Introduction
The purpose of clinical interviewing, testing, and observation is to obtain a clear, comprehensive, balanced view of the patient, which is termed a clinical formulation, and to develop a rational treatment plan to address the patient’s difficulties. Clinical interviewing, in combination with observation, is the backbone of all mental health professions, a creative and dynamic process that represents a somewhat elusive set of complex skills, including integrating a large amount of information about a person into a clinically useful formulation, developing a diagnosis, and making recommendations for treatment based on the clinical assessment. Today the clinician is required to perform many types of interviews suited to the clinical task at hand, including assessments in settings as diverse as an inpatient psychiatric unit, an inpatient medical unit, a psychotherapy practice that includes either a consultation and/or a liaison setting, and an emergency room. Psychological testing may also be needed to gain additional information and to validate a diagnosis developed during the clinical interview and observations.
Clinical Interviewing and Observation
The clinical interview can be structured, semistructured, or unstructured. In the structured interview, the clinician covers the topics in a consistent way, using one of several published guidelines. In the semistructured interview, only part of the interview uses a published interview schedule. Most clinicians use a free-flowing, unstructured exchange between the clinician and patient. No matter what format is used, the clinician will work to develop rapport with the patient so that the essential information needed to help the patient can be obtained. Observation of the patient’s verbal and nonverbal behavior is also noted during the interview.
Whether the interview is structured, semistructured, or unstructured, the clinician must produce a written record of the interview. This report is focused on the referral question, which is the reason the assessment was requested. Most clinicians begin by presenting identifying information such as the patient’s name, age, marital status, sex, occupation, race or ethnicity, place of residence and circumstances of living, and referral information. The chief complaint or the problem for which the patient seeks professional help is usually described next, stated in the patient’s own words. The intensity and the duration of the problem are noted, including any possible precipitating events, such as the loss of a loved one. Symptoms associated with the chief complaint are assessed and noted in the report.
Current and past health history, for both physical and psychological problems, is important to review. There are physical illnesses that may affect the patient’s psychological state and vice versa. Prior episodes of emotional and mental disturbances should be described. The clinician needs to inquire about and report prescribed medication and alcohol and drug use.
Personal history may include information about the patient’s parents and other family members and any family history of psychological or physical problems. The account of the patient’s own childhood and noteworthy experiences can be very detailed. Educational and occupational history are outlined, along with social, military, legal, and marital experiences. The mental status exam is also part of the clinical interview and written report.
The Mental Status Exam
The mental status exam is simply the clinician’s evaluation of the patient’s current mental functioning. It is a staple of the initial mental health examination. The mental status exam may be viewed as consisting of two major parts: the behavioral observation aspects and the cognitive aspects.
The behavioral observation aspects include noting general appearance and behavior, mood, and flow of thought of the patient. General appearance and behavior are assessed by noting such things as the patient’s apparent age in relation to stated age(for instance, does the patient look younger or older than he or she actually is?), body posture, degree of alertness, hygiene, motor activity, facial expressions, and voice quality. Anything that seems outside the general norm would be noted (for instance, agitation). The clinician should also note any physical difficulties such as the need to wear glasses. The basic quality of mood is closely monitored and noted during the interview. The basic moods can be boiled down to anger, anxiety, contentment, disgust, fear, guilt, irritation, joy, sadness, shame, and surprise. Finally, the flow of the patient’s thoughts must be described if it is unusual in any way.
It is important to clearly delineate any noteworthy aspects of the person’s appearance, behavior, mood, or thought content rather than just providing a summary statement. For example, the clinician may write in the report that the person had a sad face and appeared to be about to cry, yet claimed to be happy. Another patient may have jumped from topic to topic and seemed unaware that there appeared to be no connection between topics. Attitude toward the clinician is also important. For example, some patients might be openly hostile while others are very cooperative. All the findings made in this first portion of the mental status exam are generally discovered by observation alone.
The second part of the mental status exam, the cognitive aspect, is determined by asking the patient certain types of questions. Some clinicians fail to assess the cognitive aspects of the mental status exam, despite the critical importance of this information to the overall evaluation of the patient. These clinicians may believe that it may be insulting to ask obvious questions of a patient who appears unimpaired. The clinician can prepare the patient for such questions by explaining that these questions are just a routine part of the clinical interview. The initial questions assess the person’s orientation to person, place, and time. That is, does the patient know who he or she is, where he or she is (city, state, facility), and what the date is? Then the patient is asked to memorize three common objects. Serial sevens are conducted, a task in which the patient is asked to subtract seven from one hundred, and then subtract seven from the result and so on toward zero. After that task is completed, the patient is asked to name the three objects memorized earlier. Other tasks may include naming objects the clinician points to, such as a pencil, following three-stage commands, and copying simple designs. These tasks assess attention, concentration, language, and short-term memory. Abstract thinking ability can be assessed by asking the patient to interpret proverbs (for instance, “What does it mean when someone says that people who live in glass houses shouldn’t throw stones?”) or explain likenesses and differences (such as, “How are an orange and an apple alike?”).
