How's it going? This episode will be an overview for an approach for the psychiatric interview. If there's anything in this episode that you have questions on or you want us to elaborate on, just let us know and we'll probably include it in the part two that we will record. next week or the week after. This isn't just engagement bait. Dr. Fu specifically requested that I record this intro.
According to him, he is quote-unquote chronically online, and the only primary gain he really gets from this podcast is reading comments about what he's saying.
Today's topic, which I believe we're going to be talking about structuring the intake hour, and we have about an hour, probably less, to talk about it,
Yeah, I want today to be a relatively nice overview on how to do a psychiatric intake.
Now, as we were discussing off air, I do think it's a little bit of a clickbait title. We thought people might respond to the idea of an intake hour a little bit more. But what this really is, is it's a one way out of many to think about and structure any diagnostic interview in psychiatry, especially for brief interviewing. But I think it applies even if you have several hours to interview, which is pretty much unheard of these days.
in one block unless you're doing a forensic evaluation yeah i'm hoping it's a
relatively adaptable approach so that people because you know you kind of get thrown in there and i there's very little guidance as to how you're supposed to do an intake or how to think through it um so i think you know giving a little bit of structure and explanation for what you're supposed to be doing and how you're supposed to be doing it would be very very helpful yeah
And maybe it would make most sense to talk about what kind of issues do you think you've run into or seen or found yourself in your own development in terms of difficulty completing or doing an assessment and evaluation on the first contact with the patient? What are the challenges that you see people running into or yourself?
I think You know, the biggest one I'm seeing in today's landscape is patients requesting evaluations for specific disorders. So I have a lot of intakes where it's, I want an assessment for ADHD, or I want an assessment for autism. And I'm hoping that when we explain how we think through the initial appointment, people will understand how to better approach those questions. Because I know, I see with the people I supervise and how I felt early on, feeling very uncomfortable with that question, not knowing how to do a specific interview.
And then also, it's almost as if asking the question begets an interview that's guaranteed to get that diagnosis when you do the structured interviews that are for those specific diagnoses.
yeah exactly you know coming in and saying i wanted to be evaluated i want to be evaluated for xyz it makes sense as a patient you know it's intuitive but i think it assumes a lot about psychiatry as a field and it's practice that just isn't true it's not like you can come in and get checked out for pneumonia you know we can't just do an x-ray just doesn't work that way so i guess we'll just dive right in um You know, I would say that what you mentioned there is what I would point to as one of the major difficulties.
I think trainees, especially in the post-DSM3 era, not that I practiced before DSM3, but I think that the understanding of psychiatric diagnosis has changed. And therefore, interviewing has centered around eliciting yes or no's for diagnostic criteria. And that is not how you conduct or not how I think you should conduct an intake, a diagnostic assessment and the process of diagnosis itself.
Yeah, totally agree. There's almost like this circular thing of like we shouldn't simplify the field to patients essentially filling out, you know, self-questionnaires. Like because when you're asking yes or no questions and not thinking of how they're being answered rather than if it's just yes or no, you're really just doing a patient self-questionnaire, which I think our job is a lot more complex than that.
yeah uh think of it this way if you quote assess someone for a specific condition and you simply ask them if it's there or not you could have just asked a patient do you think you have adhd and then ended the interview okay so anyway i guess we'll start um What I like to do is I like to recommend whatever your intake time is, and people have variable intake time.
Some of them are disgustingly short. Some of them are nice and long, but there are systemic problems in the paperwork that still make it pretty unlikely that you can get a good evaluation. Whatever amount of time you have, For your first assessment of the patient, I think you should kind of think of that total amount of time and partition it out into rough percentages in a certain sequence that you're going to use to spend time on doing different activities with the patient.
Yeah, I think that's great. And I think once we explain what those percentages are, this will make a lot more sense in terms of, you know, because you really do get assigned the amount of time to do an intake. And in my opinion, for complex patients, it probably takes like three hours of questioning. And I don't know about you, I've never had a clinic offer me three hours of intake time.
Yeah, unheard of. Oh, I did want to address that too. I think at the end of this, we should talk about how do you approach lingering issues that you can't diagnostically get into on the first assessment, which is just a reality of any treatment setting today. So anyway, I think an underrated part of Even the first intake hour is the first way you present with the patient and your explanation of what is going to happen.
This is basically frame setting. You know, even if you're not getting into a psychotherapy, talking about frame boundaries explicitly can be really helpful. Some patients come locked and loaded. They've had psychiatric treatments before. Right. They're not new to this kind of thing. Nonetheless, I would say that you should have a uniform way of introducing yourself in the purpose of the meeting. to every patient, even if they're an experienced patient, because there's a lot of variation between different doctors, right?
And you want to make sure that you're both on the same page before you get into it.
I would love if you would cover first the things that you think are important to cover with each patient. And second, if we could do a little role play of your initial spiel with the patient.
