PSYCHIATRIC

INTERVIW
TECHNIQUES

Yonas Baheretibeb MD.

Department of Psychiatry
 Learning objectives
 To know objectives of psychiatric interview.
 To know the preliminary requirement to
conduct the interview.
 To learn universal interview techniques to
conduct the interview.
 To acquire knowledge how to use interview
techniques .
 To demonstrate what you learn in Role play.
 To develop skill in organizing and writing
psychiatric History
 Psychiatric Interview

” The skill of encouraging disclosure of

personal information for a specific
professional purpose” (McCready,1986).
How different is Psychiatric Assessment
from assessment in other disciplines?
There is significant differences in history
taking: Medicine, Surgery, Pediatrics…
 IN THE PAST  AT PRESENT

-Detail Hx. -Radiography

-Physical -Biopsy
examination to -CT
reach a -Biochemical
diagnosis test
-MRI a
A careful history contributes more to determining
diagnosis in medically ill patient than does physical examination which,
-other..
in turn is of greater usefulness than laboratory testing ( Anfinsen, 1992;
Hampton, 1975)
Comparison of Assessments
General Medical Assessment

P/E
Lab./Tech. Hx.

Psychiatric Assessment

MSE Hx.
P/E

Lab/Tech.
 In Psychiatry
“Old friend, Old books, Old wine are best”

 Detailed Hx.
 Thorough MSE

The single most important method of arriving to Dx.in

psychiatry is a very good psychiatric interview.
What are the purposes of
Psychiatric assessment?
 What are the objectives of
Psychiatric interview?
I-The interview is used as a way of
eliciting signs and symptoms in
psychiatry( assesses psychotic thinking,
psychotic behavior, emotion ,attitudes,
Suicidal,Homicidal thought or plan,
consider hospitalization)

II-To gain a knowledge about the Pt. and

the nature of his problem:-
(Pt.’s psychological make up, identifying
psychosocial development of the patient,
to understand the coping mechanism of
the patient, to assess his social
support,and social,religious and cultural
influence on the patient life)
 What are the objectives of
Psychiatric interview ,cont.
III-To give a chance to the Pt. to
express his/her emotion this help us
to establishes a proper rapport with
the patient.
1. A very good interview has very
good psychotherapeutic effect on
the patient.
2. If the interviewer has an ability
to understand a patient’s problem
he can easily establish good
rapport.
 What are the objectives of
Psychiatric interview ,cont.
IV- Generating and testing a set of
hypotheses to arrive at preferred
diagnosis.

V- Determining areas of further

investigation.

VI- Developing treatment plan.

 What are the functions of
Psychiatric interview
I. According to Nurcombe (1982) the
interviewers must develop an
understanding( formulation) of two
domains:-
 Nosologic;- refers to the exercise of
figuring out which conditions the patient
suffers from.
 Dynamic:- is domain involves an
application of eliciting the Bio
psychosocial aspects of the patient
illness.
 Three Phases of the Diagnostic
Interview
 Opening Phase:- :- lasts 5-10min, Attention to logistics, It
is alliance building, trustworthiness, Meeting, Learning a bit about
her life, and the shutting up and giving an interrupted minutes.

 Body of the interview:- lasts 30-40min , Initial

diagnostic hypothesis, meets DSM V etc.…

 Closing Phase:- lasts 5-10min, Psych education, Treatment

Negotiation
 Logistics Preparations what to
do before the interview
 Prepare the right time and space :- Secure a
space.

 Use paper tool effectively: questionnaire, fliers

 Develop your policies:- Contacting You, Giving or

Not giving you Cellphone Number.
 What are the preliminary requirements to
conduct the interview.
 ROOM :
Sound proof, free from interruption, privacy, safety, to every body, make
sure the interview cannot be overheard

 SEATING POSTION OF THE PATENT

Not opposite to the interviewer, at the side of the desk, chair should
not be lower than the interviewer.
 QUESTIN TECHNIQUES:
Question can be injected when a patient give appropriate leads, no leading
questions ,do not be judgmental,

 NOT TAKING AND RECORDING:

Record some verbatim statements only ,if the patient is against it is
better to stop and listen only. However it is usually better to delay the
not taking for some minutes until the patient feels that he has the your
undivided attention.

 TIME:
Not more than one hour
 Psychiatric Interview Process
 Content:- refers to what information is
obtained in an interview.

 Process:- refers to how the information

obtained. Style, or Technique .
 A well-conducted interview has
the following Process:-
 The air of a polite, objective inquiry is maintained ( Ato,
W/O, ..).
 Interviewers demonstrate curiosity and acceptance
 Patient understand the purpose , duration,
 Patients’ comfort is considered
 Patients have a chance to speak about what concerns
them.
 There are no outside intrusions or destructions
 Changes in topic are effected smoothly
 Lengthy periods of silence are avoided
 The flow and rhythm characteristic of conversation
develops
 Information about both facts and feelings is obtained.
 Two aspects Psychiatric
Interview Process
 Empathy, Rapport, and Therapeutic
alliance.

 Types of interview questions and

Interventions .

” Gaining Skill with interviewing process

takes years to develop refer to Shea 1998,
Othmer 2001, Morrison 1995
 Empathy, Rapport &
Therapeutic Alliance
 Empathy is Making a connection to
emotional state of another person.

