The Psychiatric Interview and Mental Status Examination
The Psychiatric interview is the most important component of a full psychiatric evaluation. The style, format, and duration of the interview is subject to change depending upon the context and the setting.
Safety, Setting, and Positioning
Safety. Most psychiatric interviews will take place in an office, clinic, hospital room, day room/ common room, or jail cell. Regardless of the location, the most important consideration prior to starting any interview is safety. While it is tempting to assume patients will remain calm and cooperative during the interview, it is not a safe assumption. While the majority of patients suffering with mental illness are not violent and will not become violent, it is always better to be safe than sorry. Regardless of setting, be sure you think about your safety and the safety of those around you (including your patient).
Confidentiality. Do your best to interview patients in a quiet calm place away from other patients. The psychiatric interview can be a very personal and emotional experience. Patients may reveal very personal information and/or confide in you. Providing a safe place for patients to feel safe during their most vulnerable moments is of upmost importance to create and maintain a strong therapeutic alliance. While some settings may be limited in terms of space or areas to interview, every attempt should be made to find a safe quiet place to talk.
Before introducing yourself. Before approaching a patient, assess safety by asking staff, if available, about the patient’s behavior and whether they have any safety concerns. If there is a concern for safety, consider being extra safe by politely requesting security or additional staff to be present with you during the interview. This will ensure your safety, the safety of the patient, and the safety of the staff. There is nothing more devastating than being in a room with a violent or agitated patient with no help around!
The approach. When approaching the patient, approach with a calm demeanor and at a slight angle from the front. Never approach a patient quickly, aggressively, or directly in front of them as this can be perceived as threatening. Keep your hands in front of you with your palms open so the patient can see them. Never approach with your hands behind your back. Always keep at least a legs length from the patient at all times. While making eye contact is important, making eye contact for too long can be perceived as threatening.
Don’t block the exit. When interviewing a patient in a room, position yourself in the room such that you are not blocking the exit as this can make patients feel trapped. On the other hand, never put yourself in a position where the patient is between you and the exit. See the diagrams below for safest positioning. If interviewing in an open area position yourself in such a way that you have a clear view. Never interview a patient where either of you are cornered against a wall and never interview with your back exposed to the open room. If activity is going on behind you, position yourself in such a way that you would be able to see someone approaching in your peripheral vision.
Sit or stand? Follow the patients lead. If the patient is sitting, do not interview the patient by standing over them. Find a chair and stay at eye level. If the patient doesn’t want to sit and prefers to stand, then stand at a safe distance and do not sit. Sitting with a patient sends the message “I am not a threat and I am here to listen because I care about you.” Even if you only speak for a few minutes, studies have shown that patients perceive a length of time much longer than was actually spent.
How to Position yourself in the patient’s room
Introduce yourself to the patient by informing them immediately who you are and what your role is. Then politely ask the patient for their preferred name and whether they feel comfortable talking to you in the current location. Remind the patient about the confidential nature of the information discussed and to let you know immediately if anything makes them feel uncomfortable.
The opening question will vary depending on the setting and context. In general, the best way to open the interview is to ask an open ended question such as, “What brings you in today?” Or “What can I help you with?” If the setting is an inpatient hospital and you are speaking to a patient who is involuntarily committed then perhaps the better way to open the interview would be to ask something like, “Mr. Jones, what is your understanding of the reason for being brought to the hospital today?” Open ended questions encourage the patient to speak more and allows you to quickly assess the patient’s ability to spontaneously speak. In addition, it gives you a sense of the patients thought process and verbal fluency.
Allow the patient to speak for at least 2-3 minutes before interrupting. Sometimes you will see patients who are able to articulate their thoughts and feelings well enough that you don’t really need to interrupt much as your questions can all be answered by their story. Patients who ramble on or speak tangentially or circumstantially can be very difficult to interview. Try to give the patient at least 2-3 minutes to talk uninterrupted before refocusing.
