It’s not unusual that patients we interview minimize or deny information that is unpleasant for them to share. Also, it is not unusual that they try to distract you or move you away from pursuing this sensitive information. Let me give you a recent example and explanation.

At our recent Child Adolescent Psychiatry Oral Board prep course, one candidate interviewed a 14 year old girl. When asked about her chief complaint / presenting problem, she said, “My parents had me attend an alcohol treatment group after they caught me drinking with friends back in June. But that’s all over now. I’m fine.”

The interviewing doctor generally conducted a good interview that ranged over all the important aspects of psychiatric, medical, family and personal histories. But he had a fatal flaw to his interview: he bought into the patient’s minimization of her alcohol consumption and consequent problems. In fact, at first he didn’t even include alcohol dependence or abuse in his differential.

Before discussing the particulars of this case, I want to exaplain the nature of minimization and / or denial. To infer that someone is minimizing or denying something, we have to believe that we know the truth of the matter. When interviewing a patient in our practice, we can compare the patient’s self-report to that of the information gathered through medical charts and other informers. When we characterize a patient’s description as one or denial or minimization, that means that we have found a descrepancy between self-report and others’ reports and we have greater faith in the information provided by the collateral sources than we do in the self-report. We understand that sometimes the person reporting about him or herself says things in a way to make themselves look better or have fewer problems than in reality they do. This is true of humans in general and is not a quirk of people in psychiatric treatment.

But on the board exam, you have NO access to other sources of information. So, how can you even consider the possibility of denial or minimization when there are no other sources of information to compare to? The answer is that the only way you can do so is by finding inconsistencies within the patient’s self-report.

To be a good psychiatrist, you must act like Sherlock Holmes – be a detective searching for clues buried inside the patient’s interview that will shed light on the truth of the situation. The best way to do so is to particularly focus on inconsistencies – inconsistencies between one thing the patient says and another, and between what the patient says and the emotions surrounding the topic, and between what the patient says and the consequences of that, or lack thereof, on the patient’s behavior.

So, what clues did this particular doctor miss that suggest that this 14 year old girl was minimizing the nature and degree of her alcohol use?

One, at one point in the interview she reported that she and her friends drank ‘rum and coke.’ At another point in the interview, separated by several minutes, the patient reported that she was caught by her mother who ‘found empty bottles in my room.’ When I asked the interviewing psychiatrist, he said he thought the patient may have tried alcohol once or twice with her friends, as teens are wont to do, and was then caught by mom and the problem was then quickly resolved.

I pointed out to him that the patient was drinking rum (with cola) and that her mother had found ‘empty bottles’ in her room. Note that ‘bottles’ is in the plural, thus making it clear it was at least two bottles. Now, two (at least) empty bottles of rum found in a 14 year old’s room gives a picture of perhaps a more serious problem than does, ‘I was caught drinking with friends.’

Two, the patient also reported that she started the alcohol treatment program in June and that she ended the program ‘last month.’ Since she was interviewed in November, that means her treatment lasted from June to October. Hmmm. Alcohol treatment for five months sounds like overkill if the patient’s parents believed that the patient’s drinking was simply a teen harmlessly experimenting with alocohol, as most teens in the US do. (The Monitoring The Future Study 2006 of drug use among US teens found that 73% had used alcohol at some point by 12th grade.) No, the parents and the treatment team must have considered the patient’s alcohol use to be rather more serious than that.

You may be thinking at this point, “Sure this sounds suspicious, but how much drinking did the patient actually do?” The answer is, “we don’t know because the psychiatrist never nailed that down.” He was lulled into seeing it as (evidently) a minor problem and didn’t proceed to quantify the alcohol use. And why do I assume it was a more serious problem? In addition to the two clues above, afterward another course faculty member asked me, “Did you interview in your room the 14 year old girl with alcoholism?” Evidently we did – we just didn’t know it.

Today’s Quote

“It is easy to hate and it is difficult to love. This is how the whole scheme of things works. All good things are difficult to achieve; and bad things are very easy to get.” – Confucius

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