Kaplan + Sadock's Synopsis of Psychiatry, 11e

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5.1 Psychiatric Interview, History, and Mental Status Examination

Table 5.1-6 Common Questions for Psychiatric History and Mental Status ( continued )

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? 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. 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). What place is this? What is today’s date? Do you know who I am? Where were you born? Where did you go to school? Date of marriage? Birthdays of children? What were last week’s newspaper headlines?

Visual hallucinations suggest schizophrenia. Tactile hallucinations suggest cocainism, delirium tremens (DTs). Olfactory hallucinations common in temporal lobe epilepsy. 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 content

Thought process

Loose associations point to schizophrenia; flight of ideas to mania; inability to abstract to schizophrenia, brain damage.

Sensorium

Delirium or dementia shows clouded or wandering sensorium. Orientation to person remains intact longer than orientation to time or place. 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. 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. Rule out medical cause for any defects vs. anxiety or depression (pseudodementia). Make tests congruent with educational level of patient.

Remote memory (long-term memory)

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.

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? Distance from New York City to Los Angeles. Name some vegetables. What is the largest river in the United States? What is the thing to do if you find an envelope in the street that is sealed, stamped, and addressed? Do you think you have a problem? Do you need treatment? What are your plans for the future?

Information and intelligence

Check educational level to results. Rule out mental retardation, borderline intellectual functioning.

Judgment

Impaired in brain disease, schizophrenia, borderline intellectual functioning, intoxication. Impaired in delirium, dementia, frontal lobe syndrome, psychosis, borderline intellectual functioning.

Insight level

(From Sadock BJ, Sadock V. Kaplan and Sadock’s Pocket Handbook of Clinical Psychiatry . Philadelphia: Lippincott Williams & Wilkins, 2010, with permission.)

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