght i mpl y
the sel f-negl ect character i sti c of schi zophr eni a, but i n fact i t's har d
to l ook anythi ng but di shevel ed when you'r e i n a gur ney wi th your
l i mbs r estrai ned.
That sai d, pr ofessi onal jar gon does have i ts pl ace i n the wr i te-up.
Thi s i s especi al l y tr ue i n the descr i pti on of psychoti c TP and TC.
Wor ds and phrases such as tangentiality, looseness of associations,
and ideas of r efer ence ar e techni cal ter ms wi th meani ngs that ar e
under stood thr oughout the mental heal th fi el d, and they shoul d be
used when appr opr i ate. Tabl e 33.1 l i sts some common jar gon-
contai ni ng statements and some fr esher al ter nati ves.

TABLE 33.1. Alternatives to jargon

Mental status
More descriptive alternative
jargon

She was a She answered all questions in


cooperative full but with a sense of apathy
informant. and indifference.

He had short brown hair that


He was well-
was washed and combed, and
groomed.
he was clean-shaven.

She had long black hair that


She was looked stiff and unwashed.
disheveled. Her hands were caked with
dirt.

He showed
He sat slumped over, staring
psychomotor
at the floor, and was nearly
retardation;
motionless throughout the
eye contact
interview.
was poor.

She spoke in a monotonous


Speech was and wooden tone, and so
fluent and of softly that I had to lean
low volume. toward her to understand her
words.

Affect was flat


He appeared sad and morose
and
throughout the interview.
dysthymic.

Your MSE can fol l ow the for mat outl i ned i n Chapter 20 (r ecal l the
mnemoni c: A l l Bor der l i ne Subjects A r e Tough, Tr oubl ed
Character s). A good strategy i s to l i mi t jar gon to those aspects of
the MSE that ar e nor mal and to use mor e descr i pti ve l anguage for
those par ts of the exami nati on that ar e di r ectl y r el evant to the
eventual di agnosi s.

This was a well-gr oomed, pleasant-appear ing


woman, dr essed in a pr ofessional suit and smelling
str ongly of per fume. She pr esented her self as
ser ious and engaged. Her body was tense; she
spoke r apidly and ar ticulately as she r elated her
psychiatr ic histor y. She seemed quite anxious, with
her hands clenched ar ound her billfold and her feet
tapping the floor . Her stated mood was I'm just
bar ely holding on, and I'm scar ed of having a
panic attack all the time. Her TP was coher ent in
content and without hallucinations or delusions, but
with some excessive r umination on the theme of
getting just the r ight medicine. She denied SI. On
cognitive scr een, concentr ation and memor y wer e
nor mal.

The pati ent pr esented as a somewhat di shevel ed


man wi th l ong bl ack hai r, scraggl y bear d, and
soi l ed cl othes. He wor e hor n-r i mmed gl asses and
had the l ook of an eccentr i c i ntel l ectual . He sat
qui etl y for the most par t and vol unteer ed ver y
l i ttl e i nfor mati on; he seemed apatheti c rather than
guar ded. Hi s affect was bl and, wi th a str i ki ng
di spar i ty between hi s stated mood (I'm headed for
a br eakdown. I hate thi s l i fe.)
P.259
and hi s affect. Hi s TP was coher ent and wi thout
any LOA or fl i ght of i deas. TC was i mpover i shed.
He deni ed any cur r ent hal l uci nati ons but admi tted
to havi ng hear d a voi ce cal l i ng hi s name once or
twi ce over the pr ecedi ng week. He sai d he wi shed
he wer e dead but deni ed any pl an to har m hi msel f.
On cogni ti ve scr een, concentrati on and memor y
wer e nor mal .

ASSESSMENT
The assessment shoul d be a br i ef r ecapi tul ati on of the overal l
cl i ni cal pi ctur e and a di scussi on of di ffer enti al di agnosi s. Remember
that many peopl e who r ead your wr i te-up wi l l r ead onl y thi s secti on
to get r i ght to the poi nt. Ther efor e, take pai ns to make the
assessment both conci se and i nfor mati ve.

This is a 27-year -old mar r ied, white, father of two


who pr esents with a histor y consistent with bipolar
disor der and a cur r ent clinical pictur e of major
depr ession with NVSs of hyper somnia, lethar gy,
poor concentr ation, and incr eased appetite for
sweet foods. In addition, he pr esents with
significant anxiety, but he pr obably does not meet
cr iter ia for a discr ete anxiety disor der , with the
possible exception of G AD. Significant family
conflict has contr ibuted to his cur r ent illness.

This is a 52-year -old, never -mar r ied, Afr ican-


Amer ican woman who has a long and complicated
histor y of chr onic mental illness, var iously
diagnosed as schiz oaffective disor der and chr onic
schiz ophr enia. She pr esents now in a flor id
psychotic state with AHs, ideas of r efer ence,
ir r itability, anxiety, and lack of sleep for 3 days.
The cur r ent pictur e is confusing, and it may
r epr esent an ir r itable manic episode or an agitated
depr ession with psychosis. Medication
noncompliance may have been a pr ecipitant,
although chr onic pover ty is a r elevant psychosocial
factor .

DSM-IV-TR DIAGNOSIS
It i s i mpor tant to l i st al l fi ve axes, r eal i z i ng that i nsurance
compani es i n par ti cul ar r el y heavi l y on thi s secti on i n deter mi ni ng
need for conti nui ng car e.

