Psychosis Interview

Essential Concepts

In acute settings, you are most concerned if active psychosis is present (on cross-sectional review); in other settings, a history of psychosis becomes as important (in longitudinal 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.
To establish a history of psychosis, rely on collateral information, not on patient recollection alone.
Uncharacteristic personality change (e.g., social withdrawal, neglect of hygiene) can indicate covert psychosis.
Consider malingering when supposed psychopathology is unconvincing.

“You can see a lot by observing.”

—Yogi Berra, baseball Hall of Famer, 1972

The great divide in psychiatric nosology between psychotic and nonpsychotic disorders makes identification of psychosis crucial for accurate differential diagnosis and proper treatment selection. Any psychiatric interview must, therefore, accomplish one thing: Ascertain with a reasonable degree of certainty that psychosis is either present or absent, both now and in the past. This chapter is not a comprehensive guide to the psychiatric interview but focuses on this aspect of the interview.

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. I always show patients my hospital ID tag (for the obvious problems with spelling and pronunciation of my name). 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, if this is possible. 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, ask 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 EXAMINATION

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 of brain malfunction at the time of the examination (this is often done incorrectly, e.g. hallucinations heard earlier are recorded in the 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.

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 surroundings?
What is he or she wearing? If somebody wears a T-shirt that says “Swabia Rules,” ask about it!

TABLE 2.1. Suggested Format for the Mental Status Examination

Appearance, attitude, and behavior (including psychomotor abnormalities)

Affect and mood

Speech and thought process

Perception and thought content (psychosis, obsessions, SI, HI)

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

Insight and judgment

SI, suicidal ideation; HI, homicidal ideation.

Do not interrupt a patient who talks spontaneously, but simply listen. You need a good speech sample to judge speech and thought process. Interrupt politely yet firmly the rambling and disorganized patient who needs structure, once you have a first impression: “I have to interrupt you here and switch topics, if that’s OK with you. We have not talked about your family.” A patient’s wallet and pockets 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?

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