Psychiatric Interview

Paula Gibbs, MD
Assistant Professor Department of Psychiatry
Medical Director of 5West Med-Psych
University of Utah Hospitals and Clinics
Psychiatric Interview

 The purpose of a psychiatric interview is to establish

a therapeutic relationship with the patient to collect,
organize and formulate a differential diagnosis and
treatment plan.

 A fundamental part of this interview is to establish

and foster a healthy relationship and secure
attachment between the interviewer and the
patient. This allows for open communication for
gathering information and correcting any
misunderstandings in the therapeutic relationship.
Psychiatric Interview

 Few medical encounters are more intimate and

potentially shameful like the psychiatric interview.
 The clinician needs to be mindful of the sensitive
nature of this interview and provide a safe
environment for the patient to reveal such
deeply personal information.
 The clinician needs to be mindful that patients
may have disagreements with the clinician’s
diagnosis and recommended treatments.
 Nothing in medicine is more stigmatized than
mental health and substance misuse.
Elements that Contribute to
a Secure Attachment in a
Therapeutic Relationship:
 Communication that is collaborative, resonant, mutual and
attuned to the cognitive and emotional states of the other.

 Dialogue that is reflective and responsive to the other’s

state of being. Use of empathy as a means of a shared
experience so the other is allowed to feel “heard and
seen.”

 Identify and repair fractures in miscommunications or

misunderstandings in the relationship. Miscommunication
and misunderstandings in a relationship causes
disconnection and shame responses.
Elements that Contribute to
a Secure Attachment in a
Therapeutic Relationship

 Shame responses include:

 Moving away – withdrawing from, isolation, keeping secrets

 Moving in – overcompensation to care for the clinician as a
means to be accepted
 Moving against – taking one’s shame and shaming the other

To repair communication failures (empathic failures) requires

consistent, reflective, intentional and mindful caregiving.
Psychiatric Interview

 The nature of the psychiatric interview is getting the patient’s narrative.

 Facilitate the patient’s narrative with compassionate listening and

reflection.

 Mindfulness and reflection is a form of mentoring through modeling for

the patient.

 How a patient puts the narrative of their medical and psychiatric history
together tells the clinician how integrated the patient’s mind is.

 An integrated mind can create a narrative that involves sustained

attention, memory, emotional responses, intellectual analysis, timeline,
mindfulness of self as well as mindfulness of others in their lives.
Psychiatric Interview

 The fundamental tasks of communication:

 Elicit the patient’s narrative while guiding the interview by

diagnostic reasoning.

 Open the discussion by allowing the patient to express his or her

opening statement without interruption.

 Use both open-ended and close-ended questions to gather

information, provide structure, clarify and summarize information
collected.
Psychiatric Interview

 The fundamental tasks of communication (cont’d):

 Understand the patient’s perspective by exploring contextual

issues (e.g., familial, cultural, spiritual, age, gender, and
socioeconomic status).

 Understand the patient’s perspective with eliciting beliefs,

concerns and expectations about health and illness.

 Active listening using verbal and nonverbal methods (eye

contact).
Psychiatric Interview

 The fundamental tasks of communication (cont’d):

 Share information by avoiding medical language/jargon.

 Determine if the patient understands your explanations.

 Encourage questions!
Psychiatric Interview

 The fundamental tasks of communication (cont’d):

 Reach an agreement on the problems and treatment plan by

encouraging the patient’s participation in the decision-making.

 Explore if the patient is amenable to follow a plan of treatment.

 Identify and provide resources, support groups, psychotherapy

and literature to read.

 Provide closure with follow up plans.

Psychiatric Interview

 Behavioral Observation begins the moment the patient engages with

the system of care (i.e. the initial phone call for the appointment). It is
useful to see how the patient interacts with the support staff and with
family, friends or others that may accompany him/her to the
appointment.

 The observation continues before, during and after the interview. Take
note of the patient’s:
 Grooming
 Style and state of the clothing worn
 Mannerisms
 Normal and abnormal movements
 Posture and gait
 Physical features (natural deformities, birth marks, tattoos, piercings, cut marks,
scratches, burns)
 Coloring
 Use of language
 Nonverbal clues such as eye contact, facial expression and posture.
Psychiatric Interview

 The interview of the patient starts with an open ended

question as to what brought the patient in today.
Encourage the patient to tell the story without interruption
if possible.
 Use clarification to move the interview through the data
gathering, being mindful as that patient may have a
different agenda than the diagnostic assessment (e.g.
patient is upset her spouse is unemployed but is in a manic
state during the interview). Always important to validate
the patient’s perspective!
 Remember depression, anxiety and agitation mean
different things to patients vs. Psychiatrist/PCP.
Psychiatric Interview

 It is best to focus on the chief complaint and present

issues and to incorporate the other parts of the history
around this. As the PCP, you are in a position of a long-
term trusting relationship with the patient and can redirect
the patient to ascertain additional information. Many
times the PCP knows about family dynamics as they see
the family also (alcoholism, financial, losses in the family).

