5
Assessment of Patients with Psychosis
NATASJA MENEZES AND ROBERT ZIPURSKY
INTRODUCTION
The more experience we gain in the mental health pro-
fessions, the more many of us realize the privilege we have
of getting to know our patients personally—of knowing
them not just as functions of their symptoms, but as func-
tioning beings themselves. The “art of medicine”––that is
what it is about. But what is the true art? In psychiatry,
many would say that it is knowing how to ask which ques-
tion and when. How you phrase a question—and at what
point in the interview you pose it—can make a significant
difference to both your information yield and your thera-
peutic relationship. It’s an intimidating fact! This is not at
all minimized by the fact that we have no diagnostic labo-
ratory tests and few physical signs in psychiatry, and we
must rely on our clinical and interpersonal skills to work
with our patients.
This can be all the more challenging when the
questioning revolves around psychosis. Many a student
has prefaced a psychosis screen by saying, “These
may seem like weird questions, but I ask everybody this.”
This usually reflects their own discomfort with the con-
tent, rather than the patient’s. Anybody can ask a checklist
of diagnostic criteria, but not everybody can actually
elicit an accurate history of psychosis symptoms from
the patient.
Being comfortable with what you have to know is key to
developing skills in the art of medicine. This chapter aims
to help you do just that. By the end of the chapter, the
questions should not feel weird, and you should be able to
ask them in the most efficient, high-yield way that fosters a
relationship with your patient.
Case Example 1
John first met Dr. Yates when he was 17. He had gone
through a gradual change in functioning and personality
over the last 2 years, involving a slow withdrawal from his
friends and family, an increased use of marijuana, and a
decline in his self-care, culminating in his dropping out of
school. He had become very interested in religious matters
and developed a philosophical way of thinking and express-
ing himself. Despite his parents’ concerns, he had refused
to seek help. He finally ended up in contact with Dr. Yates
when psychiatric treatment was mandated by the court as
part of his probation term. He had broken the window of
the neighbor’s car because he felt that a camera had been
placed in the body of the car to spy on his bedroom win-
dow. He never acknowledged this to Dr. Yates, although he
had previously explained his behavior to his parents. For
the first 7 months of follow-up, he denied any symptoms
or distress and came only by obligation of the court.
His mother administered his medication, so he was grudg-
ingly compliant. After the first 7 months, he started to
admit regrets at the losses he had gone through with school
and friends but continued to deny any psychotic symptoms.
He became depressed, increased his marijuana consump-
tion, and became floridly psychotic and agitated, requiring
a 3-week in-patient admission. After this admission, he
began to question what had led to his behavior and admis-
sion, and he started to work with his case manager to
understand the persecutory ideation he had been living
with. He attempted a return to school but had to drop out
because of concentration difficulties. He succeeded in
holding a part-time job in a real estate agency. He felt so
29
30 Psychiatric Clinical Skills

well that he stopped taking his medications. Since things

Box 5-1. The Categories of Psychotic Symptoms
were back to normal, he started hanging out with some new
friends from work, started a romantic relationship, and did POSITIVE SYMPTOMS
well for several months, never reporting that he had quit Delusions
his medications. Gradually, he started to reuse marijuana Hallucinations
and to withdraw, finally being fired from his job for poor
NEGATIVE SYMPTOMS
attendance. He agreed to restart medications at the urging
of his girlfriend and has been stable now for 2 years. Affective flattening
Alogia: impoverished thinking reflected in poverty of speech
Avolition: inability to initiate and sustain goal-directed
What are the issues involved in working with such a
activities
patient? This chapter can help clinicians to elicit these issues Anhedonia: loss of interest or pleasure
and work with them by using the following questions:
DISORGANIZATION SYMPTOMS
■ What diagnosis accounts for the change in personality Thought disorder
and functioning? Loose associations
■ What differential diagnosis needs to be considered? Tangentiality
■ How do you engage such a patient so that he may Word salad
Behavior
receive treatment and follow-up earlier on?
