Académique Documents
Professionnel Documents
Culture Documents
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
Dedication
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
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
Openi ng phase.
Body of the i nter vi ew.
Cl osi ng phase.
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.
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).
2
Logistic Preparations: What to Do
before the Interview
Essential Concepts
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:
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.
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?
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.
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.
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.
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.
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.
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:
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
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.
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.
Patient: What?!!!
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.
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.
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.
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.
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.
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:
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.
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
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:
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:
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
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.
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,
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
Antisocial Behavior
P.2
5
Asking Questions II: Tricks for
Improving Patient Recall
Essential Concepts
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.
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:
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.
P.2
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:
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.
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!
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:
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:
7
Techniques for the Reluctant Patient
Essential Concepts
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.
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.
Patient: Uh huh.
Patient: Maybe.
Tell me a little about how you
Interviewer: were feeling. (An open-ended
command.)
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.
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
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
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
techni ques, found the fol l owi ng techni ques useful for over l y
expr essi ve pati ents:
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?
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?
or,
9
Techniques for the Malingering Patient
Essential Concepts
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!
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.
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.
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.
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
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.
After a per i od of ti me, you wi l l want to tal k to the adol escent al one.
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:
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.
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:
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.
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
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.
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.
Thi s gi ves another i ndi cati on of how soci al l y i nvol ved your pati ent
i s.
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:
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.
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:
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
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.
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.
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.
No, I'm a
psychopharmacologist, and I
Interviewer: schedule brief follow-up visits
to check on how well the
medication is working.
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.
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:
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
12
Practical Psychodynamics in the
Diagnostic Interview
Essential Concepts
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.
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
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.)
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 .)
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.
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
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.
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).
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?
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?
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.
(Immediately feeling
Interviewer: defensive.) Well, yes, I'm the
chief resident of the unit.
(Increasingly uncomfortable
and caught off guard.) No, I
Interviewer: wouldn't say it's a particularly
political position. I supervise
the other residents.
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.
13
Obtaining the History of Present Illness
Essential Questions
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
Ask the pati ent speci fi cal l y about potenti al pr eci pi tants for her
suffer i ng:
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
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.
Rejection or abandonment
Medication noncompliance
Substance abuse
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.)
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.
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:
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:
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.
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).
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
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.
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
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.
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 :
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.
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.
How did you like wor king with your ther apist?
Was the ther apy helpful?
In what ways was it helpful?
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
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:
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:
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.
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.
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 :
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
If the pati ent's r esponse i s vague, make some suggesti ons based on
your knowl edge of dr ug effects:
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.
Review of
Patient Rationale
symptoms
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).
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.
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.
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.
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?
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):
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.
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.
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
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)
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,
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
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.
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.
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.
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?
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
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.
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.
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?
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?
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?
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:
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:
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.
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?
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?
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
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
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
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:
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:
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:
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!
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
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.
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
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)
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
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
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.
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.
20
Mental Status Examination
Essential Concepts
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
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
Aspect of
Descriptors
appearance
Affect Terms
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
Normal
Thoughtful
Articulate
Intelligent
Rapid
Staccato
Pressured
Rambling
Continuous
Loud
Soft
Barely audible
Slow
Halting
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.
CLINICAL VIGNETTE
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
Patient: Yes.
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.
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.
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.
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.
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
Often, you can make a smooth transi ti on fr om some i nfor mati on you
just obtai ned:
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
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,
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,
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:
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.
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
Then
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.
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.
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
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.
Best IQ (rough
Intelligence
effort estimate)
Retarded 2 6 <70
Borderline 2 24 70-80
Bright
2 1,536 110-120
normal
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,
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:
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
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
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
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.
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.
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.
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?
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.
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.
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.
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.
(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.)
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.
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
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
Mnemonic: SIGECAPS
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:
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).
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:
SIGECAPS Questions
Sl eep di sor der
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.
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 :
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?
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
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 :
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 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:
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.
patter n. The most common patter n i s depr essi on i n the wi nter and
euthymi a i n the summer.
23
Assessing Mood Disorders II: Bipolar
Disorder
Essential Concepts
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.
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.
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?
