PSYCHIATRIC INTERVIEW, HISTORY, AND MENTAL STATUS EXAMINATION Kaplan & Sadock’s Comprehensive Textbook of Psychiatry CHAPTER 7. DIAGNOSIS AND PSYCHIATRY: EXAMINATION OF THE PSYCHIATRIC PATIENT 7.1 PSYCHIATRIC INTERVIEW, HISTORY, AND MENTAL STATUS EXAMINATION

thinking: Somewhat concrete; similarities: apple/orange—“both fruits”; poem/statue —“both have form”; fly/tree—“both are nature, both are iridescent green, flies fly around crap, which is brown, the same color as tree bark” Insight: Poor. The patient does not recognize the presence of any illness or that his behavior is dangerous, stating, “Maybe I have a very mild case of mania, but if I need to be here, then 90 percent of everyone in the world needs to be locked up.” He initially refused to take medication and repeatedly says he doesn't need to be “locked up,” that he can take care of his minor relationship problems as an outpatient. He calls his drinking “minimal” and doesn't realize that it precipitates dangerous, self-destructive behavior. Judgment: Fair. He cooperates with staff even though he doesn't think he needs hospitalization because he fears that a history of involuntary commitment would make it difficult for him to realize his goal of becoming a teacher. He says that the next time he is angry with his boyfriend, he will “work it out,” and not try to kill himself. file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (17 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm TECHNIQUES FOR THE PSYCHIATRIC ASSESSMENT The psychiatrist wants not only to ask the questions necessary for formulating a differential diagnosis, but also to establish rapport and create an atmosphere of confidence and trust. Relaxed and trustful patients are more likely to provide useful information than those who are nervous or on guard. Time and Setting The initial psychiatric assessment usually lasts between 45 and 90 minutes, with the length of time agreed upon in advance. Sometimes additional time is necessary to complete the evaluation, in which case it is better to schedule an additional session. Extending the length of the first session unilaterally is a discourtesy to the patient whose time may be scheduled with other demands, and it risks fatigue for both parties. In addition seeing the patient at different times helps to determine more accurately which presenting features are purely situational and how they have changed with time. The evaluation should be conducted in a comfortable room with pleasant lighting. While there is no reason to make the room impersonal, dramatic paintings, panoramic views, or expensive antiques may be distracting to a patient during a first visit. The psychiatrist should budget the full amount of time allotted for the interview and attempt to ensure that there are no interruptions during the session. Routine phone calls and messages should be intercepted by an answering machine or secretary. A comfortable waiting area should be provided for patients who arrive early. Many psychiatrists prefer to have the patient's and examiner's chairs of relatively equal size and height to minimize any sense of intimidation. Interview The psychiatrist should have in mind the categories of information needed and their structural organization in the summary evaluation. However, it is seldom useful to proceed with a prescribed check-list of questions. Rather, the interview should be shaped as it progresses, with the psychiatrist's knowledge of psychopathology used to ask detailed or probing questions about significant issues as they emerge. It is often best to begin with a general, open-ended question (e.g., “How can I help you?” or “What brings you here today?”) and to allow the patient to talk freely for several minutes before interposing further questions. However, the psychiatrist must keep in mind the information needed to formulate a diagnosis and treatment plan and be prepared to structure the interview more tightly if the patient appears to be vague and rambling. If a patient talks on with no pauses or natural endings, it may be necessary to interrupt and redirect. This can be done with courtesy and minimal disruption. For example, the psychiatrist might say, “Excuse me for interrupting, but I'd like to come back for a moment to the trouble you mentioned having had with sleep. How many hours of sleep did you get last night?” Open-Ended and Closed-Ended Questions Open-ended questions ask the patient to speak spontaneously with relatively little structure or organization imposed by the examiner (e.g., “Tell me about your growing up”). Closed-ended questions on the other hand ask for factual answers to specific questions. (e.g., “How far did you go in school?”) Open-ended questions are commonly associated with psychodynamic interviewing and closed-ended questions with phenomenologic-descriptive diagnostic interviewing; this is an unhelpful oversimplification. A skillful diagnostic interview uses both types of questions. It is often useful to begin the interview with broad open-ended questions and to become more closed-ended and directive as the interview progresses. file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (18 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm There are a number of advantages in starting with open-ended questions: the content is less limited by the examiner's preconceptions, disorders of thought form are more likely to be revealed in spontaneous speech than in twoor three-word answers, and emotional responses may be more obvious. In addition, many patients prefer to tell their stories with their own words and emphases without