■ What are the phases of illness that patients go through? COGNITIVE SYMPTOMS
■ What risk factors affect the course of illness, and how do Attentional deficits
we elicit them? Memory impairment
Information-processing deficits
The American Psychiatric Association’s Diagnostic and
CATATONIC SYMPTOMS
Statistical Manual of Mental Disorders, edition 4, text revi-
Stupor: decreased awareness of the environment
sion (DSM-IV-TR),1 notes, “The term psychotic has histori-
Rigidity: rigid posture
cally received a number of different definitions, none of
Negativism: active resistance to instructions or attempts to be
which has achieved universal acceptance. The narrowest def- moved
inition of psychotic is restricted to delusions or prominent Posturing: inappropriate or bizarre postures
hallucinations, with the hallucinations occurring in the Excitement: purposeless and unstimulated excessive motor
absence of insight into their pathological nature . . . Broader activity
still is a definition that also includes other positive symptoms
of schizophrenia (i.e., disorganized speech, grossly disorgan-
ized or catatonic behavior)”. In the DSM-IV-TR, the term
Box 5-2. The Etiologies of Psychosis
psychotic refers to different combinations of delusions, hal-
lucinations, negative symptoms, disorganized speech or PRIMARY PSYCHOTIC DISORDERS
behavior, cognitive deficits, and catatonia, varying according Schizophrenia
to diagnosis (Box 5-1). We view psychosis as a syndrome with Schizophreniform disorder
different causes (Box 5-2), much as a headache can be Schizoaffective disorder
caused by a hangover, the flu, a migraine, caffeine with- Delusional disorder
drawal, a long day, or a long book chapter! Brief psychotic disorder
In this chapter, we use our own clinical experience (posi- Shared psychotic disorder
Psychotic disorder NOS
tive and negative) to provide a starting place for addressing
some of the clinical issues involved in working with people Secondary to . . .
with psychosis, with an emphasis on the schizophrenia-spec- General medical condition (e.g., dementia, delirium,
trum disorders. The chapter aims to elaborate on the clinical temporal
lobe epilepsy)
interview of a patient with psychosis, addressing the compo-
Substance-induced (e.g., illicit drugs or medication-induced)
nents and challenges of the interview, the techniques to opti- Mood disorder
mize engagement and information-gathering, and the
knowledge base to be acquired. By the end of this chapter,
you should be able to answer the following questions:
2. What are the goals of my interview with a patient with
1. What techniques can I use to sufficiently engage psychosis?
patients with psychosis so that they stay and answer the 3. What differential diagnoses do I have to keep in mind,
questions in a meaningful way? and how do I evaluate for these?
 Assessment of Patients with Psychosis
4. How do I phrase questions so they do not seem odd, but
nevertheless efficiently elicit the symptoms?
5. What should I observe?
6. What additional tools can I use?
7. What challenges should I be ready for, and how can I
get around them?
8. Where else can I get information?
9. What do I need to elicit from a patient seen in follow-up?
THE GOAL OF THE INTERVIEW
For the purposes of this chapter, we will consider the
goals of the interview to be:
1. To engage the patient;
2. To elicit a history (symptoms, etc.) leading to provisional
and differential diagnoses;
3. To determine the needs of the patient and the appropri-
ate management;
4. To make the contact a positive enough experience that
the patient will consider coming back.
Key Point:
We should strive to make every interaction with a patient a
therapeutic one in which he takes something away from the
contact. This applies to first-time consultations, follow-up
appointments, and even brief hallway encounters.
Getting Started
Before even meeting the patient, it is important to
ensure that your setting is adequate and that you are think-
ing about how to make both yourself and the patient feel
most comfortable in the upcoming interaction. Special
consideration should be paid to the following.
Comfort
■ Is the setting too warm/cold?
■ Does the patient have any basic needs (bathroom,
food/water, etc.) to be met prior to the interview?
■ Is the patient suffering any psychological/physical symp-
toms that could interfere with the process (e.g., anxiety,
side effects such as motor restlessness or extreme seda-
tion)?
■ Does the patient require any medication prior to the
interview?
■ If there are observers present, are the chairs angled such
that the patient does not feel stared at or ganged up on?
