Interview

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© Springer Nature Switzerland AG 2020
O. FreudenreichPsychotic DisordersCurrent Clinical Psychiatryhttps://doi.org/10.1007/978-3-030-29450-2_2



2. Psychosis Interview



Oliver Freudenreich1 


(1)
Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA

 


Keywords

Mental status examLongitudinal historyCollateral informationCase presentationDiagnostic mistakesMalingering



Essential Concepts






  • In acute settings, you are most concerned if active psychosis is present (on cross-sectional symptom review); in other settings, a history of psychosis becomes as important (on longitudinal symptom review).



  • Think of the entire patient interview as the mental status examination (MSE); you get data from observing and listening, supplemented by direct questioning about inner experiences and cognition.



  • Approach psychotic experiences obliquely and with sensitivity. For many patients, those experiences are confusing and frightening.



  • To establish a history of psychosis, rely on collateral information, not on patient recollection and interpretation alone.



  • As you are collecting information, keep in mind that you may need to present your findings to somebody else. The most effective way to present a case is by telling a coherent story, with a beginning, a middle, and an end, perhaps with the help of a timeline drawn on a whiteboard.



  • Uncharacteristic personality changes (e.g., social withdrawal, neglect of hygiene, easy irascibility) can indicate covert psychosis.



  • Consider malingering when supposed psychopathology is unconvincing.




You can observe a lot by watching.


-Yogi Berra, baseball Hall of Famer, 1972 [1]


The great divide in psychiatric nosology between psychotic and nonpsychotic disorders makes identification of psychosis crucial for accurate differential diagnosis and treatment selection. Any psychiatric interview must, therefore, accomplish one thing: ascertain with a reasonable degree of certainty that psychosis is either present of absent, both now or in the past. This chapter is not a comprehensive guide to the psychiatric interview but focuses solely on this critical interview goal, including how to cohesively present the information you obtained to a supervisor. Other goals of the interview (e.g., judging dangerousness) are covered in separate chapters.


The First Few Minutes


Prepare for the patient encounter, and review records that accompany the patient before you see him or her. Otherwise, you might never touch on the main reason for the patient’s presentation and completely miss the boat.


Clearly introduce yourself and describe your role. I always show patients my hospital ID tag (also for the obvious problems with spelling and pronunciation of my last name). With an outpatient, engage in some small talk on the way to your office (“Did you have trouble finding my office, finding parking?”) to put patients at ease. After you sit down, an open-ended question that puts the ball in the patient’s court is often the best way of starting: “What is the purpose of the visit with me?” or “How can I help you today?” To patients whose arms were twisted to come in, pose the question “Whose idea was it to come here today?” followed by “Does your family, the police have a point?” and “What is your side of the story?”


Looking for Current Psychosis: History and the Mental Status Exam


The MSE (Table 2.1) can be considered the equivalent of the physical examination in medicine, with the organ under examination being the mind/brain. Just like the physical examination, the MSE is a cross-sectional record of signs and symptoms of mind/brain malfunction at the time of the examination (this is often done incorrectly, e.g., hallucinations heard earlier, before the time of the MSE are recorded in the current MSE – they should be noted in the history). In contrast to the physical examination, the MSE begins with the patient encounter and is interwoven with the history taking [2]. In interpreting your exam, always take into account native language, culture, and education [3].


Table 2.1

Key components of the mental status examination


















Appearance, attitude, and behavior (including eye contact and psychomotor abnormalities)


Affect and mood


Speech and thought process


Perception and thought content (delusions, overvalued ideas, obsessions; SI, HI)


Sensorium and cognition (awareness and orientation; attention and memory; intelligence)


Insight and judgment



SI suicidal ideation, HI homicidal ideation


Data You Get from Observation


Observe your patient unobtrusively; I usually get patients from the waiting area myself so I can walk with them to my office. Is the patient laughing to himself or herself while waiting? Preoccupied and nervous? Paying attention to the surrounding or apathetic?



