Healthy interactions with “attachment figures” in early life (e.g., parents) promote robust biological, emotional, and social development in childhood and throughout the life cycle.⁴ The foundations for attachment theory are based on research findings in cognitive neuroscience, genetics, and brain development that indicate an ongoing and life-long dance between an individual’s neural circuitry, genetic predisposition, brain plasticity, and environmental influences.⁵ Secure attachments in childhood foster emotional resilience⁶ and generate skills and habits of seeking out selected attachment figures for comfort, protection, advice, and strength. Relationships based on secure attachments lead to effective use of cognitive functions, emotional flexibility, enhancement of security, assignment of meaning to experiences, and effective self-regulation.⁵ In emotional relationships of many sorts, including the student-teacher and doctor-patient relationships, there may be many features of attachment present (such as seeking proximity, or using an individual as a “safe haven” for soothing and as a secure base).⁷

What promotes secure attachment in early childhood, and how may we draw from this in understanding a therapeutic doctor-patient relationship and an effective psychiatric interview? The foundations for secure attachment for children (according to Siegel) include several attributes ascribed to parents ⁵ (Table 2-1).

Table 2-1 Elements That Contribute to Secure Attachments

• Communication that is collaborative, resonant, mutual, and attuned to the cognitive and emotional state of the child.

• Dialogue that is reflective and responsive to the state of the child. This creates a sense that subjective experience can be shared, and allows for the child “being seen.” It requires use of empathy, “mindsight,” and an ability to “see,” or be in touch with, the child’s state of mind.

• Identification and repair of miscommunications and misunderstandings. When the parent corrects problems in communication, the child can make sense of painful disconnections. Repair of communication failures requires consistent, predictable, reflective, intentional, and mindful caregiving. The emphasis here is on mindfulness and reflection. Mindfulness in this instance is an example of a parent’s ability for self-awareness, particularly of his or her emotional reactions to the child and the impact of his or her words and actions on the child.

• Emotional communication that involves sharing feelings that amplify the positive and mitigate the negative.

• Assistance in the child’s development of coherent narratives that connect experiences in the past and present, creating an autobiographical sense of self-awareness (using language to weave together thoughts, feelings, sensations, and actions as a means of organizing and making sense of internal and external worlds).

We must always be mindful not to patronize our patients and to steer clear of the paternalistic power dynamics that could be implied in analogizing the doctor-patient relationship to one between parent and child; nonetheless, if we substitute “doctor” for “parent” and similarly substitute “patient” for “child,” we can immediately see the relevance to clinical practice. We can see how important each of these elements is in fostering a doctor-patient relationship that is open, honest, mutual, collaborative, respectful, trustworthy, and secure. Appreciating the dynamics of secure attachment also deepens the meaning of “patient-centered” care. The medical literature clearly indicates that good outcomes and patient satisfaction involve physician relationship techniques that involve reflection, empathy, understanding, legitimization, and support.^8,⁹ Patients reveal more about themselves when they trust their doctors, and trust has been found to relate primarily to behavior during clinical interviews⁹ rather than to any preconceived notion of competence of the doctor or behavior outside the office.

Particularly important in the psychiatric interview is the facilitation of a patient’s narrative. The practice of narrative medicine involves an ability to acknowledge, absorb, interpret, and act on the stories and struggles of others.¹⁰ Charon¹⁰ describes the process of listening to patients’ stories as a process of following the biological, familial, cultural, and existential thread of the situation. It encompasses recognizing the multiple meanings and contradictions in words and events; attending to the silences, pauses, gestures, and nonverbal cues; and entering the world of the patient, while simultaneously arousing the doctor’s own memories, associations, creativity, and emotional responses—all of which are seen in some way by the patient.¹⁰ Narratives, like all stories, are co-created by the teller and the listener. Storytelling is an age-old part of social discourse that involves sustained attention, memory, emotional responsiveness, nonverbal responses and cues, collaborative meaning-making, and attunement to the listener’s expectations. It is a vehicle for explaining behavior. Stories and storytelling are pervasive in society as a means of conveying symbolic activity, history, communication, and teaching.⁵ If a physician can assist the patient in telling his or her story effectively, reliable and valid data will be collected and the relationship solidified. Narratives are facilitated by authentic, compassionate, and genuine engagement.

A differential diagnosis detached from the patient’s narrative is arid; even if it is accurate it may not lead to an effective and mutually designed treatment path. By contrast, an accurate and comprehensive differential diagnosis that is supported by a deep appreciation of the patient’s narrative is experienced by both patient and physician as more three-dimensional, more real, and is more likely to lead to a mutually created and achievable plan, with which the patient is much more likely to “comply.”

