As with any patient, aim for an open, empathic and non-judgemental approach and maintain non-threatening eye contact as much as possible. Start with open questions, avoid loaded questions, encourage the patient to tell his story in his own words and follow the approaches for general history taking detailed in Chapter 1. Another way of questioning is to use a normalizing statement. This is employed when you are asking about symptoms or behaviours which the patient may find embarrassing or difficult to acknowledge. For example, you might say something like ‘Sometimes when people have been feeling very depressed or have been under great stress, they may have odd experiences which they cannot explain, for example they may hear or see things which are unusual – has anything like this happened to you?’ Further examples of these are provided in the appropriate sections. Finish with a summary of what you have understood and check with the patient if you have missed anything that he feels is important.

Structure of the psychiatric history

This section details all the areas of history taking which need to be covered in a full psychiatric history. There may be situations where, in the initial assessment, they cannot all be covered, usually because the patient is too disturbed to engage with the interview process or too disorganized in his thoughts to produce comprehensible information. In these situations, the omitted information can be gathered when the patient is somewhat better. Sometimes patients do not feel comfortable sharing all aspects of their personal background at a first meeting. The interviewer needs to be sensitive to this and check with the patient if he feels comfortable discussing a topic and negotiate this.

Order of sections

The order in which the sections of the history are covered is suggested in Box 7.1 and followed in the text. Conventionally, past medical and psychiatric history goes at the end. However, if it is impossible to complete the interview on a single occasion, it is more useful to have found out about previous psychiatric illness, current contact with mental health services, medication and important medical conditions than it is to know the patient’s father’s occupation or what jobs he has done.

It can be useful to present the information obtained as a life chart which illustrates, in adjacent columns, years, patient’s age, social history, family history, relationship/psychosexual history, medical history and psychiatric history as a way of illustrating possible predisposing factors, precipitating factors and maintaining factors in a patient’s illness.

Presenting complaint

Start by establishing the main problem for which the patient is seeking help. In psychiatry, there will be situations where the patient does not have any complaints and denies problems. In this situation, the details of the presentation and behaviour reported by others, and concerns of others, should be recorded in this section. If the patient is being formally held on any section of the Mental Health Act, this should be recorded. Sometimes a patient with somatoform disorder will deny any psychiatric illness, believing that his illness is physical. In this situation, record all physical symptoms and the patient’s current main health concerns.

History of presenting complaint

Obtain a detailed description of how symptoms began, enquiring about the relationship to any life events that might have precipitated their onset. Establishing if the symptoms are recent or longer-lasting helps to clarify if the current presentation is part of longstanding personality traits or due to the acute onset of psychiatric disorder. The severity and persistence of symptoms and their impact on function should be sought. In order to fulfil diagnostic criteria for a psychiatric disorder, symptoms will be persistent across different circumstances, and severe enough to have an impact on a patient’s function in his daily life. For example, with low mood, establish whether the low mood is a brief fluctuation or whether it has persisted for a period of time (The ICD 10 specifies 2 weeks of low mood for a diagnosis of depression), how reactive it is to circumstances (unreactive mood being generally indicative of greater severity of depression) and how much it affects the patient’s function (a big impact being an indicator of severity). The evolution of symptoms over time, any help sought or given and any treatment received should all be documented.

Patients may volunteer symptoms which may be associated with the presentation. If none are volunteered, a systematic enquiry is essential. For example, in a patient presenting with depression, enquire about other symptoms in the depressive syndrome (Box 7.2) such as concentration, memory, enjoyment and social withdrawal. Anxiety and depression frequently coexist and so either presentation should lead to systematic enquiry about symptoms of the other. Somatic and psychic symptoms of anxiety are outlined in Boxes 7.3 and 7.4.

Box 7.4 Psychic symptoms of anxiety

Feelings of anxiety

Irritability

Inability to relax

Inability to concentrate

Worry/anxious rumination

Feeling of impending doom

Depersonalization

Biological symptoms are important in all mental disorders so enquiry should always be made about sleep and appetite. Particular note should be taken of any abrupt change to sleep pattern as this is more significant in diagnosis than a chronic sleep problem. Enquire about sleep onset. Delay in getting to sleep is described as initial insomnia, and initial insomnia of 1 or 2 hours or more is pathological. Enquire about wakening. Waking through the night and going back to sleep is a pattern sometimes seen in anxiety. Waking regularly in the early hours and being unable to get back to sleep is a pattern described as early morning wakening and indicative of depressive disorder. Sometimes patients have a shifted sleep phase so, although they do not sleep until late in the night, they will sleep until late in the morning, which is sometimes seen in schizophrenia. In acute confusional states, there may be excess daytime sleep and wakefulness at night. If there is a sleep problem, you should ask about sleep-related behaviours (e.g. bedtime routines, if children share the bed). Establish if sleep is refreshing. Chronic fatigue patients describe unrefreshing sleep and waking still tired, which is also seen in anxiety patients.

Ask if the patient’s appetite has changed. In typical depression, appetite is lost, but in atypical depression, there may be an increase in appetite and craving of carbohydrate-rich foods. Some patients without depression will describe eating to cope with brief episodes of low mood or upsetting events. Ask if the patient’s weight has changed. Significant weight loss (more than 5%) in a depressed patient indicates moderate to severe depression. Weight increase can indicate a major problem of mood-related eating or bulimia. Very low weight may indicate anorexia. Cycling of weight gain and loss can occur in eating disorders. It is also very important to enquire into changes in weight in relation to starting psychotropic medication. Many psychotropic medications (e.g. antidepressants, antipsychotics and anticonvulsants) tend to cause weight gain which should not be ignored, and consideration should be given to stopping the relevant drugs.

History of psychiatric disorder

Enquiry should be made about the lifelong history of mental health problems. The questions need to be asked in terms the patient will understand. For example, you could ask ‘Have you ever had any problems with your nerves or mental health in the past?’ or ‘Have you ever suffered with depression, anxiety or had any kind of mental breakdown?’ Ask about previous contact with mental health, counselling or psychology services. In women who have had children, enquire as to whether they experienced any mental health problems during or after pregnancy. Ask about previous use of psychotropic medication: ‘Have you ever been prescribed any medication for your nerves or mental health, for example taken an antidepressant, sedative or sleeping tablet?’ Establish what previous medication has been effective in similar episodes or any medication to which they have reacted adversely. Establish whether the patient is currently in contact with any mental health professionals.

