6023psy full set

Importance of determining if presenting problem is new or recurring

It is important to determine if this presenting problem is the same or similar to problems experienced in the past or if this is the first time the client has had such a problem.

Assessment of problem onset and course

Similar to the assessment of symptoms, the interviewer needs to determine when the problem first began, what impact it has had on the client’s well-being and functioning, and what course it has taken.

Mental disorder symptom course types

Some mental disorders are characterized by episodes of symptoms with full recovery in between episodes, while others have a course of continuous disturbance and deterioration of function.

Diagnostic hypothesis review

Assessment of the onset, duration, course, severity, and associated stressors prompts review of the initial list of diagnostic hypotheses, indicating which hypotheses are more or less likely.

Evaluating associated symptoms

The interviewer must determine if any associated symptom preceded the presenting problem or was present when the presenting problem was absent to evaluate their relation.

Example of symptom relationship analysis

If the presenting problem is difficulty sleeping, and problem drinking started soon after, conclusions about alcohol’s impact on sleep differ than if drinking preceded the sleep problem by years.

Assessing multiple associated symptoms

If several associated symptoms exist, the interviewer asks if they began about the same time or if some occurred independently.

Assessing previous episodes

If the presenting problem has happened before, the interviewer determines the beginning and course of each previous episode, asking questions like “Have you ever felt this way before?”

Eliciting details about previous episodes

One can ask clients to describe previous episodes to gather information about onset, duration, and course or prompt specific info, e.g., “Was it worse then?” or “Did it last longer?”

Evaluating client’s insight

Understanding the client’s explanation of the problem’s development, causes, maintaining factors, and attempts at resolution is called insight and can provide diagnostic clues.

Examples of insight questions

The interviewer may ask: “What do you think caused this problem?”, “What made it worse now?”, and “What have you tried to do about it?”

Assessment of previous treatments

Include history of traditional medical, psychotherapeutic, alternative, and nonprofessional treatments, asking when attempted, impact, discontinuation, and reasons why.

Listening for client cues

How clients convey answers can provide insight, e.g., statements indicating frustration with unexplained complaints or prior treatment failure.

Requesting additional records

Obtaining permission to contact current or previous service providers can shed light on client history and issues.

Treatment history’s diagnostic value

For example, continuous treatment for depressive symptoms over a year can rule out an acute adjustment disorder.

Summarizing presenting problem

Summarizing the problem for client verification helps clarify understanding and marks transition to next interview phase.

Example summary phrasing

“As I understand it, you began having difficulty sleeping about two months ago… Does that sound right?”

Purpose of client confirmation

Client may endorse summary or add important details, allowing interviewer to move on to social history and other developmental aspects.

Scope of social history assessment

Social history includes developmental milestones, social/sexual functioning, diversity, educational, vocational, legal, family, substance use, trauma, and medical history.

Approaches to social history assessment

Some interviewers cover each area separately, others use a chronological “biographical” method integrating all areas through life history.

Biographical method introduction

Use statements like “Okay, now I need to understand some background information. Tell me about your childhood.”

Keeping diagnostic hypotheses in mind

Ensure relevant social history information is gathered to confirm or rule out remaining diagnostic hypotheses.

Assessing developmental milestones

Inquire about pregnancy/birth complications, Apgar score, feeding problems, low birth weight, and achievement of milestones like sitting, crawling, walking, talking, and toilet training.

Significance of developmental delays

Delays are relevant only if particularly aberrant or caused difficulties; assess speech delay types and any loss of speech after normal development.

Common client memory limitations

Clients often remember nothing unusual about early development, usually indicating no significant delays or problems.

Sample developmental questions

“Did your mother tell you about any problems during pregnancy or delivery?”; “Do you know if you sat up, crawled, and walked at the usual time?”; “Do you remember anything about toilet training or bed-wetting?”

Components of family history

Family functioning and family history of disorders are essential components to assess.

Expanding family definition

Ask about family members beyond nuclear family: who lived in the household, who took parental roles, siblings, and extended family involvement.

Starting family inquiry

Begin with open-ended questions like “Tell me about your family,” then follow up based on client’s definition.

Assessing family functioning

Explore childrearing practices, reward and discipline methods, communication patterns, warmth or difficulties, and closeness or distance in relationships.

Family traditions and conflict resolution

Inquire about family traditions around holidays and life events and the nature of conflict resolution or lack thereof.

Technology use in family assessment

Assess use and effects of computers, phones, social media, video gaming on daily functioning for both children and adults.

Gathering family medical and psychological history

Encourage clients to volunteer family disorder history, and if needed, ask directly about psychological, medical, or substance use problems in family members.

