Mental Health Consultation

The interview is the principal means of assessment in clinical psychiatry. Despite major advances in neuroimaging and neurochemistry, there are no laboratory procedures as informative as observing, listening to, and interacting with the patient, and none as yet are more than supplementary to the information gathered by the psychiatric interview. This chapter deals with the interview as a means of assessing the patient and developing an initial treatment plan in clinical situations. Psychiatric interviews are analogous to the history and physical examination in a general medical assessment; they systematically survey subjective and objective aspects of illness, and generate a differential diagnosis and plan for further evaluation and treatment. They differ from other medical interviews in the wide range of biological and psychosocial data that they must take into account, and in their attention to the emotional reactions of the patient and the process of interaction between the patient and interviewer. The nature of the interaction is informative diagnostically and is a means of building rapport and eliciting the patient’s cooperation. The style and content of a psychiatric interview are necessarily shaped by the interviewer’s theory of psychopathology. Thus, a biological theory of illness leads to an emphasis on signs, symptoms, and course of illness; a psychodynamic theory dictates a focus on motivations, attitudes, feelings, and personal interactions; a behavioral viewpoint looks at antecedents and consequences of symptoms or maladaptive behaviors. In past times, when these and other theories competed for theoretical primacy, an interviewer might have viewed exploration from a particular single perspective as adequate. However, modern psychiatry views these perspectives as complementary rather than mutually exclusive, and recognizes the contributions of biological, intrapsychic, social, and environmental factors to human behavior and its disorders. The interviewer, therefore, faces the task of understanding each of these dimensions, adequately surveying them in the interview, and making informed judgments about their relative importance and treatment implications. The written psychiatric database, the mental organization that the interviewer maintains during the interview, and the structure of the interview itself may differ chapter 0001930190.INDD 65 4/10/2013 1:15:42 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 66 The Psychiatric Interview considerably from one another. The written psychiatric database is an orderly exposition of information gathered in the interview, presented in a relatively fixed format. The third structure is that of the interview itself. While guided by general principles of interviewing, this structure is the most flexible of the three, being determined not only by the purpose of the interview and the type of problem which the patient presents, but also by the patient’s mode of communication and style of interaction with the interviewer. Thus, the interviewer must hold his or her own structure in mind while responding flexibly to the patient. Goals of the Psychiatric Interview The interviewer may be thought of as seeking the answers to several basic questions about the patient and the presenting problems. These questions provide the mental framework of the interview (although not its explicit form). They begin with triaging of patients into broad categories of type and severity, and progress to inquiry about details in each salient area. Table 4.1 lists the questions that the interview addresses and the implications of each for understanding and treating the patient. The answers to the questions in Table 4.1 are presented here in greater detail. Does the Patient Have a Psychiatric Disorder? This is the most basic question which the psychiatrist is called upon to answer, and determines whether or not there is any need for further psychiatric assessment or treatment. How Severe Is the Illness? The answer to this question determines the necessary level of treatment, ranging from hospitalization with close observation to infrequent outpatient visits. The main determinants of severity are dangerousness to self and others and impairment in ability to care for oneself and function in social and occupational roles. What Is the Diagnosis? In psychiatry, as in the rest of medicine, descriptive information about signs, symptoms, and course over time is used to assign a diagnosis to the presenting problem. Not all psychiatric diagnoses have similarly studied validity, but most convey the field’s present knowledge of prognosis, comorbidity, treatment response, occurrence in family members, or associated biological or psychological findings. Even in the case of poorly understood entities, our present system of diagnosis using specific criteria maximizes uniformity in the description and naming of psychiatric disorders. One important implication of diagnoses is whether there may be reduced plasticity of brain functioning due to anatomical or physiological abnormalities. Symptoms, deficits, and behaviors that stem from such abnormalities vary less in response to 0001930190.INDD 66 4/10/2013 1:15:42 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 67 environmental and motivational factors than those behaviors that arise in the context of normal brain function. For example, mood swings in a patient with bipolar disorder, a condition for which there is strong evidence of a biological–genetic etiology, typically recur at regular time intervals, often independently of the patient’s life situation. By contrast, mood swings in a patient with narcissistic personality disorder are much more likely to be triggered by interactions with other people. Furthermore, when brain function is impaired, biological treatments are more likely to be necessary, and verbal, Table 4.1 Issues to Be Addressed in a Psychiatric Assessment Question Implications Does the patient have a psychiatric disorder? Need for treatment How severe is the disorder? Need for hospitalization Need for structure or assistance in daily life Ability to function in major life roles Are there abnormalities of brain function? Degree of dysfunction of major mental processes such as perception, cognition, communication, regulation of mood and affect Responsivity of symptoms to environmental and motivation features Responsivity of symptoms to biological treatment What is the diagnosis? Description of the illness prognosis and treatment response What is the patient’s baseline level of functioning? Determination of onset of illness State vs. trait pathology Goals for treatment Capacity for treatment What environmental issues contribute to the disorder? Prediction of conditions that may trigger future episodes of illness Need for focus on precipitating stressors Prevention of future episodes through amelioration of environmental stressors and/or increased environmental/social support What biological factors contribute to the disorder? Need for biological therapy Place of biological factors in explanation of illness presented to the patient Focus on biological factors as part of ongoing therapy What psychological factors contribute to the disorder? Responsivity of the symptoms to motivational, interpersonal, reinforcement factors Need to deal with psychological or interpersonal issues in therapy What is the patient’s motivation and capacity for treatment? Decision to treat Choice of treatment 0001930190.INDD 67 4/10/2013 1:15:42 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 68 The Psychiatric Interview interpersonal, or environmental interventions are less likely to be sufficient. Thus, the likelihood of altered brain function has major implications for understanding and treating the patient’s problems. Although the question of brain abnormalities is basic to psychiatric triaging, we do not yet have a clear-cut biological etiology for any disorder outside of those historically classified as “organic”. Standard laboratory studies (such as brain imaging or electroencephalography) are not generally diagnostic of psychopathology; however, there is research-based evidence of altered brain function in many psychiatric disorders. Table 4.2 presents an overview of the current state of knowledge of brain abnormalities in psychiatric disorders, along with known responses to biological and psychosocial treatments. What Is the Patient’s Baseline Level of Functioning? Determining what the patient has been like in his or her best or most usual state is a vital part of the assessment. This information allows the interviewer to gauge when the patient became ill, and how he or she is different when ill versus well. Environmental, biological, and psychological factors that contribute to low baseline levels of functioning may also predispose a patient to the development of psychiatric disorders. Thus, information about baseline functioning provides clues about the patient’s areas of vulnerability to future illness as well as his or her capacity to benefit from treatment. It is also an important guide to realistic goals and expectations for such treatment. Table 4.3 lists major components of functioning with examples of elements of each. What Environmental Factors Contribute to the Disorder? Environmental contributions to the presenting problem are factors external to the patient. They may be acute events that precipitate illness, or longstanding factors that increase general vulnerability. Longstanding environmental stressors may predispose the patient to the development of illness and may also worsen the outlook for recovery. It is important to identify adverse environmental influences that can be modified, and to help the patient or family make necessary changes. For example, a patient with recurrent paranoid psychosis needed yearly hospitalization as long as she worked in an office with many other people. However, she no longer suffered severe relapses when she was helped to find work that she could do in her own home. However, even irreversible precipitants, such as death of a loved one, must be identified and dealt with in the treatment plan. What Biological Factors Contribute to the Disorder? Biological factors may contribute to psychiatric disorders directly by their effects on the central nervous system and indirectly through the effects of pain, disability, or social 0001930190.INDD 68 4/10/2013 1:15:42 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Table 4.2 Brain Dysfunction in Psychiatric Disorders Disorder Evidence for Brain Dysfunction Response to Biological Treatments Response to Psychosocial Treatments Delirium, dementia, amnestic and cognitive disorders (Leigh and Reiser, 1992; Lipowski, 1984; Lishman, 1978; Popkin, 1994) Well established Reversible causes respond to appropriate treatment, neuroleptics, anxiolytics, antidepressants, lithium, and anticonvulsants. Beta-blockers may be helpful Environmental support and supportive psychotherapy may