 Empathy is a form of cognition that

enables one to comprehend another
person’s subjective experiences from his or
her own perspective ( Campbell, 2004).
 "Walk a mile in my shoes"
 Rapport
 is “a bringing back” which refers to
harmonious relationships with patients.
 Respectfull
 Being intrested in their problem
 Demonstrate competence
 Activley listening
 Ask question
 Follow the lead
 Find common ground
Empathy can be demonstrated in
many ways , including the
following:-
 Explaning the interview Process:-
 Easing Into the Interview
 Facilitating the flow of information
 Connecting with the Patient’s Emotion
 Demonstrating Your Expertise
Mrrison (1995) suggest that interviewers can
maintain an empathic focus by keeping the
following thought in mind:- What would it be like
to be this patient talking with me now?
Listen, show concern, offer support, and try to find a
way to help
 Universal interview technique
 OPEN-ENDED QUESTION
 CLOSED-ENDED QUESTION
 REFLACTION
 FACILITION
 CONFRONTATION
 POSTIVE RENFORCEMENT
 SUMMATION
 EXPLATION
OPEN-ENDED QUESTIONS
 Begin with broad open-ended questions
 Allow the patient to speak as much possible

 At the beginning of the interview the

interviewer encourages the patient to speak as
spontaneously and openly as possible

e.g. can you tell me please what troubles that

bring you today ? Then allow the patient to
speak as much as possible.

The early part of the interview is the most open

ended one the patient talks you listen
 CLOSE-ENDED QUESTIONS
 CLOSED ENDED QUESTION IS USED:-

1. to ask specific information ( age ,address,

name)
2. In eliciting information about certain
symptoms (hallucination ,delusion, suicidal
ideation)

3. To assess such factor as frequency, severity,

and duration of symptoms

 DO NOT USE CLOSED ENDED QUESTION AT THE

BEGNING OF THE INTERVIEW IT DOES NOT
ALLOW THE PATIENT TO HAVE THE OPTION.
 REFLACTION
 The interviewer repeats to the patient in
supportive manner something that the
patient has said.
 The purpose of reflection is to assure the
interviewer he has correctly understand
what the patient is trying to say and to let
the patient know that the interviewer
perceiving what being said .
 It is an empathic response
e.g. So far you told me that you have poor
sleep ,headache and low mood. Am I
correct ?
 Facilitation
 The interviewer helps the patient to
continue the interview by providing
verbal and non-verbal cues that
encourage the patient to talk.

e.g.:-nodding one’s head, leaning forward from

ones seat and saying, YES,THEN,UH-UHH,GO
ON,I see, what else, any thing else
 Confrontation
 To point out to a patient something
that the interviewer thinks the
patient is not paying attention to ,
missing, or some way denying.

 Confrontation must be done skilful

way so that the patient is not forced
to became hostile defensive
 POSTIVE -REINFORCEMENT
 The patient might have difficulty to
express his problem. When the
patient struggled with a particular
topic and is the able to express
clearly, then the interviewer signals
his approval by using positive
reinforcement

e.g. good , that helps me a lot to

understand you.
 SUMMATION
 Periodically during the the
interviewer can take some moment
and briefly summarize what patient
said

 It assure both they understand each

other
 How to use interview techniques
I- Establish rapport as early in the interview as
possible:-
-Tell me about your work or School
- Are you married, do you have children
The overall tone of the opening of the interview should
,therefore, convey warmth and friendliness
II- Determine the Patient`s chief complaint:-
- Use open-ended questions
- What brought him/her to clinic
e.g. I have been feeling very depressed
I don`t why I am here
The initial portion of the interview, devoted to eliciting
the chief complaints should take as long as is necessary
to determine the patient`s primary problem
 How to use interviewing techniques
III- Use the chief compliant to develop a
provisional differential diagnosis:-
- As in the rest of medicine, once the patient`s
primary problem has been determined you should
try to construct your mind a range of
explanations as to the specific diagnosis that
might lead to that particular problem.

e.g. C/C:- I hear voice in the absence of

others!!!!
Schizophrenia, MDD with psychotic feature, Mania,
Schizophrenform disorder, Substance Abuse , Alcohol
Halucinosis
 How to use interviewing techniques
IV- Rule the various diagnostic possibilities out or
in by using more focused and detailed
questions:-

-If the patient`s chief compliant has suggested three or

four possible diagnosis, the interviewer can determine
which is most relevant by referring to diagnostic
criteria for those disorder.

e.g Additional symptoms and Diagnostic criteria of

schizophrenia, Schozophrenform disorder, MDD with
psychotic feature, Mania
 How to use interviewing techniques
V- Let the patient talk freely enough to observe how
tightly his thought are connected.

The coherence of the pattern in which the patient`s

thoughts are presented may provide major clues to the
type of problem that he or she is experiencing

e.g. Patient with Mania, Schizophrenia , depression

 How to use interviewing techniques
VI- Do not be afraid to ask about topics that you or the
patient might find difficult or embarrassing

In the beginning the interview it might be difficult to ask

about some symptoms:-
-Sexual relationship - Hearing voice
- Some other psychotic symptoms
-Sexual Experience
-Even use of Alcohol

 If John Hinckley Jr.`s psychiatrist had been more

aggressive in inquiring about delusions, a diagnosis
schizophrenia might have been made before assassination
attempt on President Regan occurred, and a great deal of
misery could thereby have been avoided.
 How to use interviewing techniques
VII- Do not forget ask about suicidal
thoughts.
- This is another topic that may seem to fall
into the “ embarrassing”. Nevertheless, suicide
common outcome of many psychiatric illness.

e.g. “Have you ever felt life is not worth living” ?

“Have you ever thought about taking your life”?
 How to use interviewing techniques
 VIII- Give the patient a chance to ask
question at the end.

From the patient`s point of view, there is

nothing more frustrating than being interviewed
for an hour and ushered out of the room with his
questions unanswered.
 How to use interviewing techniques
IX: Conclude the initial interview by conveying a
sense of confidence and if possible, of hope.

