Taken From: Kaplan Comprehensive Textbook of Psychiatry, 8th Edition, Chapter 7.

Psychiatric Interview, History, and Mental Status

Examination

Ekkehard Othmer M.D., Ph.D.

Sieglinde C. Othmer Ph.D.
Johann Philipp Othmer M.D.

PSYCHIATRIC INTERVIEW, INTRODUCTION

Goal of the Clinical Psychiatric Interview

The goal of the initial diagnostic clinical psychiatric interview is to collect specific, detailed information about
15 topics. These topics constitute the psychiatric evaluation. Acquiring the database of information for these 15
topics enables the interviewer to make diagnoses compatible with the revised fourth edition of Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR) on five axes and to develop a treatment plan acceptable to the
patient:
1. Identifying data. The patient's name, sex, age, race, marital status, and vital signs.
2. Chief complaint. The chief complaint in the patient's own words. Alternatively, signs of disordered
functioning observed by the interviewer.
3. Informants. A list of all informants, their reliability, and level of cooperation; also previous hospital records,
if available. Such informants are essential in circumstances that prevent the patient from providing
adequate information. Choosing the right set of informants is more important than having a great number
of informants.
4. Reason for admission or consultation. The referral source; in case of hospitalization, statement of legal
status—voluntary versus involuntary—and the reason why hospitalization is the safest and least restrictive
environment for treatment.
5. History of present illness. Early manifestations and recent exacerbations of all psychiatric disorders present
(Axis I and II); review of diagnoses and treatments given by other providers.
6. Psychiatric disorders in remission. Psychiatric disorders presently in remission, especially substance abuse
disorders; psychiatric disorders first diagnosed in childhood and adolescence and their treatments.
7. Medical history. All medical disorders past and present and their treatments and childhood disorders that
involve the central nervous system (CNS). For females, pregnancy status—especially if on psychotropics or
expecting the use of psychotropics and precautions against pregnancy and concomitant pharmacological
treatment. On all patients, but particularly in consult-liaison work, the medical history includes the
interrelation of medical and psychiatric conditions.
8. Social history and premorbid personality. Early developmental history. Description of premorbid
personality as baseline for patient's best level of functioning. Impact of Axis I and II disorders on patient's
life. The patient's psychosocial and environmental conditions predisposing to, precipitating, perpetuating,
and protecting against psychiatric disorders. Premorbid versus morbid functioning. Present support
system.
9. Family history. Psychiatric history of first-degree relatives, including treatment response as a possible
genetic predisposition for the patient.
10. Mental status examination. Appearance, consciousness, psychomotor functions, speech, thinking, affect,
mood, suggestibility, and thought content; cognitive functions, such as orientation, memory, intelligence,
and executive functions; insight and judgment.

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 11. Diagnostic formulation. Summary of biological, psychological, and social factors contributing to the
patient's psychiatric disorder.
12. Differential diagnosis. Discussion of diagnostic options based on overlapping symptomatology.
13. Multiaxial psychiatric diagnosis. Information on all five axes.
14. Assets and strengths. Inventory of patient's knowledge, interests, aptitudes, education, and employment
status to be used in the treatment plan.
15. Treatment plan and prognosis. Account of psychopharmacological, psychological, and social treatment
modalities planned, frequency of visits, and list of providers; discharge criteria if inpatient.
How does the interviewer get comprehensive, clinically significant, reliable, and valid information to cover
these points in a restricted time frame of 20 to 90 minutes? To acquire the communication skills needed for this
task, the interviewer has to master the range between disorder-centered and patient-centered interviewing styles
and apply them to the four components of the interview: rapport, techniques, mental status, and diagnosing.

Disorder-Centered versus Patient-Centered Interviewing Styles

Psychiatric interviewing is a special form of human communication. The interviewer asks the patient to disclose
complaints, share problems, and reveal suffering. According to the difficulties that the patient experiences with
this request, the interviewer shifts the focus between disorder-centered and patient-centered interviewing.
Disorder-centered interviewing is based on a descriptive, atheoretical model of psychiatric disorders called the
medical model, which is the official model supported by the American Psychiatric Association (APA) and the World
Health Organization (WHO) codified in DSM-IV-TR (2000) and the International Classification of Diseases (ICD-10).
This framework views psychiatric disorders as similar to medical disorders, using criteria for diagnosis as
identifiable clusters of occurrences from a restricted menu of symptoms, signs, and behaviors that cause morbidity
and mortality. Each disorder can be differentiated from other psychiatric disorders; each has a typical natural
history, often occurs in increased frequency in first-degree relatives, with specific comorbidities, and with
somewhat predictable treatment responses. Whereas the diagnosis of an infectious disorder is established by tests
that determine the presence or absence of a specific etiological agent, tests confirming the etiology of a diagnosis
in psychiatric disorders are not available. Except for the presence of established or suspected genetic dispositions,
etiology is incomplete. Specific genetic lesions or triggered susceptibilities, perhaps arising through multifactorial
genetic factors, which form the basis of the current paradigm of the etiology of psychiatric disorders, remain to be
determined. The triggers for psychiatric disorders remain a mystery, as do the triggers for the onset of many
infectious diseases and medical conditions. Risk factors are present in more people than actually develop the
illness.
To establish a psychiatric diagnosis based on this descriptive medical model, the interviewer chooses proven,
symptom-oriented, open-ended questions with a relatively narrow scope followed up by closed-ended, nonleading
questions centering on the disorder. Prerequisites for this style are the knowledge of the DSM-IV-TR criteria and
the 15 topics to be covered. This disorder-centered interview style works for most cooperative patients, patients
whose communication skills are not impaired by their Axis I and II disorders or their defense mechanisms.
Disorder-centered interviewing is driven by the patient's help-seeking behavior. Proficiency for disorder-centered
interviewing can be acquired during the first few years of training.
In contrast, patient-centered interviewing is based on the introspective model, which emphasizes the
individuality of the patient's experience. This model attends to the intrapsychic battle of conflicts. It is sensitive to
the patient's educational, emotional, intellectual, and social background, the personality, and the individual
symptom constellations tracing their arrival to individual circumstances and the individual's unique response
(cognitive-behavioral model). One example of the introspective model is the psychodynamic model. Interviewing
based on the psychodynamic model uses nonstructured, open-ended questions with a broad scope, encouraging
free association. The psychodynamic model posits the etiology of psychiatric symptoms as responses to often
unconscious inter- and intrapersonal conflicts. It explores and interprets behaviors and sequences of answers. In
this model, the interviewer strives to help the patient overcome self-defeating intra- and interpersonal conflicts.

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The prerequisite for such an interview is the interviewer's experience and understanding of coping styles, the
knowledge of how Axis I and II disorders interfere with the doctor–patient interaction (transference), and how to
manage such interference. Switching to the patient-centered style may become necessary if the patient puts up
resistance and defenses and becomes difficult to interview. To acquire proficiency in patient-centered interviewing
is a lifelong endeavor, like training for excellence in most sports.
The disorder-centered and patient-centered interviewing styles do not exclude each other. They are end points
of a continuum. The interviewer's mobility and flexibility in gliding between the two extremes determine the
efficiency, reliability, validity, and quality of data collection. The degree of the patient's impairment determines to
which extent the disorder-centered interview has to be augmented by patient-centered strategies.

Five Phases of the Psychiatric Interview and Four Components

The psychiatric interview progresses over time, which can be arbitrarily subdivided into five phases. These
phases cover sequentially the 15 (I to XV) topics of the psychiatric evaluation.
• Phase 1: Warm-up and Chief Complaint (I to IV)
• Phase 2: The Diagnostic Decision Loop (V)
• Phase 3: History and Database (VI to X)
• Phase 4: Diagnosing and Feedback (XI to XIV)
• Phase 5: Treatment Plan and Prognosis (XV)
The five phases divide the psychiatric interview longitudinally. Cross-sectionally, the interview consists of four
components, which the interviewer must continuously monitor and propel throughout.
Rapport focuses on the doctor–patient relationship; a good rapport is a prerequisite for an effective interview.
Rapport is established in the opening; with a cooperative and insightful patient, there is often little problem in
establishing and maintaining a good rapport. However, in patients who are uncooperative or show poor insight,
establishing a workable rapport with the patient becomes a central issue.
Technique refers to the approaches the interviewer uses to keep an interview “on track.” It includes skills to
appropriately select questions to arrive at a diagnosis. Good technique is necessary to therapeutically engage and
work with difficult patients.
Mental status assessment captures the patient's experiences, symptoms, signs, behaviors, thought content,
cognitive level of functioning, insight, and judgment during the actual time of the interview. Formal testing of
mental status may take place late in the interview; however, in a patient with a significantly altered mental
status—whether it be a boisterous, irritable, and uninterruptible manic patient, a minimally responsive depressed
patient, or a paranoid patient—his or her mental status plays a significant role in the interview.
Diagnosing pursues a progression in the diagnostic decision process from chief complaint to final diagnosis.

RAPPORT
Interviewing relies on rapport, from the French verb rapporter, to bring back—that is, to bring back the
response to the sender. Creating this feedback between interviewer and patient is the essence of communication.
It is rooted in a stream of nonverbal signals. Language adds precision and complexity. If the patient's mental status
interferes with this interaction, the interviewer shifts from assessing a disorder to managing the patient's mental
status—that is, the disorder-centered interview becomes patient centered.

Disorder-Centered versus Patient-Centered Interviewing and Rapport

With a cooperative patient, the interviewer starts out in a disorder-centered mode, checking whether DSM-IV-
TR criteria for psychiatric disorders are met. He or she assumes that the patient seeks help voluntarily and will
answer all questions. As the interviewer acts in a professional manner; does not insult or offend the patient; and
asks clear, understandable, and relevant questions; the interviewer expects the patient will respond. Rapport
follows.

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 In contrast, with a difficult patient, the interviewer shifts to a patient-centered mode. To obtain a
comprehensive diagnosis and to judge the patient's capacity for staying in treatment, the interviewer explicitly
focuses on establishing a cooperative relationship with the patient. Eight elements determine the quality of this
relationship (Table 7.1-1).

Table 7.1-1 Rapport in Disorder-Centered and Patient-Centered Interviewing Styles

Elements of
Relationship Disorder-Centered Interview Patient-Centered Interview
Perspective The interviewer is in charge, knows Patient holds the key to the symptoms; without the
diagnostic criteria of the disorder. patient's genuine contributions, a valid diagnosis cannot
be made.
Comfort Most patients quickly become comfortable The patient and interviewer need to experience comfort.
with the interview situation; no special The interviewer has to address tension, especially with
attention needed. Minor discomfort by the anxious and suspicious patients.
patient may be disregarded.
Empathy The interviewer assesses symptoms and The interviewer assesses suffering and expresses
expresses understanding. empathy.
Insight Most patients know they have a disorder. The patient may not accept having a disorder. The
interviewer has to decrease the distance between the
patient's and the interviewer's view of the patient's
psychiatric problems.
Alliance The interviewer cannot diagnose or treat Striving for alliance sets the tone of the interview. The
the illness if the patient does not tell what interviewer identifies the patient's illness as the common
is wrong. If the patient becomes enemy using the patient's level of insight.
uncooperative, the interviewer may remind
the patient of that fact.
Expertise The interviewer uses a set of DSM-IV- The interviewer individualizes questions about the
TR—derived generic questions to assess specific manifestations of the patient's disorders. The
psychiatric disorders. patient contributes the knowledge about his or her
problems. The interviewer contributes his or her
knowledge about psychiatric disorders and their
treatment.
Guidance Usually at the end of the interview, the Throughout, the interviewer defines the cooperative roles
interviewer discusses the treatment plan of interviewer and patient in the treatment process.
and obtains verbal acceptance from the
patient.
Trust Expected byproduct of thorough, detailed Result of purposeful development of several levels of
interviewing. relating, i.e., providing comfort, empathy, insight,
alliance, expertise, and guidance.

Perspective
Depending on the patient's behavior, the interviewer focuses his or her attention either on the diagnostic
process (i.e., the disorders to be explored) or on the patient's immediate emotions and needs without allowing the
interview to turn into an ad hoc psychotherapy session. Although the knowledge of the diagnostic criteria is
essential for the interviewer, their implementation requires that the patient provide genuine, detailed answers. A
patient who states, “You are the doctor, you decide,” tries to skirt his or her part. Recognizing possible dependency
needs, the interviewer corrects the patient's view by making him or her aware of the expected input.

Comfort
Many patients quickly become comfortable with the interview situation. However, if the patient appears
anxious, is trembling, or has a moist handshake or a racing pulse, the interviewer may address such discomfort
indirectly: “Have you seen a psychiatrist or counselor before?” or directly: “Your pulse is over 100. Is there any
problem with your heart?” The interviewer may give the patient time to calm down by offering something to drink
or by assessing demographics: “Do you live in this neighborhood?” The interviewer also should pay attention to his
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or her own comfort if the patient is intimidatingly aggressive or demanding, offensively flirtatious, or anxious and
address this problem.
A 42-year-old, red-faced, married Irishman who was accused by his wife of drinking too much entered the office
accompanied by his dog, a mixed breed of wolf and German shepherd. The dog circled through the
interviewer's office incessantly.
Interviewer (I): Mr. M., your dog distracts me from working with you. Can you have the dog sit?
Patient (P): (Gleaming) Are you scared?
I: (The dog keeps circling in the room and staring at the interviewer) I know neither you nor your dog. Would
you like me to be scared?
P: It depends what you will tell me.
I: What are you scared of that I would tell you?
P: That I'm an alcoholic and should stop drinking.
I: (Laughing) And if I don't, you have the wolf eat me?
P: (Also laughing)
I: But you really have to tell me. Do you want to stop drinking?
P: No. I don't.
I: What did you want to accomplish when you came here?
P: My wife says she'll divorce me if I don't stop.
I: So you don't want to stop? You just want to hide your drinking better?
P: I guess that's right.
I: I appreciate your honesty. Most people who are criticized for drinking too much and get threatened with
divorce or job loss try to con me and possibly themselves by saying they want to stop. You don't. If you ever
want to stop, I believe you can do it because you are honest with yourself.
P: (To the dog who is still circling the room) Molly, come here. Sit! (Molly obeys)
I: Thank you.

Empathy
For a symptom to be counted, it has to cause the patient impairment or distress. When a patient describes his
or her symptoms, the interviewer can follow up by getting a precise description of duration and frequency of
symptoms or, alternatively, especially if the interviewer encounters denial (“otherwise, I'm healthy”), by asking
about the impairment and distress that the symptom causes and expressing empathy.
A 74-year-old, white, married, former chief executive officer of a large company.
P: I can't sleep. Otherwise, I'm healthy. I wake up at 4 AM and can't go back to sleep.
I: Do you also have problems falling asleep?
P: Off and on. But I can handle that.
I: What about waking up in the middle of the night?
P: Once or twice. I may have to go to the bathroom.
I: Besides your early morning insomnia, do you have any other problems?
P: No. I'm really pretty healthy.
I: Do you feel depressed?
P: No.
I: Do you have any hobbies?
P: I do volunteer work.
I: Can you still do it?
P: Yes. I think it serves a good purpose. I help young entrepreneurs through the ZZZ foundation.
Alternative:

P: I can't sleep. Otherwise I'm healthy. I wake up at 4 AM and can't go back to sleep.
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 I: What does your insomnia do to you?
P: It wrecks my life. I toss and turn in my bed. I'm tired during the day and worried about my sleep. When
friends come over, I'm bored. They sound so trivial.
I: (Mirroring the patient's facial expression, frowning, tight lips, then bending forward) We have to put our
heads together and find a way to get rid of your problem.
The empathic, patient-centered approach invites the patient to express his or her thoughts and feelings about
his or her symptoms and describe his or her actions. This approach breaks through the patient's denial of being
depressed, which the descriptive, strictly symptom-gathering approach does not do. The interviewer's response
reflects the patient's affect and proposes a counteraction more convincing and genuine than a statement such as,
“I understand your suffering.” The empathic response follows the golden rule: Imagine thinking and feeling from
the patient's level of insight. Let the patient know that you can understand his or her point of view and initiate
caring.

Insight
A conflict about the nature of psychiatric symptoms and disorders can arise between the interviewer and the
patient. Undetected or unresolved, such a conflict of view may lead to a breakup of the doctor–patient
relationship. Therefore, the interviewer has to be aware of such differences and strive for congruency. If the
patient agrees with the interviewer's view, the therapist calls this congruency full insight. With respect to the acute
hallucinations, delusions, and manic symptoms, experts agree that the patient has very limited insight into the
pathological nature of these perceptions, beliefs, and behaviors. To change the patient's view, confrontation and
logical arguments are ineffective. Initially, the interviewer has to emulate the patient's view and intervene at the
level of the patient's understanding.
A 38-year-old, divorced, male railroad worker.
P: It's coming up again, even after 20 years. They can't let go of it.
I: Of what?
P: You know what, [expletive]!
I: Can you help me out?
P: (With a suspicious look) That I jacked off in the woods on that hunting trip. At work, they are making digs
again.
I: What are you doing about it?
P: I try to ignore it but it's getting hard.
I: Well, you are doing the right thing. don't do or say anything. don't let them know that they get to you. I will
give you some medication that will make it easier to get over it.
P: Okay.
Rather than taking a disorder-centered view and telling the patient that he has a persecutory delusion, which
has to be treated with medication, the interviewer addresses the delusion from the patient's viewpoint that
something “real” is happening to him. This patient-centered approach does not challenge the patient's false fixed
perception but works on his level of insight, still providing effective therapeutic intervention, a neuroleptic, and
support for his behavior—namely, to keep his persecutory perceptions to himself.
Patients with a personality disorder may recognize that certain behaviors cause distress to family members but
feel the family should change and be more tolerant rather than having to change.
A 46-year-old, male, fundamental Lutheran minister.
P: My wife wants a legal separation and that tears me up. As a minister, I should be able to set an example for
my congregation. I can't have that separation.
I: Why does she want that separation?
P: She says I get so angry and critical with her and the kids. She can't take my anger outbursts any more.
I: Do you think you get angry as she says?
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 P: Yes. It's my job. If I feel I get excuses or my kids or my wife violate commandments of Christian conduct, I
become like God's hot sword cutting into butter.
I: Do you feel your anger is too much and out of proportion?
P: No. I think it's justified.
I: Can you not get angry if you wanted to?
P: That's hard to do. Maybe I carry my profession too much into my family.
I: Would it be of advantage to you if you had more of a choice to become angry or not? If you increased your
degree of freedom?
P: I probably could live with that.
I: We both have to put our minds to work on increasing the power of free will.
The interviewer discusses the patient's anger outbursts not as a result of a narcissistic perfectionistic
personality disorder but as a challenge congruent with the patient's needs. Successful anger control can increase
the patient's narcissistic pride and his choices while helping the marital relationship at the same time. Rapport is
strengthened by identifying the patient's level of insight and interviewing him from the patient's perspective.

Alliance
After the interviewer understands which symptoms, signs, and behaviors the patient identifies as disordered,
he or she can explicitly split this part off as sick. The interviewer can explore with the patient what both can
contribute to repair the sick. Because the patient guards the treasure box of his or her broken functions, he or she
has to be willing to open it so that the interviewer can examine the contents and discuss with the patient options
for repair. The interviewer stresses the need for an alliance. Thus, if the patient says, “You are the doctor, I do
what you say,” the interviewer may reply: “You are the patient, and we both have to put our heads together to
come up with the best plan to succeed. I need your input and consent.”

Expertise
Some patients feel they can receive empathy and alliance from family members and friends. So what is the
interviewer's edge? The interviewer can provide at least four things for the patient and may make him or her
aware of that fact implicitly or explicitly. The psychiatrist can acknowledge that he or she understands the
disorder. He or she can emphasize that the patient is not alone, that others share the same disorder. The
interviewer can point out that the patient's personality to deal with the disorder is unique and can contribute to
improve the disordered functions. He or she can appreciate the symptoms and signs of the disorder and the
distress that it causes. He or she may demonstrate such knowledge by asking for specific symptoms that the
patient tried to keep a secret, such as:
I: Whom in your family have you trusted enough to share your obsessions?
P: Nobody. How do you know that I feel embarrassed to talk about it to my family?
The interviewer may give the patient feedback about what is known about the disorder. Patients who read
about their condition in books and on the Internet may evaluate the interviewer more in terms of how much he or
she knows than by how much he or she cares. If the interviewer does not know the answer to a patient's question,
he or she may clearly state that he or she does not know but, “Let's find out.”
Some patients are suspicious about the interviewer's expertise but do not want to offend him or her with their
distrust. If the interviewer senses reluctance, he or she may explore the nature of the doubts rather than ignoring
them and hoping that the patient learns to trust him or her. The interviewer may pass over positive feedback from
the patient but, as a rule, should address negative signals, even though he or she may feel uncomfortable in doing
so.
The interviewer instills hope. Related to providing a perspective and giving an outlook is the interviewer's
ability to emphasize the positive factors regarding the patient's disorder, such as treatability, and the patient's
personality, such as intelligence, resilience, and ability to self-criticize.