Creating the optimal conditions for a secure attachment and the elaboration of a coherent narrative requires mindful practice. Just as the parent must be careful to differentiate his or her emotional state and needs from the child’s and be aware of conflicts and communication failures, so too must the mindful practitioner. Epstein ¹¹ notes that mindful practitioners attend in a nonjudgmental way to their own physical and mental states during the interview. Their critical self-reflection allows them to listen carefully to a patient’s distress, to recognize their own errors, to make evidence-based decisions, and to stay attuned to their own values so that they may act with compassion, technical competence, and insight.¹¹

Self-reflection is critical in psychiatric interviewing. Re-flective practice entails observing ourselves (including our emotional reactions to patients, colleagues, and illness); our deficits in knowledge and skill; our personal styles of communicating; our responses to personal vulnerability and failure; our willingness or resistance to acknowledge error, to apologize, and to ask for forgiveness; and our reactions to stress. Self-awareness allows us to be aware of our own thinking, feelings, and action while we are in the process of practicing. By working in this manner, a clinician enhances his or her confidence, competence, sensitivity, openness, and lack of defensiveness—all of which assist in fostering secure attachments with patients, and helping them share their innermost fears, concerns, and problems.

THE CONTEXT OF THE INTERVIEW: FACTORS INFLUENCING THE FORM AND CONTENT OF THE INTERVIEW

All interviews occur in a context. Awareness of the context may require modification of clinical interviewing techniques. There are four elements to consider: the setting, the situation, the subject, and the significance.¹²

The Setting

Patients are exquisitely sensitive to the environment in which they are evaluated. There is a vast difference between being seen in an emergency department (ED), on a medical floor, on an inpatient or partial hospital unit, in a psychiatric outpatient clinic, in a private doctor’s office, in a school, or in a court clinic. Each setting has its benefits and downsides, and these must be assessed by the evaluator. For example, in the ED or on a medical or surgical floor, space for private, undisturbed interviews is usually inadequate. Such settings are filled with action, drama, and hospital personnel who race around. ED visits may require long waits, and contribute to impersonal approaches to patients and negative attitudes to psychiatric patients. For a patient with borderline traits who is in crisis, this can only create extreme frustration and possibly exacerbation of chronic fears of deprivation, betrayal, abandonment, and aloneness, and precipitation of regression.¹³ For these and higher functioning patients, the public nature of the environment and the frantic pace of the emergency service may make it difficult for the patient to present very personal, private material in a calm fashion. In other public places (such as community health centers or schools), patients may feel worried about being recognized by neighbors or friends. Whatever the setting, it is always advisable to ask the patient directly how comfortable he or she feels in the examining room, and to try to ensure privacy and a quiet environment with minimal distractions.

The setting must be comfortable for the patient and the physician. If the patient is agitated, aggressive, or threatening, it is always important to calmly assert that the examination must require that everyone is safe and that we will only use words and not actions during the interview. Hostile patients should be interviewed in a setting in which the doctor is protected. An office in which an aggressive patient is blocking the door and in which there is no emergency button or access to a phone to call for help should be avoided, and alternative settings should be arranged. In some instances, local security may need to be called to ensure safety.

The Situation

Many individuals seek psychiatric help because they are aware that they have a problem. This may be a second or third episode of a recurrent condition (such as a mood disorder). They may come having been to their primary care physician, who makes the referral, or they may find a doctor in other ways. Given the limitations placed on psychiatrists by some managed care panels, access to care may be severely limited. It is not unusual for a patient to have called multiple psychiatrists, only to find that their practices are all filled. Many clinics have no room for patients, or they are constrained by their contracts with specific vendors. The frustrating process of finding a psychiatrist sets the stage for some patients to either disparage the field and the health care system, or, on the other hand, to idealize the psychiatrist who has made the time for the patient. In either case, much goes on before the first visit that may significantly affect the initial interview. To complicate matters, the evaluator needs to understand previous experience with psychiatrists and psychiatric treatment. Sometimes a patient had a negative experience with another psychiatrist—perhaps a mismatch of personalities, a style that was ineffective, a treatment that did not work, or other problems. Many will wonder about a repeat performance. In all cases, in the history and relationship-building, it is propitious to ask about previous treatments, what worked, and what did not, and particularly how the patient felt about the psychiatrist. There should be reassurance that this information is totally confidential, and that the interest is in understanding that the match between doctor and patient is crucial. Even at the outset, it might be mentioned that the doctor will do his or her best to understand the patient and the problem, but that when plans are made for treatment, the patient should consider what kind of professional and setting is desired.