31
Key Point:
Ensuring a comfortable and safe setting before starting the
interview will increase the probability that the patient will
stay long enough to complete the assessment without
distraction or interruption.
Safety
■ From what you know about the patient (ambulance or
police notes, triage assessment), do you require another
person to be present?
■ Is there an alternate escape route for the interviewer
and/or the patient?
■ Is there sufficient space that the patient won’t feel
threatened or crowded?
■ Have you secured any loose objects that might be used
to throw or strike someone?
Key Point:
It is essential that both the interviewer and the patient feel
safe. If the interviewer is anxious, it will be difficult for the
patient to feel comfortable in the interview setting.
Engagement
Engagement can encompass many different concepts
and is applicable to any interview setting. See Chapter 1 for
further general discussion on engagement.
How do you “engage” a patient with psychosis? It is an
ongoing process that can be started by considering the fol-
lowing:
■ Does the patient understand why he is here? What are
the patient’s goals/expectations for the encounter?
■ The purpose of the interview should be explained
beforehand, setting the ground for what is to
come.
■ You can address these issues in the following ways:
● “Perhaps you can start with telling me your under-
standing of the reason for our meeting today.”
● “Dr. X has asked me to meet with you today to
clarify . . . ” or “ . . . to determine whether . . . ”
● “I’ve asked you to come back for a follow-up today
so that I can have some extra time to explain . . . ”
or “ . . . so that I can get an idea of how you are
doing and whether there are any problems you
would like me to know about.”
● “Tell me what you would like to get out of today’s
meeting,” or “How I can help you?” or “What do
you need help with?”
32 Psychiatric Clinical Skills
■ Does the patient know what will be involved in the
interaction? This should include the duration and break-
down of the interview.
■ This is helpful in preventing potential stalls in the
interview, such as when the suspicious patient says,
“I don’t see why you need to know that,” or “You can
get that from the chart,” or “I didn’t know this was
going to take so long; my parking meter was up 20
minutes ago.”
■ You can address this with the following tactics:
● “In order to make recommendations, I would like
to be able to understand what has led to your com-
ing here and what you have been experiencing.”
● “I understand you saw Dr. X in consultation
2 weeks ago. The questions I ask you today may
repeat some of those. I find it helpful to hear about
people’s experiences in their own words.”
■ Does the patient understand that the discussion is confi-
dential?
■ This is particularly important for patients who are
guarded or frankly paranoid.
■ You can address this with the following statements:
● “We may discuss some personal issues today.
I would like to reassure you that all you tell me is
confidential and will only be written in a report to
your family doctor who referred you here. No one
else can have access to that information without
your permission.”
■ Does the patient feel safe? Ask the following questions:
■ “Is there anything making you uncomfortable right
now?”
■ “I noticed that you keep looking at the door. Is there
something in particular you are looking for?”
■ Are you aware of cues that the patient gives, for exam-
ple, of questions she does not understand or of uncom-
fortable topics?
■ Are you adapting your questioning style to the patient’s
capacity to understand or her level of education?
Key Point:
A key long-term goal is to keep a patient with psychosis in
treatment, given the frequent chronicity of some psychotic
illnesses. The early contacts can lay the positive foundation
for an ongoing therapeutic relationship and low dropout rate.
Key Point:
It is important to realize that many patients with psychosis
have elements of disorganization and deficits in attention. In
this context, it is helpful to make questions brief and
straightforward, sometimes using examples to clarify. Keep in
mind not to use leading questions.
■ Once the interview is underway, do you attempt to give
a context for (i.e., normalize) questions that may seem to
be of a prying/odd/judgmental nature?
■ Do not feel compelled to preface such questions by
labeling them (e.g., “Now I am going to ask you
some questions that may seem strange”). This ends
up putting the patient on guard and reduces the
probability that he will feel comfortable enough to
respond honestly. It is best to personalize it to the
patient.
● “You mentioned before that you have been under a
lot of stress lately and haven’t been feeling your-
self. In those situations, sometimes people can
have new experiences such as . . . I wonder if this
has happened to you?”
● “I noticed you hesitated when I asked you about X.
