The Psychiatric Evaluation

CAROL S. NORTH, SEAN H. YUTZY

Such is man that if he has the name for something, it ceases to be a riddle. —Isaac Bashevis Singer

The purpose of a psychiatric evaluation is to examine psychological function and to diagnose a psychiatric disorder(s) if present. To elicit enough information about the disorder(s) to make a diagnosis, one must know the signs, symptoms, course, and complications.

Eliciting clinical information is an art. It can be only partially learned in a formal manner. Establishing rapport and trust between the doctor and patient facilitates accurate history gathering, communicates empathy, and allows logical arrival at reasoned conclusions regarding clinical status and diagnosis(es). This ability is essential, and it cannot be learned from textbooks. Below we offer advice on interviewing, provide a logical framework for organizing observations, and suggest how case histories should be presented. We begin with just a few words about terminology and time.

The mental status examination is the part of the physical examination that deals with the patient’s thoughts, feelings, and behavior at a particular point in time. This term is often used as a synonym for a psychiatric examination, but mental status refers to one part of the psychiatric examination: the current thoughts, feelings, and behavior of the patient.

Psychiatric evaluation includes the past history (medical, social, family, records, collateral information) of the patient as well. The distinction between the two terms is somewhat artificial. Similar to liver status or cardiac status, what exists now is inseparable from what came before; a certain amount of historical background is unavoidable in describing the current mental status of a patient. Nonetheless, the term ‘‘mental status’’ is used when the primary focus of the questioning is on current functioning.

Internists, family practitioners, and other non-psychiatrists generally have little time to conduct a physical examination: often no more than 15 or 20 minutes. If the examination is ‘‘complete,’’ it will include some attention to the mental status of the patient. This may be limited to a few minutes. While managed care may put extra time pressure on the clinician, the expenditure of at least a few moments will broaden the perspective about the patient (whether the answers are positive or negative) and may save substantial time during the course of treatment.

For example, learning that an obviously depressed individual also has a history of one or more manic episodes will not only change the diagnosis from major depression to bipolar affective disorder but also the treatment that may have otherwise switched the patient from a depressive episode into a manic phase.

Later we will provide some screening questions that will help non-psychiatrists quickly ascertain whether the mental state of the patient is abnormal. For now, we will assume the mental status examination is being conducted by a psychiatrist, a student, or a resident in psychiatry who has the luxury of being able to spend a fair amount of time with the patient, observing him or her and asking questions.

Advice on Interviewing

Following are four rules for conducting a psychiatric evaluation:

1. Start open ended. After exchanging friendly greetings with the patient and attempting to set a relaxed tone, the interviewer should ask an open-ended question such as, ‘‘What is the problem that brings you here?’’ ‘‘What can I do for you?’’ Unless the patient is uncooperative or incapable of free expression (perhaps because of physical disability), let the patient tell his or her story with little or no interruption during the first 5 to 15 minutes.

The patient is often anxious early in the interview and this tension may indeed stimulate the information flow. A patient with a formal thought disorder (where the thoughts do not connect coherently) will reveal this quickly. Much of the information needed for the diagnosis is often provided in the first few minutes if the patient proceeds without interruption. Early steering of the interview through certain question lines may result in missing important material.

On the other hand, for a particularly tense patient, more structure at the beginning of the interview may lead to easier communication. The interviewer can ask specific questions that are emotionally neutral. Questions about the patient’s background, including where the patient grew up and attended school, marital status, employment history, and other physicians seen, can provide a comfortable transition into asking about a presenting problem.

2. Ask specific questions later. One purpose of the mental status examination is to make a diagnosis, if possible. This requires specific questions if merely to rule out remote possibilities. For example, patients often avoid volunteering information about hallucinations. ‘‘Do you hear voices or see things that others do not hear or see?’’ or some variation on this query is often necessary to determine whether the patient is psychotic. ‘‘Do you feel in danger?’’ may elicit persecutory delusions. ‘‘Do you have a special mission in life?’’ may bring out grandiose delusions. ‘‘What are your plans after leaving the hospital?’’ may bring out unrealistic thinking, raising questions about judgment.

