Chapter 1

The Psychiatric Interview and Mental Status Examination

John W. Barnhill, M.D.

The Psychiatric interview involves multiple goals. A differential diagnosis and treatment plan are expected, for example, as are a mental status examination and the interviewer's synthesized perspective on the history of the patient's present illness. The risk of suicide and homicide must be assessed, as should potentially dangerous medical conditions and substance use disorders. It can be crucial to obtain detailed information about the developmental and social history as well as prior psychiatric treatments. An alliance and a therapeutic effect are both reasonable expectations, as is some sort of psychological understanding of the patient. The completion of an often-lengthy computerized form has become an increasingly common requirement. This is a lot to complete in an hour, especially when the clinician is also expected to be kind, tactful, patient, and friendly.

The chapter will begin with a discussion of ways in which the clinician might prepare for doing the interview, including the development of a psychiatric attitude and a biopsychosocial approach. The second section focuses on the performance of the interview, including an outline of the phases of the typical interview and a range of potentially useful interviewing techniques. The third section explores ways in which the interview is affected by commonly seen clinical situations and types of patients. The chapter concludes with a discussion of the expected structure of the written or oral presentation, including an exploration of concepts and terms that are core aspects of the psychiatric interview. Although the clinician need not use this concluding section as a roadmap to the actual performance of the interview, interviewers who do not anticipate the expectations of a psychiatric write-up will likely elicit an inadequate amount of specific information.

General Preparation

Setting the Stage

Effective psychiatric interviews can be done under almost any conditions. One interview with an agitated patient might last for a few moments in a hallway surrounded by patients, staff, and security guards. Another interview might consist of an hour-long session in a calm, quiet, uncluttered outpatient office. A third might feature a patient and trainee being observed as part of a 30-minute oral examination. Although the details vary, an underlying goal of all interviews is to provide a safe and respectful opportunity for the patient to tell his or her story. Regardless of whether the interview takes a minute or an hour, each interview has a similar underlying structure that involves observation, interaction, assessment, and plan.

Clinicians who work in an emergency room (ER) or a consultation service or who are in training generally interview everyone they are assigned. Other clinicians often decline outpatient evaluations because of a lack of expertise in a specific subspecialty area, such as substance abuse or child psychiatry. After agreeing to conduct the interview, it is useful for the clinician to clarify to herself the initial goals of the patient and/or referring clinician. Clarity can ensure that the presenting issues are adequately addressed. In addition, hints of violence or other special difficulties should help steer inexperienced staff and students away from dangerous encounters.

If available, old patient records can yield important clinical information, as well as lists of medications, medical and psychiatric diagnoses, and useful contact numbers. Such information can suggest issues that might not otherwise be addressed in the interview.

Tip: All outside information should be viewed skeptically. Even if reading a trusted colleague's recent initial evaluation note, the interviewer should consider how the patient's situation might have evolved and how the prior evaluation might have been incomplete.

Taking notes during an initial interview is especially useful for facts that are important but hard to remember, such as medication doses and dates of hospitalizations. Notes are also helpful to remind the interviewer of topics that still need to be addressed. For example, if an anxious patient mentions binge drinking early in the interview but is in the midst of an emotionally important story, the interviewer might write down "alcohol" to trigger a more thorough discussion later in the session. Some interviewers bring with them an outline of an initial write-up and jot down brief notes as pertinent material comes up. Whether the interviewer is using paper and pencil or a small computer, the goal is to avoid letting the recording device interfere with the development of an alliance or with the interviewer's ability to pay attention to important nonverbal behavioral and interpersonal clues.

Prior to seeing the patient, the interviewer may discover that relatives and/or friends expect involvement, either by sitting in on the interview or via an open communication with the interviewer. Some clinicians will hardly ever involve relatives, but if family members are important to the process of data collection or are likely to be involved in the eventual treatment, they should be included in the evaluation. For example, family members are routinely involved in the evaluation of children and of patients who have a developmental disorder or a dementia. In addition, patients from most of the world anticipate that family members will be involved in their medical evaluations and treatment. The American emphasis on individuality and privacy can be seen as idiosyncratic to an immigrant family that presents en masse for a psychiatric evaluation. Adults, however, are generally allowed to refuse access to relatives. States vary somewhat in regard to privacy legislation, but they generally restrict the psychiatrist's right to contact relatives over patient objection to situations that involve acute risk. Even in emergency situations, the interviewer should aim to elicit information from the family without giving up unnecessary or confidential information.

Interviewer's Attitude

The preferred clinical attitude combines a host of desirable emotions, such as warmth and spontaneity. Of course, interviewing styles vary, but, in general, interviewers try to maintain an attitude of respectful curiosity.

Interviewers also listen differently. In interviewing a patient who presents with prominent anxiety, one psychiatrist might listen with an ear for symptom clusters that fit DSM-5 (American Psychiatric Association 2013) criteria for disorders that relate to substance use, trauma, obsessions/compulsions, or one of the anxiety disorders. A more psychodynamically oriented therapist might look for factors that contributed to the anxiety; for example, unreliable early caregivers might lead to an inhibited ability to express anger, associated with a variety of defenses (e.g., denial, undoing, reaction formation) that reduce efficacy and perpetuate the baseline anxiety (Busch et al. 2011; Cabaniss et al. 2011; Milrod et al. 2007). A couples' counselor might hear the same anxiety but listen for maladaptive patterns of interpersonal behavior, focusing less on the individual and more on the couple. A therapist with a cognitive-behavioral perspective might listen for cycles of thinking and behavior that could contribute to and exacerbate the presenting symptoms (Beck 2011). Most interviewers learn to listen in ways that conform to the needs of the patient and the situation as well as their own training and theoretical and personal biases.

Biopsychosocial Approach

Without having a broad working knowledge of psychiatry, the interviewer will be awash in unanalyzed data and will be unable to develop a coherent narrative that explains the patient's situation. Sherlock Holmes is the quintessential interviewer-observer. Underestimated, however, is the amount of background information available to him. He might notice mud on shoes, for example, and conclude that the victim (or perpetrator) had spent time in a particular quarry in the north of England. Although anyone might notice the muddy shoes, Holmes notices the relevance both because he is observant and because he maintains a vast fund of knowledge. Even with the Internet readily available, the modern interviewer needs to be able to spontaneously recognize a wide variety of triggers that should prompt further investigation.

Clinicians who study only the areas that interest them risk making systematic errors throughout their careers. Practice may make perfect, as the saying goes, but practice also makes permanent; without diligently studying the entire field, the interviewer will miss unappreciated details.

There are several ways for the interviewer to develop and maintain a knowledge base. The first is to read and study broadly via journals, texts, conferences, and review courses (Muskin 2014; Roberts and Louie 2014). Another is to read pertinent information prior to seeing a particular patient. An equally important habit is to jot notes during the interview about topics that seem potentially contributory. A quick Internet or textbook search after the interview not only can improve the quality of the interviewer's understanding of the patient but—when the search is explained to the patient at the next meeting—lays the groundwork for a deepening of the therapeutic alliance.

The types of information sought can be subdivided into three categories, conforming to the biopsychosocial model of psychiatry (Engel 1980). Although the three pillars will not be equally important in each clinical situation, there are few psychiatric interviews that can afford to completely neglect any one component of the biopsychosocial model.

