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1: The Psychiatric Interview

DOI:

10.1891/9780826162724.0001

Abstract

Psychiatric mental health nurse practitioners (PMHNPs) apply a holistic and patient-centered approach to diminish mental distress and help mental health sufferers set attainable goals and have hope for the future. Using theoretically grounded methods, PMHNPs are trained experts in the evaluation and treatment of patients with disordered feelings, thoughts, and behaviors. Structured interviews, semistructured interviews, and questionnaires have become the gold standard for diagnostic interviewing for psychiatric mental health assessments. The goal of this chapter is to offer the knowledge and skills required to conduct a mental health evaluation across populations.

Psychiatric mental health nurse practitioners (PMHNPs) apply a holistic and patient-centered approach to diminish mental distress and help mental health sufferers set attainable goals and have hope for the future. Using theoretically grounded methods, PMHNPs are trained experts in the evaluation and treatment of patients with disordered feelings, thoughts, and behaviors. Structured interviews, semistructured interviews, and questionnaires have become the gold standard for diagnostic interviewing for psychiatric mental health assessments. The goal of this chapter is to offer knowledge and skills required to conduct a mental health evaluation across populations.

In this chapter you will learn:

  1. The purpose of the psychiatric interview

  2. How to organize the initial psychiatric interview

  3. How to assess for common psychiatric disorders

  4. The purpose of the mental status exam

  5. How to identify psychiatric emergencies

THE PSYCHIATRIC INTERVIEW AND ASSESSMENT

The purpose of a psychiatric interview is to establish rapport, develop a therapeutic relationship, and elicit a patient’s personal narrative so as to collect, organize, and formulate an accurate diagnosis and treatment plan (American Psychiatric Association [APA], 2016). The PMHNP uses open-ended and closed-ended questioning and active listening techniques to ascertain the presence of particular symptoms and understand the patient. Aims of the interview include (a) discovering the chief complaint(s); (b) reviewing the patient’s history of the present illness; (c) reviewing the patient’s mood, thought content and processes, and cognition; and (d) constructing a description of the patient’s appearance, functionality, and reality. Psychiatric interviews provide an actionable psychopathologic format to derive a diagnostic classification for clinical decision-making (APA, 2016).

The primary tools used to evaluate and diagnose patients are the psychiatric interview and the mental status exam (MSE); however, history-taking and cognitive and behavioral assessments using screening tools and other evaluations are also used to aid clinicians in distinguishing between typical and atypical functioning and behaviors across a continuum. Essentially, the interview provides a method to assess a patient’s anomalies of experiences, beliefs, expressions, and behaviors (Nordgaard et al., 2013).

There is not a “one size fits all” approach to the initial psychiatric assessment; for example, information gathering from additional sources such as family members, caregivers, friends, teachers, police officers, or healthcare providers may be required. This information may be included in the initial assessment; however, it may occur at a later time. If collateral information is necessary, it is important to explain why the information may be helpful to the patient and obtain written permission for the contact.

PRIMARY AIMS FOR THE PSYCHIATRIC INTERVIEW

The primary aims of a psychiatric interview are to describe a patient’s complaints, appearance, experience(s), or existence; collect objective clinical data in an actionable psychopathologic layout for shared diagnostic classification; and guide treatment and clinical decisions.

GENERAL ASSESSMENT FOR COMMON PSYCHIATRIC DISORDERS

PMHNPs are expected to observe the significant positive and negative findings throughout the interview and document these findings into a particular format called the MSE (see Table 1.1). The MSE is the psychologic equivalent of the physical exam. It is a reliable and systematic approach to assess objective data of cognitive and behavioral functioning and subjective descriptions given from the patient. The purpose of the MSE is to provide a picture of the patient or a “snapshot” at a point in time. It is useful for the evaluation and diagnosis of a disorder and to appraise management and treatment responses (Table 1.2).

Like other assessment screenings in clinical practice, the MSE may have limitations and may be less sensitive to subtle cognitive impairments. Underlying medical conditions can elicit false-negative scores for patients who use alternative methods of coping to bypass their impairment. The MSE is also subject to the interviewer’s skill, expertise, training, and interpretive bias, all of which can influence MSE assessment accuracy.

