Mental disorders are very common, frequently coexist with physical disorders and cause much mortality and morbidity. Psychiatric assessment is therefore a required skill for all clinicians. It consists of four elements: the history, mental state examination, selective physical examination and collateral information. Each element can be expanded considerably, so the assessment must be adapted to its purpose. Is it a quick screening of a patient presenting with other problems, a confirmation of a suspected diagnosis or a comprehensive review for a second opinion?
The history
General approach
The distinction between symptoms and signs is less clear in psychiatry than in the rest of medicine. The psychiatric interview, which covers both, has several purposes: to obtain a history of symptoms, to assess the present mental state for signs, and to establish rapport that will facilitate further management.
A comprehensive history covers a range of areas ( Box 16.1 ), but the nature of the presenting problem and/or the referral question, and the setting in which the history is being taken, will determine the degree of detail needed for each. When seeing someone in the accident and emergency department with a first episode of psychosis, the focus is on symptoms, recent changes of function, family history and drug use; when interviewing someone in an outpatient clinic with a possible personality disorder, assessment concentrates instead on their personal history, which is essentially a systematised biography ( Box 16.2 ).
- •
Referral source
- •
Reason for referral
- •
History of presenting symptom(s)
- •
Systematic enquiry into other relevant problems and symptoms
- •
Past medical/psychiatric history
- •
Prescribed and non-prescribed medication
- •
Substance use: illegal drugs, alcohol, tobacco, caffeine
- •
Family history (including psychiatric disorders)
- •
Personal history
Sensitive topics
Some subjects require particular skill. The common theme is reluctance to disclose, which can arise because the information is private, and disclosure is potentially embarrassing (such as sexual dysfunction, gender identity), distressing (major traumatic experiences, such as rape, childhood sexual abuse, witnessing a death) or incriminating (illicit drug misuse, other crime, homicidal ideas). For interviews undertaken in non-clinical settings such as police stations or prisons, or for the provision of court reports, the latter is obviously especially pertinent, and it is important to be clear with the patients about any limits to confidentiality in your interview.
Try to develop rapport early in the interview, if possible, and to consolidate it before raising a sensitive topic, although sometimes you must cover such material without delay. It is particularly important to ask about suicidal thoughts.
The uncooperative patient
Adapt your approach to a patient who is mute, agitated, hostile or otherwise uncooperative during the interview, by relying more on observation and collateral information. The safety of the patient, other patients and staff is paramount, so your initial assessment of an agitated or hostile patient may be only partial.
The mental state examination
The mental state examination (MSE) is a systematic evaluation of the patient’s mental condition at the time of interview. The aim is to establish signs of mental disorder that, taken with the history, enable you to make, suggest or exclude a diagnosis. While making your specific enquiries, you need to observe, evaluate and draw inferences in the light of the history. This is daunting, but with good teaching, practice and experience you will learn the skills.
The MSE incorporates elements of the history, observation of the patient, specific questions exploring various mental phenomena and short tests of cognitive function. Like the history, its focus is determined by the potential diagnoses. For example, detailed cognitive assessment in an elderly patient presenting with confusion is crucial; similarly, you should carefully evaluate mood and suicidal thoughts when the presenting problem is depression.
Appearance
Think of this as a written account of a still photograph, prepared for someone who cannot see it. Observe:
- •
general elements such as attire and signs of self-neglect
- •
facial expression
- •
tattoos and scars (especially any that suggest recent or previous self-harm)
- •
evidence of substance misuse (such as injection tracks from intravenous drug use; spider naevi and jaundice from alcoholic liver disease)
- •
possibly relevant physical disease (such as exophthalmos from thyrotoxicosis).
Behaviour
Think of this as a written account of a video, observing such features as:
- •
cooperation, rapport, eye contact
- •
social behaviour (such as aggression, disinhibition, fearful withdrawal)
- •
apparent responses to possible hallucinations or unobserved stimuli
- •
over-activity (agitation, pacing, compulsive hand washing)
- •
under-activity (stupor, motor retardation)
- •
abnormal activity (posturing, involuntary movements, Box 16.3 ).
16.3
Behaviour: definitions
Term
Definition
Agitation
A combination of psychic anxiety and excessive, purposeless motor activity
Compulsion
A stereotyped action that the patient cannot resist performing repeatedly
Disinhibition
Loss of control over normal social behaviour
Motor retardation
Decreased motor activity, usually a combination of fewer and slower movements
Posturing
The maintenance of bizarre gait or limb positions for no valid reason
Speech
This is not a description of what the patient says (that is, content), but of how they say it (form). Assess:
- •
articulation (such as stammering, dysarthria)
- •
quantity (mutism, garrulousness)
- •
rate (pressured, slowed)
- •
volume (whispering, shouting)
- •
tone and quality (accent, emotionality)
- •
fluency (staccato, monotonous)
- •
abnormal language (neologisms, dysphasia, clanging, Box 16.4 ).