Past medical history

Enquire about any current or previous physical health problems, including operations. Note childhood operations or chronic childhood illness which can be aetiological factors in somatoform disorders. Any chronic debilitating conditions or acute life-threatening events, such as a myocardial infarct, are important risk factors for depressive and anxiety disorders. Also some psychotropic medications are contraindicated in patients with certain medical diseases. A number of neurological illnesses have important psychiatric manifestations. Ask about all contacts with health services. Frequent consultations with many different specialists for a variety of symptoms in the absence of a definite medical diagnosis raises the possibility of somatoform disorder.

Current medication

Record all the medication a patient is currently taking (including over-the-counter medications and herbal products). Overuse of some over the counter medication can exacerbate a problem (e.g. analgesic overuse headache). Record any allergies clearly.

Family history

Ask about parents: their ages, whether they are alive and, if so, whether they have any physical or mental health problem, where they live and the nature of the patient’s current relationship with them. Enquire about the parents’ occupations and personalities and the patient’s relationship with them during childhood. Establish if the parents are separated or divorced and, if so, how old the patient was at the time. If the parents have died, enquire into when they died, their age at death, the circumstances of their death, how old the patient was at the time and how the patient has coped with the grieving process.

Establish how many siblings there are, whether full or half siblings, and the patient’s order in the family. As for the parents, enquire into any siblings’ mental and physical health, place of living, marital status, occupation, personality and the patient’s relationship with them.

Some family structures can be very complicated, with parental separations, remarriages or repartnerships, and half- or step-siblings from different parental relationships. In this situation, it can be helpful to draw a family tree and annotate it with the above information. Circles are used for women, squares for men; a line through the symbol denotes death. Marriage or permanent liaisons are indicated by a line connecting the symbols, and divorce or permanent separation by two oblique lines through the connecting line.

Considerable information can emerge about relationships with parents, siblings, etc. while taking the family history which can be explored further in the personal history. Specifically enquire whether there is any family history of mental health or psychological problems. When considering the heritable component of a condition, obviously you are only interested in first-degree relatives and not in relatives by marriage.

Personal history

Birth and early developmental milestones

This begins with enquiry about the patient’s birth. Was it a normal delivery or were there any medical interventions or birth complications requiring specialist care? This is relevant to assess the possibility of any early brain injury. It can also be relevant if there were problems in early maternal bonding. Were developmental milestones reached within the normal range (see Ch. 5)? Patients may not have any knowledge about their birth and milestones. If they tell you about some problem surrounding their birth and early milestones, this may be significant and is worth recording. If no problems are identified, it is possible that the patient just does not know. Clearly an informant, such as the patient’s mother, may have more accurate information.

Family milieu, childhood health and early relationships with caregivers

Start with an open question such as ‘How do you remember your childhood?’ ‘Was it a happy or unhappy time of life?’ Cover the family atmosphere during early upbringing, relationships between parents and relationships with parents or alternative caregivers such as grandparents or foster carers. It is important to note any periods of separation from parents and the quality of alternative caregivers. Enquire about and record any loss of parents or other caring figures through death or separation or divorce. These factors are important in understanding whether there has been any early disruption of attachment bonds for the individual. Childhood health is important. Ask about operations, hospitalization or chronic illness in childhood and about family attitudes to any illness. Asking how much time was missed off school due to illness is a good indicator of childhood health, whether organic or non-organic. A happy childhood can be covered quickly, with more time spent exploring causes of an unhappy childhood experience.

Specifically ask about physical or sexual abuse. This may seem difficult at first as these feel like taboo topics. Make sure the questions are in an appropriate context (i.e. when enquiring about the patient’s experience of childhood). Then you can ask, in a matter of fact though sensitive way, questions such as the following:

Did you ever have any experience of being badly treated as a child?

Were you ever neglected and not provided with adequate physical care?

Was anyone persistently mean or cruel to you in what they said?

Were you ever hit?

Were you ever physically abused in any way?

Were you ever sexually abused by anyone as a child?

If the rapport with a patient is poor for any reason, or if you are seeing a very psychotic disorganised patient, just asking a general question and deferring exploration may be better. Sometimes a patient will indicate that he did experience abuse, in which case it is important to sensitively test out how much to explore this in an initial interview. It is useful to ascertain if this is the first time he has disclosed the abuse. If he has disclosed it previously, ask who he disclosed it to and whether he has talked about it much. A patient who has undergone a period of therapy and discussed his abusive experience at length before may be comfortable recounting his experience at first interview. A patient who has never disclosed his abuse before may find it difficult to discuss it at all, and an agreement to talk further subsequently may be appropriate. Patients should never feel coerced, either overtly or covertly, by the whole context of the interview to talk about issues which cause pain or distress. If they do, the interview itself can feel like an abusive experience.

Schooling

A person’s experience of school can be very important in terms of understanding the development of his peer relationships and indicating whether there were any behaviour problems, as well as finding out what educational level he attained and what his academic and other abilities were. Enquire about both primary and secondary school, what sort of school he attended, whether he enjoyed school, what he was good at, any experience of bullying and the nature of it, peer relationships, ease of friendships, whether he has kept friends from school and if he had any problems at school. Truancy, school refusal, exclusions from school and referral to any children’s service are all important.

Truancy is where a child misses school deliberately, usually without parental knowledge, and does something else such as working or playing with other truants. School refusal is where a child stays at home refusing to go to school despite persuasion from parents, usually due to an anxiety disorder. Sometimes parents keep children at home due to the parent’s health or practical needs (the parent may need practical help due to physical illness or with looking after other children).

Establish the patient’s level of academic achievement (qualifications attained). Ask about further education or training on leaving school and his experience of this (college or university). Further education is an important point in a person’s developmental trajectory as it is often the point at which an individual starts to live independently. How successfully this major milestone is negotiated is an important indicator of psychological health and can reveal information about emotional attachments and functioning. Enquire specifically about the transition from home to living independently, even if not for further education, or whether the patient still lives in the parental home.

