“Biggie” Assessing a Deceptive Patient in a “Gated” Simulated Patient Interview

Abstract

The simulated patient encounter represents a promising method of experiential learning with a unique capability to both assess and teach interviewing skills in an encounter with a deceptive patient. The format of a “gated” interview, containing a series of clinical challenges, facilitates the standardized assessment of interviewer performance. Detailed rating criteria facilitate the production of quantitative data regarding specific competencies, such as response to affect, identification of omissions and distortions in the patient narrative, and interpersonal warmth.

A cohort of 17 psychiatric residents participated in a simulated patient encounter depicting a homeless young man presenting with malingered psychotic symptoms in a setting of complex trauma history and associated psychopathology. The interviewer cohort displayed a high (0.78 out of a possible 100) level of competency in conducting a basic information-based interview, but significantly lower levels of competency in confrontation (56), empathy/relatedness (50), and response to affect (38). Contrary to expectation, we found a strong correlation between empathy/relatedness and effective confrontation of the patient’s nondisclosure (R = 0.64, p = 0.006) and interviewer response to affect (R = 0.54, p = 0.025) during the interview. We found no correlation between interviewer effectiveness with in-service testing scores (R = −0.01, p = 0.724) or available clinical skills verification data.

This pilot program represents an effort to render what is often considered the “art” of psychiatric interviewing into discrete competencies which can be defined, measured, and taught. Our finding that a variety of disparate skills covary in small population, independent of training level, suggests that advanced interviewing ability reflects an underlying capacity for interpersonal perception and engagement, perhaps more succinctly defined as “talent,” which some interviewers possess and others do not. If valid, our finding that “non-talented” residents tend neither to be identified nor correctively engaged is a subject for concern and further study.

Appendices

Appendix I Definitions of Selected Terms

Therapeutic Relationship

A relationship between clinician and patient characterized by a commitment to understand and help on the clinician’s part; confidence on the in the clinician’s capacity to do this on the patient’s part, and governed by an deepening sense of shared purpose as the relationship evolves.

Response to Breakthrough Affect

Positive rating: Behavior on the part of the interviewer in response to the subject’s emotional display, including direct commentary on patient’s emotional state and changes in the direction of questioning, which prioritizes observation and response to the subject’s emotional state over factual content of the material. Represents modification of the interview in response to “empathy”

• For example, “you seem sad when you say that.”

• “You’re crying – where are your tears coming from?”

• “You’re saying your dad died – but you’re smiling a little when you say that.”

Negative rating: Behavior on the part of the interviewer that reflects lack of interest or obliviousness to patient’s emotional display.

• For example, patient becomes despondent and states “that’s my life” in a forlorn tone of voice → interviewer responds with a question about domicile status.

Rapport

An ability to develop a deepening relationship with the patient, as manifest by increased elaboration of data, shared understanding, humor or other evidence of shared and mutual experience, over the course of the interview.

Positive case:

• Interviewer reuses the terms by which the patient describes their experience, and conveys a grasp of the patient’s material that makes it clear that the interviewer is listening.

• Interviewer displays evidence of collaboration in eliciting patient’s narrative.

• Patient appears to enjoy or gain satisfaction from the interaction, and shows a desire to share further information.

Empathy

Direct or indirect acknowledgment of patient’s emotional state, including the interviewer’s statements, modification of the interview, or “affective mirroring,” including changes of vocal tone and pitch by interviewer.

Positive case: Interviewer aware of and sensitive to patient’s emotional state, as evidenced by

• “Affect matching”—for example, changes in interviewer’s tone of voice, posture, facial expression, in response to patients’ inferred emotional state (e.g., sadness, humor, and anxiety).

• Modification in interview style—for example, slowing down or decreasing specificity of questioning, asking patient if it is ok to continue.

• Questions or comments that show interest and concern about the patient’s emotional state.

  • “That must have been hard for you.”

  • “I can see this isn’t easy for you to talk about – but it would really help me understand if you can answer a few more questions.”

Negative Case Examples

• Interviewer seems bored and pursues an interview template.

• Subject is obviously upset, interviewer pursues specific details of the incident without modification or apparent awareness of the patient’s distress.

• Subject discusses sensitive material showing no emotion, interviewer records factual data but doesn’t attempt to elicit information about the patient’s emotional state.

