Shorter Oxford Textbook of Psychiatry, 6th Ed.

CHAPTER 3. Assessment

Introduction

Psychiatric interviewing

The psychiatric history

The mental state examination

Other components of psychiatric assessment

Special kinds of psychiatric assessment

Patient characteristics that may affect the interview

Integrating and evaluating the information

Recording and communicating information

Standardized assessment methods

Introduction

Psychiatric assessment has three goals:

• To make a diagnosis. Despite its limitations (see Chapter 2), diagnosis is central to the practice of psychiatry, since it provides the basis for rational, evidence-based approaches to treatment and prognosis. A major goal of most assessments, especially those of new patients, is therefore to allow a diagnosis or differential diagnosis to be made. This in turn requires that the symptoms and signs of psychiatric disorder (see Chapter 1) can be elicited, and their diagnostic significance appreciated.

• To understand the context of the diagnosis. The psychiatrist needs to have sufficient information about the patient’s life history, current circumstances, and personality. This is necessary in order to understand why the disorder may have occurred; it also has a major bearing on decisions about management and prognosis.

• To establish a therapeutic relationship. The psychiatrist must ensure that the patient feels able and willing to give an accurate and full history. Without this skill, the necessary diagnostic information is unlikely to be obtained. Establishment of a therapeutic relationship is also essential if the patient is to engage fully in discussions about management, and to adhere to any treatment decisions which are agreed upon.

The process of psychiatric assessment can be broken down into the following stages:

• Preparation. This includes having the interviewing skills necessary to achieve the above goals, acquiring as much background information as is possible to help guide the assessment (e.g. the reason for referral, and whether informants are available), and anticipating whether the interview may need to be adapted (e.g. due to language difficulties, shortage of time, or a reluctant patient).

• The collection of information. This is usually addressed by means of a series of headings covering the psychiatric history, mental state examination, and other components, as described below.

• The evaluation of the information in order to arrive at a diagnosis or differential diagnosis. This is the hardest part of the process to describe to readers new to psychiatry, as it requires knowledge of the diagnostic significance of particular symptoms and symptom combinations. It is therefore suggested that this chapter should be returned to at regular intervals, in order to refine how assessments are conducted to match one’s developing knowledge and skills.

• Using the information to make treatment decisions and form prognostic opinions.

• Recording and communicating the assessment and its conclusions. The information must be shared with other health professionals involved with the care of the patient both now and in the future, and with the patient and their significant others. Various modes of communication are necessary (e.g. with regard to its nature and level of detail) depending on the circumstances of the assessment and the needs of the recipient.

This chapter covers these areas in turn, concentrating on the full initial assessment of a patient by a general adult psychiatrist. It also discusses how this process should be adapted in other circumstances. First, however, the basic process of psychiatric interviewing will be outlined. At the outset, it is worth emphasizing that the description of assessment in textbooks tends to make the process appear to be a passive, even predetermined one of extensive data collection. In practice, however, assessment is an active, selective process, in which diagnostic clues are pursued, hypotheses tested, and the focus of questioning adapted to the particular circumstances and needs of the patient. This ‘dynamic’ aspect of assessment can only be learned from practical experience. It also requires a working knowledge of the main psychiatric syndromes, in order for the significance of specific symptoms or history items which emerge during the assessment to be appreciated. It was for this reason that the preceding chapter covered psychiatric classification.

It is assumed that the reader is already competent in medical history taking and physical examination, and these topics are considered only briefly. Readers who require more information should consult a textbook of medicine.

Psychiatric interviewing

Preparing for the interview

Psychiatric assessments (interviews) have to be conducted in many settings. The following recommendations should be followed as far as is practicable, but they cannot always be achieved in their entirety. In some locations, such as an Accident and Emergency department, the setting may be far from ideal. Nevertheless, it is important to do what is possible to put the patient at ease and ensure privacy and lack of interruption.

Only a small minority of patients are potentially dangerous, but the need for precautions should be considered before every interview. The interviewer should always:

• make sure that another person knows where and when the interview is taking place and how long it is expected to last. This is especially relevant to interviews in the community

• ensure that help can be called if it is needed. In hospital, check for an emergency call button and its position, and otherwise try to arrange for another person to be within earshot

• ensure that neither the patient nor any obstruction is between him- or herself and the exit

• remove from sight any objects that could be used as weapons.

If the risk is thought to be high, or if these requirements cannot be met, it may be necessary to defer the interview.

