Clinical Examination in Psychiatry and Epidemiology of Mental Disorder
Every mentally-ill person is a special problem in diagnosis and treatment. Every mental patient is a unity, a unique example, suffering from some particular combination of events that has broken or is breaking his adaptations to life. The first task of the physician in determining the cause or the nature of the illness is the collection of pertinent data. Securing the record of the subjective complaints and the physical examination of the patient are arts, the systematic method of sorting and classifying the data and the making of a diagnosis from the facts secured is a science, and treatment is a combination of science and art. Errors in judgment, errors in analysis, errors in data, and above all errors in technique are among the reasons or sources of a mistaken diagnosis.
Interviewing remains the most basic skill of clinical examination in psychiatry. This is inspite of the major advances in understanding of the biological basis of mental illness.
Most psychiatrists, like other clinicians, are less proficient in their essential clinical skills than they realize. Interviewing, is a practical skill that the trainee can acquire by carrying out interviews under supervision and watching experienced interviewers at work. A sound knowledge of normal and abnormal mental phenomena is also essential.
Psychiatric interviews could be diagnostic or therapeutic. The former focuses on obtaining historical information and eliciting psychopathology that help the clinician to attempt diagnostic formulations. Therapeutic interviews, on the other hand, intend to bring about desirable change in mental and behavioral problems and are beyond the scope of this chapter.
The diagnostic interviews are essentially of two types. A freeform interview is directed by the clinician, allows the patient narrate his/her own story and fosters therapeutic relationship. However, with inexperienced interviewers, this may deteriorate into a social conversation and important themes may be forgotten. In standardized interviews, the wording of the questions is fixed. In semi-structured interviews, e.g. Schedules for Clinical Assessment in Neuropsychiatry (SCAN),1 there is an opportunity for interviewers to further explore the symptoms in order to determine their positive rating. No such explorations are allowed in structured interviews, e.g. Composite International Diagnostic Interview (CIDI)2 where the content, order and wording of the questions are fixed and as a result the patient may sometimes feel being interrogated. The standardized interviews are useful in research.
The constraint of time always provides a structuring framework for every interview. The interviewer should have a framework of questionnaire in mind while allowing the patient to tell his/her own story initially. As the story unfolds, it is fitted into the framework so that the gaps are filled up with further questioning.
Psychological experiences are private and personal. A patient would not normally share them with a clinician unless an atmosphere of trust and openness builds up between them, and the patient becomes aware of the confidentiality of the relationship. This relationship manifests in rapport (spontaneous emotional resonance between the client and interviewer) and lays the foundation for the subsequent interviewing tasks (collection of information, giving feedback, etc.). The relationship is established through an interpersonal interaction between the doctor and the patient. A desire to be helped enables the patient to expose his intimate thoughts and feelings. However, the following characteristics in the interviewer's approach to the patient contribute to the building of the relationship: respect for others, calm manner, genuine caring, nonjudgmental attitude, dependability, openness, warmth, honesty and consistency.
The interviewer must fully respect the patient regardless of his/her values, beliefs and social class. He cannot be the judge of the patient's life. Concern and interest should be expressed with a nonjudgmental attitude. The clinician should be open to all kinds of queries from the patient and at the same time should be spontaneous in his own enquiry. He should be honest, and consistent throughout the interaction.
These elements are useful even when the patient denies suffering and need for help as a result of lack of insight into the illness. Further aims of psychiatric interview are shown in Table 1.
Patients may be afraid that everyone else will hear about their problems. The interview should be conducted in a quiet room, relatively free from distractions. The chair of the patient should be ideally on the left side of a right handed individual and at the same level with that of the interviewer. This kind of setting puts the patient at ease and helps the interviewer take notes during the interview.
Patients should be given an opportunity to talk and be listened to attentively, particularly while describing the presenting problems. Attentive listening would encourage the patient to express thoughts and feelings. In order to listen effectively the examiner should face the patient, make eye contact, give full attention, nod head, say something like “I see”, so that the patient knows he is listened to. The interviewer should not let himself be distracted as far as possible.
The clinician must ask questions calmly and slowly. He should be thoughtful about what he asks and think about how the patient may feel in answering him. It is often useful to let the patient talk at his own pace.
The types of questions frequently asked in diagnostic interviews are shown in Table 2. Recent works3 favor the use of open ended questions in eliciting accurate information. The open ended question with checks and probes are to be used most liberally, e.g. to open the interview the examiner may ask “ tell me what brings you to the hospital”. Closed ended question need to be asked to review systems and to guide those patient who tends to talk profusely.
The interviewer may lead the conversation to get information but should continue to follow the patient's train of thought. If the patient talks about restlessness, he should be encouraged to describe the behavior further. He then should be asked what thought occurred to him, followed by how did he feel at that time.
Information about feelings are more difficult to obtain because many cultures discourage expression of feelings openly. When a safe environment is provided and the examiner appears caring and listens closely, most people would open up about their feelings. The examiner may recognize and respond to the patient's emotions in several ways that may seem appropriate during the course of the interview. The nonverbal cues may be recognized as “you appear tearful, your hands are trembling when you talked about your marriage”. Patients may be directly asked, “how do you feel”. Finally, the interviewer may enquire about any emotionally charged events in the family (e.g. quarrel, violence, drunken behavior, cruelty and neglect). The clinician must never assume that he knows how the person feels, rather he should listen to what the person has to say.
The interviewer should empathize with the patient by trying to imagine himself in the patient's position and understand how that person sees the world. The interviewer may ask himself—how does this person feel about his life, how does he view the world, what is best for this person to do?
It is possible to facilitate expression of the patient by telling him “please continue,” “ tell me more about it”, “I see”. Nonverbally, the examiner may sit slightly leaning forward, maintain eye contact, nod and smile appropriately.
Sometimes, the interview may not progress as smoothly as expected since the patient may not come out spontaneously with his problems or may like to raise unnecessary topics. The interviewer should try to control the interview in order to maintain the focus on the relevant issues. For example, calm manner and reassurance are particularly needed for an over anxious patient, whereas techniques of verbal and nonverbal facilitation should be used more with a taciturn patient. An over talkative patient may be initially told about the time limit, may need to be interrupted at the natural breaks and asked more direct questions. When the patient is hostile and resentful, the interviewer should talk about the circumstances of referral and try to persuade the patient that the interview is intended to be in his own interest. Some people may like to dominate the interview when the interviewer should interrupt gently and firmly, and ensure what is being said is relevant to the present problems.
The psychiatrist should see the patient first and obtain his permission before speaking with a family member. If any information provided by the patient needs to be discussed with the family member, the psychiatrist should also obtain the patient's permission first. Wherever possible, the patient should be present during discussion with the family. Patients with psychosis and delirium are the exceptions to these rules. Moreover, if the psychiatrist cannot obtain the patient's permission to reveal a plan for suicide or homicide and if the patient refuses hospitalization, the psychiatrist has an obligation to advice and to recommend commitment to an inpatient unit.
Table 3 shows the organization of psychiatric history.
This includes the patient's name, age, sex, marital status, occupation, income (of patient and family), language, religion, nationality, and a brief statement about the patient's place of residence and the circumstances of living. Omission of one or more of these items in written records could be a result of lack of thoroughness or countertransference problem of the interviewer. These data are useful in ascertaining the social class to which patient belongs.4,5 The relationship between mental illness and social class are reviewed elsewhere.6
Source and Reasons of Referral
This is to be mentioned clearly whenever applicable since such information provides useful background of the patient's illness and treatment.
Chief (Presenting) Complaints
Chief complaints are those for which the patient seeks professional help. These should be recorded in the patient's own words in chronological order.
History of Present Illness
Patient's version: The history begins with the examiner's impression of the reliability of the information provided. This is judged on the basis of consistency and coherence of the history, and its concordance with that of the informant. The interviewer should make an attempt to establish the nature of the problems volunteered by the patient. The problems revealed by questioning should, however, be separately mentioned. Once this is over, the following details have to be elicited.
