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. However, a comprehensive psychiatric interview consists of the same basic components:
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.
This is the safest office set-up:
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.
(A) Confirm the patient’s legal name (and preferred name) and age
(B) Chief Complaint/Reason for visit
(C) History of Present Illness
(D) Psychiatric Review of Systems
(E) Substance Use History
(F) Past Psychiatric History
(G) Past Medical History
(H) Family History
(I) Social History
(J) Medical Review of Systems
(K) Physical and Neurological Examinations (focused, if needed)
|VITAL SIGNS||T, BP, HR, RR|
|ALERTNESS ORIENTATION||Awake, Alert, Oriented to person, place, time, date, situation, drowsy, confused, sedated, not acutely distressed|
|APPEARANCE||Age, Sex, Race, Body build, clothing, grooming, hygiene, dentition, physical abnormalities, distinguishing features (tattoos, hair, scars), unusually smells, perfume/cologne, posture|
|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 current mood|
|AFFECT||Stability (labile, stable), Range (restricted/constricted, expansive, broad/normal), Appropriateness, Intensity (blunted, flattened, normal), Type (depressed, sad, happy, angry, euphoric, irritable, anxious, neutral, fearful, apathetic, pleasant)|
|THOUGHT CONTENT||Suicidal thoughts (intent, plan), homicidal or violent thoughts, depressive/negative thoughts, obsessions, compulsions, ruminations, phobias, ideas of reference, paranoid thoughts, magical thoughts, delusions, overvalued ideas, recurrent major themes discussed by patient|
|THOUGHT PROCESS||Associations, Coherence, Logic, Stream, Clang associations, perseveration, neologism, blocking, Attention|
|PERCEPTION||Hallucinations, Illusions, Depersonalization, Derealization, Déjà vu, Jamais vu|
|INTELLECT||Average, above average, below average|
|INSIGHT||Is the patient aware of their mental illness? Does the patient understand why they are being seen by a psychiatrist?|
|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 does not appropriately assess a patient’s judgement.|
|IMPULSE CONTROL||Is the patient unpredictable and/or impulsive during the interview?|
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 factual.
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.
1. General Appearance, Behavior and Attitude: Provide a description of the patient such that another provider could identify the patient after reading it. If another provider sees the patient, they should have a “flavor” of the patient’s demeanor based on the descriptions given. The following should be noted:
Age and Grooming: A brief description of the patient’s dress, neatness and the appropriateness of his appearance; his apparent and real age.
Posture: This should include such things as the way he sits or lies during the interview, restlessness, tension and bizarre or unusual positions.
Facial Expressions: A brief description of the appropriateness, mobility and expression of emotion or inner conflict which can be observed on the patient’s face such as alert, dull, stuporous, fearful, depressed, elated, etc.
Psychomotor Activity: Describe in detail the motor activity which you observe in the patient. Is this activity increased or reduced? Are his actions spontaneous? Does he initiate activity? Take note of the appropriateness of his motor activity, and of such things as compulsive rituals, fumbling at the bed clothes, assaultness, negativism, attempts to escape and so on. Is he restless, agitated, slowed, pacing, immobile, tremulous, etc.? Are there tics present?
Attitude: A description of the patient’s general manner and attitude to the interview and the impression that one gets from this such as frightened, distracted, angry, etc.
2. Speech: The rate, form, quantity, volume, prosody, spontaneity, and fluency of a patient’s speech should be documented. Pressured speech is noted when patients talk continuously without allowing the examiner to interject and is a common symptom of bipolar mania and psychosis. Prosody refers to the tune and rhythm of speech and how these features contribute to meaning. The spontaneity of speech refers to an individuals ability to speak without being prompted.
3. Mood: describes the general emotional state from the patient’s perspective. This involves feelings at the time of the examination and a few hours preceding it. Best way to assess is to ask the patient directly.
4. Affect: is the objective assessment of the emotional expression of the patient. Characteristics of affect include:
Quality: Is the patient composed, complacent? Is he irritable, angry, happy, elated or exalted? Is he boastful, self-satisfied or expansive? Is he suspicious, distant or aloof? On the other hand, is he indifferent, apathetic, dissociated, perplexed, fearful, anxious or tense?
Range: Does the patient exhibit a full range of emotion (objectively) in response to the interview? Is the range constricted, blunted, or completely absent?
Stability: Are the patient’s emotional reactions labile and quickly changing/unstable, or is the patient not easily moved?