be helpful Schizophrenia (Bellack and Mueser, 1993; Carpenter and Buchanan, 1994; Davis, 1975; Kotrla and Weinberger, 1995; Sensky et al., 2000) Strong evidence Most respond to antipsychotics; antidepressants, mood stabilizers, and anxiolytics may be helpful adjunctively Environmental support, supportive psychotherapy, cognitive–behavioral therapy, family therapy, and skills training are helpful Delusional disorder (Maber, 1992; Manschreck, 1996) Little evidence – few studies Poor to fair response to psychotics Poor response to psychotherapy Schizoaffective disorder (Keck et al., 1996; Kendler, 1991; Winokur et al., 1996) Evidence for relationship to schizophrenia and mood disorders Most respond to combinations of antipsychotics, antidepressants, mood stabilizers, carbamazepine, electroconvulsive therapy (ECT) Not well established. Similar range of treatments as for schizophrenia may be helpful Brief psychotic disorder (Jorgensen et al., 1996; Susser et al., 1995) Little evidence – few studies Not well established Environmental support and supportive psychotherapy may be helpful Bipolar disorder (Goodwin and Jamison, 1990; Janowsky et al., 1974; Tsuang and Faraone, 1990) Strong evidence Most respond to lithium, antidepressants, anticonvulsants, neuroleptics, or ECT Supportive and educative psychotherapy and family therapy may be helpful (Continued) 0001930190.INDD 69 4/10/2013 1:15:42 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Disorder Evidence for Brain Dysfunction Response to Biological Treatments Response to Psychosocial Treatments Major depressive disorder (Elkin et al., 1989; Siever and Davis, 1985; Thase and Howland, 1995) Evidence suggestive – considerable heterogeneity Often responds to antidepressants or ECT Less severe cases respond to cognitive, interpersonal, and psychodynamic psychotherapy Panic disorder (Barlow, 1988; Barlow et al., 2000; Goddard and Charney, 1997; Milrod et al., 2000) Evidence suggestive Most respond to anxiolytics or antidepressants Variable. Cognitive–behavioral therapy more effective than psychodynamic Generalized anxiety disorder (Blazer et al., 1991) Little evidence Variable. Anxiolytics may be helpful Variable. Psychodynamic or cognitive–behavioral psychotherapies are often helpful Simple phobia (Fyer et al., 1990; Marks, 1987) Little evidence Medications not usually helpful Most respond to behavioral therapy Posttraumatic stress disorder (Heim et al., 2000; Katz et al., 1996; Marks et al., 1998) Evidence suggestive Variable. Antidepressants and mood stabilizers may be helpful Psychotherapy with exploratory, supportive, and behavioral features usually helpful Obsessive–compulsive disorder (Abramowitz, 1997; Baxter, 1992; Insel, 1992) Evidence suggestive Most respond to selective serotonin reuptake inhibitors Rituals but not obsessive thoughts respond to behavioral therapy Somatization disorder (Cloninger et al., 1986; Min and Lee, 1997) Preliminary evidence Poor. Medication for comorbid depression or anxiety may help Poor. Supportive psychotherapy may help Table 4.2 (Cont’d) 0001930190.INDD 70 4/10/2013 1:15:42 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Conversion disorder (Ford and Foulks, 1985; Lazare, 1981) None known Amytal interview may help; otherwise not indicated Most respond to psychotherapy with exploratory, expressive, and behavioral features. May remit spontaneously Hypochondriasis (Ford, 1995; Kellner, 1987) None known No direct response. Medications may help for treatment of comorbid depression and anxiety Variable. Supportive–educative psychotherapy may be helpful Dissociative disorders (Brenner and Marmer, 1998; Kluft and Fine, 1993) None known No direct response. Medications may help for treatment of comorbid depression and anxiety Variable. Many respond to expressive–exploratory psychotherapy Alcoholism (Merlett, 1998; Prescott and Kendler, 1999) Strong evidence in subgroups No well-demonstrated direct effects. Opiate antagonists may be helpful Group and individual psychotherapies most common treatment modalities. Response variable, relapse high Psychoactive substance use disorders (Banmohl and Jaffe, 1995; Nesse and Berridge, 1997) Little evidence – some subgroups No well-demonstrated direct effects Group and individual psychotherapies most common treatment modalities. Response variable, relapse high Sexual disorder (LoPiccolo, 1985; Marshall and Barbaree, 1990) May be due to metabolic disorders; otherwise little evidence Medications for underlying medical conditions may be necessary. Antiandrogens or serotonergic antidepressants may be helpful for paraphilias Sexual dysfunctions often respond to behavior therapy. Couples therapy or exploratory therapy may also be helpful Eating disorders (Halmi, 1992; Johnson and Connors, 1987) Evidence suggestive Antidepressants may help ameliorate symptoms Expressive exploration, family, and behavioral therapy often helpful (Continued) 0001930190.INDD 71 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Table 4.2 (Cont’d) Disorder Evidence for Brain Dysfunction Response to Biological Treatments Response to Psychosocial Treatments Adjustment disorders (Andreasen and Hoevk, 1982; Greenberg et al., 1995) None known Medications may alleviate symptoms of anxiety or depression Supportive psychotherapy often helpful Personality disorders: Cluster A (Kendler et al., 1984; Siever et al., 1991) Evidence for relationship of schizotypal personality to schizophrenia; otherwise none known Schizotypal patients may improve on antipsychotic medication; otherwise not indicated Poor. Supportive psychotherapy may help Personality disorders: Cluster B (Bateman and Fonagy, 2001; Clarkin et al., 2007; Coccaro and Kavoussi, 1997; Tarnepolsky and Berlowitz, 1987; Zuckerman, 1996) Evidence suggestive for antisocial and borderline personalities; otherwise none known Antidepressants, antipsychotics, mood stabilizers may help for borderline personality; otherwise not indicated Poor in antisocial personality. Variable in borderline, narcissistic, and histrionic personalities Personality disorders: Cluster C (Cloninger, 1987; Cloninger et al., 1993; Millon, 1996; Svartberg et al., 2004) None known No direct response. Medications may help with comorbid anxiety, depression Psychodynamic psychotherapy and cognitive behavior therapy 0001930190.INDD 72 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 73 stigma. Thus, biological factors must be assessed through both the psychiatric history and diagnosis, and the general medical history. Biological factors affecting the central nervous system may be genetic, prenatal, perinatal, or postnatal. Conditions such as maternal substance abuse or intrauterine infections may affect fetal brain development; birth complications may cause cerebral hypoxia with resultant brain damage. In postnatal life, the entire range of diseases that affect the brain may alter mental function and behavior, as may exposure to toxins at work, in the environment, and through substance abuse. In addition, medical conditions that do not directly affect brain functioning may have profound effects on the patient’s state of mind and behavior (Clinical Vignettes 1, 2 and 3). Biological factors may both predispose to and precipitate episodes of illness. Thus, a patient with a genetic vulnerability to schizophrenic illness may have an episode of acute psychosis precipitated by heavy cocaine use. Similarly, a patient with borderline low intellectual capacity due to hypoxia at birth may have marginal ability to care for herself. An accident resulting in a fractured arm might overwhelm this person’s coping capacity and precipitate a severe adjustment disorder. Table 4.3 Assessment of Baseline Functioning Component Examples Level of symptoms Depression Anxiety, obsessions, and compulsions Delusion Hallucinations Interpersonal relations Sexual relationships and marriage Quality and longevity of friendships Capacity for intimacy and commitment Work adjustment Employment history Level of responsibility Functioning in nonpaid roles, e.g., homemaker, parent Satisfaction with work life Leisure activities Hobbies and interests Group and social activities Travel Ability to take pleasure in nonwork activities Ego functions Talents, skills, intelligence Ability to cope; reality testing Control over affects and behaviors Ability to formulate and carry through plans Stable sense of self and others Capacity for self-observation 0001930190.INDD 73 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 74 The Psychiatric Interview What Psychological Factors Contribute to the Disorder? Psychological factors are mental traits that the patient brings to life situations. While they interact with social and environmental factors, they are intrinsic to the individual, and not readily changed by outside influences. Psychological factors predisposing to illness include both general and focal deficits in coping adaptability. General deficits encompass the entire range of ego functioning, including poor reality testing, rigid or maladaptive psychological defense mechanisms, low ability to tolerate and contain affects, impulsivity, poorly formed or unstable sense of Clinical Vignette 3 A young woman became acutely depressed upon receiving her acceptance to medical school. She was the oldest of four children and had been expected to assume a major caretaking role with her younger siblings. Her mother, a busy physician, wished for her daughter to have a similar career. To the patient, entering medical school meant accepting a lifelong role as a caretaker and forever relinquishing her own wishes to be taken care of. Clinical Vignette 2 A patient functions well in a responsible job and has had a long-standing, stable marriage. However, he is driven by the need to be liked and accepted by all who know him, and has a deep-seated, but not conscious, belief that he must continually fulfill the wishes of others in order to accomplish this. At the same time, he has a chronic feeling of powerlessness and an unarticulated wish to be able to say no. At times of increased demands by family members or coworkers, he develops flu-like symptoms and stays home from work “recuperating”, relieved of responsibility for fulfilling the expectations of others. Clinical Vignette 1 A 30-year-old married woman suffers from chronic low mood and lack of enjoyment of life. She is highly dependent on her husband for practical and emotional support, although she frequently flies into rages at him, feeling that he is cold and uncaring. She has had a series of secretarial jobs which she begins enthusiastically, but soon comes to feel that her employers are highly critical and belittling, whereupon she resigns. Her friendships are limited to people with whom she can have very special, exclusive relationships. She deals poorly with change or loss, which frequently trigger episodes of acute dysfunction. When a friend is not sufficiently available to her, she feels betrayed and worthless, her mood plummets, she becomes