Onset: The patient should be asked when he was entirely well or when he first sought medical or other help. Sometimes, use of anchor dates like birth days and marriage anniversary can improve the accuracy of recall. However, there will be no clear dating of onset of the problems emerging from personality disorders.
Precipitating factors: These are the events that occur shortly before the onset of the illness or appear to have induced it. The interviewer should find out whether the patient considers that any physical (seizure, trauma, substance misuse, prescribed drugs) or psychosocial (stressful life events) factor was related to the onset of the illness. While doing this the interviewer must remember that the patient's recall of life events may be poor or he may causally link his problems to an event which could very well be a result of his illness, e.g. losing a job during a depressive episode. In order to minimize these effects the clinician should set limits to the period (one, three or six months), accurately determine the onset of the illness, concentrate on the events ‘independent’ of the illness, (e.g. birth or death) and use semi-structured interview schedules like Presumptive Stressful Life Events Scale (PSLES).7
Recognizing precipitating factors, when present, helps in reaching a diagnosis, formulating treatment and in preventing the illness in future.
Mode of onset: This may be abrupt, acute, sub-acute or insidious. Mode of onset often gives clue to the cause and has implications in prognosis.
Development of symptoms (and their change in frequency and intensity over time, and whether they co-vary or take an independent course).
This may indicate whether there is a single or multiple disorders.
Effects of the symptoms on the following:
- Self: Giving rise to euphoria or distress.
- Other mental functions: Leading to impairments like lack of concentration, inefficient thinking, poor recall, indecisiveness, anxiety or depression.
- Biological functions: Sleep, appetite, bowel and bladder habits, sexual function.
- Social functioning: Leading to disabilities like decreased ability to work, managing day to day chores, enjoying hobbies, or making use of leisure.
- Interpersonal relations: Any change in the quality of relationships with family members.
- Law: Any legal problems, arrests, ongoing cases in the court.
The extent of these problems would determine the severity of the illness.
Any perpetuating factor of the illness, which may be again physical (concomitant illness), or psychosocial (chronic stressors or conflicts) or consequences of the illness (secondary gain, relief drinking in alcoholism).
A negative history has then to be taken by enquiring about the physical or mental symptoms not elicited so far. This is necessary while making comorbid diagnoses or arranging the symptoms in a hierarchical order.
Treatment history: Nature and duration of treatment, any hospitalization and any response to treatment given so far have to be recorded. This could be obtained from the referral letter and other papers of previous consultations. At this stage, the examiner should be able to make certain diagnostic impressions in his mind so as to keep the rest of the interview most relevant and meaningful.
Informant's version: A remark should be made on the reliability of the information. Informant's observation on the patient's behavior, functioning, lifestyle and habits should be recorded here. A careful amalgamation of patient's and informant's versions is to be done while writing the diagnostic formulation. Information by an independent observer is of crucial importance in Psychiatry than in other branches of Medicine, since patients may deny illness due to lack of insight, or provide information distorted by psychopathology, or have poor appraisal of personality in cases of personality disorders.
Physical illness: Date, duration of illness, operation, accidents, etc. nature of treatment and any sequele.
Psychiatric illness: Symptoms, date, duration, nature of treatment, any hospitalization and response to treatment. All the prescriptions and the reports of investigations available should be utilized in this regard. Past history may greatly contribute to diagnosis, which depends on both longitudinal and cross-sectional profile of the illness.
Forensic history: Any history of delinquency, criminal offenses, illicit drug use, including punishments received. This may throw light on the personality and, on occasion, such behavior may be a manifestation of mental disorder.
Here onwards, begins the biography of the patient. This throws light on the hereditary and environmental forces influencing the development of the individual. This indicates predisposing factors toward the illness.
The interviewer should draw the family tree (family of origin) preferably covering at least three generations (this will indicate the nature of heredity). The interviewer should record the following details about the first degree relatives (parents and siblings).
If alive, present age. If dead, age at death and the cause of death. This may be relevant to the diagnosis, e.g. loss of mother below the age of eleven, in case of female patients, seems to contribute to later development of depressive illness. The cause of death, e.g. suicide, alcohol related accident or liver disease could suggest a familial illness. Similarly, family history of death of a brother from heart failure due to rheumatic heart disease may explain the patient's concern about chest pain. Reaction of the patient at the time of parent's death needs to be enquired into.
Separation, divorce or remarriage of the parents needs to be enquired about. Was there any prolonged absence of the parents through illness, service or marital discord? What was the nature of marital discord? In case of separation or divorce, how did the patient respond to this event? Did it cause any particular problems? If brought up by others, how did he react?
Educational background and occupational history of the first degree relatives should be asked. This will indicate the intellectual and social adjustment with which patient's own attainments could be contrasted. If there is a discrepancy, this will need to be explained.
Personality and quality of relationship to the patient may be elicited through the following enquiries, e.g. tell me about your father? What sort of person was he? What kind of person was your mother? How well did they get long? Was there any major disagreement between them? How did you get on with each one of them? Were they warm and supportive toward you? Could you confide anything in them? How would they respond? Were you encouraged to become independent?
Some personality characteristics may have definitive impact on the personality development and contribute to later development of deviant behavior or neurotic disorder, e.g. parental violence, misuse of alcohol, criminal behavior, unduly punitive, restrictive or inconsistent attitudes, or undue leniency.
The interviewer should next enquire about the family history of any illness, viz. mental illness, mental retardation, suicide, abnormal personality, alcoholism and drug abuse, epilepsy, movement disorder, dementia, and early death. Nature of the symptoms, duration of the illness, any hospitalization, impact on social and occupational functioning, treatment received and the outcome must be detailed from the patient or a key informant.
It is necessary to go into the various components of the support system, viz. sources (family, friends and organizations), types (instrumental, i.e. material or tangible, and emotional or esteem enhancing), actual behavior (who did or said what when support was last needed) versus perceived support (who you feel you can call on when need arises), and negative versus positive aspects of support. Some kinds of emotional support may hinder recovery and render relapse more likely. Taking over the roles of the patient that is more than justified by the illness, fussing over the patient, getting too involved in his problems, non-acceptance of the illness of the patient, and showing negative emotions may be harmful to the patient. Assessment of the support system is relevant to the management and rehabilitation of the patient.
The interviewer must collect some information on all the areas and expand on other pertinent areas as it is impossible to obtain the complete history of a person's life. Personal history needs to be recorded in the following way.
Prenatal history: The psychiatrist should find out whether the patient was a planned/wanted child, any problems during mother's pregnancy or delivery, any evidence of defect or injury at birth, and the parents’ reaction to the gender of the patient.
Early childhood (0−5 years): It is customary to ask about the developmental milestones8 from the mother. The details are particularly required in cases of developmental disorders. The quality of mother and child interaction during feeding is more useful than finding out whether the patient was breastfed or bottle-fed.
Could the baby single out the mother? What was the activity level? Was there any early disturbance in the sleep pattern? Was there any problem in the resolution of stranger anxiety? What was the age of gaining control over bladder and bowel? Was there any problem in toilet training? How was the early play with body parts and toys? Who were living in the patient's home? What were their roles in upbringing of the patient? Was there any serious illness during this time, especially affecting the central nervous system (CNS), e.g. febrile seizures, exanthematous fever or any head trauma that might have interfered with normal development.
Middle childhood (5−11 years): The quality of relationship of the patient with his siblings. If any, may influence the social adaptation of the patient. It is necessary to ask about any sibling rivalry as well as positive or supporting relation with the siblings. The latter may be occurring when the patient was rejected by the parents. Death of a sib before the birth of the patient or during the formative years, may lead to emotional disorder of the mother who may be unable to offer emotional nourishment to other children.
Play is a useful area to explore in studying the growing capacity for social adaptation and developing ego structures, which will indicate the future personality. The ability to concentrate, tolerate frustration, cooperate with peers, understand and comply with the rules, and any intellectual play should be enquired.