Before starting the interview, it is always worth finding out what is already known about the patient and the circumstances in which the assessment has come about. This will often be in the form of a referral letter from another doctor, or there may be notes available from previous assessments. The past information does reveal areas of enquiry that may require particular emphasis, and may modify the diagnosis which is subsequently made. Equally, every assessment should of course begin with an open mind (not least since prior diagnoses may be incorrect, or the present presentation may be different).

Starting the interview

The interviewer should welcome the patient by name, give their own name and status, and explain in a few words the reason for and purpose of the assessment. If the patient is being seen at the request of another doctor, the interviewer should indicate this. If the patient is accompanied, the interviewer should greet the companion(s) and explain how long they should expect to wait and whether they will be interviewed. It is usually better to see the patient alone first, provided that they are able to provide an adequate history. The interviewer should explain that notes will be taken, and that these will be confidential. If the interview is for the purposes of a report to an outside agency (e.g. a legal report), this should be made clear. The general structure of the interview should be explained, and the time available stated.

The patient should be comfortable and the interviewer should not face the patient directly but arrange their chair at an angle. If possible, the interviewer should also avoid sitting at a much higher level. Whenever possible the interviewer should make notes during the interview, as writing notes afterwards is time consuming and not always wholly accurate. However, it is usually better to delay note taking for some minutes until the patient feels that they have the interviewer’s undivided attention. The patient should be placed at the left side of a right-handed interviewer. With this arrangement, the interviewer can attend to the patient and maintain an informal atmosphere while writing. Occasionally, when a patient is very anxious or agitated, note taking may be deferred until after the interview.

The following techniques have been shown to improve the results of the interview (Goldberg et al., 1980). The interviewer should:

• adopt a relaxed posture and appear unhurried—even when time is short

• maintain appropriate eye contact with the patient and not appear engrossed in note taking

• be alert to verbal and non-verbal cues of distress as well as to the factual content of the interview

• control an over-talkative or discursive patient.

Continuing and completing the interview

The interview should begin with an open question (one that cannot be answered with a simple ‘yes’ or ‘no’), such as ‘Tell me about your problems.’ The patient should be allowed to talk freely for several minutes before further questions are asked. As the patient describes their problems, the interviewer should observe their responses and manner—for example, whether they are reticent or unduly circumstantial.

The first step is to obtain a clear account of the patient’s problems. It is important to separate symptoms from their consequences, and from other life problems which the patient may want to discuss. For example, a patient may have low mood, sexual difficulties, or financial worries as their presenting complaint. In each case the common denominator may prove to be depression, but it will require your assessment to discover this. Your priority at the start is to focus upon the symptoms and signs of psychiatric disorder, leaving the other kinds of problem until later.

From the start, consider the possible diagnoses and, as the interview progresses, select questions to confirm or reject these diagnoses. For example, if the patient mentions hearing voices, this immediately raises the possibility of schizophrenia and requires that, at some stage in the assessment, the other cardinal features of the disorder are sought, and their presence or absence clearly noted. The interviewer also considers what information is relevant to prognosis and treatment. Thus interviewing is not simply the asking of a routine set of questions. It is an active and iterative process in which the focus of attention is directed by hypotheses formed from the information already elicited, and modified repeatedly as more information is collected. This active process of interviewing is particularly necessary when time is short and when immediate treatment decisions must be made. Obviously, as the interviewer gains confidence and acquires more psychiatric knowledge, he or she becomes better at thinking of possible diagnoses, and proceeding in a way that rules them in or out more rapidly and convincingly.

It is generally better to establish clearly the nature of the symptoms before asking how and when they developed. If there is any doubt about the nature of the symptoms, the patient should be asked to describe specific examples. When all of the presenting symptoms have been explored sufficiently, direct questions are asked about others that have not come to light but which may be relevant. In doing this, the interviewer uses their knowledge of psychiatric syndromes to decide what further questions to ask. For example, a person who complains of feeling depressed would be asked about thoughts concerning the future, and about suicidal ideas. If suicidal thoughts are acknowledged, further specific questions should be asked. Also ask about the impact that the symptoms have had on the patient’s life, looking for evidence of functional impairment.

The onset and course of the symptoms are clarified next, together with their relationship to any stressful events or physical illness. Considerable persistence may be needed to date the onset or an exacerbation of symptoms accurately. It sometimes helps to ask how the onset related to an event that the patient is likely to remember, such as a birthday. The patient’s attempts to cope with the symptoms are noted—for example, increased drinking of alcohol to relieve distress. If treatment has already been given, its nature, timing, and effects are noted, together with the patient’s concordance with it.

