At this point, it’s time to consider the diagnostic interview. By now you know the major mental disorders you will need to master in medical settings—depression, anxiety, and prescription and other substance misuse. In the interview, you’re looking for criteria that distinguish among these disorders and their subsets. The interview format we now present describes the categories of data needed and how it can be written up for your records.
You learned in Chapter 3 to begin all interviews with the patient-centered interview.1 To briefly review, one begins any interaction by ensuring the patient’s comfort (step 1) and setting an agenda for the visit (step 2). You then proceed to the true patient-centered part of the interaction (steps 3 and 4) to determine open-endedly the patient’s physical symptom and personal story. You next elicit any emotion associated with these stories and empathically respond by Naming it, expressing Understanding of it, Respecting it, and offering Support (NURS). See Table 3-1 in Chapter 3.
Following this 3- to 5-minute patient-centered introduction, you transition to develop the details of the chief concern you elicited during agenda setting (step 2). Even in patients with a mental disorder, this step will often involve physical symptoms, and you need to pin down these details as you normally would via the history of present illness (HPI), past medical history (PMH), social history (SH), family history (FH), and review of systems (ROS). For mental disorders, the format is essentially the same.
You may have already uncovered psychological symptoms (of a mental disorder) in your patient-centered interviewing. As you expand the patient’s physical and personal stories, you will often identify them. Once you have identified these symptoms, you proceed to the clinician-centered part of the interaction to pin down crucial diagnostic details, as outlined in Chapters 4, 5, 6. On the other hand, recall that you may not have gotten many psychological symptoms in the patient-centered component, and that you will need to actively inquire about them during clinician-centered inquiry.
So how might you elicit the psychological symptoms? What are some questions you can use to screen for a mental disorder during clinician-centered interviewing? Table 7-1 presents the disorders discussed in Chapters 4, 5, 6; your clinician-centered questions will focus on differentiating among them. Table 7-2 suggests some specific screening questions for depression, mania/hypomania, and drug/alcohol abuse. Now, you generally do not ask all the questions in Table 7-2 in screening; rather, you should focus on the areas where you have suspicions. These concerns will commonly include depression and/or anxiety because the 2 are the most common disorders and often occur together. When answers to screening questions are positive, you conduct your subsequent history to elicit the differentiating material described in Chapters 4, 5, 6. Tables 7-3 and 7-4 list some less common mental disorders and present some screening questions for them. We will cover these in more detail later in the book, but know for now that they are less common and often more easily recognized.
|Major depression||Generalized anxiety disorder||Illicit drug abuse|
|Chronic depression||Panic disorder|
Prescription drug abuse
|Depression variants||Posttraumatic stress disorder||Alcohol abuse|
|Bipolar disorders I and II||Obsessive-compulsive disorder|
“Have you felt sad, depressed, blue, or hopeless over the last 2 weeks?”
“Have you felt higher or happier than usual, the opposite of depression, for 4 or more days in a row?”
“Have you had excessive amounts of energy or racing thoughts or talking a lot where you didn’t need much sleep for 4 or more days in a row?”
“Do you have persistent problems with being nervous or anxious?”
“Are there specific situations in which you regularly become anxious?”
“How much alcohol do you drink per day?”
“Do you use street drugs?”
“What prescribed medications are you taking for pain?”
Anhedonia (lack of joy)
“What have you done for fun in the last 2 weeks?”
“Have you had decreased interest or energy for pleasurable activities in the last 2 weeks?”
“Have you ever been so unusually (for you) irritable that you did things you would not ordinarily do, like start arguments or fights over 4 or more days in a row?”
“Does it take you more than 30 minutes to get to sleep or get back to sleep if you waken in the last 2 weeks?”
“Have you been sleeping more than usual in the last 2 weeks?”