5.1 Psychiatric Interview, History, and Mental Status Examination
205
Topic
Questions
Comments and Clinical Hints
Perceptual
disorders
Do you ever see things or hear voices? Do you have
strange experiences as you fall asleep or upon
awakening? Has the world changed in any way?
Do you have strange smells?
Visual hallucinations suggest schizophrenia. Tactile
hallucinations suggest cocainism, delirium tremens
(DTs). Olfactory hallucinations common in temporal
lobe epilepsy.
Thought content
Do you feel people want to harm you? Do you have
special powers? Is anyone trying to influence you?
Do you have strange body sensations? Are there
thoughts that you can’t get out of your mind? Do
you think about the end of the world? Can people
read your mind? Do you ever feel the TV is talking
to you? Ask about fantasies and dreams.
Are delusions congruent with mood (grandiose
delusions with elated mood) or incongruent? Mood-
incongruent delusions point to schizophrenia.
Illusions are common in delirium. Thought insertion is
characteristic of schizophrenia.
Thought process
Ask meaning of proverbs to test abstraction, such as,
“People in glass houses should not throw stones.”
Concrete answer is, “Glass breaks.” Abstract
answers deal with universal themes or moral
issues. Ask similarity between bird and butterfly
(both alive), bread and cake (both food).
Loose associations point to schizophrenia; flight of ideas
to mania; inability to abstract to schizophrenia, brain
damage.
Sensorium
What place is this? What is today’s date? Do you
know who I am?
Delirium or dementia shows clouded or wandering
sensorium. Orientation to person remains intact
longer than orientation to time or place.
Remote memory
(long-term
memory)
Where were you born? Where did you go to school?
Date of marriage? Birthdays of children? What
were last week’s newspaper headlines?
Patients with dementia of the Alzheimer’s type retain
remote memory longer than recent memory. Gaps
in memory may be localized or filled in with
confabulatory details. Hypermnesia is seen in
paranoid personality.
Immediate memory
(very short-term
memory)
Ask patient to repeat six digits forward, then
backward (normal responses). Ask patient to try to
remember three nonrelated items; test patient after
5 minutes.
Loss of memory occurs with cognitive, dissociative, or
conversion disorder. Anxiety can impair immediate
retention and recent memory. Anterograde memory
loss (amnesia) occurs after taking certain drugs, such
as benzodiazepines. Retrograde memory loss occurs
after head trauma.
Concentration and
calculation
Ask patient to count from 1 to 20 rapidly; do simple
calculations (2
×
4, 4
×
9); do serial 7 test (i.e.,
subtract 7 from 100 and keep subtracting 7). How
many nickels in $1.35?
Rule out medical cause for any defects vs. anxiety or
depression (pseudodementia). Make tests congruent
with educational level of patient.
Information and
intelligence
Distance from New York City to Los Angeles. Name
some vegetables. What is the largest river in the
United States?
Check educational level to results. Rule out mental
retardation, borderline intellectual functioning.
Judgment
What is the thing to do if you find an envelope in the
street that is sealed, stamped, and addressed?
Impaired in brain disease, schizophrenia, borderline
intellectual functioning, intoxication.
Insight level
Do you think you have a problem? Do you need
treatment? What are your plans for the future?
Impaired in delirium, dementia, frontal lobe syndrome,
psychosis, borderline intellectual functioning.
(From Sadock BJ, Sadock V.
Kaplan and Sadock’s Pocket Handbook of Clinical Psychiatry
. Philadelphia: Lippincott Williams & Wilkins, 2010, with
permission.)
Table 5.1-6
Common Questions for Psychiatric History and Mental Status (
continued
)
XII. Physical Examination
The inclusion and extent of physical examination will depend
on the nature and setting of the psychiatric interview. In the
outpatient setting, little or no physical examination may be
routinely performed, while in the emergency room or inpatient
setting, a more complete physical examination is warranted.
Vital signs, weight, waist circumference, body mass index, and
height may be important measurements to follow particularly
given the potential effects of psychiatric medications or ill-
nesses on these parameters. The Abnormal Involuntary Move-
ment Scale (AIMS) is an important screening test to be followed
when using antipsychotic medication to monitor for potential
side effects such as tardive dyskinesia. A focused neurological
evaluation is an important part of the psychiatric assessment.
In those instances where a physical examination is not per-
formed the psychiatrist should ask the patient when the last
physical examination was performed and by whom. As part of
the communication with that physician, the psychiatrist should
inquire about any abnormal findings.
XIII. Formulation
The culmination of the data-gathering aspect of the psychiatric
interview is developing a formulation and diagnosis (diagnoses)
as well as recommendations and treatment planning. In this part
of the evaluation process, the data gathering is supplanted by
data processing where the various themes contribute to a bio-
psychosocial understanding of the patient’s illness. Although