Contents of the Interview
(A) Confirm the patient’s legal name (and preferred name) and age
(B) Chief Complaint/Reason for visit
- Identify the patient’s chief complaint and/or reason for seeking mental health treatment (if voluntary)
- If involuntary, ask the patient what happened and what they believe the reason for involuntary treatment
(C) History of Present Illness
- The history of present illness is a narrative of events leading up to the visit or hospitalization
- Ask about the onset, duration and severity of distressing symptoms and whether there are any aggravating or alleviating factors (including recent stressful events or factors)
(D) Psychiatric Review of Systems
- Depressive Symptoms (SIGECAPS)
- Suicidal thoughts, intentions, and plans
- Weapons/Guns in the home
- Anxiety symptoms (Screen for Panic attacks)
- Obsessions or compulsions
- Manic or hypomanic symptoms (DIGFAST)
- Psychotic symptoms (hallucinations, delusions, negative symptoms)
(E) Substance Use History
- Tobacco, Alcohol, Marijuana, Methamphetamine, Cocaine, Heroin, Synthetic THC derivatives (Spike, K2), Barbiturates, Bath salts, LSD, PCP, and prescription drugs
- For each drug, ask about: First use│Quantity│Frequency│Duration│Last use
(F) Past Psychiatric History
- History of Outpatient treatment (Therapy and Psychiatric)
- History of Inpatient treatment (dates, duration of stay, reason for admission)
- Previous Medication Trials (name of medication, duration of treatment, response, side effects)
- History of Self harm and Suicide Attempts
- History of Violence
(G) Past Medical History
- Medical Problems (diabetes, seizures, cardiac disease, autoimmune disease, Chronic pain, High cholesterol, high blood pressure)
- Past Surgeries
- Medical Medications
(H) Family History
- Focus on biologically related family members
- Neurological diseases, Psychiatric disorders, suicide attempts/completions, Violence
(I) Social History
- Where was the patient born?
- Who raised the patient primarily? Two parent household?
- Developmental Milestones
- Educational History (last grade completed, special education, college, post graduate studies)
- Relationship History
- Marital status
- Current Living Situation
- Employment History and current source of income
- Social Support
- Religious preference
- Trauma and Abuse history (Physical, Emotional, Sexual, Financial)
- Legal History (Arrests, DUIs, Probation, Parole)
(J) Medical Review of Systems
- Constitutional: Fever, chills, Nausea, night sweats, weight changes, appetite, malaise, fatigue, pain
- Head: Headaches, recent head trauma, seizures, migraines, auras
- Eyes: Vision changes, burning, dryness, sensitivity to light
- Mouth: Sore throat, Dry mouth, drooling, changes in taste, sores/lesions, hoarseness
- Ears: Tinnitus, hearing impairments, vertigo
- Nose: Changes in sense of smell or experiencing unusual scents
- Neck: Stiffness, Pain
- Musculoskeletal: Bone pain, bone fractures, muscle pain, tenderness, rigidity
- Cardiopulmonary: Chest pain, Chest tightness, Palpitations, Shortness of Breath, cough, wheezing, phlegm
- Renal: Changes in the color, content, smell, and/or quantity of urine produced, flank pain/tenderness, pain when voiding, continence
- Gastrointestinal: Vomiting, Diarrhea, Constipation, Blood in stool, continence, acid reflux, pain, cramps
- Neurological: Tremors, weakness, numbness, tingling, prickling, seizures, coordination/balance problems
- Gait: Changes in ability to ambulate
(K) Physical and Neurological Examinations (focused, if needed)
The Mental Status Examination
|VITAL SIGNS||T, BP, HR, RR|
|ALERTNESS||Awake, Alert, drowsy, confused, sedated, lethargic|
|ORIENTATION||Orientation to person, place, time, date, situation,|
|APPEARANCE||Age, Sex, Race, Body build, clothing, grooming, hygiene, dentition, physical abnormalities, distinguishing features (tattoos, hair, scars), unusually smells, perfume/cologne, posture, Not acutely distressed|
|BEHAVIOR||Cooperative, eye contact, Guarded, evasive, angry, seductive, bored, distracted, disinterested, pleasant, preoccupied, sarcastic, passive-aggressive, hostile, threatening, crying, tearful, smiling, laughing (inappropriate laughing, giggling, smiling).|
|MOTOR||Retardation (slow, parkinsonian), hyperkinetic movements (chorea), Abnormal movements (Tics, dystonia, rigidity, TD, athetoid, akathisia), agitation (restless, skin picking, hand wringing, legs bouncing, foot tapping, pacing), Gait, catatonia|
