PSYCHIATRIC INTERVIEW

The psychiatric interview is the most important element in the evaluation and care of persons
with mental illness. A major purpose of the initial psychiatric interview is to obtain information
that will establish a criteria-based diagnosis. This process, helpful in the prediction of the
course of the illness and the prognosis, lead to treatment decisions. A well-conducted
psychiatric interview results in a multidimensional understanding of the biopsychosocial
elements of the disorder and provides the information necessary for the psychiatrist, in
collaboration with the patient, to develop a person-centred treatment plan.

From the very first moments of the encounter, the interview shapes the nature of the patient
physician relationship, which can have a profound influence on the outcome of treatment. The
settings in which the psychiatric interview takes place include psychiatric inpatient units,
medical non psychiatric inpatient units, emergency rooms, outpatient offices, nursing homes,
other residential programs, and correctional facilities. The length of time for the interview, and
its focus, will vary depending on the setting, the specific purpose of interview, and other factors
(including concurrent competing demands for professional services).

PURPOSE OF PSYCHIATRIC INTERVIEW:

The purpose of interview is:-
1. To obtain historical perspective of patient’s life,
2. To establish rapport and therapeutic alliance,
3. To develop mutual trust and confidence,
4. To understand present functioning,
5. To make diagnosis,
6. To establish treatment plan.

GENERAL PRINCIPLES OF PSYCBHIATRIC INTERVIEW

1. Agreement as to process :
The psychiatrist should introduce himself or herself and, depending on the circumstances, may
need to identify why he or she is speaking with the patient . The psychiatrist should obtain
permission from patient and his relatives to further continue interview. The patient should be
encouraged to identify any elements of the process that he or she wishes to alter or add.

2. Privacy and confidentiality :

Issues concerning confidentiality are crucial in the evaluation/ treatment process and may need
to be discussed on multiple occasions. Confidentiality is an essential component of the
patientdoctor relationship. The interviewer should make every attempt to ensure that the
content of the interview cannot be overheard by others.
A special issue concerning confidentiality is when the patient indicates that he or she intends
to harm another person. When the psychiatrist's evaluation suggests that this might indeed
happen, the psychiatrist may have a legal obligation to warn the potential victim. (The law
concerning notification of a potential victim varies by state.) Psychiatrists should also consider
their ethical obligations.

3. Respect and consideration :

The patient must be treated with respect, and the interviewer should be considerate of the
circumstances of the patient's condition.

4. Rapport/Empathy:
It is important that patients increasingly feel that the evaluation is a joint effort and that the
psychiatrist is truly interested in their story.

Maintaining objectivity is crucial in a therapeutic relationship and it differentiates empathy

from identification. With identification, psychiatrists not only understand the emotion but also
experience it to the extent that they lose the ability to be objective.

5. Patient-Physician Relationship:
As the physician's behaviors demonstrate respect and consideration, rapport begins to develop.
This is increased as the patient feels safe and comfortable.

There should be demonstration of physicians that they understand what the patient is stating
and emoting. This understanding must be conveyed to the patient if it is to nurture the
therapeutic relationship. The other essential ingredient in a helpful patient-physician
relationship is the recognition by the patient that the physician cares. As the patient becomes
aware that the physician not only understand but also cares, trust increases and the therapeutic
alliance becomes stronger.

6. Person-Centered and Disorder-Based Interviews:

A psychiatric interview should be person (patient) centered. That is, the focus should be on
understanding the patient and enabling the patient to tell his or her story. The individuality of
the patient's experience is a central theme, and the patient's life history is elicited, subject to
the constraints of time, the patient's willingness to share some of this material, and the skill of
the interviewer.

7. Safety and Comfort:

Both the patient and the interviewer must feel safe. This includes physical safety. On occasion,
especially in hospital or emergency room settings, this may require that other staff be present
or that the door to the room where the interview is conducted be left ajar. The interview may
need to be shortened or quickly terminated if the patient becomes more agitated and
threatening.

8. Time and Number of Sessions:

For an initial interview, 45 to 90 minutes is generally allotted. For inpatients on a medical unit
or at times for patients who are confused, in considerable distress, or psychotic, the length of
time that can be tolerated in one sitting may be 20 to 30 minutes or less.

NATURE OF PSYCHIATRIC INTERVIEW:

 Facilitate the patient’s narrative with compassionate listening and reflection.