Confrontation

Positive case: Presentation to the subject by the interviewer of comments, observations, or information (known/unknown to subject prior to that point) which significantly modifies or contradicts a patient’s account (does not necessarily imply an emotionally heated or aggressive tone).

• “You said that you took about 8 pills in the overdose, but the record says you took 68.”

• “You say you and your daughter have a close relationship, but you sound pretty angry at her.”

• “You say things are great, but I understand everyone in your family is pretty worried about you.”

Negative case: Interviewer fails to pursue contradictions during the interview.

• Patient states he never saw a psychiatrist. Interviewer has record of prior admission but doesn’t comment.

• Patient with history of repeated aggressive behavior states he was “just minding his own business” when someone else assaulted him → interviewer does not respond.

• Clarification/follows up hints: Pursuit of details and resolution of miscommunications or points of misunderstanding between the interviewer and subject.

• “How old were you when that happened?”

• “I thought you were discharged yesterday, but now it sounds like you’re talking about something that happened two months ago.”

• “Can you tell me more about that?”

Negative case: Interviewer passively takes down subject’s account with no attempt to sharpen understanding.

• Persistent clarification: Pursuit of relevant details in the face of sustained (>2) acts of evasion or non-clarity on the part of the patient.

• Warmth: Positive case: Conveys kindness, concern, and a sense of genuine personal interest in the patient’s well-being.

• Often a non-verbal quality, conveyed through empathetic vocal tone, timing of questions.

• Verbal or non-verbal disclosure of actual personal feelings (or at times information).

• Frequently reflected in feedback that validates subjects’ emotions or experience.

Negative case: Interviewer is overly formal, nervous, self-satisfied, appears to judge patient or not be interested.

Sympathetic framing: Re-statement of patients’ distressed or self-denigrating comments in a fashion that suggests compassion or respect on the part of the interviewer, and dignity on the part of the patient.

Natural Conversational Style

Patterns of speech that by tone, pitch, pacing, avoidance of technical terms and responsiveness to the other participant, invite an experience of unselfconscious engagement with the interviewer. Avoidance of “template” questioning or distancing commentary (e.g., “I’m sorry, but I have to ask you whether…”).

Hope

“Affirmative comments which directly or indirectly convey a sense that the patient is capable of growth or positive change.”

Appendix II: Correlation by Training Year

Mean Performance Scores by Training Year

		Empathy & relatedness mean	Basic interviewing mean	Confronting non-disclosure mean	Breakthrough affect mean	PRITE score mean
Training year	2	18.40	33.0	3.00	2.20	495
	3	18.00	31.4	2.81	1.81	455
	4	14.88	32.8	2.63	1.50	419

Second Training Year Versus Third Training Year

		Levene’s test for equality of variances					t-test for equality of means		95% confidence interval of the difference
		F	Sig.	t	df	Sig. (2-tailed)	Mean difference	Std. error difference	Lower	Upper
Empathy & relatedness	Equal variances assumed	0.002	0.963	0.122	11	0.905	0.40000	3.28031	−6.81992	7.61992
	Equal variances not assumed			0.124	9.089	0.904	0.40000	3.22728	−6.88978	7.68978
Confronting non-disclosure	Equal variances assumed	024	0.879	0.261	11	0.799	0.18750	0.71842	−1.39372	1.76872
	Equal variances not assumed			0.260	8.508	0.801	0.18750	0.72171	−1.45962	1.83462
Basic interviewing	Equal variances assumed	3.229	0.100	0.680	11	0.511	1.5625	2.2979	−3.4951	6.6201
	Equal variances not assumed			0.810	10.119	0.437	1.5625	1.9292	−2.7292	5.8542
Breakthrough affect	Equal variances assumed	1.469	0.251	0.472	11	0.646	0.38750	0.82019	−1.41773	2.19273
	Equal variances not assumed			0.446	7.153	0.669	0.38750	0.86817	−1.65656	2.43156
PRITE score	Equal variances assumed	0.929	0.356	0.682	11	0.509	39.475	57.879	−87.916	166.866
	Equal variances not assumed			0.634	6.768	0.547	39.475	62.297	−108.863	187.813