lethargic, has eating binges, and is unable to work or pursue her usual routine for up to weeks at a time. 0001930190.INDD 74 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 75 self, low self-esteem and hostile, distant, or dependent relationships with others. Patients with such deficits generally meet diagnostic criteria for one or more personality disorders and are at increased risk for episodes of acute psychiatric illness. An example of general deficits in psychological functioning is illustrated by the following case. Focal psychological issues may also contribute to mental disorders. These issues, which typically involve conflicts between opposing motivations, may affect the patient in certain specific areas of function or life situations, leaving other broad areas of function intact (Nemiah, 1961). Such conflicts are most likely to cause maladaptive behaviors or symptoms when the patient is not clearly aware of them. The meaning of an event in the context of the patient’s life course is another focal issue that may contribute to illness. What Is the Patient’s Motivation and Capacity for Treatment? Whatever the physician’s view of the presenting problem, the patient’s wishes and capacities are an important determinant of treatment choice. Some patients seek relief of symptoms; some wish to change their behavior or the nature of their relationships; some want to understand themselves better. Patients may wish to talk or to receive medication or instructions. The patient’s capacity for treatment must also be considered in the treatment plan. For example, a patient with schizophrenia may agree to medication but be too disorganized to take it reliably without help. The Psychiatric Database The body of information to be gathered from the interview may be termed “the psychiatric database” (Table 4.2, Table 4.3, and Table 4.4). It is a variable set of data: either very specific or general, mainly limited to the present state or focused on early life, dominated by neurological questions or inquiry into relationships. To avoid setting the impossible task of learning everything about every patient, one must consider certain factors that modify the required database. Whose questions are to be answered – the patient’s concern about himself or herself, a family or friend’s concern about him or her, another physician’s diagnostic dilemma, a civil authority’s need to safeguard the public, or a research protocol requirement? Who will have access to the data gathered and under what circumstances? What is the setting of the interview? Is the interview to be the first session of a psychotherapy regimen, or is it a one time only evaluation? What is the nature of the pathology? For example, negative responses regarding the presence of major psychotic symptoms, coupled with a history of good occupational function, will generally preclude a detailed inventory of psychotic features. A missed orientation or memory question will require careful cognitive testing. Patients with personality disorder symptoms warrant careful attention to the history of significant relationships (Nurnberg et al., 1991), work history, and the feelings evoked in the interviewer during the 0001930190.INDD 75 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 76 The Psychiatric Interview evaluation process. The database should be expanded in areas of diagnostic concern to support or rule out particular syndromes. The amount and nature of the data obtained is also, of necessity, limited by the patient’s ability to communicate and his or her cooperativeness. Table 4.4 Core Database Identifying Data Chief Complaint History of Present Illness Name Reason for Consultation Major Symptoms Age/date of birth; next of kin Time course Stressors Change in functioning Current medical problems and treatment Past psychiatric history Past medical history Family history Any previous psychiatric treatment Ever hospitalized Psychiatric illness Surgery Medications History of suicide attempts Mental status Functioning problems secondary to psychiatric symptoms Alcohol/drug abuse Personal history Educational level Appearance Ever married/committed relationship Attitude Affect Behavior Work history Speech Means of support Living situation Thought process Thought content Perception Cognition Insight Judgment 0001930190.INDD 76 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 77 Database Components Identifying Data This information establishes the patient’s identity, especially for the purpose of obtaining past history from other contacts, when necessary, as well as fixing his or her position in society. The patient’s name should be recorded, along with any nickname or alternative names he or she may have been known by in the past. This is important for women who might have been treated previously under a maiden name, or a patient who has had legal entanglements and so has adopted aliases. Date of birth, or at least age, and race are other essential parts of every person’s database. People of white, black (or African-American), Asian, Native American, and other origins are generally accepted. The additional modifier of ethnicity, especially Hispanic/ non-Hispanic, is becoming more widely used. If a patient is a member of a particular subculture based on ethnicity, country of origin, or religious affiliation, it may be noted here. A traditional part of the identifying data is a reference to the patient’s civil status: single, married, separated, divorced, or widowed. The patient’s social security number (or other national ID number) can be a very useful bit of data when seeking information from other institutions. In most cases, it is assumed that the informant (supplier of the history) is the patient. If other sources are used, and especially if the patient is not the primary informant, this should be noted at the beginning of the database. Chief Complaint The chief complaint is the patient’s responses to the question, “What brings you to see me/to the hospital today?” or some variant thereof. It is usually quoted verbatim, placed within quotation marks, and should be no more than one or two sentences. Even if the patient is very disorganized or hostile, quoting his response can give an immediate sense of where the patient is as the interview begins. If the patient responds with an expletive, or a totally irrelevant remark, the reader of the database is immediately informed about how the rest of the information may be distorted. In such cases, or if the patient gives no response, a brief statement of how the patient came to be evaluated should be made and enclosed in parentheses. History of the Present Illness Minimum Essential Database The present illness history should begin with a brief description of the major symptoms that brought the patient to psychiatric attention. The most troubling symptoms should be detailed initially; later, a more thorough review will be stated. As a minimum, the approximate time since the patient was last at his or her baseline level of functioning, and in what way he or she is different from that now, should be described, and any known stressors, the sequence of symptom development, and the beneficial or deleterious effects of interventions included. 0001930190.INDD 77 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 78 The Psychiatric Interview How far back in a patient’s history to go, especially when he or she has chronic psychiatric illness, is sometimes problematic. In patients who have required repeated hospitalization, a summary of events since last discharge (if within 6 months) or last stable baseline is indicated. It is rare that more than 6 months of history be included in the history of the present illness, and detailed history is more commonly given on the past month. Expanded Database A more expanded description of the history of the present illness would include events in a patient’s life at the onset of symptoms, as well as exactly how the symptoms have affected the patient’s occupational functioning and important relationships. Any concurrent medical illness symptoms, medication usage (and particularly changes), alterations in the sleep–wake cycle, appetite disturbances, and eating patterns should be noted; significant negative findings should also be remarked upon. Past Psychiatric History Minimum Essential Database Most of the major psychiatric illnesses are chronic in nature. For this reason, often patients have had previous episodes of illness with or without treatment. New onset of symptoms, without any previous psychiatric history, becomes increasingly important with advancing age in terms of diagnostic categories to be considered. At a minimum, the presence or absence of past psychiatric symptomatology should be recorded, along with psychiatric interventions taken and the result of such interventions. An explicit statement about past suicide and homicide attempts should be included. Expanded Database A more detailed history would include names and places of psychiatric treatment, dosages of medications used, and time course of response. The type of psychotherapy, the patient’s feelings about former therapists, his or her compliance with treatment, as well as circumstances of termination are also important. Note what the patient has learned about the biological and psychological factors predisposing him or her to illness, and whether there were precipitating events. Past Medical History Minimum Essential Database In any clinical assessment, it is important to know how a patient’s general health status has been. In particular, any current medical illness and treatment should be noted along with any major past illness requiring hospitalization. 