 Thank the patient for providing so much in formations

 Indicate that now you have better understanding of his

or her problems

 If you have a relatively good idea about the

illness that it is amenable to the treatment it is
good to explain to the patient.
What are factors that affecting the
Psychiatric Interview
 Type of Illness
 Severity of the illness
 Time for Interview
 Language
 Collaterals
 The patient
Psychiatric history writing -
 I- Identification:
Name ,age, marital status, religion,
occupation, visit,address,referred
from,escorted or brought by, source of
information, the reliability of the source of
information.

 II- Chief Compliant:

Exactly why the patient come to the
hospital ,preferably in the patient’s own words
, if the information dose not come from the
patient note who supplied it, regardless how
bizarre , implausible ,irrelevant it is you
should write it.
 Psychiatric history writing
III- History of Present Illness( HPI)
-It provides a comprehensive and chronological picture of
the events.

-this part of the psychiatric history is the most helpful

in reaching a diagnosis

For each problem elicited in the chief compliant include

the following information.
1. the time onset
2. Mode of on set
3. Development overtime
4. Precipitating or reliving factor
5. Help given
6. Impact of the problem
7. Negative and positive statement :
Suicidal ideation, High mood, Low mood, symptoms of anxiety, History
of substance abuse, History of hallucination, Passivity phenomenon.
 Psychiatric history writing
 IV-PAST PSYCHIATRIC ILLNESS
1. Was there any particular trigger?
2. What was the exact nature of the illness?
3. How long it lasted?
4. What was the treatment?
5. Was there hospitalization?
6. How long it lasted?
7. How well functioning between the episodes of mental
illness?
8. Was there suicidal ideation or attempt
 Psychiatric history writing
 V-PAST MEDICAL ILLNESS
1. Details of any previous serous medical illness
2. Treatment ,the out come, the duration
3. Number of hospitalization
 Psychiatric history writing

 VI-FAMILY HISTORY
 Patient’s parents
 Siblings
 Relationship with the family
 Are they supportive towards to him/her
 Is the psychiatric history in the family, the
diagnosis, kind of medication
 Psychiatric hospitalizing
 Suicidal behavior
 History of Epilepsy
 Is there parental violence or suicidal behavior
 Parental excessive drinking
 Psychiatric history writing-

VII-PERSONAL History
 Early life Development
 Schooling
 Occupation
 Forensic history
 Sexual history
 Children
 History of Substance abuse: alcohol, chat
-quantity,quality,frequency,poly drug abuse
 PESONALITY BEFORE ILLNESS
 VIII-MENTAL STATUS
EXAMINATION
 Like a physical examination , a mental state
examination should be orderly and systematic.
As with a physical examination the examiner
should carry out a complete MSE for every
patient .
 MSE is examiner's observation and impression
of the patient .
 MSE is the description of the
appearance ,speech, action, thought during the
interview.
 A-General Description of the
patient-1
 1- Appearance:
--Dress, color drab color for
depression ,bright color for mania,
manic patient may wear clashing color.
---Dress might be untidy ,with buttons
undone, or done incorrectly.
---Dress may be stained ,worn torn or it
might in adequate or the weather.
----Unusual combination of clothing:
wearing jacket and no shirt, cot back
ward is seen in schizophrenia, or patient
might have additional items of clothing
scarf tied around forehead
 A-General Description of the
patient-2
 Self neglect: Men may appear
unshaven, the face may be unwashed,
hair uncombed. Women may wear no
makeup or they may apply their makeup
carelessly.
 Unusual accessories: Schizophrenic
patient sometimes pack there pockets
with there belonging or carry a large
holders of personal possessions or paper
manuscripts
 Finger nails might be long and dirty
 B-Motor Activity of the
patient
 GAIT : Unusually slow, fast,unusual
character of gait.
 Abnormal Motor Activity:
Tic,Tardive Dyskinesia,
Stereotypes ,Mannerism,Posturing,N
egativism,
 C-Speech Activity of the
patient
 Speed: fast,slow ,and normal
 Volume: Loud,Low,Normal
 Quantity: Too little,too much or
normal
 Tone : Low pitched,high pitched
 None-social speech:
muttering ,neologism,ward salad
 D-Emotion
 Mood: you evaluate the mood by
asking the feeling of the patient:
sadness,elation,anxious,labile,euthimi
c,expansive

 Affect: what the interviewer

observing during the interview you
read it from facial expression of the
patient : flat, constricted,
appropriate, inappropriate, normal
range, labile
 E-perceptual disturbance
 Hallucination

 Illusions
 F-THOUGHT DISTURBANCE
 FORM: flight of ideas
circumstantialities,tangentially,loosing of
association,Clang association,thought blocking,
Neologism, pressure of thought

 CONTENT:Delusion,compulsion,idea of
reference, overvalue idea,hypochondria,
obsession Suicidal Ideation
Passivity Phenomenon thought: insertion,
withdraw, Broadcasting, Control
 G-Sensorium and level of
consciousness
 Alertness and level of consciousness
 Orientation: to time, place ,person
 Memory: Remote,Recent Immediate
 Concentration and attention
 Capacity to read and write
 Abstract thinking
 General knowledge
 H-Insight
 Has insight
 Has no insight
Case formulation
 I-Differential Diagnosis
DSM IV
 Axis I
 Axis II
 Axis III
 Axis IV
 Axis V
 PLAN OF MANAGEMENT
 PSYCHOTHERAPY

 PSYCHOPHARMACLOGY

 ECT
Ronaldo
Arnold Schwarzenneger
Celine Dion
Elton John
Madonna
Mariah Carey
Michael Jackson
Michael Jordan
Phil Collins
Anmut Kinde (Debark, Gondar)
 Definitions of Common
Signs and Symptoms and
Methods Eliciting Them

