2

THE PSYCHIATRIC
INTERVIEW

3
THE PSYCHIATRIC
INTERVIEW

Fourth Edition
Daniel J. Carlat, M.D.
Publisher
The Carlat Psychiatry Report
The Carlat Child Psychiatry Report
The Carlat Addiction Treatment Report
Associate Clinical Professor of Psychiatry
Tufts University School of Medicine
Boston, Massachusetts

Practical Guides in Psychiatry

Daniel J. Carlat, M.D.
Founding Editor

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4th edition

Copyright © 2017 Wolters Kluwer

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Library of Congress Cataloging-in-Publication Data

Names: Carlat, Daniel J., author.
Title: The psychiatric interview / Daniel J. Carlat.
Other titles: Practical guides in psychiatry.
Description: Fourth edition. | Philadelphia : Wolters Kluwer, [2017] | Series: Practical guides in psychiatry | Includes
bibliographical references and index.
Identifiers: LCCN 2016008384 | ISBN 9781496327710
Subjects: | MESH: Interview, Psychological—methods | Mental Disorders—diagnosis | Physician-Patient Relations |
Handbooks
Classification: LCC RC480.7 | NLM WM 34 | DDC 616.89/075—dc23 LC record available at
http://lccn.loc.gov/2016008384

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any
warranties as to accuracy, comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each
patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication
history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or
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for the use of this work including all medical judgments and for any resulting diagnosis and treatments.
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 To my patients, past, present, and future.
Thank you for allowing me to ask you question after question, and
thank you for answering so honestly.

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 Foreword

The Psychiatric Interview is straightforward, practical, and wise, yet often lighthearted and
funny, a breath of fresh air where comparable references have often been boring and
ponderous. It brims with extraordinary gifts for its readers. It is a scholarly review of the
research literature, yet it moves swiftly and has a light, even jaunty, tone. It is very much
up-to-date and serves as a useful introduction to many ideas, such as those from
psychodynamics, that are not widely available to contemporary students.
Best of all, the book is alive, an extraordinary achievement in view of the amount of
detailed material presented. It emphasizes the person within the patient and the need to form
an alliance with that person to secure reliable information and cooperation in treatment.
We feel the patients presented by Dr. Carlat; they are not simply diagnoses. Dr. Carlat
offsets the profession’s reputation for being cheerless and pathology minded; he illustrates
many ways by which effective relationships can be formed and shows how relationships that
are endangered can be repaired, perhaps especially at the close of an interview.
The Psychiatric Interview is designed in an easily accessible format, with aids for
memory, appendices for organizing information, and sensible guides for recordkeeping.
This is teaching by example at its best, with the examples both vivid and pointed, so that
they stick in the reader’s mind.
Truly understanding another human being is a daunting challenge, yet nothing is more
important if we are to soothe the suffering of a ravaged soul. Use this book as a guide to
reach for that understanding.

Leston Havens, M.D.

Professor of Psychiatry, Emeritus
Harvard Medical School
The Cambridge Health Alliance
Cambridge, Massachusetts

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 Preface

Over the course of a 40-year professional career, you will do ~100,000 diagnostic
interviews. The diagnostic interview is by far the most important tool in the arsenal of any
clinician, and yet the average training program directs relatively few resources to specific
training in the skills required for it. The general assumption seems to be that if you do
enough interviews with different kinds of patients, you’ll naturally pick up the required
skills. That may be true, but it can take a long time, and the learning process can be
painful.
I hatched the idea for this manual one night during my first year of psychiatric
residency. Starting my shift in the acute psychiatry service (APS), I noticed five patients in
the waiting room; the resident who handed me the emergency room beeper said that there
were two more patients in the emergency room, both in restraints. At that moment, the
beeper sounded, and I called the number. “Psychiatry? This is Ellison 6. We have a patient
up here who says he’s depressed and suicidal. Please come and evaluate, stat.” That meant
that I had a total of eight diagnostic assessments to do.
As the night stretched on, my interviews got briefer. The developmental history was the
first to go, followed quickly by the formal mental status examination. This trimming
process continued until, at 5 a.m., it reached its absurd, but inevitable, conclusion. My
entire interview consisted of little more than the following question: “Are you suicidal?”
As I handed the beeper off to my colleague at 8 a.m. (I had slept for 50 minutes, about
the length of a psychotherapeutic hour), I began to think about those interviews. Were they
too short? (I was sure they were.) Were they efficient? (I doubted it.) Had anyone come up
with a system for conducting diagnostic assessments that were rapid but at the same time
thorough enough to do justice to the patient?
Looking for such a system became my little project over the rest of my residency. I
labeled a manila file folder interviewing pearls and started throwing in bits and pieces of
information from various sources, including interviewing textbooks, lectures in our
Wednesday seminars, and conversations with my supervisors and with other residents.
When I became chief resident of the inpatient unit, I videotaped case conferences and took
notes on effective interviewing techniques. Later, during my first job as an attending
psychiatrist, I practiced and fine-tuned these techniques with inpatients at Anna Jaques
Hospital and outpatients at Harris Street Associates.
What I ended up with was a compendium of tips and pearls that will help make your
diagnostic interviews more efficient and, I hope, more fun. Mnemonics will make it easier
for you to quickly remember needed information. Interviewing techniques will help you
move the interview along quickly without alienating your patients. Every chapter begins
with an Essential Concepts box that lists the truly take-home items of information therein.

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The appendices contain useful little stocking stuffers, such as “pocket cards” with vital
information to be photocopied and forms that you can use during your interviews to ensure
that you’re not forgetting anything important.
However, if you’re looking for theoretical justifications and point-by-point evidence for
the efficacy of these techniques, you won’t find it here. Go to one of the many textbooks of
psychiatric interviewing for that. Every piece of information in this manual had to meet the
following stringent standard: It had to be immediately useful knowledge for the trainee
about to step into the room with a new patient.

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What This Manual Is
First, this is only a manual. It’s not a residency or an internship. The way to learn how to
interview patients is by interviewing them under good supervision. Only there can you
learn the subtleties of the interview, the skills of understanding the interactions between
you and your patients.
It is a tool that lends you a guiding hand in your initial efforts to interview patients. It’s
confusing territory. There are lots of mistakes to be made and many embarrassing and
awkward moments ahead. This book won’t prevent all of that, but it will catalyze the
development of your interviewing skills.
It is a handbook for any beginning clinician who does psychiatric assessments as part of
his or her training. This includes psychiatric residents, medical students, psychology
interns, social work interns, mental health workers, nursing students, and residents in other
medical fields who may need to do an on-the-spot diagnostic assessment while waiting for a
consultant.

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What This Manual Is Not
It is not a textbook of psychiatric interviewing. There are a number of interviewing
textbooks already available (Shea 1998; Othmer 2001; Morrison 2014), my favorite being
Shea’s Psychiatric Interviewing: The Art of Understanding. Although textbooks are more
thorough and encyclopedic, the drawback is that they do not guide the beginner to the
essence of what he or she needs to know. Also, textbooks aren’t portable, and I wanted to
write something that you can carry around to your various clinical settings. That said,
please buy a textbook, and have it around for those times when you want to read in more
depth.
This is also not a handbook of psychiatric disorders. There are plenty of good ones
already published, and I wrote this manual to fill the need for a brief, how-to guide to
diagnosing those disorders.
Finally, it is not a psychotherapy manual. Doing a rapid diagnostic assessment isn’t
psychotherapy, although you can extend many of the skills used in the first interview to
psychotherapy.
I hope that you will enjoy this book and that it will help you to develop confidence in
interviewing. As you embark, remember these words of Theodore Roosevelt: “The only
man who never makes a mistake is the man who never does anything.” Good luck!

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 Introduction to the Fourth Edition

It’s been 17 years since the first edition of The Psychiatric Interview was published. What
began as a little pet project while I was a chief resident at Massachusetts General Hospital
in 1995 has, surprisingly to me, become a standard text for those seeking a brief how-to
manual for the psychiatric interview.
This latest edition incorporates the changes in diagnostic criteria published in DSM-5,
the latest version of our field’s official categorization of mental disorders. There are
significant changes in how we diagnose dementia (now called major neurocognitive
disorder), substance abuse, eating disorders, ADHD, and somatization disorder (which has
evaporated from DSM-5). Beyond that, I did an updated literature review and made a few
revisions as a result.
The Psychiatric Interview has now been translated into German, Japanese, Korean,
Portuguese, and Greek. It’s gratifying to me that clinicians all over the world understand
the importance of active listening and of asking the right questions at the right times.
Becoming a great clinician requires a lifetime of dedication. As Vince Lombardi once said,
“Perfection is not attainable, but if we chase perfection we can catch excellence.”

Daniel Carlat, M.D.

Newburyport, Massachusetts, 2016

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 Acknowledgments

For this fourth edition, as in the previous three editions, I start by thanking Dr. Shawn
Shea, whose classic textbook, Psychiatric Interviewing: The Art of Understanding, got me
interested in this topic. Dr. Shea has been a great friend and mentor throughout my career.
My father, Paul Carlat, who is also a psychiatrist, has bestowed upon me whatever
personal qualities have been helpful as I work with patients. He continues to practice
psychiatry, offering a unique blend of psychotherapy and medication treatment, and is a
role model both for me and for many other young psychiatrists in the San Francisco Bay
Area who have benefited from his supervision.
Many members of the faculty of Massachusetts General Hospital (MGH), where I did
my psychiatric residency, were extremely helpful in the shaping of the manuscript. In
particular, I thank the late Dr. Ed Messner, whose very practical approach to patient care
was refreshing; Dr. Paul Hamburg, who taught empathy and innumerable other aspects of
connecting with patients; Dr. Paul Summergrad, a consummate clinician and the director
of the inpatient unit during my chief residency, who supported me in my efforts to create
an interviewing course for residents; Dr. Carey Gross, who taught me much about how to
rapidly make the right diagnosis for the most difficult patients; and Dr. Anthony Erdmann,
who generously contributed several screening questions. In addition, special thanks go to
the late Dr. Leston Havens, who was very encouraging throughout this project.
I also thank the psychiatry residents at MGH. The PGY-2 residents of the 1994 to
1995 academic year were extremely accommodating as I developed my interviewing
curriculum while teaching it; the residents and psychology fellows in my own class
constantly cheered me on, particularly Drs. Claudia Baldassano, Christina Demopulos, and
Alan Lyman; comembers of the Harvard Gardens Club; and Dr. Robert Muller,
psychologist supreme.
Finally, thanks are due to the staff of the Anna Jaques Hospital inpatient psychiatry
unit, where I have “road tested” the many techniques described in this book. I especially
thank Dr. Rowen Hochstedler, my former medical director at the hospital, and my friend,
who is living proof that excellent mentoring can continue far beyond the reaches of
academia.

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 Contents

Foreword
Preface
Introduction to the Fourth Edition
Acknowledgments

Section I. General Principles of Effective Interviewing

1. The Initial Interview: A Preview
2. Logistic Preparations: What to Do Before the Interview
3. The Therapeutic Alliance: What It Is, Why It’s Important, and How to Establish It
4. Asking Questions I: How to Approach Threatening Topics
5. Asking Questions II: Tricks for Improving Patient Recall
6. Asking Questions III: How to Change Topics with Style
7. Techniques for the Reluctant Patient
8. Techniques for the Overly Talkative Patient
9. Techniques for the Malingering Patient
10. Techniques for the Adolescent Patient
11. Interviewing Family Members and Other Informants
12. Techniques for Other Challenging Situations
13. Practical Psychodynamics in the Diagnostic Interview

Section II. The Psychiatric History

14. Obtaining the History of Present Illness
15. Obtaining the Psychiatric History
16. Screening for General Medical Conditions
17. Family Psychiatric History
18. Obtaining the Social and Developmental History

Section III. Interviewing for Diagnosis: The Psychiatric Review of Symptoms

19. How to Memorize the DSM-5 Criteria
20. Interviewing for Diagnosis: The Art of Hypothesis Testing
21. Mental Status Examination
22. Assessing Suicidal and Homicidal Ideation

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23. Assessing Mood Disorders I: Depressive Disorders
24. Assessing Mood Disorders II: Bipolar Disorder
25. Assessing Anxiety, Obsessive, and Trauma Disorders
26. Assessing Alcohol Use Disorder
27. Assessing Psychotic Disorders
28. Assessing Neurocognitive Disorders (Dementia and Delirium)
29. Assessing Eating Disorders and Somatic Symptom Disorder
30. Assessing Attention Deficit Hyperactivity Disorder
31. Assessing Personality Disorders

Section IV. Interviewing for Treatment

32. How to Educate Your Patient
33. Negotiating a Treatment Plan
34. Writing Up the Results of the Interview

Appendixes
A Pocket Cards
B Data Forms for the Interview
C Patient Education Handouts

References
Index

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I

GENERAL
PRINCIPLES
OF EFFECTIVE
INTERVIEWING

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 1 The Initial Interview: A Preview

Essential Concepts
The Four Tasks

Build a therapeutic alliance.

Obtain the psychiatric database.
Interview for diagnosis.
Negotiate a treatment plan with your patient.

The Three Phases

Opening phase
Body of the interview
Closing phase

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Four Tasks of the Diagnostic Interview
When you meet a patient for the first time, you know very little about her, but you know
that she is suffering. (Note: Throughout this book, I switch genders when discussing
theoretical patients rather than resorting to the awkward “him or her.”) While this may
seem obvious, this implies something that we often lose sight of. Our job, from the first
“hello,” is to ease our patients’ suffering, rather than to make a diagnosis.
Don’t get me wrong—the diagnosis is important. Otherwise, I wouldn’t be subjecting
you to yet another edition of this book! But diagnosis is only one step on the path of
relieving suffering. And often, you can do plenty to help a patient during the first session
without having much of a clue as to the official DSM diagnosis.
Since 2005, when the second edition of this book was published, psychiatry has begun
to question its fixation on the value of diagnostic categories. We have come to realize that
“major depression” does not imply a specific “disease” but rather a huge range of potential
problems. Each of our patients present with their own versions of depression, in other
words, and each version requires an individualized treatment approach. A 24-year-old
woman floundering around after graduating from college a few years ago is depressed—and
the solution may lie in helping her to clarify her goals. A 45-year-old public relations
manager just found out his wife has been having an affair and he is depressed—the solution
may be helping him to decide if he can ever trust her enough to engage in couple’s therapy.
A 37-year-old woman with three well-adjusted children and a good marriage says her life
seems okay but she is depressed—she may need a course of antidepressants.
My point with these examples? Before you dive into the worthy project of becoming a
world-class DSM diagnostician, experiment with spending much of your face-to-face
patient time thinking about their lives, rather than your diagnosis of their lives. Engage
your natural empathy, compassion, and intuition—because these represent the essence of
psychological healing. And even as you progress through your career and have logged
thousands of patient hours (as I have), always remind yourself of something that a wise
colleague, Brian Greenberg, once told me: “I often put the DSM manual aside and tell
myself, ‘Brian, how are you going to make this person’s journey easier?’”
The diagnostic interview is really about treatment, not diagnosis. It is important to
keep this larger goal in mind during the interview, because if you don’t, your patient may
never return for a second visit, and your finely wrought Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5) diagnosis will end up languishing in a chart in a
file room.
Studies show that up to 50% of patients drop out before the fourth session of
treatment, and many never return after the first appointment (Baekeland and Lundwall
1975). The reasons for treatment dropout are many. Some patients do not return because
they formed poor alliances with their clinicians, some because they weren’t really interested
in treatment in the first place, and others because the initial interviews alone boosted their
morale enough to get them through their stressors (Pekarik 1993). The upshot is that much

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more than diagnosis should occur during the initial interview: Alliance building, morale
boosting, and treatment negotiating are also vital.
The four tasks of the initial interview blend with one another. You establish a
therapeutic alliance as you learn about your patient. The very act of inquiry is an alliance
builder; we tend to like people who are warmly curious about us. As you ask questions, you
formulate possible diagnoses, and thinking through diagnoses leads naturally to the process
of negotiating a treatment plan.

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Build a Therapeutic Alliance
A therapeutic alliance forms the groundwork of any psychological treatment. Chapter 3,
The Therapeutic Alliance, focuses on the alliance directly, and Chapters 4 to 13 provide
various interviewing tips that will help you increase rapport with your patient.

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Obtain the Psychiatric Database
Also known as the psychiatric history, the psychiatric database includes historical
information relevant to the current clinical presentation. These topics are covered in
Section II, The Psychiatric History, and include history of present illness, psychiatric
history, medical history, family psychiatric history, and aspects of the social and
developmental history. Gleaning this information is the substance of the interview, and
throughout this step, you will have to work on building and maintaining the alliance. You
will also make frequent forays into the next task, interviewing for diagnosis.

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Interview for Diagnosis
The ability to interview for diagnosis—without sounding as if you’re reading off a checklist
of symptoms and without getting sidetracked by less relevant information—is one of the
supreme skills of a clinician, and one that you will hone and develop over the course of
your professional life. Section III, Interviewing for Diagnosis: The Psychiatric Review of
Symptoms, is devoted to this skill; it contains chapters on how to memorize DSM-5 criteria
(Chapter 19) and on the art of diagnostic hypothesis testing (Chapter 20) and several
disorder-specific chapters that focus on how to use screening and probing questions for
each of the major DSM-5 disorders (Chapters 22 to 31).

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Negotiate a Treatment Plan and Communicate It to Your
Patient
This process is rarely taught in residency or graduate school, and yet, it is probably the most
important thing you can do to ensure that your patient adheres to whatever treatment you
recommend. If your patient doesn’t understand your formulation, doesn’t agree with your
advice, and doesn’t feel comfortable telling you so, the interview may as well never have
taken place. See Section IV, Interviewing for Treatment, for tips on the art of patient
education and clinical negotiation.

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Three Phases of the Diagnostic Interview
The diagnostic interview, like most tasks in life, has a beginning, a middle, and an end.
Although this may seem obvious enough, novice interviewers often lose sight of it and
therefore fail to actively structure the interview and control its pacing. The result is usually
a panic-filled ending, in which 50 questions are wedged into the last 5 minutes.
It’s true that there’s a huge amount of information to obtain during the first interview,
and time may feel like the enemy. Excellent interviewers, however, rarely feel rushed. They
have the ability to obtain large amounts of information in a brief period, without giving
patients the sense that they are being hurried along or made to fit into a preordained
structure. One of the secrets of a good interviewer is the ability to actively structure the
interview in its three phases.

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Opening Phase (5 to 10 Minutes)
The opening phase includes meeting your patient, learning a bit about her life situation,
and then shutting up and giving her a few uninterrupted minutes to tell you why she came.
This is discussed in more detail in Chapter 3, because the opening phase is a crucial period
for alliance building; the patient is making an initial decision as to your trustworthiness.
The opening phase is based on careful, preinterview preparation, covered in Chapter 2,
Logistic Preparations: What to Do Before the Interview. Attention to logistics ensures that
you will be completely attuned to the relationship with your patient during the first 5
minutes.

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Body of the Interview (30 to 40 Minutes)
Over the course of the opening phase, you will come up with some initial diagnostic
hypotheses (Chapter 20), and you will decide on some interviewing priorities to explore
during the body of the interview. For example, you may decide that depression, anxiety,
and substance abuse are likely problems for a particular patient. You will map out an
interviewing strategy for exploring these topics, which will include asking about the history
of the present illness (Chapter 14); history of depression, suicidal ideation, and substance
abuse (Chapters 22, 23, and 26); family history of these disorders (Chapter 17); and a
detailed assessment of whether the patient actually meets DSM-5 criteria (Chapters 20, 21,
and 24) for each disorder. Once you’ve accomplished these priority tasks, you can move on
to other topics, such as the social/developmental history (Chapter 18), medical history
(Chapter 16), and psychiatric review of symptoms (Section III).

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Closing Phase (5 to 10 Minutes)
Although you may be tempted to continue asking diagnostic questions right up to the end
of the hour, it’s essential to reserve at least 5 minutes for the closing phase of the interview.
The closing phase should include two components: (a) a discussion of your assessment,
using the patient education techniques outlined in Chapter 32, and (b) an effort to come to
a negotiated agreement about treatment or follow-up plans (Chapter 33). Of course, early
in your career, it will be difficult to come up with a coherent assessment on the spot,
without the benefit of hours of postinterview supervision and reading. This skill will
improve with practice.

The most tactful question in the world is still inquisitive and requests
an answer. To some measure, it carries the memory of all questions
that could not be answered or were shaming or damning to
acknowledge.
Leston Havens, M.D.
A Safe Place

27
2 Logistic Preparations: What to Do Before
the Interview

Essential Concepts
Prepare the right space and time.
Use paper tools effectively.
Develop your policies.

The work of psychological healing begins in a safe place, to be

compared with the best of hospital experience or, from an earlier
time, church sanctuary. The psychological safe place permits the
individual to make spontaneous, forceful gestures and, at the same
time, represents a community that both allows the gestures and is
valued for its own sake.
Leston Havens, M.D.
A Safe Place

Logistic preparation for an interview is important because it sets up a mellower and less
stressful experience for both you and your patient. Often, trainees are thrown into the clinic
without training in how to find and secure a room, how to deal with scheduling, or how to
document effectively. You’ll eventually arrive at a system that works well for you; this
chapter will help speed up that process.

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Prepare the Right Space and Time
Secure a Space
A space war is raging in most clinics and training programs, and you must fight to secure
territory. Once secured, dig trenches, call for the cavalry, and do whatever you need to do.
I remember one early lesson in this reality: I was 2 months into my training and just
finishing supervision in the Warren Building of the Massachusetts General Hospital
(MGH) campus. It was 12:55 p.m., and I had a therapy patient scheduled for 1:00 p.m. in
the Ambulatory Care Clinic, a building so far from Warren that it practically had its own
time zone. I zigged and zagged around staff and patients in the hallways on their way to the
cafeteria and rushed into the clinic by 1:05 p.m. My patient was in the waiting room and
got a good view of sweat trickling down my forehead. I scanned the room schedule and
found that no rooms were free. Panic set in, until the secretary pointed out that the resident
who had room 825 for that hour had not yet shown up. So I led my patient to 825, and we
started, 10 minutes late. Five minutes later, there was a knock on the door. I opened it, and
there stood the resident and his patient. I redeposited my patient in the waiting room and
scoured the list for another room.
I won’t torture you with the rest of this saga. Suffice it to say, we were evicted from the
next room as well, and the therapy session was, in the end, only 15 minutes long, with
much humiliation on my part and good-natured amusement on my patient’s.
Here are some time-honored tips on how to secure a room and what to do with it once
you have it:

Schedule the same time every week. Try to secure your room for the same time
every week. That way, you’ll be able to fit interviews into your weekly schedule
routinely. When it comes to psychiatric interviewing, routine is your friend.
Psychodynamic psychotherapists call this routine—the same time, the same room,
the same greeting—the “frame.” Making it invariable reduces distractions from the
work of psychological exploration.
Make your room your own in some way. This isn’t easy when you only inhabit it
for a few hours a week. Clinic policy may forbid this, or it may be impolite (e.g., if
you’re using an office that belongs to a regular staff member). If possible, put a
picture on the desk or the wall, bring a plant in, place some reference books on a
shelf, hang some files. The room will feel more like your space, and it will seem
homier to your patient. In my current office, I have a photo of my two children on
my desk. In the past, I worried that this little piece of self-disclosure could cause
problems with transference. Would lonely patients envy me for having a family?
Would angry patients believe that I was “bragging” by showcasing my “beautiful
family”? In fact, these problems haven’t occurred (at least to my knowledge)—the
photo is generally a good conversation starter and, for most patients, makes me seem

29
more human and less intimidating.
Arrange the seating so that you can see a clock without shifting your gaze too
much. A wall clock positioned just behind your patient works well. A desk clock or a
wristwatch placed between the two of you is also acceptable. The object is to allow
you to keep track of the passage of time without this being obvious to your patient. It
is alienating for a patient to notice a clinician frequently looking at a clock; the
perceived message is “I can’t wait for the end of this interview.” You do need to
monitor the time, though, to ensure that you obtain a tremendous amount of
information in a brief period. Actually, keeping track of time will paradoxically make
you less distracted and more present for your patient, since you’ll always know that
you’re managing your time adequately.

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Protect Your Time
Time is but the stream I go a-fishing in.
Henry David Thoreau

This is not to say that you should go fly-casting with your patients (though you’re
usually fishing for something or other during an interview). Rather, you should protect the
time you schedule for interviews, so that it has that same peaceful, almost sacred quality.
How to do it?

Arrive Earlier than the Patient

You need time to prepare yourself emotionally and logistically for the interview. Compose
yourself. Lay out whatever forms or handouts you’ll need. Answer any urgent messages that
you just picked up at your message box. Breathe, meditate, do a crossword puzzle, or
whatever you do to relax.
I once observed an interviewer who was visibly anxious. He crossed and uncrossed his
legs and constantly kneaded his left palm with his right thumb. Eventually, the patient
interrupted the interview and asked, “Doctor? Are you all right? You look nervous.” He
laughed. “Oh, I’m fine,” he said. And no, this was not a resident, but one of my professors.

Prevent Interruptions
There are various ways to prevent interruptions:

Ask the clinic secretary to take messages for you.

Ask the page operator to hold all but urgent pages.
Put your pager on vibrate mode and only answer urgent pages.
Sign your pages out to a colleague.

Don’t Overbook Patients

Know your limits. At the beginning, it may take you an hour and a half to complete an
evaluation, not including the write-up. If so, book only one patient per 2-hour slot.
Obviously, your training program won’t allow you to maintain such a leisurely schedule for
long, but you will improve and become more efficient. Eventually, you should aim toward
completing the evaluation and write-up (or dictation) in 1 hour.

Leave Plenty of Time for Notes and Paperwork

The time required for paperwork will vary, depending on both the setting and the clinician.
The key is to figure out how long it takes you and then to make room for it in your
schedule. Don’t fall into denial. If you happen to be very slow at paperwork, admit it and

31
plan accordingly.
I know an excellent psychiatrist who has learned from experience that he has to spend
30 minutes on charting, telephoning, and miscellaneous paperwork related to patients for
every hour of clinical work he does. If he spends 6 hours seeing patients, he schedules 3
hours in the evening to take care of the collateral work. Although his hourly wage decreases,
he gains the satisfaction of knowing that he’s doing the kind of job he wants to do.
Now, that wouldn’t work for me. I schedule slightly less time with patients so that I
can finish all collateral work before I see my next appointment. The point, as Polonius said
in Hamlet, is to “Know thyself, and to thine own self be true.”

32
Use Clinical Tools Effectively
By “clinical tools,” I mean the whole array of interview forms, cheat sheets, patient
handouts, and patient questionnaires. Since the last edition of this book, many of us have
moved to electronic health records, so we might fill out the forms on the computer and we
might e-mail patients handouts. Regardless, these tools are indispensable when you see a lot
of patients every day. All of the paper versions of the tools that I discuss below are in the
appendices of this manual, and you are welcome to copy and use what you want. You
might find all, some, or none of them useful, or you may want to adapt them to better suit
your needs.

33
Psychiatric Interview Long Form
This psychiatric interview long form (in Appendix B) is adapted from the one used by
Anthony Erdmann, an attending psychiatrist at MGH. He takes notes on it while talking
to patients and puts it in his chart.

Advantages
Use of this form ensures a thorough data evaluation and saves time, because notes can be
placed directly into the chart.

Disadvantages
Some patients may be alienated if you seem more interested in completing a form than in
getting to know them.

34
Psychiatric Interview Short Form
The short form (in Appendix B) can be used for rough notes when you are going to dictate
the evaluation or write it up in a longer version later.

Advantages
This form presents less of a barrier between clinician and patient than the long form and is
easy to refer to while dictating.

Disadvantages
Use of the short form may lead to a less thorough evaluation.

35
Psychiatric Interview Pocket Card
The pocket card (in Appendix A) is used to remind you of all the topics to cover. You can
jot rough notes on a blank piece of paper or not take notes at all, if you’re able to remember
most information.

Advantages
The card allows maximum interaction between clinician and patient, since there is no form
to fill out.

Disadvantages
Required information is not fully spelled out on the pocket card, so more use of memory is
required.

Patient Questionnaire1
Some clinicians give their patients a questionnaire (in Appendix B) such as this one before
the first meeting, to decrease the time needed to acquire basic information.
1 Adapted from the questionnaire of the late Edward Messner, M.D.

Advantages
The patient questionnaire allows more time during the first session to focus on issues of
immediate concern to the patient. It may heighten the patient’s sense that he is actively
participating in his care.

Disadvantages
If all of the patient’s answers on the questionnaire are accepted at face value, invalid
information may be collected. Some patients may view filling out the questionnaire as a
burden.

36
Patient Handouts
Patients usually appreciate receiving some written information (in Appendix C) about their
disorder, and it probably increases treatment compliance.

Advantages
Patient handouts increase patients’ understanding of their diagnosis and give them a sense
that they are collaborating in their treatment.

Disadvantages
The handouts may present more information than some patients can handle early in their
treatment. Information may also be misinterpreted.

37
Develop Your Policies
From the first appointment with a particular patient, you are entering into a relationship.
You need to determine the parameters of this relationship, including issues such as how and
when you can be contacted, what the patient should do in case of an emergency, who you
can talk to about the patient, and how to deal with missed appointments. As you face this
array of decisions, the following tips and ideas should help you devise policies that fit your
personality and clinical setting.

38
Contacting You
You define the boundaries of the clinical relationship by setting limits on where and when
patients can reach you. Do this early on; if you don’t, you’ll eventually suffer for it.
I found this out the hard way with my very first therapy patient during residency. She
was a 40-year-old woman I’ll call Sally who had panic disorder and depression. I first met
her in the crisis clinic, where she came after an upsetting conversation with her father. I
spoke to her for half an hour, and I gave her a follow-up appointment for the next week—
and I gave her my pager number and told her that this was a way to reach me, “anytime.”
The next Saturday morning, over breakfast and the paper, I got my first page: “Call Sally.”
She was in the middle of a panic attack, which subsided after a 10-minute conversation.
Later that day, as I was riding my bike, I got another page. “Call Sally.” I was somewhere
on a country road in Concord, Massachusetts, and far from a phone. Ten minutes later:
“Call Sally. Urgent.” Over the next hour, I received six pages, each sounding more urgent
as the alarmed hospital operator added more and more punctuation. The last page read,
“Call Sally!!! Emergency!!!!!!” When I finally found a pay phone, my heart pounding, Sally
said, “Doctor! I just had another panic attack.”
I felt the first hint of what I later learned was “countertransference.” At the time, I
called it “being pissed off.” I tried to keep the irritation out of my voice as I told her she
didn’t have to call me every time she had a panic attack. At our next appointment, after
some good supervision, I laid out some ground rules. Sally could page me only during the
week between 8 a.m. and 5 p.m. Otherwise, she was instructed to go to the crisis clinic.
This in itself helped decrease the frequency of her panic attacks, since it took away the
reinforcement of a phone conversation with her therapist every time she panicked.

Suggestions
Never give your home or cell phone number to patients, and consider keeping an
unlisted phone number. Having made that pronouncement, I acknowledge that some
of my colleagues disagree, and give patients their cell phone numbers. They do so
with the understanding that they are to use that phone only under extraordinary, life-
threatening circumstances. They tell me that this privilege is rarely abused and that
sharing their cell phone number tells patients that you care enough about them to
make sure that they can always reach you.
You may give out your paging number, but specify the times when you’re available to
be paged. Don’t let your life revolve around your pager. Tell your patient what to do
if there is an emergency at a time when you are not available for paging. For example,
he can call the crisis clinic, and you can give the clinic instructions to page you after
hours if the on-call clinician judges that the situation warrants your immediate
involvement.
If you have a voice-mail system, have patients reach you there. Your voice mail is

39
 accessible 24 hours a day, and you can check it whenever you want and decide who
to call back and when. Some patients will call your voice mail just to be soothed by
your recorded voice.
When you’re on vacation, I suggest you sign your patients out to a clinician you
know and trust, rather than have them call the crisis clinic during regular hours. That
way, you can ensure that someone is prepared to deal with any impending crises. For
example, you may have patients who are chronically suicidal but rarely require
hospitalization and can be managed through crises with frequent outpatient support.
Letting your colleague know about these patients may prevent inappropriate
hospitalization. Before you go on vacation, don’t forget to change your outgoing
voice-mail message to tell patients how to reach your coverage. I make things easy by
writing out two scripts: one for regular outgoing messages and one for vacations.

Many clinicians use e-mail as a way of contacting patients. This can be a time-saver,
because you can answer quick questions without being at the mercy of the availability of
your patient’s cell phone or voice mail. But again, without certain ground rules, this can
(and will) get out of hand. Make sure your patients know that e-mail communication is not
a form of treatment. Specify what you are willing to use e-mail for. Typically, this will be
limited to scheduling changes and requests for prescription refills. If you start answering
more involved clinical questions over e-mail, be aware that this is part of the medical
record, and you should print out a copy of any correspondence and put it in the chart. In
addition, many authorities believe that HIPAA regulations require that you use an
encrypted e-mail system for any electronic communication. Such systems are expensive and
somewhat inconvenient, so I personally do not follow this guidance. Instead, I append a
message at the end of my e-mails to patients saying: “Please be aware that e-mail
communication can be intercepted in transmission or misdirected. Your use of e-mail to
communicate protected health information to us indicates that you acknowledge and
accept the possible risks associated with such communication. Please consider
communicating any sensitive information by telephone, fax, or mail. If you do not wish to
have your information sent by e-mail, please contact the sender immediately.” (See The
Carlat Psychiatry Report, October 2015 for information on a variety of encrypted methods
for communicating with patients).

40
Contacting the Patient
Be sure to get your patient’s various phone numbers (e.g., home, work, day treatment
program) and e-mail (if applicable to your practice). Ask whether it’s okay for you to
identify yourself when you call, because some patients don’t want employers or family
members to know that they’re in treatment. Obtain numbers of family members or close
friends so that you can contact them either to gather clinical information or in emergency
situations. You’ll need to obtain your patient’s consent for this ahead of time.

41
Missed Appointments
The usual practice is to tell patients that they must inform you at least 24 hours in advance
of any missed appointments or they will be charged, except in emergency situations. As a
salaried trainee, the financial aspects of this policy aren’t relevant, but there are important
clinical benefits. Patients who make the effort to show up for sessions show a level of
commitment that bodes well for therapeutic success. This policy encourages that
commitment.
What if a patient repeatedly cancels sessions (albeit in time to avoid paying)? First,
figure out why she is canceling. Is it for a legitimate reason, or is she acting out some
feelings of anxiety or hostility? Did you just return from vacation? If so, this is a common
time for patients to act out a sense of having been abandoned by you.
One way to approach this issue is head-on:

I notice that since I returned from vacation, you’ve canceled three

sessions in a row. What’s going on? Sometimes, people get angry at
their therapists.
I’ve noticed that since we started talking about the causes of your
bulimia, you’ve missed a lot of sessions. Should we be going a bit
more slowly with these issues?

42
 3 The Therapeutic Alliance: What It Is,
Why It’s Important, and How to Establish
It

Essential Concepts
Be warm, courteous, and emotionally sensitive.
Actively defuse the strangeness of the clinical situation.
Give your patient the opening word.
Gain your patient’s trust by projecting competence.

The therapeutic alliance is a feeling that you should create over the course of the diagnostic
interview, a sense of rapport, trust, and warmth. Most research on the therapeutic alliance
has been done in the context of psychotherapy, rather than the diagnostic interview. Jerome
Frank, author of Persuasion and Healing (Frank and Frank 1991) and the father of the
comparative study of psychotherapy, found that a therapeutic alliance is the most
important ingredient in all effective psychotherapies. Creating rapport is truly an art and
therefore difficult to teach, but here are some tips that should increase your success.

43
Be Yourself
While there is much to be learned from books and research about how to be a good
interviewer, you’ll never enjoy psychiatry very much unless you can find some way to inject
your own personality and style into your work. If you can’t do this, you’ll always be
working at odds with who you are, and this work will exhaust you.

CLINICAL VIGNETTE

My friend and colleague, Leo Shapiro, does both inpatient and outpatient work. He’s a
character, no question about it. As a patient, you either love him or hate him, but either
way, what you see is what you get.
Two examples of Dr. Shapiro’s unorthodox style:
1. Walking down the hallway of the inpatient unit, Dr. Shapiro spotted the patient he
needed to interview next.

“Hey, what’s wrong, does your face hurt?”

Patient: “No, my face doesn’t hurt.”
Dr. Shapiro: “Well, it’s killing me!”
The patient chuckled, and the rapport was solidified.

2. The Shapiro thumb wrestling ploy

An angry, depressed man was demanding to be discharged, prematurely according to

staff reports. Dr. Shapiro agreed that discharge would be risky, partly because the
patient had developed little in the way of rapport with anyone.
Dr. Shapiro: “I understand you want to be discharged?”
Patient: “Of course, this place is stupid, no one’s helping me.”
Dr. Shapiro: “If you can beat me at thumb wrestling, I’ll let you leave.”
Patient: “What?!!!”
Dr. Shapiro (putting out his hand): “Seriously. Or are you afraid of the challenge?”
Patient (reluctantly joining hands with Shapiro): “This is crazy.”
Dr. Shapiro: “One, two, three, go”
Dr. Shapiro quickly wins, as he always does. “Well, I guess you have to stay another
day. See you tomorrow.”
Patient (smiling, despite himself): “That’s it?”
Dr. Shapiro: “What? You wanna talk, OK, let’s talk.”
A significant exchange ensued, and the patient was in fact discharged that afternoon
with appropriate follow-up.
No, I’m not endorsing the Shapiro technique. It works great for him, because that’s his

44
personality, but it would be a disaster for me, a mellow Californian at heart. The key is
to be able to adapt your own personality to the task at hand—helping patients feel
better.

45
Be Warm, Courteous, and Emotionally Sensitive
Are there any specific interviewing techniques that lead to good rapport? Surprisingly, the
answer appears to be “no,” and that is good news. A group of researchers from London
have studied this question in depth and published their results in seven papers in the British
Journal of Psychiatry (Cox et al. 1981a,b; 1988). Their bottom line was that several
interviewing styles were equally effective in eliciting emotions. As long as the trainees whom
they observed behaved with a basic sense of warmth, courtesy, and sensitivity, it didn’t
particularly matter which techniques they used; all techniques worked well.
No book can teach you warmth, courtesy, or sensitivity. These are attributes that you
probably already have if you are in one of the helping professions. Just be sure to
consciously activate these qualities during your initial interview.
There are, however, some specific rapport-building techniques that you should be
aware of:

Empathic or sympathetic statements, such as “you must have felt terrible when she
left you,” communicate your acceptance and understanding of painful emotions. Be
careful not to overuse empathic statements, because they can sound wooden and
insincere if forced.
Direct feeling questions such as “How did you feel when she left you?” are also
effective.
Reflective statements, such as “You sound sad when you talk about her,” are
effective but also should not be overused, because it can seem as though you are
stating the obvious.

What do you do if you don’t like your patient? Certainly, some patients immediately seem
unlikeable, perhaps because of their anger, passivity, or dependence. If you are bothered by
such qualities, it’s often helpful to see them as expressions of psychopathology and awaken
your compassion for the patient on that basis. It may also be that your negative feelings are
expressions of countertransference, which is discussed in Chapter 13.

46
Actively Defuse the Strangeness of the Clinical
Situation
It’s easy to lose sight of the fact that an hour-long psychiatric interview is a strange and
anxiety-provoking experience. Your patient is expected to reveal his or her deepest and most
shameful secrets to a perfect stranger. There are several ways to quickly defuse that
strangeness.

Greet your patient naturally. While there are many perfectly acceptable ways to
greet patients, a general rule of thumb is to act naturally, which usually means
introducing yourself and shaking hands. I often engage in some small talk for the first
few seconds, because many patients have a distorted view of psychiatrists as
mysterious, silent types who busily scrutinize a patient’s smallest gestures. Small talk
undermines this projection and puts the patient at ease. Acceptable topics include the
weather and difficulties arriving at the office.

Hi, I’m Dr. Carlat. Nice to meet you. I hope you were able to make your way through the
maze of the hospital without too much trouble.
Ask the patient what he wants to be called, and make sure to use that name a few times
during the interview.
Do you prefer that I call you Mr. Whalen, or Michael, or something else?
Using the patient’s name, especially the first name, is a great way of increasing a sense
of familiarity.
Caveat: Some patients (as well as some clinicians) view small talk as unprofessional. I
try to size up my patient visually before deciding how to greet him or her. For example,
small talk is rarely appropriate for patients who are in obvious emotional pain or for grossly
psychotic patients, particularly if they are paranoid.

Get to know the patient as a person first. Some patients find it awkward to reveal
sensitive information to a stranger. If you sense that this is the case, you might want
to begin by learning something about them as people.

Before we get into the issues that brought you here, I’d like to know a little bit about you as
a person—where you live, what you do, that sort of thing.
Learning a bit about your patient’s demographics at the outset has the added advantage
of helping you start your diagnostic hypothesizing. There’s a reason why the standard
opening line of a written or oral case presentation is a description of demographics: “This is
a 75-year-old white widower who is a retired police officer and lives alone in a small
apartment downtown.” You can already begin to make diagnostic hypotheses: “He’s a
widower and thus at high risk for depression. He’s elderly, so at higher risk for dementia.
He apparently had a career as a police officer, so probably is not schizophrenic,” and so on.

47
Knowing basic demographics at the outset doesn’t excuse you from asking all the questions
required for a diagnostic evaluation, but it certainly helps set priorities in the direction of
inquiry.

Educate the patient about the nature of the interview. Not every patient
understands the nature of an evaluation interview. Some may think that this is the
first session in a long-term psychotherapy. They may come into the interview with
the negative, media-fed expectation of a clinician who sits quietly and inscrutably
while the patient pours out his soul. Others may have no idea why they are talking to
you, having been referred to a “doctor” by an internist who believes psychological
factors are interfering with their medical treatment. Thus, it’s helpful to begin by
asking the patient if he understands the purpose of the interview and then to give
him your explanation, including the expected length of time of the interview, what
sorts of information you’ll be asking about, and whether you will follow him for
further treatment if needed.
Interviewer (I): So, Mr. Johnson, did your doctor explain the purpose of this interview?
Patient (P): She said you might be able to help me with my nerves.I: I certainly hope I
can do that. This is what we call an evaluation interview. We’ll be meeting for about 50
minutes today, and I’ll be asking you all sorts of questions, some about your nerves, some
about your family and other things, all so I can best understand what might be causing
you the troubles you’ve been having. Depending on your problem, we may need to meet
twice to complete this evaluation, but the way our clinic works is that I won’t necessarily
be the one who will treat you over the long term; depending on what I think is going on, I
may refer you to someone else for treatment.
Address your patient’s projections. Keep in mind that a lot of shame is associated
with psychiatric disorders. Patients commonly project aspects of their own negative
self-images onto you. They may see you as critical or judgmental. Havens (1986)
recognized this and encouraged the use of “counterprojective statements” to increase
the patient’s sense of safety:

It may be embarrassing for you to reveal all these things to a stranger. Who knows how I’d
react? In fact, I’m here to understand you and to help you.

CLINICAL VIGNETTE

Paranoid patients often project malevolent intentions onto the interviewer. In this example,
the interviewer addresses these projections directly:

I: Are you concerned about why I’m asking all these questions?
P: Sure. You’ve got to wonder—What’s in it for you? How are you going to use all this
information?
I:I’m going to use it to understand you better and to help you. It won’t go any further

48
 than this room.
P: (Smirking) I’ve heard that before.
I:Did someone turn it against you?
P: You bet.
I:Then I can understand that you’d be careful about talking to me—you probably think
I’d do the same thing.
P: You never know.

With the distrust issue brought out into the open, the patient was more forthcoming
throughout the rest of the interview.

49
Give Your Patient the Opening Word
In one study of physicians, patients were allowed to complete their opening statements of
concern in only 23% of cases (Beckman and Franckel 1984). An average of 18 seconds
elapsed before these patients were interrupted. The consequence of this highly controlling
interviewing style is that important clinical information may never make it out of the
patient’s mouth (Platt and McMath 1979).
You should allow your patients about 5 minutes of “free speech” (Morrison 2014)
before you ask specific questions. This accomplishes two goals: First, it gives your patient
the sense that you are interested in listening, thereby establishing rapport, and second, it
increases the likelihood that you will understand the issues that are most troubling to the
patient and thereby make a correct diagnosis. Shea (1998) has called this initial listening
phase the “scouting period,” because you can use it to scout for clues to psychopathology
that you will want to follow up on later in the interview. It has also been called the “warm-
up” period by Othmer and Othmer (2001), because one of its purposes is to create a
comfort level between you and the patient so that the patient is not put off by the large
number of diagnostic questions to come.
Of course, you have to be flexible. Some patients begin in such a vague or disorganized
fashion that you will have to ask your questions right away, whereas others are so articulate
that if you let them talk for 10 or 20 minutes, they will tell you almost everything you need
to know.
Each clinician develops his or her own first question, but all first questions should be
open-ended and should invite the patient’s story. Here are several examples of first
questions:

What was it that brought you to the clinic today?

What brings you to see me today?
What sorts of things have been troubling you?
How can I be of help to you?
What can I do for you?

A somewhat different way of approaching the first question is to view it as a way of

immediately exploring what that patient’s goals are for the interview. Called “solution-
focused interviewing,” this approach is recommended by Chang and Nylund (2013).
Rather than asking “What brings you in?” or “What troubles you?” he recommends
“What would make this a helpful visit?” “What would you like to see different from
coming here?” This approach may work out particularly well with reluctant patients, who
may not believe they have any problems in the first place.
A related question type is “the Miracle question,” which goes like this: “Imagine that
tonight you go to bed, like you normally do. Then, imagine that while you’re asleep….
[pause)] …a miracle happens. Imagine that because of this miracle, your depression [or

50
whatever the patient’s problem is] goes away. What will your day be like tomorrow?”
Patient: “Well, I guess I would wake up, and rather than sleep in, I’d wake up on time
and get ready instead of procrastinating. Then I’d eat breakfast rather than skipping it, and
at breakfast, we’d all get along better without fighting. Then I’d go to work, and I’d have
more confidence, so I would say ‘no’ to people if they ask me to do too much….”

51
Gain Your Patient’s Trust by Projecting Competence
This is always a tricky issue for novice interviewers, who often feel anything but competent.
In fact, your patient usually gives you the benefit of the doubt here, because of something
called “ascribed” competence. This is the competence your patient attributes to you purely
because of your institutional ties. You work for Hospital X or University Y, so you must be
competent. Ascribed confidence will get you through the first several minutes of the
interview, but after that, you have to earn your patient’s respect.
Gaining a patient’s trust is easier than you might think. Even as a novice, you know
much more about mental illness than your patient, and this knowledge is communicated by
the kinds of questions you ask. For example, your patient tells you she is depressed. You
immediately ask questions about sleep and appetite. Most patients will be impressed by
your ability to elicit relevant data in this way.
Other, more prosaic ways of projecting competence include dressing professionally and
adopting a general attitude of confidence. At the end of the interview, your ability to
provide meaningful feedback will further cement your patient’s respect.

52
 4 Asking Questions I: How to Approach
Threatening Topics

Essential Concepts
Use normalizing questions to decrease a patient’s sense of embarrassment about a
feeling or behavior.
Use symptom expectation and reduction of guilt to defuse the admission of
embarrassing behavior.
Use symptom exaggeration to determine the actual frequency of a sensitive or
shameful behavior.
Use familiar language when asking about behaviors.

Always the beautiful answer who asks a more beautiful question.

e. e. cummings

Over the course of the diagnostic interview, many of your questions will be threatening
to your patient. The simple admission of psychiatric symptoms is humiliating for many
people, as is the admission of behaviors considered by society to be either undesirable or
abnormal. Such behaviors include drug and alcohol abuse, violence, and homosexuality.
Beyond this, there are other behaviors that your patients may not want to admit, because
they may think you will disapprove of them personally. These might include a history of
noncompliance with mental health treatment, a checkered work history, or a deficient
social life.
To maintain a healthy self-image, patients may lie when asked what they perceive to be
threatening questions. This has been a significant problem among both clinicians and
professional surveyors for years, and a repertoire of interviewing techniques has been
developed to increase the validity of responses to threatening questions (Bradburn 2004;
Payne 1951; Shea 1998). Good clinicians instinctively use many of these techniques,
having found through trial and error that they improve the validity of the interview.

53
Normalization
Normalization is the most common and useful technique for eliciting sensitive or
embarrassing material. The technique involves introducing your question with some type of
normalizing statement. There are two principal ways to do this:
1. Start the question by implying that the behavior is a normal or understandable response
to a mood or situation:
With all the stress you’ve been under, I wonder if you’ve been drinking more lately?
Sometimes when people are very depressed, they think of hurting themselves. Has this
been true for you?
Sometimes when people are under stress or are feeling lonely, they binge on large
amounts of food to make themselves feel better. Is this true for you?
2. Begin by describing another patient (or patients) who has engaged in the behavior,
showing your patient that she is not alone:
I’ve seen a number of patients who’ve told me that their anxiety causes them to avoid
doing things, like driving on the highway or going to the grocery store. Has that been
true for you?
I’ve talked to several patients who’ve said that their depression causes them to have
strange experiences, like hearing voices or thinking that strangers are laughing at them.
Has that been happening to you?
It’s possible to go too far with normalization. Some behaviors are impossible to consider
normal or understandable, such as acts of extreme violence or sexual abuse, so don’t use
normalization to ask about these.

54
Symptom Expectation
Symptom expectation, also known as the “gentle assumption” (Shea 1998), is similar to
normalization: You communicate that a behavior is in some way normal or expected.
Phrase your questions to imply that you already assume the patient has engaged in some
behavior and that you will not be offended by a positive response. This technique is most
useful when you have a high index of suspicion of some self-destructive activity. A few
examples follow:

Drug use. Your patient has reluctantly admitted to excessive alcohol use, and you
strongly suspect abuse of illicit drugs. Symptom expectation may encourage a
straightforward, honest response.

What sorts of drugs do you usually use when you’re drinking?

Suicidality. Your patient is profoundly depressed and has expressed feelings of

hopelessness. You suspect SI, but you sense that the patient may be too ashamed to
admit it. Rather than gingerly asking “Have you had any thoughts that you’d be
better off dead?” you might decide to use symptom expectation.

What kinds of ways to hurt yourself have you thought about?

Remember to use this technique only when you suspect that the patient has engaged in
the behavior. For example, the question “What kinds of recreational drugs do you use?”
may be appropriate when interviewing a young male admitted for a suicidal gesture while
intoxicated, but wildly inappropriate for a 70-year-old woman being assessed for dementia.

55
Symptom Exaggeration
Frequently, a patient minimizes the degree of his pathology, to fool either you or himself.
Symptom exaggeration or amplification (Shea 1998), often used with symptom
expectation, is helpful in clarifying the severity of symptoms. The technique involves
suggesting a frequency of a problematic behavior that is higher than your expectation, so
that the patient feels that his actual, lower frequency of the behavior will not be perceived
by you as being “bad.”

How much vodka do you drink each day? Two fifths? Three? More?
How many times do you binge and purge each day? Five times? Ten times?
How many suicide attempts have you had since your last hospitalization? Four? Five?

As is true for symptom expectation, you must reserve this technique for situations in
which it seems appropriate. For example, if you have no reason to suspect that a patient has
a drinking problem, asking how many cases of beer he drinks each day will sound quite
insulting!

