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8. Psychiatric History, Clinical Interview & Mental Status Exam – Vocabulary Review

General Principles of the Psychiatric Interview

  • Multidimensional, biopsychosocial exploration that informs a collaborative, person-centered treatment plan.

  • Core requirements

    • Clinician self-introduction, clarification of role & purpose.

    • Explicit consent to proceed; duration of interview stated.

    • Determine and document whether the interview is voluntary or involuntary before starting.

    • Adherence to \text{HIPAA} and strict confidentiality; outline exceptions (e.g., duty to warn in Illinois when serious threat is present).

    • Provide or secure privacy (private room, postpone sensitive topics if privacy impossible).

    • State limits of confidentiality in forensic/disability settings; specify who receives reports.

    • Handle collateral family input: obtain patient permission, see family + patient together, avoid disclosing patient data, but listen.

    • Recording or one-way mirrors in training settings → obtain informed consent; assure care is independent of willingness to be recorded.

  • Respect & consideration mitigate stigma-driven anxiety; empathy and rapport are pivotal.

    • Empathy = understanding patient’s thoughts/feelings while keeping objectivity (“That must have been very difficult”).

    • Identification ≠ empathy: loss of objectivity, risks burnout.

  • Patient–clinician relationship

    • Motivated by patient’s wish for help + belief in clinician expertise.

    • Built via respect, non-judgment, genuine interest, appropriate humor, apology for errors.

  • Unconscious dynamics

    • Transference: patient projects past relational patterns onto clinician (e.g., anger at authority); clinician must not take it personally.

    • Counter-transference: clinician projects onto patient; be self-aware, seek supervision/therapy if signs arise (boredom, missed appts, sleepiness).

  • Person-centered vs disorder-based: priority is the patient’s own story.

  • Safety & comfort

    • Ensure both parties’ safety: staff backup, door ajar, clear exit path in ED.

    • Reassure confused/psychotic patients; terminate early if agitation escalates.

  • Time frame

    • Typical initial outpatient: 45\text{–}90 min.

    • Medically ill, psychotic, or highly distressed: \le 20\text{–}30 min, possibly in segments.

Process of the Psychiatric Interview

Before the Interview

  • First contact often phone call; staff should triage suicidality/homicidality → transfer to mental-health professional or hotline.

  • Reception collects demographics, referral, insurance; gives info on session length, fees, emergency contacts.

  • Clinician may pre-call to gauge urgency; request prior records & medication bottles.

Waiting Room

  • Patient completes demographic/HIPAA forms, medication lists, PCP details, PHQ-9 or QIDS-SR questionnaires.

Interview Room Setup

  • Sound-proof, uncluttered, neutral decor.

  • Seating: patient & clinician same height, 4\text{–}6 ft apart, no desk barrier; offer chair choice.

  • Professional appearance; silence phones/pagers.

Initiation

  • Greet in waiting room, handshake if accepted, escort to room, offer coat assistance.

  • Ask preferred form of address.

  • Start with open-ended invitation: “Tell me what has led you here.”

  • Maintain open-ended questioning style throughout.

Elements of the Initial Interview

Identifying Data

  • 1–2 sentences: name, age, sex, marital/relationship status, race/ethnicity, occupation + referral source.

Source & Reliability

  • Note informant(s) and estimate reliability/consistency of data.

Chief Complaint (CC)

  • Quote in patient’s own words: “I’m depressed.”

History of Present Illness (HPI)

  • Chronological narrative of current episode.

    • Symptom description, severity, duration, fluctuations.

    • Stressors: home, work, school, legal, medical.

    • Alleviating/worsening factors: meds, supports, coping, time of day.

    • Essential 4: what, how much, how long, associated factors.

    • “Why now?”—precipitant for seeking help.

    • Prior treatment for this episode (provider, frequency, therapy vs meds).

    • End with a full Psychiatric Review of Symptoms (see below).

Psychiatric Review of Symptoms (PROS)

  • Mood

    • Depression: SIGECAPS → Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidality.

    • Mania: impulsivity, grandiosity, ↓ sleep need, \uparrow spending, pressured speech, racing thoughts, hypersexuality.

    • Mixed: irritability, mood lability.

  • Anxiety

    • GAD details (context, frequency); Panic attacks (time-to-peak, somatic signs, agoraphobia fears); OCD rituals & obsessions; PTSD (nightmares, flashbacks, startle, avoidance); social anxiety; phobias (heights, spiders…).

  • Psychosis

    • Hallucinations (auditory, visual …); delusions (persecutory, referential, somatic, grandiose); paranoia; cultural/spiritual framing.

  • Other

    • ADHD (inattention, hyperactivity, impulsivity), eating disorders (binge, purge, exercise).

Past Psychiatric History

  • Lifetime disorders, courses, comorbidities.

  • Details of each episode: onset, duration, frequency, severity.

  • Treatments:

    • Outpatient (individual, group, family therapy), partial/day, inpatient (voluntary/involuntary), support programs, vocational training.

    • Somatic: meds (dose, duration, response, side-effects, adherence), ECT, light therapy, alternatives.

  • Lethality history: ideation, intent, plans, attempts (method, lethality, rescue, notes, gifting belongings).

  • Violence/homicide history; domestic violence; self-injury (cutting, burning) incl. relief felt & concealment.

Substance Use, Abuse & Addictions

  • Substances: alcohol, illicit drugs, prescribed meds misused.