Time may not allow all aspects of schooling to be covered, but always record age at start and end of full-time education, any problems encountered and the highest level of qualifications attained. This information can be important in evaluation of cognitive state.

Occupational history

Take a history of the first job the patient had after education and what other jobs he has had, how long he remained in the jobs and the reasons he left. It is not necessary to go into exhaustive detail, but it is important to establish if the individual is able to sustain long-term periods of employment. Use a shortened approach by asking about total number of jobs, longest period of employment and highest level of employment, longest period of unemployment, difficulties at work and relationships at work. If a pattern emerges of frequent job switches after brief periods of employment, it is important to establish the reason for this pattern: is there a pattern of repeated behaviour (e.g. getting bored) or a particular problem (e.g. difficulty with authority figures or other problems in interpersonal relationships). This can give important information about ability and personality. Ask about his current job (if he has one) such as the hours worked, what it involves, if it is enjoyable and any particular current work stressors. If a patient is unemployed, establish when he last worked and the reason he is not working (e.g. illness).

Psychosexual history, including marital/relationship history and children

The psychosexual history can be a source of embarrassment for students and patients, but this is unnecessary if handled in a straightforward way. If there is a problem, the patient may be relieved to be asked about this, as he may have found it difficult to mention. Many psychotropic drugs have psychosexual side effects (e.g. erectile dysfunction with some antidepressants), but patients may not mention these side-effects unless asked. How much detail is needed will vary depending on the presenting complaint. Obviously, if the patient is complaining of marital or psychosexual difficulties, a full history of this area is relevant. The level of detail outlined in Box 7.5 is usually not necessary, but you should routinely gather basic details of the psychosexual history. In the relationship history, do not make an assumption about sexual orientation. Ask about sexual orientation in an open non-judgemental way. Look for patterns which may be indicative of relationship problems (lots of brief relationships, a repeated pattern in intimate relationships, repeatedly entering into abusive relationships). Be aware of domestic violence and the need to ask about this if there is a very difficult or aggressive relationship. Basic details about children (also in Box 7.5) can be important later if child-protection issues are raised.

Box 7.5 The psychosexual history

Women: age at menarche, menstrual history, sex education at home/school

Men: puberty, sex education at home/school

For both sexes, a full sexual history would also cover sexual fantasies, masturbation and deviant sexual behaviour (this level of detail is inappropriate unless the problem is specifically a psychosexual one)

Boyfriends/girlfriends in adolescence, age at first sexual relationship

Marital history: age at marriage, how they met, parental attitude to marriage and quality of marital relationship – confiding, conflict, separations. Establish age, occupation and health of spouse. How and why relationships ended

Current relationship: any conflict? What is the partner’s attitude to the patient’s illness? Are they supportive?

Children: how many, names, ages, who the biological parents are, who cares for them. Any worries about the children’s health, behaviour, schooling or relationships with the patient

Reproductive history in women: did they get pregnant easily? Fertility treatment? Were the pregnancies planned? History of miscarriages, terminations of pregnancy or stillbirths. Mental health problems during pregnancy or after childbirth or related to menstruation

Current social situation – see Box 7.6

Forensic history

Details of a full forensic history are beyond the scope of this chapter. It is useful routinely to enquire if the patient has ever been in any trouble with the police. You should then record the nature of any charges, court appearances, convictions and prison sentences. It is particularly important to record in detail, highlight and pass information to other health professionals about violent offences. The best predictor of future violent behaviour is past violence and there is a real risk that this information gets buried in notes and forgotten.

Box 7.6 Current social situation

Type of accommodation: council, private rented or home owner, any problems

Who else lives in the home, quality of relationship with them

Friends and social support: with whom does he confide and share problems?

Financial situation: earnings, debts, benefits, worries

Use of alcohol and non-prescribed recreational drugs

Alcohol

Ascertain quantity and frequency of alcohol intake. If the level of alcohol use is above safe drinking limits (Box 7.7), or if there are other indicators of a problem with alcohol (Box 7.8), a full drinking history should be taken and symptoms of alcohol dependence should be sought (Box 7.9). A very brief and commonly used screen for alcohol dependence is a questionnaire called the CAGE (Box 7.10). Alcohol misuse is drinking which causes physical, social or psychological harm to the drinker. Alcohol dependence is when the criteria for a dependence syndrome are met (Box 7.9).

Box 7.7 Units of alcohol and safe drinking limits

1 unit contains 10 g of pure alcohol and is equal to half a pint of beer, one small glass of table wine or one bar measure of spirits (for more detail, see Box 1.12):

Safe limits:

– men <21 units/week

– women <14 units/week

High risk of social/health problems:

– men >50 units/week

– women >35 units/week

Box 7.9 Features of alcohol dependence

A strong desire or sense of compulsion to drink alcohol (craving)

Difficulty controlling intake of alcohol in terms of not being able to control starting, stopping or amount taken

Withdrawal symptoms when alcohol intake is reduced or stopped and drinking to relieve withdrawal symptoms

Tolerance, i.e. increased amount of alcohol is required to achieve same effects as previously obtained with a lower amount

Neglect of alternative activities when drinking or recovering, e.g. leisure activities, work, time spent with family

Continued drinking despite harm caused (either physical, mental or social)

Box 7.10 The CAGE questionnaire

C – Have you ever felt you needed to Cut down on your drinking?

A – Have people Annoyed you by criticizing your drinking?

G – Have you ever felt bad or Guilty about your drinking?

E – Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?

Two or more positive replies are indicative of alcohol misuse and should lead the interviewer to take a full drinking history.

Taking a full drinking history

You need to obtain as accurately as possible an estimate of quantity, type and pattern of alcohol consumption as well as effects of alcohol on life. Patients are frequently in denial and will underestimate their intake. The most efficient way to take the history is to ask about a typical drinking day or week. Go through the day ascertaining type, quantity and context of alcohol intake. Cover the features listed in Boxes 7.8 and 7.9 to establish if there is alcohol misuse or dependence.