interruption. Other patients, such as those who are psychotic, depressed, or paranoid, may need more structured questions. Closed-ended questions are particularly useful in clarifying information, in gathering factual data efficiently, and in describing the absence of key symptoms. Patients are unlikely to spontaneously describe what does not exist. Supportive and Obstructive Interventions Psychiatrists do much more during an interview than ask questions. They provide feedback and information, offer reassurances, and respond emotionally to what the patient is saying. The psychiatrist's facial expression and body posture (correctly or erroneously) conveys information to the patient. Interventions may be classified as supportive or obstructive depending on the extent to which they increase the flow of information and enhance or diminish rapport. Interventions classified as supportive include Encouragement. Patient: I am not very good at putting things into words. Doctor: I think you have described the situation very well. Reassurance. Doctor: I can understand how those experiences must have frightened you, but I think it is very likely they'll respond to treatment. Acknowledging emotion. Doctor: Even now it brings tears to your eyes when you talk about your mother. Nonverbal communication. Body posture and facial expression that convey interest, concern, and attentiveness. Interventions classified as obstructive include Compound questions. Doctor: Have you experienced any change in your appetite and sleeping? Judgmental questions. Doctor: How do you think your wife felt when she found out about your affair? Why questions. Doctor: Why do you feel anxious when you go outside? Not following the patient's lead. Patient: I have trouble sleeping through the night. Doctor: Any change in appetite? file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (19 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm Patient: I keep waking up out of nightmares about my daughter. Doctor: Do you have less energy than usual? Minimization or dismissal. Patient: I'm not able to keep my checkbook balanced the way I need to. Doctor: Oh, I wouldn't worry about it. Lots of people don't even try. Premature advice. Patient: Work is almost unbearable. My supervisor watches me like a hawk and criticizes the tiniest little mistake I make. Doctor: Why not write her a memo and outline your grievances?” Nonverbal communication. Yawning, checking one's watch. Patients can often detect an interviewer's inattention by the absence of facial expression or body movement. Psychiatric interviewing is a complex, multifaceted task that is shaped by the personalities and circumstances of the interview. The concept of supportive and obstructive interventions has broad, general use but cannot be applied rigidly. There are circumstances in which an intervention that would be obstructive with other patients may be helpful or even necessary. For example, although it is usually most helpful to follow the patient's lead, the psychiatrist interviewing a hypochondriasis patient or a depressed patient with somatic concerns may need to ignore or interrupt perseveration about physical symptoms and redirect the interview to other topics. In addition, at times the psychiatrist may appropriately ask patients how their misdeeds are perceived by others (a judgmental question) to test empathy. Interpreting Behavior During an Initial Diagnostic Interview The psychoanalytic techniques of interpretation and clarification should be used minimally if at all during an initial diagnostic assessment. The psychiatrist is unlikely to have enough information to make accurate interpretations. Moreover, the context of a trusting long-term relationship that facilitates acceptance of interpretations will be lacking. Patients who arrive late for the session may well be manifesting anxiety or ambivalence or may equally well have been delayed by circumstances beyond their control. Rather than interpreting the lateness, the psychiatrist would do better to express regret at the late start and offer sympathetic understanding to the patient for the problems causing the lateness. Separately, the psychiatrist can ask whether the patient was nervous or had mixed feelings about coming for the evaluation. An exception to the rule against interpretations in the first session is the patient for whom a psychodynamic psychotherapy may be recommended. The psychiatrist may then want to evaluate the patient's response to a gentle test probe to assess suitability for psychodynamic work. file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (20 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm A 28-year-old woman who asked to start therapy with a psychoanalytic psychiatrist missed her first session. At the second session she reported that she simply forgot the appointment. The psychiatrist asks, “Is it possible that you let yourself forget on purpose?” The woman laughs and says, “Well to tell you the truth, it's really my boyfriend whose been pushing me to start therapy; I'm not so sure. Do you think it's a good idea?” Recording and Note Taking Electronic recording of sessions is seldom necessary and is often detrimental. Patients become self-conscious and guarded when their every word is being recorded. Many patients are concerned about the uses to which the recordings will be put and are rightfully concerned about potential abuses. Few patients are likely to feel comfortable knowing that their sometimes critical comments about another person or intimate discussion of private issues might be heard by anyone other than the