Yeah. Well, what you cover, I think, depends on your scope of practice. And, you know, a psychiatrist is a very wide range of practice these days. Maybe all you are is you're the neuro intervention guy, right? You're just doing TMS ketamine or something while they have a primary psychiatrist. Maybe you're the urgent care psychiatrist. Maybe you're somebody that is consulting on a case because it's a very complicated case.
You're at an academic center and they've referred someone to you as an expert, you know. and maybe you're just your run-of-the-mill outpatient psychiatrist but even if you're a run-of-the-mill outpatient psychiatrist practice settings of different um expectations and understanding some psychiatrists are explicitly doing some kind of a combination even in billing psychotherapy and medication management at each visit right some psychiatrists are really not doing any bona fide psychotherapy at all you know even if you're being psychotherapeutic with each medication management visit you may not actually be doing a therapy and you need to be first of all clear to yourself as a clinician what exactly your scope of practice is what's this treatment modality and then you need to communicate that to the patient so i would if we're gonna give an example of this Let's restrict it to my clinical setting, not the forensic setting.
And it's going to be pure medication management in a multidisciplinary team where the patient already has a separate therapist.
Yeah, and I think, you know, to elaborate a little bit on what you're saying, actually, the first thing I do in my appointment is establish with the patient what my role is gonna be before even giving my spiel or conducting the interview. So I currently, I work at a clinic that offers interventional treatments. So some patients are coming to the clinic wanting a therapist, some people are coming wanting a medication prescriber, and some are coming wanting an interventional treatment.
So the first thing I do, I say, I think it's really important to establish what it is that you're expecting from treatment and what your role is that you want us to provide for you. So do you have a medication prescriber that you plan to keep and will be kind of doing the consultation role of providing the intervention? Or are you expecting us to kind of manage all of your psychiatric treatment?
So step one before I can even think through the spiels and what I'm going to be asking is establishing my role as quickly as possible. This can be a little bit painful because sometimes patients are like, oh, well, I'm not really sure. But it's really important to hammer in and understand what's the role that you expect me to be doing because it completely changes how I'm going to be doing my interview.
Yeah, really nice summation of the issues there. Some settings, the patients have more of a choice, right? And then you're going to want to elicit from the patient information. Some settings, especially managed care, the patient does not have a choice of treatment they're going to be getting. And you're going to have to tell them that even if you wanted to, and I do want to give them more treatment than I can, it's just not possible under that setting.
So that's the long and the short of it. You want to say who you are, what your role is, and what it is that you're supposed to be doing together both longitudinally and within this initial diagnostic assessment.
So can you talk to me about, let's say you're at a clinic, you're the medication prescriber, what exactly do you say?
Well, I will say, again, what I say is tailored to the setting. And before I launch into that, I also want to mention There's an argument that you should do a full disclosure about your limits of confidentiality at the first visit. You know, I know not everyone's doing that. I do it for my forensic evaluations. I think the psychologists are a big fan of this in explaining the limits of confidentiality and what needs to be what is a mandatory reporting requirement.
We're not going to get into that, but. I think it's worth considering whether you want that to be part of your standard, and it doesn't hurt to have it. So you probably should be doing it like the psychologists do. But anyway, what I do is this. I say, hi, I'm Dr. Fu. I'm a psychiatrist, and I'll be your psychiatrist moving forward. And what we do here is that you're getting therapy from somebody else, but I'm going to be seeing if there's anything that we might want to treat with medications.
So what we're doing today is I'm going to be doing a medical interview to reach some kind of a diagnosis so I can figure out which medications are appropriate for you and might be able to help you out. Now, I'm not sure you've had one of these before. And even so, I might do this a little differently than other doctors that you've had in the past. So excuse me in advance.
I will be interrupting you and I will be asking you quite a lot of different questions about things that can be difficult. blah, blah, blah, other disclosures. Then I have kind of a stock line. I say, so letting your mind wander, thinking about your life and your mental health symptoms, both today and across your life, what would you say are your major mental health symptoms or problems that you think medications might be able to help you with?
That's a very specifically tailored line that I use. Why? Because if I don't overemphasize the medical diagnostic value and purpose of the encounter and the overall treatment, I find that Patients will essentially get confused, rightfully so, about why we're there. And we're not there in medication management to have patients vent. We're not there to do a supportive psychotherapy, even if we will deploy some of those techniques and the overall trajectory of the treatment can be supported in nature.
We're there to try to get as accurate as possible of a picture diagnostically and formulation wise of the patient in order to recommend them certain treatments, medications or other. That's the purpose of it. So I try to be very explicit about that or it's very, very easy for it to turn into crisis of the week. visit plus are you having side effects with medications? Do you want those changes, right?
And that's not really proper treatment, not in my mind.
Yeah, and I love that. You know, sitting in the frame really changes how treatment progresses. Two things you mentioned. I always... I always love when like our approach overlaps on things that I never explicitly read about, but kind of like learned on my own and then started doing. There were two things you mentioned that I mentioned every time on my little spiel. First is I say, you know, I always say how exactly how much time we have during that appointment.