Biological

Interviewers do not need to be psychopharmacologists, but the mention of venlafaxine, for example, should prompt the clinician to wonder if some physician had diagnosed the patient with depression. Venlafaxine, however, is also used for anxiety and panic, is frequently used for pain, and—as is true for all medications—is sometimes mistakenly prescribed. If, after mentioning venlafaxine, the patient then mentions having diabetes, the interviewer will want to consider whether the medication is being used for diabetic neuropathy and should recognize that diabetes and depression are frequently comorbid and that many psychiatric medications can lead to weight gain and diabetes (Ferrando et al. 2010; Goldberg and Ernst 2012).

The interviewer should also know the relevance when the patient indicates that he has been dutifully taking 25 mg/day (or 225 or 375 mg/day) of venlafaxine for the past 2 months, or when he mentions that he only takes it on the days he feels especially symptomatic, or when he casually mentions he ran out of pills several days earlier. Without quite a lot of practical knowledge about all of the pertinent medications, the interviewer will not know whether the patient's story includes a therapeutic trial or whether the patient's symptoms might be attributable to side effects from a high dose or side effects from withdrawal. In other words, the mention of a drug like venlafaxine or an illness like diabetes should prompt the interviewer to consider a broad array of topics, including depression, anxiety, panic, pain, metabolic syndrome, medication adherence, and medication withdrawal effects.

Psychological

The psychological understanding of patients can be separated into diagnostic descriptions (e.g., DSM-5 criteria) and narrative descriptions that are heavily informed by psychotherapeutic schools of thought (e.g., psychodynamics, cognitive-behavioral therapy, interpersonal therapy).

The currently dominant model in American psychiatry is descriptive. In the descriptive model, which is featured in DSM-5 and other medical nomenclatures such as the International Classification of Diseases, 10th Revision (ICD-10; World Health Organization 1992), symptoms are clustered into recognizable disorders. For example, people with schizophrenia do not all have the same symptoms, but they do generally have a history of psychosis, cognitive problems, and psychosocial dysfunction. It is important that when an interviewer notices one or two of these variables (e.g., long-standing homelessness and poor functioning), he or she efficiently looks for the symptoms that commonly co-occur (Black and Grant 2014; First 2014).

Tip: All combinations of information can yield a differential diagnosis that can evolve with additional information.

For example, "car wreck + 20-year-old man" should prompt some inquiry into substance abuse and impulse control problems, whereas "new-onset depression + hospitalization + elderly" should prompt a focused inquiry into delirium as well as depression. If the interviewer lacks an understanding of symptoms that tend to cluster, the interview will likely be inefficient and incomplete.

In addition, the interviewer should know which diagnoses tend to co-occur so that if, for example, a patient provides criteria for generalized anxiety disorder, the interviewer knows to make a special effort to consider substance abuse, depression, posttraumatic stress disorder (PTSD), personality disorders, and other anxiety disorders. The interviewer should also keep in mind the breadth of DSM-5 so as to avoid giving too much or too little weight to particular diagnostic categories. Errors can reflect cognitive and training biases, such as when the interviewer tends to diagnose what he or she has frequently seen or been taught to see and ignores an array of other diagnoses. Errors can also reflect therapeutic bias: a clinician may preferentially diagnose what she is best able to treat. A third common bias relates to the "loudness" of a disorder. Obvious and potentially dangerous complaints are generally recognized, whereas less obvious diagnoses (e.g., obsessive-compulsive disorder, avoidant personality disorder) can get ignored.

Description may be the dominant psychiatric paradigm, but much of the field also relies on narrative. Data gathering in psychiatry, unlike in other medical fields, involves information that is filtered through a patchwork of complex and uncomfortable wishes, fears, and memories. Such complexity presumably underlay Jerome Groopman's decision to specifically exclude psychiatrists from his best-selling book How Doctors Think. As he wrote, "How psychiatrists think was beyond my abilities" (Groopman 2007, p. 7).

The psychiatric interviewer will frequently encounter resistance, which refers to anything that prevents the patient from talking openly to the interviewer. Conscious resistance occurs when the patient knowingly neglects, distorts, or makes up important information. Unconscious resistance leads to similarly incomplete stories, but the mechanism is assessed to be out of the patient's awareness. Much of Sigmund Freud's work was based on the process of keeping material out of awareness (i.e., repression ), although later psychoanalysts focused on delineating a variety of other defenses.

Sublimation and humor are considered to be healthy defenses, and they can contribute to alliance building and treatment decisions. Other defenses are more likely to derail a successful interview. For example, a paranoid patient may project malevolent thoughts onto the interviewer, and the interviewer may accept and internalize such projections in a process known as projective identification. In such a situation, the clinician may find himself or herself behaving with uncharacteristic hostility. By recognizing his or her own internal reaction, the clinician can better maintain equilibrium while also gaining greater insight into the patient (Gabbard 2014; Yudofsky 2005).

Unconscious processes are also important in the development of transference, which is defined as the redirection of feelings from one relationship to another; most classically, the transference occurs from an early, important relationship (such as with a parent) onto the therapist. Most crucial to the interview is the positive transference, which allows patients to trust strangers with their life stories. Such automatic reactions are generally not discussed in an extended therapy, much less in a single interview, but without them, the interview would likely remain superficial (Viederman 2011). Transference is more often discussed when it interferes with the interview, such as when the patient has a negative transference. Although some so-called "difficult" patients may be manifesting negative transference, others are manifesting generic hostility. In either event, the initial interview is rarely the time for the clinician to try to explicitly interpret the transference to the patient. More typically, the interviewer should try to consciously identify the defense (e.g., devaluation or projection) to herself, which can prompt both a deeper understanding of the patient and maintenance of a professional, helpful attitude toward a patient who might otherwise be experienced as difficult.

In addition to paying attention to transference, defenses, and a variety of unconscious assumptions, the interviewer should be monitoring his or her own reactions to the patient. Often discussed under the broad heading of countertransference, these reactions can help the interviewer maintain a professional attitude under trying circumstances and can also provide crucial insight into the patient's interpersonal world.

Social

The "social" aspect of biopsychosocial refers to the sociological, religious, spiritual, ethnic, and racial issues that may be pertinent to patients. Some of this information may seem like "common knowledge," but exploring specifics will often lead to a discussion of identity, psychology, and culture that can inform an understanding of the patient (Miller et al. 2012; Peteet et al. 2011).

For example, a 20-year-old woman might come in with a chief complaint of sadness after a loss. If she then adds that she is a lesbian, African American college student, the interviewer has choices. One option is to dutifully write down these demographic details in the section for "identifying information" and then forget them, perhaps in an effort to see the patient as an individual rather than as some sort of reductionistic stereotype. This option may, however, be a mistake, because it might ignore clues that help make sense of the patient's situation (Gara et al. 2012).

Instead of passing over these demographic variables, the preferable action for the interviewer is to mull over possible links and listen for clues to their possible relevance. For example, what is this particular patient's perspective on being lesbian? In what phase of the coming out process is she? To what extent is she ambivalent about her orientation? Has she told her family? Is she dating? (Levounis et al. 2012). Similar questions might come up about her being African American. Although an interviewer from the dominant subculture (e.g., white in many areas of the United States) may view America as being beyond racial issues, such a view is not shared by many people who belong to marginalized subcultures. For them, discrimination remains an ongoing threat to mental health (Chae et al. 2011). Alternatively, if the clinician is also black or gay (or both), then shared, unanalyzed assumptions can lead to other kinds of blind spots and errors.

