So you’re going to see a psychiatrist.
Maybe your primary care doctor or gynecologist has sent you for a consultation. Perhaps family members or significant others have coerced strongly urged you to see one. Maybe the police have diverted you from jail to the psychiatric emergency room for evaluation. Maybe the psychiatrist is coming to you, if you’re in the hospital due to a severe medical or surgical problem, as a result of a request from your primary team. Or perhaps you yourself are independently seeking mental health care.
What exactly happens during a psychiatric visit? Does it involve a couch? Intrusive and aloof questions? Immediate medicating?
Maybe.
A visit to the psychiatrist is usually similar to a visit to any other physician, except without the physical exam. (In fact, the psychiatrist may even decline to shake your hand.) Ideally, the interview will comfortably unfold into a relaxed dialogue. Although there are various schools of psychiatric practice (some only prescribe medications; some engage psychoanalysis; some practice cognitive approaches; etc.), the initial psychiatric interview—which may last anywhere between 50 to 90 minutes—involves the following:
Chief complaint. Most psychiatrists usually open with some variant of the question, “What brings you in today?” The response to this initial question can significantly affect the remainder of the interview. For example, if the answer is, “I want you to take out the chip that Dick Cheney has planted in my brain,” that will likely require a different approach as compared to a response of, “Ever since my wife asked for a divorce, I’ve felt terrible.”
History of present illness. Expect to provide a narrative as to what events culminated in this visit. What happened? When did it start? What are the details? Why are you seeking treatment now, versus a month ago or next week?
Furthermore, the psychiatrist will likely ask questions to learn more about the following areas:
Depression. This will include, amongst other things, inquiries into mood, sleep, energy, daily activities, and suicidality. Most psychiatrists will also tack on a question about homicidality.
Mania. In addition to asking about energy level, reckless activities, impulsivity, and other criteria, s/he will hopefully inquire into duration, intensity, and how these symptoms may or may not interfere with daily function.
Psychosis. Do not feel offended when she asks about hallucinations, paranoia, and other seemingly non-reality-based items. She’s just doing her job.
Anxiety. Under this umbrella falls panic attacks, obsessions, compulsions, past trauma, and other symptoms of consuming worry.
A skilled psychiatrist will subtly weave these questions into the conversation. I’d like to think that most of us strive to create and maintain rapport for an interview that is both diagnostic and therapeutic, but this isn’t always the case. Sometimes we’re preoccupied. Sometimes we’re just having a bad day. Some of us just aren’t warm and, uh, interpersonally skilled.
Past psychiatric history. Here will fall inquiries into past psychiatric hospitalizations and outpatient mental health care. It will also include inquiries into past suicide attempts (how, when, why), acts of self-harm, and any experiences with past psychiatric medications. (It is supremely helpful if you know what you were prescribed, the ostensible reasons as to why you were prescribed the medication, how long you took it for, and if it was at all helpful. This can help guide current pharmacological treatment, if deemed necessary.) The psychiatrist may ask you if you had received any psychiatric diagnoses in the past, based on your previous answers.
Substance use. Most psychiatrists ask about tobacco use and, if you do smoke, will inquire into your desire to stop. This is called health maintenance. They will also ask about alcohol use (how much, how often, what type). There may also be inquiries into DUIs and other legal and social ramifications of alcohol consumption. Although alcoholism is considered a mental health diagnosis, this information also clarifies the answers you provide in other parts of the interview. For example, if you reported that you have felt depressed since you graduated from high school, but later report that you started drinking heavily on a daily basis after high school graduation, this casts doubt on a primary diagnosis of depression. Alcohol is a depressant (in every sense of the word).
Also expect inquiries into illicit substance use (cocaine and other street drugs; prescription drugs, such as Oxycontin; etc.) If, for example, you report that you must cover all the windows and mirrors in your house with linen to prevent ghosts from entering your residence and then report that you’ve smoked methamphetamine for the past ten years, it is more likely that your brain is damaged from the methamphetamine, rather than schizophrenia.