After establishing current drinking level and problems, ask about the lifetime history of drinking such as when the patient started drinking, pattern over the years, episodes of dependent drinking, previous attempts to abstain and previous treatment for alcohol problems. Remember, alcohol misuse can be an attempt by the patient to self-medicate other psychiatric disorders such as depression, anxiety or post-traumatic stress disorder.

Recreational drugs

Routine enquiry should be made into previous or current use of recreational drugs. The question can follow on from enquiry about medication using a question such as ‘Have you ever used any other non-prescribed drugs such as cannabis, cocaine, LSD or anything like that?’ The phrase ‘designer drugs’ or ‘recreational drugs’ can be used, judging the appropriate terminology for the patient. The criteria for drug dependence and problem drug use are the same as those for alcohol. The same structure can be used for taking a history of drug misuse as was outlined for alcohol, with the addition of enquiring about method of administration of the drug. This can lead on to asking about needle sharing, source of needles, HIV and hepatitis C status. Taking a full substance misuse history can be complex and time-consuming if the patient is a polysubstance abuser as each substance has to be covered in turn.

Personality assessment

Do not rely too heavily on a patient’s self-assessment of personality, though it is important to hear how he views himself. The depressed patient may paint a picture of himself as incompetent and lacking in confidence, which may be far from his premorbid personality. To avoid such misrepresentations, try to rely on objective information in the history and, where possible, talk to an informant who knows the patient well about what he is usually like. The important areas to cover in assessing personality are shown in Box 7.11.

Box 7.11 Personality assessment

Usual mood

Pessimistic and worrying or optimistic. Stable mood or mood swings.

Relationships with others

Deep and enduring or superficial short term relationships, quality of marriage, work relationships, conflict with authority figures.

Character

How he describes himself e.g. shy, sensitive, introvert, extrovert, quarrelsome, laid back, dependent, controlling. Any obsessional traits e.g. tidy, rigid.

Leisure activities and habits (including drug and alcohol use)

Risk taking activities, collecting, passive spectator or active participant, solitary pursuits or very sociable, party going, time spent on leisure versus workaholic.

Personal standards and attitudes

Religious belief and participation, moral views, attitudes to health and body, level of acculturation (if from an ethnic minority) e.g. traditional or western attitudes, dress.

The mental state examination

The mental state examination is the cornerstone of the psychiatric assessment. It enables a systematic observation of clinical symptoms and signs on which a differential diagnosis is based. Students often feel that they do not know where to start and it seems a very unfamiliar genre. However, in essence it is simple: look at and listen to the patient carefully and observe in a systematic way. The examination is a word portrait of how the patient appears, using clinical observation, informed questioning, empathic listening and accurate recording. It is helpful sometimes to take verbatim notes of what the patient says and record these in quotation marks.

Observations and interpretations should be recorded separately. A mental state examination consisting solely of the doctor’s interpretations is of little use. For example, a patient may say that the police are in a conspiracy against him and are monitoring his flat with listening devices in the walls. It is inadequate just to record that the patient has paranoid delusions. It may not be a delusion. It could be true, or he could be intentionally creating fantasy stories. The record should include what the patient actually says and then state ‘This belief seems to be a delusion’. A basic comprehensive structure is outlined in Box 7.12 with a detailed outline of what should be recorded under each heading.

Box 7.12 The mental state examination

Appearance and behaviour

Speech

Mood: subjective and objective

Thought: form and content

Perception

Cognitive assessment: including orientation, attention and concentration, registration and short-term memory, recent memory, remote memory, intelligence, abstraction

Insight

Appearance and behaviour

Appearance

Describe how the patient appears. Does his dress and general presentation seem appropriate for his age, culture, occupation and social class? Severe weight loss may indicate the loss of appetite of depression or dementia, failure to eat with delusional ideas or anorexia, disorganization in schizophrenia or it may be due to physical illness. Excess weight can occur in schizophrenic illness or can indicate an eating disorder such as bulimia. Importantly, it can be secondary to medication, either antipsychotics or antidepressants. Poor self-care such as body odour, lack of shaving and dirty clothes can be due to depression, or patients with schizophrenia or dementia may become too disorganized and lose the capacity to care for themselves.

A lowered level of consciousness indicates an organic brain disorder. Suspected altered consciousness should be checked out early on with tests of orientation, as the interpretation of the mental state examination will be different if the patient is confused or severely cognitively impaired. This situation calls for a simplified interview, with careful observation of behaviour and an attempt to interview an informant.

Behaviour

Essentially this is a description of how the patient behaves, in relation to his environment and the interviewer. Is the behaviour socially appropriate or is it unusual in some way? Included in this section would be the following:

General demeanour

Is the patient relaxed or anxious? Is he agitated (fiddling or wringing hands), angry or behaving as though suspicious? Patients with severe depression may need to pace about, unable to sit. Excitability due to mania or schizophrenia looks like agitation. Angry or suspicious behaviour can be due to persecutory delusions. A distracted or preoccupied patient may be anxious or attending to auditory hallucinations or he may be seen actively responding to auditory or visual hallucinations.

Rapport

Does he engage comfortably or is he nervous, awkward and uncomfortable with the interview? Is he warm or indifferent, suspicious, ingratiating, dismissive, supercilious or hostile? The patient’s way of relating to you could be defined by personality or mental illness. Patients with severe depression can be apathetic and indifferent. Those with schizophrenia can be suspicious and hostile. A patient with mania may be dismissive and supercilious, being irritated by the interruption of whatever important task he is about to do.

Eye contact

Does he establish good eye contact, avoid gaze or look suspiciously around? Does he have an abnormal staring eye contact or hostile way of looking at people?

Gait

Note any abnormalities of gait when a patient walks in. There may be a manneristic gait (see mannerisms below) where the patient walks in an exaggerated posing way. There may be functional gait problems, so look for inconsistencies in what can be done when walking and what is elicited on examination.

Reduced motor activity

In bradykinesia, voluntary movements are reduced and abnormally slow. The face and arms tend to be particularly affected. Bradykinesia is most commonly caused by parkinsonism due to Parkinson’s disease or medication, particularly antipsychotics. Slowness and paucity of movement may also occur in psychomotor retardation, which is a feature of depression and indicates quite severe depression. In stupor, there is severe paucity of movement and mutism. This occurs in severe depression, catatonia and organic brain disease. Catatonia is characterized by a stuporose state with additional features (see Boxes 7.13 and 7.14).