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 Guidance
Patients rank the therapist's leadership third after expertise and empathy. From the beginning of the interview,
the interviewer sets milestones for the progression of the encounter. The interviewer can reach subgoals, such as
establishing rapport and collecting information for the diagnostic process with the patient's agreement and
cooperation. Thus, if the interviewer reads the patient's expectations for the interview and makes his or her goals
congruent to these expectations, he or she steers the interview with an invisible hand. The more the interviewer is
willing to explain his or her questions and suggestions and their rationale and give options, the easier it usually is
to guide the patient through the interview with little conflict. Special situations may arise. Dependent patients may
shy from responsibility and desire to be nurtured by the “strong, all-powerful protector.” The oppositional patient
or the patient with persecutory feelings may get irritated by any hint of rule setting and may rebel against the
interviewer.
P: What do you ask me for? I'm paying you to solve my problems. It really does not make me feel good that you
always have to ask me for my view. don't you know enough that you can do it on your own? Or is this one of
those psychobabble tricks to pretend that you need my input?
With such a difficult patient, the interviewer may have to test different approaches to secure cooperation.
I: It's your problem that we are discussing. It's your desire to get help. It's your information that we need to
make a plan. So you are part of the solution. I can't do anything without having you on my side so that we
can both face your problems and find out what works best to resolve them. Right now your problem is that
you can't come to an agreement with me on how to tackle your problems. Let's discuss why that is and
what your thinking is.
A patient's negative response to the interviewer's cooperative approach may have deep-rooted resentments of
becoming dependent. Such fear may reach far beyond the present interview situation. Not all interpersonal
conflicts, such as negative transference and countertransference, can be solved in a time-efficient manner. The
patient may need medication or referral to a different provider.

Trust
From the beginning, the interviewer shows sensitivity to the patient's needs and comforts the patient. If the
patient accepts such caring, the interviewer can forge a therapeutic alliance. Building on it, the interviewer's
targeted questions prove his or her understanding and expertise, which qualify him or her as a guide for the
patient's care. The interviewer's respect for the patient's dignity allows the patient to trust him or her. Trust is
rapport's summit.

TECHNIQUE
The patient interacts on one of three levels with the interviewer: First, the patient cooperates. He or she
complains about different areas of malfunctioning and suffering and seeks help. Second, he or she resists, being
cautious, anxious, or suspicious and holding back embarrassing, painful information. Third, he or she uses
defensive strategies and obstructs the interviewing process.

Interviewing Techniques for the Cooperative Patient

The majority of outpatients and voluntarily admitted inpatients cooperate. As a general principle, even with
cooperative patients, the interviewer should formulate questions from the patient's vantage point and use familiar
language. The interviewer relies on five techniques to achieve a crisp, well-flowing dialogue: openers, clarifications,
covering a topic, steering, and transitions.

Openers
To initiate the interview or to explore a new topic, the interviewer chooses questions of specific target and
scope. The patient's responses shape the follow-up questions. Opening questions or statements target a problem
of varying scope. Narrow scope: “What troubles bring you here to see me?” The interviewer expects a prioritized

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brief list of difficulties. Problem: The patient rambles. Solution: The interviewer narrows the scope of the question
or curbs the response. For instance:
P: (Responds with a long list of events that went wrong in his or her life).
I: Just tell me what problem has troubled you most during the last 3 days.
P: That I can't sleep.
Broad scope: “Give me a sense of how your life is going.”
The interviewer expects the patient to put problems and symptoms into a life perspective. Such a broad
question works well for an intelligent, educated patient who can condense, abstract, and prioritize his or her life
experiences. It fails with a patient with obsessive-compulsive disorder (OCD) by confusing the patient and
increasing indecisiveness and anxiety. It puts a patient with bipolar disorder into overdrive. He or she may flood
the interviewer with circumstantial details and loosely connected thoughts. Broad questions also fail for a patient
who gives literal answers.
A 23-year-old, white, single medical student.
I: What brought you here?
P: My mother's car.
A patient with psychotic symptoms or low intelligence may give such concrete answers. Inability of the
interviewer to adjust the scope of the questions can disrupt the flow of the interview and threaten rapport.
A supervised interview (supervisor [S]) by a resident (R) with a white, newlywed woman (P) in her early thirties.
(1) R: What's going on in your life?
P: (Looking around helplessly, shrugging shoulders, blushing) I don't know.
(2) R: Well, for instance, have you felt depressed?
P: Is that what you think?
(3) R: No. This is just an example. I wanted to know how I could help you.
P: I don't know whether you can help me.
(4) R: Why don't you tell me what has been happening lately in your life.
P: (Hunching down in her chair) My husband got promoted. We bought a new house.
(5) R: That's not really what I meant.
P: (After a pause) I don't really know what you mean.
The supervisor intervenes:
(6) S: Well, you just said your husband got promoted and you are moving into a new house. Has that caused
any stress for you?
P: Oh yes.
(7) S: Help me understand what stresses you out about the move into a new house.
P: I can't help him enough. I feel so bad.
(8) S: What kind of help can you not give him?
P: I should be able to go out and buy things for the new house. But I can't. I get all choked up when I go to a
store.
(9) S: I can sense your frustration. What bothers you about the stores?
P: There are so many people.
When the interviewer noticed that question 1 (Q1) was too broad, he or she went to the opposite extreme and
asked a closed-ended question (Q2). Noticing the confusion, the interviewer returned to an open-ended approach
(Q3), but the patient became so anxious that she could not read the intent of the question. The interviewer
noticed her distress and reformulated Q1 but missed her clue in A4. After the resident voiced his frustration (Q5),
she responded with a frustration of her own (A5). The supervisor intervened by linking the content the patient had

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provided (A4) to her stress—that is, her anxiety level. The patient's response showed the effectiveness of this
intervention.
An experienced interviewer monitors the effectiveness of his or her questions by how closely the answers
match the intent of the questions and adjusts the scope of the questions.

Clarification
To clarify an answer, the interviewer usually asks for specifics, probes the patient's reasoning, or offers some
leads.

SPECIFICATION
Problem: The patient's complaint is vague. Solution: The interviewer uses specifying questions that focus on
the five Ws of interviewing: What? When? Where? Who? Why?
Alternatively, the interviewer may ask for general or typical examples or focus on the latest specific occurrence
and then generalize the occurrence.
A 26-year-old, white, unemployed, single woman.
(1) I: What kind of problems make you seek my help?
P: I have many problems.
(2) I: Is there any one problem that has troubled you lately?
P: (After a long hesitation) I wake up in the middle of the night.
(3) I: How does that trouble you?
P: I really don't know. I can't explain.
(4) I: What do you feel like when you wake up?
P: Kind of leery.
(5) I: Did you wake up last night?
P: Yes.
(6) I: What time was that?
P: 3:30 AM
(7) I: What did you feel?
P: I don't know. Just leery.
(8) I: Did you see anything?
P: (Puzzled) My cat's hair stood up straight.
(9) I: What did you hear?
P: A noise in the kitchen.
(10) I: What is making that noise?
P: I don't know.
(11) I: What did you feel?
P: A breeze.
(12) I: Does this happen every night?
P: Just about.
(13) I: You wake up and the cat's fur stands up on end, you hear the noise in the kitchen, and you feel a breeze?
P: That's right.
(14) I: Something that makes you leery is going on and that means (raising his voice) there is… ?
P: A spirit. A spirit lives in my place.
The set of specifying questions adds up to a composite, which the interviewer summarizes in Q13. When the
patient accepts that summary (A13), the interviewer induces the patient to complete a sentence designed to
capture the patient's interpretation of her leeriness.

10
 PROBING
Problem: The patient denies recurrence of past problems and stresses emphatically that he or she is healthy.
This emphasis alerts the interviewer to the presence of denial. Solution: The interviewer asks for recent changes—
not problems—and for the patient's interpretation.
A 47-year-old, white, married woman who had recently moved to town reports that she has been treated in the
past for major depression. She emphasizes that she is doing just fine and that she only wants checkups
because of her past problems. She works in her husband's law office answering the phone, filing, and
typing.
I: Is there anything new going on in your life since you moved here?
P: You know, I'm glad that you asked. I've always had problems getting up. But now I'm wide awake at 5:30 AM
I: Why do you think that is?
P: My sister is a nun, and at that time, she goes to mass in New Orleans. And that's when she communicates
with me.
I: How does she do that? Does she call you?
P: Oh no. We've been close. It's with telepathy.
The patient's strong intention was to be certified as healthy and asymptomatic. This emphasis alerted the
interviewer to scrutinize the patient's recent history, discovering a delusion that, as the interviewer learned later,
was an early indicator of relapse for this patient.

LEADING
Problem: A male patient, when asked how he feels, answers: I don't know. Solution: (1) The interviewer asks
how the patient dealt with others last week. Thus, reported behaviors may have to take the place of a mood
symptom. (2) The interviewer asks the patient to try to remember how he recently felt. While the patient tries to
remember, his posture and facial expression may change. The interviewer reads that emotion and feeds his or her
reading back to the patient for his confirmation. This technique, however, is suggestive and leads the patient's
response. The interviewer has to remain cognizant of possibly distorting input.
A 28-year-old, white, married man knocks holes in the wall of his kitchen with his fists. He also reports problems
sleeping.
I: Can you tell me how you feel most of the time?
P: I don't know.
I: Try to remember how you felt yesterday.
P: (Looks down, closes his eyes, makes a fist, then grins)
I: You get a frown on your face. Your knuckles turn white. You appear tense… angry… anxious.
P: Angry! Yeah.
I: Then a brief grin ran over your face. What were you thinking just now?
P: These Mexicans… when they buy one tire from me, they bring their kids… they come with all their family. Like
20 of them.
I: You get angry… then you smile… your feelings change quickly.
P: (Puzzled) I guess.
I: Mixed up… up and down… bouncing around?
P: My wife says I'm up and down.
The patient can reexperience some feelings but cannot read and express them himself.

Covering a Topic
After opening a topic and clarifying the answers, the interviewer collects information linked to this topic to
draw the big picture. Helpful techniques include asking for events that are associated in time or are logically
interrelated. The interviewer may finally summarize what he or she has learned.
11
 ASSOCIATING
When assessing clinical symptomatology, the interviewer usually encounters one major symptom (i.e., the
chief complaint). However, psychiatric disorders occur as syndromes rather than single symptoms. Therefore, the
interviewer asks what other symptoms concurred in time with the chief complaint: “What else happened during
the time of your crying spells?” or “What else happened when your crying spells were worst?” or “What else
happened when you had your spell the last time?” If the patient lists only a few symptoms, the interviewer may
actively ask for disturbances in sleep, appetite, sex drive, ability to work, or ability to relate to others.

INTERRELATING
The interviewer uses interrelating when referring to the same theme, such as medical history, psychiatric
family history, or work or marital history. Such interrelating represents logical connections. Problem: A patient
offers an illogical interrelationship. Solution: The interviewer addresses the illogical connection.
A 38-year-old, married, black, male airline engineer.
I: What brought you here?
P: My wife wanted me to have a second opinion.
I: About what?
P: About Alicia and the television. The pain in my groin should have stopped by now.
I: Fill me in. What do Alicia and the television have to do with your groin pain?
P: Man, don't you understand? I felt it most when I watched television.
I: What does that have to do with Alicia?
P: Alicia knows about witchcraft. She's a medium. She said my new television set is bewitched. I have to bring it
over to her house.
I: Did you take it over there?
P: Of course. But my pain is still there.
I: Besides your groin pain, was the television doing anything else to you?
P: It gave me messages.
I: What kind?
P: I noticed it mainly with politicians. They hold their hands with the fingers pointing down, and I understand
immediately what they mean.
I: What do they mean?
P: Isn't it obvious? That my life is going down.
I: What does your wife think about all that?
P: Oh, she's mad with me. She thinks that Alicia ripped me off and that I need to see a psychiatrist.

SUMMARIZING
Summarization should be informal, supportive, and interactive. Problem: The patient gets easily sidetracked.
While the interviewer assesses the history of present illness, the patient mentions that her mother had similar
problems. When talking about the medical history, the patient adds that her only sibling, her older brother, was
admitted for detoxification. When reviewing the social history, the patient mentions that her father is the only
person in the immediate family who did not have any psychiatric problems. To give closure to the topic of family
history, the interviewer pulls together and summarizes informally the data that belong to this topic but were
collected at different parts of the interview: “Let me make sure I'm keeping up with what you told me about your
family history.”
Problem: The patient's answers are vague, and it takes the interviewer several specifying questions to collect
relevant information. Solution: The interviewer supportively summarizes the topic intermittently, “We are getting
there,” to nudge the patient to complete the topic. Problem: A patient describes a good relationship but his or her
facial expression contradicts the words. Solution: The interviewer gives an interactive summary and confronts the
patient with inconsistencies to provoke his or her protest and to probe his or her true convictions.

12
 A 19-year-old, single, white woman.
I: You described to me some of the conflicts that you have with your stepfather, right? (Patient nods.) But you
said they were really minor. You learned to tolerate each other, did I catch that? (Patient looks down.) But
while you were saying “tolerate,” some spit came out of your mouth.
P: (Throwing her head back and rolling up her eyes) I try to be understanding because of my mother. He really
bugs me a lot.

Steering
Inside a topic and between topics, the interviewer steers the flow of information. The main choices are to
encourage the patient to continue or to redirect the focus of attention.

CONTINUATION
The interviewer tends to the patient's talk by raising eyebrows or uttering hmmms to signal to the patient
nonverbally to continue. He or she may use short tracking phrases, such as “And?” “Then what?” “How is that?” if
his or her nonverbal signals get ignored. The interviewer may also use phrases such as “That's interesting,” “What
a surprise!” “Really?” “Oh, no!” to reward the patient with his or her attention and to encourage the patient to
continue.

ECHOING
The interviewer may echo a part of what the patient has said. He or she may intend to prod the patient to
continue or to shift the emphasis.

REDIRECTION
Problem: The patient introduces a new productive topic. Solution: The interviewer follows the new lead.
Alternatively, the interviewer may delay the transition: “What you are saying is very important. We will come back
to this topic. But before we do, let's finish up on… (old topic).” Problem: The patient introduces all irrelevant
topics, such as the problems of other people or political opinions about current events. Solution: The interviewer
uses redirection. He or she interrupts the patient and asks to return to the previous topic. If the patient repeatedly
gets distracted by irrelevant subjects, the interviewer may overtly educate the patient, saying: “We have to cover
several topics. Let's not get distracted. Let's continue what we were talking about before.” If the patient remains
overtalkative, a request to make the patient just answer a series of yes-or-no questions or multiple-choice
questions may help. If the interviewer is not versatile and skillful in using redirection, the entire interview may
derail.

Transitions
To cover the 15 sections of the clinical interview, the interviewer has to transition from a completed topic to a
new one. These transitions can be smooth, accentuated, or abrupt.

SMOOTH TRANSITIONS
Smooth transitions connect topics without the seam becoming apparent. Problem: The patient startles when
new topics get introduced. Solution: (1) The patient introduces a change in topic and the interviewer follows the
new lead. (2) The interviewer portrays different topics as part of a larger theme. For example:
I: Both of your parents had problems with drinking. How did this affect your relationship with them?
P: Well, it was rough. There was a lot of fighting going on.
Thus, the interviewer has transitioned effectively from the topic of family history to social history.
The interviewer addresses a cause-and-effect relationship that also leads to smooth transition. (3) The
interviewer references a point in time to smoothly link events that occurred together. Interviewers often have
problems in transitioning to the testing of orientation and recent memory. They may introduce this topic with a
statement such as, “Psychiatrists routinely ask some strange questions, such as what is today's date?”

13
 To create a smooth transition, the interviewer may link questions about orientation to the problems that the
patient has reported.
I: You said you have felt down in the dumps and could not sleep well for the last 3 weeks. Such moods can affect
memory and sometimes the ability to track time. Have you encountered those problems?
P: I don't think so.
I: So you had no problems with tracking time?
P: Hmmm. Not really.
I: Can we test it?
P: Go right ahead.
I: What's the date today?

ACCENTUATED TRANSITIONS
An accentuated transition emphasizes the start of a new topic. Problem: The patient loses attention and
interest in the interview. Solution: The interviewer announces a new topic and freshens the patient's interest.

ABRUPT TRANSITIONS
The interviewer jumps into a new topic without preparing the patient. Problem: The patient's history shows
many contradictions. The patient seems to be lying. Solution: The interviewer jumps back and forth among
different elements of the patient's story. The patient cannot replace quickly enough the true events of his or her
story with invented ones.

Interviewing the Resisting Patient

For the initial interview, a patient may decide not to talk about certain subjects. He or she may overtly express
his or her refusal: “I don't want to talk about this.” Alternatively, the patient may divert his or her answer to a
different topic. The reason for such refusal is often a fear of loss of face. Six techniques help to overcome
resistance.

Sharing Concern
Problem: The patient refuses to disclose details of an event because he or she is not certain about legal
consequences. Solution: The interviewer shares the patient's concern but points out the negative consequences
that secrecy may have for the understanding of the problem.
A 57-year-old, white, retired man has a problem with road rage.
P: I've done some bad things in my life.
I: Such as… ?
P: (Pause) Such as bumping off two people. Do you have to report that if I tell you?
I: We could discuss the circumstances in general terms. But I have to document it. If you talk about it, it would
help us to understand your rage attacks better. I understand your concern. You may want to consult your
lawyer.

Expressing Acceptance
Problem: A patient with OCD fears that the interviewer may think he or she is “crazy” and therefore gives
vague and misleading answers. Solution: Reassuring the patient and showing understanding and acceptance of his
or her symptoms help to reveal the “ridiculous” symptoms. Accepting certain symptoms as normal often reduces
the patient's embarrassment.

Confrontation
Problem: By the patient's behavior and open refusal, a patient resists discussing a topic. Solution: Confronting
the patient repeatedly with his or her refusal or pointing out his or her evasive strategies or exploring the reasons

14
for the resistance and describing the consequences for diagnosis and treatment may convince the patient to be
more open.

Shifting Focus
Problem: A patient resists a particular line of questions that he or she dreads. Solution: Shifting the approach
without losing sight of the topic, the interviewer often secures the answers that he or she desires. The interviewer
may shift to neutral ground or to a different angle to find a new entry point.
A 57-year-old white man.
I: When did you start having problems with your mental health?
P: Oh that's all a thing of the past. I've forgotten most of it. And I'd rather talk about my future.
I: Okay. You are divorced now. Would you like to get married again?
P: Oh, yes.
I: What went wrong with your first marriage?
P: My wife got mean with me when I first got sick when I was 23 years old.
I: I'm sorry to hear that. So she did not really support you? She did not believe in the phrase “for better, for
worse?”
P: That's right.
I: What was it that bothered her?
P: That I asked the same questions over and over again, that I felt so bad, checked things, and washed my
hands. She said I leave 30 dirty towels a day. She dumped me when I was 28.
The patient did not want to recall the symptoms that gave him so much trouble in the past but was ready to
discuss his past history in connection with his still unresolved, painful divorce.

Exaggeration
Problem: A patient experiences a minor failure as a major infraction and feels that he or she will lose the
interviewer's support if he or she admits to it. Solution: The interviewer exaggerates the patient's actions to make
them fit such inflated guilt feelings. Such exaggeration may help the patient to regain perspective and give up his
or her resistance.
A 49-year-old man refused to discuss his shortcomings as a bank teller.
I: So you must have cleaned out the vault and got away with it.
P: (With a thin smile) No, not quite that bad.
I: Not that bad? But you said it is so bad that you could not talk about it.
P: I made a private long-distance call without reporting it. And I've worried about it ever since. Do you think I
should still report it?
Induction to Bragging
Problem: A patient hides his or her true motives for request of a sick leave to remain in good standing with the
interviewer. Solution: The interviewer challenges the patient's cleverness and induces bragging to uncover
the patient's motives.
A 47-year-old man, 290 lbs, requesting sick leave from his job because of stress on his delivery service job.
I: So you deliver all these advertising brochures.
P: (With a broad grin) Yes, and I'm doing a good job with that, but I'm stressed out now. That's the first time I
try this route getting disability.
I: You look quite content to me. Maybe you need a vacation rather than a sick leave.
P: I've used up all my vacation at the beginning of the year. Now I need short-term disability.
I: You said this is the first time you tried this route. Why don't you tell me why you really want the sick leave?
P: I'm telling you. These 7 years at the job have really taken a toll on me. I feel I need time off.
I: I wonder whether you have learned how to work the system.

15
 P: I've been at it for 7 years. (With a grin) I should be good at it.
I: How is that? What do you mean being good at it?
P: I have that quiet spot close to the cemetery where I can look at a lake. That's where I take a break from all
that driving. (Sheepishly) I just dump some of the printings.
I: You wouldn't have enough miles on your car if you did that.
P: don't you think I know that? I run out to my place and grab some lunch. That gives me the miles.
Induction to bragging revealed the patient's antisocial features behind his request for stress relief and sick
leave.