Past medical (and surgical) history. Certain medical problems seem to cluster with psychiatric diagnoses (like multiple sclerosis, fibromyalgia, lupus, etc.). Some medical conditions can be linked to psychiatric presentations (like hypothyroidism and depression—oft discussed, but uncommonly seen; a brain tumor can result in cognitive and personality changes). Some medical conditions psychologically contribute to mental discomfort (like a recent diagnosis of cancer). The psychiatrist should also inquire into any past seizures (as some medications can lower the seizure threshold), head trauma with losses of consciousness (which suggests potential brain injury, even if not seen on a head scan), and HIV risk factors (as HIV/AIDS can absolutely adversely affect mental status).
Allergies to medications. We don’t like to prescribe medications that may result in harm or death. I’m just saying.
Current medications. This can help clarify medical conditions (as a surprising number of people often do not know what medical problems they have). This list can also induce grief in the psychiatrist, particularly if it goes on… and on… and on… with numerous psychotropic medications. This may also include inquiries into over-the-counter medications and herbal preparations.
Social history. Unlike our medical and surgical colleagues, we inquire into more life history: Where were you born and raised? siblings? family life? abuse? education? employment history? relationships? marriage? kids? current financial situation? social support? goals? This area not only helps us understand patients more as people (rather than diagnoses), but also gives some insight as to how you cope with stress, what you identify as your strengths, how you may relate to other people (including the psychiatrist!), personality style and function, and how you view yourself in the world. (This provides the grist for the psychotherapeutic mill.)
Family history. Expect questions about who else in the family has mental health issues (”Aunt Joanne was really, really weird—she had problems” can make it into the chart), including suicides, hospitalizations, and substance misuse problems.
In addition to gathering all of this history, the psychiatrist will also conduct a “mental status exam” (a separate topic for another post) during the course of the interview. At the conclusion of the session, the psychiatrist will hopefully offer a tentative working assessment and plan for care.
It is in the psychiatrist’s best interest to build rapport with the patient. In fact, one tenet that is often repeated during our training is, “The purpose of the first visit is to ensure that the patient comes back for the second.” Much of the first visit is spent developing rapport because
- We cannot offer interventions if we do not have data. And we have very limited data if the patient does not talk. Or if the patient isn’t even present.
- Unlike our medical and surgical colleagues, we cannot affect change in one day or in one week (although we all wish that was not the case!). Changes in mental health and behavior take time.
One of my favorite supervisors offered this to me: “We’re in the business of helping people reach their hopes, dreams, goals, and desires.” And the first interview helps build the database to reach that end.
7 Oct 2007 |
Perhaps fodder for a followup post (or maybe a flowchart would be more efficient? :) ), but I am curious as to how you proceed when, say, you ask your patient if they have any history of abuse, and the other person tells you “Yes” — will you try to get any more information about that right off the bat? A little later in session 1? How do you proceed if they are unwilling to talk about it?
If the goal is to have the person come back for a second visit (and a third and so on), eventually you’re going to want to address this skeleton in the closet, no?
I would imagine how quickly you go after this particular aspect is determined by how well you feel they’re coping with it on their own, and how well-adjusted to it they seem. And of course how closely related it is to the problem that brings them to see you. If they’re in your office because of anxiety and panic issues, then probably it’s not something that you should feel needs to be addressed right off the bat? But then I suppose the anxiety could be caused by abuse — even if said abuse was in the past?
How do you address it if the person is completely unwilling to open up about it even over time? Do you just work around it?
I feel like I’ve just talked myself in a circle here. How delightful.
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And one relatively straightforward question: how far back in the family tree is mental health history relevant? Is there a point which you mentally label some piece of family history as unimportant? 25 years? 50? If a great aunt hanged herself 100 years ago, is it germane to the conversation at hand?
