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HIGH-YIELD FACTS IN

Examination
and Diagnosis

! PSYC H IAT R I C H I STO RY AN D M E N TAL STAT U S E X AM

Interviewing
MAKING THE PATIENT COMFORTABLE
The initial interview is of utmost importance to the psychiatrist. Here, he or
she has the opportunity to gather vital information by maintaining a relaxed
and comfortable dialogue. During the first meeting, the psychiatrist must es-
tablish a meaningful rapport with the patient. This requires that questions be
asked in a quiet, comfortable setting so that the patient is at ease. The patient
should feel that the psychiatrist is interested, nonjudgmental, and compas-
sionate. Establishing trust in this manner will enable a more productive and
effective interview, in turn facilitating an accurate diagnosis and treatment
plan.

Taking the History

The psychiatric history follows a similar format as the history for other types
of patients. It should include the following:
! Identifying data
! Chief complaint (in the patients own words, no matter how odd sound-
ing)
! History of present illness
! Past psychiatric history
! Past medical history
! Medications
! Allergies
! Family history
! Social history (occupation, education, living situation, substance abuse,
etc.)
! Mental status exam

WHAT SHOULD THE HISTORY OF PRESENT ILLNESS INCLUDE?

! Information about current episode:
! Why the patient came to the doctor
! Description of current episode
! Events leading up to current moment (precipitating events)
! How work and relationships have been affected

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HIGH-YIELD FACTS
Examination and Diagnosis
To assess mood, just ask,
How are you feeling
today? It is also helpful to
have patients rate their
stated mood on a scale of 1
to 10.
! The patients support system (who the patient lives with, distance
and level of contact with friends and relatives)
! Relationship between physical and psychological symptoms
! Vegetative symptoms (i.e., insomnia, loss of appetite, problems with
concentration)
! Psychotic symptoms (i.e., auditory and visual hallucinations)
! Information about past episodes:
! Chronological account of past psychiatric problems/episodes
! Establishing a baseline of mental health:
! Patients functioning when well
! Developmental historyphysical and intellectual ability at various
stages of life (outpatient setting only)
! Life values, goals (outpatient setting)
! Evidence of secondary gain
Mental Status Examination
This is analogous to performing a physical exam in internal medicine. It is the
nuts and bolts of the psychiatric exam. The mental status exam assesses the
following:
! Appearance/Behavior
! Mood/Affect
! Speech
! Perception
! Thought process/Thought content
! Sensorium/Cognition
! Insight/Judgment
! Suicidal/Homicidal ideation
The mental status exam tells only about the mental status at that moment; it
can change every hour or every day, etc.
APPEARANCE
! Physical appearanceclothing, hygiene, posture, grooming
! Behaviormannerisms, tics, eye contact
! Attitudecooperative, hostile, guarded, seductive, apathetic
SPEECH
! Rateslow, average, rapid, or pressured (Pressured speech is continuous,
fast, and uninterruptible.)
! Volumesoft, average, or loud
! Articulationwell articulated versus lisp, stutter, mumbling
! Toneangry versus pleading, etc.
MOOD
Mood is the emotion that the patient tells you he feels or is conveyed nonver-
bally.
AFFECT
Affect is an assessment of how the patients mood appears to the examiner,
including the amount and range of emotional expression. It is described with
the following dimensions:
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! Quality describes the depth and range of the feelings shown. Parameters:
Flat (none)blunted (shallow)constricted (limited)full (aver-
age)intense (more than normal)
! Motility describes how quickly a person appears to shift emotional states.
Parameters: Sluggishsupplelabile Assess the quality, motility,
! Appropriateness to content describes whether the affect is congruent with and appropriateness in
the subject of conversation. Parameters: Appropriatenot appropriate describing the affect:
Patients affect was
THOUGHT PROCESS constricted, sluggish,
This is the patients form of thinkinghow he or she uses language and puts and inappropriate to
ideas together. It describes whether the patients thoughts are logical, mean- content. . . .
ingful, and goal-directed. It does not comment on what the patient thinks,
only how the patient expresses his or her thoughts.

Examples of disorders:
Loosening of associationsno logical connection from one thought to

HIGH-YIELD FACTS
another
Flight of ideasa fast stream of very tangential thoughts. A patient who remains
Neologismsmade-up words expressionless and
Word saladincoherent collection of words monotone even when
Clang associationsword connections due to phonetics rather than ac- discussing extremely sad or
tual meaning. My car is red. Ive been in bed. It hurts my head. happy moments in his life
Thought blockingabrupt cessation of communication before the idea is has a flat affect.
finished
Tangentialitypoint of conversation never reached due to lack of goal-
directed associations between ideas
Circumstantialitypoint of conversation is reached after circuitous path

Examination and Diagnosis

THOUGHT CONTENT
This describes the types of ideas expressed by the patient. A patient who is laughing
one second and crying the
Examples of disorders: next has a labile affect.
Poverty of thought versus overabundancetoo few versus too many
ideas expressed
Delusionsfixed, false beliefs that are not shared by the persons culture
and cannot be changed by reasoning
Suicidal and homicidal thoughtsAsk if the patient feels like harming
him/herself or others. Identify if the plan is well formulated. Ask if the pa-
tient has intent (i.e., if released right now, would he go and kill himself or
harm others?). A patient who giggles while
Phobiaspersistent, irrational fears telling you that he set his
Obsessionsrepetitive, intrusive thoughts house on fire and is facing
Compulsionsrepetitive behaviors (usually linked with obsessive criminal charges has an
thoughts) inappropriate affect.