56
Reduction of Guilt
While it is true that all the techniques in this chapter boil down to reducing a patient’s
sense of shame and guilt, the reduction-of-guilt technique seeks to directly reduce a
patient’s guilt about a specific behavior in order to discover what he has been doing. This
technique is especially useful in obtaining a history of domestic violence and other
antisocial behavior.

57
Domestic Violence
I: When you argue with your wife, does she ever throw things at you or hit you?
P: She sure does. See this scar? She threw a vase at me 2 years ago.
I: Do you fight back?
P: Well, yes. I’ve bruised her a few times. Nothing compared to what she did to me.

Another version of this technique is to begin by asking about other people:

I: Do you have any friends who push around their wives or girlfriends when they have an
argument?
P: Sure. They get pushed back, too.
I: Have you done that yourself, pushed or hit your wife?
P: Yeah. I’m not proud of it, but I’ve done it when she’s gotten out of hand.

Dr. Mustafa Soomro has found the following question useful: “Have you ever been in
situations where fights occurred and you were affected?”
This is yet another variation on the nonjudgmental approach. If your patient answers
“yes,” you can flesh out whether his or her role was being a witness, a victim, or a
perpetrator (Shea 2007).

58
Antisocial Behavior
I: Have you ever had any legal problems?
P: Oh, here and there. A little shoplifting. Normal stuff.
I: Really? What was the best thing you ever stole?
P: The best thing? Well, I was into cars for a while. I spent a week cruising around in a
Porsche 924, but I returned it. I was just into joyrides. Everyone was doing it back then.

In this example, the interviewer used induction to bragging to reduce the patient’s
sense of guilt and lead to an admission of something more significant than shoplifting.

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Use Familiar Language When Asking About
Behaviors
Bradburn (2004) compared two methods of asking about alcohol use and sexuality. In the
first method, they used “standard” language—words and phrases such as intoxicated and
sexual intercourse. In the second method, they used “familiar” or “poetic” language—the
language their respondents used for the same behavior, like getting loaded and making love.
They found that the use of familiar language increased reports of these behaviors by 15%.
Apparently, patients feel more comfortable admitting to socially undesirable behaviors
if they feel the interviewer “speaks their language.” The table below suggests various
colloquial expressions to use in place of more formal language.

60
Using Familiar Language

61
 5 Asking Questions II: Tricks for
Improving Patient Recall

Essential Concepts
Anchor questions to memorable events.
Tag questions with specific examples.
Describe syndromes in your patient’s terms.

Uttering a word is like striking a note on the keyboard of the

imagination.
Ludwig Wittgenstein

Throughout the diagnostic interview, your patient’s memory will be both your ally and
your enemy. Even when the desired information is not threatening in any way, be prepared
for major inaccuracies and frustration if the events described occurred more than a few
months ago. Nonetheless, we’ve all had the in-training experience of watching an excellent
teacher elicit large quantities of historical information from a patient for whom we could
barely determine age and sex. How do they do it? Here are some tricks of the trade.

62
Anchor Questions to Memorable Events
Researchers have found that most people forget dates of events that occurred more than 10
days in the past (Azar 1997). Instead, we remember the distant past in relation to
memorable events or periods (Bradburn 2004), such as major transitions (graduations and
birthdays), holidays, accidents or illnesses, major purchases (a house or a car), seasonal
events (“hurricane Katrina”), or public events (such as 9/11 or President Obama’s election).
As an example, suppose you are interviewing a young woman with depression. You find
out over the course of the interview that she has a heavy drinking history, and you want to
determine which came first, the alcoholism or the depression. You could ask, “How many
years ago did you begin drinking?” followed by “How many years ago did you become
depressed?” but chances are you won’t get an accurate answer to either question. Instead,
use the anchoring technique:

Interviewer: Did you drink when you graduated from high school?
Patient: I was drinking a lot back then, every weekend at least. Graduation week was one big
party.
Interviewer: Were you depressed then, too?
Patient: I think so.
Interviewer: How about when you first started high school? Were you drinking then?
Patient: Oh no, I didn't really start drinking until I hooked up with my best friend toward the
end of my freshman year.
Interviewer: Were you depressed when you started school?
Patient: Oh yeah, I could barely get up in time to make it to classes, I was so down.

You’ve succeeded in establishing that her depression predated her alcoholism, which
may have important implications for treatment.

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Tag Questions With Specific Examples
In Chapter 8, you’ll learn about the value of multiple-choice questions in limiting overly
talkative patients. Tagging with examples is similar to posing multiple-choice questions, but
it is used specifically for areas in which your patient is having trouble with recall. You
simply tag a list of examples onto the end of your question.
To ascertain what medications your patient has taken in the past for depression, for
example:

Interviewer: What were the names of the medications you took back then?
Patient: Who knows? I really don’t remember.
Interviewer: Was it Prozac, Paxil, Zoloft, Elavil, Pamelor?
Patient: Pamelor, I think. It gave me a really dry mouth.

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Define Technical Terms
Sometimes, what appears to be a patient’s vague recall is actually a lack of understanding of
terms. For example, suppose you are interviewing a 40-year-old man with depression, and
you want to determine when he had his first episode:

Interviewer: How old were you when you first remember feeling depressed?
Patient: I don’t know. I’ve always been depressed.

You suspect that you and the patient have different meanings of depression, and you
alter your approach:

Interviewer: Just to clarify: I’m not talking about the kind of sadness that we all experience
from time to time. I’m trying to understand when you first felt what we call a clinical
depression, and by that I mean that you were so down that it seriously affected your
functioning, so that, for example, it might have interfered with your sleep, your appetite,
and your ability to concentrate. When do you remember first experiencing something that
severe?
Patient: Oh, that just started a month ago.

65
 6 Asking Questions III: How to Change
Topics with Style

Essential Concepts
Use smooth transitions to cue off something the patient just said.
Use referred transitions to cue off something said earlier in the interview.
Use introduced transitions to pull a new topic from thin air.

Interviewing a patient for the first time requires touching on many different topics
within a brief period. You’ll need to constantly change the subject, which can be jarring
and off-putting to a patient, especially when she is involved in an important and emotional
topic. Skilled interviewers are able to change topics without alienating their patients and
use various transitions to turn the interview into what Harry Stack Sullivan (1970) called a
“collaborative inquiry.”

66
Smooth Transition
In the smooth transition (Sullivan 1970), you cue off something the patient just said to
introduce a new topic. For example, a depressed patient is perseverating on conflicts with
her husband and stepchildren; the interviewer wants to obtain information on family
psychiatric history:

Patient: John has been good to me, but I can’t stand the way his daughters expect me to go out
of my way to make their lives easy; after all, they’re adults!
Interviewer: Speaking of family, has anyone else in your family been through the kind of
depression that you’ve been going through?

67
Referred Transition
In the referred transition (Shea 1998), you refer to something the patient said earlier in the
interview to move to a new topic. For example, at the beginning of an interview, a
depressed patient had briefly mentioned that he “didn’t know if he could take this situation
anymore.” Now, well into the evaluation, the interviewer wants to fully assess suicidality:

Patient: My doctor tried me on some medication for a while, but it didn’t do much good.
Interviewer: Earlier, you mentioned that you didn’t know how much more of this you could
take. Have you had the thought that you’d be better off dead?

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Introduced Transition
In the introduced transition, you introduce the next topic or series of topics before actually
launching into it. This transition is often begun by a statement such as “Now I’d like to
switch gears …” or “I’d like to ask some different kinds of questions now.” For example,
you need to quickly run through the PROS, but you don’t want the patient to think that
you are asking these questions because you expect that he actually experiences all of these
symptoms:

Interviewer: Now I’d like to switch gears a little and ask you about a bunch of different
psychological symptoms that people sometimes have. Many of these may not apply to you at
all, and that is a useful thing to know in itself.

69
 7 Techniques for the Reluctant Patient

Essential Concepts
Use open-ended questions and commands to increase the flow of information.
Use continuation techniques to keep the flow coming.
Shift to neutral ground when necessary.
Schedule a second interview when all else fails.

Occasionally, you run into the ideal patient. She’s troubled and eager to talk. She
briefly outlines the problems that led to her visit and then answers each of your questions in
full, stopping in preparation for your next query. You find that you’ve gathered all the vital
information in 30 minutes, and you have the luxury of exploring her social and
developmental history deeply. You feel like a real therapist. Your mind is whirring, and you
can’t wait to dust off that copy of Freud you bought the day you got into your training
program but haven’t had time to look at since.
Usually, however, your patient will fall somewhere on either side of a spectrum of
information flow. Either he’s not saying enough or he’s saying too much, and it’s not his
fault. The average patient has no way of knowing what information is and is not important
for a psychiatric diagnosis. It’s up to you to educate the patient and to steer the interview
appropriately.

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Open-Ended Questions and Commands
You can use open-ended questions and commands to increase the flow of information.
Open-ended questions can’t be answered with a simple “yes” or “no.”

What kinds of symptoms has your depression caused?

What sorts of things have you done when you felt manic?

Open-ended commands are questions altered slightly to sound more directive.

Tell me what kinds of symptoms you’ve had.

Describe for me some of the things you’ve done while you were
manic.

CLINICAL VIGNETTE

The patient was a woman in her 30s who had been admitted to the hospital after an
overdose. She was unhappy with the involuntary admission and initially resistant to
answering questions.

Interviewer: I understand that you took an overdose of your medicine last week.
Patient: Uh huh.
Interviewer: What do you think was going on? (An open-ended question.)
Patient: I don’t know. (Which doesn’t get anywhere.)
Interviewer: Were you feeling depressed?
Patient: Maybe.
Interviewer: Tell me a little about how you were feeling. (An open-ended command.)
Patient: There’s not much to tell. I took the pills, that’s all. (Still no results.)
Interviewer: I really want to help you, but the only way I can do that is to understand what
was going through your head when you took the pills. (Some education, combined with
another, more specific, command.)
Patient: I guess I thought it would be a good idea to take ’em. My husband was driving me
crazy. (Now we’re getting somewhere.)

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Continuation Techniques
Continuation techniques can be used to keep the flow coming. These expressions
encourage a patient to continue revealing sensitive information:

Go on.
Uh huh.
Continue with what you were saying about…
Really?
Wow.

They are often combined with facilitative body language, such as head nods, persistent
eye contact, holding the chin between thumb and index finger, and facial emotional
response to the material. Generally, the more spontaneous and genuine your responses to
reluctant patients, the more likely you are to disarm them.

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Neutral Ground
Some interviews begin badly and quickly deteriorate. For example, you may have had the
experience of interviewing a patient who becomes increasingly alienated as your questions
become more “psychiatric.” If this happens, try changing the subject to something
nonpsychiatric, with the intention of sidling back into your territory once you’ve gained the
patient’s trust.
I interviewed a college student who was referred by his dean for psychological
evaluation after having said he would kill himself if he was not given a better grade in a
course. He was an unwilling participant and had shown up only because he was threatened
with suspension if he did not.
After the first 5 minutes of the interview, it was clear that he was not interested in
talking about what was going through his mind, so I shifted to relatively neutral ground.

Interviewer: So how do you like college X?

Patient: It’s fine. There’s a good English department.
Interviewer: Really? Any particularly interesting classes?
Patient: King Lear and the Modern World.
Interviewer: It’s been a while since I read that. How is King Lear related to the modern world?
Patient: It’s all about money and power. Everyone sucks up to King Lear because he has all this
land to give away. It’s the same way with lobbyists in Washington. Or professors at a
university.
Interviewer: Is that the way it is at your college?
Patient: Of course. Professors sit in their offices, fat and happy, and students mean nothing to
them. Unless they can get you to be their slave.

This led to a discussion of his frustrations with school, which in turn led to his
revealing the extent of his depressive symptoms.

73
Second Interview
When all else fails, you may need to schedule a second interview. If you’re not getting
anywhere with the patient, no matter how many interviewing tricks you use, you may need
to cut the interview short with a comment such as

Why don’t we stop for now and meet again next week [or tomorrow,
for inpatient work]. That will give you a chance to think more about
the sorts of things that are bothering you, and we can take it from
there.

I’ve done this several times, and the patient is usually more forthcoming at the next
interview. I’m not sure why this works. Maybe giving the message that I accept their
reluctance paradoxically encourages them to open up, or perhaps they feel awkward about
not answering questions two interviews in a row.
Of course, before you end the interview, you must feel comfortable that the patient is
not at imminent risk of suicide or other dangerous behaviors.

74
 8 Techniques for the Overly Talkative
Patient

A man does not seek to see himself in running water, but in still
water. For only what is itself still can impart stillness into others.
Chuang-tzu

Essential Concepts
Use closed-ended and multiple-choice questions to limit the flow.
Perfect the art of the gentle interruption.
Educate the patient about the need to move along in the interview.

It was the end of a long day in the crisis clinic, and I picked up the last chart. I ushered
the patient, a middle-aged woman, into the interview room. She was well groomed and
socially appropriate, and she smiled warmly as she sat down. A good sign, I thought. She
did not look like the sort of person who would need to be hospitalized, which is a time-
consuming and exhausting process.
“How can I be of help today?” I asked.
“I am so glad I came here today,” she responded. “I cannot tell you how terrible my life
is. Sometimes I just don’t think it’s worthwhile going on. It began 21 years ago, when my
first husband—a hard-drinking bastard, a real womanizer, someone I really should never
have hooked up with and I wouldn’t have if my parents hadn’t nixed every other guy they
met—and I can tell you, it was no picnic growing up in Westchester, because even though
the average income is half a million, they treat their kids rotten.”
A virtual torrent of information followed. For the next hour, I struggled to rein in her
circumstantial and wandering stories and to get at the kernel of her complaint.
The problem with overly talkative patients is how to limit the flow of information
without seeming insensitive and impatient. Cox et al. (1988), in an experimental study of
interviewing techniques, found the following techniques useful for “overly expressive
patients”:

Closed-ended and multiple-choice questions

Redirecting questions to another topic
Structuring statements regarding information required and/or clinical procedures

In general, they found that a “brisk, highly controlling style” was helpful in limiting

75
overly expressive patients, without alienating them.

76
Use Closed-Ended and Multiple-Choice Questions
Although open-ended questions should be used with most patients, they will tend to
increase the talkativeness of circumstantial patients. With such patients, the open-ended
approach might result in something like the following:

Interviewer: How have you been sleeping?

Patient: Not great. Who knows, though? Do you think I’ve been keeping track, with each one
of my kids coming at me with a different problem, one kid a day, and with work calling to
ask when I’m coming back, and …

Closed-ended questions seek brief “yes” or “no” replies or refer to a limited range of
possible answers. Thus,

Have you been sleeping normally over the past week?

is a closed-ended question, because it can be answered with a “yes” or “no.” The

following sleep question is also closed ended:

How many hours of sleep did you get last night?

Although this one can’t be answered with a “yes” or “no,” it does refer to a limited
number of possible responses, somewhere from “none” to “12 hours.”
Multiple-choice questions limit answers to a greater extent than do closed-ended
questions. They include a list of options for possible answers to the question, giving your
patient guidance as to the level of precision expected. They are often useful in asking about
the neurovegetative symptoms of depression:

How has your appetite been over the past few weeks: better than
normal, worse than normal, or normal?
What sort of sleep problem do you have? Problems falling asleep?
Waking up throughout the night? Waking up too early in the
morning?

A common criticism of multiple-choice questions is that they may bias the patient
toward one of your prepackaged answers. Cox et al. (1981b) examined this issue and found
that patients were not biased in their replies, and that multiple-choice questions frequently
yielded clear, on-topic answers.
Generally, you should sprinkle the interview with closed-ended and multiple-choice
questions to rein in an overly talkative patient or with any patient with whom you have a
lot of ground to cover in a very short time, such as in an emergency room evaluation. Be
judicious in using these kinds of questions because some patients are alienated by them,
and you risk turning a talkative patient into a terminally reluctant patient.

77
The Art of the Gentle Interruption
Although it may feel impolite to interrupt your patient, you’re doing him no favor by
letting him ramble for so long that you have insufficient time to do a proper evaluation. In
some cases, you need to take charge of the interview actively. If you can accomplish this
with sensitivity, you will not alienate your patient. In my experience, patients with a
rambling, circumstantial style are so used to being interrupted that they barely flinch when
you cut in; in fact, they often appear grateful, especially if they are working themselves into
a state of anxiety or anger with their train of thought.
The gentle interruption is also known as a “redirecting statement” (Cox et al. 1988),
and it comes in various guises.
In the empathic interruption, you add an empathic statement to soften the blow:

I can tell that this situation’s been really hard for you to deal with.
Have you been drinking lately, to cope with it?

In the delaying interruption, you assure the patient that her topic is important and that
you’d like to come back to it later:

I can see you feel strongly about your daughter’s school troubles, and
that’s something we can talk about later, but right now I need to ask
you about some of those signs of depression you were experiencing.
Was your appetite normal through all this?

Of course, there’s also a note of empathy in that delaying statement.

The educating interruption incorporates a structuring statement in which you educate
the patient about the sorts of questions you have yet to ask and the time constraints you’re
both working under. Usually, this is done only after you’ve used the other two
interruptions several times with no results.

I’m sorry, but I need to interrupt you again. We have about 20

minutes left and a lot of ground to cover, including your treatment
history, your family background, and your medical history, and I
want to make sure we have time at the end to talk about some
medication changes. You can help by trying to answer the questions
directly and not getting too sidetracked. How does that sound?

or,

It’s important that I learn more about how you’ve been eating and
sleeping so that I can tell whether you’re suffering from a clinical
depression, so I may continue to interrupt you to get that important
information.

78
or, more simply,

We really have a lot of ground to cover over the next half hour, so I’m
going to have to ask you a lot of questions. This may mean some
interruptions, okay?

79
 9 Techniques for the Malingering Patient

Essential Concepts
Rule out malingering in

Patients on disability
Patients involved in litigation related to a psychiatric condition
Patients seeking a prescription for a controlled substance during the initial
interview

As you begin to put more and more years of practice under your belt, you will
increasingly begin to recognize that some of your patients are faking their symptoms for
secondary gain. Nobody knows how common this is, and it probably is pretty uncommon,
but you will need to know how to recognize such patients and to “smoke them out.” This
chapter provides you some helpful techniques.
But before proceeding, make sure not to confuse malingering with “factitious
disorder,” or Munchausen’s syndrome. Munchausen’s involves the self-infliction of actual
pain or injury with no clear secondary gain being served. Such patients may be motivated
by unconscious psychodynamic motivations, and while they, like malingerers, lie about
their symptoms, the ultimate treatment approach is different, because Munchausen’s
represents a recognized psychiatric syndrome unto itself, while malingering is just lying,
plain, and simple.

CLINICAL VIGNETTE

A 34-year-old single man presented to me after having been referred by employee health at
his manufacturing company. He appeared somewhat disheveled and launched into a
narrative about a work situation, saying that “It all started on June 6, when this foreman
called me into his office.” As he began describing the episode, I reached over for my pen
and clipboard. He responded to my movement with a dramatic startle response, and then
explained, “I don’t know what that is, it’s been happening ever since that day in June.” On
my prompting, he described in great detail a series of events leading to his current short-
term medical disability, including precise dates and names of all parties involved. During
the review of psychiatric symptoms, when asked about his memory and concentration, he
said, “I can’t remember a single thing since June; I can’t even read.”
Obviously, there are a number of clues to malingering here. The “startle response” was
exaggerated to the point of looking like a convulsion, and his self-described concentration

80
problems were undermined by his masterful ability to describe the “traumatic” event at
work. Over time, he failed to respond to any of the medications usually helpful for PTSD,
and once he was approved for long-term disability, he stopped coming to appointments.
The coup de grace was failure to pay his bill because of bankruptcy!
The first step in correctly diagnosing malingering is to have a high index of suspicion
that it exists. All of the following patient categories are red flags for possible malingering:

Any patient on any form of disability, whether through work or public insurance
Any patient involved in litigation having to do with the psychiatric illness
Any patients who, early on in the appointment, indicate that they are hoping to leave
the appointment with a prescription for a controlled medication

I don’t mean to sound heartless; in my experience, the majority of patients on disability

are genuinely disabled, and litigation is often legitimate. But if you raise your malingering
antennae with these types of patients, you’ll rarely find yourself duped.

81
Interviewing Clues to Malingering (and Strategies
for Responding)
The Tale Is Just Too Perfect
All of the symptoms are revealed in near perfect DSM-5 order. The quality of the
symptoms is textbook in the sense that they are presented in the way you might if you had
read their descriptions but hadn’t actually experienced them.
Suggested strategies: Be extra careful not to “lead” these patients through symptoms as
you might to with other new patients in the interest of time. Keep questions open ended. If
you suspect that they are trying to sell you on a diagnosis, throw them a little off-balance by
asking something that they are unlikely to have read much about, for example, “Did either
of your parents have these PTSD symptoms?” Depending on what the answer is, act mildly
surprised, saying, “That’s odd, in my experience it’s very unusual for the parents of
someone with PTSD to have had it as well; are you sure?” The malingerer will tend to alter
her answers as she feels it suits your expectations: “Well, that’s only what my brother said; I
always thought they were pretty normal, and I don’t think they ever saw a psychiatrist.”

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The Tale Is too Vague
If you come across as pretty savvy in your questioning (which you hopefully will after
reading this chapter!), many malingering patients will worry that they will imminently “slip
up” and reveal their ruse. Such patients may resort to answering questions so vaguely that
they can’t be wrong, for example, “It’s hard to say how I’ve been sleeping; it’s been really
loud outside my window lately, and sometimes when I wake up, I can’t tell how long I
slept.”
Suggested strategies: Use extremely closed-ended questions to nail them down (e.g., see
Chapter 8). If that doesn’t work, precede questions with obvious leads, like, “In my
experience, patients with panic attacks have tingling in their lips, has that been true?” If
previously vague answers become precise with such leading, you have a pretty big clue to
malingering.

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The Symptoms Are Unrealistic
Dr. Philip Resnick, a forensic psychiatrist with special expertise in evaluating malingering
patients, emphasizes the importance of understanding the usual characteristics of
psychiatric symptoms and then comparing them to the patient’s description. For example,
in insanity defense cases, defendants will often say that voices have told them to do illegal
things.
For example, Dr. Resnick points out that studies of genuine auditory hallucinations
have shown that “66% to 88% of patients report that their voices come from outside their
head; only 7% of auditory hallucinations are vague or inaudible.” Furthermore, she points
out that “auditory hallucinations are intermittent rather than continuous. One third of
patients who have hallucinations report having command hallucinations; the majority of
persons who have command hallucinations do not always obey them.” And while up to a
third of AH come in the form of questions, they are usually chastising rather than
information seeking (Shea 2007).
Using this information, you should ask careful, detailed questions about the nature of
patients’ hallucinations when you suspect malingering.

Interviewer: Why is it so hard for you to stop shoplifting?

Patient: These voices tell me to do it.
Interviewer: Do the voices tell you exactly what to do?
Patient: Yes, they say, “Go into Staples and take the software program.”
Interviewer: Are the voices inside your head?
Patient: Yeah—they’re like a part of me.
Interviewer: Do they ask you questions?
Patient: Yeah, like “How much is it worth?” Or “What time is the store open?”

In this case, the interviewer strongly suspected the patient was malingering, particularly
since there had been no prior history of psychosis in the patient’s history, before his arrest
for shoplifting.

84
“Nothing Works, Doc.”
If you have established that a series of standard treatments have been tried and that they
have all failed, this may simply mean that the patient has a treatment-resistant condition
(which certainly happens legitimately), but it may represent an ongoing effort to keep the
disability payments coming.
Suggested strategies: Asking in-depth questions about medication and psychotherapy
trials will give you a better sense of whether your patient was actually compliant with
anything (e.g., as a rule of thumb, you should establish at least a 4-to 6-week duration of
antidepressant treatment or at least eight sessions of therapy). If they have tried the usual
treatments and haven’t gotten better, make sure to offer more aggressive treatment. Such
offers can be very informative, as with one of my patients who declined trials of several
alternative antidepressants, citing vague reasons. I explained that it would be difficult for
me to continue filling out his disability forms if he didn’t accept needed treatment; this
turned out to be his last visit with me.

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“I Heard About This Thing Called ‘Klonopin’ From A Friend
Who Has What I Have.”
Prescription substance abusers (or pushers) have to get their supply somehow, and a
favorite method is to go doctor hopping until they find someone who writes the desired
prescription. Red flags here include the following:

The patient asks for the controlled medication very early in the evaluation.
The patient quickly insists that he has tried every other potential nonaddictive
treatment option and that they either have not worked or have caused intolerable side
effects.
The patient says he has tried a friend’s or relative’s medication.
The patient has a history of alcohol or drug abuse.

Suggested strategies: Say, “Are you aware that (Drug X) is a very dangerous and addictive
medication?” A drug seeker may respond in several different ways. He may make a big show
of being surprised and say, “Really?” He may appear unfazed and smoothly respond, “I
know people say it’s addictive, but I’ve never had a problem with it.” No particular
response is diagnostic of malingering, but it may help sway you in one direction or another.
Another helpful technique is to ask to speak to prior prescribers, be they primary care
doctors, nurse practitioners, or psychiatrists. Any hedging or hesitation in response to this
entirely reasonable request is cause for suspicion.

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 10 Techniques for the Adolescent Patient1

1With contributions from David Sorenson, M.D., and Alan Lyman, M.D.

87
 Essential Concepts
Involve the family.
Overcome the “I don’t know” syndrome.
Develop strategies for asking about drugs, sex, and conduct problems.

Don’t laugh at a youth for his affectations; he is only trying on one

face after another to find his own.
Logan Pearsall Smith

There are three reasons to include a chapter on adolescents in a book otherwise devoted
to adult psychopathology: (a) Child and adolescent treatment is a part of most general
training programs; (b) many primarily “adult” clinicians are called on to evaluate
adolescents; and (c) many “adult” patients are still struggling through late adolescence,
which begins during the later teen years and extends to the early 20s. If you can master the
techniques of evaluating adolescents, you will find yourself using these same techniques for
many of your adult patients, of any age.

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The Family Interview
Your initial interview with an adolescent will usually include family members for at least
part of, and sometimes all of, the session. Adolescents are great minimizers and deniers, and
you often will need to interview the family separately to ascertain the presence of any
problem at all. In addition, many psychiatric disorders in adolescents are strongly related to
family issues, with family dynamics sometimes contributing significantly to them (e.g.,
oppositional defiant disorder, depression) and at other times being the cause of family strife
(e.g., attention deficit hyperactivity disorder [ADHD]). Finally, treatment can rarely
happen without the consent and cooperation of family members.
Thus, for the first appointment, plan to invite the entire family into your office.
Usually, I walk out to the waiting room and greet the patient with an introduction and
handshake and then face the family, saying, “Why don’t we all go in for the first part of the
hour, then maybe I can have some time to chat with _____ afterward.”
Once in the office, allow the family to decide where to sit, and then shut up and listen
for a while, just as you would with your adult patients. If there is some initial silence, you
can get things going with questions such as

What brings us all together today?

What sort of issues have been coming up?

or, more simply,

Okay, who wants to do the talking?

A parent usually begins, and it is important that you listen closely, because a family’s
desires may be quite different from what you suspected or from what you can provide.

CLINICAL VIGNETTE

Two parents brought in their 17-year-old son for an evaluation. Once in the office, the
mother’s first words were, “I want you to commit my son for his drug addiction.”
The son, taken aback, turned to her and said, “Are you crazy?”
What developed was that the parents had suspected the son of drug use but had told
him that this was a family therapy meeting to “work out some family issues.” The mother’s
expectation was that the clinician would immediately have a police officer escort the patient
from the office to a substance abuse treatment facility. The clinician explained that this was
not possible and went on to explain the state’s legal criteria for involuntary commitment.
Eventually, the adolescent agreed to outpatient treatment of substance abuse and
depression.

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 Allow at least 5 minutes of free speech, in which you simply listen to family members
discussing the perceived problem. Aside from clueing you into diagnostic possibilities, this
will allow you to understand the communication style and family dynamics. After listening
for a few minutes, you will want to jump in with various questions to ascertain elements of
the psychiatric and social history. It is important to adopt a neutral attitude so as not to
appear that you are taking the parents’ side. If the parents constantly speak over the patient
(or vice versa), make a corrective comment, such as

Everyone obviously has a lot of feelings about this issue, but it is

important that I get a chance to hear everyone’s viewpoint without
too much interrupting.

After a period of time, you will want to talk to the adolescent alone.

I enjoyed meeting you, and now, I’d like to talk about some things
with Matthew. Afterward, we’ll get back together and discuss what
we’ve talked about.

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The Individual Interview
Initial Questions and Strategies
How much time should you devote to the individual interview? There are no hard-and-fast
rules. A full hour of individual discussion may be appropriate for a sensitive and
sophisticated 14-year-old adolescent with depression, whereas an angry and involuntary 17-
year-old adolescent with conduct disorder may be able to tolerate no more than 5 minutes
alone with you. The more verbal and engaged the patient seems, the more time you will
want to allot for your individual interview with her.
So there you are, in the room alone with your adolescent patient. Clinicians who spend
most of their time with adults often freeze at this point. What do you say to a 15-year-old,
who may feel quite awkward and embarrassed, especially now that his parents have left the
room?
You want to avoid awkward gaps in the conversation as much as possible, which may
involve doing more talking than you normally do. Some degree of self-disclosure may be
acceptable too, to build rapport. You can start with some tension-relieving statements such
as:

Okay. Now I get to hear your side of the story.

We have a half hour or so to talk confidentially now. I hope you’ll
feel comfortable telling me your side of what’s been going on at home.

If the family discussion was heated, react to that in some way:

Whew, things got pretty hot there; what do you think?

Remember that adolescents may have had no prior experience with a professional who
asks very personal questions. Thus, it may be helpful to begin with a comment such as

Do you mind if I ask you some personal questions?

I may ask some questions that you’re uncomfortable answering, and
you don’t have to answer if you don’t want to.

At some point during the interview, say something about the limits of confidentiality.
Relay the statement with terms such as “worry”:

I won’t tell your parents about anything you say unless I’m really
worried that your life might be in danger.

Later, before you bring the family back in, ask

Is there anything you don’t want me to tell your parents?

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 Is it okay if I tell your parents about these things?

If they say “yes,” follow up with

Do you want to tell them or do you want me to?

This way, you’re maximizing your patient’s sense of control.

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“I Don’t Know” Syndrome
Adolescents tend to have difficulty describing their internal emotional state. Sometimes,
this is because they don’t want to seem vulnerable; other times it’s because their emotional
vocabulary is underdeveloped. Thus, asking direct questions about feelings is likely to lead
to the following type of exchange:

Interviewer: Have you been feeling depressed?

Patient: I don’t know.
Interviewer: Have you been feeling angry?
Patient: I don’t know.
Interviewer: How have you been feeling?
Patient: Okay, I guess.

How does one get beyond the “I don’t know” syndrome? One way is to give the patient
permission to plead the fifth:

Look, if you really don’t know something, that’s fine. But if you don’t
want to tell me something, that’s okay too. Just say, “I don’t want to
say.”

Another strategy is to ask the “fly on the wall” question:

If I were a fly on the wall when you get into one of your moods, what
would I see?

or, a slight variation,

What would your friend look like if he looked like you in one of your
moods?

These questions invite the patient to describe his behavior, a less threatening
proposition than describing a subjective state.
A third strategy is to rely on the defense mechanism of displacement. Ask your patient
if he has any friends with problems:

Do you have any friends who are in trouble? What’s going on with
them?

This might lead into an elaborate discussion of a friend’s antisocial or suicidal behavior,
which may actually be autobiographical.

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Topics to Cover
Often, the trick with adolescents is to get them talking, much less getting them to reveal
personal information. The best strategy is to adopt an attitude of curiosity and respect; a
sense of humor is always a plus.
Most adolescents are interested in music, so this is as good a place to start as any.

Do you like music? Who do you like?

Chances are that you will have never heard of their favorite group. You could respond
with

I have no idea what kind of music that is. Me, I like jazz and, I’m
ashamed to admit, Barry Manilow.

If you’re square and goofy, and most of us over 30 are, admit it. This is disarming to
most adolescents and is better than trying to pose as “cool.”

Asking about School and Other Activities

Other questions that help open up a shut-down adolescent include questions about school,
friends, and interests. Each line of inquiry can also serve as a jumping-off point for
diagnostic questions.

Where do you go to school?

What’s that school like?
Is it fun?
Is it easy?
What are the other kids like there?
Who do you hang out with?

After asking these nonthreatening questions, ask about grades. If his grades are low or if
he looks disappointed in his grades, follow up with

Is that the same as you’ve always done, or have your grades changed
recently?

A change in grades may signal the onset of depression or involvement with substance
abuse. You might also ask

Are there any particular subjects that are hard?

The DSM-5 classifies learning disorders under the traditional categories of reading,
writing, and arithmetic, and you can pick up a hint of a learning disorder by asking this

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question. However, children are usually diagnosed with a learning disability long before
their teenage years.

What do you do with your time after school?

Are you involved in any extracurricular activities, like sports or clubs?
What do you enjoy doing the most?

Besides being good questions for opening up your patient and establishing rapport,
these are good screening questions for depression. Withdrawal from social activities is a
common feature of teenage depression. Conversely, the patient who expresses clear interest
and excitement in any activity is less likely to be depressed.

How many hours of TV do you watch on the average school night?

How many hours do you spend on the computer?

This gives another indication of how socially involved your patient is.

Asking about Drugs and Alcohol

Using the techniques discussed in Chapter 4 is helpful in communicating a nonjudgmental
attitude when asking about drug use. Thus, you can use normalization:

I hear there’s a lot of drinking and drug use at your school. Do you
know anyone who uses drugs?
You read in the paper that 90% of kids use drugs these days. Do you
ever use drugs?

or symptom expectation:

How often do you have a drink?

What drugs do you use?

Other patients respond quite well to a direct query:

Do you drink or use drugs?

Asking about Sex

Although asking about sex is important when interviewing adolescents, use judgment and
common sense in determining when such questions are appropriate. If your rapport is
shaky, you may want to delay such questions for follow-up visits, or you may decide not to
raise the questions at all. It’s vitally important that any questions about sex not be seen by
your patient as idle or lurid interest, but rather that they are seen as an essential component
of your psychiatric evaluation. A sexual history is important for a variety of psychiatric and
medical issues, including assessing risk for AIDS, discovering a history of sexual abuse, and

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assessing the presence of sexual acting-out as a symptom of depression, mania, substance
abuse, or other disorder.
A good way to approach this uncomfortable topic is to begin talking about “romance”
rather than “sex.”

Do you have any romantic relationships?

How long have you been seeing this person?
What’s his/her name?
What do you like about_____?

Now that you’ve given a human face to the relationship, you can introduce the topic of
sex:

Would you feel comfortable if we talked about your sex life?

Are you sexually active?
Are you using protection?
Do you know about AIDS?
Do you ever do things sexually that you later regret, like not using
protection or having sex with people you don’t know very well?

You can also approach sexuality by embedding it in a list of health-related questions:

I want to ask a few questions about your health:

Do you get headaches?
Stomachaches?
Do you have sexual problems?
Are you sexually active?
Do you smoke?
Do you use drugs or alcohol?

If it seems appropriate, ask about sexual orientation:

Have you ever wondered whether your sexual feelings are normal?
Do you ever think that your feelings about sex are different from
other kids’ feelings?

Note that neither of these questions uses terms such as sexual orientation and sexual
identity, either of which may confuse or alienate adolescents.

Asking about Conduct Problems

Conduct disorder and oppositional defiant disorder are common reasons for referral, and
you’ll often be faced with the task of getting patients to admit to illegal behavior. Usually,
the parents will have disclosed such behavior during the family meeting. A good way to
begin a private interview in such circumstances is as follows:

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 It looks like your mom feels there’s been a lot of stealing (or whatever
alleged behavior), and I have no way of knowing if it’s true, but if
you were stealing, I’m sure there was a good reason for it. Maybe it
was the only way you could get something? Or maybe your friends
challenged you to do it?

or, more simply,

Do you know what your parents are saying about what you’ve been
doing?

If the rapport is good, and you don’t mind using some humor, use the “inducing to
brag” approach:

So, I hear you’re an excellent thief. What’s the best thing you’ve
stolen?

Remember that you aren’t asking these questions just to get your patient to confess to
bad behaviors; rather, you’re primarily interested in finding out why he does these things. Is
it peer pressure? A way of expressing anger toward his parents? A symptom of a manic
episode? Follow up on an admission of antisocial behaviors with questions designed to
address these topics.

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 11 Interviewing Family Members and
Other Informants

Essential Concepts
Try to have some contact with informants as part of all your initial evaluations.
Develop an efficient approach to asking informants questions about your patient.
Be prepared to provide basic psychoeducation to informants.

Interviewing a patient’s informants—that is, their family members, friends, coworkers, etc.
—is such a crucial part of many psychiatric evaluations that some clinicians will not see
patients unless they agree to an informant meeting at some point during the treatment. In
my experience, it is not always necessary, but when I have bothered to make it happen, it
has always added something of value to my understanding of patients.
Before getting into specific suggestions, I have found it useful to think about the
following three goals for interacting with family members and other informants:
1. Let the family know they are not alone.
2. Provide support and allow informants to vent.
3. Instill hope for change (adapted from Mueser and Glynn 1999).

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How to Broach the Issue of Talking to Informants
I usually ask something like:
“As part of my evaluation of patients, I find it helpful to talk to someone else involved
in your life. Would that be okay with you?”
Most patients will agree to this and will typically be impressed that you care enough to
go that extra mile in conducting your evaluation. Assuming they agree, you should figure
out who would be the best person to talk to—a parent, a significant other, a roommate, a
friend, etc.
Sometimes patients will decline having an informant become part of the treatment,
which is certainly their right. But it’s helpful to find out the root of their discomfort. At
times, it may be that there is something they want to hide from you, such as drug use or
other behaviors at odds with their recovery. But other times, the reasons are
understandable.

CLINICAL VIGNETTE

I had seen a man in his 30s for a couple of years for depression, which had gradually
improved with treatment, but he continued to complain of not feeling very fulfilled with
his life, and he qualified for the diagnosis of dysthymia. He acknowledged that one of the
major issues in his life was the fact that his wife wanted to have more children but he
didn’t. Several times, I had encouraged him to bring his wife into a meeting—not for
couples therapy, but in order to better understand the nature of their relationship so that I
could help him in therapy. He eventually said that she would be able to attend our next
session. But he came alone.
“Where’s your wife?” I asked, surprised.
“I thought a lot about it, and I agreed that it might be helpful for her to come in to the
session. But then I realized that this is my time with you.”
Ultimately, my ready acceptance of his decision strengthened our alliance and improved
the quality of our therapy.

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Be Ready with a List of Questions
Your patient has shown up with his mother as you requested. What kinds of questions are
you going to ask? You may feel that the pressure is on, since this may be the only time you
will have to interview the informant. Therefore, it’s best to be ready with a list of questions.
As with interviewing patients, when interviewing families, you’ll want to start with an
open-ended approach and then drill down to specific questions.
I’ll often start by asking, “How do you think Nancy has been doing?” Some informants
will arrive brimming with a wealth of specific and useful information, but others might
answer more sparsely, with something like, “She’s been okay. Sometimes she gets nerved
up, but then she takes her happy pills and seems better.”
In this case, the informant is not speaking your clinical language and needs education
about the specific kind of information you are looking for.
Murray-Swank et al. recommend the following series of questions for informant
interviews:
1. “What do you think has caused [name] to have these problems?”
2. “Has anybody ever given you a diagnosis for his/her problems?” (If they have been told
of a diagnosis, it is useful to follow up with a question such as “What is your
understanding of what that diagnosis means?”)
3. “Are there things that make things better for [name]?”
4. “Are there things that make things worse?”
These kinds of questions allow you to teach the informant the kind of vocabulary that
you will find most useful in tracking your patient’s progress.
Going back to our case of nerved-up Nancy, you might say, “I think when you said
that Nancy gets ‘nerved up,’ she is having what we think of as a panic attack, and that the
‘happy pill’ is Ativan, an anxiety medicine that helps her get over her panic problem.” This
type of psychoeducation may ultimately help your patient understand when to use her
medication appropriately because it puts her and her informant on the same page.
Specific pieces of information that you might want to obtain (depending on the
specific problem) include the following:

Suicidality
Violence
Ability to function day to day
Do they go to work?
Do they do anything, or just sit on the couch all day long?
Do they sleep?
What do they eat?
Are they concentrating OK?
Have they always been this way, or is this a recent change?

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 Another way to help you organize your questioning is to try to ascertain the typical day
in the life of your patient.
“Mrs. Smith, when I see your husband, it is only for about a half hour every month or
so—I see only a tiny slice of his life. I’d like to know more. Beginning with when he wakes
up in the morning, what is a typical day like in your husband’s life?”

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What to Do When an Informant is Confrontational
Sometimes, when a family member pops in, they are doing so because they are not
particularly happy with how the patient is doing and they may be wondering if you are
competent. If I sense this is true, I will meet the issue head-on.
“How do you think I’ve been doing with Nancy? Do you think I’ve been helping her at
all? Am I the best doctor for her? Do you have any ideas for how I might be able to help her
more?”
Obviously, you are not necessarily asking for a medication consultation from a
layperson, but you’d be surprised what comes out. In one situation, I had treated a woman
with a series of antidepressants. She was currently on Celexa, and I thought she was doing
reasonably well on it. When her husband came to a session, it was clear that he was
dissatisfied with her treatment.
“I don’t think she’s doing very well on this medicine,” he said. “My sister is taking Paxil
and she’s doing great.”
I had no problem with Paxil—to me, it was just one of a dozen or so equally effective
antidepressants, but psychologically, it appeared to be what both the husband and my
patient wanted, so I prescribed it, and the patient did well—no doubt with a large placebo
component at play.

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When an Informant is “Antimedication”
Occasionally, a patient will tell me that a family member disapproves of medication
treatment. If I believe that the medication is effective and necessary, I will strongly
encourage an informant meeting. Sometimes, I will simply pick up the phone then and
there, with the patient’s permission.
At times, the informant is responding to sensationalized media reports of the dangers of
psychiatric drugs, and a short meeting will help set his or her mind at ease. Other times, the
informant is adamant that medications are the wrong approach, and if I feel that the
patient is stable and might do well with a trial off meds, I’ll readily agree to a gradual taper.
In my experience, in the majority of such cases, both the patient and the informant return
to my office within several months to request a medication resumption—but that is not
always the case.
Sometimes, it may seem that an informant is “antimed,” when in fact he or she is anti-
ineffective med.
For example, one patient with bipolar disorder had literally been on every psychiatric
medication that I knew of over the course of his life—I was the latest in a long line of
psychiatrists. The mother, supposedly antimedication, came in and said, “I’m tired of Jack
being a guinea pig. You doctors keep putting him on all these medications, and I think they
make him really tired.”
I asked her if any medication had worked for him. “The only medication that really
works for him is lithium.” Paradoxically, I had discontinued lithium several months earlier.
So the informant who was billed as “antimed” ended up convincing me to put the patient
back on a medication with a pretty hefty side effect burden, but it ended up being relatively
effective.

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What Do Informants Want Information About?
In my experience, informants frequently come into a meeting with one or more of the
following underlying thoughts and worries.

Are you going to screw around with the medications that have kept my loved one
stable?
Are you going to blame me for the patient’s problems?
Are you going to give me a bunch of new responsibilities?
Are you a competent doctor?
Are you going to be evaluating my mental health?
Is this couples or family therapy?

There’s no specific answer to each of these concerns, but it’s helpful to review this list
before you meet with an informant. During your conversation, you may well pick up on
one of these possible concerns and then you can address it.

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How to Deal with Privacy Issues in the Age of
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA) actually gives you more,
not less, latitude in sharing patient information with other health care providers. Once your
patient signs a HIPAA form, you are allowed to talk to therapists or other doctors without
getting specific permission each time. However, HIPAA does not allow you to talk to
family members without consent. The exception is when the patient’s life is in danger.
What happens when a family member calls you? Can you talk to them? Yes, you can, as
long as you are a recipient of information only. But they often have the misconception that
they can’t talk to you at all without a signed release. When an informant calls, I say, “I can
listen to anything you have to say, but I won’t be able to share anything your wife has told
me without her consent.”
I try to get the informant’s agreement that I can tell the patient about the phone call
and about the information I received. Sometimes, the informant is scared of the patient’s
possible reactions. A typical scenario is a wife calling about a husband who I am treating
individually. The wife tells me that her husband had been drinking more and becoming
verbally abusive. She may be terrified that if I share this phone call with the husband, he
will become more abusive toward her. Obviously, if you believe that the informant is in
imminent danger from your patient, you are duty bound to intervene, regardless of consent
forms. But in most cases, these are judgment calls. If I feel that the information is so crucial
that it will affect treatment (such as the revelation that a patient is a drug abuser), I may
sometimes insist that the informant agrees to be named, because in my experience the
patient figures out where I got the information pretty quickly.

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Inpatient Work
Dealing with informants when you are doing inpatient work carries its own challenges and
therefore merits a separate section of this chapter. Here is a typical inpatient informant
scenario:
It’s 10 a.m., and you have been scurrying around the unit trying to get your work done
quickly, because you have to be at the outpatient clinic by 1 p.m. You look at your index
card, and there are eight patients on your list. You have to talk with each one, meet with
nurses and social workers, and write a note.
Robert Jones is next. A 23-year-old, he was admitted to the hospital 3 days ago after an
apparent suicide attempt by overdose. But after having evaluated him, you feel certain that
he is not truly suicidal. You found out that his “overdose” was on fifteen 1-mg pills of
Klonopin—hardly enough to do much damage, especially considering that his normal
prescription was 3 mg per day. The “overdose” came immediately after a telephone call
with his ex-girlfriend during which she refused to consider renewing their relationship.
Distraught, he took the pills and then immediately called both his father and 911. Within
10 minutes, he was in the local emergency room, from where he was admitted to the
psychiatric unit. Over the course of the past 3 days, you and the rest of your team have
determined that he was not suicidal and developed an outpatient treatment plan involving a
referral to a local clinic that better integrates psychotherapy and psychopharmacological
treatment.
Today, you walk into his room to say your goodbyes and to make sure that he
understands his discharge plan. But you are surprised to see three people in the room, who
turn out to be his two parents and his sister. The first question from the father is, “Are you
really discharging him? After only 3 days? He just tried to kill himself!”
What do you do? A long meeting will throw your schedule off—but clearly, the family
deserves to have some significant contact with their loved one’s psychiatrist. Although from
your perspective, this patient is one of a long list of people you must help, for the family
there is only one person on their list—their loved one. Empathizing with the family will go
a long way toward helping you do the right thing.
The wrong way to respond would be: “I’m sorry, but I don’t have time for a meeting
right now—but I can set up a time for you to speak with the social worker or one of the
nurses.” To the family, the underlying message is, “I don’t really care,” or “I don’t have
time for you,” or “Your loved one’s issues are not important enough to require my time.”
Instead, no matter how hurried you feel, take a deep breath, smile, and say, “I’m really
glad we are having a chance to meet.” Make sure to find a place to sit down, because
nothing says “rushed” more than a meeting while standing. Next, explain your time
constraints apologetically. “I wish we had a good hour to talk about Robert, but today
unfortunately, I can only meet for about 10 minutes. I’m really sorry about this, but I also
think we can get a lot done to help you understand what’s going on with Robert in those
10 minutes. And if you have any other questions, I’ll arrange for you to meet with our

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social worker.”

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Psychoeducation
What are you realistically going to be able to accomplish in those measly 10 minutes?
Primarily, you are going to be educating the family about the purposes and the limitations
of inpatient psychiatric treatment. Families often think that psychiatric hospitalizations are
meant to provide a definitive “answer” to a problem that has been going on for years. They
may expect that you will come up with the perfect medication and that you will fix a wide
range of problems, such as family dynamics issues, work problems, social problems, or
school problems. If so, they need you to educate them about the realities of inpatient
admissions:
“In the past, hospitalizations went on for a long time, sometimes many months. But
these days, they are brief, and our goal is to solve the immediate crisis and to make sure
patients are safe before they leave. We also work hard on setting up a good outpatient
program, because that is where the work of healing takes place—over the long term, out in
the real world.”
Some clinicians will also mention that ever-present big white elephant in the room—
the insurance company: “Unfortunately, insurance companies will no longer pay for
admissions longer than a few days, unless the patient will be clearly unsafe if discharged.”
This is a card you don’t want to play too much, however, because the family may get
the message that you are discharging the patient prematurely because you are not getting
paid.

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Learning from the Family
Psychoeducation is a two-way street. What kinds of questions are most crucial for you to
ask of family during an inpatient admission? Well, since this is a major crisis, you’ll want to
focus on immediate triggers and safety concerns.
“It’s important that I understand the events leading up to Suzie’s admission here. I’d
really like to hear your perspective on how things have been going.”
Often, the family will give you a very different account from the impression you may
have received from interviewing the patient.

CLINICAL VIGNETTE

A 50-year-old woman was admitted after having walked into the emergency room saying
that she wanted to die. She said she believed her husband didn’t love her anymore and
suspected he was seeing another woman. The psychiatrist held a meeting with the husband
and the patient’s grown daughter the next morning.

Interviewer: Vicki tells me she’s been concerned about your relationship.

Husband: (Looking confused). What do you mean “concerned”?
Interviewer: She told me that you have been distant, spending nights out, and maybe seeing
someone else.

The husband and the daughter looked bewildered and shook their heads.

Husband: I haven’t gone out at night without Vicki since last winter, when I went to a work
Christmas party that she didn’t want to go to. We’re basically joined at the hip.
Interviewer: So what had been happening in the few days before she came to the ER?
Daughter: Mom has been saying strange things. She’s been worried about everything. We went
to the mall together and she wouldn’t go into any of the stores. She said they were dangerous
and that there was a “code orange” and there might be terrorists planting bombs in the
store.

On further evaluation, it turned out that the patient was suffering a psychotic
depression with the paranoid delusion that her husband had been sleeping with a terrorist.
In sum, whether you are evaluating patients in an office setting or in the hospital, do
not neglect one of your most valuable resources—the people who know your patients the
best.

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 12 Techniques for Other Challenging
Situations

Essential Concepts
The hostile patient
The seductive patient
The tearful patient

Be firm, fair, and understanding. Hold the reins in one hand and a
lump of sugar in the other.
Elvin Semrad

The Heart of a Therapist

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The Hostile Patient
When a patient becomes hostile during an initial interview, remember that it’s not your
fault. Unless you’re laughably incompetent or a real creep, a hostile attack is a product of
the patient’s pathology. Common causes of patient anger during the first meeting include
paranoid psychosis, irritability due to depression or mania, and borderline personality
disorder. The best way to defuse hostility is to diagnose its cause and then target your
intervention accordingly.

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The Hostile, Paranoid Patient
The hostile, paranoid patient is angry at you because he perceives you as a direct threat or
perhaps as part of an elaborate conspiracy. A good way to counteract this false projection is
to use self-effacing humor or general goofiness, which is easier to pull off. The patient
usually perceives this attitude as inconsistent with evil intentions.

CLINICAL VIGNETTE

A patient with the diagnosis of bipolar disorder was admitted involuntarily to the inpatient
unit because of paranoia concerning her husband, who she believed was trying to have her
killed. It was clear from the outset of the interview that she thought that she had been
wrongly committed and wanted to leave immediately.

