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IntroductionTop
The purpose of this chapter is to provide a framework for the nonpsychiatrist physician to collect a thoughtful and thorough psychiatric history and conduct a mental status examination (MSE). This should provide the physician with enough information to construct a differential diagnosis, institute initial management/treatment, and determine whether referral for psychiatric consultation is indicated.
Psychiatric assessment is based on detailed history and observation. Psychiatric history follows the basic format of a medical history, including identifying data and chief complaints. Once the chief complaint has been established, more targeted questions can be asked to determine if the described symptoms fit a cluster suggestive of a particular syndrome. All psychiatric histories should include an exploration of personal history and screening for harm to self and others. Suicide assessment is described in detail elsewhere (see Suicide Risk Assessment). Observation (ie, MSE) is pivotal to adding information for diagnostic and management purposes.
The psychiatric interview touches upon very personal information; thus, privacy and confidentiality are of utmost importance. Given this, patients should be told a priori about the limits of confidentiality (eg, imminent risk to self or others, abuse of a child or elderly person, driving safety issues related to illness). In situations of mandatory reporting, the physician must take steps to ensure safety and meet reporting obligations (these can vary by jurisdiction; see Medical Practice and the Law).
Setting the stage is important for the psychiatric interview. The room should be quiet and afford privacy. Both interviewer and patient should feel safe. As the interviewer, try to sit at the same eye level as the patient. Even for a brief interview, give your patient your undivided attention. Given the potential for agitation with some psychiatric conditions, safety measures include consistently having an exit route from the interview room and ensuring that the patient is not seated between you and the exit. There are times when additional staff or security should be in the vicinity in case of increased risk of agitation or aggression.
The psychiatric interview is not substantively different from the typical medical interview, and the MSE mostly relies on careful observation. These skills can identify imminent risk issues and provide information to make appropriate psychiatric referrals with subsequent treatment of psychiatric illness in medical patients; this may lead to better outcomes with reduced morbidity, mortality, and readmission rates.
Psychiatric HistoryTop
Introduce yourself to the patient! This is very important and sets the tone for the interview. It is also valuable to briefly explain the purpose of the interview. The introduction need not be lengthy and may entail something along the lines of: “Over the next X minutes I’ll be asking you several questions. Some of these questions may be very private. I’m doing this to better understand you and how I may be able to help you.”
Ask the patient about the name, age, occupation, marital status, children, and place of residence. This is important to ask even if you know the information, particularly in hospitalized patients, as it is a preliminary screening test of cognition. If the patient cannot answer these questions, consider performing focused cognitive testing (see Dementia).
Ask an open-ended question to find out why the patient thinks they are seeing you and identify concerns from their perspective. This question also serves to evaluate insight. If you can resist interrupting for a few minutes, allow the patient to elaborate on their perception of symptoms or lack thereof. This uninterrupted listening is key to the mental status assessment, because it provides an opportunity to observe the organization of the patient’s speech and the content of their thoughts. Once you have an idea of why they think you are seeing them, you can ask for elaboration, timelines, and details. There will be patients who talk at length because they are disorganized, manic, anxious, agitated, or intoxicated, for example. In these cases, you may need to interrupt and redirect the patient.
Asking about specific psychiatric symptoms is guided by what the patient has already told you, your preexisting knowledge of the patient, and MSE observations you have already made. The questions discussed below capture most major symptoms of commonly encountered psychiatric syndromes.
When screening for depression, it is helpful to have the patients describe their mood using one word. The 2 best follow-up questions to screen for major depression are, “Have you felt down, hopeless, sad, or blue most days?” and “Have you realized you no longer find pleasure in things you once did?”
Key point: Some depressed patients will not identify their mood as sad or depressed. Elderly people in particular will often report somatic symptoms such as “tired” or “sore.”
Patients in the midst of a classic manic episode are usually easy to diagnose, given their typical elated mood, pressured speech, grandiosity, and irritability. However, mania is more difficult to diagnose when patients are in the early stages of becoming manic or are partially treated. Screening for past episodes of mania can also be challenging. In fact, many patients who have had documented mania will not recall their symptoms. Helpful screening questions include, “Have you felt full of energy? Thinking of big plans? Have you ever had several days of not sleeping much but still felt full of energy?” and “Has your family ever noted you to be sped up, in thought and movement, with a notable change in mood?”
Key point: It is common for patients to have limited recollection of past manic and hypomanic events. If you are suspicious of bipolar illness, collateral history from the family, partners, or close friends is particularly useful.