|SPEECH||Rate, Rhythm, Volume, Amount, Articulation, Spontaneity|
|MOOD||Patient will tell you his or her mood|
|AFFECT||Stability, Range, Appropriateness, Intensity, Type (depressed, sad, happy, angry, euphoric, irritable, anxious, neutral, fearful, apathetic, pleasant)|
|THOUGHT CONTENT||Suicidal ideations (passive, active), homicidal ideations, depressive cognitions, obsessions, ruminations, phobias, ideas of reference, paranoid ideation, magical ideation, delusions, overvalued idea, recurrent major themes discussed by patient|
|THOUGHT PROCESS||Associations, Coherence, Logic, Stream, Clang associations, perseverative, neologism, blocking, Attention|
|PERCEPTION||Hallucinations, Illusions, Depersonalization, Derealization, Déjà vu, Jamais vu|
|INTELLECT||Average, above average, below average|
|INSIGHT||Awareness of illness and situation|
|JUDGEMENT||Does the patient have good judgement? Ask a question RELATED TO THE CURRENT SITUATION. Asking a patient what they would do if they found a stamped letter on the ground or if the doorbell rings tells you nothing.|
|IMPULSE CONTROL||Are they unpredictable and impulsive?|
Definitions and Terms to Know
Anxiety: Apprehension, tension or uneasiness which stems from the anticipation of danger, the source of which is largely unknown or unrecognized. Anxiety is primarily of intrapsychic origin, in contrast to fear which is the emotional response to a consciously recognized and usually external threat or danger. Anxiety and fear are accompanied by similar physiologic changes. Anxiety may be regarded as pathologic when it is present to such extent as to interfere with effectiveness in living, the achievement of desired realistic goals or satisfactions, or reasonable emotional comfort.
Apathetic: Showing lack of interest, or indifference; lacking feeling.
Association: Relationship between ideas or emotions by contiguity, by continuity, or by similarities.
Autism (autistic thinking): A form of thinking which attempts to gratify unfulfilled desires without due regard for reality. Objective facts are distorted, obscured, or excluded in varying degree.
Blocking: Difficulty in recollection, or interruption of a train of thought or speech, due to emotional factors usually unconscious.
Circumstantial: A characteristic of conversation that proceeds indirectly to its goal idea, with many tedious details and parenthetical and irrelevant additions.
Clang Association: Associations that are governed by rhyming sounds, rather than meaning, e.g., “This what I thought, bought, knot, caught, rot, sought.”
Compulsion: An insistent, repetitive, intrusive, and unwanted urge to perform an act which is contrary to the person’s ordinary conscious wishes or standards. A defensive substitute for hidden and still more unacceptable ideas and wishes. Anxiety results from failure to perform the compulsive act.
Confabulation: The more or less unconscious, defensive “filling in” of actual experiences, often complex, that is recounted in a detailed and plausible way as though they were fact
Delusion: A false belief out of keeping with the individual’s level of knowledge and his cultural group. The belief is maintained against logical argument and despite objective contradictory evidence. Common delusions include:
Delusions of Grandeur: Exaggerated ideas of one’s importance or identity.
Delusions of Persecution: Ideas that one had been singled out for persecution.
Delusions of Reference: Incorrect assumption that certain casual or unrelated remarks or the behavior of others applies to oneself.
Depersonalization: Feelings of unreality or strangeness concerning either the environment or the self.
Depression: Psychiatrically, a morbid sadness, dejection or melancholy; to be differentiated from grief which is realistic and proportionate to what has been lost. A depression may vary in depth from neurosis to psychosis. See post on grief vs depression.
Dissociation: A psychological separation or splitting off; an intrapsychic defensive process which operates automatically and unconsciously. Through its operation, emotional significance and affect are separated and detached from an idea, situation, or object. Dissociation may, unconsciously, defer or postpone experiencing the emotional impact, as for example, in selective amnesia.