Other patients may come reluctantly or even with great resistance. Many arrive at the request or demand of a loved one, friend, colleague, or employer because of behaviors deemed troublesome. The patient may deny any problem, or simply be too terrified to confront a condition that is bizarre, unexplainable, or “mental.” Some conditions are ego-syntonic, such as anorexia nervosa. A patient with this eating disorder typically sees the psychiatrist as the enemy—as a doctor that wants to make her “get fat.” For resistant patients, it is often very useful to address the issue up front. With an anorexic patient referred by her internist and brought in by family, one could begin by saying, “Hi, Ms. Jones. I know you really don’t want to be here. I understand that your doctor and family are concerned about your weight. I assure you that my job is first and foremost to understand your point of view. Can you tell me why you think they wanted you to see me?” Another common situation with extreme resistance is the alcoholic individual brought in by a spouse or friend, clearly in no way ready to stop drinking. In this case you might say, “Good morning, Mr. Jones. I heard from your wife that she is really concerned about your drinking, and your safety, especially when driving. First, let me tell you that neither I nor anyone else can stop you from drinking. That is not my mission today. I do want to know what your drinking pattern is, but more, I want to get the picture of your entire life to understand your current situation.” Extremely resistant patients may be brought involuntarily to an emergency service, often in restraints, by police or ambulance, because they are considered dangerous to themselves or others. It is typically terrifying, insulting, and humiliating to be physically restrained. Regardless of the reasons for admission, unknown to the psychiatrist, it is often wise to begin the interview as follows: “Hi, Ms. Carter, my name is Dr. Beresin. I am terribly sorry you are strapped down, but the police and your family were very upset when you locked yourself in the car and turned on the ignition. They found a suicide note on the kitchen table. Everyone was really concerned about your safety. I would like to discuss what is going on, and see what we can do together to figure things out.”

In some instances, a physician is asked to perform a psychiatric evaluation on a patient who is currently hospitalized on a medical or surgical service with symptoms arising during medical/surgical treatment. These patients may be delirious and have no idea that they are going to be seen by a psychiatrist. This was never part of their agreement when they came into the hospital for surgery, and no one may have explained the risk of delirium. Some may be resistant, others confused. Other delirious patients are quite cognizant of their altered mental status and are extremely frightened. They may wonder whether the condition is going to continue forever. For example, if we know a patient has undergone abdominal surgery for colon cancer, and has been agitated, sleepless, hallucinating, and delusional, a psychiatric consultant might begin, “Good morning, Mr. Harris. My name is Dr. Beresin. I heard about your surgery from Dr. Rand and understand you have been having some experiences that may seem kind of strange or frightening to you. Sometimes after surgery, people have a reaction to the procedure or the medications used that causes difficulties with sleep, agitation, and mental confusion. This is not unusual, and it is generally temporary. I would like to help you and your team figure out what is going on and what we can do about this.” Other requests for psychiatric evaluation may require entirely different skills, such as when the medical team or emergency service seeks help for a family who lost a loved one.

In each of these situations, the psychiatrist needs to understand the nature of the situation and to take this into account when planning the evaluation. In the aforementioned examples, only the introduction was addressed. However, when we see the details (discussed next) about building a relationship and modifying communication styles and questions to meet the needs of each situation, other techniques might have to be employed to make a therapeutic alliance. It is always helpful to find out as much ancillary information as possible before the interview. This may be done by talking with primary care physicians, looking in an electronic medical record, and talking with family, friends, or professionals (such as police or emergency medical technicians).

The Subject

Naturally, the clinical interview needs to take into account features of the subject, including age, developmental level, gender, and cultural background, among others. Moreover, one needs to determine “who” the patient is. In families, there may be an identified patient (e.g., a conduct-disordered child, or a child with chronic abdominal pain). However, the examiner must keep in mind that psychiatric and medical syndromes do not occur in a vacuum. While the family has determined an “identified patient,” the examiner should consider that when evaluating the child, all members of the environment need to be part of the evaluation. A similar situation occurs when an adult child brings in an elderly demented parent for an evaluation. It is incumbent on the evaluator to consider the home environment and caretaking, in addition to simply evaluating the geriatric patient. In couples, one or both may identify the “other” as the “problem.” An astute clinician needs to allow each person’s perspective to be clarified, and the examiner will not “take sides.”

Children and adolescents require special consideration. While they may, indeed, be the “identified patient,” they are embedded in a home life that requires evaluation; the parent(s) or guardian(s) must help administer any prescribed treatment, psychotropic or behavioral. Furthermore, the developmental level of the child needs to be considered in the examination. Young children may not be able to articulate what they are experiencing. For example, an 8-year-old boy who has panic attacks may simply throw temper tantrums and display oppositional behavior when asked to go to a restaurant. Although he may be phobic about malls and restaurants, his parents simply see his behavior as defiance. When asked what he is experiencing, he may not be able to describe palpitations, shortness of breath, fears of impending doom, or tremulousness. However, if he is asked to draw a picture of himself at the restaurant, he may draw himself with a scared look on his face, and with jagged lines all around his body. Then when specific questions are asked, he is able to acknowledge many classic symptoms of panic disorder. For young children, the room should be equipped with toys, dollhouses, and material to create pictures.