0001930190.INDD 78 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 79 Expanded Database An expanded database could well include significant childhood illnesses, how these were handled by the patient and his or her family, and therefore the degree to which the patient was able to develop a sense of comfort and security about his or her physical well-being. Illnesses later in life should be assessed for the degree of regression produced. The amount of time a patient has had to take off work, how well he or she was able to follow a regimen of medical care, his or her relationship with the family physician or treating specialist can all be useful in predicting future response to treatment. A careful past medical history can also at times bring to light a suicide attempt, substance abuse, or dangerously careless behavior, which might not be obtained any other way. Family History Minimum Essential Database Given the evidence for familial, genetic factors in so many psychiatric conditions, noting the presence of mental illness in biological relatives of the patient is necessary. It is important to specify during questioning the degree of family to be considered – usually to the second degree: aunts, uncles, cousins, and grandparents, as well as parents, siblings, and children. Expanded Database A history of familial medical illness is a useful part of an expanded database. A genogram (pedigree), including known family members with dates and causes of death and other known chronic illnesses is helpful. Questioning about causes of death will also occasionally bring out hidden psychiatric illness, for example, sudden, unexpected deaths, which were likely suicides or illness secondary to substance abuse. Personal History Minimum Essential Database Recording the story of a person’s life can be a daunting undertaking and is often where a database can expand dramatically. As a minimum, this part of the history should include where a patient was born and raised, and in what circumstances – intact family, number of siblings, and degree of material comfort. Note how far the patient went in school, how he or she did there, and what his or her occupational functioning has been. If he or she is not working, why not? Has the patient ever been involved in criminal activity, and with what consequences? Has the patient ever married or been involved in a committed relationship? Are there any children? What is his or her current source of support? Does he or she live alone or with someone? Has he or she ever used alcohol or other drugs to excess, and is there current use? Has he or she ever been physically or sexually abused or been the victim of some other trauma? 0001930190.INDD 79 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 80 The Psychiatric Interview Expanded Database An expanded database can include a great deal of material beginning even prior to the patient’s conception. What follows is an outline of the kind of data that may be gathered, along with an organizational framework. Family of Origin Were parents married or in committed relationships? Personality and significant events in life of mother, father, or other significant caregiver. Siblings: number? their ages, significant life events, personality, relationship to patient. Who else shared the household with the family? Prenatal and Perinatal Was the pregnancy planned? Quality of prenatal care; mother’s and father’s response to pregnancy. Illness, medication or substance abuse, smoking, trauma during pregnancy; labor – induced or spontaneous? Weeks gestation, difficulty of delivery, vaginal or Caesarean section. Presence of jaundice at birth, birth weight, Apgar score. Baby went home with mother or stayed on in hospital. Early Childhood Developmental milestones: smiling, sitting, standing, walking, talking, type of feeding – food allergies or intolerance. Consistency of caregiving: interruptions by illness, birth of siblings. Reaction to weaning, toilet-training, maternal separation. Earliest memories: problematic behavior (tantrums, bedwetting, hair-pulling, or nail-biting). Temperament (shy, overactive, outgoing, fussy). Sleep problems: insomnia, nightmares, enuresis, parasomnias. Later Childhood Early school experiences: evidence of separation anxiety. Behavioral problems at home or school: firesetting, bedwetting, aggressive toward others, cruelty to animals, nightmares. Developmental milestones: learning to read, write. Relationships with other children and family: any loss or trauma. Reaction to illness. Adolescence School performance: ever in special classes? Athletic abilities and participation in sports. Evidence of gender identity concerns: overly “feminine” or “masculine” in appearance/ behavior, or perception by peers. 0001930190.INDD 80 4/10/2013 1:15:43 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 81 Ever run away? Able to be left alone and assume responsibility. Age of onset of puberty (menarche or nocturnal emissions), reaction to puberty. Identity Sexual preference and gender identity, religious affiliation (same as parents?). Career goals: ethnic identification. Sexual History Early sexual teaching: earliest sexual experiences, experience of being sexually abused, attitudes toward sexual behavior. Dating history, precautions taken to prevent sexually transmitted diseases and/or pregnancy. Episodes of impotence and reaction. Masturbating patterns and fantasies. Preoccupation with particular sexual practices, current sexual functioning, length of significant relationships, ages of partners. Adulthood Age at which left home, level of educational attainments. Employment history, relationships with supervisors and peers at work, reasons for job change. History of significant relationships including duration, typical roles in relationships, patterns of conflict: marital history, legal entanglements, and criminal history, both covert and detected, ever victim or perpetrator of violence. Major medical illness as adult. Participation in community affairs. Financial status: own or rented home, stability of living situation. Ever on disability or public assistance? Current family structure, reaction to losses of missing members (parents, siblings), if applicable. Substance abuse history. Mental Status Examination It can be helpful to conceptualize the recording of the Mental Status Examination (MSE) as a progression. One begins with a snapshot: what can be gained from a cursory visual exam, without any movement or interaction – appearance and affect. Next, motion is added: behavior. Then comes sound: the patient’s speech, though initially only as sound. The ideas being expressed come next: the thought process and content, perception, cognition, insight, and judgment. Table 4.5 gives a summary of areas to be commented on, along with common terms. At every level of the MSE, preference should be given for explicit description over jargon. Stating that a patient is delusional is less helpful than describing him as believing that his neighbors are pumping poisonous gases into his bedroom while he sleeps. 0001930190.INDD 81 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 82 The Psychiatric Interview Table 4.5 Mental Status Examination Appearance Level of consciousness (alert, hypervigilant, somnolent, stuporous) Dress (casual, appropriate for weather, eccentric, careless, disheveled) Grooming (style of hair, degree of makeup, shaven/unshaven, clean, malodorous) Idiosyncrasies – tattoos (professional or amateur), prominent scars, religious emblems Attitude Cooperative, hostile, evasive, threatening, obsequious Affect Range (restricted, expansive, blunted, flat) Appropriateness to items discussed Stability (labile, shallow) Quality (silly, anxious) Mood Response to question: “How are you feeling/How’s your mood been?” Behavior Psychomotor agitation or retardation Speech Rate (rapid, slowed, pressured, hard to interrupt) Volume (loud, soft, monotone, highly inflected, or dramatic) Quality (neologisms, fluent, idiosyncratic) Thought process Goal-directed, disorganized, loose associations, tangential, circumstantial, flight of ideas Thought content Major preoccupations, ideas of reference, delusions (grandiose, paranoid, bizarre; state exactly what it is the patient appears to believe) Thought broadcasting, insertion, or withdrawal Suicidal or homicidal ideation. Plan and intent to carry out ideas Perception Illusions and hallucinations – type (auditory, visual, olfactory, tactile, gustatory), evidence (patient spontaneous report, answer to interviewer question, observation of patient attending or responding to nonexistent external stimuli) Patient’s beliefs about hallucinatory phenomenon (do they seem to originate from the outside or inside, how many voices, what gender, talking to patient or to other voices, are they keeping up constant commentary on the patient) Cognition Orientation: time, place, person, situation Memory: number of remembered objects, digit span, presidents backward, recent events 0001930190.INDD 82 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 83 Conduct of the Interview: Factors That Affect the Interview A skillful interview will not necessarily yield all the relevant information but will make the most of the opportunities in a clinical situation, given the limitations which both the patient and interviewer bring. Factors that influence the development of an alliance and the amount that can be learned in the interview include the following. The Patient’s Physical or Emotional Distress Patients who are in acute distress either from physical discomfort or from emotional factors such as severe depression or anxiety will be limited in their motivation and ability to interact with the interviewer. The interviewer may be able to enhance communication by addressing the patient’s discomfort in a supportive manner. However, he or she must  also recognize times when the patient’s discomfort necessitates a more limited interview. The Cognitive Capacities of the Patient Patients who are demented, retarded, disorganized, thought-disordered, amnesic, aphasic, or otherwise impaired in intellectual or cognitive capacity have biologically based deficits, which limit the amount of information they can convey. Concentration: serial 7s, world spelled backward Abstraction: proverb interpretation – what would someone mean by “The grass is always greener on the other side of the fence” (“Get off my back”) Similarities: (How are these things alike – apple–orange, table–chair, eye–ear, praise–punishment?) Computation: number of digits successfully added or subtracted, ability to calculate change (How many quarters are in $1.50? If you bought a loaf of bread for 89 cents and gave the cashier a dollar, what change would you get back?) Insight Knows something is wrong, that he or she is ill, that illness is psychiatric; understands ways in which illness disrupts function Judgment Response to standard questions (If you found a sealed, addressed, stamped letter, what would you do? If you smelled smoke in a crowded theater?) Evidence from behavior prior to and during interview (Was the patient caring for himself or herself properly, handling business affairs well? Does the behavior during the interview match his or her stated goals, e.g., if he or she wishes to be thought to be in control, is he or she keeping the voice down and movement in check?) 