The Psychiatric Interview
Primer
The Psychiatric Interview involves a balance of being empathetic, asking the right questions, and thinking about the diagnostic criteria carefully for psychiatric disorders. Remember, everyone has a different way of interviewing, but every question you ask should have a purpose. Are you trying to elicit symptoms? Understand someone's life history? Understand their safety risks? Just as a good surgeon makes no unnecessary incisions on the patient during a surgery, a good psychiatrist should ask no unnecessary questions during the interview. This does not mean that your interview be devoid of substance or empathy, but that you make every question count. Below is a template to guide you.
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General Tips
Ask neutral questions early (e.g. - age, workplace, medical history, medications)
Ask “threatening/challenging” questions later (e.g. - psychotic symptoms, suicide/homicidal thoughts, substance use, trauma,
cognitive testing questions)
Be careful of using leading questions and piggybacking multiple symptoms along. (e.g. - “How's your sleep, appetite, and mood?”; ask each individual item separately)
Remember, the one of the main goals of the interview is generate a diagnosis: you have one brain, and you can only have so many diseases/diagnoses going on at the same time.
It is always a good idea to have a balance of open-ended and close-end questions. This allows you to have some balanced of control over the interview.
Open-ended questions are questions that cannot be answered with a simple “yes” or “no” response (e.g. - “Tell me about your childhood.”)
Closed-ended questions can be answered from multiple choices or a “yes” or “no” response (e.g. - “On a scale of 1 to 10, how would you rate your mood?”)
Emergency Room Interviewing Tips
For patients in crisis:
Avoid using reflexive words/phrases like “OK” or “I understand…” in the ER.
They may tell you “It's not OK!” (because it really isn't “OK” for them right now), or tell you “No, you don't understand!” (because you really don't actually understand everything that is happening. How could you? You just met them today!)
Watch out for these verbal “tics”!
Try to instead address the elephant in the room (the affect):
Or be radically honest:
Other questions to consider asking:
“Why here, and why now?” (the reason they came to the ER or reason for the crisis event)
“What can we do for you? What were you hoping we could do for you?”
Acknowledge that the ER may not be a time to be making major life decisions:
Show empathy!
Identify your patient's strengths and coping skills throughout the interview
Subspecialty
If assessing a child, adolescent, or older adult, the interview and assessment will be significantly different. See the pages above.
Patient ID
Ask the pertinent social history upfront: this allows you to frame the interview and understand your patient's social situation.
Name
Age
Relationship status and children (if any)
Disability/welfare status
Occupation/Education
Living situation (where? with whom?)
Family/siblings
Health care providers: GP, psychiatrist, specialists, etc.
History of Presenting Illness
Start with close ended questions, do not ask leading questions. Make them direct!
Who brought you here? Who sent you here?
Allow your patients to tell you the story. Doctors have a bad habit of interrupting patients within the first few minutes of meeting a patient.
You should focus on their symptoms for the past month (and up to 1 year if necessary)
Always Establish the Chronology of Events
Timing is everything. Use these questions to help you get a sense of the timeline:
“How do you feel now?”, “How do you feel compared to your well self?”, “When did you last feel 'normal/well'?”
Always compare the patient's current symptoms to their baseline
Are there any acute stressors presently?
What are their coping strategies?
The Psychiatric Review of Systems
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It will be difficult to get through all these areas in a one-time assessment, and the clinician should use their clinical judgment to determine which questions will be the most helpful and high yield.
An example of a relatively comprehensive psychiatric review of systems is detailed below, but is by no means exhaustive. Some individuals early on may find using a checklist helpful to keep themselves organized.
Depression
Mood
“Tell me about your mood right now,” “How's your mood right now?”
On a scale of 0 to 10 (0 = worst you've ever felt, and 10 = best mood you ever had)
When someone says they are “depressed,” it is important to clarify what they mean by that, don't just take it at face value
If someone says they've “always been depressed,” try to get them to describe what their earliest memory of being depressed was like
Substance-induced mood/anxiety disorder?
When there is concomitant substance use in the context of mood symptoms, ask specifically: did the mood symptoms appear
before, or
after the substance use started? Substance use can masquerade as a depression or anxiety disorder (
substance-induced mood disorder or
substance-induced anxiety disorder).
“Now I'm going to ask you about some other symptoms people might feel when they're depressed.”:
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Interest (Anhedonia)
Guilt
Energy
Concentration
ADHD screen may be applicable here
Appetite
Now may be a good time to ask about
eating disorders (always ask, because patients do not always volunteer eating disorder information!):
How much weight loss?