Patient: How can you keep me here? You have no right. I can call a lawyer.
Interviewer: You can certainly call a lawyer. The reason we…
Patient: (Interrupting) I can call a lawyer, but it’s not going to do any good, is it? All the
lawyers are part of a big game, and they’re going to say just what you want them to say.
Interviewer: What kind of game do you think this is? Last I checked, this was just a psychiatric
hospital.
Patient: You know exactly what’s going on here, and wipe that innocent look off your face.
Interviewer: I’m not innocent. I plead guilty to being a psychiatrist. I’m trying to help you.
And if you believe that, I have a bridge in Brooklyn you might be interested in.
Patient: What bridge?
Interviewer: Oh that’s just an old joke, and a bad one. I find that I have to use humor to keep
me sane here, you know? But enough about me. What were we talking about?
Patient: The people who are trying to have me killed.

At this point, the patient opened up significantly, and a productive conversation

ensued. The attempt at humor was unexpected enough to derail an increasingly hostile
train of thought.

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The Irritable, Depressed Patient
Depressed patients can come across as hostile, but it is a hostility that cloaks a reservoir of
pain. A good technique is to make a fairly direct interpretation, such as

You sound angry, but I think there’s some sadness underneath that
anger.
I can understand how you would be angry with me, but I wonder if
there isn’t something beneath the anger that’s eating at you?

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The Patient with Borderline Personality Disorder
Like the irritable, depressed patient, the borderline patient’s anger overlies pain. Because of
immature coping skills, the patient cannot “sit” with her pain and rationally problem-solve.
Instead, she tends to project and externalize, resulting in lashing out that can be quite
uncomfortable for you. It isn’t easy to maintain your composure during these times, but it
helps if you can see the anger as a crisis of aloneness. Be compassionate, and fight against
the natural tendency to either fight back or to withdraw into a protective shell of aloofness.
Defensiveness will only rile your patient further, and aloofness will deepen her sense of
abandonment.
Instead, be curious, interested, and caring. Effective statements for patients with
borderline personality disorder often include the following:

For the sake of our discussion, what do you think just happened?
You’re very angry at me, and I’m wondering what that anger is
about.
I’ve done (or said) something that upset you, and I hope to
understand what that is so that we can put it behind us and move on
with the important work we have to do to help you feel better.

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The Seductive Patient
Although seductive behavior often does not become apparent until follow-up sessions, it is
helpful to have some idea of how best to respond to overtly seductive behavior. To begin
with, renew your own absolute commitment never to become sexually involved with your
patients. Aside from breaking professional ethical codes, it is always destructive, to both
your patient and yourself. Any practitioner who often finds himself tempted to breach this
boundary should obtain therapy or supervision or find another career.
This is not to say that you will never have sexual feelings toward your patients. Of
course you will, but if your commitment never to act on such feelings is absolute, you can
manage these feelings while continuing to deliver excellent care.
Seductive behavior comes in two guises, subtle and blatant. Subtle behavior includes
significant glances, revealing clothes, and excessive curiosity about the interviewer’s personal
life. Such subtle behavior can be managed in several ways:

Keep the trappings of the therapeutic relationship relatively formal.

Use the patient’s title and last name.
Keep the interview focused on the presenting symptoms.
Avoid small talk.

Deflect requests for personal information with statements such as “The purpose of this
interview is for us to get a better understanding of what’s been troubling you, and I really
think that should be the focus.”
Blatant seductive behavior involves more direct questions about the interviewer’s
availability and requests to be touched or hugged by the therapist or to spend some time
outside of the treatment session with her. These behaviors require a direct and
unambiguous response that makes it clear that such contact is inappropriate and impossible
and explains why. The following vignette illustrates this type of situation.

CLINICAL VIGNETTE

The patient is a woman in her 30s who is in the process of divorcing her husband. She has
scheduled a diagnostic interview to evaluate her depression. The interviewer is a married
man also in his 30s. The vignette begins toward the end of the interview, and the clinician
has already recommended an antidepressant.

Interviewer: I also think it would be helpful for you to see a therapist.

Patient: Can’t you be my therapist?
Interviewer: No, I’m a psychopharmacologist, and I schedule brief follow-up visits to check on
how well the medication is working.
Patient: But I like you.

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 Interviewer: (Beginning to sense a hint of seductiveness) That’s good, because I’ll continue to
monitor your medication, but I think you’d benefit from seeing a therapist for more
frequent sessions.
Patient: (Smiling seductively) What I’d really like is to meet someone who could be both my
therapist and my lover.
Interviewer: Wait a minute. Let’s back up a little. It’s very destructive for therapists or
psychiatrists to have anything other than a professional relationship with their patients.
That will never happen during our treatment, nor will it happen with any therapist you
might see. From what you’ve told me today, I can see you’ve been feeling lonely, and I think
it would be good for you to work on building up friendships, but that will have to happen
outside of treatment sessions.

The patient eventually accepted a therapy referral and continued in treatment without
overt seductiveness.

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The Tearful Patient
Many patients cry during the initial appointment, and as a beginning clinician, you may
feel at a loss when this happens. You will typically feel your own share of emotions in such
situations, which may range from poignant empathy to anxious discomfort. You will
probably instinctively want to behave as you would when a close friend or family member
cries in front of you, which may include a pat or a hug and comforting words. That is
usually a mistake in a professional relationship. So what should you do?
The proper approach will vary from patient to patient. When a patient cries, try to
understand the meaning of the tears, which is not always obvious. For example, the patient
who cries while describing a recent marital separation may be crying for several reasons,
including a feeling of abandonment, a fear of future financial hardship, a sense of personal
failure, and a relief that the relationship is over.
When a patient becomes tearful, I recommend offering some tissues, which should
always be in your office, waiting empathetically for a few seconds, and then asking any of
the following questions:

What is it about what you are saying that is so painful?

I can see you’re feeling emotional now; what are your tears about?
What’s on your mind now as you’re crying?

It’s also helpful to ask about the frequency of crying:

Have you been crying a lot about this?

It’s quite common for patients to say they have not cried until that very moment,
which is usually a validation of your interviewing skills.
If a patient expresses some shame or embarrassment about crying, make a validating
statement such as

Crying can be a good release.

Go ahead and cry as much as you need to. It’s good that you feel
comfortable enough here that you’re allowing yourself to cry.
Crying is a big part of the healing process.

Of course, lest I leave you with the impression that crying is a wonderful thing, I
should remind you that tears indicate intense emotional pain and should prompt you to be
especially vigilant for SI (see Chapter 22).

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 13 Practical Psychodynamics in the
Diagnostic Interview

Essential Concepts
Assess your patient’s degree of reality distortion.
Detect negative transference and move beyond it.
Identify defense mechanisms and coping responses.
Use your countertransference diagnostically.

It might be said of psychoanalysis that if you give it your little finger

it will soon have your whole hand.
Sigmund Freud

Keeping an ear open for psychodynamic material can help you in a number of ways as you
conduct your diagnostic interviews. First, you can increase the accuracy of your diagnosis,
because symptoms are often the product of life circumstances and dysfunctional ways of
responding to them. Psychodynamics provides the preeminent language for describing
defense mechanisms, and it also helps you understand how to use countertransference
toward patients productively. Second, understanding psychodynamic principles will help
you manage the interview itself, especially if your patient has negative transference toward
you. Finally, understanding defense mechanisms will help you to diagnose personality
disorders, which are covered in more detail in Chapter 31.

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Reality Distortion
Reality distortion is often the first clue that significant psychodynamic factors may be at
work in your patient’s psychology. Psychosis is the extreme of reality distortion, but many
nonpsychotic patients distort reality as well. Examples include the depressed woman who
unfairly castigates herself for being the cause of all misfortune in her family, the narcissist
who tells you that all his past therapists have been substandard and therefore unhelpful, and
the alcoholic who says her husband is being ridiculous in criticizing her drinking habits.
Often, reality distortions will jump out at you over the course of the interview.
Occasionally, you’ll need to dig for them. In Chapter 27, I suggest some screening
questions to elicit the presence of the delusions. In these patients, however, we’re not
talking about frank delusions; we’re talking about milder distortions. The way to elicit
distortions is to be curious about how your patients interpret the motivations of others or
how they make sense of events overall.

CLINICAL VIGNETTE

The patient is a 25-year-old woman with a history of panic disorder with agoraphobia and
comorbid alcohol abuse. She recently terminated visits to her last psychiatrist because he
refused to prescribe benzodiazepines for her anxiety disorder.

Patient: Dr. X said, “Absolutely not. I won’t give you any Xanax.”
Interviewer: What do you think was on his mind when he said that? (You are probing for her
world view.)
Patient: To tell you the truth, I have no idea. Maybe that’s his rule.
Interviewer: What sort of rule do you mean?
Patient: Maybe he never prescribes those kinds of drugs for people like me.
Interviewer: People like you?
Patient: People with anxiety; people who really need them.
Interviewer: Why wouldn’t he prescribe meds to people who need them?
Patient: Who knows. He’s probably burned out. Most shrinks are.

The patient presents a jaded view of psychiatrists, possibly reflecting a more general
view of the world as uncaring. Alternatively, her statements may reflect the defense
mechanism of projection, in which the patient disavows her own anger at being deprived of
an addictive drug and projects it onto her psychiatrist, who then appears sadistic to her
because he doesn’t prescribe medications to people who need them. Whatever the nature of
her distortions, you can be certain that you will not be exempt from them, and you can
begin to prepare your own strategy to prevent future struggles. This might include making
statements that demonstrate an understanding of her world view:

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 As I listen to you, it sounds like you’ve gotten the short end of the stick
over and over again in life. I wouldn’t be surprised if you’re assuming
that it’s going to be the same way here, too.

Once you detect a reality distortion, determine whether defense mechanisms or

transference is at work.

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Negative Transference
Whenever two people meet there are really six people present. There is
each man as he sees himself, each man as the other person sees him,
and each man as he really is.
William James

In transference, your patient unconsciously reenacts a past relationship and transfers it

to a present relationship; this doesn’t necessarily pose a problem in the initial interview.
Your patient may have a positive transference toward you, in which you remind him of
someone he admired, like his mother, causing him to automatically ascribe to you all kinds
of wonderful qualities. Sit back and enjoy it.
Negative transference, however, can be problematic, especially when it involves anger.
Your patient may have been poorly treated by people throughout his life, and he expects
you to be no different. Look for negative transference when there is a sense of tension.
Perhaps your patient is making angry comments or asking provocative questions. Perhaps
he is giving monosyllabic answers to your questions.
In psychoanalytic psychotherapy, negative transference is actually elicited, because its
interpretation is the backbone of treatment. In the diagnostic interview, however, negative
transference is usually counterproductive, and the best way to deal with it is to recognize it
and make an empathic comment that neutralizes it. Although there’s no easy way of
learning how to make these comments—other than practice, practice, and more practice—
the following list contains some common statements (in italics) made by patients during
diagnostic interviews. Most of these statements reflect negative transference or a defense
mechanism of some sort. All of these statements tend to throw novice interviewers for a
loop.
Possible hidden meanings are listed after each patient statement; the emphasis is on
possible. Sometimes, such statements have no hidden meaning and are a statement of fact.
For example, you may look bored during an interview and, in fact, feel bored. If the patient
is making an accurate observation, don’t try to interpret the comment. That is dishonest
and unfair to your patient. In addition, the hidden meanings I’ve listed are illustrative only.
They don’t imply that all patients making such a statement actually mean what I suggest.
You should interpret each statement individually, based on your knowledge of the
particular patient.
In general, the possible responses are ways of moving beyond the negative statement, so
that the work of the diagnostic interview can proceed. Note that this is a very different
approach from what you would do if you were engaged in psychodynamic therapy.

You’re not a very helpful doctor.

Possible hidden meaning: No one has ever cared for me, and you’re no exception.

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Possible response (while nodding empathically): “You know, that’s not the first time I’ve
heard that, and when I’m not being helpful to a patient I always ask, ‘How can I be more
helpful? Because I really do want to help.’” (This communicates that you really do care and
implies that the therapeutic alliance won’t be damaged by your patient’s comment, but may
actually be strengthened by it.)
Possible hidden meaning: I’m a very special patient, and you should treat me unusually well.
Possible response: “I bet it feels disappointing to have a doctor who doesn’t come up to snuff. Is
it possible, though, that you’re judging prematurely?” (Empathize with the patient’s injured
sense of specialness, while giving him an out to repair the relationship.)

You look bored.

Possible hidden meaning: Of course you are bored; I’m such a boring person.
Possible response: “I’m actually not at all bored, but do you think that the things you’re saying
are boring?”
Possible hidden meaning: I expect you to respond lovingly and immediately to everything I say;
if you are silent, I have to assume that you’re feeling something negative toward me.
Possible response: “In my profession, silence rarely means boredom. It usually means
concentration and interest.”

Is that all you’re going to do, just sit there silently and nod?

Possible hidden meaning: You’re just like my parents, who never expressed any kind of interest
in me, who never responded to anything I said.
Possible response: “Does that seem unhelpful? I actually have a lot to say, but I always try to
bite my tongue so that my patients get a chance to tell their whole story. I usually find that
I’m most helpful to patients only after I’ve really listened to them and understood them
well.”

What kind of credentials do you have?

Possible hidden meaning: I’m in a lot of pain, and I’m not certain whether you or anybody
else can help me.
Possible response: (Begin by stating your credentials quickly.) “I’m_____ (e.g., an intern, a
resident) at_____ (i.e., name of school or hospital). Are you concerned about my ability to
help you?”
Possible hidden meaning: I’ve been made to feel ineffectual all my life, and I want you to get a
taste of what that feels like. (This is an example of an immature defense mechanism known
as projective identification.)
Possible response: (State your credentials.) “But my main credential is that I’m here with you;
I want to understand you and to help you as best I can.” (By this, you demonstrate that self-
esteem does not depend on getting someone else to say you are effectual.)

You don’t show much understanding of what I’m saying.

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Possible hidden meaning: I’m angry at you for not understanding me implicitly and fully
without my having to be explicit. I want you to be the perfectly empathic parent I never
had.
Possible response: “You know, I couldn’t agree more. It is so hard for one person to really
understand another person. But why don’t we talk some more, and I’ll give it my best shot.”

Are you married?

Possible hidden meaning: I wish I were married to you.

Another possible hidden meaning: I’ll bet you are married, and that you have a wonderful
spouse, proving how much better you are than I am and what a loser I am.
Possible response (with a smile): “Wait a minute! I thought I was the one who’s supposed to be
asking the questions here.”
Another possible response: “You know what? I’ve found that when I start answering questions
about my personal life, it can get in the way of my understanding you better, and isn’t that
the whole point of our hour together?”

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Defense Mechanisms and Coping Responses
When uncomfortable and unpleasant emotions arise, we all have ways of lessening the
brunt of them. We use defense mechanisms. The classifications in Table 13.1 are adapted
from Vaillant’s (1988) hierarchy of defense mechanisms.

TABLE 13.1. Classification of Defense Mechanisms

Adapted from Vaillant, G. E. (1988). Defense mechanisms. In A. M. Nicholi, Jr. (Ed.), The New Harvard Guide to
Psychiatry (p. 81). Cambridge, MA: Harvard University Press.

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Main Defense Mechanisms
Following are brief definitions and examples of the different defense mechanisms. The
examples included here are various ways that a patient might react if, in this instance, her
husband left her.

Mature Defenses
Mature defenses usually arise from, and lead to, psychological health rather than from
dysfunction.

Suppression
Definition: Emotion remains conscious but is suppressed.
Example: I’m disappointed and sad, but I won’t let these emotions interfere
significantly with my life.

Altruism
Definition: Suppressing the emotion by doing something nice for others.
Example: I’ll volunteer at a women’s shelter.

Sublimation
Definition: Transmuting the emotion into a productive and socially redeeming
endeavor.
Example: I’ll start immediately on a book about how to cope with rejection.

Humor
Definition: Expressing the emotion in an indirect and humorous way.
Example: This is great! I’ve been trying for years to get rid of 180 pounds of ugly fat.

Neurotic (Transitional) Defenses

Neurotic defenses are less healthy than mature defenses because they tend to cause
psychological distress either immediately, as with repression or displacement, or in the
future, when the actual pain eventually surfaces.

Denial

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 Definition: Denying that the emotion exists.
Example: The rejection doesn’t bother me at all.

Repression
Definition: Stuffing the emotion out of conscious awareness. (Unfortunately, the
emotion typically returns to haunt the repressor in unpredictable ways.)
Example: I didn’t feel at all bad about his leaving me, but for the past few weeks, I’ve
had this splitting headache, and I don’t know why.

Reaction Formation
Definition: Forgetting the negative emotion by transforming it into its opposite.
Example: We’ve become such close friends since this happened. He is really a
wonderful person.

Displacement
Definition: Displacing the emotion from its original object to something or someone
else.
Example: My boss has really been getting under my skin lately.

Rationalization
Definition: Inventing a convincing, but usually false, reason why you are not
bothered.
Example: I’ve been wanting to make some major life changes anyway. This finally
gave me the boost I needed to do all the things I’ve been wanting to do.

Immature Defenses
Immature defenses lead to more severe distress and often have a negative impact on other
people.

Passive Aggression
Definition: Expressing anger indirectly and passively.
Example: Oh, I’m sorry, dear. I gave all your clothes to the Salvation Army last week.
I didn’t realize you wanted them.

Acting Out
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 Definition: Expressing the emotion in actions rather than keeping it in awareness.
Example: (The patient makes harassing, late-night phone calls.)

Dissociation
Definition: Dissociating instead of feeling the pain.
Example: I was really spaced out all of last week; my memory of him leaving me is
very hazy.

Projection
Definition: Disavowing the anger and ascribing it to the object of the anger.
Example: I’m convinced that ever since he left me, he’s been bad-mouthing me to all
our friends.

Splitting (Idealization/Devaluation)
Definition: Defining the rejecting person as being all bad versus having seen him as
all good before the rejection, thereby transforming pain into anger and accusation.
Example: I always knew he was a horrible person, and this proves it. May he rot in
hell.

Psychotic Defenses
Psychotic defenses so completely flaunt external reality that they signal a psychotic thought
process (TP).

Denial of External Reality

Definition is self-explanatory.
Example: He never left me.

Distortion of External Reality

Definition is self-explanatory.
Example: He didn’t leave me! He went off on a business trip. He’ll be back next
week.

In the diagnostic interview, identifying defense mechanisms is useful to quickly sense

whether your patient may have a personality disorder (such patients typically use immature
defenses) and to give you a sense of prognosis (patients who use higher level defenses tend
to do better than others).

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 As you listen to your patient with a psychodynamic ear, ask yourself the following
questions:

How does the patient seem to shelter himself from the psychological pain that he is
sharing with you?
Does he tend to use mature or immature defenses?
Do his defenses tend to bring him out of his misery (mature defenses) or steep him
more deeply in it (neurotic and immature defenses)?
If you were his therapist, which of his defenses would you encourage and which
would you point out to him as unproductive?

At the end of the interview, before you write up the evaluation, you’ll find it helpful to
review the defenses (see the pocket cards in Appendix A) and determine which one(s) the
patient seems to use. Make a habit of spending at least a few moments thinking about the
defenses your patients use. This will help you to better recognize defenses in the future.

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Coping Styles
Coping styles and defense mechanisms are similar concepts. Vaillant (1988) distinguishes
coping responses from defense mechanisms: Coping, he says, “involves eliciting help from
appropriate others” and “voluntary cognitive efforts like information gathering, anticipating
danger, and rehearsing responses to danger” (Vaillant 1988, p. 200). Defense mechanisms,
on the other hand, are involuntary cognitive responses to stressors that usually fit into one
of the categories listed in the prior section.
Think of coping as a series of active behavioral and cognitive responses designed to
overcome a stressful event. You will typically be able to evaluate your patient’s coping styles
by listening to her HPI and hearing how she dealt with the distress. It is not surprising that
the coping responses of many psychiatric patients are not very effective.
How did your patient respond to the main problems described in the HPI? If
depression is the problem, did he cope adaptively, by, for example, contacting friends or
family for support; decreasing his responsibilities for a while; or doing something that he
knew would give him pleasure, such as seeing a movie or going on a vacation? Or did he
cope maladaptively, by isolating himself, by lashing out at people close to him, or through
self-mutilating behavior?
If anxiety is a major problem, did he use positive coping strategies, such as telling
himself the anxiety will pass, taking deep breaths, taking a walk? Or did he use more
negative strategies, such as visiting hospital emergency rooms excessively, using alcohol or
other drugs, or bingeing on sweets?
As with defense mechanisms, seek to encourage positive coping responses and to
discourage negative ones.

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Using Countertransference Diagnostically
Countertransference refers to the whole range of emotions that you may feel toward your
patient, whether positive or negative. Novice interviewers have a tendency to try to suppress
or ignore such feelings, especially when they are negative. Don’t. These countertransference
feelings represent some of the most clinically valuable material available to you. Whatever
feelings your patient elicits in you are feelings she probably elicits in most other people she
encounters in her life. Knowing this can give you powerful insight into the nature of her
problems.

CLINICAL VIGNETTE

A 45-year-old man was admitted to the psychiatric unit for depression and suicidal ideation
(SI). He had recently been fired from his job, and he complained of loneliness, as he had
lost most of his friends over the years. I did the admission interview, and the following
exchange occurred 5 minutes into it.

Interviewer: How long had you been feeling depressed?

Patient: Quite a while. But tell me, aren’t you just a resident?
Interviewer: (Immediately feeling defensive.) Well, yes, I’m the chief resident of the unit.
Patient: (He narrows his eyes.) Chief resident. I see. That’s a pretty political position, isn’t it?
Interviewer: (Increasingly uncomfortable and caught off guard.) No, I wouldn’t say it’s a
particularly political position. I supervise the other residents.
Patient: Yes, but there’s always someone watching over you, isn’t there? If you do well, maybe
you’ll get a nice job in the department. I know how it works. I’d prefer to talk to a full
attending, someone who isn’t always looking over his shoulder.
Interviewer: (Feeling enraged and suppressing the urge to scream at him and kick him out of
the office.) In fact, you will be talking to an attending in the morning, but I do need to
talk to you briefly this afternoon.

The patient agreed to proceed with the interview and answered questions briefly and
disdainfully. On further assessment, a picture of severe narcissistic personality disorder
emerged, and my countertransference reaction made it graphically understandable how he
had managed to alienate all the important people in his life, leading to his current
depression.

The bottom line is that when you feel a negative emotion toward your patient, don’t
act on it. Instead, analyze its possible connection to your patient’s psychopathology.

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II

THE PSYCHIATRIC
HISTORY

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14 Obtaining the History of Present Illness

Essential Questions
What has been happening over the past week or two that has brought you into the
clinic?
Have there been any events that you think have caused your problem or made it
worse?
Have you sought any treatment for this problem?

Recommended time: 10 minutes

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What is the History of Present Illness?
The HPI is probably the most important part of the psychiatric interview, and yet, there is
disagreement on exactly what it should entail. Even experienced clinicians differ in how
they approach the HPI. Some think of it as the “history of present crisis” and focus on the
preceding few weeks. Such clinicians begin their interviews with questions such as, “What
has been going on recently that brings you into the clinic today?” Others begin by eliciting
the entire history of the patient’s primary syndrome: “Tell me about your depression. How
old were you when you first felt depressed?” These clinicians work forward to the present
episode.
Each of these approaches may be useful, depending on the clinical situation. If a patient
has a relatively uncomplicated and brief psychiatric history, it might make sense to explore
that first and then move to the HPI. If the psychiatric history is long, with many
hospitalizations and caregivers, starting at the beginning may bring you too far from the
present problem.
The most common pitfall for beginners is spending too much time on the HPI. It’s
easy to do, because this is the time for your patient to share the most difficult and painful
part of his story, and cutting your patient off as time begins to pass may seem unempathic.
Thus, it is vital that you keep in mind the advice offered in Section I about asking
questions and changing topics sensitively. Use these techniques to gently but persistently
bring the patient back to the HPI.
In the following sections, I describe techniques for the two major approaches to the
HPI; you should decide which to use for a given patient.

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The History of Present Crisis Approach
The American Heritage Dictionary defines crisis as “A crucial point or situation in the course
of anything; a turning point.” As you begin the interview, ask yourself, “Why now? Why is
this a crucial point in this person’s life? What has been happening recently to bring her into
my office?” Often, psychiatric crises occur over a 1- to 4-week period, so focus your initial
questions on this period.

What has been happening over the past week or two that has brought
you into the clinic?
Tell me about some of the stressors you’ve dealt with over the past
couple of weeks.

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History of the Syndrome Approach
Alternatively, you can begin your questioning by ascertaining when the patient first
remembers signs of the illness.

When did you first begin having these kinds of problems?

When was the last time you remember feeling perfectly well?

Ensuing questions track the course of the illness through months or years, arriving
eventually at the present.

Now let’s talk about this current episode. When did it start?

One nice thing about this approach to the HPI is that most case write-ups are
organized in this format—they often begin, “The patient was without any psychiatric
problems until age 18, when she became depressed….”

MAKING THE INTERVIEW ELEGANT, OR THE “BARBARA WALTERS

APPROACH”
At its best, a well-conducted interview resembles a dance in which the give and take
between clinician and patient flow effortlessly throughout the hour, giving the patient the
sense that he just participated in a fascinating conversation about his life rather than a
“psychiatric” interview. One way to set the stage for this type of experience is to begin the
interview by showing genuine interest and curiosity about the patient’s job, hobbies, or life
situation and to allow the patient to steer the discussion toward clinical topics. Imagine that
you are Barbara Walters interviewing a celebrity, bringing that same intense curiosity to
your patient:

Interviewer: I see from your intake sheet that you work for the IRS. What do you do with
them?
Patient: I’m in their call center, but it’s only seasonal.
Interviewer: So when I call the IRS to ask for a form, you might answer?
Patient: Yes, but I do a lot more. I can answer questions about a customer’s return.
Interviewer: Wait, you’re kidding. If I were to call you and ask how much I owed, you’d be
able to pull that information up while I was on the phone?
Patient: Oh yes, we have the whole database available, at least when the computers aren’t
down! It’s really a great job, my first good job, but during the summer I’m usually laid off,
and I don’t know why (patient appears dejected).
Interviewer: That’s too bad, why do they lay you off? (The patient begins to describe difficulties

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leading up to her current depression.)

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Elicit a Chronologic Narrative, Emphasizing
Precipitants
Many patients automatically jump into a chronologic narrative of their problems when
prompted by one of the preceding questions. If this happens, it is a time to fall silent for a
while and listen. Remember, this is your “scouting period” (see Chapter 3), during which
you are observing, listening, and hypothesizing. However, if your patient begins to jump
around into other issues or time frames, you may want to refocus him.

Patient: I felt so angry when my wife yelled at me. But she’s always been that way. Back when
I was in law school, she nagged at me constantly. I’d have to spend late nights at the law
library, and she refused to understand.
Interviewer: I’d like to hear more about that period later, but right now let’s focus on what’s
been happening over the last 2 weeks or so. You said you got angry at her. What happened
then?

Ask the patient specifically about potential precipitants for her suffering:

Have there been any events that have caused your problem or made it
worse?

Occasionally, the patient will deny any precipitants. This is particularly true of patients
who view their psychiatric illness from a medical model. Such a patient might answer the
question above with

No, I can’t think of anything that’s causing it. My life is going pretty
well; I just keep getting these depressions.

Certainly, some psychiatric illnesses, such as bipolar disorder, can have lives of their own,
but it’s unusual for patients to decompensate without some precipitant. Often, patients
haven’t associated particular events with their pain and simply need their memories jogged.
Make it a practice to dig by asking about specific events that commonly destabilize patients
(Table 14.1). You won’t necessarily ask about every item on this list, of course. You may
already have some clues from an earlier part of the interview that one of these events is
particularly likely. As you ask these questions, remember that correlation does not equal
causality. A stressful psychosocial event may have occurred around the time of a psychiatric
problem and yet be unrelated to it.

TABLE 14.1. Common Precipitants of Psychiatric Syndromes

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138
Launch into the Diagnostic Questions Right Away
One of the secrets of efficient and rapid diagnostic interviewing is a gentle tenacity; when
the patient mentions a depressed mood, immediately assess for the presence of the
diagnostic criteria for depression.

Patient: I think the worst problem over the past couple of weeks is that I’ve felt so down about
myself.
Interviewer: Has that down feeling been affecting your sleep?
Patient: I haven’t slept more than 2 or 3 hours a night, and the next day, I can barely drag
myself to work. I should probably quit anyway; it’s a boring job.
Interviewer: Have you had problems focusing on your work because of your depression?

Here, the interviewer stays on the depression topic by cueing off what the patient has said
about work (see the discussion of the smooth transition in Chapter 6). If the interviewer
had not actively structured the interview this way, the patient might have discussed details
of his work environment that would be less relevant to the diagnosis of major depression.
Later, when ascertaining the social history, the interviewer can refer to what the patient said
about work:

Interviewer: Earlier, you mentioned that your work is boring. How did you get into that line
of work? (Note the use of the referred transition.)

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Current and Premorbid Level of Functioning
The now outdated DSM-IV-TR diagnostic scheme included an “Axis V” in which you
noted the patient’s “GAF,” or global assessment of functioning, on a scale of 0 to 100.
Although I never found it useful to assign a specific number to functioning (only insurance
companies were obsessed with that number), I do think that Axis V was an important
reminder to the interviewer to ask about both current and baseline functioning.
To assess overall functioning, ask about the three basic aspects of life: love, work, and
fun. Love includes all important relationships: family, spouse, and close friends. In addition
to paid employment, work includes school, volunteer activities, and the structured day
activities in which many chronically mentally ill patients participate. Fun refers to hobbies
and recreational pursuits.

How has your illness been affecting your work, relationships, and
leisure pursuits?

The phrasing of this question automatically targets the patient’s premorbid functioning.
Some patients have a hard time distinguishing a psychiatric illness from the rest of their
lives. If so, you will have to follow up with another question to assess their baseline
functioning.

Before you started to have these anxiety spells (or other symptoms),
how was work going?
How were you getting along with your family and your wife?
What kinds of things were you doing for fun?

For patients who have more chronic illnesses with multiple exacerbations and remissions,
ask the same types of questions about periods between exacerbations:

Think about the last time that you were feeling your best, when you
weren’t hearing any voices and you didn’t feel suicidal. How was
your life going then? (Follow up with questions about love, work, and
fun.)

Asking about current versus baseline functioning is important diagnostically. The classic
example is the difference between schizophrenia and bipolar disorder. In schizophrenia, the
patient’s level of functioning gradually decreases over months or years, whereas in bipolar
disorder, the patient may have been functioning dramatically better within the past few
weeks. Determining baseline functioning is also important in setting treatment goals. You
might aim to help the patient achieve his best level of functioning over the past year, for
example.

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CLINICAL VIGNETTE

A resident was working in a busy psychiatric crisis clinic and interviewed a patient who was
brought by ambulance for psychotic and disorganized behavior. The patient was a 32-year-
old woman and carried the diagnosis of “schizoaffective disorder” in her previous
emergency department records. The phrase “history of multiple psychiatric
hospitalizations” in the old chart caused the resident to assume that the patient was a
chronically poorly functioning woman who could rarely stay out of a hospital. In assessing
her psychosocial functioning, the resident was surprised to learn that the patient had been
working as a secretary for a research department of a local hospital until 1 year ago, when
she had the first of a series of recent hospitalizations. This information caused the resident
to pay closer attention to the patient’s history and to entertain the possibility of a different
diagnosis, such as borderline personality disorder or PTSD, both of which would be more
consistent with her good premorbid functioning.

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 15 Obtaining the Psychiatric History

Essential Questions
Syndromal history:
How old were you when you first had these symptoms?

How many episodes have you had?

When was the last episode?

Mnemonic for treatment history: Go CHaMP

General questions.
Who is your current Caregiver?
Have you been psychiatrically Hospitalized?
Have you taken Medications for these symptoms?
Have you had Psychotherapy?

Recommended time: 10 minutes

The past psychiatric history (PPH) risks becoming a tedious exercise in documentation.
You can avoid this by realizing how vital the PPH is to your twin goals of establishing a
diagnosis and formulating a treatment plan.
Specific psychiatric disorders have specific natural histories, with characteristic risk
factors, prodromal signs, ages at onset, and prognoses. Obtaining a detailed PPH for a
particular patient allows you to compare the course of her illness with the textbook’s version
of the course of illness, increasing the likelihood that you will make a correct diagnosis.
Often, patients will come to you after having been treated for many years. One reason
such patients are eventually referred to an expert consultant is that experts are great at
eliciting a detailed history of prior treatments. They can determine exactly what has been
tried in the past and whether past treatment trials have been adequate. From this
information, they can present informed recommendations about what should be tried next.
And they can do all this in one or two 50-minute sessions.
Potential pitfalls in obtaining the PPH are similar to those lurking during the HPI. At
one end of the continuum, some interviewers become so caught up in the intricacies of the
PPH that they spend most of the evaluation time on it, to the detriment of, for example,
the PROS. At the other end, the PPH can become a rote exercise and may be obtained too
superficially, depriving the interviewer of information necessary to make a firm diagnosis.

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Obtain the Syndromal History
Generally speaking, the HPI will take between 5 and 10 minutes, at the end of which you
should have a few provisional diagnoses in mind. Your next job is to obtain the history of
these syndromes. Specifically, you want to learn age at onset, premorbid functioning, and
history of subsequent episodes up to the present.

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Age at Onset
How old were you when you first had your symptoms?

Knowing the age at onset may help you to decide between potential diagnoses, with anxiety
disorders having a much earlier onset than either mood disorders or schizophrenia (Jones
2013).

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Premorbid Functioning or Baseline Functioning
See Chapter 14 for a discussion of premorbid functioning/baseline functioning.

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History and Precipitants of Subsequent Episodes up to
Present
Include questions about the severity of episodes and exacerbations, as well as the duration
of episodes. Often, this information comes out when you are obtaining the treatment
history. For example, episodes of mania or exacerbations of schizophrenia often correspond
with hospitalizations.
As with hospitalizations, a time-efficient method of asking about episodes is to ask
about the first one, the latest one, and the total number of episodes.

When did you have your first breakdown?

How many have you had in total?
When was your last one?

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Obtain the Treatment History
You ask about prior treatments mostly to help with future treatment decisions but also to
help nail down a diagnosis. For example, if lithium was helpful for an affective episode,
bipolar disorder would be high on your list. You want to know what has been tried in the
past and whether it has worked. Accuracy and detail are important here, because a sloppy
treatment history can lead to poor future treatment decisions. For example, patients may be
falsely labeled “treatment resistant” on the basis of old records indicating that numerous
medications were “tried but were unsuccessful.” On closer questioning, such patients may
in fact have had few adequate trials of medication.
I suggest the following format for obtaining the treatment history:

General questions
Current caregivers
Hospitalization history
Medication history
Psychotherapy history

Use the mnemonic Go CHaMP so that you don’t miss any category.
You won’t necessarily ask your questions in the above order—in fact, you will obtain
much of this information during the HPI—but it’s helpful to think about these five aspects
of the treatment history to make sure that you haven’t neglected to ask important
questions. At some point during the interview, mentally review whether you have obtained
enough information about each of these categories.

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General Questions
What sort of treatment have you had for your depression?
What was the most helpful?

More sophisticated and forthcoming patients will tell you almost everything you need
to know about the treatment history in response to a general question. Other patients will
require more specific questioning.

What was going on in your life during the period when you were
depression free?

In some cases, the best “treatment” for a particular patient was a close relationship with
someone or their escape from a dysfunctional relationship. You can learn this from a careful
history, and it may become a part of your treatment recommendations.

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Current Caregivers
You will need to know who your patient is seeing currently. If he is a new patient, you may
be the only caregiver. If you are interviewing a patient with a chronic mental illness, he will
likely have both a therapist and a psychopharmacologist, and he may also have a case
worker (usually a social worker), a group therapist, and a primary care doctor (a family
practitioner or an internist) and may be involved in day treatment or residential treatment.

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Hospitalization History
Have you ever been hospitalized for a psychiatric problem?

For patients who have had multiple hospitalizations, do not spend your time
ascertaining the names of the hospitals and dates of each admission; this could take the
entire 50 minutes. Instead, find out when they were first and last hospitalized and about
how many hospitalizations they’ve had over their lifetime. If a patient has had many
hospitalizations, try to find out if they are clustered around a specific few years. Some
patients will have had several hospitalizations earlier in the course of their disorder because
they had little insight into their problem and were noncompliant with their medications.
Later in life, their hospitalizations may be spaced much farther apart. Alternatively, the
opposite pattern may appear, in which an affective disorder worsens with age. Think of
hospitalizations as markers of disease severity.

When were you first hospitalized?

How many hospitalizations have you had in your life?
How many have you had in the past year?
When was your last hospitalization?

In addition to asking these questions, it is often useful to ask why your patient was
hospitalized:

In general, what sorts of things have caused you to need to be in the

hospital?

Your assumptions about reason for hospitalization may be wrong, as illustrated by the
following example.

CLINICAL VIGNETTE

A patient with chronic schizophrenia stated that he’d been hospitalized several times over
the past 2 years. The resident initially assumed that these hospitalizations were for psychotic
decompensations, but when asked, the patient said that most were alcohol detoxification
admissions. This prompted the resident to obtain a much more thorough substance abuse
history than he had planned.

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Medication History
The most important limit on the bioavailability of medication has
nothing to do with pharmacodynamics or pharmacokinetics; rather,
it is patient noncompliance.
Dr. Ross Baldessarini

Chief of Psychopharmacology

McLean Hospital

Have you been on medications for your depression?

To the extent possible, document all the medications the patient has tried. Many
patients will not remember generic names or may only remember what the pill looked like
or the side effect it caused. Obviously, the more you know about alternative names, shapes,
and side effects of medication, the more efficiently you will be able to obtain this history. I
find smartphone apps such as Epocrates to be helpful, because they have photographs of
medications, which help patients identify them. For psychologists and social workers, a
number of books have been published that teach the basics of psychopharmacology to non-
MDs, and I recommend that you become familiar with this information.

For how many weeks did you take your medications?

Many psychiatric medications take several weeks to have a therapeutic effect.

Antidepressants take 4 to 6 weeks. Antipsychotics may take 1 to 2 weeks or longer,
depending on the clinical situation. Thus, merely documenting that a patient has tried a
particular medication does not mean that he’s had an adequate trial.
At this point, a normalizing question may be helpful:

Often, people do not necessarily take their medications every day but
will take them every so often, depending on how they feel. Was that
true for you?

HOW ACCURATE ARE PATIENTS WHEN RECALLING PRIOR

TREATMENTS?
A fascinating study examined this clinically relevant but underexplored question (Posternak
and Zimmerman 2003). An independent evaluator interviewed 73 patients who had been
treated in an academic psychiatric clinic for an average of 3.5 years. After the interview,

151
researchers reviewed clinic charts to determine how accurately the patients recalled their
antidepressant trials. The results? They did pretty well, overall, recalling 80% of the
monotherapy (single medication) trials over the prior 5 years. However, they only
remembered 26% of augmentation trials (i.e., when a second medication is added to the
first to boost the response). And augmentation trials that were over 2 years old were not
remembered by anybody. The bottom line is that your patient will accurately recall
medications tried if the regimen has always been simple, but those who have taken
combinations of medications will be much less reliable.

CLINICAL VIGNETTE

A resident was doing a psychopharmacologic evaluation of a 46-year-old married Latino

woman with a several-year history of depression and anxiety. During the treatment history,
the patient stated that she had taken a number of different antidepressants from different
classes with only minimal effectiveness. The resident asked a normalizing question about
whether the patient had taken her medications consistently; she responded that she only
took them when she felt anxious, which varied from daily to once every 2 weeks. In fact,
the resident was unable to document an adequate trial of any antidepressant and
subsequently focused on educating the patient on the necessity of consistently taking
medications.

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Psychotherapy History
In recent years, psychotherapies have become increasingly tailored to specific disorders, and
evidence of effectiveness has become irrefutable (Barlow 2014). In addition, it has become
clear that therapy can have negative side effects, as can medication. Thus, obtaining a
history of psychotherapeutic treatments is important.

Have you ever had counseling or therapy for your problem?

How often did you see your therapist?
How long did you see him/her?

These basic parameters of session frequency and length of treatment are usually
nonthreatening and easy to elicit.

What sort of therapy did you have?

Did it have a name, like “cognitive therapy,” “behavior therapy,” or
“psychodynamic therapy”?

More often than not, your patient will not know the technical name of the therapy he
received. You can compensate for this by describing the therapy.

Did your therapist focus on “automatic thoughts” that make you

more anxious or depressed?
Did she give you homework assignments between sessions?
Did she have you practice doing things that caused you anxiety? (For
cognitive-behavioral therapy.)
Did your therapist focus on your childhood experiences and how those
affect your current life? (For psychodynamic therapy.)

You can also ask a more open-ended question:

Without going into too much detail, what sorts of things did you
focus on in therapy?
Was your therapist a psychologist, a psychiatrist, or a social
worker?

Knowing this may or may not be useful. For example, a patient may say she had a
therapist, when in fact she was seen by a psychiatrist once a month for brief visits. This was
more likely psychopharmacologic management than psychotherapy.

How did you like working with your therapist?

Was the therapy helpful?
In what ways was it helpful?

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 This information will be particularly valuable in assessing the patient’s suitability for
further therapy.

How did you leave treatment?

The way a patient ended treatment may tell you much about how he viewed treatment
and may help you plan how to proceed with your own treatment of the patient. Some
patients, for instance, have a history of ending therapy by simply not showing up for the
next session. Others may have had a stormy termination. Others may have terminated “by
the book” but continue to feel unexpressed sad or angry feelings toward the therapist.

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 16 Screening for General Medical
Conditions

Screening Questions
Mnemonic: MIDAS

Do you take any Medications now?

Do you have any medical Illnesses?
Do you have a primary care Doctor?
Have you ever had Allergies, reactions, or side effects from any medications?
Have you ever had any Surgery?

Medical review of systems.

Recommended time: 3 minutes

There are two major reasons for asking about the medical history in psychiatric patients:

To screen for medical illnesses. Many psychiatric patients, particularly patients with
chronic schizophrenia in public care systems, have very poor medical follow-up, both
because they are indigent and because their psychiatric disorder leads to poor
compliance with appointments (Hall et al. 1980). Thus, they may have a high
prevalence of undiagnosed medical conditions. Whether these conditions affect their
psychiatric status or not, you will do them a large service by screening for medical
conditions for which they may not be receiving treatment.
To uncover general medical causes of psychiatric illness. A number of medical
illnesses and medications can cause psychiatric syndromes and aggravate preexisting
ones (David and Fleminger 2012). This is a convenient section of the interview for
asking about such illnesses.

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Midas
If you can develop the MIDAS touch, you’ll never forget to ask about the medical history:

Medications
Illness history
Primary care Doctor
Allergies
Surgical history

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Medications
Obtain a list of all medications, including those for general medical conditions. Ascertain
whether the patient has been taking them as prescribed.

157
History of Medical Illnesses
You can begin with a screening question such as

Do you have any medical problems?

Have you ever had a medical illness?

However, a common problem with this approach occurs when the patient says “no”
without thinking carefully, as the following vignette illustrates.

CLINICAL VIGNETTE

A 36-year-old woman with several past hospitalizations for depression was asked if she had
any medical problems, to which she replied, “No.” Later, when the resident asked what
medications she took, she listed a number of psychotropics and then said, “and I also take
Synthroid.” The resident said, “I thought you had no medical problems,” to which the
patient replied, “I don’t. I used to have hypothyroidism, but that was corrected with the
Synthroid.”

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Primary Care Doctor
In the preceding vignette, asking about illness elicited invalid information. One way to
increase the validity of your medical history questions is to first ask if the patient is being
seen by a doctor.

Do you see a doctor regularly?

What does he/she treat you for?

By referring to a relationship with a caregiver, you will typically jog the patient’s
memory for past diagnoses and treatments. You can also learn information about the
patient’s character:

Interviewer: Do you see a doctor regularly?

Patient: Yeah, I see someone at the clinic. Not that he gives a damn about me.

Such a statement could be explored further and might be a clue to character traits that
may interfere with treatment, such as passive-aggressive or self-defeating traits.
While you’re at it, ask the patient if you may contact his doctor to share information.
Discussing the patient with the primary care physician will help round out your evaluation,
as well as provide useful information to the caregiver who referred the patient to you.

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Allergies
The usual screening question is

Do you have allergies to any medications?

This may work, but again there are potential pitfalls. Some patients have idiosyncratic
understandings of what constitutes an allergy. They may think you’re asking about serious
allergic reactions, such as bronchospasm, and therefore may answer in the negative even if
they’ve had milder allergic reactions. They also may not realize that you’re interested in
hearing about any negative reactions to medications, and not just allergies per se. Better to
ask

Have you ever had any allergies, reactions, or side effects to any
medication?

A patient may say that he is allergic to a number of medications that only uncommonly
produce true allergic reactions, such as neuroleptics and antidepressants. If so, pursue the
nature of the allergy.

What kinds of reactions did you have to that medicine?

If the patient’s response is vague, make some suggestions based on your knowledge of
drug effects:

Did the Haldol give you muscle spasms? Did it make your hands
shake or your body move slowly?

When you document allergies in your write-up, specify the nature of the reaction. For
example, writing that a patient is “allergic to neuroleptics” is probably inaccurate and might
mean that the patient will never again be offered a neuroleptic, even if she could benefit
from it. A more accurate statement would be, “Haldol causes dystonia.” This leaves the
door open to trials of other neuroleptics.

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Surgical History
It is important to ask specifically about previous surgery; many patients do not volunteer
this information when asked about “medical problems,” either because it was too long ago
or because they do not consider an operation to have indicated a medical problem per se.

CLINICAL VIGNETTE

A 54-year-old man with major depression had mentioned gastritis as his only medical
problem. Midway through the interview, he mentioned in passing, “I divorced my wife
back in ’84 or so, just after they took out part of my pancreas.” On further exploration, the
patient considered that operation to be a turning point in his life, because he made the
decision to stop drinking then and had been sober since.

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Medical Review of Systems
The purpose of the review of symptoms is to note medical problems that the patient may
have forgotten to describe in response to the MIDAS questions. Whether it’s necessary to
do a review of symptoms for every patient is a matter of controversy. The MIDAS
questions may miss seemingly minor symptoms that may be the first clues to a big problem,
such as the occasional cough that signals lung cancer. But the review of symptoms takes a
lot of time, and most mental health clinicians refer their patients to an internist for physical
examinations anyway.
Here’s a compromise. I’ll outline two approaches to the review of symptoms, a brief
review of symptoms (1 minute) and a more extended one (5 minutes) (Table 16.1). Which
approach is better depends on the patient and the clinical setting.

TABLE 16.1. Brief Versus Full Review of Symptoms

Both the brief and extended reviews of symptoms begin with systemic questions and
progress in head-to-toe order, which is an easy way to remember them and to ensure that
you do not forget to ask important questions.

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Brief Review of Systems
I’m going to ask whether you’re having problems with various parts
of your body, moving from your head to your toes. Any problems with
headaches or seizures? Vision or hearing problems? Smelling, taste, or
throat problems? Thyroid problems? Problems with your lungs like
pneumonia or coughing? Heart problems? Stomach problems like
ulcers or constipation? Problems with urination? Joint problems?
Problems walking?

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Extended Review of Systems

General
Overall, do you feel healthy?
Do you have joint problems or skin problems? (May indicate systemic
lupus.)
Do you have excessive bleeding or anemia? (Anemia can cause
depression.)
Do you have diabetes or thyroid problems? (Diabetes can cause
lethargy; thyroid problems can cause depression or mania.)
Have you ever had cancer?
Do you have any infections, such as HIV or tuberculosis (TB)? (HIV
can mimic many psychiatric disorders; TB can mimic depression.)

HEENT (Head, Eyes, Ears, Nose, and Throat)

Do you get headaches? (Can be caused by brain tumor.)

Have you ever had a head injury? (Can lead to neuropsychiatric

conditions.)
Any problems with your vision or your hearing?
Do you ever see or hear things that other people don’t notice?
(Provides a convenient place to ask about psychotic phenomena in a
nonthreatening way.)
Do you get nosebleeds?
Do you smell things that other people don’t? (Often a sign of temporal
lobe epilepsy.)
How are your teeth?
Do you often get sore throats?

Cardiovascular and Respiratory

Do you have any heart problems?
Do you have chest pains; do you have palpitations of your heart?
Do you have high blood pressure?
Do you experience shortness of breath (emphysema, coronary artery
disease)?
Do you cough excessively (lung cancer)?
Do you wheeze (asthma)?

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 Notes
Differentiate panic attack from cardiac disease; rule out congestive heart failure as a cause of
lethargy and fatigue that might be mistakenly diagnosed as depression. Look for diagnostic
clues to the presence of lung cancer, which can mimic the anorexia and weight loss of
depression.

Gastrointestinal
Do you have problems with nausea or vomiting?
Do you ever make yourself vomit? (A screen for bulimic behavior.)
Do you have problems swallowing?
Do you have constipation or diarrhea?
Have you noticed any change in your stool?

Notes
Rule out hidden colon or stomach cancer; diagnose irritable bowel syndrome, which often
accompanies psychiatric complaints. Answers to these questions may provide direction in
the choice of medications (e.g., you’d want to avoid a tricyclic antidepressant in a patient
with preexisting constipation).

Genitourinary and Gynecologic

Do you have problems with urination, such as burning or excessive
urination?
Do you have retention of urine or incontinence?
Do you have any problems with sexual functioning or sexual drive?
Have you ever had a venereal disease (HIV, syphilis)?
When were your last Pap smear and mammogram?
Do you have any problems with menstruation? When was your last
menstrual period?
Might you be pregnant?

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 Notes
Rule out bladder cancer; prostate cancer in men; and uterine, ovarian, or breast cancer in
women. Establish amenorrhea of anorexia nervosa. Determine contraindications to the use
of anticholinergic medications, such as an enlarged prostate.

Neurologic
Have you had seizures?
Have you ever passed out?
Have you ever had a stroke?
Any tingling in your arms or legs?
Any problems with walking, coordination, and balance?
Any problems talking or thinking?
Any changes in your handwriting?

Notes
Detect brain tumor, epilepsy, and stroke. Screen for multiple sclerosis, Parkinson’s disease,
and dementia.

Assessing HIV Risk

1I thank Stephen Brady, Ph.D., for suggesting many of these questions.

I’ve set up a separate category for HIV risk because it’s particularly important, and it
can be an awkward subject to bring up. Later in the interview, during the social history,
you’ll ask some questions about intimate relationships to assess your patient’s capacity for
relatedness. Here, you focus on sexual functioning as it relates to risk of HIV, but this may
lead to a discussion of other concerns.
Begin with an introductory statement such as

Here are some questions I routinely ask. Some may be uncomfortable;

let me know if they are.
If I may, I’d like to ask you some sexual history questions, because
many people are concerned about AIDS.

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 Then, go on to the screening questions for HIV:

Are you sexually active, or have you ever injected drugs, even once?
Do you have any reason to believe you are at risk for HIV?

