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Chapter 1. The Psychiatric Interview and Mental Status Examination

Linda B. Andrews, M.D.
DOI: 10.1176/appi.books.9781585623402.290000

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An effective psychiatric interview allows the clinician both to connect with a patient and to gather pertinent data. Although medical technology has advanced tremendously and has increased the amount of laboratory and neuroimaging information available to assist psychiatrists in making more accurate diagnoses and developing more specific treatment plans for patients, these tests cannot supplant the importance of gathering critical data via the traditional psychiatric interview. The psychiatric interview is the single most important method of arriving at an understanding of a patient who exhibits the signs and symptoms of a psychiatric illness (Scheiber 2003). Patients usually communicate the most important aspects of their illnesses to their physicians during the doctor–patient interview. The psychiatrist listens and then responds to the patient in an effort to understand the patient's problems in the context of the patient's culture and environment (MacKinnon and Yudofsky 1991; MacKinnon et al. 2006). The psychiatric interview is similar to the general medical interview in that both include the patient's chief complaint, history of present illness, past history, social and family history, and review of systems. However, the psychiatric interview differs from the traditional medical interview because the psychiatric interview also includes a more thorough examination of the patient's developmental history, including the patient's feelings about significant life events and exploration of the patient's significant interpersonal relationships, patterns of adaptation, and character traits (MacKinnon et al. 2006; Scheiber 2003). The psychiatric interview includes a formal examination of the patient's mental status as well.

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TABLE 1–1. Tasks for the therapist conducting a psychiatric interview
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TABLE 1–2. Outline of the psychiatric interview
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TABLE 1–3. Outline of the mental status examination
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TABLE 1–4. Steps in developing a diagnostic formulation and treatment plan
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TABLE 1–5. DSM-IV-TR multiaxial assessment and differential diagnosis
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Establish rapport and communicate respect. Introduce yourself, use patient's name, make eye contact, and limit interruptions.

Use empathic connection to guide and adjust interview to match the particular patient and situation. Follow the patient's leads or cues whenever possible and use open-ended questions to increase depth of understanding and information gathered (fewer topics covered, greater depth). Use focused questions to increase breadth of understanding and information gathered (more topics covered, less depth). Increase focus of questions for patients with disturbances of thought content or production, perceptual disturbances, or cognitive deficits. Abbreviate the interview for acutely agitated, dangerous, or medically compromised patients. Use words that the patient can understand—avoid medical jargon; assess the patient's education, language, and cultural needs; and use a translator when necessary. Clarify and verify that the patient understands you and that you understand the patient.

Assess the patient's safety, including assessment of suicide risk in every patient. Assess dangerousness early and often during an interview with a potentially dangerous patient.

Take notes to record necessary data, but do not let note taking interfere with your ability to establish and maintain rapport with the patient. Review available medical records and test results before completing your assessment and developing your treatment plan. Interview other relevant persons in the patient's life.

Cover all key elements of the psychiatric history and mental status examination. Psychiatric history includes chief complaint, history of present illness, past psychiatric history, past medical history, social history, developmental history, family psychiatric and medical history, and review of systems. For the mental status examination, observe or assess the following aspects of behavior and thought: general appearance; orientation; speech; motor activity; affect and mood; thought production; thought content; perceptual disturbances; suicidal or homicidal ideation; attention, concentration, and memory; abstract thinking; and insight/judgment.

Formulate the data gathered during psychiatric interview and develop a biopsychosocial formulation and a thorough differential diagnosis, including information for all five DSM-IV-TR axes. Develop a treatment plan that includes appropriate biological, psychological, and social interventions and considers the patient's overall prognosis. Ensure that the patient understands the treatment goals and plan, and verify that the patient can afford the treatment recommendations. Document if the patient refuses treatment. Establish follow-up plans (e.g., next appointment, tests to complete).

References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000
 
Folstein MF, Folstein SE, McHugh PR: "Mini-Mental State": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198, 1975
[PubMed]
 
Gabbard GO: Long-Term Psychodynamic Psychotherapy. Washington, DC, American Psychiatric Publishing, 2004
 
Kassaw K, Gabbard GO: Creating a psychodynamic formulation from a clinical evaluation. Am J Psychiatry 159:721–726, 2002
[PubMed]
 
MacKinnon RA, Yudofsky SC: Principles of the Psychiatric Evaluation, 2nd Edition. Philadelphia, PA, JB Lippincott, 1991
 
MacKinnon RA, Michels R, Buckley PJ: The Psychiatric Interview in Clinical Practice, 2nd Edition. Washington, DC, American Psychiatric Publishing, 2006
 
Perry S, Cooper AM, Michels R: The psychodynamic formulation: its purpose, structure and clinical application. Am J Psychiatry 144:543–551, 1987
[PubMed]
 
Scheiber SC: The psychiatric interview, psychiatric history, and mental status examination, in The American Psychiatric Publishing Textbook of Clinical Psychiatry, 4th Edition. Edited by Hales RE, Yudofsky SC. Washington, DC, American Psychiatric Publishing, 2003, pp 155–188
 
Vergare MJ, Binder RL, Cook IA, et al: Practice guideline for the psychiatric evaluation of adults, 2nd Edition. Am J Psychiatry 163:1–36, 2006
 
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Sample questions:
1.
The first and probably most important task of the psychiatric interview is. . .
2.
It is usually best to begin the psychiatric interview. . .
3.
Which of the following is not a component of the mental status examination?
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