When interviewing people from differing backgrounds, the interviewer need not become either deskilled or a cultural anthropologist. If "sadness after a loss" is the patient's chief complaint, cultural factors may or may not be vital components to the assessment. When in doubt, the interviewer can simply ask for the patient's perspective.

Performance of the Interview

The psychiatric interview begins with observation, but the interviewer needs to recall that first impressions work both ways. At the same time that the clinician is silently creating and discarding potential diagnoses, the patient is likely formulating questions of her own. Does the interviewer seem nice? Trustworthy? Knowledgeable? Although discussion of interview "performance" focuses on the spoken words, it would be difficult to overstate the importance of nonverbal communication to the psychiatric interview.

For purposes of discussion, the interview is divided into three phases (for an overview of the structure of an interview, see Table 1-1). The initial phase should allow the patient to voice his or her chief concern, whereas the later phase will become increasingly driven by efforts to clarify the history, mental status exam, and DSM-5 diagnoses. The interview concludes with a period of negotiation and summary. It should be noted that whereas these phases might overlap with the expected structure of the writeup (discussed later in chapter in the section "Structure of the Write-Up of the Psychiatric Interview"), the actual performance of the interview does not generally follow the template presented in Table 1-5 ("Outline of the interview write-up").

Following discussion of these three interview phases, this section of the chapter concludes with a roster of interview techniques.

Initial Phase: Patient's Chief Concern

The initial phase of the interview has two main goals: The first is to understand and explore the patient's current chief concern. The second is to give the interviewer the time and the information to begin to make a set of tentative hypotheses about the patient. Also called the "scouting period" (Shea 1998) and the "warm-up and screening phase" (Othmer et al. 2014), this phase allows the patient to present a story.

While the patient is talking, the clinician should notice how the individual is dressed and how he or she moves, speaks, and interacts. The observant interviewer should start developing a broad range of theories about the patient within a few minutes of meeting him or her.

An opening, nondirective question might be "Tell me about what brought you here today." The initial interview is not, however, the moment to become a caricature of a mid-20th-century psychoanalyst—that is, a silent, dour, and impassive observer. Even silence should be active: nonverbal encouragements can include nods of the head, appropriate amounts of eye contact, and body language that conveys attentive concern. Short requests can help—for example, "Tell me more about what you mean"—as can specifically going back to a point that the patient made moments earlier. An empathic stance is surprisingly difficult to maintain, however, and the interviewer may feel tempted to quickly shift the interview to fit his or her own agenda and associations. Nevertheless, under most circumstances, it is helpful for the interviewer to preserve this initial phase for the patient's point of view.

When given an opportunity to speak freely, some patients will present a crystalline story that fits exactly what the interviewer is looking for. Others will spin a story that may be internally consistent but barely touches on the issues that brought the patient in for the evaluation. Still others will founder and either drift across seemingly unrelated life events or grind to a halt within a few moments. It is important, therefore, to be flexible and attentive. If the patient has veered off course, the clinician should tactfully bring the patient back to the reason he or she has appeared for the interview. One way to accomplish this redirection is to ask the patient to speculate on what it was that caused others to be concerned about him (e.g., "Do you have any thoughts about what might have prompted your wife to call the ambulance?").

While providing the patient with the opportunity to speak freely, the interviewer should be developing a tentative differential diagnosis and history of present illness. The rest of the interview will be devoted to gathering additional information and testing hypotheses.

Tip: The interviewer should practice developing a differential diagnosis that spans diagnoses from several DSM-5 chapters before investigating any one of them.

Techniques vary during this early phase. Open-ended questions are most often recommended (see subsection "Techniques" following discussion of phases), but some patients do best with "warm-up" questions that are intended to yield straightforward demographic information and yes/no answers. Some people prefer to begin with small talk, and others resent discussion that does not refer specifically to their most pressing issues. Patients generally allow attentive and well-meaning interviewers the opportunity to try out different approaches to determine what works.

Later Phase

By the end of the initial phase of the interview, the clinician should have a sense of likely diagnoses as well as tentative narratives that incorporate the diagnoses. Much of the rest of the interview consists of completing three tasks that were begun during the initial phase: further development of the history of present illness, collection of other aspects of the patient's history, and performance of the mental status examination (MSE).

An important goal of this phase is for the interviewer to make a conscious effort to shift the patient's story of his or her present illness into the interviewer's story of the patient's present illness. To do so, the interviewer considers silent hypotheses, likely comorbidities, and the breadth of possible diagnoses, including behaviors, thoughts, and feelings that the patient would—either consciously or unconsciously—prefer not to discuss. The clinician should elicit such information while further developing an alliance and beginning to formulate a treatment plan that takes into account the patient's preferences and strengths. Part of this assessment includes a shift to a more active assessment of symptoms, including their severity, frequency, duration, onset, and context.

The interviewer should elicit a significant amount of other information, including psychiatric, medical, family, developmental, and social histories. As described later in the section "Components of the Psychiatric Write-Up," historical information may not be directly related to the presenting complaint but may play a crucial role in the development of a treatment plan.

A crucial part of the interview is the performance of an MSE. The MSE is a cross-sectional evaluation of the patient and is a core aspect of every psychiatric contact. It includes assessments of the patient's general appearance, mood, affect, speech, thought process, thought content (including suicidality and homicidality), perceptions, cognition, and executive functioning. Mental status is assessed throughout the interview, although some aspects of the MSE, such as cognition and memory, tend to be more formally assessed toward the end of the interview. See the section titled "Mental Status Examination" later in chapter for definitions and a more thorough discussion of these terms.

The later phase of the interview features an increasing number of closed-ended questions that seek clear-cut answers. It is important not to lose the connection that was developed in the early part of the interview. Approving nods and tactful eye contact can encourage the patient who might otherwise resent the fact that he or she is no longer encouraged to talk freely. It is fine for the clinician to explicitly explain the situation, saying, for example, "We are short on time, so let's move on to talk about your work" or "It sounds like the situation at work has been rough, but let's shift gears to talking about your family." Transitions can often be smoothly effected by making use of any topics or words that the patient has recently used. If, for example, the patient has been talking about her family at length, the interviewer might say, "You mentioned that your husband has been having some "senior moments." Have you been having problems with your own memory?" Regardless of the answer to that question, the interviewer can then shift to a more formal cognitive assessment.

Prior to ending this phase, it can be useful for the interviewer to ask the patient if there is anything else the clinician should know about the situation.

Negotiation

The interview is generally incomplete without some discussion of diagnosis and treatment. This conversation might take place at the end of the initial session, or it might occur during an ensuing session after the interviewer has had a chance to obtain more information, seen the patient for a second (or third) visit, or received supervision. This phase of the process is not part of the standard oral exams taken by trainees and may seem superfluous to the interviewer, but to the patient it is often the key element of the evaluation. Active patient participation is strategically crucial because cooperation and adherence will be important to most suggested treatments, and patient preference is an important variable in the success of the intervention (van Schaik et al. 2004).

The negotiation phase is also important for psychoeducation, referral to another clinician or clinic, and gaining a sense of whether the patient has been satisfied by the assessment process. Before the interview ends, it can be useful to anticipate treatment obstacles by asking whether the patient expects to follow through with the recommended treatment.

Techniques

Verbal and nonverbal communications are central to the psychiatric interview. These communications can be divided into three overlapping types: nonspecific, nondirective, and directive. Nonspecific interview techniques are used throughout the interview to enhance the patient's experience and lay the groundwork for an alliance and a more productive interview. Nondirective techniques encourage the patient to continue on a train of thought. Directive techniques narrow the focus, perhaps to a factual answer or a topic change. Table 1-2 lists these core interview techniques.