Box 7.13 Movement changes in the mental state examination

Dystonia: due to older major antipsychotic drugs

Choreiform: Huntington’s chorea – common with l-dopa therapy (for Parkinson’s disease)

Tics: quite frequent in childhood and during periods of emotional stress

Mannerisms:

– habitual repetitive voluntary movements or behaviour patterns

– can be part of normal behaviour, e.g frequent raising of eyebrows

– bizarre occurrences in schizophrenia, e.g saluting frequently or raising one leg every few strides. They can be voluntarily controlled

Stereotypies: repeated uniform movements or utterances, purposeless (unlike mannerisms), regularly occurring (unlike unpredictable tics), e.g. rocking to and fro on a chair. Stereotypies are found most commonly in patients with learning difficulties

Tardive dyskinesia: syndrome of abnormal movements, e.g. facial grimaces, writhing movements, abnormal rolling of tongue. It can be a delayed side-effect of older antipsychotic medication. Onset may be months or years after starting the medication and, paradoxically, it can worsen initially after stopping it

Catatonia: (see also Box 7.14) striking condition characterized by stupor, sometimes alternating with excited motor and behavioural features. Motor excitation can be extreme and lead to injury or exhaustion, which can be lethal

Box 7.14 Variable features of catatonia

Waxy flexibility: the patient maintains a posture in which he has been placed by the examiner

Negativism: the patient seems to behave in the opposite way to that requested by the examiner

Aversion: the patient turns away when addressed

Mannerisms: see Box 7.13

Grimacing: common in schizophrenia. Schauzkramp is a facial grimace in which the lips are drawn up towards the nose in a pout

Stereotypies: see Box 7.13

Posturing: the patient adopts an unusual posture for a prolonged period, e.g. symbolic like a cross

Automatic obedience: the patient shows excessive compliance (opposite of negativism)

Echopraxia: the patient exactly imitates the interviewer

Advertance: the patient frequently turns to the interviewer in an exaggerated way

Mitgehen: the interviewer can move the patient’s limbs with fingertip pressure

Ambitendence: the patient will start and then reverse a movement, e.g. putting out a hand and withdrawing it

Increased motor activity

Note any excessive activity and whether it is purposeful or not. Manic patients may just be overactive and distractable. Agitation has a different quality, being driven by an unpleasant inner sense of tension. It is a general restlessness in which there may be apparently purposeful activity but it is not carried through properly. There may be repetitive purposeless behaviour such as hand-wringing, scratching, rubbing hands on knees and pacing up and down. See Box 7.13.

Speech

This is divided into two components: rate and structure of speech.

Rate

Slowed speech with a long latency between question and answer may be a component of psychomotor retardation in depression, can occur in dementia or in psychosis due to distraction by hearing voices, or in the very anxious patient. Lack of spontaneous speech occurs in depression, as a negative symptom of schizophrenia and in some dementias. It may be due to expressive aphasia caused by a cerebral lesion. There may be excessive spontaneous speech, as in a manic patient or also in some dementias where there is loss of appropriate social markers of reciprocal speech. ‘Pressure of speech’ refers to an increase in both rate and amount of speech. It is characteristic of mania. In mania, speech can be increased in amount and speed (pressured) so that it becomes incomprehensible. Mute patients will not speak at all, as in states of stupor due to severe depression, schizophrenia or organic brain disease, but occasionally as a hysterical symptom. Elective mutism, where the patient will speak in some situations but not in others, occurs mostly in children.

Structure

This can be disrupted in a variety of ways and due to a range of disorders (Box 7.15).

Box 7.15 Disorders of structure of speech

Circumstantial: frequent digressions, taking a long time to get to the point, e.g. in obsessive compulsive disorder, epilepsy and organic brain disorders

Tangentiality: answers seems unrelated or only slightly related to questions, e.g. in schizophrenia, severe anxiety

Disorders of the form of thought: abnormality of the structure of thought manifest in speech. There are three main types of formal thought disorder – flight of ideas, loosening of associations or perseveration:

– Flight of ideas: speech speeds from one idea to an associated one but with loss of the end goal. The associations can be based on meaning or similarities of sound

– Loosening of associations: jumps from one idea into another apparently unrelated one, making understanding very difficult. E.g. ‘Knight’s Move’ speech in schizophrenia and, in extreme forms, a mixture of unrelated words (‘word salad’)

– Perseveration: repetition of a theme or answer when no longer appropriate (in ‘echolalia’, the patient repeats what the interviewer says), e.g. in organic brain disease and some forms of schizophrenia

Other abnormalities of speech that should be noted are any evidence of dysphasia or dysarthria which would indicate neurological disease.

Mood

This is usually divided into subjective and objective mood. For subjective mood, record how the patient actually feels, for example ‘really fed up’, ‘sad’, ‘frightened’, etc. It is useful to record this verbatim. Interpreting mood is particularly difficult in people whose first language is not English.

Ask an open question first, e.g. ‘How have you been feeling in yourself, or in your mood or spirits recently?’ If there is no clear response, ask a more closed question: ‘Have you been feeling low, sad or miserable recently?’ or ‘Have you been feeling depressed?’

If the patient acknowledges low mood, you should explore severity and persistence. Persistently low mood indicates more severe depression than mood which is reactive to events. Is it worse at any time of day? Feeling very depressed on waking with mood lifting later is called diurnal mood variation and is a good marker for significant depression. Thoughts related to depression are considered below.

To assess elated mood after the initial open question about mood, ask ‘Have you been feeling in very good spirits, unusually happy or very elated for no reason recently?’ If the patient says yes, you can ask ‘What is that like? Can you describe it to me?’ Do not take what patients say at face value; always try to get a good description of what they are actually experiencing. Thoughts related to an elated mood are considered below.

Enquire about irritability, as this often accompanies low mood and can occur in mania. If present, explore its severity. In particular, note physical violence as it could result in domestic violence or there could be child-protection issues. Enquire about an anxious mood: ‘Have you suffered with feeling very nervous, frightened or anxious recently?’ A particular type of anxious mood found with anxiety and accompanying depression is called anxious foreboding, in which the patient constantly feels a sense of dread as though something awful is going to happen but he does not know what.

