Chapter 4: The Psychiatric Interview

INTRODUCTION

Human behavior is complex¹. When it becomes dysfunctional because of environmental stress or brain disease, it can mystify the inexperienced clinician. This is especially true of neurobehavioral disorders, which involve neuropsychiatric changes in cognition and emotion that overlap the boundary of psychiatry and neurology. The clinician must appreciate and assess the signs and symptoms of neurobehavioral disorder with the same discernment as in physical syndromes such as myocardial infarction or infectious disease.

This chapter describes the psychiatric history and mental status examination (MSE), in the conduct of an effective psychiatric interview. The steps of the interview process are described along with the techniques the clinician must master in order to elicit information relevant to a diagnostic formulation in an orderly, reliable, and comprehensive manner. The components of the psychiatric history and the MSE are described in accordance with the stages of the interview during which they would usually be obtained.

What can be achieved at the initial psychiatric interview? The outcome depends on the situation in which it is conducted and what the physician and the patient are seeking. For example, a brisk, focused interview in an emergency room contrasts with the more extensive survey appropriate to an outpatient clinic. Both types of interview differ from what is possible at the bedside of a patient who is severely ill in a medical or surgical ward. Despite these observations, fundamental issues can be addressed to varying degree in any clinical situation, as illustrated in Table 4–1. We return to these issues in our discussion of the elements of the psychiatric history.

THE STAGES OF THE PSYCHIATRIC INTERVIEW

Inception

If the interviewer works in a clinic, at the opening of the psychiatric interview he or she goes to the waiting room, introduces himself or herself to the patient, accompanies the patient to the interview room, and shows him or her to a seat. After taking identifying data from the patient, the interviewer can tell the patient what he or she already knows. This approach avoids unnecessary mysteries and clears the way for action. Consider the following example:

• Psychiatrist: Your parents came to see me yesterday. They told me they're worried because your schoolwork has fallen off, although you've always been a good student; you've dropped most of your friends; and you seem ...