Psychiatric examination

Consist of
Psychiatric interview
Mental state examination

Psychiatric History
The psychiatric history is the record of the
patient's life; it allows a psychiatrist to understand
who the patient is, where the patient has come
from, and where the patient is likely to go in the
future.
The history is the patient's life story told to the
psychiatrist in the patient's own words from his or
her own point of view.
Many times, the history also includes information
about the patient obtained from other sources,
such as a parent or spouse.
Obtaining a comprehensive history from a patient
and, if necessary, from informed sources is
essential to making a correct diagnosis and
formulating a specific and effective treatment plan.

 A psychiatric history differs slightly from histories

taken in medicine or surgery.
In addition to gathering the concrete and factual data
related to the chronology of symptom formation and
to the psychiatric and medical history, a medical
doctor strives to derive from the history the elusive
picture of a patient's individual personality
characteristics, including both strengths and
weaknesses.
The psychiatric history provides insight into the nature
of relationships with those closest to the patient and
includes all the important persons in his or her life.
Usually, a reasonably comprehensive picture can be
elicited of the patient's development from the earliest
formative years until the present.

 The most important technique for obtaining a

psychiatric history is to allow patients to tell their
stories in their own words in the order that they
consider most important. As patients relate their
stories, skillful interviewers recognize the points
at which they can introduce relevant questions
about the areas described in the outline of the
history and mental status examination.
The structure of the history and mental status
examination presented in this section is not
intended to be a rigid plan for interviewing a
patient; it is meant to be a guide in organizing
the patient's history prior to its being written.

Outline of Psychiatric History

Identifying data
Chief complaint
History of present illness
Onset
Precipitating factors
Past illnesses
Psychiatric
Medical
Alcohol and other
substance history
Family history

Personal history (anamnesis)

Prenatal and perinatal
Early childhood (Birth through age
3)
Middle childhood (ages 311)
Late childhood (puberty through
adolescence)
Adulthood
Occupational history
Marital and relationship history
Military history
Educational history
Religion
Social activity
Current living situation
Legal history
Sexual history
Fantasies and dreams
Values

Outline of a Developmental History

Prenatal and perinatal

Infantmother relationship
Problems with feeding and sleep
Significant milestones

Standing/walking
First words/two-word sentences
Bowel and bladder control

Other caregivers
Unusual behaviors (e.g., headbanging)
Preschool and school experiences
Separations from caregivers
Friendships/play
Methods of discipline
Illness, surgery, or trauma

Onset of puberty
Academic achievement
Organized activities (sports, clubs)
Areas of special interest
Romantic involvements and sexual
experience
Work experience
Drug/alcohol use
Symptoms (moodiness, irregularity of
sleeping or eating, fights and
arguments)

Young adulthood

Middle childhood

Adolescence

Full-term pregnancy or premature

Vaginal delivery or caesarian
Drugs taken by mother during
pregnancy (prescription and
recreational)
Birth complications
Defects at birth

Infancy and early childhood

Meaningful long-term relationship

Academic and career decisions
Military experience
Work history
Prison experience
Intellectual pursuits and leisure
activities

Middle adulthood and old age

Changing family constellation

Social activities
Work and career changes
Aspirations
Major losses
Retirement and aging

Sexual History

Screening questions
Are you sexually active?
Have you noticed any changes or problems with sex recently?
Developmental
Acquisition of sexual knowledge
Onset of puberty/menarche
Development of sexual identity and orientation
First sexual experiences
Sex in romantic relationship
Changing experiences or preferences over time
Sex and advancing age
Clarification of sexual problems
Desire phase
Presence of sexual thoughts or fantasies
When do they occur and what is their object?
Who initiates sex and how?
Excitement phase
Difficulty in sexual arousal (achieving or maintaining erections, lubrication), during
foreplay and preceding orgasm
Orgasm phase
Does orgasm occur?
Does it occur too soon or too late?
How often and under what circumstances does orgasm occur?
If orgasm does not occur, is it because of not being excited or lack of orgasm despite
being aroused?
Resolution phase
What happens after sex is over (e.g., contentment, frustration, continued arousal)?