Interviewing the Defensive Patient

Defense mechanisms may disrupt the interviewing process. Nevertheless, the interviewer has to deal with
them. The DSM-IV-TR groups 31 defense mechanisms in seven levels of adaptation.
The interviewer can spot a defense mechanism by its observable, characteristic behavior (Table 7.1-2). The
interviewer may identify the emotional conflicts, stressors, and the processes that activate the defense if the
defense interferes with the interview. If the interviewer identifies a defense mechanism, he or she may determine
its adaptive levels. For each of the levels, a general strategy is outlined that may help the interviewer to address
the defense.
Table 7.1-2 Defense Mechanisms on Seven Levels (DSM-IV-TR)
Defense Mechanism Observable Behavior or Emotional Conflict and Process
Symptom Stressors
High adaptive level
Affiliation Formation of work and Isolation, imperfection, Sharing of anxiety and rewards
troubleshooting teams; responsibility
striving for cooperation
Altruism Unconditional offer of help Defeat in competition Replacing aggression and
competition by support
Anticipation Predicting probable events Sudden, overwhelming Projecting events and coping
and planning countermeasures threats strategies
Humor Highlighting amusing aspects Failure, loss, or Converting anxiety of threat to
of threat destruction comedy or irony
Self-assertion Expression of impulses in Fear, anxiety, and anger Transformation of fear, anxiety,
socially acceptable form and aggression into socially
acceptable expressions
Self-observation Reflection on own feelings, Fear, anxiety, failures, Enhancing awareness of feelings,
impulses, and thoughts aggression impulses, and thoughts
Sublimation Socially acceptable behavior Unacceptable feelings or Rechanneling of impulses into
impulses socially acceptable expressions
Suppression Avoidance of discussing Painful event, sadistic or Intentional blocking of recall
painful problems, wishes, or sexual impulse
feelings
Mental inhibitions level
Displacement Phobias Fear and threat by an Transferring a feeling from its
object or love and hate for actual object to a substitute
an object
Dissociation Multiple personality, fugue, Promiscuous, hostile, or Temporary alteration of
amnesia irresponsible behavior, consciousness, memory,
painful events perception, and identity
Intellectualization Abstract thinking, doubting, Disturbing feelings and Removal of the emotional and
indecisiveness, thoughts personal components of an event
generalizations
Isolation of affect Obsessions, talking about Painful emotions and Separation of content and affect,
emotional events without memories removal of affect
feeling
Reaction formation Devotion, self-sacrificing Feelings of hostility and Substitution by wishes or feelings
16
 behavior, correctness, disinterest opposite of the true feelings
cleanliness
Repression Gaps in memory Threatening memories, Banning thoughts and feelings
feelings, fears, wishes from recall
Undoing Compulsive behavior Sadistic wishes, Symbolic negating of an impulse
unacceptable impulses
Minor image distortion
level
Devaluation Derogatory statements about Positive qualities of others, Ignoring of positive and
others or self, “sour grapes” unattainable goal exaggeration of negative qualities
about a goal of self, others, or object
Idealization Exaggerated praising of self Negative qualities of self Ignoring of negative and
or others or significant others exaggeration of positive qualities
of self or others
Omnipotence Self-glorification, Inferiority feelings, failure, Converting inferiority into
presumption, entitlement low self-esteem superiority feelings and actions
Disavowal level
Denial Stubborn and angry negation Painful reality Refusal to acknowledge the
of some reality obvious to awareness of some reality
others
Projection Ideas of reference, prejudice, Hostility, other Attributing one's own feelings to
suspiciousness, injustice unacceptable attitudes, others
wishes, desires
Rationalization Self-serving explanations and Socially unacceptable Giving false but socially
justification of behavior impulses, low self-esteem acceptable explanations for
behavior
Major image distortion
level
Autistic fantasy Daydreaming Unsatisfied impulses and Imagined wish fulfillment
wishes
Projective Accusing others of causing Hate, anger, and hostility Converting own hostile impulses
identification distress, hostility, and anger into justifiable reactions to other
people's aggression
Splitting of self-image Idealization alternating with Experience of negative andStripping off either all positive or
or image of others devaluation of self or others positive qualities of self or all negative qualities of self or
others others
Action level
Acting out Violent acts, stealing, lying, Sexual and aggressive Nonreflective, uncontrolled wish
rape impulses fulfillment
Apathetic withdrawal Decreased emotions, activity, Needs, impulses, wishes Responding to needs with
and social interactions increasing passivity
Help-rejecting Depicting oneself with self- Hostility and reproach Converting hostility into
complaining pity as unsavable victim toward others victimization
Passive aggression Procrastination, lack of Aggressive, hostile Expression through inactivity
follow-through impulses, resentment
Level of defensive
dysregulation
Delusional projection Persecutory delusions Overpowering, Attributing own impulses to others
unacceptable and in spite of contradicting reality
uncontrollable impulses
Psychotic denial Negation of obvious reality Overpowering, painful Profound annulment of obvious
reality reality
Psychotic distortion Obviously unrealistic Overpowering, Profound misperception and
statements and claims and unacceptable impulses and misinterpretation of external
irrational actions reality reality and feelings
From Othmer E, Othmer SC. The Clinical Interview Using DSM-IV-TR. Vol 1. American Psychiatric Press;
2002:82–85, with permission.

17
 High Adaptive Level
These eight defense mechanisms can be viewed as assets for the patient.
I: I admire your sense of humor. It will help you to deal better with your depression. You are able to take the
Viennese approach and say, “The situation is hopeless but not serious.”

Mental Inhibitions Level

The seven defense mechanisms on this level deprive the patient of some degrees of freedom in decision
making. Usually, the patient has insight into the pathological nature of phobias, obsessive-compulsive behavior,
and dissociative identity disorders without being aware of the underlying process. In the case of intellectualization,
isolation of affect, reaction formation, and repression, the patient misses that a defense mechanism inhibits his or
her ability to recognize his or her true feelings. Confrontation with the observable behavior may allow the patient
to recognize his or her true feelings.
I: What value do you attach to life?
P: I feel as a Christian it is a sin to even think about suicide. God gave us our life and he is the one who should
take it.
I: You mentioned suicide when I just wanted to know what you think about life.
P: don't you think suicide is a sin?
I: I'm more concerned about your generic answer. It hides your feelings. What are your feelings about your
present life?
P: (Starts crying) It's awful. I would not care if I didn't wake up in the morning.

Minor Image Distortion Level

A patient may idealize an interviewer at the beginning of the interview and subsequently devaluate the
interviewer because of a minor perceived failure, such as asking an embarrassing question. When idealization,
devaluation, or omnipotence interfere with the interview, the overt behavior itself may have to be addressed.
I: How quickly I end up in the doghouse! Let's find out what got me there.

Disavowal Level
From the three defense mechanisms on the disavowal level, projection is the most disruptive during an
interview.
A patient accuses the interviewer of not liking her. When asked whether she herself dislikes the interviewer, she
answers, “How could I like you if you don't like me?” When he asks her whether there is anything that she
does not like about him she answers: “The way how you make me feel. I don't like sex.” Solution: The
interviewer has to make the patient aware that her feelings and not his actions cause her difficulties. He
may accept her feelings as normal and repeatedly discuss them with her to neutralize them.

Major Image Distortion Level

The three defense mechanisms on this level have to be identified and addressed but not interpreted.
A 45-year-old, white, married truck driver avoided his mother for several years because he believed she made
him sick. He then quit his job because his coworkers rejected him. He felt hate and anger toward them. In
the interview, he told his psychiatrist that his questions were making him sick. The interviewer pointed out
to him that he had felt the same way about his mother and later about his coworkers. Avoiding his mother
and quitting his job did not give him peace of mind. Therefore, he and the interviewer had to find new ways
of dealing with the patient's social discomfort other than accusing people next to him. “Let's work on your
anger and distrust of me and others. With your help, we can find out what actions and medications make
you less sensitive to other people's remarks.”

18
 The interviewer recognized the accusations as projective identification. Instead of an interpretation that is
usually not effective, the interviewer offered support and medication.

Action Level
Problem: A patient acts out his or her anger. Solution: The interviewer sets limits rather than trying to interpret
the behavior. The diagnosis helps to decide which combination of behavioral and medical intervention is necessary
to manage this patient.

Level of Defensive Dysregulation

The three defense mechanisms on this level produce all psychotic symptoms. If, for instance, the interviewer
challenges a delusion as nonsensical, the patient may get angry and distrustful and break off the interview.
Therefore, the interviewer has to adopt the patient's vantage point and offer support accordingly.
A 43-year-old, white, single farmer claims that spacemen at night cause his headaches.
I: I will protect you against these spacemen. I'll put you in the hospital, and I will give you medication that will
make you immune to their attacks.
P: So you believe me that spacemen cause my headaches?
I: I can't tell you that. But I know that you feel this, and I know that the medication may help.
Recognizing the behaviors that, according to a psychodynamic view, represent an unconscious defense
mechanism is in the realm of descriptive psychiatry. However, descriptively oriented psychiatrists doubt the
validity of the underlying psychological mechanisms and therefore prefer behavioral and medical management
over interpretation.

MENTAL STATUS
The third component of psychiatric interviewing is the online monitoring of the patient's mental status. The
interviewer screens the mental status to detect signs and symptoms of mental disorders (Tables 7.1-3 and 7.1-4)
with four assessment methods: observation, conversation, exploration, and testing.
Table 7.1-3 Quantitative Changes in Frequency, Duration, and Intensity of Mental Status Functions
Secondary to Some Axis I and II Disorders
Function and
Assessment
Method Category Increased In Decreased In
Appearance (O) Apparent vs. stated age AD, MDD, Schiz with chronic course, MA, HistrPD
SRD, precocious puberty
Grooming and clothing OC-PD, HistrPD, narcissistic PD AD, MDD, SRD, Schiz
(mint condition), MA
Eye contact DelD (hostile) GAD, DelD, MA, ADHD
Nutritional status SRD (antihistamine use), MDD SRD (stimulants), AN,
atypical, SD; use of medication: MDD (cachectic)
olanzapine, valproic sodium,
clozapine, lithium, mirtazapine
Attitude toward Cooperation Dependent PD, HistrPD, MA Ds with psychotic
interviewer (C, E, features, MA,
T) intoxication, MDD, AD,
AsPD, conduct D
Consciousness (O, Alertness SRD (stimulants), GAD, SRD (alcohol, sedatives)
C, T) posttraumatic stress disorder, paranoid
D
Psychomotor (O, Posture MA MDD, dementia
C, T)
Movements
Reactive MA, GAD, SRD MDD, Schiz (catalepsy)
Grooming SocPh, ADHD, GAD MDD
19
 Symbolic MA, cluster B PD MDD, Schiz (catalepsy)
Illustrative MA, SD MDD, Schiz (catalepsy)
Expressive MA, GAD, SD, HistrPD MDD, Schiz (catalepsy)
Goal directed MA, ADD MDD, Schiz
Speech (C, E, T) Articulation — SRD, neurological Ds
Flow MA PD, MDD
Speed MA, GAD PD, MDD
Volume MA MDD
Latency of response MDD MA, ADHD
Inflection MA MDD
Thinking (C, E, T) Speed MA, SRD MDD, SRD, AD, OCD,
Parkinson's disease
Abstraction — Mental retardation, Schiz,
AD, frontal lobe
dementia
Tightness of association OCD, OC-PD MA, Schiz, SRD
Goal directedness — MA, Schiz, OCD, AD,
SRD
Affect (O, C, E, T) Quality MA MDD, AnxD, AN,
bulimia nervosa,
intermittent explosive D
Reactivity MA, SD, SRD, AD, retarded MDD, AD, MDD, OCD
OCD
MA, SD, HistrPD MDD, OCD, Schiz
Intensity MA, AnxD, EatD MDD
Range MA Schiz, MA, GAD, SocPh
Appropriateness — Schiz, D with psychotic
features
Mood (E, T) Quality MA, SRD MDD, AnxD, EatD, SRD
Stability MDD AsPD, BID mixed, SRD,
SD
Intensity MA, OCD MDD
Duration OCD, OC-PD, MDD BID rapid cycling, SRD
Thought content Congruency of delusions and Schizoaffective D (see Table 7.1-4) —
(C, E) hallucinations to mood;
pathological content (see Table
7.1-4)
Cognition (C, E, T) See Tables 7.1-4 and 7.1-6 — See Tables 7.1-4 and 7.1-
6
Insight (C, E) Being sick, needing help — AD, SRD, MA, Schiz,
Pick's
Judgment (C, E) Future plans, dealing with — MA, MDD, Schiz, AD,
friends and money Pick's, SRD
AD, dementia of Alzheimer's type; ADHD, attention-deficit/hyperactivity disorder; AN, anorexia nervosa; AnxD,
anxiety disorder; AsPD, antisocial personality disorder; BID, bipolar disorder; C, conversation; D, disorder; DelD,
delusional disorder; E, exploration; EatD, eating disorders; GAD, generalized anxiety disorder; HistrPD, histrionic
personality disorder; MA, mania; MDD, major depressive disorder and depression; O, observation; OCD, obsessive-
compulsive disorder; OC-PD, obsessive-compulsive personality disorder; PD, personality disorder; Pick's, Pick's
disease; Schiz, schizophrenia; SD, somatization disorder; SocPh, social phobia; SRD, substance-related disorders; T,
testing.

20
 Table 7.1-4 Qualitative Changes in Mental Status Functions Secondary to Some Axis I and II Psychiatric
Disorders and Syndromes
Function and Assessment
Method Symptom, Sign Disorder, Syndrome
Appearance (O) Needle marks SRD
Scars on forearm and wrist MDD, BID, borderline PD, Cl B PD
Inappropriate attire MA, PsychD
Missing eyelashes, eyebrows, hair ID, trichotillomania
Bitten-off nails ID, AnxD, PsychD
Reddened, chapped hands OCD
Excessive piercing or tattoos Cl B PD
Consciousness (O, T) Hyperalertness SRD (sedative withdrawal or stimulant Intox)
Lethargy, stupor, coma SRD sedation (Intox), psychiatric D due to a
medical condition
Psychomotor (O, C, T) Rigidity ParkD, neuroleptic malignant syndrome,
extrapyramidal symptoms
Tremor Idiopathic, S induced, S withdrawal, ParkD
Tics (motor, vocal) TOUR, other tic D
Restless fidgeting, squirming, ADHD
overflow
Choreatic, athetotic movements TD
Buccolingual movements TD
Catalepsy Schiz, D with psychotic features, AD, FLD
Gegenhalten (opposing movement) Schiz
Echopraxia Schiz
Pseudoaphonia, pseudoparalysis, Conversion D
pseudoseizures
Avoidance of touching OCD
Apraxia FLD, AD, NeurolD
Seizures SRD (sedative withdrawal)
Cataplexy Narcolepsy
Micrographia ParkD
Stereotypical movements Pervasive developmental D
Speech (C, E, T) Stuttering, stammering AnxD, generalized anxiety D, NeurolD
Vocal tics TOUR
Aphasias FLD, AD, NeurolD
Push of speech MA
Thinking (C, E, T) Blocking and derailment PsychD
Circumstantiality OCD
Flight of ideas MA
Loose associations MA, PsychD, Schiz
Perseveration FLD
Verbigeration PsychD (catatonia), NeurolD
Palilalia NeurolD
Clang association Schiz, MA
Nonsequitur Schiz
Fragmentation Schiz
Rambling Delirium, SRD
Driveling Aphasia (Wernicke's), Schiz
Word salad PsychD, Aphasia (global)
Tangentiality Schiz, NeurolD, D with psychotic features
Affect (O, C, E, T) Lability BID, SRD, MDD
Inappropriateness D with psychotic features
Thought content (C, E) Suicidality, homicidality MDD, SRD, Schiz, BID
Hallucinations, delusions BID, MDD, Schiz, SRD, AD
Obsessions, compulsions OCD
Panic attacks MDD, panic D

21
 Medically unexplained pain Somatization D
Derealization, depersonalization DissD
Cognition (C, E, T; see Table Confabulation Amnestic D
7.1-6)
Dissociative amnesia DissD
AD, dementia of Alzheimer's type; ADHD, attention-deficit/hyperactivity disorder; AnxD, anxiety disorder; BID,
bipolar disorder; BPD, borderline personality disorder; C, conversation; Cl, cluster; ConvD, conversion disorder; D,
disorder; DissD, dissociative disorder; E, exploration; FLD, frontal lobe dementia; ID, impulse-control disorder;
Intox, intoxication; MA, mania; MDD, major depressive disorder and depression; NeurolD, neurological disorders;
O, observation; OCD, obsessive-compulsive disorder; ParkD, Parkinson's disease; PD, personality disorder; PsychD,
psychotic disorders; S, substance; Schiz, schizophrenia; SRD, substance-related disorders; T, testing; TD, tardive
dyskinesia; TOUR, Tourette's disorder.

Observation
For observation, the interviewer does not need the patient's cooperation. Besides sex and race, the
interviewer observes appearance, level of consciousness, psychomotor functions, body language, and affect.
Through the power of observation, Sherlock Holmes could deduce a person's life history and occupation. Similarly,
for the astute interviewer, observation can give clues to diagnosis.

Conversation
Even if the patient refuses to speak about him- or herself or his or her symptoms or suffering, the interviewer
can draw conclusions from conversation about the patient's speech, thinking, affect, thought content,
concentration, memory, intelligence, insight, and judgment.

Exploration
Exploration requires the patient's willingness to disclose information about mood; content of thinking, such as
obsessions, compulsions, suicidal ideation, delusions, hallucinations, panic attacks, avoidance behaviors, and
“spells;” amnesias; personality changes; and pain sensations. To verify his or her impression, the interviewer may
feed back to the patient his or her reading of symptoms and signs assessed during the interview. Thus, the
patient's mental status becomes the object of exploration.

Testing
Testing of the patient's mental functions, whether intact or impaired, demands the highest degree of
cooperation. Testing adds a quantitative component to the interview.
Combining observation, conversation, exploration, and testing, the interviewer screens at least 12 mental
status functions often affected by psychiatric disorders. Table 7.1-3 lists the mental status function and the
method of its assessment, the categories that are assessed for the individual functions, the mental disorders that
may show an increase, and the mental disorders that may show a decrease in the specific category. The
interviewer identifies signs and symptoms of disorders in these mental status functions. Table 7.1-4 lists mental
status functions and assessment methods, symptoms and signs, and the disorders and syndromes in which the
symptoms and signs are frequently encountered. The mental status functions of Tables 7.1-3 and 7.1-4 are
discussed subsequently.
In Tables 7.1-3, 7.1-4, 7.1-5, and 7.1-6 the term MDD is used to designate major depressive disorder as well as
depression due to other disorders, such as dysthymia, bereavement, or adjustment disorder, substance use, or a
general medical condition.
Table 7.1-5 Change in Emotional Response as an Indicator of Some Psychiatric Axis I and II Disorders
Emotion Event Action Increase Decrease
Surprise Unexpected Evaluation, PTSD, MDD, MA, GAD, PanD, SocPH MDD, Schiz
stimulus integration
Interest Need reducing Exploration MA, ADHD MDD, Schiz PD, MDD,
stimulus dementia of Alzheimer's

22
 type, frontal lobe dementia
Elation Expected Satisfaction of MA MDD, ADHD, GAD
satisfaction of need
need
Contentment Completed need Relaxation — SocPH, PTSD
satisfaction
Anger Obstacle Destruction of MA, delusional disorder, ADHD MDD, Schizoid PD?
obstacle cluster B PD, intermittent explosive
disorder, substance-related disorder,
PanD, AsPD
Disgust Intrusion Expulsion or Anorexia nervosa, bulimia nervosa, Paraphilias
withdrawal OCD, SpecPH, SocPH
Anxiety Threat Avoidance SocPH, agoraphobia, SpecPH, PTSD, MA
OCD
Sadness Loss Undoing, MDD, PTSD, histrionic PD MA, AsPD
replacement
Guilt Violation of Remorse, self- MDD, borderline PD AsPD, MA, ID
code punishment
ADHD, attention-deficit/hyperactivity disorder; AsPD, antisocial personality disorder; GAD, generalized anxiety
disorder; ID, impulse-control disorder; MA, mania; MDD, major depressive disorder and depression; OCD,
obsessive-compulsive disorder; PanD, panic disorder; PD, personality disorder; PTSD, posttraumatic stress disorder;
Schiz, schizophrenia; SocPH, social phobia; SpecPH, specific phobia.

Appearance
Table 7.1-3 lists quantitative and Table 7.1-4 qualitative changes in appearance that may be due to a
psychiatric disorder. The onset of some disorders is age related (Table 7.1-3). Gender is associated with certain
diagnoses. For instance, anorexia and bulimia nervosa, somatization disorder, and major depression are more
common in women, whereas antisocial personality disorder and alcohol abuse predominate in men.
Race and ethnic background are important: First, rapport across racial and ethnic boundaries may be impeded.
Second, the attitude toward mental illness varies from culture to culture and may delay consultation. Third, race
and ethnicity affect the incidence of some psychiatric disorders.

Attitude
The patient's attitude reflects his or her disorder and his or her evaluation of the doctor–patient relationship. A
patient may hide his or her uncooperative attitude behind vagueness, memory loss, or one-word answers or
express it openly. He or she may refuse to answer questions or refuse to be tested.

Consciousness
Most common disturbances of consciousness are due to intoxication or substance withdrawal resulting in
increased or decreased reactivity. More severe disturbances of consciousness (Table 7.1-4) can be assessed by
bedside tests (Table 7.1-6).

Psychomotor Function
Besides posture, humans display types of movements that differ in their purpose (Table 7.1-3). Reactive
movements are directed toward a new stimulus, such as responses to phone ringing or door knocking. Grooming
movements control appearance, such as straightening out clothes, hair, or mustache. Such movements frequently
indicate discomfort with the situation. Symbolic movements are culture specific and can replace language. Instead
of saying, “We will win,” a presidential candidate, for instance, may form a V with his or her arms. During an
interview, a patient may sometimes make an unintended symbolic gesture that reveals hidden thoughts.
Illustrative movements duplicate what is said—they are redundant. Expressive movements reflect in a rudimentary
form the motor action that a patient would like to undertake in response to an emotion-provoking stimulus; for
instance, an angry patient who says he or she will take on his or her employer assumes an erect posture and makes
a fist as if anticipating a fight. Goal-directed movements occur as a part of a physical action, such as reaching for a
23
coffee cup. Psychiatric disorders can affect frequency and intensity of such movements (Table 7.1-3), but they can
also induce qualitative changes, such as pathological movements specific to psychiatric or neurological disorders
(Table 7.1-4).