Euphoria: An exaggerated feeling of physical and emotional well-being not consonant with apparent stimuli or events; usually of psychologic origin, but also seen in organic brain disease and toxic states.
Flattened Affect: Displaying an abnormally small range of emotional expression.
Flight of Ideas: Verbal skipping from one idea to another before the last one has been concluded; the ideas appear to be continuous, but are fragmentary and determined by chance associations.
Hallucination: A false sensory perception in the absence of an actual external stimulus; may be of emotional or external chemical (drugs, alcohol, etc.) origin, and may occur in any of the five senses.
Illusion: The misinterpretation of a real, external sensory experience.
Inappropriate: Emotional expressions that are not in accord with the Affect situation, or what is being said, e.g., giggling when talking about the death of a parent.
Insight: Self-understanding; a major goal of psychotherapy; the extent of the individual’s understanding of the origin, nature, and mechanisms of his attitudes and behavior. More superficially, recognition by the patient that he is mentally ill.
Loss of Goal: Failure to follow a chain of thought through to a logical conclusion usually elicited by asking a question which the patient starts to answer, but then seems to wander off the subject.
Neologism: In psychiatry, a new word or condensed combination of several words coined by a patient to express a highly complex meaning related to his conflicts; not readily understood by others; common in schizophrenia.
Obsession: Persistent, unwanted idea or impulse that cannot be eliminated by logic or reasoning.
Orientation: Awareness of oneself in relation to time, place and person.
Perseveration (stereotype): Persistent, mechanical repetition of an activity, common in schizophrenia.
Phobia: An obsessive, persistent, unrealistic fear of an external object or situation such as heights, open spaces, dirt, and animals. The fear is believed to arise through a process of displacing an internal (unconscious) conflict to an external object symbolically related to the conflict.
Sensorium: Roughly approximates consciousness. Includes the special sensory perceptive powers and their central correlation and integration in the brain. A clear sensorium conveys the presence of a reasonably accurate memory together with a correct orientation for time, place, and person.
American Psychiatric Association Practice Guidelines: The Psychiatric Interview
- Stern, T. A., Freudenreich, O., Fricchione, G., Rosenbaum, J. F., & Smith, F. A. (2018). Massachusetts General Hospital handbook of general hospital psychiatry. Edinburgh: Elsevier.
- Levenson, J. L. (2019). The American Psychiatric Association Publishing textbook of psychosomatic medicine and consultation-liaison psychiatry. Washington, D.C.: American Psychiatric Association Publishing.
- Blumenfeld, Hal. Neuroanatomy Through Clinical Cases. 2nd ed. Sunderland, Mass.: Sinauer Associates, 2010.
- Bear, Mark F.,, Barry W. Connors, and Michael A. Paradiso. Neuroscience: Exploring the Brain. Fourth edition. Philadelphia: Wolters Kluwer, 2016.
- Higgins, E. S., & George, M. S. (2019). The neuroscience of clinical psychiatry: the pathophysiology of behavior and mental illness. Philadelphia: Wolters Kluwer.
- McCarron, Robert M., et al. Lippincotts Primary Care Psychiatry: for Primary Care Clinicians and Trainees, Medical Specialists, Neurologists, Emergency Medical Professionals, Mental Health Providers, and Trainees. Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.
- Focus Psychiatry Review, Dsm-5: Dsm-5 Revised Edition by Deborah J. Hales (Author, Editor), Mark Hyman Rapaport (Author, Editor)
- The American Psychiatric Association Publishing Textbook Of Neuropsychiatry And Clinical Neurosciences, Sixth Edition. Edited By: David B. Arciniegas, M.D., Stuart C. Yudofsky, M.D., Robert E. Hales, M.D., M.B.A.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
- Benjamin J. Sadock, Virginia A. Sadock. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia :Lippincott Williams & Wilkins, 2000.
- Ebenezer, Ivor. Neuropsychopharmacology and Therapeutics. John Wiley & Sons, Ltd. 2015.