And I say, During the first appointment, I interrupt, I jump around, I ask a lot of questions. I promise moving forward, I'm going to be better at listening. There's just so much information I need to gather in this first appointment. So I tend to be a little bit more scatterbrained and interrupting more than normal. I say that almost every time. And the second thing I do also say is a lot of times, sometimes we'll broach topics that are overwhelming.
You know, it's important for me to get this information, but it's not so important that if you feel like something's overwhelming or at any point something's kind of making you feel strong emotions that are a little bit overwhelming, let me know. It's not super important that we have all the details today.
Yeah, that's really good. And I do do that as well. What I do is, in my setting, I don't see patients exactly blind. They've already had some form of assessment before. So when I know that a patient is a traumatized patient, I open with that as well. You know, when I can expect that the interview is going to naturally cause some kind of dysregulation for most people.
Yeah, that was something I learned for a lot of times when I'm collecting all this information, I'm not, you know, my brain is in the mode of organizing and putting things into different boxes and like in flowchart mode that you can miss a patient's internal state. And for a lot of patients, reviewing their history is... really overwhelming. Like, you know, when you're asking about their past hospitalizations, their past traumas, their relationship history.
For patients who have really traumatic pasts, it brings up a lot. And it can activate defenses. It can make people really upset. You know, just during one intake, I was in that information gathering mode and I accidentally pushed a patient too far and they got really upset and overwhelmed. And ever since that time, I let them know, like, I don't need to know every single detail. We can have a black box from this appointment knowing that there's some things there that we're not going to touch on today, but we'll hopefully get to them eventually when you're feeling more safe.
yeah and the sort of associated skill that it's good to develop is your ability to simultaneously interview diagnostically and track the affect and anxiety level and dysregulation of a patient that's really something i think you learn more from some practice of formal psychotherapy but of course you can develop that as a medication management doctor you know yeah dysregulation doesn't get you good information anyway and dysregulation can look subtle and can be freezing rather than aggressive active so you just want to be aware of that Should we touch a little on maybe how this would be changed by the setting?
Like if you're an emergency doc or inpatient?
Maybe let's because I don't want to broaden it to a point where like, you know, we're touching on too many things. So maybe unless you had a specific point, I think maybe I guess I'll just do it quickly.
Yeah. I mean, I guess you might want to emphasize the purpose of the meeting. inpatient or urgent if it's involuntary I think it's good to touch on why you ask these things and try to orient it towards what most patients are kind of interested in you know a lot of people are there involuntarily you might say And, you know, this information is important because it's going to help us figure out when we might be able to let you go.
You know, just something that you can touch on. But the purpose of the frame is not only to intellectually tell the patient what is actually going to happen, but also to try to establish some common ground between you and the patient. So there can be the beginnings of the therapeutic alliance that you're aligned on the goals and the tests.
Yeah, that's great. One other thing I also want to touch on in regards to starting out with your intro and setting the frame, how warm and likable you are and come across. There's actually kind of a sweet spot in regards to... To me, I'm making sure to balance how warm, friendly, and professional I am. Because certain patients will pull you into certain things. And there's a lot of practitioners who will actually get pulled into being too friendly, too warm, too likable, too joking.
This is something that takes kind of a lot of experience until you have a lot of experience. You try to keep things as similar as possible. But a lot of patients... We'll try to pull you into being their friend, pull you into being, you know. And we've kind of talked about how the psychiatric relationship is not a normal social relationship. And my goal is not to be as likable and as friendly as humanly possible.
My goal is to balance them feeling warmth towards me, but also understanding that this is a professional relationship. So... noticing how much there is a pull to like you know not be my normal doctorly self and instead be like hey bro or you know like be too likable um and and resisting or
it's just a disinterest you might be automatically disinterested for some patients
you gotta balance it as you say so somebody's got to turn up the friendliness and sometimes you got to turn it down Yeah, yeah, exactly.
I like the barometer of, I've read this somewhere, I can't remember where, physicianly concerned. Okay. Yeah. Your level of warmth should be physicianly concerned and interest. You know, interested and warm, but not overly so. Something balanced. If that's not too helpful, I would recommend you go on YouTube and you search interviews by Les Havens, L-E-S, space, H-A-V-E-N-S. I think he kind of embodies that in the majority of his interviews.
OK, so that part should not take more than a couple of minutes, though you'll be sometimes surprised and what some patients that's going to suck you into a whole discussion that can take up a lot of time. But I'm going to tell you right now, if it does that, that's a good thing. OK, you spending that extra time at the beginning is going to save you a lot of headache down the road.
If this is not something that a patient can immediately accept and understand and get on the same page as you would, as with you.
Yeah, and it's a great point. Another small little topic that comes up is sometimes I've had appointments end at this point because, you know, I think in residency, one patient came in wanting, they had a severely autistic child who was nonverbal and they wanted help with the behavioral component. That's not my, like I had to explain to them, I have no experience in that. That's not my specialty and referred out and it would have wasted both our time.
Exactly, right. Inappropriate referrals. It's a great way to get through that. Absolutely.