Speech
Speech is a motor function driven by the patient's thought processes. Therefore, most disorders that affect
motor functions in frequency and intensity affect speech as well. Rapid speech is seen in mania and in anxiety
disorders (Table 7.1-3). A constant rapid flow of speech that can be interrupted is called push of speech. If it is
difficult to interrupt, it is called pressure of speech. Both forms are seen in mania (Table 7.1-4). Qualitative changes
of speech are usually of diagnostic significance (Table 7.1-4). If speech centers in the brain are damaged, specific
forms of aphasia (inability to speak) occur. Bedside tests help to determine which type of aphasia is present (Table
7.1-6). Developmental disorders affect speech. Speech is noticeably impaired in patients with low intelligence
quotient (IQ) or with dementias.

Thinking
The interviewer judges thinking according to the categories listed in Table 7.1-3. The interviewer's impression
and a patient's report may conflict. Some patients report racing thoughts but talk with a normal rate or even
slowly. Such a mismatch may be more common in anxiety disorders, psychotic disorders, or hypomania; in mania,
racing thoughts are usually accompanied by increased rate of speech. The ability to understand the abstract
meaning of words varies with the level of intelligence and is not pathognomonic for schizophrenia. The ability to
abstract can be tested by asking for communality of categories and proverb interpretation (Table 7.1-6).
Concreteness of thinking in first-episode psychosis may be associated with lack of insight.
Association between sentences can be loosened by several psychiatric disorders (Tables 7.1-3 and 7.1-4).
Thoughts seem to jump from topic to topic and their goal gets lost, a phenomenon called flight of ideas (Table 7.1-
4). The associations between thoughts can become very close, and the patient may be unable to omit irrelevant
details, making his or her thinking circumstantial. Some patients lose the goal of their answer but touch on the
general topic, called tangential thinking (Table 7.1-4).

Affect
Affect communicates to the interviewer the emotional value that the patient puts on his or her experience. The
interviewer sees affect expressed in the patient's posture, face, and body movements. He or she hears it in the
patient's voice. External events and internal experiences, such as thoughts, ideas, and memory, evoke affect. The
interviewer has to explore to what extent immediate circumstances, such as being pressured by a family member
to see a psychiatrist, contribute to the present affect. The nine basic emotions that Carroll Izard and others have
identified are transcultural, innate expressions (Table 7.1-5). Each is triggered by a specific event and urges the
individual to take a specific action (Table 7.1-5). The quality of the first four emotions—surprise, interest, elation,
and contentment—is positive; the last five have a negative quality—anger, disgust, anxiety, sadness, and guilt.
Most psychiatric disorders influence affect and mood (Table 7.1-5). They shift a patient's emotional response
toward a dominating affect and mood, thus increasing the intensity of that specific affect but at the same time
restricting the range of responsiveness. For instance, in mania and some substance-related disorders, elation
dominates. In depression, sadness and guilt are prominent. In eating disorders, disgust is prominent, and in anxiety
disorders, anxiousness is of course prevalent. Therefore, the interviewer gets significant clues about psychiatric
disorders by noticing the shift in quality and intensity of affect (Tables 7.1-3 and 7.1-5). Furthermore, psychiatric
disorders influence the reactivity of affect. For instance, patients with bipolar disorder may display dramatic, rapid
changes in quality and intensity of affect in response to changing thought content (Table 7.1-3). The interviewer
then observes a labile affect (Table 7.1-4). Psychiatric disorders with psychotic features often affect the
appropriateness of affect to thought content. A patient may report and show elation but have delusions of being
forced to commit suicide, thus showing thought content incongruent to mood. For instance, a patient may giggle
while describing her mother's funeral (Table 7.1-4). Without being sad or depressed, some patients may lack an
24
affective response, which is often described as flat or bland affect in contrast to full affect. To evaluate affect, the
interviewer may explore the patient's response to events listed in Table 7.1-5. For instance, he or she may ask a
salesman, “How does it make you feel when you meet a representative of a competing company in your territory?”
The mixture of anger about the obstacle, disgust about the intrusion, and anxiety about the threat may give
valuable clues of the patient's emotional responsiveness. A second method to assess mood is by brief tests (Table
7.1-6). With respect to affect, the interviewer can ask the patient to enact the nine basic affects (Table 7.1-6). As in
all these areas, patients may exhibit situationally driven responses due to recent stressors or external
circumstances of the interview.

Mood
Mood refers to the predominant, longer-lasting quality of experienced emotion. Therefore, if the interviewer
wants to evaluate the patient's mood, he or she has to ask. The interviewer can judge to what extent the observed
affect and the reported mood correspond to each other. A patient with high social skills can often display an affect
inconsistent with the mood. This apparent discrepancy between affect and mood occurs more frequently when
the patient speaks. When the patient listens and feels unobserved, the happy mask may drop. Prolonged periods
of depression, as seen in major depressive disorder, show a pathological stability and duration of mood. A patient
with OCD or obsessive-compulsive personality disorder may also report that his or her dysphoric mood lasts for a
long time, yet it may be unstable because of his or her anger outbursts. Depending on the severity of a psychiatric
disorder, the predominant mood can be intense.

Thought Content
During exploration, the interviewer searches the patient's past for the occurrence of pathological thought
content (Table 7.1-4). To assess suicidality, the interviewer may discuss the patient's quality of life, thus getting a
better reading of suicide risk than with direct questioning. Follow-up questions for suicide risk include past
attempts, immediate intent, lethal plan, availability of means, family history of suicide, and perceived outcome.
Concurrent presence of psychotic features, such as command hallucinations, as well as depression, substance
abuse, recent loss of social support, male gender, white race, and middle age or older, may increase the risk of
suicide. The comorbidity of major depression and substance use disorder leads to the highest risk of suicide. A
mnemonic for risk factors of suicide is helpful: SAD PERSONS.
• Sex: Women are more likely to be attempters, men more likely to be committers.
• Age: Highest rate of suicide is in teenagers and the elderly.
• Depression: 15 percent commit suicide.
• Previous attempts: 10 percent of previous attempters finally succeed.
• Ethanol abuse: 15 percent of alcoholics commit suicide.
• Rational thinking loss, psychosis. 10 percent of chronic schizophrenics commit suicide.
• Social support is lacking.
• Organized plan increases the suicide risk.
• No spouse increases the suicide risk.
• Sickness. Chronic illness increases the risk.
Homicidality may become apparent if the interviewer discusses the patient's enemies. As in the assessment of
suicidality, previous homicidal attempts or completions, intent, lethality of plan, and available means have to be
assessed. Patients at risk for homicide are those with persecutory delusions, antisocial personality disorder, and
substance-related disorders. To increase the likelihood that a patient admits to homicidal ideas or plans, use the
golden rule: Approach the subject from the patient's point of view as understandable. Use questions such as “Are
there people in your life who have harmed you and who deserve to die for what they have done?” “Are there
people whom you wish to be dead?” If the patient voices an intent to harm such foes, introduce the subject of safe
management, including warning of identified victims, which is the interviewer's duty. Contrary to expectation, to
tell the patient about the duty to warn has only minimal impact on the alliance with the patient.

25
 When asked about experiences with extrasensory perception (ESP), the patient may report hallucinations and
delusions. Hallucinations and delusions can be staged according to the patient's level of insight (Table 7.1-6).
Hallucinations and delusions are also evaluated by their mood congruency. Because the patient usually has good
insight into obsessions, compulsions, panic attacks, unexplained pain, derealization, and depersonalization, the
interviewer can explore these thought contents and experiences with targeted questions. However, the patient
may consider some obsessions and compulsions as embarrassing and may attempt to hide them.

Cognition
The interviewer judges cognition by the patient's ability to comprehend questions and express the responses.
Even if the interviewer finds no evidence of a cognitive disturbance during conversation and exploration, he or she
still may select a few brief tests that assess orientation, attention, recent memory, remote memory, abstraction,
and intelligence (Table 7.1-6).

Insight
The interviewer asks the patient to what extent he or she feels sick. Usually, a patient with schizophrenia,
mania, dementia, or substance-related disorders may deny being sick, yet some such patients have partial insight.
They may acknowledge being depressed but explain that the depression is a response to the scolding voices. A
patient may acknowledge that he or she needs help but deny being sick. Such a patient may accuse other people
and factors—the employer, the spouse, the lack of resources—as being the cause of his or her problems. Insight is
often reported as being good, fair, or poor. A more informative technique is to describe to what extent the patient
recognizes being sick.

Judgment
Review of significant life events, money management, and personal relationships reflects a history of the
patient's judgment. Judgment often varies in accordance with the patient's state of illness. In patients with bipolar
disorder, judgment may deteriorate during mania but may be fully intact during euthymic or even depressed
states. Assessing a patient's current judgment in comparison with his or her historical judgment may provide a
measure of the impact of a disorder. If a patient's judgment is not apparent or inconsistent with the diagnosis,
judgment can be more formally assessed. Some psychiatrists use questions from the Wechsler Intelligence Test to
assess judgment. Example: What do you do when you first detect a fire in a crowded theater? Such questions do
not involve the patient's affect, mood, and motivation and, therefore, may fail to measure the appropriateness of
judgment. A more powerful question is to ask about future plans. If these plans appear consistent with the
educational background and resources, the patient appears to have appropriate judgment.

Testing
Testing is a highly structured form of exploration. To get valid results, the patient has to be fully compliant. The
majority of the brief tests that a psychiatric interviewer uses at the bedside or office measure some aspect of
cognitive function (Table 7.1-6). Interviewers select bedside tests according to the patient's complaints or
demonstrated cognitive deficits apparent during the interview. Table 7.1-6 shows the function to be tested, the
test, the description of abnormal response, the clinical evaluation, and key examples of disorders that may test
positive. Table 7.1-6 covers 15 cognitive and three noncognitive functions—affect, suggestibility, and abnormal
perception. The testing of two of the noncognitive functions and the staging of hallucinations as part of abnormal
perception are discussed above. Suggestibility may be tested if the patient shows dissociative symptoms. A high
degree of suggestibility need not be a weakness but can be a strength used for therapeutic purposes. Thus,
suggestibility is not a symptom of a psychiatric disorder. However, high suggestibility is a prerequisite for
dissociative disorders and conversion disorder, in which a patient nearly automatically convinces him- or herself of
being amnestic of a particular traumatic event (dissociative amnesia) or feels, for instance, that he or she is
paralyzed (conversion disorder).

26
 The interviewer uses some of the cognitive tests in most diagnostic interviews—that is, vigilance or
concentration, short- and long-term memory, orientation, abstract thinking, and intelligence. Severe anxiety,
major depression with psychomotor retardation, and attention-deficit/hyperactivity disorder (ADHD) may interfere
with concentration and lead to the impression of an impaired recent memory. If the interviewer evidences poor
concentration, he or she should make an effort to obtain error-free immediate recall. Major depression and other
noncognitive psychiatric disorders may interfere only with retrieval of information and not with storage. Hints or
multiple-choice options may help to overcome the retrieval block. If storage of information is impaired, such as in
dementia of Alzheimer's type, this help fails. The interviewer may focus on evaluating abstract thinking (Table 7.1-
6) and intelligence testing if the quality of the patient's answers during the interview suggests that concentration,
orientation, and memory are intact. The interviewer selects any one of the other tests in Table 7.1-6 when he or
she believes that a particular function may be impaired and needs documentation.
If not already assessed, at the end of the mental status examination, the interviewer evaluates four risk factors
for the patient's and others' safety, summarized by the acronym SOAP. The interviewer explores which of the
major psychiatric disorders is responsible for these key risk factors and makes plans for their immediate
management.
• Suicidality, homicidality, physically assaultive, unpredictable, explosive, and self-injurious behaviors and
implied or overt threats.
• Organic disturbances of cognitive functions: disorientation, memory disturbances, decline of executive
functions, aphasias and apraxias that prevent the patient from exercising the activities of daily living (ADL).
• Alcohol and other substance abuse, ranging from occasional social use to uncontrollable addictive behavior
and dependency that may endanger the patient's and others' safety on the road and in legal, marital,
occupational, and financial status.
• Psychotic features, such as delusions, especially delusions of control, and hallucinations, especially
command hallucinations, and their dangerousness and the patient's obedience to these experiences.
Included here are illogical thinking and speech and catatonic behavior.
The interviewer compares the patient's psychiatric history with the patient's mental status to confirm the
diagnostic impression. Inconsistencies have to be explored. Such inconsistencies may raise the possibility of
incomplete assessment by the interviewer or of factitious intentions, lying, or malingering on the patient's part.

DIAGNOSIS
For the treatment plan, the interviewer verifies one or more Axis I or II, or both, psychiatric diagnoses and
excludes others. The interviewing style matches the patient's responses. Usually, a strategy that strikes a balance
between a disorder- and a patient-centered approach is appropriate. The diagnostic process can be arbitrarily
divided into five phases.

Phase 1: Assessing the Chief Complaint

To choose an opening for the chief complaint is the beginning of a chain of eight decisions (A to H) in a
diagnostic loop (Fig. 7.1-1). The interviewer may link these decisions in an order suggested by the clues that the
patient offers.

Openings for Chief Complaint

The interviewer selects one out of several possible openings that leads to the patient's genuine chief complaint
(Box A in Fig. 7.1-1). Below are some options.

DIRECT QUESTIONING
“What brought you here?” “What kind of problems do you have?” “What's going on in your life?”
Such questions target the patient's chief complaint and may lead to the history of the present illness.

27
 CONFRONTATION WITH A SIGN
The interviewer confronts the patient with a possible sign of a mental illness, such as wearing dark glasses
indoors, walking with a cane, exuding the smell of alcohol, or having slurred speech, cold and clammy hands, ataxic
gait, or bruises on the face.
I: I notice you are wearing dark glasses.
P: (Looking behind the interviewer at the door, whispering) Yes, I don't like people to see my eyes. They can look
right through me and read my mind.
I: Is this fear the reason why you came?
P: My colleagues at work really look at me. They want to get into my head, but I won't let them.
Such an entry leads the interviewer to the chief complaint, the history of present illness, and the mental status
evaluation.

MEDICAL HISTORY
P: (Obviously anxious; her hands make wet imprints on the interviewer's desk)
I: Have you ever been to a psychiatrist's office before?
P: Never. I'm so ashamed. Why do you have “Psychiatric Center” written above your door? I had a hard time
coming because of that.
I: Well, have you had the same feeling at your family doctor's office?
P: Of course not.
I: What did you see the general practitioner for?
P: Oh, I have a thyroid condition. I'm on Synthroid.
I: Any other medicines you take?
Here, the interviewer shows sensitivity to the patient's anxiety. To give the patient time to calm down, the
interviewer assesses the medical history first before returning to the psychiatric chief complaint, which may center
on anxiety and persecutory thoughts.

FAMILY HISTORY
P: (After the greeting ceremony) I never thought I would have to see a psychiatrist myself.
I: Oh? Who had to see a psychiatrist before you?
P: My mother did. She was in and out of psychiatric hospitals.
I: Tell me about it. It may give us some clues about your own problem.
Family history provides a link to the chief complaint.
SOCIAL HISTORY
P: (Looking around, anxious) I didn't expect Monet and Degas prints at a doctor's office.
I: Do you have any art background?
P: Well, not really, but I'm a professional fundraiser, and sometimes we run into some interesting pieces. I have
developed an eye for it. And art really interests me.
I: How long have you been into fundraising?
P: For 12 years now. And it hasn't always been easy.
The interviewer picks up on the patient's clue and starts with the social history, which leads to stressors in the
patient's life and offers an entry for the chief complaint.After the interviewer has solicited a chief complaint, he or
she clarifies the chief complaint and translates it into a DSM-IV-TR criterion if possible (see the section Technique).

Phase 2: Diagnostic Decision Loop

The chief complaint leads to a diagnostic decision loop, which assists the interviewer in including and excluding
DSM-IV-TR Axis I and II disorders and in assessing their history.

28
 Clinical Significance: Morbidity—Mortality
The first step is to determine whether the elicited chief complaint causes increased risk of mortality or
morbidity—that is, interferes with the patient's life, work, or health or requires treatment or hospitalization (Box B
in Fig. 7.1-1). This concept of a psychiatric disorder is based on the presence of dysfunction that causes the patient
a handicap.
A 27-year-old white housewife, Ms. Cheryl X.
I: You say that for the last 3 weeks you have been so scared that you cannot go to the mailbox. What other
problems have you experienced?
P: I startle when the phone rings. I don't want to leave the house. My husband has to do the shopping. It all
started 3 weeks ago in church. I had to run out of the service. My husband came after me, and then I felt
like a knife was rammed into my chest. I could not breathe.
I: What did you do?
P: I thought I had a heart attack and had to die. But in the emergency room, they took an electrocardiogram
and drew blood and told me after a few hours that my heart is okay. And they told me to make an
appointment with you.
I: Did you use any alcohol or drugs at that time?
P: No. Drugs never. As a teenager, I drank beer. It helped me to talk to the boys. But that was many years ago.
In the case of Cheryl X., the symptoms led to an emergency department visit and interfered with the patient's
ability to leave the house. Morbidity was obvious. Its degree can be assessed with the Global Assessment of
Functioning (GAF) Scale. Cheryl X. may be rated GAF 35 because she is not able to leave the house. If the
interviewer cannot establish clinical significance, the option is to diagnose no psychiatric disorder (a “no” response
to Box B in Fig. 7.1-1).

Symptoms Associated and Not Associated with the Chief Complaint

The interviewer gathers symptoms that occur approximately at the same time as the chief complaint (Box C in
Fig. 7.1-1). Excluded should be symptoms, signs, or laboratory results that the chief complaint suggests but cannot
be verified.
In the case of Cheryl X., the interviewer found psychiatric symptoms associated with the chief complaint. At the
same time, the interviewer excluded cardiac disorders and drug and alcohol abuse as associated conditions.
Infrequently, the interviewer may elicit a chief complaint without being able to identify associated symptoms. In
this case, he or she considers a psychiatric disorder not otherwise specified (NOS), or, if clinical significance is
lacking, he or she may not diagnose a psychiatric disorder at all (a “no” response to Box C in Fig. 7.1-1).

Criteria for Axis I or II Met?

After the interviewer has elicited with open-ended questions a list of symptoms associated with the chief
complaint, he or she checks whether sufficient criteria for an Axis I or II disorder are met (Box D in Fig. 7.1-1). If
yes, the diagnosis can be made (Box E). If no, additional questions have to be asked to satisfy the set of criteria
needed for a diagnosis. An incomplete set of criteria may only allow a diagnosis NOS (a “no” response to Box D in
Fig. 7.1-1).
Ms. Cheryl X.'s initial answers suggest the onset of Axis I panic disorder with agoraphobia. At this point, the
interviewer may ask whether an attack like the one during church service had occurred before and, if so, how
often. Furthermore, the interviewer may elicit other symptoms that have occurred during the panic attack but
were not spontaneously mentioned by the patient.

Longitudinal History versus Cross-Sectional Comorbidity

After the interviewer has established a psychiatric disorder, the interviewer reaches a major decision point in
the diagnostic process. He or she has to decide whether to assess other comorbid psychiatric disorders or pursue
the history of the already established disorder (Box F in Fig. 7.1-1).

29
 In the case of Cheryl X., the interviewer could either assess the presence of other anxiety disorders, such as
social phobia, special phobias, OCD, and generalized anxiety disorder, mood disorders, or substance-related
disorders or follow up on historical symptoms of panic disorder with agoraphobia (Box F in Fig. 7.1-1).
I: The attack that you had in church is called a panic attack. If you think back, have you ever experienced any
type of spell like this?
P: No. I don't think so. Wait… You know, when I was in high school, we had to jog, and then we had to work on
the high bar. All of a sudden, I felt I could not breathe, and I had to lie down. But I never had anything like
that again.
I: Have you ever had the feeling you could not leave the house?
P: When I was 12, I did not want to go back to school after the summer vacation.
How does the interviewer decide whether to pursue comorbid disorders or the history of the already
diagnosed disorder?
First, if the patient provides a clue, the interviewer may follow the lead. For instance, if Cheryl X. had said,
“Since I had the attack, I started drinking again,” the interviewer would follow this lead and explore this
comorbidity of alcohol abuse. If Cheryl X. had said, “Now that you ask me all these questions about my attack, I
think I've had some mild ones before,” the interviewer would take the history of the panic disorder.
Second, the interviewer may follow up on comorbidity if the chief complaint or associated symptoms suggest
the presence of a more serious psychiatric disorder. For instance, if Cheryl X. mentions she cannot go to the
mailbox because the neighbors do not like her, the interviewer may want to explore the presence of ideas of
reference or persecutory delusions. Such exploration may lead to disorders with psychotic features and reveal
possible homicidal and suicidal tendencies.
Third, the clinical significance of the disorder may guide the interviewer: If the disorder is severe, the
interviewer may pursue its history; if the disorder is mild, the interviewer may explore comorbidity to exclude a
more severe disorder.
Fourth, if the patient is circumstantial or has difficulties in focusing or abstracting, the interviewer may
complete the history of the disorder already diagnosed to avoid confusing the patient.
Finally, if leads are lacking, the interviewer is left with an arbitrary decision.