Even with the advantage of a long interview, the psychiatric examiner must ask specific questions bearing on a reasonable differential diagnosis. There is usually no point, for example, in going through a complete review of systems if the patient experiences excellent health and presents with symptoms of a psychiatric condition in which physical symptoms do not usually play a role. Details about positive early life experiences rarely bear on the problem of making a differential diagnosis in adults. School and social history are often important, but not always, particularly in dealing with elderly people.

3. Establish the chronology of the illness. Kraepelin (3) noted that the course of a psychiatric illness is as important as the symptoms. Sydenham (5) said that ‘‘true’’ illnesses should have common symptoms and a common course. Few, if any, pathognomonic symptoms exist in psychiatry. We agree with Kraepelin that establishing the course of an illness is as important as recognizing current symptoms. When did the symptoms begin? Was the patient ever free of psychiatric symptoms? When? Age of onset is an important clue to diagnosis as many conditions typically begin at particular times in life.

Has the illness been continual, always present with fluctuations, or episodic in the sense that symptoms sometimes go away entirely? How rapid was the onset? (Psychotic illnesses with abrupt onsets generally have a better prognosis than those with a gradual onset.) Have professional interventions (medications, psychotherapy) altered the course of illness? In general, has the patient tended to improve or get worse? ‘‘Diagnosis is prognosis’’ is an old saying in medicine, and knowledge of the course of illness as well as the symptoms forms the basis for determining prognosis.

4. Be friendly, sympathetic, respectful. Establish good eye contact and listen attentively. Encourage the patient to tell his or her history through noninterfering encouragement (e.g., smiling, nodding, reflecting the patient’s expressed feelings). Adult patients should be called ‘‘Mr.’’ or ‘‘Mrs.’’ or ‘‘Ms.,’’ at least until the clinician knows them well. Clinicians should never insult patients. They should never make fun of them. This may seem obvious, but there are subtle ways of betraying disrespect.

Be sensitive to the emotional state of the patient. If certain questioning makes the patient angry, anxious, depressed, or tearful, this may offer an opportunity to enhance the patient’s ability to communicate, though sometimes a return to more neutral ground is indicated so that the patient is not overwhelmed by emotion.

A word about the uncooperative patient: to say, ‘‘I can’t help you unless you help me’’ sometime works, but usually it does not. Asking specific questions such as ‘‘What led to your coming here?’’ or ‘‘Whose idea was it that you come here?’’ may help lower resistance. Sometimes the interview must be postponed until another time when the patient may be more helpful.

Anger toward the uncooperative patient is never appropriate. Psychiatry, probably more than any other specialty, benefits greatly from informants—friends and family who will tell what the patient will not
(or cannot). Although caution should be exercised in judging the merit of such information, it can be very helpful in making a diagnosis. One should also remember to obtain permission from the patient before seeking outside or collateral information.

The Decision Tree

Except for open-ended questions at the beginning and specific questions toward the end, history taking should flow easily and casually, as in a conversation. Initially, patients should be permitted to talk about what they want to talk about, but eventually they should be gently guided back into channels that provide information the examiner requires for a diagnosis. From the moment a patient walks into the examination room, however, the examiner’s mental ‘‘computer’’ starts making relevant observations.

How is the patient dressed and groomed?
Does the patient have a normal gait and range of motion?

Is the patient hostile or friendly?

How old does the patient appear to be?

Based on early impressions, the interviewer starts constructing the differential diagnosis. Over the course of the interview, the examiner’s choices about probable diagnoses will determine which areas to emphasize and which to skip over lightly or omit entirely. The examiner’s mind, indeed, functions as a computer. By the end of the interview—if it is successful—the choices will have narrowed to one or a few.

The first important decision concerns psychosis. Is the patient psychotic or nonpsychotic? Psychosis can be both broadly and narrowly defined. Broadly defined, it refers to the gravity or seriousness of the condition; a suicidal patient might be called psychotic because suicide is serious. Narrowly defined, as here, psychosis means the presence of persistent hallucinations and/or delusions and/or disordered thoughts.