evaluating psychiatrist. Recordings must never be made without the patient's knowledge and consent. Psychiatrists vary in the extent to which handwritten notes are taken during a session. Some examiners take no notes at all during the evaluation and then write a summary after the patient has gone. They argue that note taking is a distraction to both psychiatrist and patient, that it becomes a barrier to subtle emotional observation and understanding, and that some patients become preoccupied by what is being written down, thus contaminating what they say. By not taking notes during the interview they train themselves to remember better the details of the session. They point out that when they do rely on notes they are unlikely to remember anything that was not written down. Other psychiatrists take almost continuous notes. They believe it is possible to do so unobtrusively and that it provides subtle reassurance to patients about the seriousness with which the examiner is taking their statements. The result, they believe, is a more accurate record, not vulnerable to the distortions of memory. Still other psychiatrists take notes selectively, when they believe that accurate and detailed documentation is necessary (e.g., a complicated history of previous medication treatments and variable responses). Individual psychiatrists develop techniques that work well for them, but they must remain mindful of the impact their individual decisions have on the ability to get useable information. Flexibility and common sense must not be lost. It would be destructively unfeeling for a psychiatrist to continue note taking in the middle of an intense emotional moment with the patient sobbing. Requests by the patient that notes not be taken may be explored but should always be respected. Whether or not notes are taken during the session, psychiatrists have a medical and legal obligation to maintain a written record of every patient encounter. Such records document that the encounter occurred and that the assessment was complete. The record contains the historical and mental status data on which a diagnosis and treatment recommendations are based. The physician describes in detail all treatment recommendations and other advice given. (Psychiatrists should also routinely compile written descriptions of all telephone exchanges with patients. This is particularly important if the telephone file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (21 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm exchange includes a change in treatment.) It is helpful to keep in mind the legal rule of thumb: “If it isn't written down, it didn't happen.” Special Problems in Interviewing PSYCHOTIC PATIENTS Patients with psychotic symptoms have difficulty thinking clearly and reasoning logically. Their ability to concentrate may be impaired, and they may be distracted by hallucinations and delusional beliefs. Psychotic patients are often frightened and may be quite guarded. Quite often, the evaluation of a patient with psychotic symptoms needs to be more focused and structured than that of other patients. Open-ended questions and long periods of silence are apt to be disorganizing. Short questions are easier to follow than long ones. Questions calling for abstract responses or hypothetical conjectures may be unanswerable. For patients with hallucinations, the full phenomenology of the hallucination should be explored. The patient is asked to describe the sensory misperception as fully as possible. For auditory hallucinations this includes content, volume, clarity, and circumstances; for visual hallucinations, this includes content, intensity, the situations in which they occur, and the patient's response. The evaluator should distinguish between true hallucinations on the one hand and illusions, hypnagogic and hypnopompic hallucinations, and vivid imaginings on the other. Hallucinations are perceived as real sensory stimuli and should not be dismissed as fanciful; however the psychiatrist should ask questions about their fixity and the patient's level of insight. “Does it ever seem that the voices are coming from your own thoughts?” or “What do you think is causing the voices?” Delusions by definition are fixed, false beliefs. Delusional patients often come to psychiatric evaluation having had their beliefs dismissed or belittled by friends and family. They will be on guard for similar reactions from the examiner. It is possible to ask questions about delusions without revealing belief or disbelief (e.g., “Does it seem that people are intent on hurting you?” rather than, “Is there a plot to hurt you?”). Careless use of psychiatric jargon should be avoided, particularly in evaluating delusions. Words such as grandiose, paranoid, and indeed the word delusion itself will seem harsh and judgmental and are unlikely to be helpful in eliciting information. Many psychiatrists have found that patients can speak more freely when asked to talk about the accompanying emotions rather than the belief itself (“It must be frightening to think there are people you don't know who are plotting against you.”) Although the psychiatrist does not attempt to reason them away, a gentle probe may determine how tenaciously the beliefs are held (“Do you ever wonder whether those things might not be true?”). Patients with paranoid delusions (and patients with high levels of nondelusional suspiciousness) are best evaluated with a respectful, but somewhat distant, formality and with scrupulous honesty. Efforts to reassure or ingratiate often increase suspicion. The psychiatrist must keep in mind the