Yonas Baheretibeb
(M.D)
Department of
Psychiatry
AAU
 Signs and symptoms
 Signs-objective findings observed by the
clinician (e.g. constricted affect and psychomotor
retardation).
 Symptoms are subjective experiences described
by the patient.
-Example- depressed mood and decreased
energy.
 A syndrome- is a group of signs and symptoms
that occur together as a recognizable condition
that may be less than specific than a clear-cut
 Signs and symptoms cont..
 Most psychiatric conditions are, in fact,
syndromes
 Becoming an expert in recognizing specific signs
and symptoms allows the clinician to
understandably communicate with other
clinicians, accurately make a diagnosis,
effectively manage treatment, reliably predict a
diagnosis, and thoroughly explore
pathophysiology, causes, and psychodynamic
issues.
 Signs and symptoms cont…
 Mood: a pervasive and sustained emotion,
subjectively experienced and reported by
the patient and observed by others;
examples include depression, elation,
anger, anxiety.
 Dysphoric mood: an unpleasant mood
 Euthymic mood: normal range of mood,
implying absence of depressed or elevated
mood.
 Signs and symptoms cont…
 Expansive mood: expression of one’s
feelings without restraint, frequently with
an over estimation of one’s significance or
importance.
 Irritable mood: easily annoyed and
provoked to anger,
 Mood swings (labile mood): oscillations
between euphoria and depression or
anxiety
 Signs and symptoms cont…
 Elevated mood: air of confidence and enjoyment;
a mood more cheerful than usual.
 Euphoria: intense elation with feelings of
grandeur
 Depression: psychopathological feeling of
sadness.
 Anhedonia: loss of interest in and withdrawal
from all regular and pleasurable activities, often
associated with depression
 Grief or mourning: sadness appropriate to a
real loss
 Signs and symptoms cont..
 Emotion: a complex feeling state with psychic,
somatic, and behavioral, components that is
related to affect and mood.
 Affect: observed expression of emotion; may be
inconsistent with patient’s description of emotion
 Appropriate affect: condition in which the
emotional tone is in harmony with the
accompanying idea, thought, or speech; also
further described as a broad or full affect, in
which a full range of emotion is appropriately
expressed.
 Signs and symptoms cont..
Inappropriate affect: disharmony
between the emotional feeling tone and the
idea, or speech accompanying it.
Blunted affect: a disturbance in affect
manifested by a severe reduction in the
intensity of externalized feeling tone.
Restricted or constricted affect:
reduction in intensity of feeling tone less
severe than blunted affect but clearly
reduced.
 Signs and symptoms cont…
Flat affect: absence or near absence of any
signs of affective expression: voice
monotonous, face immobile
Labile affect: rapid and abrupt changes in
emotional feeling tone, unrelated to
external stimuli.
 Signs and symptoms cont….
Other emotions:
Anxiety: feeling of apprehension caused by
anticipation of danger, which may be
internal or external.
Free floating anxiety: pervasive,
unfocused fear not attached to any idea
Fear: anxiety caused by consciously
recognized and realistic danger.
 Signs and symptoms cont….
 Agitation: severe anxiety associated with motor
restlessness
 Tension: increased motor and psychological
activity that is unpleasant
 Panic: acute, episodic, intense attack of anxiety
associated with overwhelming feelings of dread
and autonomic discharge
 Apathy: dulled emotional tone associated with
detachment or indifference.
 Signs and symptoms cont…
 Ambivalence: coexistence of two
opposing impulses toward the same thing
in the same person at the time
 Shame: failure to live up to self
expectations
 Guilt: emotion secondary to doing what is
perceived as wrong
 Abreaction: emotional release or
discharge after recalling a painful
experience
 Signs and symptoms cont…
Physical Disturbances associated with mood
 Signs of somatic (usually autonomic) dysfunction
of the person, most often associated with
depression (also called vegetative signs).
 Anorexia: loss of or decrease in appetite
 Hyperphagia: increase in appetite and in take of
food.
 Insomnia: lack of or diminished ability to sleep
a. Initial insomnia: difficulty in falling asleep
 Signs and symptoms cont..
b. Middle insomnia: difficulty in sleeping
through the night without waking up and
difficulty in going back to sleep
c. Terminal insomnia: early morning
awaking
 Hypersomnia: excessive sleeping
 Diurnal variation: mood is regularly
worst in the morning, immediately after
awakening, and improves as the day
progress.
 Signs and symptoms cont…
 Motor Behavior (conation): the aspect of the
psyche that includes impulses, motivations,
wishes, drives, instincts, and cravings, as
expressed by a person’s behavior or motor
activity.
 Echopraxia: pathological imitation of
movements of one person by another
 Catatonia: motor anomalies in nonorganic
disorders (as opposed to disturbances of
consciousness and motor activities secondary to
organic pathology).
 Signs and symptoms cont..
 Diminished libido: decreased sexual
interest, drive, and performance (increased
libido is often associated with manic
states).
 Constipation: inability or difficulty in
defecating
 Signs and symptoms cont…
 Motor Behavior (conation): the aspect the
psyche that includes impulses, motivations,
wishes, drives, instincts, and cravings, as
expressed by a person’s behavior or motor
activity.
 Echopraxia: pathological imitation of
movements of one person by another
 Catatonia: motor anomalies in nonorganic
disorders (as opposed to disturbances of
consciousness and motor activity secondary to
organic pathology).
 Signs and symptoms cont..
 Catalepsy: general term for an immobile
position that is constantly maintained.
 Catatonic excitement: agitated,
purposeless motor activity, uninfluenced
by external stimuli.
 Catatonic stupor: marked slowed motor
activity, often to a point of immobility and
seeming unawareness of surroundings.
 Signs and symptoms cont…
 Catatonic rigidity: voluntary assumption of a
rigid posture, held against all efforts to be moved.
 Catatonic posturing: voluntary assumption of
an inappropriate or bizarre posture, generally
maintained for long periods of time
 Cerea flexibilitas(waxy flexibility): the person
can be molded into a position that is then
maintained; when the examiner moves the
person’s limb, the limb feels as if it were made of
wax.
 Signs and symptoms cont…
 Negativism: motiveless resistance to all attempts
to be moved or to all instructions
 Cataplexy: temporary loss of muscle tone and
weakness precipitated by a variety of emotional
states
 Stereotypy: repetitive fixed pattern of physical
action or speech
 Mannerism: ingrained, habitual involuntary
movement
 Signs and symptoms cont..
 Automatism: automatic performance of an act or
acts generally representative of unconscious
symbolic activity