Second Training Year Versus Fourth Training Year

		Levene’s test for equality of variances					t-test for equality of means		96% confidence interval of the difference
		F	Sig.	t	df	Sig. (2-tailed)	Mean difference	Std. error difference	Lower	Upper
Empathy & relatedness	Equal variances assumed	0.109	0.751	0.985	7	0.358	3.52500	3.58019	−4.94081	11.99081
	Equal variances not assumed			0.995	6.791	0.354	3.52500	3.54386	−4.90759	11.95759
Confronting non-disclosure	Equal variances assumed	0.023	0.884	0.442	7	0.672	0.37500	0.84805	−1.63033	2.38033
	Equal variances not assumed			0.443	6.628	0.672	0.37500	0.84595	−1.64835	2.39835
Basic interviewing	Equal variances assumed	0.119	0.740	0.163	7	0.875	0.2500	1.5370	−3.3845	3.8845
	Equal variances not assumed			0.158	5.639	0.880	0.2500	1.5851	−3.6895	4.1895
Breakthrough affect	Equal variances assumed	6.256	0.041	0.743	7	0.482	0.70000	0.94188	−1.52720	2.92720
	Equal variances not assumed			0.788	6.658	0.458	0.70000	0.88882	−1.42379	2.82379
PRITE score	Equal variances assumed	2.130	0.188	1.090	7	0.312	75.350	69.154	−88.172	238.872
	Equal variances not assumed			1.153	6.703	0.289	75.350	65.377	−80.641	231.341

Third Training Year Versus Fourth Training Year

		Levene’s test for equality of variances					t-test for equality of means		95% confidence interval of the difference
		F	Sig.	t	df	Sig. (2-tailed)	Mean difference	Std. error difference	Lower	Upper
Empathy & relatedness	Equal variances assumed	0.059	0.812	0.902	10	0.388	3.12500	3.46512	−4.59576	10.84576
	Equal variances not assumed			0.951	7.011	0.373	3.12500	3.28699	−4.64499	10.89499
Confronting non-disclosure	Equal variances assumed	0.000	1.000	0.245	10	0.812	0.18750	0.76623	−1.51977	1.89477
	Equal variances not assumed			0.245	6.105	0.815	0.18750	0.76583	−1.67863	2.05363
Basic interviewing	Equal variances assumed	1.856	0.203	−0.502	10	0.627	−1.3125	2.6158	−7.1409	4.5159
	Equal variances not assumed			−0.613	9.784	0.554	−1.3125	2.1411	−6.0975	3.4725
Breakthrough affect	Equal variances assumed	0.421	0.531	0.417	10	0.685	0.31250	0.74922	−1.35686	1.98186
	Equal variances not assumed			0.459	7.860	0.659	0.31250	0.68098	−1.26271	1.88771
PRITE score	Equal variances assumed	660	0.435	0.689	10	0.506	35.875	52.061	−80.124	151.874
	Equal variances not assumed			0.735	7.245	0.485	35.875	48.787	−78.704	150.454

Appendix: III—Biggie Scenario Documents

Background Information for Standardized Patient

Introduction

A small-time hustler, Raquan Smith or “Biggie” has manufactured a false history of auditory hallucinations in order to get himself admitted to the hospital, after he fended off a group of juvenile gang bangers who tried to rob him, and now want to kill him, due to the humiliation they suffered at his hands when he fought them off.

Unknown to himself, Biggie suffers from a pervasive compensated depression, post-traumatic hypervigilance, and psychosocial problems which have left him uneducated and homeless. He was raised by his grandmother, and suffered a catastrophic loss when she died when he was 9, which precipitated a suicide attempt and psychiatric hospitalization (see records below).

In spite of these problems, and his intense underlying rage, there’s something irrepressible about Biggie—and he’s right when he says most people like him. He’s funny, extroverted, and despite his lack of education and potty mouth, highly observant and intelligent.

But Biggie has also reaching a breaking point—he was sexually abused in residential, has been repeatedly robbed since he’s been living on the streets. He lives with a fair amount of self-directed hatred, but this is boiling and anger, leading to the circumstances that precipitated his fight with the kids who tried to rob him.

A successful interview will at the very least raise questions about the genuineness of biggie psychotic symptoms, as well as expose his intense effort to survive against an interior backdrop of emotional pain and desperation.