    • Route, frequency, amount, tolerance, withdrawal, functional impact, legal issues (DWI).

  • Screening: CAGE (Cut-down, Annoyed, Guilty, Eye-opener).

  • Sobriety length & context (jail, mandated).

  • Treatments: detox, rehab, outpatient, AA, NA.

  • Behavioral addictions: tobacco, caffeine, gambling, internet, eating; assess change-readiness (pre-contemplative → action). OA & GA 12-step resources.

Medication History

  • Current psych & non-psych meds (OTC, herbals, sleep aids): duration, adherence, efficacy, ADRs.

  • Document drug allergies.

Past Medical History

  • Major medical illnesses, surgeries, current conditions.

  • Psychiatric-medical interactions:

    • Medical precipitating psych disorder (e.g., new cancer → anxiety).

    • Medical mimic (hyperthyroidism → anxiety).

    • Psych treatment causing medical issue (SGA → metabolic syndrome).

    • Medical status guiding psych Rx (renal disease affects lithium choice).

  • Note seizures, head injury, pain disorders.

  • Prenatal, birth, developmental milestones.

  • Female pts: menstrual history & pregnancy potential (“How do you know you’re not pregnant?”).

Family History

  • Psychiatric & medical illnesses across relatives (consider questionable diagnoses).

  • Genetic loading informs risk, treatment decisions (e.g., diabetes influences antipsychotic selection).

  • Family traditions/beliefs impacting illness course.

  • Identify supports & stressors.

Developmental & Social History

  • Prenatal/birth data if available.

  • Childhood: home environment, friendships, school performance, special ed needs, abuse history.

  • Education/work: job types, performance, reasons for changes, finances, insurance coverage.

  • Military: rank, combat, discipline, discharge.

  • Relationships: marriages, partnerships, sexual orientation/practices, intimacy capacity.

  • Current ties with family across generations.

  • Legal issues (charges, lawsuits).

  • Hobbies, pets, leisure changes.

  • Cultural/religious background & current practice.

Review of Systems (ROS)

  • Catch remaining physical/psych symptoms by organ system.

Mental Status Examination (MSE)

  • Psychiatry’s “physical exam” – snapshot at interview time, baseline for follow-up.

  • Includes but is not limited to cognitive screening (e.g., MMSE ≠ full MSE).

Components & Descriptors

  1. Appearance & Behavior

    • Apparent age, distinguishing marks, hygiene, distress level.

    • Cooperation, agitation, disinhibition, appropriateness (e.g., involuntary pt may be guarded).

    • Classic clues: stooped posture in depression, pinpoint pupils in opioid use.

  2. Motor Activity

    • Normal / bradykinesia / hyperkinesia.

    • Note gait, posture, pacing, tics, tremors, hand-wringing, akathisia, TD signs.

  3. Speech

    • Fluency, amount (↑ in mania, ↓ in depression), rate (pressured vs slowed), tone, volume.

  4. Mood

    • Subjective, sustained emotion in pt’s own words (“sad,” “anxious”).

  5. Affect

    • Objective display: quality (tearful, irritable), range (full, restricted, flat), appropriateness to context.

  6. Thought Content

    • Obsessions, compulsions, delusions (grandiose, somatic), paranoia (mild → severe), suicidality, homicidality (must probe ideation, intent, plan, prep).

  7. Thought Process (Form)

    • Organization/flow: linear, goal-directed, vs formal thought disorders (circumstantial, tangential, flight of ideas, loose associations).

  8. Perceptual Disturbances

    • Hallucinations (auditory most psychiatric; visual/olfactory/tactile suggest neuro/withdrawal).

    • Illusions, hypnagogic phenomena.

    • Depersonalization, derealization.

  9. Cognition / Sensorium

    • Alertness & orientation (person, place, time, situation).

    • Concentration (serial 7s), memory (immediate, recent, remote), calculation, fund of knowledge.

    • Intellectual level relative to education.

  10. Abstract Reasoning

    • Explain similarities (apple vs orange) or interpret proverb.

  11. Insight

    • Awareness of illness: none / partial / full; reality-testing component.

  12. Judgment

    • Practical decision-making (e.g., stamped envelope scenario); impaired in delirium, schizophrenia, intoxication.

Techniques to Facilitate the Interview

  • Reinforcement: “I see,” “Go on.”

  • Reflection: repeat key phrases to show listening.

  • Summarizing: periodic recaps to validate & organize.

  • Reassurance: only if factual; otherwise promise ongoing help.

  • Encouragement: validate difficulty of seeking help.

  • Acknowledge emotion: offer tissues, label feelings.

  • Nonverbal facilitation: nodding, leaning forward, open posture, eye contact, placing pen down, raised eyebrows of concern.

Obstructive Interventions to Avoid

  • Closed-ended & compound questions; excessive “Why?” questions.

  • Judgmental phrasing; minimizing concerns.

  • Premature advice/interpretation before full data.

  • Abrupt transitions interrupting salient issues.

  • Negative body language: checking watch, yawning, refreshing computer → signals boredom/annoyance.

Closing the Interview

  • Signal time remaining (“We have ~10 min left”).

  • Invite final questions (“Anything else you’d like to ask?”).

  • For single evaluation: share diagnosis & treatment options (except forensic/disability—clarify at outset).

  • Communicate with referring PCP, if applicable.

  • If ongoing care: set agenda for next session, agree on appointment time, escort patient out.

End of notes.