I ask you that because in working with people who
have had similar experiences, we have noticed that
they often report X, and I was wondering—has
that been the case for you?”
● “It is important for me to have a clear idea of
the amount of drugs you have been using
because we know that they can sometimes have a
role in X.”
COLLECTING INFORMATION
FROM THE PATIENT
After your initial contact and introduction, you are
finally underway with the interview. Depending on the
situation, the chief complaint (not the whole story, but a
brief introduction to the problem in the patient’s own
words) is a reasonable way to get started, while giving you
and the patient a focus on the goal of the interview. For
those patients who are not comfortable starting with an
elaboration of their difficulties, and who may need a
more neutral lead-in, nonthreatening data-gathering can
also be an acceptable place to start, while giving you a
larger contextual view of the patient (e.g., name, age, liv-
ing situation).
Key Point:
It may be helpful to start with the chief complaint because it
permits the patient a few minutes to talk freely, in the
absence of structuring or directive questions. This allows you
to observe thought form, reliability, processing capacity, etc.
It gives you a sense of how organized the patient is and how
open-ended your interview should be. This also permits you
to develop a targeted structure for the remainder of the
interview, driven by your hypotheses about the primary
diagnosis and its differential.
 Assessment of Patients with Psychosis
The History of Present Illness
The history of the present illness (HPI) is the foundation
of your database, the big picture overlying the details of
what has led this patient to you. A properly conducted HPI
should be directed by your hypotheses about the diagnosis
and its differential. These hypotheses evolve from the time
you first see the patient (e.g., Is she euphorically singing in
the hallway while waiting for the interview? Is she stooped
over with poor eye contact?) and should also be directed by
the patient’s cues. It is important to feel comfortable
enough with what you need to know by the end of the inter-
view and to ensure that you are not formulaic during the
interview. It is helpful to be flexible with the order in which
you elicit information.
Case Example 2
Sara is a 21-year-old waitress who was brought in to the
psychiatry emergency department by police. She was found
in the street, stripped to the waist, singing in the snow with
no shoes on, claiming that if she stopped singing, the devil
would take her in punishment for her sins. In the emergency
department, she refused to talk for the first 2 hours, appear-
ing to be asleep. Her vital signs were stable; she refused to
comply with any blood or urine tests, and there were no
signs of intoxication. She had no identification on her, and
there was no source of collateral information. On waking,
she was irritable and suspicious, demanding to leave. She
agreed to a 10-minute interview with the psychiatry resident
and swore that she would stop talking after that time.
The issues:
■ How do you collect information from an uncooperative
patient?
■ What type of details should be prioritized in information
collection?
■ What emergency issues need to be considered?
■ What other sources of information can be used?
In evaluating psychosis, there are several key features
that must be clear by the end of the interview (they do not
necessarily have to be elicited in this order, although a good
start is to get an idea of the cross-section of the psychosis
and its qualities and then to use this information to drive
the questioning of the differential diagnosis and evolution
of symptoms):
■ Why now? What was the trigger for consultation being
solicited at this time?
■ “I understand that things have been different for you
recently. I wonder what led you to seek help right
now?”
33
■ What are the actual symptoms of psychosis? Remember
that you want to phrase the screening questions in such
a way as to elicit more than just “yes” or “no.” Or, if that’s
what you get, you should follow up with something such
as “Tell me more about that,” or “Can you give me an
example?” (Table 5-1).
Key Point:
Accurate data-gathering implies exploration of what patients
say, and not just taking all they say at face value.
■ It is important to keep in mind that most patients will
have some difficulty freely expressing psychotic symp-
toms. It can be helpful either to normalize the ques-
tion or to personalize it to this particular patient’s
context. You should at least start with broad concep-
tual questions and then hone in on the actual delu-
sional content.
■ “You mentioned earlier that when you smoke a joint,
you get paranoid. Can you tell me a little bit more
about that?” (In other words, ensure that the patient
is using the word “paranoid” in the same way you
understand it.) “Does that ever occur unrelated to
pot?”
