Textbook of Postgraduate Psychiatry (2 Volumes) JN Vyas, Shree Ram Ghimire
INDEX
Page numbers followed by f refer to figure and t refer to table
A
Abortive infection 1212
Absorption 1364, 1365, 1384
Acanthocytosis 2024
Acetylcholine 375
Acid peptic disease 130
Acne
excoriee 812
vulgaris 814
Acquired immunodeficiency syndrome 47, 1188, 1208
Acroagonine theory 2119
Acupuncture 2060
Addison's disease 787
Adiadochokinesia 1174
Adjustment disorder 553, 556, 563, 569, 704
Adolescent and School Mental Health Program 1885
Adolescent depression study 1063
Adolescent drinking index 986
Adoption studies 248, 256, 311, 912
Adrenergic cholinergic balance hypothesis 307
Adrenergic system 1193
Adrenocorticotropic hormone 308
Adult bipolar disorders 353
Adult insomnia, classification of 1437t
Aggression
agonistic 1411
biological models of 1780
theories of 1779
Agnosia 51, 1163
Agoraphobia 493, 499, 527, 528, 530
Air pollution 66
Ajax's suicide 300
Alanine aminotransferase 142, 178
Alcohol 121, 987, 1008
abuse 1599
dehydrogenase 180
dependence 163, 178, 1244, 2034
intoxication 107, 129
treatment of 161
metabolism 180
misuse 166, 185, 2047
diagnosis of 2030
use disorder 36, 176, 178
identification test 143t, 165, 177, 184
management of 186
withdrawal 107, 186, 1387
Aldehyde dehydrogenase 149, 180
Allergic encephalitis 1213
Allers’ syndrome 464
Allostasis 373
Alopecia areata 814
Alzheimer's and Related Disorders Society of India 61, 62
Alzheimer's dementia 62, 64, 67, 2054
Alzheimer's disease 51, 62, 65, 241, 244, 258, 373, 376, 828, 842, 1180, 1182, 1184, 1246, 14821484, 2058, 2117
assessment scale 58, 64
drug treatment of 1433
types of 63
Amenorrhea 961
idiopathic 648, 652
American Academy of Child and Adolescent Psychiatry 1091
American Academy of Neurology 1981
American Association for Intellectual and Developmental Disability 1022
American College of Obstetrics and Gynecology 751
American Diabetes Association 875
American Epilepsy Society 1981
American Group Psychotherapy Association 1581
American Orthopsychiatric Association 2118
American Psychiatric Association 2074, 2098, 2117, 2122
Amino acid 2054
Amisulpride 267, 1352, 1456, 1794
Amnesia 610, 1917, 1919, 1920
disorders, assessment of 1918
dissociative 610, 611t, 1920
Amnesic disorders 1913, 1918, 1920
causes of 1921
Amoxapine 321, 377
Amphetamines 125, 988, 1955, 1957
Amplitude 1390
Amygdala 1166
Amygdalectomy 1412
Amygdaloid nuclear complex 1166
Amygdalotomy 1412, 1413
Amyloid
cascade hypothesis 65
precursor protein 64
Amyotrophic sclerosis 1216
Anesthesia 1397
Angelman syndrome 1027
Angiotensin converting enzyme 1418
Anorexia 959
nervosa 644, 730, 735, 735t, 810, 959, 1656
Anosmia 1163
Anterograde amnesia 131, 1919
Antiamyloid therapies 1434
Antianxiety drugs 1386
Antibodies
measurement of 1218
syndrome 837
Anticatecholamine drugs 308
Anticipatory nausea 797
Antidepressant 324, 354, 1092, 1363, 1369, 1389, 1466, 1472
drug 359, 365, 1417, 1721
therapy 1363
treatment 305
medication 380, 1611
pharmacotherapy 369
Antidiuretic hormone 962
Antiepileptic drug 358, 359, 859, 1397, 1472, 1477
Antihypertensive drugs 1472
Antioxidant 1434, 2018
systems 340
Anti-parkinsonian drugs 374
Antiphospholipid antibody syndrome 837
Antipsychotic 1093, 1354, 1357t, 1360, 1361, 1457, 1468
classification of 267
drugs 228230, 274, 307, 710, 1342, 1423, 1964
choice of 1432
medication 229, 273, 282
therapy 267
withdrawal syndrome 1356
Antirape bill 990
Antisocial personality disorder 675, 1553
Anton's syndrome 21
Anxiety 322, 492, 530, 795, 841, 843, 1837
elation psychoses 482
hysteria 603
management of 795
neurosis 493
reactions 616
recognize symptoms of 1893
spectrum disorders 1371
symptoms of 2058
treatment of 163
Aphasia 815, 1163, 2115
Apomorphine 695, 1939
Apraxia 51
Aptitude treatment interaction 1609
Arginine vasopressin 648, 1393
Aripiprazole 267, 326, 382, 403, 1033, 1453, 1454, 1458, 1795
Arithmetical skills 1036
Arthus reaction 1203
Artificial reproductive technology 1801
Ascetic syndrome 1817
Aseptic meningitis, benign 1212
Asparagus racemosus 695
Aspartate aminotransferase 142, 178
Asperger's disorder 970, 971
Asperger's syndrome 977
Astasia abasia 607
Asthenia 1173
Asthma 1403
Ataxia 82
Atonia 1173
Atonomic functions 1177t
Atopic dermatitis 813, 818
Attention deficit hyperactivity disorder 353, 835, 976, 979, 1005, 1020, 1024, 1038, 1046, 1069, 1083, 1086, 1092, 1248, 1553, 1662, 2024, 2056
Augmentation therapy 1466
Autism 968, 979, 980, 981, 1074, 1093, 1248, 1661
diagnostic observation scale 977
Society of India 980
spectrum 972
disorder 968, 969, 972, 977
quotient 981, 981t
screening questionnaire 977
Autistic spectrum disorders 1006
Autoantibodies 1208
Autodysesmophobia 466
Autoerythrocyte sensitization 811
Autonomic nervous system 300, 1176, 1177, 1780
Autonomy 1600
Autopsy 921, 1037
Ayres’ biodevelopmental theory 1671
B
Bacterial infections 818
Balint's syndrome 21
Barbiturates 1388
Basal forebrain 1921
infarction 69
Basal ganglia 244, 1165, 1922
disorders of 310
Beck's cognitive therapy 321, 404
Beck's specific cognitive therapy 407
Bell's mania 484
Benton visual retention test 1245
Benzamide 267
Benzisothiazolels 1353
Benzisoxazole derivatives 1353
Benzodiazepines 324, 374, 384, 502, 506, 580, 710, 1384, 1425
antagonist 1388
common withdrawal symptoms of 1388t
general structure of 1384f
metabolism of 1385
overdose, treatment of 161
Berkson's fallacy 1274
Binge eating disorder 731, 736, 1656, 1657
Binswanger's disease 70
Bipolar affective disorder 247, 303, 1579t
Bipolar depression 1456
treatment of 325, 342, 361
Bipolar disorder 302, 303, 314, 324, 325, 330, 331, 336, 344, 353, 355, 357, 358t, 360, 385, 391, 413, 419, 436, 872, 1053, 1073, 1078, 1092, 1189, 1387, 1449, 1479, 1577, 1767
diagnosis of 337, 341
genetic of 330, 411
genetics 330
heritability of 361
pathogenesis of 330
pharmacological treatment of 346
prevention of 1613
subtypes 336
treatment of 342, 416
Bipolar spectrum 347
Birth trauma 2117
Blood 1366
alcohol concentration 122, 129, 129t, 141
brain barrier 67
pressure 875
Body
dysmorphic disorder 597, 1932, 2046
image disturbances 16
mass index 644, 733, 837, 873
Borderline personality disorder 303, 611, 677, 915, 1607, 1969, 1970
Botulinum toxin 1473, 2018, 2026
Bradyphrenia 840
Brain 362, 364, 1083, 1167, 1194f, 1766, 1874
anatomy 1191
damage 1920
derived neurotrophic factor 364, 367, 402, 1393, 2058
diseases 2113
disorder, causes of 249
dysfunction 85, 244, 1428
function therapy 1903
growth 701
imaging studies 310, 496
injury 569, 2046
stimulation 283
ventricles of 1167
vesicles 1152f
Brainstem 1172
Breastfeeding 857, 1368, 1796
Brenner's criteria 280
Briquet's syndrome 1931, 2113
British national formulary 1449
Broca's area 2115
Bronchial asthma 643, 650
Bulimia nervosa 730, 736, 753t, 1656
Burr hole 1407
Buspirone 1388, 1426
Butaperazine 267
Butyrophenones 267, 1348
Butyrylcholinesterase gene 72
C
Caffeine intoxication 137
Calcitonin gene-related peptide 1445
Calcium channel blockers 1472
Cancer 648, 793, 798, 1660
diagnosis of 793
metastatic 1576
psychiatric aspects of 788
Cannabis intoxication 135
Cannabis psychosis 135
Capgras’ delusion 468
Capgras’ syndrome 1920
Carbamazepine 321, 1382, 1422, 1795, 1796
Carbohydrate deficient transferrin 142t, 178t
Carbon dioxide therapy 2119
Cardiac arrhythmias 321, 322
Cardiac disease 323
Cardiac disorders 1402
Cardiac pacemakers 1402
Cardiovascular disease 872
Cardiovascular system 642, 1385
Caregiver sleep intervention 801
Castration anxiety 494, 504
Catastrophic reaction 2119
Catatonia 261, 2114
