Essential Concepts
Uttering a word is like striking a note on the keyboard of the imagination.
Ludwig Wittgenstein
Throughout the diagnostic interview, your patient’s memory will be both your ally and your enemy. Even when the desired information is not threatening in any way, be prepared for major inaccuracies and frustration if the events described occurred more than a few months ago. Nonetheless, we’ve all had the in-training experience of watching an excellent teacher elicit large quantities of historical information from a patient for whom we could barely determine age and sex. How do they do it? Here are some tricks of the trade.
Researchers have found that most people forget dates of events that occurred more than 10 days in the past (Azar 1997). Instead, we remember the distant past in relation to memorable events or periods (Bradburn 2004), such as major transitions (graduations and birthdays), holidays, accidents or illnesses, major purchases (a house or a car), seasonal events (“hurricane Katrina”), or public events (such as 9/11 or President Obama’s election).
As an example, suppose you are interviewing a young woman with depression. You find out over the course of the interview that she has a heavy drinking history, and you want to determine which came first, the alcoholism or the depression. You could ask, “How many years ago did you begin drinking?” followed by “How many years ago did you become depressed?” but chances are you won’t get an accurate answer to either question. Instead, use the anchoring technique:
Interviewer: Did you drink when you graduated from high school?
Patient: I was drinking a lot back then, every weekend at least. Graduation week was one big party.
Interviewer: Were you depressed then, too?
Patient: I think so.
Interviewer: How about when you first started high school? Were you drinking then?
Patient: Oh no, I didn't really start drinking until I hooked up with my best friend toward the end of my freshman year.
Interviewer: Were you depressed when you started school?
Patient: Oh yeah, I could barely get up in time to make it to classes, I was so down.
You’ve succeeded in establishing that her depression predated her alcoholism, which may have important implications for treatment.
In Chapter 8, you’ll learn about the value of multiple-choice questions in limiting overly talkative patients. Tagging with examples is similar to posing multiple-choice questions, but it is used specifically for areas in which your patient is having trouble with recall. You simply tag a list of examples onto the end of your question.
To ascertain what medications your patient has taken in the past for depression, for example:
Interviewer: What were the names of the medications you took back then?
Patient: Who knows? I really don’t remember.
Interviewer: Was it Prozac, Paxil, Zoloft, Elavil, Pamelor?
Patient: Pamelor, I think. It gave me a really dry mouth.
Sometimes, what appears to be a patient’s vague recall is actually a lack of understanding of terms. For example, suppose you are interviewing a 40-year-old man with depression, and you want to determine when he had his first episode:
Interviewer: How old were you when you first remember feeling depressed?
Patient: I don’t know. I’ve always been depressed.
You suspect that you and the patient have different meanings of depression, and you alter your approach:
Interviewer: Just to clarify: I’m not talking about the kind of sadness that we all experience from time to time. I’m trying to understand when you first felt what we call a clinical depression, and by that I mean that you were so down that it seriously affected your functioning, so that, for example, it might have interfered with your sleep, your appetite, and your ability to concentrate. When do you remember first experiencing something that severe?
Patient: Oh, that just started a month ago.