Gerald Hurowitz, M.D.·Published 14 May 2009·12 min read
Key points
Psychiatric diagnosis involves use of generic clinical assessment skills, such as combining open-ended and close-ended questions, as well as specialized skills needed to address challenges associated with psychiatric impairments.
Some challenges to interviewing may begin even before the interviewee has actually attended the interview or met the interviewers.
The validity of the information collected may be seriously compromised in the extreme case of a particularly guarded or suggestible interviewee.
Common effects of these symptoms and impairments are distractions that disrupt the flow of the interview and hinder collaboration.
Psychiatric diagnosis involves use of generic clinical assessment skills, such as combining open-ended and close-ended questions, as well as specialized skills needed to address challenges associated with psychiatric impairments. In this section we discuss guidelines for interviewing people with schizophrenia, focusing on particular challenges to interviewing, and highlighting clinical communication skills in particular.
Guideline 1: Preinterview "Baggage"
Some challenges to interviewing may begin even before the interviewee has actually attended the interview or met the interviewers. These may be related to the interviewees' feelings, expectations, and concerns generated perhaps by past experience. For instance, even before coming to the interview, the interviewee may feel threatened, expect to be harshly judged and criticized, and be concerned about the possible consequences of the interview. Such preinterview feelings may manifest themselves in a range of different ways.
For example, an interviewee who is feeling threatened may be very guarded or may be aggressive as a response to his or her perceived threat. Similarly, an interviewee who expects to be harshly judged may be hesitant and reluctant to interact or even hostile and antagonistic toward the interviewer. Finally, an interviewee who is concerned with the consequences of the interview might be busy trying to guess how he or she might "best" respond to questions asked by the interviewer, which would seriously threaten the validity of the information elicited.
Because the effectiveness and quality of all interviews depend on rapport, a starting point for the interviewer meeting an interviewee with features described earlier would be to develop empathy and understanding of the potential origins of the interviewee's "baggage." This may include recognizing that the interviewee may have been in several clinical settings and situations in the past that he or she perceived as threatening (e.g., being interviewed at a teaching hospital in front of trainees who were all strangers), that he or she was indeed judged harshly (e.g., for discontinuing medication against medical advice or using substances), or suffered from perceived consequences of previous interviews (e.g., forced interventions or involuntarily hospitalization). In addition, the interviewer may use his or her clinical skills to help the interviewee feel more comfortable and at ease by expressing concern and empathy, and reacting to the interviewee and his or her story in a nonjudgmental manner. It is often useful in such cases not to ignore the "elephant in the room" but rather to focus first on the interviewee's immediate feelings and address the discomfort that he or she might be feeling ("I have a sense that you are not feeling very comfortable. I was wondering if you might be willing to share how you are feeling right now"). In addition to addressing the interpersonal context, there are several practical ways in which the interviewer might be able to help the interviewee feel more at ease.
Written and revised by
Gerald Hurowitz, M.D.
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Examples include introducing him- or herself, describing what to expect in terms of the format of the interview (its nature, rationale, and length) and what will follow. The interviewer should offer the interviewee the option to ask questions and to have his or her concerns addressed before proceeding. Forming a collaborative atmosphere in which the interviewee is viewed as an active participant rather than a passive subject of an interview is important. In addition, respecting the interviewee's style and pacing oneself to better match his or her tempo gradually increase the interviewee's trust and participation.
Finally, when the interviewee is uncomfortable, it is particularly useful to start the actual interview with a "warm-up" phase that includes easy-to-answer, factual questions to help the interviewee gradually become more at ease. As the interviewee feels more comfortable, follow-up questions can be particularly helpful in gathering more information about particular areas of significance.
Guideline 2: Lack of Insight into Illness Because the interview usually takes place in a clinical setting (outpatient clinic or hospital), a typical early question is "What brought you here?" or "How did you come to be in the hospital?". These questions are meant to provide a neutral stimulus to encourage the interviewee to reveal the sequence of events that preceded the current situation. One potential challenge is that the interviewee may lack insight into his or her behaviors, experiences or beliefs that impacted the events preceding the interview. The interviewee may deny having a problem ("I do not know. Everything was just fine") or believe that what led to being treated is not his or her problem ("They [family] wanted me taken away, because they needed the room in the house"), or that he or she has a problem but not a mental problem ("I was feeling weak, but they wanted me to go to the psychiatrist").
These various degrees and styles reflecting a lack of insight are common among people with schizophrenia and present a potential obstacle for the interviewer seeking to obtain an overview of the current episode and psychiatric history.