There are many ways to develop interview skills. Observation is the classic method, and the novice interviewer will quickly see that senior interviewers have a variety of styles that are more or less effective with different patients. In preparation for oral examinations, trainees often practice with each other, sometimes interviewing actual patients and sometimes interviewing each other. For some interviewers, guidebooks can serve as a useful adjunct (e.g., Evans et al. 2010). Knowledge of core techniques can improve all aspects of the interaction (as can the avoidance of derailing errors).

Tact and timing are crucial. For example, a patient might say, 'Tve been so sad since my mother died." In response to that important piece of information, the interviewer has choices. For example, she might decide to explore the patient's emotional reaction to the mother's death by looking directly at the patient, appearing warmly interested, and saying, "Could you tell me more about it?" An attentive, open-ended approach can allow the patient to express reactions to the death that are more complex than relatively straightforward sadness. If the patient then discusses ambivalence or relief, the interviewer might decide to tactfully make use of a confrontation (e.g., "It sounds like you've been very sad since your mother's death, and that her death after so many years of suffering has also felt like a relief."). On the other hand, time might be short or the patient may be especially dramatic or tangential, and the pursuit of an emotional story could distract from the goals of that phase of the interview. The clinician might then choose to use closed-ended questions to inquire more specifically about depressive symptoms or to explore specific historical details about the mother's death.

Other interviewing behaviors are more likely to be derailing errors—comments and questions that tend to reduce clinical effectiveness (Table 1-3). For example, the interviewer might respond to the news about the patient's mother's death by wanting to psychologically back away from the patient, leading him to becoming silent and distant, perhaps by ducking behind a laptop to take notes. Alternatively, clinician discomfort might lead to excess personal disclosure (e.g., "I know how you feel. My own mother died a few months ago, and I'm a wreck.") or to premature advice (e.g., "How about a support group?"). Although such behaviors and comments might negatively affect the interview, patients generally rebound quickly from the derailment if they perceive the interviewer to be flexible and well-meaning. In addition, so-called derailing errors are potentially helpful if used tactfully with the right patient at the right time. For example, it can feel reassuring to the patient for the clinician not to appear overwhelmed, and so some distancing may be helpful. Similarly, self-disclosure and supportive suggestions can be tactically useful in a variety of interview-and therapeutic situations.

Interviewing strategies depend heavily, therefore, on the goals of the particular phase of the clinical interaction. Two other variables that significantly influence the interviewer's minute-to-minute decisions are the type of situation and the type of patient.

Types of Situations

Although all interviews should yield a safety assessment and putative diagnosis, there are many types of interviews, each with a different goal and a different primary concern (Table 1-4).

For example, an elderly man is being evaluated in the ER for cognitive decline, agitation, and depression. The interviewer would likely be aiming to do a solid interview and presentation, but her primary goals would be safety (determining whether the patient is suicidal, homicidal, or unable to care for himself) and triage (considering whether the patient should be admitted, discharged, transferred to medicine, or held overnight). If the interviewer decides that the patient has mild cognitive decline, a serious depression, and an inability to care for himself, the patient is likely to be admitted to psychiatry. If that same patient is deemed to be safe—perhaps because of excellent social supports—but with the same psychiatric diagnoses, he will likely be discharged to outpatient treatment. In that setting, definitive diagnosis becomes less important than the triage decision.

When that same patient is admitted to the adjacent impatient psychiatric unit, the next clinician's interview will have a different mandate. On the unit, dangerousness is again assessed, but the focus is on making the most accurate possible diagnosis and fine-tuning a treatment strategy. It will become important to decide whether the patient has a dementia, and, if so, which kind. It will also become important to determine whether the patient has a major depression, a history of successful or unsuccessful treatments, and any comorbidities. Even more than the interviewer in the ER, the inpatient clinician will likely seek out old records, collateral sources, and any other pieces of information that can help clarify the situation.

That same patient may then agree to take part in an oral examination that is performed annually in all psychiatric residencies accredited by the Accreditation Council for Graduate Medical Education. In many ways, the oral examination has become the prototypical psychiatric interview. In it, an examiner observes an interviewer conduct a 30-minute interview with a patient; after the patient leaves, the interviewer is asked to present and discuss the case over the ensuing half hour. Evaluation is focused on ensuring competency in about 25 areas that are organized under five major categories (physician-patient relationship, psychiatric interview, case presentation, differential diagnosis, and treatment plan). The goal for this examination is to demonstrate broad competence. This situation is typical in some ways (talking to a patient for half an hour) but quite unique in others (a silent observer, no collateral information, no follow-up, and no actual treatment relevance aside from the possibility of a therapeutic effect of doing the interview). Most pertinent to this discussion, the primary goal is demonstration of overall competency (i.e., examination success), and, generally speaking, the primary concern is inability to demonstrate broad competency (i.e., examination failure).

While that patient is hospitalized, his son might recognize his own caretaker stress from being the primary patient's only living relative. The son might then seek a consultation in an outpatient psychotherapist's office. The outpatient therapist might recognize that the son lacks a major mental illness but is instead tired and worried. That interviewer-therapist might devote a modest amount of time to diagnosis, minimal time to dangerousness, and extensive time to issues that may be justifiably given short shrift in an ER or inpatient unit. For example, a psychodynamically oriented clinician might do an initial screen and then focus on such topics as psychotherapy history, relationship stability, psychological mindedness, empathy, ability to trust, intelligence, school or work history, and impulse control. In deciding on treatment options, these variables can play as large a role as the DSM-5 diagnosis. By the end of the evaluation, the son may have decided two things: that he was interested in psychotherapy and that he was unwilling to have his father live with him.

The inpatient clinician may decide that the father has a dementia and an improving depression and begin treatment. If the patient improved psychiatrically but insisted on returning home despite a marginal ability to safely live alone, the team might call for a nontherapeutic interview to assess capacity. In this interview, a clinician would assess the patient's ability to discuss the risks and benefits of the proposed disposition. Diagnosis would play a role in this assessment, but capacity does not hinge on diagnosis (i.e., people with schizophrenia and dementia often retain capacity). Perhaps most importantly, even though this particular interviewer likely sees herself as providing a service to the patient, her role is evaluator, not therapist.

Types of Patients

Interviews are affected by the type of patient as well as the type of situation. Excellent texts discuss how diagnosis affects the clinical interview (e.g., MacKinnon et al. 2006), but such an approach presupposes knowledge of the diagnosis. For the purposes of this chapter, I subdivide patients into four groups—revved up, down, odd, and evasive—based on what can generally be observed within a few minutes.

Revved-Up Patient

Revved-up patients appear excited or high and tend to display psychomotor agitation. Likely diagnoses include mania, psychosis, hyperactive delirium, withdrawal, and/or intoxication.

There are two stages to the evaluation of the revved-up patient. First, the interviewer and other staff should ensure safety. This will likely involve stationing themselves near the doorway and ensuring the availability of helpful staff members, security guards, and sedating medications. In addition to being watchful for dangers to the staff, the interviewer needs to be alert to the possibility that the revved-up patient could hurt herself or could be withdrawing from a substance like alcohol. Pursuit of more routine information generally needs to be deferred when safety is at stake.

