Clinical Diagnosis and Assessment 97
years with the Air Force; his stories often involved his heroic actions that saved others
(such as fi xing a broken sluicegate at Hoover Dam or safely landing a plane after an
engine failed). According to Jeannette, “Dad always fought harder, fl ew faster, and
gambled smarter than everyone else in his stories. Along the way, he rescued women
and children and even men who weren’t as strong and clever” (Walls, 2005, p. 24). A
clinical assessment could help determine the extent to which Rex’s stories were merely
embellishments to make him look good or were delusions. It can be useful to obtain
information from family, friends, or other people who are in a position to confi rm or
modify a patient’s report in order to distinguish delusions from embellishments.
Here’s an example of how simply asking patients about themselves during clini-cal interviews may not always lead to an accurate picture of their psychological
functioning, despite their honesty. One of the authors of this book (Rosenberg)
once worked in a hospital emergency room, evaluating people who came to the
emergency room for psychiatric reasons. One day, she was asked to interview a
man in his 30s who was dressed appropriately and spoke somewhat slowly. He had
a history of schizophrenia and depression, and his psychiatrist was affi liated with
the hospital. The patient reported that he came to the hospital because his mother
wanted him to come (in fact, she drove him there), but he wasn’t exactly sure why.
He said that he wasn’t hearing voices, and he didn’t feel sad, depressed, or suicidal.
In response to questions, his mental processes and mental contents seemed normal.
Rosenberg telephoned his psychiatrist, who was puzzled about why the patient had
come to the emergency room. The psychiatrist could shed no light on the matter; he
had an appointment scheduled with the patient the following week, but he did not
know why the patient’s mother brought him to the hospital.
Rosenberg asked the patient’s permission to speak with his mother; he consented.The mother, a woman in her 60s, reported that she thought her son had been more
depressed lately. She went on to explain that for the last month he hadn’t gotten out
of bed unless he had a doctor’s appointment. On those days, she harangued him until
he bathed, groomed himself, and put on appropriate clothes (as she had also done
the day he came to the emergency room). The other days he stayed in bed in his pa-
jamas. When Rosenberg spoke to the psychiatrist, he had not known that his patient
was depressed, or that the only reason the patient was appropriately dressed and
groomed for appointments was because of his mother’s insistence. When Rosenberg
then spoke with the patient again, explaining what the mother had said, he admitted
that he had a hard time getting out of bed, and didn’t have much energy or interest in
things, although he didn’t feel depressed. He agreed that it made sense for him (and
his mother) to be interviewed by staff in the inpatient psychiatric unit to determine
whether he should be hospitalized; Rosenberg did not see him again, but later found
out that he in fact had been hospitalized for depression.
This experience brings home the limitations of relying solely on people’s self-reports of their emotional states (Achenbach et al., 2005; Meyer, 2002). This pa-
tient said that he didn’t feel depressed, but key aspects of his behavior at home,
in particular, his diffi culty getting out of bed and his lack of energy or interest in
previously interesting activities, were clear symptoms of depression. But because the
patient didn’t realize that these behaviors were a problem, he didn’t report that he
was having those symptoms. Thus, although a patient’s self-report is important, it
has limitations. Similarly, when interviewing children, the clinician must be sensitive
to the fact that they may lack adequate insight and/or the verbal ability to be reli-
able reporters of their mental health status.
Semistructured Interviews
Because clinicians sometimes want to be sure to cover specifi c ground with their
questions, they may use a semistructured interview format, asking a list of stan-
dard questions but formulating their own follow-up questions. The follow-up
questions are based on patients’ responses to the standard questions. One set
of questions that assesses a patient’s mental state at the time of the interview is
themental status exam. In a mental status exam, the clinician asks the patient to
Some problematic behaviors may be obvious to a
mental health professional while interacting with a
patient. Other behaviors, which occur infrequently
or only in specifi c types of environments, such as
avoiding stepping on cracks (which some people
with obsessive compulsive disorder do) are less
likely to be observed. If the patient doesn’t view
these behaviors as a problem, he or she may not
report them.Creatas/Punchstock