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Anyway, I enjoyed your post. As usual.
Maria says: Regarding the abuse question—patience, young grasshopper. When people are ready to talk about it, they’ll talk about it. If not, you wait. Nothing destroys rapport like forcing someone to talk about something they don’t want to talk about. And about the family history: Most people can’t remember beyond two generations. Furthermore, since mental conditions are stigmatized, such information often isn’t passed through the generations.
Comment by RJS | 7 Oct 2007 @ 7:56pm
(In fact, the psychiatrist may even decline to shake your hand.)
Why?
Maria points to the comment Cara left below.
Comment by Burn | 7 Oct 2007 @ 9:14pm
gynecologist?
Maria says: Hello, Maria. :) Some women have gynecologists as their primary care docs.
Comment by Maria | 7 Oct 2007 @ 10:27pm
What a terrific post. I have sat through many med reviews where the patient says “everything is fine and going well” and then the doctor asks “are you feeling suicidal?” The patient is very puzzled about this question until I explain, “she has to ask, part of the procedure”. Sighs of relief. I wonder if they think they are giving off sucidal vibes.
Maria appreciates the interpretative services you provide for physicians!
Comment by donnalee | 8 Oct 2007 @ 5:19am
Neurology is close to psychiatry in that, in many patients, so much hangs on the history, its depth, its quality (as you allude to), and in my experience the worst histories happen when someone is just going down some kind of checklist filling in blanks. You always have to be ready to take the possibly off-topic side road to see where it goes, even if in the end you decide this was a decoy, a manipulation, trying to hide some other, more interesting avenues.
I try to let patients speak, sometimes ramble, since the quality of spontaneous history can be so much better than Q&A. The longer they talk, the more you can concentrate on the many layers of interpreting what they’re saying and not be thinking about the next question. You watch the body language, what’s almost said but not, what’s between the lines, the Freudian slips — all grist for the mill.
The interesting thing about extensive medication lists is that they immediately invite the possibility of improving the patient’s condition by getting rid of one or more of them.
Maria says: I agree with the “let the patient talk” stance and the grand opportunities to simplify medication regimens!
Comment by Greg P | 8 Oct 2007 @ 6:44am
Ohhhh it was DICK CHENEY!! It’s all suddenly starting to make sense…
LOL all jokes aside, I actually have a question. Do you think it’s possible for someone who might need psychiatric help to see this post and learn about the interviewing process? By the time this person finally visits a psychiatrist, he’ll totally know what to say, right? Like, he may withhold information about Aunt Joanne, about the couple beers he drinks before sleep every night, about the chip Dick put in his head?
“Do you have suicidal thoughts?”
“Uh… no?”
I’m not making fun or pointing fingers… I’m really curious about this since this kind of information (about interview process) is so easily accessed by anyone who’s interested.
Maria says: I’m not worried about people learning about the interviewing process; the more transparency, the better. If someone wants psychiatric help, playing “fool the shrink” at the first visit is counterproductive. Furthermore, given that much of psychiatric care occurs over a period of time, any “slips” of information will likely be rectified in the future… and that provides more opportunities for self-reflection (e.g. “I wonder why I had difficulties talking about this sooner….”). We also obtain information from other avenues—see Greg’s comment above.
Comment by SWP | 8 Oct 2007 @ 9:28am
(In fact, the psychiatrist may even decline to shake your hand.)
Why?
Some psychiatrists (and psychologists) may not believe that any physical contact, including handshaking, is appropriate. Sometimes patients may find physical contact uncomfortable or even upsetting, depending upon their current psychological problems; sometimes psychiatrists simply want to remain neutral, which means that they will not engage in physical contact of any sort.
Maria thanks Cara.