The interviewer completes the relevant parts of the full interview schedule described below. If time is short, it may be better to examine the mental state after the present complaints have been clarified. This can make it easier to select the key points to be asked about in the rest of the history. When time is adequate, the mental state is usually examined at the end of the interview, together with any relevant physical examination.

Throughout the interview, allow the patient, as far as possible, to describe their problems spontaneously. In this way, unexpected material may be volunteered that might not be revealed by the answers to questions. However, questions may be needed to bring the patient back to the point after a digression, and to elicit specific information—for example, about the relationship between symptoms and stressful events. Whenever possible, the interviewer should use open rather than leading or closed questions (a leading question suggests the answer, whereas a closed question allows only the answers ‘yes’ or ‘no’). Thus, for example, instead of the closed question ‘Are you happily married?’, the interviewer might ask ‘How do you and your wife get on?’ When there is no alternative to a closed question, the answer should be followed by a request for an example.

Before ending the interview, it is good practice to ask a general question such as ‘Is there anything that I have not asked you about, that you think I should know?’ It is also useful to summarize for the patient what you consider to be the key points, to check for any errors of fact, and to see whether the patient agrees with your initial understanding of events.

Box 3.1 summarizes some techniques that promote effective interviewing.

Interviewing informants

Whenever possible, the patient’s history should be supplemented by information from a close relative or another person who knows them well. This is much more important in psychiatry than in the rest of medicine, because some psychiatric patients are unaware of the extent of their symptoms. Other patients are aware of their problems but do not wish to reveal them—for example, people who misuse alcohol often conceal the extent of their drinking. Patients and relatives may also give quite different accounts of personality characteristics, or have contrasting interpretations of recent events and symptoms. Interviews with a partner or relative are used not only to obtain additional information about the patient’s condition, but also to assess their attitudes to the patient and the illness, and often to involve them in the subsequent management plan. In addition, they provide an opportunity to learn what burdens the illness has placed on the partner or relative, and how they have tried to cope. A history from an informant is essential when the patient is unable to give an accurate account of his or her condition (e.g. because of impaired memory). Finally, when it is important to know about the patient’s childhood, an interview with a parent or older sibling may reveal important information.

Box 3.1 Some techniques for effective psychiatric assessments

• Help the patient to talk freely. This can be done using open questions, and by cues such as nodding or saying ‘Go on’ or ‘Tell me more about that.’

• Keep the patient to relevant topics. Again non-verbal cues are useful, as well as specific interventions such as ‘At this point I’d like to ask you more about how you’ve been feeling. We can return to your money worries later.’

• Make systematic enquiries, but avoid asking so many questions that other, unanticipated issues are not volunteered.

• Check your understanding, and that you have enquired about all of the areas the patient thinks are important, by summarizing the key points of the history back to the patient. This step also helps you to begin to formulate your views on the diagnosis and causes.

• Be flexible in assessments, with regard to both their length and sequence. Select questions according to the emerging possibilities regarding diagnoses, causes, and plans of action.

Informants can either be seen separately from the patient, or invited to join the interview. The choice depends on both the assessor’s and the patient’s preference, but in both instances the patient must give their consent. If the patient refuses to allow an informant to be interviewed, explore the reasons for this and explain the difficulties that it will pose. There are a few situations in which the patient’s permission is not required before interviewing a relative or other informant—for example, if the patient is a child, or when adult patients are mute or confused. In other cases, the doctor should explain to the patient the reasons for interviewing the informant, while emphasizing that confidential information given by the patient will not be passed on. If any information needs to be given to a relative—for example, about treatment—the patient’s permission should be obtained. Questions from relatives should be dealt with in the same way.

The interviewer begins by explaining the purpose of the interview, and may need to reassure the informant. A relative may fear that the interviewer will view them as responsible in some way for the patient’s problems, or make demands on them. The interviewer should be sensitive to such ideas and, when appropriate, discuss them in a reassuring way, but without colluding with them or becoming involved in ways that might conflict with their primary duty to the patient. If the informant has been interviewed separately from the patient, the psychiatrist should not tell the patient what has been said unless the informant has given their permission. This is important even when the informant has revealed something that should be discussed with the patient—for example, an account of excessive drinking.

Sometimes it is necessary to speak to employers, friends, police, or others in order to collect further information about the patient and their illness. This should be done only with the patient’s permission, unless there are legal or safety issues which override this principle—for example, if the patient is in custody, or if there are grounds for concern that the patient may harm a third party.

