Tidbits on Psychiatric Technique

Don't Tango with Rango

This piece was originally published here on Sensible Medicine.

During the final year of my psychiatry residency, I was supervising an intern consulting on a twenty-something gentleman in the emergency department. He had no known psychiatric history and had been brought in the previous night after causing a fracas while drunk. The intern was understandably, and appropriately, focused on mastering the fundamentals of the interview process—learning the textbook way before she developed her own style. She performed well. She established rapport, asked about the right symptoms, gathered the relevant facts, and over time pieced together the story of a young man who recently turned to alcohol to cope with his abusive family, ultimately losing control and acting out in bizarre ways. He was anxious throughout the process but kept his cool. Wrapping up the interview she asked him, “so, given everything that’s happened, what do you think you’ll take away from this experience?” I liked the question—she wants to assess his judgment and it calls for some reflective thought on his part.  

“Well,” he said with a grave and pensive expression, “I’ll say I’ve really learned my lesson, that’s for sure.” She gave a nod and looked at me to see if I had any follow up questions. Something didn’t sit right with me. It may have been his odd posture, subtly abnormal eye contact, or more likely his idiosyncratic but often slightly off-the-mark choice in words, but I had the feeling that there was something more.

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Early in my training I was surprised by how often my non-psychiatrist medical colleagues failed to realize that their patients were psychotic. This was most common when we consulted on medically hospitalized patients, where consultations for delirium, anxiety, and depression would not infrequently reveal someone suffering somewhere on the psychotic spectrum. Incidentally, my recent experience is the opposite, and I see far more false positives—patients being diagnosed as psychotic when they are not—especially among those who are younger, suggestible, and spend large amounts of time online.    

Whether under- or over-diagnosis, this points to the difficulties in recognizing certain kinds of psychosis, especially for those who either do not encounter it often, do not take sufficient time in an interview, or do not have a knack for spotting it. I have also noticed some common interview techniques which reliably cause people to fail to recognize psychosis, two of which I will note briefly here. As a caveat, I should stress that psychiatrists are not exempt from my criticisms and are in some ways the worst offenders.

First is a relative overreliance on patients’ subjectively reported symptoms, especially those elicited from checklist-style questions, while neglecting more objective signs. I believe this is actually a larger problem within psychiatry more broadly, but it is particularly relevant in the case of, say, hallucinations, one of the cardinal features of psychosis. Varieties of “do you hear voices when no one is there or that other people don’t hear?” can yield both false negative and false positive results, especially if, as is too often the case, there are no follow-up questions. If your patient really is hallucinating and denies it—perhaps concealing his symptoms due to paranoia—then objective signs like talking to oneself or appearing to listen to or engage with non-present entities may be more helpful. On the other hand, non-psychotic patients report “psychotic” symptoms all the time. I routinely see anxious ruminations, a self-accusatory inner monologue in a depressed patient, the compulsive silent repetition of phrases in OCD, and mild perceptual disturbances in borderline personality disorder get mislabeled as psychotic hallucinations. 

Psychiatric patients learn our lingo fast, and for various reasons may start describing their experiences as hallucinations. Too often their clinicians take this report at face value without further elaboration. I recently had a patient whose prior psychiatrist wrote that he was hallucinating because he had said “I just have this voice in my head telling me I’m worthless over and over again.” One need not be a psychiatrist to speculate—and subsequent conversation with the patient confirmed—that he was terribly depressed, but not psychotic. The point of course is not to ignore what our patients tell us – always critical -- but to remember that because of the nature of mental distress, we can over-rely on verbal reports of inner dysfunction at the expense of noticing its external manifestations.

The second interview technique that sets us up to miss psychosis is a failure to let patients talk without interruption. This isn’t just to give them more time to describe their symptoms (although they can), but rather because disorganized speech is one of the most common signs of a thought disorder, and the more a patient talks, the more likely it is to become apparent. Medical students are taught from day one to use open ended questions and give patients time to tell their stories, while residents learn just how aspirational this goal is in practice. And even when we do give patients time to talk, take a moment to consider how often we, instead of fully and attentively listening, are using that time to think of the next questions we are going to ask (assuming we aren't just typing the whole time). The thing is, the more we do the talking, the more mental work we do providing a conversational structure our patients can hang on to, freeing up their mental resources to better contain and conceal their dysfunction.  

My own strategy for mitigating this tendency has been to try to start all my initial patient evaluations, once introductions are complete, with a simple “tell me about yourself.” It is even more open-ended than “tell me what brought you to the hospital today” and often yields surprising responses. Perhaps tellingly, many patients say they have never heard a doctor ask them this question and that they don’t really know what to say. I try to give them a solid 5 minutes to talk before I say anything more than some version of “please, do go on.” In an inpatient unit where people are usually in crisis, it is challenging to keep a thought disorder concealed for long. Some people shut down early, sometimes from paranoia, or the overwhelming anxiety of being responsible for the direction of the conversation while simultaneously having to rein in their own mental chaos. For others, the uninterrupted space to talk may be all that's needed for their manic symptoms to kick into high gear or decide that now is a good time to clue me in on the CIA’s recent and extensive wiretapping of their home. 

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“…I’ve really learned my lesson, that’s for sure.” 

“And what was that lesson, exactly?” I was genuinely curious, but I immediately regretted asking it in that way. I had given him an easy out, practically telling him to tell me that he’d learned not to drink so much. A “please, go on” would have been better. But instead, he sat motionless, glancing back and forth between the intern and myself. Clearly, he had not expected my question. After a few seconds he began haltingly, pausing between each word as if trying to recall it from a distant memory.

“Don’t…tango…with…”—he hesitated for a beat—” ...Rango?” He raised one eyebrow quizzically as he said Rango, looking at me as if I would tell him whether he had guessed the right word.   

Alright, I thought, now we’re getting somewhere. “Don’t tango with Rango?” I wanted to confirm I had heard him correctly since neither tangos nor Rangos had featured in our conversation thus far. 

“Yeah”, he said, now quite confident in his response.  

“Okay,” I paused, going back through his story and making sense of it in the light of what I now suspected was a new-onset psychotic illness, “anything else?”

He seemed much more comfortable now that we were back in yes/no territory.  “No, I think that’s about it,” he said, and nodded approvingly with an “I rest my case” kind of satisfaction.  

The intern and I excused ourselves from his room to debrief before going back in to explore his psychosis further and work on admitting him to the hospital. We reviewed what we had just seen, and I explained to her what clang associations were (associating words based on sound/rhyme rather than meaning, a common finding in psychosis).

First and foremost, however, I tried to impress that what ultimately gave away his condition was not a thorough questionnaire but his being free to allow his symptoms to show themselves.

Martin Greenwald, M.D.