Adolescents raise additional issues. While some may come willingly, others are dragged in against their will. In this instance, it is very important to identify and to empathize with the teenager: “Hi, Tony. I can see this is the last place you want to be. But now that you are hauled in here by your folks, we should make the best of it. Look, I have no clue what is going on, and don’t even know if you are the problem! Why don’t you tell me your story?” Teenagers may indeed feel like hostages. They may have bona fide psychiatric disorders, or may be stuck in a terrible home situation. The most important thing the examiner must convey is that the teenager’s perspective is important, and that this will be looked at, as well as the parent’s point of view. It is also critical to let adolescents, as all patients, know about the rules and limits of confidentiality. Many children think that whatever they say will be directly transmitted to their parents. Surely this is their experience in school. However, there are clear guidelines about adolescent confidentiality, and these should be delineated at the beginning of the clinical encounter. Confidentiality is a core part of the evaluation, and it will be honored for the adolescent; it is essential that this is communicated to them so they may feel safe in divulging very sensitive and private information without fears of repercussion. Issues such as sexuality, sexually transmitted diseases, substance abuse, and issues in mental health are protected by state and federal statutes. There are, however, exceptions; one major exception is that if the patient or another is in danger by virtue of an adolescent’s behavior, confidentiality is waived.¹⁴

The Significance

Psychiatric disorders are commonly stigmatized, and subsequently are often accompanied by profound shame, anxiety, denial, fear, and uncertainty. Patients generally have a poor understanding of psychiatric disorders, either from lack of information, myth, or misinformation from the media (e.g., TV, radio, and the Internet).¹⁵ Many patients have preconceived notions of what to expect (bad or good), based on the experience of friends or family. Some patients, having talked with others or having searched online, may be certain or very worried that they suffer from a particular condition, and this may color the information presented to an examiner. A specific syndrome or symptom may have idiosyncratic significance to a patient, perhaps because a relative with a mood disorder was hospitalized for life, before the deinstitutionalization of mental disorders. Hence, he or she may be extremely wary of divulging any indication of severe symptoms lest life-long hospitalization result. Obsessions or compulsions may be seen as clear evidence of losing one’s mind, having a brain tumor, or becoming like Aunt Jesse with a chronic psychosis.¹² Some patients (based on cognitive limitations) may not understand their symptoms. These may be normal, such as the developmental stage in a school-age child, whereas others may be a function of mental retardation, Asperger’s syndrome, or cerebral lacunae secondary to multiple infarcts following embolic strokes.

Finally, there are significant cultural differences in the way mental health and mental illness are viewed. Culture may influence health-seeking and mental health–seeking behavior, the understanding of psychiatric symptoms, the course of psychiatric disorders, the efficacy of various treatments, or the kinds of treatments accepted.¹⁶ Psychosis, for example, may be viewed as possession by spirits. Some cultural groups have much higher completion rates for suicide, and thus previous attempts in some individuals should be taken more seriously. Understanding the family structure may be critical to the negotiation of treatment; approval by a family elder could be crucial in the acceptance of professional help.

ESTABLISHING AN ALLIANCE AND FOSTERING EFFECTIVE COMMUNICATION

Studies of physician-patient communication have demonstrated that good outcomes flow from effective communication; developing a good patient-centered relationship is characterized by friendliness, courtesy, empathy, and partnership building, and by the provision of information. Posi-tive outcomes have included benefits to emotional health, symptom resolution, and physiological measures (e.g., blood pressure, blood glucose level, and pain control).¹⁷^–²⁰

In 1999 leaders and representatives of major medical schools and professional organizations convened at the Fetzer Institute in Kalamazoo, Michigan, to propose a model for doctor-patient communication that would lend itself to the creation of curricula for medical and graduate medical education, and for the development of standards for the profession. The goals of the Kalamazoo Consensus Statement ²¹ were to foster a sound doctor-patient relationship and to provide a model for the clinical interview. The key elements of this statement are summarized in Table 2-2, and are applicable to the psychiatric interview.

Table 2-2 Building a Relationship: The Fundamental Tasks of Communication

• Elicit the patient’s story while guiding the interview by diagnostic reasoning.

• Maintain an awareness that feelings, ideas, and values of both the patient and the doctor influence the relationship.

• Develop a partnership with the patient, and form an alliance in which the patient participates in decision-making.

• Work with patients’ families and support networks.

Open the Discussion

• Allow the patient to express his or her opening statement without interruption.

• Encourage the patient to describe a full set of concerns.

• Maintain a personal connection during the interview.

Gather Information

• Use both open- and closed-ended questions.

• Provide structure, clarification, and a summary of the information collected.

• Listen actively, using verbal and nonverbal methods (e.g., eye contact).