Nonpsychotic	Psychotic	Impaired Memory
Anxiety disorders Panic Obsessional Phobic Somatization disorder Antisocial personality Other personality disorder Chemical dependence Affective disorders	Schizophrenia Acute Chronic Affective disorders Depression Mania Both Chemical dependence	Chronic (Dementia  or Retardation) Acute (Delirium)

As shown in the Table, the diagnostic possibilities for a nonpsychotic person would include the anxiety disorders (there are twelve in DSM-IV-TR) (1), mood disorder, chemical dependence, antisocial personality, other personality disorder, eating disorders, and somatization disorder. Thus, in some conditions such as mood disorders and drug dependence, the patient may or may not be psychotic. A psychotic individual may suffer from schizophrenia, a mood disorder, or drug intoxication. Hallucinogens, amphetamines, and phencyclidine (PCP) are commonly associated with psychosis.

The second early decision concerns memory. If the memory is abnormal, one moves toward the right of in the Table. Memory problems can usually be sorted into acute or chronic conditions. The nomenclature and presentations could be reviewed in detail. Several issues warrant review.

First, poor intellectual functioning is associated with, and often indistinguishable from, bad memory. Impaired memory produces impaired intellectual functioning. Intelligence encompasses more than memory, but even those skills not normally associated with memory (e.g., reasoning ability) often suffer when memory is impaired.

Second, patients with major depression sometimes have difficulty with memory, and this is called ‘‘pseudodementia.’’ Their memory improves as their depression improves. Finally, patients with gross memory impairment (as distinguished from absentmindedness, normal forgetting, or ‘‘not paying attention’’) may display any psychiatric symptom associated with disorders on the left side of  the Table.

While symptoms of disorders on the left side of the Tables may temporally correspond to or antedate onset of memory impairment, identification of a new organic impairment is of paramount importance. Diagnosis of a new onset of an organic disorder is one of the most important things a psychiatrist can do because it initiates a search for the cause of the disorder that may be treatable.

Physicians are uniquely qualified among mental health professionals to identify the organic disease. Trained in anatomy, physiology, and biochemistry, and aided by modern imaging and laboratory techniques, physicians can evaluate the entire range of sources of organic disorders, including brain tumors, endocrine disorders, metabolic illness, and infections.

In most hospitals, about one-fifth of the patients who clearly have psychiatric abnormalities do not meet criteria for the categories in the Table. The suitable label for these people is undiagnosed. One advantage of this term is that physicians who deal with the patient in the future will not be biased by having a poorly grounded diagnosis in the chart. Another advantage is the sense of modesty it correctly implies. In particular, there is no diagnostic test to conclusively establish a psychiatric diagnosis other than delirium and dementia.

Unfortunately, many insurance companies require a diagnosis. One can include the most likely diagnosis or diagnoses prefaced by the term ‘‘rule out.’’ Many insurance companies will accept this practice. Alternatively, use of the diagnostic category, Not Otherwise Specified (NOS) (e.g., anxiety disorder, Not Otherwise Specified) may suffice and be clinically useful because it conveys the core symptom(s) without overstating certitude.

Outside of hospitals, many patients who consult psychiatrists do not have a diagnosable illness. They even lack symptoms of sufficient severity to justify being called ‘‘undiagnosed.’’ One label for these more or less normal people who see psychiatrists is ‘‘problem of living,’’ which suggests, if nothing else, that no conventional diagnosis seems to fit them.

The Mental Status Format

The purpose of the mental status format is to help the interviewer organize and communicate his or her observations about a patient. Minor deviations occur in the format from expert to expert, but some framework for observations is necessary to facilitate thinking and communication. The format presented here is commonly used and includes the following categories:

Appearance and behavior
Form and content of thought
Affect and mood
Memory and intellectual functioning
Insight and judgment

Appearance and Behavior

The patient’s appearance is often relevant to the diagnosis. Patients with schizophrenia, for example, may sometimes appear poorly groomed or even dirty. Patients with major depression can be negligent about their dress and grooming. Patients with mania may wear odd or unusual clothing. Sunglasses
worn indoors may suggest paranoia; a puffy face and red palms are suggestive, but not diagnostic, of alcohol abuse/dependence. A physical appearance older than the patient’s stated age may suggest depression or long-term substance abuse. If this is the case, a more youthful appearance may be restored as the patient recovers.