The psychiatric history

The main parts of a psychiatric assessment are the psychiatric history and the mental state examination. The latter covers the symptoms and signs present during the interview, and the former deals with everything else. The assessment is then completed by the physical examination, and sometimes by further investigations. This section covers the psychiatric history, followed by the mental state examination, and then the other aspects of the assessment.

A commonly used scheme for history taking is given below. For ease of reference, the scheme is presented as a list of headings and items. More details, and some background information to the questions, are provided in the subsequent notes. As noted above, much of the interview is designed to elicit diagnostic symptoms, but other questions are intended to obtain information about the patient’s life and circumstances, while the interview as a whole must try to establish the rapport needed to achieve these goals and form the basis for a subsequent therapeutic relationship.

The following scheme is comprehensive and systematic, as an ability to conduct this form of assessment is essential before briefer interviews are attempted. Modification of the interview for use in briefer or specific settings is described later. Moreover, although it is neither possible nor necessary to take a full history on every occasion, the information that has been elicited should always be recorded systematically and in a standard order. This practice helps the interviewer to remember all of the potentially important topics and to add further information later. The practice also makes it easier for colleagues who need to refer to the notes in the future. This order can be followed in the written or electronic record, even when it was not possible to elicit the information in the desired sequence. This and all other entries in the notes should be dated and, whenever possible, signed.

A scheme for history taking

Information is grouped under the headings shown in Table 3.1. For brevity, this section is written in the style of short notes and illustrative questions. The next section explains why these topics are relevant, and some of the problems that may occur when covering them.

Informant(s)

• Usually the principal informant is the patient. If not, state the reason.

• The name(s), relationship to the patient, and length of acquaintance of any other person(s) interviewed.

• The name of the referrer and the reasons for referral.

History of present condition

This section is in many ways the core of the interview, often providing most of the key diagnostic information.

• List the symptoms, with the onset, duration, and fluctuation of each.

Table 3.1 Outline of the psychiatric history

Name, age, and address of the patient

Name(s) of informant(s) and their relationship to the patient

History of present condition

Family history

Personal history (expanded in Table 3.2)

Past illness

Personality (expanded in Table 3.3)

• Ask about and record symptoms which might have been expected but which are not present (e.g. no suicidal ideation in a person with low mood, no first-rank symptoms of schizophrenia in a patient with delusions).

• The temporal relationship between symptoms and any physical disorder, or psychological or social problems.

• The nature and duration of any functional impairment caused by the symptoms.

• Any treatment received, and its effects and side-effects.

Family history

• Parents and siblings—age, current state of health or date and cause of death, occupation, personality, quality of relationship with patient, and psychiatric and medical history.

• Social position of family.

• When the family history is complex and relevant, summarize it as a family tree.

Personal history (see Table 3.2)

• Pregnancy and birth abnormalities (e.g. infections, prematurity, problems with labour).

• Early developmental milestones—walking, talking, sphincter control, etc.

• Childhood—any prolonged separation from the parents, and the patient’s reaction to it. Any emotional problems (age of onset, course, and treatment). Any serious illness in childhood.

• Schooling and higher education—type, courses, qualifications, extracurricular achievements, relationships with teachers and other students. Any experience of bullying (nature, duration, and impact).

• Occupations—present job (dates, duties, performance, and satisfaction), earlier jobs (list them, with reasons for changes).

• Significant relationship—identity and gender of current partner, duration and nature of relationship (e.g. married). Partner’s health, attitude to the patient’s illness, and the quality of the relationship. Nature and number of previous relationships.

• Sexual history—attitude to sex, any sexual difficulties and their relationship to current symptoms. heterosexual and homosexual experience. Knowing how and how far to enquire about sexual matters is discussed further on p. 368.

• Children—identities, date of any abortions or stillbirths, temperament, emotional development, mental and physical health.

• Social circumstances—accommodation, household composition, financial situation.

• Use of alcohol, tobacco, illicit drugs—which ones, when, and how much. Problems arising from substance use.

• Forensic history—arrests, convictions, imprisonment. Nature of the offences, especially with regard to dangerousness. For a minority of patients, the forensic history is a key part of the assessment (see Chapter 24).

Table 3.2 Outline of the personal history

Mother’s pregnancy and the birth

Early development

Childhood: separations, emotional problems, illnesses, education

Occupations

Relationships and sex

Children

Social circumstances

Substance use

Forensic history

Past psychiatric and medical history

• Past psychiatric illnesses—nature and duration, and their similarity to current episode. Include any episodes of self-harm. Date, duration, nature, location, and outcome of any treatment.

• Past medical history—illnesses, operations, accidents, and drug treatments.