16.4
Speech: definitions
Term
Definition
Clang associations
Thoughts connected by their similar sound rather than by meaning
Echolalia
Senseless repetition of the interviewer’s words
Mutism
Absence of speech without impaired consciousness
Neologism
An invented word, or a new meaning for an established word
Pressure of speech
Rapid, excessive, continuous speech (due to pressure of thought)
Word salad
A meaningless string of words, often with loss of grammatical construction
Mood
Mood is the patient’s pervasive emotional state, while affect is the observable expression of their emotions, which is more variable over time. Think of mood as the emotional climate and affect as the weather. Both have elements of subjective experience (that is, how the patient feels, according to their own report and your specific questions) and how the patient appears to feel, according to your own objective observation. So a depressed patient might describe feeling sad, hopeless and unable to enjoy any aspect of life, and at interview appear downcast, withdrawn and tearful, with little brightening even when talking about their much-loved children.
Pervasive disturbance of mood is the most important feature of depression, mania and anxiety, but mood changes commonly occur in other mental disorders such as schizophrenia and dementia. You might ask patients ‘How has your mood been lately?’, ‘Have you noticed any change in your emotions recently?’ and ‘Do you still enjoy things that normally give you pleasure?’ Abnormalities of mood include a problematic pervasive mood, an abnormal range of affect, abnormal reactivity and inappropriateness or incongruity. Some terms relating to mood are defined in Box 16.5 .
| Term | Definition |
|---|---|
| Blunting | Loss of normal emotional sensitivity to experiences |
| Catastrophic reaction | An extreme emotional and behavioural over-reaction to a trivial stimulus |
| Flattening | Loss of the range of normal emotional responses |
| Incongruity | A mismatch between the emotional expression and the associated thought |
| Lability | Superficial, rapidly changing and poorly controlled emotions |
Some patients prompt affective responses in the interviewer, via the process of countertransference . The elated gaiety of some hypomanic patients can be infectious, as can the hopeless gloom of some people with depression. Recognising these responses in yourself can be helpful in understanding how the patient relates to others and vice versa.
Thought form
As with speech, this is a not an assessment of what the patient is thinking about, but how they think about it. Assess it by observing how thoughts appear to be linked together, and the speed and directness with which the train of thought moves, considering rate, flow, sequencing and abstraction. Some terms relating to thought form are defined in Box 16.6 .
| Term | Definition |
|---|---|
| Circumstantiality | Trivia and digressions impairing the flow but not direction of thought |
| Concrete thinking | Inability to think abstractly |
| Flights of ideas | Rapid shifts from one idea to another, retaining sequencing |
| Loosening of associations | Logical sequence of ideas impaired. Subtypes include knight’s-move thinking, derailment, thought blocking and, in its extreme form, word salad |
| Perseveration | Inability to shift from one idea to the next |
| Pressure of thought | Increased rate and quantity of thoughts |
Thinking may appear speeded up, as in hypomania, or slowed down, as in profound depression. The flow of subjects may be understandable but unusually rapid, as in the flight of ideas that characterises hypomania, or unduly ‘single track’ and perseverative, as in some cases of dementia. Sometimes thinking appears to be very circumstantial, and the patient hard to pin down, even when asked simple questions.
More severe disruption of the train of thought is termed loosening of associations or formal thought disorder, in which the patient moves from subject to subject via abrupt changes of direction that the interviewer cannot follow. This is a core feature of schizophrenia. Concrete thinking, in the sense of difficulty handling abstract concepts, is a common feature of dementia, and can be assessed by asking the patients to explain the meaning of common proverbs.
It may help to illustrate your assessment with verbatim examples from the interview, chosen to illustrate the patient’s manner of thinking and speaking.
Thought content
Thought content refers to the main themes and subjects occupying the patient’s mind. It will become apparent when taking the history but may need to be explored further via specific enquiries. It may broadly be divided into preoccupations, ruminations and abnormal beliefs . These are defined in Boxes 16.7 and 16.8 .
| Term | Definition |
|---|---|
| Hypochondriasis | Unjustified belief in suffering from a particular disease in spite of appropriate examination and reassurance |
| Morbid thinking | Depressive ideas, e.g. themes of guilt, burden, unworthiness, failure, blame, death, suicide |
| Phobia | A senseless avoidance of a situation, object or activity stemming from a belief that has caused an irrational fear |
| Preoccupation | Beliefs that are not inherently abnormal but which have come to dominate the patient’s thinking |
| Ruminations | Repetitive, intrusive, senseless thoughts or preoccupations |
| Obsessions | Ruminations that persist despite resistance |
| Term | Definition |
|---|---|
| Delusion | An abnormal belief, held with total conviction, which is maintained in spite of proof or logical argument to the contrary and is not shared by others from the same culture |
| Delusional perception | A delusion that arises fully formed from the false interpretation of a real perception, e.g. a traffic light turning green confirms that aliens have landed on the rooftop |
| Magical thinking | An irrational belief that certain actions and outcomes are linked, often culturally determined by folklore or custom, e.g. fingers crossed for good luck |
| Overvalued ideas | Beliefs that are held, valued, expressed and acted on beyond the norm for the culture to which the person belongs |
| Thought broadcasting | The belief that the patient’s thoughts are heard by others |
| Thought insertion | The belief that thoughts are being placed in the patient’s head from outside |
| Thought withdrawal | The belief that thoughts are being removed from the patient’s head |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