Sometimes patients describe a loss of feeling and numbness. He may describe no longer feeling love for a spouse or children and it is very distressing. It is seen in depression, depersonalization and post-traumatic stress disorder.

An objective assessment of mood should be recorded, for example depressed, anxious or angry. Observe and record objective indicators of mood during the interview such as body language, behaviour and facial expression (e.g. weeping, sad expression, laughing or irritability). Opinion varies as to whether biological symptoms of depression or somatic symptoms of anxiety should be recorded in the mental state or as part of the history.

Important features of mood to observe are variation and whether it is appropriate to the circumstance. Mood may be appropriately reactive to what is being described, or a persistently low mood may indicate severe depression. Mood may be excessively reactive and labile, switching from laughing and joking to floods of tears, which is strongly associated with organic brain disease and, sometimes, manic depressive illness. Incongruous affect (e.g. a patient laughing while talking about their baby’s death) is a feature of schizophrenia. It can be worth asking a patient why they smiled or laughed while discussing something upsetting. Blunting of affect, also seen in schizophrenia, describes the loss of the normal variation of mood.

Thought

Attention should be paid to both the form of thought and its content. Thought form refers to whether the patient’s thoughts are ordered in a logical way or whether his thinking jumps about with discontinuities and moves from topic to topic with no clear links discernable to the listener. It is the flow of a patient’s speech which will indicate the presence of thought disorder, and these abnormalities of form of thought have therefore been described above in the section on speech. However, the presence of thought disorder should be recorded in this section.

Attention should be paid to the content and theme of what the patient discusses as it gives a window into what is on his mind. Consider the overall theme of what is being discussed as this will indicate mood (e.g. depressive, manic, persecutory). Often the content of thought will have already emerged from the history taking. However, there are some questions worth asking to explore specific issues in more detail, or to raise them if they have not already come up.

The exploration of depressive thoughts is described in Box 7.16. It is important always to establish whether or not a patient experiences suicidal thoughts, and this is part of risk assessment. It is negligent to perform a psychiatric assessment without a basic risk assessment. Medical students and doctors may feel uncomfortable asking about suicidal ideas or may fear that asking about suicidal thoughts increases the likelihood that the patient will act upon them. Research has shown that the opposite is the case. Patients are often relieved to share these feelings, and welcome this opportunity.

Box 7.16 Exploration of depressive thoughts

Guilt

Do you ever feel guilty about anything, or blame yourself for things, or feel ashamed?

Self-esteem/self-worth

What is your opinion of yourself compared to other people?

Are you as good as other people?

Do you run yourself down?

Hopelessness

How do you see the future?

Do you ever feel hopeless about your situation?

Suicidal thoughts

A good time to ask these questions is after exploring depressive cognitions with the questions suggested above. It is best to ask about suicidal feelings with a graded series of questions:

Do things ever get so bad that you feel you don’t want to carry on?

Do you ever wish you did not wake up in the morning (passive suicidal feelings)?

Do you ever have thoughts about doing something to harm yourself?

Do you ever have thoughts about ending your own life?

Some patients self-harm for reasons other than wanting to end their life. For example, patients may deliberately self-harm by cutting themselves as a way of getting a sense of release from unpleasant emotions, or they may overdose to draw attention to their distress. A suitable question covering both suicidal ideas and self-harm might be ‘Have you ever had thoughts of harming yourself in any way, for example by taking too many tablets or by cutting yourself?’

It is important to pursue a risk assessment to determine the likelihood of patients acting on thoughts of suicide or self-harm. Ask what he has thought of doing and whether he has done anything to prepare (e.g. saving up tablets). Look for protective factors by asking what it is that stops him acting on his suicidal thoughts and how he copes with the thoughts. Box 7.17 summarizes important risk factors for completed suicide which the student should know about and explore in assessing risk.

Exploring thoughts in elevated mood

Patients with elevated mood states (mania or hypomania) will often mention all kinds of grandiose ideas while you are taking a history and may have disinhibited behaviour. Specific questions to ask if they have not already come up are listed in Box 7.18.

Box 7.18 Exploring thoughts in elevated mood

You may find some of these questions a bit unusual and they don’t apply to everyone, but I need to ask them just to check whether you have had any of these experiences:

– Do you ever feel as though you can do some things much better than other people?

– Have you seemed especially efficient at work or in other activities?

– Do you ever feel you have special abilities, talents or powers which other people do not have?

– Have you got any new projects in mind or new plans for the future?

– Have you ever had the thought that you may be a special person and, if so, who?

– Have you had thoughts of doing rather reckless things which are out of character and you would not normally do, for example planning to spend a lot of money on a shopping spree, or thinking of starting affairs or relationships which may not be wise?

Obsessional thoughts

Obsessional thoughts are repeated stereotyped thoughts that intrude into a person’s mind – they are usually experienced as unpleasant, silly and irrational. They are not delusional but the person is unable to stop them occurring. Attempts at resistance often produce anxiety. The patient is clear that they are his own thoughts, unlike the experience of thought insertion. Common obsessional thoughts are those of contamination (e.g. the patient feels his hands are dirty and so feels compelled to wash them) or checking (e.g. the patient cannot stop doubting that he locked the door). The compulsive motor act that accompanies the thought (e.g. hand washing or door checking) is called an obsessional ritual. Obsessional thoughts and other obsessional phenomena are part of the normal range of experience; however, when severe and disabling, they form the central psychopathology in obsessive compulsive disorder. Ask screening questions for obsessional symptoms. If a patient acknowledges any of these problems, explore frequency, severity, attempts to resist and the extent of functional disability as a result (i.e. how long he spends on these things and whether it disables him).

Abnormal beliefs

The main types of abnormal belief are primary and secondary delusions, overvalued ideas and sensitive ideas of reference (Box 7.19).

Box 7.19 Definition of delusion and overvalued ideas

A delusion is a fixed false belief, held with complete conviction, which is not amenable to alteration by any argument, and which is not shared by others of the same social and cultural background.

