CLINICAL HANDBOOK OF SCHIZOPHRENIA

122 II. ASSESSMENT AND DIAGNOSIScircumstantiality, and thought blocking). Although delusions may at times be readily assessedbecause of the interviewee’s preoccupation with the theme or idea, at other timesengagement in lengthier discussions is required before the interviewee begins to revealmuch about his or her delusional ideas. In addition, observing the interviewee’s behaviorand affective expressivity during the interview can help the interviewer detect symptomssuch as constricted or inappropriate affect. Finally, the interviewer may ask him- or herselfwhether he or she is losing track of the point the interviewee is trying to make, whichcan serve as a useful cue to consideration of different symptoms, such as tangentialspeech or derailing.Guideline 5: Symptoms Getting in the WayDuring some interviews, the characteristic symptoms of schizophrenia make it difficult tosecure sufficient and sound information, for example, when the interviewee is activelyhallucinating or delusional; displaying disorganized thought or behavior; and presentingsevere negative symptoms, cognitive impairments, or comorbid symptoms such as anxiety.Common effects of these symptoms and impairments are distractions that disrupt theflow of the interview and hinder collaboration.There are various ways to address such disruptions. One way is to break up the interviewinto smaller parts to accommodate the person’s short attention span. This can involvetaking more frequent rest breaks or conducting the interview over a few days. Thisapproach can also be used within the interview by breaking questions down into smallerones, so that the person can more easily retain and process them. Finally, it is also oftenuseful to explain the benefits of the interview and provide token rewards, so that the personparticipates as fully as possible in the interview.Guideline 6: Beyond Isolated Symptoms:The Importance of the ContextAnother challenge may be a lack of sufficient information on the personal or culturalcontext within which the diagnostic information may be meaningfully understood. Thismay occur in transcultural situations, in which the interviewer is not versed in the interviewee’slanguage and culture. Because the interviewer functions as a yardstick to somedegree to evaluate the interviewee’s beliefs, it is imperative that he or she be familiar with,or at least be sure to assess, the interviewee’s general and health beliefs in relation tothose of the culture to which the person belongs.To understand the personal context it is useful to explore how symptoms relate tovarious domains of a person’s life. To gather such information, it is important that theinterviewer ask about a range of other contexts, including work, living, leisure, and socialrelationships, to try to identify the often complex mutual influences between thesecontexts and symptoms. Another important aspect of the context is its longitudinalcourse (e.g., time of onset of the first psychotic episode), which may have an impact onthe developmental abilities of the interviewee (e.g., educational level and interpersonalexperiences). The interviewer should also be sensitive to paranoia or to a traumatic historyon the part of the interviewee that may disrupt the interview, and use appropriatecommunication skills to build trust. For instance, the interviewer should fully disclosethe possible risks and expected benefits of the interview, give the interviewee as muchcontrol as possible over the interview (e.g., by asking open-ended questions and invitingthe person to tell his or her life story), use empathic verbalizations, and more. Lastbut not least, the interviewer should be sensitive to the interviewee’s cultural (and spiri-