AXIS I
Axis I r efer s to the mai n psychi atr i c di agnosi s. Al though busy
cl i ni ci ans often get l az y i n thi s secti on and wr i te an unoffi ci al or

tr uncated di agnosti c l abel , I suggest that you get i nto the habi t
ear l y of maki ng sur e your di agnosi s i s actual l y l i sted as such i n the
DSM-IV-TR. The way to make sur e you do thi s i s to wr i te down the
DSM-IV-TR code ever y ti me, an admi ttedl y tedi ous (and, to some,
cl i ni cal l y i r r el evant) task. Wr i ti ng down the code has the addi ti onal
advantage of savi ng ti me l ater i n the tr eatment when you r equest
mor e tr eatment sessi ons and you have to wr i te the DSM-IV-TR code
on the author i z ati on r equest for m.
To make thi s easi er for you, I have i ncl uded a pocket car d i n
Appendi x A wi th a l i st of the mor e common di agnoses and thei r
DSM-IV-TR codes.
AXIS II
The axi s II secti on i s wher e you code PDs and mental r etar dati on.
Because i t i s so har d to defi ni ti vel y di agnose a PD after a si ngl e
i nter vi ew, i t i s common practi ce to ei ther note a r ul e out
di agnosi s (e.g., Rul e out bor der l i ne per sonal i ty di sor der.) or use
the ol d standby, per sonal i ty di sor der NOS, often speci fyi ng several
candi date trai tsfor exampl e, Per sonal i ty di sor der NOS wi th
bor der l i ne, hi str i oni c, and nar ci ssi sti c trai ts. One commonl y sees
defer r ed as the axi s II di agnosi s, whi ch means that the cl i ni ci an
coul d not obtai n enough i nfor mati on to deci de whether a PD exi sted.
Al though thi s may be the case, tr y not to use defer r ed too much,
as i t can tur n i nto a cop-out fr om your cl i ni cal duty to acti vel y
pr obe for evi dence of PD trai ts.

AXIS III
Note any general medi cal condi ti ons that ar e si gni fi cant, ei ther i n
ter ms of contr i buti ng towar d the psychi atr i c di agnosi s (e.g.,
hypothyr oi di sm aggravati ng depr essi on) or affecti ng the pati ent's
cur r ent functi oni ng (e.g., hear t di sease, causi ng shor tness of
br eath). You don't have to menti on your pati ent's eczema or
chi l dhood tonsi l l ectomy i n thi s secti on, unl ess the pr obl em i s
r el evant.

AXIS IV
The axi s IV secti on i s wher e you shoul d note any psychosoci al
pr obl ems that may be aggravati ng the psychi atr i c condi ti on or, i n
some cases, may be the r esul t of i t. DSM-IV-TRgr oups these
pr obl ems i nto ni ne hel pful categor i es:

1. Pr obl ems wi th pr i mar y suppor t gr oup


2. Pr obl ems r el ated to the soci al envi r onment
3. Educati onal pr obl ems
4. Occupati onal pr obl ems
5. Housi ng pr obl ems
6. Economi c pr obl ems
7. Pr obl ems wi th access to heal th car e ser vi ces
8. Pr obl ems r el ated to i nteracti on wi th the l egal system
9. Other psychosoci al and envi r onmental pr obl ems

Remember that some appar entl y posi ti ve events can contr i bute to
psychi atr i c pr obl ems as wel l , as i n the exampl e of the pati ent who
fi nal l y gets a bi g pr omoti on and devel ops pani c di sor der r el ated to
fear of fai l ur e i n the new posi ti on.

AXIS V
The gl obal assessment of functi oni ng (G AF ) i s a numer i c scal e fr om
1 to 100 that i ndi cates the degr ee to whi ch the cl i ni cal di sor der has
i mpai r ed your pati ent's psychol ogi cal , soci al , and occupati onal
functi oni ng. I consi der i t one of the mor e annoyi ng contr i buti ons of
the DSM-IV to the mental heal th car e system, because the scor es
ar e subjecti ve and var y wi del y among di ffer ent practi ti oner s. My
G AF of 60 may be a col l eague's G AF of 45. To make matter s wor se,
most managed-car e compani es r equi r e you to note the G AF on
tr eatment author i z ati on for ms, meani ng that you have no choi ce but
to l ear n the scal e, no matter how usel ess you may fi nd i t to be.
Her e's my own abbr evi ated G AF -made-easy scal e that may
faci l i tate your scor e-assi gnment chor e (Tabl e 33.2).

TABLE 33.2. GAF-made-easy scale

GAF
Applicable clinical situation
score

90 Probably none. Very few people with


and absent or minimal symptoms will
above make it into your office.

Patients who were once symptomatic


but who have been successfully treated
80
and are continuing to see you to
maintain remission.
Mild depression, mild anxiety, mild
70
problems functioning.

Moderate symptoms, moderate


60
functioning problems.

Serious symptoms, serious functioning


50
problems.

Severe symptoms. You will be


40 considering hospitalization for patients
with GAF of 40 or below.

30 Very severe symptoms. If this patient


and is not yet in the hospital, call an
below ambulance immediately.

Rul es of thumb:

In a typi cal outpati ent mental heal th practi ce, pati ents wi l l wal k
i nto your offi ce wi th G AF scor es of 50 or 60 and wi l l i mpr ove to
G AF scor es of 70 or 80.
In a typi cal i npati ent setti ng, pati ents ar e admi tted wi th G AF
scor es of 40 or bel ow and wi l l be di schar ged wi th G AF scor es of
ar ound 50.

