What interview questions are appropriate for an adult patient with a diagnosis of schizophrenia or other psychotic disorder, considering their past medical history, demographic information, and current treatment plan, including medications such as risperidone (generic name: risperidone) or olanzapine (generic name: olanzapine)?

Interview Questions for Psychotic Patients

Essential Diagnostic Interview Framework

When interviewing adult patients with schizophrenia or other psychotic disorders, structure your assessment to establish symptom duration, type, number, and combinations required for diagnosis, while elucidating the pattern of symptom development and course of illness. 1

Core Psychotic Symptom Assessment

Ask specific questions about hallucinations and delusions, as these psychotic features are required to make the diagnosis: 1

• Hallucinations: "Do you hear voices when no one is around? What do they say? Do they comment on your actions or talk to each other about you?" 1
• Delusions: "Do you have any beliefs that others find unusual? Do you feel people are watching you or trying to harm you? Do you have special powers or abilities?" 1
• Thought disorder: "Do your thoughts ever feel jumbled or disconnected? Do you have trouble organizing your thoughts when speaking?" 1
• Disorganized behavior: "Have others noticed changes in how you take care of yourself or complete daily tasks?" 1
• Negative symptoms: "Have you noticed less interest in activities? Less emotional expression? Difficulty starting or completing tasks?" 1

Critical Temporal and Duration Questions

Establish the 6-month duration criterion, including at least 1 month of active symptoms, as this distinguishes schizophrenia from brief psychotic episodes: 2

• "When did you first notice these symptoms?" 1
• "Have these symptoms been present continuously for at least 6 months?" 2
• "During the past month, how many days have you experienced these symptoms?" 2
• "Do the symptoms come and go, or are they constant?" 1

Mood Episode Relationship (Critical Differential)

The single most critical diagnostic step is determining when psychotic symptoms occur relative to mood episodes through longitudinal assessment: 2

• "Have you experienced periods of extremely elevated mood, increased energy, or severe depression?" 2
• "When you have these mood changes, do the voices or unusual beliefs get worse, better, or stay the same?" 2
• "Do the voices or unusual beliefs ever occur when your mood is normal?" 2
• "How long do the psychotic symptoms last compared to mood episodes?" 2

Functional Impairment Assessment

Document marked deterioration in functioning below previous levels, as this is required for diagnosis: 2

• "Before these symptoms started, what was your highest level of functioning in work or school?" 1
• "How has your ability to work, attend school, or maintain relationships changed?" 2
• "Can you complete self-care activities like bathing, eating, and managing finances?" 1
• "Compare your current functioning to one year ago—what specific activities have become difficult?" 2

Medical and Substance-Induced Causes (Rule-Out Questions)

All patients with psychotic symptoms must receive evaluation to rule out organic psychosis before assuming a primary psychiatric disorder, as medical causes are found in approximately 20% of patients with acute psychosis: 2

Substance Use History

• "What substances do you use, including alcohol, cannabis, stimulants, or prescription medications?" 3
• "When did you last use cannabis or other substances? What dose and frequency?" 3
• "Did the psychotic symptoms start during or within one month of substance use?" 3
• "Have symptoms improved when you stopped using substances?" 3

Medical Conditions

• "Have you had any recent infections, particularly urinary tract infections or pneumonia?" 1
• "Do you have any history of head injury, seizures, or neurological problems?" 2
• "Have you experienced recent changes in memory, attention, or level of alertness?" 1
• "Do you have thyroid problems, vitamin deficiencies, or autoimmune diseases?" 2, 4

Delirium Screening (Critical Safety Issue)

Distinguish delirium from primary psychosis, as delirium is a disturbance of impaired attention with waxing and waning course, while psychotic patients typically have intact awareness and level of consciousness: 1

• "Does your confusion or unusual experiences come and go throughout the day?" 1
• "Have you had difficulty paying attention or staying focused?" 1
• "When did these symptoms start—suddenly over hours/days or gradually over weeks/months?" 1

Suicide and Safety Assessment

The risk of suicide or accidental death directly due to behaviors caused by psychotic thinking is at least 5%, with adult schizophrenia carrying approximately 10% lifetime suicide risk: 1

• "Do the voices tell you to hurt yourself or others?" 1
• "Have you had thoughts of ending your life?" 1
• "Do your beliefs make you feel you need to protect yourself from others?" 1
• "Have you acted on any commands from voices or beliefs?" 1

Family Psychiatric History

Review family psychiatric history, focusing on psychotic illnesses, mood disorders, and schizoaffective disorder in relatives: 2

• "Has anyone in your family been diagnosed with schizophrenia, bipolar disorder, or severe depression?" 2
• "Have family members been hospitalized for psychiatric reasons?" 2
• "Has anyone in your family experienced similar symptoms to yours?" 2

Premorbid Functioning and Developmental History

Most patients with early-onset schizophrenia have significant premorbid developmental and/or personality abnormalities, though these are neither necessary nor sufficient for diagnosis: 1

• "How were you doing socially and academically before these symptoms started?" 1
• "Did you have friends growing up? How were your relationships?" 1
• "Were there any developmental delays or learning difficulties?" 1

Current Treatment and Medication History

For patients already on antipsychotics like risperidone or olanzapine, assess treatment response and adherence: 1, 5, 6

• "How long have you been taking your current medication?" 1
• "Have you noticed improvement in specific symptoms since starting medication?" 1
• "Do you take your medication as prescribed every day?" 1
• "What side effects have you experienced?" 1
• "Have you tried other antipsychotic medications before? What was your response?" 1

Structured Interview Tools

Structured interviews, symptom scales, and diagnostic decision trees may serve as important aids to ensure reliability and veracity of diagnosis: 1

• Consider using the Positive and Negative Syndrome Scale (PANSS) for comprehensive symptom assessment 1
• The Brief Psychiatric Rating Scale (BPRS) psychosis cluster is particularly useful for assessing actively psychotic patients 5
• Clinical Global Impression (CGI) provides overall clinical state assessment 5

Common Diagnostic Pitfalls to Address

Misdiagnosis is a common problem, especially at the time of onset, requiring periodic diagnostic reassessments: 1, 2

• Cultural context: Ask "Are these beliefs consistent with your cultural or religious background?" to avoid misinterpreting culturally normative experiences as psychotic 2
• Developmental considerations: In younger patients, distinguish true psychotic symptoms from idiosyncratic thinking due to developmental delays or overactive imagination 1
• Clinician bias: Be aware that African-American patients are more likely to be misdiagnosed with psychotic conditions and less likely to receive mood disorder diagnoses 2

Longitudinal Follow-Up Questions

Patients must be followed longitudinally with periodic diagnostic reassessments to ensure accuracy: 1

• "Have your symptoms changed in type or severity over time?" 1
• "Have there been periods when symptoms completely resolved?" 1
• "What triggers make symptoms worse or better?" 1