Search for an Additional Chief Complaint

If the interviewer screens for comorbidity (a “yes” response to Box E in Fig. 7.1-1), he or she searches for an
additional chief complaint.
Ms. Cheryl X.
I: Besides your panic attacks and your difficulty with leaving your home, do you have any other problems?
If Cheryl X. mentions a second chief complaint, the interviewer loops back to Box B, assessing clinical
significance and associated symptoms (Box C), followed by the decision whether the symptoms fulfill sufficient
criteria for an Axis I or II psychiatric disorder (Box D).
Depending on the symptomatology, the interviewer may complete the diagnostic decision loop B through H
several times. With each newly made diagnosis, the interviewer lengthens the list of established Axis I and II
disorders, shortens the list of unexplored disorders, and may add to the list of excluded disorders.

Screening for Additional Diagnoses

If the interviewer runs dry of new chief complaints or significant psychiatric symptoms, he or she may switch
from open-ended to closed-ended questions and actively screen for all those psychiatric disorders that have not
been covered yet (Box H in Fig. 7.1-1). Closed-ended screening questions, most well researched, are reproduced in
Table 7.1-7. For each positive answer, the interviewer may establish clinical significance. The Standardized
Assessment of Personality–Abbreviated Scale (SAPAS) for example, may be a helpful screening tool for personality
disorders.

30
 Table 7.1-7 Screen for Psychiatric Disorders (Axis I and II)
Disorder Questions
Cognitive disorders Use tests of memory, orientation, aphasia, and apraxia in Table 7.1-6.
Mental retardation While you were in school, did anyone ever say that you were a very slow learner?
Did you ever have to go into a special education class when you were in school?
Substance-related Has heavy drug or alcohol use ever caused you problems in your life?
disorders
Have you ever used pot, speed, crack, heroin, ice, or any other drugs to make yourself feel
good?
Psychosis Have you ever heard voices or seen things that no one else could hear or see?
Have you ever felt your mind or body was being secretly controlled or controlled somehow
against your will?
Have you ever felt others wanted to hurt you or really get you for some special reason, maybe
because you had secrets or special powers of some sort?
Have you ever had any other strange, odd, or very peculiar things happen to you?
If yes to any of the above: Did this happen even when you were not drinking or taking drugs?
Bipolar disorder, Have there ever been times when you felt unusually high, charged up, excited, or restless for 1
manic episode week at a time?
Have there ever been times when other people said that you were too high, too charged up, too
excited, or too talkative?
Have these high, excitable moods ever stayed with you most of the time for at least 1 week?
Major depressive Have there ever been times when you felt unusually depressed, empty, sad, or hopeless for
disorder several days or weeks at a time?
Have there ever been times when you felt very irritable or tired most of the time for hardly any
reason at all?
Have these feelings ever stayed with you most of the time for as long as 2 weeks?
Panic disorder Have you ever had sudden spells or attacks of nervousness, panic, or a strong fear that just
seems to come over you all of a sudden, out of the blue, for no particular reason?
If yes: Did you have these attacks even though a doctor said that there was nothing seriously
wrong with your heart?
Phobic disorders Have you ever been much more afraid of things the average person is not afraid of? Like flying,
heights, animals, needles, thunder, lightning, the sight of blood, or things like that?
Have you ever been so afraid to leave home by yourself that you would not go out, even though
you knew it was really safe?
Have you ever been afraid to go into places like supermarkets, tunnels, or elevators because you
were afraid of not getting out?
Have you ever been so afraid of embarrassing yourself in public that you would not do certain
things most people do? Like eating in a restaurant, using a public restroom, or speaking out in a
room full of people?
If yes to any of the above: When your fears were the strongest, did you try to avoid or stay away
from (name feared stimulus) whenever you could?
Obsessive- Have you ever been bothered by certain embarrassing, scary, or ridiculous thoughts that came
compulsive disorderinto your mind over and over even though you tried to ignore or stop them?
If yes: Please describe them.
Have you ever felt you had to repeat a certain act over and over even though it did not make
much sense? Like checking or counting something over and over or washing your hands over
and over again, although you knew they were clean?
Posttraumatic stress Have you ever experienced flashbacks when you found yourself reliving some terrible
disorder experience over and over again?
Generalized anxiety Have there ever been days at a time when you felt extremely nervous, anxious, or tense for no
disorder special reason?
If yes: Have you sometimes felt this way even when you were at home with nothing special to
do?
If yes: Have these nervous or anxious feelings ever bothered you off and on for as long as 6
months or more at a time?
Somatization Have you had a lot of physical problems in your life that forced you to see different doctors?
disorder

31
 If yes: Have doctors had trouble finding what caused these physical problems?
Did you start having any of these problems before you were 30 years of age?
Dissociative Do you experience at times a loss of memory for hours or longer without being under the
disorder influence of a drug?
If yes: Do you travel during such periods?
Have you felt not yourself, or have you been told that you use a name other than your own?
Sexual disorders Do you have problems with your sex life?
Do you get sexually aroused by exposing yourself, by female undergarments, by rubbing against
nonconsenting people, or by children?
Do you intensely wish to be a member of the opposite sex?
Anorexia nervosa Have you ever deliberately lost so much weight on a diet that people started to seriously worry
about your health?
If yes: Were you afraid of getting fat even when other people said you were thin enough?
Bulimia nervosa Did you ever have a problem with binge eating, when you would eat so much food so fast that it
made you feel sick?
If yes: When you were doing this, did you feel your eating binges were not really normal?
If yes: Was the urge to binge sometimes so strong that you could not stop, even though you
wanted to?
If yes: After you had binged, did you often feel depressed, ashamed, and disgusted with
yourself?
If yes: Did you ever vomit after eating, use laxatives, or excessively exercise?
Adjustment In the last 3 months, have you been very worried or upset about something that happened to
disorder you? Like the death of a loved one, loss of a job, separation, divorce, an accident, serious
illness, or that sort of thing?
If yes: Do you feel that you had more trouble handling this situation than most people would
have had?
Sleep disorders Do you have insomnia or inability to fall asleep or wake up at a desired time?
Do you have sleep attacks during the day, or do you feel always tired?
Do you snore or wake up gasping for air?
Do you have nightmares, wake up in terror, or do you sleepwalk?
Personality
disorders
Cluster A Are you a person who usually is suspicious of other people, who does not care much about the
company of other people, or who realizes that things have a second meaning beneath the
surface?
Cluster B Are you a person who feels that if you want to be paid attention to and be respected you have to
really put it on, express yourself loudly, and make your point?
Do you feel you are denied what you are entitled to?
Cluster C Are you a person who, to feel less anxious, tries to be perfect, gives in to others, does what they
want to do, or tries to avoid public exposure?
Adapted from Othmer E, Penick EC, Powell BJ. Psychiatric Diagnostic Interview-Revised (PDI-R). Manual and
Administration Booklet. Los Angeles: Western Psychological Services; 1989.
If the patient endorses any of the symptoms targeted by the screening questions, the interviewer loops back in
the diagnostic decision loop to search for clinical significance (Box B) and associated symptoms (Box C in Fig. 7.1-1).
This active process often yields psychiatric disorders in remission, especially substance-related disorders, and
disorders that start during childhood, such as learning disabilities, attention-deficit disorder with and without
hyperactivity, conduct disorder, and personality disorders. Active screening for the disorders (Box H in Fig. 7.1-1)
assures their inclusion in the multiaxial diagnoses and their effect as predisposing factors for current psychiatric
disorders (Table 7.1-8). Instruments such as the Psychiatric Diagnostic Interview (PDI) or the Structured Clinical
Interview for DSM-IV may ensure diagnostic thoroughness. The interviewer may also keep track of all disorders
excluded by negative answers to the screen, thus lengthening the list of excluded psychiatric disorders.
Table 7.1-8 Biopsychosocial Conditions Presenting as Predisposing, Precipitating, Perpetuating, and
Protective Factors of Psychiatric Axis I Disorders
Factor Bio Psycho Social
PredisposingPositive psychiatric family history; delayImpaired premorbid personality, Neglect, abuse, low
32
 in reaching developmental milestones; isolation, suspiciousness, poor education, poor parental
psychiatric disorders first diagnosed in impulse control, anxiousness, role models, antisocial
infancy, childhood, or adolescence; perfectionism, presence of behavior, substance use,
medical history (head injury, central personality disorders (Axis II), low poverty
nervous system disorders Axis III) adaptive defense mechanisms
Precipitating Onset of severe medical disorders Stress intolerance, poor impulse Trauma, loss of job or
control, self-pity, blaming partner, increased stress
(projection) (Axis IV)
Perpetuating Chronic medical illness Poor insight, judgment, and impulse Social isolation,
control; low IQ; noncompliance unemployment, poverty
with Rx.
Protective Good health maintenance, absence of Good insight, judgment, and Extended support system;
chronic medical disorders impulse control; high IQ; well-paying, satisfying
compliance with Rx. (high ego job
strength, high adaptive defense
mechanisms)
IQ, intelligence quotient; Rx., prescription.

Taking the Psychiatric History

After the interviewer has established the presence of one or more psychiatric Axis I and II disorders, he or she
establishes their history if not already done during the diagnostic looping. The interviewer may follow a timeline,
going either backward from the present (e.g., when did it happen last before this time) or forward, starting with
childhood. Important points of the history are onset, course, and treatment responses.
The onset can be assessed with a double question: When did you first notice a symptom of your present
psychiatric disorder? Up to which age do you feel you were at your best and had no psychiatric problems?
Often, patients give different ages for the end of their healthy, premorbid state and the beginning of their
psychiatric disorder.
I: When did you first experience any problems with depression?
P: During the seventh grade, I had a time where I did not want to get out of bed, felt tired and sad all the time,
and did not even want to talk to my friends on the phone.
I: For how long did this last?
P: Two or 3 months.
I: If you look back on your life, when was the last time that you felt at your best and did not have any problems?
P: Maybe when I was 8 years old. I remember in the second or third grade, I was often tearful for no reason. It
did not last very long. My mother told me that I was very sensitive.
The answers to these two questions indicate that the patient had either a preexisting personality disorder or a
prolonged prodromal state to the onset of his or her major depressive disorder. This dual questioning is a powerful
tool to identify premorbid states, personality disorders, and prodromal states to Axis I psychiatric disorders.
The onset of personality disorders can be traced back by focusing on a symptom or behavior of which the
patient is aware, such as shyness or problems with authority figures. For example: When did you first notice that
you were shy? When did you first notice that you rebelled against authority figures?
An alternate approach is to identify a present conflict that the interviewer judges to be due to a personality
disorder and search the patient's past for similar conflicts. The interviewer should be able to trace personality
disorders back to at least teenage years because they represent lifelong patterns of maladjusted behaviors. The
course of the psychiatric disorder can help to confirm the presence of the Axis I disorders.
To draw a profile of the course of a psychiatric disorder gives an idea about exacerbations and remissions. Of
importance are the intervals in which the disorder appears to be in remission. These intervals can identify the
patient's capacity of functioning when relatively well and can help to define the goal of treatment. Patients often
have difficulties in relating their psychiatric history to calendar years. The interviewer should introduce anchors of
memorable events, such as getting married, moving, or job changes.
33
 History of treatment responses provides information about what treatments have led to improvement,
remission, failure, or adverse effects. Treatment response may be judged as being consistent or not consistent
with the diagnosis.

Psychiatric Disorders in Full or Partial Remission

The diagnostic decision loop also helps to detect psychiatric disorders in full or partial remission. They can be
listed according to the developmental stages before adulthood such as disorders diagnosed in infancy, childhood,
and adolescence.

Phase 3: History and Database

Diagnosing psychiatric disorders may arouse the patient's sensitivities and activate defenses. Such responses
are mostly absent when family, medical, and even social history and routine mental status items are assessed.
Therefore, the interviewer can take a disorder-centered approach.

Medical History (Axis III)

The medical history is of importance to the psychiatric interviewer for three reasons: (1) Medical disorders can
cause symptoms of panic, anxiety, depression, and delusional thinking diagnosed as “psychiatric disorder due to a
medical condition;” (2) side effects of medications prescribed for medical disorders may mimic psychiatric
symptoms and disorders; and (3) any medical disorder and its treatment can complicate course and treatment of
psychiatric disorders and vice versa. Drug–drug interactions can range from mild to severe.
Biopsychosocially, a chronic medical disorder may be a predisposing and perpetuating factor of a psychiatric
disorder. The onset of a severe medical disorder may precipitate a psychiatric disorder (Table 7.1-7).
A 51-year-old farmer without a family or personal history of any psychiatric disorder developed a severe
depression after he had a myocardial infarction. He feared that his physical incapacity to work might prevent him
from paying off his expensive equipment.
The absence of a medical disorder in combination with good health maintenance is a protective factor in the
fight against psychiatric disorders. A dual approach helps to detect medical disorders, asking open endedly for the
patient's medical health and reviewing all systems as usually done in general medicine. The open-ended questions
may be followed by a request to list all medical disorders that the patient presently is treated for, by what
specialist, and with which medications. A history of surgeries and medication allergies rounds up this first
approach. The review of systems covers all medical specialties.

Family History
Psychiatric Axis I and II disorders are familial. Monozygotic twin and adoption studies suggest that the familial
occurrence is not merely learned but follows a genetic disposition. The familial occurrence in first-degree relatives
and their treatment response can therefore confirm the patient's diagnosis and predict the treatment response.
Furthermore, the parental natural history may provide a prognostic look into the patient's course. Therefore,
family history is the most important predisposing factor of the biological part of the patient's biopsychosocial
condition. The drawing of a pedigree with men as squares and women as circles is an effective way to assess the
family history with the patient's collaboration. Psychiatrically affected members are represented by blackened
shapes, questionable members are striped. Names, ages, type of disorder, and treatment all fit into the genogram.

Developmental History
Even if a psychiatric diagnosis during childhood or adolescence is not made, the interviewer should consider
five important areas:
• Developmental milestones: delayed psychomotor and speech development and toilet training may point to
early developmental problems.
• Ability to learn in school: slow learning or repetition of the first grade may point to mental retardation;
circumscribed deficits, such as dyslexia or acalculia, may indicate a learning disorder.

34
 • Attention problems with hyperactivity and poor impulse control may contribute to substance abuse and to
the development of a personality disorder, such as antisocial personality disorder.
• Disciplinary problems may cover a broad range. Arguments with teachers, objections to rules, temper
tantrums, resentfulness, and vindictiveness point to oppositional defiant disorder. Fighting, stealing,
vandalism, and school discipline problems characterize males; lying, truancy, running away from home,
substance use, and prostitution characterize females with conduct disorder. Furthermore, symptoms such as
violent behavior toward superiors, peers, or animals and fire setting also suggest conduct disorder, which, in
later adolescence, may progress to antisocial personality disorder. The earlier the onset of conduct disorder,
the worse the prognosis and the greater the risk for later mood, anxiety, somatoform, and substance-related
disorders.
• During childhood and adolescence, social withdrawal with decline in hygiene, truancy, and anger outbursts
may herald schizophrenia; phobias, obsessions, compulsions, and depressive symptoms may precede
adulthood psychiatric disorders.

Social History
A biographical, detailed social history of key life events may be informative but may not serve the assessment
of social factors in the patient's psychiatric disorders. The relationship between social factors and psychiatric
disorders is reciprocal. To tease out this reciprocal relationship is the interviewer's task in addition to
sociodemographic fact finding. The interviewer should target four topics:
• Premorbid versus postmorbid psychosocial functioning. Premorbid functioning represents the highest level
of patient performance measurable by the social component of the GAF. The difference between the
present and the past GAF scores measures the morbidity caused by the psychiatric disorder. The return to
the premorbid level of functioning is a goal of psychosocial rehabilitation. Therefore, the interviewer wants
to clarify the patient's premorbid versus postmorbid level of functioning with respect to family life and work,
including school and military, friends, and community functions such as church and social organizations.
• Social factors as risks for psychiatric disorders. Social factors can predispose to a psychiatric disorder,
precipitate its onset, perpetuate its course, or protect the patient against morbid influences (Table 7.1-7). A
history of physical, sexual, and emotional abuse, rejection and neglect during upbringing, and provision of
poor role models can become a predisposing factor for the development of psychiatric disorders. For
instance, patients with dissociative disorders, including dissociative identity disorder, often report a history
of physical and sexual abuse, especially during childhood. Barring memory distortions, the presence of abuse
can often be confirmed by outside evidence. Severe life-threatening trauma can predispose and precipitate
the onset of posttraumatic stress disorder (PTSD). Acute or chronic stressors, single or multiple, can
predispose, precipitate, and perpetuate adjustment disorders with symptoms of depression, anxiety, or
disturbances in conduct. These factors are listed on Axis IV as psychosocial and environmental problems.
• Social support. In contrast, the absence of abuse, rejection, and neglect and the presence of strong, positive
role models and an extensive support system in the past and present that secured adequate childrearing
and education can be strong protective factors against exacerbations of psychiatric disorders. Social support
can improve prognosis. It can motivate the patient to comply with treatment.
• Negative impact of psychiatric disorders on social advancement. Psychiatric disorders can impede the
patient's social development and can lead to demotion, job loss, and divorce.

Mental Status Exploration and Testing

The interviewer monitors the patient's mental status throughout the interview. Toward the end, the
interviewer usually addresses some mental status areas directly, especially by exploration (Tables 7.1-3, 7.1-4, and
7.1-5) and testing (Table 7.1-6). If not previously assessed, the interviewer explores risk factors such as suicidality,
homicidality, cognitive impairment, substance abuse, and psychotic symptomatology, including command
hallucinations.

35
 Phase 4: Diagnosing and Feedback
Throughout the session, the interviewer collects data that he or she organizes in a biopsychosocial
formulation—assets and strengths, differential diagnoses, if applicable, and multiaxial diagnosis. He or she feeds
this information back to the patient when the interviewer discusses the evaluation of the patient. The interviewer
also uses this information in phase 5 when he or she proposes the treatment plan and discusses the prognostic
outcome.

Biopsychosocial Formulation
The interviewer may summarize the findings of the session in the form of a biopsychosocial formulation. The
biopsychosocial conditions that contribute to the development, onset, and course of a psychiatric disorder can be
classified according to their impact as predisposing, precipitating, perpetuating, or protective factors (Table 7.1-8).

Assets and Strengths

The interviewer also assesses the patient's assets and strengths. This evaluation should be made in descriptive
terms. It includes the patient's knowledge, interest, skills, aptitude, experience, education, and employment
status, all items that are closely related to the protective factors of Table 7.1-8.

Differential Diagnosis
Initial psychiatric diagnostic interviews may yield incomplete, vague, and contradictory information so that the
interviewer believes he or she cannot make a diagnosis with confidence. A differential diagnosis that weighs the
pros and cons for a group of Axis I and II psychiatric disorders may then take the place of a specific diagnosis. The
advantage of the differential diagnosis is that it comprehensively captures the perimeter of psychopathology that
the interviewer takes into account.

Multiaxial Diagnosis
DSM-IV-TR encourages multiple diagnoses on Axis I and II. The more pervasive disorder receives priority over
the less pervasive one. For instance, a patient who has the diagnosis of schizophrenia may not receive the
additional diagnosis of dysthymic disorder because dysthymic disorder is believed to be an associated feature of
schizophrenia. If a psychiatric disorder is judged to be due to a medical condition, such as reserpine-induced
depressive disorder, the interviewer should not make the additional diagnosis of major depressive disorder. DSM-
IV-TR uses a host of specifiers to increase the precision of the diagnosis. Their discussion exceeds the frame of this
chapter. However, some determinations are particularly useful:
• Principal diagnosis. The interviewer assigns this determination to the psychiatric disorder that most reliably
and comprehensively explains the present symptomatology and is the focus of treatment.
• Provisional diagnosis. The interviewer believes a patient fulfills sufficient criteria for a particular psychiatric
diagnosis; however, the interviewer lacks documentation for some of the criteria.
• Psychiatric disorder NOS. The patient does not have sufficient symptoms to fulfill criteria for a specific
diagnosis, even though the information appears accurate and complete.
• Past psychiatric diagnosis. This widespread term is replaced in DSM-IV-TR by specifiers such as “in full
remission, partial remission, or residual state.”

Axis III Disorders

These are the medical disorders. If a medical disorder is considered as the cause of the psychiatric disorder, it is
listed on Axis I as a mental disorder due to a general medical condition and on Axis III as medical disorder.

Axis IV
On Axis IV, the interviewer lists psychosocial and environmental problems that were present during the
preceding year of the diagnosis and that may affect diagnosis, treatment, course, and prognosis. However,
stressors that clearly relate to the present psychiatric disorder, such as a life-threatening trauma in PTSD, may also
be included even if they fall outside the 1-year time frame. DSM-IV-TR lists nine categories that usually qualify as
36
stressors: problems with primary support group, social environment, education, occupation, housing, economics,
health care access, legal system, and psychosocial and environmental.

Axis V: Global Assessment of Functioning

The GAF scale is a dual scale. It measures two aspects of psychiatric disorders: severity of symptoms and level
of psychosocial functioning. It ranges from 100 (superior functioning, no symptoms) to 1 (persistent danger to
others and self with inability to maintain minimal personal hygiene). The interviewer assigns a score that reflects
the lowest level of either of the two. This score can be assessed through key points of the patient's psychiatric
history, and it can trace the course of the illness. Usually, the interviewer measures the present level of functioning
and the highest level of functioning during the last year.