PERCEPTION
! Hallucinationssensory experiences not based in reality (visual, audi-
tory, tactile, gustatory, olfactory)
! Illusionsinaccurate perception of existing sensory stimuli (Example of
illusion: Wall appears as if its moving)

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Examples of delusions:
! Grandeurbelief that
one has special powers
or is someone important
(Jesus, president)
! Paranoidbelief that
one is being persecuted
! Referencebelief that
some event is uniquely
related to patient (e.g., a
TV show character is
sending patient
HIGH-YIELD FACTS
messages)
! Thought broadcasting
belief that ones thoughts
can be heard by others
! Religiousconventional
beliefs exaggerated
(e.g., Jesus talks to me)
Examination and Diagnosis
To test ability to abstract,
ask:
1. Similarities: How are an
apple and orange alike?
(Normal answer: They See Cognitive Disorders chapter for detailed description. The areas tested in-
are fruits. Concrete clude:
answer: They are
round.)
2. Proverb testing: What is
meant by the phrase,
You cant judge a book
by its cover? (Normal
answer: You cant judge
people just by how they
look. Concrete answer:
Books have different
covers.) General Approaches to Types of Patients
SENSORIUM AND COGNITION
Sensorium and cognition are assessed in the following ways:
! Consciousnesspatients level of awareness; possible range includes:
Alertdrowsylethargicstuporouscoma
! Orientationto person, place, and time
! Calculationability to add/subtract
! Memory
! Immediatecan repeat several digits or recall three words 5 minutes
later
! Recentevents within past few days
! Recent pastevents within past few months
! Remoteevents from childhood
! Fund of knowledgelevel of knowledge in the context of the patients
culture and education (Who is the president? Who was Picasso?)
! Attention/Concentrationability to subtract serial 7s from 100 or to
spell world backwards
! Reading/Writingsimple sentences (must make sure the patient is lit-
erate first!)
! Abstract conceptsability to explain similarities between objects and
understand the meaning of simple proverbs
INSIGHT
This is the patients level of awareness and understanding of his or her prob-
lem. Problems with insight include complete denial of illness or blaming it on
something else.
JUDGMENT
This is the patients ability to understand the outcome of his or her actions
and use this awareness in decision making. You can ask, What would you do
if you smelled smoke in a crowded theater?
Mini Mental State Examination (MMSE)
The MMSE is a simple, brief test used to assess gross cognitive functioning.
! Orientation (to person, place, and time)
! Memory (short term)
! Concentration and attention (serial 7s, spell world backwards)
! Language (naming, repetition, comprehension)
! Reading and writing
! Visuospatial ability (copy of design)
! I N T E RV I E W I N G S K I LLS
VIOLENT PATIENT
One should avoid being alone with a potentially violent patient. To assess vi-
olence or homicidality, one can simply ask, Do you feel like you want to hurt
someone or that you might hurt someone? If the patient expresses imminent
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threats against friends, family, or others, the doctor should notify potential
victims and/or protection agencies when appropriate (Tarasoff rule).

DELUSIONAL PATIENT
Although the psychiatrist should not directly challenge a delusion or insist In assessing suicidality, do
that it is untrue, he should not imply he believes it either. He should simply not simply ask, Do you
acknowledge that he understands the patient believes the delusion is true. want to hurt yourself?
because this does not
DEPRESSED PATIENT
directly address suicidality
A depressed patient may be skeptical that he or she can be helped. It is impor- (he may plan on dying
tant to offer reassurance that he or she can improve with appropriate therapy. in a painless way). Ask
Inquiring about suicidal thoughts is crucial; a feeling of hopelessness, sub- directly about killing self or
stance use, and/or a history of prior suicide attempts reveal an increased risk suicide. If contemplating
for suicide. If the patient is planning or contemplating suicide, he or she must suicide, ask the patient if
be hospitalized or otherwise protected.
he has a plan of how to do

HIGH-YIELD FACTS
it and if he has intent; a
detailed plan, intent, and
! D IAG N O S I S AN D C L A S S I F I C AT I O N the means to accomplish it
suggest a serious threat.
Diagnosis as per DSM-IV-TR Multiaxial Classification Scheme
The American Psychiatric Association uses a multiaxial classification system
for diagnoses. Criteria and codes for each diagnosis are outlined in their Diag-
nostic and Statistical Manual of Mental Disorders, 4th edition, text revision
(DSM-IV-TR).
Axis I: All diagnoses of mental illness (including substance abuse and de-
velopmental disorders), not including personality disorders and mental re-

Examination and Diagnosis

tardation
Axis II: Personality disorders and mental retardation
Axis III: General medical conditions
Axis IV: Psychosocial and environmental problems (e.g., homelessness,
divorce, etc.)
Axis V: The Global Assessment of Function (GAF), which rates overall
level of daily functioning (social, occupational, and psychological) on a
scale of 0 to 100. (See table on next page.) Rate current GAF vs. high
GAF during the past year.