Catecholamine hypothesis 306
Catechol-O-methyl-transferase 546
Cathexis, mobility of 1525
Caudate strokes 69
Cell
functions 1211
mediated immunity 1211
transformation 1212
tropism 1211
types 1160
Central nervous system 5, 498, 881, 1193, 1179, 1195f, 1215, 1385, 1420, 1462
blood supply of 1167
peptides 1199
stimulants 1032
Central pontine myelinosis 132
Central tendency, measurement of 1290
Cerebellar ataxia 1174
Cerebellar degeneration 132
Cerebellar dysfunctions 871
Cerebellum 1155, 1156f, 1173, 1192
Cerebral amyloid angiopathy 70
Cerebral angiography 2119
Cerebral artery 69
Cerebral asymmetry, principle of 1236
Cerebral cortex 1192
Cerebral disorders 870
Cerebral localization, principle of 1237
Cerebral organization 1160
Cerebral palsy 2024
Cerebral tumors 832
Cerebrospinal fluid 238, 306, 881, 1152, 1167, 1171, 1207, 1462, 2051
Cerebrospinal nervous system 1169
Cerebrovascular accident 1220, 1403
Cerebrovascular disease 68, 375, 376, 831, 2024
Cerebrum 1160, 1174
Chemotherapy 798
Chicago study 31
Child interpersonal skills 1011
Child psychiatric disorders 1355
Child sexual abuse 989, 991, 992
accommodation syndrome 991
Child substance abuse 983
Childhood
Asperger syndrome test 977
autism 968
bipolar disorder 1053
depression 1663
disintegrative disorder 971, 972
migraine 1441
psychopathology measurement schedule 1261
Children's apperception test 940
Chi-square test 1294
Chloral hydrate 1388
Chlorpromazine 267, 307, 1343, 1795, 2121
Cholecystokinin 240
Choline acetyltransferase 1193
Cholinergic system 1193
Cholinesterase inhibitors 67, 71, 1435, 1482, 1485, 1485t
Chromosome, structure of 1302
Cingulomotomy 1409f
Circadian rhythm 310
sleep-wake disorders 710
Cirrhosis, alcoholic 130
Classic antipsychotic drugs 238
Classical psychiatric disorders 22
Claviceps purpurea 1466
Clitoris, removal of 1778
Clomethiazole 1426
Clonidine 374
hydrochloride 1032
Clopenthixol 1348
Clozapine 267, 281, 382, 1430, 1432, 1458, 1795
Cluster headache 1448
Cocaine 125, 988, 1955, 1957
anonymous 157
intoxication 134, 1661
Coffin-Lowry syndrome 1028
Cognitive adverse effects 1394
Cognitive analytic therapy 963
Cognitive behavioral therapies 1437, 1440, 1461, 1481, 1482, 1607, 1616
types of 1437t
Cognitive deterioration 1435
Cognitive development, theories of 1016
Cognitive disorders 88
Cognitive enhancers 1466, 1467t
Cognitive functions, measurement of 1262
Cognitive impairment 51
Cognitive profile psychological disorders 1665t
Cognitive stimulation 60
Cognitive therapy 328, 377, 404, 579, 1320, 1561, 1611, 1626, 1651, 1664, 1666, 1667, 1685
Beck's version of 405
Cohen-Mansfield agitation inventory 64
Collaborative Longitudinal Personality Disorder Study 1974
College Mental Health Program 1885
Combination therapy 1654, 1657
studies 1452
Combined hormonal contraceptive 1448
Community reinforcement therapy 150
Co-morbid depression 1356
Complex partial seizures 610, 612, 781
Comprehensive cascade model 919, 920t
Comprehensive Crime Control Act 2074
Computed tomography 1219, 1220
Conduct disorder 1001, 1661
Conflict tactics scale 1783
Confusion assessment method 49
Congenital central hypoventilation syndrome 706
Congenital cytomegalovirus 1029
Congenital hypothyroidism 1029
Congestive cardiac failure 1403
Conscious exaggeration scale 767
Consciousness 8, 48
clouding of 46, 870
Constipation 961
Constitutional Amendment Act 1786
Contiguous gene deletion syndromes 1027
Conventional antidepressants 1479
Conversion disorder 24t, 591, 606, 1932, 2041
Conviction, degree of 12
Convulsion, timing of 1399
Convulsive status epilepticus 860
Cornu ammonis 1917
Coronary artery disease 366, 642, 650
Corpus callosum 376
Corpus striatum 1164, 1165, 1176
Cortex
fibers of 1161
types of 1161
Cortical blindness 2046
Corticobasal syndrome 75
Corticotropin releasing hormone 308, 363, 390, 546, 1206
Costello syndrome 1028
Cranial autonomic nerve fibers 1177
Cranial nerve 1154, 1154f, 1155
Craniotomy 1407
C-reactive protein 822, 826
Creatine phosphokinase 131
Creutzfeldt-Jakob disease 53t, 73, 74, 828, 834, 1178, 1187
Criminal Law Revision Committee 2073
Crisis
intervention 1545
theory 1728
Cuff technique 1399
Culture bound syndrome 615, 487, 1816, 1825, 1838
Cushing's disease 309, 364
Cushing's syndrome 787, 836
Cyclic guanosine monophosphate 1936
Cycloid psychoses 481, 482
Cyclothymia 300, 302, 303, 2114
Cyclothymic disorder 303, 329, 330, 336
Cytokines 1200, 1206
role of 869
Cytomegalovirus 1218
D
Da Costa syndrome 493
Darlington family assessment system 1589
Death penalty 2084
Deep brain stimulation 1458, 1464
Defense mechanisms 1529, 1558, 1631t
Degeneration, theories of 2114
Dehydroepiandrosterone 1780
Delirious mania 305
Delirium 50, 59t, 825, 1723, 2005, 2006t, 2106
pharmacologic treatment of 2009t
tremens 129, 130, 147
management of 186
Delusion 226, 313
Delusional disorder 327, 329, 456, 458, 472t, 486
Delusional dysmorphophobia 466
Delusional halitosis 466
Delusional mania 305
Delusional misidentification syndromes 468
Delusions
content of 263
origin of 263
simulations of 1906
Dementia 22, 47, 5153, 53t, 59t, 61, 63, 71, 76, 81, 132, 323, 373, 709, 827, 827t, 841, 1178, 1182, 1224, 1246, 1482, 1484, 1576, 1724, 2051, 2052, 2114
anatomy and pathology of 1180
causes of 56, 57t, 828t
definition and prevalence of 1180
diagnosis of 1181
epidemiological surveys of 1724t
infantilis 968, 971
late onset 51
paranoides 456
precox 2115
raised incidence of 1751
symptoms of 1245
Dependent personality disorder 630, 681
Depression 163, 312, 323, 365, 373, 374, 379, 399, 404, 405, 435, 455, 530, 744, 781, 793, 841, 843, 883, 909, 909t, 1077, 1081, 1092, 1286, 1400, 1460, 1464, 1813, 1837, 1872, 2051
acute treatment of 369
drug treatment of 399
executable dysfunction syndrome 375
late onset 374
management of 794
medical treatment of 378, 421
substance induced 374
subsyndromal symptoms of 391
symptoms of 372, 373, 375, 378
treatment and prevention of 1611
Depressive disorder 303, 304, 314, 354, 1655
Depressive neurosis 326, 387, 1720
Depressive spectrum disease 305
Depressive syndromes 375
Depth psychology 1523, 1531
Dermatopsychiatric disorders 807
Dermatoses 810, 813
Desipramine 321
Detoxification
duration of 147
methods of 146
Dexamethasone 364
suppression test 308, 326
Dextropropoxyphene 374
Dhat syndrome 1816, 1826
Diabetes 1368, 1576
mellitus 647, 651, 836, 872, 874
psychiatric aspects of 872
Diabetic ketoacidosis 874
Dialectical behavior therapy 1607
Diarrheal diseases 378
Dibenzodiazepines 267, 1351, 1353
Diencephalic amnesia, prototype of 1916
Diencephalic syndromes 829
Digit span test 13
Diphenylbutylpiperidines 267, 1350
Direct decision therapy 1544
Disaster, victims of 895
Dispersion, measurement of 1291
Disseminated leucoencephalomyelitis, acute 1213
Dissociative disorders interview schedule 622
Distress 797
District Mental Health Program 1884
Disulfiram ethanol reaction 149
Disulfiram therapy 149
Divorce mediation 1597
Dixyrazine 267
Dizygotic twins 361
Dopamine 200, 238, 307, 1427, 1956, 1957
crucial role of 238
Dopaminergic antidepressant drugs 1364
Dopaminergic system 1194
Dorsal neocortical structures 375
Dorsal raphe nucleus 911
Dorsolateral prefrontal cortex 371, 1921, 1962
Dose titration method 1391
Dot blot hybridization 1218
Double blind combination therapy studies 1453
Down syndrome 1026
Downward-arrow technique 1563
Dowry Prohibition Act 1786
Drug
attitude 1356
induced liver injury 786
interactions 1366, 1370, 1387, 1418, 1419, 1422, 1423, 1425, 2024
monitoring 1988
overdose 1417
therapy 623
Dry mouth 321
Dry skin 961