Unmet emotional needs as well as exaggerated power struggles give rise to the various problems in childhood, including thumb sucking, temper tantrums, tics, nightmares, fears, eating disorders, excessive masturbation, bed wetting and nail biting. The predictive validity of these early neurotic traits to later mental disorders is, however, not known.
Schooling provides important clues regarding intellectual, social and moral development of the patient. How did he take the first separation from mother? Did he make friends easily? Was he popular? Did he belong to gangs or groups? How did he perceive his teachers? How did he compare himself with other children? Was there any problem with discipline? Was there any failure or discontinuation or change in school. If so, what were the reasons? Was there any prolonged absence? What were the reasons? How was the ability to read, write and learn, and ability to concentrate on the task at hand? How was the activity level? Early patterns of assertion, impulsiveness, aggression, passivity, anxiety or antisocial behavior often emerge in the context of school relationships.
Later childhood (adolescence): The unfolding and con-solidation of adult personality occurs during later childhood. During this time, through relations with peers and group activity, a person begins to develop independence from his parents. The psychiatrist should attempt to define the values of his social group and whom he idealized. To what extent did he become independent from the parents?
The progress in secondary education should be explored. Was there problem with teacher, peers or rules? Any discrepancy between potential and achievement should be noted with reasons. Results in public examinations and subsequent higher education, achievements, and any disruption should be noted.
Adolescence is also the time of experiencing various problems, like emotional problems (anxiety, inferiority feelings), physical problems (weight loss or gain) and behavioral problems (experimentation with drugs, antisocial behavior, running away from home).
Psychosexual history: The interviewer should use discretion regarding how much to ask in this area. The questions should be asked in a matter-of-fact manner, e.g. “do you mind if I ask you regarding physical aspects of relationship?” Enquiries should be made about any infantile sexuality, sexual curiosity or sexual games during early childhood, or any history of sexual transgression on the patient during childhood? How did he react? How did he learn about sex? Was he instructed adequately? Did he have any misconceptions? What was the attitude of the parents to sex and its development? How does he recall his reaction to achieving a true sense of sexual identity and maturity; any problems did it give rise to? How did he feel about the onset of puberty and secondary sexual changes? Was there any precocity or any embarrassment? Did he masturbate? What did he use to think at that time? Any dating, heterosexual experiences, any inclination toward his own sex, or any homosexual relations? Whenever necessary, interviewer should ask about any promiscuity, incestuous behavior and asexual deviant practices, and any history of contracting sexually transmitted disease?
Occupational record: Type of jobs the patient has had, duration, reasons for changes, any period of unemployment, income at different stages (provide guide to his progress), ways of coping with his work, e.g. overconscientious, difficulty in delegating to others, tendency of double checking, reluctant to take holidays, level of job satisfaction. For retired people, the way time is spent and satisfaction with work, if any, should be asked. Occupational record may indicate the level of stress at work, as well as personality traits. Was there any service or war experience, promotion, awards received or any disciplinary problems?
Menstrual history: Age of menarche, attitude to periods, regularity and amount, any dysmenorrhea, premenstrual tensions, age of menopause, any symptoms, and date of last menstruation. How did she learn about menstruation?
Marital history: The time the couple had known each other, previous relationships and marriage engagements, ages and occupation at marriage (indicate their compatibility), parental consent, health, present age, occupation and personality of the spouse. The quality of marital relationship is indicated by (a) adequacy of sexual relationship, (b) methods of contraception/family planning, (c) the way in which roles are allocated between the partners-sharing of decisions and responsibilities, (d) extent to which each partner is involved in outside interests and relationships, (e) possibility of extramarital relationship to be considered with discretion, and (f) present couple living as nuclear/extended/joint family-relationship with others. Date of birth of the children and their age, health, education, occupation, any problem in their development and in relationship, and any illness during pregnancies in case of women.
The patient's personality consists of his life-long persistent and enduring characteristics and attitudes, including ways of thinking (cognition), feeling (affectivity) and behaving (impulse control, and ways of relating to others and handling interpersonal relation). Personality traits may contribute to or influence the manifestations of a mental disorder in several ways. Personality may change following severe emotional trauma, brain damage, or mental disorder, when it becomes imperative to know about premorbid personality.
Premorbid personality may be assessed from the patient (recall may be distorted due to illness particularly when the illness is recurrent and thus certain allowance should be given to this), close relatives and colleagues who know him well, and observing his behavior at interview.
Premorbid personality should be described under the following headings:
Self: How does he describe himself? What kind of person is he? What are his strengths and abilities? What are his shortcomings? Does he see himself as worthwhile? Can he plan ahead ? How resilient is he in the face of adversity? How assertive is he? What are his hopes and ambitions?
Relations: Does he prefer company or solitude? Is he shy or makes friends easily? Are the relationships close or lasting? How is his relation with people of his own or opposite sex? How does he handle others’ mistakes or inconsistencies? Does he always want to be the center of attraction? How does he tolerate others’ criticisms?
Work and leisure: How is his relations with workmates or superiors (vide occupational record)? What are his hobbies and interests? Is he affiliated to any society, club or organization?
Mood: What is his mood like? How changeable is it? How quickly the mood changes appear, how long they last, do they follow life events? Can he express feelings of love, anger, frustration or sadness? Does he ever lose control over his feelings? Has he ever been violent? Is he usually anxious, cheerful, despondent, optimistic, pessimistic or self-depreciating?
Character: While taking the personal history, the interviewer will already have gathered some impression of character. Further information should he sought by asking whether he was reserved, timid, self-conscious, sensitive or suspicious, resentful or jealous, irritable, selfish, or self-centered.
Attitudes and standards: Attitudes to the body, health and illness, as well as religious and moral standards should be asked for. Personal history would have indicated about some of these.
Habits: Use of tobacco, alcohol, drugs, and food habit should be asked for.
It is not a must that the personality of the patient has to resemble any of those described in the present classificatory systems. In fact, a person is likely to have a mixture of various traits. However, the examiner should always try to make a balanced assessment of the positive and negative attributes of the personality of the patient. If there is any doubt of abnormal personality further assessment may be done with International Personality Disorder Examination (IPDE).9
Mental Status Examination
Mental status examination (MSE) is defined as a standardized format (Table 4) in which the clinician records the psychiatric signs and symptoms present at the time of the interview. This appears to correspond to the physical examination in medical cases. MSE reveals conscious mental experiences (phenomenological data) and several of them rely on the subjective information provided by the patient. Physical examination, on the other hand, is done in a much more objective way. MSE conducted efficiently generates reliable data of high diagnostic utility. However, the fact that a small sample of behavior of the patient is observed in a rather artificial situation tends to limit the scope of MSE.
The techniques involved in doing MSE are shown in Table 5. It is evident that the interviewer will have gathered information on most of the areas of the mental state whilst taking the history. The clinician should offer a lucid account of his observations to substantiate his conclusions. This makes the MSE a reliable document for potential use by other clinicians in future. The observations made in the MSE should be evaluated against the background information from the family members who have observed the patient in real life situation.
The nursing and occupational staffs may observe an in-patient over a greater length of time. Their reports include the behavior in the ward, interpersonal behavior, any variability from time to time over day, and any difficulties over a given task. The psychiatrist should pay a great deal of attention to these reports while interpreting his own observation.
Mental status examination should describe all the areas of mental functioning. However, some areas may deserve differential emphasis according to the clinical impressions that may arise from the history, e.g. it is necessary to expand on mood and thought in depression, while cognitive functions and mood need more emphasis in dementia.
Mental status examination is a hierarchical examination and cannot be approached haphazardly. If inattention is missed early in MSE, memory and higher cognitive functions may be improperly judged. Similarly, if aphasia is missed, the thought content may be misinterpreted as psychosis. The outline of MSE followed here is shown in Table 5.