Understand the Patient’s Perspective

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

• Elicit beliefs, concerns, and expectations about health and illness.

• Validate and respond appropriately to the patient’s ideas, feelings, and values.

Share Information

• Avoid technical language and medical jargon.

• Determine if the patient understands your explanations.

• Encourage questions.

Reach Agreement on Problems and Plans

• Welcome participation in decision-making.

• Determine the patient’s amenability to following a plan.

• Identify and enlist resources and supports.

Provide Closure

• Ask if the patient has questions or other concerns.

• Summarize and solidify the agreement with a plan of action.

• Review the follow-up plans.

BUILDING THE RELATIONSHIP AND THERAPEUTIC ALLIANCE

All psychiatric interviews must begin with a personal introduction, and establish the purpose of the interview; this helps create an alliance around the initial examination. The interviewer should attempt to greet the person warmly, and use words that demonstrate care, attention, and concern. Note taking and use of computers should be minimized, and if used, should not interfere with ongoing eye contact. The interviewer should indicate that this interaction is collaborative, and that any misunderstandings on the part of patient or physician should be immediately clarified. In addition, the patient should be instructed to ask questions, interrupt, and provide corrections or additions at any time. The time frame for the interview should be announced. In general, the interviewer should acknowledge that some of the issues and questions raised will be highly personal, and that if there are issues that the patient has real trouble with, he or she should let the examiner know. Confidentiality should be assured at the outset of the interview. These initial guidelines set the tone, quality, and style of the clinical interview. An example of a beginning is, “Hi, Mr. Smith. My name is Dr. Beresin. I am delighted you came today. I would like to discuss some of the issues or problems you are dealing with so that we can both understand them better, and figure out what kind of assistance may be available. I will need to ask you a number of questions about your life, both your past and present, and if I need some clarification about your descriptions I will ask for your help to be sure I ‘get it.’ If you think I have missed the boat, please chime in and correct my misunderstanding. Some of the topics may be highly personal, and I hope that you will let me know if things get a bit too much. We will have about an hour to go through this, and then we’ll try to come up with a reasonable plan together. I do want you to know that everything we say is confidential. Do you have any questions about our job today?” This should be followed with an open-ended question about the reasons for the interview.

One of the most important aspects of building a therapeutic alliance is helping the patient feel safe. Demonstrating warmth and respect is essential. In addition, the psychiatrist should display genuine interest and curiosity in working with a new patient. Preconceived notions about the patient should be eschewed. If there are questions about the patient’s cultural background or spiritual beliefs that may have an impact on the information provided, on the emotional response to symptoms, or on the acceptance of a treatment plan, the physician should note at the outset that if any of these areas are of central importance to the patient, he or she should feel free to speak about such beliefs or values. The patient should have the sense that both doctor and patient are exploring the history, life experience, and current symptoms together.

For many patients, the psychiatric interview is probably one of the most confusing examinations in medicine. The psychiatric interview is at once professional and profoundly intimate. We are asking patients to reveal parts of their life they may only have shared with extremely close friends, a spouse, clergy, or family, if anyone. And they are coming into a setting in which they are supposed to do this with a total stranger. Being a doctor may not be sufficient to allay the apprehension that surrounds this situation; being a trustworthy, caring human being may help a great deal. It is vital to make the interview highly personal and to use techniques that come naturally. Beyond affirming and validating the patient’s story with extreme sensitivity, some clinicians may use humor and judicious self-revelation. These elements are characteristics of healers.²²

An example should serve to demonstrate some of these principles. A 65-year-old deeply religious woman was seen to evaluate delirium following cardiac bypass surgery. She told the psychiatric examiner in her opening discussion that she wanted to switch from her primary care physician, whom she had seen for over 30 years. As part of her postoperative delirium, she developed the delusion that he may have raped her during one of his visits with her. She felt that she could not possibly face him, her priest, or her family, and she was stricken with deep despair. While the examiner may have recognized this as a biological consequence of her surgery and postoperative course, her personal experience spoke differently. She would not immediately accept an early interpretation or explanation that her brain was not functioning correctly. In such a situation, the examiner must verbally acknowledge her perspective, seeing the problem through her eyes, and helping her see that he or she “gets it.” For the patient, this was a horrible nightmare. The interviewer might have said, “Mrs. Jones, I understand how awful you must feel. Can you tell me how this could happened, given your longstanding and trusting relationship with your doctor?” She answered that she did not know, but that she was really confused and upset. When the examiner established a trusting relationship, completed the examination, determined delirium was present, and explained the nature of this problem, they agreed on using haloperidol to improve sleep and “nerves.” Additional clarifications could be made in a subsequent session after the delirium cleared.