 Mindfulness and reflection is a form of mentoring through modeling for the patient.
 How a patient puts the narrative of their medical and psychiatric history together tells
the clinician how integrated the patient’s mind is.
 An integrated mind can create a narrative that involves sustained attention, memory,
emotional responses, intellectual analysis, timeline, mindfulness of self as well as
mindfulness of others in their lives.
 Understand the patient’s perspective by exploring contextual issues (e.g., familial,
cultural, spiritual, age, gender, and socioeconomic status).
 Understand the patient’s perspective with eliciting beliefs, concerns and expectations
about health and illness.
 Active listening using verbal and nonverbal methods (eye contact).
 Reach an agreement on the problems and treatment plan by encouraging the patient’s
participation in the decision-making.
 Explore if the patient is amenable to follow a plan of treatment.
 Identify and provide resources, support groups, psychotherapy and literature to read.
 Provide closure with follow up plans.

COMPONENTS OF PSYCHIATRIC INTERVIEW:

 Behavioral Observation begins the moment the patient engages with the system of care
(i.e. the initial phone call for the appointment). It is useful to see how the patient
interacts with the support staff and with family, friends or others that may accompany
him/her to the appointment.
 The observation continues before, during and after the interview. Take note of the
patient’s:
Grooming
Style and state of the clothing worn
Mannerisms
Normal and abnormal movements
Posture and gait
Physical features (natural deformities, birth marks, tattoos, piercings, cut marks,
scratches, burns)
Coloring
Use of language
Nonverbal clues such as eye contact, facial expression and posture.
  The interview of the patient starts with an open ended question as to what brought the
patient in today. Encourage the patient to tell the story without interruption if possible.
 Use clarification to move the interview through the data gathering, being mindful as
that patient may have a different agenda than the diagnostic assessment (e.g. patient is
upset her spouse is unemployed but is in a manic state during the interview). Always
important to validate the patient’s perspective!
 Remember depression, anxiety and agitation mean different things to patients vs.
Psychiatrist/PCP.
 It is best to focus on the chief complaint and present issues and to incorporate the other
parts of the history around this. As the PCP, you are in a position of a longterm trusting
relationship with the patient and can redirect the patient to ascertain additional
information. Many times the PCP knows about family dynamics as they see the family
also (alcoholism, financial, losses in the family).
 A key component of the psychiatric interview is the determination of safety. Questions
about suicide, homicide, domestic violence and abuse should not be omitted from the
review of the current situation!

COMMON ERRORS IN THE PSYCHIATRIC INTERVIEW:

 Premature closure and false assumptions about symptoms
 False reassurances about the patient’s condition or prognosis
 Defensiveness with aggressive or arrogant patients
 Omission of significant parts of the interview
 Recommendations for treatment when diagnostic formulation is incomplete
 Inadequate explanation of psychiatric disorders and treatment options
 Empathic failures by inadvertently shaming or embarrassing the patient
 Countertransference issues with the patient
 Not exploring in depth safety issues with the patient
 Check to see if the patient has access to weapons or guns.
 PSYCHIATRIC INTERVIEW

 Name of the patient: Chandrakant s/o Pratap Singh Rana

 Age: 27 years
 Sex: male
 Address: Haryana
 Date of admission: 14/05/2019
 Under the section of IPC- 89
 CRF no. – 19-5-31442
 Ward: Female open ward
 Education: B. Tech
 Occupation: Unemployed
 Religion: Hindu
 Marital status - unmarried
 Bed no. 06
 Languages spoken – Hindi , English
 Doctor in charge: Dr. Pravesh
 Informant: Patient and his brother
PHASE 1: Warm-up and chief complaint
N: Good morning chandarkant…..
P: Good morning ma’am (speaks slowly, not maintained eye-eye contact)
N: Ap kaise ho?
P: Thik ..hu Mai ….hmmm Thik.. hu.. mai ( speaks slowly)
N: Ap yahan par kaise aye?
P: Mai bimar tha..
N: Apko kya takleef thi?
P: Mujhe nind nhi ati thi…..
N: Apko ye sab kab se ho raha hai?
P: Pichle mahine se ho raha hai …….(speaks slowly, not maintained eye-eye contact)
N: Apko ye sab pehle bhi huya hai?
P: Ha…ekkk..saal ..pehle bhi huya tha…
N:Jab apko ye takleef huyi thi to apne iska treatment karwaya tha
P: Hanji ….humne treatment karwaya tha ( difficulty in speaking)
N: Apko lagta hai koi problem hai ?
P: ha …mujhe lagta hai ki koi..problem to hai ( difficulty in speaking, not maintained eye to
eye contact)
Rapport: The patient maintained rapport with the nurse but not eye to eye contact. He speak
slowly.