Table 1.1
Primary Aims for the Psychiatric Interview
Primary AimSteps
Identify patient and informant(s)
Establish rapport

  • ■ Identify chief complaint

  • ■ Identify symptoms

  • ■ Allow patients time to tell their narrative

Elicit explicit information

  • ■ History of the present problem

  • ■ Precipitating factors

  • ■ Developmental history

  • ■ Allergies

  • ■ Medications (current and past)

  • ■ Past medical history

  • ■ Past psychiatric history

  • ■ Family background and medical/psychiatric history

  • ■ Social history and behavior patterns

  • ■ MSE

  • ■ General physical and neurologic exam

  • ■ Safety assessment

Manage the patient

  • ■ Form a diagnostic impression

  • ■ Review management and treatment recommendations

  • ■ Ask about unanswered questions or concerns

MSE, mental status exam

Table 1.2
Domains of the MSE
AppearanceAge; facial features; posture; grooming; weight; physical abnormalities
BehaviorEye contact; alertness; cooperativeness; gait; movements; agitation
SpeechRate; rhythm; volume; content
MoodThe patient’s internal emotional state; personal internal experience; answer to the question “How are you feeling right now?”
AffectObservable emotional state; external emotional expression
Thought ProcessFlow of thoughts; associations of thoughts
Thought ContentSpecific ideas and beliefs; perceptual disturbances
CognitionLevel of consciousness; general level of intellectual ability; memory; attention; general knowledge; executive functioning
Insight/JudgementAbility to understand one’s own situation and ability make decisions to protect self and others

MSE, mental status exam

Fast Facts

Sensitivity and Specificity

  • ■ Sensitivity refers to those who have a disease or test positive; it represents or the true positive rate.

  • ■ Specificity refers to those who do not have the disease or who test negative; it represents the true negative rate.

Fast Facts

To accurately assess the MSE, remember to do the following:

  • ■ Collect information on the patient’s education, culture, religion, worldview, and other social factors. For example, education level, insight, and judgment are fundamentally subjective, and personal beliefs may influence a patient’s response.

  • ■ Ascertain the patient’s norms; for example, some individuals always talk fast.

THE THERAPEUTIC ALLIANCE

The therapeutic alliance is a collaborative partnership between the patient and the provider. A therapeutic alliance occurs when the patient and provider are jointly engaged in purposive work centered around the patient’s needs, goals, and desires (Allen et al., 2017). Every encounter with the patient can have therapeutic potential when providers use empathetic and deliberate dialogue. Characteristics of a therapeutic relationship include trust, acceptance, genuineness, empathy, respect, interpersonal authenticity, and maintenance of professional boundaries (Johnson & Vanderhoef, 2016). The therapeutic relationship includes three distinct phases, as outlined in Table 1.3.

Fast Facts

A strong alliance built on trust and respect has been shown to empower patients, decrease symptomatology, and promote positive treatment outcomes (McLeod et al., 2016). It includes the following:

  • ■ Building a therapeutic relationship

  • ■ Consistency

  • ■ Positive regard

  • ■ Attunement

  • ■ Attention to nonverbal cues

  • ■ Empathy

  • ■ Eye contact

  • ■ Educate and keep patient informed

  • ■ Use of developmentally appropriate language (i.e., consider other methods for nonverbal patients)

EVALUATION FOR PHYSICAL COMORBIDITIES

The considerable overlap in symptomatology between mental health disorders and physical disease processes complicates the clinical picture in the mental health arena. Unrecognized and untreated physical disorders have the potential to burden and negatively impact the care continuum.

It is important for clinicians to inquire about the patient’s last comprehensive physical examination that included lab testing. Consider past and present core symptoms with attention to patterns and problem areas in the body, brain, and environment domains. PMHNPs are well equipped to detect underlying medical problems, distinguish normal versus abnormal symptoms, and identify when referrals are warranted. Consider using screening or rating scales when patients are experiencing substance comorbidities such as substance misuse.