Anxiety disorders, particularly panic and generalized anxiety disorders, are common and occur at higher rates in medically unwell patients, especially those with cardiac or respiratory illnesses. To screen for panic disorder, you can ask, “Do you ever feel suddenly panicked and have physical symptoms like a racing heart, sweating, or trouble catching your breath?” Note that in general a psychiatric diagnosis is a diagnosis of exclusion, and medical causes for symptoms need to first be ruled out. Generalized anxiety can be screened for by asking, “Do you worry about things all the time?” Everyone has worries, of course, but patients with generalized anxiety disorder are disabled by their anxiety and can usually identify this.
The key to conducting a reliable and valid psychosis assessment is to start with general, more open-ended questions and then becoming more targeted and specific. For example, when screening for paranoia it can be helpful to ask if the patient has had any concerns about people around them lately (eg, family, neighbors, copatients, staff), or if it has felt as if anyone has been more bothersome to them lately.
Hallucinations can be visual, auditory, olfactory, tactile/somatic, or gustatory. If you are aware of the possibility of psychosis, ask direct questions without judgment, such as, “Have you heard voices when there is no one around?” or “Have you ever seen things and thought maybe other people don’t see them?” It is important to screen for command hallucinations, as the presence of such may increase the risk of harm to self and others. Visual hallucinations are more suggestive of an organic cause, particularly in the absence of auditory hallucinations or delusional thought content.
Similarly, when asking about delusions (fixed false beliefs), do so in an open and empathic way. For instance: “Have you felt that people are out to get you? Watching you? Or perhaps following you?” In hospitalized patients with psychotic symptoms be sure to ask about delusions involving staff, as this may interfere with care. Appropriate questions in this situation include, “Do you trust your nurses and doctors? Do you think they are looking out for your best interests?”
Assessment of cognition relies on multiple sources of information such as collateral history from reliable sources and MSE. Often patients with neurocognitive disorders may not have full insight into their deficits. Cognitive changes may also occur with primary psychiatric illnesses. Nonetheless, in patients where you suspect a cognitive disorder it is important to screen for memory problems by asking, “Have you had problems with your memory or concentration?” Aphasia can be screened for by asking, “Do you have problems remembering words or using the wrong words?” Apraxia can be screened for by asking, “Do you find yourself having difficulties doing tasks you used to find easy, like turning on the television or brushing your teeth?”
Key point: If you suspect a cognitive disorder, you should screen for safety, such as leaving the stove on, driving, wandering, and forgetting to take medications or even taking double doses because the patients have forgotten they took their medication.
It is also important to screen for symptoms common to a number of psychiatric disorders, such as disturbances to sleep, appetite, energy, and motivation. Specifically, one should ask about weight loss, quantify the amount lost, and establish if the loss was intentional (see Eating Disorders). Sleep should be quantified as well (see Insomnia). Depending on presentation, knowledge of the patient, and information already gathered, physical symptoms can be explored, such as pain, headache, seizures, and abnormal movements.
Past psychiatric history is a crucial part of psychiatric examination. It is important to document all past diagnoses, hospitalizations, courses of outpatient treatment, and medication trials, as well as suicide attempts and other dangerous behaviors. Assessing past suicide attempts: see Suicide Risk Assessment.
This part of examination is identical to the past medical history taken during a medical examination. Of particular note, infectious (eg, HIV), autoimmune (eg, lupus; medications such as prednisone), and neurologic illnesses (eg, seizures, migraine, stroke, movement disorders) should be explored, as these can often present with psychiatric symptoms. Ask about head injury and severity of any such injuries (eg, if the patient required neurosurgical intervention or hospitalization).
A full list of all medications, both prescription and over-the-counter, needs to obtained.
A screen of substance use and abuse may be the main clinical focus during the psychiatric history and deserves careful clinical attention. All substances of abuse should be documented including the amount used, route, period of time of use, last time used, adverse effects, withdrawal, and past substance abuse treatment. Smoking, including the amount and duration of use, should be assessed because of possible interactions with medications and increased risk of physical illness. Check for polysubstance use.
Family history of psychiatric illness should be explored. Specific diagnoses of family members, particularly first-degree relatives, are important. Exploring a family tree for ≥3 generations may be useful. This information may guide diagnosis and treatment options for your patient. Family history of completed and attempted suicides should be explored, as suicide has significant heritability. Note that families often do not openly discuss psychiatric illnesses, and so general (rather than diagnosis-specific) questioning may be more helpful (eg, “Have you had any siblings, parents, cousins, aunts/uncles who may have had problems with their nerves/mood/functioning/behavior?”).