 Mutism: voicelessness with out structural
abnormalities
 Akathisia: subjective feeling of muscular tension
secondary to antipsychotic or other medication,
which can cause restlessness, pacing, repeated
sitting and standing; can be mistaken for
psychotic agitation.
 Dipsomania: compulsion to drink alcohol
 Signs and symptoms cont..
 Kleptomania: compulsion to steal
 Nymphomania: excessive and compulsive need
for coitus in a woman
 Satyriasis: excessive and compulsive need for
coitus in man
 Trichotillomania: compulsion to pull out one’s
hair
 Ataxia: failure of muscle coordination;
irregularity of muscle action
 Polyphagia: pathological overeating
 Signs and symptoms cont..
 Hyper activity (hyper kinesis): restless,
aggressive, destructive activity, often associated
with some underlying brain pathology
 Hypo activity (hypokinesis): decreased motor
and cognitive activity, as in psychomotor
retardation; visible slowing of thought, speech,
and movements.
 Aggression: forceful goal-directed action that
may be verbal or physical; the motor counter part
of the affect of rage, anger or hostility
 Signs and symptoms cont…
Thinking: goal-directed flow of ideas,
symbols, and associations initiated by a problem
or a task and leading toward a reality oriented
conclusion; when a logical sequence occurs,
thinking is normal
General disturbances in form or process of
thinking.
 Mental disorder: clinical significant behavior or
psychological syndrome, associated with distress
or disability, not just an expected response, to a
particular event or limited to relations between
the person and society.
 Signs and symptoms cont..
 Psychosis: inability to distinguish reality from fantasy;
impaired reality testing, with the creation of a new reality
(as opposed to neurosis; mental disorder in which reality
testing is intact, behavior may not violate gross social
norms, relatively enduring or recurrent with out
treatment).
 Reality testing: the objective evaluation and judgment of
the world outside the self
 Formal thought disorder: disturbance in the form of
thought, instead of the content of thought; thinking
characterized by loosened association, neologism, and
illogical constructs; thought process is disordered, and the
person is defined as psychotic.
 Signs and symptoms cont…
Autistic thinking: preoccupation with inner,
private world.
Specific disturbances in form of thought
 Neologism: new word created by the patient,
 Word salad: incoherent mixture of words and
phrases
 Circumstantiality: indirect speech that is
delayed in reaching the point but eventually gets
from original point to desired goal;
 Signs and symptoms cont..
Tangentiality: inability to have goal-
directed associations of thought; patient
never gets from desired point to desired
goal.
Incoherence: thought that, generally, is
not understandable, running together of
thoughts or words with no logical or
grammatical connection, resulting in
disorganization.
 Signs and symptoms cont..
 Perseveration: persisting response to a prior
stimulus after a new stimulus has been presented,
often associated with cognitive disorders
 verbigeration: meaningless repetition of
specific words or phrases
 Echolalia: psychopathological repeating of
words or phrases of one person by another, tends
to be repetitive and persistent.
 Irrelevant answer: answer that is not in
harmony with question asked (patient appears to
ignore or not attend to question).
 Signs and symptoms cont..
Loosening of association: flow of thought in
which ideas shift from one subject to another in a
completely unrelated way; when severe, speech
may be incoherent.
Derailment: gradual or sudden deviation in train
of thought without blocking; some times used
synonymously with loosening of associations.
Flights of ideas: rapid, continuous
verbalizations or plays on words produce
constant shifting from one idea to another, the
ideas tend to be connected, and in the less severe
from a listener may to follow them.
 Signs and symptoms cont…
 Clang association: association of words
similar in sound but not in meaning; words
have no logical connection.
 Blocking: abrupt interruption in train of
thinking before a thought or idea is
finished; after a brief pause, the person
indicates no recall of what was being said
or was going to be said (also known as
thought deprivation).
 Sifns and symptoms cont….
Specific Disturbances in content of thought
 Poverty of content: thought that gives little
information because of vagueness, empty
repetitions.
 Overvalued idea: unreasonable, sustained false
belief maintained less firmly than a delusion.
 Delusion: false belief, based on incorrect
inference about external reality, not consistent
with patient’s intelligence and cultural back
ground, that cannot be corrected by reasoning
 Signs and symptoms cont…
 a. Bizarre delusion: an absurd, totally implausible,
strange false belief (for example, invaders from space
have implanted electrodes in the patient’s brain).
 Systematized delusion: false belief or beliefs unite by a
single event or theme (for example, patient is being
persecuted by the CIA, FBI, the Mafia, or the boss).
 Mood-congruent delusion: delusion with mood-
appropriate content (for example, a depressed patient
believes that he or she is responsible for the destruction
of the world).
 Mood-incongruent Delusion: delusion with content that
has no association to mood or is mood-neutral (for
example, a depressed patient has delusions of thought
control or thought broadcasting).
 Signs and symptons cont…
 Nihilistic delusion: false feeling that self, others,
or the world is nonexistent or ending.
 Delusion of poverty: false belief that one is
bereft, or will be deprived of all material
possessions.
 Somatic Delusion: false belief involving
functioning of one’s body (for example, belief
that one’s brain is rotting or melting).
 Paranoid delusions: includes persecutory
delusions and delusions of reference, control, and
grandeur (distinguished from paranoid delusion,
which is suspiciousness of less than delusional
proportion).
 Signs and symptoms….
 Delusion of persecution: false belief that one is being
harassed, cheated, or persecuted; often found in litigious
patients who have a pathological tendency to take legal
action because of imagined mistreatment.
 Delusion of grandeur: exaggerated conception of one’s
importance, power, or identity.
 Delusion of reference: false belief that the behavior of
others refers to one self; that events, objects, or other
people have a particular and unusual significance, usually
of a negative nature; derived from idea of reference, in
which one falsely feels that one is being talked about by
others (for example, belief that people on television or
radio are talking or about the patient).
 Signs and symptoms cont…
 Delusion of self-accusation: false feeling of remorse and
guilt
 Delusion of control: false feeling that one’s will,