Durham rule 2073
Durkheimian tradition 1755
Dyselectrolytemia 1403
Dysmorphophobia 597, 809
Dyspareunia 1801
Dysphoric disorder 647
Dysrhythmias 1402
Dysthymia 301, 302, 327, 385, 388390, 394, 425
treatment of 393
Dysthymic disorder 162, 303, 315, 326328, 372, 375, 393
symptoms of 326
treatment of 392
E
Eating disorder 644, 729, 734t, 959, 1656, 1933
Eclectic theories 619
Ego
analysis 1549
boundaries, concept of 1845
defense, mechanisms of 2120
pathological 1533
restriction of 1530
strength 1268
Electroconvulsive therapy 88, 283, 301, 314, 322, 323, 325, 365, 377, 384, 400, 472, 781, 844, 1389, 1458, 1722, 1797, 1899, 2090, 2119
Electroencephalogram 396, 701, 850, 940, 1224, 1459, 2058
Electron microscopy 1217
Emile Durkheim's classification 901
Emotion 1322
theories of 1323
Emotional attitudes 1719
Empirical method 2115
Employee assistance program 1602
Encephalitis 1166, 1212
Encephalopathies, subacute 833
End stage renal disease 784
Endocrinal disorders, psychiatric aspects of 787
Energy therapies 2050
Environmental model of stress 1727
Enzyme monoamine oxidase 362
Epigastric distress 321
Epilepsy 236, 781, 833, 858, 861, 1386, 1387, 1460, 2106
chronic 1475
neuropsychiatric complications of 833t
simulations of 1906
treatment of 1980
Epileptic aphasia, acquired 977
Epileptic seizures 609t
Episodic psychosis 484
Epstein-Barr virus 1217
Erectile disorder 1937
Erectile dysfunction 689, 692t, 1935, 1937t
prevalence of 1935t
Erhard seminars training 1551
Ericksonian psychotherapy 1552
Erikson's developmental stages 1539t
Erlanger's and Gasser's classification 1169t
Erythrocyte sedimentation rate 822, 962
Estrogens 374
Ethanol challenge test 150
Ethnic psychosis 1835
European Collaboration on Dementia Group 51
European Medicines Evaluation Agency 2064
Excessive daytime sleepiness 705
Excited delirium syndrome 48
Exhaustive psychoses, acute 485
Experiential family therapy 1592
Exposure plus response prevention 1617
Expressive language disorder 1035
Expressive speech function 1239
Extracerebral disorders 835
Extrapyramidal cortex 1164
Extrapyramidal disorders 871, 1424t, 1964
Extrapyramidal system 1164
Extrapyramidal tracts 1170
Eye signs, abnormal 23
Eysenck's theory 1257
F
Factitious cheilitis 810
Factitious disorder 632, 633, 635, 1933, 2047
Falciparum malaria, pathophysiology of 868
Family and marital
therapy 1581, 1682
disorder 1581
Family focused therapy 344
Family therapy, strategic methods of 1592t
Fasciculus lenticularis 1165
Fast alcohol screening test 177
Fatal leukopenia 325
Fatigue 1816, 1995
syndrome, chronic 654, 767, 1929, 2057
Fatty acids 241, 2053
Female sexual dysfunction, treatment of 1801
Fetal alcohol syndrome 131, 1029
Fibromyalgia 2057
Firestorm test 195t
Fixed dose method 1391
Floropipamide 1350
Fluanisone 267
Fluoxetine 321323
Flupenthixol 1348
decanoate 1348
Fluphenazine 267, 1347
hydrochloride 1347
Fluspirilene 267, 1349
Fluvoxamine 321
Focal cognitive disorders 828
Focal electrically administered seizure therapy 1392
Follicle stimulating hormone 967, 1790
Food and Drug Administration 197, 267, 357, 369, 720, 1361, 1377, 1438, 1471, 1947, 1981, 2061
Fracture, types of 996
Fragile X syndrome 976, 977, 1026
Free thyroxine index 325
Fregoli's delusion 469
Frontal convexity syndrome 21
Frontal lobe syndromes 828
Frontostriatal dysfunction 376
Frontotemporal dementia 47, 53, 74, 75
Frontotemporal lobar degeneration 74
Functional family therapy 1593
Functional magnetic resonance imaging 572, 1224, 1458, 1463
Functional neurological symptom disorder 591
Functional somatic syndrome 1926t
Fusiform cells 1160
G
Gabapentin 1987
Gamblers anonymous 2034
Gambling disorder 2028, 2029t, 2030
categories of 2028
causes of 2032
heterogeneity of 2032, 2033
homogeneity of 2032
pathophysiology of 2031
pathways of 2032
prevalence rates of 2033
Gamma amino butyric acid (GABA) 196, 239, 282, 495, 498, 503, 720, 1191, 1198, 1204, 1385, 1466, 1981, 2055, 2058
agonists 2018
hypothesis 308
Ganser syndrome 1920
Gas liquid chromatography 141
Gastritis 130
Gastrointestinal disorders 640
psychiatric aspects of 787
Gastrointestinal tract 1365, 1386
Gene mutations 1306
General paresis dementia paralytica 78
General population surveys 36t
Generalized anxiety disorder 38, 493, 503, 507, 509, 510, 513, 554, 561, 952, 1093, 1569, 1616, 1799, 1901
Geriatric depression disorders 372
Geriatric mental status 1717
Geriatric psychiatry 1717
Gestalt therapy 1550
Ghost sickness 1828
Gilliam Asperger's disorder scale 978
Gilliam Autism Rating Scale 978
Glandular disorders 1037
Glaucoma 323
Glial fibrillary acidic protein 1179
Global deterioration scale 58
Glomerular filtration rate 967
Glucocerebrosidase 77
Glutamate 240, 1198
neurotransmission 365
Glycine system 1198
Gonadal dysfunction 837
Gonadotropin releasing hormone 967,1790
Graded exercise therapy 657
Granule cells 1160
Group therapy, technique of 1574
Growth hormone 242
Guilt and shame, nature of 1851
H
Hair
loss 961
patterns, abnormal 818
Hallucinations 226, 252, 313, 372, 2112
Haloperidol 1348
decanoate 1349
Hamilton rating scale 1286, 2051
Head injury, neuropsychiatric consequences of 832
Headache 645, 651, 961, 1442, 1447, 1659
classification 1441
pathophysiology of 1443
Health care delivery, monitoring of 1909
Healthy Child Program 946
Helicobacter pylori 1024
Heller disorder 971
Hemiplegia alternata 1164
Hemiplegia cruciata 1163
Hemorrhage
subarachnoid 871
subdural 997
Hendin's classification 902
Hepatitis, alcoholic 130
Hepatolenticular disease 1166
Herpes simplex
encephalitis 1213
virus 235
High performance liquid chromatography 83, 141
High potency drugs 1356
Hippocampal atrophy 395
Histaminergic system 1197
Histrionic personality disorder 678
Holtzman inkblot technique 1267
Homer's iliad 300
Homocysteine 2051
conversion of 2051
Homocystinuria 2024
Homovanillic acid 239, 307
Hormone replacement therapy 695, 1434, 1802
Hospital anxiety and depression scale 1372
Hull's drive reduction theory 1255
Human immunodeficiency virus 103, 834, 1188, 1211, 1212
associated dementia 79, 80, 881
associated neurological disease 79
infection 173, 883, 884, 886
psychiatric aspects of 788
Human serotonin reuptake transporter 1314
Human T-lymphotropic virus 1216
Huntington's chorea 247, 1166
Huntington's disease 72, 1188, 2016, 2024
Hydralazine 374
Hyperactivity disorder 1048
Hyperhidrosis 646, 812
Hyperkinetic syndrome 1005
Hyperlipidemia 382
Hyperprolactinemia 695, 787
Hypersensitivity 1387
Hypersomnia 706
idiopathic 706
Hypertension 642, 650
control of 377
systemic 1402
Hyperthyroidism 646, 651, 787
Hypertrichosis 818
Hyperventilation syndrome 650
Hypnosis 616, 650, 817, 1552, 2110, 2112
Hypnotherapy 580, 2058
Hypochondriasis 372, 530, 593, 765, 1615, 1723, 2110
Hypomania 303, 305, 323
symptoms of 314
Hypomanic episode 315, 316, 329, 349, 356
Hypothalamic pituitary
adrenal axis 308, 364, 1204
growth hormone axis 309
prolactin axis 309
thyroid 243, 309
Hypothalamotomy 1412, 1413
Hypothalamus 1158, 1159f, 1176, 1192
dysfunction of 310
Hypothesis 868, 869, 1315, 1666
testing 1292t
Hypothyroidism 787
Hysterectomy 1769
Hysteria 24t, 603, 768, 1837, 2105, 2109, 2110
concept of 603
Hysterical psychosis 482, 483
Hysteroid dysphoria 387
I
Identity disorder, dissociative 615, 1920
Idiopathic torsion dystonia 2015t
Immune electron microscopy 1218
Immune system 1202, 1207t
cellular components of 1203t
Impaired glucose tolerance 1044
In situ hybridization 1218
In vitro fertilization 1801
Inadequate sleep hygiene 704, 1042
Incubation 1257
Indian Council of Medical Research 38