Outline for the Mental Status

Examination

Appearance
Overt behavior
Attitude
Speech
Mood and affect
Thinking
Form
Content

Perceptions
Sensorium
Alertness
Orientation (person,
place, time)
Concentration
Memory (immediate,
recent, long term)
Calculations
Fund of knowledge
Abstract reasoning

Insight
Judgment

Interviewing Techniques with

Special Patient Populations
Various types of patients fall under the rubric of
special patient populations. They include patients
with urgent issues, the severely mentally ill, patients
from different cultural backgrounds who are
unassimilated, those who cannot communicate well
because of difficulties with the language, and
patients whose personality problems make them,
difficult, demanding, uncooperative, or likely to
engage in power struggles.
Inherent in the management of all such cases is the
doctor's understanding of the emotions, fears, and
conflicts that the patient's behavior represents.
Different patient types and special situations and
guidelines for handling them are discussed in this
lecture.

Psychotic Patients
By definition, psychotic patients have poor or
absent reality testing abilities.
Therefore, the evaluation of a patient with
psychotic symptoms needs to be more focused
and structured than that of other patients.
Open-ended questions and long periods of silence
are apt to be disorganizing.
Short questions are easier to follow than long
ones.
Questions calling for abstract responses or
hypothetical conjectures may be unanswerable.

 Thought Disorders
Disorders of thought can seriously impair effective
communications.
The evaluating psychiatrist should note formal thought
disorders while minimizing their adverse impact on the
interview.
When derailment is evident, the psychiatrist typically
proceeds with questions calling for short responses.
For a patient experiencing thought blocking, the
psychiatrist needs to repeat questions, to remind the
patient of what was already said, and, in general, to
provide an organization for thinking that the patient is
unable to provide.

 Hallucinations
Hallucinations are false sensory perceptions.
For patients with hallucinations, the full phenomenology
of the hallucination should be explored.
The patient is asked to describe the sensory
misperception as fully as possible. For auditory
hallucinations, this includes content, volume, clarity, and
circumstances; for visual hallucinations, this includes
content, intensity, the situations in which they occur, and
the patient's response.
The evaluator should distinguish between true
hallucinations, on the one hand, and illusions, hypnagogic
and hypnopompic hallucinations, and vivid imaginings.
Hallucinations are perceived as real sensory stimuli and
should not be dismissed as fanciful; however, the doctor
should ask questions about their fixity and the patient's
level of insight: Does it ever seem that the voices are
coming from your own thoughts? What do you think is
causing the voices?

 For example, in response to the question,

Why did you come to the clinic?
a patient responded: When I got up this morning, I
showered and dressed. I was angry at my landlord for
not fixing the faucet in my bathroom. I tried to get
him on the phone. He wouldn't talk to me. I'll call my
lawyer. You see, my rent is supposed to be paid by the
Department of Welfare, but they're so nasty.
[But why did you come to the clinic?]
I'm coming to that, Doctor. You see, they don't care
about an upright citizen. I did so much for my
community. No one can say I wasn't a hard worker,
etc.

After repeated questioning, she finally stated she

was worried about being constipated.

 Delusions
Delusions are fixed, false beliefs not in keeping with the culture.
Delusional patients often come to psychiatric evaluation having
had their beliefs dismissed or belittled by friends and family.
They are on guard for similar reactions from the examiner. It is
possible to ask questions about delusions without revealing
belief or disbelief (e.g., Does it seem that people are intent on
hurting you? rather than Do you believe there is a plot to hurt
you?).
Careless use of psychiatric jargon should be avoided,
particularly in evaluating delusions. Many psychiatrists have
found that patients can speak more freely when asked to talk
about the accompanying emotions rather than the belief itself
(It must be frightening to think there are people you do not
know who are plotting against you).
Although the psychiatrist does not attempt to reason them
away, a gentle probe may determine how tenaciously the beliefs
are held (Do you ever wonder whether those things might not
be true?).

