What we’ve said about Psychiatric interview

“readying and guiding patients during interview is pretty much the key to you getting patients. any kind of diagnostic data. And it's kind of like, how good is your MRI, right? If your interviewing and therapy technique isn't good, then your MRI is going to be very low resolution”

“a psychiatrist any diagnostician in mental health needs to recognize that their questions are the exam your questions and the interview every moment of it has its own positive predictive value and negative predictive value and sensitivity and specificity”

“the positive predictive value the negative predictive value changes based on prevalence So when you see a patient, you should already, based on the information that you have at hand, have some kind of a pretest probability idea of how likely it is to have certain disorders”

“A diagnosis is not what a patient tells you. A diagnosis is your whole thing. consideration of all the medical evidence. So try not to give leading questions or yes or no questions. Elicit story, elicit narrative”

“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”

“The way that they answer the question is so much more important than the answer itself”

“I would say for any intake or any time that you're assessing for a specific diagnosis, don't ask your structured interview questions or the DSM criteria. for at least the first 20% of your interview”

“you may find that you get a richer narrative or more information that you would not have gotten if you prompt people to continue talking on one line of thought one line of narrative rather than asking specific questions”

“One question he likes is, what was that like for you? And that's what we're trying to get when we interview”

“we're trying to get to the primary source and the primary source is the patient's own recollection of their experiences. rather than their summary of their experiences through specific questions”

“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”

“if you get any positive screens, don't first go for the diagnostic criteria. That's confirmatory testing in my mind. OK, still get narrative”

“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”

“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”

“that's why i'm saying semi-structured structured interviewing in my opinion does not have a place outside of research”

“if the clinician thinks concentration, top of the differential diagnosis of concentration is ADHD. Tell me about what you were like as a child. Did you have problems with attention or concentrating then? That's going pretty far afield from the material”

“just kind of sitting down in the interview until I have a story that can make some sort of sense is just a helpful guiding principle in interviews”

“And then remember, a yes is not the end. A yes is to start. You say, oh yeah, I probably noticed that when I was 12. Tell me about that. What was that like? What was happening? Why do you suppose that happened”

“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”

“there are many patients where you'll even specify time frame at least 48 hours in a row and they'll still say oh yeah i totally had a lot of energy well how long did it last three hours okay you really have to ask follow-up questions”

“you'd have been asking something about phases of relatively higher energy, be it anxious or productivity or thinking or just energy underneath your skin. And then whatever you're hearing, you just go further with it. Tell me more about that”

“as a clinician, you should be comfortable, familiar with being the whiny five-year-old who won't stop asking why. Don't take it for granted already. Once she says, oh, I never sent it and I don't want you to talk to the boyfriend. Ask why”

“Have the patient describe the events step-by-step, moment-to-moment in a hallucinatory level of detail. Obviously, you're not going to have time for this in med management, but in the therapy, in the forensic interview”

“Don't be afraid to interrupt. Say, hold on. This thing that you're telling me about right now, you know, that sounds really stressful, awful, and like it's really been occupying a lot of time. But I have to go back, if you're willing”

“when you notice a pattern or you notice a problem, it is your job as the clinician to stop the narrative, at least temporarily, make an observation out loud to the patient about what you're seeing”

“So in a formal therapy, I would say you should be doing these by session three at the latest, okay? You should always do them gently and with adequate groundwork, but you should be doing them”

“If you immediately assume that you understand what the patient means by anxiety, let's say, or you go directly to an intellectual framework of generalized anxiety disorder or state anxiety versus trait anxiety, if you immediately begin to do that, you're going to close off the opportunity”

“I go, let's try our best to not use clinical terms because it can mean different things to different people. When you say you had an increased anxiety, what did you experience? What are you referring to”

“sometimes labels and symptoms are a way of patient and provider colluding not to get into the material”

“Don't be afraid as a clinician to ask what seems like very obvious and stupid questions. And I'm an advocate of simply apologizing if you feel uncomfortable with this. Say, you know, I'm afraid this may sound like a stupid question”

“you feign, in some sense, ignorance and curiosity. And the goal is to help the patient not be defensive, It fosters trust and reduces the defensiveness and encourages self-reflection”

“you should let go of your own sense of mastery of the patient's material or who the patient is. And this may be even more important for the experienced clinician because, you know, we begin to see the same case over and over”

“We all have baggage. Patients have baggage. Clinicians have baggage. We bring it into the room and it's going to alter how we perceive or notice or act clinically. And so if we're not aware of that, we're in trouble”

“It's possible for both on the clinician end and on the patient end to hyper focus, hyper energize on one topic or particular problem. And in a way that obscures another, maybe deeper or at least parallel and important problem”