Table 1.3
Phases of Therapeutic Relationship
PhaseCharacteristics
Orientation Phase

  • ■ The introductory phase, which marks the start of the relationship and determines roles

  • ■ Relationship parameters are established, contracting (confidentiality, meeting length and time)

  • ■ Diagnostic evaluation

  • ■ Immediate concerns addressed

  • ■ Establish goals

  • ■ Key principles: effective communication, trust, and honesty

Working Phase

  • ■ The working phase of the relationship

  • ■ Data collection

  • ■ Issues and challenges are identified, problem-solving skills

  • ■ Exploration and identification of thoughts and ideas, explore view of self and others

  • ■ Continual assessment and identification of new problems

  • ■ Validation of thoughts and support positive change

  • ■ Measure outcomes and reprioritize aims; adjust management accordingly

Termination Phase

  • ■ The final phase of the relationship

  • ■ Appraise progress

  • ■ Reflect on accomplishments

  • ■ Promote self-management strategies

  • ■ Communicate feelings related to termination of relationship

  • ■ Disengage and refer if indicated

  • ■ Set parameters for further communication

Clinicians should screen for both psychiatric and nonpsychiatric conditions. Initial lab testing to identify possible organic causes of illness includes (a) complete blood count (CBC); (b) chemistry panel; (c) hepatic panel; (d) thyroid labs; (e) vitamin D, B12, and folate; (f) urine drug toxicology screen; (g) syphilis screening; (h) HIV screen; and (i) adrenal fatigue. Clinicians identify any abnormal neurologic findings and determine if brain imaging or a referral to a specialist is warranted.

Clinicians should assess the following environmental and lifestyle factors when screening for psychiatric and nonpsychiatric conditions:

  • ■ Attachments (insecure, disorganized, avoidant, ambivalent)

  • ■ Exercise

  • ■ Isolation

  • ■ Maladaptive behaviors

  • ■ Nutrition and diet, gluten sensitivity/allergy

  • ■ Relationship patterns

  • ■ Sexuality

  • ■ Sleep hygiene, insomnia, sleep apnea

Clinicians should also assess other considerations, such as trauma, singular traumatic events, complex trauma, disassociation, stressors and functioning, family, situational crises, employment, and relationships.

Fast Facts

Additional Screenings Specific to Children/Adolescents/Young Adults

  • ■ Development milestones assessment

  • ■ Lead screening

  • ■ Vision/hearing

  • ■ Sexually transmitted infections if suspected abuse or sexually active

  • ■ Thyroid disease

  • ■ Multiple sclerosis or other brain lesions

  • ■ Infection

  • ■ Dehydration

  • ■ Nutritional deficiencies

  • ■ Sexual activity and interest

  • ■ History of a head injury

  • ■ Sleep patterns

Fast Facts

Additional Screenings Specific to Older Adults

  • ■ Cancer screening exams (mammogram/colonoscopy/prostate exam)

  • ■ Lymph node exam

  • ■ New onset of cognitive deficits when older than 45 years of age

  • ■ Vision/hearing

  • ■ History of a head injury

  • ■ Sexually transmitted infections

  • ■ Thyroid disease

  • ■ Dehydration

  • ■ Infection

  • ■ Delirium

  • ■ Dementia

  • ■ Nutritional deficiencies

  • ■ Sexual activity and interest

  • ■ Sleep patterns

Fast Facts

  • ■ At birth, the average baby’s brain is about a quarter of the size of the average adult brain and doubles in size in the first year. By age 3, the brain is about 80% of the adult size and nearly full grown by the age of 5 (Stiles & Jernigan, 2010).

  • ■ Childhood psychopathology requires a deep understanding of the complex interplay between neurobiologic, developmental, and environmental factors.

PUTTING IT ALL TOGETHER TO FORMULATE A DIAGNOSIS

Diagnoses are used in psychiatry to describe a syndrome or a cluster of both observable and reported symptomology (phenomenology) that co-occur and describe the patient’s state. The Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD) provide clinicians with a standardized diagnostic nomenclature that uses a descriptive and scientific algorithmic and categorial method toward psychopathology (Aboraya et al., 2016). The DSM-5 (APA, 2013) serves as a guide to ensure diagnostic accuracy and has improved diagnostic reliability; however, increasing the validity of the DSM-5 remains challenging (APA, 2016).