I feel bad because early on, I would go through that full intake and then be like, I don't really know anything about the condition we're talking about. It hurts the patient up front when they spend time on a wait list and wasted these five minutes with you, but it's much better than them having to pay for the intake, spending an hour and a half, divulging all their history, and then you going like, Oh, actually, the whole time I knew I wasn't being able to treat you.
Exactly. Yeah. Even if they don't pay a cent, they are paying emotionally. And that is a big toll.
Okay, so that's kind of the preamble, right? You're setting the frame. I would say that the next and most important part of the psychiatric intake of the diagnostic evaluation is a period that I call eliciting free association or building up narrative. I don't know if I have one uniform way I refer to it. But you should know that it's not just having patients ramble, and it's not free association purely in the sense of we only want them to free associate.
But what I'm emphasizing here is that the first, I would say, 20% of your time spent in a diagnostic evaluation should never consist of structured interview questions or eliciting specific diagnostic criteria. That is a poor way of getting to a diagnosis. Instead, there are two primary questions, topics that I want the patient to riff on. I want the patient to free associate on these prompts and to spin out their narrative and I'm going to use, uh, empathic mirroring and clarification techniques.
Um, we're not gonna get into that right now, uh, in order to get them to broaden the details and the depth of their mind wandering upon these questions. And the two questions I'm sure anyone's who had a solid psychiatric training, this was probably drilled into them. Um, two questions are, uh, why now? And what is your chief complaint or your chief complaints? Right. And so that goes back to that question I ask.
When I ask, what are the main symptoms or problems with your mental health that you think medications can help you with? I will often ask that question repeatedly, not verbatim, but I'll say, OK, so you say you have depression, anxiety. Is there anything else that bothers you or you think is a problem? Is there anything else? Is there anything else? Is there anything else? OK. When did these problems start for you?
Okay, was that really the first time you had that? Did you ever have it in a more minor way before? Then, having collected some of that information, I will say, and so if those problems started then, what sort of made you feel like this was the time to come in? What changed in your life? and then beyond that the free association includes depression and anxiety tell me about that what's that like for you what happens or what changed with your life day to day that made you know that you had these problems just open-ended non-specific questions have the patient described to you genuinely what they've gone through what their day-to-day life is like or how things have changed and if you do this enough you're going to find that probably 90 of patients with genuine psychopathology are going to be capable of simply telling you DSM diagnostic criteria without you ever mentioning the DSM criteria, because that's their lived experience.
Another 5% are sufficiently alexithymic that they cannot do so without some kind of assistance, and that's okay. Then you'll capture that on DSM structured interviewing. Then I got the percentages wrong, but 1% will be malingering. Less than 1%. So just break down these percentages appropriately.
This, and I think this 20% is the most important part of the interview. A big problem, and when I supervise different clinicians, it's funny because I have to communicate the same thing that I try to communicate to the patients. A lot of times they'll come in and say, oh, they have depression, anhedonia, and they list very clinical terms. I push so hard. Give me the narrative. Give me a picture.
When you say depression or anhedonia, I don't have a picture in my head of what's going on or this person. I like a free-form narrative. And when patients, a lot of patients now that, you know, TikTok psychiatry and everything, they come in and say, I have, you know, I have ADHD. I have rejection sensitivity. All these clinical terms. I say... that's great that you're up to date with these terms.
I wanna hear a narrative. I wanna kind of understand what's going on. And a lot of times these clinical terms can obfuscate more than they, they make it harder to understand what's going on than actually clarifying what's going on. So having an understanding of who this person is, what's going on in their life requires a narrative and not a list of symptoms or criteria.
Absolutely. I guess another way to look at this is that it's not simply about feeding patients symptoms that they can just agree with. That is one issue, right? It's not just about the fact that jargon and abstracted terms can kind of disguise a lot of truth or reality because it's just an extremely fast way of summarizing something. We don't want the summary. We want to try to get down to the details when we do diagnosis.
It's also that on your end, on the physician's end, you're not doing a diagnostic test when you collect DSM criteria. DSM criteria is not a diagnostic test. It's not... they treat it that way especially the psychologists who build these instruments in these psychological tests okay that's not a test that is a description of a syndrome and it's the incomplete description of a syndrome okay you the physician you're trying to get a medical history in the traditional sense the way you were taught in medical school you're getting a medical history so that you can form a differential diagnosis on it so that's going to include everything that you can think of onset you know a character right duration, aggravating leaving factors, timing, periods of remission, and any of the associated issues, okay?
And you need to paint out a picture of the time course of their lives, this patient. You want to know when they were troubled, when they were not troubled, why, fluctuations. Think of drawing out a graph of this patient's life from birth to the time that they've seen you and that you're going up and down in terms of levels of psychopathology or types of psychopathology and life functioning.
You're not just looking at the slice today and saying, do you have the DS criteria?
