What we’ve said about Psychiatric intake

“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”

“Psychiatry was fundamentally not about medications, which did not really exist for psychiatry until about the 60s. Psychiatry is about formulation and being able to give explanations to the patient that are adaptive”

“It's a process of assessment, of being in their world to understand their world, and then coming back to yourself and using your expertise and your pattern recognition and your experience with how patients report symptoms to formulate a diagnosis”

“Never trust, this is somebody else's comment, I read it on Reddit a long time ago, never trust the last psychiatrist's diagnosis, even if you were the last psychiatrist, the last person to make the diagnosis, right”

“you really, you need to be thinking on multiple different levels and understanding how to think on multiple different levels and not get stuck on a certain level”

“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”

“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”

“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”

“OK, you have to accept that if you're going to practice a, in my opinion, ethical and thorough version of psychiatry, the way that should be, you're going to need more time. It doesn't matter what the economy or the payer says”

“the diagnosis personality truly relies very strongly on getting a honest and relatively thorough accounting of the patient's psychosocial life and their course in development. And yeah, that's going to take some time”

“how are you going to build in a systematic information assessment that you get before you sit down with anybody? Maybe you're getting their PHQ-9s now. That's fairly common. But you need a rapid mood screener. Also, you want to use the modified version”

“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”

“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”

“I try to be extremely clear about two things. Why we're meeting, basically the modality of the treatment, and also diagnosis. Okay, and treatment recommendations”

“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”

“You got to get an idea first, not of your ideas, but of the patient's ideas of how do you feel like this is going to go and what's a problem for you? So that's what I start with. So what's been a problem for you”

“the story that the patient comes with, their chief complaint, why now? That stuff will lead you down the road to determine what you should even be asking about specifically”

“when I tried, as usual, to simply ask that patient for him to describe his day-to-day life and what symptoms and problems he was having, he was almost confused. He sort of went, well, I have these diagnoses”

“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”

“Essentially, what you usually do is that you stimulate some kind of memory in them and they're almost free associating and giving you a narrative about that. And that's a good thing. We don't always want direct answers to our questions”

“unless somebody is really flowing with narrative and emotions you may be missing information. And it's not because the patient is withholding it deliberately, but they may not even be accessing it if they're essentially too closed off from themselves”

“If you do technical containment within a interview for diagnosis, for example, judiciously, you will, in my opinion, jaw bolster, even in that moment, the patient's ability to elaborate on experiences and it builds rapport to and it really helps you get the more information”

“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”

“I think it's so important to get a longitudinal history, not just of symptoms, but of the person's life. Because when it comes to anxiety, depression, or group adjustment disorders into there, you'll hear things that make it clear that Things were going really well”

“early identify some theme in their life that I can use as an anchor. And I start there and then I fill in the pictures using that anchor of the other variables”

“You may want to skip ahead in a sense and go to social history and just talk about their work and school and relationship history. Basically get a sense of their overall functioning over time, because then that can start to serve you as a timeline”

“Then I say, well, how often have you had that throughout your life? How long has it usually lasted? How much time do you get in between? Have you ever felt fully free of the depression for at least a month since the start? How long”

“I'm determining the longitudinal course and stability of the patient and the frequency, intensity, and duration of the episodes when they get depressed, looking at the residual symptoms between episodes”

“I'm not asking what are your prior medications just to get a list. Oh, you've been on Lexapro, Zoloft, and Prozac. Great. I'm asking for a timeline”

“Has this patient ever been treated with any prescription psychiatric medications, including the ones that he didn't take”

“The first things that you have to do, that you have to prioritize, are getting a thorough medical history, a thorough medication treatment history, including non-psychiatric medications, and probably the most important, depending on your patient population, a really detailed substance use timeline”

“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”

“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”

“I want to know things like, what's the longest job you've had? Were there any gaps in your educational history and into your work history? Why did those gaps happen? Did you get injured? Did you develop some kind of medical condition? Were you unsure of what you wanted to do”

“You want to know a number of relationships, duration of relationships, how they met, how they broke up. You don't necessarily have all the time for this, but you can get a sense of it sometimes automatically”

“it's not enough to ask, how's your sleep? Are you sleeping? How much are you sleeping? I want to know, when do you go to bed? How long does it take before you actually fall asleep”

“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”

“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”

“when it comes to diagnosis, most of the time we're dealing with a two person reality. Right. And that gets really a lot harder to determine. And that's why it's nice to have collateral, right, on records”