The patient’s attitude toward the interviewer may be significant. Patients who are paranoid are often suspicious, guarded, or hostile. Patients with somatization disorder sometimes try to flatter interviewers by comparing them favorably with previous doctors; they are often dramatic, friendly— sometimes seductive. During manic episodes, patients may crack jokes and occasionally are quite funny—when they are not irritable or obnoxious. Sociopathic patients may seem like con men—and sometimes are. The patient may be agitated—unable to sit still, moving constantly. Others are retarded, slumping in their seats, slow in movement and speech. Talking may seem an effort. Disturbance of motor function may have several causes.

Neuroleptic medications may produce a restlessness called ‘‘akathisia,’’ in which the patient cannot sit still and feels compelled to walk. Neuroleptics also may produce Parkinson-type symptoms, including tremor and an expressionless face. Pacing and handwringing may be expressions of depression; joviality and volubility may portray mania.

Neuroleptics are given so commonly that it is often impossible to determine whether abnormal movements are drug induced or are catatonic symptoms. In fact, similar involuntary movements were observed in schizophrenia years ago before medications were introduced. It is said that catatonic symptoms (cataplexy, stupor, hyperkinesiae) are disappearing, but what previously was called catatonic may now be interpreted as drug induced without knowing whether medications are responsible.

Schizophrenia also may involve psychomotor disturbances such as mannerisms, posturing, stereotypical movements, and negativism (doing the opposite of what is requested). Also seen is echopraxia, in which movements of another person are imitated, and catalepsy, in which awkward positions are maintained for long periods without apparent discomfort. Some patients say nothing. Called ‘‘mutism,’’ this behavior may be seen in schizophrenia, depression, delirium/dementia, and drug intoxication.

Form and Content of Thought

Form refers to intelligibility related to associations: Does the patient have ‘‘loose associations’’ in the sense of being circumstantial, tangential, or incoherent? Older people may be circumstantial. They return to the subject but only after providing excessive detail. Tangentiality is a flow of thought directed away from the subject being inquired about, with no return to the point of departure. Patients with schizophrenia are often tangential.

Pressure of speech and flight of ideas are seen in mania and in drug intoxication. The patient with pressured speech seems to be compelled to talk. Manic speech flits from idea to idea, sometimes linked by only the most tenuous connections. Unlike tangentiality, however, manic speech frequently has connections that can be surmised. Patients in manic episodes often rhyme or pun and make ‘‘clang’’ associations, using one word after another because they sound similar. They tend to be over-inclusive, including irrelevant and extraneous details.

Patients with somatization disorder or borderline personality disorder can be almost maddenly circumstantial (providing excessive detail of little clinical importance) while at the same time being quite vague (lacking specific information being sought); when severe, this ‘‘nonpsychotic thought disorder’’ pattern (4) can be mistaken for the tangentiality of formal thought disorder observed in patients with psychosis.

Derailment, often seen in schizophrenia, is a form of speech in which it is impossible to follow the logic of the associations. Patients with schizophrenia may invent new words (neologisms) that presumably have a private meaning. Sometimes patients with schizophrenia display poverty of thought, conveying little information with their words. Echolalia refers to occasions when the patient repeats words back to the interviewer.

Other abnormal speech patterns associated with schizophrenia (as well as dementia) are perseveration, in which the patient seems incapable of changing topics, and blocking, in which the flow of thought is suddenly stopped, often followed by a new and unrelated thought. Patients who persistently display any of these symptoms (excluding poverty of thought) are said to have a formal thought disorder, meaning that the structure or form of thinking is disordered.

Content of thought refers to what the patient thinks and talks about. This category comprises hallucinations, delusions, obsessions, compulsions, phobias, suicidal/homicidal thoughts, and preoccupations deemed relevant to the psychiatric problem.

Delusions are fixed false beliefs neither amenable to logic or social pressure nor congruent with the patient’s culture. They should be distinguished from overvalued ideas; fixed notions that most people consider false but that are not entirely unreasonable or that cannot be disproved, such as certain superstitions. Delusions occur in delirium/dementia, schizophrenia, affective disorders, and various intoxications.

Jaspers (2) believed the subject of the delusion had diagnostic significance. If the delusional ideas were ‘‘understandable,’’ they more likely occurred in depressed patients. Understandable delusions included those in which persons were convinced they had a serious life-threatening illness such as cancer, were impoverished, or were being persecuted because they were bad persons. Jaspers pointed out that healthy, prosperous, and likable people often worry about their health, finances, and approval by others. Such delusions are thus understandable.