Second, the interviewer will need to be primed to shift to an unusually active approach (Freed and Barnhill 2008). Instead of offering a wide-open time for the agitated, threatening patient to clarify her complaints, the interviewer will likely shift to a series of binary choices: "You are too excited now to be safe, so I would like to offer you a choice. Would you like to go to your room and remain quiet, or would you like medication?" This question would likely be followed by, "Would you like to take these medications by mouth or by a shot?"

The interview is also adapted for revved-up patients who are not dangerous. Revved-up patients should prompt the interviewer to be especially clear, soft-spoken, and calming. The patient might pull for humor and banter—and these can be used judiciously to develop an alliance—but they can further rev up the patient and distract the interview. In addition, the revved-up presentation should motivate the interviewer to focus on likely diagnoses (e.g., mania, substance use, delirium), potentially at the expense of other aspects of the interview.

Down Patient

The so-called down patient appears depressed and/or speaks little. Shrugs abound. While interviews often begin with a period of "free speech," the down patient may manage only a few monotonous words. This behavior can feel disheartening to the interviewer, but, as in working with the revved-up patient who veers immediately away from talking about useful information, the clinician should begin creating a silent differential diagnosis and quickly adapt the interview to the needs of the patient.

Tip: Before trying to fine-tune the type of major depression in an apparently down patient, the interviewer should consider the possibility that the apparent depression is secondary to a medical condition, substance intoxication, or substance withdrawal, any of which can be an acute emergency.

Appearing constricted and quiet can reflect depression, of course, but it can also reflect anxiety, a neurocognitive disorder, a developmental delay, or a variety of disorders that can involve wariness and a concern about how the individual is perceived (e.g., body dysmorphic disorder, PTSD, psychosis, avoidant personality disorder). In other words, the differential diagnosis of the down patient should extend outside the DSM-5 "Depressive Disorders" chapter.

Different sorts of down patients warrant different interviews. For example, the deeply depressed patient may be quiet because he feels the situation is hopeless. The psychotically paranoid patient may be quiet because she does not trust the interviewer. The depressed patient tends to feel isolated and abandoned, so the interviewer should sit a bit closer and amp up the warmth. The interviewer might also comment on the patient's appearance (e.g., "You look very sad"). The paranoid patient—who fears attack—often responds best to an interview style that is notably sober-minded and clear and in which the interviewer sits a few inches further away than usual. It would probably be a tactical error for the interviewer to sit with a silent, frightened, paranoid patient and start off by saying, "Your biggest worry is that people can read your mind." While perhaps true, the patient's core psychotic concern has just come true. Stated later and more tactfully, such a communication can help the patient trust the situation.

There are, of course, multiple variations of paranoia and depression, and the alert interviewer will look attentively for patterns. A paranoid, clean, but disheveled man in the ER might receive a tentative diagnosis of acute stimulant intoxication, whereas more chronic signs of self-neglect (e.g., grimy fingernails) point toward long-standing substance abuse or a chronic psychosis like schizophrenia.

Anxiety—either acute and situational or long-standing—can often lead to a stymied interview. Like the depressed or paranoid patient, the anxious patient is often able to relax with an interviewer whose words and style directly counterbalance the patient's primary concerns. In other words, if the patient is anxious, the clinician should be tactfully reassuring.

Odd Patient

When asked to tell their stories, some patients do not make complete sense. Such patients can frustrate the interviewer who is seeking a sturdily explanatory psychiatric narrative, marked by a crisp roster of symptoms.

Initially odd or idiosyncratic behavior should lead to a broad differential diagnosis. Many psychotic and manic patients present with odd or disorganized speech, but so do people with substance use disorders and several types of neuropsychiatric problems (e.g., aphasias, neurocognitive disorders). Interview adaptations focus on helping structure the patient, serving as an external "container" for the disorganization.

For example, the interviewer should be prepared to tactfully interrupt (e.g., "I know you have much to tell me, but I need to shift to getting some basic information") and to ask questions that pull for brief answers (e.g., "I see you've thought a lot about the previous treatment team, but could you tell me when you had that last hospitalization?").

Evasive Patient

Other patients are coherent but evade meaningful content. An obsessional patient is liable to focus on relatively trivial or dry details, for example, and the interviewer might try to "follow the affect" by picking up on scraps of emotionally laden content. A histrionic patient may talk at length but not provide the sort of meaningful narrative that helps with the diagnosis; the interviewer will likely need to shift gears and "follow the content" in order to gather a sufficient amount of concrete detail.

Other patients are deceptive or self-deceptive. For example, some may under-report substance use, which complicates diagnosis and treatment. Motivational interviewing focuses on nonjudgmentally exploring the patient's substance use and interest in treatment and may reduce deception (Levounis and Arnaout 2010; Miller and Rollnick 1991). Transparency can often remain elusive, however, and clinicians who seek a substance use history often combine information from the interview with collateral information and suggestive labs. It is also common practice to double the self-estimated substance use and move on with other aspects of the history.

Other patients evade for a variety of reasons. Dissociative patients may provide incomplete histories because of memory gaps, whereas patients with PTSD may steer away from relevant material to avoid painful memories and feelings. Malingering patients consciously lie, whereas patients with factitious disorder know they are creating an untrue story but do not know why. Patients with somatic symptom disorders tend to answer psychological inquiries with physical symptoms and a lack of insight.

The interviewer should try to quell frustration for each of these types of patients and present himself or herself as open-handed, direct, and curious. Tactfully allying with healthy aspects of the patient is a generally useful effort, but it is especially important when working with patients who tend to elicit hostility and frustration from clinicians who expect their patients to be honest and/or to manifest reasonable self-awareness. The clinician should also keep in mind that it is often very difficult to distinguish between the types of evasive patients, and most of them are not deliberately trying to undercut the interview process.

Local Cultures

Psychiatric subcultures vary across regions, hospitals, and even different services within the same institution. Often unspoken and incompletely clarified, these cultural/institutional differences dramatically affect the interviewer. The following is a sampling of questions affected by local cultures: Should a male interviewer wear a tie? What should a 25-year-old female patient be called? Should the clinician call her "Ms." or "Miss," use her first name, or just avoid calling her anything? What should the patient be expected to call the clinician? Generally speaking, dress code and name conventions should be gauged so as not to interfere with the work; clinicians who choose to assert their individuality against the locally prevailing professional custom are likely to encounter resistance.

In contrast, the prevailing model of the mind is more important, more variable, and less visible. As with other variations from expectations, culturally dystonic models of the mind are likely to lead to conflict. For example, one inpatient service might expect a psychodynamic life narrative on every patient (Perry et al. 1987; Summers 2003). A different service might expect every case discussion to include a careful pursuit of DSM-5 symptom clusters, specifiers, and multiple diagnoses. A third team—even on the same physical unit—might instead focus on a perspective that explicitly addresses several specific methods of explanation (McHugh and Slavney 1998). Medical and neurological inquiries may be standard or they may be exceptional. As part of a biopsychosocial assessment, the Cultural Formulation Index (CFI) might be done on every patient (see the "Cultural Formulation" chapter in DSM-5 Section III [Emerging Measures and Models]). Alternatively, no one on another unit might have ever heard of the CFI. Does the local culture encourage an attempt to "do it all"? Or does the local culture encourage the pursuit of only the most pertinent components of the evaluation? Does the culture encourage dissent?

Many U.S. clinicians work outside of an institution, but few work beyond the reach of such organizations as Medicaid, Medicare, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). These bureaucracies do not intrude into the subtleties of the interview, but their rules directly affect reimbursement, malpractice, documentation, and ultimately the expected interview.