TREATMENT PLAN
A good, conci se tr eatment pl an shoul d i ncl ude

Any di agnosti c testi ng pl anned (i .e., neur opsychol ogi cal testi ng,
l aborator y tests)

Pl ans for medi cati on, i f you can pr escr i be


Pl ans for therapy, i f needed
Refer ral s to other heal th car e practi ti oner s, i f appl i cabl e
When you pl an to see your pati ent agai n

For exampl e,

The plan is to obtain electr olytes, complete blood


cell count, and thyr oid panel to scr een for or ganic
causes of his symptoms; to star t ser tr aline (Zoloft)
at 25 mg per day, incr easing to 50 mg per day, as
toler ated (patient was infor med of, and under stood,
potential r isks and benefits of medication); and to
star t weekly cognitive behavior al ther apy. I will see
him again in 1 week.

The plan is to begin psychodynamic ther apy to


addr ess her gr ief issues and to r efer to a
psychiatr ist for possible antianxiety medication. I
will see her again in 1 week.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ba c k o f Bo o k > Re s o urc e s > A - Po c k e t C a rds

A
Pocket Cards

Psychiatric evaluation

Section of
Relevant data
evaluation

Current complaint
Source

Identifying
Chronology, precipitants,
data/history of
neurovegetative symptoms
present illness

Past psychiatric
history
Go CHaMP
Suicidal
ideation/suicide
attempt

Drug of choice, first use, last


Substances use, longest sobriety,
detoxifica- Tions, history of
seizure, delirium tremens

Legal history

Depression, mania, anxiety,


psychosis, attention-deficit
Psychiatric hyper- activity disorder,
review of emotional
symptoms Disorder/disturbance,
borderline, schizoid,
antisocial

Past medical MIDAS, head trauma, brain


history studies, review of systems

Raised, abuse, education,


Social history
work, relationships

Family history

Mental status
examination
Appearance, behavior,
Physical
speech, mood, affect,
examination
thought process, thought
Narrative
content, cognitive
assessment
DSM-IV-TR
axes Plan
DSM-IV-TR mnemonics

SIGECAPS (4/8)
Major depression ACHEWS (2/6)
Dysthymia DIGFAST (3/7)
Manic episode Delusions Herald
Schizophrenia Schizophrenic's
Bad News (2/5)

Tempted With Cognac


Substance abuse
(3/7)

Alcoholism CAGE (2/4)

Heart (3)
Panic attack Breathlessness (5)
Fear (5) (4/13)

Obsessive- Washing and


compulsive Straightening Make Clean
disorder Houses (1/5)

Remembers (1) Atrocious


Posttraumatic
(3) Nuclear (3) Attacks
stress disorder
(2)

Macbeth Frets Constantly


Generalized
Regarding Illicit Sins
anxiety disorder
(3/6)
Somatization Recipe 4 Pain: Convert 2
disorder Stomachs to 1 Sex (8/8)

Bulimics Over-Consume
Bulimia nervosa
Pastries (4/4)

Weight Fear Bothers


Anorexia nervosa
Anorexics (4/4)

Memory BREW (Memory


Dementia
+ 1/4)

Delirium Medical FRAT (5/5)

Attention-deficit
hyperactivity MOAT (6/9)
Disorder

Borderline
personality I DESPAIRR
disorder

Note: The numbers in parentheses reflect the


number of criteria required for diagnosis out of
the total possible criteria.

Defense mechanisms

Suppression
Mature Altruism
defenses Sublimation
Humor

Denial
Repression
Neurotic
Reaction formation
defenses
Displacement
Rationalization

Passive aggression
Acting out
Immature Dissociation
defenses Projection
Splitting
(idealization/devaluation)

Psychotic Denial of external reality


defenses Distortion of external reality

Appearance terms

Aspect Appearance descriptors

Bald, thinning, close-cropped,


short, long, shoulder-length,
crew-cut, straight, curly, wavy,
Hair frizzy, braided, pony tail, pig
tails, afro, relaxed, dreadlocks,
unevenly cut, stiff, greasy, dry,
matted

Clean-shaven, neatly trimmed


Facial hair beard, long scraggly beard,
goatee, unshaven

Attractive, nice-looking, pleasant,


plain, pale, drawn, mongoloid,
Face ruddy, flushed, bony, thin, broad,
moon-shaped, red-nosed, thickly
made-up

Good, shifty, averted, staring,


Eyes fixated, dilated, downcast,
(gaze) forceful, intense, aggressive,
piercing

Thin, cachectic, lean, frail,


underweight, normal build,
muscular, husky, stocky,
Body overweight, moderately obese,
obese, morbidly obese, short,
medium height, tall, tattooed
arms

No abnormal movements, fidgety,


bobbing knee, facial tic or twitch,
lip-smacking, lip-puckering,
Movements
tremulous, jittery, restless,
wringing hands, motionless, rigid,
limp, stiff, slumped
Casually dressed, neat,
appropriate, professional,
Clothes immaculate, fashionable, sloppy,
ill-fitting, outdated, flamboyant,
sexually provocative, soiled, dirty,
tight, loose, slogans on clothes