Delusions that are not understandable are seen in schizophrenia, according to Jaspers. Schizophrenic delusions tend to be bizarre; for example, one’s acts are controlled by outside forces (delusions of control or influence) or one believes that one is Jesus or Napoleon. Schizophrenia-like delusions occur often in amphetamine psychosis and, less commonly, in other intoxicated states (e.g., from cocaine or cannabis). The delusions of schizophrenia fall outside the ordinary person’s experience: the examiner finds it difficult to identify with the schizophrenic’s private world; hence, the term ‘‘autistic,’’ derived from ‘‘auto,’’ is often applied to schizophrenic thinking.

Religious delusions are sometimes hard to interpret. Religious beliefs often seem delusional to those who do not accept the beliefs but normal to those who do. Among fundamentalist religious people, truly pathological delusions are usually identified without difficulty by others in the congregation.

Content also encompasses perceptual disturbances. In illusions, real stimuli are mistaken for something else (e.g., a belt for a snake). Hallucinations are perceptions without an external stimulus. Auditory hallucinations may consist of voices or noises. They are associated primarily with schizophrenia but occur in other conditions such as alcoholic hallucinosis and affective disorders. Visual hallucinations are most characteristic of organic disorders, especially delirious states. They also occur with psychedelic drug use and in schizophrenia. (Certain hallucinations are more common in some conditions, but no type of hallucination is found exclusively in any illness.)

Hypnagogic hallucinations arise in the period between sleep and wakefulness, especially when falling asleep. Hypnopompic hallucinations occur when awakening from sleep. These sleep cycle hallucinations are normal except when they are a symptom of narcolepsy.

Olfactory hallucinations are sometimes associated with complex partial seizures that involve the temporal lobes. Haptic (tactile) hallucinations occur in schizophrenia and also in cocaine intoxication and delirium tremens. The sensation of insects crawling in or under one’s skin (formication) is particularly common in cocaine intoxication, but it also happens in delirium tremens.

In extracampine hallucinations, the patient sees objects outside the sensory field (e.g., behind his head). In autoscopic hallucinations, the patient visualizes himself projected into space. The patient occasionally has a doppelga¨nger (sees his double). Other perceptual distortions include depersonalization (the feeling that one has changed in some bizarre way) and derealization (the feeling that the environment has changed).

In one study of non-psychiatric patients, 40% reported hallucinations, particularly seeing dead relatives. They had no other psychiatric symptoms and the hallucinations were not judged to be clinically important. Thus, a history of transient hallucinations or other perceptual disturbances, which occur occasionally during exhaustion or grief, does not necessarily signify the presence of psychosis. Such disturbances must be interpreted in the context of the overall clinical picture.

Affect and Mood

Affect refers to a patient’s outwardly (externally) expressed emotion, which may or may not be appropriate to her reported mood and content of thought. For example, if a person smiles happily while telling of people trying to poison her, the affect would be described as inappropriate. If one describes unbearable pain but looks as if she were discussing the weather, the affect again would be inappropriate.

Affect is sometimes referred to as ‘‘flat,’’ meaning that the usual fine modulation in facial expression is absent. Patients with schizophrenia sometimes have a flat affect, but so do patients taking neuroleptic medications, and depressed patients may show little change of expression while speaking. ‘‘Flat affect’’ is probably the most overused and misused term in the psychiatric examination. It should only be used if the affect is extremely ‘‘flat’’ or ‘‘blunted.’’ Inappropriate and flat affects are especially associated with schizophrenia.

Sometimes patients with hysteria have an inappropriate affect in that they describe excruciating pain and other extreme distress with the same indifference or good cheer with which they would describe a morning of shopping. (The French call this la belle indiffe´rence.)

Mood refers to what the patient says about his internal emotional state. ‘‘I am sad,’’ ‘‘I am happy,’’ and ‘‘I am angry’’ are examples. Mood and affect are sometimes labile, meaning there is rapid fluctuation between manifestations of happiness, sadness, anger, and so on. Labile affect is often seen in patients with mania, somatization disorder, and delirium/dementia.