0001930190.INDD 83 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 84 The Psychiatric Interview The Emotionally Based Biases of the Patient Patients bring to the interview a wide variety of preconceptions, expectations, and tendencies toward distortion, which influence how they view and relate to the interviewer. Such biases are commonly referred to as transference because they frequently can be understood as arising from interactions with important figures in childhood, such as parents, which serve as imprinted templates of perceptions of others. Transferential biases may be positive or negative. Thus, even before the start of the interview, one patient may be primed to view the doctor as a wise and kindly healer, while another will be predisposed to see him or her as an exploitative charlatan. Clearly, such biases affect the amount of openness and trust that the patient brings to the interview and the quality of information he or she provides. The Emotionally Based Biases of the Interviewer The interviewer, like the patient, may have feelings stirred up by the interaction. The interviewer’s emotional reactions to the patient can be an invaluable asset in assessment if he or she can be conscious of them and reflect on their causes. For example, an interviewer finds himself or herself becoming increasingly annoyed at a highly polite patient. On reflection, he realizes that the politeness serves to rebuff his attempts to establish a warmer, more spontaneous relationship and is a manifestation of the patient’s underlying hostile attitude. When the interviewer is unable to monitor and examine his or her emotional reactions, they are more likely to impede rather than enhance understanding of the patient. This is most likely to happen when emotional reactions are driven more by the interviewer’s own biases than by the patient’s behavior. Such reactions are referred to as the interviewer’s countertransference. The entire range of countertransferential interviewer attitudes toward the patient, from aversion to infatuation, might similarly bias judgment. Situational Factors Patients’ attitudes toward the interview will be strongly influenced by the situation in which the consultation arises. Some patients decide for themselves that they need treatment, while others come reluctantly, under pressure from others. Patients who are being evaluated for disability or in connection with a lawsuit may feel a need to prove that they are ill, while those being evaluated for civil commitment or at the insistence of family members may need to prove that they are well. Similarly, a patient’s past history of relationships with psychiatrists or with health professionals in general is likely to color his or her attitude toward the interviewer. The interviewer may also be affected by situational factors. For example, pressure of time in a busy emergency service may influence the interviewer to omit important areas of inquiry and reach premature closure; the experience of a recent patient suicide may bias the interviewer toward overestimation of risk in someone with suicidal thoughts. As  with countertransference reactions, it is important for the interviewer to minimize distortions due to situational factors by being as aware of them as possible. 0001930190.INDD 84 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 85 Racial, Ethnic, and Cultural Factors The degree of racial, ethnic, cultural, and socioeconomic similarity between the patient and interviewer can influence the course and outcome of the interview in many ways (see also Chapter 2). It may affect the level of rapport between patient and interviewer, the way both view the demands of the situation, the way they interpret each other’s verbal and nonverbal communications, and the meaning the interviewer assigns to the patient’s statements and behaviors. Not only racial or cultural prejudice but also well-intentioned ignorance can interfere with communication and accurate assessment. Some cultures, for example, place a higher value on politeness and respect for authority than does Western culture. A patient from such a background might be reluctant to correct or disagree with the interviewer’s statements even when they are erroneous. The interviewer might not suspect that he or she was hearing distorted information, or conversely, might see the patient as pathologically inhibited or unemotional. Many nonWestern cultures place a higher value on family solidarity than on individuality. Pressing a patient from such a culture to report angry feelings toward family members might raise his or her anxiety, decrease rapport with the interviewer, and produce defensive distortions in the material. General Features of Psychiatric Interviews Setting The ideal interview setting is one which provides a pleasant atmosphere and is reasonably comfortable, private, and free from outside distractions. Such a setting not only provides the physical necessities for an interview but conveys to the patient that he or she will be well cared for and safe. Providing such a setting may pose special problems in certain interviewing situations. For example, it may be necessary to interview highly agitated patients in the presence of security personnel; interviewers on medical–surgical units must pay special attention to the patient’s comfort and privacy. Verbal Communication Verbal communication may be straightforward imparting of information: “Every year around November, I begin to lose interest in everything and my energy gets very low”. However, patients may convey information indirectly through metaphor, or use words for noninformational purposes, such as to express or contain emotions or to create an impact on the interviewer. In metaphorical language, one idea is represented by another with which it shares some features. For example, when asked how she gets along with her daughter-in-law, a woman replies: “I can never visit their house because she always likes to keep the thermostat down. It’s never as warm as I need”. Such a reply suggests that the woman may not feel “warmly” accepted and welcomed by her son’s wife. Metaphor may also use the body to represent ideas or feelings. A man who proved to meet the diagnostic criteria 0001930190.INDD 85 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 86 The Psychiatric Interview for major depressive disorder described his mood as “OK” but complained that his life was being ruined by constant aching in his chest for which the doctors could find no cause. In this instance, the pain of depression was experienced and described metaphorically as a somatic symptom. Language may be used to express emotions directly, but more often is used indirectly by influencing the process of the interview. Patients may shift topics, make off-hand remarks or jokes, ask questions, and compliment or belittle the interviewer as a way of expressing feelings. The process of the interview frequently expresses the patient’s feelings about his or her immediate situation or interaction with the interviewer. For example, a woman being evaluated for depression and anxiety suddenly said: “I was just wondering doctor, do you have any children?” The further course of the interview revealed that she was terrified of being committed to a hospital and abandoned. The question was an attempt to establish whether the interviewer was a good parent and therefore safe as a caretaker for her. Language may also be used in the service of psychological defense mechanisms to contain rather than express emotions. For example, a young man with generalized anxiety was asked whether he was sexually active. He replied by talking at length about how all the women he knew at college were either unappealing or attached to other men. Further discussion revealed that he developed severe symptoms of anxiety whenever he was with a woman to whom he felt sexually attracted. His initial reply represented an automatic, verbal mechanism (in this case, a rationalization) for keeping the anxiety out of awareness. Another form of process communication is the use of language to make an impact on the interviewer. A statement such as “If you can’t help me I’m going to kill myself” might convey suicidal intent, but may also serve to stir up feelings of concern and involvement in the interviewer. Similarly, the patient who says “Dr X really understood me, but he was much older and more experienced than you are” may be feeling vulnerable and ashamed, and unconsciously trying to induce similar feelings in the interviewer. When language is used in this way, the interviewer’s subjective reaction may be the best clue to the underlying feelings and motivations of the patient. Nonverbal Communication Emotions and attitudes are communicated nonverbally through facial expressions, gestures, body position, and movements, interpersonal distance, dress and grooming, and speech. Some nonverbal communications such as gestures are almost always conscious and deliberate, while others often occur automatically outside one’s awareness. The latter type are particularly important to observe during an interview because they may convey messages entirely separate from or even contradictory to what is being said. The interviewer will automatically decode these signals but may ignore the message due to countertransference or social pressure from the patient. For example, a patient may say, “I feel very comfortable with you, doctor”, but sit stiffly upright and maintain a rigidly fixed smile, conveying a strong nonverbal message of tension and mistrust. The nonverbal message may be missed if, for example, the interviewer has a strong need to be liked by the patient. Another patient denies angry feelings while sitting with a tightly 0001930190.INDD 86 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 87 clenched fist. The interviewer may unconsciously collude with the patient’s need to avoid his anger by ignoring the body language. As with any medical examination, observation of nonverbal behavior may provide important diagnostic information. For example, a leaden body posture may indicate depression, movements of the foot may arise from anxiety or tardive dyskinesia, and sudden turning of the head and eyes may suggest hallucinations. Nonverbal communication proceeds in both directions, and the nonverbal messages of the interviewer are likely to have a considerable effect on the patient. Thus, the interviewer who sits back in his chair and looks down at his notes communicates less interest and involvement than one who sits upright and makes eye contact. Similarly, an  interviewer who gives a weak handshake and sits behind a desk or far across the room from the patient will communicate a sense of distance, which may interfere with establishing rapport. It is important that the interviewer be aware of his or her own nonverbal messages and adapt them to the needs of the patient. Listening and Observation The interviewer must remain open to literal and metaphorical messages from the patient, to the impact the patient is trying to make and to the degree to which nonverbal communication complements or contradicts what is being said. Doing this optimally requires that the interviewer also be able to listen to his or her own mental processes throughout the interview, including both thoughts and emotional reactions. Listening of this kind depends upon having a certain level of comfort, confidence, and space to reflect, and may be very difficult when the patient is hostile, agitated, demanding, or putting pressure on the interviewer in any other way. With such patients, it may take many interviews to do enough good listening to gain an adequate understanding of the case. Another important issue in listening is maintaining a proper balance between forming judgments and remaining open to new information and new hypotheses. On the one hand, one approaches the interview with knowledge of diagnostic classifications, psychological mechanisms, behavioral patterns, social forces, and other factors that shape one’s understanding of the patient. The interviewer hears the material with an ear to fitting the information into these preformed patterns and categories. On the other hand, the interviewer must remain open to hearing and seeing things that extend or modify his or her judgments about the patient. At times, the interviewer may listen narrowly to confirm a hypothesis, while at others, he or she may listen more openly, with relatively little preconception. Thus, listening must be structured enough to generate a formulation but open enough to avoid premature judgments. Attitude and Behavior of the Interviewer The optimal attitude of the interviewer is one of interest, concern, and intention to help the patient. While the interviewer must be tactful and thoughtful about what he or she says, this should not preclude behaving with natural warmth and spontaneity. Indeed, these qualities may be needed to support patients through a stressful interview process. 