As noted earlier, reliable mirroring of the patient’s cognitive and emotional state and self-reflection of one’s affective response to patients are part and parcel of establishing secure attachments. Actively practicing self-reflection and clarifying one’s understanding helps to model behavior for the patient, as the doctor and patient co-create the narrative. Giving frequent summaries to “check in” on what the physician has heard may be very valuable, particularly early on in the interview, when the opening discussion or chief complaints are elicited. For example, a 22-year-old woman gradually developed obsessive-compulsive symptoms over the past 2 years that led her to be housebound. The interviewer said, “So, Ms. Thompson, let’s see if I get it. You have been stuck at home and cannot get out of the house because you have to walk up and down the stairs for a number of hours. If you did not ‘get it right,’ something terrible would happen to one of your family members. You also noted that you were found walking the stairs in public places, and that even your friends could not understood this behavior, and they made fun of you. You mentioned that you had to ‘check’ on the stove and other appliances being turned off, and could not leave your car, because you were afraid it would not turn off, or that the brake was not fully on, and again, something terrible would happen to someone. And you said to me that you were really upset because you knew this behavior was ‘crazy.’ How awful this must be for you! Did I get it right?” The examiner should be sure to see both verbally and nonverbally that this captured the patient’s problem. If positive feedback did not occur, the examiner should attempt to see if there was a misinterpretation, or if the interviewer came across as judgmental or critical. One could “normalize” the situation and reassure the patient to further solidify the alliance by saying, “Ms. Thompson, your tendency to stay home, stuck, in the effort to avoid hurting anyone is totally natural given your perception and concern for others close to you. I do agree, it does not make sense, and appreciate that it feels bizarre and unusual. I think we can better understand this behavior, and later I can suggest ways of coping and maybe even overcoming this situation through treatments that have been quite successful with others. However, I do need to get some additional information. Is that OK?” In this way, the clinician helps the patient feel understood—that anyone in that situation would feel the same way, and that there is hope. But more information is needed. This strategy demonstrates respect and understanding, and provides support and comfort, while building the alliance.

DATA COLLECTION: BEHAVIORAL OBSERVATION, THE MEDICAL AND PSYCHIATRIC HISTORY, AND MENTAL STATUS EXAMINATION

Behavioral Observation

There is a lot to be learned about patients by observing them before, during, and after the psychiatric interview. It is useful to see how the patient interacts with support staff of the clinic and with family, friends, or others who accompany him or her to the appointment. In the interview one should take note of grooming, the style and state of repair of clothes, mannerisms, normal and abnormal movements, posture and gait, physical features (such as natural deformities, birth marks, or cutting marks, scratches, tattoos, or pierces), skin quality (e.g., color, texture, and hue), language (including English proficiency, the style of words used, grammar, vocabulary, and syntax), and nonverbal cues (such as eye contact and facial expressions). All these factors contribute to clinical formulation.

The Medical and Psychiatric History

Table 2-3 provides an overview of the key components of the psychiatric history.

Table 2-3 The Psychiatric History

Identifying Information

Name, address, phone number, and e-mail address
Insurance
Age, gender, marital status, occupation, children, ethnicity, and religion
For children and adolescents: primary custodians, school, and grade
Primary care physician
Psychiatrist, allied mental health providers
Referral source
Sources of information
Reliability

Chief Complaint/Presenting Problem(s)

History of Present Illness

Onset
Perceived precipitants
Signs and symptoms
Course and duration
Treatments: professional and personal
Effects on personal, social, and occupational or academic function
Co-morbid psychiatric or medical disorders
Psychosocial stressors: personal (psychological, medical), family, friends, work/school, legal, housing, and financial

Past Psychiatric History

Previous Episodes of the Problem(s)

Symptoms, course, duration, and treatment (inpatient or outpatient)

Psychiatric Disorders

Symptoms, course, duration, and treatment (inpatient or outpatient)

Past Medical History

Medical problems: past and current
Surgical problems: past and current
Accidents
Allergies
Immunizations
Current medications: prescribed and over-the-counter medications
Other treatments: acupuncture, chiropractic, homeopathic, yoga, and meditation
Tobacco: present and past use
Substance use: present and past use
Pregnancy history: births, miscarriages, and abortions
Sexual history: birth control, safe sex practices, and history of, and screening for, sexually transmitted diseases

Review of Systems

Family History

Family psychiatric history
Family medical history

Personal History: Developmental and Social History

Early Childhood

Developmental milestones
Family relationships

Middle Childhood

School performance
Learning or attention problems
Family relationships
Friends
Hobbies

Adolescence

School performance (include learning and attention problems)
Friends and peer relationships
Family relationships
Psychosexual history
Dating and sexual history
Work history
Substance use
Problems with the law

Early Adulthood

Education
Friends and peer relationships
Hobbies and interests
Marital and other romantic partners
Occupational history
Military experiences
Problems with the law

Midlife and Older Adulthood

Career development
Marital and other romantic partners
Changes in the family
Losses
Aging process: psychological and physical

Adapted from Beresin EV: The psychiatric interview. In Stern TA, editor: The ten-minute guide to psychiatric diagnosis and treatment, New York, 2005, Professional Publishing Group.