Suspicious Patients
Some persons, usually those with a paranoid personality,
have a chronic, deeply ingrained suspicion that other people
want to cause them harm.
Although their suspiciousness does not crystallize into a
delusion, they misinterpret neutral events as evidence of a
conspiracy against them.
They are critical and evasive, and are sometimes called
grievance collectors because they tend to blame other
people for everything bad in their lives.
They are extremely mistrustful and may question everything
the doctor says or does. The physician should try to maintain
a respectful but somewhat formal and distant approach with
these patients. Expressions of warmth often heighten their
suspicions.
The doctor should explain in detail every decision and
planned procedure and should try to respond nondefensively to the patient's suspiciousness.

Depressed and Potentially Suicidal

Patients
Severely depressed patients may have difficulty
concentrating, thinking clearly, and speaking
spontaneously.
The psychiatrist evaluating a depressed patient
may need to be more forceful and directive than
usual. Although depressed patients should not be
badgered, long silences are seldom useful, and the
examiner may need to repeat questions more than
once.
Ruminative patients for example, those who
continually repeat how worthless or guilty they are
need to be interrupted and redirected.

 All patients must be asked about suicidal thoughts;

however, depressed patients may need to be
questioned more fully.
A thorough assessment of suicide potential addresses
intent, plans, means, and perceived consequences, as
well as history of attempts and family history of suicide.
The examiner must feel sufficiently comfortable to ask
simple, straightforward, non-euphemistic questions.
Asking about suicide does not increase the risk. The
psychiatrist is not raising a topic that the patient has
not already contemplated. Specific, detailed questions
are essential for prevention

 Intent
The examiner must determine the seriousness of the wish to
die. Some patients report that they wish that they were
dead, but would never intentionally do anything to take their
own lives. This level of intent is sometimes referred to as
passive suicidal ideation.
Other patients express greater degrees of determination. At
the most extreme level of determination are the patients
who are the most difficult to help, those who tell no one
about their suicidal plans and proceed in a deliberate,
systematic manner.
It is useful to ask about restraining influences, internal and
external (e.g., Do you worry that you might not be able to
resist those impulses? or How have you been able to keep
from hurting yourself so far?).
Patients with auditory hallucinations commanding them to
kill themselves often describe the hallucinations as
irresistible despite not having any real desire to die.

 Plans
Patients with well-formulated plans are
generally at greater risk than patients who do
not know what they would do, but the method
of suicide is not always a reliable indication of
the risk.
The examiner should also ask about
preparatory actions, such as giving away goods
and putting one's estate in order.

 Means
Asking patients about the intended means of
suicide is helpful in two ways.
First, it clarifies the urgency of the situation.
Second, the understanding of intent is
sharpened by knowing whether a patient has
thought through the steps necessary to carry
out the action.

 Perceived Consequences
Patients who see something desirable resulting from their deaths
are at increased risk for suicide (e.g., reunion fantasy, the belief
that a person will be reunited with a deceased loved one).
On the other hand, some potentially suicidal patients are
restrained by what they see as negative consequences (e.g., My
children need me too much; they'd never be able to get along
without me).
The psychiatric history and the family history for all patients,
even those not currently suicidal, should mention any previous
suicide attempt or suicides by family members. Both
circumstances are recognized to increase the current risk, even
if previous attempts were thought to be superficial.
In rare circumstances, the threat of suicide is so imminent that
immediate action must be taken to hospitalize the patient. Even
during a first evaluation session, the examiner must be prepared
to make whatever professional response is necessary to
safeguard the well-being of the patient.