Follow the preceding questions, depending on whether you are talking to a man or
woman, with these:

(For men): Have you had sex with a man in the past 15 years? (If
yes): Can I ask what kind of sex that was? Was it oral sex or anal sex?
Did you use a condom?
(For women): Have you had sex with a man who sleeps with other
men or who injects drugs?
(For both men and women): How many sexual partners have you
had over the past year?

At this point, you’ve done an adequate assessment for HIV risk. You may want to
follow up with some general questions about sexual functioning, which is often affected by
psychiatric disorders and by the medications used to treat them.

Are you satisfied with your sexual functioning?

Do you find that your sexual functioning changes when you get
depressed (or substitute other relevant psychiatric symptom)?

If you are interviewing someone who you suspect has been sexually abused or raped,
this is a good time to ask about it.

Sometimes people have sex against their will. Has that ever happened
to you?
Have you ever been coerced into having sex?

Notes
These questions avoid the loaded terms rape, molest, and abuse. This is useful for patients
who have been sexually coerced by a spouse or a relative and who may not want to think of
their experiences in such terms.

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 17 Family Psychiatric History

Screening Questions
Has any blood relative ever had nervousness, a nervous breakdown, depression,
mania, psychosis or schizophrenia, alcohol or drug abuse, suicide attempts, or
hospitalization for nervousness?
Has any blood relative ever had a medical or neurologic illness, such as heart
disease, diabetes, cancer, seizures, or senility?

Recommended time: 2 minutes for bare bones; 5 minutes for genogram.

The family history may be approached in one of two ways. One is the bare-bones approach,
which aims to ascertain the patient’s inherited risk of developing a psychiatric or medical
disorder. The second approach is more extensive and is a way of beginning the social
history part of the interview. I describe both approaches here and let you decide which
works best for you.

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Bare-Bones Approach
Ask the following long, high-yield question, which is adapted from a question suggested by
Morrison and Munoz (2009):

Has any blood relative ever had nervousness, nervous breakdown,

depression, mania, psychosis or schizophrenia, alcohol or drug abuse,
suicide attempts, or hospitalization for nervousness?

Because the question is so long, you have to ask it very slowly, pausing after each
disorder so that the patient has time to think about it. You should also define blood relative.

By blood relative, I mean parents, brothers, sisters, uncles, aunts,

grandparents, and cousins.

TIP
If the patient answers with a definitive “no,” you can move on. If there was a “yes,” you
should try to determine exactly what the diagnosis was. Unless your patient is in the mental
health field and is familiar with its jargon, this may not be easy. It’s helpful to ask about
specific treatments the relative may have received, such as lithium, carbamazepine
(Tegretol), divalproex sodium (Depakote) (clues to bipolar disorder), antipsychotics [older
examples are haloperidol (Haldol) and chlorpromazine (Thorazine); newer ones are
risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone
(Geodon), aripiprazole (Abilify), lurasidone (Latuda), and several others], electroconvulsive
therapy (clue to depression, bipolar disorder, or schizophrenia, depending on when the
treatment was administered), antidepressants, and antianxiety agents. Remember that
medications were used differently 20 years ago. For example, in its heyday, diazepam
(Valium) was given to many patients for depression, whereas now, a history of
benzodiazepine treatment is a clue for the presence of an anxiety disorder.

To determine a family history of transmissible medical and neurologic problems, ask

Has any blood relative ever had a medical or neurologic illness, such
as heart disease, diabetes, cancer, seizures, or senility?

How does it help diagnostically to know that a patient has a first-degree relative with a
psychiatric disorder? Table 17.1 lists those psychiatric disorders for which there is
significant evidence of familial transmission. The relative risk compares the risk for people
with such a family history against the risk of people in the general population, who are

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assigned a relative risk of 1.0. For example, the relative risk of developing bipolar disorder is
25; this means that if your patient’s father is bipolar, she is 25 times more likely to develop
bipolar disorder than the average person. The baseline lifetime prevalence of each disorder
is also listed in the table.

TABLE 17.1. Psychiatric Disorders with Significant Evidence of Familial

Transmission

aRelative
risk figures from Reider, R. O., Kaufmann, C. A., et al. (1994). Genetics. In R. E. Hales, S. C. Yudofsky, and
J. A. Talbott (Eds.), American Psychiatric Press Textbook of Psychiatry. Washington, DC: American Psychiatric Press. See
text for explanation.
b
Lifetime prevalence figures from Kessler, R. C., Berglund, P., Demler, O., et al. (2005). Lifetime prevalence and age-
of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General
Psychiatry, 62, 593–602.
cData from Hudson, J. L., Hiripi, E., Pope, H. G., et al. (2007). The prevalence and correlates of eating disorders in the

National Comorbidity Survey Replication. Biological Psychiatry, 61, 348–358.

Typically, family information is used in conjunction with other clinical information.

For example, family history is crucial in deciding whether a patient with new-onset
psychosis has schizophrenia or is in the manic phase of bipolar disorder.

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The Genogram: Family History as Social History
Doing a genogram takes a while, which probably explains its lack of popularity in most
clinical settings. But it doesn’t take that long, and the time investment usually pays off in
terms of richness of information. The genogram serves the additional function of
introducing you to the patient’s developmental history.
The technique is simple. Begin by telling your patient that you’d like to draw a family
diagram to better understand her family. Draw small squares for males and circles for
females. Obtain the following information about each relative:

Age
If dead, year, age, and cause of death (put slash mark through square or circle if dead)
Presence of psychiatric problem, substance abuse, or major medical problem
Status of the patient’s relationship with relative (e.g., close, estranged, a perpetrator
or victim of sexual or physical abuse)

Begin by diagramming the first-degree relatives, with the oldest sibling on the right
(Fig. 17.1).

FIG. 17.1. Basic genogram.

Once you have the skeleton of the chart, ask about each family member and embellish the
chart with the information obtained. Although you will likely develop your own

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preferences, it is standard to write the age within the circle or square, to use slashes to
represent the deceased, and to use double slashes to represent a divorce. In the example in
Figure 17.2, the patient is a divorced 34-year-old man with two children who has a family
psychiatric history significant for alcoholism and depression.

FIG. 17.2. Elaborated genogram.

Once you have completed a genogram, you have accomplished three tasks: you have
obtained (a) the family psychiatric history, (b) the family medical history, and (c) the bare
bones of the social and developmental history. Also, the physical layout of the genogram
makes it a quick way to remind yourself of the patient’s social situation, a particularly nice
feature if you rarely see the patient.

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 18 Obtaining the Social and
Developmental History

Essential Concepts
Can you tell me a bit about your background, where you grew up, and how you
grew up?
Explore the following topics chronologically:
Early family lifeSchool experiences, emphasizing friendshipsWork
experiencesIntimate relationships and sexual historyCurrent social support
networkGoals and aspirations

Recommended time: 5 minutes

In the days when psychoanalysis was king, the social and developmental history was the
psychiatric interview. Residents were instructed to cover everything from breast-feeding to a
patient’s first sexual fantasies, a process that could well take several hours. The results were
written up and used to develop a psychoanalytic formulation, focusing on Freudian notions
of psychosexual conflict.
In our age of psychopharmacology, interviewers sometimes reach the other extreme,
asking about little more than their patient’s job and marital status before moving on to the
DSM-5 diagnostic questions.
What is the purpose of the social and developmental history in a brief diagnostic
interview? How extensive should it be? The social history is useful in two closely related
ways: (a) It allows you to get to know the patient as a person rather than as a diagnosis, and
(b) you can approach the diagnosis of a personality disorder through the social history (see
Chapter 31).
The essential questions take 5 minutes to ask, whereas the extended version takes 10 to
20 minutes and should be reserved for occasions on which you can take two sessions to do
the evaluation.

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Early Family Life
Begin with the following introductory question:

Can you tell me a bit about your background, where you grew up,
and how you grew up?

Proceed to more specific questions, moving chronologically through the stages of life.

How many siblings did you have, and where were you in the birth
order?

Each family configuration has a unique impact on psychological development. Typical

scenarios include the loneliness of the only child, the eldest child of a large family who was
forced into the role of a parent, the ignored middle child, and the youngest child who grew
up as the resented apple of his mother’s eye.

What did your parents do for a living?

Parental employment may have affected the patient’s relationship with her parents. For
example, a father who worked as a traveling salesman may not have been home much. This
question also gives you a sense of socioeconomic situation: Did the patient grow up amid
poverty or affluence?

How did you get along with your parents?

Although there’s not enough time to do this topic justice in the diagnostic interview,
these questions will give you an idea of the general flavor of the home. Was it a peaceful,
loving environment, or was it angry and chaotic?

What did they do when you disobeyed?

This question can gently introduce the topic of physical or sexual abuse. Depending on
the answer, you can follow up with a more explicit question, such as

Were you abused physically or sexually as you grew up?

Were there any other important adults in the home?

Often, another relative was a major factor in the patient’s early life, with either a
positive or a negative effect.

How did you get along with your siblings?

A close relationship with siblings can often compensate for a terrible relationship with
parents.

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Who were you closest to, growing up?

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Education and Work
Did you enjoy school?

This question will give you a sense of how the patient managed her first encounter with
the social field outside of the family.

Did you have many friends, or did you keep to yourself?

Did you have a best friend?

The patient’s lifelong pattern of relating is often apparent in the first few years of
school.

What kinds of grades did you get?

Grades are a rough measure of intelligence and perseverance.

What did you do after you graduated (or dropped out)?

Did she take the straight and narrow course to college or into the job world? Or did she
wander for a while, not certain what to do with her life?

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Asking about Work
While I have categorized asking about work under the social and developmental history,
this is often something you will ask quite early in the interview, as you are “breaking the
ice.” But how should you ask this question, which is a loaded one for some patients. For
some patients, a straightforward “What do you do for a living” is entirely appropriate. But
if you suspect that your patient may not be working, a couple of tactful inquiries are “Do
you have a job or are you between jobs?” or “Are you working at the moment?” Perhaps the
safest single question to ask is “How do you support yourself?” Such a question allows a
patient who is on disability to reply, “I’m on disability,” or allows a nonworking partner to
say “My spouse brings in the money for us” (Suggestions adapted from Shea 2007).

Did you like your work?

How well did you get along with employers and colleagues?

Did the patient’s pattern of relating continue unaltered as she entered the work
environment?
Did she have any difficulties dealing with authority figures?

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Intimate Relationships (Sexual History)
How does one ask about sexuality? It’s always an awkward topic, and patients are usually
guarded about revealing sexual information, especially when it pertains to sexual
orientation. One study showed that adolescents are four times more likely to reveal a
history of homosexual contact to a computer than to a person, but even the responses
revealed to the computer were well below estimates of the actual prevalence of
homosexuality in adolescents (Turner et al. 1996). Thus, asking about sexual history
requires extra sensitivity.
Recall that in Chapter 16, I suggested some sexual history questions in the context of
the medical history and the assessment of the risk for HIV. An alternative tactic is to
approach these issues from within the social history. Here, the rationale for obtaining a
sexual history is not so much to assess HIV risk as it is to assess the quality of the patient’s
intimate relationships. Is she capable of relating intimately with another? Are her intimate
relationships stable or transient and chaotic, as in the case of patients with borderline
personality disorder?
As with the rest of the social history, proceed chronologically:

When did you first begin dating?

Eventually, you’ll decide on a way of asking about sexual orientation that is

comfortable for you. The trick is to be nonjudgmental.

Were you attracted to men, women, or both?

The above question should be asked in a very matter-of-fact way, with the unspoken
message that it will not faze you if the patient says that he is attracted to the same sex.
Other options are as follows:

Precede your question with a normalizing statement, such as “Adolescents often

experiment with different sexual lifestyles; was that true for you? What’s your current
sexual preference?”
At the beginning of the interview, slip your question into a checklist of routine
questions: “How old are you? What’s your marital status? And your sexual
preference?”
Ask during the medical history when you ask about risk factors for HIV: “Do you
have any risk factors for the HIV virus? Have you had homosexual sex?”

Are you satisfied with your sex life?

Are there things about your sex life or your sexual desires that make
you uncomfortable?
When did you have your first important relationship?
What attracted you to that person?

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 Is the patient capable of establishing an intimate relationship? Can he describe other
people in three-dimensional terms?

CLINICAL VIGNETTE

An attending clinician was interviewing a 40-year-old divorced man in the hospital for
depression. His wife and daughter had left him 2 years earlier. He had a lifelong pattern of
brief and shallow relationships. The following exchange took place as the attending
clinician was exploring the relationship history:

I: Tell me about your girlfriends.

P: They were animals.
I: Pick one, and tell me about her.
P: I met a woman last year; she was a stray cat.
I: Why do you say she was a stray cat?
P: She had no connections.
I: What was it that you were attracted to?
P: Her body.
I: Okay. What kicked in about her personality later?
P: What do you mean?
I: If I met her, what would I notice about her?
P: It’s tough to answer. Her attitude.
I: How was that?
P: It was good.

The patient was unable to discuss any important person in his life in more than a
superficial way, which mirrored his fears of intimacy.

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Current Activities and Relationships
What attracted you to your current significant other?
How has your marriage (relationship) gone?
Do you have any close friends (aside from your spouse)?
Are you in touch with your family?

Does the patient have a social support system in place? Who would she call if she were
in trouble?

What do you do during your leisure time?

Does she enjoy sports, hobbies, reading, going to movies, and other activities, or does
she only work?

What do you think you’ll be doing 5 years from now, and what
would you like to be doing?

This question provides a window into the patient’s view of her future and her dreams
and aspirations.

CLINICAL VIGNETTE

An attending clinician was interviewing a 32-year-old single woman who had worked as an
extremely successful attorney until a year ago, when she was fired while in the middle of a
major depression. During the social history, she related that she disliked physicians in
general, because her abusive father was a physician.
Toward the end of the interview, the attending clinician asked

I: What do you think you’ll be doing in 5 years, and what would you like to be doing?
P: I’ll probably be dead. I’d like to be a physician.

The attending clinician then productively explored the meaning of her seemingly
paradoxical desire to become a physician.

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III

INTERVIEWING
FOR DIAGNOSIS:
THE PSYCHIATRIC
REVIEW OF
SYMPTOMS

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 19 How to Memorize the DSM-5 Criteria

Essential Concepts
DSM-5 Mnemonic:

Depressed Patients Sound Anxious, So Claim Psychiatrists

Depression and other mood disorders
Psychotic disorders
Substance abuse disorders
Anxiety disorders
Somatic disorders
Cognitive disorders
Personality disorders

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 Everything should be as simple as it is, but not simpler.
Albert Einstein

In this chapter, I describe an approach to memorizing the criteria for the major DSM-5
disorders. These mnemonics are a way of sorting information into manageable chunks.
Those who have researched the way expert clinicians think have found that this “chunking”
process is quite common (Kaplan 2011). The father of chunking, Miller (1957), showed
that humans can only process about 7 (±2) bits of information at a time, which is,
presumably, why phone numbers have seven digits. You have to be able to process more
than seven items to master the DSM-5, but mnemonics help by grouping items into
information-packed chunks.

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Memorize the Seven Major Diagnostic Categories
Begin by mastering the following mnemonic for the seven major adult diagnostic categories
in the DSM-5:

Depressed Patients Sound Anxious, So Claim Psychiatrists.

Depression and other mood disorders (major depression, bipolar disorder, dysthymia)
Psychotic disorders (schizophrenia, schizoaffective disorder, delusional disorder)
Substance abuse disorders (alcohol and drug use, psychiatric syndromes induced by drug
and alcohol use)
Anxiety disorders (panic disorder, agoraphobia, generalized anxiety disorder [GAD],
obsessive-compulsive disorder [OCD])
Somatic disorders (somatic symptom disorder, eating disorders)
Cognitive disorders (dementia, mental retardation, ADHD)
Personality disorders

Notice that these categories deviate somewhat from DSM-5 dogma. For example, I call
ADHD a “cognitive disorder,” whereas the DSM-5 classifies it as a “neurodevelopmental
disorder.” Also, I classify eating disorders under somatic disorders, whereas the DSM-5 puts
them in a separate chapter. My purpose here is not to create a new classification of
psychiatric disorders but simply to rearrange them into seven categories for ease of
memorization.

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Focus on Positive Criteria
Now that you’ve memorized the major disorders, you need to memorize the diagnostic
criteria. Begin by disregarding the voluminous exclusions and modifiers listed by the DSM-
5 and instead focus on the actual behaviors and affects needed to make the diagnosis.
For example, under schizophrenia in the DSM-5 are six categories of criteria, labeled A
through F. B is the usual proviso that the disorder must cause significant dysfunction,
which is true for all the disorders, so you don’t need to memorize it. D tells you to rule out
schizoaffective and mood disorder before you diagnose schizophrenia—another obvious
piece of information; don’t use up valuable neurons memorizing it. E reminds you to rule
out substance abuse or a medical condition, which you should do before making any
diagnosis, and F deals with the arcane issue of diagnosing schizophrenia in someone who’s
autistic. So, only two essential criteria are left: A (symptoms) and C (duration).
This section lists mnemonics for most of the major disorders, but it does not cover how
to ascertain the diagnoses, which involves the skillful use of screening questions and specific
follow-up questions. These are covered in detail in Chapters 23 to 31, where the full DSM-
5 criteria are spelled out.

KEY POINT
How should you use these mnemonics? They are primarily an aid to ensure that you
remember to ask about major diagnostic criteria. Do not ask the questions in the same
order as the mnemonics; doing so would lead to a very stilted interview. Try to ask
diagnostic questions when they seem to fit naturally into the context of the interview, using
some of the techniques for making transitions already discussed in Chapters 4 and 6.
Unless stated otherwise, these mnemonics are the products of my own disordered brain.

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Mood Disorders

Major Depression: SIGECAPS

Four out of these eight, with depressed mood or anhedonia, for 2 weeks signify major
depression:

Sleep disorder (either increased or decreased sleep)

Interest deficit (anhedonia)
Guilt (worthlessness, hopelessness, regret)
Energy deficit
Concentration deficit
Appetite disorder (either decreased or increased appetite)
Psychomotor retardation or agitation
Suicidality

This mnemonic, devised by Dr. Carey Gross of the MGH Department of Psychiatry,
refers to what might be written on a prescription sheet for a depressed, anergic patient—
SIG: Energy CAPSules. Each letter refers to one of the major diagnostic criteria for a major
depressive disorder. To meet the criteria for an episode of major depression, your patient
must have had four of the preceding symptoms and depressed mood or anhedonia for at
least 2 weeks.

Persistent Depressive Disorder (Dysthymia): ACHEWS

Two out of these six, with depressed mood, for 2 years signify persistent depressive
disorder:

Appetite disorder (either decreased or increased)

Concentration deficit
Hopelessness
Energy deficit
Worthlessness
Sleep disorder (either increased or decreased)

The dysthymic patient is “allergic” to happiness; hence, the mnemonic refers to a

dysthymic patient’s (misspelled) sneezes (achoos) on exposure to happiness. To meet the
criteria, the patient must have had 2 years of depressed mood with two of the six symptoms
in the mnemonic.

Manic Episode: DIGFAST

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Elevated mood with three of these seven, or irritable mood with four of these seven, for 1
week signify a manic episode:

Distractibility
Indiscretion (DSM-5’s “excessive involvement in pleasurable activities…”)
Grandiosity
Flight of ideas
Activity increase
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)

I don’t know who came up with this jewel, but I use it all the time. DIGFAST
apparently refers to the speed with which a manic patient would dig a hole if put to the
task. A complication in the diagnosis is that if the mood is primarily irritable, four of seven
criteria must be met to qualify.

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Psychotic Disorders

Schizophrenia: Delusions Herald Schizophrenic’s Bad News

Requires two symptoms for 1 month, plus 5 months of prodromal or residual symptoms.
At least one symptom must be one of the three highlighted core symptoms (delusions,
hallucinations, speech disorganization).
Mnemonic: Delusions Herald Schizophrenic’s Bad News

Delusions
Hallucinations
Speech/thought disorganization
Behavior disorganization
Negative symptoms

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Substance Use Disorder
The same mnemonic, Tempted With Cognac, is used for criteria for any drug or alcohol
dependence (two of the following eleven criteria are required):

Tolerance, that is, a need for increasing amounts of alcohol to achieve intoxication
Withdrawal syndrome
Loss of Control of alcohol use (nine criteria follow):
More alcohol ingested than the patient intended
Unsuccessful attempts to cut down
Much time spent in activities related to obtaining or recovering from the effects
of alcohol
Craving alcohol
Alcohol use continued despite the patient’s knowledge of significant physical or
psychological problems caused by its use
Important social, occupational, or recreational activities given up or reduced
because of alcohol use
Failure to fulfill major role obligations at work, school, or home
Persistent social and interpersonal problems caused by alcohol
Recurrent alcohol use in situations in which it is physically hazardous

For alcohol use, the CAGE questionnaire is often used:

“Have you felt you should Cut back on your drinking?”

“Has anybody Annoyed you with comments on your drinking?”
“Have you felt Guilty about your drinking?”
“Have you ever had an Eye-opener in the morning to get rid of a
hangover?”

Two or more affirmative answers indicate a high probability of alcohol use disorder
(Ewing 1984).

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Anxiety Disorders

Panic Attack (4 of 13)

With so many separate criteria to remember (13 total), trying to recall them with an
acronym or phrase is not practical. My trick instead is to break the symptoms down into
three clusters: (a) the heart, (b) breathlessness, and (c) fear. To remember them, I visualize a
panicking patient clutching his chest (heart cluster), hyperventilating (breathlessness
cluster), and shaking with fear (fear cluster). Finally, I imagine him screaming out, “Three-
five-five! Three-five-five!”—presumably as a way of distracting himself from the panic
attack. The numbers refer to the number of criteria in each cluster: The heart cluster has
three criteria, and the other two clusters have five each.
I admit that this all sounds hokey, but believe me, you’ll never forget the criteria if you
do it!

Heart Cluster: Three

I think of symptoms that often accompany a heart attack:

Palpitations
Chest pain
Nausea

Breathlessness Cluster: Five

I think of symptoms associated with hyperventilation, which include dizziness, light-
headedness, tingling of the extremities or lips (paresthesias), and chills or hot flashes:

Shortness of breath
Choking sensation
Dizziness
Paresthesias
Chills or hot flashes

Fear Cluster: Five

I associate shaking and sweating with fear. To remember derealization, think of it as a way
of psychologically escaping panic.

Fear of dying
Fear of going crazy
Shaking
Sweating

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 Derealization or depersonalization

Aside from remembering the cluster names, remember the pattern 3-5-5 to keep from
missing any of the 13 criteria. Your patient must have experienced four symptoms to meet
the criteria for a full-scale panic attack.

Agoraphobia
I have no mnemonic for agoraphobia, because there are really only two criteria: a fear of
being in places where escape might be difficult and efforts to avoid such places. See Chapter
25 for details.

Obsessive-Compulsive Disorder
The requirement for the diagnosis of OCD is the presence of obsessions, compulsions, or
both to a degree that causes significant dysfunction. The definitions of obsessions and
compulsions are easily learned and remembered (see Chapter 25), so a mnemonic is not
necessary. Instead, I have chosen some of the most common symptoms seen in clinical
practice; none of them is specifically required to be present by DSM-5.

Washing and Straightening Make Clean Houses:

Washing
Straightening (ordering rituals)
Mental rituals (e.g., magical words, numbers)
Checking
Hoarding (in DSM-5, there is now a separate “hoarding disorder”)

Posttraumatic Stress Disorder

The PTSD patient Remembers Atrocious Nuclear Attacks.

Reexperiencing the trauma via intrusive memories, flashbacks, or nightmares (one of

which is required for diagnosis)
Avoidance of stimuli associated with trauma
Negative alterations in cognitions and mood (e.g., amnesia for the trauma, negative beliefs
about oneself or the world, irrationally blaming oneself for the trauma, negative
emotional state, restricted interests and activities, detachment, and inability to have
positive emotions; two required for diagnosis)
Arousal increase, such as insomnia, irritability, hypervigilance, startle response, reckless
behavior, and poor concentration (two required for diagnosis)

Generalized Anxiety Disorder (Three of Six)

The first part of the diagnosis of GAD is easy: The patient has worried excessively about

191
something for 6 months. The hard part is remembering the six anxiety symptoms, three of
which must be present. The following mnemonic is based on the idea that Macbeth had
GAD before and after killing King Duncan:

Macbeth Frets Constantly Regarding Illicit Sins:

Muscle tension
Fatigue
Concentration problems
Restlessness, feeling on edge
Irritability
Sleep problems

If this elaborate acronym isn’t to your liking, an alternative is imagining what you
would experience if you were constantly worrying about something or other. You’d have
insomnia, leading to daytime fatigue. Fatigue in turn would cause irritability and
problems concentrating, and constant worry would cause muscle tension and restlessness.

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Eating Disorders

Bulimia Nervosa
Bulimics Over Consume Pastries (all four of these):

Binging
Out-of-control feeling while eating
Concern with body shape
Purging

Anorexia Nervosa
Weight Fear Bothers Anorexics (all three of these):

Weight significantly low

Fear of fat
Body image distortion

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Cognitive Disorders

Dementia
At least one of the following six symptoms:
Memory LAPSE
1. Memory
2. Language
3. Attention (complex)
4. Perceptual-motor
5. Social cognition
6. Executive function
See Chapters 21 and 28 for further information on assessing these symptoms.

Delirium
Medical FRAT (all five of these):

Medical cause of cognitive impairment

Fluctuating course
Recent onset
Attention impairment
Thinking (cognitive) disturbance

Because delirium is caused by a medical illness, being part of the “medical fraternity”
helps to diagnose it. To merit the diagnosis, all five criteria must be present. See Chapter 28
for details.

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Attention Deficit Hyperactivity Disorder
There are 18 separate, though often redundant, criteria for ADHD, making memorization
impossible for anyone without a photographic memory (Table 19.1). As with panic
disorder, I suggest breaking the symptoms into four broad categories, which can be
remembered by the mnemonic MOAT (you’ll need a MOAT around the classroom for the
hyperactive child):

TABLE 19.1. DSM-5 Criteria for ADHD

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
Washington, DC: American Psychiatric Association.

Movement excess (hyperactivity)

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Organization problems (difficulty finishing tasks)
Attention problems
Talking impulsively

196
Personality Disorders
Chapter 31 outlines a system for diagnosing personality disorders in general, including
mnemonics for all ten of the personality disorders, which are not repeated here.

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 20 Interviewing for Diagnosis: The Art of
Hypothesis Testing

Essential Concepts
Use the free speech period for generating hypotheses.
Investigate each hypothesis with screening and probing questions.
Make graceful transitions to diagnostic questions throughout the interview.
Use the PROS for “cleanup.”

The problem is how to come up with a complete and accurate diagnosis in a very limited
amount of time. Early in training, this is less of an issue, when you are encouraged to spend
what you will later consider to be inordinate amounts of time interviewing your patients.
But after training, you will quickly realize that there is a correlation between the number of
patients that you see per day and your ability to afford a mortgage on that new home. You
will be torn between the need to do things quickly and the need to do things right.
The way things are done in most busy community clinics is probably not so “right.”
One study compared “routine diagnoses” as found in the medical chart with a “gold
standard diagnosis” generated using the SCID (Structured Clinical Interview for Diagnostic
and Statistical Manual of Mental Disorders, Revised Third Edition [DSM-III-R]) plus chart
review as well as an additional interview with a highly qualified psychiatrist or psychologist.
There was only about a 50% rate of agreement between routine and gold standard
diagnosis, and in one half of all cases of disagreement, feedback to the original clinicians
resulted in significant changes in patient care (Ramirez Basco et al. 2000).
Does this mean that you should give the SCID to all of your patients before the
interview? Thankfully not, because the techniques discussed in this section, involving
screening and probing questions, mirror the SCID gold standard, adapting it to the realities
of clinical practice.
One might assume that the best way to reach a diagnosis is to follow a two-step
process:
1. Obtain all potentially relevant data about the patient.
2. Examine the data to determine which diagnosis fits best.
This strategy would work well if time were limitless. Because it isn’t, clinicians have
developed ways of determining in advance what is likely to be relevant data for a particular
patient, thereby vastly increasing the efficiency of the diagnostic interview.
How do expert clinicians make diagnoses? A number of researchers have done

198
observational studies to answer this question (Elstein et al. 1978; Kaplan 2011). They have
found that experienced clinicians begin by carefully listening to the patient’s initial
complaint and asking open-ended questions. Based on this preliminary information, they
generate a limited number of diagnostic hypotheses (the average being four) early in the
interview, usually within the first 5 minutes. They then ask a number of closed-ended
questions to test whether each hypothesis is true. This process is known as pattern matching,
in which the patient’s pattern of symptoms is compared with the symptom pattern required
for a diagnosis.
Another way to view this approach is to think of a “closed cone” of questions (Lipkin
2002). The initial questions are open ended and exploratory; they become more closed
ended to pursue a specific diagnosis to an endpoint of verification or exclusion.
In accordance with these research-based conceptions, I suggest the following four stages
for rapidly establishing diagnoses during the psychiatric interview.

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Free Speech Period
In Chapter 3, I emphasize the value of giving the patient the opening word as a way of
helping to create a therapeutic alliance, but it’s also valuable for beginning the process of
generating hypotheses. Generating diagnoses begins the moment you first see your patient
and continues throughout the interview. It’s important that your mind should be especially
active during the first few minutes.
Keep the mnemonic “Depressed Patients Sound Anxious, So Claim Psychiatrists” in
mind as you listen to your patient. Does she appear depressed or manic? Is she speaking
coherently, and is her reality testing good? Does she seem anxious? Does she seem sharp or
cognitively impaired? Is she beginning the interview complaining of numerous somatic
symptoms? Does she have alcohol on her breath? Does she seem inappropriately angry or
entitled? You will quickly be able to generate a mental list of likely diagnoses, which you
should follow up on later in the interview with appropriate screening and probing
questions.

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Screening and Probing Questions
Once you’ve generated your short list of likely diagnoses, go on to test your hypotheses.
Begin by asking a screening question that gets at the core feature of the disorder. Each
disorder-specific chapter in Section III suggests one or more screening questions. For
instance, a screening question for bipolar disorder (see Chapter 24) is

Have you ever had a period of a week or so when you felt so happy
and energetic that your friends said that you were talking too fast or
that you were behaving differently and strangely?

If the patient answers “yes,” go right into the mnemonic for manic episodes
(DIGFAST) and ask primarily closed-ended questions about each criterion. If the patient
answers “no” and you are certain that he understood the question, you should conclude
that bipolar disorder is unlikely and move onto another part of the interview.
Interviewing for diagnosis is an active, probing process in which you will often do as
much talking as your patient. Is such an active style really more effective in eliciting
diagnostic information than a quieter, listening style? Common sense dictates that it is, and
the Maudsley Hospital researchers concluded that it is as well. In one of their papers
examining techniques for eliciting factual information (Cox et al. 1981b), they found that a
focused and directive style, in which interviewers used many probing questions and often
requested detailed information, led to better data than did a more passive style. The best
data were obtained when interviewers used at least nine probing questions per symptom.
Data were judged to be “better” when, in addition to the mere mention of a symptom,
such as depression, interviewers could obtain information about the frequency, duration,
severity, context, and qualities of the symptom, all of which are extremely important for
diagnostic decision making.
The concern remains that a directive style may elicit great factual data at the expense of
shutting the patient down emotionally with too much questioning and not enough
listening. Cox et al. (1981a) examined this issue and found that more directive interviewers
actually elicited slightly more feelings than did interviewers with a less directive style.

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Transition Gracefully to Diagnostic Questions

KEY POINT
Don’t try to turn the diagnostic interview into a long checklist of diagnostic questions. This
gives the interview a mechanical feeling and will diminish patient rapport. Instead, ask
diagnostic questions at relevant points in the interview, using the transition skills you
learned in Chapter 6. Much of Section III gives you tips for accomplishing such transitions;
here are a few examples as a preview.

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Illustrative Transitions to Diagnostic Areas
Depression

With things so bad in your marriage, I wonder how it’s been

affecting your mood.

OCD

You said you’re often late. Are there rituals you do at home that make
you late, like checking or cleaning things?

Substance abuse

Given all the stress you’ve been under, do you have a drink now and
then to deal with it?

Suicidality

With things going so poorly in your life, I wonder if you’ve been

debating whether it’s worth it to go on?

Borderline personality disorder

Earlier you mentioned that your husband left you years ago; how do
you normally deal with rejection?

Psychosis

You’ve been through so much stress lately—does it ever cause your

mind to play tricks on you, so that you hear voices or have strange
ideas?

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Psychiatric Review of Symptoms

TIP
It’s not uncommon to forget to ask important questions during an interview, even if you
use all the mnemonics in Chapter 19. The PROS is a helpful way to prevent this from
happening. At some point toward the end of the interview, mentally review the DSM-5
mnemonic (Depressed Patients Sound Anxious, So Claim Psychiatrists) and ask screening
questions for any disorder that you haven’t yet explored. This step resembles the survey
approach that I decried earlier, but it’s usually quite brief, because by this time you already
will have covered the priority topics.
The PROS is usually best begun with an introduced transitional statement, such as
Now, I’d like to switch gears a little and ask you about a bunch of different psychological
symptoms some people have.

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 21 Mental Status Examination

Essential Concepts
Mnemonic for Elements of the Mental Status Examination:
All Borderline Subjects Are Tough, Troubled Characters
ABSATTC

Appearance
Behavior
Speech
Affect
Thought process
Thought content
Cognitive examination

Nothing in the psychiatric assessment is as misunderstood as the mental status examination

(MSE). Two misconceptions are ubiquitous. The first is that the MSE takes place at the
particular point in the interview when you test orientation and recall. In fact, the MSE
occurs throughout the entire interview, during which you are constantly evaluating affect,
concentration, memory, and insight. The second myth is that the MSE is identical to the
Folstein Mini-Mental State Examination (MMSE). In fact, the Folstein MMSE is a specific
screen for dementia. Increasingly, its use in the routine psychiatric interview is being
questioned, but we’ll talk more about that later.
The MSE is your evaluation of your patient’s current state of cognitive and emotional
functioning. Although most of the initial interview is specifically focused on your patient’s
past, doing an excellent MSE requires that you attend at the same time to his present. Here,
your “third ear” comes into play. How is your patient presenting himself? What is his TP
like? How is he emoting? It will take you years to hone your powers of observation, and this
is certainly the most interesting part of the diagnostic interview.
An MSE accomplishes two purposes. First, it helps make a diagnosis, especially in those
cases in which historical data are unreliable or equivocal. A patient could send you an e-
mail listing all of his depressive symptoms, but it requires direct observation—an MSE—to
assess the degree of his anguish and his need for treatment. Second, the MSE allows you to
create a vivid patient description for your records. Using this, you can more easily track
your patient’s progress from visit to visit, and you can give clinicians to whom you refer a
more accurate sense of his condition.

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Elements of the Mental Status Examination
The MSE has roughly seven components. This mnemonic will help you to remember
them:
All Borderline Subjects Are Tough, Troubled Characters:

Appearance
Behavior
Speech
Affect
Thought process
Thought content
Cognitive examination

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Appearance
How does your patient’s appearance help you in your evaluation? At the extremes, a specific
diagnosis might immediately suggest itself. For example, a disheveled man wearing bizarrely
mismatched layers of clothes is schizophrenic until proven otherwise. Likewise, a
flamboyant and seductively dressed woman with bright makeup who bounces into your
office with energy to spare strongly suggests mania.
In usual clinical practice, however, these pathognomonic presentations are rare, and
appearance provides more subtle, but no less useful, information. Qualities to note include

Self-esteem: Does the patient care about his appearance? Compare the following two
patient descriptions:

The patient was a mildly overweight man with unruly black curly
hair, dressed in ill-fitting baggy jeans and a T-shirt so tight that his
stomach was visibly bulging above his belt.
The patient was a slim man who appeared younger than his 47
years, with fashionably cut short brown hair, an ironed button-down
shirt, new jeans, and polished penny loafers.

Both patients were diagnosed with depression, but they presented very differently and
required different treatment plans.

Personal statement: Does the appearance say something specific about your patient’s
interests, activities, or attitudes?

The patient came into the office dressed in a pressed electrician’s

uniform, with his name stitched over his breast pocket.
She wore a T-shirt with the slogan, “Every day I’m forced to add one
more name to the list of people who piss me off.”

Memorable aspects: Describe whatever particularly strikes you about your patient.
For example, if he is particularly attractive, note it, since degree of attractiveness is
usually relevant to self-image. However, I have yet to see any report describe a patient
as “unattractive,” and I wouldn’t recommend it, because it implies that you disliked
him. Instead, describe the unattractive aspects.

This was a man of normal build who had a round, acne-covered face
and was essentially bald, with the exception of small amounts of oily
black hair on either side.

Sometimes, a particular feature jumps out at you:

She had short curly brown hair, and her left eye was congenitally

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 deviated toward the left, giving her a somewhat unsettling
appearance.

TIP
The more vivid the notation, the better. I find it helpful to actually jot down a few
descriptors at the beginning of the interview, during the free speech period.
Comment on height and build; hair color, style, and quality, including facial hair, if any;
facial features, including eyes; clothes; movements; and any other prominent features of
appearance, like tattoos or scars.
Table 21.1 (included in Appendix A as a pocket card) may appear to restate the obvious,
but it’s useful to me when I lack the right descriptive words.

TABLE 21.1. Appearance Terms

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209
Behavior and Attitude
How did your patient behave toward you when you first met her? Was she friendly and
cooperative, or did she seem indifferent and apathetic? Did she sit right down and face you,
or was she agitated, pacing around the room and talking rapidly without really attending to
your questions? The context of the interview may also be important to making sense of the
behavior. Was it a scheduled evaluation interview or did it take place in an emergency
room?
Descriptors of attitude are similar to descriptors of affect (Table 21.2), but the
emphasis is on words that describe a relationship toward someone. Often, a sentence of
description is important. Here are some examples:

TABLE 21.2. Affect Terms

He presented himself as someone who was very anxious to tell his story
and to gain relief from his symptoms. He had an attitude of
submissive respect, saying things like, “Do you think you can help me,
doctor? What do you think I have?”
She presented as indifferent and apathetic. Her general attitude was
that this was just the latest in a long string of unhelpful interviews.

Often, your patient’s attitude toward you will change over the course of the interview.

He was initially reluctant to answer questions and seemed irritable.

Over the course of the interview, he became more self-revealing and
tearful.

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Speech
Description of speech has great overlap with description of TP, because we can only know
our patients’ thoughts through speech. Qualities of speech to consider include

Rate: Does he speak rapidly or slowly? Rapid or “pressured” speech is usually a

buzzword for manic speech, but you need to be careful not to overpathologize. Rapid
speech can signal anxiety or even be the normal speech pattern. We all know people
who speak very rapidly but are not manic.
Volume: Patients who speak loudly may be manic, irritable, or anxious. Very low
volume may signal depression or shyness. Again, loud or quiet speech may also be a
nonpathologic variant of normal.
Latency of response: Normally, when you are asked a question, you’ll think for a
fraction of a second before responding. This is the normal latency of response. Manic
patients may respond so quickly that they seem to jump onto the last few words of
your questions. Depressed or psychotic patients may show an increased latency of
response, waiting several seconds before answering simple questions.
General quality: Does your patient speak thoughtfully and in an articulate manner,
or does she ramble in a vague and disconnected way, making her hard to follow? The
terms in Table 21.3 are discussed in more detail in Chapter 27, in the section on
disorders of TP.

TABLE 21.3. Speech Terms

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Affect and Mood
Traditional teaching distinguishes mood from affect, with mood defined as a patient’s
subjective report of how he feels, and affect defined as your own impression of his
emotional state. Although many clinicians do not make this distinction in clinical work,
you should become familiar with it, because it is widely used.
Like observation of appearance and behavior, accurate observation of affect is a skill
that takes years to master. Although the overall emotional flavor is usually obvious, the
gradations and subtleties are not, and assessing degree of affect can be vitally important for
such things as determining imminence of SI or predicting the likelihood of aggressive
acting out.
Often, you won’t have to explicitly ask your patient how he’s been feeling, because he’ll
report it spontaneously. However, what do you do when your patient is vague about his
emotions or is reluctant to reveal himself?
The obvious (and easiest) approach is to come right out and ask.

How do you feel right now? How has your mood been over the past
few days?

If the patient answers with a vague term, follow up with questions aimed at giving a
more refined name to the affect, a name on which you both can agree but which you have
not “fed” the patient.

CLINICAL VIGNETTE

Interviewer: How have you been feeling over the past few days?
Patient: Not so great.
Interviewer: Hmmm. Not so great. Can you give that feeling a name?
Patient: Just… really lousy.
Interviewer: I mean an emotion word, like sad, nervous, angry, and so on.
Patient: Sad, I guess.

One particularly difficult situation is when your patient says he feels “up and down” or
that he has “mood swings.” Suddenly you are faced with a huge diagnostic differential.
Does the patient have bipolar disorder? Cyclothymia? Does he have depression with mood
reactivity? Does he have a personality disorder? An anxiety disorder? A substance use
disorder? All of these are compatible with an up-and-down mood.
Your questioning strategy should be based on trying to locate an enduring, persistent
mood beneath the variations. Or, if there is true mood instability, you should determine
whether the lows meet criteria for major depression and the highs satisfy criteria for mania.

212
I’ll have more to say about these issues in Chapters 23 and 24, but here’s an example of a
strategy that usually works well:

CLINICAL VIGNETTE

Interviewer: How have you been feeling over the past few days?
Patient: (Shaking head, looking at interviewer intensely.) Totally up and down.
Interviewer: Tell me about the downs first. When you say “down,” do you mean sad or
depressed, or something else?
Patient: Really depressed.
Interviewer: Do you feel depressed nearly every day?
Patient: Sometimes I get really happy.
Interviewer: I want to talk about the happy times, too, in a second. To focus on the down
times, do you have depressed periods nearly every day?
Patient: Yes.
Interviewer: Is your concentration affected during those depressed periods?

[The interviewer goes through the neurovegetative symptoms (NVSs) of depression and
determines that the patient meets criteria for a major depressive episode.]

Interviewer: Now, tell me more about the really happy times you’ve been having. What do you
mean by “ups”?
Patient: Feeling great, feeling on top of the world.
Interviewer: Okay. Do you really feel great nearly every day?
Patient: No, not every day, but sometimes I do.
Interviewer: Over the past 2 weeks, how many days would you say you felt really great?
Patient: Oh, a couple. My parents gave me a car for graduation. I was so happy.
Interviewer: How long did that happy mood last?
Patient: Couple of days.
Interviewer: Then how did you feel?
Patient: Down, as usual.

The eventual diagnosis was major depression, because the patient’s pervasive mood had
been depression, with a number of the required NVSs. The “ups” turned out to be brief
reprieves from the persistent depressed mood.

Table 21.2 (included as a pocket card in Appendix A) is a useful reference while you’re
writing up the MSE. Use it to enrich your emotional vocabulary, so that you don’t get in
the habit of using a single word to describe all patients with a particular kind of affect.

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Qualities of Affect
Four qualities of affect are commonly taught, but, as with the distinction between mood
and affect, the usefulness of these distinctions is controversial. My opinion is that there is
too much hairsplitting in academic psychiatry and that clinical work would be simpler and
just as effective without worrying about the following distinctions. Nonetheless, many
would disagree, and you should at least become familiar with the terms, whether or not you
use them.
1. Stability of affect: This refers to a continuum from stable affect (generally defined as
normal) to labile affect (generally abnormal). Marked lability of affect (e.g., when a
patient alternates between giggling and uncontrollable sobbing) is usually a marker of
either mania or acute psychosis, but it may also be seen in dementia and other
neuropsychiatric syndromes.
2. Appropriateness: A patient who laughs uncontrollably while talking about her mother’s
death is exhibiting inappropriate affect, and this is useful to record. Inappropriate affect
is often seen in psychosis or mania. Don’t overpathologize, however; many intact
people smile a bit when talking about sad things. This may reflect a defense mechanism
such as denial, rather than psychosis.
3. Range of affect: Mentally healthy humans exhibit a full range of affect. At some moments
they feel happy, at other moments annoyed, and at others sad. Depressed patients are
said to exhibit constricted affect, and patients with schizophrenia are often said to
exhibit flat affect. The problem, of course, is that many healthy people exhibit a narrow
range of affect. This may be especially true during a psychiatric interview, because
patients may not feel emotionally safe exposing themselves to a stranger. Thus, the
diagnostic specificity of a limited range of affect is suspect and should not be
overinterpreted.
4. Intensity of affect: Intensity is often hard to distinguish from range of affect, and like
range, the diagnostic specificity is unknown. The usual jargon describes three grades:
intense, flat, and blunted. Flat and blunted are usually reserved for descriptions of
severely depressed patients or patients with negative symptoms of schizophrenia. Intense
is often used for manic or histrionic patients, but remember that many completely
healthy people come across as passionate or intense.

214
Thought Process
TP refers to the flow of thought (coherent vs. incoherent) and is covered in detail in
Chapter 27.

215
Thought Content
Thought content (TC) refers to unusual or dangerous ideas and includes SI and homicidal
ideation (HI) (see Chapter 22); psychotic ideation, such as delusions and hallucinations
(see Chapter 27); and any significant themes that came up during the interview and relate
to the psychiatric diagnosis.

216
Cognitive Examination
What are the essential components of the screening cognitive examination? There is no
general agreement on this issue, and many clinicians argue that much of what is commonly
taught as essential to the cognitive examination is of questionable use (Rapp 1979). For
example, most training programs continue to teach the serial sevens subtraction test (SSST)
of attention, even though studies have demonstrated that it has little validity in separating
demented patients from healthy patients. (See the section on Attention and Concentration
for a more complete discussion.) Many of the other commonly taught elements of the
cognitive examination are equally suspect, including the digit span test, abstractions,
similarities, proverbs, and judgment questions (Keller and Manschreck 1989).
I focus here on what is truly useful in helping you to differentiate between normal and
impaired cognition. You should be aware, however, that this is a screening approach only.
Specialized tests of cognitive abilities, usually conducted by a neuropsychologist, should be
done if your screening indicates a potential problem.
▼ Caveat: Studies have shown that low educational attainment correlates with poor
performance on cognitive testing in the absence of dementia or other organic impairments
(Manly et al. 1999; Murden et al. 1991). Most studies have defined poorly educated as 8 or
fewer years of education—that is, no high school. The implication for clinicians is that you
should ask about educational level before testing and be cautious about overinterpreting
cognitive abnormalities in poorly educated patients.
The elements of cognition that you should assess include

Level of awareness or wakefulness

Attention and concentration
Memory
Judgment
Insight

Perception is important too, of course, but its assessment is discussed in Chapter 27.

217
Level of Awareness or Wakefulness

KEY POINT
The continuum of wakefulness ranges from comatose to fully alert. Determining the level
of wakefulness is important for two reasons. First, it will clue you in to certain diagnoses,
such as benzodiazepine or alcohol abuse in the drowsy patient or mania or stimulant abuse
in the hyperalert patient. Second, it will give you guidance in how to proceed with the rest
of the cognitive examination. For example, a full cognitive examination is not valid in a
patient who is nodding off throughout the interview.

The assessment of wakefulness is easy enough. Your first 10 seconds of contact with a
patient will tell you whether he is alert enough to greet you appropriately and tell you his
name. If he seems sleepy, you have at your disposal an entire lexicon for describing degrees
of sleepiness: sleepy, drowsy, lethargic, somnolent, stuporous, obtunded, and comatose.
Because there are no generally agreed-on definitions of most of these terms, it’s best to
describe the degree of sleepiness in plain English. Thus, instead of “stuporous,” say:

The patient was sleepy and could only be awakened by my calling his
name loudly and shaking his shoulder.

Instead of “drowsy,” say:

The patient yawned frequently during the interview but attended

well to all questions.
The patient nodded off frequently and had difficulty resuming his
train of thought.

These descriptions help the reader of your assessment to draw conclusions regarding
the reliability of the rest of the MSE.

218
Attention and Concentration
You want to assess whether your patient can sustain attention over a period of time. The
continuum of attention runs from attentive and focused at one end to confused and
distractible at the other.
Most training programs teach two tests for assessing attention: the digit span test and
the SSST. In the digit span test, the patient is given five to seven numbers and asked to
repeat them forward and backward; in the SSST, the patient is asked to subtract seven from
100 and to continue counting back by sevens until told to stop. Both of these tasks
intuitively seem like reasonable tests of attention; however, research studies have not
endorsed them.
In one study (Smith 1967), the SSST was given to 132 normal adults aged 18 to 63, all
of whom were fully employed and the majority of whom had at least 16 years of education.
The professions represented included psychiatry, psychology, neurology, and pediatrics.
Only 42% of these subjects had errorless performance on the SSST. Fully, 31 of the
subjects made between 3 and 12 errors, and 14 either gave stereotyped responses
(supposedly consistent with frontal lobe disease) or totally abandoned the task. In another
study (Milstein et al. 1972), 325 hospitalized psychiatric patients were given the SSST. No
difference in performance between patients and 50 healthy control subjects appeared, and
there was no association between poor performance on the test and the presence of organic
cognitive impairments. With regard to the digit span test, Crook et al. (1980) found no
difference in seven-digit recall among 60 elderly patients who had memory impairment and
44 elderly people who were healthy.
On the other hand, the months backward test (MBT), in which you ask the patient to
recite all 12 months in reverse, appears to be fairly sensitive. The vast majority of
cognitively normal adults can complete the test accurately in about 20 seconds, and any
errors of omission are strongly suggestive of cognitive impairment (Meagher et al. 2015).
Simply ask your patient to recite the months backward, beginning with December.

TIP
The best way to assess attention and concentration is simply to talk to your patient and
observe how she thinks. Is she able to concentrate on your questions? Can she maintain a
train of thought as she answers you? If the answer to these questions is “yes,” your patient’s
attention is intact.

219
Memory
You should assess both short-term memory (memory of things learned a few minutes to a
few days ago) and long-term memory (memory of things learned longer than a few days
ago). Studies have documented that the most clinically valid tests of these are (a)
orientation, (b) three-object recall, (c) recall of remote personal events, and (d) recall of
general cultural information (Keller and Manschreck 1989).

Orientation
Orientation to person, place, and time is often thought to be a specific test of delirium or
confusion, but it is actually a test of memory. One’s name, one’s location, and the date are
all pieces of information that must be learned and retained. Whereas one’s name is
invariant and therefore is encoded in long-term memory, both the date and the place
change often, offering ideal ways to test whether people are capable of retaining new
information.
Because asking people where they are and what the date is can feel awkward, here are
some ways to transition into these questions smoothly. You can introduce all your memory
questions with a statement such as

I’d like to change gears here and ask you a few questions to test your
memory.

Often, you can make a smooth transition from some information you just obtained:

(The patient just told you her father had Alzheimer’s disease.)
Speaking of that, how has your memory been? I’d like to ask you some
questions to test your memory.
(The patient said his concentration has been poor while he’s been
depressed.) Speaking of concentration, I’d like to ask a few questions
to test how your memory and concentration are doing now.

Once you’ve introduced the need to assess memory, you can go into your orientation
questions with a question such as

Do you keep track of time pretty well?

Regardless of the response, you can follow up with

For example, would you be able to tell me today’s date?

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 TIP
If your patient is taking a while and struggling to remember, a time-saving tip is to ask
about specific components, going from easiest to hardest.

What year is it? What month? What day of the week? And what’s the date?