Appearance + Behavior

Biggie is a large, friendly, somewhat obese, tough-looking kid who is either a minority or “Wigger” (white kid who behaves like a street black kid). His cheerful, laid-back demeanor masks his vigilance. He’s very good at figuring out what other people want to hear. He’s grown up in a string of institutions, and generally gets along well with staff he trusts.

He’s aware that a complaint of hallucinations and suicidal ideation will virtually guarantee that he will be hospitalized—he has seen this device used before.

Biggie has a very large and recent bruise over his left eye and check, and crusted blood in his nose.

History of Present Illness

“Hey what’s up? My name is—well everybody just calls me Biggie. People call you all kinds of shit—that doesn’t mean it’s real, am I right? I am what I believe I am, not what you believe I am—if you want to say that’s same for you, I don’t have a problem with that. I don’t go looking for problems with people. I don’t have problems with nobody.

The thing is Doc, I’m hearing these voices, these shit-ass scary voices. They’re telling me I got to kill myself. Sometimes I get so loud, I feel like I’m good have to do it. How long has this been going on? It started about 2 or 3 weeks ago. Yeah, maybe I heard them before that, sometimes—but never this bad.

What kind of voices? I don’t know exactly. I guess one of them is the scary old man. He just says “you gonna die” and “you better kill yourself” over and over again. And then there’s this other one, she’s like an old woman, and she just says “I hate you.” Most the time, I don’t pay no mind, when they get really loud and shit, sometimes I feel like I just got to do what they say and kill myself.

(If asked about suicidal ideation)

Did I ever actually think about killing myself? Yeah—just this morning, I was walking on McClean Avenue, you know the bridge where it goes over the throughway. And both of them started screaming at me, and I almost jumped over. That’s what as I know you guys can help me. I think I got a take medication or something.

(If asked about other signs and symptoms of psychosis and schizophrenia, such as the notions of “thought broadcasting,” mind control, and somatic delusions)

Biggie will essentially endorse as many symptoms as he can, as long as he thinks this will be credible and lead to his hospitalization. When asked to elaborate further, he will be vague, and say “it’s hard to explain… I just don’t feel right.”

(If asked about drug use)

No, weed just makes me bug out—I see weird shit.

(Continues only if asked) I see my grandmother’s dead body, and shit. It just makes me bug out.

I don’t do any other kinds of drugs. I don’t use no K2—they put turpentine in that shit, did you know that? I drink a beer now and then, but I’m not into any of that crap.

(if asked about the bruise on his face)

Huh? Oh that—that ain’t nothing. Some motherfuckers tried to rob me.

(If asked for further details)

Well, there was three of them—they think they fucking own my corner, and one of those niggers sucker-punched me, and they tried to get my cigarettes—that’s it. That’s all.

(Biggie is avoiding revealing that he pulled a knife.)

(If asked for further details)

What do you want me to say, doc? You need me to explain it to you? They were fucking street niggers, that’s it—three of them. They’re gonna rob you if you let them. That’s it. I don’t let nobody do shit to me—I don’t care what they say they gonna do to me—cause the minute you let somebody do that to you—they own you. That’s it. No fucking way—that’s not me.

(If interviewer expresses interest or respected how biggie was able to defend himself against three assailants, Biggie will relax, and enjoy telling a “war story”)

Yeah, that shit-ass punk thought if he come up and tap me the fight would be over—but that fight was just starting, you feel me. He was like this (imitates blow) and I come back and get them right in the chest—I mean hard, so he went down. And then the other nigger is try to get my backpack, and I get them in the head right behind the ear (imitates blow), and they are still thinking there’s three of them against me—and I said “this is just getting started. You going to fuck with me, it gets real.” They say they’re going to come back with some fucking iron (i.e., gun) and do me—then bring it. Fuck that. Bring it. I just can’t take this shit any more.

Gate: does interviewer follow up reference to “I just can’t take this shit any more”?

(If asked what he means by “I just can’t take this shit any more”)

You know, people robbing you. Everybody try to get over on you, all the time, everybody is talking with you. Sometimes, sometimes you just say fuck it—you know what I mean?

Gate: does interviewer follow-up veiled reference to suicide?