Affect terms

Affect Terms

Appropriate, calm, pleasant,


Normal relaxed, normal, friendly,
comfortable, unremarkable

Cheerful, bright, peppy, content,


self-satisfied, silly, giggly,
Happy
grandiose, euphoric, elated,
exalted

Sad, gloomy, sullen, depressed,


Sad pessimistic, morose, hopeless,
discouraged

Anxious, worried, tense, nervous,


Anxious apprehensive, frightened,
terrified, bewildered, paranoid

Angry, irritable, disdainful, bitter,


Angry arrogant, defensive, sarcastic,
annoyed, furious, enraged, hostile

Indifferent, shallow, superficial,


cool, distant, apathetic, aloof,
Indifferent
dull, vacant, affectless,
uninterested, cynical

Rapid IQ test, Wilson Rapid Approximate


Intelligence Test

Intelligence Best effort IQ

Retarded 2 6 <70

Borderline 2 24 7080

Dull normal 2 48 8090

Average 2 196 90110

From Wilson, I. C. (1967). Rapid approximate


intelligence test. American Journal of
Psychiatry, 123:12891290, with permission.

Heritability and prevalence of psychiatric


disorders
Lifetime Lifetime
DSM-IV-TR relative risk if prevalence
disorder first-degree in general
relative has population b
disorder a

Bipolar
25 1
disorder

Schizophrenia 19 1

Bulimia
10 2c
nervosa

Panic
10 4
disorder

Alcoholism 7 14

Generalized
anxiety 6 5
disorder

Anorexia
5 1c
nervosa

Simple
3 11
phobia

Social phobia 3 13

Somatization
disorder 3 2d

Major
3 17
depression

Obsessive-
compulsive ? 3e
disorder

Agoraphobia 3 5

a Relative risk figures from Reider, R. O.,


Kaufmann, C., et al. (1994). Genetics. In R. E.
Hales, S. C. Yudofsky, and J. A. Talbott (Eds.),
American Psychiatric Press Textbook of
Psychiatry. Washington, DC: American
Psychiatric Press. See Chapter 15, page 90, for
explanation.
b Lifetime prevalence figures from Kessler, R.

C., McGonagle K. A., Zhao, S., et al. (1994).


Lifetime and 12-month prevalence of DSM-III-R
psychiatric disorders in the United States.
Archives of General Psychiatry, 51, 819; and
Regier, D. A., Farmer, M. E., et al. (1990).
Comorbidity of mental disorders with alcohol
and other drug abuse. Journal of the American
Medical Association, 264, 25112518.
c From Halmi, K. A. (1994). Eating disorders:

Anorexia nervosa, bulimia nervosa, and


obesity. In R. E. Hales, S. C. Yudofsky, and J.
A. Talbott (Eds.), American Psychiatric Press
Textbook of Psychiatry. Washington, DC:
American Psychiatric Press.
d From Martin, R. L., and Yutzy, S. H. (1994).

Somatoform disorders. In R. E. Hales, S. C.


Yudofsky, and J. A. Talbott (Eds.), American
Psychiatric Press Textbook of Psychiatry.
Washington, DC: American Psychiatric Press.
e From Hollander, E., Simeon, D., et al. (1994).

Anxiety disorders. In R. E. Hales, S. C.


Yudofsky, and J. A. Talbott (Eds.), American
Psychiatric Press Textbook of Psychiatry.
Washington, DC: American Psychiatric Press.

Weight table for women

Ideal weight (lb, for 15%


Height
medium frame) under

410 113 96

411 115 98

50 118 100

51 121 103

52 124 105

53 127 108
54 130 111

55 133 113

56 136 115

57 139 118

58 142 120

59 145 123

510 148 126

511 151 128

60 154 131

Weight table for men

Ideal weight (lb, for 15%


Height
medium frame) under

52 137 116

53 139 118

54 141 120
55 143 122

56 145 123

57 148 126

58 151 128

59 154 131

510 157 133

511 160 136

60 163 139

61 167 142

62 171 145

63 175 149

64 179 152

Comman DSM-IV-TR diagnoses

Numeric
Diagnosis
code
Alcohol abuse 305.00

Alcohol dependence 303.90

Anorexia nervosa 307.1

Anxiety disorder NOS 300.00

Attention-deficit hyperactivity
314.01
disorder, combined type

Bipolar I disorder, depressed episode 296.52

Bipolar I disorder, manic episode 296.42

Borderline personality disorder 301.83

Bulimia nervosa 307.51

Delirium 293.0

Dementia of the Alzheimers type,


290.0
late onset, uncomplicated

Dysthymic disorder 300.4

Generalized anxiety disorder 300.02

Major depression, single episode,


296.22
moderate
Major depression, recurrent, 296.32
moderate

Obsessive-compulsive disorder 300.3

Panic disorder without agoraphobia 300.01

Panic disorder with agoraphobia 300.21

Personality disorder NOS 301.9

Polysubstance dependence 304.80

Posttraumatic stress disorder 309.81

Schizoaffective disorder 295.70

Schizophrenia, paranoid type 295.30

Schizophrenia, undifferentiated type 295.90

Social phobia 300.23

Somatization disorder 300.81

Global Assessment of Functioning (GAF)-


made-easy scale

GAF
score Applicable clinical situation

90 Probably none. Very few people with


and absent or minimal symptoms will
above make it into your office.

Patients who were once symptomatic,


but who have been successfully treated
80
and are continuing to see you to
maintain remission.

Mild depression, mild anxiety, mild


70
problems functioning.

Moderate symptoms, moderate


60
functioning problems.

Serious symptoms, serious functioning


50
problems.