• Current medication, including contraceptive pill, over-the-counter medicines, and alternative remedies. Any allergic or other adverse reactions.

Personality

• By this stage in the interview, the patient’s manner and description of their history will have provided some indication of their personality. However, a specific focus is also essential, covering the domains noted in Table 3.3. Personality can be a relatively difficult area of the history, as outlined below in the section ‘Notes on history taking’.

• Relationships—friendships (few or many, superficial or close, with own or opposite sex), relationships with work colleagues and superiors.

• Use of leisure time—hobbies and interests.

• Predominant mood and emotions (e.g. anxious, despondent, optimistic, pessimistic, self-deprecating, overconfident, stable or fluctuating, controlled or demonstrative).

• Character traits (e.g. perfectionist, obsessional, isolated, impulsive, sensitive, controlling).

• Attitudes and standards—moral and religious, attitude towards health and the body.

• ‘Ultimate concern’—what or who matters most in their life?

Table 3.3 Assessment of personality

Relationships

Leisure activities

Prevailing mood and emotional tone

Character

Attitudes and standards

‘Ultimate concern’

Notes on history taking

The scheme outlined above lists the items to be considered when a full history is taken, but gives no indication as to why these items are important or what sort of difficulties may arise when eliciting them. These issues are discussed in this section, which is written in the form of notes approximating to the headings used above.

The reason for referral

Only a brief statement need be given—for example, ‘severe depression, failing to respond to drug treatment.’ The reason for referral usually, but not always, proves to be the main focus of the interview. Check that the patient has the same understanding as to why they have been referred. If not, this in itself is useful information. For example, the patient may disagree that they are depressed, believing that they have cancer; this may be diagnostically significant (e.g. suggestive of hypochondriasis), and it may also affect their willingness to engage fully in the assessment or subsequent treatment.

History of present condition

Because it is central to the assessment, it is always worth spending sufficient time on this part of the history to identify the key elements. There will often be several such symptoms, and each should be characterized fully in order to appreciate its diagnostic significance. Record the severity and duration of each symptom, how and when it began, what course it has taken (increasing or decreasing, constant or intermittent), and what factors affect it. Indicate which symptoms co-vary. As noted above, record the symptoms or features which would have diagnostic significance but which are not present (e.g. lack of anhedonia in a person complaining of low mood).

Note any treatments that have been given during this episode, the response, and any adverse effects. If a drug was ineffective, ask whether the patient took it regularly and at the required dosage.

Family history

A family history of psychiatric disorder may indicate genetic or environmental influences. A genetic explanation is more likely for some disorders than for others, and increases as more relatives are affected. Although family environment has, as a rule, proved to be less important than genes in explaining family history (see Chapter 5), knowledge about the family’s circumstances remains part of the basic information required for understanding the origin and presentation of the patient’s problems.

Recent events in the family may have been stressful to the patient—for example, the serious illness or divorce of a family member. Events in the family may throw light on the patient’s concerns. For example, the death of an older sibling from a brain tumour may partly explain a patient’s extreme concern about headaches.

Personal history

Pregnancy and birth

Events in pregnancy and delivery are most likely to be relevant when the patient is learning disabled, although they are also risk factors for several psychiatric disorders. An unwanted pregnancy may be followed by a poor relationship between mother and child.

Child development

Few patients know whether they have passed through developmental stages normally. Failure to do so may be a sign of learning disability and also a risk factor for later disorders such as schizophrenia. However, this information is usually more important if the patient is a child or adolescent, in which case the parents are likely to be available for interview. The effects of separation from the mother vary considerably, and depend in part on the age of the child, the duration, and the reason for separation. Questioning about the child’s emotional development provides information about early temperament and emerging personality, and abnormalities or delays may serve as risk factors for, or early signs of, later problems. However, childhood behavioural characteristics as a rule are weak predictors of adult disorders, and only require detailed consideration when assessing children and adolescents. Assessment in child psychiatry is covered in Chapter 22.

Education

The school record gives an indication of intelligence, achievements, and social development. Ask whether the patient made friends and got on well with teachers, and about success at games and other activities. Negative events such as bullying or exam failures may be equally important stressful memories. Similar questions are relevant to higher education.

Occupational history

Information about the present job helps the interviewer to understand the patient’s current abilities, interests, and financial and social circumstances, and may be a potential source of stress. A list of previous jobs and reasons for leaving is relevant to the assessment of personality. If the status of jobs has declined, this may reflect chronic illness or substance misuse.