Appropriateness to content and situation: Is the affect compatible and appropriate to the ideas expressed. In other words, if the patient is discussing a depressing subject are they laughing and giggling or sad?
5. Thought Process/Form: This is the verbal record of how (as opposed to what) a patient is thinking. Normal thought process is logical and goal directed. A formal thought disorder may be characterized by circumstantiality or tangentiality, blocking, neologisms, clang associations, flight of ideas, loose associations.
6. Thought Content: This refers to what the patient is thinking with less emphasis on the form or process. This would be an appropriate place to address delusions, obsessions, ruminations, suicidal ideations or plans, or homicidal ideations/plans. Hallucinations and illusions are part of the patient’s perceptions and should NOT be placed in this section.
7. Perceptions: Perceptions include hallucinations, illusions, and somatic complaints.
Illusions: Have you ever found yourself misinterpreting shadows or noises? Did you ever feel you were being touched? Did you ever see a ghost?
Hallucinations: assess all sensory modalities (Auditory, visual, gustatory, olfactory, somatic)
8. Alertness, Attention, and Orientation: Is the patient awake and alert or is the patient awake and drowsy/sedated/lethargic? Is the patient able to focus during the interview or is the patient inattentive requiring frequent refocusing? Determine how well the patient is oriented in the realm of time, place, persons present and in the present situation. When documenting the orientation, it is important to put the patient’s specific answers in quotes. It is no help if you write “oriented x2” as the next provider has no way of knowing what that meant.
9. Memory: The following are to be recorded:
Recall of Remote Past Experiences: Test the recall of personal experiences which generally are considered of importance and evaluate any discrepancies and contradictions in time relationships. It may frequently happen that all the pertinent data, with careful recording of the time relationships, have been obtained from the patient when the “personal history” was taken. In this case, the physician may merely refer to these facts. The following points should be tested–time and place of birth, of various schools, of occupations or jobs; date of marriage and birth of children (with recording of their names) and of patient’s illness.
Recall of Recent Past Experiences: Test for occurrences in the past twenty-four hours and whether any change in memory functions has occurred since the onset of the present illness.
Recall of Immediate Impressions: Repetition of three non-related words (e.g., “table,” “red,” “63 Broadway”) and recall after three minutes. Present the patient with the three words, telling him you will ask him to repeat these soon. Continue your history taking and after timing three minutes, ask the patient to recite the three words previously presented.
10. Abstraction: These proverbs may be interpreted at several different levels of abstraction. Using the proverb, “a rolling stone gathers no moss” as an example, the following are illustrations of the different levels of abstraction:
Refusal or Inability to Interpret: The patient says “I don’t know,” or he refuses to cooperate.
Literal Interpretation: The patient repeats the proverb with no or only very slight modifications. For instance, “a stone that keeps rolling doesn’t stay still long enough to have moss grow on it.”
Concrete Interpretation: The patient remains literal and emphasizes a concrete situation although not the same situation as is referred to in the proverb. For instance, “if you run around, you don’t get any moss; that is, you don’t get any money.”
Egocentric Interpretation: The patient says something like, “that’s me, I never get anywhere.”
Incoherent or Bizarre Interpretation: The patient might say, “a rolling stone gathers no moss-Christ, breaking chain stores all together, independency.”
Adequate Abstraction: The patient may say, “a person who goes from place to place gains no success in the world,” or “if an individual does not seek new challenges, he will vegetate.”
The Over-abstract Interpretation: The patient in his attempt to abstract over-shoots the mark. For instance, “dissipation of energy rather than concentration.”
10. Insight and Judgment: This refers to the extent to which the patient realizes that he or she suffers from an illness or from personal difficulties and to the extent to which he or she recognizes the need for treatment. It includes the understanding of his illness in general. When assessing judgement, asking what a patient would do if he or she found a stamped envelope or if the doorbell rang does nothing. Ask hypothetical situations relevant to the situation at hand. Consider the following responses from the SAME patient to the below questions (do you think this patient has “good judgement”?) The patient has a delusion that the cartel is after him and often wear business suits.
Question 1: What would you do if the doorbell rang?
Response 1: Open the door.
Question 2: What would you do if you were walking down the street and you noticed a man wearing a business suit approaching you?
Response 2: I would kill him in self-defense!
If the patient was discharged based on response to question 1 and then killed someone and the family then sued, how are you going to explain to the judge why you felt his judgement was good? “I asked what he would do if the doorbell rang and he said he would answer the door.” Good luck with that.