Severe symptoms. You will consider


40 hospitalization for patients with GAF of
40 or below.

30 Very severe symptoms. If this patient


and is not yet in the hospital, call an
below ambulance immediately.

Age- and education-adjusted norms for th


Examinataion (mean

Age (
Education
level (yr) 18 25 30 35 40 45 50
24 29 34 39 44 49 54

04 22 25 25 23 23 23 23

58 27 27 26 26 27 26 27

912 29 29 29 28 28 28 28

College
and 29 29 29 29 29 29 29
higher

From Crum, R. M., Anthony, J. C., Bassett, S. S., a


Population-based norms for the MiniMental State E
level. Journal of the American Medical Association,
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ba c k o f Bo o k > Re s o urc e s > B - Da t a F o rm s fo r t he Int e rv ie w

B
Data Forms for the Interview
INITIA L PSYCHIA TRIC EVA LUA TION (SHORT FORM)
INITIA L PSYCHIA TRIC EVA LUA TION (LONG FORM)*

PA TIENT QUESTIONNA IRE*

P.278

Footnote
*Adapted fr om the eval uati on for m of Anthony Er dmann, M.D.
*Adapted fr om the questi onnai r e of Edwar d Messner, M.D.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ba c k o f Bo o k > Re s o urc e s > C - Pa t ie nt Educ a t io n Ha ndo ut s

C
Patient Education Handouts

MAJOR DEPRESSION*
Pati ent Infor mati on Handout

Who Gets Depressed?


Major depr essi ve di sor der, often r efer r ed to as clinical depr ession, i s
a common i l l ness that can affect anyone. Dur i ng any 1-year per i od,
17.6 mi l l i on Amer i can adul ts, or 10% of the popul ati on, suffer fr om
ei ther a major or mi nor depr essi on.

What Is Depression?
Depr essi on i s not just feel i ng bl ue or bei ng down i n the dumps.
It i s mor e than bei ng sad or feel i ng gr i ef after a l oss. Depr essi on i s
an i l l ness (i n the same way that di abetes, hi gh bl ood pr essur e, and
hear t di sease ar e i l l nesses) that affects your thoughts, feel i ngs,
physi cal heal th, and behavi or s day after day.
Depr essi on may be caused by many thi ngs, i ncl udi ng the fol l owi ng:

Str essful or depr essi ng l i fe events


Fami l y hi stor y and geneti cs
Cer tai n medi cal i l l nesses
Cer tai n medi ci nes
Dr ugs or al cohol
Other psychi atr i c condi ti ons

Cer tai n l i fe condi ti ons (e.g., extr eme str ess or gr i ef ) may br i ng on a
depr essi on or pr event a ful l r ecover y. In some peopl e, depr essi on
occur s even when l i fe i s goi ng wel l . Depr essi on i s not your faul t,
nor i s i t a weakness. It i s an i l l ness, and i t i s tr eatabl e.

How Will I Know Whether I Am Depressed?


Peopl e who have major depr essi ve di sor der have a number of
symptoms near l y ever y day, al l day, for at l east 2 weeks. These
al ways i ncl ude at l east one of the fol l owi ng:

Loss of i nter est i n thi ngs you used to enjoy


Feel i ng sad, bl ue, or down i n the dumps

You may al so have at l east thr ee of the fol l owi ng symptoms:

Feel i ng sl owed down or r estl ess and unabl e to si t sti l l


Feel i ng wor thl ess or gui l ty
Incr ease or decr ease i n appeti te or wei ght
Thoughts of death or sui ci de
Pr obl ems concentrati ng, thi nki ng, r emember i ng, or maki ng
deci si ons
Tr oubl e sl eepi ng or sl eepi ng too much
Loss of ener gy or feel i ng ti r ed al l of the ti me

Wi th depr essi on, other physi cal or psychol ogi cal symptoms ar e often
pr esent, i ncl udi ng the fol l owi ng:

Headaches
Other aches and pai ns
Di gesti ve pr obl ems
Sexual pr obl ems
Feel i ng pessi mi sti c or hopel ess
Bei ng anxi ous or wor r i ed

How Is Depression Treated?


Depr essi on i s tr eated wi th ei ther psychotherapy (counsel i ng) or
medi cati ons, or wi th both tr eatments combi ned.
Psychotherapy
The most effecti ve psychotherapi es for depr essi on ar e

Cogni ti ve therapy, i n whi ch the therapi st poi nts out ways that
your thi nki ng i s negati ve and may actual l y cause you to be mor e
depr essed.
Inter per sonal therapy, i n whi ch the focus i s on i mpr ovi ng the
qual i ty of your r el ati onshi ps wi th i mpor tant peopl e i n your l i fe.

Psychotherapy may take one to several months to cur e your


depr essi on.

Medications
Many effecti ve medi cati ons for depr essi on exi st. The most commonl y
pr escr i bed ar e the sel ecti ve ser otoni n r euptake i nhi bi tor s (SSRIs),
whi ch have names l i ke Pr oz ac, Zol oft, Paxi l , and Luvox. These ar e
popul ar because they have ver y few si de effects when compar ed
wi th ol der medi cati ons.
When someone begi ns taki ng an anti depr essant, i mpr ovement
general l y wi l l not begi n to show i mmedi atel y. Wi th most of these
medi cati ons, i t wi l l take fr om 1 to 3 weeks befor e changes begi n to
occur. Some symptoms di mi ni sh ear l y i n tr eatment; other s, l ater.
For i nstance, a per son's ener gy l evel or hi s sl eepi ng or eati ng
patter ns may i mpr ove befor e hi s depr essed mood l i fts. If ther e i s
l i ttl e or no change i n symptoms after 5 to 6 weeks, a di ffer ent
medi cati on may be tr i ed. Some peopl e wi l l r espond better to one
than to another. Because ther e i s no way of deter mi ni ng befor ehand
whi ch medi cati on wi l l be effecti ve, the doctor may have to pr escr i be
fi r st one, then another, unti l an effecti ve medi cati on i s found.
Tr eatment i s conti nued for a mi ni mum of several months and may
l ast up to a year or mor e.