Agitated and Potentially Violent

Patients
When interviewing potentially violent patients, the
task is to conduct an assessment and to contain
behavior and limit the potential for harm.
Most unpremeditated violence is preceded by a
prodrome of accelerating psychomotor agitation.
Researchers and clinicians in emergency
psychiatry suggest that the prodrome lasts from 30
to 60 minutes before erupting into physical
violence.
Thus, the psychiatric evaluator has early signals of
impending violence and a period of time in which
the agitation may be quieted.

 Several steps can be taken to minimize the agitation and

potential risk. The interview should be conducted in a quiet, nonstimulating environment. Sufficient space should be available for
the comfort of the patient and the examiner, with no physical
barrier to leaving the examination room for either of them.
During the interview, the psychiatrist should avoid any behavior
that could be misconstrued as menacing: standing over the
patient, staring, or touching.
The psychiatrist should ask whether the patient is carrying
weapons and may ask the patient to leave the weapon with a
guard or in a holding area.
The examiner should not request that the patient hand over any
weapons. If the patient's agitation continues to increase, the
psychiatrist may need to terminate the interview.
Depending on the setting, assistance from security personnel or
physical or chemical restraints may be appropriate. The
physician's own subjective sense of comfort or fear should be
heeded.

Seductive Patients

Seductiveness can be manifested in a patient's dress, behavior, and

speech. It runs the gamut from gentle suggestion to explicit proposition.
Of course, sex is not the only enticement with which examiner can be
seduced. Patients may offer insider information for profitable trading in
the stock market, may promise an introduction to a movie star friend, or
may suggest that they will dedicate their next novel to the examiner.
Whatever the offer, the examiner's response is the same. In the course
of ongoing psychotherapy and in the context of an established
relationship, seductive behavior is discussed and examined in an effort
to understand its meaning.
The examiner should make it clear that what is being offered will not be
accepted, in a way that preserves good rapport and does not
unnecessarily assault the patient's self-esteem.
Seductive behavior during an initial psychiatric assessment must be
handled somewhat differently. When the behavior is mild and indirect, it
may be best to ignore it. More explicit propositions call for more direct
responses and may afford the examiner the chance to explain the
nature of the therapeutic relationship and the need to establish
boundaries.
The examiner should also make clear that it is the violation of those
boundaries that is being rejected and not the patient.

Obsessive Patients
Obsessive patients are orderly, punctual, and so
concerned with detail that they often do not see the
larger picture.
They may appear unemotional, even aloof, especially
when confronted with anything disturbing or frightening.
They have a strong need to be in control of everything in
their lives and may struggle with their doctor whenever
they feel that decisions are being imposed.
Underneath, obsessive patients are often frightened of
losing control and of becoming helpless and dependent.
Their physicians should try to include them in their own
care and treatment as much as possible.
Doctors should explain in detail what is going on and
what is being planned, allowing the patient to make
choices on his or her own behalf.

Patients from Different Cultures and

Backgrounds
Differences in race, nationality, and religion and other
significant cultural differences between patient and
interviewer can impair communication and can lead to
misunderstandings.
In addition, it may be difficult for a culturally naive
examiner to evaluate symptoms that are relative rather
than absolute.
There is usually no difficulty in documenting the presence of
auditory hallucinations regardless of cultural differences.
Assessing whether a delusion is bizarre (as required by
DSM-IV-TR for delusional disorder) is more difficult, however,
because the term bizarre has meaning only in reference to
cultural norms.
Apart from diagnostic categories, the vocabulary used to
describe emotional distress varies from culture to culture.
Sometimes, symptoms that are commonplace within a
culture are unheard of to outsiders.

