Interview skills and the art of history taking
History taking and examination is the mainstay for diagnosis of a medical problem in a patient. It is the most important skill which should be imbibed by all medical practitioners. History taking is more of an art required for best application of the scientific knowledge and clinical skills learnt through our medical training. It is often said that medicine is as much art as science but this overlooks an additional dimension particularly pertinent to psychiatry – that of craft (Owens DC et al 2001). Obtaining a comprehensive history from a patient and, if necessary, from informed sources is essential to making a correct diagnosis and formulating a specific and effective treatment plan. The most important technique for obtaining a psychiatric history is to allow patients to tell their stories in their own words in the order that they consider most important.
Broadly we need to be aware of the process of the psychiatric interview and structure in organizing clinical material. Whereas the patient’s history remains stable, the patient’s mental status can change from day to day or hour to hour. The mental status examination is the description of the patient’s appearance, speech, actions, and thoughts during the interview.
‘Listen to the patients because they will be telling the diagnosis’ William Osler
The process of interview is very much necessary as that of the facts to be collected. Our ability to be effective in promoting a good clinical outcome can be linked to the competence of our communication skills. Some of the important elements of psychiatric interview includes empathy and engagement.
Empathy and Engagement
Patients and their relatives will judge a doctor, whether he or she is trust worthy or not at the first consultation! The important requirement to develop trust is to have empathy towards patients.
Empathy – Empathy refers to the ability to place oneself in the emotional perspective of another – while maintaining one’s own emotional perspective. Empathy is an active process which should be ongoing throughout any interview.
Empathy can be expressed during an interview by expressions of personal concern or interest (e.g. about the patient’s family), or raising matters of common interest (the weather!) – i.e. beginning with things unrelated to the purpose of the visit.
Empathy may be seen as one of the principle process mechanisms whereby one achieves engagement of the patient in the interview and its purposes, though it is not the only one. Engagement is clearly helped by being ‘engaging’ – by projecting a warm, friendly and interested demeanor from the start, but there are risks in misjudging the means of doing this.
Tips towards improving empathy and engagement for the interviewer/doctor:
- Being sensitive: Sensitivity to the subtleties of human interaction, both verbal and nonverbal behaviors is required
- Attitude: A nonjudgmental attitude is being able to convey a sensitivity to their dilemma and provide alternative models against which their situation may be appraised.
- Appearance: A demeanor where there is confidence without dogmatism – an open and friendly approach and respect for the patient as an individual, their beliefs and aspirations
- Being aware: Awareness of the process and content of interview will reflect the individual’s doctor’s involvement in the patient’s problems.
The Interview space:
Most conducive environment can be taken as an empathic gesture. Privacy is a basic expectation of anyone attending a psychiatric interview.
Tips towards making interview room patient friendly
- Avoid large consultation table which in addition to creating physical barriers, creates psychological ones by reinforcing hierarchies
- Seats should be high, comfortable and of comparable height for doctor and patient
- In arranging seating, it is best to avoid a direct face-to-face alignment, which can feel inquisitorial
- Seating should be slightly off-center, allowing the patient the opportunity to avoid the examiner
- Avoid the attractive table tops or ornamental items as they may become a missile!!
Informing the patient of who you are is common courtesy. It is generally better to make it clear not only who but is the purpose of your meeting from the start in situations when patients are not aware of the meeting with a psychiatrist. Following that it is also reasonable to inform the patient what it is you are going to discuss and include an indication of the time the interview is likely to take.
Any preparation, no matter how brief, should be done in private, before first introduction. Starting to write is something else best left till after one has clarified the ‘Presenting Complaint’. A skilled interviewer will cultivate the art of recording while maintaining the flow of the interview with simple social exchanges, facilitating the interview.
Types of interview:
- Structured interviews – Structured interviews have their origins in research and their form is determined by the requirements of the recording instrument, which may relate to just the areas that require to be covered or may in addition specify the precise questions. the Present State Examination (Wing et al 1974 ), which comprises a mixed set of 140 symptom and behavioral items, bases its reliability largely on the fixed questioning presented in the manual and precise adherence to predefined anchor points.
- Semi structured interviews – it is the usual format in routine clinical practice. Interviewer accepts a proactive role in establishing a core body of factual information and the structure within which such information can be sensitively acquired and evaluated.
- Unstructured interviews – associated with dynamically orientated practice, in which the way information emerges and its symbolic significance (i.e. the narrative) is considered as important as factual material.