Phase 5: Treatment Plan and Prognosis

In phase 5, the roles of interviewer and patient stay reversed: The interviewer answers the patient's asked or
unasked questions. The interviewer decides first which level of care the patient requires. He or she discusses with
the patient the diverse treatment options and their possible adverse effects. The interviewer may identify the
immediate targets of treatment and tell the patient what to expect if he or she cooperates. The interviewer's
interventions are most effective if he or she has been able to forge an alliance with the patient. If the patient is
severely disabled, such as being suicidal, homicidal, violent, or psychotic, or has lost impulse control, is disoriented,
or intoxicated, the patient may need hospitalization. Most patients can be treated as outpatients without
interruption of their work schedule. Some need temporary disability or home supervision.
The interviewer designs a biopsychosocial treatment plan. To improve the biological condition, the interviewer
may use medication. Most psychotropic medications have a delayed onset of action, as, for example, the selective
serotonin reuptake inhibitors (SSRIs) and mood stabilizers. Therefore, the interviewer may, for the immediate
temporary effect, combine substances with delayed onset of action with those with an immediate onset, such as
anxiolytics, low dosages of atypical neuroleptics, and, in rarer cases, stimulants.
A woman who has a major depression with psychomotor retardation and no history of substance abuse who in
3 days wants to attend her daughter's wedding may be prescribed a stimulant for the day of the festivity.
Furthermore, she may design strategies to manage key symptoms of the disorders behaviorally or cognitively. For
the psychological dimension, the interviewer may design psychotherapeutic interventions used in cognitive
therapy that increase insight, correct perceptual distortions and maladjusted behaviors, and support psychological
functioning.
Social conditions may be improved, for instance, by activating family support, with short-term relief of stress
by sick leave, by arranging vocational rehabilitation, or by facilitating the ventilation of traumatic events. Strategies
used in interpersonal psychotherapy may help. Referral to a psychologist or social worker as case manager may be
considered. The interviewer may contrast the natural history of the untreated disorder with the course that may
be achieved if the patient cooperates fully and the treatment is effective. The patient's clear understanding of the
difference can be a strong motivating factor for the patient's compliance.

PSYCHIATRIC INTERVIEW: A SAMPLE

The four components of interviewing are integrated and run simultaneously. Their course can be divided into
five phases, illustrated in the sample interview below.

Phase 1: Warm-up and Chief Complaint

The interviewer puts the patient and him- or herself at ease (rapport). The interviewer sets the scope of the
open-ended screening questions (technique); observes the patient's appearance, movements, speech, and affect
(mental status); and notices clues and the chief complaint (diagnosis).

37
 Phase 2: Diagnostic Decision Loop
Interviewer and patient forge an alliance (rapport). The interviewer progresses from questions with broader to
narrower scope. In case of an acute trauma, such as in cases of bereavement, divorce, rape, or recently diagnosed
cancer, the interviewer reduces anxiety by addressing the emotions evoked by the trauma (technique). He or she
explores the thought content, such as hallucinations, delusions, obsessions, compulsions, avoidance behavior,
panic attacks, and dangerousness to others and self (mental status). He or she relates the chief complaint to
concurring symptoms, signs, precipitating events, and stressors. He or she verifies and excludes specific diagnoses
(diagnosis).

Phase 3: History and Database

The interviewer demonstrates expertise in handling the patient's problems and offers guidance (rapport). He
or she transitions from topic to topic to fill in gaps, follow clues, and reconcile inconsistencies (technique). He or
she probes judgment and insight and tests cognition and suggestibility (mental status). The interviewer assesses
the patient's social, family, and medical history (diagnosis).

Phase 4: Diagnosing and Feedback

The interviewer discusses the diagnosis with the patient and secures the patient's acceptance (rapport). He or
she explains the nature of the disorder and the treatment options (technique). He or she reflects on the patient's
behavior during the interview (mental status) and summarizes the diagnostic findings on five axes (diagnosis).

Phase 5: Treatment Plan and Prognosis

The interviewer outlines the future therapeutic relationship, his or her availability, and the need for
compliance (rapport) and obtains consent for the treatment plan (technique) using the patient's language and level
of insight (mental status). The interviewer shares the prognostic outlook with the patient (diagnosis).

Sample Interview
Ms. Lorraine R. is a 56-year-old, white, mildly obese female with puffy, red eyes, and washed out mascara who
is tearful and shaking.

Phase 1: Warm-Up and Chief Complaint

(1) I: Hello, Ms. R. I'm Dr. O. Please come in and take a seat.
P: (Walking slowly into office, with a quivering voice) Hi. Please call me Lorraine. (slumping into the chair)
(2) I: What's going on? (Pause) You are all tears. …
P: (Looking up, sobbing, breathing rapidly, and pumping her shoulders) I cried all night. I heard my
gynecologist's voice again and again: “Sorry, Ms. R. It's stage 1 breast cancer.”
(3) I: Your friend Joan called me yesterday. She told me I really had to see you today.
P: Yeah. It hit me yesterday afternoon. (Crying) I called Joan because she went through the same thing.
(4) I: So that's why Joan called me.
P: Yes, she said you had helped her. (wipes her nose, stops crying)
(5) I: (Looking at her with concern) Hmm. I'm glad she feels this way.
P: (Wiping her eyes but with a firmer voice) I had the biopsy yesterday morning.
(6) I: When did he first suspect it?
P: (Even more collected) A week ago. I had a mammogram, and he told me he felt a lump.
(7) I: How did that strike you?
P: Like an out-of-body experience. I heard it without hearing it.
(8) I: And yesterday?
P: It hit me right here. (grabbing her chest) I couldn't stop crying. (her eyes fill with tears again)

38
 RAPPORT
The patient requested to be called by her first name, expressing her need to have a personal, close, possibly
dependent relationship to the interviewer (answer 1 [A1]). The interviewer addressed the patient's tearful affect,
thus immediately shifting toward a patient-centered interviewing mode. When the patient reported that she cried
all night (A2), the interviewer avoided empathizing with her (Q3) by saying something such as, “You must have
really been torn up.” Instead of catharsis, the interviewer put her emotional pain into a social framework to
remind her of her support system and steered her toward a cognitive management of her emotions. Referring to
Joan, he introduced her relationship to the interviewer as a model of alliance.

TECHNIQUE
The interviewer opens by addressing the patient's mental status. The patient responds by describing her chief
complaint (Q2, A2). As a continuation technique, the interviewer points to the urgency of the patient's problems
(Q3), which results in the description of the trauma and the patient's emotional response (A3 to A8) aided by
specifiers (Q6 to Q8).

MENTAL STATUS
The patient displayed a sad affect, which intensified when she reported the gynecologist's telephone call.
However, this affect reacted to the interviewer's neutralizing remark (Q4, 5), excluding a melancholic depression.
The patient's initial emotion to the gynecologist's telephone call indicated a dissociative traumatic response (A7),
which raised the possibility that the patient is suggestible. The patient's emotional responsiveness confirmed her
reactivity (A8) noted above (A4, 5), excluding the possibility that her affect was frozen into a depressive state but
reacted according to thought content.

DIAGNOSIS
In the dual opening approach, by asking for the chief complaint and by confronting the patient with her affect,
the interviewer found an economic, individualized pathway to her chief complaint (Q2; Box A in Fig. 7.1-1).
Clarifying her emotions (Q7), the interviewer found a dissociative traumatic response (A7), suggesting the onset of
an acute stress disorder, which may turn into an acute PTSD if untreated. Alternatively, an adjustment disorder
with mixed anxiety and depressed mood could be considered.

Phase 2: Diagnostic Decision Loop

(9) I: Could you sleep?
P: (Wiping her eyes again, even though she is not crying) Not at all. All night I heard the gynecologist's voice:
(coldly) “Sorry, Ms. R., it's stage 1 breast cancer.”
(10) I: So you relived the bad news…
P: (Interrupting) Over and over again. His voice stirred me up. (Sitting up erect) Like from a bad dream. After the
mammogram, I was, like, in a daze. Nothing sank in. (Closes her eyes)
(11) I: So it really shook you up.
P: (Looking past the interviewer) Yeah. I forgot to make a new appointment. I didn't even fix my breakfast this
morning. Felt, like, paralyzed. No appetite. (Bites her lower lip) Instead, I started smoking again. Five
cigarettes yesterday and one this morning.
(12) I: Has anything like this ever happened to you before?
P: Not really. … when my husband asked me for a divorce I felt numbed at first, but we had problems for a long
time.
(13) I: Ever felt down like you feel now?
P: (Tilting her head left to right) During the last 5 years, I felt down most of the time. I never felt really normal,
but work kept me busy.
(14) I: Did you get any treatment for depression lately?

39
P: Not recently. Only for smoking. But 15 years ago, I was treated for depression with Prozac and then again 10
years ago before I got divorced.
(15) I: When you were depressed in the past, what changed in your life?
P: I stayed away from people (with a sigh), even from my own family. But I wanted them to tell me that that
they love me. I did not want to do anything. I was so tired all the time, couldn't fall asleep but overslept in
the mornings. I ate a lot of junk food and gained weight.
(16) I: How did you value your life then?
P: I dropped to an all-time low.
(17) I: Did you ever want to die?
P: I wished I wouldn't wake up in the morning.
(18) I: Ever tried to do anything to hurt or kill yourself?
P: (With a frown) I thought about it, but I have my children.
(19) I: Did you get down when you had your children?
P: No.
(20) I: The baby blues?
P: (With an open smile) No. I felt good.
(21) I: Did those suicidal thoughts come back since yesterday?
P: (Firmly) No. I want to live.
(22) I: When you felt down and depressed, did you ever feel that people were against you?
P: I was hiding from them.
(23) I: Did you ever get so down that your thoughts became loud?
P: I thought I was worthless.
(24) I: Did you hear voices telling you that?
P: No, just my thoughts.
(25) I: Ever heard any voices when nobody was around?
P: No. (Frowning) I don't think I was crazy. (Shaking her head)
(26) I: So your depression was never so severe that you heard voices or that you were serious about killing
yourself?
P: I thought I was losing it, but I didn't hear or see things. And then I would smoke more and that helped my
mood.
(27) I: Did your mood ever become so good that you were full of energy or didn't seem to need much sleep?
P: (With a laugh) I don't think so.
(28) I: Ever become hypersexual. … have affairs. … (patient frowns and shakes her head), or go on buying
sprees?
P: Sometimes when I was depressed, I liked to buy things, but it didn't make me feel better. (The corners of her
mouth drop)
(29) I: Have cleaning sprees?
P: (With a sour smile) No, just chain-smoking sprees.
(30) I: Were you a heavy smoker?
P: Two and a half packs a day. (Looking down) But I quit 3 months ago. (Looking the interviewer in the eye)
(31) I: What helped you quit?
P: (Fast, with a firm voice and nodding) The patches and Zyban. I took them for 2 months.
(32) I: How did that help you?
P: (Smiling) It lifted my mood, too.
(33) I: You felt depressed?
P: I think I have always been somewhat unhappy—for the last 4 or 5 years, or more. Did not want to do much,
was irritable and anxious, and cried easily. (Swallows)
(34) I: Did you ever feel better in between?
40
 P: (Shaking her head) Maybe for a few weeks, but it never lasted.
(35) I: How did Zyban help?
P: I started to do more things and felt better. I could stop smoking.
(36) I: Did you drink also?
P: (With disgust) I hate alcohol. It makes me woozy.
(37) I: Do you drink coffee?
P: No. I drink soda pop with caffeine.

RAPPORT
Rapport remained intact. The patient actively participated in the interview, interrupting the interviewer (A10)
and volunteering details in answering the interviewer's expert questions, thus engaging in a cooperative alliance
(A9 to 11, 14, 15, 26, 28, 30, 33). Her answers portrayed good insight into the pathological nature of her mood
symptoms. The interviewer worded the empathic statement (Q11) in a manner that elicited a description of her
traumatic symptoms. Because the patient showed her emotions freely, the interviewer believed that the patient
was comfortable with him (A9 to 11, 13, 15, 18, 20, 21, 27 to 34, 36), making interventions to improve rapport
unnecessary.

TECHNIQUE
The interviewer completed the coverage of the topic of her recent traumatic response (Q9 to 12). She followed
the interviewer's smooth transition when the interviewer screened for depression (Q13 to 15), suicidal tendencies
(Q16 to 18), postpartum depression (Q19, 20), psychotic symptoms (Q22 to 26), mania (Q27 to 29), nicotine
addiction (Q30 to 32), dysthymia (Q33 to 35), and alcohol (Q36) and caffeine use (Q37). The interviewer overcame
the patient's evasive answers (A22, 23, 26) by more direct questions for hallucinations (Q24, 25) and by
summarizing the patient's responses (Q26). The patient agreed with all the interviewer's summaries, documenting
good verbal understanding (Q10, 11, 26).

MENTAL STATUS
The patient responded with relevant details to closed-ended questions or statements (Q9 to 14, 17 to 30, 33,
34, 36, 37), showing that she remained verbally productive in spite of her depressed affect. She handled open-
ended questions in an appropriate, goal-directed manner (Q15, 16, 31, 32, 35), showing her ability to focus and to
interpret questions accurately. Her affect remained reactive and was appropriate to the content of her answers
(A9 to 11, 13, 15, 18, 20, 21, 25, 27 to 32, 36) but showed a depressive quality (A9, 11, 15, 18).

DIAGNOSIS
The interviewer assessed symptoms associated with the chief complaint (Q9 to 11; Box C in Fig. 7.1-1), reliving
the traumatic experience, derealization (A10), and impaired functioning (A10, 11; Box B in Fig. 7.1-1), confirming
the initial impression of a first-time acute traumatic disorder (A12; Box D in Fig. 7.1-1). With Q13, the interviewer
searched for a second chief complaint (a “yes” response to Box G in Fig. 7.1-1) and found 5 years of anhedonia
(A13, 33 to 35) with only short remissions of a few weeks (A34), suggesting dysthymic disorder, which the
interviewer did not pursue any further. The interviewer also established clinical significance for a third chief
complaint, depression (A14; a “yes” response to Box G in Fig. 7.1-1). This chief complaint was associated with
several symptoms (Box C in Fig. 7.1-1): social withdrawal, loss of initiative, tiredness and insomnia (A15), death
wish (A17), suicidal ideation, feelings of worthlessness (A23), and losing her mind (A26). A history of suicide
attempts (A18) or present suicidal thoughts (A21) were missing. These findings confirmed the diagnosis of major
depressive disorder currently in remission (A14; Box D in Fig. 7.1-1). The patient denied persecutory delusions
(A23) or hallucinations (A23 to 26), excluding a major depression, severe, with psychotic features (Box D in Fig. 7.1-
1).
Actively, the interviewer screened for essential symptoms of other psychiatric disorders (Box H in Fig. 7.1-1).
The interviewer excluded mania (A27 to 29) and alcohol abuse (A36; Box H in Fig. 7.1-1) but found evidence for

41
nicotine dependence in early partial remission (A29 to 33). The reported depressed, irritable, and anxious feelings
(A33) may have been related to nicotine dependence and intermittent withdrawal because smoking relieved the
depressed feelings (A26). Alternatively, the depressive symptoms could be part of a dysthymic disorder with late
onset (A33, 34) that, besides smoking, was improved by Zyban (bupropion) (A35).

Phase 3: History and Database

MEDICAL HISTORY
(38) I: What prescription medications or over-the-counter medicines do you take?
P: No prescriptions any more. My gynecologist stopped my hormones when he felt the lump. But I have a
chronic cough, and I take some cough drops.
(39) I: Do you have any other medical problems? (Speaking slowly) Such as thyroid problems? Diabetes? High
blood pressure? A head injury? Allergies?
P: (Shaking her head) No, not that I know of.
FAMILY HISTORY
(40) I: Who in your family had problems with mood like you?
P: My three kids are okay, but I'm adopted (her voice cracking). I don't know my biological parents or siblings.
(41) I: Your voice changed when you said adopted.
P: Yeah. My adoptive parents always told me I was special. (With sad contempt) Yes, special. I always fought
rejection.
DEVELOPMENTAL HISTORY
(42) I: How did you feel in school?
P: I felt I had to prove myself, but I was a good student.
(43) I: And in front of a class?… or in front of strangers? Any spells of anxiety?
P: I got a lump in my throat and butterflies in my stomach, but it excited me. I could do it.
SOCIAL HISTORY AND SUPPORT
(44) I: How do you feel about rejection now?
P: That's the worst. I feel my daughter will stay away from me. She will reject me because of my cancer.
(45) I: Stay away from you? How's that?
P: Well… I stayed away from my cousin for her last year when she had breast cancer. I panicked when I saw her.
I did not know how to deal with it. Now I feel I'll lose my daughter over this. And I don't know what to do.
(46) I: Do you have other children?
P: Yes. I also have two sons, all are from my ex.
(47) I: How is their support?
P: Good. But my daughter is my friend, and I hate to lose her. I couldn't bear it. None of my children know what
depression is. They are all so healthy.
(48) I: What about your ex?
P: What's left of him is a big settlement. He divorced me to marry his secretary. He rejected me, too, when I
went through the changes.
(49) I: So you experienced rejection. What images come to mind?
P: My cousin. (With expression of fear and disgust) How she shriveled away when she had cancer. How I could
not take it when she shriveled away.
(50) I: So you can't shrivel away yourself.
P: You're right. But how do I do that?
(51) I: By rejecting yourself. Reject your cancer! Stay strong! Fear and depression may weaken your immune
system.

42
 P: Everybody tells me I can do it. My friends say I can fight it. (With a thin smile and frown) I heard it over and
over again since yesterday.
(52) I: They don't want you to shrivel away.
P: That's right. They don't want me to shrivel away. (With a sigh of relief) They say it for their own sake.
(53) I: That's right. They don't want to see you shrivel away like your cousin. (With emphasis) Your friends and
your daughter look at you as an example. They want you strong for their own sake. Do you have any ties to
religion?
P: No. I'm not going to mass, but I believe in a higher power.
(54) I: Do you pray?
P: No.
(55) I: You told me you see your cousin shrivel away. Do you work through your eyes?
P: Yes. I'm an interior designer.
(56) I: Oh? How did that start?
P: I have a college degree in design. Decorating became my profession. I still enjoy my work and my colleagues.
MENTAL STATUS EXPLORATION AND TESTING
(57) I: So you can image things. We will use imagining to fight your fears and your depressions and teach you to
imagine your cancer shriveling.
P: (Smiles)
(58) I: Let's see how strong your imagining is. Please pass me your ring. (The patient hands the interviewer her
wedding band). I'm going to attach a string to your ring (interviewer does). Let me show you how one can
move the ring with imagining. (The interviewer swivels his chair around away from his desk and sits now in
front of the patient. The interviewer holds the string in his right hand and unsupported arm with the ring
hanging 1 in. above the floor.) Now I can swing the ring around like this (swings the ring). I do this with my
will power like we do many things. But I can also move the ring without swinging it voluntarily. (He brings
the ring to a standstill.) I can just let it hang down and start imagining. I imagine now that the ring starts to
swing… swing in a circle… swing in a circle (the ring moves slightly back and forth, not in a circle). Now I
imagine that the ring swings in a circle, the circle gets rounder and rounder, the circle becomes bigger and
bigger (the ring actually swings in a circle of a 5-in. diameter). You can train yourself in imagining. (The
interviewer offers the string to the patient.) Now you try.
P: (Takes the string with the ring)
(59) I: Swing the ring around in a circle.
P: (Complies)
(60) I: That's what we don't want to do. We want to use our imagination. Hold the swinging.
P: (Complies)
(61) I: Now let the ring hang down still and start imagining that the ring starts moving. (The ring swings back
and forth in a 1-in. swing). Now imagine that the ring starts to go in a circle, rounder and rounder, in a
circle, bigger and bigger. (The ring starts to move in a 3-in. circle). You can train yourself to do this. It's
called the pendulum test. It tests your imagination.
In addition to the ring test, the interviewer also uses the sway test, the Spiegel Eye Test, and the finger sticking
test (see X. Mental Status Examination). The four tests show the patient's moderate ability to follow images with
motor action.
61. P: (Smiling and shaking her head as in disbelief) I can use my imagination to help me.
Because the interviewer is in a testing mode, he also examines orientation, recent memory, and abstraction by
interpreting proverbs and identifying the common category of bicycle and airplane and finds the patient to be fully
oriented and have intact cognitive functioning. Furthermore, the patient has at least average intelligence because
she could multiply 2 × 192 on the Wilson Approximate Intelligence Test and by her responses to the Kent Test.
43
 (62) I: We need your fighting spirit. Can you believe?
P: I don't trust easily.
(63) I: Can you believe in science?
P: I'm not sure.
(64) I: Do you believe in medical science?
P: I'm not sure, but I will do what they tell me.
(65) I: I'm so glad that your cancer was detected at an early stage and that you got your diagnosis 24 hours
after the biopsy. That means treatment can start soon. Have you met the oncologist?
P: No. But I've heard of him. My friends recommend him.
(66) I: So you don't plan to go out of state to the X Institute?
P: No. I'll stay with the doctors here.

RAPPORT
Reviewing the medical history signaled to the patient thoroughness and concern about her general health
(Q38, 39). The interviewer addressed the cracking in her voice, showing sensitivity to her affect about her adoption
(Q41). The interviewer used her fear of rejection (A41 to 45) to explore her own rejecting of the cousin. The
interviewer channeled the patient's tendency to reject toward her cancer rather than toward herself (A51). The
interviewer built up her confidence in her ability to imagine her cancer to shrivel (Q57) and to turn her imagination
into action (Q58 to 61). This approach initiated her positive outlook and cognitive restructuring, including
imagining. With these interventions, the interviewer added to the diagnosis-centered interview a patient-centered
therapeutic intervention. Such ad hoc crisis intervention activated the therapeutic alliance and put guidance into
action.