Structure of the Write-Up of the Psychiatric Interview

Prior to meeting with the patient, the interviewer should anticipate what will be expected in regard to a write-up. Although interviews vary dramatically in terms of duration and structure, all initial psychiatric notes should include the same basic categories (Table 1-5).

Interviewers who do not anticipate these expectations will not be able to elicit enough specific information. At the same time, the amount of required information can seem daunting and lead the interviewer to feel like a rushed interrogator. Integration of these expectations will be discussed throughout this chapter.

Although longhand writing is still used by some clinicians, the electronic medical record (EMR) has revolutionized note creation. The resultant write-up generally mirrors the categories listed in Table 1-5. This information goldmine is crucial to clinical care, both at the time of the interview and into the future.

The EMR often affords the option of clicking boxes for much of the write-up, allowing the development of a multipage document without writing a sentence. The interviewer should be vigilant to avoid letting expectations drive the actual interview into a single-minded quest to obtain information, and should also not allow the sheer quantity of potentially available material to clutter the pursuit of a coherent history of present illness and differential diagnosis. Whether obtained directly from a living person or via cut-and-paste from elsewhere in the chart, information that is not scrutinized and put into perspective is unlikely to help.

Components of the Psychiatric Write-Up

Identifying information can either be limited to gender and age or include a lengthy list of potentially important demographics. For most purposes, it is useful to target variables that are pertinent to the particular interview. For example, if an urgent situation calls for an abbreviated clinical summary, it would probably not be appropriate to begin the written or oral summary with a list of all known demographic variables, most of which will be distracting red herrings.

The chief complaint is intended to be the patient's primary psychiatric concern and is generally written as a quotation. It is, therefore, not the spouse's biggest complaint, or the prior therapist's biggest concern, or the interviewer's assessment of what should be the chief complaint. This brief section belongs to the patient. Quoting nonsensical or tangential responses can provide an excellent window into the patient's mental status. Clearly marking the patient's priority is crucial because later treatment plans that do not explicitly address the patient's concerns are likely to founder.

The history of present illness (HPI) is the interviewer's integrated narrative of the patient's current psychiatric illness. The development of an accurate and effective HPI can be deceptively difficult. The present illness needs to be identified, and the clinician might need to attend, for example, to a 35-year-old man's report of having become hopelessly lonely after being abandoned by his girlfriend 3 months earlier, to the girlfriend's report that she left him after he had become violent while abusing crystal methamphetamine, to the ER doctor's report that the patient was admitted after an acetaminophen overdose the day before, and to the patient's mother's report that her son had been difficult for the prior three decades. After weighing the available information, the first sentence of the HPI might become: "Asked to assess for depression and suicidality in this 35-year-old man after he was admitted to the ER with an acetaminophen overdose in the context of crystal methamphetamine abuse, a relationship break-up 3 months earlier with subsequent dysphoria and social isolation, and chronic interpersonal difficulties."

Once the actual illness has been clarified, the HPI should feature a narrative that includes important precipitants as well as the onset, duration, intensity, and debility of symptoms. Commonly associated comorbidities and symptoms should be specifically included or excluded. It is worth noting that many of these historical details may not be accurately recalled or recounted, and that, throughout the interview, the clinician will need to be both earnestly curious and tactfully skeptical.

A model for the HPI is provided by news journalism. The newspaper headline focuses the story, as does the first sentence, and ensuing sentences explain and flesh out the details. When the newspaper suggests that the reader turn to page 19A, the reader can be assured that the initial thesis of the story will not be refuted on the later page. A similar literary technique stems from an assertion generally attributed to the playwright Anton Chekhov over a century ago: If a gun appears in the first act, it needs to be fired by the end of the play. "Don't bury the lead" is a central demand of journalism, just as it is crucial for playwrights to present a coherent story with an economy of detail. For the author of an HPI, it is equally important not to get distracted by red herrings that may be true but which do not contribute to a focused understanding of the patient's present illness.

Tip: One way to consider the HPI is as an argument to persuade the reader of the interviewer's point of view about the patient's current illness.

The journalistic approach to the HPI contrasts with another common HPI style, that of the essay. An "essay" sort of HPI builds to a point, eventually, but too often it reflects interviewer uncertainty. Such an HPI might begin with a lengthy description of identifiers that may or may not be relevant, followed by the chief complaint, followed by the beginnings of a story of the illness, the clinician's obstacles in the pursuit of that perspective, quotations from the interview with the patient, and somewhat random collateral and historical information. At that point, the presenter often looks up, waiting for questions, or, if it is a written HPI, the note simply progresses to other aspects of the write-up. This approach may be the expectation in certain hospital cultures—and trainees do need to be attentive to expectations—and it makes particular sense for situations such as case conferences, in which the audience is expected to think along with the clinician in the pursuit of understanding the patient. Nevertheless, there are problems with the "essay" form of HPI. The first is that every reader/listener has to develop his or her own perspective on the case, and that leads to errors, extra effort, and unnecessary ambiguity. At least as importantly, it can cause the clinician to suspend an effort to develop a working narrative and lead to the incorrect assumption that all true information is equally valid.

The past psychiatric history should focus on data that can guide current and future evaluations. Ideally, historical diagnoses should be accompanied by a list of pertinent symptoms and potential contributors, such as substance abuse. In discussing hospitalizations, the clinician would ideally elicit the name of the institution, the reason for admission, the discharge diagnosis, and the treatment and its efficacy. Mention of a medication or psychotherapy should be followed by the interviewer's best estimate of duration, intensity, adverse effects, level of adherence, and effect. Collateral information is important because patient recall can be fuzzy (Simon et al. 2012). Furthermore, it is important to recall that psychiatric illness tends to be chronic but that the specific diagnosis often develops over time (Bromet et al. 2011).

Substance use disorders are so common that even their apparent absence should be specifically mentioned in the HPI and/or the past psychiatric history section. It is also useful to recall that some assessments warrant inclusion in all three time frames; in other words, the HPI, past psychiatric history, and MSE might all include assessments of psychosis, suicidality, and homicidality.

Past medical history is potentially critical because psychiatric and nonpsychiatric medical conditions are frequently comorbid. In addition to eliciting a list of prescribed medications, the clinician should inquire about over-the-counter, complementary, and alternative medications, as well as activities that may potentially be therapeutic, such as exercise, yoga, and meditation.

Tip: The interviewer should not overvalue medical issues when handed a thick medical chart. Similarly, the interviewer should not undervalue medical issues when no collateral medical information is immediately available.

Family history refers to pertinent disorders found in biological relatives. Schizophrenia in a brother definitely should be recorded in this section. Diabetes in a first-degree relative may also be pertinent, especially given the link between metabolic syndrome and many psychiatric medications, and between diabetes and depression. Parental divorce and depression in a stepmother belong, on the other hand, in social history.

The developmental and social history will vary significantly in relevance. For children and adolescents and for any patient whose primary diagnosis appears in the DSM-5 chapter "Neurodevelopmental Disorders," much of the interview might focus on developmental and social issues. For other patients, this section is fairly irrelevant to a relatively brief evaluation and is unlikely to affect the eventual differential diagnosis. Cursory or careless reviews can lead to missing many types of pertinent findings, however, and even a "normal" childhood will be filled with experiences that could bear on better understanding the patient. A thorough developmental and social history can also point to strengths and weaknesses that might play a crucial role in treatment decisions.