Types of questioning:
This is the most important component of professional interviewing and concerns the verbal and Nonverbal interactions of both interviewer and interviewee
- Open questions require some opinion or judgement from the respondent and allow for answers which are open to variability and debate. ‘What did you have for breakfast?’
- Closed questions, on the other hand, are usually geared towards some factual response about which there is little room for debate. Did you have idlis in the morning?’ – ‘Yes’/’No’
In general, ‘open’ questions open up an interview, allowing a freer exchange of information, while ‘closed’ questions trim things down to basic, largely factual, exchanges. All interviews should start with an open question. As a rule, ‘open’ questions should predominate in the earlier part of the interview, with ‘closed’ questions coming in later to fill in factual blanks.
Nonverbal components of communication:
While focusing on the verbal, do not ignore the nonverbal components of communication. Particularly on the facial expressions and eye contact. For speakers, continuous eye contact is not essential but for listeners, it is necessary.
Utilize recapitulation and summarizing statements:
Use recapitulation and summarizing while interviewing to validate the information provided by the patient and to confirm its appropriate understanding by the interviewer. Facilitators are words, or more usually short phrases or sentences, which make it easier for the patient to respond, by conveying involvement or providing reinforcement of their efforts so far.
When the interview is about to end, it is better to summarize and clarify for the patient. It is good idea to allow patients to ask any further questions or allow then to speak if there are any information. By the end of interview, interviewer needs to be clear about future steps to be taken towards the problem presented.
Tips for appropriate questions during psychiatric interview
Crucial Paradox – ‘In the consultation the doctor makes the treatment decision, after the consultation, decision making lies with the patient!’
Format for History Taking In Psychiatry:
Psychiatric history taking is a complicated and extensive process, partly due to the need to obtain considerable amounts of information in order to place the patient’s symptomatic material in its personal and social context.
Template for History Taking In Psychiatry
Preparing a template before interviewing is essential for proper diagnosis and management. Eliciting appropriate history in limited time is an important skill of clinicians have to develop and hone it. Organizing extensive information and making meaningful application will require significant time and effort. Most clinical textbooks give a flowchart under which history and information to be organized.
Informants and quality of information
Information is said to be reliable when it is consistent, continuous, corroborates and complete. It should be primarily elicited from the patient and close relatives. Information is said to the adequate when it is sufficient enough to make a diagnostic conclusion at the end of the interview.
Presenting complaint: Reason for referral / contact
All symptoms should be evaluated for the following aspects
- Onset – abrupt/acute/subacute/insidious
- Duration and course of symptoms
- Precipitating factors
- Associated or co-occurring symptoms
- Evaluate for causes of current symptoms
- Treatment history
- Evolution of symptoms with time has diagnostic significance. Abrupt onset and rapidly progressive symptoms are usually associated with underlying neurological causes like seizures or vascular events. Similarly acute onset with episodic course is seen in bipolar disorders.
- Duration and course of illness is important as it has both diagnostic and prognostic significance. Many psychiatric disorders have been classified based on the duration of symptoms and majority of disorders are chronic in nature. Shorter duration illness usually have better improvement and prognosis. Course of illness with time can be either continuous or episodic. Schizophrenia related psychotic conditions are usually continuous, while mood disorders are known to be traditionally episodic in nature.
- Precipitating factors help us in understanding the etio-pathogenesis of the presenting symptoms. Most common precipitating factors include life events like death of close family members, drug default, fever or onset of medical/ neurological illness should be considered.
- Associated symptoms are essential to look at the syndromal diagnosis. Most neuropsychiatric conditions have been co-occurrence of symptoms, when present together form a particular diagnosis. Hence all symptoms based on the current classificatory system has to be checked. During the process of establishing a diagnosis, normal occurrence of problem behaviors needs to be differentiated from abnormal or pathological symptoms. Any symptom associated with dysfunction for the patient or the family needs to be addressed. How has the symptom affected the individual at his personal functioning including sleep, appetite and routine should be elicited. Is the person having any difficulties in his social occupational or legal issues secondary to presenting symptoms should be looked for. Eliciting positive and negative history related to the presenting symptoms will help in evaluating the inclusive and exclusive symptoms for making a diagnosis.
- Evaluate for causes of current symptoms from any discernable cause. Substance abuse should elicited as majority of the psychiatric manifestations have been associated with use of alcohol and cannabis. Other causes of psychiatric manifestations include neurological disorders which include epilepsy, cerebrovascular lesions, chronic infections including HIV, syphilis, endocrinal causes including thyroid related conditions and drugs. Drugs which have been commonly associated with psychiatric manifestations include steroids, antitubercular drugs.