 A key component of the psychiatric interview is the

determination of safety. Questions about suicide,
homicide, domestic violence and abuse should not be
omitted from the review of the current situation!
Chief Complaint/Presenting Problems(s)

 What is the chief complaint?

 Onset

 Perceived precipitants

 Signs & Symptoms

 Course and duration

 Treatments: professional and personal

 Effects on the patient’s function: personal, occupational, social or

academic

 Co-morbid psychiatric or medical disorders

 Psychosocial stressors: personal (psychological or medical), family,

friends, occupation/academic, legal, housing and financial
Review of Psychiatric Symptoms

 Depression

 Mania

 Anxiety

 OCD/PTSD

 Attention

 Eating Disorder

 Thought Disorder
Past Psychiatric History

 Previous episode of the problem(s)?

 Symptoms, course, duration and treatment (inpatient,

outpatient, psychopharmacology, psychotherapy)

 Psychiatric diagnoses

 Suicide attempts: #s and how the patient attempted

 Self mutilation: cutting, burning, head banging,

scratching, tattoos

 ECT
Past Medical History

 Medical: past and current

 Surgical: past and current

 Accidents: Include TBI

 Allergies

 Current medications: prescribed and OTC with

dosages

 Other treatments: acupuncture, chiropractic,

homeopathic, yoga, mediation
Substance Use History
 Tobacco: past and current, type of tobacco and
amount per day for how many years, vaping
 Alcohol: first use, last use, pattern of use, blackouts,
DUIs, loss of relationships secondary to use, how does it
make you feel
 Cannabis: first use, last use, pattern of use, how does it
make you feel
 Stimulants: what is used (pills, methamphetamine,
cocaine), how is it ingested (oral, snort, smoke, IVDU,
anal), first use, last use, pattern of use, legal issues
secondary to use, medical issues secondary to use,
how did it make you feel
Substance Use History

 Opiates: what is used (pills, heroin), how is it ingested

(oral, snort, smoke, IVDU), first use, last use, pattern of
use, legal issues secondary to use, medical issues
secondary to use, how did it make you feel

 Hallucinogens: what is used (LSD, mushroom), first use,

last use, pattern of use, still experiencing flashback or
bad trips

 Club Drugs: what is used (GHB, Ecstasy, Poppers,

Ketamine), first use, last use, pattern of use
Substance Use History
 Detox:
 How many times?
 Complications (dTs, seizures)?

 Rehab:
 How many times?
 Completed?

 Longest sobriety
Family History

 Family psychiatric history

 Family medical history
Social History

 Place of birth and birth order

 Family relationships

 School performance/learning, attention problems

 College/trade school performance

 Relationships as an adult

 Occupational history

 Military experiences

 Sexual history

 Legal history
Collateral Information

 If possible, and if the patient gives permission with ROI.

 Collateral information from PCP, therapist, partner,

spouse, parents, adult children, friends, or clergy can be
helpful with the assessment.

 With obtaining permission to talk with collateral informants

also allows the opportunity to engage in the treatment
process.
Mental Status Examination
 This is the physical exam for the psychiatrist.

 General appearance: grooming, posture, abnormal

movements, mannerisms, tattoos, scars
 Behavior: normal, fidgety, restless, hyperactive,
hypoactive/retardation, anxious, tense, agitated, tics
 Attitude: cooperative, uncooperative, hostile, indifferent,
oversensitive, negative, polite
 Eye contact: normal, limited, poor, eyes closed, darting,
looking away as if looking at something and distracted
 Speech: rate, flow, latency, coherence, logical, goal
directed, prosody, disorganized, mumbled, volume, rapid,
pressured
Mental Status Examination
 Mood: what the patient reports including normal,
anxious, depressed, sad, elevated, euphoric, on top of
the world, irritable, numb

 Affect: what the provider sees including euthymic,

depressed, elevated, euphoric, irritable/labile,
agitated, perplexed, confused

 FOT: slow, rapid, pressured, blocking, incoherent,

disorganized, logical, linear, circumstantial, tangential,
loose associations

 COT: hallucination, delusions

Mental Status Examination

 Safety: suicidal, homicidal (is there an identified

victim), self harm-intent, plans, means, impulsive

 Insight: good, fair, minimal

 Judgment: good, impaired, minimal

 Motivation: high, moderate, low

 Cognition: level of consciousness, orientation,

attention/concentration, memory, calculation,
abstraction
Mental Status Examination
 FOT

 Circumstantiality: a disorder of association with the

inclusion of unnecessary details until one arrives at the goal
of the thought (over-inclusive)
 Tangentiality: use of oblique, irrelevant and digressive
thoughts that do not convey the central idea to be
communicated
 Loose Associations: jumping from one unconnected topic
to another
 Flight of Ideas: rapid speech with abrupt changes from
topic to topic usually based on understandable links
between topics, distracting internal stimuli or a play on
words
Mental Status Examination
 FOT