The technique used: Addressing the patient’s mental status. The patient responds his
problems. Disorder centred interview was conducted.
Mental status: Patient displayed a sad affect when answering the questions.

PHASE 2 : DIAGNOSTIC DECISION LOOP:

N: Apko nind ati hai ?
P: Nhi ..mujhe raat ko nind kamm ati hai ( speaks slowly , with sad facial expressions)
N: Phir jab apko nind nhi ati to ap kya karte ho…
P: Mai leta rehta hu ….bas …
N: Apne padhayi kitna kiya hai …
P: Maine B.tech ki hai
N: apne B. tech kounsi ki hai
P: maine Civil engineering ki hai ( speaks slowly)
N: Kahan se ki hai apne study?
P: Maine Haryana mai hi ki hai
N: Apne B.tech kahan se ki hai
N: Apko akele rehna psand hai?
P: Hanji… mujhe akela rehna psand hai…
N: ap free time mein kya karte ho ?

P: Main free time mein bas leta rehta hu… kisi se baat karne ka mann nhi karta( looking
down)
N: Jab ap pehle bimar the tab bhi same hi problem thi?
P: Hanji … same hi thi
N: apke mann me marne ke khayal ate hai ?
P: Hanji .. ate hai…. Par ab kamm hog ye hai
N: Apne kabhi marne ki koshish ki hai ?
P: Hanji… maine marne ki koshish ki hai…
N: kab ki thi apne marne ki koshish … ???
P: Last year …. Jab meri shaadi thi use ek din… pehle maine marne ki koshish ki thi ….
N: Uske baad kabhi kosish ki ….

P: Hanji…… uske baad phir se maine marne ki koshish ki … maine khud nu kaat liya
tha……( with sour smile)
N: Apko kyu lagta hai ki apko marna chahiye …

P: Mujhe lagta hai ki abhi meri zindagi mein kuch nhi raha …..( looking in the interviewer
eyes)
N: Apne kabhi job ke liye try nhi kiya?
P: Maine bhut bar try kiya par mein successful nhi huya.
N: Ap shaadi nhi karna chahte the? ( looking down, shaking his head)
P: Nhi mai …shaadi nhi karni chahta tha…
N: Ap ne study complete kab kiya
P: maine 2013 mein … complete kar li thi…
N: Ab ap kya karna chahte ho ??
P: mein ab GAT KI preparation kar raha tha …. (looking down, sad mood)
N: Ap koi nasha to nhi karte ?
P: Nhi ……
N: apm smoking karte ho ?
P: nhi kabhi nhi ….
N: Kabhi beer piya hai???
P: nhi ….
N: Apko logo par shak hota hia ki who hamesha apka bura hi sochte hai?
P: hanji…kabhi kabhi mann mewin aise khyal ate hai.
N: apko awaazein sunayi ya dikhayi to nhi deti ?
P: aisa kujh nhi hai ….

Rapport : Rapport with patient remained intact. The patient moderately participate in the
interview, answers questions voluntarily and cooperates . His answers show grade III of
insight . The patient shows his emotions with little discomfort.

Technique : The interview covers the topic of his traumatic response. The interview screens
suicidal tendencies , psychotic symptoms , insight, depression , physical symptoms . The
patient agreed with all the interviewer summaries, documenting good verbal understanding .
Mental status: The patient responded with relevant details to close ended questions ,
showing that he remained verbally productive irrespective of depressed affect. The content of
answers was understandable.

Diagnosis : The interviewer assessed symptoms associated with the chief complaint . The
patient has chief complaints of loss of sleep, loss of appetite, worthlessness, helplessness,
suicidal ideations , hopelessness, sad affect , guilt , delusion of presecution. The complaints
of the patient leads to suicidal ideation .