What is their ideal weight?
What specifically makes this ideal?
Are they pre-occupied with their weight
Current weight and highest weight
Compensatory behaviour: medications, purging, laxatives, diuretics
Psychomotor Slowing
Suicide (leave this for later, unless your patient brings it up)
Anxiety
Always ask about anxiety and depression at the same time since these symptoms often overlap and are “co-morbid.” Key questions to ask include:
Find your worry is difficult to control?
Do you easily blanking out or have difficulty concentrating?
Easily fatigued?
Sleep changes (difficulty falling or staying asleep, or restless, unsatisfying sleep)?
Feel keyed up, on edge, or restless?
Feel irritable, or others comment on it?
Experience muscle tension when you are worried?
Would you describe yourself as a worrier?
Mania
“Now I'm going to ask you about some symptoms when people feel the opposite of depressed.”
Distractibility
Irritability
Grandiosity
Flight of Ideas
Activity
Sleep
Talkative
Key questions to ask about bipolar symptoms and course of illness:
Do you spend most of your time feeling depressed or manic?
-
Was there a period of time (>2 weeks) where you did not feel depressed/manic, but still had psychotic symptoms? (think
schizoaffective disorder)
When was your first manic/depressive episode? (The index event is important, this informs you: what is the natural history of the illness in the person? Do they tend to have a depressive or manic presentation?)
In patients with a history of multiple manic and depressive episodes, it can often be overwhelming and not practical to ask about the course of each specific episode. It is useful to obtain in broad strokes the following details instead:
Key Features of a Good Bipolar Disorder History
Mania | Depression |
# of lifetime manic episodes | # of lifetime depressive episodes |
Index episode | Index episode |
Last episode | Last episode |
Triggers/precipitants | Triggers/precipitants |
Psychosis
“Do you ever feel things are not real?
“Do you worry that people might be against you or after you?”
“Do you ever hear things other people don't hear?”
“Do you ever things other people don't see?”
“Are the voices outside or inside your head?” (auditory hallucinations are more likely to be heard “outside,” and often patients will look for the voice)
“Do you ever feel that thoughts are being put into your head?” (thought insertion)
“Do you ever feel that thoughts are being taken out of your head?” (thought withdrawal)
“Do you ever feel that your thoughts are being broadcasting so that other people know what you are thinking?” (thought broadcasting)
“Do you feel like there are special messages for you?”
Ask about hallucinations types, are they: auditory, visual, tactile, or olfactory? - this may indicate brain pathology or lesions!
Substance-induced psychosis?
When there is concomitant substance use in the context of psychosis, ask specifically: did the psychotic symptoms appear before, or after the substance use started?
Obsessions and Compulsions
Most individuals with OCD will have both obsessions and compulsions. High sensitivity screening questions and a good OCD history includes the following:
Obsessions: Do you ever get intrusive or unwanted thoughts, images, or impulses that repeatedly enter your mind, despite you trying to get rid of them?
Compulsions: Do you ever feel driven to do certain things over and over again?
e.g. - repeatedly washing hands, cleaning, checking doors or work over and over, rearranging things to get it just right, or repeating thoughts in your mind to feel better?
Does this waste significant time or cause problems in your life (Criterion B of DSM-5 criteria)?
The Relationship Between Obsessions and Compulsions
Compulsions are usually performed in response to an obsession (e.g. - obsession about contamination → compulsion of hand washing rituals; obsession about a situation being incorrect → compulsion of repeating rituals until it feels “just right”)
For individuals with OCD, compulsions reduce the distress triggered by the obsession, or prevent a feared event from occurring (e.g. - getting sick, hurting someone)
It is important to note that compulsions are not connected in a realistic way to the feared event (e.g. - arranging items in a certain colour to prevent harm to a loved one) or are significantly excessive (e.g. - washing hands for 30 minutes at a time due to fears of contamination)
Compulsions that are performed are not pleasurable! Rather, they allow the individual to experience relief from their anxiety or distress
Safety
Suicide
Asking the question
You can normalize the question, and ask directly:
Or turn the question around and ask it another way:
History
Always ask about the index suicide attempt (when, how, why?)
Are there any self-harm behaviours that might put their safety at risk? Could this lead to an “inadvertent suicide”?
Did they carry out their suicide attempt(s) with the expressed intent to die? (Sometimes a “suicide attempt” is not actually an attempt, but an accidental overdose - it is important to clarify this with your patient)
Current safety
Is there any plan?
