Identification

Present basic issues here. For example:

History of presenting complaint

This is an account of the circumstances leading up to the current presentation. It should detail the relevant recent events in the person’s life, the sequence of their responses to these circumstances, and the main presenting symptoms. Some detail should be provided of the major symptoms and behaviours with which the patient presents, relevant to why and how they are presenting for help at this time in this way. Details of help-seeking behaviour, including recent interventions and treatments, should be assessed.

Other psychiatric symptoms

This is an opportunity to go through a quick checklist of psychiatric symptoms and behaviours other than those elicited under ‘presenting complaint’. Positives and salient negatives should be enumerated. For example, in a patient presenting with social anxiety disorder, other anxiety symptoms, the presence of panic attacks, mood state and use of drugs or alcohol are relevant. In the patient with an exacerbation of psychotic symptoms, comorbid depression is important to elicit, expressly if linked to suicidality.

Past psychiatric history

Full details are needed of past psychiatric illnesses, including first manifestation of psychiatric symptoms, first contact with a health professional for a mental health problem, and longitudinal course of psychiatric problems, including any hospitalisations; self-harm and suicide attempts should be asked about specifically. An overview is required of treatments received (psychological, medication and electroconvulsive therapy (ECT)); engagement with and adherence to such treatments; and treatment response and any adverse effects experienced. A list of current medications should be obtained.

Past medical history

An overview is required of any relevant medical conditions, injuries and times spent in hospital for medical conditions. Longstanding, expressly debilitating and painful medical conditions are especially important, given their impact on quality of life and on psychiatric symptoms. Treatments should be reviewed, with particular attention to those with psychiatric side effects, such as beta-blockers (depression) or dopaminergic agents (psychotic symptoms). Allergies, medication sensitivities and current medications should be documented.

Family history

The family history should encompass any history of psychiatric or physical health problems. This should include established or suspected diagnoses, and treatments received. It is useful to draw a genogram, which is often best done with the patient. Collateral history from another family member greatly enhances accuracy of the family history.

Personal history

The personal history is best mapped in a longitudinal manner.

Drug and alcohol history

People are often averse to discussing drug and alcohol problems, and can become evasive. It is, however, critical to assess this in anyone presenting with psychiatric symptoms. A reasonably non-threatening screening instrument is the CAGE, which was initially developed for alcohol abuse, but which can be adapted for other drugs. Ask:

C Have you thought about Cutting down your alcohol/drug use?

A Have you become Angry or Annoyed at others criticising your drinking/drug use?

G Have you felt Guilty about the extent of your alcohol/drug use?

E Have you found you need an Eye-opener in the mornings after heavy drinking/had to use a drug to settle you down?

Any two positives should prompt a full alcohol/drug history. This should include assessment of the longitudinal course, including first exposure, first regular usage, first problematic usage, periods of abstinence, and periods of heavy use. Treatments, successful and unsuccessful, should be recorded. A typical drinking/drug use day should be mapped, with a view to eliciting elements of the dependence syndrome, such as narrowing of the drinking repertoire, and salience (see also Ch 20). Current use, including quantity and type of substance and route of administration (e.g. intravenous), should be recorded.

The impact of alcohol/drug use on the person’s life should be explored (e.g. impact on relationships, work and studies, physical health and finances). An assessment of the person’s ‘stage of change’ can also be helpful in planning treatment (see Ch 20).

Forensic history

Ask about the person’s forensic history, but in an unthreatening way. For example, ‘Have you ever been in trouble with the law?’ Detail patterns of misdemeanours and consequences, especially convictions and imprisonments.

Current life situation

This covers current work and social arrangements. Include details of: housing; finances; friendship networks; and relationships with family, spouse and children.

Hobbies

Ascertain what the person does for enjoyment, and how often they manage to engage in such activities.

Premorbid personality

The assessment of personality is difficult, and cross-sectional interviews are suboptimal for this task, especially in the setting of an Axis I disorder (see Ch 12). However, one can get a sense of the person’s inner world, and their way of reacting to others and to the world around them, from the personal history elicited above. At the end of the interview it is instructive to ask: ‘So, what sort of words would you use to describe the “real you”?’ Another approach is: ‘How do you think people who know you well would describe the person you really are?’ A few adjectives can provide a flavour of the person’s view of self.

Appearance and behaviour

The idea here is to describe the patient in sufficient detail that a colleague could pick the patient out of a waiting room full of people. Gender, apparent age and ethnicity are all relevant. Clothing should be described, especially if it provides a clinical clue to the working diagnosis, such as flamboyant colours in hypomania, or ill-kempt smelly clothing with numerous layers, in chronic schizophrenia. Florid gaudy make-up can also signal a manic or hypomanic mood state.