Consciousness is best conceptualized as having two components viz. alertness and awareness. The former refers to the readiness to respond to a stimulus and is maintained by the state of activation (arousal) of the cortex by the reticular activating system. Awareness (content of consciousness) refers to the higher cognitive and emotional functioning, and is sub served by the faculty of attention. Alertness and awareness can vary independently and the final level of consciousness represents a dynamic balance between cortical and ascending reticular activating system. In neurological sense, only alertness is assessed whereas a true appreciation of the level of consciousness must include assessment of both the components.
There are three aspects in the assessment of the level of alertness. First, the intensity of stimulation needed to arouse the patient should be indicated: calling the patient's name in a normal conversational tone, calling in a loud voice, light touch on the arm, vigorous shaking of the shoulder, painful stimulation. Second, the highest level of responses should be described. This is best done with the Glasgow Coma scale10 in which a numeric value is given to the best response in each of the three categories (eye opening, verbal, motor). Third, it is helpful to make a chart in the progress notes so that a rapid assessment of changing levels of consciousness can be made. This can be done objectively with the Glasgow Coma scale at regular intervals and plotted as a graph.
Most clinicians distinguish five principal levels of alertness representing different points on a continuum: normal alertness, somnolence, obtundation, stupor and coma.
Early or subtle changes in consciousness may only involve awareness of the environment with little or no change in alertness. This predominantly manifests in impairment of attention and other cognitive functions. Thus, the assessment includes behavioral observations (viz. neglect of appearance and needs, slowed responses, losing thread of conversation, episodes of incontinence and altered sleep wakeful cycle), formal tests of attention as well as comprehension, orientation, memory, other changes in mental status such as illusions, hallucinations (visual and tactile mainly), fleeting delusions, perplexity and euphoria, and any change in the mental state over the day.
In psychiatry, global assessment of consciousness is important with an emphasis on altered awareness. Following disorders of consciousness are relevant in psychiatry: delirium, clouding of consciousness, twilight state and stupor. The interested reader is referred to references.11,12
General Appearance and Behavior
Although MSE is based on mainly what the patient says, observation of nonverbal behavior can offer a great deal of diagnostic clues.13 In doing this, however, the examiner must not forget to take into account the nuances of personality and sociocultural background of the patient, as these to a great extent shape the customs of grooming and social behavior.
The examiner should note the appearance of the patient for chronological age and his body build. Height and weight need to be recorded in certain cases. A lean and thin appearance with clothes that appear too loose might suggest recent weight loss and may occur in physical illness (e.g. malignancy), anorexia nervosa and depression.
Personal cleanliness (indicated by the state of skin, hair, nails, teeth and beard), the dress and grooming, and their appropriateness to the situation should be described next. Self-neglect suggested by untidy dress and dirty look may be associated with several conditions such as dementia, schizophrenia, depression and substance use disorders. Patients with mania may prefer colorful dress and make excessive use of cosmetics (women). Dress inappropriate for sex, e.g. men wearing women's clothes and make-up may suggest transvestism or trans-sexualism. Any asymmetry in cleanliness or dress, e.g. unshaven left side of the face, undone hair of the left side, may indicate sensory inattention due to nondominant parietal lobe lesion.
Facial expression, eye contact and posture are the most obvious nonverbal indices of the patient's mood. The examiner should describe the facial expression as well as its mobility during the conversation. In depression, the patient's eyes are often downcast with medial ends of the brows raised obliquely, vertical furrows in the forehead and down turning of the corners of the mouth. In severe depression, this look of misery may be unchanging. The patient sits with the shoulders hunched up, head bent forward, with arms kept close to the body. A still, expressionless face may be seen in chronic schizophrenia as well as in parkinsonism (idiopathic or drug induced). Anxiety in general may be associated with raised eye brows, widening of the palpebral fissures, mydriasis and the presence of horizontal furrows on the forehead. The patient sits upright on the edge on the chair with head erect, with fine tremor of the hands and perspiration over the face.
Social Behavior and Attitude
The examiner should note how the patient relates to him. For example, an anxious patient may relate in a tense manner. A depressed patient may be withdrawn, may not exhibit the usual social smile, and make few social contacts with the examiner. Increased social contact, with over familiarity and disinhibition, may characterize the manner of relating in a manic patient. A schizophrenic patient may be guarded or aggressive during the interview. Inappropriate, odd responses may be seen in mental retardation, dementia or delirium. The attitude of the patient may be assessed in the areas of cooperativeness, friendliness, trust, purposefulness, seductiveness, ingratiation, hostility, evasiveness and guardedness.
An instantaneous emotional resonance between the patient and the interviewer usually develops early in the interview (vide supra). It is necessary to indicate whether rapport is established or not. It is difficult to establish rapport with patients with psychosis (e.g. schizophrenia) and certain personality disorders (e.g. antisocial personality). A positive rapport is necessary for a constructive therapeutic alliance.
Motor Behavior (Conation)
This can be assessed by observing the patient enter the interview room as well as his movements during the interview.
Usually, the gait is examined in a neurological sense. However, observation of gait is worthwhile in several psychiatric conditions. This is done as the patient enters the interviewer's room. Unusually, slow gait may occur in depression. Slow rigid gait with short shuffling steps, with loss of automatic associated movements, is associated with parkinsonism. Manic patients may walk relatively fast. In schizophrenia, gait may be abnormal due to mannerism, ambitendency or blocking of the movements. Broad-based staggering gait, with tendency to collapse at intervals and to cling to the nearest person for support, is seen in dissociative paraplegia (astasia-abasia).
A normal individual may change the posture to get more comfortable, use gestures appropriate to his needs and context of conversation. An exaggeration of normal movements is seen in anxiety disorder (fidgeting with an object and frequent change in posture). The examiner should make following observations of the patient's motor behavior: How fast does the patient initiate and carry out the movements? Is the speed uniform throughout the movement? Are the movements goal-directed? Does the patient show appropriate gestures? Do the movements occur spontaneously or in response to any stimulus?
Underactivity may be due to psychomotor retardation (as in retarded depression) or obstruction (as in catatonia). The former uniformly slows down the movements. Whereas, the movements are rather irregularly interrupted in catatonia. Increased goal directed activities occur in mania as well as in obsessive compulsive disorder (compulsive acts). Aimless increased activity is seen in severe agitation (wringing of the hands, pacing up and down, etc.), in depression and in akathisia (constant movements of the legs) due to neuroleptic drugs.
Certain catatonic features become obvious on inspection during the interview, e.g. stereotypy, echolalia, echopraxia, while other catatonic features such as automatic obedience, waxy flexibility, cooperation, and negativism may have to be elicited. Presence of catatonia indicates organic as well as functional psychoses.
Hallucinatory behavior in the form of muttering to self, making gestures at imaginary figures, keeping the head tilted at an angle while listening to the voices should also be described here.
Tardive dyskinesia (central or peripheral), tremor, dystonia, chorea, athetosis, tics and other involuntary movements should be described according to the following points: parts of the body affected, present only at rest, on movement or both, does voluntary movements increase or suppress it, is it affected by emotion, is it altered by eye closure, does it persist in sleep, if the patient is aware of it, can he describe its onset, and is it present when the patient does not know he is being observed.
Speech can be described in terms of its quantity, rate of production, and quality. The patient may be described as talkative, garrulous, voluble, taciturn, unspontaneous, or normally responsive to cues from the interviewer. Speech can be rapid or slow, pressured, hesitant, emotional, dramatic, monotonous, loud, whispered, slurred, staccato or mumbled. Speech impairment such as stuttering, are included in this section. Any unusual rhythms or accent should be noted. The patient's speech may be spontaneous.
Mood and Affect
DSM IV25 defines mood as ‘a pervasive and sustained emotion that colors the perception of the world’. Common examples include depression, elation, anger and anxiety.
The assessment of mood includes:
Quality: This is assessed in two ways: (a) subjectively—by asking the patient ‘how do you feel in yourself’ or ‘how do you feel in your spirits’, (b) objectively—this is to be based on history, general appearance, behavior, posture and speech. Types of quality include euthymia, euphoria, elation, dysphoria and irritability among others.