Memory and Intellectual Functioning

Subsumed under memory is orientation, meaning orientation for person, place, and time. To be disoriented for time, the patient should be more than 1 day off the correct day of the week and more than several days off the current date. Misidentifying people (e.g., thinking the nurse is one’s aunt) is a clear case of disorientation, as is giving the wrong year or the wrong city and wrong hospital where one is currently.

This part of the mental status is exceedingly important because, if a patient has a gross memory impairment (and is not malingering), he or she almost always has an organic disorder and all other psychiatric symptoms may be explainable in this context. (The exceptions are substance dependence and pseudodementia.)

There are many tests for memory and intellectual functioning. Memory can be subdivided into immediate, short-term, recent, and remote memory.

Immediate memory can be tested by asking the patient to repeat a series of digits. Serially subtracting 7 from 100 is a test of immediate memory (assuming the person’s arithmetic was ever adequate for the task) as are tests of attention and concentration. Short-term memory loss can be tested by asking patients to remember three easy words you have spoken or showing them three objects and then, 5 to 15 minutes later, asking them to repeat what they heard or saw. A short-term memory deficit is the sine qua non of Korsakoff’s syndrome.

Recent memory refers to recall of events occurring in recent days, weeks, or months; remote memory involves recall of events occurring many years before, such as the winner of a long-ago presidential election. In early dementia, recent memory is usually more severely impaired than remote memory.

As noted earlier, tests of intellectual functioning should be interpreted with the patient’s background, education, cooperativeness, and mood state in mind. A history major should be able to name seven presidents, but a ‘‘normal’’ person with a 3rd-grade education may not be able to do so. Depressed patients may be too slowed down or distractible to concentrate. One approach would be to questions that are crafted to the particular situation that the examiner opines the patient should be able to answer. Another approach might be to ask the patient about his or her interests and then test the patient’s fund of information in those areas.

Insight and Judgment

A person who has insight will know whether he is (or was) psychiatrically ill. If he says, for example, that the voices are ‘‘real,’’ he lacks insight. If he says it was simply his imagination playing tricks on him, he has insight.

If he says there is nothing wrong with him but that his evil uncle has arranged for his hospitalization because of a Communist conspiracy, he may or may not have insight. (Even paranoids, as the saying goes, sometimes have real enemies.) Psychosis and delirium/dementia are associated with lack of insight.

The term ‘‘judgment’’ is used here in the same sense as ‘‘competence’’ is used in a court of law: a competent person is able to understand the nature of the charges and to cooperate with counsel. It implies that a person is realistic about his limitations and life circumstances. A good question to ask is, ‘‘What are your plans when you leave the hospital?’’ If the patient says that he plans to start a chain of restaurants and has no money, this displays impaired judgment. Severe impairment of judgment is seen most often in dementia and psychotic disorders.

Excluding Psychiatric Disorders

Sometimes for all physicians and often for non-psychiatric physicians, examination of the ‘‘mind’’ must be accomplished quickly, lest the liver, lungs, heart, and deep tendon reflexes be slighted. For the major disorders described in this book (and the less valid ones), a single question may suffice to strongly suggest ruling out the possibility the patient has the disorder. Some disorders will be
missed, but one or two questions will identify the great majority of patients who do not have a particular psychiatric illness:

Depression: Although it seems obvious, just ask the patient if he or she has periods of feeling down or depressed for days on end. Rare is the seriously depressed individual who will deny these feelings.

Mania: Ask if the patient has ever had elevated mood or felt too good for days at a time. People with a history of mania love to reflect on past times when they felt ‘‘really good.’’

Schizophrenia: Ask if the patient has ever heard or seen things that other people did not hear or see. Ask if he has ever been afraid of being poisoned or controlled by external forces. Hallucinations sometimes occur in normal people, but the presence of both hallucinations and delusions in a person with more or less normal mood suggests schizophrenia.

Panic disorder: Has the patient ever thought she was having a heart attack that did not occur? Does she ever become intensely apprehensive for no apparent reason? Patients with panic disorder report both. At church, does she find a seat on the aisle close to the back? Patients with panic disorder almost always do. They feel the need to make a quick exit if a panic attack seems impending.