possibility of being incorporated into a delusional belief and should ask about it directly (“Are you concerned that I might try to hurt you?”). Disorders of thought form can seriously impair effective communications. The evaluating psychiatrist file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (22 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm should note formal thought disorders while minimizing their adverse impact on the interview. When derailment is evident, the psychiatrist typically proceeds with questions calling for short responses. For a patient experiencing thought-blocking, the psychiatrist needs to repeat questions, remind the patient of what was already said, and in general provide an organization for thinking that the patient is unable to provide. DEPRESSED AND POTENTIALLY SUICIDAL PATIENTS Severely depressed patients may also have difficulty concentrating, thinking clearly, and speaking spontaneously. The intensity of mood disturbance can seem all consuming and may well lead to distortions in thinking and perception. Some depressed patients will have psychotic symptoms in addition to cognitive difficulties. The psychiatrist evaluating a depressed patient may need to be more forceful and directive than usual. It will sometimes seem that the examiner must provide all the emotional and intellectual energy for both participants. Although depressed patients should not be badgered, long silences are seldom useful, and the examiner may need to repeat questions more than once. Ruminative patients—for example, those who continually repeat how worthless or guilty they are—will need to be interrupted and redirected. All patients must be asked about suicidal thoughts. Depressed patients may need to be questioned more fully. A thorough assessment of suicide potential addresses intent, plans, means, and perceived consequences as well as history of attempts and family history of suicide. Many patients will mention their thoughts of suicide spontaneously. If not, the examiner can begin with a somewhat general question such as, “Do you ever have thoughts of hurting yourself?” or “Does it ever seem that life isn't worth living?” These can then be followed up with more specific questions. The examiner must feel comfortable enough to ask simple, straightforward, noneuphemistic questions. Asking about suicide does not increase the risk. The psychiatrist is not suggesting a course of action the patient has not already contemplated. Specific, detailed questions are essential for prevention. Intent The examiner must determine the seriousness of the wish to die. Some patients report that they wish they were dead but would never intentionally do anything to take their own lives. This level of intent is often referred to as passive suicidal ideation. Other patients express greater degrees of determination. Near the other end of the spectrum of intent is the patient who says, “I've decided I have to kill myself and nothing you can say or do will change that.” At the most extreme level of determination are the patients most difficult to help, those who tell no one about their suicidal plans and proceed in a deliberate, systematic manner. It is also useful to ask about restraining influences, both internal and external (e.g., “Do you worry that you might not be able to resist those impulses?” or “How have you been able to keep from hurting yourself so far?”). Patients with auditory hallucinations commanding then to kill themselves often describe the hallucinations as irresistible despite any real desire to die. Plans Patients with well-formulated plans are generally at greater risk than patients who don't know what they would do, but the method of suicide is not always a reliable indication of the risk. Even though some actions such as jumping or shooting are much more likely to be fatal than others, patients make mistakes. A pill overdose taken at the time a spouse is expected to arrive home may become deadly if the spouse is delayed in traffic. The psychiatrist should also ask about preparatory actions such file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (23 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm as giving away goods or putting one's estate in order. Means Asking patients about the intended means of suicide is helpful in two ways. First it clarifies the urgency of the situation; persons wanting to shoot themselves who have a loaded gun at home are more dangerous than those who have no idea where to find a gun. Second, the understanding of intent is sharpened by knowing whether a patient has thought through the steps necessary to carry out the action. Perceived Consequences Patients who see something desirable resulting from their deaths are at increased risk for suicide. A reunion fantasy, the belief that a person will be reunited with a deceased loved one, may be a powerful motivating force toward suicide. On the other hand, some potentially suicidal patients are restrained by what they see as negative consequences (e.g., “My children need me too much; they'd never be able to get along without me,” or “I couldn't hurt myself. My parents would never get over their grief.”). The psychiatric history and the family history for all patients, even those not currently suicidal, should mention any previous suicide attempt or suicides by family members. Both circumstances are recognized to increase the current risk, even if previous attempts were thought to be superficial. At times treatment must take precedence over evaluation. In rare circumstances the threat of suicide is so imminent that immediate action must be taken