Fast Facts

Reliability and Validity

Reliability refers to the consistency of a measure (diagnosis); for example, a patient presenting with distinct symptoms would receive the same diagnosis if evaluated by different clinicians.

Validity is the extent to which the measure (diagnostic criteria) represents the variable (syndrome) it is intended to characterize; for example, clinicians who are determining validity consider whether the diagnosis represents the patient’s actual symptomology or condition.

The use of labels (diagnosis) has the potential to be harmful and stigmatizing; however, in psychiatry, diagnoses are used to facilitate communication among clinicians and nonclinicians, and to facilitate interprofessional communication. Diagnoses also help support and gauge treatment outcomes (prognosis), measure incidence and prevalence of populations, identify population needs and other public health efforts, and provide opportunities and resources to those in need.

Fast Facts

Incidence and Prevalence

Incidence refers to the frequency of the disease or syndrome in a specific population.

Prevalence refers to the proportion of a specific population that has been impacted by the disease or syndrome at a distinct point in time.

Fast Facts

Factors That Influence Diagnostic Reliability, Validity and Classification Accuracy When Using the Diagnostic and Statistical Manual of Mental Disorders

  • ■ Data collection inconsistencies, time factor, and errors in self-administered questionaries and screenings

  • ■ Poor historian secondary to patient’s state or ability to communicate

  • ■ Caretaker, guardian, or proxy’s low health literacy, inability, or unwillingness

  • ■ Lack of clinician skill, experience, or training

  • ■ Atypical presentation of syndrome

Case Formulations

In psychiatry, case formulations or biopsychosocial formulations are a structured systematic approach toward methodologically conceptualizing and understanding the origin of a patient’s symptom beyond a diagnostic label during a point in time. As the link between assessment and management, case formulations are descriptive integrations of the patient’s information that help clinicians explore distinct, etiologic, behavioral, and treatment-prognostic dimensions and guide the course of treatment (Savander et al., 2019). Assessment based on case formulation enables clinicians to hypothesize about the origins, precipitants, and influences of a person’s psychologic, interpersonal, and behavioral problems (Savander et al., 2019).

An astute clinician will systematically examine and decipher normal versus abnormal variations from presented assessment data to determine the severity of risk (prioritizing), identify problems, and denote symptoms of mental disorders captured by the DSM-5 categories. This information helps clinicians formulate a diagnosis and initiate management (Savander et al., 2019). Unlike other medical specialties, definitive diagnostic tests and lab tests do not exist in psychiatry; therefore, a large part of the data is subjective or reported. Throughout the course of treatment, the data obtained from the interview, the physical assessment, and other diagnostic procedures are used to appraise diagnostic accuracy and course of treatment.

What Constitutes a Psychiatric Emergency?

The origin of what represents an emergency is danger. Suicide is a worldwide phenomenon impacting all populations; thus, suicide is the most common psychiatric emergency. Approximately 800,000 people die by suicide each year worldwide. Currently, data do not indicate that routine screenings for suicide reduce mortality (GBD 2015 Mortality and Causes of Death Collaborators, 2016; World Health Organization [WHO], 2021). Eighty percent of suicide victims had contact with a primary-care clinician within a year of their death (Stene-Larsen & Reneflot, 2019). Psychiatric emergencies can be difficult to identify; however, it is essential for all clinicians to screen and identify if a patient is demonstrating suicidal ideation, self-inflicted harm, or harm to others.

Warning signs of acute suicide risk include (a) threats, remarks, speaking, or writing about a desire or plan to hurt or kill oneself; (b) searching for a means to inflict harm or kill oneself (i.e., obtaining a gun or pills); and (c) engaging in unconventional activities that are out of the norm (American Association of Suicidology, n.d.). Clinicians must be prepared to recognize these warning signs to ensure safety to themselves, patients, and others. It is also important for clinicians to determine if a patient needs to be voluntarily or involuntarily detained for surveillance. Additional screening methods include reviewing a patient’s past attempts, access to firearms, repeated thoughts of suicide or dying, self-harm behaviors, and substance abuse.