Stability: To what extent mood is consistent over the day.
Reactivity: Change of mood with external events.
Persistence: How long does the mood last, i.e. days, weeks, months.
According to DSM IV, affect is a pattern of observable behavior that is the expression of a subjectively experienced feeling state (emotion). Affect is a variable over time in response to changing emotional states, whereas mood refers to a pervasive and sustained emotion.
The following aspects of affect need evaluation:
Quality: (vide supra)
Range: The spectrum of emotional changes displayed over a period of time in reference to various themes or topics during the interview. It is interpreted as full, increased (in mania), or constricted (in depression or schizophrenia).
Appropriateness: Congruity of emotion to the prevailing thought or speech. A normal person usually shows various emotions in relation to the various topics. For example, when the subject giggles on the matters of recent death of mother, it is an inappropriate affect which is hardly communicated to the interviewer. This is seen in schizophrenia (e.g. hebephrenic type).
Mobility: The ease with which affect changes from one mode to the other. This is decreased in depression (monotonic affect) and increased in mania. Rapid changes of affect from one mode to the other is called lability. This may occur in organic brain syndrome (e.g. dementia, pseudobulbar palsy), drug intoxications, early in schizophrenia, and some types of neurotic or personality disorders.
Relatedness (communicability): Capacity to connect with the interviewer, usually present in mania with infectious jocularity but absent in schizophrenia.
Intensity of expression (depth of affect): Increased in mania, and certain personality disorders, and decreased (blunted) or absent (flat) in schizophrenia.
What is considered the normal range of the expression of affect varies considerably both within and among different cultures. It is thus essential to describe affect under several parameters so as to minimize the examiner's bias or error in assessment.
Speech (verbal behavior) is the vehicle of thought. Thus speech, language and communication become essential parts of the examination of thought. There are four aspects of thought: stream, form, possession and content. The interviewer must document verbatim samples of speech and, if required, written samples in order to substantiate the inferences.
Stream: The examiner should comment on rate, reaction in, quality, volume and tone of speech.
Rate of speech refers to the number of words spoken in a given time. Decreased rate with increased pauses in between the sentences is associated with retarded depression and dementia. In the process, the reaction time (interval between question asked and responses from the patient) may be prolonged. Rate may be increased with shortened reaction time (acceleration) in mania.
Quantity of speech may be reduced in depression and in schizophrenia with negative symptoms. In extreme form, speech may be reduced to monosyllabic answers. Decreased quantity is also seen in shy and less intelligent people. Quantity is increased in mania either in the form of volubility (copious amount of goal directed speech) (logorrhea) or pressure of speech (uninterruptible). Increased quantity without acceleration may be seen in anxiety disorders, anankastic personality and hypochondriasis.
Volume is low in depression, often punctuated by sighing with a drop in volume, giving an impression of mournful cadence. Manics speak in volume louder than necessary. Restricted normal variation of tone with low pitched voice is seen in depression. A monotonous voice without low pitch occurs in negative schizophrenia and parkinsonism.
Form: Normal form indicates that thought is logical, coherent and sequential, makes use of symbols and is goal directed. Disorder of form of thought may mean abnormalities in language, communication or thought per se. The diagnostic specificity of thought disorders is rather low. This is in contrast to the previous views.
Doubts about abnormal form is raised when the patient's speech is poorly understandable. This could be either reported by the informant or recognized by the interviewer. It is also tested by asking the patient to describe verbally or in writing a neutral topic that is unrelated to the delusional system of thinking, e.g. patient's profession, religion, climate etc. at length. While analyzing the sample, the examiner should look for the following characteristics.
Are there logical and meaningful (semantic) connections between the successive ideas? If not, there is likely to be shift between two sentences or in the middle of a sentence. Then the examiner should check whether these shifts are based on some understandable and superficial (e.g. phonetic) connections like clang association (words rhyming), punning (words with more than one meaning), assonance (words sounding similar), word association or any external cues. If so, that will indicate flight of ideas which, when associated with pressured speech, is often seen in mania. When no such connections (semantic or phonetic) are found but the grammatical structure (syntax) is preserved, the shifts between the ideas make the speech difficult to understand and indicate loosening of association (derailment), which is seen in some cases of chronic schizophrenia. When the grammatical structure is also lost, the speech is reduced to a string of unrelated words called verbigeration (word salad, incoherence).
Are the responses relevant to the question? If there is a shift between the question and the answer, the reply is made in an oblique, irrelevant manner (tangentiality).
Is the amount of speech more than the information it conveys so that the content becomes vague and lacks in focus (poverty of content of speech)?
How goal directed is the speech? Does it reveal tedious, boring details and is long winded in reaching the goal (circumstantially)?
Is the patient able to shift focus whenever required? If not, there will be persistent repetition of words, ideas, or subjects beyond the point of relevance (preservation).
Is there any coinage of a new word or a known word used in a personal way (neologism)?
A written sample of speech could be further subjected to certain linguistic tests: (i) type/token ratio: ratio of different words to the total number of words.14 A low score means limited language repertoire. (ii) cloze score: every fifth word in the paragraph is obliterated and normal people are asked to guess the deleted word.15 The cloze score is the ratio of number of correct guesses to the number of words deleted and measures the readability of language, (iii) contextual constraint refers to the extent the language is grammatically correct.16 The practical utility of such tests is limited at present, although they were originally used to explain thought disorder in schizophrenia.
There are further tests for thought disorder. Inability to maintain conceptual boundaries (over inclusive thinking) is tested by asking the patient to make conceptually similar sortings from several dissimilar objects. Impaired abstraction (vide supra) is tested by proverb test. Idiosyncratic personal constructs based on Kelly's personal construct theory is tested by Bannister and Fransella grid test.17
For detailed reading on the various types of thoughts disorder, the reader is referred to further references.18–21
Possession: Normally, the subject experiences his thinking as having two qualities: sense of personal possession and sense of control over his thinking. Disorder of the former is alienation experiences and of the latter indicate obsessions and compulsions. However, these are currently subsumed under content of thought.
Content of thought: This includes:
- Preoccupation: It is repetitive reference to one major idea. This could be normal or morbid. The latter has the quality of worries, i.e. unpleasantness, not being controlled with diversion of mind, and excessive to the topic worried about. The content of the preoccupation could be ideas of reference, persecution, grandeur, worthlessness, hopelessness, sin, guilt, nihilism, wishes, suicidal ideas, impoverishment, hypochondriasis, or dysmorphophobia.
- Phobia: Patient should be asked, when people get anxious and panicky they often feel their heart beating fast, or they start shaking or sweating, or cannot get their breath. Have you had feeling like that? Does it occur only in certain situations? If the patient says yes, their exact nature has to be clarified. While describing phobia, the examiner should mention, the extent of avoidance, anticipatory anxiety, any generalization to other innocuous situations and other commonly associated anxiety symptoms, viz. panic attacks and free floating anxiety.
- Obsession: Do you have any thoughts which keep coming to your mind. Are they unpleasant or unwanted thoughts? Do you try to resist them? Do you ever find you have to do anything repeatedly like washing things repeatedly that are already clean? How do you feel about it? How much does it interfere with your daily life? The examiner should describe the obsession with its content (ideas, thoughts, doubts impulses, imagery, rumination, phobia, symmetry and the orderliness), associated compulsions (motor or mental, yielding or neutralizing), along with slowness (primary or secondary). The most important quality of obsession is the ego dystonic quality (that they are intrusive and inappropriate and they are not normally expected to occur in mind, not merely a part of worries about day-to-day events, and cause distress). Ego syntonic obsession-like ideas occur in anankastic personality, schizotypal disorder and in psychosis as a symptom.
- Somatization: Although this must have been indicated from history, it is important to ask about all the somatoform symptoms.
An overvalued idea is an unreasonable belief maintained with less than delusional intensity (i.e. the person is able to acknowledge the possibility that the belief is not true) and held idiosyncratically (i.e. not shared by the members of his sociocultural group). However, it is understandable in terms of the circumstances and the development of a particular personality. Such ideas, sometimes, may be normal.