Yeah, and that's, you know, I feel like I learned that most when I was trying to learn how to do a bipolar assessment where I have the same thing where I like to have, be able to close my eyes and see a visual of the X axis being time and the Y axis being their mood and saying, you know, for a lot of patients, it's like, okay, you say you have depression.
How many depressive episodes have you experienced? And the answer to that will give you a ton of information because some patients will look at you very confused and go like, what do you mean episodes? um and and and really trying to have a visual in your like deciding that you're gonna try to in your head draw that visual helps you structure questions to make it so that you can obtain that information um exactly and it to me like having that visual of the ups and downs in mood for the mood disorders is crucial for understanding prognosis for understanding my recommendations um so yeah i really like the life course perspective especially for for mood disorders
Yeah, so you've gotten basically kind of a broader life course of the psychopathology, hopefully. You've gotten also the narrative description of the symptoms, problems, and impairments that the patient goes through as a result of these periods of psychopathology, okay? You've done so without revealing exactly what it is that you're looking for. What do you do next? Well, before you even move on, I would say that while this process happens, you should be already forming your differential diagnosis.
In your mind, you should ideally be thinking of major categories of mental health conditions, psychopathology that can explain this life course and the presenting symptoms and problems. So if you can get major categories in your mind, I would say the top three of what diagnoses you think the patient that could explain, at least in part, the patient's lives, their life so far, that's going to get you really on the right step towards the rest of the intake.
And in terms of categories of diagnosis, I do think the DSM is useful for that. using the major DSM chapters, being aware of their names, use that as your major differential diagnosis. Don't drill down to a specific diagnosis within each chapter just yet. Simply think of the major category first.
You mentioned talking about the chapters. I'll walk through all of them. It's like psychosis, bipolar, depression, anxiety, OCD, trauma, dissociative disorders, somatic disorders, eating disorders, sleep problems, sexual problems, impulse control, addiction. neurodevelopmental neurocognitive personality and then medication side effects i'm
not using the and personality is the most neglected one i'm gonna say personality is the most clinically neglected category today uh but we'll leave that side um
just on that topic as you say personality is disregarded um you know As we're talking about this, I will say that a lot of times as I'm trying to conduct my intake, as you mentioned, like trying to get that free form narrative, asking questions, there's a large subsection of patients who I'm not able to get an answer in my head for any single question. And as a novice physician, like you really need to gain confidence to understand that that's not coming from you.
And that like, I now know that 90% of my intakes, I'm able to ask these questions and get the answers. And when I start to beat myself up during an intake, or I'm like, I have no idea what the heck's going on. I've asked 10 questions and I still haven't gotten the answer to a single one. And each question actually opens up more questions. Remember that you're paying attention to the process.
So that is a ton of information. I shouldn't, I'm now experienced enough that I should not feel stupid during an intake so that if I am, that's diagnostic information as to what's going on.
There's a sort of fragmentation of narrative and self-awareness or at minimum that this is a very complicated patient that may have very unusual things going on and does not present like a DSM diagnosis, right? Yeah. the lack of information as you say is information the response to the test is part of the test and i do think that brings us to our next point in that once you've done your minimum 20 time spent on free association and elaboration narrative in the service of finding about onset and why now and timing you have kind of a branch point in what you're going to do next and there are two options option one is i think what most people think is the entire diagnostic interview asking structured or semi-structured questions to elicit dsm criteria okay that can be done and shouldn't be done to confirm diagnosis based on the initial evaluation and your top three dsm categories But especially if you don't have a strong set of differential diagnosis categories that you're working with, you're confused, the patient is confused, this is the time to avoid structured questioning.
Now you should go into the rest of the history. You probably all were trained to collect all these random things in a standard intake, right? The history. By the way, I would disregard the quote review of systems. That is a artifact of insurance. It's not part of the medical interview. All right. But if you don't have a solid set on the, you don't have a solid grasp on the differential after that first part, I would just go straight to history.
Okay. And that includes all the history you can think of. Social history, psychiatric history, family history, medical history, treatment history, and am I missing anything? Oh, substance use history. That's a big one. And drawing out the timeline of that as well.
Maybe to elaborate what you're saying and when you're saying structured interviewing, you're either naming specific things like going through the SCID or for ADHD, the Diva. These are kind of little structured things that go through each of the DSM criteria. Or even, you know, for in my practice, they want us to do a lot of scales, you know, doing like the Madras, the Ham A. What you're saying is that it's not that helpful to, at this point in the interview, kind of anchor yourself into those things.
And it's much better to kind of to get more of the history of the present illness to understand better past history and what's going on now.
yeah because if someone has insufficient recall or uh defended recall of past illness history then you need to guess get past living history or health history so to speak right we're still in the project of drawing out the patient's whole life more or less their level of functioning and any presence or absence of impairments This is something I really began to focus on when a lot of my evaluations were competency to stand trial evaluations.
These are people who generally have little to no insight of their psychotic disorder or bipolar disorder. and are being referred under a context where they are extremely motivated to consider themselves and present themselves as mentally healthy. So if you go into that kind of evaluation and you do a structured interview, they're just going to deny every single symptom that you ask about. They'll say, no, doctor, I'm perfectly fine.