Overvalued ideas are beliefs which are very prominent in the patient’s mind and with which he is unreasonably preoccupied, but the patient is able to acknowledge that the belief may not be true and may be able to challenge it.

Primary delusions (also called true delusions) are delusions which are not secondary to other abnormal mental processes such as abnormal mood or hallucinations. A particular example of a primary delusion is a delusional perception in which a patient has a normal perception to which he attaches delusional significance. For example, a patient may see a waiter pick up a glass (a normal perception) and the patient realizes immediately that the waiter is an envoy of the devil (delusional significance). Primary delusions are generally associated with schizophrenia provided they occur in clear consciousness (i.e. they are not occurring in an organic confusional state). Indeed they are one of the Schneiderian first-rank symptoms of schizophrenia (see Boxes 7.20 and 7.21).

Box 7.20 Diagnosis of schizophrenia

Schneider described what he called first-rank symptoms of schizophrenia. The presence of any one symptom in the absence of organic brain disease is regarded as diagnostic of schizophrenia, but first-rank symptoms are not always present. This is not a comprehensive list of the clinical features of schizophrenia, but they are symptoms which are quite specific to it (as long as there is no organic disease). The first-rank symptoms are:

Box 7.21 Distinction between positive and negative symptoms of schizophrenia

Positive symptoms

Tend to occur in the acute phase and generally respond to antipsychotic medication

Hallucinations including thought echo

Delusions, primary and secondary, including delusions of thought control and passivity experiences

Disturbance of emotional control – there may be outbursts of emotion, e.g. laughter or anger, without appropriate cause

Disturbed thinking with thought disorder or neologisms

Negative symptoms

Tend to be chronic and accumulate as the illness progresses

Poverty of speech – the patient has little to say and very little spontaneous speech

Poverty of thought and movement – speech indicates loss of richness and complexity of thought. Movement is lacking and slowed

Blunting of affect – absence of normal modulation of mood and lack of emotional response

Lack of volition – loss of motivation; can be extreme when patient neglects basic self-care

Social withdrawal

Secondary delusions (also called delusion-like ideas) are secondary to an abnormal mood state or hallucinatory experience. Unlike primary delusions, they are understandable in the light of the patient’s mood and life history. For example, a severely depressed mother may become convinced that she is evil and that she is not worthy to bring up her child. Secondary delusions lack diagnostic specificity but their content may relate to the diagnosis.

Sensitive ideas of reference can be described when patients falsely believe that things actually occurring in their environment are specifically referring to them, and occurs in depression, body dysmorphic disorder and paranoid personality types. For example, a patient may feel that others are looking or laughing at him. In delusions of reference, the patient is completely convinced that people are talking about them and laughing at him. Sometimes patients will be convinced that a TV presenter is saying things which refer directly to him. Questions to elicit these sorts of ideas might be ‘Have you felt that other people are too interested in you?’, ‘Do you feel that people comment on you or say things behind your back?’ or ‘Do people seem to drop hints for you or say things with double meaning?’

When eliciting delusional beliefs, and because psychotic symptoms are often very bizarre, it is wise to put patients at ease by making some kind of normalizing statement and asking a very open general question first. For example, you might say ‘Some people find that when they are feeling very stressed or having difficulties with how they are feeling, they have some rather odd experiences. Has anything very odd or unusual happened to you recently?’ Follow up on any positive responses with open questions, asking the patient to describe his experiences in detail. If there are no positives, you can screen for certain sorts of delusions. Some of these, and suggested screening questions, are given in Box 7.22.

Box 7.22 Types of delusional ideas

Persecutory delusions

‘Do you ever have the feeling that people are against you or out to get you in some way?’ They may occur in organic psychoses such as confusional states, dementia, alcohol and drug-induced psychoses, in stress-induced psychogenic psychoses and sometimes in people with paranoid personalities, particularly with advancing age and where sensory deficits such as visual and hearing impairment occur. They may also occur in schizophrenia.

Delusional misinterpretation

This is a type of delusion of reference. Patients will ascribe particular significance to normal objects in their environment. For example, they will see a coded message intended for them in a car number plate.

Delusions of grandeur

Patients are delusionally convinced that they are special in some way, for example they have been given a special purpose by God or that they are famous. It is characteristic of syphilitic general paralysis of the insane (now rarely seen). They can also occur in mania and schizophrenia but are uncommon.

Hypochondriacal delusions

Patients believe that some part of their body is abnormal or diseased. This is common in depressive psychosis, as are delusions of guilt, self-blame and poverty.

Nihilistic delusions

Seen in severe psychotic depression, they involve delusional belief that parts of one’s body (internal organs usually) are rotting away.

Delusions of jealousy

This is a delusional conviction that one’s spouse or partner is being unfaithful. It occurs in substance misuse, in schizophrenia and in people with a suspicious personality. It is important to take these delusional beliefs seriously and do a full risk assessment.

Erotomanic delusions

Patients hold delusional beliefs that someone (usually famous) is in love with them. They occur mainly in schizophrenia and in organic psychoses. They may lead to stalking behaviour, so take these delusions seriously and do a full risk assessment.

Fantastic delusions

These are bizarre delusions – for example, that aliens have landed and are causing things to change in some way or they are involved in some other attempts to interfere with the patient’s life. These occur in schizophrenia.

Delusional memory

The patient describes remembering things which are clearly delusional. For example, the patient remembers, and can give graphic descriptions of, being abducted by aliens and experimented upon.

Delusions of passivity

These are a group of bizarre phenomena in which the core experience is of loss of the normal sense of boundary between the self and the outside world (ego boundaries). They include: thought insertion (the experience that one’s thoughts are not one’s own) and the accompanying belief that thoughts have been inserted into one’s mind; thought broadcasting (where the patient experiences his mind as open to others so that thoughts can leave it and be picked up by others); and thought withdrawal (where the patient feels thoughts are actually extracted from his head). These experiences are very specific and, in the absence of organic brain disease, are diagnostic of schizophrenia.