Importance of genetic relations

Determine if family members with disorders are blood relatives to assist diagnosis of disorders with genetic contributions.

Example genetic disorder relevance

Schizophrenia is more prevalent in first-degree relatives of people with schizophrenia than in the general population.

Impact of family disorders on functioning

Explore how family member disorders affected family functioning, such as caregiver absences or changes in discipline.

Sample family history questions

“Tell me about your family when you were growing up.”; “Who lived in the household?”; “How did you get along with them?”; “Did anyone in your family have psychological problems?”

Key elements of educational history

When client started school, highest grade completed, learning strengths and difficulties, and educational program participation.

Approach to discussing education

Start with strengths and interests (“What were your best and worst subjects?”) before exploring difficulties or grades.

Educational history’s diagnostic value

Helps evaluate neuropsychological function, intellectual capacity, and supports diagnoses like intellectual disability or pervasive developmental disorder.

Sample education questions

“When did you start school?”; “What subjects did you like best and least?”; “Did you have any difficulties in school?”; “What was the last grade you completed?”

Presenting Problem

The initial issue or complaint the client presents during the first interview, which can be a symptom, conflict, stressor, emotion, behavior, or sometimes a non-problematic event needing further explanation.

Purpose of Presenting Problem in Interview

To gather clear, descriptive information about the client's difficulty that guides diagnosis, treatment planning, and case conceptualization.

How to Ask About Presenting Problem

Using general or open-ended questions like "Please tell me what brought you here today" or "How can I help you today?"

Forms of Presenting Problem

Symptoms (e.g., trouble sleeping), conflicts (e.g., relationship discord), stressors (e.g., unemployment), emotions (e.g., anxiety), behaviors (e.g., fighting), or other issues.

Generating Diagnostic Hypotheses

Immediately after learning the presenting problem, the clinician should generate at least five diagnostic hypotheses based on likely disorders associated with that problem.

Purpose of Diagnostic Hypotheses

To guide the interviewer's focus on specific information that can confirm or rule out potential disorders.

Differential Diagnostic Process

Using knowledge of psychopathology, the clinician works from symptoms upwards to consider all possible disorders related to the presenting problem.

Examples of Diagnostic Hypotheses for "Difficulty Sleeping"

Sleep disorders (primary insomnia, nightmare disorder, sleep apnea), anxiety disorders (generalized anxiety disorder), bipolar disorders (manic or depressive episodes), depressive disorders, substance-related disorders, adjustment disorders.

Examples of Diagnostic Hypotheses for "Fighting"

Conduct disorder, adjustment disorder with conduct disturbance, intermittent explosive disorder, antisocial personality disorder, substance-related disorders.

Inclusion of Disorders Without Presenting Symptom in Criteria

Some disorders may not list the presenting symptom but can reasonably be hypothesized if they might manifest the symptom (e.g., psychotic symptoms in manic episodes).

Top-Down vs. Bottom-Up Approach to Diagnoses

Psychopathology is usually learned top-down (from disorder to symptoms), but hypothesis generation is bottom-up (from symptom to possible disorders).

Clarifying Presenting Problem

Interviewers must ask detailed questions to understand what the client means by the problem, e.g., distinguishing "fighting" as arguing, angry outbursts, or physical assault.

Importance of Cultural and Contextual Framework

Understanding cultural and contextual factors is essential to avoid misdiagnosis and inappropriate treatment.

Key Aspects to Assess in Presenting Problem

Onset, duration, course, severity, and associated stressors.

Questions to Assess Onset

Examples: "When did you begin having trouble sleeping?" "When did you first have this problem?"

Onset Types

Can be specific date/time (acute) or general timeframe (insidious/gradual).

Questions to Assess Duration and Course

Examples: "How long has this been going on?" "Has it been getting worse, better, or fluctuating?"

Assessing Severity

Includes frequency, intensity, and impact on functioning.

Questions to Assess Frequency

Examples: "How many panic attacks have you had in the past month?" (for discrete events).

Questions to Assess Intensity or Amount

Examples: "How many hours do you sleep at night?" (for ongoing problems).

Questions to Assess Impact

Examples: "How does difficulty sleeping affect your work?" or "Are you experiencing legal problems due to fighting?"

Assessing Associated Stressors

Includes events around onset and stressors resulting from the problem.

Questions to Assess Stressors at Onset

Examples: "What else was happening when this problem began?"

Questions to Assess Stressors Resulting from Problem

Examples: "Has the fighting caused other problems for you?"

Questions to Assess Precipitating Stressors Leading to Seeking Help

Examples: "What made you decide to seek help now?" or "Why now?"

Investigating Associated Symptoms

Based on diagnostic hypotheses, ask about symptoms that confirm or rule out each hypothesis (e.g., depressed mood, elevated mood, worry, nightmares).