to hospitalize the patient. Even during a first evaluation session, the psychiatrist must be prepared to make whatever professional response is necessary to safeguard the well-being of the patient. AGITATED AND POTENTIALLY VIOLENT PATIENTS Whether in a private office or a psychiatric emergency room, psychiatrists sometimes find themselves interviewing potentially violent patients. In these circumstances, the task is twofold: to conduct an assessment but also to contain behavior and limit the potential for harm. Most unpremeditated violence is preceded by a prodrome of accelerating psychomotor agitation. The patient may begin pacing and pounding the fist in a hand. Speech may become loud, abusive, obscene, and threatening. The temporal arteries may begin to throb. Researchers and clinicians in emergency psychiatry suggest that the prodrome may last from 30 to 60 minutes before erupting into physical violence. Thus the psychiatric evaluator has both early signals of impending violence and a period of time in which the agitation may be quieted. Several steps can be taken to minimize the agitation and potential risk. The interview should be conducted in a quiet, nonstimulating environment. There should be enough space for the comfort of both patient and psychiatrist, with no physical barrier to leaving the examination room for either of them. During the interview, the psychiatrist should avoid any behavior that could be misconstrued as menacing: standing over the patient, staring, or touching. The psychiatrist must ask the questions necessary to complete an adequate evaluation but must attempt not to be provocative. It is certainly appropriate to allow the patient to drink water, use a bathroom, and, file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (24 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm for extended evaluations in an emergency room, eat food. However, these should never be offered as bargaining chips (“I'll let you get a drink of water if you'll tell me what happened just before the police brought you here.”) The examiner must also avoid promising outcome in exchange for cooperation (“If you'll just talk with me for another half hour, I'll make sure you don't have to go into the hospital.”) The psychiatrist should ask whether the patient is carrying weapons and may ask the patient to leave the weapon with a guard or in a holding area. The psychiatrist should not request that patient hand over any weapons. Dangerous mishaps can occur during the transfer; moreover, the sudden shift in power created by an armed psychiatrist may feel extremely threatening to paranoid patients. If the patient's agitation continues to increase, the psychiatrist may need to terminate the interview. Depending on the setting, assistance from security personnel, physical, or chemical restraints may be appropriate. The physician's own subjective sense of comfort or fear should be heeded. A frightened, intimidated examiner may be incapable of an accurate professional evaluation. PATIENTS FROM DIFFERENT CULTURES AND BACKGROUNDS Differences in race, nationality, and religion and other significant cultural differences between patient and interviewer can impair communication and lead to misunderstandings. Despite its widespread use throughout the world, the possible cultural biases of DSM-IV are still being debated; for example, the distinctions between mood disorders and somatoform disorders appear less valid in some countries than in the United States. In addition, it may be difficult for a culturally naive psychiatrist to evaluate symptoms that are relative rather than absolute. There is usually no difficulty in documenting the presence of auditory hallucinations regardless of cultural differences. However, assessing whether or not a delusion is “bizarre” (as required by DSM-IV for delusional disorder) is more difficult because “bizarre” has meaning only in reference to cultural norms. The belief by East Africans in the direct intervention of ancestral spirits in the day-to-day life of individuals is commonplace. The chief executive officer of an American corporation who announces that he will divest the company of two subsidiaries because of signals he received that morning from ancestral spirits will be thought exceedingly bizarre by colleagues and shareholders. Personality disorders, whose criteria are preponderantly relative rather than absolute (e. g., “shows arrogant, haughty behaviors or attitudes”), are notoriously difficult to diagnose crossculturally. Apart from diagnostic categories, the vocabulary used to describe emotional distress varies from culture to culture. European-Americans commonly describe symptoms in terms of named emotions (“I've been feeling anxious and depressed all week”). Hispanic-Americans are more likely to describe physical symptoms (“I've had a headache all week, and I'm so tired I can hardly move”). Sometimes symptoms that are commonplace within a culture are unheard of to outsiders. Residents of Anglophonic countries in East and West Africa often describe the sensation of a snake crawling under their skin, moving from one part of the body to another. This appears to be a symptom of general emotional distress without particular diagnostic significance. Heard by a Western physician, the symptom may be misinterpreted as a somatic delusion or ignored altogether, because it does not register in the examiner's conceptual understanding of disorders. file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (25 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm Additional problems are encountered when doctor