“Did you have a period of a week where you had tons of energy? Yes. Was it all day? Yes. Walk me through that day. I woke up super tired. And then around 4 p.m., I started texting a lot of people”

“a lot of psychiatrists, a lot of clinicians are afraid to do what are essentially technical confrontations. They can detect certain things that don't exactly add up, but because of their human kindness, they don't want to question about it”

“I said, you know, it's a little unusual. You told me about some traumas and you told me about a recovery from it. Yet, you know, three years ago, you started really declining and you didn't tell me about anything happening that year. What was stressing you out that year”

“I should not feel stupid during an intake so that if I am, that's diagnostic information as to what's going on”

“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 will tell patients, listen, we're not here to get you sucked back into trauma memories. I'm trying to reach a medical diagnosis today, and so we will have to go over some difficult stuff. But tell me if you need a break, if we need to pause or stop, or if you're not ready to talk about something”

“she was slightly getting more and more irritated by my questions because I think it was that they were triggering. And when I finally got to something that was really, really upsetting for her and because I wasn't doing a great job monitoring. She got really emotional, she got angry at me”

“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”

“I think that's a big part is giving them back the agency saying like, I acknowledge these questions are distressing. Any point you want to stop. And also not as a practitioner, like in residency, it's like I needed to gather these hundred questions and all the answers”

“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”

“part of the trauma psychopathology is the avoidance of discussion of trauma, thinking about trauma, feeling about trauma. And I don't want to force anyone, but I also do not want to even implicitly, through the frame of how I approach things, communicate that talking about this stuff is very dangerous or hurtful”

“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”

“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”

“as I get more and more experienced, the amount of uncertainty I have goes up and up. And the amount of times that I communicate to patients, I say almost at the end of every intake, I wish I could talk to someone for 45 minutes and tell them all their problems”

“because she felt understood by me and because we reviewed the her history and i i went through her past even aspects that didn't feel directly connected to what she was experiencing now she trusted me more because she felt like i understood her as a person”

“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”

“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”

“the diagnostic criteria for ADHD have become almost useless because if someone is motivated enough for any reason, unconsciously or inadvertently or just based on their understanding of what is or is not ADHD. If someone is motivated to answer an affirmative to structured interview questions”

“ADHD has become a general marker for psychosocial distress of some kind. Right. And so it's almost meaningless in terms of a chief complaint. All it tells us is that this person is not functioning to the degree that they want to be in their work or school”

“college age, you know, like the 18 to 25 range is when a lot of the more serious mental illnesses start to develop. And there often is a prodromal phase where the core symptoms that they experience might be inattention”

“if your problems with concentration are happening because of a stressor of fear over losing an unfortunate relationship or all these fights that keep happening over and over in your relationship, then the method of successfully treating that is not going to be Zoloft”

“Most people have at least some kind of a more subtle early onset of axis one problems that have essentially deviated their path towards the life that they want to have. And so if you just focus on one diagnosis and one medication and not everything else, you're going to be a little limited in your treatment effects”

“anxiety is complicated. It might not be its own thing in most cases, that there are many different sources for anxiety and that you got to do a thorough assessment before you can make reasonable recommendations”

“just hundreds of people being, you know, I really liked, you know, just a touch of Abilify. Is no one going to ask what's going on in this woman's life”

“a patient will come and say, I have anxiety. They could be blatantly manic and it's like, oh, their problem is anxiety. To me, it's irresponsible To me, it's It's irresponsible to be treating someone without them knowing your diagnosis”

“the vast majority of people coming in are not med-seeking. Even if they would like a stimulant, who wouldn't like a stimulant? I'd like a stimulant. Kind of joking, not joking. But even if they would like a stimulant, most people are making an effort to come in because they have some genuine problem in their lives”

“Even if they don't pay a cent, they are paying emotionally. And that is a big toll”

“Onset, location, duration, character, aggravating and alleviating factors, radiation, timing. So don't forget to apply these wherever possible, even to voice hearing”

“the thing to sharpen your senses for, to listen carefully for, is any indication that someone is, again, intolerant of uncertainty, that they always want to be sure of things, that they want to be extra sure of things, and they even check things multiple times”

“Remember that for many people, they have no feeling of being bothered by their OCD in their day to day subjective experience, but their family hates it”

“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”

“patients, I would recommend you try to come into your visits just talking about what your problems are. Don't come in with a diagnosis in mind. The process of diagnosis is so complex and fuzzy”