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I. Overall strategy
A. Do not be overconfident
1. Being a good clinician is not enough
2. This format is peculiar, and must be practiced
3. Be prepared to interview very sick, very difficult patients, as well as "non-patients"
B. Understand the purpose of the examination
1. To ascertain that you treat patients with decency, kindness, respect and appropriate firmness, where indicated
2. To ascertain that you can take a competent history
3. To ascertain that you can generate an appropriate differential diagnosis
a. This means not just the most likely diagnosis, but other important possibilities
b. These almost always include consideration of what organic entities could be implicated as causal/contributory
4. To ascertain that you can generate an appropriate treatment plan, with due regard to clarifying the diagnosis as well as initiating appropriate treatment
II. Interviewing guidelines
A. Practice, practice
B. Over the course of the interview, you will want to try to cover the following areas:
1. Identifying information
2. History of present illness
3. Past psychiatric history
4. Past medical history
5. Family and developmental history
6. Social history
7. Focused review of systems
8. Mental status examination
C. Of course, in many or most instances, you will not be able to move smoothly and easily from each of these categories to the next; you will need to modify your interview to accommodate the patient. However, in generating your differential diagnosis, you will need information from each of these categories.
D. Welcome, thank the patient; explain the purpose and the process; be friendly and try to put the patient at ease
E. Open with general, identifying information such as age, living situation, marital status, work, etc and current treatment situation -- this will give you many cues and clues
F. History of Present Illness
1. This is the most important aspect in terms of generating the differential
2. It is vital to understand, in detail, the current episode of illness
3. Ideally, one would like to know the course of events since the patient was last well, but this is not always possible; otherwise, one wants to know the course of events in the current exacerbation
4. Follow the course sequentially, tracing in all symptoms
5. Go from general to specific; let the patient tell the story, especially in the early going
6. When you get down to detailed questioning, establish all positive and negative symptoms, eg
a. For instances in which thought disorder is present be sure you inquire about hallucinations in all sensory modalities
b. For instances in which there is a mood disturbance, be sure to establish all "SIGECAPS" (Sleep, interest, guilt, energy, concentration, appetite, psychomotor agitation/retardation, suicide)
c. Be sure to ask about recent med changes, stressors, changes in living situation, etc
7. Be especially sure to establish when, how and why the patient came to the hospital
8. Be dogged; consider asking others' perspectives
G. Past psychiatric history
1. Hospitalizations
2. Other treatment
3. Other, unrelated psychiatric problems
H. Past medical history
1. Surgical procedures
2. Medical hospitalizations
3. Major illnesses
4. Medications
5. Allergies
6. Alcohol, nicotine, and other substance abuse
I. Family History
1. Always ask for history of family psychiatric illness
2. Circumstances of development
3. Consider asking sexual and physical abuse history
J. Social History
1. Marital status and history
2. Work status and history
K. Review of systems: focused
L. Mental status examination
1. Infer where possible because of the constraints of time
2. You will need however to be aware of these categories
a. General appearance
b. Nonverbal behavior
c. Speech: latency, prosody, content, flow
d. Mood: reported and observed
e. Affect: range, amplitude and appropriateness
f. Thought: form (coherence, associations, blocking, insertion, derailing tangentiality, circumstantiality) and content (hallucinations in all sensory modalities, illusions, delusions, phobias, obsessions, etc)
g. Neurovegetative signs ("SIGECAPS")
h. Suicidality and homicidality
i. Cognitive exam, including level of consciousness, memory, fund of information, judgment, and insight, and more specifics where indicated; this is not always necessary and may be inferred; however, be ready to do a formal cognitive exam
M. I recommend "Guided Interviewing": as you move from one category to the next, explain what you are doing; this serves the function of:
1. Helping you keep straight the categories you want to cover and where you are in the process
2. Cuing the patient as to the information you're seeking
3. Demonstrating to your examiners that you know what you're doing
III. Common interviewing errors
A. Introductory phase
1. Impoliteness to pt
2. Failure to explain process
B. History of present illness
1. Premature closure on primary problem
a. Thereby cutting the patient off
b. Not letting the patient tell his story
c. Missing important clues/lines of inquiry
2. Failure to fully flesh out syndrome
3. Failure to establish full symptom profile
a. Range of symptoms
b. Pertinent positive as well as negative signs
c. Associated events: medical/psychological/social
4. Failure to establish circumstances of hospitalization
5. failure to trace treatment
C. Past psych history
1. Failure to establish past episodes of similar or related illness
2. Failure to establish other unrelated psychiatric illness
D. Past medical history
1. Failure to ask at all
2. Failure to establish possible "organic" links
3. Failure to establish substance abuse history
E. Family history
1. Failure to establish family history of psych illness
2. Failure to establish abuse history
F. Mental status examination
1. Failure to comprehensively sample all symptoms of thought disorder
2. Failure to establish mood
3. Failure to establish "SIGECAPS"
4. Failure to establish suicidal/homicidal ideation
5. Inadequate cognitive exam where necessary for differential diagnosis
V. Presenting the case and fielding questions
A. Briefly, succinctly summarize the case in about five minutes, touching lightly on the identifying information, HPI, and then mentioning the pertinent positive and negative findings from each subsection.
B. Present a differential diagnosis
1. First note the syndromal clusters to be dealt with, eg, "a psychotic disorder in a 35-year-old man with a history of arthritis, substance abuse and depression" or "a depressive episode in a 40 year-old woman with a recent history of multiple losses"
2. Then present the spectrum of diagnostic possibilities, a. usually including (wherever possible) organic etiologies and contributions b. Axis I possibilities c. then Axis II d. then Axis III, IV, V e. then prioritize, eg, "the most likely primary diagnosis is major depression, however it will be essential to rule out Organic Mood Disorder; less likely possibilities include Adjustment disorder with depressed mood against a background of dysthymia"
3. Be prepared to say why one possibility is more likely than another but avoid "defending" one possibility against all others
C. In fielding questions
1. Answer fully and at length, particularly regarding questions you know the answer to
2. There is nothing wrong with basic clinical information
3. Stick to the main question as it is asked
4. Avoid argument: acknowledge the thrust of the question and respond to it
5. If you do not know the answer, show that you understand why the question is important and how you would deal with the problem in a real, clinical situation, ie, how you would find the answer
6. If you make a mistake, acknowledge it, as well as showing that you know it is important and how you would rectify such an error in a clinical situation
7. Be prepared to address issues of treatment, including agents, doses, contraindications, side effects, multidisciplinary treatment, especially as they bear on in-patient treatment
D. Common errors of presentation/defense
1. Too restricted a differential
2. Incorrect differential
3. Focusing on one alternative
4. Missing organic possibilities
5. Trying to read the examiner's mind
6. Going blank
7. Inability to explain why one diagnosis is more likely than another
8. Arguing with the examiner
9. Being "brilliant"
10. Being smug
11. Missing the forest for the trees