A delusion is a false, incorrigible (briefly or not at all susceptible to change by experience or evidence to the contrary) conviction or judgment based on incorrect inference about external reality, and out of keeping with socially shared beliefs. Primary delusions are incomprehensible in terms of life history and personality of the patient (delusional mood, sudden delusional idea and delusional perception) and are usually characteristic of acute schizophrenia. Secondary delusions arise from either a morbid mood state (when they may be mood-congruent or mood-incongruent) or personality trait like suspicion. There could be delusional elaboration of a primary phenomenon like hallucination or thought alienation experience. Induced delusions mean that the delusion of a psychotic patient is shared with a previously normal person(s) when they are emotionally dependent on each other over a long period of time. This may involve two (folie a deux), three (folie a trois) or four (folie a quatre) people. Once a half-a-dozen or more people share a belief, it is likely to be subcultural and within the range of normal behavior.
Delusions would have been indicated from the history. When not, certain screening questions should be asked to the patient.
Primary delusions: Have you had the feeling that something odd is going that you cannot explain? Do you feel puzzled by strange happenings that are difficult to account for (delusional mood)? Did the idea occur to you fully formed (sudden delusional idea)? When you saw… the event (an example of misinterpretation) how did you know what it meant? Is there any explanation (delusional perception)?
Other questions: Can you think clearly or does there seem to be some kind of interference with your thoughts? Are you fully in control of your thoughts and actions? Have you felt that people are unduly interested in you? Have you felt that things were arranged so as to have a special meaning, or even that harm may come to you?
Once the content (reference, persecution, grandiosity, erotomania, jealousy, guilt, control, thought broadcast, thought insertion, etc.) is clear, it is important to go on assessing the following aspects of delusions.
- Degree of conviction: By confronting the patient with evidence to the contrary. The level of certainty may vary or may be concealed. At times it is inferred from the behavioral responses
- Systematization: A delusion often has an organizing nucleus and a system of other ideas to support it. Systematization refers to what extent the system is logical and internally consistent, thus, when the basic idea is accepted, the rest should get automatically explained
- Bizarreness: This indicates to what extent the patient's culture would regard the phenomenon of his delusion as implausible
- Involvement of other areas of life and relationships
- Affective responses
- Acting upon the delusions
- A delusion without d, e, f, is described as encapsulated.
When multiple delusions are present it is important to find out the interconnectedness of these delusions or whether they are multiple. This could be of diagnostic importance.
Perception refers to the process of being aware of a sensory experience and being able to recognize it by comparing it with the previous experiences. Disorders of perception include the following:
Sense distortions: (a) changes in intensity, e.g. hyper- or hypoesthesia, (b) change in quality, e.g. colored perception of the visual stimuli, (c) change in spatial form (dysmegalopsia), e.g. micropsia or macropsia.
The interviewer should ask the following questions in relation to this area. Do things seem to change in size or shape or color in a puzzling way? Have things looked gray or flat lacking their usual color and detail? Do surroundings seem unnaturally clear, objects look vividly colored, or pattern seem particularly vivid and interesting?
Experiences of sense distortion may occur in depression (decreased intensity), mania (increased intensity), prodromal phase of schizophrenia, drug induced states and in delirium.
Sense deceptions: This includes illusion and hallucination. Behavior suggestive of experiencing hallucinations would have been indicated in the history or from the nurses’ report in case of inpatients. In other cases, the interviewer should open the area tactfully. The patient may be asked, ‘do you ever seem to hear noises or voices when there is nobody about or see or feel things that others cannot’? Once the modality is clear, it is essential to ask about other modalities, if relevant. The interviewer should look for the following features: (a) continuous or discontinuous (frequency), (b) three dimensionality—voices can be located to a point, at a distance, visual images have the three dimensional qualities, (c) clarity and veridicality, i.e. life like qualities, (d) control—when the experience can be started or stopped by the subject on his will, (e) objective or subjective space: whether the experience occurs within the inner space of the mind or from external space, (f) content and emotional reaction, (g) elementary, partially formed or formed, (h) insight: whether the experience is true or a product of imagination.
Based on above characteristics, distinction has to be made among true hallucination (which has true-to-life quality, occurs in the objective space, cannot be controlled and the person lacks insight), pseudohallucination (lacks clarity and vividness, occurs in the subjective space, cannot be controlled and the person retains insight) and imagery (has the qualities of pseudohallucination and is in the person's control). In case of auditory hallucination, further enquiries have to be made on the lines of Schneiderian hallucinations. Do your hear voices commenting on thoughts, repeat what you are reading or doing? Do you hear single or multiple voices? Does the voice refer to you in second (as you) or third (he or she) person? Do the voices talk among each other about you? Second person auditory hallucination should be distinguished from delusion of reference. In case of visual hallucination, it is necessary to distinguish it from illusion. Dissociative experiences (talking to, seeing other well-known persons in the context of religion) should be distinguished from true hallucination.
Enquiries about special types of hallucination also have to be made (autoscopy, synesthesia, cenesthopathic, fantastic, functional, reflex hallucination).
Other Psychotic Phenomena (Somatic Passivity)
This may be elicited by asking the patient “do you feel that your will has been replaced by that of some force or power outside yourself, e.g. voice, action, thought, impulse, affect? Do you feel some sensations are caused by external agencies?”
Other experiences: (derealization, depersonalization and body image disturbances).
Have you felt that the world is unreal only like a stage set, cardboard cutout? Did other people seem to be acting a part like actors in a play or have you felt you yourself were not a real person. Do you experience time seems to have changed? Does it go fast or slow? Interviewer should try to clarify with examples from the patient. When the patient appears to have a conviction of such experience, this should be recorded as delusion under content of thought.
Body image: Have you worried too much about putting on weight or getting too fat? Do others think you are too fat? Do they think you are too thin?
Attention and Concentration
The capacity to attend to a stimulus is an integral part of consciousness (vide supra). Attention has four qualities: to focus and discriminate, to mobilize, to sustain and to shift. Concentration (vigilance) is the ability to sustain the focus over an extended period.
Valid information regarding the patient's attentiveness may be obtained by observing his ability to continue coherent sequence of conversation and noting any evidence of distractibility, and any fluctuation in the level of attention over the day. Attention is tested in the following ways:
Digit span test: Present one digit per second in a normal tone, the patient should listen carefully and repeat them after the examiner. An example with a two number sequence should be given and continued until the patient fails. Numbers should be presented randomly without any natural sequence. A normal person can repeat five to seven digits without any difficulty. Inability to repeat three digits or more suggests poor attention. Digit span may be asked to be repeated in a backward fashion with increasing span till the patient fails.
Vigilance can be tested by uttering (one letter per second) a long series of letters. The patient should tap the desk the moment he hears the letter ‘A’. Three types of errors may occur in organic brain syndromes viz. omission (failure to tap), commission (tapping with letters other than ‘A’) and preservation (failure to stop tapping on subsequent presentation of letters). The two tests mentioned above cannot be done in patients with aphasia.
Serial subtraction test, e.g. counting backward from 100–7 until the remainder is <7. The time taken together with the number of errors are noted. This test is not useful when the patient has poor arithmetic skills. Alternative tests exist, e.g. serial subtraction by threes from 40, counting 1 to 20, months of the year, days of the week forward and backward.
Language is the building block of the cognitive functions. Its integrity needs to be established in order to assess cognitive functions. Several aspects of language are required to be assessed, viz. articulation, fluency, comprehension, repetition, naming, word finding, reading, writing and prosody. Invaluable information is obtained from the spontaneous speech of the patient. Some additional tests may be necessary in certain cases.