So instead, I want to know, What was your schooling like? Any learning disabilities? Any pedic grade special education? Did you ever get referred for testing or for treatment as a young child or as a teenager? What happened with your high school? Did you ever get delayed? Did you graduate on time? And what did you do afterwards? Have you worked? Have you ever had disability payments? Have you ever been homeless?
Have you ever done XYZ? You're going to have to titrate the kind of questions you ask to the patient population that you usually see, right? But the example here is that many patients would have an abrupt decompensation at some point in their early 20s where they basically developed a bipolar psychotic disorder. The bipolar patients would have periods of remission and malfunctioning, right? But you would not have had that information until uh you actually asked about it and paint out a timeline and only then could i say so when you started getting homeless there in your 20s what was going on can you remember what was going on in your life or what was causing you to have so many problems there sometimes the answer would be well i got kicked out of my mom's house because i was doing metal Oh, well, that's simple, right?
And sometimes it would be, well, you know, certain agents from the Mexican mafia started following me around all the time and harassing me and it couldn't work. Ah, suddenly you have some evidence for a psychotic disorder that the patient would not have automatically volunteered, especially if they had some partial insight and you were asking them about any delusions or paranoia.
Yeah, I like, like, as you say, it really depends on your patient population for what is the thing that you're kind of trying to get the fine strokes about. Like, you know, right now I work in a treatment-resistant depression clinic. And here I spend a lot of time just on the past psychiatric history in terms of what doctors did you have and what medication trials did you have.
And using that structure... even though it seems like it's just factual information, I can get almost an entire life course for patients who have tried tons of different medications because figuring out, you know, they switch medications every year for the last 10 years. And then I find out what happened before that medication switch. What were the side effects from that medication? And I almost get a full narrative life history just by like...
filling in all those details as to why they switched medications and what was going on during that medication switch. And through that, I often get a part of their relationship history, their work history. So, I mean, you mentioned like being homeless and using that, you know, like their work history or something, kind of diving into one aspect that is representative of a bigger picture of the patient.
Yeah, and ideally, in a perfect world, we'd have time to get a nice, full, detailed picture of every one of these categories of the past life history, right? But it just doesn't work that way. You're going to run out of time. So in a way, you spend more time on one or the other or one particular slice of the life history based on your initial narrative interview.
You have some suspicion at the end of that first 20 percent of the time, 20, 30 percent of what the problem is, right? And then, so if you think there might be more substance stuff, you're going to spend more time on substance. You might even spend most of an interview getting their substance use and remission history, their history of treatments. Why did they relapse, right? Or if you're a suspecting personality, then you're going to want to have a deeper dive into work history, history of conflicts, firings, arrests, you know, How many times you've been in a relationship, how long does it usually last, how you usually meet, how does it usually go wrong, anything like that, right?
And of course, do not neglect medical history. Medical history is so important. And unfortunately, many people may not have an accurate or good full recall of their medical history, but... Any history of treatments and medical conditions, that's part of the work here, right? I think that's something that is often missed by non-psychiatrist diagnosticians, unfortunately, medical causes.
All right, so to recap where we've gone and where we are, you start your interview establishing and defining your role to the patient. You anchor the appointment as to what the purpose of it is and set the therapeutic frame. You spend the first 20% on free-form narrative, essentially having the patient kind of elaborate on their problems, trying to avoid clinical language, trying to understand them. That anchors you into figuring out which DSM chapter you feel like they fit into.
And you probably have about three that you're starting to think about. And then you spend the next 60% on focused history taking. As you said, we don't like to use structured interviewing at this point. We like to more just elaborate on the history of the present or past illness.
Yeah. And as I said previously, it's a bifurcation point after that first narrative part. Right. Sometimes you already have such a strong indicator of what the problem is that you can dive directly into structured interviewing and you're just there to confirm the diagnosis. You know, sometimes it's just really obviously PTSD and then you can just get into that. So I would say you can do either in either order.
You can even swap around different parts of this area. But broadly speaking, after that first 20 percent time, You'll spend about half the total interview time on both of these things. Again, gathering the life history and course of psychopathology in other ways by asking about their life details and then structured interviewing to confirm DSM or other diagnosis by asking about specific presence or absence of symptoms. and you know you don't have to ask those questions in a leading way by the way and i would recommend that when possible especially if time permitting you should ask uh specific dsm criteria without giving the game away in a sense uh why it lets you be a little bit more certain again the the fear here is not that patients are here belingling it's that just by nature of the psychiatric interview and relationship Patients want to please you, and if unconsciously, I think, you're trying to get certain answers, people are going to want to respond, yes, this is just a natural human thing.
So rather than saying, did you have racing thoughts, you might ask, what happened with your thoughts around that time? Did anything change about that?
Yeah, and kind of as we're saying, the way patients answer, the narrative of how they answer is so much more important than the binary answer that they give. I'm thinking of when I do, you know, quote unquote, ADHD, patients who want ADHD assessments, even if I were to follow the, you know, I have followed the DIVA exactly to a T and their answer of yes or no is so much less important than how they respond.