■ “Often when people have gone through a period
of difficulty sleeping, they may start to feel that
their thinking is different. Has that ever hap-
pened to you? Can you tell me about that? Or,
you don’t think it has? Perhaps if I give you an
example that I often see, it might help. Patients
report that when they haven’t been sleeping well,
they start to question things or have thoughts that
run in circles, like ‘I’m being followed’ or ‘Is it
safe here?’ Have you ever experienced something
similar?”
■ You must be cautious and ask initial questions as
broadly as possible so as to not lead the patient toward
your anticipated answer (Box 5-3). Patients can often
be passive, and their simple answer of “yes” may not
reveal much information and may in fact be mislead-
ing.
■ As mentioned earlier, in the context of attention
and processing deficits intrinsic to psychosis, it is also
important to not ask single questions that cluster
multiple experiences (e.g., “Have you ever felt your
life was in danger or that people were following
you or meaning you harm?” The questions are dif-
ficult to follow for a patient with psychosis, and
the answer will rarely be reflective of the true
experience.
34 Psychiatric Clinical Skills

Table 5-1. Questioning Psychotic Symptoms

Symptoms Examples Questions

“Do you ever get the feeling that:

Delusions Persecutory . . . others mean to harm you/your life is in danger?”
Control . . . some outside force is controlling your actions/thoughts?”
Mind reading . . . others know what you think/you can read others’ minds?”
Grandiosity . . . you have some special skills/have been selected for some special mission?”
Reference . . . things seem to happen because of you?”
. . . people are talking about you?”
Thought insertion . . . you think something and it just didn’t come from you?”
Thought broadcasting . . . your thoughts were being broadcast, on television or radio for example?”
Thought withdrawal . . . your thoughts are taken out of your head by some outside force?”
Somatization . . . something has changed in your body recently?”
Hallucinations Auditory “Do you ever hear things (whispers, sounds, voices) that others don’t
hear, or that you wonder if they are real?”
Quality “Do they come from inside/outside your head? Do you hear them like my
voice now? Do you ever turn to see who spoke? Do they ever answer back?”
Number of voices “Are there one or more voices? Are they recognizable?”
Running commentary “Are the voices are doing a play-by-play on your actions, like in a hockey
game?”
Command “Are the voices telling you what to do?”
Visual “Do you see things other people don’t see and wonder if they are really there?”
Other (e.g., tactile, olfactory, “Do you notice any strange smells, tastes, or sensations on your skin?”
gustatory)
Negative Affective flattening “Have others commented that your facial expression is different (e.g., that
you don’t smile as much)?”
Poverty of speech or content “Do you ever find that you don’t have much to say?”
Apathy (self-care) “Has there been any change in your motivation to do things, or do you
just not feel like it (e.g., showering, going to movies)?”
Anhedonia
Asociality
Interpersonal “Do you still see your friends? Who initiates this?”
Recreational “What did you enjoy doing 5 years ago? Has there been any change in the
level of enjoyment of those things?”
Attention
Cognitive inattention “Has there been any change in your concentration/memory or
distractibility? Can you read a book?”

(Note: Examples are not exhaustive.)

■ The conviction of a belief must be evaluated to confirm
that it meets criteria for a delusion (i.e., a firmly held,
fixed belief that is discordant with cultural norms). If
the conviction is not there, it may suggest an
idiosyncratic overvalued belief, or a prodromal
symptom.
■ “You spoke about being followed everywhere you go.
Have there been times when you questioned whether
this could really be true? Or times when you thought
you were being followed and then you told yourself,
‘But that’s impossible, it doesn’t make sense’? Have
you talked yourself out of believing it? What have you
done about it?”
■ “When you have such a thought, how much do you
believe it, with 100% being that it is the truth and you
are convinced, and 0% being you don’t believe it at
all?”
■ “Do you think that X is happening to you only, or
does it happen to others as well? Why would you be
selected more than anyone else? What is your under-
standing of what is happening?”
■ It can be diagnostically helpful to evaluate the quality
(i.e., content) of the psychotic symptoms. This can help
to drive the rest of your questioning in clarifying the dif-
ferential diagnosis. For example:
■ A mood-congruent delusion can be suggestive of
a mood disorder (e.g., a grandiose delusion in mania,
a nihilistic delusion in depression).