thoughts, or feelings are being controlled by external
forces
 thought withdrawal: delusion that one’s thought are
being removed from one’s mind by other people or forces
 Thought insertion: delusion that thoughts are being
implanted in one’s mind by other people or forces
 Thought broadcasting: delusion that one’s thoughts can
be heard by others, as though they were being broadcast
into the air.
 Thought control: delusion that one’s thoughts being
controlled by other people or forces
 Signs and symptoms cont…
 Delusion of infidelity (delusional jealousy):
false belief derived from pathological jealousy
that one’s lover is unfaithful
 Erotomania: delusional belief, more common in
women than in men, that someone is deeply in
love with them (also known as Clerabult-
Kandinky complex)
 Pseudologia phantastica: a type of lying, in which
the person appears to believe in the reality of his
or her fantasies and acts on them; associated with
Munchausen syndrome, repeated feigning of
illness
 Signs and symptoms cont…
 Egomania: pathological self-preoccupation
 Monomania: preoccupation with a single object
 Hypochondria: exaggerated concern about one’s
health that is based not on real organic pathology
but, rather, on unrealistic interpretations of
physical signs or sensations as abnormal
 Obsession: pathological persistence of an
irresistible thought or feeling that cannot be
eliminated from consciousness by logical effort
which is associated with anxiety (also termed
rumination)
 Signs and symptoms cont..
Common themes of obsessional thoughts:
Dirt and contamination- the idea that the hands
are contaminated with bacteria
Aggressive actions- the idea that the person may
harm another person or shout angry remarks
Orderliness- the idea that objects have to be
arranged in a special way or clothes put on in a
particular order
 Signs and symptom cont…
Illness- the idea that the person may have cancer
(idea of contamination may also refer to illness-
that the disease may result from the feared
bacterial contamination)
Sex- usually thoughts or images of practices that
the person finds disgusting
Religion- doubts about the fundamentals of
belief –eg. Does God exist? Or about the
adequacy or completeness of a religious ritual
such as confession
 Signs and symptoms cont…
Compulsions- abnormal actions, repeated,
stereotyped
Common themes of compulsion
Checking rituals –often concerned with
safety, -eg-checking repeatedly that a gas
tap has been turned off
Cleaning rituals- such as repeated
handwashing or domestic cleaning
 Signs and symptoms cont…
Counting ritual- such as counting to a
particular number or counting in threes
Dressing rituals- in which the clothes are
set out or put on in a particular way
 Signs and symptoms cont…
Phobia
 -Persistent, irrational, exaggerated, and invariably
pathological dread of some specific type of stimulus or
situation; results in a compelling desire to avoid the
feared stimulus.
 Specific phobia: circumscribed dread of a discrete object
or situation (for example, dread of spider or snakes)
 Social phobia: dread of public humiliation, as in fear of
public speaking, performing, or eating in public
 Acrophobia: dread of high places
 Agoraphobia: dread of open places
 Algophobia: dread of pain
 Signs and symptoms cont…
 Ailurophobia: dread of cats
 Erythrophobia: dread of red ( refers to a
fear of blushing)
 Panphobia: dread of everything
 Claustrophobia: dread of closed places
 Xenophobia: dread of strangers
 Zoophobia: dread of animals
 Signs and symptoms cont…
Speech
 -Ideas, thoughts, feelings as expressed through language;
communication through the use of words and language
Disturbances in speech
 Pressure of speech: rapid speech that is increased in
amount and difficult to interrupt
 Poverty of speech: restriction in the amount of speech
used; replies may be monosyllabic
 Nonspontaneous speech: verbal responses given only
when asked or spoken to directly; no self-initiation of
speech
 Signs and symptoms cont…
 Poverty of content of speech: speech that is
adequate in amount but conveys little information
because of vagueness, emptiness, or stereotyped
phrases
 Dysprosody: loss of normal speech melody
(called prosody)
 Dysarthria: difficulty in articulation, not in word
finding or in grammar
 Excessively loud or soft speech: loss of
modulation of normal speech volume; may
reflect a variety of pathological conditions
ranging from psychosis to depression to deafness
 Signs and symptoms cont…
 Stuttering: frequent repetition or prolongation of
a sound or syllable, leading to markedly
impaired speech fluency
Aphasic disturbances
 -disturbances in language output
 Motor aphasia: disturbance of speech caused by
a cognitive disorder in which understanding
remains but ability to speak is grossly impaired;
speech is halting, laborious, and inaccurate (also
known as Broca’s, nonfluent, and expressive
aphasia)
 Signs and symptoms cont…
 Sensory aphasia: organic loss of ability to
comprehend the meaning of words; speech
is fluid and spontaneous but incoherent
and nonsensical (also known as Wernick’s,
fluent, and repetitive aphasia)
 Syntactical aphasia: inability to arrange
words in proper sequence
 Global aphasia: combination of a grossly
nonfluent aphasia and a severe fluent
aphasia
 Signs and symptoms cont…
perception
 -process of transferring physical stimulation into
psychological information; mental process by
which sensory stimuli are brought to awareness
Disturbances of perception
 Hallucination: false sensory perception not
associated with real external stimuli; there may
or may not be delusional interpretation of the
hallucinatory experience
 Signs and symptoms cont..
 Hypnagogic hallucination: false sensory
perception occurring while falling asleep;
generally considered nonpathological
phenomenon
 Hypnopompic hallucination: false perception
occurring while awakening from sleep; generally
considered nonpathological
 Auditory hallucination: false perception of
sound, usually voices but also other noises, such
as music; most common hallucination in a
psychiatric disorders
 Signs and symptoms cont..
 Visual hallucination: false perception involving
sight consisting of both formed images (for
example, people) and unformed images (for
example, flashes of light): most common in
medically determined disorders
 Olfactory hallucination: false perception of
smell; most common in medical disorders
 Gustatory hallucination: false perception of taste,
such as unpleasant taste caused by an uncinate
seizure; most common in medical disorders
 Signs and symptoms cont…
 Tactile (haptic) hallucination: false perception of
touch or surface sensation, as from an amputated
limb (phantom limb), crawling sensation on or
under the skin (formication)
 Somatic hallucination: false sensation of things
occurring in or to the body, most often visceral in
origin (also known as cenesthesic hallucination)
 Lilliputian hallucination: false perception in