And for patients that do, you know, for ADHD, there's particular responses that I ask the questions and it's almost like they light up and it's like they can think of 11 different examples without trying to, you know, It's almost like naturally they think of like, oh yeah, in fourth grade, I would always, I got sent to the principal's office the most times out of any other student.
The way that they answer the question is so much more important than the answer itself.
Yeah, it's a mental status exam, right? It's the process on top of the content. You do this long enough, you begin to recognize the difference between somebody who is simply having their memory activated and converting that into a story to you live versus somebody who is prepared and wants to present consciously or unconsciously, mind you, a certain story about who they are and why they're presenting. And for good reasons or bad, people will always come in with their story and their interpretation of events.
And that's important to be cognizant of because we're trying to, to the best of our ability, make some kind of a neutral medically justifiable diagnosis. Because if we can be accurate in that diagnosis and formulation, we have the best hope of helping the patient get to where they want, even if they already have a preconceived idea of what it is. And I think that brings us to the final part.
So as you do this, you should keep an eye on the clock. And I think that you need to budget at minimum 20% time, but ideally 30% time to the end of your intake period, whatever it might be, even if it's 10 minutes in the emergency room, hopefully more time than that. It needs to be treatment planning and discussion of initial diagnostic impression. Okay, you need to do that part.
That's really important.
Before we get to that, I think we should go back to what you were saying in terms of the past history, like collecting past, you know, filling out the past medical, past psychiatric, past social history. As we were kind of saying, I do like to get a narrative. And here's like a little, you know, being totally transparent. there are times during the interview like it is ideal that you follow this perfect structure and you're making the connection you have the differential you're asking all the perfect questions there are a lot of times that i mean especially early on where i would get confused and i would get a little bit lost and i wasn't quite sure where i was in the interview um or i wasn't you know the differential was kind of evading me i almost always had in front of me the past history questions that i needed to get answered and those are just the absolute basics we're talking about past psychiatric history diagnosis prior medications uh family history past medical history diagnoses medications allergies past social history living history legal history work history I almost always have those questions in front of me so that if at any point I get confused, I can just resort back to those questions.
And oftentimes, I don't actually need the sheet. Just having it in front of me makes me feel more comfortable. And once they start answering one of the other questions that I ask off that sheet, I'll get more calibrated as to where I am in the appointment.
yeah you know i'm actually a big advocate of that i always have the template in front of me um i did that in training i do that now uh it's just worth it and i don't think we should be afraid to take notes uh we are not in the past if it was in the past and we had those four hours or whatever that's in my imagination i don't know how long they really had uh to do a diagnostic evaluation Fine.
Don't take notes. But, you know, you can even counter in that situation. You're going to forget a lot of information. You better take notes. It's not a psychotic psychotherapy. It is not even the CBT. You're here to make a diagnosis. You should be taking notes. And I do warn patients about that. I'll even say, OK, hold on for a second. I'm going to take some notes on that, you know, and it will help you make sure you get a thorough assessment.
And I also very, very commonly stop and go, hold on, let me look and make sure I got everything. And I'll sit there for a minute and then look at my sheet and be like, all right, so I got the diagnoses. Oh, I forgot substance use. Oh, my God. I think that's really helpful because it's so much better to... take a minute, catch your breath, think about things, make sure you have everything, than to have them walk out and be like, oh my God, I forgot about the family psychiatric history.
And those things have so much important information in them. So yeah, I, to this day, stop the interview, say, let me think for a minute, look through, make sure I have all those questions answered. And at the end, kind of catch up on those things that I missed.
Yeah, excellent point. A lot of early practitioners, I think, are very afraid of seeming weak or inadequate in front of a patient. That's just a normal human thing when you're not sure about your own abilities. But in the diagnostic interview or psychotherapy, don't be afraid to pause for a second. Give me a moment. I'm going to have to sit with that and think about that. I'm not afraid to think in front of the patient.
I hope I am thinking in front of the patient because the fact is this process of learning about oneself and one's problems is incredibly complex. It should make me puzzled at some point, I would hope, outside of the most simple cases. So yeah, take some time and just let the patient know what you're doing.
So yeah, thank you for letting me do that small diversion. That was very important. You're mentioning spending the last 20-ish percent discussing your findings. I'm also going to say, obviously, I think that's incredibly important. Another thing I often do is, let's say, an interview is taking much longer than I expected. I have an hour set aside, and this is a super complex patient. And usually at the last 20% say, just a heads up, I realize this interview, I'm not quite getting all the information I need.
I think I actually want to spend some time, talk with my supervisor, think about it for a little bit. If it's okay with you, let's schedule another appointment next week. Maybe we can spend 30 minutes then to kind of finish up and wrap up my thoughts and my recommendations. And it's funny, as I get more and more in my career, I do that more and more often.