Handedness: This is allied to cerebral dominance for language function. Besides, this may have to be determined in two other situations, (a) for interpretation of neuropsychological test findings, (b) while assessing the patient for unilateral electroconvulsive therapy. The examiner should try to assess handedness of the patient by asking him (a) whether he is right or left handed, (b) to demonstrate which hand he uses to hold a knife, throw a ball, and flip a coin, (c) any tendency to use the opposite hand for any skilled movement, and (d) any family history of left handedness or ambidexterity. An accurate picture is obtained by asking questions from Annett handedness questionnaire.22
Articulation may be tested by asking the patient to pronounce tonguie twisters like “West Register Street”, “The Leith Police dismisseth us” or from the local language.
Fluency: Patient is asked open questions about his work, hobby or weather, and to write spontaneously on a topic or on dictation. The examiner should look for grammatical errors, word finding difficulties, uses of nouns and verbs, and any word substitution (paraphasia).
Comprehension is tested by asking the patient: (a) to point to the objects in room or articles from the pocket of the examiner in increasing sequences. Brain damaged persons fail to point to more than four objects in a sequence, (b) questions that can be answered with “Yes” or “No” at random, e.g. is it your right eye? do you take lunch before dinner? is this a school?, (c) to corn carry out two steps or three step commands (Marie's 3 paper test—three pieces of papers of different sizes are put before the patient, he is told to take the biggest one and hand it to the examiner; take the smallest one, throw it to the ground; and take the middle sized one, put it in his pocket), (d) to read a written material and explain.
Repetition: To begin with monosyllables, going to sentences.
Naming and word finding: Patient should have different categories of objects in the room. Asking to describe objects and actions in a picture could test his word finding ability. The reader is referred to further reference11 for formal test of language.
Important information is obtained from nurses’ report on the behavior of the patient in the ward as well as that during the interview. Orientation to time (time, day, date, month, year, season), place (ward, building, floor), person (self and others) should be described. The sense of passage of time may be assessed by asking a question “how long do you think has passed since we have started talking?”
Any difficulty in remembering day-to-day events would have been asked while taking the history. In MSE, each of the aspects of memory should be assessed in some detail. This will allow the examiner to distinguish the type of memory deficit (if any), the degree of memory loss, and the impact of the memory deficit on the patient's ability to function in a vocational or social role.
Immediate memory is tested by digit span test (vide supra).
Recent memory (new learning ability) is assessed by:
- Recall of the events of last 24–48 hours and by corroborating it from a reliable informant. Particular attention needs to be paid to the temporal sequencing of the events, any confabulation or false memories in the retrieval, any selective loss of memory about any special incident or theme, any anterograde or retrograde amnesia in case of patients with head injury, epilepsy or those on treatment with electroconvulsive therapy, and the attitude of the patient to the loss of memory like indifference, concern or distress.
- Recent verbal memory is tested by the interviewer introducing himself carefully and then asking the patient to repeat his name once to ensure that he has registered it. Then continuing the interview for 3–5 minutes, he asks the patient to repeat his name. An amnesic patient may not recall or may deny having been told the name at all.The examiner may present an address with five facts, the patient is asked to repeat it and then after 3–5 minutes of continued interview. Failure to recall less than three facts indicate impairment in recent memory. Once the digit span is determined, then the ability to extend the list by one or two items is assessed by repeated presentation. Amnesic subjects can perform adequately on the straight forward digit span test, but show a breakdown in performance as soon as this is exceeded. This is called as supradigit span test.
- Recent visual memory is tested by presenting 3 or 5 unrelated objects. Interviewer should ask the patient to name all of these to exclude nominal aphasia and visual agnosia. Then, he should hide the objects in different places while allowing the patient to watch. After a gap of 3–5 minutes of conversation on other topics, he should ask the patient to tell and take out the objects from the respective places. Less than 3 recall is abnormal.
Patient may be asked to reproduce a simple geometric figure after an interval of 5 minutes (Fig. 1).
Remote memory is tested by asking the patient about:
- Personal events, e.g. to describe the day he married, his first child was born, he joined the job or resigned from the job and so on. It is important to ask “can you describe the day of your marriage rather than the date of your marriage?” The first question requires mobilization of actual memories.
- Impersonal events, e.g. well known, political, public events in country, state or locality.
Important information may be also obtained from the observation made by the nurses and occupational therapists, how he learns daily routine, names of staff and other patients, forgetting where he has put things, where to find his bed and so on.
Topographic memory: The ability to trace the path back home and the layout of the wards are to be tested historically as well as on observation.
Memory of skills: Playing cards or chess, cooking, tailoring, computer skills, mainly to be obtained from the history.
Intelligence is the ability to think and act logically and rationally. This is to be interpreted from education, occupational history (these will throw light on adaptive functioning-ability to adjust in novel situation and to cope with the challenges), clinical behavior and test performance on comprehension, abstraction, judgment, general information and calculation.
General information: To be assessed with reference to the subject's background. For illiterate people may be asked about local rivers, well known religious places, local or state politics, panchayats, important festivals, seasons, and agricultural market prices.
Calculation: Verbal and written—one or two step problem.
Whenever necessary, patients should be referred for standardized psychological assessment. The above battery of tests can often be abbreviated when responses are accurate from the start. It is important, however, to gain a clear understanding of the patient's capacities under each of these headings whatever form the presenting illness may take. The headings presented above are not, of course, mutually exclusive. Orientation and memory, e.g. are interrelated. Moreover, some of these factors are impaired in organic as well as in functional disorders (e.g. attention and concentration). However, memory and orientation have been shown to discriminate, relatively better, organic from functional states.23
An ability to think in the abstract depends on education, level of intelligence and an abstract attitude. This is tested by:
- Proverb interpretation: The patient is first enquired whether he has heard of proverbs. If yes, a proverb may be presented with the instruction that it has a literal and inner meaning. He is required to give the inner meaning. About 5 proverbs need to be asked. In case he is not familiar with those presented by the examiner, he may be asked to recall a proverb on his own and offer the interpretation. The interpretation may be concrete, semiabstract or abstract.24
- Test of similarity and dissimilarity between two overtly dissimilar situations, which requires analysis of relationships, formation of verbal concepts and logical thinking, e.g. car-airplane, poem-novel.
Poor abstraction is difficult to interpret as there is wide variation in normal interpretation. However, poor abstraction may occur in dementia, mental retardation and schizophrenia—in the former two it could be purely concrete, in the latter personalized or delusional meaning may be given.
This refers to the ability to differentiate between internal and external reality, plan ahead and show responses appropriate to the situations. Three types of judgment are to be described.
- Social: This is inferred from historical information and observation of behavior in the ward (vide social manners)
- Personal: Personal logic about present and future. How do you explain the present state, what is your plan about future?
- Test: Responses in test situations; a letter on the road or house on fire; this component, has poor validity.
Insight is a patient's degree of awareness and understanding about being ill. It usually becomes clear by this time about the patient's awareness of the morbid phenomena or illness. There are three components of insight that require to be assessed.
Does the patient feel that his thoughts, and emotions are excessive, experiences are morbid, out of the ordinary?
Does he recognize he is ill, if so, what is the nature of illness (physical or mental)? Does he feel he needs help?
Insight need to be described and recorded as present, partial or absent.
Physical Examination and Higher Cortical Function Tests
The associations between physical and mental illness could be causal, coincidental and consequential, and so carrying out a complete physical examination is mandatory at the time of first assessment of the patient. A detailed neurological examination including the higher cortical functions11 is essential, especially when any kind of brain insult is suspected. Some of these functions (consciousness, attention, language, orientation and memory) have been already described. The rest is briefly mentioned here:
Apraxia is an inability to perform purposive volitional acts which does not result from paresis, incoordination, sensory loss or involuntary movements. Constructional apraxia and visuospatial agnosia are tested in a similar way. Patient is asked to construct geometric designs (star, pentagon) with match sticks or copy certain two or three dimensional figures of increasing complexity (Fig. 2).
Inability to put on items of clothing indicates dressing apraxia. Ideomotor apraxia refers to inability to perform single step motor acts, viz. “blow out a match”, “flip a coin”, “kick a ball”. Failure to perform motor acts of multiple steps suggest ideational apraxia and is tested by, for example, asking the patient to fold a letter, place it in an envelope, seal it, addressing it and place a stamp on the envelope.
