The Psychiatric Interview as a Diagnostic Assessment Tool
Carlos E. Berganza Chair, Section on Classification World Psychiatric Association
Introduction
The single most important tool by most textbooks of psychiatry Means to establish rapport Elucidating data Observing the patient’s behavior Course of the clinical condition
E.g., biography, personality, adaptation
Formats: Determinants
Purpose of the interview Theoretical loyalties Medical model Psychodynamic concepts Systemic considerations Nature of the clinical condition
Goals and Purposes
Engaging the patient as a reliable partner Collecting essential (valid) information Understanding of the patient Developing appropriate diagnostic hypotheses Preparing the patient
Further procedures: diagnosis or treatment
Engaging the Patient
Physician-patient relationship
Core of medical (and psychiatric) practice Rapport promotes a constructive therapeutic relationship It may uncover issues of basic trust in early development Source of strength for the patient
Collecting Essential Information
Probably most structured part Complement information provided spontaneously Explore consistency of patient’s discourse Confirm or rule out initial diagnostic hypotheses Complete mental status examination
Understanding the Patient
Genuine understanding (Jaspers) Attention to the subjective experience Conveying empathic intent to “connect” Validate internal experience as valid, unique and meaningful Address concerns
Symptoms, Labels, Stigma, Causes of illness
Appropriate Diagnostic Hypotheses
Organize the database into sensible list of clinical problems leading to treatment Influenced by school of thought Ideally to be agreed upon with patient and family Consider the complex nature of problems
Multiple determinants Various axes of assessment Multiple strategies of treatment
Preparing for Further Procedures
More than one interview usually needed First meeting critical for engagement Determinant for the future approach to diagnostic or therapeutic needs
Techniques of Effective Interviewing
Setting and time allocation Developing and maintaining rapport Attitudes conducive to mutual understanding
Cultural issues Language barriers
Systematic anamnesis Promote self-esteem, autonomy and hope
Setting and Time Allocation
Select setting according to circumstances
Comfortable for both patient and clinician Protect privacy Minimize external distractions
Time agreed upon with the patient
Keep length of time previously accorded Agree on further sessions if needed Be respectful of patient’s time
Developing and Maintaining Rapport
Poor rapport leads to clinical failures Beware subtleties of communication
Transference and counter-transference
Facilitates trust and openness
Empathy and unconditional positive regard
Be aware of your own emotions
Feelings, not usually the problem; ignoring them will surely be
Building Mutual Understanding
Interview a dynamic process
Leading to mutual understanding
Patient-Clinician
Without blurring respective roles
Attitudes of clinician are important
Attentive interested listening Conveying respect at all times
Cultural issues must be considered
Including potential language barriers
Systematic Anamnesis
Information on major problems
Onset and course
Time
frame, mode, circumstances
Clinical signs and symptoms Concomitant functional difficulties Contextual factors Treatments received and effects upon illness Additional efforts to restore health
Closing the Interview
By the end further steps ought to be specified and agreed upon
Diagnostic and therapeutic
Interviewing
relatives and others Reviewing documentary sources of information Supplementary assessment procedures
Closure must promote:
Self-esteem, sense of hope, cooperation and clarity of goals
Final Comments
Psychiatric interviewing is a skill
Art and technique (science) Compassion and systematic thinking
Allows therapeutic alliance
For understanding the problems Delineating treatment
Single most important diagnostic tool