▼ Caveat: Don’t overinterpret an inaccurate date. Many cognitively intact people

don’t keep close track of the date. To prove this to yourself, ask yourself what the date is
today. If you’re off by a day, you’re normal. Thus, in recording your MSE, rather than
writing “patient was not oriented to date,” record instead what the patient said. Assuming,
for example, that the true date is Monday, November 30, 2015, there is a world of
difference between the patient who says “Monday, November 29, 2015,” and the patient
who answers, “sometime in ‘98.”

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Three-Object Recall
Recall of three objects after at least 2 minutes has been shown to be a useful test in
diagnosing cognitive impairments (Hinton and Withers 1971). Say to your patient:

Repeat the following three words: ball, chair, purple.

Make sure your patient can repeat them correctly before moving on. You must be
satisfied that your patient has correctly registered all three of the words, because otherwise
your test of memory will not be valid. Some elderly patients may have difficulty repeating
the words because of a hearing problem. (One of my hard-of-hearing patients repeated the
words as “pall, share, gurgle.”) In such cases, repeat the words more loudly until they have
registered. You may encounter a similar problem if English is not your patient’s first
language. Of course, if your patient is extremely demented or confused, she will not be able
to repeat the words for that reason. However, patients with such severe cognitive
impairment will have already been diagnosed because of difficulties in answering basic
informational questions early in the interview.
Once you are satisfied that your patient has registered all three words, say:

Now I want you to remember those three words, because I’m going to
ask you to repeat them in a couple of minutes.

In the meantime, ask your patient general knowledge questions (see below) about
general cultural and personal information. Then ask him to repeat the three words.
If your patient has trouble, use the following hints:

One of them is something you can play with.

One is a piece of furniture.
One is a color.

Cognitively, normal people usually remember all three words, and if they forget one,
they will remember it after your hint. Performance any worse than that indicates a possible
problem in short-term memory.

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General Cultural Knowledge
Certain items of cultural and historical information have been so widely taught that you
can assume any American with at least a high school education has learned them. Inability
to recall at least half of these items is presumptive evidence of long-term memory
impairment.

TIP
The traditional task is to name the last five presidents, although there’s no evidence that
there is anything magical about the number five. In practice, cognitively intact patients may
have problems remembering that George Bush came before Clinton and that Reagan came
before Bush. Therefore, I recommend asking about the last three presidents.

Last three presidents: Begin with

Who is the current president?

Then

Who was president before Obama?

Who was before George W. Bush?

Other famous figures: I ask about people who are so enduringly famous that the
average person can’t get through a typical month without hearing a reference to
them.

Who was_____? What was he/she famous for?

Here are a few of these famous people, along with what a cognitively intact person
should be able to tell you about them:

George Washington, first president

Abraham Lincoln, freed the slaves
Martin Luther King, Jr., civil rights leader
Princess Diana, British princess killed in car accident
William Shakespeare, writer
Christopher Columbus, discovered America

Famous dates: In asking these questions, you should not expect a precisely correct
response, but rather a response that names a year in the ballpark.

223
 When did World War II happen? (Any time in the 1930s or 1940s
is adequate.)
When was John F. Kennedy assassinated? (Sometime in the 1960s.)

Lists of information: A highly sensitive approach to screening for dementia is the set
test, first described in 1973 (Isaacs and Kennie 1973). The procedure is to ask your
patient to name as many items (up to ten) as he can recall in each of four categories:
colors, animals, fruits, and towns. Out of a maximum of 40, a score of 25 or above
excluded the diagnosis of dementia in the original study.

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Personal Knowledge
Personal knowledge includes aspects of current life as well as memory of remote personal
events. Cognitively intact patients should be able to tell you

Current address and phone number

Names and ages of spouse, siblings, and children
Spouse’s birthday, wedding anniversary, and date and place of marriage (if married)
Parents’ names and birthdays (primarily for younger patients who are not married)

TIP
How do you know if the patient’s answer is accurate? Address, phone number, and spouse’s
name are often on the chart’s registration sheet. You can check the other information by
calling a family member. Generally, however, patients do not blatantly confabulate,
alcoholic dementia being the major exception to this, and you can often get a sense of
cognitive status without resorting to time-consuming phone calls.

225
Intelligence
As with concentration, you can get a general idea of level of intelligence via the rest of the
interview. Think of intelligence as the ability to manipulate information. High levels of
educational and job attainment usually correlate with high intelligence.

TIP
For a quick and dirty measure of intelligence quotient (IQ), you can give the easy-to-
remember Wilson Rapid Approximate Intelligence Test (Wilson 1967) (Table 21.4). Start
with 2 × 48 as a screening test. If the patient can calculate this, she’s very unlikely to be in
the borderline or retarded range, and you can end the testing. Patients who can’t calculate 2
× 24 are likely to meet IQ criteria for mental retardation and should definitely be referred
for formal neuropsychological testing. The usual caveat regarding educational level applies:
You should only give this test to patients who have completed high school.

TABLE 21.4. Wilson Rapid Approximate Intelligence Test

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Insight

KEY POINT
Although the term insight has many layers of meaning, for the purposes of the evaluation
interview, you are most interested in whether your patient knows that he has an illness and
has some realistic conception of its causes and possible treatments.

Sometimes, a patient’s lack of insight is blatant. Such is the case with many patients
with mania and schizophrenia, who may be absolutely convinced of the veracity of their
delusions. Documenting poor insight in such cases is easy, but in many cases, you have to
probe for degree of insight by asking, often toward the end of the interview:

So, why do you think you’ve been having these problems?

What do you think needs to happen for your life to improve?

Insightful patients will be able to identify some psychosocial stressors related to their
disorder (either as cause or effect). Patients with poor insight might respond with phrases
such as:

I don’t know. You’re the doctor.

People need to stop hassling me. (A paranoid patient.)

Whereas complete lack of insight is often seen in psychotic disorders or dementia, poor
insight might point you at a diagnosis of a character disorder or low intelligence.

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Judgment
The standard question for testing judgment is by now widely recognized as unhelpful in
assessing the sort of judgment in which clinicians are interested:

If you found a stamped and addressed envelope laying on the

sidewalk, what would you do?

Instead, you should assess judgment based on the material gathered throughout the
interview. Did your patient decide to seek help when she felt depressed? Did she apply for
unemployment benefits when she lost her job? These show good judgment. Did she decide
that the best treatment for her depression was to go on a cocaine binge? This shows poor
judgment.
Often, students lump tests of abstraction with tests of judgment. These include the
interpretation of proverbs and the recognition of similarities. These tests show very low
interrater reliability (Andreasen et al. 1974), they show no demonstrated usefulness in the
diagnosis of organic problems, and good performance is highly correlated with intelligence
(Keller and Manschreck 1989), which is generally not what the tests are supposed to be
testing.

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Should You Use the Folstein Mini-Mental State
Examination?
The Folstein MMSE (Folstein et al. 1975) contains 11 categories of scored questions. The
maximum possible score is 30, and scores below 30 may indicate cognitive impairment,
with the precise cutoff point varying by age and education. The sensitivity of the test is
high—you’re unlikely to miss cases of dementia—but the specificity is low, meaning that
many patients who are cognitively healthy will be misclassified as demented. This happened
in 17% of patients in one study (Anthony et al. 1982).
Whether the MMSE should be used in all psychiatric evaluations is a matter of great
controversy. Opponents argue that the test’s positive predictive value is unacceptably low
and that it is less sensitive and specific than clinical judgment that is based on the results of
the entire interview (Harwood et al. 1997; Tangalos et al. 1996). Proponents argue that its
high sensitivity makes it essential and that a numerical measure of cognitive functioning is a
great help in tracking the course of dementia. But even the usefulness of the MMSE for
tracking cognitive decline has come into question. Researchers examined a large registry of
patients with Alzheimer’s disease and followed MMSE scores over several years. Although
they found that there was a 3.4-point average annual decline, the measurement error of the
test was almost as large (2.8), and even after 4 years of follow-up, 15.8% of patients had no
clinically meaningful decline in the MMSE score.
The MMSE is most useful for clinicians with little training in the psychiatric interview
who need a standardized format for asking a series of questions. It is less useful for mental
health clinicians, because we can skillfully ascertain cognitive functioning from the
interview as a whole and can target particular questions to assess specific areas of possible
impairment. In addition, the MMSE includes one test that has been found to be invalid for
evaluating cognitive impairment (SSST) and does not include other questions that are very
important in assessing for dementia, such as questions about personal and general
knowledge.
Notwithstanding the many limitations of the MMSE, it is used so widely in a variety of
clinical settings that you should become familiar with it.

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Mini-Cog
A more recent streamlined dementia screen, called the Mini-Cog, has been validated and is
easy and quick to administer. This combines two tests: the three-item recall (of MMSE
fame) and the clock-drawing task (CDT). Studies comparing the Mini-Cog with the
MMSE have shown no real differences in sensitivity or specificity, and the Mini-Cog is
much faster to administer and avoids most of the cultural and language problems associated
with the MMSE (Tsoi et al. 2015).
The Mini-Cog is administered in two steps. First, you ask your patient if you can test
his memory by asking him to repeat and memorize three simple words (the specific words
are up to you). Then you give him a paper and pen and ask him to draw a clock, with the
hands pointing to “11:10” (or pick another time in which there is a hand on each side of
the clock). Once the clock is drawn, ask him to repeat your three words.
How do you interpret your patient’s performance? Use the results of the three-item
recall as a screen. Patients who recall all three words are not demented, those who can
remember none of them are demented, whereas those who remember one or two might be
demented. For patients in the middle, their performance on the CDT provides crucial
information that may or may not convince you to seek neuropsychological testing.

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 22 Assessing Suicidal and Homicidal
Ideation

Essential Concepts
Suicidal Ideation

Learn the SAD PERSONS risk factors for suicide.

Use the CASE approach for assessing suicide risk.
Assess passive suicidality.
Assess active suicidality.
Assess imminent plan.

Homicidal Ideation

Learn the risk factors for homicide.

Ask about HI.
Know your Tarasoff duties.

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We cannot tear out a single page from our life, but we can throw the
whole book into the fire.
George Sand

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Risk Factors for Suicide
The reason an assessment of suicidality is necessary in every diagnostic interview is obvious
enough: We hope to prevent suicide. However, the mental health field has not yet devised
tools that allow prediction of suicidal behavior in a particular patient. On the other hand,
researchers have discovered a number of factors that increase the statistical risk for suicide.
It is important to be aware of these risk factors as you interview any potentially suicidal
patient.
In evaluating suicidality during the initial interview, you have two goals. The first and
most important is to assess whether an immediate risk of a suicide attempt exists. Your
second goal is to determine current or past suicidality to help you formulate an accurate
DSM-5 diagnosis. You can achieve both of these goals with the same line of questioning.
Before reviewing the types of questions to ask, you should be familiar with the risk
factors for suicide. An excellent mnemonic for the major risk factors is “SAD PERSONS,”
devised by Patterson et al. (1983).
Mnemonic: SAD PERSONS (risk factors for suicide):

Sex: Women are more likely to attempt suicide; men are more likely to succeed.
Age: Age falls into a bimodal distribution, with teenagers and the elderly at highest risk.
Depression: Fifteen percent of depressive patients die by suicide.
Previous attempt: Ten percent of those who have previously attempted suicide die by
suicide.
Ethanol abuse: Fifteen percent of alcoholics commit suicide.
Rational thinking loss: Psychosis is a risk factor, and 10% of patients with chronic
schizophrenia die by suicide.
Social supports are lacking.
Organized plan: A well-formulated suicide plan is a red flag.
No spouse: Being divorced, separated, or widowed is a risk factor; having responsibility
for children is an important statistical protector against suicide.
Sickness: Chronic illness is a risk factor.

Although useful for determining a patient’s long-term risk for committing suicide,
these risk factors are less useful for assessing imminent risk, and imminent risk is the most
important factor to assess during a diagnostic interview. While not much research has been
done on imminent risk factors, the American Association of Suicidology has agreed on the
following short-term warning signs of suicidal behavior (Rudd et al. 2006):

Rage
Recklessness
Feeling trapped
Increased substance use
Social withdrawal

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Anxiety/agitation
Insomnia or hypersomnia
Mood change
Lack of purpose or reason for living

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Assessing Suicidal Ideation: Interview Strategies

KEY POINT
Suicidality can be a difficult topic to broach, but you must ask about it in every diagnostic
interview. Patients are rarely angry or embarrassed about suicidality questions. A majority
of depressed patients have at least passing suicidal thoughts from time to time (Winokur
1981), and many patients are relieved when they are asked about suicidality, because it
allows them to reveal the true depth of their depression. If they really have not thought
about suicide, they will say something like, “Oh no, I could never do anything like that,”
and will tell you why not.

Another common disincentive to asking about suicidality is the interviewer’s fear of a

positive response. You may feel a sense of panic when first confronted with a suicidal
patient, but with experience, you will realize that there are degrees of suicidality and that
not all suicidal patients require urgent hospitalization.

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The CASE Approach
By far, the best method of assessing suicide risk is the CASE approach, which was devised
by one of my mentors, Dr. Shawn Shea, and published in his book The Practical Art of
Suicide Assessment (Shea 2011). I highly recommend that you read this book, as I have,
because it provides much more detail regarding his technique and includes innumerable
clinical examples.
CASE stands for Chronological Assessment of Suicidal Events and will help you to
remember to ask about everything relevant to a particular patient’s suicidal risk. The
technique goes like this:
1. Start by assessing the presenting SI or event.
2. Elicit information about any SI over the past 2 months.
3. Explore past SI.
4. Return to the present and explore any immediate suicidality.
The rationale here is that the process of exploring the presenting event and the past
allows you to establish rapport with your patient. This rapport will make it more likely that
he or she will be open with you about any imminent suicidal plans, which is really what
you most need to assess during the interview.
How does one go about asking the questions required for the CASE approach?
Regardless of the time period being explored, the issue of suicidality can be approached in a
number of ways. The direct approach can be perfectly acceptable. For example, as part of
your evaluation of the SIGECAPS of depression, you can say:

Have you felt suicidal?

Have you had thoughts of wanting to hurt yourself?

TIP
In some situations, however, this approach may feel jarring to the patient, and a smooth
transition may be better:

Sometimes when people feel depressed, they think that they’d be better off dead. Has that
thought crossed your mind at all?
Considering all the things you’ve told me, have you felt so bad that it seems that life is not
worth living?

These are both normalizing questions that inquire about “passive” SI. If you get a “yes,”
you should ask about active SI.

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 Have you thought about suicide?
What sorts of ways have you thought about to hurt yourself? (Phrased as a behavior
expectation.)

Many people with mild to moderate depression endorse passive SI but deny having
thought of actually taking some action to harm themselves. This is an important clinical
distinction, and you can generally breathe easier if your patient’s SI has never gotten
beyond the passive stage. If, however, your patient admits to active SI, you’ll need to ask an
additional series of questions. You want to find out how elaborate and how realistic the
suicide plan is.

Have you thought about cutting yourself?

Taking an overdose?
Jumping from the window?
Shooting yourself?
Hanging yourself?

Don’t worry that you are putting ideas into their heads. By inquiring specifically about
common suicidal behaviors, you are giving patients permission to be truthful and
communicating that you’re familiar with this difficult topic and won’t be put off by a
positive answer.

How close have you come to actually hurting yourself?

Have you planned it out in your mind?
Have you acquired any of the things you would need to do
something?

Here, you’re asking about the presence of a plan and getting a sense of how close the
patient has come to carrying out his plan.

Have you actually had the pills in your hand with a glass of water in
front of you?
Have you put the pills in your mouth?
What prevented you from actually swallowing them?

This continues specific questioning. The same line of questioning can be used with any
other method of suicide the patient may have been fantasizing about.

Do you have a gun in the house?

Do you have access to a rope?
Do you have pills at home?

You should assess how realistic the plan communicated by your patient is. If a patient

237
says he wants to shoot himself, this sounds quite serious, but does he own a gun? If not,
does he have access to a friend’s or relative’s gun? Has he located a shop at which he plans
to buy a gun?

Have you written a suicide note?

Have you done anything to put your affairs in order in
preparation for your death?

Arrangements such as these are particularly ominous indicators of an imminent suicide

attempt.

Are you feeling suicidal right now? Do you have any specific plan to
hurt yourself?

Here, you are asking about the immediacy of the intention, so that you can determine
the necessity for hospitalization or other urgent intervention.

What has kept you from killing yourself?

This is a very useful topic to introduce. Many desperate patients remain adamantly
opposed to suicide for specific reasons, often because they have dependent children or on
religious grounds. If you can identify compelling factors that are keeping your patient in
the land of the living, reinforce them.

If you were to feel more suicidal over the next few days, do you think
you could promise to pick up the phone and talk to someone before
actually hurting yourself, or would you be in so much pain that you
wouldn’t want to ask for help?

TIP
Here, you are trying to discover whether the patient is able to “contract for safety.” The
whole notion of a safety contract is controversial, and such a contract can certainly provide
a false sense of reassurance to the clinician. My feeling is that safety contracts at least do no
harm and that they probably have saved lives, because they offer a concrete plan to
someone who may be experiencing too much turmoil to think clearly. A good safety
contract includes names and numbers of people the patient agrees to contact and a way for
her to contact you or your coverage.

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Assessing Homicidal Ideation

KEY POINT
Although I have combined the assessment of HI with the assessment of SI, the two are very
different creatures. You should assess SI in every patient you interview, but you will ask
about HI only in patients you feel are at risk of becoming homicidal. This includes patients
in groups who have been identified by researchers as at high risk for homicide (Asnis et al.
1994; Tardiff 1992), such as those who are paranoid, antisocial, or substance abusers or
who tell you they are angry at someone in particular.

HI is not the easiest topic to broach during the interview. Interview techniques (see
Chapter 4) such as normalization and reduction of guilt are helpful. Once you have
introduced the topic, your strategy should be to determine exactly who is the target of the
HI and then to assess the seriousness of the ideation. This process is analogous to the
assessment of SI, in which you must locate the ideation on a continuum from passive to
active to a specific and imminent plan.

CLINICAL VIGNETTE

A 35-year-old woman was admitted to the hospital with the delusion that her mother had
been replaced by an impostor who was attempting to take possession of the family home.
Knowing that paranoia is a risk factor for HI, the interviewer decided to assess this
possibility.

Interviewer: How do you feel about this woman? (Referring to the “impostor” mother.)
Patient: How would you feel? She’s taking away all that is mine.
Interviewer: I’d be very angry.
Patient: There you go. I’m being wronged.
Interviewer: I imagine someone in your situation would go to great lengths to prevent this from
happening. (Using normalization.)
Patient: I’d say so.
Interviewer: Even to the extent of wanting to do away with that person?
Patient: She’s raping my heritage. Death would be too good for her.
Interviewer: It sounds like you’d be happy if she were dead.
Patient: (Looking at interviewer incredulously.) Of course I would.

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 (At this point, the interviewer has established passive HI; he must now assess whether
there is active HI.)

Interviewer: Have you thought about killing her yourself?

Patient: I wish I could. But there are too many others just like her. If I killed her, they would
know who did it, and they’d come after me.
Interviewer: So you haven’t come up with a plan for killing her?
Patient: Plenty of plans, but where will that get me? I told you, I can’t do it.
Interviewer: What sorts of plans?
Patient: The best way would be to cremate her in the house that she wants so much.
Interviewer: You mean set fire to the house?
Patient: It would break my heart to lose the house, but that may be necessary.

The interviewer concluded that the patient was at high risk of following through on her
plan to torch her mother’s house as a homicide attempt.

This vignette brings up the important issue of what you should do when a patient
expresses HI. The Tarasoff decision of 1976 provides guidelines for mental health
professionals (Felthous 1991). In essence, you have a responsibility to protect the potential
victim. This generally entails informing both the potential victim and the police.
If you do decide to issue a Tarasoff warning, informing your patient of your intentions
is a good idea. In such cases, a straightforward approach works best.

The law requires me to do what I can to keep this person safe. That
means I’m going to try to call him and also call the police.

You may worry that telling the patient about your intentions will harm the therapeutic
alliance. However, according to the only study that actually looked at this issue, in most
cases, issuing a warning had either a minimal negative or a positive effect on the alliance
(Binder and McNiel 1996).

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 23 Assessing Mood Disorders I: Depressive
Disorders

Essential Concepts
Screening Questions

Are you depressed?

Have you ever gone through a 2-year (for the diagnosis of dysthymia) period of
feeling sad most of the time?

Mnemonic: SIGECAPS
Recommended time: 1 minute if screen is negative; 5 minutes if screen is positive.

Diagnosis of the different types of depressive disorders begins with diagnosis of a major
depressive episode (Table 23.1). Once you become an expert at assessing the presence of the
NVSs of depression, you will be able to diagnose quickly major depression, atypical
depression, seasonal affective disorder (SAD), and dysthymic disorder.

TABLE 23.1. DSM-5 Criteria for Major Depressive Episode

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

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 KEY POINT
It is equally important that you know when not to diagnose a depressive disorder. Major
depression tends to receive a disproportionate amount of attention in mental health
education, partly because it is genuinely common and partly because we are so good at
treating it. Nonetheless, you do a disservice to a patient by diagnosing him with major
depression if instead he has an adjustment disorder with depressed mood and would benefit
more from brief psychotherapy than from medication.

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Major Depressive Episode
Mnemonic: SIGECAPS
A useful mnemonic to guide your questioning of the NVSs of depression is SIGECAPS. It
was devised by Dr. Carey Gross at MGH and refers to what one might write on a
prescription sheet for a depressed, anergic patient: SIG: Energy CAPSules. Each letter
refers to one of the major diagnostic criteria for major depressive disorder:

Sleep disorder (either increased or decreased)*

Interest deficit (anhedonia)
Guilt (worthlessness,* hopelessness,* regret)
Energy deficit*
Concentration deficit*
Appetite disorder (either decreased or increased)*
Psychomotor retardation or agitation
Suicidality

For dysthymic disorder, two of the six starred symptoms must be present.

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Asking About the Symptoms of Depression
The main difficulty for beginning clinicians is in translating the DSM-5 terminology into
language that is meaningful for the patient. A related difficulty is distinguishing true-
positive from false-positive responses to questions about symptoms. Most people experience
some of the symptoms of major depression to some degree at some time. Establishing that
your patient has symptoms severe enough to meet DSM-5 criteria takes creativity,
persistence, and experience.
In this chapter, I discuss techniques for assessing each of the NVSs in turn. First, here
are some general tips:

Establish that the symptom is truly a change from baseline. Many patients may have
difficulties with concentration, energy, appetite, and so forth that may be chronic and
have little to do with depression. If so, these symptoms cannot “count” toward your
diagnosis of a major depressive episode.
Establish that the symptom has occurred almost every day for 2 weeks. Many patients
may react to upsetting events with a few days of NVSs. This does not constitute a
major depressive episode, although it may be an adjustment disorder with depressed
mood. It’s useful to remind patients that you are asking about a specific period.

Think back carefully: Have you felt depressed pretty much every day
over the past 2 weeks?

Try not to ask leading questions. An example of a leading question is “Has your
depression made it hard for you to concentrate?” This implies that decreased
concentration would be expected, and a suggestible or malingering patient might
answer with a false “yes.” An example of a nonleading question would be “Do you
think your concentration has been better or worse than normal over the past 2
weeks?” Of course, you can substitute any of the NVSs for “concentration” in this
template.

CLINICAL VIGNETTE

An intern was interviewing a 45-year-old nightclub owner. When asked, “How have you
been sleeping for the past 2 weeks?” the patient responded, “Terribly. I can’t fall asleep
before 4 a.m., and then I get up at 10. I’m always tired.” The resident considered this
statement sufficient to meet criteria for the insomnia of depression, until the patient
mentioned that this had been his sleep pattern for the past 6 years and that it had been
unchanged over the past 2 weeks. The patient was referred to a sleep clinic and was
eventually diagnosed with sleep apnea.

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Screening Questions
Are you depressed?

One study showed that this simple question had 100% sensitivity and specificity in
diagnosing major depression in the terminally ill, outperforming elaborate screening
instruments such as the Beck Depression Inventory (Chochinov et al. 1997).

How has your mood been recently?

This is a nonleading question, but note that it is more specific than asking, “How have
you been doing?” or even, “How have you been feeling?” If your patient starts talking about
his distress at this point, go to the NVSs of depression. However, if he says “fine,” you
should move to the more specific question:

Have you ever felt very down or depressed, so depressed that your
whole life was affected by it for at least 2 weeks?

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SIGECAPS Questions
Sleep disorder

Have you been sleeping normally? (A good initial screening question

for a sleep problem.)
What has your sleep pattern been like lately?

(Depending on the adequacy of your patient’s response to this question, you may or
may not need to follow up with the following questions.)

What time do you lie down to fall asleep?

What time do you actually fall asleep?

(To diagnose difficulty falling asleep.)

Do you sleep through the night, or do you wake up often during the
night?

(To diagnose frequent awakenings.)

What time do you usually wake up in the morning?

Do you generally feel rested when you wake up?
Do you feel more or less depressed when you wake up?
How does your mood change as the day goes on?

(To diagnose early morning awakening and diurnal variation in mood.)

Interest deficit (anhedonia): Anhedonia is a surprisingly difficult symptom to

ascertain. Obviously, no patient is going to come right out and say, “Doctor, I’ve
been really anhedonic lately.” You will more likely hear words like, “I’m bored all the
time,” “I have no motivation,” or “I don’t care about anything.” One problem is that
patients may not understand what we mean if we ask, “Can you describe your
interest level?” or “Have you been taking pleasure in things?” A patient may only
associate pleasure with extraordinary experiences, such as going on vacation, or she
may say she has been taking an interest in things when in fact her level of interest has
decreased markedly since the onset of depression. Because of these potential pitfalls,
it’s important to be specific in your questioning.

Before you felt really sad, what sorts of things would you do for fun or
for relaxation?
What sorts of hobbies did you have?
Did you read?
Did you play sports or follow the sports teams?

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 Did you go out to movies?
Did you go out with friends?

This establishes a baseline against which to compare the depressed period. You can
then go on to ask about how the depression has affected the patient’s activities:

Since you have felt depressed, have you noticed that you’ve been any
less interested in these pursuits?
Have you found that you’ve been able to enjoy the things that you
used to be able to enjoy?
Have you given up doing anything that you normally like to do?

TIP
If the person you are evaluating is already on an antidepressant, particularly if this is a
selective serotonin reuptake inhibitor (SSRI), he may seem to have anhedonia, whereas he
may actually have “apathy syndrome” secondary to the antidepressant. This occurs in up to
20% to 30% of patients on newer antidepressants and may be caused by lowered levels of
brain dopamine.

Guilt, worthlessness, hopelessness: Here, you want to obtain a sense of how

negatively the patient feels about himself. Starting with questions that assess the
patient’s self-worth often works well:

How have you been feeling about yourself, in terms of self-esteem,

since you’ve been depressed?
Do you feel that you are essentially a good person, or do you have
your doubts?
Have you felt especially critical of yourself lately?

These questions touch specifically on the theme of hopelessness:

How do you see your future?

Do you have hope that things will get better, or does it look pretty
bleak?
Do you feel helpless to change your situation?

TIP

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In assessing guilt, simply asking “Do you feel guilty?” may not be enough, because the
patient may not be feeling guilty at that moment, even if she’s been feeling guilty
frequently over the last few weeks. For this reason, it is helpful to ask about some specific
aspects of living that depressed people often feel guilty about.

Have you been feeling guilty or regretful about things that you’ve done or haven’t done? Like
not being productive, not reaching your potential, being a burden?

Energy deficit: Begin with a screening question.

How has your energy level been over the past couple of weeks?

If the patient answers “Lousy,” make sure that the low energy coincides with the onset
of the depression, rather than being a constant feature of her physical state.

Is this a change for you? Did you feel significantly more energetic
before your depression?

Because medical illness can cause anergia in the absence of depression, you may be
misled about the source of the loss of energy, particularly when dealing with patients
with chronic medical illnesses or geriatric patients. In such cases, asking about the
pattern of energy throughout the day is helpful. Patients with medical illnesses are at
their most energetic when they wake up and then feel worse as the day progresses,
whereas depressed patients often wake up feeling low and anergic and feel better later
in the day.
Concentration deficit.

Have you been able to focus on things well? How has your
concentration been?

(These general questions are sometimes sufficient for screening purposes.)

Have you felt more absentminded than usual?

Have you noticed any changes in your memory?

(These get at the pseudodementia sometimes seen in depression.)

Have you had problems making decisions?

Sometimes, the first sign of concentration problems is difficulty in making basic

decisions such as “What should I make for dinner?” or “Should I go out tonight or not?”

If you were to sit down with a newspaper in front of you, would you
be able to read an entire article from start to finish without losing

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 your concentration, or do you have to read the same sentence over
and over again?
Can you watch a half-hour television show from start to finish
without losing your focus?
Have you noticed that you haven’t been able to get quite as much
done at work as before?

Concentration questions such as these can be tailored to the patient, depending on

what sorts of activities he normally engages in. One study of 31 depressed patients found
that the activities most commonly reported to be impaired were television watching (71%),
reading (68%), and household jobs (65%) (Pilowsky and Boulton 1970).

KEY POINT
We are often taught to look mainly for loss of appetite and consequent weight loss in
depression, with the exceptions of atypical depression and SAD. However, studies show
that weight gain is quite common in typical major depression as well (Stunkard et al. 1990;
Weissenburger et al. 1986). In one study of 93 patients with typical depression, 37%
gained weight, 32% lost weight, and 31% showed no change in weight (Weissenburger et
al. 1986), so you’ll want to make sure to phrase your appetite question in a nonleading
way.

Appetite

Since you’ve been depressed, have you noticed that your appetite has
increased, decreased, or stayed about the same?
Have you lost or gained weight since you’ve been depressed?
Do your clothes fit you differently?
How many meals a day do you eat?

These questions often lead to more accurate information; you can quantitate how
much the patient is actually eating, and the patient may in fact be surprised to realize that
he has been eating less or more than usual.

Does food taste good to you?

Depressed patients sometimes identify their eating problem not so much as a decrease
in appetite, but as a sense that food has become tasteless and unenjoyable, “like cardboard,”
as one patient told me.

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 TIP
This part of the interview provides a natural transition for asking about symptoms of eating
disorders. For example, if a patient tells you that she overeats when depressed, ask if she
binges and purges as well (see Chapter 29).

Psychomotor agitation and retardation: Although the DSM-5 specifies that

psychomotor agitation and retardation should be diagnosed based on what you
observe in the patient during the evaluation, the following questions may also be
helpful:

Sometimes when people get depressed, they notice that their

movements really slow down, almost as though their limbs are made
of lead. Has that happened to you? (For psychomotor retardation.)
Have you been more restless than usual? Have you been pacing,
wringing your hands, unable to sit down for long? (For psychomotor
agitation.)

Suicidality (see Chapter 22)

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Other Depressive Syndromes
Persistent Depressive Disorder (Dysthymia)
Mnemonic: ACHEWS. Two of these six, with depressed mood, for 2 years are indicative of
persistent depressive disorder, which in DSM-IV was called “dysthymia.”

Appetite disorder (either decreased or increased appetite)

Concentration deficit
Hopelessness
Energy deficit
Worthlessness (low self-esteem)
Sleep disorder (either increased or decreased sleep)

The persistently depressed patient is “allergic” to happiness; hence, the mnemonic

refers to a patient’s (misspelled) sneezes (achoos), brought on by exposure to happiness. To
meet the criteria, the patient must have 2 years of depressed mood, along with two of the
six symptoms in the list.
Persistent depressive disorder (PDD) is often diagnosed early in the interview in the
context of the chief complaint. When a patient presents with symptoms of depression, a
good screening question for PDD is

When was the last time you remember not feeling depressed?

The typical PDD patient will answer “many years.” In fact, the average duration of the
disorder is 16 years (Klein et al. 1993).
Along with depressed mood, you also have to establish the continuous presence of at
least two of the ACHEWS symptoms for 2 years or more. The most efficient way to do this
is to start with depressive symptoms that your patient has already mentioned, rather than
going through your list. Thus, if you have already heard about her lethargy, ask about that:

Over these last 2 years, in which you say you’ve been depressed, has
your energy been low most of the time?

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Atypical Depression
Atypical depression is a depressive subtype characterized by “reverse” NVSs (e.g., increased
appetite rather than anorexia and increased need for sleep rather than insomnia), mood
reactivity (the ability to be cheered up by positive events), a pattern of rejection sensitivity
throughout one’s adult life, and a feeling of being weighed down (“leaden paralysis”).
Research has cast doubt on the validity of this diagnosis (Lam and Stewart 1996), but
it’s still worth asking about it because patients with these features probably respond
particularly well to MAOI antidepressants.

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Seasonal Affective Disorder
Once you have established that the patient has episodes of major depression, ask if these
episodes follow any seasonal pattern. The most common pattern is depression in the winter
and euthymia in the summer.

Have you noticed that your depressions consistently come on or get

worse in the winter and then go away when the weather improves?

SAD is similar to atypical depression in that reverse NVSs are usually present, such as
carbohydrate craving (with consequent weight gain) and hypersomnia.
If your patient is having a hard time remembering a seasonal aspect to the depression,
you can jog his memory by asking

Do you generally go on vacation to a sunny place during the winter?

Do you find that your mood dramatically improves during the
vacation?

Obviously, anybody’s mood improves to some extent during vacation, but the patient
with SAD will report a more extreme mood shift that often lasts for several weeks after his
return, with a gradual lapsing back into depression thereafter. This mimics the response to
light therapy.

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 24 Assessing Mood Disorders II: Bipolar
Disorder

Essential Concepts
Screening Questions

Have you ever had a period of a week or so when you felt so happy and energetic
that you didn’t need to sleep and your friends told you that you were talking too
fast or that you were behaving differently and strangely?
Have you had periods when you were snapping at people and getting into
arguments?

Mnemonic: DIGFAST
Recommended time: 1 minute if negative screen; 5 minutes if positive screen.

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Manic Episode
Bipolar disorder tends to be under diagnosed by beginning clinicians. Most patients who
present for psychiatric interviews appear demoralized, depressed, or anxious, and one isn’t
intuitively moved to ask about periods of extreme happiness. It’s helpful to realize that
bipolar disorder usually presents first as a major depression and that up to 20% of patients
with depression go on to develop bipolar disorder (Blacker and Tsuang 1992).
Even when you do remember to ask about mania, there is another roadblock: a high
rate of false-positive responses. Many patients report periods of euphoria and high energy
that represent normal variations in mood rather than mania. Thus, the most effective
screening questions for mania ask about other people’s perceptions as well as the patient’s
self-perception.
In general, you should keep referring to a particular period as you ask your questions,
because many people experience the separate diagnostic criteria of mania at various points
in their lives (e.g., spending foolishly, talking unusually fast, being unusually distractible),
but unless a number of these symptoms have co-occurred during a discrete period (at least
1 week or 4 days for hypomania), a manic episode cannot be diagnosed (Table 24.1).

TABLE 24.1. DSM-5 Criteria for Manic Episode

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

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Screening Questions
Have you ever had a period of a week or so when you felt so happy
and energetic that you didn’t need to sleep and your friends told you
that you were talking too fast or that you were behaving differently
and strangely?

If you get a “yes” here, find out when that period was and how long it lasted, and then
continually refer to that period when you ask about the diagnostic criteria for mania. If the
patient cannot remember such a period lasting an entire week, you should suspect that
mania is not the diagnosis. Determine the circumstances of the elevated mood. Being really
happy for a couple of days after college graduation, for example, is not mania.

Has there been a time when you felt just the opposite of depressed, so
that for a week or so you felt as if you were on an adrenaline high
and could conquer the world?

The preceding question about mania is handy if you have just finished asking about
symptoms of depression.

Do you experience wild mood swings in which you feel incredibly

good for a week or more and then crash down into a depression?

Interpret responses to this question cautiously, because some patients who respond
with an emphatic “yes” are referring to recurrent episodes of depression without mania or
hypomania.

Have you had periods when you were snapping at people all the time
and getting into arguments with them?

This gets at the diagnosis of irritable, mixed, or dysphoric mania. Obviously, false-
positive responses abound here, and following up with questions establishing that this
period of irritability represented a manic episode, rather than a depression or simply a
transient foul mood, will be no small task.

Has anyone ever said that you were manic or that you had bipolar
disorder?

If someone answers “yes” to this, pay close attention. It’s not common for healthy
people to have been called manic by someone.

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Use DIGFAST to Elicit Diagnostic Criteria
The author of the DIGFAST jewel is unknown, but it’s very useful in remembering the
diagnostic criteria for a manic episode. The term apparently refers to the speed with which
a manic patient would dig a hole if put to the task.
Mnemonic: DIGFAST

Distractibility
Indiscretion (DSM-5’s “excessive involvement in pleasurable activities”)
Grandiosity
Flight of ideas
Activity increase
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)

In addition to expansive mood, the patient must qualify for three of the seven
DIGFAST symptoms, or four of seven if the primary mood is irritable.
When you ask about the symptoms of mania, precede your questions with something
such as, “During the period last year when you felt high, were you …?” This way, you can
ensure that all the symptoms have occurred within the same time frame.

TIP
Be sure to ask whether these behaviors occurred in the context of alcohol or drug abuse. If
so, you’ll have to judge whether the manic behavior is actually secondary to a substance
abuse problem or whether the substance abuse is secondary to mania. This is often a
difficult question to sort out.

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Distractibility
Were you having trouble thinking? Was this because things around
you would get you off track?

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Indiscretion
During the period we’ve been talking about, how did you spend your
time?
Were you doing things that were out of character or unusual for you?

These are nice questions to start with, because they are relatively unbiased and unlikely
to lead the patient to invalid responses.

Were you doing things that caused trouble for you or your family?

This is a good question because it doesn’t imply a judgment of the morality of any
particular behavior—it merely asks if a behavior has caused trouble for anyone.

Were you doing things that showed a lack of judgment, such as

driving too quickly, running red lights, or spending too much money?
Did you do anything sexual during this period that was unusual for
you?

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Grandiosity
During this period, did you feel especially self-confident, as if you
could conquer the world?
Did you have particularly good ideas?
Did you feel that you were right and that everybody else was wrong?

Often, this is a good opportunity to elicit the grandiose delusions that are so common
in mania:

Did you feel like you had any special powers?

Did you feel more religious than normal?

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Flight of Ideas
Did you have so many ideas that you could barely keep up with
them?
Were thoughts racing through your head?
Were other people having a hard time understanding your ideas?

When assessing flight of ideas, be aware that “racing thoughts” per se are not specific to
bipolar disorder. Patients with anxiety disorders, ADHD, or depression with anxious
ruminations commonly describe their thoughts as “racing.” A good way to distinguish
manic racing from anxious racing is to ask:

Were your thoughts racing in a good way or in an unpleasant,

worried, or depressed way?

Patients experiencing manic episodes often have a sense of an “accelerated” thought

process that is like a joyride in a stolen car. Patients with anxiety or depression will feel very
differently.

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Activity Increase
The activity increase criterion is similar to indiscretion but focuses specifically on the
frenetic nature of the activity.

Were you more active than usual?

Were you constantly starting new projects or hobbies?
Did you have so much energy that you felt it was hard to calm down?

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Sleep Deficit
Did you need less sleep than usual?
Did you ever stay up all night doing all kinds of things, such as
working on projects or calling people?

TIP
Be careful not to confuse the sleeplessness of depression or anxiety with mania. Patients
with mania stay awake because they have so much to think about and do, whereas
depressed patients stay awake because they feel tortured by their feelings. Therefore, be sure
to ask patients what sorts of things they do when they can’t sleep. Patients with mania will
report productive activities, whereas depressed patients will read or watch television as they
wait for the solace of sleep.

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Talkativeness
Did you find it hard to stop talking?
Did other people tell you that they had trouble understanding you?
Did friends have to interrupt you to get a word in edgewise?
Were you using the phone more than usual?

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Other Tips for Diagnosing Mania
History of hospitalization: If a patient was hospitalized during a “hyper” period,
chances are good that this was indeed a manic episode.
Interview with relatives and friends: One of the hallmarks of mania is a lack of
insight, making verification of historical information particularly important.
Family history of bipolar disorder: Bipolar disorder is one of the most inheritable of
all psychiatric disorders (see Chapter 17).

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Bipolar Disorder, Type II: The Hypomanic Episode
In bipolar disorder, type II, patients have a history of depressive and hypomanic episodes.
Hypomania can be hard to diagnose (Table 24.2). Essentially, it amounts to a psychiatric
diagnosis for exuberant and often very productive happiness. However, patients with
bipolar II spend much of their nonhypomanic time in depression, which is why bipolar II is
important not to miss. Use the same DIGFAST questions to diagnose hypomania that are
used to diagnose mania. The patient with hypomania will describe definite high periods
that have not caused real problems in her life. When hypomanic periods alternate with
depressed periods, the proper diagnosis is bipolar, type II disorder.

TABLE 24.2. DSM-5 Criteria for Hypomanic Episode

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

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 25 Assessing Anxiety, Obsessive, and
Trauma Disorders

Screening Questions
Are you a worrier?
Have you ever had a panic or anxiety attack?
Are you uncomfortable in social situations?
Do you have any special fears, such as fear of insects or of flying?
Do you have symptoms of OCD, such as needing to wash your hands all the time
because you feel dirty, constantly checking things, or having annoying thoughts
pop into your head repeatedly?
Do you have PTSD, which means having painful memories or dreams of a terrible
experience, such as being attacked by someone or surviving a natural disaster?

Recommended time: 3 minutes

Anxiety is a common symptom and can be a frustrating diagnostic issue for beginning
interviewers because of the enormous number of disorders that can present with anxiety.
For example, many patients with major depression, mania, and schizophrenia also report
significant anxiety, even in the absence of a specific anxiety disorder (Brown et al. 2001).
Nonetheless, it is important to be systematic about diagnosing anxiety disorders,
particularly because many disorder-specific psychotherapies have been developed. For
example, the cognitive-behavioral approach to the treatment of panic disorder is very
different from the cognitive-behavioral approach to social phobia (Barlow 2014).
You should develop a systematic approach to asking about the major DSM-5 anxiety
disorders, in addition to OCD and PTSD (DSM-5 removed the latter two disorders from
its anxiety section, but I believe they are still most usefully considered disorders of
fear/anxiety).
1. Panic disorder
2. Agoraphobia
3. GAD
4. Social anxiety disorder
5. Specific phobia
6. OCD
7. PTSD
Even if you ask all the right questions, distinguishing among some of these disorders,

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especially the first four, can be tricky. A useful aid is the DSM-5 Handbook of Differential
Diagnosis (First 2013), which contains excellent tables to guide you in differentiating one
disorder from another.
Following are suggested questions for diagnosing the anxiety disorders, along with brief
reminders of the diagnostic criteria for each disorder.

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Panic Disorder
The first step in diagnosing panic disorder is establishing that your patient has had panic
attacks. Remember, however, that a panic attack does not imply panic disorder. In fact,
~35% of healthy people report having had a panic attack within the past year (Norton et al.
1986), whereas only 4.7% of the population will ever develop full-blown panic disorder
(Kessler et al. 2005). Panic attacks are often responses to specific situations that people can
successfully avoid (e.g., claustrophobia, specific phobias). Panic may signal a disorder other
than panic disorder, such as social phobia or PTSD. Finally, many people experience panic
and anxiety that are not quite severe enough to meet criteria for a DSM-5 disorder (Table
25.1).

TABLE 25.1. DSM-5 Criteria for Panic Disorder

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

The initial screening question for panic is straightforward:

Have you ever had a panic or anxiety attack?

Most people have heard the term panic attack. However, a positive response to this
question requires verification, because many people define a subpanic level of anxiety as a
panic attack. This seems especially true of patients with GAD. Such patients may respond,
“I’m always having a panic attack. I’m having one right now.” Other patients will ask you
what you mean by a panic attack. You need to provide a good definition in lay terms to
effectively diagnose panic attack:

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 A panic attack is a sudden rush of fear and nervousness in which
your heart pounds, you get short of breath, and you’re afraid you’re
going to lose control or even die. Has that ever happened to you?

In my experience, this question is highly sensitive and specific for diagnosing true panic
attack. Patients who hear this definition and say unequivocally, “Oh no, I’ve been nervous
before, but I’ve never had anything like that,” are unlikely to have ever had a panic attack.
For patients who answer “yes,” ask them to describe the experience:

When did you last have one of these attacks? Can you describe that
attack for me? What were you doing when it started? How did it
make you feel, and how long did it last?

The best way to assess the clinical significance of a panic attack is to listen to your
patient describe one. You will find out which anxiety symptoms are present and whether
the attacks have a specific precipitant.

When you have these attacks, do you notice any of the following
symptoms: sweating, shaking, tingling in your hands or lips, shortness
of breath, choking, your heart pounding, chest pain, nausea, or a
feeling that you’re about to die or go crazy?

Although I’ve listed all these symptoms in one paragraph for convenience, you should
ask about them one by one to give your patient time to think about each. Use the symptom
cluster technique (heart, breathlessness, fear) to remember each of the symptoms.

When you have a panic attack, does it come out of the blue, or do you
pretty much know what’s going to cause it?

Remember that to meet criteria for panic disorder, the panic attacks have to be
unexpected (i.e., out of the blue). Otherwise, panic attacks may signify social phobia, if the
trigger is a social situation; PTSD, if the trigger is a flashback; agoraphobia, if the trigger is
a hard-to-escape place; or a specific phobia with a variety of possible triggers.

Has one of these attacks ever woken you up at night?

Do you remember when you had your first panic attack?

These two questions will increase the specificity of your exploration. If a patient is
awakened at night by panic, it’s very likely a true, unexpected panic attack. (Some clinicians
would also wonder about a history of sexual abuse.) In addition, people with true panic
disorders often distinctly remember their first panic attack.
Beyond simply establishing the bare bones of the diagnosis, you should make some
attempt to assess whether the patient might be a good candidate for cognitive-behavioral
therapy (CBT). In many cases, CBT works better than medication for panic disorder,

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particular over the long haul (Barlow et al. 2000). Patients who will respond well to CBT
are those who can identify “catastrophic cognition” in response to the panic sensations. A
typical interchange follows:

Interviewer: When you have panic attacks, what exactly goes through your mind?
Patient: I think I’m going to pass out, or worse.
Interviewer: Do you think you’re going to die?
Patient: Yes, that’s when I really get scared.
Interviewer: You mean the panic sensations become more intense when you have those
thoughts?
Patient: Definitely.
Interviewer: But have you ever actually passed out?
Patient: No.
Interviewer: Do you think it’s possible that your thought process makes you feel even
more anxious than you’d otherwise feel?
Patient: I never thought about it that way, but I guess you’re right.

Such a patient would likely be a good prospect for referral to a cognitive-behavioral

therapist after you have finished your diagnostic interview.

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Agoraphobia
Agoraphobia (Table 25.2) often develops as a complication of panic disorder, thought it
can be a free-standing disorder (American Psychiatric Association 2013). Usually, the
patient has a few panic attacks and gradually begins to avoid situations that he associates
with those attacks, a process termed phobic avoidance. The agoraphobic avoids situations in
which a quick escape would be difficult. Typical examples include crowded places (e.g.,
restaurants, stores, trains, buses) and driving a car, especially in heavy traffic or far from
home.

TABLE 25.2. DSM-5 Criteria for Agoraphobia

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

Have you started to avoid things because of your panic attacks?

Ask this question of every patient with panic disorder. Agoraphobia accompanies panic
disorder so commonly that the DSM-III-R describes no diagnosis of agoraphobia without
panic disorder.

Do you have problems with crowds? Buses or subways?

Restaurants? Bridges? Driving places?

Be sure not to confuse agoraphobia, a generalized fear of a variety of situations in which

escape might be difficult, with a specific phobia of bridges or buses or with PTSD, in which
a specific situation reminiscent of a past trauma may provoke a fear response.

Do you get anxious when you leave home?

At its worst, the agoraphobic’s world constricts so much that leaving the home is a
terrifying prospect.

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Generalized Anxiety Disorder
The patient with GAD is the prototypical worrier, who worries about several things for
months on end and is incapable of relaxing.
Begin with this screening question:

Are you a worrier?

Like the screening question for panic disorder, this question is exceedingly unlikely to
elicit a “no” answer from someone who truly has GAD.

What do you worry about?

Common topics of generalized anxiety include the health of relatives (especially

children), the quality of a romantic relationship, job or school performance, and the
possibility that possessions will break down or be stolen. However, certain topics of worry
suggest other diagnoses. For example, excessive worry about performance in social
situations may indicate social phobia, worry about having a panic attack suggests panic
disorder, and excessive worry about bodily sensations points to somatization disorder.
Don’t make the mistake of overdiagnosing GAD when the actual diagnosis is something
more specific.
On the other hand, some patients experience free-floating anxiety without having a
particular focus for their worries. Such patients do not meet criteria for GAD or any other
anxiety disorder; diagnostic possibilities to consider include major depression,
schizophrenia, or a medication side effect such as akathisia (i.e., a feeling of restlessness
caused by antipsychotic medication).

Over these past few months of worrying, have you noticed that you’ve
been feeling jittery? Irritable? Do you feel tension in your muscles? Do
you tire easily? Do you have insomnia? Do you have problems
concentrating?

The DSM-5 requires that GAD patients experience at least three of the preceding six
NVSs (Table 25.3). Otherwise, too many quite happy and functional worriers would be
receiving psychiatric diagnoses.

TABLE 25.3. DSM-5 Criteria for GAD

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Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

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Social Anxiety Disorder
The person with social phobia fears embarrassment and humiliation in a range of different
public situations, such as public speaking, meeting someone new, or eating in front of
others. All of us fear some of these things to some extent, but the social phobic’s fear is
unusually intense, to the point of having a panic attack (Table 25.4). Social phobics will
often give you a clue to their condition by being shy and awkward during the interview,
avoiding eye contact, and laughing nervously.

TABLE 25.4. DSM-5 Criteria for Social Phobia

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

The screening question is

Are you uncomfortable in social situations?

You may need to specify the situations you have in mind:

I mean situations such as public speaking, asking questions in front of

a class, or being at a party or in a meeting.

If you get a “yes” to the screening question, ask

How uncomfortable do you get? Do you get to the point of having a

panic attack?
Is this anxiety so intolerable that you would go out of your way to
avoid any social situations?

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Specific Phobia
A specific phobia is easily diagnosed with the questions

Do you have any special fears, such as a fear of insects or a fear of

flying?
Have you ever had a panic attack when you’ve been around this
thing that you fear?

If you get positive responses to these questions, you must further establish that the
specific phobia interferes significantly with psychosocial functioning (Table 25.5).

TABLE 25.5. DSM-5 Criteria for Specific Phobia

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

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Obsessive-Compulsive Disorder
OCD is a commonly overlooked diagnosis because patients rarely volunteer such
embarrassing symptoms without being asked. Thus, including OCD questions as part of
your routine PROS is particularly important.
Begin with the following high-yield screening question:

Do you have symptoms of an obsessive-compulsive disorder, such as

needing to wash your hands all the time because you feel dirty,
constantly checking things, or having annoying thoughts pop into
your head over and over?

Although this may sound like an excessively long question, so much information is
packed into it that if you get a flatly confident “no” in response, you are unlikely to find
OCD by digging further. A “yes” requires further probing, because patients will often say
that they check or wash, but on detailed questioning, they may not meet criteria for OCD
(Table 25.6).