The Mental Status Examination

The mental status examination is part and parcel of any medical and psychiatric interview. Its traditional components are indicated in Table 2-4. Most of the data needed in this model can be ascertained by asking the patient about elements of the current problems. Specific questions may be needed for the evaluation of perception, thought, and cognition. Most of the information in the mental status examination is obtained by simply taking the psychiatric history and by observing the patient’s behavior, affect, speech, mood, thought, and cognition.

Table 2-4 The Mental Status Examination

General appearance and behavior: grooming, posture, movements, mannerisms, and eye contact

Speech: rate, flow, latency, coherence, logic, and prosody

Affect: range, intensity, lability

Mood: euthymic, elevated, depressed, irritable, anxious

Perception: illusions and hallucinations

Thought (coherence and lucidity): form and content (illusions, hallucinations, and delusions)

Safety: suicidal, homicidal, self-injurious ideas, impulses, and plans

Cognition

• Level of consciousness

• Orientation

• Attention and concentration

• Memory (registration, recent and remote)

Perceptual disorders include abnormalities in sensory stimuli. There may be misperceptions of sensory stimuli, known as illusions, for example, micropsia or macropsia (objects that appear smaller or larger, respectively, than they are). Phenomena such as this include distortions of external stimuli (affecting the size, shape, intensity, or sound of stimuli). Distortions of stimuli that are internally created are hallucinations and may occur in any one or more of the following modalities: auditory, visual, olfactory, gustatory, or kinesthetic.

Thought disorders may manifest with difficulties in the form or content of thought. Formal thought disorders involve the way ideas are connected. Abnormalities in form may involve the logic and coherence of thinking. Such disorders may herald neurological disorders, severe mood disorders (e.g., psychotic depression or mania), schizophreniform psychosis, delirium, or other disorders that impair reality testing. Examples of formal thought disorders are listed in Table 2-5.^24,²⁵

Table 2-5 Examples of Formal Thought Disorders

• Circumstantiality: a disorder of association with the inclusion of unnecessary details until one arrives at the goal of the thought

• Tangentiality: use of oblique, irrelevant, and digressive thoughts that do not convey the central idea to be communicated

• Loose associations: jumping from one unconnected topic to another

• Clang associations: an association of speech without logical connection dictated by the sound of the words rather than by their meaning; it frequently involves using rhyming or punning

• Perseveration: repeating the same response to stimuli (such as the same verbal response to different questions) with an inability to change the responses

• Neologism: words made up; often a condensation of different words; unintelligible to the listener

• Echolalia: persistent repetition of words or phrases of another person

• Thought-blocking: an abrupt interruption in the flow of thought, in which one cannot recover what was just said

Disorders of the content of thought pertain to the specific ideas themselves. The examiner should always inquire about paranoid, suicidal, and homicidal thinking. Other indications of disorder of thought content include delusions, obsessions, and ideas of reference (Table 2-6).²⁵

Table 2-6 Disorders of Thought Content

• Delusions: fixed, false, unshakable beliefs

• Obsessions: persistent thought that cannot be extruded by logic or reasoning

• Idea of reference: misinterpretation of incidents in the external world as having special and direct personal reference to the self

The cognitive examination includes an assessment of higher processes of thinking. This part of the examination is critical for a clinical assessment of neurological function, and is useful for differentiating focal and global disorders, delirium, and dementia. The traditional model assesses a variety of dimensions (Table 2-7).²⁶

Table 2-7 Categories of the Mental Status Examination

• Orientation: for example, to time, place, person, and situation.

• Attention and concentration: for example, remembering three objects immediately, in 1 and 3 minutes; spelling “world” backward; performing digit span.

• Memory: registration, both recent and remote. Registration is typically a function of attention and concentration. Recent and remote memory are evaluated by recalling events in the short and long term, for example, the names of the presidents provided backward.

• Calculations: evaluated typically by serially subtracting 7 from 100.

• Abstraction: assessed by the patient’s ability to interpret proverbs or other complex ideas.

• Judgment: evaluated by seeing if the patient demonstrates an awareness of personal issues or problems, and provides appropriate ways of solving them.

• Insight: an assessment of self-reflection and an understanding of one’s condition or the situation of others.

Alternatively, the Mini-Mental State Examination ²⁷ may be administered (Table 2-8). It is a highly valid and reliable instrument that takes about 5 minutes to perform and is very effective in differentiating depression from dementia.