which objects are seen as reduced in size
(micropsia)
 Signs and symptoms cont…
 Mood-congruent hallucination: hallucination in which
the content is consistent with either depressed or manic
mood example, a depressed patient hears voices saying
that the patient is a bad person; a manic patient hears
voices saying that the patient is of inflated worth, power,
and knowledge)
 Mood-incongruent hallucination: hallucination in
which the content is not consistent with either depression
or manic mood –
-example, in depression, hallucinations not involving
such themes as guilt, deserved punishment, or
inadequacy;
-in mania, hallucinations not involving such themes as
inflated worth or power
 Signs and symptoms cont…
 Hallucinosis: hallucinations, most oten auditory,
that are associated with chronic alcohol abuse
and that occur within a clear sensorium, as
opposed to delirium tremens (DTs),
hallucinations that occur in the context of a
clouded sensorium
 Illusion: misperception or misinterpretation of a
real external sensory stimuli
Disturbances associated with cognitive
disorder
agnosia: an inability to recognize and interpret the
significance of sensory impressions
 Signs and symptoms cont…
 Anosognosia (ignorance of illness): inability to
recognize a neurological deficit as occurring to
oneself
 somatopagnosia (ignorance of the body):
inability to recognize a body part as one’s own
(autotopagnosia)
 Visual agnosia: inability to recognize objects or
person
 Astereognostic: inability to recognize objects by
touch
 Prosopagnosia: inability to recognize faces
 Apraxia: inability to carry out specific tasks
 Signs and symptom cont…
Disturbances associated with conversion and
dissosciative phenomena:
-somatization of repressed material or the
development of physical symptoms and
distortions involving the voluntary muscle or
special sense organs; not under voluntary control
and not explained by any physical disorder
 Hysterical anesthesia: loss of sensory modalities
resulting from emotional conflicts
 Macropsia: state in which objects seem larger
than they are
 Signs and symptoms cont…
 Micropsia: state in which objects seem smaller
than they are
- both Macropsia and Micropsia can also be
associated with clear organic conditions, such as
complex partial seizures
 Depersonalization: a subjective sense of being
unreal, strange, or unfamiliar to oneself
 Derealization: a subjective sense that the
environment is strange or unreal; a feeling of
changed reality
 Signs and symptoms cont…
 Fugue: taking on a new identity with amnesia for
the old identity; often involves travel or
wandering to new environments
Memory:
 Function by which information stored in the
brain is later recalled to consciousness
Disturbances of memory
 Amnesia: partial or total inability to recall past
experiences; may be organic or emotional in
origin
 Signs and symptoms cont…
 Anterograde: amnesia for events occurring after a
point in time
 Retrograde: amnesia prior to a point in time
Level of memory
 Immediate: reproduction or recall of perceived
material within seconds to minutes
 Recent: recall of events over past few days
 Recent past: recall of events over past few
months
 Remote: recall of events in distant past
 Signs and symptoms cont…
Intelligence:
 The ability to understand, recall, mobilize, and
constrictively integrate previous learning in meeting new
situations
 Dementia: organic and global deterioration of intellectual
functioning without clouding of consciousness
 Dyscalculia (acalculia): loss of ability to do calculations
not caused by anxiety or impairment in concentration
 Dysgraphia (agraphia): loss of ability to write in cursive
style, loss of word structure
 Alexia: loss of previously possessed reading facility; not
explained by defective visual acuity
 Signs and symptoms cont…
 Pseudo-dementia: clinical features resembling a
dementia not caused by an organic condition;
most often caused by depression (dementia
syndrome of depression)
 Concrete thinking: literal thinking; limited use
of metaphor without understanding of nuances of
meaning; one-dimensional thought
 Abstract thinking: ability to appreciate nuances
of meaning; multidimensional thinking with
ability to use metaphors and hypotheses
appropriately
 Signs and symptoms …
Consciousness: state of awareness
 Apperception: perception modified by one’s own
emotions and thoughts
 Sensorium: state of cognitive functioning of the
special senses (sometimes used as a synonym for
consciousness). Disturbances of consciousness
are most often associated with brain pathology
Disturbances of consciousness
 Disorientation: disturbances of orientation in
time, place, or person
 Signs and symptoms cont…
Clouding of consciousness: incomplete clear-
mindedness with disturbances in perception and
attitudes
Stupor: lack of reaction to and unawareness of
surrounding
Delirium: bewildered, restless, confused,
disoriented reaction associated with fear and
hallucinations
Coma: profound degree of unconsciousness
Coma vigil: coma in which the patient appears to
be asleep but ready to aroused (akinetic Mutism)
 Signs and symptoms cont…
Twilight state: disturbed consciousness with
hallucinations
Dreamlike state: often used as a synonym for
complex partial seizure or psychomotor epilepsy
Somnolence: abnormal drowsiness
Disturbances of attention: attention is the
amount of effort exerted in focusing on certain
portions of an experience, ability to sustain a
focus on one activity; ability to concentate
 Signs and symptoms cont..
Distractibility: inability to concentrate attention;
attention drawn to unimportant or irrelevant
external stimuli
Selective inattention: blocking out only those
things that generate anxiety
Hypervigilance: excessive attention and focus on
all internal and external stimuli, usually
secondary to delusional or paranoid states
Trance: focused attention and altered
consciousness, usually seen in hypnosis,
dissociative disorders, and ecstatic religious
experiences
 Signs and symptoms cont…
 Insight: ability of the patient to understand the
true cause and meaning of a situation (such as a
set of symptoms)
 Intellectual insight: understanding of the
objective reality of a set of circumstances without
the ability to apply the understanding in any
useful way to master the situation
 True insight: understanding of the objective
reality of a situation, coupled with the motivation
impetus to master the situation
 Signs and symptoms cont…
 Impaired insight: diminished ability to
understand the objective reality of a situation
 Judgment: ability to assess a situation correctly
and to act appropriately within that situation
 Critical judgment: ability to assess, discem, and
choose among various options in a situation
 Automatic judgment: reflex performance of an
action
 Impaired judgment: diminished ability to
understand a situation correctly and to act
appropriately
General Principles
of PSYCHIATRIC
INTERVIW