Posttraumatic stress disorder: Was the patient involved in, or eyewitness to, a violent or physically traumatic event? After such an experience, did the patient develop new problems with jumpiness or
sleeplessness, or intrusive memories of the experience? Are reminders of the event so upsetting that the patient will go to great lengths to avoid them?

Somatization disorder: Mostly women. Inquire in a neutral manner roughly how many doctors the patient has consulted for various symptoms and what surgical procedures she has had. If the patient has consulted few physicians and has all of her abdominal and pelvic structures intact, it is unlikely that the patient has somatization disorder.

Obsessive-compulsive disorder: Does the patient, sitting in a waiting room, count things, such as the number of tiles on the floor? Does the patient repeatedly check a door to see if it is locked or an oven to see if it is turned off? Counting and checking are so common in this disorder that, if absent, the diagnosis should be questioned.

Phobic disorders: Does the patient avoid certain situations or things because they frighten him or her? Is the fear unreasonable?

Alcohol dependence: Has the patient ever stopped drinking for a period of time? If so, and the reason is not medical or a desire to lose weight, the patient probably stopped because he was worried about his drinking. At this point, the clinician can ask why he was worried, and this may break down the denial that is characteristic of alcoholism. Almost every patient with alcohol dependence has stopped, or tried to stop, at some time in his life. This is a better approach than asking, ‘‘Do you drink too much?’’

Drug dependence: ‘‘Have you ever worried about a drug habit?’’ is probably as good an opener as any.

Antisocial personality (sociopathy): Ask if the patient was frequently truant in grade and high school. Rare is the sociopath who did not cut classes and get in trouble with school authorities as a teenager.

Borderline personality disorder: Ask if the patient suffers from reactive mood swings characterized by brief intense episodes of dysphoria, or irritability or anxiety lasting a few minutes, hours, or days. If not, only a rare chance of the disorder.

Dementia: Ask if the patient forgets where she parks her car. If this happens often, there should be some concern about her memory. Or simply ask, ‘‘How is your memory?’’ Many people with memory problems are relieved to have the chance to talk about them.

Anorexia nervosa: If the person is intelligent, ask her (and it is usually a her) if she has ever been told she had anorexia nervosa. Patients with this disorder usually know their diagnosis; the disorder is well described in popular media. Does the patient stuff herself (or himself) with food and then induce vomiting? This practice, called ‘‘bulimia,’’ often goes with anorexia in both sexes. Another question: ‘‘Are you the right weight?’’ If the patient is five foot seven inches, weighs 92 pounds, is not a model, and says, ‘‘I’m too fat,’’ the diagnosis is strongly suggested.

Sexual problems: ‘‘Do you have any sexual issues?’’ is usually sufficient. This is a neutral approach to sexual problems.

These questions when answered in the negative will eliminate most people who have the above disorders. There will be few false-negatives. There will be many false-positives. (Some people who do not have depression or anxiety disorders sleep poorly and sit at the back of churches.) But for the physician trying to rule out disorders, false-positives are much less important. They simply mean probing is required. Probing takes time, and referral to a psychiatrist may be in order.

Suggestions for Presenting Cases

There is obviously a good deal of latitude in presenting case histories for teaching purposes. Different institutions and different teachers within the institutions will have their own advice on the subject. However, discussions with these teachers reveal some agreement about certain points. Following are some general rules for presenting patients:

1. Do not read the history.
2. Do not exceed 10 to 15 minutes (allowing for interruptions).
3. Start with identifying data: name, age, race, marital status, vocation.
4. Provide a clue to the problem you will highlight, for example, ‘‘This patient presents a diagnostic problem,’’ ‘‘He has not responded to standard treatments,’’ ‘‘She comes from an unusual family.’’ Such clues offer a framework for your audience into which the rest of the presentation will fit.
5. Avoid dates. Open with ‘‘Patient was admitted to [hospital] ______ (days, weeks, months) ago. Do not refer to events occurring on December 3, 1937, but say, ‘‘At the age of 15, the patient ______.’’ Instead of saying, ‘‘Between November and January of 1955 and 1956,’’ say, ‘‘For a three month period when the patient was twenty years old, he ______.’’ It may be easier for patients to remember events by dates, but the listener has to translate dates into ages and, for the unmathematically inclined, this may be difficult while concentrating on the presentation.
6. Begin with the psychiatric history. A good way to begin is, ‘‘The patient had no psychiatric problems until age ______ (or ______ days, weeks, or months ago) when he (slowly or rapidly) developed the following symptoms: ______,’’ then list the symptoms in order of severity. Tell
how long the symptoms persisted (for weeks, months, years, or to the present) and what happened as a result (hospitalization, other treatment, full or partial recovery). Often, of course, establishing time of onset is difficult or impossible, particularly when dealing with a poor historian or a complicated case. The onset of illness in a mentally retarded person would be ‘‘from birth,’’ which does not help much. But an attempt to establish onset can be of considerable help because different illnesses characteristically begin at different ages.
7. It is important to know whether the illness has been chronic, perhaps with fluctuations, or episodic with full remissions between episodes. If the patient has had more than one episode, describe subsequent episodes, briefly giving the same information that was given for the first episode. Symptoms and life events obviously are interrelated, but emphasize the symptoms rather than the life events unless the life events appear to be causally related to the symptoms.
8. A brief family history should include the following: whether a close blood relative of the patient had a serious psychiatric illness requiring treatment (and what the treatment was, if known), pertinent medical illnesses, and suicide, alcohol or drug problems.
9. Social history should include (very briefly) circumstances of upbringing, particularly whether the parents were divorced or separated or whether the patient was brought up by both parents; parental vocation; siblings; years of education and how well the patient did in school from the standpoint of grades and adjustment; military and employment history; marital history; and number and ages of children.
10. Review the medical history only as it is pertinent to the psychiatric problems. The same applies to the review of systems, physical findings, and laboratory results.
11. Give the mental status as it was obtained either on admission or at the first opportunity to fully examine the patient. The mental status findings should be presented in the order provided in the previous section.
12. End the presentation with course in hospital. Tell how the patient has been doing, whether he has improved, and what treatment he is receiving. In other words, bring the patient up to the present
moment.
13. With rare exceptions, all this can be presented in 10 to 15 minutes. The trick is to keep in mind at all times the goal of the presentation. If it is diagnostic, the differential diagnosis and the points for and against each of the reasonably likely diagnoses should be given. If you start out by saying the patient was psychiatrically well until the age of 60, dwelling on such diagnoses as mental retardation, schizophrenia, somatization disorder, or panic disorder is unlikely to be useful. Assuming the history is correct (though, granted, this is often a dubious assumption), people who are well until the age of 60 and then develop major psychiatric problems generally have either an affective disorder or delirium/dementia.
14. The reasons for presenting the history and mental status according to the above sequence are to avoid leaving out important information and to make it easier for the listeners to follow the narration. There are many variations on this format, and none is perfect. (People’s lives are much more complicated than formats.) Unlike written psychiatric histories, however, oral presentations should not attempt to be comprehensive. They should touch on the following categories, but not all with equal emphasis.

HISTORY

Identifying data
Focus of the presentation
Psychiatric history
Family history
Social history
Medical history
Review of systems
Physical findings
Laboratory results

MENTAL STATUS

Appearance and behavior
Form and content of thought
Affect and mood
Memory and intellectual functioning
Insight and judgment

REFERENCES IN

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision. Washington, DC: Author, 2000.
2. Jaspers, K. General Psychopathology. Chicago: University of Chicago Press, 1963.
3. Kraepelin, E. Dementia Praecox and Paraphrenia (Barclay, R. M., Robertson, G. M., trans.). Edinburgh: E. & S. Livingstone, 1919.
4. North, C. S., Kienstra, D. M., Osborne, V. A., Dokucu, M. E., Vassilenko, M., Hong, B., Wetzel, R. D., and Spitznagel, E. L. Interrater reliability and coding guide for nonpsychotic formal thought disorder. Percept. Mot. Skills, 103:395–411, 2006. 5. Sydenham, T. Selected Works of Thomas Sydenham, M.D. London: John Bales &
Sons, Danielson, 1922.

References

CAROL S. NORTH, SEAN H. YUTZY,  2010, Goodwin and Guze’s Psychiatric Diagnosis, Sixth Edition, Oxford University Press, Inc

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