Tip


Note what a patient is wearing. If a patient wears a T-shirt that says “Swabia Rules,” ask about it! Also note tattoos. Tattoos are the “bumper stickers of the soul,” ask about the story behind the tattoos.


A patient’s wallet, pockets, and purse can be windows to his or her functioning. Where does he or she put the prescriptions you wrote? How long does it take the patient to write down the new appointment date on a piece of paper or type into the smart phone?


Do not interrupt a patient who talks spontaneously, but simply listen. You need a good speech sample to judge speech and thought process. However, interrupt politely yet firmly the rambling and disorganized or the overinclusive patient who needs structure, once you have a first impression: “I have to interrupt you here and switch topics, if that is OK with you. We have not talked at all about your family.” Do not call a patient a “poor historian,” but try to understand his life story. It is not the patient’s but your job to structure the interview and (re-)interpret the story as told from the patient’s perspective so it makes sense psychiatrically.


Data You Need to Inquire About


Although you can sometimes deduce your patient’s inner experiences from behavior (e.g., patient is yelling back at voices), you usually have to inquire about them specifically.



Tip


To screen for psychosis, I ask every patient two questions: “Have you ever had the sense that your thoughts were not private?” and “Have you noticed any coincidences lately?” The first question gets at audible thoughts and thought broadcasting or related experiences, the second at ideas or delusions of reference.


With patients in whom I suspect a psychotic illness, I always go through a complete list of psychotic symptoms and tell patients that I will ask them about experiences they might or might not have had. “If this has never been your experience, simply say no.” Table 2.2 provides a list of questions that are helpful in “sniffing out” psychosis. The two most unhelpful questions that you might as well skip are, “Do you hear voices?” and “Are you paranoid?” You need to approach the symptoms of psychosis more obliquely. Referring to hallucinations as “thoughts” is less threatening than referring to “voices.” Similarly, using vague langue (“they” or “it”) initially helps to get patients comfortable.


Table 2.2

Sniffing out psychotic symptoms










































Paranoia


 Do you trust people, or do you think that it is better not to? Do you have reasons for not trusting easily?


 Do people have tried on purpose to hurt you? Does it feel at times like everyone or somebody is against you or is trying to get you in trouble? Are people obstructing you?


 Do you sometimes feel that people/parents/family spend too much time watching you or monitoring you? Do they ever put microphones or cameras in your room for instance?


Hallucinations


 Does it ever happen to you to see something from the corner of your eyes and when you turn around, it is not there? Like a shadow or a shape or more elaborate images?


 Does your mind or your ears play tricks on you? Does your mind come up with weird ideas? Like what?


 Do you ever worry that your mind is going crazy? What makes you think so? Is it scary?


 Do you ever have thoughts that pop into your head out of nowhere, at times telling you what to do or making comments about you or people around you?


 Does it ever happen to you that you seem to hear a noise, footsteps, or even your name being called and when you look around, there is no one there? Do you hear sometimes someone muttering something that you cannot quite understand? Does this tell you what to do or is making comments about people around you, that sometimes make you want to laugh? Are those thoughts pleasant or helpful like warning you about danger or about not trusting some people? Or do they keep you company or seem comforting to you?


 Do they tell you what to do? Is it hard to resist?


 Do you sometimes feel like there is an argument in your mind with one side saying one thing and the other the opposite? Does it consume a lot of your time?


Schneiderian first-rank symptomsa


 Do you ever have a sense that people can read your mind like a book or hear your thoughts?


 Do you ever sense that your actions are not yours?


Delusions


 Do sometimes people make fun of your beliefs or of your view on politics or on the way the world works? Give me an example.


 Do you find difficult to share your thoughts and understanding about the way the system works with others because people would not understand?



Courtesy of Dr. Michel Mennesson


aSee Table 1.​3 for a longer list of useful questions to elicit Schneiderian first-rank symptoms

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Aug 14, 2021 | Posted by in PSYCHIATRY | Comments Off on Interview

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