As cited in Potter et al. (2020), the Substance Abuse and Mental Health Services Administration (2009) developed the Five-Step Evaluation and Triage screening tool to identify suicide risk, severity, and protective factors. This tool assesses and documents (a) identifiable risk factors; (b) protective factors; (c) suicide inquiry, including thoughts, plans, and intent; (d) determination of risk or level of intervention; and (e) risk, plan, and follow-up (Table 1.4 Potter et al., 2020; Weber & Estes, 2016).

Psychiatric emergencies may include severe life-threatening events, such as abrupt behavioral changes that encompass (a) self-harm with or without suicidality; (b) homicide; (c) abuse; (d) severe psychomotor agitation; (e) catatonia; (f) anaphylaxis or allergic drug reactions; (g) toxic ingestion; (h) marked loss of consciousness; or (i) abrupt changes in cognition, delirium, psychosis, and abnormal vital signs (Wilson et al., 2017). Clinicians must determine if medical attention supplants psychiatric care in certain medical emergency situations.

Table 1.4
Suicide Screen: Mnemonic SAD PERSONS
SAD PERSONS Suicide CriteriaScoring
S - Male1 point
A - Age (<19 or >45 years)1 point
D - Depression or hopelessness2 points
P - Previous attempt or psychiatric care1 point
E - Excessive alcohol or drug use1 point
R - Rational thinking loss2 points
S - Single, separated, divorced, or widowed1 point
O - Organized previous suicide attempt2 points
N - No social support1 point
S - Stated future intent2 points
Score 6–8 = emergency psychiatric evaluation; >9 immediate psychiatric hospitalization

Source: Adapted from Patterson, W. M., Dohn, H. H., Bird, J., & Patterson, G. A. (1983). Evaluation of suicidal patients: The SAD PERSONS scale. Psychosomatics, 24, 343–345, 348–349. https://doi.org/10.1016/S0033-3182(83)73213-5

Fast Facts

Key Points for Suicide Risk

  • ■ Perform ongoing risk assessment.

  • ■ Develop collaborative safety plan to manage suicidal behaviors.

  • ■ Establish care coordination protocols for rapid referrals to evidence-based suicide-specific care.

  • ■ Give attention to means reduction (firearms, substances, etc.).

  • ■ Enact consistent engagement efforts and cultivate connections.

  • ■ Offer continual support during high-risk periods.

(Stanley et al., 2018)

Fast Facts

There are two main categories of psychiatric emergency:

  1. Acute psychomotor agitation

  2. Suicidal or self-destructive behavior

Psychiatric emergencies require immediate intervention. The goal is to prevent harm or other serious consequences to patients and/or others. The main steps include (a) triage (environment, safety), (b) screening (underlying medical or neurologic cause of behavior), (c) assessment (intoxification, substance use or withdrawal, dementia), and (d) treatment (inpatient vs. outpatient).

It is of critical importance that contact with patients during an emergency prioritize safety for both the patient and the clinician.

Fast Facts

  • ■ Globally, suicides are the fourth leading cause of premature mortality in individuals aged 15 to 29 (WHO, 2021).

  • ■ Men complete suicide almost twice as often as women; however, women attempt suicide more often.

  • ■ Suicide rates were highest for men above 75 years old and lowest for those aged 10 to 14 (Centers for Disease Control and Prevention, 2020).

  • ■ Percentage of suicide attempts is 10 to 30 times higher than completed suicides (Bachmann, 2018).

  • ■ Mental health illness increases the risk for completed suicides by 98% (Bachmann, 2018).

  • ■ Mood disorders account for one-third of fatal suicide attempts.

  • ■ The most predictive factors for suicide are associated with suicide ideation, non-suicidal self-injurious behaviors and prior suicide attempts (Fosse et al., 2017).