Mental Status Examination

To a psychiatrist, the MSE is as important as the physical examination is to the general internist. As a relatively objective cross-sectional evaluation, it plays a key role in shaping and informing the history, labs, collateral information, and eventual treatment strategy. The assessment of mental status begins the moment the interviewer sees the patient, and most of it can be accomplished casually and outside the patient's awareness.

Tip: The MSE does not require a patient's cooperation or the interviewer's ability to read minds. The MSE is based on an interview-long snapshot of what the patient says and does.

When reviewed days, months, or even years later, an effective MSE can provide crucial data for a more longitudinal perspective. On balance, every MSE should include a basic set of information, as listed in Table 1-6.

Regarding general appearance and behavior, the interviewer notes the patient's level of consciousness, behavior, dress, grooming, and attitude toward the examiner. A well-considered assessment of appearance can, therefore, contribute heavily to the development of a differential diagnosis. For example, a disheveled, distracted, hypoactive elderly hospitalized patient presents a differential diagnosis that centers on delirium even before the interviewer or patient says a word. Level of cooperation can contribute directly to an understanding of the patient as well as to the meaning of the results of aspects of the interview that require some degree of motivation (e.g., the history, cognitive testing).

Tip: As with much of the rest of the examination, the interviewer should pay attention to details that do not quite fit the rest of the story. Appearance "idiosyncrasies" might include prominent tattoos on an otherwise buttoned-down businessman.

Mood and affect are often linked within the MSE. Mood refers to the patient's predominant emotional state during the interview, whereas affect is the expression of those feelings. The interviewer infers mood from the patient's posture and appearance as well as his own account of his mood. Affect is described in multiple ways, including range (e.g., labile or constricted), appropriateness to the situation, congruency with the thought content, and intensity (e.g., blunted).

Mood is sometimes said to be akin to climate in that it reflects long-standing emotions. Using temporal course as the key variable, affect becomes the more changeable weather (see the DSM-5 Glossary of Technical Terms). One problem with this definition is that the interviewer will be tempted to shift from having a cross-sectional perspective on the patient (i.e., based on an assessment of the patient's mood at the time of the interview) to making an estimate of the patient's mood during the entire course of his or her illness. In so doing, the interviewer's assessment of mood and affect has shifted from being a component of the cross-sectional MSE into the more longitudinal HPI. A third way to assess mood is directly from the patient's self-report, so that mood is summarized in quotation marks; the interviewer's assessment is affect. Putting the mood in quotations readily identifies the patient's perspective and reduces the need for the interviewer to infer mood.

These latter definitions of mood and affect can be confusing to trainees, at least partly because they do not conform to standard English. The mood-as-climate, affect-as-weather dichotomy is often misremembered by trainees, whereas quoting a patient's perspective on her own mood often requires the interviewer to list a mood state that is clearly inaccurate. While the quotation "fine" reveals something about the patient's level of insight into her mood and psychiatric situation, it does not address her actual mood (Serby 2003).

Tip: The interviewer should pay attention to local customs and expectations. Expectations for the HPI, the MSE, and even words like mood and affect will vary across different clinical services at the same institution, as well as across different institutions, regions, and countries.

Speech patterns are a useful window into the patient's thought process. For example, rate, volume, and organization of speech should be observed throughout the interview. Pressured, tangential speech is often found in mania. Slow speech with impoverished content is often found in depression, schizophrenia, and delirium. Guarded, withholding speech can accompany paranoia.

Tip: Based on patterns of communication, diagnoses can often be tentatively made within moments of meeting a patient.

The evaluation of thought content focuses on unusual, preoccupying, or dangerous ideas. Delusions are common in psychosis, for example, whereas ruminations of guilt are common in depression. Such thoughts can be intrusive and unpleasant (e.g., some obsessions in obsessive-compulsive disorder) or gratifying (e.g., some overvalued personal beliefs).

Suicidality and homicidality are integral to the evaluation of thought content. For both, the interviewer should assess for ideation, intent, and plan, as well as access to weapons. Interviewers will sometimes shy away from such exploration, perhaps fearing that introduction of the topic will cause the patient to become irritable, offended, or destructive or that any mention of suicidality or homicidality will inevitably lead to psychiatric admission. Such concerns are generally unwarranted. Passive suicidal and homicidal thoughts are common, and discussion can often lead to a deepening of the alliance. Furthermore, most such thoughts do not lead to involuntary treatment. More importantly, people who do eventually kill themselves or others have often sent out clear warnings beforehand. Although assessments are imperfect, the psychiatric interview is a crucial time to identify people at risk (Fowler 2012).

As with other aspects of the MSE, the suicide and homicide assessment is intended to focus on the patient's current thought content (Perry and Stein 1985). If the patient is denying all suicidal ideation the day after a clear suicide attempt, the MSE might indicate the following: "Denies all suicidal ideation, intent, and plan (but did overdose yesterday; see HPI)."

Perceptions refers to any perceptual abnormalities, including hallucinations, illusions, derealization, and depersonalization. Distinguishing between these types of misperceptions is crucial for both diagnosis and treatment.

Hallucinations have the clarity and impact of true perceptions but without the pertinent sensory input (see the DSM-5 Glossary of Technical Terms). For example, someone who "hears voices" is hearing a voice coming from outside her head that generally consists of meaningful sentences or phrases. Hallucinations that occur just prior to falling sleep and just prior to waking are termed hypnagogic and hypnopompic, respectively, and are considered normal. Talking to oneself is not considered an auditory hallucination (even if so labeled by the patient), nor is misinterpretation of actual voices from the hallway (those are often misperceptions and/or reflections of paranoia). Auditory hallucinations have long been associated with schizophrenia, but they are also present in psychoses related to mania, depression, delirium, substance abuse, and dementia. Hallucinations can occur in any of the five senses, although nonauditory hallucinations tend to be symptoms of neuropsychiatric and/or systemic medical disease.

Illusions are misperceptions of actual sensory inputs. For example, a delirious patient might misinterpret the shadows on a television screen as crawling bugs.

Depersonalization refers to a sense of being detached from one's own thoughts, body, or actions, whereas derealization refers to detachment from one's own surroundings. They often co-occur. These symptoms are less often explored than hallucinations or illusions; if found, however, they can trigger further search into often comorbid conditions that range from substance abuse to PTSD to dissociative disorders.

Assessment of cognition is an important part of the MSE. The same interviewers who freely ask their patients about sex, money, and a variety of socially undesirable behaviors often become sheepishly apologetic when faced with doing a formal cognitive assessment. It is important to be straightforward. For patients with no risk factors or signs of cognitive decline, a cognitive screen can be done quickly, and experience with normal cognitive examinations is helpful when faced with abnormal examinations. For patients with apparent neuropsychiatric dysfunction, it is crucial to have a working knowledge of typical symptom clusters and disorders that can help make sense of the functional decline (Yudofsky and Hales 2012).

Orientation is generally assessed by the patient's accurate recitation of name, location, and date (i.e., orientation to person, place, and time). Some texts refer to a fourth dimension, the situation, whereas others probe more deeply into specifics (e.g., orientation to person requires not only a knowledge of one's name but also one's address, phone number, age, occupation, and marital status). The inability to correctly state the exact date and location is fairly common and may reflect problems with memory and motivation rather than orientation.

A brief MSE screens for three types of memory dysfunction. Immediate recall is essentially an assessment of attention and is most often tested by asking patients to repeat the names of three unrelated objects (e.g., apple, table, penny).