“You want to make links between causes and effects and put things together. into some kind of abstract name so that you can refer to it with the patient, regardless of the source”

“the level system. Again, I do not recommend you do it in session. Don't think about the levels when you're in the session. It's for retrospective analysis only”

“i'm still not going personally to ask about mania or hypomania to be frank i only do that in the beginning when i think with this particular patient there's extremely low Pre-interview probability that they have a bipolar type disorder”

“I like to start with just asking about the most extreme version. I want to say, in your whole life, can you ever remember having a time where where you were totally awake, zero sleep at all for 48 hours, two days in a row at least”

“I'll typically ask, has there been a period of at least four days where you had less sleep than normal and you felt a little bit more energy, you felt a little bit irritable, you felt different, other people kind of noticed that you were different”

“has there ever been a time where you were not your normal self for at least two or three days in a row? That's 48 to 72 hours where you slept a lot less than usual. let's say four or five hours or less in the 24-hour period”

“So I do find these long questions are helpful because the patient kind of will hear one thing that sticks out to them and then it helps them elaborate”

“Ask about energy and activity level, but don't ask yes or no. Say, what was your energy and activity like during that time? What were you doing”

“When you talk about energy, I find that a lot of people often interpret having energy as feeling good. You have to really drill down on that one. People who have agitated depression, who are very anxious or irritable, they may say, oh, I didn't have energy”

“But sometimes if I've gotten the major depressive episode history and then I ask, when it goes away, how do you feel? What's different about what you do? They begin to describe hypomania”

“the hallmarks are different than normal self. Almost all day, almost every day, two weeks in a row and changes in any of the following, but distinctly energy, sleep, appetite. Okay. More of a wholesale change in biological functioning than a subjective state of depression”

“rather than saying, did you have racing thoughts, you might ask, what happened with your thoughts around that time? Did anything change about that”

“most people in the community, at least where I am, when they say bipolar, they mean mood swings of a person with personality type issues or trauma”

“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”

“I don't just stop at saying, like, do you use any substances? I'll talk about alcohol, then marijuana. And then I'll say, was there ever a time that you used anything else like cocaine, drugs? painkillers, methamphetamines, you know, normalize it and make them feel comfortable kind of talking about those things”

“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”

“if you are overly fearful or anxious about talking about this topic and thinking about this topic and assessing this topic, you are going to consciously or unconsciously show this to the patient”

“Asking about self-harm is standard. It should be standard in every single encounter with a patient”

“it's actually really doing a lot of danger because it teaches patients that like if I want to get discharged in the hospital I just have to answer these questions the way I know they expect to be answered and then I'm done”

“a resident, you go to start an interview with a resident and they go up to the patient and they go like, are you being suicidal? And then that's going to activate defenses”

“I'm less likely to jump in and say something by my own misinterpretations where it's like, oh, no, no, no. They, of course, discharged me”

“being honest with a healthcare provider of any kind is key for you to actually get better”

“you should avoid dysregulating the patient in the interviews, right? You're not doing a psychotherapy when you're doing a diagnosis. You're just trying to get information. And I will tell patients, listen, we're not here to get you sucked back into trauma memories”

“If you look at the research of Elizabeth Loftus, you, the clinician, can absolutely induce memories of traumas and abuse in your life. unknowing patients by suggesting them. Don't suggest that things have happened. Simply look to see if something has happened”

“I didn't say... You must have been abused or traumatized during that time. No, 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”

“The way you should challenge in a clinical interview is not a true challenge. I think it should be with the air of disbelief of someone who really does want to understand more and believe”

“Ask them, how is it that you came to understand this to be true? What experiences and when did you start to believe this, or suspect it at least”

“You can't define a delusion based on its truth value, first of all. Because you can be delusional about something even if you're right about it”

“You can't just limit yourself to asking people about their delusions and testing them under delusions. You have to also test the deeply held beliefs, not in a mean way, but you should, you know, poke at and go into some death on the deeply held beliefs of people who are without psychotic disorders”

“if someone thinks that their childhood is 100% great, generally, there's probably some defensive nature in that or splitting aspect, right? What is considered mature or at least normal is to be able to recognize both the positive and negative aspects of yourself and others”

“it's very important to assess these things in ostensibly normal patients. What do I mean by ostensibly normal? I mean patients that seem to have relatively normal personality functioning just on the face of it”

“using questions from this type of R, in my opinion, gets you a lot of clinical data automatically for all the four elements of personality functioning that you see in the alternative model”

“I would recommend when you start out doing everything the same way every time because that helps build a habit first once you do that you'll be able to deviate more from the interview process”