Is there access to the means of death? (firearms, medications, poisons, etc.)
Do they plan on doing this immediately?
What are the chronic, acute, and imminent risk factors that might lead to suicide?
Homicide
Are there any threats to others due to psychotic symptoms?
Are there any threats to specific individuals?
“If you were to leave the hospital now, would you want to hurt anyone?”
“If you saw [person they wanted to hurt] on the street, what would you do? Would you defend yourself? Would you want to hurt/kill them?”
Driving
Are there any symptoms that cause dangerous driving? If patients have suicidal idea, homicidal ideation, mania, or psychosis, this is a critical safety question to ask
Has their license ever been revoked?
Medications
What medications are they on now?
Have they been on any psychiatric medications? Now? In the past? What doses?
Are they using any supplements? (e.g. - anabolic steroids, vitamins, herbals)
Patients often forget about this, and it is important to prompt them. Certain supplements (e.g. -
St. John's wort) can have significant drug-drug interactions.
Allergies
Substance Use History
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-
-
-
-
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Caffeine (this is important if your patient complains of anxiety!)
Substance-induced Psychiatric Symptoms?
When there is substance use, there can be a substance-induced
mood (depression or mania),
anxiety, or
psychosis.
Past Medical History
Various medical conditions can relate to psychiatric symptoms, and can also have medication interactions. In brief, you should always ask:
Past Psychiatric History
If someone has a very long psychiatric history, it is best to ask:
How many life-time hospital admissions?
How many total depressive episodes?
How many total manic episodes?
How many total psychotic episodes?
By staying general, but detailed enough to get broad strokes of a person's history, you can avoid getting bogged down in too much detail.
Have they ever had ECT or neurostimulation?
Family History
Any family history of mental illness?
Any family members die by suicide (or unexplained deaths)?
Any family members with problematic alcohol or substance use?
Any family members hospitalized for psychiatric reasons?
Any family members with neurodegenerative disorders and dementias (for geriatric patients)
Social History
Place of birth
Developmental
Any issues with development/birth?
Were you raised by your parents?
Are your parents still together?
Parent's occupation and finances
Relationship with mother and father?
Relationship with your siblings?
Would you say you generally had a happy childhood? (individuals with a generally unhappy childhood are more likely to be dysthymic)
What was school like for you?
How would you describe yourself as a child?
Bullying at school?
Religion
Education
Housing
Employment
Who is your support?
Trauma
While obtaining your social history, this is a good time to touch on any possible history of trauma.
It is good to have a non-threatening opener, such as: “Stressful life experiences can affect your health, and it can be helpful for us as healthcare providers to understand this. You can skip these questions if you don't want to answer them, and they are non-mandatory.”
“Have you ever experienced anything in your life that you would consider traumatic?,”
Or more point-blank, “Have you ever experienced any physical, emotional, or sexual abuse?”
Personality Traits/Disorders
This is a good time to screen for things like borderline personality disorder:
Ask about self-esteem, sense of self, impulsivity
“Are you by nature an impulsive person?”
“Do you feel that you have a poor sense of self?”
“Is it hard for you when people in your life leave you?”
“Do you frequently feel empty inside?”
“Do you ever harm yourself such as cutting or burning?”
Remember, you cannot diagnose someone with a personality disorder while they are having a primary mental disorder going on (e.g. - depression, psychosis, mania, etc.)
Being able to tease out personality disorders can help you differentiate between diagnoses (i.e. - cluster B traits vs. bipolar disorder)
Legal/Forensic History
“Any issues with the law? Or being in jail?”
Past arrests, incarceration, court dates, murder, assault, violence?
Closing the Interview
Close with:
“Did you have any thoughts on how we might be able to help you today?”
“Did we go through the main concerns that you hoped to talk about today?”
Thank the patient for their time and sharing a “snippet” of their life with you today
Mental Status Examination (MSE)
During the interview, you should pay attention to the mental status examination (MSE). The MSE is a systematic way of describing a patient's mental state at the time you were doing a psychiatric assessment.
Now that you have finished gathering information, the next steps will be to establish a diagnosis and to formulate the patient.
The Rule of Parsimony
Even though the DSM II was published in 1968 (!) the following excerpt is sage advice even (and especially) today.
A Tip From the DSM-II...
The diagnostician, however, should not lose sight of the rule of parsimony and diagnose more conditions than are necessary to account for the clinical picture. The opportunity to make multiple diagnoses does not lessen the physician's responsibility to make a careful differential diagnosis.
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