Diagnostic Interview

THE SEVEN STEPS IN INTERVIEW CONSTRUCTION

 Writing diagnostic questions
• The diagnoses to be made are divided among the authors, who then write
questions that follow the manual as faithfully as possible while using
language expected to be comprehensible and acceptable to respondents.

• At least one question is devoted to each diagnostic criterion. These criteria

include symptoms, duration of symptoms, age at onset, chronicity,
impairment, and overlaps in time between this disorder’s own symptoms
and symptoms of possibly preemptive diagnoses.
 Symptom questions

• Questions must cover symptoms whenever they occurred in the

respondent’s lifetime to allow assessing the manual’s criteria for the
minimum number of symptoms. They must also ask when symptoms first
occurred and last occurred to assess whether criteria for age at onset and
duration were met. Questions are also needed for ascertaining in what
years symptoms were present.

• Dating of symptoms also allows assessing whether disorders are currently

active.
 Psychiatric relevance

• Many symptoms of psychiatric disorders resemble

symptoms of physical diseases, injury, or substance
ingestion. For each symptom, the interview must enable
a decision as to whether the symptom was plausibly
explained by psychiatric disorder.

• Probe questions are written (and repeated for each

symptom) to exclude reported symptoms that either do
not qualify as causing impairment or distress or can be
fully explained by physical causes.
Assessing the questions

• The first step in assessing the author’s success in writing appropriate

questions is to have all other authors review his or her work. These authors
consider whether all symptoms have been assessed and whether symptoms
are assessed for both lifetime and present occurrence. The authors circulate
suggested revisions and then meet to reach consensus on each question.
 Testing respondents’ reception of the questions

• To answer the interview’s questions correctly,

respondents must understand them, have the
information requested, and be willing to share it with an
interviewer.
Testing respondents’ reception of the questions

• Symptoms of psychiatric disorder that involve sexual

behavior, alcohol abuse, and so forth, may embarrass a
respondent or be considered too private to discuss with
a stranger. Questions not acceptable to respondents
lead to denial of their symptoms or refusal to answer.
• Such questions can be rephrased to make them less
objectionable, can be preceded by reassurance about
confidentiality, or can be put in an audiotape or a
questionnaire so that the respondent need not answer
the interviewer face-to-face.
• Testing revisions
• Selecting the format
• Questionnaires and audiotapes
• Devising a scoring program to make diagnoses
FIVE STAGES OF A CLINICAL INTERVIEW
Opening
• The opening provides an initial focus. Most mental health
practitioners begin clinical assessments by asking
something like,
“What concerns bring you to counseling today?”
• This question guides clients toward describing their
presenting problem (i.e., psychiatrists refer to this as the
“chief complaint”). Clinicians should be aware that opening
with questions that are more social
(e.g., “How are you today?” or “How was your week?”)

• Many contemporary therapists prefer opening statements

or questions with positive wording.
 Body
• The interview purpose governs what happens during the
body stage. If the purpose is to collect information
pertaining to psychiatric diagnosis, the body includes
diagnostic-focused questions.
• In contrast, if the purpose is to initiate psychotherapy, the
focus could quickly turn toward the history of the problem
and what specific behaviors, people, and experiences
(including previous therapy) clients have found more or less
helpful.
 Closing
• As the interview progresses, it is the clinician’s responsibility
to organize and close the session in ways that assure there
is adequate time to accomplish the primary interview goals.
Tasks and activities linked to the closing include;
• (1) providing support and reassurance for clients,
• (2) returning to role induction and client expectations,
• (3) summarizing crucial themes and issues,
• (4) providing an early case formulation or mental disorder
diagnosis,
• (5) instilling hope, and, as needed,
• (6) focusing on future homework, future sessions, and
scheduling.
 Termination
• Termination involves ending the session and parting ways.
The termination stage requires excellent time management
skills; it also requires intentional sensitivity and
responsiveness to how clients might react to endings in
general or leaving the therapy office in particular. Dealing
with termination can be challenging.
• Often, at the end of an initial session, clinicians will not have
enough information to establish a diagnosis. When
diagnostic uncertainty exists, clinicians may need to
continue gathering information about client symptoms
during a second or third session. Including collateral
informants to triangulate diagnostic information may be
useful or necessary.
Tips for the Diagnostic
Interview
• The Relationship Comes First:
The first interview is a challenging moment, risky but
potentially magical. Great things can happen if a good
relationship is forged and the right diagnosis is made.
• Make Diagnosis a Team Effort.
Make the search for the diagnosis a joint project that
displays your empathy, not a dry affair that feels invasive
and always provide information and education. The client
should walk out feeling both understood and enlightened.
Never forget that this evaluation may be a crucial tipping
point that can change the patient’s entire future.
• Maintain Balance in the First Moments.
There are two opposite types of risk that occur in the first
moments of the first interview. Many clinicians
prematurely jump to diagnostic conclusions based on
very limited data and stay stuck on incorrect first
impressions, blinded to subsequent contradictory facts.
At the other extreme are those who focus too slowly,
missing the amazingly rich information that immediately
pours forth on the first meeting with a patient. Patients
come in primed to convey a great deal to you,
intentionally and unintentionally, through words and
demeanor. Maintain balance be extra alert in those first
few minutes, but don’t jump quickly to diagnostic
conclusions.
Balance Open-Ended with
Checklist Questions
• Until DSM-III, training in interviewing skills emphasized
the importance of giving the patient the widest freedom
of expression. This was extremely useful in bringing out
what was most individual in each person’s presentation,
but the lack of structure and specific questioning led to
very poor diagnostic reliability. Clinicians can agree on
diagnosis only if they gather equivalent information and
are working off the same database.
Don't Misunderstand
Comorbidity.
• in order to facilitate reliability, DSM is a splitter’s (not a
lumper’s) system; the diagnostic pie has been cut into
many very small slices. Many patients present with
more than one cluster of symptoms and require more
than one diagnosis. Noting all the pertinent diagnoses
adds diagnostic precision and provides a more rounded
view of the person. But having more than one disorder
doesnt mean that each is independent of one another.
• The multiple diagnoses may reflect one underlying
etiology and may respond to one treatment.
•Diagnosis
•Treatment plan
•prognosis
Thank You
For Your
Attention