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):
    • e.g. - “I can see you are very upset/very angry/pissed off, etc…”
  • Or be radically honest:
    • e.g. - “I can't even pretend to understand what you're going through right now, but I will do my best to listen and try to understand.”
  • 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:
      • e.g. - “Not making a decision is also a decision in and of itself.”
    • 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.[1]
  • You should focus on their symptoms for the past month (and up to 1 year if necessary)
    • Anything further in the past should be considered as past psychiatric history

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

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.”:

  • Sleep
    • Sleep is more than just good or bad, you need to ask specific questions about the nature of the sleep:
      • “Tell me about your sleep”
      • Ask about sleep hygiene (screen time)
      • How long are you asleep?
      • What time do you fall asleep?
      • What time do you get up?
      • Are there night time awakenings?
      • Are you told you snore at night? (think about sleep apnea, which can cause depressive symptoms)
      • Do you ever experience nightmares? (could be a sleep disorder or a trauma disorder)
  • 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
    • “Found if easy to jump from one idea to another?” (more of a physical observation in the patient)
  • Irritability
    • Have your friends or family recently commented on this?
  • Grandiosity
    • Ever get the feeling you have superpowers, or invincible?
  • Flight of Ideas
    • “Racing thoughts in your head?” (more of the patient's subjective experience)
  • Activity
    • “Have you been doing a lot more at work? Sexual indiscretion when you normally wouldn't? Having sexual relations with strangers?”
  • Sleep
    • “Decreased to the point where you don't have to sleep for days?”, more specifically, are not sleeping because you have so much energy?
  • Talkative
    • “Talking more rapidly?”

Key questions to ask about bipolar symptoms and course of illness:

  • Do you spend most of your time feeling depressed or manic?
  • Do you tend to get psychotic symptoms when you have depressive or manic symptoms? (think: either depression with psychotic features, or mania with psychotic features)
  • 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 the voices ever command you do to things?”
  • “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:

  1. 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?
    • e.g. - worries about dirt/germs, or thoughts of bad things happening
  2. 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?
  3. Does this waste significant time or cause problems in your life (Criterion B of DSM-5 criteria)?
    • e.g. - interfering with school, work, or seeing friends?

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:
    • “Some people might think of suicide when their mood is low, has this ever crossed your mind?”
  • Or turn the question around and ask it another way:
    • “You're going through the loss of a loved one, has your own death or suicide ever crossed your mind?

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
  • Do they have any allergies to medications? Any specific reactions to psychiatric medications?

Substance Use History

  • Tobacco/Nicotine
    • What age? How many packs per day? Ever use nicotine replacement therapy?
  • Opioids
    • What age? What kind? IV/PO? Naloxone?
  • Alcohol
    • What age? How much? History of blackouts? Have you ever been a binge drinker? Alcohol withdrawal? Seizures?
    • This may be a good time to screen for alcohol use disorder (CAGE):
      • “Ever feel you need to cut down your drinking?”
      • “Have people annoyed you by criticizing your drinking?”
      • “Have you ever felt bad or guilty about your drinking?”
      • “Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?”
  • Cannabis
    • What age? How much? What specific effects from the cannabis do they like or not like? Do they get paranoia?
  • Stimulants
    • What age? How much? What effects?
  • Benzodiazepines/Anxiolytics/Others
    • What age? How much? What effects?
  • Caffeine (this is important if your patient complains of anxiety!)
    • How much caffeine do they use? What time of day? How many cups?

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?
    • If they aren't sure, you can specifically ask the patient if they observed any unusual behaviours or symptoms in that family member
  • 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
    • Location raised
  • 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
    • Do you have any religious affiliation?
  • Education
    • “How did you do academically?”, “What is your highest level of education?”
  • Housing
    • “Do you live by yourself/with others?”, “House, condo, etc.?”
  • Employment
    • “What kind of jobs did you have?”
  • Who is your support?
    • Friends? Family? Co-workers?

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.

Diagnosis and Biopsychosocial Formulation

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.

Resources

Books
For Clinicians

References

1) Dyche, L., & Swiderski, D. (2005). The effect of physician solicitation approaches on ability to identify patient concerns. Journal of general internal medicine, 20(3), 267-270.