TABLE 25.6. DSM-5 Criteria for OCD

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

For example, if a patient says that he checks things, you must establish that he is
uncomfortably driven to do so:

When you check to make sure the door is locked, do you feel like you

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 really have to check it, and that if you didn’t you’d feel very
uncomfortable?

You must establish that the checking takes up enough of a person’s time to significantly
interfere with day-to-day activities:

How many times do you check the door usually? Is it just once or
twice or do you have to check it 10 or 20 times to be satisfied that it’s
locked?

Patients may present with a number of different types of obsessions and compulsions.
You can often ask about obsessions and compulsions in the same question:

Do you wash your hands excessively because of worries about dirt or

germs?
Do you feel the need to check things around the house because of a
fear that bad things might happen if you don’t?
Do you feel the need to save every little scrap of paper because of a
fear that you’ll need them all sometime?

For mental rituals, ask

Do you often find yourself counting things or naming things for no

particular reason?

To determine the degree of functional impairment caused by the symptoms, you can
ask

How much time do you usually need to get ready to leave the house in
the morning?

A patient with many cleaning and dressing rituals may take 2 to 3 hours or more to get
showered and dressed.

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Posttraumatic Stress Disorder
Because most people have heard of PTSD, the screening question can include the term,
along with a brief definition.

Do you have posttraumatic stress disorder, which means having

memories or dreams of a terrible experience, like being attacked by
someone or surviving a natural disaster?

Researchers have found that listing examples of traumatic events increases patient recall
in PTSD (Solomon and Davidson 1997). If your patient answers “no” to such questions,
PTSD is unlikely. A positive response requires that you establish the presence of the DSM-
5 criteria (Table 25.7).

TABLE 25.7. DSM-5 Criteria for Posttraumatic Stress Disorder

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

What sort of experience was it?

Asking in this general manner, rather than inquiring directly about the experience,
gives your patient permission to answer vaguely, which may be all she can tolerate.
Remember that a hallmark of PTSD is the need to avoid the memory of the trauma; allow
your patient to do this if she needs to.
Once you have established that a traumatic experience occurred, ask about each of the

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criteria.

Reexperience (Remembers)

Does the experience come back to haunt you from time to time?
Have you had nightmares or flashbacks of this experience?

If your patient doesn’t understand what you mean by flashbacks, you can elaborate:

Do you find that you’re remembering the event and you truly feel like
you’re back there again?

Avoidance (Atrocious)

Do you find yourself avoiding things that you associate with the
memory?

Inquiring about specific activities or situations related to the actual trauma is better
than using this general question. For example, if the trauma was a rape, you might ask

Do you find yourself avoiding going out with men to avoid

remembering what happened?

If the experience was an automobile accident, you might ask

Do you avoid driving or even getting into cars because of that

experience?

Negativity (Nuclear): In DSM-IV, this criterion was called “numbing.” DSM-5

broadened it to include not just symptoms of numbing but other kinds of emotional
or cognitive negativity. Many are similar to symptoms of depression, especially
anhedonia and decreased energy. You may have asked about them earlier in the
interview. Others relate to a more general sense of unhappiness (such as fear, anger,
and shame) or a general negative view of oneself and the world.

Since the trauma, has your interest in life gone downhill?

Your patient may describe a diminished range of activities.

Have friendships suffered? Has it been harder to have feelings for

loved ones?
Has your sense of the future changed?

A PTSD patient may respond with “I don’t see any future” or “I don’t even think
about the future.”

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 Do you think the world in general is a good place or a bad place?

While simplistic, this question is good at opening people up to a discussion of how the
trauma has affected the way they see the world.

Arousal (Attacks): As in numbing, many symptoms of hyperarousal are also typical

symptoms of major depression, such as insomnia, difficulty concentrating, and
irritability. Hypervigilance and a startle response are more specific to PTSD.

Since the trauma, have you felt hyper and on edge much of the time?
Do you startle easily?

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 26 Assessing Alcohol Use Disorder

Essential Concepts
Do you enjoy a drink now and then?
Ask CAGE questions.
Do you use any recreational drugs, such as marijuana, LSD, or cocaine?

Recommended time: 2 minutes for screening; 5 to 10 minutes for probing, if screen is

positive.

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 First you take a drink, then the drink takes a drink, then the drink
takes you.
F. Scott Fitzgerald

In an initial diagnostic interview, you will probably not have time to do a complete
assessment of the history, extent, and consequences of a patient’s substance abuse problem.
Such an assessment requires a full session in itself. What, then, are your more limited goals?
There are three:
1. Determine whether your patient meets DSM-5 criteria for alcohol/drug use disorder.
2. Get a sense of the severity of the problem.
3. Determine how the alcohol use interacts with any comorbid psychiatric disorders
present.
The most important tip for beginners is to be nonjudgmental. This requires some
soul-searching because most of us have negative prejudices about substance abusers, and we
tend to see them as being morally suspect. Be aware of the extent to which you hold such
attitudes, and evaluate whether they are accurate. Try to meet with recovered alcoholics.
Their stories are often poignant and will help you to develop a more sympathetic and
compassionate attitude. Learn about the disease model of alcoholism (Vaillant 1995). The
more you can view alcoholism as similar to the other psychiatric disorders you treat, the
fewer prejudices you will retain.

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Assessment Techniques
Screening Questions

TIP
The best quick screen for alcoholism remains the tried-and-true CAGE questionnaire (see
below; Ewing 1984), in which a positive response to two or more of the items implies a
95% chance of alcohol abuse or dependence. However, one study (Steinweg and Worth
1993) suggests that the way interviewers transition to the CAGE questions profoundly
affects the questionnaire’s sensitivity. Researchers divided 43 confirmed alcoholics into two
groups. In group I, the CAGE was introduced with an open-ended question, such as “Do
you have a drink now and then?” In group II, patients were first asked to quantitate their
alcohol intake with the question, “How much do you drink?” Sensitivity toward the CAGE
questions was dramatically higher in group I (95%) than in group II (32%), demonstrating
the importance of beginning the screening in a nonjudgmental way.

CAGE questionnaire:

Cut down: “Have you felt you should cut down on your drinking?”
Annoyed: “Have people annoyed you by getting on your case about your drinking?”
Guilty: “Have you ever felt bad or guilty about your drinking?”
Eye-opener: “Have you ever needed to take a drink first thing in the morning to steady
your nerves or get rid of a hangover?”

Begin your screen with the nonthreatening question:

Do you enjoy a drink now and then?

If a patient answers, “I never drink,” you should ask, “Why not?” Most people of the
American culture have a drink occasionally; people who make a point of not drinking are
uncommon. They may avoid drinking because they are recovered alcoholics, because they
have a family member with a serious drinking problem, or for religious or ethical reasons.
Most people will answer with something like, “Oh, I have glass of wine with dinner” or “I
have a beer when I barbecue.”

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 TIP
Kevin Rice, LCSW, says that “When asking about substance abuse, I find that the word
‘experiment’ almost always elicits a more accurate response than the word ‘use.’ An inquiry
into the possible use or abuse of marijuana would begin, ‘Have you ever experimented with
marijuana?’” (Shea 2007).

Once you have ascertained any use of alcohol of other substances, jump right into the
CAGE questions:
Cut down: Have you ever tried to cut down on your drinking?
A cardinal feature of alcoholism is the loss of control over drinking, and this question
gets at that issue. If the patient answers “yes,” follow up with

What made you decide to cut down?

The answer to this question will likely move you into an exploration of the adverse
consequences of drinking that the patient experienced. (See next section.)
Annoyed: Have you ever been annoyed about friends’ or family’s criticism of your
drinking?
The severe alcoholic will not only have been criticized by loved ones for his drinking
but may have completely alienated most important people in his life.
Guilty: Have you ever felt a little guilty about your drinking?
Again, a positive response is an invitation to further exploration.
Eye-opener: Have you ever felt hungover or shaky in the morning and taken a drink to
get rid of that feeling?
This behavior is a good indicator of out-of-control drinking.
As your final screening question, ask matter-of-factly:

Do you think that you have a drinking problem?

I have been amazed at how many patients answer “no” to all the CAGE questions and
then answer “yes” to this one.
If the patient has answered “no” to the CAGE questions and the drinking problem
question, and if there were no clues to a drinking problem (e.g., the odor of alcohol on the
breath), the patient has no drinking problem, and you can ask the general question:

Do you use any recreational drugs, like marijuana, LSD, or cocaine?

If the patient gives a negative answer to this question, you can move out of the
substance abuse area.

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 TIP
If a patient has admitted to a drinking problem, I have found it useful to ask about other
types of substance abuse by using the interviewing technique of symptom expectation:

Aside from drinking, what sorts of recreational drugs do you use regularly? Cocaine?
Marijuana? Speed? Heroin?

The phrasing here not only communicates the assumption that your patient has used these
drugs but that he uses them on a regular basis; this is an example of symptom exaggeration.
The result is that the patient who abuses these drugs occasionally will feel less ashamed to
admit such use (e.g., “I don’t use them all the time—I’ve gone on a few coke binges, and
I’ve shot dope a few times, but I keep it under control”).

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Probing Questions

DSM-5 Criteria for Alcohol Use Disorder

The following list refers to the mnemonic: Tempted With Cognac. For the diagnosis of
alcohol use disorder, the patient must meet at least two of the following eleven criteria:

Tolerance, that is, a need for increasing amounts of alcohol to achieve intoxication
Withdrawal syndrome
Loss of Control of alcohol use (nine criteria follow):
More alcohol ingested than the patient intended
Unsuccessful attempts to cut down
Much time spent in activities related to obtaining or recovering from the effects
of alcohol
Craving alcohol
Alcohol use continued despite the patient’s knowledge of significant physical or
psychological problems caused by its use
Important social, occupational, or recreational activities given up or reduced
because of alcohol use
Failure to fulfill major role obligations at work, school, or home
Persistent social and interpersonal problems caused by alcohol
Recurrent alcohol use in situations in which it is physically hazardous

Once your screening questions have established that your patient has a substance use
problem, your next step is to use probing questions to definitively establish the DSM-5
substance use disorder diagnosis and to assess severity. One way to approach establishing
the diagnosis would be to go down the list of criteria, beginning with tolerance, and to
simply ask about each one. While this may be time efficient, it tends to produce unreliable
information, particularly in the patient who is ashamed of her addiction or is trying to hide
the extent of it for other reasons.
The better approach is to ask open-ended questions about your patient’s drinking
history and transition to specific questions about DSM-5 criteria as you go along.

Do you remember your first drink?

Alcoholics often remember their first drink vividly and get a twinkle in their eye. For
some, this was the first time they ever felt at peace with themselves.

When did you start drinking frequently?

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 KEY POINT
The earlier alcoholism began the more severe and refractory the problem is likely to have
become. Research shows that 25% of male drinkers have an early-onset form of alcoholism
called type II alcoholism. This is usually inherited from the father and is a particularly severe
form of the disorder, with a high prevalence of violence and comorbid depression and
suicidality (Cloninger et al. 1996).

When were you drinking most heavily?

This question allows you to ascertain the sorts of life situations that have been most
associated with heavy drinking, and it also serves as a good jumping-off point for a series of
questions relating to tolerance, withdrawal, and adverse consequences.

Have you found that you’ve needed more drinks to get the same high?

Frequent drinkers develop tolerance to the effects of alcohol. A general rule of thumb is
that a nonalcoholic person will feel drunk after consuming three to four average drinks on
an empty stomach over the course of an hour (Clark 1981). An alcoholic may require two
or three times that amount.

When you’ve cut down or stopped drinking for a few days, have you
developed problems such as insomnia, the shakes, or convulsions?

You should become familiar with the usual time course and the symptoms of alcohol
withdrawal. Patients generally repeat patterns of withdrawal that they have experienced in
the past. This is important for you to know so that you can decide whether to recommend
inpatient detoxification to a patient who just stopped drinking.

Have you found over the years that you’ve had trouble controlling
your intake of alcohol?

This is essentially a rephrasing of the “cut-down” question of the CAGE, and it gets at
the crucial issue of lack of control of alcohol intake, as expressed in criteria 3 and 4 of the
DSM-5.
The next few questions are directed toward finding out whether alcohol use has had a
negative effect on the patient’s life in some objective way. I stress objective because many
alcoholics will deny that they have a subjective problem; via skillful interviewing, you can
demonstrate that alcohol has caused problems. In this way, your assessment can, in itself,
contribute toward the earliest stage of alcoholism treatment, in which the alcoholic accepts

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that he has a problem.
In an insightful and cooperative patient, you can get reliable information about adverse
effects by asking straightforward questions:

How has your alcoholism affected your relationships? Your work?

Other aspects of your life? Have you gotten into fights or been arrested
because of your drinking?

TIP
When interviewing a patient in denial, however, you will have to obtain this information
indirectly, via the social history and medical history. A severe alcoholic’s social history will
be replete with failed relationships, job changes, and legal difficulties, and his medical
history will be significant for emergency room visits or hospitalizations for alcohol-related
injuries. As you glean such information, gingerly introduce the issue of alcohol use:

You must have felt pretty down when your wife left you.Was drinking any solace for you then?

Note that this is a normalizing question, with the implicit message: “Anyone in a similar
situation might have reached for the bottle; that’s not something to be ashamed of.” If your
patient admits to drinking, follow up with:

Was your drinking an issue with your wife? Did she leave you because of it?

You can use the same technique with other aspects of the social history. When you hear
some clue of alcoholism-related adverse consequences, ask if alcohol was involved.

Finally, once you’ve finished getting the remote alcoholism history, you should ask
about recent use. This will help you to determine the need for detoxification hospitalization
and the extent to which recent alcohol use may be affecting the patient’s mental status. For
these questions, you should try to ascertain quantity of both the amount consumed and the
frequency.

I need to know about how much you’ve been drinking over the past 2
weeks so that I can come up with some good treatment ideas for you.
How many fifths have you been able to put away per day—one? two?
more?

This question combines a number of defusing strategies. First, you introduce the
question by saying why you’re asking it, not to condemn the patient, but to help him.
Second, you appeal to his narcissism by saying “How many fifths have you been able to put

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away?” Finally, you use symptom exaggeration by suggesting a degree of use higher than
you expect: one, two, or more fifths per day.

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“Blame it on the Alcohol” Technique
Another good way of helping your patient ponder ways in which alcohol might have
become a real problem (described by White and Epston 1990) is to give it an exterior
identity, almost as if it were a separate person. This way, you and your patient can join
forces against an outside “enemy.” For example, you can ask such questions as “If it were
possible, would you like to limit the way that alcohol pushes you around? … How has
alcohol been tricking you into withdrawing and avoiding people? … What would life be
like if alcohol weren’t around anymore?”

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Special Techniques in Dual Diagnosis
If your patient has a substance abuse problem, chances are high that he has another
psychiatric disorder, as well. According to the largest American epidemiologic study to look
at this question, 37% of alcoholics and 53% of drug abusers have had another psychiatric
disorder at some point in their lives (Regier et al. 1990). Using a particularly common
example, that of depression combined with alcoholism, two disorders can interact with each
other in two ways: Depression can drive a person to drink, or drinking can cause
depression, either directly via a depressant effect on the nerve cells or indirectly via the
psychosocial chaos that alcoholism causes.
Patients with dual diagnoses are complicated, and you may need to schedule two
sessions to complete your diagnostic assessment. Here are some suggestions for making
these assessments easier. For ease of presentation, I use the example of depression and
alcoholism, but any other dual diagnoses can be approached similarly.

When was your longest period of sobriety?

You want to identify a period of sobriety lasting at least 2 months, preferably longer.
Refer to that period in further questions.

How was your life going during that period? Were you suffering from
depression or anxiety?

Try to determine if the patient met DSM-5 criteria for a major depressive episode
during her sobriety. It doesn’t count if she was depressed for only a few weeks after she
stopped drinking and the depression resolved on its own. That’s the typical course of
alcohol-induced depression. Look for depression that was separated from their alcohol use
by at least 1 month.

Why did you begin drinking again?

Was it because of depression, or just because the temptation to drink
was too great?
Which do you think is a bigger problem for you, alcohol dependence
or depression?

Sometimes, the patient will have a good sense as to which disorder is his central
problem. However, you should be wary of the antisocial patient who tries to convince you
that he is depressed (rather than alcoholic) to obtain disability benefits or a psychiatric
admission.

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 27 Assessing Psychotic Disorders

Screening Questions
Have you had any experiences like dreaming when you’re awake?
Have you had any strange or odd experiences lately that you can’t explain?
Do you ever hear or see things that other people can’t hear or see?
Do you ever feel that people are bothering you or trying to harm you?
Does it seem that strangers look at you a lot or make comments about you?

Recommended time: 2 minutes for screening; 5 to 10 minutes for probing if screen is

positive.

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 A body seriously out of equilibrium, either with itself or with its
environment, perishes outright. Not so a mind. Madness and
suffering can set themselves no limit.
George Santayana

The first important point for novice interviewers is that psychosis and schizophrenia are
not interchangeable. Psychosis is a general term referring to disordered processing of thought
and impaired grasp of reality. As such, psychosis can occur as a part of many psychiatric
syndromes other than schizophrenia, including:

Depression
Mania
Overwhelming stress (brief reactive psychosis)
Dissociative disorders
Dementia and delirium
Substance intoxication or withdrawal
Personality disorders (PDs)

In terms of the rapid diagnostic evaluation, this means that you must ask every patient you
interview, not only those whom you suspect of having schizophrenia, screening questions
about psychotic ideation.
The second useful point, related to the first, is that there are two types of psychotic
patients: (a) those who are obviously psychotic and (b) those whose psychoses are not
obvious. In most outpatient settings, the typical patient will not appear psychotic at first
glance. He will speak coherently, will not volunteer any delusional material, and will not
appear to be hallucinating. However, many of these patients will have a subtle or hidden
psychosis that will require a number of screening questions to uncover. These screening
questions and techniques are described in the first part of this chapter.
On the other hand, patients who are obviously psychotic don’t require subtle screening
questions. Instead, you will ask probing questions to better understand the precise type of
psychosis with which you are dealing. In the second part of this chapter, I define the more
common thought disorders and then describe strategies for ascertaining which are present
in a particular patient.

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General Screening Questions
When you are interviewing a patient who speaks coherently and has a good grasp of reality,
it is tempting to skip questions regarding psychosis. This is a mistake, because hidden
psychosis is common, especially in major depression, dementia, and substance abuse. In
addition, a nonpsychotic patient may have a history of psychosis, which in turn may
influence your diagnosis or treatment.
Two good initial questions are as follows:

Have you had any experiences like dreaming when you’re awake?
Have you had any strange or odd experiences lately that you can’t
explain?

Patients who answer “no” to both of these questions may still be psychotic, and if you
suspect this, you should follow up with

Do you ever hear or see things that other people can’t hear or see?

This asks directly about auditory and visual hallucinations but is more graceful than the
old standby, “Do you hear voices?”

TIP
Not all people who hear voices have a psychiatric syndrome. Epidemiological research has
documented that 3% to 4% of people in the general population report a history of auditory
hallucinations (AHs), and less than one half of them meet criteria for schizophrenia or
dissociative disorder. In one study comparing patient with nonpatient “voice hearers,” the
nonpatients often reported the onset of AHs before age 12, and 93% of them thought that
the voices were predominantly positive (Honig et al. 1998).

Have people been harassing you or trying to harm you?

This question screens for paranoid ideation in a nonjudgmental way. You are not
asking your patient if she is paranoid, but rather whether she feels others are wronging her.
A subtly paranoid patient may welcome this chance to vent her complaints about the
Federal Bureau of Investigation’s (FBI’s) wiretapping activities.

Does it seem that strangers look at you a lot or make comments about
you?

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 This is a screen for ideas of reference, a common psychotic delusion in which the
patient believes that apparently neutral events have a special significance or communication
for her. Ideas of reference can be very subtle and difficult to diagnose, as the following
vignette illustrates.

CLINICAL VIGNETTE

An intern was admitting a 63-year-old widowed woman with major depression. The
patient had become increasingly depressed since her husband died 1 year earlier, and she
had not responded to antidepressants thus far, prompting an admission for more intensive
diagnostic evaluation and treatment. After establishing criteria for major depression, the
intern asked her screening questions for psychotic ideation:

Interviewer: Do you ever feel that people you don’t know are looking at you or making
comments about you?
Patient: No.
Interviewer: Do you ever hear voices or see things that other people can’t see?
Patient: No.
Interviewer: Has anyone been bothering you or harassing you?
Patient: Just the kids in the neighborhood.
Interviewer: What have they been doing?
Patient: What kids do, yelling and carrying on.

At this point, the intern was tempted to drop this topic and move on to another section
of the interview, but she had a vague sense that there was something more to this story than
the “carrying on” of neighborhood kids.

Interviewer: What sorts of things have the kids been yelling?

Patient: Saying bad things about me.
Interviewer: What sorts of things?
Patient: Oh, that I’m a prostitute. That I run a whorehouse. They’re yelling it day and night.

As it turned out, the patient had major depression with psychotic features (AHs and
ideas of reference) and required combination therapy with an antidepressant and a
neuroleptic before she improved.

TIP
You can also make any of these questions sound less threatening by using smooth

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transitions and normalization techniques, covered in Chapters 4 and 6.
For example, your patient has just told you how depressed she has been, and you follow up:

Deep depression sometimes causes people to have strange experiences, such as hearing voices or
feeling that others are trying to harm them. Has that happened to you?

Of course, you can use many other symptoms as springboards for asking about
psychosis, including the following:

Anxiety: Has your anxiety gotten to the point where your imagination is working in
overdrive, so that you hear voices or think people are trying to harm you?
Substance abuse: Have these drugs ever caused your mind to play tricks on you, such
as…?
Dementia: When you misplace things around the house, do you ever suspect that
someone’s been stealing them?

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Probing Questions: How to Diagnose Schizophrenia
There is both good news and bad news about diagnosing schizophrenia. The good news is
that it is fairly easy; the bad news is that we have made it seem complicated by creating a
plethora of colorful, though confusing, terms for describing psychosis. To illustrate, here is
a partial list of terms in current use:

Tangentiality
Circumstantiality
Distractibility
Derailment
Looseness of associations (LOAs)
Disjointed speech
Flight of ideas
Pressure of speech
Racing thoughts
Word salad
Incoherence
Loss of goal
Illogical thinking
Rambling
Thought blocking
Poverty of speech
Poverty of thought
Poverty of content
Nonsequiturs
Perseveration
Clanging
Neologism
Paraphasias
Echolalia
Stilted speech
Self-reference
Persecutory (paranoid) delusions
Delusion of jealousy
Erotomania
Delusion of control
Delusion of guilt or sin
Delusion of grandiosity
Delusion of mind reading
Ideas of reference

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 Delusion of replacement
Nihilistic delusion
Somatic delusion
Thought broadcasting
Thought insertion
Thought withdrawal
Magical thinking
Poor reality testing
Attending to internal stimuli

To begin to simplify this semantic onslaught, it’s helpful to review the basic criteria for
schizophrenia.

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Schizophrenia
The DSM-5 criteria for schizophrenia are listed in Table 27.1.

TABLE 27.1. DSM-5 Criteria for Schizophrenia

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

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Delusions (Disorders of Thought Content)
A common and useful distinction is made between TC and TP. Both TC and TP can be
impaired in psychosis. Impaired TP is covered under the speech disorganization criterion
for schizophrenia later in this chapter. Impaired TC refers to delusional thinking. A delusion
is a belief about the world that most people would agree is impossible. Most delusions fit
into two broad categories: paranoid delusions and grandiose delusions.

Paranoid Delusions
According to a World Health Organization study of 811 individuals with schizophrenia
worldwide (McKenna 1994), paranoia was the most common single delusion, affecting
60% of patients. Paranoid patients believe that people are harassing them, chasing them,
spying on them, spreading rumors about them, or trying to kill them. Large organizations
are frequently thought to be involved, such as the FBI, the Central Intelligence Agency, or
the Mafia. For example, a young man believed that his wife was an undercover FBI agent
determined to kill him for having “blown her cover.”
A number of subcategories of paranoid delusions may or may not be present in a
particular psychotic patient.

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Delusions (or Ideas) of Reference
The patient having delusions of reference believes that casual events have a special (and
usually dangerous) significance in reference to her. Thus, strangers waiting at a subway stop
may be thought to be staring at or talking about her. In its more severe form, the patient
may believe that people on the radio or TV are discussing him or speaking directly to him.

Note
Delusions of reference can also occur as a feature of grandiose delusions but are most
common in paranoia. For example, a woman thought she was being pursued by a hit
squad. At work, she noted that coworkers appeared to be whispering things about the plot
against her. While she was driving, she perceived an elaborate system of communication
among other cars, in which turn signals and headlights were used to indicate her precise
location to the killers.

Following are questions for delusions of reference:

Have you noticed that strangers on the street have been looking at you
or talking about you?
Have you felt that people on the radio or TV were talking about you
in their reports, or giving you special messages?
Do you get any messages from books or newspapers?

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Delusions of Control or Influence
The patient with delusions of control believes he is being controlled by some outside force.
For example, an immigrant from Latin America believed he was being forced to stay in the
United States by the President, who he believed was transmitting ensnaring rays through
his television set.

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Delusions of Replacement (Capgras Syndrome)
A delusion of replacement is a belief that important people in one’s life have been replaced
by impostors. For example, a woman believed that her mother had been replaced by a
stranger who was in league with a fringe religious group attempting to seize possession of
her home.

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Delusions of Jealousy
A delusion of jealousy is a belief that one’s spouse is unfaithful, despite no supporting
evidence.

305
Somatic Delusions
The patient having somatic delusions believes that she has an illness or is being poisoned
despite the absence of medical evidence. If you suspect somatic delusions, you can elicit
them with these questions:

Are you worried about your body?

Do you think you have cancer or another serious disease?
Do you suspect that someone has poisoned you?
Has anyone been altering your medication?
Is a particular person responsible for your physical symptoms?

Note
Many of these questions are also appropriate for assessing somatization disorder, which is
not a psychotic disorder.

Somatic delusions frequently occur as an associated feature of depression.

CLINICAL VIGNETTE

A 38-year-old married woman presented to the emergency room with symptoms of anxiety
and depression. In the interview, she said she was afraid that she had HIV infection and
syphilis, despite several recent normal blood test results. These fears began after an
extramarital affair in which her partner had not used a condom. The patient began to
ruminate about the possibility that she had contracted a venereal disease. She became
convinced that her entire neighborhood knew about it and that, because of this, she had
brought “doom” on her family. These fears led her to consider overdosing on medication as
a suicide attempt.

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Grandiose Delusions
Often seen during a manic episode, grandiose delusions entail the belief that one has special
powers and is accomplishing (or will accomplish) extraordinary things. Two common types
of grandiosity exist: religious and technological.

Religious Delusions
A religious delusion is a very common type of grandiose delusion in which the patient
believes she is God-like. In an example of this, a 40-year-old woman was evaluated in the
emergency room after having been found standing in the middle of traffic holding her
hands high above her head, palms facing oncoming cars. She explained this behavior by
saying she was the Messiah and was healing all the people in their cars during rush hour.
The following questions are for religious delusions:

Do you consider yourself to be a religious person?

Do you have a special relationship with God?
Do you have any special religious powers or abilities?

Technological Delusions
The patient with technological delusions believes that he is somehow connected to
computers or other electrical appliances, allowing him to exert immense power. For
example, a 30-year-old former taxi driver described a business idea. He proposed to
coordinate large fleets of taxis that would be in business with restaurants, theaters, and
workplaces in a large city. Because all of these settings had financial stakes in people’s
arriving and leaving, they would be happy to pay the patient for his services. “I wouldn’t
need any staff,” he continued. “I could do it all myself, through the license plates.” His
intention was to have a transmitter inserted into his brain that could send messages to each
cabbie via receivers in the license plates. In an effort to reality test, it was pointed out to
him that no such device existed. He responded, “I have it already,” pointing to what looked
like a large pimple on his forehead.

307
General Interviewing Tips for Asking About Delusions

Nonjudgmental Questions
The general strategy in interviewing patients you suspect to be paranoid is to portray
yourself as nonjudgmental. If you come across as critical, you are likely to become part of
their delusional system.

Has anyone treated you badly or annoyed you in any way that was
unusual?
Has anyone been paying particular attention to you, watching you, or
talking about you?

Both of these questions imply that you want to become the patient’s ally, rather than
his enemy.

Counterprojective Statements
In some cases, your patient may be so paranoid that he clearly distrusts you, incorporating
you into his delusional system. A counterprojective statement can work well here. In it, you
explicitly acknowledge and sympathize with your patient’s projection (Havens 1986; see
also Chapter 3).

CLINICAL VIGNETTE

Interviewer: What brought you into the hospital?

Patient: (Looking suspicious) You would know, wouldn’t you?
Interviewer: I don’t know. That’s why I’m asking.
Patient: I was forced here for surveillance. The Secret Service is involved. That’s all I’m saying,
because I know my rights.
Interviewer: (Using counterprojective statement) And then here I come, looking all official in
my coat and tie, saying I’m a psychiatrist. … You probably think I’m part of the Secret
Service too, which would be understandable.
Patient: Can anyone hear us?
Interviewer: Nope. The door’s closed.
Patient: Okay, here’s what happened. (Patient opens up significantly.)

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Techniques for Reality Testing
Reality testing refers to your efforts to see how strongly your patient believes in his delusion.
It helps you to determine the severity of a psychotic disorder and also will help you monitor
the patient’s response to treatment. Studies of the natural course of delusions have revealed
three phases (Sacks et al. 1974):
1. An initial phase in which the patient is totally convinced of the belief
2. An intermediate, “double-awareness” phase in which the patient begins to question the
delusion
3. A nondelusional phase
Sensitive questioning will help you determine just which phase your patient is in.
Rather than labeling her belief as delusional, frame the delusion in such a way that it is
normalized.

TIP
Frame delusions in terms of the patient’s imagination:

Do you think your imagination has been getting the best of you?
Has your imagination been working in overdrive?
Have you been imagining things?

Blame it on the mind:

Has your mind been playing tricks on you lately?

Do you think your mind pulled a fast one on you when you thought that?

Ask about fantasy:

Do you think you might have been fantasizing any of this?

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Hallucinations
Hallucinations occur in approximately one half of all patients with schizophrenia (Flaum
1995), but they also commonly occur in depression, bipolar disorder, substance abuse
disorders, dissociative disorders, and dementia.

Have you had any unusual experiences lately, such as hearing voices
when there’s no one else around?

Once you’ve established the presence of AHs, ask in more detail about the quality and
content of the voices. Adopting an interested and curious attitude often helps break the
patient’s guard.

I’ve never heard voices before, and I’m curious what it’s like for you.
Tell me more about these voices. Is there one voice or more than one?
Is it male or female? If I were to put a microphone to the voices, what
exactly would I hear?

Ask specifically if the patient is hearing command hallucinations.

Are the voices telling you to do anything?

Are they saying bad things about you, or telling you to hurt yourself
or anyone else?

Another way to ask about hallucinations is to ask in the context of your questions
about depression.

Sometimes when people get very depressed, their mind plays tricks on
them, and they think they hear things that others can’t hear. Has that
happened to you?

This diminishes the embarrassing nature of a positive response by normalizing the

experience (see Chapter 4).

Have you heard, seen, smelled, or felt things that other people
couldn’t?

Here, you are asking about all the major types of hallucinations in one fell swoop:
auditory, visual, olfactory, and tactile.

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Disorganized Speech
What the DSM-5 terms disorganized speech is also known as disorder of thought process or
formal thought disorder, because there is a disorder of the form, rather than the content, of
thought.
To understand how to recognize a disorder of TP, consider your own thinking style.
When you think or talk about something, you do so in a linear and logical way—that is,
one thought leads naturally to another. In addition, you normally think your thoughts at a
comfortable speed, so that when you are speaking, other people can understand you.
Patients with a formal thought disorder do not make sense, because their thinking is
neither linear nor logical, and there is often a disorder in the speed of their thoughts.
All of the jargon concerning disorganized speech can be fit into one of two clusters: the
LOA cluster and the velocity cluster.

Looseness of Association Cluster

LOA refers to a veering off from the subject at hand. There is a range of severity of LOA,
from circumstantiality at one end to word salad at the other. A patient who exhibits any
one of these qualities to a significant degree fulfills the disorganized speech criteria for
schizophrenia.
Although a number of terms describe different degrees of LOA, the most useful thing
to do clinically is to document that the patient exhibits LOA; describe it as mild, moderate,
or severe; and give a brief example (verbatim from the interview) in the write-up. This
allows you to track the patient’s response to treatment and enables other clinicians who
read your notes to compare their observations with yours.

Circumstantiality
The patient with a circumstantial thinking style makes many digressions in her speech and
adds extraneous details. These digressions are usually related, however distantly, to the
subject matter at hand, and after a while, the speaker will return to that subject matter.
You’ll recognize a circumstantial style because you will feel impatient and will be forced to
interrupt often and redirect to finish the interview within a reasonable period.
Circumstantiality is not necessarily pathologic. Nonpatients who are circumstantial are
popularly termed long winded. College lecturers and great storytellers are famous for
circumstantiality. Within the realm of the DSM-5, demented or anxious patients often
present with circumstantial style.

Tangentiality
Whereas circumstantial speech is basically understandable, though tedious, tangential
speech begins to approach incoherence. Digressions are more abrupt and less obviously

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relevant to the subject at hand. Unlike the circumstantial patient, the tangential patient will
never return to the topic of your question, no matter how long you wait. This usually
indicates either psychosis or dementia.

Example
Interviewer: Have you ever been hospitalized before?
Patient: I went into the hospital in 1992 and again in 1993. I’m a wanderer, and where
people tell me to go, there I will go. Last night, I wandered into the room at the end of the
hall here and there were some flies buzzing around. I told the nurse about it but she didn’t
see that as her job, so I swatted them. Do you have any control over the hygienic
circumstances here?

Here, the patient has veered from the subject of her PPH to that of flies in the unit.
However, she is basically coherent and with frequent redirection will be able to give
meaningful historical information.

Related Term
Rambling: The same as tangentiality, but it is classically reserved for describing demented
patients.

Looseness of Association
LOA is a more severe version of tangentiality. The patient makes statements that lead to
other statements in a very loose way, so that the associative leaps are unclear. There are
clearly associations going on somewhere in your patient’s mind, but you can’t make them
out.

Example
Interviewer: What brings you into the clinic today?
Patient: I don’t know. I might be thrown out. Benito Mussolini actually came alive out in the
waiting room. I figured it out. There was a picture in a book. If it’s not my mother, it
could have been Hitler. What if that was one of his armed guards. Mussolini was hanging
from a tree! Thank you for letting me reason it out. Oh, that’s another thing that I wanted
to talk to you about… being brainwashed. I didn’t buy the Beatles tape, I never did.

The patient is following some pretty disjointed associations in his brain, and it is
unlikely that you will be able to obtain a meaningful history. However, the sentences are
grammatically correct and internally coherent.

Related Terms

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 Derailment: Equivalent term.
Disjointed speech: Equivalent term.
Loss of goal: Refers to speech that doesn’t lead to any particular point and that doesn’t come
close to answering your question; the cause is generally LOA.
Flight of ideas: Refers to LOA when thoughts are moving rapidly.
Racing thoughts: Refers to coherent thoughts that are moving rapidly.

Word Salad
Word salad is an extreme version of LOA, in which the changes in topic are so extreme and
the associations so loose that the resulting speech is completely incoherent. It differs from
LOA in that the digressions occur within a particular sentence, between words, in addition
to between sentences.

Example
Interviewer: How did you end up at the hospital?
Patient: It was a section 8 day. I’m not saying there’s a utilitarian. I just had no patience with
the curfew system.
Interviewer: Why did you go to the halfway house?
Patient: I’m helpless as a savant idiot. There was a circulation of their publicity. Would you
like it?
Interviewer: What kind of work did you do?
Patient: I worked in computer electricities. It was a nondilated baccalaureate. I mean a
nondiluted baccalaureate.

In this case, individual sentences make no sense. You feel almost as though your patient
is speaking a different language.

Related Terms
Incoherence: The direct consequence of word salad.
Non sequiturs: Out-of-context words placed into sentences.
Neologisms: Spontaneously made up words that often accompany word salad; “nondiluted
baccalaureate” is an example.
Clang associations: Associations based on the sounds of words.

Velocity Cluster
In addition to an impaired ability to associate one thought with another, psychotic patients
often show an abnormality in the speed or rate of production of their thoughts. This ranges
from mutism at one end of the continuum to flight of ideas at the other.

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Mutism
A patient exhibiting mutism simply will not speak. This may mean that he is having few, if
any, thoughts, which can occur as a negative symptom of schizophrenia. It can occur in the
catatonia of affective disorders. Mutism may also be a response to a delusional system.

Example
A young woman who was admitted to a psychiatric unit remained mute for several days
until she began responding to antipsychotic medication. She later related that she had been
told by God that her absolute silence was the only thing preventing the collision of matter
with antimatter and the consequent annihilation of the world.

Poverty of Thought
Your patient has poverty of thought if he offers very little spontaneous speech and if his
answers to questions are with the minimum number of words required. You have to
distinguish this type of psychotic patient from the angry and resistant patient who is
admitted involuntarily to a hospital unit or who is under court order to seek therapy. The
psychotic patient will often show other negative symptoms of schizophrenia, such as poor
hygiene, flat affect, or a history of social isolation.

Example (from Andreasen 1979)

Interviewer: Were you working at all before you came to the hospital?
Patient: No.
Interviewer: What kinds of jobs have you had in the past?
Patient: Oh, some janitor jobs, painting.
Interviewer: What kind of work do you do?
Patient: I don’t. I don’t do any kind of work. That’s silly.
Interviewer: How far did you go in school?
Patient: I’m still in eleventh grade.
Interviewer: How old are you?
Patient: Eighteen.

Related Terms
Poverty of speech: Equivalent term.
Lack of spontaneous speech: Equivalent term.
Thought blocking: Your patient begins to say something, then stops in midthought and
forgets what he was going to say.

Interviewing Strategies

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You will recognize poverty of thought easily. You will find yourself asking questions far
more frequently than usual, because the patient provides no information beyond a minimal
response to each question. It is often difficult in these patients to discover whether there are
any positive symptoms of schizophrenia, such as delusions or hallucinations. One way to
elicit a flow of spontaneous speech is to ask open-ended and provocative questions about
general topics:

What do you think about the legalization of marijuana?

Who was your favorite teacher in high school?
What kind of person are you?
Do you believe in God?

Poverty of Content
Your patient may produce a copious amount of speech but somehow communicate very
little information or discernible meaning. This is usually because the speech is overly
abstract.

Interviewer: Why do you think it would be better for you to move out of your mother’s house?
Patient: It would be exactly because of the things we were talking about before, and which I
was talking to some of the other counselors about. I think we were talking about supervised
housing and that would be related to how I might find another place to live, away from my
mother, and that would change who I would communicate with. Of course my mother is a
person and she would like to communicate with me, and I communicate with her all the
time. I think the difference is that it would be a different situation and in a different place.
I would have to talk to my case worker about moving. I’m sure my mother wants it, too.

You find yourself scratching your head. Your question hasn’t been answered, but not
because the patient has veered away from the topic of moving, as in LOA. His response has
remained on topic, but he hasn’t said anything meaningful about it.

Related Term
Perseveration: Your patient talks but dwells on a single idea or preoccupation over and over.
This can be seen in both OCD and dementia, as well as in psychosis.

Racing Thoughts
Racing thoughts refers to the subjective sense of one’s thoughts going so fast that they’re
hard to keep track of, which may or may not be associated with pressured speech. Some
patients who are not talkative report having racing thoughts, often occurring with anxiety.
Racing thoughts also occur commonly in substance-abusing patients undergoing
detoxification. To ascertain the presence of racing thoughts, ask:

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 Are you having trouble keeping up with your thoughts?
Are your thoughts moving so quickly that you can’t keep up with
them?

Related Term
Pressured speech: This is very rapid speech that is difficult to interrupt and is often loud and
intense. When racing thoughts are converted directly into speech, the result is pressured
speech, and the diagnosis is almost always mania.

Example
Interviewer: How did you come into the hospital?
Patient: (While pacing back and forth in her room) I could remember taking care of business. I
felt like I was here, there, and everywhere. I know I was not sick, because a sick human
cannot remember everything there is to remember, like that (she snaps her fingers), and I
could, and do you know why? Ask the Master, the Master is everywhere, the Master knows
everything, the Master is God, and that’s why I’m still here. …

Flight of Ideas
Flight of ideas is a special case of LOA when the incoherent associations occur very rapidly.
As such, it is not necessarily equivalent to either pressured speech, which can refer to quite
coherent but rapid speech, or racing thoughts, which can also be coherent.

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Disorder of Behavior (Disorganized Behavior)
Disorganized behavior is diagnosed primarily by observation during the interview, although
obtaining information from outside sources is often helpful. Observational clues include
poor grooming, body odor, and bizarre clothing combinations. Another clue can be
obtained by asking your patient to complete a simple task. This can be done in the context
of the cognitive examination (see Chapter 21) or simply by asking your patient for his
insurance or appointment card. A typically disorganized patient will pull out a torn,
bulging purse or wallet and will rummage through a seemingly random array of material
before finding anything.

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Paucity of Thought, Affect, and Behavior (Negative
Symptoms)
Symptoms of schizophrenia have been classically divided into positive symptoms (e.g.,
delusions, hallucinations) and negative symptoms (e.g., flat affect, apathy, asociality,
poverty of speech) (Andreasen 1982). The patient with negative symptoms will tend to say
very little, speak slowly, show very little affect, have few spontaneous movements, and be
poorly groomed. His social history will reflect lack of motivation and inability to persist in
school or work activities. Family members may report that he spends most of his time
sitting around, doing little, and that he has few, if any, friends.

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 28 Assessing Neurocognitive Disorders
(Dementia and Delirium)

Screening Questions
Orientation
What’s your full name?
Where are we right now?
What’s today’s date?
Short-term memory

Repeat these three words: ball, chair, purple.

Keep them in mind, because I’m going to ask you to repeat them in a couple of minutes.

Personal and general information

Name the last three presidents.
Who was George Washington? Abraham Lincoln? Martin Luther King, Jr.?
Shakespeare?
When was World War II? When was John F. Kennedy assassinated?
What’s your address and phone number?
What are your spouse’s/children’s/siblings’/parents’ names and birthdays?
When and where were you married?

One of the major terminology changes of DSM-5 was to classify dementia and delirium as
“neurocognitive disorders.” Delirium is still called delirium, but dementia has now become
“major neurocognitive disorder,” while a milder form of dementia has been called “mild
neurocognitive disorder.”
In Chapter 21, I outline a rapid cognitive examination with components based on
studies showing them to be effective in identifying patients with cognitive deficits. In this
chapter, I show you how to tailor your questions to the patient who may have either
delirium or dementia. In delirium, attention is impaired, and all of the cognitive processes
are therefore also impaired. In dementia, attention is intact, but the cognitive processes,
particularly memory, are impaired.
With this in mind, let’s look at the DSM-5 criteria for both dementia and delirium and
then review interview techniques for making the diagnoses.

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Delirium
Impaired Attention
The key to diagnosing delirium is establishing an impairment in your patient’s attention. A
delirious patient has difficulty sustaining his attention for a significant period. As in
Chapter 21, I discourage reliance on traditional and unproved tests of attention, such as the
subtraction of serial sevens test (SSST), and instead encourage you to rely on your patient’s
ability to respond to routine questions (Table 28.1).

TABLE 28.1. DSM-5 Criteria for Delirium

Adapted from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

Most of your interviews with delirious patients will occur in a hospital setting, often
when you have been asked to see the patient by the primary care physician. In such settings,
there are two types of delirious patients: the loud and the quiet. The loud delirious patient
will typically be rambling incoherently and may be struggling against restraints in an effort
to leave the hospital bed or to pull out intravenous lines.
The quiet delirious patient, on the other hand, requires some verbal probing to make a
diagnosis. It’s often helpful to begin by saying nothing—that is, by walking into the room
and observing your patient’s behavior. A person with normal cognitive abilities will
generally look at you and make some kind of greeting and then wait for you to respond. A
delirious patient may glance at you briefly and then pay little attention to you. He may be

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talking softly to himself. He may be looking all around the room, tracking a hallucinated
bird or insect.

Hello, Mr. Brown. What brings you into the hospital?

The patient should be able to answer coherently. If the patient answers incoherently,
you have to assess the nature of the incoherence. In many mental disorders, the patient’s
attention is normal, but the TP or TC is disordered in some way.
Of the following three clinical vignettes, for example, only the third describes true
delirium.

Clinical Vignette 1

A hospitalized psychotic patient gave me this answer:

I got tricked into this, but I won’t complain, because exactly at this
moment, there are stereoscopic beams coming into this room from
transmitters, and they are focused on my brain cells. Please stay still,
because the beams are coming around you now.

On further questioning, it was apparent that the patient was suffering a fixed, bizarre,
paranoid delusion, but his attention was quite intact.

Clinical Vignette 2

Another patient responded with the following:

This is no hospital, this is my home, because I can see my

granddaughter out there. She was just about to bring me in some tea.
Oh, I know you. You’re that man they sent in to help me.

The patient had a profound impairment of short-term memory, secondary to

Alzheimer’s dementia. She could not remember that she was in a hospital, but her attention
was intact.

Clinical Vignette 3

A truly delirious patient responded:

Hello! (He looked up at the ceiling.) Something… what is that? (He

was quickly oblivious to my presence. I asked again why he was in the

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 hospital.) I’m in the hospital for… (He looked confused.) There’s
something here in the hospital, my son said… (He looked at me
again as if scrutinizing me, then turned away, again seeming to
forget about my presence as he looked at the ceiling.)

The patient seemed to understand my words, but he had no ability to maintain his
attention to me or to continue a single train of thought. As it turned out, the patient was in
delirium tremens after having abruptly stopped his prescribed alprazolam (Xanax) 3 days
earlier.

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Change in Cognition
Almost all delirious patients will have great difficulty with the three-object recall task, as
their attention is too impaired to register the words in the first place. Visual or auditory
hallucinations are also extremely common.

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Recent Onset and Fluctuating Course
You have to rely on gathering history from sources other than the patient to ascertain that
the onset of the cognitive impairment has been relatively recent (days to weeks), excluding
the diagnosis of dementia. With regard to fluctuations in attention, the best way for you to
determine this is to examine the patient at least twice during the day. If you can’t see the
patient again, ask other caregivers to report whether she was able to coherently answer
simple questions (e.g., “Why are you here?”).

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Neurocognitive Disorder
Interviewing Family Members
Interviews with family members and other informants are vitally important in making the
diagnosis of neurocognitive disorder (NCD) (Table 28.2). This is because the patient
himself will often deny or minimize his memory problem and, at any rate, an affected
patient’s self-reported history will be unreliable. Therefore, the best way to diagnose NCD
is by combining the MSE with interviews of informants. In fact, studies that have
compared the two approaches (the MSE vs. informant questionnaires) have found
informant interviews to be the more sensitive of the two (Harwood et al. 1997).

TABLE 28.2. DSM-5 Criteria for Dementia

Adapted from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

When you interview family members, you should begin by asking them to compare the
patient’s current cognitive abilities with the patient’s abilities of 10 years ago. This will put
the focus on a gradual decline in functioning, which is what differentiates NCD from
delirium.
The general form of your questioning should follow the format of the Informant
Questionnaire on Cognitive Decline in the Elderly (IQCODE; Jorm 1991), from which
most of the following questions are derived. Ask the following questions:
Compared with 10 years ago, how is this person at:

Remembering things that have happened recently?

Remembering where things are usually kept?
Remembering things about family and friends, such as names, occupations,
birthdays, or addresses?

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Making decisions on everyday matters?
Handling financial matters?
Finding the right word when talking about things?
Knowing how to do everyday things around the house, such as cooking and cleaning?
Following social cues, such as making appropriate comments in conversations? Has
there been a personality change?

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Interviewing the Patient
In order to diagnose an NCD, DSM-5 requires you to demonstrate that your patient is
significantly impaired in at least one of six “neurocognitive domains.” The domains are as
follows:
1. Memory
2. Complex attention
3. Executive function
4. Language
5. Perceptual-motor
6. Social cognition
For those of you used to DSM-IV, you’ll notice that diagnosing dementia is now more
complicated. It used to be that the key piece of the diagnosis was a memory impairment,
followed by one of four other impairments. But with DSM-5, memory impairment is no
longer a requirement, and you have to assess the six domains, some of which are somewhat
confusing.
1. Memory. Though DSM-5 may longer require memory loss for the diagnosis, it would
be the very rare person with dementia who does not have this impairment. I suggested
an approach to assessing memory in Chapter 21, which I won’t repeat here. Remember
that before you go too far in your examination, do your basic delirium screen (see
above). If the patient is delirious, you won’t be able to conclude anything about NCD
based on the examination; if the patient is awake and attentive, proceed with the rest of
the cognitive examination as outlined in Chapter 21.
2. Complex Attention. Problems with complex attention are different from the impaired
attention that we see in delirium. The patient might be able to sustain attention long
enough to have a simple conversation with you (unlike the delirious patient). But put
them in a situation with multiple sources of stimuli at the same time, the attentional
abilities get stressed. You will have a hard time establishing this by talking to the
patient, but high-yield questions to ask informants include:

Does he tend to get easily distracted from a conversation when other

things are going on in the room, like other conversations, or music, or
kids playing?
Does she seem to have a harder time focusing on tasks that used to be
simple, like repeating a phone number that she just heard, or writing
down something while taking on the phone?

3. Executive function. Here, you are testing a complex ability—the ability to plan and
think abstractly. A deficit in executive functioning will often come through during the
history. This is especially true if the patient was employed as the dementia began. You
will hear about job difficulties, inefficiencies accomplishing tasks that were once easy,

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 and the like. Occasionally, it may be difficult to distinguish this from the personality
changes that occur in dementia—new-onset indifference and irritability can play havoc
with job performance, especially in service-oriented jobs.
To test executive functioning, you can use the three-step command (described earlier).
However, the classic screening test for this is the clock-drawing task, in which you give the
patient a sheet of paper with a circle and a dot in the center and tell her

I’d like you to write in all the numbers of a clock and then to draw
in the hands to represent 2:30.

Patients with poor executive function may exhibit a number of different errors, such as
bunching numbers too closely together, skipping or repeating numbers, or drawing the
hands incorrectly. One potential problem with this task is that performance varies by
education (Ainslie 1993). Thus, you should give it only to patients with at least some high
school education. Otherwise, you may falsely interpret a poor clock as meaning that a
patient is cognitively impaired, when in fact he is merely poorly educated.
4. Language problems (also known as aphasia). The most common language problem in
dementia is a difficulty finding the right word for something. If present, word-finding
difficulty will have become apparent over the course of the interview. In mild cases, the
right word seems to be on the tip of the patient’s tongue:
Interviewer: Who was George Washington?
Patient: Oh, he was that man, the uh… top man of the whole thing.
Interviewer: What do you mean by the “top man”?
Patient: The whole country voted for him.
Interviewer: Do you mean the “president”?
Patient: Right! The president!
A specific screening test for aphasia is to point out common objects in the room and
ask your patient to name them (e.g., your pen, your watch, or a chair). However, doing so
will only pick up severe cases of aphasia. Interviewing informants is often an excellent way
to pick up an early aphasia.
5. Perceptual-motor problems (often termed apraxia). This refers to difficulty
accomplishing simple, everyday activities despite an intact nervous system. Think of it
as a kind of behavioral confusion. Apraxic patients may have difficulty getting dressed
in the morning because they have forgotten how to button clothes or tie shoes. Or they
may have problems driving correctly, whereas in that past, driving was taken for
granted. The best way to determine if this has been a problem is by asking family
members questions such as

Does your father have problems getting dressed on his own?