BIPOLAR DISORDER
Pati ent Infor mati on Handout

What Is Bipolar Disorder?


Bi pol ar di sor der, whi ch i s al so known as mani c-depr essi ve i l l ness, i s
a mental i l l ness i nvol vi ng epi sodes of ser i ous mani a and depr essi on.
The per son's mood usual l y swi ngs fr om over l y hi gh and i r r i tabl e to
sad and hopel ess and then back agai n, wi th per i ods of nor mal mood
i n between. Bi pol ar di sor der typi cal l y begi ns i n adol escence or ear l y
adul thood and conti nues thr oughout l i fe. At l east 2 mi l l i on
Amer i cans suffer fr om mani c-depr essi ve i l l ness. Bi pol ar di sor der
tends to r un i n fami l i es and i s bel i eved to be i nher i ted i n many
cases.

Key Features of Bipolar Disorder


Bi pol ar di sor der i nvol ves cycl es of mani a and depr essi on.
Si gns and symptoms of mania i ncl ude di scr ete per i ods of

Incr eased ener gy, acti vi ty, r estl essness, raci ng thoughts, and
rapi d tal ki ng
Excessi ve hi gh or euphor i c feel i ngs
Extr eme i r r i tabi l i ty and di stracti bi l i ty
Decr eased need for sl eep
Unr eal i sti c bel i efs i n one's abi l i ti es and power s
Uncharacter i sti cal l y poor judgment
A sustai ned per i od of behavi or that i s di ffer ent fr om usual
Incr eased sexual dr i ve
Abuse of dr ugs, par ti cul ar l y cocai ne, al cohol , and sl eepi ng
medi cati ons
Pr ovocati ve, i ntr usi ve, or aggr essi ve behavi or
Deni al that anythi ng i s wr ong

Si gns and symptoms of depression i ncl ude di scr ete per i ods of

Per si stent sad, anxi ous, or empty mood


Feel i ngs of hopel essness or pessi mi sm
Feel i ngs of gui l t, wor thl essness, or hel pl essness
Loss of i nter est or pl easur e i n or di nar y acti vi ti es, i ncl udi ng sex
Decr eased ener gy, a feel i ng of fati gue or of bei ng sl owed down
Di ffi cul ty concentrati ng, r emember i ng, or maki ng deci si ons
Restl essness or i r r i tabi l i ty
Sl eep di stur bances
Loss of appeti te and wei ght, or wei ght gai n
Chr oni c pai n or other per si stent bodi l y symptoms that ar e not
caused by physi cal di sease
Thoughts of death or sui ci de; sui ci de attempts

How Is Bipolar Disorder Treated?


The most effecti ve tr eatment for bi pol ar di sor der i s one of a var i ety
of mood-stabi l i z i ng medi cati ons. The most wel l -known of these i s
lithium, whi ch was the fi r st medi cati on i ntr oduced for bi pol ar
di sor der. Mor e r ecentl y, two other medi cati ons have been
i ntr oduced: Tegretol and Depakote. Al though al l medi cati ons for
bi pol ar di sor der ar e effecti ve, si de effects, i ncl udi ng sedati on,
wei ght gai n, and l i ght-headedness, often occur. Psychi atr i sts can
mi ni mi ze these si de effects by adjusti ng the dosage and for mul ati on
of medi cati ons.
In addi ti on to medi cati ons, psychotherapy i s hel pful , especi al l y
dur i ng the depr essed phase of bi pol ar di sor der. Combi nati on
tr eatment (medi cati ons i n combi nati on wi th therapy) l eads to the
best r esul ts for most pati ents.