Indian Lunatic Asylum Act 2113
Indian Nursing Council 1892
Indian Penal Code 990, 1777
Indian Psychiatric Interview Schedule 31
Indian Psychiatric Society 2101, 2120
Indian Psychiatric Survey Schedule 1261
Infant sleep apnea 706
Infantile autism 968
Infantile sexuality, theories of 2116
Inkblot test 2117
Inner granular layer 1161
Inner pyramidal layer 1161
Insight oriented couple therapy 1602
Insomnia 322, 703, 718, 720, 722t, 1387, 1659
assessment of 716
chronic 715
symptoms of 717
Insufficient sleep syndrome 706
Insulin tolerance test 309
Intelligence tests 471, 1263, 1265
International Classification of Amnesic Disorders 1914
International Classification of Disease 47, 177, 194, 195, 303, 565, 751, 780
International Index of Erectile Function 1939
International Pilot Study of Schizophrenia 1812
Interpersonal disputes, diagnosis of 1564
Interpersonal psychotherapy 1563, 1611, 1633, 1633t, 1642, 1646, 1688
Intoxication 136, 137, 709, 2075
Intracavernosal injection therapy 1940
Intracortical fibers 1160
Intracranial infections 834
Intracranial pressure 1403
Intractable migraine 1446
Intraurethral therapy 1940
Irresistible impulse test 2072
Irritable bowel syndrome 641, 787, 1576, 1929
Irritant dermatitis 818
Ischemic heart disease 378, 2043
J
Jablensky's method 352
Jacksonian epilepsy 1164
Jet lag disorder 704
Juvenile delinquency 1598
K
Kanner's autism 968
Kanner's syndrome 2120
Kempf's disease 485
Keratosis pilaris 818
Kleine-Levin syndrome 706
Kleinian psychoanalysis 1548
Korsakoff's syndrome 83, 132, 783, 1920
Kraepelin's notion 301
L
Labeling theory 1750, 1752
Lacunar amnesia 1919
Lamotrigine 326, 1796, 1986
Langer-Giedion syndrome 1028
Language acquisition device 1017
Language development, theories of 1016
Language disorder 977, 1034, 1035, 1039
Larval epilepsy 2114
Laryngeal dystonia 2046
Leonhard's system 305
Lesch-Nyhan syndrome 2024
Lethargy 961
Leukoencephalopathy 70
Leukotomy 1405
Levetiracetam 1985
Levomepromazine 267, 1345
Lewinsohn's treatment 404
Lewy body 47, 53, 53t, 76, 1178, 1184, 1484
dementia 842
disease 842t
Lichen simplex 812
Life event scale 1728
Light therapy 1480
Limbic brain 1410
Limbic system 1166, 1175, 1192, 1410
Limbic-thalamic nuclei 1921
Lithium 321, 324, 1377, 1379, 1421, 1795, 1796, 1817
carbonate 370
toxicity 1422
Litigious paranoia 464
Liver
disease 1368
alcohol related 187
chronic 785
dysfunction 785, 786
transplantation 187
Lloren's theory 1671
Lobe function tests 19
Locus coeruleus system 910
Log rank test 1298
Loin pain hematuria syndrome 1933
Low backache 645, 651
Low frequency neurotherapy system 2059
Low potency drugs 1356
Luria's neuropsychological investigation 1238
Lymphokines 1203t
Lysergic acid diethylamide 239, 988
M
Madness, treatment of 2110
Magnetic resonance
diffusion 830
imaging 248, 782, 1189, 1219, 1221, 1428, 1899
perfusion 830
spectroscopy 310, 830, 1224
Magnetic seizure therapy 400, 401, 1392
Major depressive disorder 303, 304, 312, 313, 316, 317, 320, 349, 361, 366, 372, 378, 388, 391, 408, 441, 445, 530, 554, 1072, 1568, 1793, 2056
Malabsorption syndrome 130
Malaria 868, 872
neuropsychiatric manifestation of 869
Malarial psychosis 870
Male erectile disorder 1598
Malignant anxiety 1840
Malleus maleficarum 604
Mania 300, 308, 319, 323, 470, 883, 1400, 1454, 1722, 1730, 2111, 2114
acute 305, 357
classification of 305
placebo-controlled monotherapy studies 1449
symptoms of 314
treatment of 342
Manic depression 301
Manic episode 315, 356, 360
Manic syndrome 314
Man-made disasters 39
Mann-Whitney U-test 1294
Marathon groups 1552
Marijuana 987
Marital therapy
scope of 1593
task of 1595
technique of 1595
types of 1595t
Masculine protest 1536
Mass motor hysteria 614
Masturbation 686
Maternity Benefit Act 1785
McMaster model 1587
McNaughten rules 2071t
Mean corpuscular volume 142t
Medial frontal lobe syndrome 19
Medical illnesses, chronic 372, 376, 377
Medical termination of pregnancy 1786
Medication overuse headache 1448
Medication refractory depression 322
Medicines and Healthcare Products Regulatory Agency 965
Medulla oblongata 1173
Melancholia 1720
Mellory Weiss syndrome 130
Memantine 1434, 14841486
Memory 1319
function 1239
tests of 1264
Meninges 1171
Meningovascular syphilis 78
Menopausal distress 647, 651
Menopause disorders 1768
Menstrual cycle 1790
Menstrual migraine 1448
Mental disorders 401, 1738, 1766, 1768, 1769, 1809, 2106, 2113
classification of 1808
definition and classification of 1260
epidemiology of 27
facts of 1554
field of 1540
nature of 2110
prevalence studies of 37t
statistical manual of 843
treatment of 2110, 2113
Mental health 373, 377, 793, 1782
assessment 961
care 1807, 2086, 2091
spiritual model of 1870
Mental hygiene 2117
Mental illness 251, 1207, 1730, 1834, 2090, 2091, 2093
boundaries of 2097
presumption of 2095
Mental retardation 286, 405, 977, 1022, 1033, 1036, 1093, 2088
Mental sweating 812
Mental test 2115
Mesoridazine 267, 1346
Metabolic disorders 646, 977
Metal toxins 66
Methanol poisoning 131
Methotrimeprazine 1345
Methyldopa 374
Methylenedioxymethamphetamine 125, 495
Methylperidol 1349
Methylphenidate hydrochloride 1032
Michigan alcohol screening test 114, 143
Microsomal ethanol-oxidizing system 122
Migraine 1445t, 1448, 1470, 1745
chronic 1442
diagnosis of 1441
genetic of 1443
headache 645
management of 1441
pharmacological prevention of 1470
prevention of 1471
treatment, acute 1444
Mild cognitive impairment 52, 67, 2052
Mild depression 394
Mild neurocognitive disorder 56, 79
Milieu therapy 1543
Miller-Dieker syndrome 1028
Mind, theories of 1326
Minnesota multiphasic personality inventory 471
Minor depressive disorder 372, 391
symptoms of 328
Mirtazapine 580, 1368
Missense mutations 1307
Mixed anxiety depressive disorder 391
Modus operandi 1406, 1408, 1411
Molindone hydrochloride 1350
Moniliform hamartoma 817
Monoamine deficiency hypothesis 362
Monoamine oxidase 1314, 1367, 1720
inhibitors 321, 380, 392, 401, 580, 1352, 1364, 1367, 1370, 1419, 1420, 2062
Monomania 456, 2112
Monozygotic twins 247
Montgomery-Asberg depression rating scale 357, 369, 1286, 1451, 1456
Montreal cognitive assessment 57
Mood disorder 300, 353, 391, 1005, 1241, 1599, 1606, 1655, 1812
alcohol induced 132
classification of 348
Kraepelin's concept of 347
management of 312
spectrum concept of 353
substance induced 391
treatment of 354
Mood stabilizers 324, 382, 885, 1092, 1096t, 1377, 1378, 1454, 1796
benefits of 1378
Mood, sadness of 1816
Morrison's behavior modification technique 623
Motivational enhancement therapy 964
Motor disorders
dissociative 607
types of 2022t
Motor function 1034
abnormalities of 1164
Motor neuron disease 1216
Motor skill disorder 1036, 1039
Movement disorder 835, 1424
Multidimensional rehabilitation 1675
Multiple hypothesis testing 1279
Multiple personality disorder 611, 1920
Multiple sclerosis 835, 1216
Multiple significance testing 1292
Multiple sleep latency test 702
Munchausen's syndrome 1933
Muscle relaxation 1387
Musculoskeletal disorders 644
Music therapy 2058
Myalgic encephalomyelitis 654, 1217
Mycobacterium tuberculosis 786
Mycoses 818
Myelitis 1212
Myocardial infarction 322, 1403
N
N-acetylaspartate 66, 2054
Naltrexone 695
Narcissistic disorder 1535
Narcissistic neurosis 274
Narcissistic personality disorder 679
Narcolepsy 705, 708, 1043
Narcotic Drugs and Psychotropic Substances Act 2083
National AIDS demonstration research 174
National Comorbidity Survey 32, 115, 233, 533
National Crime Records Bureau 1777
National Family Health Survey 115
National Health and Social Life Survey 1935