Yonas Baheretibeb MD.

Department of Psychiatry
 Learning Objectives
 To understand the Initial Interview

 To Know Logistic Preparation

 To understand the therapeutic Alliance

 To Know how to ask question

 Basic Principles of Psychiatric Interview

 Four Tasks of the Diagnostic
Interview
 The Diagnostic Interview is really about
treatment not Diagnosis.

 Studies show that up to 50% of patients drop out

before the 4th session of treatment and many
never return after the first appointment (Baekeland
and Lundwall 1975).

 The upshot is that much more than diagnosis

should occur during the interview: Alliance
building, Morale boosting, and treatment
negotiating are also vital.
I- Build a Therapeutic Alliance
 A therapeutic alliance forms the
groundwork of any psychological
treatment .
 The therapeutic alliance is feeling that you
should create over the course of diagnostic
interview- a sense of rapport, trust, and
warmth.
 The most effective ingredient in all
effective psychotherapies is good
therapeutic alliance.
 II- Obtain the Psychiatric
Database
 Gather Historical information relevant to
the current clinical presentation.
 Presenting Chief Compliments, HPI,
Personal History, Past Psychiatric History,
Family History…
 Gleaning this information is the substance
of the interview, and throughout this step ,
you will have to work on building and
maintaining alliance.
 III-Interview for Diagnosis

The ability to interview for diagnosis – with

out sounding as if you are reading off a
checklist of symptoms and without getting
sidetracked by less relevant information is
one of the supreme skills of clinician and you
will develop it over the course of
professional life.
 IV- Negotiate a Treatment Plan
and communicate it to your
patient
 How to negotiate and communicate a
treatment plan is rarely taught in residency or
graduate school and yet it is probably
important thing you can do to ensure that
your patient adheres to whatever treatment
you recommend.
 If your patient does not understand your
formulation, does not agree with your advice
and does not feel comfortable telling you so, as
the result you fee the assessment never been
done.
 Time
 Psychiatric assessment and psychological
treatments take time.

 Spending time listening to and clarifying
patients problems, and making an attempt to
understand how they feel and why they feel
that way, is therapeutic in itself.

 Unfortunately, the pressure of work in general
practice makes it difficult to find this time.
 One solution is to spread the assessment out
over several sessions.
 Reassurance
 As a rule, it is better to try to understand a persons
experience more clearly than to give bland reassurance.

 Although you may mean well, he or she may perceive a

reassuring comment as presumptuous or rejecting.

 However, reassurance does have a place when it is true

and does not dismiss the persons experience.

 Unhelpful comments vs ‘Helpful comment:-

(To a depressed man) When people are depressed, they
often feel that nothing can be done to help. There are
effective treatments for depression and I know that I
can help you.‘
 Transference
 Transference can be broadly defined as the feelings that the
patient has for you. Some of these feelings are reality-based, for
example, respect for your expertise in medicine.

 Others have unconscious origins and arise from the transference

on to you of feelings that are held towards others who are
significant in the person’s past or present.

 For example, being perceived by a young man as an authority

figure, you may elicit transference feelings that he has towards
his parents, teachers and other authority figures in his life
 Countertransference
 Countertransference refers to the feelings that you have towards
the patient. Again, these will, in part, be reality-based. Some will
arise in response to the transference.
 Some will be similar to feelings that are elicited in other people
who deal with that person, while others will reflect aspects of
your own past and present relationships transferred on to the
patient. Most will be a combination of all of these.
 It is normal, of course, that you should experience these feelings.
The important thing is to be aware of them and to acknowledge
them to yourself, even if they seem unacceptable - for example,
feeling angry or bored with a person, feeling overly concerned
about or even feeling attracted to him or her.

 By acknowledging these feelings to yourself and making them

conscious you are much less likely to act inappropriately upon
them. For example, it is quite normal to feel angry with certain
people, but it is likely to be damaging and unprofessional to act
out this anger.