Additional problems are encountered when doctor and

patient speak different languages. When an interpreter is
needed, the person should be a disinterested third party,
unknown to the patient.
Translators must be instructed to translate verbatim what
the patient say a difficult task for even the most
experienced professional translators. Some words and
expressions are simply untranslatable. It may be impossible
to convey a formal thought disorder through translation.
An additional difficulty can arise in establishing rapport
between doctor and patient of different ethnic or cultural
groups. Patients from minority groups may be guarded in
speaking with a doctor from the majority group.
The evaluating psychiatrist must proceed with humility and
respect. Rather than offer reassurances of understanding
and acceptance, it is usually better to ask, Have I
understood this in the way that you meant it?

Patients Who Do not Cooperate

Lack of patient cooperation can take many forms: failure to

keep appointments, refusal to talk or to take the session
seriously, failure to pay for services.
Causes of non-cooperation include manifestations of the
patient's underlying pathology, anger at the psychiatrist,
feelings of being coerced into an evaluation or treatment
against one's will, or manifestations of transference. How
the examiner responds depends on the setting and context.
The evaluation of an uncooperative patient during an
emergency necessarily proceeds differently from that
during non-emergencies; an emergency psychiatric
evaluation must often proceed without full cooperation or
even against the patient's will.
In such situations, sedation or restraint is sometimes
necessary to complete even a basic triage assessment. The
patient's refusal to cooperate is superseded by concern for
the patient's life and the safety of others.

 The patient who has been engaged in a meaningful

therapy for some time and then becomes
uncooperative is sending a powerful signal to the
examiner, the meaning of which must be explored.
The change in behavior may be a manifestation of
resistance to upsetting material that is beginning to
emerge in therapy or of transference. It may also be
in response to real life interactions between doctor
and patient.
Although transference and counter-transference are
important concepts in psychoanalytic
psychotherapies, their use in other modalities, such
as cognitive-behavioral therapy, may be inappropriate
and counterproductive.

 Little basis exists for pursuing the meaning of

uncooperative behavior when a examiner is meeting
with a patient for the first time.
The examiner may need to insist on change in the
patient's behavior as a precondition for proceeding. This
can be done in a nonjudgmental and non-punitive
manner.
For patients who cannot or will not cooperate, the
treatment contract may need to be renegotiated, for
example, by changing the frequency of sessions,
switching to a different psychotherapeutic modality, or
focusing on medication management rather than
psychotherapy.
In certain circumstances however, the initial assessment
or therapy has to be terminated because of a patient's
uncooperative behavior.

Practical Aspects of the Psychiatric

Interview
Session Length
The initial consultation lasts for 30 minutes to 1 hour,
depending on the circumstances.
Interviews with patients who are psychotic or medically ill
are brief because patients may find the interview
stressful.
Similarly, emergency room interviews vary in length.
Initial interviews to evaluate patients for
pharmacotherapy or psychotherapy tend to be longer;
second visits and ongoing therapeutic interviews vary in
length.
The American Board of Psychiatry and Neurology, in its
clinical oral examination in psychiatry, allows 30 minutes
for candidates to conduct a psychiatric examination.

Seating and Arrangement of Office

The arrangement of chairs in the psychiatrist's
office affects the interview.
Both chairs should be of approximately equal
height, so that neither person looks down on
the other.
Most psychiatrists think that it is desirable to
place the chairs without any furniture between
the clinician and the patient.
If the room contains several chairs, the
psychiatrist indicates his or her own chair and
then allows the patient to choose the chair in
which he or she will feel most comfortable.

Types of Interventions
Psychiatrists do much more during an interview
than ask questions.
They provide feedback and information, offer
reassurances, and respond emotionally to what
the patient is saying.
The psychiatrist's facial expression and body
posture also convey information to the patient.
Interventions are described as supportive or
obstructive depending on the extent to which
they increase the flow of information and
enhance or diminish rapport.

Ending the Interview

At the end of the evaluation, the psychiatrist
must give the patient his or her impressions
and suggestions, even if they are preliminary.
Patients seeing a psychiatrist for the first
time are often apprehensive. They wonder if
they are crazy, if their problems can be
understood, if they will be judged, and most
importantly whether they can be helped.