PHASE 3 : HISTORY AND DATABASE

a. Medical history
N: Apko koi aur takleef hi ..?
P: Nhi mujhe aur koi takleef nhi hai
N: Apka BP badhta hai ya phir kabhi fits aye hai apko ?
P: Aisa kabhi nhi huya
N: Kabhi bhukhar huya ho …. Uske baad mein fits aye ho?
P: nhi aisa kabhi nhi huya .
N: Apko kisi cheez se allergy to nhi hai …?
P: nhi mujhe nhi hai ( with smile)
b. Family history
N: Apki family mein koun koun hai ?
P: Meri family mein mere bhai , mata pita , aur bhabi hai.
N: Apke kitne bhai hai ?
P: Hum 4 bhai hai …behn koi bhi nhi hai….
N: Apke parivar mein pehle bhi yeh problem hai kisi ko ?
P: Nhi pehle to nhi hai ……kisi ko bhi …..( with disgust )
c. Developmental history
N: Apke kitne dost hai …?
P: mere jyada dost nhi hai …… ( with sad affect)
N: Apko logo se milna psand hai ?
P: Mujhe jyada logo se baat karna psand nhi hai … mujhe apne gharwalo se hi baat
karna psand hai
N: Apne teachers se kabhi ladayi ki ?
P: Nhi maine kabhi aisa nhi kiya
d. Social history & support
N: Parivar mein sab apko support karte hai?
P: hanji …parivar mein sab support karte hai mujhe
Patient’s brother : Hamare pita ji gusse wale hai ….woh hamesha hi negative
baatein hi karte hai .
N: Baki risthedaar sab support karte hai apko ?
P: hanji sab support karte hai ….
N: Apki koi GF thi ?
P: Hanji thi… par use brakup ho gya tha …wo college time thi….
N: Apko bhagwaan par bhrosa hai…
 P: Hanji …hai bhi hai …nhi bhi hai ( looking down)
N: Ap mandir jaate ho?
P: Ha kabhi –kabhi
e. Mental status exploration & testing
N: apko yahan par koun leke aya tha ?
P: mujhe yahan par mera bhai leke aya tha
N: us waqt apki condition kaisi thi
P: mujhe kujh bhi yaad nhi hai
N: ap yahan par kab aye the ?
P: mein yahan par 19-05 ko aya tha
N: Apka last ECT kab huya tha ?
P: mera last ECT kal huya tha
N: subah apne kya khaya
P: subah maine dudh peey aaur bread khaya
N: Iss hospital ka kya name hai ?
P: Iss hospital ka name IHBAS hai
N: Ye kounsi state mein padhta hai ?
P: Ye delhi mein hai …..
N: Apko maths psand hai?
P: Hanji ( with smile)
N: 35×50 kitna hota hai ?
P: hmmm…………………..1750 hota hai .
Rapport : The rapport with the patient remains intact. Reviewing the medical history
signalled the patient thoroughness and concern about general health. The patient
explore his social support , orientation , developmental history .
Technique : Using a smooth transition, the interviewer attempted to complete the
database , opening up medical , developmental, and social history with open ended
and close ended questions .
Mental status examination :
Tests of orientation, recent memory , abstraction, calculation are within normal range.

PHASE 4 : DIAGNOSIS & FEEDBACK

N: Apko lagta hai ki ab apko apni life mein age badhna chahiye ?
P: Hanji mujhe …lagta hai ( looking in interviewer eyes, with smile)
N: Apko mann ka jo darr hai uska dur karna hoga ?
P: Hanji
N: Aur apne career par concentrate karna hoga ….
P: Hanji

Rapport : The interviewer show her expertise in in addressing the patient’s dependency
needs from the patient’s insight , orientation. The patient accepts that he has some problem
but he don’t understand the actual problem.
Technique : With an accentnauted transition, the interviewer prepares the patient for the
diagnostic feedback, a role reversal .

Mental status examination: The patient’s affect has been changed from the beginning of the
interview. He has switched from sadness, anxiety to an empathetic approval of the
interviewer’s feedback, expressing openness, and interest in interviewer’s questions.

PHASE 5 : TREATMENT PLAN & PROGNOSIS

N: Apko medicine ki wajah se koi takleef to nhi ho rehi ?
P: nhi … bas mann udas rehta hai …. Par pehle se thik hai
N: Apko apne as paas walo se baat karni chahiye
P: hanji

N: jab ap logon se baat karna shuru karoge to apka mann thik rahega … par agar ap akele
baithe rahoge to mann me bhut sare thoughts ate hai …unme se kuch negative bhi hote hai…
jo hamare mann ko udass karte hai …isliye esa nhi karna…dwai time par khani hai … beech
mein chodna nhi hai….dwai ke saath khane peene ka bhi dhyan rakhna hai….
P: ji ….( with smile)