PANIC DISORDER
Pati ent Infor mati on Handout

It star ted 10 year s ago. I was si tti ng i n a semi nar i n a hotel


and thi s thi ng came out of the cl ear bl ue. I fel t l i ke I was dyi ng.
For me, a pani c attack i s al most a vi ol ent exper i ence. I feel l i ke
I'm goi ng i nsane. It makes me feel l i ke I'm l osi ng contr ol i n a
ver y extr eme way. My hear t pounds r eal l y har d, thi ngs seem
unr eal , and ther e's thi s ver y str ong feel i ng of i mpendi ng doom.
Between attacks ther e i s thi s dr ead and anxi ety that i t's goi ng
to happen agai n. It can be ver y debi l i tati ng, tr yi ng to escape
those feel i ngs of pani c.
What Is Panic Disorder?
Peopl e wi th pani c di sor der have feel i ngs of ter r or that str i ke
suddenl y and r epeatedl y wi th no war ni ng. They can't pr edi ct when
an attack wi l l occur, and many devel op i ntense anxi ety between
epi sodes, wor r yi ng when and wher e the next one wi l l str i ke.
Between epi sodes they feel a per si stent, l i nger i ng wor r y that
another attack coul d come any mi nute. When a pani c attack str i kes,
your hear t most l i kel y pounds, and you may feel sweaty, weak,
fai nt, or di z z y. Your hands may ti ngl e or feel numb, and you mi ght
feel fl ushed or chi l l ed. You may have chest pai n or smother i ng
sensati ons, a sense of unr eal i ty, or fear of i mpendi ng doom or l oss
of contr ol . You may genui nel y bel i eve you'r e havi ng a hear t attack
or str oke, l osi ng your mi nd, or on the ver ge of death. Attacks can
occur any ti me, even dur i ng nondr eam sl eep. Most attacks average
a coupl e of mi nutes, but occasi onal l y they can go on for up to 10
mi nutes. In rar e cases, they may l ast an hour or mor e.
Pani c di sor der i s often accompani ed by other condi ti ons, such as
depr essi on or al cohol i sm, and may spawn phobi as, whi ch can
devel op i n pl aces or si tuati ons wher e pani c attacks have occur r ed.
For exampl e, i f a pani c attack str i kes whi l e you'r e r i di ng an
el evator, you may devel op a fear of el evator s and star t avoi di ng
them. Some peopl e's l i ves become gr eatl y

r estr i ctedthey avoi d nor mal , ever yday acti vi ti es such as gr ocer y
shoppi ng, dr i vi ng, or even l eavi ng the house. They may be abl e to
confr ont a fear ed si tuati on onl y i f accompani ed by a spouse or other
tr usted per son. Basi cal l y, they avoi d any si tuati on they fear woul d
make them feel hel pl ess i f a pani c attack occur r ed. When peopl e's
l i ves become so r estr i cted by the di sor der, as happens i n about one-
thi r d of al l peopl e wi th pani c di sor der, the condi ti on i s cal l ed
agoraphobi a. A tendency towar d pani c di sor der and agoraphobi a
r uns i n fami l i es. Never thel ess, ear l y tr eatment of pani c di sor der can
often stop the pr ogr essi on to agoraphobi a.
Pani c attack symptoms i ncl ude

Poundi ng hear t
Chest pai ns
Li ght-headedness or di z z i ness
Nausea or stomach pr obl ems
F l ushes or chi l l s
Shor tness of br eath, or a feel i ng of smother i ng or choki ng
Ti ngl i ng or numbness
Shaki ng or tr embl i ng
Feel i ngs of unr eal i ty
Ter r or
A feel i ng of bei ng out of contr ol or goi ng craz y
Fear of dyi ng
Sweati ng

Who Gets Panic Disorder?


Pani c di sor der str i kes at l east 1.6% of the popul ati on and i s twi ce
as common i n women as i n men. It can appear at any age, but most
often i t begi ns i n young adul ts. Not ever yone who exper i ences pani c
attacks wi l l devel op pani c di sor derfor exampl e, many peopl e have
one attack but never have another. For those who do have pani c
di sor der, though, i t's i mpor tant to seek tr eatment.

How Is Panic Disorder Treated?


Studi es have shown that pr oper tr eatmenta type of psychotherapy
cal l ed cogni ti ve-behavi oral therapy, medi cati ons, or possi bl y a
combi nati on of the twohel ps 70% to 90% of peopl e wi th pani c
di sor der. Si gni fi cant i mpr ovement i s usual l y seen

wi thi n 6 to 8 weeks. Cogni ti ve-behavi oral appr oaches teach pati ents
how to vi ew the pani c si tuati ons di ffer entl y and demonstrate ways
to r educe anxi ety (e.g., usi ng br eathi ng exer ci ses or techni ques to
r efocus attenti on). Exposur e therapy, a techni que used i n cogni ti ve-
behavi oral therapy, often hel ps to al l evi ate the phobi as that may
r esul t fr om pani c di sor der. In exposur e therapy, peopl e ar e ver y
sl owl y exposed to the fear ful si tuati on unti l they become
desensi ti zed to i t. Some peopl e fi nd the gr eatest r el i ef fr om pani c
di sor der symptoms when they take cer tai n pr escr i pti on medi cati ons.
Such medi cati ons, l i ke cogni ti ve-behavi oral therapy, can hel p to
pr event pani c attacks or r educe thei r fr equency and sever i ty. Two
types of medi cati ons that have been shown to be safe and effecti ve
i n the tr eatment of pani c di sor der ar e anti depr essants and
benzodi azepi nes.

OBSESSIVE-COMPULSIVE DISORDER
Pati ent Infor mati on Handout

What Is Obsessive-Compulsive Disorder?


Obsessi ve-compul si ve di sor der (OCD), one of the anxi ety di sor der s,
i s a potenti al l y di sabl i ng condi ti on that can per si st thr oughout a
per son's l i fe. The i ndi vi dual who suffer s fr om OCD becomes trapped
i n a patter n of r epeti ti ve thoughts and behavi or s that ar e sensel ess
and di str essi ng but extr emel y di ffi cul t to over come. OCD occur s i n a
spectr um fr om mi l d to sever e; i f sever e and untr eated, i t can
destr oy a per son's capaci ty to functi on at wor k, school , or even
home.