Efficiency in Symptom Inquiry

Ask about the most essential symptoms first to rule out disorders quickly.

Awareness of Assessment Error

Clinicians must recognize their subjective bias and risk of misinterpretation during assessment.

Diagnostic Hypothesis Exercise

Write presenting problem, generate diagnostic hypotheses, list associated symptoms to check, and plan questions to assess these symptoms.

Example: Presenting Problem "Difficulty Sleeping"

Hypothesis: Sleep disorders

Symptoms: Difficulty falling asleep, nightmares, snoring

Questions:

"How long does it take to fall asleep?" "Do you have nightmares?" "Do you snore loudly?"

Hypothesis: Anxiety disorders

Symptoms: Excessive worry, numbness, intrusive memories

Questions:

"Do you worry about many things?" "Do you feel emotionally numb?" "Are you troubled by memories of trauma?"

Hypothesis: Mood disorders

Symptoms: Depressed mood, loss of interest, elevated mood

Questions:

"How is your mood?" "Have you lost interest in activities?" "Do you feel unusually 'on top of the world'?"

Hypothesis: Substance abuse

Symptoms: Use, tolerance, withdrawal

Questions:

"How much alcohol or drugs do you use?" "Do you need more to feel effects?" "What happens if you stop?"

Hypothesis: Adjustment disorder

Symptoms: Depressed mood, nervousness

Questions:

"Are you feeling depressed or nervous?"

Social and Sexual Functioning

The interviewer will need to ask the client about social relationships and development, romantic relationships, and sexual activity. Childhood friendships, afterschool activities, membership in organizations, and participation in athletic or sport activities all give the interviewer information about the client’s social development and degrees of relatedness. It is often convenient to ask about these activities while gathering information about the client’s educational activities, such as “Did you have a few close friends in school,” “Did you participate in organized sports while in school,” or “Were you a member of Scouts or something like that?” It is important to inquire about romantic or dating relationships in a culturally sensitive way, not assuming a heterosexual development of interest, or intruding unnecessarily on cultural or religious values or prohibitions. One can ask about the development of romantic interest, and about first sexual experiences in a rather open way, and then follow up with more specific questions: “Do you remember when you first developed a romantic interest in someone,” and then, “Who was that?” “When was your first sexual experience,” and then, “What was the sexual contact and activity?” Clients are often reticent to volunteer information about sexual activity, dysfunction, and abuse due to social and cultural norms that discourage such self-disclosure to strangers (Fontes, 2008). This information is clinically important, so the interviewer will need to inquire about it in a matter-of-fact, straightforward way, indicating that sensitive discussion of sexuality is accepted and expected. The interviewer will want to understand the client’s history of formal and informal liaisons, such as marriages or committed relationships, and whether or not the client has children. Note that this inquiry may initiate a discussion of pregnancy loss (e.g., miscarriage, stillbirth, or abortion) which is an important psychosocial component of the client’s history. Establishment of new family structures then needs to be understood, so the interviewer will want to ask some of the same kinds of questions to understand the new family functioning as were asked about the client’s family of origin, including child-rearing practices, division of responsibilities, methods of conflict resolution, and so on.

Sample questions for Social and Sexual Functioning:

• Tell me about your childhood friends.

• What sorts of social activities did you enjoy?

• Did you belong to any clubs or organizations?

• How about friendships now?

• What do you do for fun?

• Do you remember your first romantic interest? Who was that?

• When did you start dating?

• When was your first sexual contact? What was it? With whom?

• Have you been in a committed relationship or marriage?

• Do you have any children? Do they live with you?

• Who lives in your household now?

Vocational History

The client’s history of work activities should be assessed. This line of questioning may flow naturally after inquiry about educational history, as people often begin work after completing some course of education. The interviewer should not assume, however, that clients did not work while they were in school, or that they went to work after they were no longer in school. One might ask “Did you have a job while you were in school,” and “Then what did you do” to inquire about occupations after formal schooling. The nature of work activities informs the diagnostic process as well: occupations that do not appear to be consistent with their educational achievements or a series of jobs of short duration rather than a career of rather stable positions in the same or similar fields may indicate maladaptive patterns consistent with personality disorders. It is important to inquire about military service and the nature of all employment activities, such as exposure to trauma and occupational hazards and stressors. Some occupations require exposure to solvents, while others include frequent exposures to dangerous conditions. It is also important to understand periods of unemployment in the chronology and what led to the unemployment or changes in occupation. All of this information helps the interviewer understand and interpret the client’s behavior and functioning.

Sample questions for Vocational History:

• What kinds of work or jobs have you done?

• Have you served in the military?

• How about volunteer work or positions?