Although it may be frustrating for the interviewer, it is not useful to be confrontational or to repeat the question with the hope that the interviewee will eventually "gain insight." It is important instead to acknowledge the potential value in the information collected rather than to get angry or anxious about failing to elicit the "required" information. There are a number of reasons why information collected "even" with an interviewee who seems to have limited insight into his or her condition may be of value: First, discrepancies between the perceptions of interviewees and mental health providers may not always indicate lack of insight (Roe, Leriya, & Fennig, 2001). Second, even if the interviewee clearly lacks insight, it is clinically useful to explore and to understand how he or she perceives and experiences different events (Roe & Kravetz, 2003). In addition, lack of insight may in some cases serve as a defense against the threat to self posed by the illness, and its social and personal meaning (Roe & Davidson, 2005). Thus, acknowledging the clinical value of the interviewee's report, even if it is not concurrent with one's own, may help the interviewer to convey genuine respect for the interviewee's views rather than to become impatient, angry, or confrontational regarding the interviewee's "lack of insight."
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Guideline 3: Challenges of the Extremes:
The Guarded and the Suggestible Interviewee
The validity of the information collected may be seriously compromised in the extreme case of a particularly guarded or suggestible interviewee. At one extreme, the guarded interviewee may not reveal much information, particularly in relation to symptoms. Be cause clinical assessment in psychiatry is dependent to a great degree on self-report, interviews with guarded interviewees may create the false impression that they experience fewer symptoms than they actually do. At the other extreme are the suggestible interviewees, who are easily influenced by the interviewer's questions and "convinced" that they have experienced symptoms they may never have had, and may therefore be assessed as more symptomatic than they are in actuality. Regardless of which extreme a person represents, the information collected through the interview may not reflect his or her condition in a valid manner.
{embed="ref/48"} There are a number of possible solutions to these issues. First, the interviewer can be explicit about the value of eliciting the most valid information and its importance in helping to generate the most beneficial and tailored treatment plan. Second, he or she can gently explore whether the interviewee has understood the questions. Third, once the interviewer identifies such a tendency, he or she should be particularly careful about asking leading questions that imply to the interviewee that there is a "right" answer (which would motivate the guarded interviewee to deny having the symptom, and the suggestible interviewee to become convinced that he or she has it). Finally, it is important that the interviewer use his or her judgment and clinical skills to evaluate whether other sources (including observations within the interview) are in concurrence with the interviewee's self-report.
Guideline 4: Assessing Symptoms Many of the reviewed challenges in collecting reliable information during an interview are intensified when an interviewer tries to elicit information about symptoms. These challenges make it particularly difficult to achieve the primary goal of a diagnostic interview - to assess the interviewee's symptoms in a reliable manner. In the absence of laboratory test markers and indicators, psychiatric diagnosis depends heavily on self-report, which is subject to many distortions (although it may provide valuable information on subjective experience).
Fortunately, the interview's inherent limitations are also its strength: The complex process and data gathering that get in the way of generating a diagnostic hypothesis may also facilitate it. For instance, by evaluating the content and logical flow of the interviewee's verbalization, the interviewer may be able to learn about the presence of symptoms such as hallucinations and thought disorganization (e.g., loose associations, circumstantiality, and thought blocking). Although delusions may at times be readily assessed because of the interviewee's preoccupation with the theme or idea, at other times engagement in lengthier discussions is required before the interviewee begins to reveal much about his or her delusional ideas. In addition, observing the interviewee's behavior and affective expressivity during the interview can help the interviewer detect symptoms such as constricted or inappropriate affect. Finally, the interviewer may ask him- or herself whether he or she is losing track of the point the interviewee is trying to make, which can serve as a useful cue to consideration of different symptoms, such as tangential speech or derailing.
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Guideline 5: Symptoms Getting in the Way
During some interviews, the characteristic symptoms of schizophrenia make it difficult to secure sufficient and sound information, for example, when the interviewee is actively hallucinating or delusional; displaying disorganized thought or behavior; and presenting severe negative symptoms, cognitive impairments, or comorbid symptoms such as anxiety. Common effects of these symptoms and impairments are distractions that disrupt the flow of the interview and hinder collaboration.
There are various ways to address such disruptions. One way is to break up the interview into smaller parts to accommodate the person's short attention span. This can involve taking more frequent rest breaks or conducting the interview over a few days. This approach can also be used within the interview by breaking questions down into smaller ones, so that the person can more easily retain and process them. Finally, it is also often useful to explain the benefits of the interview and provide token rewards, so that the person participates as fully as possible in the interview.