How Common Is Obsessive-Compulsive


Disorder?
For many year s, mental heal th pr ofessi onal s thought of OCD as a
rar e di sease, because onl y a mi nor i ty of thei r pati ents had the
condi ti on. The di sor der often went unr ecogni zed because many of
those affl i cted wi th OCD, i n effor ts to keep thei r r epeti ti ve thoughts
and behavi or s secr et, fai l ed to seek tr eatment. However, a sur vey
conducted i n the ear l y 1980s by the Nati onal Insti tute of Mental
Heal th showed that OCD affects mor e than 2% of the popul ati on,
maki ng i t mor e common than such sever e mental i l l nesses as
schi zophr eni a, bi pol ar di sor der, or pani c di sor der. OCD str i kes
peopl e of al l ethni c gr oups. Men and women ar e equal l y affected.

Key Features of Obsessive-Compulsive


Disorder
Obsessions
Obsessi ons ar e unwanted i deas or i mpul ses that r epeatedl y wel l up
i n the mi nd of the per son wi th OCD. Common ar e per si stent fear s
that har m may come to sel f or a l oved one, an unr easonabl e
concer n wi th becomi ng contami nated, or an excessi ve need to do
thi ngs cor r ectl y or per fectl y. Agai n and agai n, the i ndi vi dual
exper i ences a di stur bi ng thought, such as, My hands may be
contami natedI must wash them, I

may have l eft the gas on, or I am goi ng to i njur e my chi l d. These
thoughts ar e i ntr usi ve, unpl easant, and pr oduce a hi gh degr ee of
anxi ety. Someti mes the obsessi ons ar e of a vi ol ent or a sexual
natur e, or they concer n i l l ness.

Compulsions
In r esponse to thei r obsessi ons, most peopl e wi th OCD r esor t to
r epeti ti ve behavi or s cal l ed compul si ons. The most common of these
ar e washi ng and checki ng. Other compul si ve behavi or s i ncl ude
counti ng (often whi l e per for mi ng another compul si ve acti on such as
hand-washi ng), r epeati ng, hoar di ng, and endl essl y r ear rangi ng
objects i n an effor t to keep them i n pr eci se al i gnment. Mental
pr obl ems, such as mental l y r epeati ng phrases, maki ng l i sts, or
checki ng, ar e al so common. These behavi or s general l y ar e i ntended
to war d off har m to sel f or other s. Some peopl e wi th OCD have
r egi mented r i tual s; other s have r i tual s that ar e compl ex and
changi ng. Per for mi ng r i tual s may gi ve the per son wi th OCD some
r el i ef fr om anxi ety, but i t i s onl y temporar y.

How Is Obsessive-Compulsive Disorder


Treated?
OCD i s tr eated wi th ei ther psychotherapy (counsel i ng) or
medi cati ons, or wi th both tr eatments combi ned.

Psychotherapy
The most effecti ve psychotherapy for OCD i s cogni ti ve-behavi oral
therapy. In thi s techni que, your therapi st wi l l have you practi ce
exposi ng your sel f to those si tuati ons that make you anxi ous and
cause you to act out a compul si on (such as checki ng or washi ng).
Your therapi st wi l l hel p you to pr event the OCD r esponse. Some of
the exposur e i s done i n the therapi st's offi ce, but most of i t i s done
at home and i s assi gned as homewor k.
Cogni ti ve-behavi oral therapy i s ver y effecti ve, especi al l y for those
pati ents who suffer pr i mar i l y fr om compul si ons. In such pati ents,
therapy i s often mor e effecti ve than medi cati on.

Medications
Many effecti ve medi cati ons for OCD exi st. The most commonl y
pr escr i bed ar e the sel ecti ve ser otoni n r euptake i nhi bi tor s (SSRIs),
whi ch have names l i ke Pr oz ac, Zol oft, Paxi l ,

and Luvox. These ar e popul ar because they have ver y few si de


effects when compar ed wi th ol der medi cati ons. Another effecti ve
medi cati on i s Anafrani l , whi ch tends to have mor e si de effects than
the SSRIs.
When someone begi ns taki ng an OCD medi cati on, i mpr ovement
general l y wi l l not begi n to show up i mmedi atel y. Wi th most of these
medi cati ons, i t takes fr om 1 to 3 weeks befor e changes begi n to
occur. If ther e i s l i ttl e or no change i n symptoms after 5 to 6 weeks,
a di ffer ent medi cati on may be tr i ed. Because ther e i s no way of
deter mi ni ng befor ehand whi ch medi cati on wi l l be effecti ve, the
doctor may have to pr escr i be fi r st one, then another, unti l an
effecti ve medi cati on i s found. Tr eatment i s conti nued for a mi ni mum
of several months and may l ast up to a year or mor e.

Footnote
*Thi s handout was adapted fr om publ i c domai n i nfor mati on suppl i ed
by both the Nati onal Insti tute of Mental Heal th and the Agency for
Heal th Car e Pol i cy and Resear ch (an agency of the U.S. Publ i c
Heal th Ser vi ce).
Thi s handout was adapted fr om publ i c domai n i nfor mati on suppl i ed
by the Nati onal Insti tute of Mental Heal th.
Thi s handout was adapted fr om publ i c domai n i nfor mati on suppl i ed
by both the Nati onal Insti tutes of Heal th and the Nati onal Insti tute
of Mental Heal th.
Thi s handout was adapted fr om publ i c domai n i nfor mati on suppl i ed
by the Nati onal Insti tute of Mental Heal th.
Editors: Carlat, Daniel J.
Title: Psychiatric Interview , The: Practical Guides in
Psychiatry, 2nd Edition
Copyr i ght 2005 Li ppi ncott Wi l l i ams & Wi l ki ns
> Ba c k o f Bo o k > Re fe re nc e s

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