Collecting a comprehensive social history can be very challenging. It is impossible to gain more than a gist of someone’s life story through 10 minutes of history taking. The interviewer should have an idea of the patient’s work, love, and play. Important elements to understand are developments (eg, premorbid personality and any changes, how far along in school the patient got), trauma, and life events, such as marriage and losses. An exploration of recent stressors is often indicated.
Mental Status ExaminationTop
The second component of the psychiatric examination is the MSE. The MSE is the psychiatric equivalent of the physical examination. It provides information on areas such as emotions, speech, thoughts, perception, cognition, insight, and judgment at the time of the assessment. The MSE is performed mainly through observation of the patient while collecting the history in addition to specific questions. The core components of the mental status examination are listed below. Additionally, in all hospitalized patients presenting with psychiatric symptoms, a full physical examination, including a detailed neurologic assessment, is required.
1. General appearance, behavior and movements: Take note of dress, grooming, posture, and general health. Note if the patient can focus and shift attention appropriately. Are there any alterations in the level of consciousness? Also, be mindful of any abnormal movements such as tremor, chorea, dyskinesia, or parkinsonian slowing. It is important to test tone for rigidity and cogwheeling. Antipsychotic medications are a common cause of parkinsonism.
2. Speech: Take note of rate, rhythm, volume, tone, quality, and spontaneity. Depressed patients may have slow sparse speech, whereas hypomanic or manic patients typically have fast and pressured (difficult to interrupt) speech. Word-finding difficulties or substituting the wrong word is suggestive of a neurocognitive disorder.
3. Mood and affect: The assessment of mood and affect is helpful for psychiatric diagnosis. Mood is the subjective emotional state as described by the patient. Affect is the examiner’s appreciation of the patient’s emotional state in terms of quality (eg, anxious, sad, euthymic, euphoric), range (flat, blunted, restricted, or full), and stability (stable versus labile). Obviously, a patient who reports their mood as depressed needs a careful assessment of depression, while an anxious affect suggests an anxiety disorder. Furthermore, there may be discrepancies between the described mood and the affect. For instance, patients with apathy may have blunted affect and look depressed but describe their mood as normal.
4. Thought process: Take note of general coherence and stream. Abnormalities that should be noted include tangentiality (changing the topic), circumstantiality (inability to answer questions without giving excessive detail), thought-blocking (abrupt stop in a train of thought), flight of ideas (jumping from one idea to another), perseveration (repetition of words or ideas even when the interviewer tries to change the subject), and echolalia (repeating what the interviewer says).
5. Thought content: Take note of any delusional thoughts and their nature. There are many different types of delusions, including persecutory (paranoid, with the patient believing others are trying to harm or monitor him or her in some way), referential (believing radio, television, or printed media have messages directed to the patient), grandiose (believing there is something special about self), religious, and somatic, among others. Thought content can also include obsessional thoughts, ruminations (repetitive worries), and somatic preoccupations. Assessment of content also includes asking questions about the current risk (eg, thoughts of harm to self or others). Remember that patients sometimes endorse “paranoia” but are in fact describing situations of anxiety that make them more sensitive to their environment and others.
6. Perception: Describe the nature of any hallucinations. In the case of auditory hallucinations, describe any command hallucinations. Assessment of possible hallucinations includes actively asking the patient but also observing for objective signs (eg, if the patient appears to be responding to internal stimuli). Remember that a patient’s endorsement of “voices” does not always mean they are having auditory hallucinations.
7. Cognition: If there are symptoms of a neurocognitive disorder elicited through the interview, performing the Montreal Cognitive Assessment (MoCA), available at www.mocatest.org, is a quick and sensitive tool for evaluating cognitive disorders. The MoCA can be used to evaluate for mild cognitive impairment, dementia, or delirium. At a more basic, bedside-screening level, you can ask for orientation, recall (say 3 words and have the patient repeat), memory (ask the patient to remember the 3 words and repeat them in 5 minutes), attention and concentration (spell “world” backwards), language (repeat a complex sentence), and specific tests for frontal lobe function such as similarities (how are an apple and orange alike?), abstraction (interpretation of proverbs), and verbal fluency (the FAS test, in which the patient names as many words that start with “f,” “a,” and “s” in one minute). When pressed for time, you can ask the patient to draw a clock face with hands at 10 past 11; a perfect clock makes a cognitive disorder unlikely.