- Has the patient being treated for the above symptoms till date and details of the same has to be documented. Treatment history will help in understanding the effects, side effects of the medications along with non-compliance to medications needs to be elicited. Finally is the patient on any medications currently, as it may be difficult to abruptly stop or change over the medications.
Presence of co-occurring medical or neurological conditions like diabetes mellitus, hypertension, drug allergies, neurological illness needs to be elicited. Treatment for the medical illness should be included while considering medications.
Past psychiatric history:
In case of previous history of mental illness, it should be evaluate for
- Onset, duration of illness, predominant symptoms, treatment given and recovery needs to be documented
- Previous history of drug use and treatment response
Past medical history:
Any significant medical or neurological illness, which may have bearing on the current psychiatric manifestations should be included.
In family history we need to look for both genetic vulnerability and environmental causes for the psychiatric disorders. Research in the recent year has been clearly pointing towards the gene environment interaction being an important cause for most psychiatric disorders. Majority of psychiatric disorders are inherited genetically and is familial. Well accepted genetic model of inheritance include non-Mendilian polygenic inheritance. Hence a three generation pedigree charting of the family members should be drawn and all the affected members should be indicated. Medical, neurological and psychiatric disorders should be indicated as more evidence is for co-occurrence of the above conditions.
The other important aspect is the environment in which the individuals has grown and live currently. Socio economic status, emotional environment, interpersonal relationship among the family should be elicited. It has significant bearing on drug compliance, symptoms relapse and support structures of the patient. Getting to know the social cultural background will be helpful in giving appropriate advice on the management of the patient.
Birth and developmental history:
History related to any complications or illness during the time of pregnancy and birth of the patient should be elicited from a reliable informant.
Developmental milestones with detailed accounts on the social and language milestone development should be elicited. In case there is developmental delay, then current level of development with questions related to the intellectual functioning should be elicited.
Early behavioral problems in the form of internalizing behaviors like separation anxiety, social anxiety should be looked for. Similarly externalizing spectrum including history of attention deficit hyperactivity disorder, conduct disorder or symptoms should be elicited.
Schooling history should be elicited with the specific focus on learning difficulties in the form of reading difficulties, mathematics difficulty and writing difficulties. Till what grade of schooling and grades secured during schooling will help in understanding the intellectual development.
Employment record with any attainments or failures like promotion/demotion/dismissals needs to be elicited.
Sexual identity and orientation needs to be looked in certain conditions, primarily in adolescent and early adulthood.
History of sexual knowledge, sexual practices including masturbatory practices should be looked elicited in adolescent and early adulthood.
Sexual intercourse related issues in the form of hypoactive sexual activity, erectile dysfunction or premature ejaculation or organismic dysfunction, pain during sexual intercourse needs to be elicited in patients presenting with any sexual act related problems.
Marriage and cohabitation history needs to be elicited with the focus on the relationship between both the couples. Children and parenting styles needs to be elicited when required.
Menstrual history: age at menarche, menstrual cycles – pattern and regularity and last menstrual period.
Mood symptoms related to the menstrual cycle should be elicited.
If conceived, any symptoms of mental illness during pregnancy and postpartum phase needs to be elicited, with a particular focus on mood symptoms.
Premorbid personality is the pattern of individual social relations, mood, thinking and character, which may change with the onset of illness. Before 18 years, premorbid temperament should be evaluated.
Social and interpersonal relations:
Check for interest in having social relations by having friends, spending time with friends before the onset of illness. Interpersonal relation should be evaluated for consistent relationships or inability to maintain relationships.
Mood before the onset of mental illness should be looked for, as it gives a baseline emotional status of the individual. Need to check any mood fluctuations prior to the onset of illness and were they secondary to events or without any cause. Presence of easy irritability or responding emotionally needs to be checked.
Character and attitude:
Whether the person was taking responsibilities for work at home or other places. Was he avoiding or externalizing responsibility in the family or at work. Was the individual able to accept others view or used to give importance to his own views and gains.
Handling difficult situations: how did the person handle demanding situations or stressful situations like examinations or loss of family members.
Energy and initiative:
Was the individual able to take initiative in taking decisions or used to depend on others for the same. Was the individual seen as energetic in any tasks or activities.
Hobbies and fantasy life:
Did the individual have any hobbies or favorite activities which he was doing regularly? Did the individual fantasize excessively or dwell in fantasy thinking for longer times. Did the individual fantasize about abnormal concepts.
– Dr Girish Babu N