A Gentle Way of Raising the Topic of Psychosis in an Initial Interview

Mar 08, 2017

“Nobody knows what is going on inside a marriage except for the people in it. Even to them, it is sometimes a mystery.”

David Corn
Television commentator

A Gentle Way of Raising the Topic of Psychosis in an Initial Interview

TISA Description of the Problem: In all initial interviews, even when there is no evidence of psychosis, it is still important to explore for psychotic process. For one reason, it can be quietly hiding under surprisingly normal affect and presentation as can be seen with the early emergence of psychosis in disorders such as schizophrenia or a serious mood disorder. In addition psychotic process is easily missed in delusional disorders in which the only psychotic process may be the pervasive underlying delusion as seen with delusional erotomanic stalkers. Such patients may not have any other psychotic processes such as hallucinations, loosening of associations, cognitive difficulties or abnormal affect. Much more commonly, micropsychotic episodes lasting minutes to hours can be seen with people coping with complex personality disorders such as borderline personality disorder, schizotypal personality disorder, and paranoid personality disorder. Even clients presenting with narcissistic and histrionic personality disorders may experience such micropsychotic episodes when heavily stressed. Seldom do such clients present while actively experiencing their micropsychotic episodes, and the only way to uncover their historical existence is to explore for it. The following excellent tip from Kris Jenkins, LCSW, CSAC demonstrates an excellent way of raising the topic of psychosis in a gentle fashion that is not disengaging.

Tip: I find that the following question seldom disrupts my alliance with patients, while providing a way for me to raise the topic of psychosis in a patient, who has no outward appearance of being psychotic:

“Do you ever see or hear things that other people do not see or hear?”

TISA Follow-up: One of the powers of this clinical interviewing tip from Kris is the simplicity of its approach, in which the subject of psychotic process is being raised yet it allows a little “wiggle room” for the client. Almost everyone has, at times, picked up on a real sound or movement that others may have missed because of inattention, consequently there are different ways to interpret this question. It is not necessarily viewed as “the crazy question”.

Another way of softening the question can be achieved by adding the interviewing technique known as “normalization” (Shea, 1998) as with: “When people are being as stressed as you have been describing and getting really poor sleep night after night, the stress can be so intense that their minds play tricks on them and they feel like they are seeing or hearing things other people are not seeing or hearing, has that ever happened to you?”

Shea, SC (1998) Psychiatric Interviewing: the Art of Understanding, 2nd Edition,
W.B. Saunders, Inc., Philadelphia.

Tip provided by:

Kris Jenkins, LCSW, CSAC