Does he need any help with shaving or putting on a tie?
Can he throw a sandwich together easily?

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 You can sometimes assess apraxia during the interview by observing your patient doing
something (e.g., pulling her hospital registration card from her wallet), or you can ask the
patient to write down your office phone number and observe her ability to procure a piece
of paper and pen and correctly write down the number.
The Folstein MMSE includes a standard three-step command for assessing apraxia:

Now I want to see how well you can follow instructions. I’m going to
give you a piece of paper. Take it in your right hand, use both hands
to fold it in half, then put it on the floor.

6. Social cognition. This is DSM-5’s jargon for what we sometimes call “personality
changes.” As dementia develops and worsens, patients have problems reading social cues
and behaving appropriately. They may withdraw from conversations or bring up
awkward things, like topics relating to sex, politics, or religion. You may observe this in
your conversation with your patient, and you can ask informants if this has become a
problem.

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29 Assessing Eating Disorders and Somatic
Symptom Disorder

Screening Questions
Eating disorders: Have you ever thought you had an eating disorder, like anorexia
or bulimia?
Somatic symptom disorder: Do you worry a lot about your health?

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Eating Disorders

KEY POINT
Eating disorders are relatively easily diagnosed (Tables 29.1, 29.2, and 29.3). The problem
is that many clinicians don’t ask about them, and many sufferers don’t volunteer their
symptoms, either because they aren’t bothered by them, as in anorexia, or because they’re
too ashamed of them, as in bulimia and binge eating disorder. Therefore, screening
questions for eating disorders should always be included in your PROS.

TABLE 29.1. DSM-5 Criteria for Anorexia Nervosa

Adapted from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

TABLE 29.2. DSM-5 Criteria for Bulimia Nervosa

Adapted from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

TABLE 29.3. DSM-5 Criteria for Binge Eating Disorder

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Adapted from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

When time is truly of the essence, you can begin with a direct question:

Have you ever had an eating disorder, such as anorexia or bulimia?

However, if you have the sense that your patient may be particularly ashamed of a
suspected eating disorder, a too blunt approach might endanger the therapeutic alliance. In
these cases, you can approach the issue more indirectly:

Have you ever thought you were overweight?

If the answer is “no,” it is unlikely that your patient has an either anorexia or bulimia.
If the answer is yes, and you suspect anorexia, ask:

Have you ever dieted?

Almost everyone, and women in particular, has dieted at some point. You’re probing
here for a particularly severe diet, perhaps a starvation diet (i.e., fasting) or a diet in which,
for example, the patient ate only salad or fruit.

Have you ever weighed much less than people thought you should
weigh? What was your lowest weight? And what is your height?

You want to determine what your patient’s lowest body mass index (BMI) was. The
BMI is calculated as a person’s weight in kilograms divided by the height in meters squared.
There are plenty of free online BMI calculators. While DSM-IV required that a patient’s
weight be no more than 85% of the ideal body weight to qualify for anorexia, that’s no
longer the case with DSM-5. Instead, there are suggested BMI benchmarks to help you to
judge the severity of the disorder, which are printed in the DSM-5.

Did you think you were overweight at your lowest weight?

Anorexic patients will report feeling overweight, even obese, at a weight that is far

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below their ideal weight. Often, the patient will fixate on a particular body part, such as the
thighs or the stomach.

Were you afraid of gaining weight?

For both bulimia and binge eating disorder (BED), good screening questions are:

Have you ever felt like your eating was out of control?
Do you have eating binges when you eat a large amount of food than
you should and feel like you can’t stop eating?

TIP
You have to be somewhat skeptical of a “yes” answer, because what the patient considers a
binge may seem like a normal meal to someone else. Ask your patient to describe the
contents of a typical binge and decide whether it seems like an unusually large meal.

If she binges, ask if she has ever purged afterward.

After you’ve binged, have you ever gotten rid of the food in some way,
such as vomiting or taking laxatives?

Establish the frequency of the behavior with a symptom exaggeration question:

At the most, how often were you binging and purging? Once a day?
Twice a day? More?

If the patient has binged but has never purged, then you should ask some or all of the
following questions to rule in or out BED.

Tell me a little more about your binging. Do you eat quickly? Do you
eat to the point of feeling too full? Do you binge alone? Do you feel
bad about yourself afterward? Do you ever binge even though you’re
not hungry?

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Somatic Symptom Disorder and Illness Anxiety
Disorder
In DSM-IV, somatization disorder, or hypochondriasis, was used to diagnose patients who
worried excessively about multiple somatic symptoms—which were medically unexplained.
DSM-5 has abolished somatization disorder, substituting two different diagnoses, which
differ in subtle ways:

Somatic symptom disorder (SSD) refers to people who have actual somatic symptoms
(which may or may not be caused by an established medical problem) but who are so
excessively preoccupied with the symptoms that they have problems functioning
(Table 29.4).
Illness anxiety disorder refers to people who do not actually have somatic symptoms but
who are extremely worried that they have an illness—in the absence of any medical
evidence that they do (Table 29.5).

TABLE 29.4. DSM-5 Criteria for Somatic Symptom Disorder

Adapted from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

For either disorder, an excellent screening question is

Do you tend to worry a lot about your health?

If the patient says “no,” you can avoid the probing questions. If he says yes, proceed as
below. In truth, a patient with either disorder will have likely already hinted at the problem
when you elicited the history of present illness (HPI), much of which will have been
devoted to discussions of health issues.
Your next job is to determine if there are any actual symptoms.

You mentioned that you worry about your health. What health issues
are you worrying about? What kinds of symptoms do you have?

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 The patient with SSD will launch into a list of somatic symptoms, like pain, fatigue,
diarrhea, palpitations, and the like. On the other hand, the patient with anxiety illness
disorder will not provide much information about specific symptoms and will instead say
something like: “It’s pretty vague, I just know I’m sick and I’m pretty sure it’s cancer.”
As you can see, it can be hard to differentiate between these two conditions. Generally,
patients who used to qualify for “somatization disorder” (which required at least seven
discrete somatic symptoms) will likely be diagnosed with new disorder, SSD. Patients with
the new illness anxiety disorder may describe some symptoms as well, but the symptoms
will be described more vaguely and there won’t be as many of them.
The somatic disorders were reorganized in this way not in order to confuse us—though
that will surely happen. The major impetus was to remove some of the stigma that has
become attached to somatization disorder and the derogatory label “hypochondriac.” Such
patients are often made to feel that their symptoms are “all in their head,” when in fact they
actually do perceive symptoms, along with an overlay of anxiety that makes the symptoms
feel worse.

TABLE 29.5. DSM-5 Criteria for Illness Anxiety Disorder

Adapted from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

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 30 Assessing Attention Deficit
Hyperactivity Disorder

Screening Question
When you were young, did you have problems with hyperactivity or with paying
attention in school?

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Attention Deficit Hyperactivity Disorder
Patients must meet either criterion 1 or criterion 2 (must have six of nine
disorganization/inattention symptoms or six of nine impulsivity/hyperactivity symptoms—
but for those aged 17 or older, the threshold number of symptoms is lowered to five of
nine) plus criteria 3 and 4 (Table 30.1):

TABLE 30.1. DSM-5 Criteria for Attention Deficit Hyperactivity Disorder

Data from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed.
Washington, DC: American Psychiatric Association.

1. Organization/inattention
Organization problems

Can’t organize tasks

Loses things needed for tasks
Has problems finishing tasks
Attention problems
Poor focus
Easily distracted
Doesn’t listen
Forgets easily
Makes careless mistakes
Avoids tasks requiring concentration

2. Impulsivity/hyperactivity symptoms

Talks too much

Blurts out answers
Interrupts others
Can’t play quietly
Movement excess
Fidgets and squirms
Leaves seat
Is restless

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 Is on the go
Can’t wait for his turn

3. Some symptoms must have been present before age 12.

4. Symptoms occur in two or more settings, such as school (or work) and at home.
ADHD is one of those disorders, such as panic disorder, that involve a long list of
criteria, making it impractical to memorize each one. To make matters more confusing,
many of the criteria are so similar as to be redundant (e.g., is there really a difference
between “often fails to pay close attention” and “often has difficulty sustaining attention”?).
Therefore, as was true for panic disorder, the most rational approach is to clump criteria
into meaningful clusters by using a mnemonic, in this case MOAT.
To meet the criteria, your patient must have six of nine symptoms of
inattention/disorganization or six of nine symptoms of hyperactivity/impulsivity.

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Attention Deficit Hyperactivity Disorder in
Children
Although it may seem counterintuitive, diagnosing ADHD is generally easier in children
than in adults. This is because children and adolescents come to the appointment with an
adult who is (hopefully) a reliable source of behavioral information. Also, one of the key
difficulties in establishing the diagnosis in adults is documenting that symptoms occurred
as a child; this is a nonissue when you have a living, breathing child in front of you!
For tips on evaluating adolescent patients, review Chapter 10. Generally, you’ll begin
your evaluation with family in the room. The parents have brought their child to you for
an ADHD evaluation, so get right down to it:

So what makes you think Johnny has ADHD?

Parents will often come bearing testing reports from the school and will also often have
misconceptions about how easy (or hard) the condition is to diagnose. (“We’re not sure
whether or not Johnny has ADHD, and we were hoping you could test him for it. Do you
do testing here?”)
Now it’s time for some basic psychoeducation about ADHD. The diagnosis is based on
a synthesis of different people’s reports and observations of the child, and there is no
definitive “test” apart from good interviewing and deduction.

What we’ll do today is talk about Johnny’s behavior, both at home

and at school, and based on that, we’ll come up with a good idea of
whether he has ADHD.

The essence of the diagnosis is asking about all the DSM-5 criteria, and the approach
that works best for me is to simply photocopy the DSM-5 criteria for the parents and
patient to look over, and to go down the list, asking about each one in turn. You can read
the criteria verbatim, or you can paraphrase it to make it more understandable, depending
on the sophistication of your informants.
For example, for organization problems, you would say something like

Does Johnny not pay close attention to details, or does he make

careless mistakes at school or at home?

For each criterion, I try to establish not only that it happens but that it happens in two
different settings, and I also ask for a specific example to assess how significant the
symptom is. I recommend writing all these examples down; later, after treatment has
begun, it’s very helpful to go through all these examples to assess how much better things
are than before you worked your treatment magic!
Once you are done, you can say:

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 Well, it looks like Johnny definitely meets diagnostic criteria for
ADHD, because as you can see, he has almost all the symptoms listed
here.

Occasionally, you’ll be able to observe blatant hyperactivity (12-year-old tearing around

your office, causing damage to the cherished painted giraffe you bought in Oaxaca), but
usually not. Certainly, if the patient has ADD without the “H,” it’s very hard to notice
poor focus in a highly charged and focused setting like a psychiatric office.

KEY POINT
As you ask the DSM-5 questions, remember that many psychiatric disorders other than
ADHD can cause problems of impulsivity or concentration, including substance abuse,
depression, mania, and anxiety disorders (Biederman 1991). If a child meets only a few
ADHD criteria but is still causing the parents’ conniption fits, move your questioning to
these other diagnostic categories.

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Attention Deficit Hyperactivity Disorder in Adults
Adult ADHD has become quite the rage in recent years. Some days, it seems that every
other patient entering your office ends up wondering if they should try methylphenidate
(Ritalin), which seems to work so well for their son or daughter. Unfortunately, it is easy to
feign symptoms of ADHD, and one study found that a quarter of adult patients either
feigned or exaggerated ADHD symptoms, presumably in order to get a prescription for
stimulants, which are highly abusable (Marshall et al. 2010).
DSM-5 made it easier for adults to qualify for the diagnosis in two ways: first, the
required onset of symptoms was moved from age 7 to age 12; second, the minimum
threshold of required symptoms was lowered from 6 to 5 for adults but not for kids. For
tips on figuring out if a patient is malingering, review Chapter 9.
As usual, begin with some screening questions:

When you were in elementary or junior high school, did you have
problems with hyperactivity or paying attention in class?

If the response is positive, ask

Do you still have those sorts of problems?

If the answer is negative, it’s probably not worth your time to continue with probing
questions to verify an old diagnosis of ADHD. If the answer is positive, move on to
questions establishing the diagnosis. You can whip out the DSM-5 criteria as was
recommended above, or you can ask questions in a less structured fashion, starting first
with questions pertaining to inattentiveness and then moving on to questions about
impulsivity.

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Inattentiveness and Disorganization
Do you have a hard time paying attention to things?
Do you have trouble concentrating?

Some patients find that they are able to concentrate on engaging tasks, such as
watching a football game or reading a tabloid, but not on tasks that are less fun, such as
writing a report at work or studying for school.

Are you distractible?

Because many people will not know what this means, you might need to follow up
with

Do you know what that means? It means that you can’t listen to the
teacher if the guy next to you is talking or if something’s happening
outside the window.
Do you have a hard time finishing things?

Some patients may not think of their problem as inattentiveness, but they do find that
they get distracted in the middle of a task and don’t finish projects. If the patient’s parent is
present, ask

Was he the type of kid who, if you said, “Go to your room and get
your shoes,” wouldn’t come back because he got interested in
something else and forgot about the shoes?

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Talking Impulsively and Hyperactivity
Were you the class clown?

The typical ADHD patient will break into a smile and say, “Oh yeah, let me tell
you…” and may describe some choice antics. A variation on this question is

When you were in class, was the teacher always having to say to you,
“Now, Johnny, you need to stop doing this or that”?

Some patients will say that they are hyperactive when what they mean is overly
energetic, as in a manic episode, or anxious. Ask your patient for his definition:

What do you mean when you say that you’re hyperactive?

Provide your own definition, if necessary:

By hyperactive, I mean a feeling that you can’t sit still, almost as

though you had a little motor running inside you all the time that
you can’t turn off.

Other specific questions to ask include

Do you have a hard time keeping still?

Do you tend to be fidgety?

Although hyperactivity in children may be observable during an initial session, in

adolescents and adults it presents more subtly. You may observe constant foot tapping or
rapid hand gestures. The personality style will often be characteristic—outgoing, chatty,
and lively—although these are hardly diagnostic of ADHD and are reminiscent of mania.
To ask about impulsive talking, a good question is

Is it easy for you to sit quietly at meetings or in class, or do you tend

to blurt things out a lot?

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Formal Rating Scales and Family Interviews
Interviewing a patient’s parents (even when the patient is an adult) will always make an
ADHD diagnosis easier. Often, the parent will say, “Oh yes, he was diagnosed with
ADHD in school,” and will brandish psychological test reports.
The most common rating scale is the Conners’ Scale, available through school systems
and in most institutional child psychiatry departments. If a parent or spouse is present,
complete the scale with him during the initial visit. In addition, give the patient a copy to
take home to be filled out by a teacher or employer. Remember that you have to establish
that your patient’s symptoms occur in at least two different settings to make the diagnosis
of ADHD.

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 31 Assessing Personality Disorders

Essential Concepts
Use the ground-up technique to assess for PDs from the social history.
Use the symptom-window technique to assess for PDs that might be linked to
specific symptoms.
Memorize self-statements, probing questions, and mnemonics for each disorder.

The DSM-5 emphasizes the medical model of psychiatric disorders. Each disorder is
presented as though it was a discrete syndrome that a patient “has,” in the same way that
she might “have” diabetes or asthma. Most clinicians realize that this is a simplistic view
and understand that each patient has an underlying personality that interacts and often
contributes to the formation of a psychiatric syndrome. Earlier versions of DSM included
an “Axis II,” which was specifically for personality disorders (PDs), and served the useful
function of forcing to at least give some thought to every client’s personality traits. While
DSM-5 eliminated the diagnostic axes, it still goes to great lengths describing PDs and
includes a new section on an alternative model for PDs. While interesting, this model is
complex and still under review and is not something you need to know (yet) in evaluating
your patients.
PDs are notoriously difficult to diagnose. It is the rare clinician who can confidently
conclude after a single interview that a patient has a PD. Thus, this chapter does not
assume that you will be able to diagnose a PD quickly, but rather that you will be able to
formulate some good hypotheses. Such hypotheses are usually noted in the chart as “rule
out_____personality disorder.”

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Two General Approaches
Two general strategies are useful for assessing PDs in the interview. They are not mutually
exclusive, and clinicians commonly use both over the course of the evaluation.

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Strategy 1: The Ground-Up Technique
In the ground-up technique, you gradually fashion a picture of your patient’s personality by
working from the ground up—that is, by learning about her life history chronologically in
the context of the social and family history. As outlined in Chapter 18, the formal social
history often begins with a general question about family life.

Tell me a bit about what growing up was like for you.

As you ask chronologic questions about your patient’s life, especially those aspects of
life that involve interpersonal relationships, try to identify any dysfunctional patterns of
relating. Recurrent patterns are the hallmark of PDs. Memorize one or two probing
questions for each PD (see the following examples) and ask them at appropriate times.
A typical example is the patient who relates a pattern of having had few close
friendships throughout the early years of his life. Depending on the patient’s behavior
toward you during the interview (see the section on Behavioral Clues), you may have some
hypotheses about which PD is most likely. Perhaps, the patient appears anxious and shy
during the interview, leading you to suspect avoidant PD. You would then ask a probing
question, such as

Have you tended to have few friends in your life because you didn’t
want to have friends, or because you were scared of getting close to
someone who might reject you?

Using the ground-up technique, you will usually be able to arrive at a good hypothesis
for a PD or personality traits.
Consider the following example.

CLINICAL VIGNETTE

The interviewer is asking a patient about his work history:

Interviewer: What sorts of jobs have you had?

Patient: I’ve had a whole bunch of different jobs. I don’t stick with any one job for very long.
Interviewer: What usually happens with these jobs?
Patient: I usually quit, because the people I work with end up backstabbing me.

At this point, the interviewer suspects paranoid PD and asks the probing questions.

Interviewer: Have you found in your life that people have turned against you for no good
reason?
Patient: Yeah, beginning with my parents.

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 Interviewer: Do you tend to think of people in general as being disloyal or dishonest?
Patient: Well, I’ve found that you just can’t trust anyone, because they’ll always try to do you
in if you let down your guard.

The interviewer, having established two of the four criteria required to make the
diagnosis of paranoid PD, will then go on to ask questions regarding other criteria.

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Strategy 2: The Symptom-Window Technique
The symptom-window technique entails beginning with your patient’s major symptoms
and using them as “windows” for exploring possible roots in PDs. This is generally done
toward the end of the past psychiatric history (PPH), by which time you will have
identified the major symptoms and delineated the syndromal and treatment history. The
next step is to ask questions about events that may have occurred each time the symptoms
arose. Were these interpersonal events? Were they related to life transitions? In your
judgment, do the symptoms seem to be reasonable responses to the events, or do they seem
exaggerated?
The nature of the symptoms per se does little to point to a specific PD, but using the
symptoms as windows to the personality is often productive. For example, a major
depression can be a product of virtually any of the PDs, but each patient will arrive at the
depression by a different route. Here are some typical examples:

Narcissistic PD: The patient finds that nobody meets his high standards, thereby
alienating friends and family, leading to a social isolation that can cause depression.
Avoidant PD: The patient avoids friendships for fear of rejection, leading to
loneliness and depression.
Dependent PD: Patient develops a sense of worthlessness and demoralization because
of an inability to make life decisions without relying on someone else.
Borderline PD: A chronic sense of inner emptiness may lead to depression,
suicidality, and other problems, such as substance abuse, bulimia, and impulse
control disorder.

As an example, assume you are interviewing a patient with major depression who recently
considered overdosing on some medication after being rejected by her boyfriend. You
suspect borderline PD. You can broach the issue with a referred transition:

Earlier, we were talking about your depression and some of the

suicidal thoughts you had after your boyfriend left you. Have you
reacted in this way to rejection at other times in your life?

After you’ve gotten the ball rolling by using the referred transition, you can run
through the rest of the criteria, jogging your memory with the mnemonic I DESPAIRR.
You can introduce these questions with a remark such as

I’d like to ask a few more questions about your personality and the
ways that you tend to react to certain situations. I’m interested in
learning about what sort of person you’ve been since your teenage
years, not only how you’ve been over the last few weeks.

This helps to ensure that your patient answers in terms of enduring personality traits

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rather than recent symptoms.

KEY POINT
This last point deserves repeating: A PD refers to a persisting pattern of dysfunctional
relating styles over many years, at least since adolescence or young adulthood. Thus, when
you ask about criteria for a PD, make clear to your patient that you’re interested in the
long-term view. Beginners often forget this and may end up falsely diagnosing a PD when
the patient actually has an acute Axis I disorder. For example, depressed patients commonly
appear irritable, needy, and suicidal, features that could easily lead to the diagnosis of
borderline PD. Once the depression clears, such patients may magically shed their Axis II
pathology.

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Specific Personality Disorders: Self-Statements,
Probing Questions, and Behavioral Clues
I have listed below all 10 DSM-5 PDs. For each, there is a patient “self-statement,” which is
a hypothetical description that a patient with the given disorder would make about himself.
The statements are simplistic and stereotypic and are only meant to be used as memory
aids, so that you can dependably fix the main features of each PD in your mind. Two
suggested probing questions, along with common behavioral clues that might increase your
suspicion of a particular disorder, are listed beneath each statement. Finally, a mnemonic is
given for each PD, all of which (except the one for borderline PD) were written by Harold
Pinkofsky (1997). If you obtain positive responses to your probing questions, follow up
with more questions related to specific diagnostic criteria, using the mnemonics as aids. As
an illustration, I have included questions that can be used for each of the criteria for
borderline PD.

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Borderline Personality Disorder
Self-statement: “I need people desperately, and when people reject me I fall apart
completely. I hate them, and I get suicidal.”
Probing questions:

Have people often disappointed you in your life?

When something has gone really wrong in your life, such as losing a
job or getting rejected, have you often done something to hurt
yourself, such as cutting yourself or overdosing?

Behavioral clues: May alternatively idealize and devalue you over the course of the
interview; may be unusually emotionally labile.

Mnemonic: I DESPAIRR
Identity disturbance

Have you generally been pretty clear about what your goals are in life
and what sort of person you are, or do you have trouble knowing
who_____is? (Say patient’s name.)

Disordered, unstable affect owing to a marked reactivity of mood

Are you a moody person?

Chronic feelings of Emptiness

Do you often feel empty inside?

Recurrent Suicidal behavior, gestures, or threats, or self-mutilating behavior

Looking back, when something has gone really wrong in your life,
like losing a job or getting rejected, have you often done something to
hurt yourself, such as cutting or overdosing?

Transient, stress-related Paranoid ideation or severe dissociative symptoms

When you’re under stress, do you feel you lose touch with your
environment or with yourself? During those times, do you feel as if
people are ganging up on you?

Frantic efforts to avoid real or imagined Abandonment

When someone abandons or rejects you, how do you react?

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 Impulsivity in at least two areas that is potentially self-damaging

Do you see yourself as an overly impulsive person?

Have you ever done things that can get you into trouble, such as
spending all your money, driving like a maniac, using a lot of drugs,
having a lot of sex, and so forth?

Inappropriate, intense Rage or difficulty controlling anger

What do you do when you get angry?

Do you hold it inside or let loose with it so that everybody knows how
you’re feeling?

A pattern of unstable and intense interpersonal Relationships characterized by

alternating extremes of idealization and devaluation

Do your relationships tend to be calm and stable or stormy and

unstable, with lots of ups and downs?

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Cluster A (“Odd”)

Paranoid
Self-statement: “Others are untrustworthy, and they try to take advantage of me.”
Probing questions:

Have you often found that people in your life have not been
trustworthy?
Have people turned against you for no good reason?

Behavioral clues: Patient appears guarded and suspicious; patient answers questions
reluctantly and with an air of suspicion.

Mnemonic: SUSPECT (four of these seven)

Spousal infidelity suspected

Unforgiving (bears grudges)
Suspicious of others
Perceives attacks
Views everyone as either an Enemy or a friend
Confiding in others feared
Threats perceived in benign events

Schizoid
Self-statement: “I prefer to be alone; my world is completely empty.”
Probing questions:

Are you a people person, or are you someone who prefers to be alone?
(Prefers to be alone.)
Can you name some things that you really enjoy doing? (Takes
pleasure in few, if any, activities.)

Behavioral clues: Patient appears shy and aloof. Patient seems to be preoccupied, in
her own world.

Mnemonic: DISTANT (four of these seven)

Detached (or flattened) affect

Indifferent to criticism or praise
Sexual experiences of little interest

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Tasks (activities) performed solitarily
Absence of close friends
Neither desires nor enjoys close relations
Takes pleasure in few activities

Schizotypal
Self-statement: “I’d like to have friends but it’s hard, because people find me pretty
strange.”
Probing questions:

Do you tend to feel pretty uncomfortable around other people?

Do you sometimes have ideas that other people don’t really
understand or find unusual?
Behavioral clues: Patient appears odd in any number of ways—for
example, she may be disheveled, wearing strange clothes, or have odd
mannerisms. Patient describes strange ideas that border on psychotic.

Mnemonic: ME PECULIAR (five of first nine plus “rule out” specifier)

Magical thinking or odd beliefs

Experiences unusual perceptions
Paranoid ideation
Eccentric behavior or appearance
Constricted (or inappropriate) affect
Unusual (odd) thinking and speech
Lacks close friends
Ideas of reference
Anxiety in social situations
Rule out psychotic disorder and autistic disorder

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Cluster B (“Dramatic”)

Borderline
See the earlier Borderline Section.

Antisocial
Self-statement: “I love to take advantage of other people, and I never feel bad about
it.”
Probing questions:

Do you admire a good scam when you see it?

Have you ever done anything that could have gotten you in trouble
with the law?

Behavioral clues: The patient is excessively cocky and arrogant. The patient always
portrays self as innocent and a victim in violent or criminal circumstances.

Mnemonic: CORRUPT (three of these seven)

Conformity to law lacking

Obligations ignored
Reckless disregard for safety of self or others
Remorse lacking
Underhanded (deceitful, lies, cons others)
Planning insufficient (impulsive)
Temper

Histrionic
Self-statement: “I’m quite an emotional and sexually charming person, and I need to
be the center of attention!”
Probing questions:

Do you like to be the center of attention? (Yes.)

When you feel an emotion, do you keep it inside or do you express it?
(Express it.)

Behavioral clues: The patient is flamboyantly and seductively groomed or dressed.

The patient is rapidly and dramatically self-revealing to the point of
inappropriateness, even in the context of a psychiatric evaluation.

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Mnemonic: PRAISE ME (five of these eight)

Provocative (or sexually seductive) behavior

Relationships (considered more intimate than they are)
Attention (uncomfortable when not the center of attention)
Influenced easily
Style of speech (impressionistic, lacks detail)
Emotions (rapidly shifting and shallow)
Made up (physical appearance used to draw attention to self)
Emotions exaggerated (theatrical)

Narcissistic
Self-statement: “I’m an extremely talented and special person, better than most
people, and yet I get angry and depressed because people don’t recognize how great I
am!”
Probing questions:

Do you often find yourself getting frustrated because other people

don’t meet your standards? (Yes.)
What are your ambitions for yourself? (Will be unrealistically high.)

Behavioral clues: The patient may appear haughty and excessively critical of your
credentials or experience. She may begin the interview with a litany of angry
complaints about how unfairly others have treated her.

Mnemonic: SPEEECIAL (five of these nine)

Special (believes he is special and unique)

Preoccupied with fantasies (e.g., of unlimited success, power)
Envious
Entitlement
Excessive admiration required
Conceited
Interpersonal exploitation
Arrogant
Lacks empathy

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Cluster C (“Anxious”)

Avoidant
Self-statement: “I’m really afraid of what people will think of me, so I avoid making
new friends to prevent rejection.”
Probing questions:

Do you tend to avoid meeting people or getting close to people? (Yes.)

Is that because you prefer to be alone or because you’ve been
rejected before and you don’t want it to happen again? (The latter.)

Behavioral clues: The patient may appear shy and nervous but with a poignant
eagerness to make contact. He may begin the interview reluctant to open up and will
typically become quite self-revealing once rapport has been established.

Mnemonic: CRINGES (four of these seven)

Certainty of being liked required before willing to risk involvement

Rejection possibility preoccupies his thoughts
Intimate relationships avoided
New relationships avoided
Gets around occupational activities that involve interpersonal contact
Embarrassment potential prevents new activities
Self viewed as unappealing, inept, inferior

Dependent
Self-statement: “I’m pretty passive and dependent on others for direction, and I go
far out of my way not to displease people who are important to me.”
Probing questions:

Do you consider yourself a completely independent person, or have

you tended to lean on others in your life for emotional support and
guidance? (Lean on someone else.)
Who has made most major decisions in your life, you or your_____
(spouse, parents, or other, depending on situation)? (Someone other
than the patient.)

Behavioral clues: The patient will seem to make extraordinary attempts to

immediately gain your affection.

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Mnemonic: RELIANCE (five of these eight)

Reassurance required for decisions

Expressing disagreement difficult (because of fear of loss of support or approval)
Life responsibilities assumed by others
Initiating projects difficult
Alone (feels helpless and a sense of discomfort when alone)
Nurturance (goes to excessive lengths to obtain nurturance and support)
Companionship sought urgently when close relationship ends
Exaggerated fears of being left to care for self

Obsessive-Compulsive
Self-statement: “I’m a perfectionist. I keep lists, I drive myself hard, and I’m very
serious about life.”
Probing questions:

Do you consider yourself a perfectionist?

Do you drive yourself so hard with your work that you find you have
no time for leisure activities?

Behavioral clues: The patient is meticulously groomed and dressed. He will tend to
give an excessively detailed and accurate account of his symptoms.

Mnemonic: LAW FIRMS (four of these eight)

Loses point of activity

Ability to complete tasks compromised by perfectionism
Worthless objects (unable to discard)
Friendships (and leisure activities) excluded (owing to preoccupation with work)
Inflexible, scrupulous, overconscientious
Reluctant to delegate
Miserly
Stubborn

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IV

INTERVIEWING
FOR TREATMENT

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 32 How to Educate Your Patient

Essential Concepts
Briefly state your diagnosis.
Find out what your patient knows about the disorder.
Give a minilecture about the disorder, if indicated.
Ask if there are any questions.
Give your patient written educational materials.

Does this mean I’m crazy?

Is this medication going to turn me into a zombie?
Am I going to be this way for the rest of my life?

These are the sorts of questions that patients will ask you, often toward the end of the
diagnostic interview. Clinicians eventually develop an effective approach to answering such
questions in lay terms. Although patient education is rarely formally taught in training
programs, from the patient’s perspective, it is often the most important part of the initial
evaluation.
Educating your patient about his disorder is helpful for various reasons. First,
education decreases his anxiety. As clinicians, we tend to take mental illness for granted, but
patients are often terrified by their disorders. By giving an illness a name and showing that
its prognosis and treatment are well understood and that millions of other people have
experienced it, we can significantly decrease the patient’s anxiety.
Second, patient education improves adherence to treatment, both for medications and
for therapy. Misconceptions about psychiatric treatment abound in our society; most
people get their information about psychiatry from television shows, newspapers, and the
Internet, which leads to a mismatch between reality and fantasy. For example, many
patients believe that psychotherapy is a long-term process in which painful family dynamics
are rehashed for years on end. Such a misconception decreases the likelihood that patients
will commit to therapy. When educated about the fact that most present-day therapy is
brief and focuses on current problems, patients become more receptive to referrals.
Misinformation about medications also abounds. Patients often believe that
antidepressants are to be discontinued once they feel better, as opposed to the 6 to 12
months of continuous therapy recommended. Other patients consider antidepressants to be
rapid mood boosters. One patient for whom I had prescribed Prozac for depression came
back in a month reporting that she had only “needed to take” the Prozac four or five times.
Her belief had been that the medication was to be taken only on those mornings that she

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awoke feeling very depressed.
In this chapter, I guide you through a commonly used strategy for providing patient
education that can be applied to a wide variety of mental disorders.

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Briefly State Your Diagnosis
Although this is self-explanatory, I would add that you needn’t always phrase the diagnosis
in DSM-5 terminology. For example, I often tell patients that they have a “clinical
depression” rather than a “major depression,” because I know from experience that more
patients have heard of the former than the latter.

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What Your Patient Knows About the Disorder
The way I generally find out what my patient knows about the disorder is as an extension
of providing a diagnosis. Thus:

I think that you’ve been suffering from a clinical, or major,

depression. Do you know what that is?

If the patient says “yes,” I ask him to elaborate a bit:

What is your definition of depression?

As a prelude to treatment negotiation, I often ask whether the patient has any
expectations about treatment.

Do you have any ideas about treatment?

Some patients may overtly request a particular form of treatment, such as

psychotherapy or medication, whereas others may tell you what they don’t want.

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Minilecture About the Disorder
Not all patients want to hear you wax poetic about their disorders. For example, a well-
informed patient who has just delineated each of the DSM-5 criteria of OCD might be
insulted to hear you repeat them. Other patients may be quite uninformed but, taking the
attitude that you, and not they, are the doctor, might feel uncomfortable with your efforts
to educate them and involve them in their treatment. There’s no firm rule about which
patients should get a minilecture. Accordingly, you can ask the patient something like this:

Would you like me to give you some information on depression?

Although it is the rare patient who responds with a flat “no,” even if he’d prefer not to
have the information, you can generally gauge the degree of interest based on the response
and adjust the length of your minilecture accordingly.
As a guide for structuring your minilecture, I turn to the experience of the researchers
at the University of Pittsburgh, who used a psychoeducational program that helped them
achieve a remarkably high (90%) adherence to treatment over 3 years (Frank et al. 1995;
Jacobs et al. 1987). Their program was devised to teach patients and their families about
depression. Its components included the following:

Define the illness. Ask your patient to identify all the symptoms that he has
experienced. A chalkboard, or, more realistically, a piece of paper on which to write,
is helpful. Define the disorder as an illness that has many symptoms, including the
ones your patient has identified; try to portray it as an illness similar to the medical
illnesses of diabetes or hypertension. This helps decrease the stigma associated with
mental illness.
Discuss the prevalence and course of the illness. (Refer to Appendix A for a pocket
card listing the prevalence for the major mental disorders.)
Discuss the causes. Although we don’t know the causes of most mental illnesses, you
can discuss some different theories.
Discuss the options for treatment.
For medications, discuss side effect profiles and emphasize the fact that individuals
experience different side effects. Over the past decade, a larger proportion of
psychiatric visits have involved medication management, and we are often confronted
with patients who are ambivalent about taking the treatments we prescribe. As Shea
(2006) points out in his excellent book on medication adherence, a helpful trick for
prodding reluctant patients into considering medications is to borrow a pediatrician’s
technique called “inquiry into lost dreams.” As quoted in Shea’s book, “I find it
useful with my kids with asthma to ask them this question or a variation of it, ‘Is
there anything that your asthma is keeping you from doing that you really wish you
could do again?’ What I find with this age group is that there is often a quick answer
to this question, and the answer is often related to a sport, say, football or soccer.”

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You can readily adopt this technique to psychiatric issues: “Is there anything that your
anxiety is keeping you from doing that you wish you could do again?” The answer may
help your patient better appreciate the potential benefits of medications.
Here is an example of a minilecture for major depression:

A major depression is a breakdown in a person’s ability to cope with

stress. While we all get sad from time to time when things go poorly, a
person with major depression feels so down that the basic functions of
living are affected. As with medical illnesses, depression causes specific
symptoms. In your case, you haven’t been able to sleep, you’ve lost
your appetite, you haven’t been able to concentrate at work, and
you’ve had some scary suicidal thoughts.
Depression is quite common; about 10% of people develop it at some
point in their lives. What causes it isn’t clear. For some people,
stressors seem to cause depression; this may be the case for you, since
you felt bad after your divorce. In other cases, depression seems to be a
biologic disorder.
The good news about depression is that it’s very treatable. There are
two main techniques, medication or talk therapy. A combination of
the two is often most effective. In your case, I’d recommend the
combined treatment. Do you have any questions about all this?

I’ll also give you an example of a minilecture for borderline personality disorders, just
to prove that you can discuss personality disorders with patients without sounding critical.

I: You’re suffering from borderline personality disorder. Do you know what that is?
P: No, but it sounds bad, like being on the edge.
I: You’re not far off. It is a bit like being on the edge. People with borderline personality
disorder tend to have poor self-esteem, and this causes them to be very moody, especially
when it comes to dealing with friends and family. For instance, you told me earlier that
when people reject you, you don’t just get depressed, you get suicidal. And when you get
angry at people, you really lose control.
P: That’s just the way I’ve always been; I didn’t know it was an official disorder.
I: It is, and believe me, you’re not alone. Studies show that about 2% of all people have the
same problem. No one knows exactly what causes it, but the early family environment
usually plays a role. The best treatment is long-term therapy, with medications from time to
time to treat depression.

You’ll develop your own style of educating patients, and your lecture will inevitably
vary depending on the patient. As much as possible, you want to speak your patient’s
language, which will vary with level of intelligence and education, cultural background, age,
and other factors.

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Questions
Even if you are feeling the pressure of the end of the hour, give your patient plenty of time
to think about questions.

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Written Educational Materials
Giving written educational materials to your patients allows them to consider the
information in privacy and at greater length. You may use the handouts in Appendix B, all
of which are public domain documents that can be reproduced with or without
acknowledgments.

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 33 Negotiating a Treatment Plan

Essential Concepts
Elicit the patient’s agenda.
Negotiate a plan that you and your patient can agree on.
Help the patient implement the agreed-on plan.

Once you’ve come up with a diagnosis, you have to determine a treatment plan based on
that diagnosis. A treatment plan is something you should arrive at with your patient, rather
than handing it to her like a prescription. The more you involve your patient in planning
treatment, the more likely that she will follow through with the plan.
Compliance was once a popular term for describing good follow-up, but now that term
is being gradually replaced with adherence, which implies less passivity. A patient chooses to
adhere, whereas he is made to comply. Researchers have found that when clinicians and
patients negotiate a treatment plan together, both adherence and clinical outcomes are
improved (Eisenthal et al. 1979). Lazare et al. (1975) have outlined an approach to
negotiating a treatment plan that makes good sense, from which the following schema is
adapted.

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Elicit the Patient’s Agenda
Your patient’s agenda may not be as obvious as it first appears. You can begin to elicit it
with a simple question, such as

How do you hope I can help you?

Note that this is a less confrontational way of asking about your patient’s agenda than
asking

What do you want?

What do you expect?

At this point, the patient may answer vaguely or put the ball back in your court:

I want to feel better.

I don’t know. You’re the doctor.

It’s often important to clarify what sort of information you’re seeking:

How were you hoping that I could help you to feel better?

TIP
Often, patients come into an interview with a few specific requests, such as a desire for
medication, therapy, a community referral, a letter to their employer, and so on. Some
patients may feel embarrassed about divulging their requests so blatantly and may need
some encouragement from you:

Sometimes patients have a pretty clear idea of what they’d like, for instance medication,
counseling, or a piece of advice about something, a letter to someone. (A normalizing
response.)

However, many patients who come to see a clinician really don’t have a specific request
or agenda. This is often the case with patients who are new to the mental health care system
or who are less familiar with the modern consumer model of health care. Don’t force the
issue with these patients; if they say that they want to hear what your recommendation is
and they’ll follow it just because you are the expert, go along with it.

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Negotiate a Plan
Remember that eventual treatment adherence is enhanced when the patient and
practitioner agree on the nature of the problem. The next phase of negotiation involves
arriving at this agreement. If you and your patient agree at the outset about a plan, go
directly to the implementation phase. However, often enough, you’ll find that your
patient’s request is either unrealistic or not clinically indicated. Thank your stars that you
elicited the request with time to spare, because now you must negotiate a mutually agreed-
on goal. Each negotiation will be different, depending on the nature of the request.
Creativity is a plus.
Common problematic requests, along with possible negotiation strategies, are as
follows:

Request: Your patient asks you for medication, but you cannot prescribe.
Strategy: Determine how urgent the need for medication is. If it’s not urgent, make a
referral to a psychiatrist, and teach the patient a psychological method for symptom
relief, such as relaxation exercises, hypnosis, or cognitive restructuring. Now is a good
time to reach into your file of patient handouts. If the need is urgent, refer the patient
to an emergency room or crisis clinic, leaving enough time for you to call the clinic to
inform the psychiatrist of the patient’s diagnosis and medication needs.
Request: Your patient asks for inappropriate medication, such as benzodiazepines for
someone with a history of benzodiazepine abuse or antidepressants for mild or
transient depressive symptoms.
Strategy: Present a minilecture about the patient’s disorder, complete with handouts and
recommendations of books.
Request: The patient seeks hospitalization for a problem that can be treated in an
outpatient setting.
Strategy: This has become an increasingly problematic request in our era of managed care,
and patients may need some education about this issue:

These days, insurance companies rarely pay for hospitalizations unless

the patient is suicidal, because we have a lot of outpatient treatments
that work well.

An important thing to keep in mind is the possibility that the patient is suffering much
more than she originally indicated and that her request for hospitalization is her way of
obliquely disclosing that. You may need to reassess her for SI at this point. If you’re still
satisfied that hospitalization is not indicated, discuss some other options, such as

Day hospitalization
Respite care
Staying with a friend or relative for a while if the home situation is intolerable

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Taking a few days off from work
Having the patient call you (or another clinician) for daily check-ins during a crisis period
Setting up more frequent appointments
A short course of an antianxiety medication

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Implementing the Agreed-on Plan
Your agreed-on plan will likely fall into one or both of the following categories:

A follow-up therapy appointment with you or someone else

Medication trial

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Follow-Up Appointments
Your job is to increase the chances that your patient will show up at the follow-up
appointment, regardless of where that is. You’ve already contributed to this cause by
involving the patient in the process of deciding on a plan. What more can you do?
The research shows that the highest follow-up adherence rates occurred under the
following circumstances (Eisenthal et al. 1979):

The wait for follow-up appointments is short.

Referrals are made to specific clinicians rather than to a clinic.
Specific appointments are made at the time of disposition.
The patient speaks directly to someone at the referral clinic during the evaluation
session.

The closer you can come to implementing these guidelines, the better. Of course, this
requires plenty of preinterview preparation (see Chapter 2 on logistical preparation),
including the following:

Have an efficient system for booking your follow-up appointments.

Have a list of specific clinicians who do not have excessive waiting periods for
appointments.
Have a list of referral clinics with their phone numbers so your patient can call and
make the appointment from your office.

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Medication Trials
If you have truly collaborated with your patient in deciding on a medication trial, you’re
well on your way toward achieving adherence to the regimen. Here are some practical issues
regarding medications and suggestions for dealing with them:
1. Determine how your patient will pay for medication. While most insurance companies
pay for medications, copays vary widely, depending on what was prescribed and the
generosity of the insurance company’s benefits. Some patients can’t afford the copays,
and if so, you may be able to provide samples, depending on their availability at your
clinic.
2. Make sure your patient understands the side effect profile of the medication.
3. Simplification increases recall and compliance. Thus, instead of “Take 20 mg of Prozac
once a day and 50 mg of trazodone at night, as needed for insomnia,” say, “Take the
green capsule every morning and the white pill at night if you can’t sleep.”
4. Having your patient repeat what you say increases her recall of your instructions.

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 34 Writing Up the Results of the Interview

I’ve had a long and stormy relationship with the dreaded write-up. During medical school,
the requirement of a novel-length write-up was a welcome reprieve from the stresses of
rounding on patients and making oral presentations. In residency, I became annoyed with
the write-up, which seemed a pesky intrusion into the limited time I had to spend with
patients. At the end of a long day, I would sit down heavily at the Dictaphone (remember
those?) and try to gather my thoughts, hoping that the resulting transcription would be
coherent.
It wasn’t until I had been in clinical practice for a few years that I came to terms with the
write-up. Having come full circle, I’m back to (sort of) liking it, viewing it as a welcome
few minutes of quiet thought and synthesis between patient appointments.
I hope this chapter helps you to work through some of the more painful moments in your
own relationship with the write-up. I outline some formats for you to choose among, and I
provide some tips to help you streamline the process.
Every write-up represents a balancing act among three objectives:
1. Thoroughness
2. Time efficiency
3. Readability
The ideal write-up incorporates all three objectives. It is thorough enough to document the
basis for a diagnosis and treatment plan; it does not require so much time that it would be
unfeasible for a busy clinician to produce; and it is not so lengthy as to provoke sighs from
equally busy colleagues who must read the write-up because of their involvement in the
patient’s treatment.
In general, a write-up should not take you more than 10 to 15 minutes to produce,
whether you dictate it or write it yourself. It should not be longer than two or three typed
pages if you really want colleagues to read it. If you use electronic health records (EHRs) for
documentation, you may be constrained by the particular software you or your employer
has chosen. At their worse, EHR write-ups become clicking fests through dozens of
checkboxes defining different aspects of the mental status exam. I recommend that you use
the free-text fields when possible, so that you can build up a narrative picture of your
patient that will be more informative to you and others.

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Identifying Data
The identifying data should be a fairly long initial sentence that sets the stage for the entire
evaluation. You want to not only identify who the patient is but also to locate her within
the context of social and cultural norms. This includes age, sex, marital status, and source
of referral at a minimum and may include other information such as occupation, living
situation, and presence of other family.
This is a 45-year-old, twice-married woman with two grown children, who is an
accountant for her husband’s carpet cleaning business and who was referred by her
primary care doctor because of increasing anxiety and the possibility that she is abusing
anxiety and pain medication.
or
This is a 29-year-old, single, white man on psychiatric disability, living in a group
home downtown, with a long history of paranoid schizophrenia, who was admitted to
the hospital after group home staff members found him in the process of drinking a
bottle of methyl alcohol in an apparent suicide attempt.

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Chief Complaint
The chief complaint should be a verbatim sentence of the patient’s, usually in response to
your question as to the reason he is seeking help.

My wife made me come here. There’s nothing wrong with me.

My mother just died. I can’t deal with it.
I just figured it was time to see a therapist to work out some issues.

Each of these statements reflects a different sense of purpose and urgency for treatment,
and consequently, this information is helpful in setting the stage for the report to follow.

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History of Present Illness
In Chapter 14, I describe two different definitions of the history of present illness (HPI),
one referring to the history of the illness, which may begin years before the interview
(history of syndrome approach), and the other referring more narrowly to events of the past
few weeks (history of present crisis approach). Which definition to use is a matter of
personal or institutional preference. Following are examples of both approaches.

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History of Syndrome
Mr. M has a long history of bipolar disorder, beginning in his junior year of college. He
was hospitalized for manic behavior, which included studying for days at a time to the
point of exhaustion. In addition, he exhibited grandiose, disorganized behavior when
he “occupied” the chancellor’s outer office and stated that he was the chancellor of the
university. He was started on lithium at that point and did well for several years, until
he had a series of hospitalizations in the early 1990s for depression and alcohol use after
a divorce from his wife.
His last hospitalization was 2 years ago for depression, and he has done fairly well
since then, taking medications (venlafaxine [Effexor] and valproic acid [Depakote]) and
going to regular therapy and medication appointments.

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History of Present Crisis
Mr. M has a long history of bipolar disorder with several hospitalizations but had been
doing fairly well for the past 2 years until about 2 weeks ago, when his girlfriend
noticed a pattern of manic behavior, which began after a promotion to a new position
at his company. He has slept an average of 3 hours a night because of a need to “prepare
for his day,” he has been talking more rapidly than usual, and he has been making
unrealistic plans to become the president of his company. He consented to this
admission on the advice of his girlfriend and his outpatient caregivers.

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Past Psychiatric History
The nature of the past psychiatric history (PPH) section of your write-up depends on how
thorough you have been in the HPI. Generally, the PPH is a time to go into some detail on
what sort of psychiatric treatment your patient has had in the past. In Chapter 15, I
recommend the mnemonic Go CHa MP as a way of organizing your questioning, and you
can also use this for your write-up. You can begin with a General statement, such as
The patient feels that he has received fairly intense, and overall successful,
treatment for his depression over the years.
or
The patient has started treatment at various times but by his own admission has
been generally noncompliant.
In CHaMP, the C is for current Caregivers, if any. Documenting Hospitalizations is
straightforward, and usually the detail is limited by your patient’s memory. Noting the date
of the last hospitalization is important, because it has implications for the severity of the
current problem. Having a separate heading for “Medication trials” is often very helpful,
both for other caregivers and for easy reference if you have to make a medication change
several months or years after the first visit. Finally, documentation about past
Psychotherapy should include a note about whether the patient found it helpful and why or
why not.

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Substance Use History
Where in the evaluation should you document history of substance use? This varies by
practitioner, with some including it in the PPH, others in the social history, and still others
in the medical history, usually under “habits.” My preference is to use a main heading
devoted to the issue, because it is such an important and often overlooked part of the
psychiatric history.
Under substance use, I include tobacco and caffeine use, as well as the usual array of
more insidious substances, such as alcohol or cocaine.

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Review of Symptoms
The review of symptoms is where you can really impress your readers with your diagnostic
thoroughness. Simply go through the major diagnostic categories, indicating whether the
patient met any of the criteria and excluding those that you already mentioned in the HPI
and in the substance abuse section, if you have included one.
On review of psychiatric symptoms, the patient denied any history of mania or
hypomania. She described a history of frequent panic attacks in the past, with some
accompanying agoraphobic avoidance, but said that these events had abated
spontaneously 2 years ago. While she considers herself a “perfectionist,” she denied
frank obsessions or compulsions. There was no history of eating disorders, ADHD,
dissociative disorders, or psychotic phenomena. With regard to personality disorders,
there was a hint of dependent traits in her description of her relationships with her
husband and her best friend.

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Family History
If you draw a genogram directly on the evaluation form, this will suffice for the family
psychiatric history, although you may want to add a one-line comment to highlight some
facet of the history, such as
The patient has a strong genetic loading for bipolar disorder, as shown in the
genogram.
If you are dictating the evaluation, I suggest drawing a genogram on a blank sheet that
you can staple to the back of the transcription, with the note “see attached genogram” in
the family history section.

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Social History
The thoroughness and length of the social history depend on clinician preference and the
purpose of the evaluation. Obviously, a more lengthy social history is necessary in a
psychotherapeutic evaluation than a psychopharmacologic evaluation. In addition, some
clinical problems are more influenced by psychosocial issues than others. PTSD, for
example, will always require a fairly extensive social history, whereas schizophrenia often
develops independently of the social milieu.
At a minimum, your social history should include these pieces of information:

Where your patient was born and raised

Number of siblings
Birth order of patient and siblings
Who was present in the household during the formative years
Educational level
Work history
Marital and parenting history of patient
Typical daily activities other than work

The patient was born and raised in Lowell, Massachusetts, and is the youngest of
three children, with a brother aged 50 and a sister aged 53. He describes his childhood
as “normal” until his father died in a car accident when the patient was 10 years old,
after which his mother was “always depressed.” His grades in high school were Bs and
Cs, and he went to technical school to study auto mechanics for 2 years. He eventually
opened his own auto body business, which he still runs. He married his current wife,
Diane, when he was 24, and they now have two children, both girls, ages 21 (Laura)
and 24 (Angie). He is close to both of them. He works 6 days a week, and when he is
not at work, he often watches television while drinking a beer and occasionally goes
fishing with male friends. He described his relationship with his wife with the
comment, “We get along.”