TECHNIQUE
Using a smooth transition (Q38), the interviewer attempted to complete the database, opening up medical,
family, developmental, and social history with open-ended questions (Q38, 40, 42, 44), followed by closed-ended
questions and some open-ended ones (Q47 to 49). When the interviewer noticed a sign of fear and sadness in the
patient's voice (A40), the interviewer clarified this sign (Q41) and searched for associated symptoms to be able to
fit the sign into a possible diagnosis. Because the patient expressed fear and disgust (A49), the interviewer decided
to make an immediate therapeutic intervention against her harmful self-image of shriveling away. The interviewer
reverted the patient's tendency to project on herself to projecting on her cancer (Q51). This reversal fed into the
supportive statements of the patient's friends (Q51 to 53) and initiated training in image control (Q55 to 61).

MENTAL STATUS
The patient showed fear of abandonment (A40, 44), possibly based on her phobia of physically crippling
disease, which she projects on her daughter. Tests of suggestibility (A58 to 61), orientation, recent memory, and
abstraction are within the normal range. Suggestibility is tested for two reasons: (1) to examine whether increased
suggestibility can lead to pathological autosuggestions (i.e., dissociative and conversion symptoms), and (2) to
increase the patient's control over imaging directing it against her cancer.

DIAGNOSIS
The medical history is positive for chronic cough (Q38, 39). The patient's fear of abandonment encountered
during the assessment of the family history adds an additional chief complaint and reopens the diagnostic decision
process (A40; Box F in Fig. 7.1-1). The interviewer screens the patient's developmental history for associated
symptoms of fear of rejection. Social phobia and learning disability (A42) are excluded, but the patient's response
suggests the possibility of generalized anxiety (“butterflies in my stomach”), somatization, or conversion symptoms
(“lump in my throat;” A43). Obsessions and compulsions are not assessed. The fear of rejection (Q44) signifies a
special phobia of physical decay (A49) also projected onto her daughter (A44, 45, 47), which intensifies her phobia
of cancer. She fears less premature death than abandonment because of her physical decay. This specific phobia of

44
a terminal, crippling disease (A45, Q49) is based on the defenses of suppression and repression operating on a high
adaptive and mental inhibition level, respectively. Her projection operated on the disavowal level and not at the
level of defensive dysregulation, as is the case in delusional projection. The coding of defenses on a sixth axis, the
defensive functioning axis, is under consideration in the DSM-IV-TR.
The patient's average level of suggestibility may lower the risk that her acute stress disorder progresses to a
PTSD with pathological dissociation (A61) as a result of negative autosuggestion. The interviewer limited the
assessment of predisposing, precipitating, perpetuating, and protective factors for the social history taking to the
extent that it may be relevant for Axis IV. For time reasons, the interviewer omitted exploration of relationships to
parents, coworkers, and friends other than Joan. Besides her children, the patient did not seem to have support
from her church or self-support from prayers (A53, 54) or confidence in medical science (Axis IV).

Phase 4: Diagnosis and Feedback

(67) I: Let me tell you what I have learned from our meeting today. You were overwhelmed when you learned
that you have stage 1 breast cancer. You felt numbed and had flashbacks of the gynecologist's message.
Such response may mark the onset of an acute stress disorder. You fear your friends, especially your
daughter, will avoid you as you avoided your cousin, so they don't have to deal with your wasting away. You
are sensitive to such abandonment because lifelong you fought with the rejection that you imagined
occurred from your biological parents.
P: (Emphatically) Yes, yes, yes! What can I do about it?
(68) I: Believe in your daughter. She does not have your anxiety of shriveling away. She will not avoid you. With
her, we want to fight the progression of your traumatic stress response and prevent recurrence of
depression.
P: How?

RAPPORT
The interviewer shows his or her expertise in addressing the patient's dependency needs from the patient's
point of insight, namely, as sensitivity to abandonment (Q67). The patient accepts the diagnosis (A67) and shows
interest in the interviewer's approach to her treatment (Q68).

TECHNIQUE
With an accentuated transition, the interviewer prepares the patient for the diagnostic feedback, a role
reversal. Now the interviewer and not the patient provides the bulk of information (Q67).

MENTAL STATUS
The patient's affect has dramatically changed since the beginning of the interview. She had switched from
sadness, anxiety, and despair to an emphatic approval of the interviewer's feedback, expressing openness and
interest in the interviewer's treatment plan showing her affective reactivity (A67).

DIAGNOSIS
The interviewer initiates the diagnostic feedback based on biopsychosocial information, including the patient's
assets and strengths, and multiaxial diagnoses.

Phase 5: Treatment Plan and Prognosis

(69) I: Well, you have conquered your addiction to nicotine with your determination and with the help of Zyban
or Wellbutrin, which is an antidepressant. You had depression in the past and Wellbutrin has helped you. So
did Prozac. Since you started smoking again, I think Zyban can become our Old Faithful again. We should
start it now. Do you recall its major risk?
P: What do you mean?
(70) I: The potential for a seizure.

45
 P: Yes, I know.
(71) I: Did you ever have a seizure in your life? Like as a child?
P: No.
(72) I: Did you have one when you took the Zyban?
P: No.
(73) I: You told me you don't drink much. Alcohol withdrawal could possibly make you more sensitive to the
seizure risk by Zyban.
P: I'm somewhat afraid of that. But Zyban made me feel well before.
(74) I: If you wake up and have soiled your clothes or bitten your tongue, stop Zyban and call me immediately.
Now, your ability to tolerate the medication in the past gives us an edge.
P: I understand the risk, and I will take it again.
(75) I: Psychologically, you have strong feelings about rejection. This feeling can hurt you, but it also can help
you.
P: How's that?
(76) I: (With emphasis) It's you who rejects rather than you being rejected.
P: I can never do that.
(77) I: You've done it before. You rejected the cigarettes. Your determination against cigarettes helped you.
Taking Zyban would not have made you stop smoking. It's you who make the drug work. You noticed how it
lifted your spirits. You have to use this spirit to tell yourself you will do everything you can to fight the
cancer. See the physicians, stay with the treatment, and have the image of strength. You said yourself
others want you to be strong for their sake. Your cancer will shrivel away, (with emphasis) not you. You
think in images. We will work to implant the image in your mind how the cancer is shriveling under the
therapy.
P: But my cousin's…
(78) I: (Interrupting her) Purge that image like you purged the cigarettes. Purge it like you'll purge your cancer.
That image of your wasting cousin is a cancer of the mind.
P: But how do I fight it?
(79) I: Whenever your cousin's image pops up in your mind, straighten your posture, take a deep breath, and
envision how your own body rejects cancer cells after removal of the small lump in your breast.
P: (With a questioning expression in her face and straightening her posture)
(80) I: As homework to strengthen your imagination, use the pendulum as often as you can but at least three
times a day. I will see you weekly at the beginning and work with you on other imagining exercises, on
positive thoughts, and I'll check the effects of the Zyban and the need for additional medication to control
anxiety and depression. But I need your help. We have to put our heads together to make it work. And we
may ask your daughter to come in with you and maybe even Joan.
P: I will take my medication and try to work on the exercise. I will also talk to my daughter and to Joan.
(81) I: Our success depends on how well we can control depression and anxiety. You had success in overcoming
smoking and depression in the past and that bodes well for the future.
P: (With a broad smile) I feel so much better now. I'll call Joan and thank her for getting me here.

RAPPORT
Because the patient has accepted the interviewer as an expert, the interviewer continues this role as a guide
for a biopsychosocial treatment plan: Biologically, the interviewer refers to the patient's positive experiences with
Zyban and Prozac and emphasizes the concern about the safety of treatment (Q69 to 74). Psychologically, the
interviewer uses the patient's thinking in images to combat her self-destructive vision. Socially, the interviewer
uses the patient's desire to be supported by her daughter, which rounds out the interviewer's role as a trustworthy
guide.

46
 TECHNIQUE
The interviewer summarizes the patient's positive experiences and strengths that she had shown in the
interview as a basis for the treatment plan.

MENTAL STATUS
The prominent feature (Q,A69 to 81) is the patient's change from an anxious and doubtful to a confident
affect.

DIAGNOSIS
The patient's emotional reactivity to the interviewer's input added to a favorable prognosis of the patient's
traumatic stress reaction.

Case Summary

I. IDENTIFYING DATA
Ms. Lorraine R. is a 56-year-old, white, divorced, mildly obese, Catholic woman and the mother of three
children who had an acute stress response to a recent diagnosis of breast cancer.

II. CHIEF COMPLAINT

“I cried all night. I heard my gynecologist's voice again and again: Sorry, Ms. R. It's stage 1 breast cancer.”

III. INFORMANTS
The patient and her friend, a former patient, who requested that the patient had to be seen immediately.

IV. REASON FOR CONSULTATION

Acute stress response to a recent diagnosis of breast cancer.

V. HISTORY OF PRESENT ILLNESS

The day before the interview, the patient was diagnosed with stage 1 breast cancer. She cried all night and
replayed in her mind the gynecologist's telephone message of having breast cancer. Two days ago, she had been
forewarned of such a diagnosis. She felt “numb” and avoided discussing it with her family and friends. She never
had experienced a life-threatening trauma before. The patient reported concurrent depressive symptoms with
anhedonia and ruminations of being abandoned because of her crippling disease, as she had avoided her cousin
dying of cancer. These chronic, continuous depressive feelings were present over the last 5 years. The patient had
two periods of acute depressive episodes with social withdrawal, loss of energy and initiative, oversleeping,
overeating, weight gain, sensitivity to rejection, and suicidal ideation but no attempts lasting for several months.
Her depression had responded to fluoxetine (Prozac). However, she had no evidence of any mood elation,
overactivity, excessive spending sprees, reduced need of sleep, hypersexuality, or other symptoms of mania or
hypomania. She had no history of alcoholism or substance abuse except for nicotine abuse for which she was
treated successfully with Zyban 5 months ago but had relapsed for 1 day. She reported avoidance behavior
regarding a female cousin in her adopting family who became physically emaciated due to treatment-resistant
progressive breast cancer. The patient gave no evidence of generalized anxiety disorder, panic disorder, or social
phobia. OCD was not assessed. She denied ever having had any psychotic symptoms.

VI. PSYCHIATRIC DISORDERS IN REMISSION

A major depressive disorder, recurrent, was in remission for the last 10 years. Her nicotine abuse was in early
partial remission, but she had a relapse for 1 day.

VII. MEDICAL HISTORY

Positive for a recent diagnosis of breast cancer stage 1 and chronic cough; menopause; no allergies.

47
 VIII. SOCIAL HISTORY AND PREMORBID PERSONALITY
The patient has been divorced for the last 10 years. She has three children by the same man, works as an
interior decorator, and is financially well off due to her divorce settlement and her present income. Premorbid
personality: The patient has a college education and had functioned well before her first major depressive episode
and intermittently between two episodes.

IX. FAMILY HISTORY

A psychiatric family history of parents and siblings is unknown because of patient's adoption. However, her
children show no evidence of psychiatric disorder.

X. MENTAL STATUS EXAMINATION

Appearance
The patient is a 56-year-old, mildly obese, white, Catholic woman who is alert, has good eye contact, and is
cooperative during the interview. She wore makeup, but the tears had washed out some of the mascara.
Movements
Appropriate reactive movements when addressed. Grooming movements were limited to wiping her eyes even
when not crying. Goal-directed movements were appropriate but showed some slowing when she entered the
office and when sitting down. No illustrative movements but appropriate expressive movements when she
discussed how she avoided her cousin.
Speech
Voice was quivering at the beginning of the interview. She talked with normal rate and appropriate
modulation. Initially, she breathed rapidly with pumping of shoulders. Comprehended questions well and
answered in a goal-directed, precise, mildly dramatic manner, volunteering appropriate details.
Mood and Affect
Mood was depressed and anxious. Affect was sad, labile, and anxious but became brighter and hopeful toward
the end of the interview, showing reactivity.
Thought Content
Denied any psychotic symptoms in the past or present. She had decreased interest in living during her two
depressed episodes but expressed a strong will to live now. No evidence of panic attacks. Obsessions or
compulsions not assessed. Fearful of being emotionally abandoned like she felt about her being given up for
adoption. Brief dissociative experience during the last 48 hours. Suggestibility approximately average.
Cognition
Oriented to place, time, and person. Recent memory is intact. Spelling backward and serial sevens are normal.
She was able to interpret proverbs and to abstract the commonalties of categories. Her IQ is at least average
according to the Wilson Approximate Intelligence Test and the Kent Test.
Insight
Aware that she has a depressive disorder and nicotine addiction but less insight into the pathological nature of
her response to the cancer diagnosis. Limited insight that her fear of abandonment is not based on facts but on
projection of her own behavior toward her cousin.
Judgment
Affected by her recent trauma. Expected a terminal course of cancer and abandonment not based on facts of
her prognosis or her daughter's behavior.

XI. DIAGNOSTIC FORMULATION

Biological
• Predisposing factors: Except for three healthy children, family history of psychiatric disorders is unknown. No
history of head injury. History of major depression and possibly dysthymic disorder. Both may negatively
impact on her traumatic stress response.

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• Precipitating: Concurrent cancer, future pain, and the side effects of cancer therapy may worsen the course of
her acute stress disorder, major depression, and nicotine addiction.
• Perpetuating: History of intermittent smoking may lead to dysphoric withdrawal reaction. Concurrent stage 1
breast cancer.
• Protective: Good response to antidepressant medication to both depression and smoking.
Psychological
• Predisposing: Phobic response to crippling disorders with avoidance and projection. Both mechanisms operate
on a level below mature adjustment. Her ability to emotionally support herself is limited.
• Precipitating: The patient fears a terminal cancer course and abandonment.
• Perpetuating: Cancer therapy will be a steady reminder of her cancer risk.
• Protective: Past success with therapy for her depression and smoking, cooperation with treatments. She
avoided a possible conflict between local physicians and out-of-town experts. The patient was receptive to
controlling her images of the course of her cancer.
Social
• Predisposing: Interpreted her adoption as a rejection by her biological parents. Avoided a cousin who had
cancer. Interpreted her divorce as rejection by her husband. Assumed the victim role.
• Precipitating: Experiences the gynecologist's voice as cold, replays his message repeatedly in her mind.
• Perpetuating: The memory of the crippling and fatal course of the cousin's cancer.
• Protective: Has strong support from her friend who had a positive response to therapy; support from friends
who have expressed confidence in her ability to fight the cancer. The patient is still working as an interior
decorator. She enjoys her work and her colleagues, which distract her from her illness.

XII. DIFFERENTIAL DIAGNOSIS

• Risk for an acute stress disorder progressing to a PTSD
• Adjustment disorder with anxious and depressed mood
• Onset of a third major depressive episode precipitated by acute stress
• Special phobia of crippling terminal illness
The patient developed a special phobia but not an acute stress disorder to the terminal course of cancer in a
cousin. She responded with a major depression to her divorce. Therefore, a recurrence of major depression is
likely. An adjustment disorder may be an initial response but could progress to a major depressive episode. Early
intervention may reduce the risks for all three disorders.

XIII. MULTIAXIAL PSYCHIATRIC DIAGNOSIS

Axis I:
• Acute stress disorder (308.3)
• Major depressive disorder with atypical features, recurrent, in full remission (296.36)
• Specific phobia (300.29)
• Rule out dysthymic disorder (300.4)
Axis II: features of dependent and histrionic personality
Axis III:
• Breast cancer, stage 1
• Rule out chronic bronchitis
• Rule out asthma
• Rule out pulmonary cancer
Axis IV:
• Traumatic response to recent diagnosis of breast cancer
• Fear of loss of support
Axis V: current GAF equals 35, highest last year was 70
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 XIV. ASSETS AND STRENGTHS
The protective factors discussed in the section XI. Diagnostic Formulation are identical with the patient's assets
and strengths.

XV. TREATMENT PLAN AND PROGNOSIS

Biological
• Bupropion (Wellbutrin/ Zyban) has helped her in the past with both smoking and depression: bupropion, 150
mg #1 AM, in 1 week #1 twice a day (BID).
• In case of incomplete response, consider combining bupropion with fluoxetine (Prozac).
• Pursue cancer therapy and make an appointment immediately.
Psychological
• Patient to take control and actively reject the cancer. Visualize the cancer as shriveling.
• Instill hope by telling the patient that her cancer has been detected early and that early detection has
excellent prognosis to respond to therapy.
• Include her daughter in some of the upcoming therapy sessions.
Social
• Reframe the fact that the patient has been selected by her adoptive parents as acceptance.
• Discuss her criticism of the husband, helping her to overcome the victim role and appreciate her own
contribution to the divorce.
• Emphasize the expediency of cancer diagnosis in 24 hours, which allows timely treatment.
• Point out support by her friend Joan.
Prognosis
Cooperated with treatment in the past with good response. Psychiatric symptoms appear to be manageable
with therapy, thus preventing disability. Psychiatric prognosis appears good. The main risk factor for psychiatric
well-being is a poor response to cancer therapy.

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 SOMATIZING PATIENTS
Some patients experience and describe emotional distress in terms of physical symptoms. This is certainly true
for the group of somatoform disorders, but it also occurs in some mood and anxiety disorders and adjustment
disorders and as a component of personality style or personality disorder. Somatizing patients pose a number of
difficulties for the consulting and the treating psychiatrist. They are often referred by an internist or primary care
physician, and the referral itself may be experienced as dismissive. Somatizing patients may be reluctant to engage
in self-reflection and psychological exploration. Moreover, somatic distress without physical findings can lead to
diagnostic uncertainty, which, in turn, makes treatment less certain. Antidepressant or anxiolytic medications may
be helpful, but side effects are often less tolerable to individuals who are already highly attuned to small changes
in body sensations.
Many somatizing patients live with the fear that their symptoms are not taken seriously and the parallel fear
that something medically serious may be overlooked. Psychiatrists' main task in dealing with these patients is to
acknowledge the suffering conveyed by the symptoms without necessarily accepting the patient's explanation for
the symptoms. Clinicians should be curious about not only the nature of the physical complaints, but also the
impact of those complaints on the patient's life (e.g., “It must be very difficult to keep on working with such severe
headaches,” or “It sounds as though your illness has crowded everything else out of your life.”).
It is essential that somatizing patients feel that their physical complaints are not being dismissed. Rather than
limiting the scope of inquiry to psychological issues, the psychiatrist wants to expand discussion to include all
aspects of the patient's well-being, emotional health, and physical health. Many patients become more willing to
discuss personal issues, such as job-related stress or relationship difficulties, when they believe the psychiatrist will
not automatically assume that those issues are the cause of physical symptoms. It is often helpful for the physician
to propose a purely pragmatic approach—one that stresses a willingness to use whatever works to relieve the
patient's suffering without causing harm. At times, this may include nonstandard approaches, such as meditation,
yoga, or acupuncture, in addition to psychotherapy.
It is especially important for the psychiatrist working with a somatizing patient to form a collaborative
relationship with the primary medical doctor and to obtain thorough copies of medical records and evaluations
and for them to consult freely with one another about the patient's health and symptoms. An important goal of
treatment is to minimize the harm caused by aggressive and unwarranted medical interventions. These patients
often do better with frequent, short medical consultations that are scheduled in advance, rather than urgent visits
prompted by new symptoms or an intensification of old symptoms, in which case high levels of anxiety make a
sober assessment more difficult. In addition, the momentary relief of medical reassurance after negative tests may
behaviorally condition the patient and may increase the likelihood of future crises.
A degree of humility and flexibility is always desirable in working with psychiatric patients, and this is certainly
true with somatizing patients. It is foolhardy for the psychiatrist to assume with absolute conviction that a patient's
physical complaints have no real medical basis. Knowledge of medicine is constantly expanding but still
incomplete. New disorders are described, and the range of symptoms recognized for known disorders changes.
Meanwhile, the ability to detect and to diagnose accurately physical disease may lag behind. For example, it is
almost certain that some patients with Lyme disease—presenting with vague, shifting, ill-defined physical
complaints, fatigue and lethargy—were misdiagnosed as having a somatoform disorder before the disease was
well-described and diagnostic markers were identified. The psychiatrist's task is not to close the door on medical
investigation, but to invite patients to consider an even larger range of factors, including emotional and
psychological issues, all of which may affect their health.
A 45-year-old man was convinced he had acquired immune deficiency syndrome (AIDS), despite having no risk
factors. He repeatedly sought out human immunodeficiency virus (HIV) testing and blood cell counts. When
tests reported that he was not HIV positive, he felt considerable, but short-lived, relief. He soon began to
doubt the accuracy of the tests and reporting. “Can you tell me with certainty, that there is 100 percent no
51
 chance of error?” he asked his medical doctor. Over several months, his anxiety and depression increased,
and he accepted referral to a psychiatrist.
The psychiatrist reframed the issue by saying that the major cause of the patient's distress was not AIDS, but
the fear of AIDS. He observed that frequent testing had not provided reassurance but, in fact, had increased the
patient's anxiety. The psychiatrist stressed that he would not ignore the patient's physical health. The patient
agreed to scheduled medical consultations every 6 months and, in the course of psychotherapy, became more
open in discussing considerable nonsomatic concerns. He also benefited from antidepressant medication.