National Institute for Health and Clinical Excellence 165, 184, 408, 848, 999, 1012, 1372, 1474, 1480, 1483
National Institute of Clinical Excellence 537
National Institute of Health 1073
National Institute of Mental Health 1072, 2056
National Institute on Drug Abuse 110, 174
National Mental Health Program 1884
National Rural Health Mission 2063
National Youth Suicide Prevention Strategy 1948
Neonatal sleep myoclonus, benign 706
Nerve
conduction studies 608
fibers
classification of 1168
types of 1174
Nervous exhaustion 2110, 2115
Nervous system 1926
functional division of 1168, 1168f
Nervous terminalis 1166
Neural tube, internal structure of 1153f
Neurasthenia 493, 1829, 2110, 2115
Neurasthenic neurosis 386
Neurocognitive disorder 47, 55
Neurodegenerative diseases 244
Neuroendocrine cells 1206
Neuroleptic drugs 1032
Neuroleptic malignant syndrome 1424, 2121
Neurologic diseases 2007, 2007t
Neurologic disorders 22, 365
Neuropeptides 241
Neuropsychiatric disorders 242, 822, 1240, 1401
Neuropsychiatric systemic lupus erythematosus 837
Neuropsychological theory 594
Neuroregulator systems 118
Neuroses 37, 387, 604, 1722, 1837, 2110
symptoms of 2109
theories of 2118
Neurosyphilis 78, 834
Neurotic depression 387
Neurotic disorders 1834
Neurotransmitter
classification of 1172
systems 503
Neurotrophic peptide 364
Neurovascular reflex 1936
Nicotine 125, 1957
replacement therapies 197
Nicotinic receptors 365
Nightmare 706, 708
disorder 1045
Nissl's stain 2116
Nitric oxide 1200, 1936
enhancers 694
Nitro-benzodiazepines 1384
N-methyl-d-aspartate 180, 572, 1199, 1482, 1987, 1955, 1987
Nocturnal dissociative disorders 709
Nocturnal epilepsy 709
Nocturnal leg cramps 706, 708
Nocturnal panic attacks 708
Nocturnal paroxysmal dystonia 706
Nonarteritic ischemic optic neuropathy 695
Nonconvulsive status epilepticus 1985
Noncytocidal productive growth 1212
Nondopaminergic antipsychotics 1354
Nonepileptic attacks, diagnosis of 2043
Nonepileptic seizures 608
Nonmendelian inheritance 1308
Non-nucleoside reverse transcriptase inhibitor 81
Non-organic psychotic disorders 1355
Nonpsychotic postpartum depression 1793
Nonrapid eye movement sleep arousal disorder 1045
Nonsense mutations 1307
Non-steroidal anti-inflammatory drugs 67, 1419
Noradrenergic system 239
Norepinephrine 239, 306, 495
reuptake inhibitors 380
serotonergic antidepressant drug 1364
serotonin reuptake
enhancer 1364
inhibitors 1364
Normal pressure hydrocephalus 81
Nosological systems 387
Nucleotide
polymorphism 332334, 394
reverse transcriptase inhibitors 80
Nutritional disorders, psychiatric aspects of 782
Nystagmus 1174
O
Obesity 644, 651, 1658
Objectively identifiable disease 1926
Obsessive compulsive disorder 265, 364, 470, 493, 517519, 530, 746, 783, 954, 1093, 1240, 1242, 1366, 1464, 1617, 1654, 1649, 1798, 1898, 2025, 2054, 2056
symptoms of 519f
Obstructive pulmonary disorders, chronic 1403
Obstructive sleep apnea 709
Occipital lobe disorders 21
Occupational therapy 1543, 1670, 1689
Oedipus complex 1526, 1528
Official classification system 303
Olanzapine 267, 326, 343, 382, 1353, 14521454, 1456, 1457, 1795
Olfactory delusions 809
Olfactory nerves 1166
Opioid 122, 1954, 1956
hypothesis 308
intoxication 133
overdose, treatment of 161
receptor 123
antagonists, pharmacology of 124
tolerance 1957
Optics, principle of 1727
Oral contraceptives 857
Orbitofrontal cortex 396, 1921
Orbitofrontal syndrome 19
Organ
damage, alcohol related 180
inferiority theory 1536
transplantation 1576
Organic anxiety disorder 86
Organic brain syndrome 405
Organic delusional disorder 470
Organic hallucinosis 86
Organic hysteria 615
Organic mental
disorders 45, 85, 87, 824, 831, 2107
syndromes 1723
Organic personality disorder 87, 824, 831, 1355
causes of 831t
Organic psychotic disorder 830
Orgasmic disorder 1800
Oxcarbazepine 1982
Oxidative stress 65, 340, 341
Oxytocin 243
P
Pain 1031, 1461, 1606
disorder 595
management 1626
sensations, mental control of 1626
Painful bruising syndrome 811
Pallidohypothalamic tract 1165
Pallidothalamic fibers 1165
Pancreatic surgery 187
Pancreatitis 130
Panic attacks 319
provocation of 497t
Panic disorder 364, 497, 502t, 507, 530, 532, 1387, 1569, 1653, 1798
treatment of 538
Parahippocampal gyrus 396
Paralysis 1163
agitans 1166
Paranoid
disorders 467, 1723
personality disorder 470, 530, 670
spectrum 468f
Paraphilias 696
Paraphilic disorders 696
Paraphrenias 456
Parasitic memories 256
Parasitosis, delusion of 808
Parasomnias 703, 706, 712, 1044, 1045
Parasuicide 903f
Paraventricular nucleus 1204, 1936
Parent child subsystem dysfunction 1588t
Parietal lobe syndromes 829
Parkinson's disease 71, 86, 241, 310, 323, 361, 363, 781, 835, 843, 844, 1166, 1464, 1484, 2043
dementia of 2055
Paroxetine 321, 402
Passiflora incarnata 1466
Paternal psychiatric disorders 1076, 1077
Peabody individual achievement test 940
Pediatric
autoimmune neuropsychiatric disorders 955
malignancy 799
Pedophilia 696
Penfluridol 1350
Pentosan polysulphate 74
Peptic ulcer 641, 650
Perimenopausal mood symptoms, management of 1802
Perinatal panic disorder, treatment of 1798
Periodic catatonia 261, 485
Periodic hypokalemia 708
Periodic limb movement disorder 703
Peripheral nervous system 1153
disorders of 871
Permeability hypothesis 868
Persistent depressive disorder 327, 389
Persistent meningitis 1215
Personal digital assistant 1460
Personality disorders 665, 669t, 670, 927, 1575
assessment of 668
classification of 667, 668t
Pervasive developmental disorders 968, 1019
Petasites hybridus 1472
Phencyclidine 988
Phenelzine 1368
Phenothiazines 1343
Pheochromocytoma 837
Phobia 528, 530, 1617, 2105
Phobic anxiety
depersonalization 615
disorders 496
Phobic disorder 526, 1902
Phobic states 809
Phosphatidylcholine 241
Phosphatidylethanolamine 241
Phosphatidylserine 241
Phospholipids 241
Phrenitis 2070, 2106
Phytomedicines 2055
Piagetian theory 1325
Pimozide 267, 1350
Pipamperone 267
Piper methysticum 1466
Piperacetazine 1346
Piperazine phenothiazines 1347
Pituitary disorder 837
Placebo controlled monotherapy studies 1453
Plasma hornocysteine 377
Platelet monoamine oxidase 306
Polymerase chain reaction 1218
Polyneuritis psychosis 2115
Polysomnography 702, 706708
Polyunsaturated fatty acids 54
Poriomania 611
Positron emission tomography 191, 238, 245, 310, 496, 503, 830, 1219, 1222, 1434, 1460, 1899, 1964, 1980
Postconcussion syndrome 2046
Post-event role transition 1645
Posthypnotic amnesia 1920
Post-malarial neurological syndrome 869
Postpartum bipolar disorder 1794
Postpartum depression 1793
Postpartum psychiatric disorders 743, 1768
Postpartum psychoses 743, 1794, 2105
Postschizophrenic depression 262
Post-traumatic amnesia 1920
Post-traumatic hypersomnia 706
Post-traumatic stress disorder 38, 364, 555, 561, 568, 571, 615, 745, 896, 950, 956, 957, 1569, 1607, 1618, 1783, 1799
Prader-Willi syndrome 1027
Premature dementia 336
Premenstrual disorders 751
Premenstrual dysphoric disorder 751, 752, 1790, 1791
Premenstrual syndrome 364, 647, 751, 753, 1792
treatment of 755t
Premenstrual tension 751
Presumptive stressful life events scale 4, 1729
Presynaptic cells 362
Presynaptic neuron 362
Prochlorperazine 267
maleate 1346
Progressive multifocal leukoencephalopathy 1215
Progressive non-fluent aphasia 53t, 75
Progressive rubella panencephalitis 1215
Progressive supranuclear palsy 75, 842
Projective personality tests 1321
Promazine 1345
Pruritus 813
vulvae 646
Pseudocyesis 1800
Pseudodementia 22, 1920
Pseudopsychosis 483
Pseudoseizure 608
Pseudoworking alliance 1534
Psoriasis 815
Psychasthenia 2116