Fast Facts

Codeterminants and Protective Factors

Codeterminants of increased suicide risk:

  • ■ Demographics

  • ■ Social status

  • ■ Social change

  • ■ Community

  • ■ Environment

  • ■ Chronic physical and mental illnesses

  • ■ Abuse of alcohol and substances

  • ■ Previous attempts

Protective factors:

  • ■ Absence of risk factors

  • ■ Past history of self-control

  • ■ Cultural or religious beliefs that are against suicide

  • ■ Fears of letting down others

  • ■ Safety planning

(Stanley et al., 2018; Welton, 2007).

Fast Facts

Suicide Assessment Mnemonic

IS PATH WARM?

  • ■ (Suicide) ideation (SI): Reports SI, or desire to kill oneself? Purchase or access to a gun or other weapon?

  • ■ Substance abuse: Heightened or new onset of alcohol or drug usage?

  • ■ Purposelessness: Expresses a lack or loss of purpose or a reason to live?

  • ■ Anger: Does the client express feelings of rage or uncontrolled anger? Expresses wanting revenge against others? Intense anger or rage, blaming of others?

  • ■ Trapped: Feelings of being trapped or stuck? Feelings of agony or pain? Feeling that death is the only solution?

  • ■ Hopelessness: A negative sense of self, others, and future? Expresses hopelessness?

  • ■ Withdrawing: Indicates the desire to withdraw from family, friends, and society? Isolates self?

  • ■ Anxiety: Feelings of anxiousness, agitation, or unable to sleep? Lacks ability to relax? Increased sleep or poor sleep quality?

  • ■ Recklessness: Reckless or engages in risky activities, seemingly without considering consequences?

  • ■ Mood change: Reported dramatic mood shifts or states?

(American Association of Suicidology, n.d.)

SUMMARY

Structured interviews, semistructured interviews, and questionnaires have become the gold standard for diagnostic interviewing for psychiatric mental health assessments across populations. Psychiatric evaluations are a diagnostic tool employed by mental health clinicians to collect patient information and assess for anomalies of experience, belief, thought process, expression, behavior, and overall functioning. This information is useful in helping clinicians determine if symptoms are present, assess the severity of the symptoms, formulate a diagnosis, triage patient needs, plan an appropriate course of treatment, and guide ongoing clinical decisions. It is essential that clinicians assess severe symptoms requiring immediate intervention, such as suicidal behaviors, harmful gestures to self or others, delusions, hallucinations, or acute disturbance in thought, behavior, and/or mood. It is also important to consider the patient’s mental and physical health throughout psychiatric examinations.

REVIEW QUESTIONS

1.

What the drug does to the body is referred to as which one of the following?

  1. a.

    Pharmacologic distribution

  2. b.

    Pharmacokinetics

  3. c.

    Pharmacodynamics

  4. d.

    Pharmacoregulation

2.

Which one of the following statements is true?

  1. a.

    Men attempt suicide more than females and have fewer suicide-related deaths.

  2. b.

    The percentage of suicide attempts is 10 to 30 times higher than completed suicides.

  3. c.

    Predictive factors for suicide include being a White male with no prior attempts.

  4. d.

    Suicide assessments are only performed during the initial interview.

3.

Reliability refers to which one of the following?

  1. a.

    Consistency of a measure and the ability to reproduce results under equivalent conditions

  2. b.

    The extent to which the results really measure what they are intended to measure

  3. c.

    An operational systematic process for defining variable indicators

  4. d.

    Tests wherein the purpose is clear

4.

During the termination stage of the therapeutic relationship, which one of the following occurs?

  1. a.

    Key principles are effective communication, trust, and honesty.

  2. b.

    The therapist suggests self-management strategies.

  3. c.

    The therapist and patient establish goals.

  4. d.

    Issues and challenges are identified and problem-solving skills are developed.

5.

Which one of the following statements is accurate?

  1. a.

    Sensitivity refers to those who have a disease test negative, and specificity refers to those who do have the disease test negative.

  2. b.

    Sensitivity refers to the false-positive rate, and specificity refers to those who do not have the disease test positive.

  3. c.

    Sensitivity refers to those who have a disease test positive or true positive rate, and specificity refers to those who do not have the disease, test negative, or the true negative rate.

  4. d.

    The DSM-5 has a high sensitivity and specificity.

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