Table 2-8 Mini-Mental State Examination

SHARING INFORMATION AND PREPARING THE PATIENT FOR TREATMENT

The conclusion of the psychiatric interview requires summarizing the symptoms and history and organizing them into a coherent narrative that can be reviewed and agreed on by the patient and the clinician. This involves recapitulating the most important findings and explaining the meaning of them to the patient. It is crucial to obtain an agreement on the clinical material and the way the story holds together for the patient. If the patient does not concur with the summary, the psychiatrist should return to the relevant portions of the interview in question and revisit the topics that are in disagreement.

This part of the interview should involve explaining one or more diagnoses to the patient (their biological, psychological, and environmental etiology), as well as a formulation of the patient’s strengths, weaknesses, and style of managing stress. The latter part of the summary is intended to help ensure that the patient feels understood. The next step is to delineate the kinds of approaches that the current standards of care would indicate are appropriate for treatment. If the diagnosis is uncertain, further evaluation should be recommended to elucidate the problem or co-morbid problems. This might require one or more of the following: further laboratory evaluation; medical, neurological, or pediatric referral; psychological or neuropsychological testing; use of standardized rating scales; or consultation with a specialist (e.g., a psychopharmacologist or a sleep disorders or substance abuse specialist).

Education about treatment should include reviewing the pros and cons of various options. This is a good time to dispel myths about psychiatric treatments, either pharmacotherapy or psychotherapy. Both of these domains have significant stigma associated with them. For patients who are prone to shun pharmacotherapy (not wanting any “mind-altering” medications), it may be useful to “medicalize” the psychiatric disorder and note that common medical conditions involve attention to biopsychosocial treatment.¹² For example, few people would refuse medications for treatment of hypertension, even though it may be clear that the condition is exacerbated by stress and lifestyle. The same may be said for the treatment of asthma, migraines, diabetes, and peptic ulcers. In this light, the clinician can refer to psychiatric conditions as problems of “chemical imbalances”—a neutral term—or as problems with the brain, an organ people often forget when talking about “mental” conditions. A candid dialogue in this way, perhaps describing how depression or panic disorder involves abnormalities in brain function, may help. It should be noted that this kind of discussion should in no way be construed or interpreted as pressure—rather as an educational experience. Letting the patient know that treatment decisions are collaborative and patient-centered is absolutely essential in a discussion of this order.

THE EVALUATION OF CHILDREN AND ADOLESCENTS

Psychiatric disorders in children and adolescents will be discussed elsewhere in this book. In general, children and adolescents pose certain unique issues for the psychiatric interviewer. First, a complete developmental history is required. For younger children, most of the history is taken from the parents. Rarely are young children seen initially apart from parents. Observation of the child is critical. The examiner should notice how the child relates to the parents or caregivers. Conversely, it is important to note whether the adult’s management of the child is appropriate Does the child seem age appropriate in terms of motor function and growth? Are there any observable neurological impairments? The evaluator should determine whether speech, language, cognition, and social function are age appropriate. The office should have an ample supply of toys (including a dollhouse and puppets for fantasy play, and building blocks or similar toys), board games (for older school-age children), and drawing supplies. Collateral information from the pediatrician and schoolteachers is critical to verify or amplify parental and child-reported data.

Adolescents produce their own set of issues and problems for the interviewer.²⁸ A teenager may or may not be brought in by a parent. However, given the developmental processes that surround the quests for identity and separation, the interviewer must treat the teen with the same kind of respect and collaboration as with an adult. The issue and importance of ensuring confidentiality have been mentioned previously. The adolescent also needs to hear at the outset that the interviewer would need to obtain permission to speak with parents or guardians, and that any information received from them would be faithfully transmitted to the patient.

Although all the principles of attempting to establish a secure attachment noted previously apply to the adolescent, the interview of the adolescent is quite different from that of an adult. Developmentally, teenagers are capable of abstract thinking and are developmentally becoming increasingly autonomous. At the same time, they are struggling with grandiosity that alternates with extreme vulnerability and self-consciousness and managing body image, sexuality and aggression, mood lability, and occasional regression to dependency—all of which makes an interview and relationship difficult. The interviewer must constantly consider what counts as normal adolescent behavior and what risk-taking behaviors, mood swings, and impulsivity are pathological. This is not easy, and typically teenagers need a few initial meetings for the clinician to feel capable of co-creating a narrative—albeit a narrative in progress. The stance of the clinician in working with adolescents requires moving in a facile fashion between an often needed professional authority figure and a big brother or sister, camp counselor, and friend. The examiner must be able to know something about the particular adolescent’s culture, to use humor and exaggeration, to be flexible, and to be empathic in the interview, yet not attempt to be “one of them.” It is essential to validate strengths and weaknesses and to inspire self-reflection and some philosophical thinking—all attendant with the new cognitive developments since earlier childhood.