Psychiatric disorders 22, 109, 116, 127, 331, 332, 335, 385, 709, 798, 823, 830, 830t, 881, 1007, 1043, 1215, 1718, 1719, 1791, 1792, 1872, 2043, 2046
low prevalence of 38
presence of 2042
prevalence of 38, 1718t
treatment of 2051
Psychiatric manifestations, treatment of 884
Psychiatric mental health nursing care, standards of 1894
Psychiatric morbidity
prevalence of 33t, 1883t
surveys 36t
Psychiatric nursing, principle of 1891
Psychiatry 1, 793, 1260, 1302, 1789, 1863, 2104
abuse of 2090
development of 1581
sociology of 1739
Psychic energy 1318
Psychic secretion 1250
Psychoanalysis 1540, 1627, 1629t, 1709
achievement of 1541
functions of 1540
method 1533
psychotherapy 1627, 1631, 1632, 1709
technique, principle of 1631t
theories 119, 277, 387, 494, 498, 504, 527, 1392, 1671
Psychodynamic theories 120, 326, 392, 580, 592, 595, 616, 1557, 1728
Psychogenic amnesia 22, 1920
Psychogenic mental disease 477
Psychological development, theories of 1017
Psychological mindedness assessment procedure 1558
Psychoses 476, 477
pathology of 1188
Psychosexual dysfunctions 796
Psychosexual function, development of 1527
Psychosis 89, 225, 483, 484, 486, 782, 798, 841, 883, 1766, 1873, 2113
Psychosocial stress 639
Psychosocial theories 311
Psychosocial therapy 230
Psychosomatic diseases 586
Psychosomatic disorder 636, 1837
concept of 585
Psychosomatic medicine 585, 599
models of 639
Psychosomatic theory 637
Psychostimulant 306, 884
drugs 710
Psychosurgery 1404, 1722
Psychosynthesis 1552
Psychotherapies 328, 360, 377, 382, 384, 392, 393, 472, 505, 530, 562, 622, 802, 1523, 1541, 1548, 1687, 1693, 1721, 1818, 1973, 2113
transcultural aspects of 1850
types of 1556
varieties of 1542
Psychotic depression 372, 378
treatment of 370
Psychotic disorder 329, 405, 467, 476, 1056, 1075, 1657
alcohol induced 132
chronic 391
substance induced 470
Psychotic phenomena 13, 2109
Psychotomimetic phencyclidine 243
Psychotropic medication, withdrawal of 1417
Puberty 1789
Pulse
frequency 1391
width 1391
Pyramidal cells 1160
Pyramidal system 1163
Pyramidal tracts 1170
Pyrolisoquinolines 1352
Q
Qualitative methods 1875
Qualitative studies 1273
Quantitative methods 1875
Quantitative trait loci 1308
Quetiapine 267, 326, 382, 1452, 1455, 1456, 1458, 1795
fumarate 1353
R
Race 1744
Radiotherapy 798
Randomized controlled trails 398, 1061, 1973, 2026, 2053, 2056
Rape victim 896
Rapid eye movement 76, 310, 510, 1157, 1367
sleep behavior disorder 710, 1045
Rapid situation assessments 115
Rash 856
Rational emotive therapy 321, 1561
Receptive language disorder 1035
Receptor down-regulation hypothesis 308
Reciprocal inhibition 1258, 1653
Recognized neurological disease 2040
Recognizing childhood daytime sleepiness 1041
Recovery environment 578
Recurrent unipolar depressive disorder 337f
Reflex
action 1170
hallucinations 265
Regional pain syndrome 2046
Regression analysis 1297
Rehabilitation
services, delivery of 1676
team 1680
Relaxation exercises 548
Relaxation training 1625, 1652
Remitting atypical psychoses 483
Remote memory 14
Remoxipride 1352
Renal
calculi 856
dialysis 1576
disease 1368
disorders, psychiatric aspects of 784
dysfunction 784
Repetitive strain injury 767
Repetitive transcranial magnetic stimulation 522
Repression 1318, 1529
Reserpine 374, 1352
Residual schizophrenia 262
Resistance skills training 171
Resistant depression, treatment of 1092
Respiration 1385
Respiratory disorders 643
Restless leg syndrome 703, 1042, 1046, 2054
Reticular formation 1172
Retrograde amnesia 1919
Retrosplenial cortex 1921
Rett syndrome 972, 1028
Rheumatic disease 1576
Rheumatic pain modulation disorder 645
Rheumatoid arthritis 644, 651
Rhythmic movement disorder 706, 707
Right parietal lobe syndrome 21
Risperidone 267, 326, 382, 1033, 1353, 1455, 1456, 1457, 1795
Rorschach test 265, 471
Rostral cingulated cortex 371
Rubella virus 235
Rubinstein-Taybi syndrome 1028
Rutgers alcohol problem index 987
S
Sach's sentence completion test 471
Sacral autonomic nerve fibers 1177
S-adenosyl methionine 20512053
Sangue dormido 1829
Schizoaffective disorder 226, 334, 1768
Schizoid personality disorder 671
acute 484
bizarre symptoms of 256
cardinal symptoms of 2117
chronic 264, 265, 2107
course of 234, 1811
dimensions of 265
drug therapy of 1426
epidemiology of 232
negative symptoms of 274
neurodevelopmental theory of 235
neuropathology of 245
pathophysiology of 242, 266
phenomena of 263
positive symptoms of 252
psychoanalytic psychotherapy of 277
psychotic symptoms of 228, 230
symptoms of 226, 228, 244
treatment of 228, 231, 268
Schizophrenic episode, acute 484
Schizophreniform psychoses 478, 479
Schizotypal personality disorder 672
Schneider's criteria 258
Schneidman and Farberow's classification 903
Scholastic skills disorders 1035, 1039
Sclerosing panencephalitis, subacute 1214
Scream therapy 1551
Seasonal affective disorder 1478, 1482, 2056
Seborrheic dermatitis 815
Secretan's syndrome 811
Seizure 22, 323, 976, 1224, 1387
disorder 848
monitoring 1398
Selective dopamine receptor blockers 1354
Selective serologic reuptake inhibitors 153, 321, 360, 367, 377, 380, 392, 512, 520, 547, 562, 570, 580, 689, 781, 786, 833, 884, 965, 1061, 1092, 1370, 1418, 1463, 1616, 1668, 1794, 1796, 1947, 2056, 2062
Semantic amnesia 53, 75, 1919
Semrad's triad 275
Senile dementia 2105
Sensorimotor stage 1016, 1325
Separation anxiety disorder 951
Septum pellucidum 1166
Septum verum 1166
Serotonin hypothesis 307
Serotonin norepinephrine
dichotomy hypothesis 308
reuptake inhibitors 377, 401, 547, 1794, 1796
Serotonin reuptake inhibitor 754, 1617, 2052
Serotonin syndrome 402
Serotonin system 1196
Sexual abuse 1007
recognition and nondisclosure inventory 992
Sexual arousal disorder 1800
Sexual aversion disorder 1801
Sexual behavior 1160, 1175
Sexual deviations 1837
Sexual disorders 685, 687, 688t, 693t
Sexual dysfunction 131, 268, 321, 687t, 689, 689t, 690, 692t, 694, 1365, 1366, 1368, 1800
Sexual gratification, intention of 1779
Sexual inadequacies, management of 692
Sexual maturation disorder 696
Sexual orientation 687, 1805
Sexual pain disorders 1598
Sexual problems, causes and management of 693f
Sexually transmitted infections 1781, 1782
Shneidman's revised definition 900
Shock 560
treatment 2106
Siblings subsystems 1583
Sick building syndrome 813
Sickness syndrome 794
Sildenafil citrate 694
Simple deteriorative disorder 262
Simple dissociative disorder 608
Simple partial seizures 781
Simple phobia 1654
Simple schizophrenia 262
Simple somatoform disorders 1931
Simultaneous psychotic disorder 467
Single gene mutation syndromes 1028
Single manic episode 303
Single photon emission computed tomography 310, 830, 851, 1219, 1223, 1980
Skills, development of 2034
Skin 1026, 1366, 1425
conductance 310
disease 817
disorders 645
Sleep 390
apnea 703
architecture 390, 701
bruxism 706
consolidation 703
diary 702
disorders 701, 703, 709, 796
breathing related 710, 712
management of 702
electroencephalograms 310
enuresis 706
hygiene 702, 1042
paralysis 706, 708
periodic leg movements of 708
problems, assessment of 702
talking 706, 708
terrors 706708, 1045
wake
disorders 710
regulation, mechanisms of 1041
transition disorders 706, 707
walking 706707, 1045
Slow wave sleep 1157
Small molecule neurotransmitters 1172
Smith-Lemli-Opitz syndrome 1028
Smith-Magenis syndrome 1027
Smooth muscle relaxants 695
Smooth pursuit eye movement 23
Snowball technique 111
Social anxiety disorder 366, 529, 544, 546f, 547t, 548, 953
Social drift hypothesis 257
Social dysfunction 1588t
Social learning theory 494, 1256, 1259