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:
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?
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.
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?
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 ?
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).
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:
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.
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.
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:
Patient: Definitely.
Patient: No.
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.
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.
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.
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).
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.
You may need to speci fy the si tuati ons you have i n mi nd:
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:
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:
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:
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:
If your pati ent doesn't under stand what you mean by flashbacks,
you can el aborate:
If the exper i ence was an automobi l e acci dent, you mi ght ask
25
Assessing Alcohol Dependence and
Drug Abuse
Screening Questions
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 .
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.
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?
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:
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
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.)
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.
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:
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.
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.
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.
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.
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.
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.
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.
How was your life going dur ing that per iod? Wer e
you suffer ing fr om depr ession or anxiety?
26
Assessing Psychotic Disorders
Screening Questions
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.
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
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).
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:
Patient: No.
Patient: No.
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.
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:
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?
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.
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.
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.
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 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:
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.
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
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.
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
(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?
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):
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 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.
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.
Ask speci fi cal l y i f the pati ent i s hear i ng command hal l uci nati ons.
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.
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.
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
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
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
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?
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
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.
Patient: Eighteen.
Related Terms
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:
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.
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:
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
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.
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?
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
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 :
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:
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:
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.
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).
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
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
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.
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.
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.
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.
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.
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
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.
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
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
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.
2. G astr oi ntesti nal symptoms (must have two, other than pai n)
3. Sexual /r epr oducti ve symptoms (must have one, other than pai n)
29
Assessing Attention-Deficit
Hyperactivity Disorder
Screening Question
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):
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:
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.
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,
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:
Because many peopl e wi l l not know what thi s means, you mi ght
need to fol l ow up wi th
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
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
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:
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.
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
CLINICAL VIGNETTE
The i nter vi ewer i s aski ng a pati ent about hi s wor k hi stor y:
At thi s poi nt, the i nter vi ewer suspects paranoi d PD and asks the
pr obi ng questi ons.
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.
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.
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
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.
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
Recur r ent Sui ci dal behavi or, gestur es, or thr eats, or sel f-
muti l ati ng behavi or
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
Cluster A (Odd)
Paranoid
Sel f-statement: Other s ar e untr ustwor thy, and they tr y to take
advantage of me.
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:
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:
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:
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
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:
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:
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
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:
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:
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:
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
31
How to Educate Your Patient
Essential Concepts
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
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.
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.
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.
32
Negotiating a Treatment Plan
Essential Concepts
At thi s poi nt, the pati ent may answer vaguel y or put the bal l back
i n your cour t:
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:
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 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:
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.
or
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.
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.
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.
or
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.
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.
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:
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:
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 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.
Mental status
More descriptive alternative
jargon
He showed
He sat slumped over, staring
psychomotor
at the floor, and was nearly
retardation;
motionless throughout the
eye contact
interview.
was poor.
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.
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.
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:
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).
GAF
Applicable clinical situation
score
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)
For exampl e,
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
Legal history
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)
Heart (3)
Panic attack Breathlessness (5)
Fear (5) (4/13)
Bulimics Over-Consume
Bulimia nervosa
Pastries (4/4)
Attention-deficit
hyperactivity MOAT (6/9)
Disorder
Borderline
personality I DESPAIRR
disorder
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)
Appearance terms
Affect terms
Affect Terms
Retarded 2 6 <70
Borderline 2 24 7080
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
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
60 154 131
52 137 116
53 139 118
54 141 120
55 143 122
56 145 123
57 148 126
58 151 128
59 154 131
60 163 139
61 167 142
62 171 145
63 175 149
64 179 152
Numeric
Diagnosis
code
Alcohol abuse 305.00
Attention-deficit hyperactivity
314.01
disorder, combined type
Delirium 293.0
GAF
score Applicable clinical situation
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
B
Data Forms for the Interview
INITIA L PSYCHIA TRIC EVA LUA TION (SHORT FORM)
INITIA L PSYCHIA TRIC EVA LUA TION (LONG FORM)*
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
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:
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.
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
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.
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
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
PANIC DISORDER
Pati ent Infor mati on Handout
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
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
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.
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 ,
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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