Recent or short-term memory is typically tested by asking the patient to recall after a few minutes the three objects repeated as part of the test for immediate recall. If the patient was unable to repeat the objects in the first place, the inability to recall after 3-5 minutes does not necessarily indicate the loss of short-term memory but could instead reflect inattention or amotivation.

Long-term memory is generally assessed during the course of the interview through the patient's ability to accurately recall events in recent months and throughout the course of a lifetime. Many patients with dementia will retain long-term memory, whereas patients with a dissociative disorder often present with clinically relevant memory gaps. Distortions and embellishments of the past may be psychologically motivated and not indicative of cognitive decline and would therefore not be addressed in this category. Confabulations, on the other hand, are false memories that are created to fill in memory gaps; they are linked to neurocognitive disorders and are therefore included in the MSE.

Attention refers to the ability to sustain interest in a stimulus, whereas concentration involves the ability to maintain mental effort. Counting backward by 7s (serial 7s) requires that the patient retain interest in the task, recall the last number, subtract 7, and then continue to the next number. The task also requires competence at math. Spelling world backward is a similarly good screening test of attention and concentration, but only for people who are fairly good spellers. For other patients, it is preferable to use a test that is less dependent on education, such as reciting the months backward.

Tip: All formal cognitive assessments demand some awareness of the patient's cultural and educational background and any variables that could impact performance, such as motivation, anxiety, or pain.

Disturbances of orientation, memory, attention, and concentration often cluster together and may reflect a wide range of diagnoses, including dementia, depression, attention-deficit disorder, and dissociative disorders. When disturbances are found, it is generally wise to do a more detailed screening. Brief, validated tools for cognitive assessment include the Mini-Mental Status Examination (Folstein et al. 1975), the Montreal Cognitive Assessment (Nasreddine et al. 2005), and the Clock Drawing Test (Sam-ton et al. 2005). Each has its strengths and weaknesses and is available free on the Internet. None of these assessments is diagnostic, however, and a thorough assessment of the patient will require integration of the findings from the MSE with the rest of the interview.

Abstract reasoning can generally be assessed during the course of the interview. Proverb interpretation is often used as an adjunctive assessment. For example, the interviewer might ask, "How would you explain the following to a child: 'You can't judge a book by its cover'?" Patients with mania often respond with a tangential riff, whereas many other types of patients respond with concreteness and a lack of imagination. Proverbs are notoriously bound to cultural and educational norms, however, so the clinician should be careful not to be misled by suboptimal answers.

Insight and judgment are often linked within the MSE because both are part of interrelated skills and behaviors that include such executive functions as reasoning, impulsivity, initiation, organization, and self-monitoring. Because psychiatric diagnoses are rooted in the concept of dysfunction (without dysfunction, there is generally no disorder), a clear assessment of these functions is crucial.

Insight refers to how well the patient understands her own current psychiatric situation; it does not refer to insightful perspectives on politics, sports, or the interviewer. Judgment is often extrapolated from recent behavior or by asking such questions as "If you were in a movie theater and smelled smoke, what would you do?"

The assessments of insight and judgment depend heavily on context. For example, the structured calm of the interview setting can lead many patients to appear healthier than their recent history might suggest. For example, a clinician might interview a patient during his fourth ER visit in as many weeks, and all four have involved relationship conflicts, illicit substance use, and sublethal suicide attempts. If the patient describes his situation insightfully and is able to indicate what he might do in the burning theater, few clinicians would be content to describe his insight and judgment as being "intact." If the MSE emphasizes, however, that the patient has poor insight and judgment based on recent history, the interviewer is intermingling the HPI—which extends over recent days, weeks, or months—with the MSE, which is intended to be a cross-sectional snapshot. One option is to explicitly distinguish between the longitudinal and cross-sectional types of assessments within the MSE (e.g., "Judgment: currently able to discuss choices reasonably [recent judgment, however, has been poor; see HPI]").

Assessment and Plan

The psychiatric interview often has multiple goals, but an ultimate focus is the development of an integrated assessment and treatment plan.

Expectations for an assessment vary dramatically. A brief narrative of the patient's story is generally useful, especially if it very cleanly illuminates the presenting problem, but the assessment section is not an opportunity to rehash the entire clinical situation. Verbiage reduces the likelihood of the reader's focusing on the important. The assessment section should, however, always include specific DSM-5 diagnoses.

The concluding plan should be brief but aim for biopsychosocial completeness. In other words, "sertraline 50 mg in the morning" is not a plan if it is not accompanied by some reference to who is going to write that prescription, whether psychotherapy is recommended, and whether the patient's environment should be adapted in some way.

The interviewer may be expected to provide, in addition to the write-up, a brief written or oral summary of the patient. The particulars of the summary will depend very much on the situation. For example, insurance companies and other institutions will probably want the summary to be limited to codes for diagnosis and procedure; the clinician will then need to be prepared, of course, in case they request access to the full written evaluation.

For clinical purposes, most curbside discussions between colleagues will feature a focused version of the history, assessment, and plan. For example: "This is a 27-year-old man who presented with hallucinations and paranoid delusions that began a month ago in the context of some marijuana use and insomnia, as well as a lengthy prodrome of declining function and odd behavior. Our tentative assessment is schizophrenia, but we will need to specifically evaluate for substance-induced psychosis. Our plan is to admit him to psychiatry, get more collateral information, provide support and structure, ensure sleep, and begin antipsychotic medication." Such a summary is too brief to satisfy all needs, but it provides a framework for further exploration.

Key Clinical Points

• Nonverbal communication and observation are crucial.
• Without a strong fund of knowledge, the interviewer will get lost.
• Information is useful only when interpreted.
• Not all information is relevant'.
• The interview should be adapted to fit the patient and the situation.
• The history of present illness is a creation of the interviewer.
• The history of present illness is longitudinal.
• The mental status examination is cross-sectional.
• It is difficult to balance the many mandates of the psychiatric interview, but the task is made easier through the active cultivation of such interpersonal characteristics as curiosity and warmth.

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Peteet JR, Lu FG, Narrow WE (eds): Religious and Spiritual Issues in Psychiatric Diagnosis: A Research Agenda for DSM-V. Washington, DC, American Psychiatric Publishing, 2011

Roberts LW, Louie AK: Study Guide to DSM-5. Washington, DC, American Psychiatric Publishing, 2014

Samton JB, Ferrando SJ, Sanelli P, et al: The clock drawing test: diagnostic, functional, and neuroimaging correlates in older medically ill adults. J Neuropsychiatry Clin Neurosci 17:533-540, 2005

Serby M: Psychiatric conceptualizations of mood and affect within the mental status examination. Am J Psychiatry 160:1527-1529, 2003

Shea SC: Psychiatric Interviewing: The Art of Understanding, 2nd Edition. Philadelphia, PA, WB Saunders, 1998

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Suggested Readings

Barnhill JW (ed): DSM-5 Clinical Cases. Washington, DC, American Psychiatric Publishing, 2013

MacKinnon RA, Michels R, Buckley PJ: The Psychiatric Interview in Clinical Practice. Washington, DC, American Psychiatric Publishing, 2006

Othmer E, Othmer SC, Othmer JP: The Clinical Interview Using DSM-5. Washington, DC, American Psychiatric Publishing, 2014 (in press)

Shea SC: Psychiatric Interviewing: The Art of Understanding, 2nd Edition. Philadelphia, PA, WB Saunders, 1998