(If asked at this point about suicidal ideation)

Yeah, sometimes I think about it. Yeah—there’s a lot of times I wish I was dead—but then I’m just like—yeah, fuck that—bring it. Bring it. You know what I mean?

(Biggie is unaware at this point that he’s contradicting his stated complaint of command hallucinations inducing suicidal ideation. If confronted about this, he will immediately recover, and resume his original complaint that he is hallucinating and at risk of committing suicide.)

(If asked, Biggie will now go on to describe pulling a knife—if specifically asked if this is what happened, in a sympathetic non-judgmental fashion)

Past Psychiatric History

No, I’ve never seen a psychiatrist. I just live with those voices, on and off. They didn’t get real bad, until now.

(If confronted with records of his psychiatric hospitalization at age 9)

oh yeah… I forgot about that. That was right after—all kinds of shit happened. (If asked) you know, like my grandmother dying and all. I bugged out—that’s why didn’t remember. But then I went to residential, and a whole bunch of those components. I didn’t have no problems after that (eyes fill with tears). Forget it, I don’t want to talk about that shit.

Gate

A more capable interviewer will note the flooding emotion on mention of grandmothers death and “follow the affect.” A highly skilled interviewer will back off if rebuffed, and return to the subject tactfully later.

(If interviewer persists) There ain’t much to say. My grandma was the one who took care of me, and then she died, and I went into residential. That’s what happened—that’s it. (continues to fight back tears) I don’t want to talk about it.

(If interviewer persists tactlessly) I said I didn’t want to talk about it, doc. Are you fucking deaf?

Sexual History: I’ve never had what you call a full-time girlfriend. A little of this, a little that. You know what I mean. That’s about all I can handle right now. (Big is actually gay, but he would never reveal this)

Social History

I’m 19 years old, and I live in South Yonkers—I don’t have an exact address, I tend to move around a lot. Sometimes they let me sleep in the basement of AME Church, sometimes I crash at other places—a little of this and a little of that. It doesn’t bother me. I’ve got friends everywhere—understand. I make a little money—I do some odd jobs here and there, and yeah I sell loosies (loose cigarettes)—you got a problem with that? Then don’t buy them from me, man. Weed? I don’t so no weed (he is lying) and I definitely don’t sell no other kinds of drugs—that just get you into trouble with all kinds of fuck-ass assholes, and gangs, and people try to rob you.

I grew up in Yonkers (skips grandmothers death), and then I was in residential, and then all these crappy foster homes. That’s it. There’s nothing much to say.

I got a GED last year, because the social worker said it would help me get a job—but it didn’t—in any way I don’t want no job. (Proudly) I’m a businessman. I sell loosies, lighters, you know—whatever people need.

Family History

You want to know about my family? I think my father’s dead. I don’t exactly know. My mother? She’s doing a bid, you know what I mean? She’s in prison, way the fuck upstate. I don’t exactly know what for, and I don’t care what for. I got taken away from her when I was about 9 years old—and I don’t think she gave a shit, except for the check. She called me once, and she was like “where’s my money?” And I was like—shit, don’t you even want to try to pretend you’re my mother? I mean, fuck that—you know?

I had an older brother, but I never did nothing with him. He was into gangs and shit, and he got shot, down on Locust Hill Avenue. There is a lot of fucked up shit that goes on down there—but there’s shit everywhere, you know what I mean?

But none of that shit bothers me. It’s like what this guy at the residential told me—Mr. J—do you know him? He was all right—anyway, he said you don’t get to choose where you come from, but you do get to choose where you’re going. And I’m going to be a record producer. They let me DJ sometimes at club X, you know, down on McClean Avenue? That’s my future, all right? That’s where I’m going

Critical Information

Items Biggie will not reveal under any circumstances:

• The fact that he is lying about having auditory hallucinations (and pressing about this will only alienate him).

• The fact that he is gay (this is a source of overwhelming shame and self-hatred).

Items Biggie will not reveal spontaneously but will reveal if directly questioned in a sympathetic fashion:

• The fact that he pulled a knife on his assailants.

• The devastating impact on him of his grandmother’s death, and the subsequent desperate circumstances of his life history.

• Episodes of profound depression and loneliness, which he is usually able to fight off.

• The fact that he has at times considered suicide (although he will never reveal the underlying precipitant, that is, self-disgust regarding his own sexuality).