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Guideline 6: Beyond Isolated Symptoms: The Importance of the Context
Another challenge may be a lack of sufficient information on the personal or cultural context within which the diagnostic information may be meaningfully understood. This may occur in transcultural situations, in which the interviewer is not versed in the interviewee's language and culture. Because the interviewer functions as a yardstick to some degree to evaluate the interviewee's beliefs, it is imperative that he or she be familiar with, or at least be sure to assess, the interviewee's general and health beliefs in relation to those of the culture to which the person belongs.
To understand the personal context it is useful to explore how symptoms relate to various domains of a person's life. To gather such information, it is important that the interviewer ask about a range of other contexts, including work, living, leisure, and social relationships, to try to identify the often complex mutual influences between these contexts and symptoms. Another important aspect of the context is its longitudinal course (e.g., time of onset of the first psychotic episode), which may have an impact on the developmental abilities of the interviewee (e.g., educational level and interpersonal experiences). The interviewer should also be sensitive to paranoia or to a traumatic history on the part of the interviewee that may disrupt the interview, and use appropriate communication skills to build trust. For instance, the interviewer should fully disclose the possible risks and expected benefits of the interview, give the interviewee as much control as possible over the interview (e.g., by asking open-ended questions and inviting the person to tell his or her life story), use empathic verbalizations, and more. Last but not least, the interviewer should be sensitive to the interviewee's cultural (and spiritual) context by using an interpreter when needed, recognizing that the interviewee's health beliefs and health-related behaviors may be very different from those of the interviewer.
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Guideline 7: Differential Diagnosis
The symptoms of schizophrenia often overlap with those of many other psychiatric disorders; thus, the presence of other syndromes should be assessed and ruled out before the diagnosis of schizophrenia can be made. Schizoaffective and mood disorders are commonly confused with schizophrenia, because they are mistakenly thought to simply include both psychotic and affective symptoms (i.e., in bipolar disorder and major depressive disorder with psychotic features). But it is not the predominance of the psychotic versus the affective component that determines the diagnosis; rather, it is the timing of psychotic and affective symptoms. If psychotic symptoms and affective symptoms always overlap, the person is diagnosed with an affective disorder, whereas if psychotic symptoms are present some of the time, in the absence of an affective syndrome, the person meets criteria for either schizoaffective disorder or schizophrenia (the former, if the mood symptoms are prolonged).
Recent research has revealed high rates of exposure to trauma and posttraumatic stress disorder (PTSD) comorbidity among people with a severe mental illness such as schizophrenia (Switzer et al., 1999). These findings, and the overlap in symptom presentation, make PTSD a highly relevant disorder when assessing schizophrenia. Dissociative or intrusive (reexperiencing) symptoms, such as trauma-related auditory phenomena and flashbacks, may be mistakenly interpreted as schizophrenia, so special attention is required to rule them out. {embed="ref/48"}
Substance use disorders such as alcohol dependence or drug abuse can either be a differential diagnosis or a comorbid disorder of schizophrenia. With respect to differential diagnosis, substance use disorders can interfere with a clinician's ability to diagnose schizophrenia, and if the substance use is covert, lead to misdiagnosis (Kranzler et al., 1995). Psychoactive substances, such as alcohol, marijuana, cocaine, and amphetamines, can produce symptoms and dysfunction that mimic those found in schizophrenia, such as hallucinations, delusions, and social withdrawal (Schuckit, 1989). The most critical recommendations for diagnosing substance abuse in schizophrenia include (1) maintain a high index of suspicion of substance abuse, especially if an interviewee has a past history of substance abuse; (2) use multiple assessment techniques, including self-report instruments, interviews with interviewees, clinician reports, reports of significant others, and biological assays; and (3) be alert to signs that may be subtle indicators of the presence of a substance use disorder, such as unexplained symptom relapses, increased familial conflict, money management problems, and depression or suicidality.
Many general medical disorders, such as hyperthyroidism, and cognitive disorders, such as dementia of various types, can present with schizophrenia-like symptoms. In many of these disorders the cognitive impairments are similar (e.g., in some cases of head injury). Hence, the differential diagnosis of schizophrenia in relation to these disorders may be difficult, particularly when past history is not conclusive (e.g., when a first psychotic episode started after a head injury). Moreover, the impact of comorbidity, such as whether a head injury that occurred after the onset of schizophrenia is contributing to symptom severity and cognitive impairment, may be very difficult to determine, because the natural course of schizophrenia in itself is not a uniform one. Still, a thorough medical and psychiatric history is helpful in this respect, as are laboratory tests - blood tests for hormones and many other factors, brain imaging such as computed tomography and magnetic resonance imaging, and other tests - to rule out or to confirm general medical and cognitive disorders.
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