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Medical History
You may use the mnemonic MIDAS to organize the medical history. I usually begin with a
statement about the patient’s general health, such as:
The patient reports that she is in good overall health.
The patient has suffered a number of chronic medical problems.
List any illnesses, surgeries, prescribed medications, and medication allergies. Note the
name of the primary care physician. If you have asked questions from the medical review of
systems, note any relevant answers. At a minimum, note whether the patient has had any
seizures or head injuries, both of which are often germane to psychiatric problems.
The patient is in good general health and denies any history of major illnesses,
surgeries, head injuries, or seizures. She takes no medications aside from birth control
pills, and she reports an allergy to penicillin. She has regular gynecologic examinations
with Dr. L.
The patient has a significant and complicated medical history, including heart
disease, diabetes, and neurologic problems stemming from the diabetes. She had
coronary bypass surgery last year. Currently, she has shortness of breath when she walks
a half block, and she has constant pain in her feet. She recalls having had a concussion
after falling off a horse when she was young, but she denies any seizure history. Her
primary care physician is Dr. R, and her medications include insulin, captopril,
furosemide (Lasix), potassium supplement, hydrocodone (Vicodin) for pain, and
paroxetine (Paxil) (20 mg a day). She once had an allergic reaction to bupropion
(Wellbutrin), involving a total body rash.

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Mental Status Examination
In writing up or dictating the mental status section of your diagnostic evaluation,
temporarily shed your clinician’s mantle and become a creative writer. Describe your
patient so well that a reader would be able to recognize him from your description alone.
Compare the following two descriptions of the same patient:
The patient was a 32-year-old man who was tired but cooperative with the
interview. He was disheveled. Eye contact was good. Mood and affect were angry and
irritable.
The patient was interviewed in a medical bay of the emergency room. He was lying
on his back on a gurney in four-point restraints, wearing a hospital gown. He had
received 5 mg of haloperidol (Haldol) intramuscularly shortly before the interview. As I
walked in, he lifted his head and looked at me intensely, saying, “Will you get me the
hell out of these shackles?” I assured him that I would do so if he posed no danger to
himself or others. He was resigned and cooperative from that point on.
The second version gives a more vivid sense of the patient’s mental status. Yes, he is
angry and irritable, but this is in reaction to something in his environment. Furthermore,
he’s able to modulate his affect in response to the interviewer’s statement, indicating a
degree of control over his emotional state not communicated by the first summary. The
“disheveled” of the first write-up might imply the self-neglect characteristic of
schizophrenia, but in fact it’s hard to look anything but disheveled when you’re in a gurney
with your limbs restrained.
That said, professional jargon does have its place in the write-up. This is especially true
in the description of psychotic thought process (TP) and thought content (TC). Words and
phrases such as tangentiality, looseness of associations, and ideas of reference are technical terms
with meanings that are understood throughout the mental health field, and they should be
used when appropriate. Table 34.1 lists some common jargon-containing statements and
some fresher alternatives.

TABLE 34.1. Alternatives to Jargon

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 Your MSE can follow the format outlined in Chapter 21 (recall the mnemonic: All
Borderline Subjects Are Tough, Troubled Characters). A good strategy is to limit jargon to
those aspects of the MSE that are normal and to use more descriptive language for those
parts of the examination that are directly relevant to the eventual diagnosis.
This was a well-groomed, pleasant-appearing woman, dressed in a professional suit
and smelling strongly of perfume. She presented herself as serious and engaged. Her
body was tense; she spoke rapidly and articulately as she related her psychiatric history.
She seemed quite anxious, with her hands clenched around her billfold and her feet
tapping the floor. Her stated mood was “I’m just barely holding on,” and “I’m scared of
having a panic attack all the time.” Her TP was coherent in content and without
hallucinations or delusions, but with some excessive rumination on the theme of getting
“just the right medicine.” She denied SI. On cognitive screen, concentration and
memory were normal.
The patient presented as a somewhat disheveled man with long black hair, scraggly
beard, and soiled clothes. He wore horn-rimmed glasses and had the look of an
eccentric intellectual. He sat quietly for the most part and volunteered very little
information; he seemed apathetic rather than guarded. His affect was bland, with a
striking disparity between his stated mood (“I’m headed for a breakdown. I hate this
life.”) and his affect. His TP was coherent and without any LOA or flight of ideas. TC
was impoverished. He denied any current hallucinations but admitted to having heard a
voice calling his name “once or twice” over the preceding week. He said he wished he

389
were dead but denied any plan to harm himself. On cognitive screen, concentration and
memory were normal.

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Assessment
The assessment should be a brief recapitulation of the overall clinical picture and a
discussion of differential diagnosis. Remember that many people who read your write-up
will read only this section to get right to the point. Therefore, take pains to make the
assessment both concise and informative.
This is a 27-year-old married, white, father of two who presents with a history
consistent with bipolar disorder and a current clinical picture of major depression with
NVSs of hypersomnia, lethargy, poor concentration, and increased appetite for sweet
foods. In addition, he presents with significant anxiety, but he probably does not meet
criteria for a discrete anxiety disorder, with the possible exception of GAD. Significant
family conflict has contributed to his current illness.
This is a 52-year-old, never-married, African American woman who has a long and
complicated history of chronic mental illness, variously diagnosed as schizoaffective
disorder and chronic schizophrenia. She presents now in a florid psychotic state with
auditory hallucinations, ideas of reference, irritability, anxiety, and lack of sleep for 3
days. The current picture is confusing, and it may represent an irritable manic episode
or an agitated depression with psychosis. Medication noncompliance may have been a
precipitant, although chronic poverty is a relevant psychosocial factor.

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DSM-5 Diagnosis
Earlier versions of DSM included five axes: Axis I, the main psychiatric diagnosis; Axis II,
personality disorders and developmental disabilities; Axis III, medical issues; Axis IV,
psychosocial issues; and Axis V, global assessment of functioning. DSM-5 dropped this
multiaxial system, so now you simply list all the diagnoses, without subcategorizing them.

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Treatment Plan
A good, concise treatment plan should include:

Any diagnostic testing planned (i.e., neuropsychological testing, laboratory tests)

Plans for medication, if you can prescribe
Plans for therapy, if needed
Referrals to other health care practitioners, if applicable
When you plan to see your patient again

For example:
The plan is to obtain electrolytes, complete blood cell count, and thyroid panel to
screen for organic causes of his symptoms; to start sertraline (Zoloft) at 25 mg per day,
increasing to 50 mg per day, as tolerated (patient was informed of, and understood,
potential risks and benefits of medication); and to start weekly cognitive behavioral
therapy. I will see him again in 1 week.
The plan is to begin psychodynamic therapy to address her grief issues and to refer
to a psychiatrist for possible antianxiety medication. I will see her again in 1 week.

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 A Pocket Cards

Psychiatric Evaluation

394
DSM-5 Mnemonics

Note: The numbers in parentheses reflect the number of criteria required for diagnosis out of the total possible criteria.

Defense Mechanisms

395
Appearance Terms

396
Affect Terms

397
Rapid IQ test, Wilson Rapid Approximate Intelligence Test

Data from Wilson, I. C. (1967). Rapid approximate intelligence test. American Journal of Psychiatry, 123, 1289–1290.

Heritability and Prevalence of Psychiatric Disorders

398
aRelative
risk figures from Reider, R. O., Kaufmann, C. A., and Knowles, J. A. (1994). Genetics. In R. E. Hales, S. C.
Yudofsky, and J. A. Talbott (Eds.), American Psychiatric Press Textbook of Psychiatry. Washington, DC: American
Psychiatric Press. See text for explanation.
bLifetime prevalence figures from Kessler, R. C., Berglund, P., Demler, O., et al. (2005). Lifetime prevalence and age-

of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General
Psychiatry, 62, 593–602.
cData from Hudson, J. L., Hiripi, E., Pope, H. G., et al. (2007). The prevalence and correlates of eating disorders in

the National Comorbidity Survey Replication. Biological Psychiatry, 61, 348–358.

Common DSM-5 Diagnoses

399
Age- and Education-adjusted Norms for the Folstein Mini-Mental State
Examination (Mean Scores)

Data from Crum, R. M., Anthony, J. C., Bassett, S. S., and Folstein, M. F. (1993). Population-based norms for the
Mini-Mental State Examination by age and educational level. Journal of the American Medical Association, 269,
2386–2391.

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 B Data Forms for the Interview

Initial Psychiatric Evaluation (Short Form)

401
402
403
Initial Psychiatric Evaluation (Long Form)
1Adapted from the evaluation form of Anthony Erdmann, M.D.

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Patient Questionnaire
2Adapted from the questionnaire of Edward Messner, M.D.

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 C Patient Education Handouts

Major Depression
1This handout was adapted from public domain information supplied by both the National Institute of Mental Health
and the Agency for Health Care Policy and Research (an agency of the U.S. Public Health Service).
Patient Information Handout

431
Who Gets Depressed?
Major depressive disorder, often referred to as clinical depression, is a common illness that
can affect anyone. Each year, about 6.7% of US adults experience major depressive
disorder. Women are 70% more likely than men to experience depression during their
lifetime.

432
What Is Depression?
Depression is not just “feeling blue” or being “down in the dumps.” It is more than being
sad or feeling grief after a loss. Depression is an illness (in the same way that diabetes, high
blood pressure, and heart disease are illnesses) that affects your thoughts, feelings, physical
health, and behaviors day after day.
Depression may be caused by many things, including the following:

Stressful or depressing life events

Family history and genetics
Certain medical illnesses
Certain medicines
Drugs or alcohol
Other psychiatric conditions

Certain life conditions (e.g., extreme stress or grief) may bring on a depression or prevent a
full recovery. In some people, depression occurs even when life is going well. Depression is
not your fault, nor is it a weakness. It is an illness, and it is treatable.

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How Will I Know Whether I Am Depressed?
People who have major depressive disorder have a number of symptoms nearly every day,
all day, for at least 2 weeks. These always include at least one of the following:

Loss of interest in things you used to enjoy

Feeling sad, blue, or down in the dumps

You may also have at least three of the following symptoms:

Feeling slowed down or restless and unable to sit still

Feeling worthless or guilty
Increase or decrease in appetite or weight
Thoughts of death or suicide
Problems concentrating, thinking, remembering, or making decisions
Trouble sleeping or sleeping too much
Loss of energy or feeling tired all of the time

With depression, other physical or psychological symptoms are often present, including the
following:

Headaches
Other aches and pains
Digestive problems
Sexual problems
Feeling pessimistic or hopeless
Being anxious or worried

434
How Is Depression Treated?
Depression is treated with either psychotherapy (counseling) or medications, or with both
treatments combined.

Psychotherapy
The most effective psychotherapies for depression are

Cognitive therapy, in which the therapist points out ways that your thinking is
negative and may actually cause you to be more depressed.
Interpersonal therapy, in which the focus is on improving the quality of your
relationships with important people in your life.

Psychotherapy may take one to several months to cure your depression.

Medications
Many effective medications for depression exist. The most commonly prescribed are the
selective serotonin reuptake inhibitors (SSRIs), which have names like Prozac, Zoloft,
Celexa, and others. Other popular antidepressants include Effexor, Cymbalta, and
Wellbutrin. These newer medications have fewer side effects when compared with older
medications, such as the tricyclics and the MAOIs.
When someone begins taking an antidepressant, improvement generally will not begin
to show immediately. With most of these medications, it will take from 1 to 3 weeks before
changes begin to occur. Some symptoms diminish early in treatment; others, later. For
instance, a person’s energy level or his sleeping or eating patterns may improve before his
depressed mood lifts. If there is little or no change in symptoms after 5 to 6 weeks, a
different medication may be tried. Some people will respond better to one than to another.
Because there is no way of determining beforehand which medication will be effective, the
doctor may have to prescribe first one, then another, until an effective medication is found.
Treatment is continued for a minimum of several months and may last up to a year or
more.

435
Bipolar Disorder
2This handout was adapted from public domain information supplied by the National Institute of Mental Health.

Patient Information Handout

436
What Is Bipolar Disorder?
Bipolar disorder, which is also known as manic-depressive illness, is a mental illness involving
episodes of serious mania and depression. The person’s mood usually swings from overly
high and irritable to sad and hopeless and then back again, with periods of normal mood in
between. Bipolar disorder typically begins in adolescence or early adulthood and continues
throughout life. At least two million Americans suffer from manic-depressive illness.
Bipolar disorder tends to run in families and is believed to be inherited in many cases.

437
Key Features of Bipolar Disorder
Bipolar disorder involves cycles of mania and depression.

Signs and symptoms of mania include discrete periods of

Increased energy, activity, restlessness, racing thoughts, and rapid talking

Excessive high or euphoric feelings
Extreme irritability and distractibility
Decreased need for sleep
Unrealistic beliefs in one’s abilities and powers
Uncharacteristically poor judgment
A sustained period of behavior that is different from usual
Increased sexual drive
Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
Provocative, intrusive, or aggressive behavior
Denial that anything is wrong

Signs and symptoms of depression include discrete periods of

Persistent sad, anxious, or empty mood

Feelings of hopelessness or pessimism
Feelings of guilt, worthlessness, or helplessness
Loss of interest or pleasure in ordinary activities, including sex
Decreased energy, a feeling of fatigue or of being “slowed down”
Difficulty concentrating, remembering, or making decisions
Restlessness or irritability
Sleep disturbances
Loss of appetite and weight or weight gain
Chronic pain or other persistent bodily symptoms that are not caused by physical
disease
Thoughts of death or suicide; suicide attempts

438
How Is Bipolar Disorder Treated?
The most effective treatment for bipolar disorder is one of a variety of mood-stabilizing
medications. The most well known of these is lithium, which was the first medication
introduced for bipolar disorder. Other mood stabilizers include Tegretol and Depakote. In
addition, there are many antipsychotics that are also effective for bipolar disorder. Although
all medications for bipolar disorder are effective, side effects, including sedation, weight
gain, and light-headedness, often occur. Psychiatrists can minimize these side effects by
adjusting the dosage and formulation of medications.
In addition to medications, psychotherapy is helpful, especially during the depressed
phase of bipolar disorder. Combination treatment (medications in combination with
therapy) leads to the best results for most patients.

439
Panic Disorder
3This handout was adapted from public domain information supplied by both the National Institutes of Health and
the National Institute of Mental Health.
Patient Information Handout

“It started 10 years ago. I was sitting in a seminar in a hotel and this thing came out
of the clear blue. I felt like I was dying.”
“For me, a panic attack is almost a violent experience. I feel like I’m going insane. It
makes me feel like I’m losing control in a very extreme way. My heart pounds really
hard, things seem unreal, and there’s this very strong feeling of impending doom.”
“Between attacks there is this dread and anxiety that it’s going to happen again. It can
be very debilitating, trying to escape those feelings of panic.”

440
What Is Panic Disorder?
People with panic disorder have feelings of terror that strike suddenly and repeatedly with
no warning. They can’t predict when an attack will occur, and many develop intense
anxiety between episodes, worrying when and where the next one will strike. Between
episodes, they feel a persistent, lingering worry that another attack could come any minute.
When a panic attack strikes, your heart most likely pounds, and you may feel sweaty, weak,
faint, or dizzy. Your hands may tingle or feel numb, and you might feel flushed or chilled.
You may have chest pain or smothering sensations, a sense of unreality, or fear of
impending doom or loss of control. You may genuinely believe you’re having a heart attack
or stroke, losing your mind, or on the verge of death. Attacks can occur any time, even
during nondream sleep. Most attacks average a couple of minutes, but occasionally, they
can go on for up to 10 minutes. In rare cases, they may last an hour or more.
Panic disorder is often accompanied by other conditions, such as depression or
alcoholism, and may spawn phobias, which can develop in places or situations where panic
attacks have occurred. For example, if a panic attack strikes while you’re riding an elevator,
you may develop a fear of elevators and start avoiding them. Some people’s lives become
greatly restricted—they avoid normal, everyday activities such as grocery shopping, driving,
or even leaving the house. They may be able to confront a feared situation only if
accompanied by a spouse or other trusted person. Basically, they avoid any situation they
fear would make them feel helpless if a panic attack occurred. When people’s lives become
so restricted by the disorder, as happens in about one third of all people with panic
disorder, the condition is called agoraphobia. A tendency toward panic disorder and
agoraphobia runs in families. Nevertheless, early treatment of panic disorder can often stop
the progression to agoraphobia.
Panic attack symptoms include

Pounding heart
Chest pains
Light-headedness or dizziness
Nausea or stomach problems
Flushes or chills
Shortness of breath or a feeling of smothering or choking
Tingling or numbness
Shaking or trembling
Feelings of unreality
Terror
A feeling of being out of control or going crazy
Fear of dying
Sweating

441
Who Gets Panic Disorder?
Panic disorder strikes at least 1.6% of the population and is twice as common in women as
in men. It can appear at any age, but most often it begins in young adults. Not everyone
who experiences panic attacks will develop panic disorder—for example, many people have
one attack but never have another. For those who do have panic disorder, though, it’s
important to seek treatment.

442
How Is Panic Disorder Treated?
Studies have shown that proper treatment—a type of psychotherapy called cognitive-
behavioral therapy, medications, or possibly a combination of the two—helps 70% to 90%
of people with panic disorder. Significant improvement is usually seen within 6 to 8 weeks.
Cognitive-behavioral approaches teach patients how to view the panic situations differently
and demonstrate ways to reduce anxiety (e.g., using breathing exercises or techniques to
refocus attention). Exposure therapy, a technique used in cognitive-behavioral therapy, often
helps to alleviate the phobias that may result from panic disorder. In exposure therapy,
people are very slowly exposed to the fearful situation until they become desensitized to it.
Some people find the greatest relief from panic disorder symptoms when they take certain
prescription medications. Such medications, like cognitive-behavioral therapy, can help to
prevent panic attacks or reduce their frequency and severity. Two types of medications that
have been shown to be safe and effective in the treatment of panic disorder are
antidepressants and benzodiazepines.

443
Obsessive-Compulsive Disorder
4This handout was adapted from public domain information supplied by the National Institute of Mental Health.

Patient Information Handout

444
What Is Obsessive-Compulsive Disorder?
Obsessive-compulsive disorder (OCD), one of the anxiety disorders, is a potentially
disabling condition that can persist throughout a person’s life. The individual who suffers
from OCD becomes trapped in a pattern of repetitive thoughts and behaviors that are
senseless and distressing but extremely difficult to overcome. OCD occurs in a spectrum
from mild to severe; if severe and untreated, it can destroy a person’s capacity to function at
work, school, or even home.

445
How Common Is Obsessive-Compulsive Disorder?
For many years, mental health professionals thought of OCD as a rare disease, because only
a minority of their patients had the condition. The disorder often went unrecognized
because many of those afflicted with OCD, in efforts to keep their repetitive thoughts and
behaviors secret, failed to seek treatment. However, a survey conducted in the early 1980s
by the National Institute of Mental Health showed that OCD affects more than 2% of the
population, making it more common than such severe mental illnesses as schizophrenia,
bipolar disorder, or panic disorder. OCD strikes people of all ethnic groups. Men and
women are equally affected.

446
Key Features of Obsessive-Compulsive Disorder

Obsessions
Obsessions are unwanted ideas or impulses that repeatedly well up in the mind of the
person with OCD. Common are persistent fears that harm may come to self or a loved one,
an unreasonable concern with becoming contaminated, or an excessive need to do things
correctly or perfectly. Again and again, the individual experiences a disturbing thought,
such as, “My hands may be contaminated—I must wash them,” “I may have left the gas
on,” or “I am going to injure my child.” These thoughts are intrusive, unpleasant, and
produce a high degree of anxiety. Sometimes, the obsessions are of a violent or a sexual
nature, or they concern illness.

Compulsions
In response to their obsessions, most people with OCD resort to repetitive behaviors called
compulsions. The most common of these are washing and checking. Other compulsive
behaviors include counting (often while performing another compulsive action such as
hand-washing), repeating, hoarding, and endlessly rearranging objects in an effort to keep
them in precise alignment. Mental problems, such as mentally repeating phrases, making
lists, or checking, are also common. These behaviors generally are intended to ward off
harm to self or others. Some people with OCD have regimented rituals; others have rituals
that are complex and changing. Performing rituals may give the person with OCD some
relief from anxiety, but it is only temporary.

447
How Is Obsessive-Compulsive Disorder Treated?
OCD is treated with either psychotherapy (counseling) or medications, or with both
treatments combined.

Psychotherapy
The most effective psychotherapy for OCD is cognitive-behavioral therapy. In this
technique, your therapist will have you practice exposing yourself to those situations that
make you anxious and cause you to act out a compulsion (such as checking or washing).
Your therapist will help you to prevent the OCD response. Some of the exposure is done in
the therapist’s office, but most of it is done at home and is assigned as “homework.”
Cognitive-behavioral therapy is very effective, especially for those patients who suffer
primarily from compulsions. In such patients, therapy is often more effective than
medication.

Medications
Many effective medications for OCD exist. The most commonly prescribed are the SSRIs,
which have names like Prozac, Zoloft, Paxil, and Luvox. These are popular because they
have very few side effects when compared with older medications. Another effective
medication is Anafranil, which tends to have more side effects than the SSRIs.
When someone begins taking an OCD medication, improvement generally will not
begin to show up immediately. With most of these medications, it takes from 1 to 3 weeks
before changes begin to occur. If there is little or no change in symptoms after 5 to 6 weeks,
a different medication may be tried. Because there is no way of determining beforehand
which medication will be effective, the doctor may have to prescribe first one, then another,
until an effective medication is found. Treatment is continued for a minimum of several
months and may last up to a year or more.

448
 References

Ainslie, N. K., & Murden, R. A. (1993). Effect of education on the clock-drawing

dementia screen in non-demented elderly persons. Journal of the American Geriatrics
Society, 41(3), 249–252.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders, 5th ed. Washington, DC: American Psychiatric Association.
Andreasen, N. C. (1979). Thought, language, and communication disorders. I. Clinical
assessment, definition of terms, and evaluation of their reliability. Archives of General
Psychiatry, 36, 1315–1321.
Andreasen, N. C. (1982). Negative symptoms in schizophrenia: Definition and reliability.
Archives of General Psychiatry, 39, 784–788.
Andreasen, N. J., Tsuang, M. T., and Canter, A. (1974). The significance of thought
disorder in diagnostic evaluations. Comprehensive Psychiatry, 15, 27–34.
Anthony, J. C., LeResche, L., Niaz, U., et al. (1982). Limits of the ‘Mini-Mental State’ as
a screening test for dementia and delirium among hospital patients. Psychological
Medicine, 12, 397–408. doi: 10.1017/S0033291700046730.
Asnis, G. M., Kaplan, M. L., van Praag, H. M., et al (1994). Homicidal behaviors among
psychiatric outpatients. Hospital and Community Psychiatry, 45, 127–132.
Azar, B. (1997). Poor recall mars research and treatment. The APA Monitor, 28, 1.
Baekeland, F., and Lundwall, L. (1975). Dropping out of treatment: A critical review.
Psychological Bulletin, 82, 738–783.
Barlow, D. (Ed.). (2014). Clinical Handbook of Psychological Disorders, 5th ed. New York,
NY: The Guilford Press.
Barlow, D. H., Gorman, J. M., Shear, M. K., et al. (2000). Cognitive-behavioral therapy,
imipramine, or their combination for panic disorder: A randomized controlled trial.
Journal of the American Medical Association, 283, 2529–2536.
Basco, M. R., Bostic, J. Q., Davies, D., et al. (2000). Methods to improve diagnostic
accuracy in a community mental health setting. American Journal of Psychiatry, 157,
1599–1605.
Beckman, H. B., and Franckel, R. M. (1984). The effect of physician behavior on the
collection of data. Annals of Internal Medicine, 101, 692–696.
Biederman, J. (1991). Attention deficit hyperactivity disorder (ADHD). Annals of Clinical
Psychiatry, 3, 9–22.
Binder, R. L., and McNiel, D. E. (1996). Application of the Tarasoff ruling and its effect
on the victim and the therapeutic relationship. Psychiatric Services, 47, 1212–1215.
Blacker, D., and Tsuang, M. T. (1992). Contested boundaries of bipolar disorder and the
limits of categorical diagnosis in psychiatry. American Journal of Psychiatry, 149,

449
 1473–1483.
Bradburn, N. M., Sudman, S., and Wansink, B. (2004). Asking Questions: The Definitive
Guide to Questionnaire Design. San Francisco, CA: Jossey-Bass.
Brown, T. A., Campbell, L. A., Lehman, C. L., et al. (2001). Current and lifetime
comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample.
Journal of Abnormal Psychology, 110, 585–599.
Chang, J., and Nylund, D. K. (2013). Narrative and solution-focused therapies: A
twenty-year retrospective. Journal of Systemic Therapies, 32(2), 72–88.
Chochinov, H. M., Wilson, K. G., Enns, M., et al. (1997). Are you depressed? Screening
for depression in the terminally ill. American Journal of Psychiatry, 154, 674–676.
Cloninger, C. R., Sigvardsson, S., and Bohman, M. (1996). Type I and type II
alcoholism: An update. Alcohol Health & Research World, 20, 18–23.
Cox, A., Holbrook, D., and Rutter, M. (1981a). Psychiatric interviewing techniques. VI.
Experimental study: Eliciting feelings. British Journal of Psychiatry, 139, 144–152.
Cox, A., Hopkinson, K., and Rutter, M. (1981b). Psychiatric interviewing techniques. II.
Naturalistic study: Eliciting factual information. British Journal of Psychiatry, 138,
283–291.
Cox, A., Rutter, M., and Holbrook, D. (1988). Psychiatric interviewing techniques. A
second experimental study: Eliciting feelings. British Journal of Psychiatry, 152, 64–72.
Crook, T., Ferris, S., McCarthy, M., et al. (1980). Utility of digit recall tasks for assessing
memory in the aged. Journal of Consulting and Clinical Psychology, 48, 228–233.
David, A., and Fleminger, S. (2012). Lishman’s Organic Psychiatry: A Textbook of
Neuropsychiatry. Boston, MA: Wiley-Blackwell.
Eisenthal, S., Emery, R., Lazare, A., et al. (1979). “Adherence” and the negotiated
approach to patienthood. Archives of General Psychiatry, 36, 393–398.
Elstein, A. S., Shulman, L. S., and Sprafka, S. A. (1978). Medical Problem-Solving: An
Analysis of Clinical Reasoning. Cambridge, MA: Harvard University Press.
Ewing, J. A. (1984). Detecting alcoholism. The CAGE questionnaire. Journal of the
American Medical Association, 252, 1905–1907.
Felthous, A. R. (1991). Duty to warn or protect: Current status for psychiatrists.
Psychiatric Annals, 21, 591–598.
First, M. (2013). DSM-5 Handbook of Differential Diagnosis. Washington, DC: American
Psychiatric Press.
Flaum, M. (1995). The diagnosis of schizophrenia. In C. Shriqui, and H. Nasrallah
(Eds.), Contemporary Issues in the Treatment of Schizophrenia. Washington, DC:
American Psychiatric Press.
Folstein, M. F., Folstein, S. E., and McHugh, P. R. (1975). “Mini-mental state.” A
practical method for grading the cognitive state of patients for the clinician. Journal of
Psychiatric Research, 12, 189–198.
Frank, J. D., and Frank, J. B. (1991). Persuasion and Healing. Baltimore, MD: The Johns
Hopkins University Press.
Frank, E., Kupfer, D. J., and Siegel, L. R. (1995). Alliance not compliance: A philosophy

450
 of outpatient care. Journal of Clinical Psychiatry, 56(suppl 1), 11–16.
Hall, R. C., Gardner, E. R., Stickney, S. K., et al. (1980). Physical illness manifesting as
psychiatric disease. II. Analysis of a state hospital inpatient population. Archives of
General Psychiatry, 37, 989–995.
Harwood, D. M., Jr., Hope, T., and Jacoby, R. (1997). Cognitive impairment in medical
inpatients. I. Screening for dementia—Is history better than mental state? Age and
Ageing, 26, 31–35.
Havens, L. (1986). Making Contact. Cambridge, MA: Harvard University Press.
Hinton, J., and Withers, E. (1971). The usefulness of clinical tests of the sensorium.
British Journal of Psychiatry, 119, 9–18.
Honig, A., Romme, M. A. J., and Ensink, B. J. (1998). Auditory hallucinations: A
comparison between patients and nonpatients. Journal of Nervous Mental Disorders,
186, 646–651.
Isaacs, B., and Kennie, A. (1973). The set test as an aid to the detection of dementia in
old people. British Journal of Psychiatry, 123, 467–470.
Jacobs, M., Frank, E., Kupfer, D. J., et al. (1987). A psychoeducational workshop for
depressed patients, family, and friends: Description and evaluation. Hospital and
Community Psychiatry, 38, 968–972.
Jones, P. B. (2013). Adult mental health disorders and their age at onset. British Journal of
Psychiatry, 202, s5–s10.
Jorm, A., Scott, R., Cullen, J. S., et al. (1991). Performance of the Informant
Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a screening test for
dementia. Psychological Medicine, 21, 785–790.
Kaplan, C. (2011). Hypothesis testing. In M. J. Lipkin, S. M. Putnam, and A. Lazare
(Eds.), The Medical Interview. New York, NY: Springer-Verlag.
Keller, M. B., and Manschreck, T. C. (1989). The mental status examination. II. Higher
intellectual functioning. In A. Lazare (Ed.), Outpatient Psychiatry: Diagnosis and
Treatment. Baltimore, MD: Williams & Wilkins.
Kessler, R. C., Berglund, P., Demler, O., et al. (2005). Lifetime prevalence and age-of-
onset distributions of DSM-IV disorders in the national comorbidity survey
replication. Archives of General Psychiatry, 62, 593–602.
Klein, D. N., Riso, L. P., and Anderson, R. L. (1993). DSM-III-R dysthymia:
Antecedents and underlying assumptions. Progress in Experimental Perspectives in
Psychopathologic Research, 16, 222–253.
Lam, R. W., and Stewart, J. N. (1996). The validity of atypical depression in DSM-IV.
Comprehensive Psychiatry, 37, 375–383.
Lazare, A., Eisenthal, S., and Wasserman, L. (1975). The customer approach to
patienthood—Attending to patient requests in a walk-in clinic. Archives of General
Psychiatry, 32, 553–558.
Lejoyeux, M., Ades, J., Tassain, V., et al. (1997). Phenomenology and psychopathology of
uncontrolled buying. American Journal of Psychiatry, 153, 1524–1529.
Lipkin, M. L. (2002). The medical interview and related skills. In W. T. Branch, Jr. (Ed.),

451
 Office Practice of Medicine. Philadelphia, PA: W. B. Saunders.
Llark, C. M., Sheppard, L., Fillenbaum, G. G., et al. (1999). Variability in annual Mini-
Mental State Examination score in patients with probably Alzheimer disease. Archives
of Neurology, 56, 857–862.
Manly J. J., Jacobs D. M., Sano M., et al. (1999). Effect of literacy on neuropsychological
test performance in nondemented, education-matched elders. Journal of the
International Neuropsychological Society, 5(3), 191–202.
Marshall, P., Schroeder, R., O’Brien, J., et al. (2010). Effectiveness of symptom validity
measures in identifying cognitive and behavioral symptom exaggeration in adult
attention deficit hyperactivity disorder. The Clinical Neuropsychologist, 24,
1204–1237.
McKenna, P. J. (1994). Schizophrenia and Related Syndromes. Oxford, UK: Oxford
University Press.
Meagher, J., Leonard, M., Donoghue, L., et al. (2015). Months backward test: A review
of its use in clinical studies. World Journal of Psychiatry, 22, 305–314.
Miller, G. A. (1957). The magical number seven, plus or minus: Some limits on our
capacity for processing information. Psychological Review, 63, 81–97.
Milstein, V., Small, J. G., and Small, I. F. (1972). The subtraction of serial sevens test in
psychiatric patients. Archives of General Psychiatry, 26, 439–441.
Morrison, J. (2014). The First Interview. New York, NY: The Guilford Press.
Morrison, J., and Munoz, R. A. (2009). Boarding Time: A Psychiatry Candidate's Guide to
Part II of the ABPN Examination. Washington, DC: American Psychiatric Press.
Mueser, K. T., and Glynn, S. M. (1999). Behavioral Family Therapy for Psychiatric
Disorders, 2nd ed. Oakland, CA: New Harbinger Publications.
Murden, R. A., McRae, T. D., Kaner, S., et al (1991). Mini-Mental State exam scores
vary with education in blacks and whites. Journal of the American Geriatric Society, 39,
149–155.
Norton, G. R., Dorward, J., and Cox, B. J. (1986). Factors associated with panic attacks
in nonclinical subjects. Behavior Therapy, 17, 239–252.
Othmer, E., and Othmer, S. C. (2001). The Clinical Interview Using DSM-IV-TR.
Washington, DC: American Psychiatric Press.
Patterson, W. M., Dohn, H. H., Bird, J., et al. (1983). Evaluation of suicidal patients:
The SAD PERSONS scale. Psychosomatics, 24, 343–349.
Payne, S. L. (1951). The Art of Asking Questions. Princeton, NJ: Princeton University
Press.
Pekarik, G. (1993). Beyond effectiveness: Uses of consumer-oriented criteria in defining
treatment success. In T. Giles (Ed.), Handbook of Effective Psychotherapy. New York,
NY: Plenum Press.
Pilowsky, I., and Boulton, D. M. (1970). Development of a questionnaire-based decision
rule for classifying depressed patients. British Journal of Psychiatry, 116, 647–650.
Pinkofsky, H. B. (1997). Mnemonics for DSM-IV personality disorders. Psychiatric
Services, 48, 1197–1198.

452
Platt, F. W., and McMath, J. C. (1979). Clinical hypocompetence: The interview. Annals
of Internal Medicine, 91, 898–902.
Posternak, M. A., and Zimmerman, M. (2003). How accurate are patients in reporting
their antidepressant treatment history? Journal of Affective Disorders, 75, 115–124.
Rapp, M. S. (1979). Re-examination of the clinical mental status examination. Canadian
Journal of Psychiatry, 24, 773–775.
Regier, D. A., Farmer, M. E., Rae, D. S., et al. (1990). Comorbidity of mental disorders
with alcohol and other drug abuse. Journal of the American Medical Association, 264,
2511–2518.
Reider, R. O., Kaufmann, C. A., and Knowles, J. A. (1994). Genetics. In R. E. Hales, S.
C. Yudofsky, and J. A. Talbott (Eds.), American Psychiatric Press Textbook of
Psychiatry. Washington, DC: American Psychiatric Press.
Rudd, M. D., Berman, A. L., Joiner, T. E., et al. (2006). Warning signs for suicide:
Theory, research, and clinical applications. Suicide and Life-threatening Behavior, 36,
255–262.
Sacks, M. H., Carpenter, W. T., Jr., and Strauss, J. S. (1974). Recovery from delusions.
Three phases documented by patient's interpretation of research procedures. Archives
of General Psychiatry, 30, 117–120.
Shea, S. C. (1998). Psychiatric Interviewing: The Art of Understanding. Philadelphia, PA:
W. B. Saunders.
Shea, S. C. (2006). Improving Medication Adherence. Philadelphia, PA: Lippincott
Williams & Wilkins.
Shea, S. C. (2007). Clinical interviewing: Practical tips from master clinicians. Psychiatric
Clinics of North America, 30, 219–225.
Shea, S. C. (2011). The Practical Art of Suicide Assessment. Stoddard, NH: Mental Health
Presses.
Smith, A. (1967). The serial sevens subtraction test. Archives of Neurology, 17, 78–80.
Solomon, S. D., and Davidson, J. R. T. (1997). Trauma: Prevalence, impairment, service
use, and cost. Journal of Clinical Psychiatry, 58(suppl 9), 5–11.
Steinweg, D. L., and Worth, H. (1993). Alcoholism: The keys to the CAGE. The
American Journal of Medicine, 94, 520–523.
Stunkard, A. J., Fernstrom, M. H., Price, A., et al. (1990). Direction of weight change in
recurrent depression. Archives of General Psychiatry, 47, 857–860.
Sullivan, H. S. (1970). The Psychiatric Interview. New York, NY: W. W. Norton and Co.
Tangalos, E. G., Smith, G. E., Ivnik, R. J., et al. (1996). The Mini-Mental State
Examination in general medical practice: Clinical utility and acceptance. Mayo Clinic
Proceedings, 71, 829–837.
Tardiff, K. (1992). The current state of psychiatry in the treatment of violent patients.
Archives of General Psychiatry, 49, 493–499.
Tsoi, K. K., Chan, J. Y., Hirai, H. W., et al. (2015). Cognitive tests to detect dementia: A
systematic review and meta-analysis. JAMA Internal Medicine, 175, 1450–1458.
Turner, C. F., Ku, L., Sonenstein, F. L., et al. (1996). Impact of audio-CASI on bias in

453
 reporting of male–male sexual contacts. In R. B. Warnecke (Ed.), Health Survey
Research Methods. Hyattsville, MD: National Center for Health Statistics.
Vaillant, G. E. (1988). Defense Mechanisms. In A. M. Nicholi, Jr. (Ed.), The New
Harvard Guide to Psychiatry. Cambridge, MA: Harvard University Press.
Vaillant, G. E. (1995). The Natural History of Alcoholism Revisted. Cambridge, MA:
Harvard University Press.
Weissenburger, J., Rush, A. J., Giles, D. E., et al. (1986). Weight change in depression.
Psychiatry Research, 17, 275–283.
White, M., and Epston, D. (1990). Narrative Means to Therapeutic Ends. New York, NY:
W.W. Norton & Company.
Wilson, I. C. (1967). Rapid approximate intelligence test. American Journal of Psychiatry,
123, 1289–1290.
Winokur, G. (1981). Depression: The Facts. Oxford, UK: Oxford University Press.

454
 Index

A
ADHD. See Attention-deficit hyperactivity disorder (ADHD)
Adolescent patient
family interview
individual interview
asking about conduct problems
asking about drugs and alcohol
asking about school and other activities
asking about sex
“i don’t know” syndrome
Affect terms
Agoraphobia
AHs. See Auditory hallucinations (AHs)
Alcohol dependence and drug abuse
assessment techniques
CAGE questionnaire
probing questions
dual diagnosis
Alcohol technique
Allergies, screening question
Anorexia nervosa
Antisocial behavior
Anxiety disorders
agoraphobia
DSM-5
generalized anxiety disorder (GAD)
obsessive-compulsive disorder (OCD)
panic disorder
posttraumatic stress disorder (PTSD)
screening questions
social phobia
Aphasia
Appearance terms

455
Appetite disorder
Apraxia
Attention-deficit hyperactivity disorder (ADHD)
in adults
formal rating scales and family interviews
inattentiveness and disorganization
talking impulsively and hyperactivity
in children
DSM-5
Atypical depression, mood disorders I
Auditory hallucinations (AHs)
history of
malingering patient

B
Barbara Walters approach
Bare-bones approach
Bipolar disorder
activity increase
DIGFAST
distractibility
flight of ideas
grandiosity
hospitalization, history of
hypomanic episode
indiscretion
manic episode
patient education handouts
screening questions
sleep deficit
talkativeness
Borderline personality disorder
challenging situations
illustrative transitions
probing questions
Breathlessness cluster
Bulimia nervosa

456
CAGE questionnaire
Capgras syndrome
CASE approach
CBT. See Cognitive-behavioral therapy (CBT)
Challenging situations
borderline personality disorder
hostile patient
irritable, depressed patient
paranoid patient
seductive patient
tearful patient
Change topics with style
introduced transition
referred transition
smooth transition
Chronological assessment of suicidal events
Closed-ended questions, talkative patient
Cognitive disorders, DSM-5
attention-deficit hyperactivity disorder (ADHD)
delirium
dementia
Cognitive-behavioral therapy (CBT)
Complex attention
Concentration deficit
Continuation techniques
Coping styles
Counterprojective statements
Countertransference diagnostics

D
Defense mechanisms
classification of
immature defenses
acting out
dissociation
passive aggression
projection
splitting (idealization/devaluation)
mature defenses

457
 altruism
humor
sublimation
suppression
neurotic (transitional) defenses
denial
displacement
rationalization
reaction formation
repression
pocket cards
psychotic defenses
denial of external reality
distortion of external reality
Delirium
change in cognition
fluctuating course
impaired attention
Delusions
Dementia
interviewing family members
interviewing the patient
screening questions
Depakote
Depressed patient, challenging situations
Depression
atypical
illustrative transitions
SIGECAPS
symptoms, asking about the
Depressive disorders
major depression
patient education handouts
SIGECAPS
mood disorders I
atypical depression
dysthymia
screening questions

458
 seasonal affective disorder (SAD)
SIGECAPS
symptoms of
Diagnostic interview
phases
body of interview (30 to 40 minutes)
closing phase (5 to 10 minutes)
opening phase (5 to 10 minutes)
psychodynamics
coping styles
countertransference diagnostically
defense mechanisms and coping responses
negative transference
reality distortion
tasks
ability to interview
psychiatric database
therapeutic alliance
treatment plan and communicate, patient
DIGFAST, manic episode
Direct feeling questions
Disorder of behavior
Disorganization, ADHD
Disorganized behavior
Disorganized speech, DSM-5
Distractibility
Domestic violence
Drug use
DSM-5
agoraphobia
anorexia nervosa
attention-deficit hyperactivity disorder (ADHD)
breathlessness cluster
bulimia nervosa
delirium
dementia
depressive episode
diagnoses

459
 diagnostic categories
disorganized speech
eating disorder
fear cluster
generalized anxiety disorder (GAD)
heart cluster
hypomanic episode
manic episode
mnemonics
obsessive-compulsive disorder (OCD)
panic disorder
personality disorders
positive criteria
anxiety disorders
mood disorders
psychotic disorders
substance abuse
posttraumatic stress disorder (PTSD)
psychiatric review of symptoms
schizophrenia
social phobia
somatization disorder
writing up, interview results
Dysthymia
DSM-5
mood disorders I

E
Eating disorders
Educating interruption
Empathic interruption
Empathic/sympathetic statements
Energy deficit
Executive function

F
Family history
genogram
writing up, interview results

460
Family interviews
adolescent patient
attention-deficit hyperactivity disorder (ADHD)
Family members, interviewing. See Patient’s informants
Family psychiatric history
bare-bones approach
genogram
Fatigue
Fear cluster, DSM-5
agoraphobia
generalized anxiety disorder (GAD)
obsessive-compulsive disorder (OCD)
panic disorder
posttraumatic stress disorder (PTSD)
Folstein Mini-Mental state examination
Folstein mini-mental state examination
Formal rating scales, ADHD

G
Generalized anxiety disorder (GAD)
anxiety disorders
DSM-5
Genogram
Gentle interruption
Grandiose delusions
Ground-up technique
Guilt

H
Hallucinations
Heart cluster
History of present illness (HPI)
Barbara Walters approach
chronologic narrative, emphasizing precipitants
diagnostic questions
functioning, current and premorbid level of
multiple psychiatric hospitalizations
present crisis approach
syndrome approach

461
 writing up, interview results
Homicidal ideation
Hopelessness
Hospitalization history
HPI. See History of present illness (HPI)
Hyperactivity, ADHD
Hypothesis testing
free speech period
illustrative transitions
psychiatric review of symptoms
screening and probing questions

I
“I don’t know” syndrome
Illness anxiety disorder
Immature defenses mechanisms
Inattentiveness, ADHD
Individual interview, adolescent patient
asking about conduct problems
asking about drugs and alcohol
asking about school and other activities
asking about sex
“i don’t know” syndrome
initial questions and strategies
Informants, interviewing. See Patient’s informants
Initial psychiatric evaluation
long form
short form
Insomnia
Interest deficit
Interview results. See Writing up, interview results
Introduced transition
Irritability
Irritable patient, challenging situations

L
Language problems
Lithium
LOA. See Looseness of association (LOA)

462
Logistic preparations
paper tools effectively
patient handouts
patient questionnaire
psychiatric interview long form
psychiatric interview pocket card
psychiatric interview short form
policies, developing tips and ideas
right space and time
protect the time
secure a space
Looseness of association (LOA)

M
Major depression
patient education handouts
SIGECAPS
Malingering, interviewing clues to
Malingering patient
Mania. See also Bipolar disorder
Mature defenses mechanisms
Medical history
allergies
illness history
medications
primary care doctor
writing up, interview results
Medical illnesses
history of
screen for
Medical review of systems
brief review of systems
extended review of systems
cardiovascular and respiratory
gastrointestinal
general
genitourinary and gynecologic systems
HEENT
HIV risk, assessing

463
 neurologic systems
symptoms, brief vs. full review
Medications
medical conditions
patient education handouts
treatment history
trials
Memory
Mental status examination (MSE)
affect
appearance
aspect of appearance
memorable aspects
personal statement
self-esteem
attention
attitude
awareness/wakefulness, level of
behavior
cognitive examination
concentration
Folstein mini-mental state examination
general cultural knowledge
intelligence
judgment
memory
Mini-Cog
mood
personal knowledge
qualities of affect
appropriateness
intensity of affect
range of affect
stability of affect
speech
general quality
latency of response
rate

464
 volume
thought content (TC)
thought process (TP)
three-object recall
writing up, interview results
Missed appointments, logistic preparations
Mood disorders
atypical depression
DSM-5
dysthymia
major depression
manic episode
dysthymia
hypomanic episode
manic episode
activity increase
DIGFAST
distractibility
DSM-5
flight of ideas
grandiosity
hospitalization, history of
indiscretion
screening questions
sleep deficit
talkativeness
screening questions
seasonal affective disorder (SAD)
SIGECAPS questions
symptoms of
MSE. See Mental status examination (MSE)
Multiple psychiatric hospitalizations, history of
Multiple-choice questions, talkative patient
Muscle tension
Mutism

N
Negative transference, psychodynamics
Neurocognitive disorder

465
 interviewing family members
interviewing patient
Neurotic (transitional) defenses mechanisms
Nonjudgmental
Nonjudgmental questions
Normalizing statement

O
Obsessive-compulsive disorder (OCD)
anxiety disorders
DSM-5
illustrative transitions
patient education handouts
Open-ended questions and commands

P
Panic attack
Panic disorder
anxiety disorders
patient education handouts
Paranoid delusions
Paranoid patient, challenging situations
Past psychiatric history (PPH)
writing up, interview results
Patient education
diagnosis, information
disorder
minilecture about
patient knows about
questions
written educational materials
Patient education handouts
advantages and disadvantages
bipolar disorder
major depression
obsessive-compulsive disorder
panic disorder
Patient questionnaire
Patient recall tricks

466
 anchor questions, memorable events
tag questions with specific examples
technical terms
Patient’s informants
anti-medication
confrontational
HIPAA
inpatient work
issue of
list of questions
thoughts and worries
Perceptual-motor problems
Personality disorders
antisocial
anxious
borderline personality disorder
DSM-5
ground-up technique
histrionic
narcissistic
paranoid
schizoid
schizotypal
symptom-window technique
Posttraumatic stress disorder (PTSD)
anxiety disorders
DSM-5
PPH. See Past psychiatric history (PPH)
Present crisis approach, history of
Primary care doctor
Probing questions
antisocial
assessment techniques
borderline personality disorder
histrionic
narcissistic
obsessive-compulsive
paranoid

467
 schizoid
schizophrenia
schizotypal
and screening
Psychiatric disorders
familial transmission
heritability and prevalence of
Psychiatric evaluation
Psychiatric history
Psychiatric illness, uncover general medical causes of
Psychiatric interview
long form
short form
Psychiatric interview pocket card
advantages and disadvantages
affect terms
appearance terms
defense mechanisms
DSM-5
diagnoses
mnemonics
psychiatric disorders, heritability nd prevalence of
psychiatric evaluation
Wilson rapid approximate intelligence est
Psychiatric review of symptoms
DSM-5
writing up, interview results
Psychodynamics
coping styles
countertransference diagnostically
defense mechanisms and coping responses
negative transference
reality distortion
Psychomotor retardation or agitation
Psychosis, illustrative transitions
Psychotherapy
patient education handouts
treatment history

468
Psychotic defenses mechanisms
Psychotic disorders
circumstantial thinking style
delusions of reference
capgras syndrome
control/influence
grandiose delusions
jealousy
somatic delusions
DSM-5
flight of ideas
looseness of association (LOA)
mutism
poverty of content
poverty of thought
probing questions
racing thoughts
schizophrenia
delusions (disorders of thought ontent)
DSM-5
paranoid delusions
screening questions
tangentiality
word salad
PTSD. See Posttraumatic stress disorder (PTSD)

R
Reality distortion, psychodynamics
Referred transition
Reflective statements
Reluctant patient
continuation techniques
neutral ground
open-ended questions and commands
second interview
Review of symptoms
medical problems
writing up, interview results

469
S
SAD. See Seasonal affective disorder (SAD)
SAD PERSONS, risk factors for suicide
Schizophrenia
Capgras syndrome
counterprojective statements
delusions of control/influence
delusions of reference
disorders of thought content
disorganized speech
DSM-5
grandiose delusions
religious delusions
technological delusions
hallucinations
jealousy
nonjudgmental questions
paranoid delusions
probing questions
reality testing, techniques for
somatic delusions
Seasonal affective disorder (SAD)
Secure a space, logistic preparations
Seductive patient, challenging situations
Selective serotonin reuptake inhibitors (SSRIs)
Sexual history
SIGECAPS, major depression
Sleep deficit
Sleep disorder
Smooth transition
Social and developmental history
current activities and relationships
early family life
education and work
intimate relationships (sexual history)
Social cognition
Social history
genogram

470
 writing up, interview results
Social phobia, anxiety disorders
Somatic symptom disorder
Somatic symptom disorder (SSD)
SSRIs. See Selective serotonin reuptake inhibitors (SSRIs)
Substance abuse
DSM-5
illustrative transitions
screening questions
Substance use history
Suicidal ideation
Suicidality
illustrative transitions
major depression
threatening topics
Suicide, risk factors for
Surgical history
Symptom exaggeration
Symptom expectation
Symptom-window technique
Syndromal history
age at onset
premorbid functioning/baseline functioning
subsequent episodes
Syndrome approach, history of

T
Talkative patient
closed-ended and multiple-choice questions
educating interruption
gentle interruption
Talkativeness
Talking impulsively, ADHD
Tearful patient, challenging situations
Technical terms, patient recall tricks
Tegretol
Therapeutic alliance
clinical situation
competence

471
 direct feeling questions
empathic/sympathetic statements
good interviewer
patient opening statements
reflective statements
Threatening questions
behaviors, using familiar language
guilt, reduction of
antisocial behavior
domestic violence
normalization
symptom exaggeration
symptom expectation
Treatment history
current caregivers
general questions
Go CHaMP, mnemonic for
hospitalization history
medication history
psychotherapy history
Treatment plan
agreed-on plan
follow-up appointments
medication trials
negotiation
patient’s agenda
writing up, interview results

W
Wilson rapid approximate intelligence test
Word salad
Worthlessness
Writing up, interview results
assessment
chief complaint
family history
history of present illness
identifying data
medical history

472
mental status examination
past psychiatric history
review of symptoms
social history
substance use history
treatment plan

473