■ Schneiderian symptoms (e.g., audible thoughts,
voices arguing or discussing, voices commenting,
 Assessment of Patients with Psychosis
thought influencing or withdrawal or broadcasting,
delusions) can be suggestive of schizophrenia.
Although they may occur in other illnesses with psy-
chosis, such as mania, these bizarre symptoms are
weighted more heavily in the DSM-IV-TR criteria
for schizophrenia.
■ Catatonia is more often due to a mood disorder than
to a medical disorder or schizophrenia.
■ Explore the evolution of the psychosis phase.
■ Was the onset gradual or abrupt? When did it start?
The duration of symptoms is important for establish-
ing a diagnosis.
■ Are there any triggering factors or precipitants?
Acute stressors?
■ How did it evolve until now?
■ When was the first contact for help, and what was
done?
■ What is the current status? Are symptoms/function-
ing better than before? Worse? The same?
■ What has been the evolution of events and symptoms
predating the onset of psychosis?
■ It can be diagnostically helpful to have a clear time-
line of functioning, symptoms, and changes in these
domains, given their characterization of schizophre-
nia.2 The chronology can be elicited for the following
phases (some components of the early premorbid
personality can be elicited in the personal/develop-
mental history section of Chapter 1).
● Premorbid. It is helpful to have an idea of the
personality at baseline, with a focus on capacity for
interpersonal relations, odd features of personality
(e.g., with respect to interests), behavioral difficul-
ties, etc. A history suggestive of schizoid or schizo-
typal personality may be present before the onset
of full psychosis.
● Prodrome. This refers to the period when some
changes in functioning and mild symptoms have
begun. In this period, patients may have some
psychotic symptoms, but they are of a transient
nature or attenuated intensity (e.g., ideas, not
delusions, of reference). Patients may have new
interests (e.g., philosophy, religion), a change in
their thinking style (e.g., more abstract), percep-
tual changes, and bizarre ideas with abnormal
affect. Prodrome is differentiated from full-
blown psychosis by its attenuated symptoms.
These can be explored with the following ques-
tions:
● “When did you first notice that things seemed
different or not right?”
● “You suggested earlier that you just weren’t
doing well; can you tell me a little bit about
what that means?”
35
● “You mentioned you were having a tough time
with things; can you tell me what impact this
had on your schooling? On your friends? Your
family? How did you deal with that?”
● “Patients have often told me that when they
were feeling stressed, similar to what you have
described, they might start to question things a
lot, for example, whether people were looking at
them differently. Has that been the case for
you? Or, they might start to notice a lot of coin-
cidences or connections between things; for
example, it seems like whenever they cross the
street, the light turns red because of them. Has
something similar happened to you?”
■ What is the current level of functioning, and how is this
a change?
■ “Has there been any change in your sleep/
appetite/energy? What was it like before?”
■ “What is an average day like for you these days?
What do you do? How does this compare to 2 years
ago?”
■ “If I had met you 5 years ago, what would you have
been like compared to today? What would have been
similar/different?” (This can be a high-yield question
for eliciting symptoms and changes in personality,
functioning, interpersonal capacity, etc.)
■ Are there cognitive difficulties?
■ Impairments in concentration, memory, processing,
and executive functioning are common in schizo-
phrenia and important for management. They can
also be more predictive of outcome and functioning
than positive symptoms alone, and thus are impor-
tant to evaluate from the patient’s perspective:
● “Have you noticed a change in your ability to
remember things? Do you forget names? Misplace
objects?”
● “How is your concentration lately? Do you have
difficulty doing two things at once, for example,
watching TV and having a conversation?”
■ Are there safety/risk issues?
■ Self-care
● “How many times do you shower in a week? Is this
a change?”
● “Is there anything that has affected how often you
eat? Has there been a change? Do you ever go for
a few days without eating because you are X? Has
there been any problem with your food?”
■ Activities of daily living (This can also give you an
idea of the patient’s capacity for self-care and his
executive functioning.)
● “How often do you forget to pay the rent? How do
you keep track? Have you had any problems with
your landlord lately?”