Marital history

This heading includes all enduring intimate relationships. Ask about the current and any previous lasting relationships, preferably phrased in a way that does not assume the gender of the partner(s). Frequent broken relationships may reflect abnormalities of personality. The partner’s occupation, personality, and state of health are relevant to the patient’s circumstances and, like the nature of the relationship itself, will affect the partner’s role in the care and management of the patient.

Sexual history

The interviewer should use common sense when deciding how much to ask the individual patient, depending on the response to initial questions, demographic factors, and the nature of the presenting complaint. Usually the interviewer is concerned to establish generally whether the patient’s sexual life is in any way involved in their current difficulties, whether as a cause, a correlate, or a consequence. If so, then more detailed enquiry is appropriate, as it is of course if the patient is seeking help for sexual dysfunction (see Chapter 14).

Judgement must also be used about the optimal timing and amount of detail of questioning about childhood abuse, especially sexual abuse. Unfortunately, such past experiences are sufficiently common (and more so in women) to merit questioning. However, often it may not be appropriate to raise the matter in a first interview, unless prompted by the patient or in the light of background information available to the interviewer. The decision to raise the topic also depends on the clinical suspicion, and the time and expertise available to the interviewer. Questions relevant to sexual disorders are considered further in Chapter 14. Sensitivity is also necessary when deciding what information to record and with whom it should be shared.

Children

Pregnancy, childbirth, miscarriages, and terminations are events that are sometimes associated with adverse psychological reactions. Information about the patient’s children is relevant to present worries and the pattern and characteristics of family life.

Consideration of the welfare and needs of any children is always integral to an assessment, as their health may be adversely affected by the parent’s illness or its treatment. For example, if a seriously depressed woman has a young baby, due steps to ensure the baby’s well-being are essential, and the situation may influence decisions about the mother’s care (e.g. about medication if she is breastfeeding, and about hospital admission).

Social circumstances

Questions about housing, finances, and the composition of the household help the interviewer to understand the patient’s circumstances. Assets and resources (including potential carers) are assessed, as well as problems and sources of stress. There can be no general rule about the amount of detail to elicit, and this must be guided by common sense.

Substance use and misuse

This includes past as well as present consumption of alcohol and other substances, and the impact of their use on the patient’s health and life. Misuse of prescribed drugs should also be considered. The patient’s answers may be evasive or misleading, and may need to be checked with other informants and sources of information (e.g. urine screens, blood tests) (see Chapter 17 for further information about interviewing in this area).

Past psychiatric and medical history

Previous medical or surgical treatment should always be asked about (Phelan and Blair, 2008), and particularly careful inquiries made about previous psychiatric disorders. A previous diagnosis increases the probability that the current diagnosis will prove to be similar, but it is important always to keep an open mind, as the diagnosis may have changed, or the previous diagnosis may have been incorrect. Patients or relatives may be able to recall the general nature of the illness and treatment, but it is nearly always appropriate to request information from others who have treated the patient.

The medical history may be directly related to the presentation (e.g. a recurrence of hypothyroidism presenting with lethargy), but may also be indirectly relevant (e.g. via the psychosocial effects of chronic ill health, or as a sign of somatoform disorder).

Assessment of personality

This is important because:

• it helps the interviewer to understand the patient as a person, and to put their current difficulties into context

• personality traits can be a risk factor for psychiatric disorders (e.g. obsessionality increases the risk of developing depressive disorder)

• personality traits can affect the presentation of psychiatric disorder

• personality can be disordered, and personality disorder may be a differential or comorbid diagnosis.

Aspects of personality can be assessed by asking for a self-assessment, by asking others who know the patient well, and by observing behaviour. Good indications of personality can often be obtained by asking how the patient has behaved in particular circumstances, especially at times when social roles are changing, such as when starting work, marrying, or becoming a parent. However, mistakes can arise from paying too much attention to the patient’s own assessment of their personality, especially during a single interview. Some people give an unduly favourable account of themselves. For example, antisocial people may conceal the extent of their aggressive behaviour or dishonesty and, conversely, depressed patients often judge themselves negatively and critically. When assessing personality from behaviour at interview, take into account the artificiality of the situation and the anxiety that it may provoke. These factors mean that it is essential to interview other informants whenever possible, and to avoid drawing premature or unjustified conclusions about personality. Personality tests are now rarely used in clinical practice, but interview schedules for diagnosis of personality disorder are widely used in forensic and other settings (see Chapters 7 and 24).

Relationships

Is the patient shy or do they make friends easily? Are their friendships close and are they lasting? Leisure activities can throw light on personality, by reflecting the patient’s interests and preference for company or solitude, as well as their levels of energy and resourcefulness.