In this part of the mental status exam, the patient’s content of thought is noted, particularly bizarre ideas. A delusion
is a fixed, false belief that cannot be explained by the patient’s culture and education. Types of delusions include delusions of grandeur (such as believing that one is a musical virtuoso when one actually has little musical ability), body change (such as believing that one’s insides are rotting), reference (such as believing that others are always talking about one), and thought broadcasting (such as believing that one’s thoughts can be transmitted across the world). Hallucinations are false sensory perceptions that occur in the absence of a related sensory stimulus. Any of the five senses can be involved in hallucinations, but it is the auditory or visual modalities that are typically involved. For example, a patient may see someone who is not there. A phobia
is an unreasonable and intense fear associated with some object (such as spiders) or some situation (such as closed spaces). Finally, the presence of obsessions
and compulsions
needs to be assessed. An obsession is a belief, idea, or thought that dominates the patient’s thought content, while a compulsion is an impulse to perform an act repeatedly in a way that the patient realizes is neither appropriate nor useful.
Interviewing Informants
While most patients will tell clinicians all they need to know, it is often useful to obtain information about the patient’s present difficulties from other sources such as relatives, friends, and other mental health professionals. In some instances, verifying data or seeking additional information is essential. For example, information gained from children, adolescents, and adults who are psychotic or have limited cognitive ability may need to be verified and supplemented. Having a personality disorder may not particularly bother the patient, but family and friends suffer and can offer specific examples of problems involving the patient. Informants can also give information about cultural norms, childhood health history, and other relevant facts. Therefore, valuable information can be gained from people who know the patient well.
Interviewing informants will provide the opportunity to gain additional insight into the patient’s interpersonal relationships. The extent and quality of emotional and tangible support available to the patient may also be determined. Emotional support is having someone to talk to about problems, everyday occurrences, and triumphs. Types of tangible support include financial assistance, a place to live, and transportation to work and doctor appointments.
Psychological Testing
Testing may be requested by the mental health professional to clarify issues that came up in the clinical interview and to validate a diagnostic impression. Psychological testing is essentially assessing a sample of behavior using an objective and standardized measure. Although all mental health professionals are trained to conduct clinical interviews, typically, applied psychologists conduct and interpret the testing required. Applied psychologists include school, clinical, and counseling psychologists. The type of testing requested depends on what information is needed to answer the referral question or questions. For example, if there were some question about the patient’s level of intelligence, cognitive testing would be needed. The types of testing requested may include personality assessment, cognitive assessment, and assessment of specific abilities or interests. Personality assessment is the measurement of affective aspects of a person’s behavior such as emotional states, motivation, attitudes, interests, and interpersonal relations using standardized instruments. Cognitive assessment includes intelligence, achievement, and neuropsychological testing. Neuropsychological testing is used to assess brain dysfunction. The measurements of specific abilities or interests include assessing multiple aptitudes such as the potential to do well in a certain type of job (such as mechanical skills) and the measurement of values and interests. Information gathered from the clinical interview, observations, and the results of the tests are integrated into a formal report usually written by a psychologist.
Although some instruments can be administered by those trained by a psychologist, others require rather extensive training. For example, most pencil and paper instruments such as the well-known Minnesota Multiphasic Personality Inventory II (MMPI-2), a comprehensive personality assessment instrument, require little training to administer. Others, such as individual intelligence tests and most projective instruments (such as the Rorschach inkblot test), require extensive advanced training to administer. Interpretation of psychological tests needs to be done by doctoral-level applied psychologists.
Behavioral observations are also done during the testing process. How does the patient approach the task? For example, one patient may approach a task in a careful, systemic way, while another patient may use a trial-and-error approach. Verbalizations during testing are noted and may reveal a pattern of behavior. Some patients, for example, may consistently make excuses for what they perceive as poor performance on tests. Signs of anxiety, restlessness, boredom, anger, or other noteworthy reactions are important data.
Information gleaned from various psychological tests, the clinical interview, and behavioral observations are formed into a comprehensive and useful report with a diagnosis and specific recommendations for treatment. Writing this type of psychological report is a highly developed skill formed in graduate-level coursework and during extensive supervised experience.
The DSM
The results of the clinical interview, observations, and any psychological testing are used to develop a clinical formulation and to decide on a diagnosis. The American Psychiatric Association’s (APA)
Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), which was released in 2013, is the primary diagnostic system used by all mental health professionals. Whereas the previous edition of the DSM (DSM-IV-TR. Rev. 4th ed., 2000) summarized information according to five axes that organized, discussed, and evaluated syndromes, disorders, codes, assessments, and diagnoses, the DSM-5 utilizes a nonaxial documentation of diagnosis (formerly Axes I–III in the DSM-IV) with separate notations for significant psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V). Psychosocial and contextual factors covered in the DSM-5 are provided in an expanded set of V codes, which allow clinicians to note other conditions affecting diagnosis, prognosis, or the course of treatment of a primary disorder. The GAF (Global Assessment of Functioning) and C-GAS (Children's Global Assessment Scale for children ages four through sixteen), which were covered under Axis V in the DSM-IV and provided a scoring system to help clinicians assess and diagnose the severity of a psychiatric illness, were also changed in the DSM-5: separate measures of the severity of symptoms and disability are now listed for individual disorders. The DSM-5 also provides what it calls a "crosswalk," which serves to help clinicians match DSM-5 diagnosis codes with the codes used by insurance companies for billing purposes. Insurance companies only accept ICD-9 codes (International Classification of Diseases, ninth revision) when submitting invoices, and the ICD-9 codes do not always match the codes provided in the DSM. One of the APA's goals in revising the DSM-5 was to bring it more in-line with approaches and terminology consistent with the World Health Organization (WHO) and the Centers for Disease Control and Prevention's (CDC) International Classification of Diseases.
Bibliography
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