N: Apne ap ko kisi na kisi activity mein vyasat rakhna hai …. Taki apka mann udas nah o
…try to concentrate on your future ….. talk to your family … read books and do physical
exercise also …. You can do it .
P: ji …

N: koi bhi problem hai to usko apni family ke saath share karna hai taki usko solve kiya ja
sake ….they will understand your issues and try to solve them as much as they can . Har ik
baat ko jyada nhi sochna aur khud ki tarf concentrate karna hai…
P: Ji ma’am. Ab mujhe kuch accha lag raha hai (with smile)

Rapport : The patient has accepted the interviewer as an expert . The interviewer uses the
patient’s desire to be supported by family .

Technique : The interviewer summarizes the patient’s positive experiences and strengths that
he had shown in the interview as a basis for treatment plan.
Mental status: the prominent feature is the patient’s change from an anxious , sad affect to a
confident affect.

Diagnosis : The patient’s emotional reactivity to the interviewer’s input added to good
prognosis of patient’s suicidal ideation.

CASE SUMMARY
A. Identifying data : Mr. Chandarkant , 27 years old male , brownish , belongs to a
hindu family and 3rd in birth order.
B. Chief complaint: The patient has feeling of worthlessness, hopelessness, loss of
appetite , loss of sleep. Delusion of persecution, suicidal ideation.
C. Informants : The patient was accompanied by his elder brother.
D. Reason for consultation : Suicidal ideation
E. History of present illness : The patient face the problem of loss in appetite, loss of
sleep , hopelessness, suicidal ideation from last one month. He tried 2 times to
commit suicide . He has continuous suicidal thoughts. He also had periods of social
withdrawal , loss of energy , sensitivity to rejection. The patient has delusion of
persecution.
F. Psychiatric disorders in emission: The patient had faced same problems last year
and treated .
G. Medical history : No significant history
H. Social history : The patient lives in a joint family . He has 3 brothers . The family
provides full support to the patient. The patient had cordial relationships with the
friends, family and society before illness.
I. Family history : No significant history was found in the family
J. Mental status examination
i. General appearance & behaviour : The patient is a 27 year old , brownish
man , alert , not maintained eye to eye contact , but cooperative during
interview.
ii. Movements : Appropriate reactive movements when addressed.
iii. Speech: Voice was quivering at the starting of interview. He talked with
normal rate . answered in a precise, goal-directed manner, volunteering
appropriate details.
iv. Mood & affect: Mood was depressed and affect was sad. The effect was
changed at the end of the interview.
v. Thought: He had lost interest in the living. Delusions of persecution are
present. No obsessions are present.
vi. Cognition: the patient was oriented to time, place and person. Memory was
intact. able to calculate numbers.
vii. Insight: He had an awareness that he had some problem.
viii. Judgement: intact
K. Diagnostic formulation
A. Biological
 Predisposing factors: No family history, no head trauma
 Precipitating factors: Course of stress worsen the symptoms
 Perpetuating factors: Dysphoric withdrawal reaction
 Protective factors: Good response to antipsychotics
B. Psychological
 Predisposing factors: Ability to emotionally support himself is limited.
 Precipitating factors: feeling of worthlessness, helplessness, hopelessness,
insomnia
 Perpetuating factors: Dysphoric withdrawal reaction
  Protective factors: Able to understand his problem.
C. Social
 Predisposing factors: Delusion of persecution , worthlessness, introvert
personality.
 Precipitating factors: helplessness, social withdrawal, loneliness, not able to
share feelings
 Perpetuating factors: Failure in life after several attempts
 Protective factors: Has strong support from family.

L. Differential diagnosis
The patient has developed delusion of persecution, feeling of worthlessness,
dysphoric withdrawal reaction, social withdrawal, not able to share feelings,
loneliness, helplessness, suicidal ideas. Therefore, occurrence of depression, paranoid
schizophrenia, suicide are more likely. Early intervention may reduce the risk of
paranoid schizophrenia , depression and suicidal ideas.
M. Diagnostic criteria according to DSM 5:
a. Following symptoms are present
 Delusions
 Negative symptoms
 Disorganised speech
 Failure to achieve expected level of interpersonal and occupational
functioning.
 Duration : continuous signs of symptoms persist for more than 1 year
 Multiple episodes, currently in acute episode.
N. Assets and strengths :
Has strong support from family