Mood

Ask whether the patient is generally cheerful or gloomy and whether they experience marked changes of mood, and if so, how quickly these moods appear, how long they last, and whether they follow life events. Information about prevailing mood and mood swings may also reveal evidence suggestive of mood disorder, which can be enquired about further.

Character

Common sense and experience will indicate the depth and focus of character assessment that are needed for each patient. If the patient (or informant) has difficulty describing their character with an open question, offer them options—for example, ‘Would you call yourself an optimist or a pessimist? A loner or a socialite?’ Do not focus entirely on negative attributes, but ask about positive ones, including resilience in the face of adversity. This is important not just to gain a balanced impression, but because strengths are usually better targets for intervention if personality proves to be therapeutically relevant.

For further details on the assessment of personality, see Cloninger (2009). The assessment of personality disorder has been described in detail by Banerjee et al. (2009), and is discussed in Chapter 7.

The mental state examination

The history records symptoms up to the time of the interview. The mental state examination is concerned with symptoms, signs, and behaviour during the interview, and is usually conducted after the history. Although the distinction is traditional, and conceptually useful, in practice the boundary between the history and the mental state examination is somewhat blurred. In particular, very recent symptoms and signs are often recorded in the mental state examination, even if the phenomena are not experienced or elicited during the interview. The mental state examination is also sometimes used to elicit and record symptoms and signs which, for whatever reason, have not been covered previously in the interview (e.g. whether the patient is suicidal).

The mental state examination uses a standard series of headings under which the relevant phenomena, or their absence, are recorded (see Table 3.4). The symptoms and signs referred to in the following account are described in Chapter 1 and, with a few exceptions, are not repeated. Mental state examination is a skill that should be learned by watching experienced interviewers and by practising repeatedly under supervision, as well as by reading. The mental state examination provides, in conjunction with the history of the present condition, most of the key diagnostic information. The ability to carry out and record an accurate and comprehensive mental state examination is therefore a core skill required by all psychiatrists and other mental health professionals.

Appearance and behaviour

General appearance

Much diagnostically useful information can be obtained from the patient’s appearance and behaviour. Indeed, as discussed later, experienced clinicians often make provisional diagnoses within minutes of meeting a patient, relying heavily on this information. The process of observation starts from the first moment you see the patient. For example, what is their manner and behaviour in the waiting room? Are they sitting quietly, pacing around, or laughing to themselves? When greeted, what is their response? As they walk towards the interview room, is there evidence of parkinsonism, ataxia, or unsteadiness? Note their general attire. A dirty, unkempt appearance may indicate self-neglect. Manic patients may wear bright colours, or dress incongruously. Occasionally an oddity of dress may provide the clue to diagnosis—for example, a rainhood worn on a dry day may be the first evidence of a patient’s belief that rays are being shone on their head by persecutors. An appearance suggesting recent weight loss should alert the observer to the possibility of depressive disorder, anorexia nervosa, or physical illness.

Table 3.4 Summary of the mental state examination

Appearance and behaviour

Speech

Mood

Thoughts

Perceptions

Cognitive function

Insight

Facial appearance and emotional expression

The facial appearance provides information about mood. In depression, the corners of the mouth are turned down, and there are vertical furrows on the brow. Anxious patients have horizontal creases on the forehead, widened palpebral fissures, and dilated pupils. Facial expression may reflect elation, irritability, or anger, or the fixed ‘wooden’ expression due to drugs with parkinsonian side-effects. The facial appearance may also suggest physical disorders (e.g. thyrotoxicosis).

Posture and movement

Posture and movement also reflect mood. A depressed patient characteristically sits with hunched shoulders, with the head and gaze inclined downwards. An anxious patient may sit on the edge of their chair, with their hands gripping its sides. Anxious people and patients with agitated depression may be tremulous and restless—for example, touching their jewellery or picking at their fingernails. Manic patients are overactive and restless. Other abnormalities of movement include tardive dyskinesia (see p. 525), and the motor signs seen mainly in catatonic schizophrenia (see p. 16).

Social behaviour

The patient’s social behaviour and interactions are influenced by their personality and by their attitude to the interview, as outlined above. However, such behaviour can also be influenced by psychiatric disorder, so it provides another potential source of diagnostic information. Manic patients tend to be unduly familiar or disinhibited, whereas those with dementia may behave as if they were somewhere other than in a medical interview. Patients with schizophrenia may be withdrawn and preoccupied. Patients with antisocial personality disorders may behave aggressively. If the patient’s social behaviour is highly unusual, note what exactly is unusual, rather than using imprecise terms such as ‘bizarre.’