Comment by Cara | 8 Oct 2007 @ 9:46am
Wonderful post! Thank you for giving a peak into the process of psychiatry. I’ve been there, as a patient, before being diagnosed with multiple sclerosis and hypothyroidism in recent years. In college, the doc’s suggestion was that Seasonal Affective Disorder was causing my difficulties as I was living in gray Bloomington, IN and had grown-up in sunny Oklahoma. I was one who didn’t always make it back into the office during those college days.
From the practitioner’s perspective, there must be a balance between personal privacy and openness. My brother is a licensed counselor and shared a situation (anonymously of course) he experienced with a patient who was also under the psychopharmacological care of a psychiatrist. The patient struggled with images of hachetts embedded in the heads of pretty women. After one visit during which the patient commented that my brother had a beautiful wife (as seen in a family photo), my brother promptly removed all personal photos and items from his office.
As the psychiatrist/counselor must develop raport to be able to help the patient, s/he must also maintain boundaries, including something as simple as a handshake.
Maria also thanks Lisa.
Comment by Lisa Emrich | 8 Oct 2007 @ 3:16pm
Since any action, verbal or physical, has the potential for broaching some boundary better not crossed, I am imagining that shaking hands is seen by some as having a lot more negative potential than possibility for establishing rapport? Shaking hands, after all, sort could be seen as less valuable by virtue of it being a somewhat “automatic” interaction, and there might be better ways to “touch” someone, e.g., through words.
Comment by Don | 9 Oct 2007 @ 10:24am
“The interesting thing about extensive medication lists is that they immediately invite the possibility of improving the patient’s condition by getting rid of one or more of them.”
Ah…so true! My neurologist had me on a slew of meds to treat NDPH and chronic cluster headache. At one point, I was on 5 different preventatives, plus meds for reflux, ADD, restless leg syndrome, and other things. By the time I saw my psychiatrist, I forget what meds I was taking, but over the first year and a half, my neuro had me on and off a number of meds. My psychiatrist is the one who actually simplified the list by convincing me to come off most of them, as they really weren’t doing anything and just giving me all kinds of side effects. I think he truly wanted to see what I was really like without the meds, since many of them have the ability to affect mood. Unfortunately, as my headaches are worse, the neuros are adding a few meds back here and there, which I guess is counter to the whole process we completed of getting off them, but sometimes it just has to happen that way. Prior to seeing my psychiatrist and having him work so hard to simplify my meds, I never even thought about the potential mood effects of the antiseizures I was on, and all the rest of them. Complicated, but I can see the importance of stripping them away to find out what really lies beneath…
Excellent post, as always! I have been working with my psychiatrist for 3 years now - started working with him when he was a 2nd year resident at the same hospital where I work. Then followed him as he did a geriatric psychiatry fellowship, and now am seeing him (45 minute drive, but worth it!) at a clinic in NJ where he does general psychiatry and geriatrics. I cannot remember the initial appt at all, but sometimes wish that I could! When I first started seeing him, I went because I needed someone to prescribe my concerta. At the first appt, he asked how much I could afford to pay to come every week, and things just grew from there!
Take care,
Carrie :)
Comment by Carrie | 9 Oct 2007 @ 2:16pm
“The purpose of the first visit is to ensure that the patient comes back for the second.”
What’s the purpose of the second visit?
Maria says: Well, if the purpose of care is therapy, the purpose of the second (and third and fourth…) visit is to help achieve goals through psychotherapeutic interventions. If the purpose of care is for medication management, the purpose of the visit is follow-up on the applicable issues… as in any other medical appointment.
Comment by Clare | 11 Oct 2007 @ 1:59am
I do not think anyone should go to a psychiatrist. They are exploitive, and abusive. Also, your records will be used against you if you ever are part of a legal proceeding, where you truly are a victim. They lie or are sloppy in their records. Even if you like your dr. ask to see your records now….
http://martalyall.typepad.com/living_here_mapping_iii/2007/11/the-swarm-expan.html
Comment by still2 | 23 Nov 2007 @ 4:39am