0001930190.INDD 87 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 88 The Psychiatric Interview Similarly, the interviewer must try to use natural, commonly understood language and avoid jargon or technical terms. The interviewer must communicate his or her intention to keep the patient as safe as possible, whatever the circumstances. Thus, while one must at times set limits on the behavior of an agitated, threatening, or abusive patient, one should never be attacking or rejecting. Empathy is an important quality in psychiatric interviewing. While sympathy is an expression of agreement or support for another, empathy entails putting oneself in another’s place and experiencing his or her state of mind. Empathy comprises both one’s experiencing of another person’s mental state and the expression of that understanding to the other person (Barrett-Lennard, 1981). For example, in listening to a man talk about the death of his wife, the interviewer may allow himself or herself to resonate empathetically with the patient’s feelings of loneliness and desolation. Based on this resonance, he or she might respond, “After a loss like that, it feels as if the world is completely empty”. As a mode of listening, empathy is an important way of understanding the patient; as a mode of response, it is important in building rapport and alliance. Patients who feel great emotional distance from the interviewer may make empathic understanding difficult or impossible. Thus, the interviewer’s inability to empathize may itself be a clue to the patient’s state of mind. Structure of the Interview In reconnaissance phases, the interviewer inquires about broad areas of symptomatology, functioning, or life course: “Have you ever had long periods when you felt very low in mood?” “How have you been getting along at work?” “Tell me what you did between high school and when you got married”. In responding to such questions, patients give the interviewer leads, which then must be pursued with more detailed questioning. Leads may include references to symptoms, difficulty in functioning, interpersonal problems, ideas, states of feeling, or stressful life events. Each such lead raises questions about the nature of the underlying problem, and the interviewer must attempt to gather enough detailed information to answer these questions. Reliance on yes or no “gate questions” to rule out areas of pathology has been shown to increase the risk of missing important information. In general, the initial reconnaissance consists of asking how the patient comes to treatment at this particular time. This is done by asking an open-ended question such as “What brings you to see me today?” or “How did you come to be in the hospital right now?” A well-organized and cooperative patient may spontaneously provide most of the needed information, with little intervention from the interviewer. However, the patient may reveal deficits in thought process, memory, or ability to communicate, which dictate more structured and narrowly focused questioning. The patient’s emotional state and attitude may also impede a smooth flow of information. For example, if the patient shows evidence of anxiety, hostility, suspiciousness, or indifference, the interviewer must first build a working alliance before trying to collect information. This usually requires acknowledging the emotions that the patient presents, helping the patient to express his or her feelings and related thoughts, and discussing these concerns in an accepting and empathic manner (Strean, 1985). As new areas of content open up, the interviewer must continue to attend to the patient’s reactions, both verbal and nonverbal, and to identify and address resistance to open communication. 0001930190.INDD 88 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 89 Setting an appropriate level of structure is an important aspect of psychiatric interviewing. Psychiatric patients may spontaneously report a low number of symptoms, and initial diagnostic impressions may be misleading (Herran et al., 2001). Over the past two decades, a variety of structured interview formats have been developed for psychiatric assessment. In these interviews, the organization, content areas, and, to varying degrees, wording of the questions are standardized; vague, overly complex, leading or biased, and judgmental questions are eliminated, as is variability in the attention given to different areas of content. The major benefits of such interviews are that they ensure complete coverage of the specified areas and greatly increase the reliability of information gathered and diagnostic judgments. In addition, formats that completely specify the wording of questions can be administered by less highly trained interviewers or even as patient self-reports. The disadvantages of highly structured interviews are that they diminish the ability to respond flexibly to the patient and preclude exploration of any areas not specified in the format. They are therefore used to best advantage for interviews with focused goals. For example, such interviews may aim to survey certain DSM V disorders, to assess the type and degree of substance abuse, or to delineate the psychological and behavioral consequences of a traumatic event. They are less useful in a general psychiatric assessment where the scope and focus of the interview cannot be preordained. In the usual clinical situation, while the interviewer may have a standardized general plan of approach, he or she must adapt the degree of structure to the individual patient. Open-ended, nondirective questions derive from the psychoanalytic tradition. They are most useful for eliciting and following emotionally salient themes in the patient’s life story and interpersonal history. Focused, highly structured questioning derives from the medical/descriptive tradition and is most useful for delineating the scope and evolution of pathological signs and symptoms. In general, one uses the least amount of structure needed to maintain a good flow of communication and cover the necessary topic areas. Phases of the Interview The typical interview comprises an opening, middle, and closing phase. In the opening phase, the interviewer and patient are introduced, and the purposes and procedures of the interview are set. It is generally useful for the interviewer to begin by summarizing what he or she already knows about the patient and proceeding to the patient’s own account of the situation. For example, the interviewer may say, “Dr Smith has told me that you have had several episodes of depression in the past, and now you may be going into another one”, or “I understand that you were brought in by the police because you were threatening people on the street. What do you think is happening with you?” or “When we spoke on the phone you said you thought your marriage was in trouble. What has been going wrong?” Such an approach orients the patient and sets a collaborative tone. The opening phase may also include clarification of what the patient hopes to gain from the consultation. A question such as “How were you hoping I could help you with the problem you have told me about?” invites the patient to formulate and express his or her request and avoids situations in which the patient and interviewer work at cross-purposes. The interviewer must also be explicit about his or her own goals and the extent to which they fit with the patient’s expectations. This is especially important when the interests of a third party, such as an employer, a family member, or a court of law, is involved. 0001930190.INDD 89 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 90 The Psychiatric Interview The middle phase of the interview consists of assessing the major issues in the case and filling in enough detail to answer the salient questions and construct a working formulation. Most of the work of determining the relative importance of biological, psychological, environmental, and sociocultural contributions to the problem is done during this phase. The patient’s attitudes and transferential perceptions are also monitored during this phase so that the interviewer can recognize and address barriers to communication and collaboration. When appropriate, formal aspects of the MSE are performed during the middle phase of the interview. While most of the MSE is accomplished simply by observing the patient, certain components such as cognitive testing and review of psychotic symptoms may not fit smoothly into the rest of the interview. These are generally best covered toward the end of the interview, after the issues of greatest importance to the patient have been discussed and rapport has been established. A brief explanation that the interviewer has a few standard questions he or she needs to cover before the end of the interview serves as a bridge and minimizes the awkwardness of asking questions that may seem incongruous or pejorative. In general, note-taking during an assessment interview is helpful to the interviewer and not disruptive of rapport with the patient. Notes should be limited to brief recording of factual material such as dates, durations, symptom lists, important events, and past treatments, which might be difficult to keep in memory accurately. The interviewer must take care not to become so involved in taking notes as to lose touch with the patient. It is especially important to maintain a posture of attentive listening when the patient is talking about emotionally intense or meaningful issues. When done with interpersonal sensitivity, note-taking during an assessment interview may actually enhance rapport by communicating that what the patient says is important and worth remembering. This is to be distinguished from note-taking during psychotherapy sessions, which is more likely to diminish the treater’s ability to listen and respond flexibly. In the third or closing phase of the interview, the interviewer shares his or her conclusions with the patient, makes treatment recommendations and elicits reactions. In situations where the assessment runs longer than one session, the interviewer may sum up what has been covered in the interview and what needs to be done in subsequent sessions. Communications of this kind serve several purposes. They allow the patient to correct or add to the salient facts as understood by the interviewer. They contribute to the patient’s feeling of having gained something from the interview. They are also the first step in initiating the treatment process because they present a provisional understanding of the problem and a plan for dealing with it. All treatment plans must be negotiated with the patient, including discussion of mutual goals, expected benefits, liabilities, limitations, and alternatives, if any. In many cases, such negotiations extend beyond the initial interview and may constitute the first phase of treatment. Dimensions of Interviewing Techniques To classify interviewing techniques, it is convenient to think about four major dimensions of interviewing style: degree of directiveness, degree of emotional support, degree of fact versus feeling orientation, and degree of feedback to the patient. The interviewer must seek a balance among these dimensions to best cover the needed topics, build rapport, and arrive at a plan of treatment. 