Behaviours should be described in terms that are understandable and easily identifiable by a third party. Examples include withdrawal, apathy and avoidance of eye contact in depression or severe anxiety; tearfulness in depression; histrionic, overfamiliar and seductive behaviour in the patient with borderline personality disorder; and arousal, pacing and threatening behaviour in the patient with paranoid psychosis.

Certain specific behaviours should be commented on, as positives or salient negatives: for example, a Parkinsonian facies, tardive dyskinesia, or stereotypies and mannerisms in chronic schizophrenia; responding to external stimuli such as hallucinations may also be apparent.

Speech

Careful description of the form of the patient’s speech gives a window into the form of their thoughts. This has nothing to do with content of thought, which is described separately (see below). A useful analogy is of a river flowing from the mountains (A) to the sea (B):

Route taken. The route may be direct from A to B, such as in clear goal-directed speech, or meandering and taking a long and convoluted path but eventually getting to B (circumstantiality, or being circumlocutory). This is seen in anxious people, in obsessionality and in mild schizophrenic thought disorder. In more severely disordered thought, the river runs off at a tangent (tangentiality), or unexpectedly jumps its banks and starts on a completely unconnected route (derailment or knight’s move). In extreme forms, the river gets nowhere at all, meanders around disconnectedly and ends up in a series of eddies (sometimes referred to as word salad).

Amount and speed of flow. The amount of water in the river can be miniscule (paucity of content—seen in both negative symptom schizophrenia and severe depression) and a slow trickle (e.g. short unembellished answers to questions); or a torrent delivered at high speed (pressure of speech—classically, in mania).

Amount of surface variation on the river (prosody) and volume. The water can be still and languid, with no waves (little variation in prosody—monotonous and dull, with a soft voice, as in depression); show the usual lilt of spontaneous speech; or have excessive variation and be too loud, as in mania.

Affect and mood

Affect is the external expression of internal emotion. It is assessed by observing the patient’s facial expression throughout the interview. Affect occurs on a spectrum from normal reactivity through restricted affect (e.g. in depression or severe anxiety) to flat to blunted affect (almost no affective expression, as in negative symptom schizophrenia). Remember that restriction of affect can also occur in Parkinson’s disease, or in the Parkinsonian syndrome seen with some antipsychotic drugs. Affect can also present as incongruent (e.g. smiling inanely while talking about something sad, which is usually a sign of schizophrenia or schizotypy).

Mood is assessed by both patient report and through objective observation. Assessment of objective mood uses features noted under ‘appearance and behaviour’ above. Subjective mood can be gauged in response to what the patient volunteers and/or responses to direct questions, such as: ‘How do you feel in terms of your mood? How happy or sad are you feeling?’ Mood can be anxious, depressed, irritable or euphoric.

Thought content

This describes the predominant themes of the patient’s account of themself. It is useful to present this in the context of the whole clinical picture. For example, depressive themes are emphasised in patients with a mood disorder. Overvalued ideas and delusional beliefs, where present, provide excellent keys to the formulation, and should be presented in some detail.

Perceptions

Any abnormal perceptions are presented here. These include hallucinations in any of the sensory modalities, namely: auditory (hearing); visual (seeing); olfactory (smell); tactile (touch); gustatory (taste); and somatic (bodily sensation).

Insight

This is a multifaceted construct, encompassing insight into:

whether the symptoms experienced are ‘real’ or part of an illness

whether they are suffering from a mental illness, and

the fact that they will benefit fromtreatment.

Interestingly, there can be an inconsistency across these parameters (e.g. a patient who absolutely denies having schizophrenia, but agrees the voices he hears may be ‘abnormal’ and takes antipsychotic medication to help alleviate them). It is also important to understand the cultural background of the individual, and the attitudes towards mental illness and treatment in that culture.

Judgment

This is generally an indication of how well the patient can make balanced appraisals of life circumstances, and act accordingly.

Cognition

It is always required that a brief cognitive screen is performed in patients presenting with psychiatric symptoms, as delirium and dementia can often be missed in their milder forms, and may help explain the rest of the mental state. The use of the full mini-mental state examination (MMSE) (see ‘References and further reading’) has virtue in its being a well-established instrument and a useful screen for dementia, but in some ways individual item scores are more instructive than the total score; nor are all items required in all patients. It is suggested that the items shown in Box 1.3 are a useful brief screen in patients who are not suspected of having a predominant cognitive element to their illness.

A specific area to cover in patients with suspected schizophrenia is that of concreteness of thinking. Ask about similarities and differences (e.g. a wall and a fence) and interpretation of sayings or proverbs (e.g. ‘a rolling stone gathers no moss’); a very literal response suggests concrete thinking (e.g. ‘if a stone rolls down a hill it won’t have any moss growing on it’).