! D I AG N O ST I C T E ST I N G

Intelligence Tests
Aspects of intelligence include memory, logical reasoning, ability to assimilate
factual knowledge, understanding of abstract concepts, etc.

INTELLIGENCE QUOTIENT (IQ)

IQ is a test of intelligence with a mean of 100 and a standard deviation of
100. These scores are adjusted for age and sometimes gender. An IQ of 100
signifies that mental age equals chronological age and corresponds to the 50th
percentile in intellectual ability for the general population.

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Examination and Diagnosis HIGH-YIELD FACTS

Global Assessment of Function (GAF) Scale

110 1120 2130 3140 4150 5160 6170 7180 8190 91100
Persistent danger Gross Behavior is Some Serious Moderate Some mild If symptoms are Absent or No symptoms
of severely impairment in considerably impairment in symptoms. symptoms. symptoms. present, they are minimal
hurting self or communication. influenced by reality testing or transient and symptoms.
others. delusions or communication. Suicidal Flat affect and Depressed expectable
Largely hallucinations. ideation, severe circumstantial mood, mild reactions to Mild anxiety
Recurrent incoherent or Speech is at obsessional speech, insomnia. psychosocial before an exam.
violence. mute. times illogical, rituals, frequent occasional panic stressors. Generally
obscure, or shoplifting. attacks. satisfied with
irrelevant. Difficulty life.
14

concentrating No more than

after family everyday
argument. problems or
concerns.
Occasional
argument with
family members.
Serious suicidal Some danger of Serious Major Any serious Moderate Some difficulty No more than Good Superior
act with clear hurting self or impairment in impairment in impairment in difficulty in in social, slight functioning in functioning in a
expectation of others. communication several areas, social, social, occupational, or impairment in all areas, wide range of
death. or judgment. such as work or occupational, or occupational, or school social, interested and activities.
Suicide attempts school, family school school functioning. occupational, or involved in a
without clear Sometimes relations, functioning. functioning. school wide range of Lifes problems
expectation of incoherent, acts judgment, Occasional functioning. activities, never seem to
death, frequently grossly thinking, or No friends, Few friends, truancy, or theft socially get out of hand.
violent, manic inappropriately, mood. unable to keep a conflicts with within the Temporarily effective.
excitement. suicidal job. co-workers. household, but falling behind in
preoccupation. Depressed man generally school work.
avoids friends, functioning
neglects family, pretty well, has
and is unable to some meaningful
work. Child interpersonal
frequently beats relationships.
up younger
children, is
defiant at home
and is failing in
school.
Persistent Occasionally Inability to Sought out by
inability to fails to maintain function in others because
maintain minimal almost all areas. of his or her
minimal personal hygiene many positive
personal Stays in bed all qualities.
hygiene. Smears feces. day, no job,
home, or friends.
9130_Section 2 1/27/05 4:55 PM Page 15

Intelligence tests assess cognitive function by evaluating comprehension, fund

of knowledge, math skills, vocabulary, picture assembly, and other verbal and
performance skills. Two common tests are:
Wechsler Adult Intelligence Scale (WAIS)
! Most common test for ages 16 to 75
! Assesses overall intellectual functioning
IQ Chart
! Two parts: Verbal and visual-spatial Very superior: > 130
StanfordBinet Test Superior: 120129
! Tests intellectual ability in patients ages 2 to 18 High average: 110119
Average: 90109
Low average: 8089
Objective Personality Assessment Tests Borderline: 7079
These tests are questions with standardized-answer format that can be objec- Mild mental retardation:
tively scored. The following is an example: 5070
Minnesota Multiphasic Personality Inventory (MMPI-2) Moderate mental
! Tests personality for different pathologies and behavioral patterns retardation: 3549

HIGH-YIELD FACTS
! Most commonly used Severe mental retardation:
2534
Profound mental
Projective (Personality) Assessment Tests retardation: < 25
Projective tests have no structured-response format. The tests often ask for in-
terpretation of ambiguous stimuli. Examples are:
Thematic Apperception Test (TAT)
! Test-taker creates stories based on pictures of people in various situa-
tions.
! Used to evaluate motivations behind behaviors
Rorschach Test
! Interpretation of ink blots

Examination and Diagnosis

! Used to identify thought disorders and defense mechanisms

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