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

1. 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.
2. 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.

Everything he wears is tucked into something else. The dirty white tube socks poking out of his scuffed black sneakers are pulled over the cuffs of his blue sweatpants. Underneath his puffy brown jacket is a grey paisley shirt—fully buttoned, with the collar standing straight up—that is tucked into his sweatpants. Underneath the paisley shirt is a faded yellow tee-shirt, though only the frayed collar peeks out. Fuzzy green gloves cover his hands and swallow the cuffs of his paisley shirt, which in turn are consumed by the arms of his brown jacket. His unruly brown hair is somehow entirely contained within the cheap baseball cap that sits precariously upon his head. The hat reads “HOT DOG” in red letters across the front.

His handshake is limp and tired, like the skin that hangs from his face. He’s not old. Just withered.

He looks to the left, then to the right, then at me. “I can’t tell you about that, no, I can’t, because technically it’s information from someone else and—well, it’s a secret,” he says.

Leading the conversation away from the sensitive topic, I offer, “That’s fine. It seems like you really enjoy learning about birds, though.”

His left leg begins to bob up and down.

“Yes. Birds are interesting. They fly up in the sky, very high, never ask why, they say good-bye.” He pauses and looks at his leg. He sighs and, with resignation in his voice, comments, “See, I don’t know why this happens. I’m not doing this, no, I’m not, it happens. It’s the machines and cameras. They think they have the right—the right, the privilege, the honor—to do this to me without permission. They don’t ask. I don’t offend anyone. I’m not offensive. They offend me. Why do people offend me like this?”

Mildly exasperated, he returns his gaze to me. His leg continues to bob up and down. He resumes speaking: “I know I won’t ever go to college, but that doesn’t mean that I can’t learn. I can still read and maybe get a job, a simple job, and I can still write. I can write a book”—he separates his hands, as if holding a toaster—”and people can still read it. I might not be able to be a professor, a teacher, a scholar, a professional, but I can still read and maybe get a simple job.”

I watch him struggle with who he is and who he wants to be. His leg continues to bob up and down.

“You see, ma’am”—I wish he wouldn’t call me that—”the birds can get away from the machines and cameras. The clouds block the view and the wind carries them away. There are stories in the sky, way up high, where the sun won’t die, where God doesn’t lie, and I can write them. I won’t ever be a doctor, but I can still write and people can still learn.”

His leg abruptly stops bobbing up and down. Both legs are still. He doesn’t seem to notice this.

“What’s the best way I can help you today?” I ask.

“Yellow dye, custard pie,” he answers.

2002: Transition and Revelations.

Autumn has indeed arrived. The winds are shaking the trees, the leaves are swirling in the air and tumbling haphazardly onto the ground, the skies are streaked with October clouds.

I never thought I would like family practice, but I am enjoying it (regardless of my attending). Can I do this for the rest of my life? I don’t know.

I wonder if I will, truly, one day look back at these days and curse myself for not enjoying them more.

2003: Conquest.

I shall conquer Step 2 tomorrow! 368 questions! 8 hours! 1 computer! 2 earplugs! 1 lunch! Many bathroom breaks!

And hopefully I didn’t kill too many brain cells futzing with the weblog instead of studying.

2004: An Open Letter to the Person Who Mailed MoonPies to Me.

Dear Giver of MoonPies,

I must admit that I was reluctant to open the non-descript brown cardboard box resting against my door this evening. I was not expecting any packages and I immediately became suspicious when I did not recognize the name or address of the sender. The anthrax scare from a few years back has left an indelible impression on me. My imagination conjured up images of home-grown explosives, packets of white powder, or other projects of malice (hundreds of scorpions or spiders, etc.) within the box. Against my better judgment, I shook the lightweight box.

Nothing happened.

2005: Relieved.

It is the last day of September which means that I have managed to survive my rotation this month. And what better way to end a rotation than to have a patient say to me, “I’m gonna f@#$ you up.”

2006: On Apathetic Medical Students.

Medical training can become an overly cerebral exercise—there are so many tests for and demands placed on students. And maybe all I can do is wait for the day when these seemingly apathetic students finally come across a patient whose illness and associated suffering finally touches the emotive parts of their brains—and maybe that will provide the impetus for them to fully engage in patient care.

2007: It’s cold and rainy in Seattle and, as I review these past entries, I realize that I’m getting old.