0001930190.INDD 90 4/10/2013 1:15:44 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 91 Directiveness Directiveness in the interview ensures that the necessary areas of information are covered and supplies whatever cognitive support the patient needs in discussing them. Table 4.6 lists interventions that are low, moderate, and high in directiveness. Low-directive interventions request information in the broadest, most open-ended way and do not go beyond the material supplied by the patient. Moderately directive Table 4.6 Degrees of Directiveness in the Interviewer Directiveness Intervention  Examples Low Open-ended questions “What brings you to the hospital?” “Tell me about your current situation in life”. Low Repetition Patient: “Last night I suddenly started to feel so terrible I was afraid I was going to die”. Interviewer: “You were afraid you were going to die”. Low Restatement P: “Nobody is on my side anymore – even my family is out to get me”. I: “So it seems as if everyone has turned against you”. Low Summarization “To review what we have been discussing, over the last month you’ve been very low in mood, you felt overwhelmed even by small chores, and you no longer want to see any of your friends”. Low Clarification “You told me that it ‘upsets’ you to have to say no. It seems that when you say no to your boss your feeling is fear, but when you say no to your children you feel guilty”. Low Nonverbal “Uh-huh”; nodding of head. acknowledgment Low Attentive listening In talking about the recent death of his wife, the patient became tearful and hesitant in speech. The interviewer remained silent, but attentive, allowing the patient time to express himself or herself. Moderate Broad-focus questions “What do you notice about yourself lately that is different from usual?” “What is it about your job that you find stressful?” Moderate Use of examples “Sometimes illness seems to be triggered by something that happens, like a change in finances or living situation, or losing someone who’s close to you. Has anything like that been happening to you?” (Continued ) 0001930190.INDD 91 4/10/2013 1:15:45 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 92 The Psychiatric Interview Directiveness Intervention  Examples Moderate Confrontation “You told me you got a ‘terrible’ evaluation at work, but in 9 of 10 categories, your rating was actually excellent”. “You don’t feel the medicine does you any good, but whenever you’ve stopped it, you’ve had to go back into the hospital. How do you account for that?” Moderate Interpretation “Part of the tension between you and your wife is that you forget things she tells you. Perhaps this is what you do when you are angry at her”. High Narrow-focus questions “Do you have trouble getting to sleep or staying asleep?” “How much alcohol do you drink in a week?” High Question repetition I: “How has your daily routine changed in the last month?” P: “I used to like to read, but now I don’t anymore. My husband thinks I would feel better if I pushed myself to keep busy, but I tell him that this dizziness makes it impossible for me to do anything. I don’t know what to think anymore”. I: “How else has your routine changed lately?” High Redirection P: “I’ve always thought that my father’s personality caused a lot of my troubles in life”. I: “I’d like to hear more of your thoughts about that, but first I need to get a clearer picture of what’s been happening with you lately. When did you decide to make the appointment with me?” High Change of topics “You mentioned before that your brother had similar problems to yours. Can you tell me how many brothers and sisters you have, and if they’ve had any emotional problems?” “We’ve been talking about your marriage, but now I’d like to know something about your work”. High Limit-setting “I’m going to have to interrupt you because there are a few more things we need to cover in the time left”. “I know you feel restless, but I have to ask you to try to stay in your chair and concentrate on what we’re talking about”. Table 4.6 (Cont’d) 0001930190.INDD 92 4/10/2013 1:15:45 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 93 interventions are narrower in focus and may extend beyond what the patient himself or herself has said. For example, confrontation makes the patient aware of paradoxes or inconsistencies in the material and requests him or her to resolve them; interpretation requests the patient to consider explanations or connections that had not previously occurred to him or her. Highly directive interventions aim to focus and restrict the patient’s content or behavior. Such interventions include yes/no or symptom–checklist-type questions and requests for the patient to modify behaviors that impede the progress of the interview. Supportiveness Patients vary considerably in the degree of emotional and cognitive support they need in the interview. Table 4.7 lists examples of emotionally supportive interventions. Each such intervention supports the patient’s sense of security and self-esteem. While some patients may come to the interview feeling safe and confident, others have considerable anxiety about being criticized, ridiculed, rejected, taken advantage of, or attacked (literally so in the case of some psychotic patients). Overt manifestations of insecurity range widely from fearful demeanor and tremulousness to requests for reassurance to haughty contemptuousness. The interviewer’s task is to identify such anxiety when it arises and respond in a manner that conveys empathic understanding, acceptance, and positive regard. Table 4.7 Supportive Interventions Intervention Examples Encouragement Patient: “I’m not sure I’m making any sense today doctor”. Interviewer: “You’re doing very well at describing the troubles you’ve been having”. Approval “You did the right thing by coming in for an appointment”. “You’ve been doing your best to keep going under very difficult circumstances”. Reassurance “What you are telling me about may seem very strange to you, but many people have had similar experiences”. “You feel like you will be sick forever, but with treatment you have a very good chance of feeling better soon”. Acknowledgment of affect “You look very sad when you talk about your brother”. “I have the impression that my question made you angry”. Empathic statements “When your boyfriend doesn’t call you, you feel completely helpless and unloved”. “It seems unfair for you to get sick so many times while others remain well”. Nonverbal communication Smiling, firm handshake, attentive body posture, gentle touch on shoulder. Avoidance of affectladen material Interviewer elects to defer discussion or probing of topics that arouse intense feelings of anxiety, shame, or anger. 0001930190.INDD 93 4/10/2013 1:15:45 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 94 The Psychiatric Interview Obstructive interventions are those that (usually unintentionally) impede the flow of information and diminish rapport. Table 4.8 lists common examples of such interventions. Compound or vague questions are often confusing to the patient and may produce ambiguous or unclear answers. Biased or judgmental questions suggest what answer the Table 4.8 Obstructive Interventions Intervention Examples Suggestive or biased questions “You haven’t been feeling suicidal, have you?” “You’ve had six jobs in the last 2 years. I guess none of them held your interest”. Judgmental questions or statements “How long have you been behaving so selfishly?” “What you’ve told me is typical of delusional thinking”. “Why” questions “Why can’t you sit still?” “Why do you keep choosing men who can’t make a commitment to you?” Ignoring the patient’s leads Patient: “I’m afraid I’m going to fall apart”. Interviewer: “Have you had any odd experiences, such as hearing voices?” P: “No, but I just feel as though I can’t cope and I wanted to talk to someone about it”. I: “Has your sleep pattern or appetite changed?” P: “Well, I don’t sleep as well as I used to, but it’s getting through the days that’s the hardest”. I: “Have you had any suicidal thought?”, etc. Crowding the patient with questions P: “I just can’t get it out of my mind that this cancer of mine is a punishment of some kind because I …” I: “Have you been in a low mood or been tearful?” Compound questions “Have you ever heard voices or thought that other people were out to harm you?” Vague questions “Do you feel socially self-conscious a lot?” “How much trouble do you have with your memory?” Minimization or dismissal P: “I don’t seem to be able to enjoy my life as much as I think I should”. I: “You’re doing well at your job and have a nice family – you’re probably just feeling some minor stress”. Premature advice or reassurance P: “I’ve been having terrible headaches and I forget a lot of things. There’s nothing wrong with my brain, is there?” I: “Headaches and forgetfulness are very common and are probably due to some minor cause in your case”. P: “I’ve started to have thoughts that I married the wrong man and I should leave my husband”. I: “Maybe the two of you ought to take some time away together”. Nonverbal questions Sitting at a distance, yawning, looking at watch, fidgeting, frowning, rolling of eyes. 0001930190.INDD 94 4/10/2013 1:15:45 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 95 interviewer wants to hear or that he or she does not approve of what the patient is saying. “Why” questions often sound critical or invite rationalizations. “How” questions better serve the purposes of the interview (“How did you come to change jobs?” rather than “Why did you change jobs?”). Other interventions are obstructive because they disregard the patient’s