I realize that an hour is not enough time for me to thoroughly think through the patient and discuss with them what I think is going on. So I let them know I'm gonna spend this whole hour doing information collecting and we'll defer to next week to finish off the interview.
That's an incredibly important point. You know, that 20 to 30% when you're communicating your findings and your impression and your treatment plan, that includes your lack of findings and your lack of impressions and lack of treatment plan. So yes, part of that time may be to say, hey, we're getting close to the end of our time and I don't have enough information to reach any conclusions with you today.
Yet, based on the conclusions that we have so far, this is what I may recommend. Or I can't recommend anything right now because I just don't see enough support that it'll help you rather than harm you in some fashion. It just depends on what you found. And I think this is extremely important. You need to be explicit in telling the patient what you found and what has led you to believe.
And then why are you calling it that way? What do I really mean when I say bipolar? I don't mean flying off the handle. I don't mean having a bad personality, right? A lot of our terms are loaded and have lay person understanding that's inaccurate. you need to spend some time communicating why because you are uh showing your work to the patient number one and you're trying to at this stage again strengthen the therapeutic alliance we want to make sure that both you and the patient have at least some working agreement on what the problem is what our goals are and how we're going to accomplish that the treatment modality
Yeah, and I think, I hope one of the core points of our podcast is the core of our work is having a diagnosis and then using evidence-based treatments. I hate the term evidence-based, but still, it's like the core of our work is not fixing symptoms. It's not giving a medication. To me, the crux is figuring out the diagnosis, communicating and being on the same page with the patient, and then giving treatments to fit that diagnosis.
Yeah. And, you know, for that matter, this is really translatable even to psychotherapy where we're not really interested in DSM diagnoses beyond billing. Right. It's about getting to the formulation. You're not going to get to the formulation at the end of your first therapy hour. You know, you're going to have some impressions. But, you know, at one point, ideally within the first seven hours, you're going to have a formulation.
And you should have an explicit formulation that you can put together in language that the patient will understand and communicate to that patient. It's the same principle. You know, it's just spread out over a little bit more time. But with medication management these days or inpatient or urgent cares, you don't have much time. and so we do have to speed things up but i do think that you have to explicitly discuss these things so you can also discuss disagreements and i like to be i like to be very clear i say and i really want to know if you disagree or you're not sure about this okay i want to make sure we're on the same page how do you feel about my impressions does that make sense to you do you agree or disagree how do you feel about my recommendations do you feel good or bad about taking this medication or doing this or that treatment uh is that going to work for you what do you think
That's great. And something I want to magnify that you said very quickly is using language and concepts that the patient can understand and agree with. If you're a psychiatrist or psychiatric provider, yes, you're probably reading a lot about complex PTSD versus borderline personality disorder and understanding the murkiness of concepts. That's not that helpful for patients. So using language that they can understand, don't bog them down with the complexities and the conflicts in our field.
Explain things in a way that they can understand it. I think that's super important.
Yeah. So, you know, a lot of people feel a lot of trepidation about this process or insure themselves. How do you actually get to be able to do this well? Well, it's all practice, practice, practice. OK. And in addition to that, it's actually seeing patients with different types of psych pathology. And you also have to learn. the life course and variations and different kinds of psychopathology and if you have not read through all the dsm-5 you should do so because each diagnosis has a differential diagnosis section under the diagnostic criteria that can help you really strengthen your core knowledge and the practice is not just about observing different patients and listening to their histories it's about getting comfortable in your ability to interview And of course, there's some great textbooks on this.
This is just a one hour podcast. You're not going to learn anything from listening to this. Practice and read and just reflect on your diagnostic evaluations and re-diagnosis. You're not done at the end of the first one. You might need to pick up at the future date. Spend more time on that instead of medication management or crisis of the week. You might need to schedule more diagnostic evaluation.
Yeah, that's great. And one final point is that how this actually looks in practice is totally dependent on the types of patients you're seeing. When I'm seeing high-functioning patients that are doing really well, I can do this full interview in 45 minutes and twiddle my thumbs for the last 15 minutes. And then in complex patients in certain settings, I've done two hour and a half interviews and I'm still not able to communicate everything.
It really depends on your patient population for what this actually looks like. But I think this is a really helpful approach. This is a really helpful structure that you can apply at the start of really any clinic or whatever you're doing.
You know, I wonder if anyone would be interested in a second follow up episode to cover things about psychiatric assessment or intakes that they have doubts about or they're curious about. If people are willing to leave comments with their lingering questions, thoughts or things that they want discussed, if there's enough of those to fill another episode, maybe we could do that.
Yeah, that'd be great. And I want to say, I feel bad. There's comments on Spotify that I don't really know how to reply on Spotify. So there's, you know, a few people who are leaving great comments and I feel bad that we're not responding to them. I think we try to get to almost all the Reddit and, you know, the thoughtful YouTube comments. So if you're on Spotify or some weird thing, I apologize if we're not responsive to you.
I'm reading them, though. I use Spotify. I like Spotify. All right. Well, I think that's our time for today. I'll see you next time.
All right. See you.