and patient speak different languages. When an interpreter is needed, the person should be a disinterested third party, unknown to the patient. Using family or friends to translate inevitably invites distortions in what the patient is said to report. Translators must be instructed to translate verbatim what the patient says—a difficult task for even the most experienced professional translators. Some words and expressions are simply untranslatable. It may be impossible to convey a formal thought disorder through translation. An additional difficulty may arise in establishing rapport between doctor and patient of different ethnic or cultural groups. The use of honorifics, the extent of direct eye contact considered appropriate, or whether it is acceptable for men and women to shake hands, all vary considerably among different groups. Patients from minority groups may be quite guarded in speaking with a doctor from the majority group. Some groups such as traditional Chinese-Americans strongly believe that family problems should not be discussed outside the family, including with physicians. The evaluating psychiatrist must proceed with humility and respect. Rather than offer reassurances of understanding and acceptance, it is usually better to ask, “Have I understood this in the way you meant it?” SEDUCTIVE PATIENTS The warmth, openness, acceptance, and understanding that are helpful to most psychiatric interviews may engender feelings of romantic longing in some patients, especially (but not exclusively) those who are lonely and socially isolated. Other patients may have flirtatious and seductive ways as their habitual style of relating with other people. Seductiveness may be manifested in a patient's dress, behavior, and in what is said. It runs the gamut from gentle suggestion to explicit proposition. A young man may sit with his legs spread wide apart, a young woman may wear a low-cut revealing dress, or a middle-aged woman, when shaking hands, may hold the psychiatrist's hand a few seconds longer than appropriate for the situation. Of course sex is not the only enticement with which psychiatrists can be seduced. Patients may offer insider information for profitable trading in the stock market, promise an introduction to a movie star friend, or suggest that they will dedicate their next novel to the psychiatrist. While it is easy to understand that some offers by patients such as the possibility of a sexual involvement cannot be acted on without considerable harm to the patient, others may seem more innocuous. However, because they nearly always introduce a different agenda into the therapy than that originally contracted for and because they create additional, more ambiguous levels of obligation between therapist and patient, any psychiatric work is inevitably contaminated, and the ability to help the patient is compromised. Consequently, gaining material or social benefit from the patient other than the agreed upon fee is unethical. Whether to offers of sex, money, or celebrity, the psychiatrist's response is the same. In the course of ongoing psychotherapy and in the context of an established relationship, seductive behavior is discussed and examined in an effort to understand its meaning. Is it for example, a way of distancing, of gaining control, or of compensating for feelings of vulnerability and inferiority? To what extent are the feelings being expressed by the patient part of the transference? The psychiatrist should make it clear that what is being offered will not be accepted, in a way that preserves good rapport and does not unnecessarily file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (26 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm assault the patient's self-esteem. Seductive behavior during an initial psychiatric assessment must be handled somewhat differently. When the behavior is mild and indirect, it may be best to ignore it; commenting on a woman's exposed cleavage only makes it clear that the psychiatrist is picking up sexual cues and is most unlikely to facilitate the interview. More-explicit propositions call for more-direct responses and may afford the psychiatrist the chance to explain the nature of the therapeutic relationship and the need to establish boundaries. The psychiatrist should also make clear that it is the violation of those boundaries that is being rejected and not the patient. For example, to the patient who offers a celebrity introduction, the interviewer might reply, “That's very nice of you to propose, but I think I will best be able to help you if we pretty much stick to the issues that brought you in to see me.” PATIENTS WHO LIE A fundamental stance in psychiatric interviewing is recognizing that what is being heard may not be literal truth. The unreliability of memory and the vagaries of psychopathology through which a patient's narrative is processed will distort and falsify. The interviewer understands that what is historically untrue may nevertheless be emotionally true and is therefore a meaningful part of the diagnostic assessment or psychotherapy. At times patients lie consciously with the explicit intent of deceiving the therapist. The purpose may be secondary gain (e.g., exemption from jury duty, a supply of psychoactive drugs, a leave of absence from graduate school), in which case the person is malingering. Malingering is not a mental disorder in DSMIV. More rarely a patient will explicitly lie not for any obvious external advantage but simply for whatever psychological benefit is conferred by assuming the sick role, in which case the person may have a factitious