36 Psychiatric Clinical Skills
● “Where do you get your groceries? Are there ever
times where you don’t have food for a few days?”
● “How do you keep track of your medications?
What do you do if you forget?”
■ Dangerousness
● “It sounds like you’ve been going through tough
times lately . . .
● “ . . . have you ever felt like giving up?”
● “ . . . have you ever wanted to escape it all by
dying?”
● “ . . . have you made a plan to escape by killing
yourself?”
● “ . . . have you tried to hurt/kill yourself?”
● “ . . . have you taken any steps to prepare (e.g.,
buying a gun or rope)?”
● “You’ve spoken a lot about being followed and feel-
ing your life is in danger. What steps have you
taken to protect yourself? What weapons do you
have access to?”
● “What would you do if you ever found out the
identity of the people responsible for spreading
these rumors? Have you made any attempt to con-
tact them? To hurt them? Have you had thoughts
or fantasies of killing them?”
Key Point:
Note that in clinical interviewing, it is often more efficient
to start with an assumption, for example, “What steps have
you taken to protect yourself?” versus “Have you taken
steps . . . ?” the latter of which permits them to answer “no”
easily. This is important in other sensitive areas of
questioning, such as substance use. It is best to start with
an assumption that they do use.
Box 5-3. Steps for Questioning
■ Start broad →”You mentioned earlier you have been having
trouble getting along with others. Can you tell me more
about that?” Or, if the patient has not endorsed this, you
can simply start by asking, “How have you been getting
along with others lately? Any conflicts with
work/friends/landlord?”
■ Use the patient’s example and get more specific → “Sometimes
when people experience difficulty getting along with others,
trust becomes an issue. Has that ever been the case for you?”
■ Question in a more detailed way → “For example, you might
start to feel that your friends do not have your best intentions
at heart, and that they are out to get you. Have you felt like
that?” Or, “When you walk in a hallway, you may feel that
people are talking about you behind your back, making a plan
to hurt you. Has that ever crossed your mind?”
You have now set the ground to question different elements of a
persecutory delusion, having eased the patient into it.
■ Are there any comorbid conditions?
■ Part of evaluation and management is evaluating
what other diagnostic entities may contribute to the
current state.
■ Patients with schizophrenia have a high rate of
comorbidity with certain illnesses such as depression
(which can be concurrent or secondary) and anxiety
disorders (including social phobia and obsessive-
compulsive disorder, which have had comorbid
prevalence rates as high as 46% reported).3 A screen-
ing of these disorders should be done. In fact, in
examining the criteria for major depression, you can
see that they cover crucial components (sleep,
energy, appetite, concentration, suicidality, etc.) and
should always be questioned, irrespective of the
diagnosis.
The Differential Diagnosis of Psychosis
The goal of collecting detailed information is to confirm
the presence of psychosis and to arrive at a provisional diag-
nosis with a differential. Based on the criteria for each
diagnosis (refer to the DSM-IV for the diagnostic criteria
and to Chapters 6 and 7 on mood disorders), the following
specific items and questions can help differentiate certain
diagnoses.
Schizophrenia
It is helpful to note that, whereas two or more psychotic
symptoms are required during the majority of 1 month to
make a diagnosis, only one criterion is required if the delu-
sions are bizarre or the hallucinations are Schneiderian-like
(i.e., running commentary or more than two voices con-
versing with each other).
Schizophreniform Disorder
This disorder is differentiated from schizophrenia only
by its duration criterion; an episode lasts between 1 and
6 months, including the prodromal, active, and residual
phase.
Bipolar Disorder, Severe, with Psychotic Features
■ You should be aware that a number of studies have sug-
gested that adolescent boys with a first episode of mania
tend to have prominent psychotic symptoms. These,
combined with symptoms of psychomotor agitation,
grandiosity, disorganization, and decreased sleep, are
also seen in schizophrenia and can thus obscure the
diagnostic picture.
■ It is important to evaluate the quality of the psychotic
symptoms. A mood-congruent delusion of grandiosity
(particularly in the absence of any other psychotic symp-
toms) may lend more support to a diagnosis of mania.