 Clanging Associations: pattern of speech in which the

sounds of words, rather than their meaning guide the
choice of words. Puns and rhymes e.g. “Where do I lie? If I
lie, will I die?”
 Perseveration: repeating the same response to stimuli with
an inability to change the response, such as the same
verbal response to different questions
 Neologism: words that are made up; often an
condensation of different words which is unintelligible to
the listener
Mental Status Examination

 FOT

 Echolalia: persistent repetition of words or phases of

another person like the interviewer
 Thought-Blocking: an abrupt interruption in the flow of
thought, in which one cannot recover what was just
said
Mental Status Examination

 COT

 Obsessions: persistent thought(s) that cannot be extruded

by logic or reason
 Phobias: fears such as germs, cancer/AIDs, snakes, heights,
etc.
 Suicidal Ideation
 Homicidal Ideation
Mental Status Examination
 COT

 Hallucinations (perceptions): a sensory perception in the

absence of an actual external stimulus
 Auditory: hearing voices, noises, sounds, music, static,
distorted sounds
 Visual: seeing people, faces, animal, shapes , colors, flashes
of light
 Olfactory: smells that may be sweet or noxious
 Tactile: associated with touch such as feeling something on
the skin or in the skin
 Hypnogogic: considered a pseudo-hallucination with falling
asleep and associated with abnormal sleep states
 Hypnopompic: considered a pseudo-hallucination with
awakening from sleep and associated with abnormal sleep
states
Mental Status Examination
 COT

 Depersonalization: a altered sense of one’s physical being

such as out of body experiences or one’s body is changes in
shape and size
 Derealization: a sense that one’s environment has changed
and is different than way it was before but the individual
cannot identify tangible elements of change
 Déjà Vu: the feeling that one has already experiences a
particular moment of event before
 Jamais Vu: the feeling of unfamiliarity in familiar situations
Mental Status Examination

Delusions: a fixed, false belief that is not

shared with members of the individual’s
culture or religion. This belief is held even in
the face of contradictory evidence. 14
categories of delusions:
Mental Status Examination

 Delusions of control: Delusional belief that one’s behavior,

will, thoughts or feelings are not under personal control but
imposed by an external force.

 Delusions of guilt or sin: Delusional belief of responsibility for

tragedy or disaster to which there is no personal connection.
Delusional belief of having done something terrible and now
must face the deserved punishment.

 Delusions of grandiosity: Delusional belief of special power,

talent, abilities, or identity.
Mental Status Examination

 Delusions of jealousy: With little or no evidence, the person

believes one’s partner is unfaithful.

 Delusion of mind reading: Delusional belief that people can

read one’s mind and know one’s thoughts. This does not
include sensing what someone is thinking/feeling bases on
body language or facial expression.

 Delusion of persecution: Delusional belief that one is in

danger, being followed or monitored, harassed or
conspired against. This includes the government, police,
criminal groups, neighbors, coworkers or family.
Mental Status Examination

 Delusion of reference: Delusional belief that ordinary

insignificant comments, objects or events refer to or have a
special meaning for the patient. Messages in music/TV to only
the patient.

 Delusion of replacement: Delusional belief that someone

important to the patient has been replaced by a double.

 Erotomania: Delusional belief that one is loved, perhaps

secretly by another person, Usually the other one is of higher
status than the patient.

 Nihilistic delusion: Delusional belief that the person, a part of

the person’s body or the world does not exist.
Mental Status Examination

 Somatic delusion: Delusional belief that one’s body is

diseased, damaged or changed.

 Thought broadcasting: Delusional belief that as thoughts

occur or are so loud, they heard by others.

 Thought insertion: Delusional belief that thoughts are not

one’s own, but have been placed there by some other
person, group, or force from outside of them.

 Thought withdrawal: Delusional belief that one’s thoughts

have been removed or taken away by someone or
something from the outside.
Mental Status Examination

 Cognition:
 Orientation-date, person, place and situation
 Attention/Concentration-3/3, spelling WORLD backwards, digit span
 Memory-recent and remote events
 Calculations-serial &s
 Abstraction-proverbs
 Judgment-appropriate resolution of a problem

 Insight: an assessment of self-reflection and an understanding of

condition or the situation

 MMSE

 MoCA
Common Errors in the
Psychiatric Interview

 Premature closure and false assumptions about symptoms

 False reassurances about the patient’s condition or

prognosis

 Defensiveness with aggressive or arrogant patients

 Omission of significant parts of the interview

 Recommendations for treatment when diagnostic

formulation is incomplete
Common Errors in the
Psychiatric Interview

 Inadequate explanation of psychiatric disorders and

treatment options

 Empathic failures by inadvertently shaming or

embarrassing the patient

 Countertransference issues with the patient

 Not exploring in depth safety issues with the patient

 Check to see if the patient has access to weapons or

guns!
Psychiatric Interview – Tools

 Visit www.integration.samhsa.gov for screening tools.

 Massachusetts General Hospital Comprehensive

Clinical Psychiatry; Stern TA, Rosenbaum JF, Fava M,
Biederman J, Rauch SL; 2008

 Interview Guide for DSM 5 Psychiatric Disorder;

Zimmerman M; 2013