disorder, which is a DSM-IV mental disorder. Because psychiatrists do not have recourse to biologic markers or other external validating criteria, the patient's report must be accepted as an honest statement of experience. There is no way to establish whether a person is experiencing auditory hallucinations other than through self-report. Nevertheless, an experienced clinician may detect subtle discrepancies, internal inconsistencies, or suspiciously atypical symptoms; these can certainly be queried without necessarily assuming that the patient is lying. A 29-year-old woman describes almost unremitting migraine headaches and is asking for narcotic pain medication. Patient: I really need your help. The pain is unbearable. I can't do anything anymore. I just want to lie in bed in a dark room with the cover pulled over my head. Doctor: That does sound miserable. But I'm struck by the fact that you obviously care about your appearance and have given some time and attention to your hair, makeup, and the way you are dressed. Was that despite the pain you have been describing? Of course the examiner is more likely to be deceived during the initial diagnostic assessment than in an file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (27 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm ongoing psychotherapy in which the therapist has much more knowledge of a patient's background, thinking, and functioning over time. It may be difficult to catch a practiced liar in an initial session. Arguably the interviewer should not try. Being lied to angers most people, certainly no less psychiatrists who must depend on trust to perform their work. However, believing a patient's lies is not a professional failure. Psychiatrists are trained to detect, understand, and treat psychopathology, not to function as lie detectors. While a certain level of suspicion is essential in the practice of psychiatry, the clinician determined never to be taken in by deceitful patients will approach patients with such exaggerated suspiciousness that therapeutic work is not possible. Finally, not all patients' untruths are conscious lies. Patients with somotoform disorders such as conversion disorder or pain disorder are presumably unaware of the emotional bases of their physical complaints. In describing their somatic symptoms they are stating a psychological reality, not attempting to deceive the interviewer. Empathy A diagnostic interview often provides considerable relief to patients. Puzzling and sometimes frightening symptoms are framed in the context of medical understanding. Bizarre experiences can be rationally understood and intelligently organized in meaningful ways that allow us to make informed predictions about treatment response and recovery. Of equal importance to an intellectual understanding is our capacity to understand emotionally the experiences of our patients. Empathy is an essential characteristic of psychiatrists, but it is not a universal human capacity. An incapacity for normal understanding of what other people are feeling appears to be central to the disturbance of certain personality disorders such as antisocial and narcissistic personality disorders. While empathy can probably not be created, it can be focused and deepened through training, observation, and self-reflection. It manifests in clinical work in a variety of ways. An empathic psychiatrist may anticipate what is felt before it is spoken and can often help patients articulate what they are feeling. Nonverbal cues such as body posture and facial expression are noted. Patients' reactions to the psychiatrist can be understood and clarified. Patients sometimes say, “How can you understand me if you haven't gone through what I'm going through?,” but clinical psychiatry is predicated on the belief that it is not necessary to have other people's literal experiences to understand them. The shared experience of being human is often enough. Whether in an initial diagnostic setting or in an ongoing therapy, patients draw comfort from knowing that we are not mystified by their suffering. SUGGESTED CROSS-REFERENCES Section 9.3 deals with the typical signs and symptoms of psychiatric illness, Section 9.5 deals withneuropsychological and intellectual assessment of adults, and Section 9.8 deals with psychiatric ratingscales. Similarly, Chapter 10, on the clinical manifestations of psychiatric disorders, is an essentialcorrelate to interviewing and examining the patient. More-specialized focus is provided in Section 2.1,which deals with the clinical assessment and approach to diagnosis in neuropsychiatry. Section 3.1 on file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm (28 of 31)2/1/2004 11:29:24 AM file:///C|/Documents%20and%20Settings/BOB/My%20Documents/CLASSES/Biomed%20370/articles/Hx_and_MS.htm perception and cognition and Section 3.4 on the biology of memory amplify points made in this section.Section 29.1 includes more-detailed information on suicide, and Section 29.2 includes information onother psychiatric emergencies. Additional relevant information is found in Chapter 45, which deals withmood disorders and suicide in children and adolescents. Taking a developmental history impliesfamiliarity with the aspects of normal and abnormal development; readers may find the followingsections of special interest: Section 6.2 deals with Erik H. Erikson and his ideas about child and adultdevelopment; Chapter 32 deals extensively with normal development in children and adolescents; adultdevelopment is covered at great length in Chapter 50; and normal aging is the focus of Section 51.2c.