feeling state or what he or she is trying to say. Paradoxically, this may include premature reassurance or advice, that is, when given before the interviewer has explored and understood the issue, this has the effect of cutting off feelings and coming to a premature closure. Fact versus Feeling Orientation Interviews differ in the degree to which they focus on factual–objective- versus feeling– meaning-oriented material. Table 4.9 and Table 4.10 provide examples of interventions of both types. The interviewer must determine what the salient issues are in a given case and develop the focus accordingly. For example, at one extreme, the principal task in assessing a cyclically occurring mood disorder might be to delineate precisely the symptoms, time course, and treatment response of the illness. At the other end of the spectrum might be a patient with a circumscribed difficulty in living, such as the inability to achieve an intimate, lasting love relationship. In such a case, the interviewer may focus not only on the facts of the patient’s interactions with others but also on the feelings, fantasies, and thoughts associated with such relationships. Table 4.9 Fact-oriented Interventions in the Psychiatric Interview Intervention Examples Questions about symptoms “Do the voices seem to come from within your own head or from outside?” “When did you first begin to check your door lock many times before going out?” Questions about behavior “What do you do when you fly into a rage – do you yell, hit the furniture, or hit people?” “Since you’ve had your pain, how is your daily routine different than it used to be?” Questions about events “What was the next thing you did after you took the overdose of medication?” “What led up to your decision to move out of your parents’ home?” Request for biographical data “Who lived with you when you were growing up?” “How many times have you been in a psychiatric hospital?” “Tell me about your close relationships with women”. Requests for medical data “What medicines do you take?” “What conditions do you see a doctor for?” 0001930190.INDD 95 4/10/2013 1:15:45 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 96 The Psychiatric Interview Feedback Interviews differ in how much the interviewer conveys to the patient of his or her own thoughts, feelings, conclusions, and recommendations. Table  4.11 presents common types of feedback from the interviewer. Judicious statements about the interviewer’s ongoing thoughts and feelings can be used to pose questions or make clarifications or interpretations while enhancing rapport and trust. Communication of factual information, formulations of the problem, and treatment recommendations are the foundations of joint treatment planning with the patient. Responding to questions and giving advice may serve an educational purpose as well as enhancing the alliance. When responding to requests for advice or information, the interviewer must first take care to be sure of what is being asked, and for what reason. There is little systematic data on the superiority of one clinical interviewing style over another, but what there are suggest that many styles can be used effectively. Rutter and his colleagues have investigated this question in a series of naturalistic and experimental studies of interviews of parents in a child psychiatry clinic (Cox et al., 1981, 1988; Rutter et al., 1981). The major findings of these studies are as follows: 1. Active, structured techniques are no better than nondirective styles in eliciting positive findings (i.e., areas of pathology). However, active techniques are better in eliciting more detailed and thorough information in areas where pathology is found and are also better at delineating areas without pathology. 2. An active, fact-gathering style does not prevent the interviewer from effectively eliciting emotional reactions from informants. 3. Use of open questions, direct requests for feelings, interpretations of feelings, and expressions of sympathy are associated with greater expression of emotions by informants. Table 4.10 Feeling-oriented Interventions in the Psychiatric Interview Intervention Examples Questions about feelings in specific situations “Some people might have been angry in the situation you told me about. Did you feel that way?” “How did you feel when your doctor told you that you had a heart attack?” “I’ve noticed your voice got much quieter when you answered my last question. What were you feeling just then?” Questions or comments about emotional themes or patterns “Growing up, you never felt like you measured up to your mother’s expectations. Do you feel that same way in your marriage?” Questions or comments about the personal meaning of events “You are concerned about becoming enraged at your daughter. When she disregards your wishes, what do you feel that means about you as a parent?” 0001930190.INDD 96 4/10/2013 1:15:45 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. Chapter 4 • The Psychiatric Interview: Settings and Techniques 97 Table 4.11 Feedback in the Psychiatric Interview Intervention Examples Sharing of ongoing thoughts “As you were talking I began to wonder if you had ever lost anyone very close to you”. “As I hear your story it occurs to me that you’ve been an outsider every place you’ve lived in”. Sharing of subjective reactions “What you are saying makes me feel quite sad”. “You’ve told me how you left treatment with your last psychiatrist, but I still feel a bit confused about what happened”. “I notice I’m feeling somewhat tense right now and I wonder if you might be feeling it too”. Imparting of information “About 75% of people with your condition respond well to medication”. “The tendency to develop the kind of symptoms you have described runs in families, and probably is inherited”. Proposing a formulation “I think the immediate cause of your depression and insomnia is your heavy drinking”. “When you are under stress you tend not to think clearly and to develop unrealistic fears. It seems as though your present stress comes from the way you and your family are getting along at home”. Making treatment recommendations “In order for you to keep safe and begin treatment I think it would be best to go into the hospital for a while”. “Medication should help you get out of your depression much faster. When you are feeling better, it would be a good idea for us to try to understand how you got so isolated from your friends and family”. Advice “It might be better not to decide about changing jobs until you’re feeling back to your regular self”. Response to questions Patient: “What type of psychiatrist are you, doctor?” Interviewer: “I’m a general psychiatrist who uses medication and psychotherapy. I also have a special interest in anxiety disorder”. P: “Have you ever seen another patient like me?” I: “I can answer your question better if you tell me what there is about you that I might have never seen before”. P: “Do you think I’m a terrible person?” I: “I don’t think you are terrible, but I wonder what you think about yourself that you would ask me that”. 0001930190.INDD 97 4/10/2013 1:15:45 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 98 The Psychiatric Interview 4. Less activity on the interviewer’s part is associated with more informant talkativeness and spontaneous emotional expression. Less directive techniques also tend to produce more emotional responses at times when they are not specifically requested. Conversely, more active styles of asking about feelings may be more effective for informants who are low in spontaneous emotional expression. 5. In summary, techniques that actively elicit both facts and emotions are likely to produce the richest, most detailed database. When skillfully used, these do not impair the doctor–patient relationship. References Abramowitz JS (1997) Effectiveness of psychological and pharmacological treatments for obsessive–compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology 65, 44–52. Andreasen N and Hoevk PR (1982) The predictive value of adjustment disorders. A follow-up study. American Journal of Psychiatry 134, 584–590. Banmohl J and Jaffe JH (1995) History of alcohol and drug abuse treatment in the United States, in Encyclopedia of Drugs and Alcohol, Vol. 3 (ed. Jaffe JM). Macmillan, New York. Barlow DH (1988) Anxiety and Its Disorders – The Nature and Treatment of Anxiety and Panic. Guilford Press, New York. 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Chapter 4 • The Psychiatric Interview: Settings and Techniques 99 Cloninger R, Martin RL, Guze SB et al. (1986) A prospective follow-up and family study of somatization in men and women. American Journal of Psychiatry 143, 873–878. Cloninger CR, Surakic DM and Przybeck TR (1993) A psychobiological model of temperament and character. Archives of General Psychiatry 50, 975–990. Coccaro ER and Kavoussi RJ (1997) Fluoxetine and impulsive-aggressive behavior in personality-disordered subjects. Archives of General Psychiatry 45, 1081–1088. Cox A, Holbrook D and Rutter M (1981) Psychiatric interviewing techniques VI. Experimental study. Eliciting feelings. British Journal of Psychiatry 139, 144–152. Cox A, Rutter M and Holbrook D (1988) Psychiatric interviewing techniques. A second experimental study: Eliciting feelings. British Journal of Psychiatry 152, 64–72. Davis JM (1975) Overview: Maintenance therapy in psychiatry. I. Schizophrenia. American Journal of Psychiatry 132, 1237–1245. 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Chapter 4 • The Psychiatric Interview: Settings and Techniques 101 Nesse RM and Berridge KC (1997) Psychoactive drug use in evolutionary perspective. Science 278, 63–66. Nurnberg HG, Raskin M, Levine PE et al. (1991) Hierarchy of DSM-III R. Criteria efficiency for the diagnosis of borderline personality disorder. Journal of Personality Disorders 5, 211–244. Popkin MK (1994) Syndromes of brain dysfunction presenting with cognitive impairment or behavioral disturbance. Delirium, dementia, and mental disorders due to a general medical condition, in The Medical Basis of Psychiatry, 2nd edn (eds Winokur G and Clayton PJ). WB Saunders, Philadelphia, pp. 17–37. Prescott CA and Kendler KS (1999) Genetic and environmental contributions to alcohol abuse and dependence in a population-based sample of male twins. American Journal of Psychiatry 156, 34–40. Rutter M, Cox A, Egert S et al. (1981) Psychiatric interviewing techniques IV. Experimental study. Four contrasting styles. 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Neuropsychobiology 34, 125–129. 0001930190.INDD 101 4/10/2013 1:15:46 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved. 0001930190.INDD 102 4/10/2013 1:15:46 AM Tasman, Allan, et al. The Psychiatric Interview : Evaluation and Diagnosis, John Wiley & Sons, Incorporated, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=1187749. Created from ashford-ebooks on 2017-10-10 15:34:29. Copyright © 2013. John Wiley & Sons, Incorporated. All rights reserved.