Social phobia 529, 530, 546f, 953, 1569, 1616, 1654
Social readjustment rating scale 1728
Social rhythm therapy 345
Social skills
education 1674
training 270, 272, 285, 328, 548, 1652
training techniques 276
Social support system 1844, 1847
Sociocultural theories 594, 618
Socratic method 2105
Sodium valproate 1422
Somatic illnesses 464
Somatic inkblot series 1268
Somatization 1858
disorder 589, 1931
Somatoform autonomic dysfunction 598
Somatoform disorders 470, 587, 598, 599, 766, 1814, 1881
classification of 589t
Somatoform dissociation questionnaire 622
Somatotropin cells 242
Specific serotonin reuptake inhibitors 1314, 1364, 1365
Speech disorder 23, 1034, 1039
Speech sound disorder 1035
Spinal cord 1152, 1153t, 1167, 1169, 1192
physiology of 1171f
Spinal disorders 871
Spinal nerves 1153
Spindle cells 1160
Spinocerebellar ataxia, stages of 2043
Spirit possession 1866
Spiritual direction 1820
Spiritual eco-maps 1876
Spiritual genograms 1876
Splice-junction mutations 1307
Spongiform encephalopathies/unconventional slow viral diseases 1215
Spontaneous speech 21
Spontaneously hypertensive rat 1051
Sporadic depressive disease 305
Spouse-system dysfunction 1588t
Standard operating procedures 2064
Stanford acute stress reaction questionnaire 568
State Mental Health Authority 2091, 2092
Stellate cells 1160
Stereotaxic amygdalotomy 1412
Stereotaxic cingulomotomy 1409
Stereotaxic leukotomy 1406
Stereotaxic surgery, technique of 1414
Sterling county study 31
Steroids 374
Strategic family therapy 1590
Streptococcal infections 955
Stress 302, 363, 376, 648, 1623, 1838
cancer link 800
concept of 585
diathesis model 256, 617
disorder, acute 567t, 569
inoculation 579
management 579, 1660
measurement of 1728
medical model of 1727
neurobiology of 1732
occupational 1765
psychological model of 1727
reaction, acute 565, 567t
related disorders 1881
sensitization 1463
system 364, 1958
Stressor, issue of 620
Structural functional dysfunction 1588t
Stupor 2114
Subcortical dementia 1247
Subcortical infarcts 70
Substance abuse 105, 108t, 704, 797, 1078, 1783
disorder 35, 105
Substance intoxication delirium 2005
Substantia nigra 1164
Subsyndromal delirium 48
Subthalamus 1157, 1164
Sudden infant death syndrome 706
Sudden unexplained nocturnal death syndrome 706
Suicide 227, 318, 375, 899, 900, 903t, 906f, 909t, 914, 1087, 1721, 1783, 1944, 2075
attempt 899
classification of 901
cluster 899
correlates of 900
counters 900
gesture 899
methods 1945
prevention 1886, 2090
rates 905t
risk factors 916
total number of 906f
types of 902t
Sulforidazine 267, 1346
Sullivanian psychodynamics 253
Sulpiride 267, 1351
Supportive expressive group therapy 803
Supportive psychotherapy 275, 320t, 1542, 1565, 1627, 1635, 1635t, 1709
Supportive therapy 559, 580, 802
Supradigit span test 14
Surgery 2026, 2007t
Switching antidepressants 1376
Sydenham's chorea 1166
Symptom severity rating scales 1286
Syphilitic encephalitis 78
Syphilophobia 810
Systematic genome screens 331
Systems theory model 1596
T
Tactile function 1239
Tactile performance test 1243
Tadalafil 695
Taiwan psychiatric epidemiological project 32
Tamoxifen 374
Tanacetum parthenium 1473
Tardive akathisia 268, 2014
Tardive dyskinesia 229, 240, 268, 1362, 2012
treatment of 1468
Tardive dysphrenia 268
Tardive dystonia 2014
Tardive myoclonus 2015
Tardive parkinsonism 2015
Tardive stereotypy 2014
Tardive syndromes 20122016
classification of 2012, 2013
spectrum of 2012
Tardive tics 2015, 2024
Tardive tremor 2015
Temporal lobe
disorders 21
syndromes 828
Tension headache 645, 651, 1447
Tetrabenazine 1352
Tetrahydrocannabinol 188
Tetraplegia 1164
Thalamic vascular dementia 69
Thalamotomy 1408
Thalamus 1157, 1159f, 1176
Thanatomania 1839
Thematic apperception test 471, 940, 1268, 1321
Theoretical emphasis 1638t
Therapeutic communication 1892
Therapeutic plasma concentration 1343
Therapist assisted exposure 1650
Thienobenzodiazepines 1353
Thin layer chromatography 141
Thioproperazine 267
mesylate 1347
Thioridazine 267, 1346
Thiothixene 267, 1347
Thioxanthenes 267, 1347
Thyroid
disorder 836
dysfunction 1403
hormone 322
releasing hormone 243
stimulating hormone 309, 1393, 1422
supplement 382
Thyrotropin releasing hormone 309, 1191
Tiagabine 1985
Tiapride 267, 1352
Tic disorders, epidemiology of 2023
Timiperone 267
Tobacco addiction 194
Tonic-clonic seizures 781, 860
Topiramate 1985
Topographical amnesia 1919
Tourette's disorder 1038, 1093, 2023
Tourette's syndrome 2022, 2023, 2025
management of 2025
Toxic delirium 2105
Toxoplasmosis gondii 235
Trait theory 2118
Transcranial magnetic stimulation 283, 371, 399, 401, 844, 1392, 1415, 1460
Transference neurosis 1535
Transient developmental disorders 1022
Transient epileptic amnesia 610, 1920
Transient global amnesia 85, 1920
Transient neurological phenomenon 1394
Tranylcypromine 321, 377, 1368
Trauma victims 1576, 1751
Traumatic alopecia 818
Traumatic brain injury 65, 88, 977
Traumatic keratoses 818
Traumatic stressor 572
Trazodone 321, 323, 377, 695, 1367
Treponema pallidum 78, 79, 2117
Triazolo-benzodiazepines 1384
Trichotillomania 811
Tricyclic antidepressants 360, 321, 384, 401, 517, 537, 580, 689, 884, 1072, 1364, 1365t, 1367, 1370, 1418, 1418t, 1794
Tricyclic drugs 1817
Trifluoperazine 267, 1346
Trifluperidol 267, 1349
Triflupromazine 267, 1345
Trisomy 21 1026
Tryptophan hydroxylase gene 1971
Tuberculosis 786
psychiatric aspects of 786
Tuberous sclerosis 976
Tumor necrosis factor 873, 1994, 2007
Twin method 248
Twin studies 310, 912, 1311
Two factor learning theory 1317
Typical antipsychotic drugs 1964
U
Ulcerative colitis 641, 651
Unipolar depression 302, 305
Unipolar disorder 1768
Unipolar mania 305
United Nations International Drug Control Program 111
Urinary incontinence 81
Urinary retention 321
Urticaria 814
V
Vaccines 67
Vagal nerve stimulation 401
Vaginismus 1801
Vagus nerve stimulation 1458, 1988
Valeriana edulis 1466
Valeriana officinalis 1466
Validation therapy 60
Valproate 1381, 1795, 1796
Valproic acid 321, 323
Vascular cognitive impairment 68
Vascular dementia 47, 53, 6870, 1185, 1484
acute 69
subacute 69
treatment and prevention of 70
Vascular depression 375
Vascular malformation 1403
Vasoactive intestinal peptide 1206, 1790
Vasopressin 309
Velocardiofacial syndrome 250, 1313
Venlafaxine 402, 1366
Ventriculoperitoneal shunts 1403
Vinblastine 374
Vincristine 374
Vineland adaptive behavior scales 978
Violence 227, 895, 1782, 1783
types of 1778
Violent motor reaction 619
Viral diseases, acute 1213
Viral infection 249
Visual evoked potential 608
Vital depression 361
Vitamin 2051
B1 deficiency, psychiatric aspects of 782
B12 2052
deficiency, psychiatric aspects of 783
Voltage-gated potassium channel 837
antibody-mediated syndromes 837
Vomiting 797
Vulnerability stress
hypothesis 252
model 256
W
Warts 809
Weber-Fechner psychophysical law 2114
Weberian tradition 1755
Wechsler's adult intelligences scale 1241, 1264
Wechsler's memory scale 1241, 1245
Weight gain 321, 872
Wernicke's encephalopathy 82, 83, 132, 186, 782
Wernicke-Korsakoff syndrome 1245
Wide ranging achievement test 940
Wilhelmsen-Lynch disease 842
Williams syndrome 1027
Wilson's disease 782, 1166, 2024
Winokur's familial system 305
Witchcraft’ syndrome 813
Wolf-Hirschhorn syndrome 1027
World Health Organization 104, 1372, 1777, 1779, 1937t
Y
Yerkes-Dodson law 494
Young mania rating scale 1449, 1454
Z
Zaleplon 1426
Ziprasidone 267, 358, 382, 403, 1353, 1455, 1458, 1795
Zolpidem 1426
Zonisamide 1984
Zopiclone 1389, 1426
Zotepine 267
Zuclopenthixol 267
×
Chapter Notes