AGITATED AND POTENTIALLY VIOLENT PATIENTS

Whether in a private office or a psychiatric emergency department, psychiatrists sometimes find themselves
interviewing potentially violent patients. In these circumstances, the task is twofold: to conduct an assessment and
also to contain behavior and to limit the potential for harm.
Most unpremeditated violence is preceded by a prodrome of accelerating psychomotor agitation. The patient
may begin pacing and pounding the fist in a hand. Speech may become loud, abusive, obscene, and threatening.
The temporal arteries may begin to throb. Researchers and clinicians in emergency psychiatry suggest that the
prodrome lasts from 30 to 60 minutes before erupting into physical violence. Thus, the psychiatric evaluator has
early signals of impending violence and a period of time in which the agitation may be quieted.
Several steps can be taken to minimize the agitation and potential risk. The interview should be conducted in a
quiet, nonstimulating environment. There should be enough space for the comfort of the patient and the
psychiatrist, with no physical barrier to leaving the examination room for either of them. During the interview, the
psychiatrist should avoid any behavior that could be misconstrued as menacing: standing over the patient, staring,
or touching.
The psychiatrist must ask the questions that are necessary to complete an adequate evaluation but must
attempt not to be provocative. It is certainly appropriate to allow the patient to drink water, to use a bathroom
and, for extended evaluations in an emergency room, to eat food. However, these should never be offered as
bargaining chips (“I'll let you get a drink of water if you'll tell me what happened just before the police brought you
here”). The examiner must also avoid promising outcome in exchange for cooperation (“If you'll just talk with me
for another 30 minutes, I'll make sure you don't have to go into the hospital”).
The psychiatrist should ask whether the patient is carrying weapons and may ask the patient to leave the
weapon with a guard or in a holding area. The psychiatrist should not request that the patient hand over any
weapons. Dangerous mishaps can occur during the transfer; moreover, the sudden shift in power created by an
armed psychiatrist may feel extremely threatening to paranoid patients. If the patient's agitation continues to
increase, the psychiatrist may need to terminate the interview. Depending on the setting, assistance from security
personnel or physical or chemical restraints may be appropriate. The physician's own subjective sense of comfort
or fear should be heeded. A frightened, intimidated examiner may be incapable of an accurate professional
evaluation.

SEDUCTIVE PATIENTS
The warmth, openness, acceptance, and understanding that are helpful to most psychiatric interviews may
engender feelings of romantic longing in some patients, especially (but not exclusively) those who are lonely and
socially isolated. Other patients behave in flirtatious and seductive ways as their habitual style of relating with
other people. Seductiveness may be manifested in a patient's dress, behavior, and speech. It runs the gamut from
gentle suggestion to explicit proposition. A young man may sit with his legs spread wide apart, a young woman
may wear a low-cut, revealing dress, or a middle-aged woman, when shaking hands, may hold the psychiatrist's
hand a few seconds longer than is appropriate for the situation.
Of course, sex is not the only enticement with which psychiatrists can be seduced. Patients may offer insider
information for profitable trading in the stock market, may promise an introduction to a movie star friend, or may

52
suggest that they will dedicate their next novel to the psychiatrist. Although it is easy to understand that some
offers by patients, such as the possibility of a sexual involvement, cannot be accepted without considerable harm
to the patient, others may seem more innocuous. However, because they nearly always introduce a different
agenda into the therapy than that originally contracted for, and because they create additional, more ambiguous
levels of obligation between therapist and patient, any psychiatric work is inevitably contaminated, and the ability
to help the patient is compromised. Consequently, gaining any material or social benefit from the patient other
than the agreed-on fee is unethical.
Whether to offers of sex, money, or celebrity, the psychiatrist's response is the same. In the course of ongoing
psychotherapy and in the context of an established relationship, seductive behavior is discussed and examined in
an effort to understand its meaning. Is it, for example, a way of distancing, gaining control, or compensating for
feelings of vulnerability and inferiority? To what extent are the feelings being expressed by the patient part of the
transference? The psychiatrist should make it clear that what is being offered will not be accepted, in a way that
preserves good rapport and does not unnecessarily assault the patient's self-esteem.
Seductive behavior during an initial psychiatric assessment must be handled somewhat differently. When the
behavior is mild and indirect, it may be best to ignore it: Commenting on a woman's exposed cleavage only makes
it clear that the psychiatrist picks up sexual cues, and it is most unlikely to facilitate the interview. More explicit
propositions call for more direct responses and may afford the psychiatrist the chance to explain the nature of the
therapeutic relationship and the need to establish boundaries. The psychiatrist should also make clear that it is the
violation of those boundaries that is being rejected and not the patient. For example, to the patient who offers a
celebrity introduction, the interviewer might reply, “That's very nice of you to propose, but I think I will best be
able to help you if we pretty much stick to the issues that brought you in to see me.”
A woman who was pregnant and in her late trimester began acting seductively toward her obstetrician. She
would rub against him whenever possible and constantly asked him questions about his personal life.
Recognizing this behavior as unusual, the obstetrician decided to explore the possible underlying reasons for
the change. He began by asking what prompted her husband to have a child at this time and how each of
them was feeling about becoming a parent. The patient quickly told how difficult it was to think about
becoming a mother, because she was afraid that her husband would no longer find her sexually attractive.
Further discussions about her past history revealed that the patient's parents did not seem interested in
each other as a husband and wife once they became parents. There was even a strong suspicion that, after
the birth of the patient's younger sister, the patient's father had an affair. She now began to recognize that
she was afraid that her husband would react in exactly the same way as her father did. In this transference
reaction, the patient was responding to her husband as though he were her father. After discussing the
problem further, the obstetrician suggested to the patient that she share her concerns with her husband. As
she did, the marital relationship improved considerably, and the patient's sexual interest in her obstetrician
disappeared.

PATIENTS WHO LIE

A fundamental stance in psychiatric interviewing is recognizing that what is being heard may not be the literal
truth. The unreliability of memory and the vagaries of psychopathology through which a patient's narrative is
processed distort and falsify. The interviewer understands that what is historically untrue may nevertheless be
emotionally true and is therefore a meaningful part of the diagnostic assessment or psychotherapy. At times,
patients lie consciously with the explicit intent of deceiving the therapist. The purpose may be secondary gain (e.g.,
exemption from jury duty, a supply of psychoactive drugs, or leave of absence from graduate school), in which case
the person is malingering. Malingering is not a mental disorder in the revised fourth edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR). More rarely, a patient explicitly lies not for any obvious
external advantage, but simply for whatever psychological advantage is conferred by assuming the sick role, in
which case the person has a factitious disorder that is a DSM-IV-TR diagnosis.

53
 Because psychiatrists do not have recourse to biological markers or other external validating criteria, the
patient's report must be accepted as an honest statement of experience. There is no way to establish whether a
person is experiencing auditory hallucinations other than through self-report. Nevertheless, an experienced
clinician may detect subtle discrepancies, internal inconsistencies, or suspiciously atypical symptoms; these can
certainly be queried without necessarily assuming that the patient is lying.
A 29-year-old woman describes an almost unremitting migraine headache and is asking for narcotic pain
medication.
Patient: I really need your help. The pain is unbearable. I can't do anything anymore. I just want to lie in bed in a
dark room with the cover pulled up over my head.
Doctor: That does sound miserable. I'm struck by the fact that you obviously care about your appearance and
have given some time and attention to your hair, makeup, and the way you are dressed. Was that despite
the pain that you have been describing?
Of course, the examiner is more likely to be deceived during the initial diagnostic assessment than in an
ongoing psychotherapy in which the therapist has much more knowledge of a patient's background, thinking, and
functioning over time. It may be difficult to catch a practiced liar in an initial session. Arguably, the interviewer
should not try to do so. Being lied to angers most people, certainly no less psychiatrists who must depend on trust
to perform their work. However, believing a patient's lies is not a professional failure. Psychiatrists are trained to
detect, to understand, and to treat psychopathology, not to function as lie detectors. Although a certain level of
suspicion is essential to the practice of psychiatry, the clinician determined never to be taken in by deceitful
patients approaches patients with such exaggerated suspiciousness that therapeutic work is not possible.
Finally, not all patients' untruths are conscious lies. Patients with somatoform disorders, such as conversion
disorder or pain disorder, are presumably unaware of the emotional bases of their physical complaints. In
describing their somatic symptoms, they are stating psychological reality, not attempting to deceive the
interviewer.

PATIENTS WHO DO NOT COOPERATE

Lack of patient cooperation can take many forms: failure to keep appointments, refusal to talk or to take the
session seriously, failure to pay for services. Causes of noncooperation include manifestations of the patient's
underlying pathology, anger at the psychiatrist, feelings of being coerced into an evaluation or treatment against
one's will, or manifestations of transference. How the psychiatrist responds depends on the setting and context.
The evaluation of an uncooperative patient during an emergency necessarily proceeds differently from that
during nonemergencies; an emergency psychiatric evaluation must often proceed without full cooperation or even
against the patient's will. Neuroleptic malignant syndrome and delirium tremens, for example, are life-threatening
emergencies, and an evaluation must be conducted as quickly as possible, with or without the patient's
cooperation. Similarly, the assessment of an agitated psychotic patient with paranoid delusions who is brought to
an emergency department by police after threatening to harm others cannot be deferred because of patient
noncooperation. In these situations, sedation or restraint is sometimes necessary to complete even a basic triage
assessment. The patient's refusal to cooperate is superseded by concern for the patient's life and the safety of
others.
The evaluation of an uncooperative patient is different in a nonemergency outpatient setting. The patient who
has been engaged in a meaningful therapy for some time and then becomes uncooperative is sending a powerful
signal to the psychiatrist, the meaning of which must be explored. The change in behavior may be a manifestation
of resistance to upsetting material that is beginning to emerge in therapy or of transference. Not every emotional
reaction of a patient toward the psychiatrist, however, is transference; it may be in response to real life
interactions between doctor and patient.

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 A 52-year-old man who had been in psychotherapy for 1.5 years following difficulties in his marriage began
missing sessions and arriving late. This followed several last-minute cancellations by the psychiatrist who
offered neither explanation nor apology.
When asked about his absences, the man quickly acknowledged how angry he was at the therapist for standing
him up. “I see no reason why I should have to be more responsible than you,” he said. The lateness and
absences in therapy were motivated by anger at the psychiatrist's unprofessional behavior.
Pursuing transferential meaning while ignoring real interactions between physician and patient is unbeneficial
and may worsen the situation if the patient believes that the psychiatrist is using therapeutic techniques to avoid
responsibility for his or her own behavior. It should also be borne in mind that, although transference and
countertransference are important concepts in psychoanalytic psychotherapies, their use in other modalities, such
as cognitive-behavioral therapy, may be inappropriate and counterproductive.
The situation is different during an initial nonemergency assessment. There is little basis for pursuing the
meaning of uncooperative behavior when a psychiatrist is meeting with a patient for the first time. Here, the
psychiatrist's task is not to accept uncritically any and all behavior, but rather to guarantee a setting in which an
honest evaluation or productive therapy can take place. The psychiatrist may need to insist on change in the
patient's behavior as a precondition for proceeding. This can be done in a nonjudgmental and nonpunitive manner.
In the same way that a surgeon is obligated and justified to say, “These are the conditions I must have to perform a
safe and successful surgery,” the psychiatrist must be willing to say “These are the conditions that are necessary
for me to do my work.” For patients who cannot or will not cooperate, the treatment contract may need to be
renegotiated, for example, by changing the frequency of sessions, switching to a different psychotherapeutic
modality, or focusing on medication management rather than psychotherapy. There are circumstances however, in
which the initial assessment or therapy has to be terminated because of a patient's uncooperative behavior. This
does not represent a therapeutic failure. On the contrary, failing to recognize and to respond to the limitations
imposed by patient noncooperation may itself be an error of clinical judgment.
A third-year psychiatry resident working in the outpatient clinic of a large hospital was assigned, for twice-a-
week psychodynamic psychotherapy, a 26-year-old man with mild anxiety and depression and career
difficulties. From the start of treatment, however, the patient came no more than three or four times per
month, usually calling in advance to cancel, but sometimes simply not showing up. The resident struggled to
build a treatment alliance and to interpret the man's behavior by using the little that she knew about him,
but the pattern of noninvolvement continued. After 3 months, a new supervisor pointed out to the resident
that therapy had never really started and that her first task was to create a situation in which therapy could
occur. The resident explained to her patient that meaningful therapy was possible only with his full
cooperation and that they needed to decide what level of involvement he could commit to. The patient
agreed to come once a week. He was able to keep that schedule for the most part and, over the next 6
months, engaged in a beneficial supportive therapy.

Compliance versus Noncompliance

One of the most common forms of noncooperation is noncompliance with medication. This can be especially
frustrating for the psychiatrist when medication is clearly effective in controlling symptoms, and noncompliance
results in relapse. Anger on the part of the physician may be understandable, but it is never helpful. Rather than
assuming that noncompliance is due to a patient's perversity or character defect, an honest effort must be made
to understand the reasons for noncompliance. Some of the common reasons are listed in Table 7.2-3.
Understanding what is motivating the patient to stop medication makes intervention to improve compliance much
more possible. Compliance can be increased when physicians explain to patients the value of a particular
treatment outcome and emphasize that following the recommendation produces this outcome. Compliance can
also increase if patients know the names and effects of each drug they are taking.

55
 Table 7.2-3 Common Reasons for Noncompliance with Medication
The instructions are poorly given or the patient incompletely understands them.
Example: A 34-year-old woman with a first episode of major depression is prescribed paroxetine (Paxil) 20 mg per day. She responds well
with full resolution of all symptoms within 4 weeks. Two weeks later, feeling back to normal, she stops taking the medication. Three weeks
later, she has a relapse.
Comment: The woman did not understand (perhaps it was not well explained) that it would be necessary to continue the medication for
several months after full recovery to minimize the risk of a relapse.
The patient may find side effects intolerable.
Example: A 20-year-old man is given a provisional diagnosis of schizophrenia when he begins to experience auditory hallucinations. He is
treated with haloperidol (Haldol) 5 mg twice a day. The hallucinations resolve, but he begins to experience erectile dysfunction and stops
the medication without telling anyone.
Comment: Common potential side effects and toxicities should always be reviewed with patients before they start medication. It is equally
important to encourage the patient to discuss with the physician any adverse experiences and to reassure the patient that it is not necessary
to put up with intolerable side effects, because there are alternative medications that can be tried.
Psychiatric symptoms interfere with treatment.
Example: A 41-year-old woman with a diagnosis of paranoid schizophrenia is admitted to an inpatient service with the delusion that she is
being poisoned by an alien force. She is treated with risperidone (Risperdal) 2 mg per day and discharged after 1 week. She stops taking
medication on the day of her discharge, believing it also to be poison and part of the plot to hurt her.
Comment: The clinician must be alert to the possibility that symptoms may interfere with treatment, must establish a trusting rapport as
best as possible, and must inquire about the possibility that the patient distrusts the clinician (“Are you sometimes frightened that I might
want to hurt you too?”). If medications are prescribed, they must be in doses that are sufficient to provide benefit.
Patients like their symptoms and don't want them treated.
Example: A 37-year-old man with bipolar disorder, well controlled with lithium (Eskalith) for 2 years, begins to feel mildly euphoric, more
energetic, and more gregarious than usual. He stops taking lithium, because he feels it slows him down. Within 2 weeks, he is in a full manic
episode.
Comment: Psychoeducation is part of the ongoing therapeutic process and may take time to be fully accomplished. Compliance is more
easily achieved when a solid collaborative relationship has been established, when the physician is receptive to the patient's subjective
experience of illness and treatment, and when the patient fully understands that mildly pleasant symptoms can become destructive and
unpleasant if they are inadequately treated.
The lives of some patients are so chaotic and disorganized that good compliance is difficult without close monitoring and follow-up.
Example: A 47-year-old homeless woman with a diagnosis of chronic undifferentiated schizophrenia was treated in an emergency room, was
given a prescription for a 1-month supply of an antipsychotic, and was told to come back to the outpatient clinic in 1 month. After discharge,
the woman lived in a series of shelters and church refuges. Her bags containing her Medicaid and Medicare cards, prescription, and
appointment card were stolen. She could not remember the date or place of follow-up and did not attend.
Comment: Failure to provide close, structured follow-up for this patient almost guaranteed treatment failure. Individual case managers help,
although sometimes the number of cases that they are assigned to follow is overwhelming.
Patients stop taking medications because they cannot afford them.
Example: An elderly man living on a modest fixed income consulted his internist because of fatigue. She diagnosed depression and
prescribed a relatively new selective serotonin reuptake inhibitor. When the man went to fill the prescription at his pharmacy, he was told a
1-month supply would cost $300. He did not fill the prescription and was embarrassed to tell his internist why he did not fill it.
Comment: The cost of medications is too seldom factored into prescribing decisions. This is particularly important for patients relying on
Medicare, because Medicare currently has no outpatient prescription benefits. Generic drugs are always cheaper than brand-name
equivalents. However, when a drug is new and still under patent, there may be no low-cost alternative. Many pharmaceutical companies
have patient assistance programs, in which a physician can apply for substantially reduced-cost brand-name prescription medication for
patients with limited resources.

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PATIENTS FROM DIFFERENT CULTURES AND BACKGROUNDS
Differences in race, nationality, and religion and other significant cultural differences between patient and
interviewer can impair communication and can lead to misunderstandings. Despite its widespread use throughout
the world, the possible cultural biases of DSM-IV-TR are still being debated; for example, the distinctions between
mood disorders and somatoform disorders appear less valid in some countries than in the United States.
In addition, it may be difficult for a culturally naïve psychiatrist to evaluate symptoms that are relative rather
than absolute. There is usually no difficulty in documenting the presence of auditory hallucinations regardless of
cultural differences. However, assessing whether a delusion is bizarre (as required by DSM-IV-TR for delusional
disorder) is more difficult, because the term bizarre has meaning only in reference to cultural norms. The belief by
East Africans in the direct intervention of ancestral spirits in the day-to-day life of individuals is commonplace. The
chief executive officer of an American corporation who announces that he will divest the company of two
subsidiaries because of signals he received that morning from ancestral spirits will be thought exceedingly bizarre
by colleagues and shareholders. Personality disorders, whose criteria are preponderantly relative rather than
absolute (e.g., “shows arrogant, haughty behaviors or attitudes”), are notoriously difficult to diagnose cross-
culturally.
Apart from diagnostic categories, the vocabulary used to describe emotional distress varies from culture to
culture. European Americans commonly describe symptoms in terms of named emotions (“I've been feeling
anxious and depressed all week”). Hispanic Americans are more likely to describe physical symptoms (“I've had a
headache all week, and I'm so tired I can hardly move”). Sometimes symptoms that are commonplace within a
culture are unheard of to outsiders. Residents of Anglophone countries in East and West Africa often describe the
sensation of a snake crawling under their skin, moving from one part of the body to another. This appears to be a
symptom of general emotional distress without particular diagnostic significance. Heard by a Western physician,
the symptom may be misinterpreted as a somatic delusion or may be ignored altogether, because it does not
register in the examiner's conceptual understanding of disorders.
Additional problems are encountered when doctor and patient speak different languages. When an interpreter
is needed, the person should be a disinterested third party, unknown to the patient. Using family or friends to
translate inevitably invites distortions in what the patient is said to report. Translators must be instructed to
translate verbatim what the patient says—a difficult task for even the most experienced professional translators.
Some words and expressions are simply untranslatable. It may be impossible to convey a formal thought disorder
through translation.
An additional difficulty may arise in establishing rapport between doctor and patient of different ethnic or
cultural groups. The use of honorifics, the extent of direct eye contact considered appropriate, and whether it is
acceptable for men and women to shake hands all vary considerably among different groups. Patients from
minority groups may be quite guarded in speaking with a doctor from the majority group. Some groups, such as
traditional Chinese Americans, strongly believe that family problems should not be discussed outside the family,
including with physicians. The evaluating psychiatrist must proceed with humility and respect. Rather than offer
reassurances of understanding and acceptance, it is usually better to ask, “Have I understood this in the way that
you meant it?”

EMPATHY
A diagnostic interview often provides considerable relief to patients. Puzzling and sometimes frightening
symptoms are framed in the context of medical understanding. Bizarre experiences can be rationally understood
and intelligently organized in meaningful ways that allow informed predictions about treatment response and
recovery to be made. Of equal importance to an intellectual understanding is the capacity to understand
emotionally the experiences of patients.

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 Empathy is an essential characteristic of psychiatrists, but it is not a universal human capacity. An incapacity for
normal understanding of what other people are feeling appears to be central to certain personality disturbances,
such as antisocial and narcissistic personality disorders. Although empathy can probably not be created, it can be
focused and deepened through training, observation, and self-reflection. It manifests in clinical work in a variety of
ways. An empathic psychiatrist may anticipate what is felt before it is spoken and can often help patients articulate
what they are feeling. Nonverbal cues, such as body posture and facial expression, are noted. Patients' reactions to
the psychiatrist can be understood and clarified.
Patients sometimes say, “How can you understand me if you haven't gone through what I'm going through?”
but clinical psychiatry is predicated on the belief that it is not necessary to have other people's literal experiences
to understand them. The shared experience of being human is often enough. Whether in an initial diagnostic
setting or in an ongoing therapy, patients draw comfort from knowing that psychiatrists are not mystified by their
suffering.

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