The Psychiatric Interview

Allan Tasman, MD, is Professor and Chair of the Department of Psychiatry at the University of Louisville. An internationally known educator and psychoanalyst, he has received numerous national and international academic awards. He is the founding Senior Editor of Psychiatry, an internationally acclaimed comprehensive textbook. He is past president of the American Psychiatric Association and the Pacific Rim College of Psychiatrists. He recently completed service as Secretary for Education of the World Psychiatric Association and now leads the WPA Section on Psychotherapy. Dr. Kay is a Fellow of the American College of Psychiatrists and Distinguished Life Fellow of the American Psychiatric Association and has served as the chair of the APA Committee on Medical Student Education, the Council on Medical Education and Career Development, the Vestermark Award Board, and the Committee on the Practice of Psychotherapy. He chairs the World Psychiatric Association Task Force on Undergraduate and Post Graduate Curriculum as well as the APA Committee on College Mental Health. Dr. Kay is the immediate past chair of the Psychiatry Residency Review Committee of the ACGME and the Founding Editor of the Journal of Psychotherapy Practice and Research and Associate Editor of the American Journal of Psychotherapy. He has published extensively on the topics of medical and psychiatric education, medical ethics, child psychiatry, psychoanalysis, psychotherapy, the neurobiology of psychotherapy, and psychosocial aspects of AIDS and of cardiac transplantation, and has edited numerous books. Dr. Kay serves as the Associate Director of the Comprehensive Neuroscience Center at Wright State University. He received the 2001 APA Seymour Vestermark Award for contributions to psychiatric education. Dr. Kay's current research examines fMRI in borderline personality disordered patients with self-harm behavior.

The patient interview is at the heart of psychiatric practice. Listening and interviewing skills are the primary tools the psychiatrist uses to obtain the information needed to make an accurate diagnosis and then to plan appropriate treatment. The American Board of Psychiatry and Neurology and the Accrediting Council on Graduate Medical Education identify interviewing skills as a core competency for psychiatric residents.

Contributors ix Preface xi Acknowledgments xiii Chapter 1 Listening to the Patient 1 Listening: The Key Skill in Psychiatry 1 The Primary Tools: Words, Analogies, Metaphors, Similes, and Symbols 3 How Does One Hear Words in This Way? 4 Listening as More Than Hearing 6 Common Blocks to Effective Listening 7 Crucial Attitudes That Enable Effective Listening 10 Theoretical Perspectives on Listening 14 Using Oneself in Listening 16 To Be Found: The Psychological Product of Being Heard 18 Listening to Oneself to Listen Better 20 Listening in Special Clinical Situations 23 Growing and Maturing as a Listener 26 Chapter 2 Physician--Patient Relationship 31 Formation of the Physician--Patient Relationship 34 Special Issues in the Physician--Patient Relationship 42 The Physician--Patient Relationship in Specific Populations of Patients 44 Conclusion 46 Chapter 3 The Cultural Context of Clinical Assessment 47 Introduction: The Cultural Matrix of Psychiatry 47 What Is Culture? 48 Culture and Gender 50 The Cultural Formulation 51 Ethnocultural Identity 52 Illness Explanations and Help-Seeking 53 Psychosocial Environment and Levels of Functioning 55 Clinician--Patient Relationship 56 Overall Assessment 57 Cultural Competence 57 Working with Interpreters and Culture-Brokers 60 Conclusion: The Limits of Culture 62 Chapter 4 The Psychiatric Interview: Settings and Techniques 65 Goals of the Psychiatric Interview 66 The Psychiatric Database 75 Database Components 77 Mental Status Examination 81 Conduct of the Interview: Factors That Affect the Interview 83 General Features of Psychiatric Interviews 85 Chapter 5 Psychiatric Interviews: Special Populations 103 Randon Welton and Jerald Kay Psychiatric Interview in Special Circumstances 104 Psychiatric Interview in Special Patient Populations 115 Conclusions 131 Chapter 6 Formulation 135 Allison Cowan, Randon Welton and Jerald Kay Biological Contributions 136 Social Factors 138 Psychological Factors 140 Summary 146 Chapter 7 Clinical Evaluation and Treatment Planning: A Multimodal Approach 147 Psychiatric Interview 147 Identifying Information 149 Chief Complaint 149 History of Present Illness 150 Past Psychiatric History 150 Personal History 150 Family History 151 Medical History 152 Substance Use History 152 Mental Status Examination 153 Physical Examination 157 Neurological Examination 158 Psychological and Neuropsychological Testing 159 Structured Clinical Instruments and Rating Scales 159 Laboratory Assessments 159 Neurophysiologic Assessment 159 Brain Imaging 162 Special Assessment Techniques 163 Assessment of Risk 164 Suicide Risk 164 Differential Diagnosis 167 Initial Treatment Plan 170 Conclusion 171 Chapter 8 Professional Ethics and Boundaries 173 Introduction 173 Ethical Behavior and Its Relationship to the Professional Attitude 174 WPA Guidelines on Euthanasia 176 WPA Guidelines on Torture 177 WPA Guidelines on Sex Selection 177 WPA Guidelines on Organ Transplantation 177 WPA Guidelines on Genetic Research and Counseling in Psychiatric Patients 177 WPA Guidelines on Ethnic Discrimination and Ethnic Cleansing 178 WPA Guidelines on Psychiatrists Addressing the Media 178 The Coherent Treatment Frame and the Role of Therapeutic Boundaries in Effective Psychiatric Treatment 178 Boundary Violations 179 Components of the Coherent Psychiatric Frame 180 Stability 181 Avoiding Dual Relationships 182 Autonomy and Neutrality 183 Coherent and Noncollusive Compensation 183 Confidentiality 184 Anonymity 184 Abstinence 185 Self-respect and Self-protection 186 Summary 187 Index 191