Perception

There is a wide range of abnormal perceptual experiences, some of which can be part of normal experience and others which are indicative of mental illness or organic disease of the brain. It may be obvious from his behaviour that a patient is seeing things or attending to auditory hallucinations. Gentle enquiry about what the patient sees or hears will often elicit a description of the experience. Record as much detail as possible. Patients may be embarrassed to mention having had abnormal experiences, so specific enquiry is needed. For patients who have not had these experiences, being asked about them can be quite threatening as they may feel the doctor is suggesting they are ‘mad’. To deal with this, it may be appropriate to make a normalizing statement first, and then ask a screening question for abnormal perceptual experiences: ‘It is quite common for people to have unusual experiences which may puzzle them. For example, some people may hear noises, music or voices when there is no one there, or people may see things which others are not able to see. Have you ever had any experiences like these?’ If the patient has had such experiences, they can then be explored in more detail (Box 7.23).

Abnormal perception

Abnormal perception can occur in any of the sensory modalities: hearing, vision, smell, taste and somatosensory modalities (touch etc.). When perception is distorted, the perceived object is correctly recognized but altered in some way, such as alteration of intensity of sound, quality, colour or distortions of form. These occur in psychiatric disorders but also many organic conditions such as epileptic seizures or toxic/metabolic states.

Illusions occur when the object is real but is misperceived, usually due to particular conditions in the perceptual environment, for example an anxious person in a dimly lit street seeing a tree as a figure in pursuit. They are often caused by sensory deficit (partial blindness or deafness) or a lowered level of consciousness (common in acute confusional states).

Hallucinations are perceptions that are not based on any real external stimulus. They can occur in any sensory modality but the commonest are auditory, for example a voice being heard by the patient but no one else hears it. Auditory hallucinations occur in many disorders including schizophrenia, organic brain disease and manic depressive illness. Voices can be heard speaking in the second or third person. In severe depression, voices are often second person and the content may be mood congruent, for example ‘Look at you, you are useless, do away with yourself’. The manic patient may hear God’s voice telling him he has special powers. Third-person hallucinations in the absence of organic disease suggest schizophrenia (see Box 7.20 for first-rank symptoms).

Visual hallucinations are uncommon in psychiatric illness and are more suggestive of organic conditions, particularly acute brain syndrome (e.g. delirium), illicit drug use (e.g. amphetamines or LSD) or drug withdrawal (e.g. delirium tremens). However, they do occasionally occur in schizophrenia or manic depressive illness.

Visual hallucinations vary from elementary, for example flashes of light (from visual pathways and occipital lobe) to complex visions of objects or scenes (from visual processing areas and temporal lobes). In confusional states, small animals are often seen. In temporal lobe epilepsy, complex visual hallucinations (scenic) may occur as may polymodal ones (involving multiple sensory modalities).

Hallucinations can also occur in other sensory modalities, for example olfactory, gustatory and tactile. Some patients with epilepsy commonly have olfactory and gustatory hallucinations (smelling odd smells or tasting unusual tastes). These experiences often precede an epileptic seizure. Patients with severe depression may have olfactory hallucinations, perceiving themselves as smelling unpleasant (cacosmia).

Tactile hallucinations are difficult to distinguish from illusions. In cocaine psychosis, patients may complain that insects are crawling over them (formication). Patients with schizophrenia can describe tactile hallucinations which may be incorporated into their delusional beliefs, for example a patient may feel sensations on their skin and believe this is due to aliens taking specimens from them. In the absence of organic brain disease, tactile hallucinosis is a first-rank symptom of schizophrenia (see Box 7.20).

Hallucinations can occur in the absence of mental illness, for example in extreme fatigue or in between sleep and waking, and can occur in bereaved individuals, usually being experiences of either seeing or hearing the lost loved one, and are generally experienced as comforting. They are a normal part of grief in some people and do not indicate psychopathology. Some people complain that, when alone, they feel the presence of someone else beside them. This may occur in grief reactions; when the patient is frightened; as a manifestation of hysteria; or in organic brain disease and schizophrenia.

Abnormal experiences of self and environment are listed in Box 7.24.

Box 7.24 Abnormal experiences of self and environment

Déjà vu

Patients feel that they have been in their current situation before – it can be normal or occur in temporal lobe epilepsy.

Capgras’ syndrome

The patient asserts that people are not who they claim to be, but are their double – occurs most commonly in schizophrenia but also in dementia.

Fregoli syndrome

The patient delusionally identifies a stranger as being a familiar person.

Depersonalization

An unpleasant sense that one is altered in some way and as if one is no longer completely real – patients will struggle to describe it. Often a manifestation of heightened anxiety and occurs in depression and severe fatigue.

Derealization

Patients say that their surroundings feel unreal, or grey or colourless. Some patients say it is ‘as if’ they are on a stage set and the world no longer feels real. This often accompanies depersonalization and can occur in severe fatigue.

Cognition

An assessment of cognitive function is a routine part of any mental state examination. It is impossible to interpret the significance of a variety of other symptoms, such as hallucinatory experiences or paranoid ideas, unless a basic assessment has been done of state of consciousness and presence of grossly normal brain function. In elderly people, or when organic brain disease is suspected (e.g. in acute confusional states), assessment of cognitive state is extremely important.

It can be difficult to perform a full assessment of cognitive function at a first interview, either because the patient is too disturbed or because there is a poor rapport, and patients will resent an implication there is something wrong with their mind. Even where formal cognitive testing is impossible or undesirable, a minimum assessment must be made as follows:

What is the patient’s level of consciousness?

Does it fluctuate?

Is he fully alert and behaving appropriately for the context?

Does he seem to be orientated in time and place?

In the majority of patients, it is possible to conduct a basic assessment of cognitive function. This should be preceded by an explanation that it is important for you to do a check of his memory and concentration, with a normalizing statement that this is routine with all patients.

Basic assessment of cognitive function

A useful and commonly used semi-quantitative measure is the Mini-Mental State Examination (MMSE) (Box 7.25). Scores are to some extent dependent on educational level. The test has subcategories related to orientation, registration, attention, recall and language. The maximum score is 30, and scores lower than 21 are associated with cognitive impairment. The MMSE cannot differentiate multifocal from diffuse organic brain disease, but it provides a useful baseline assessment of a patient’s cognitive performance.

Box 7.25 Mini-Mental State Examination