Agnosia is an inability to interpret and recognize the significance of sensory information which does not result from impairment of sensory pathways, mental deterioration, disorder of consciousness and attention. Agnosia can occur in any sensory modality. In astereognosis objects cannot be recognized by palpation. A graphesthesia is present if the patient is unable to identify with closed eyes, numbers or letters traced on his palm. In finger agnosia, patient is unable to recognize individual fingers, either his or another person's, with eyes closed. Agnosia for colors indicate inability to name colors perfectly although color sense is still present.
Right-left orientation is the ability to point to the objects around him on the right or on the left, or touching right ear with left hand and so on.
Body image disturbances: Hemiasomatognosia is present when the patient feels that a limb (which is present) is missing. Phantom limb indicates continued awareness of a missing limb.
Tests of dynamic organization of the motor act: The subject is required to perform a series of movements whose components follow in a connected alternating sequence, e.g. alternately changing the position of the hands on the table, one with fist and the other with fingers extended; tapping the table twice with the right hand and once with the left hand in an ongoing alternating sequence; making fist and ring alternately with the same hand.
In clinical situation, there are three aims for carrying out the laboratory tests: (i) to look for organic etiology, e.g. endocrine disorders, CNS infections, psychoactive substance use, etc; (ii) to check for physical complications of psychiatric disorders, e.g. nutritional deficiency, organ damage in substance use disorders; (iii) to detect metabolic disorders which may influence pharmacotherapy, e.g. renal function tests must precede lithium therapy.
A range of tests may be relevant to the investigations in psychiatric illnesses, e.g. tests of blood, urine and cerebrospinal fluid; imaging techniques like electroencephalography, event related potentials, computerized tomography and magnetic resonance imaging; finally, karyotyping in case of developmental disorders. However, in a given case, the nature of symptoms and differential diagnoses would indicate such investigations.
These are standardized measurement of cognition and behavior. The primary aim is to measure the deficits and impairments, as well as the preserved strengths and abilities in patients with brain damage. The second aim is to differentiate organic (e.g. dementia) from psychiatric conditions (e.g. depressive pseudodementia). A third aim is to monitor the neuropsychological status of the patients who have undergone treatment (medical or surgical). The fourth aim is to identify developmental disorders including learning difficulties.
Tests of Clinical Psychology
Various types of tests are available to assess intelligence, personality traits, thought disorder, ego functions, and intrapsychic and interpersonal conflicts.
Several rating scales (self-rated, observer-rated, or interview-based) are now available to quantity psychopathology. These are useful to monitor change in response to interventions.
Clinical Assessment of Ego Functions
This is relevant while attempting a psychodynamic formulation and planning dynamically-oriented psychotherapy. The following clinical parameters are useful:
- Ability to resolve intrapsychic conflicts and cope with stressors, and bring down anxiety. This is mediated by automatic psychological processes called defence mechanisms.25,26 Preponderance of mature over primitive defenses, patient's resilience under stress and his ability not to regress to more immature levels of defence organization is a sign of healthy ego
- Ability to postpone gratification of drivers, control impulses and tolerate the resulting sense of frustration and tension
- Capacity for deep relationship with others as manifested by mutual love, sharing and empathy coupled with an ability to tolerate normal frustration and anger evoked within the relationship
- A sense of self-worth and self-confidence enough to obtain gratification of needs, reasonable control over life and to ensure survival. Fluctuating sense of self-worth is a sign of ego weakness
- Capacity to organize mental functions in a disorganizing environment, e.g. to read and concentrate in noisy surroundings
- Ability to release the perceptual and cognitive attention in order to allow for new experiences in pleasurable areas, e.g. sex, music, art, food, literature, sleep, creative imagery, falling in love
- Ability to discriminate between internal and external reality, i.e. whether a given stimulus originates from inside or outside, to be aware that one is the thinker of one's thought, perception of self and how one is viewed by others
- Intact functioning of primary autonomy of ego that includes language, motor function, conceptualization, memory, concentration, attention, judgment, and capacity to integrate new experiences with reconciliation of inconsistencies.
In summary, ego strength means good capacities that are well developed and unimpaired by conflict.
Psychiatric symptoms could be manifestations of medical, neurological and psychiatric disorders. The clinician should be broad and open-minded in his approach to a patient. The examiner should have a direct, calm, nonthreatening and nonjudgmental attitude and one of showing concern. The examiner may have to rely more on supplementary information from the accompanying persons or police mainly, in case of uncooperative patients. A skill of rapid clinical assessment is essential. The examiner should be able to decide what to enquire and what to defer in history and mental status examination. An efficient, physical examination with discrete use of laboratory tests is needed since the evaluation in emergency is more time limited than in other settings.
Homicidal and Aggressive Patient
The interview should not be conducted in a cramped room situated in an isolated place. The patient and the examiner should be positioned in such a way that both have access to the door. The examiner should be preferably towards the door. The examiner should be vigilant about the signs of impending violence: loud and threatening speech, increased muscle tension—sitting on the edge of the chair or gripping the arms, pacing up and down, slamming the doors or knocking over furniture, carrying weapons, and alcohol or drug intoxication.
The examiner must take certain steps to minimize harm, e.g. patient must surrender the weapons, if any, before interview proceeds; four or five persons should be around, sometimes the presence itself is enough to make the patient calm down; and keep the available means of restraint (physical or sedatives) ready.
The examiner should show concern and should not be humiliate the patient. His requests should be treated in a forthright manner, e.g. where he should take a seat and asking for a glass of water. The examiner should develop some rapport with the patient before asking specific question about violence. Questions about violence should be direct and honest. The patient should be assured of all kinds of help for him to stay in control of violent impulses. If necessary, limits may be set by talk, sedation or physical restraint.
Potentially Suicidal Patient
All suicidal threats should be taken seriously. If a patient refuses to discuss suicidality at all, it is helpful to ask the friends and family about the patient's behavior.
Suicide is a personal matter. The patient must be approached in an empathic and circumspect manner. Rapport needs to be established before direct questions are asked about suicide. It is better to talk to the patient alone and whenever in doubt to enquire from the relatives. It is an error to avoid the subject of suicidality for fear of doing so. In fact, patient feels relieved when he is allowed to talk about it. Patient should not be given premature reassurance as this may be perceived by the patient as a sign of lack of empathy. The clinician should listen, evaluate and then make a decision.
Patient with Altered Sensorium
A more medical approach is useful, e.g. examining his pulse and blood pleasure, taking the temperature. It is wise to assess the cognitive functions directly. If the patient is hyperkinetic, it is right to defer the interview and to interview another informant.
History should be obtained from a reliable informant. A detailed physical examination is to be conducted and level of consciousness has to ascertained. Psychiatric examination should be done following the format of Kirby (1921).27
In case of mutism, it is necessary to find out whether it is elective, situational or in relation to some persons only.28 Does the patient attempt to communicate by signs? Is there any distress in the patient? Does he write when offered a pen ? Is partial vocalization preserved? Are there any lip movements or coughing? Does he speak very occasionally or chiefly on restricted themes, or after a long delay?
Primary Care Interview
Patients usually present with physical symptoms in the primary care setting and the psychological basis of these complaints is likely to be missed by the primary care physicians.29 The physician should have a positive attitude to mental illness. He should be aware that bodily symptoms could occur out of psychosocial problems and may be the presenting features of anxiety and depression, and underlie misuse of alcohol and drugs. Moreover, he should be oriented to the basic interviewing skills (vide supra) in order to be able to correctly establish the nature of presenting symptoms.
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- Loranger AW, Sartorius N, Andreoli A, et al. The International Personality Disorder Examination: The World Health Organization/Alcohol, Drug Abuse and Mental Health Administration International Pilot Study of Personality Disorders. Arch Gen Psychiatry. 1994;51:215.
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