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Clinical Examination in Psychiatry and Epidemiology of Mental Disorder

Clinical Examination in PsychiatryCHAPTER 1

Somnath Sen Gupta
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.
 
PSYCHIATRIC INTERVIEWING
 
Types
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.
 
Goals
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 2should 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.
 
Techniques
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.
Table 1   Goals of psychiatric interviewm
1.
To build relationship of trust and openness
2.
To collect historical information in details relevant to the presenting problems
3.
To assess personality of the patient
4.
To conduct a mental status examination and assess psychopathology
5.
To write a diagnostic formulation and list the differential diagnoses
6.
To explain to the patient what the clinician thinks is wrong with him and discuss the action he intends to take
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.
Table 2   Type of questions used in psychiatric interview
Type
Example
Likely responses
Remarks
Open ended
How are you feeling?
Narrative unfocused
To be used at the beginning and while opening a new area in the history
Checks (Conjunction to open question)
Tell me more about it
Narrative
Used for clarification
Closed ended
Do you feel sad?
Focussed,
Yes/No
To be used at the beginning to check the extent of symptoms; toward the end as screening questions
Probes (Conjunction to open and closed questions)
Has it been mild, moderate or severe? How much of the time were you low?
Specific details or examples
Clarifying and screening questions
Leading
How sad do you feel?
Confusion
To be used rarely with over talkative patients
Double
How are your sleep and appetite?
Confusion
To be avoided
Multiple choice
Do you feel happy, sad or angry?
Confusion
To be avoided
3
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.
 
Interviewing Relatives
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.
 
PSYCHIATRIC HISTORY
Table 3 shows the organization of psychiatric history.
 
Sociodemographic Data
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.
Table 3   Organization of psychiatric history
Sociodemographic data
Source and reasons of referral
Chief complaints
History of present illness
  • Patient's version
  • Informant's version
Past history
  • Physical illness
  • Psychiatric illness
  • Forensic history
Family history
  • Education, occupation and personality of the parents and siblings. Quality of relationship with the patient, family history of mental illness, social support system
Personal history
  • Prenatal period
  • Early childhood
  • Middle childhood
  • Late childhood (adolescence)
Psychosexual history
Occupational history
Menstrual history
Marital history
Premorbid personality
 
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. 4The 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.
 
Past History
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.
 
Family History
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.5
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.
 
Personal History
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 6the 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.
 
Premorbid Personality
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?7
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.
Table 4   Mental status examination
Consciousness
Alertness
Awareness
General appearance and behavior
Appearance
Grooming
Facial expression and posture
Social behavior and attitude
Rapport
Motor behavior
Speech
Mood and affect
Thought
Stream
Form
Possession
Content
Perception
Sense distortions
Sense deceptions
Other psychotic phenomena:
Somatic passivity phenomena
Other experiences:
Derealization and depersonalization
Body image disturbances
Cognitive functions
Attention and concentration
Language functions
Orientation
Memory
Intelligence
Fund of general knowledge
Abstract thinking
Judgment
Insight
8
Table 5   Differential contribution of various components of clinical examination to assessment of psychopathology
Mental function
Historical information
Observation of nonverbal behavior
Active enquiry
Formal tests
Consciousness
++
+
++
++
Appearance and behavior
+
++
Language
++
++
++
Orientation
++
+
++
++
Memory
++
++
++
Abstraction
++
++
Judgment
++
++
+
Thought
++
+
++
+
Mood and affect
++
++
+
Perception
++
+
++
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
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.
 
Appearance
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.9
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.
 
Rapport
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
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.10
 
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.
 
Thought
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 11the 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.1821
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.
  • Abnormal beliefs: (including overvalued ideas and delusions). These have to be viewed in relation to the beliefs prevalent in the social, cultural, political and religious group the patient belongs to.12
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.
  1. 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
  2. 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
  3. Bizarreness: This indicates to what extent the patient's culture would regard the phenomenon of his delusion as implausible
  4. Involvement of other areas of life and relationships
  5. Affective responses
  6. Acting upon the delusions
  7. 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
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.13
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?
 
Cognitive Functions
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 Functions
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.14
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.
 
Orientation
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?”
 
Memory
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.15
zoom view
Fig. 1: Simple geometric figure
 
Intelligence
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
 
Abstract Thinking
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.
 
Judgment
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
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.
 
FURTHER EVALUATION
 
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).16
zoom view
Fig. 2: Geometric designs including two- or three-dimensional figures
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.
 
Physical Tests
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.
 
Psychological Assessment
 
Neuropsychological Tests
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 17by 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.
 
SPECIAL INTERVIEWS
 
Emergency Evaluation
 
General Guidelines
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 18hyperkinetic, it is right to defer the interview and to interview another informant.
 
Unresponsive Patient
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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