Speech

Speech and thoughts are recorded in different parts of the mental state examination, even though it is only through speech that thoughts become known to the interviewer. By convention, the ‘speech’ section covers rate, quantity, difficulties with speaking, and flow of speech. The content of speech, in the sense that it reveals the patient’s thoughts (e.g. preoccupations about death, grandiose delusions) is deferred until the ‘Thoughts’ section.

Rate and quantity

Speech may be unusually fast and increased in amount, as in mania (‘pressure of speech’), or slow, sparse, and monotonous, as in depression. Depressed or demented patients may pause for a long time before replying to questions, and then give short answers, producing little spontaneous speech. The same may be observed among shy people or those of low intelligence.

Difficulties with speaking

If the patient is having problems finding or articulating words, consider the possibility of dysphasia or dysarthria. For further details, see Box 3.2 and consult a neurology textbook.

Neologisms

Neologisms are private words invented by the patient, often to describe morbid experiences.

Flow of speech

Abnormalities in the flow of speech may simply reflect an anxious, distracted patient, or one of low intelligence. More significantly, such abnormalities may be evidence of disturbances in the stream or form of thoughts (see p. 14). For example, sudden interruptions may indicate thought blocking, and rapid shifts from one topic to another suggest flight of ideas. It can be difficult to be certain about these abnormalities; if possible, write down a representative example.

Mood

Conventionally, the mood section includes recording of other emotions and also related phenomena, including suicidal thoughts. The phenomenology of mood and its disorders are discussed in more detail in Chapter 10.

Depression and mania

The assessment of mood begins with the observations of behaviour described already, and continues with direct questions such as ‘What is your mood like?’ or ‘How are you in your spirits?’ To assess depression, questions should be asked about a feeling of being about to cry (actual tearfulness is often denied), pessimistic thoughts about the present, hopelessness about the future, and guilt about the past. Suitable questions are ‘What do you think will happen to you in the future?’ or ‘Have you been blaming yourself for anything?’ Questions about elevated mood correspond to those about depression—for example, ‘How are you in your spirits?’ followed, if necessary, by direct questions such as ‘Do you feel in unusually good spirits?’ Note that the mood in mania can be irritable as well as cheerful.

A distinction is sometimes drawn between ‘objective’ and ‘subjective’ mood. The latter is the patient’s view of their own mood; the former refers to the interviewer’s conclusion based upon their observation of the patient during the interview and the responses to their questions. On occasion the two may differ—for example, a severely depressed person may deny low mood. It is important therefore to record the presence of the various symptoms and signs of depression (or mania) during the mental state examination.

Both depressed and elevated mood, if clinically significant, are accompanied by other features of depression and mania, respectively—for example, anhedonia, tiredness, or poor concentration in depression. In practice, therefore, it is common to extend this part of the mental state examination to include questioning about other diagnostic features of mood disorder, if these have not been asked about already. Whether the interviewer chooses to record them in the notes under this heading, or to insert them into the relevant part of the history, is a matter of personal preference and convenience.

Fluctuating and incongruous mood

As well as assessing the prevailing mood, the interviewer should ascertain how mood varies. When mood varies excessively, it is said to be labile—for example, the patient appears dejected at one point in the interview but quickly changes to a normal or unduly cheerful mood. Any lack of emotional response, sometimes called blunting or flattening of affect (see p. 5), should also be noted.

Normally, mood varies during an interview in parallel with the topics that are being discussed. The patient appears sad while talking about unhappy events, angry while describing things that have irritated them, and so on. When the mood is not suited to the context, it is recorded as incongruent—for example, if the patient giggles when describing the death of their mother. Before concluding that such behaviour reflects an incongruous mood, consider whether it could be a sign of embarrassment or an effort to conceal distress.

Suicidal ideation

Some inexperienced interviewers are wary of asking about suicide due to fear that they may suggest it to the patient. There is no evidence to warrant this caution, and an explicit assessment of suicide risk should be part of every mental state examination. Nevertheless, questioning should be handled sensitively and in stages, starting with open questions such as ‘Have you ever thought that life is not worth living?’ and, if appropriate, going on to ask ‘Have you ever wished that you could die?’ or ‘Have you ever considered any way in which you might end your life?’, and then leading on to direct questioning about current suicidal intent or plans. The interviewer may also be concerned that they will not be able to cope if the patient does admit to being suicidal. A basic training in this topic, and knowledge of self-harm and suicide, should preclude these worries. Questions about suicide are considered further on p. 427.

Anxiety

Anxiety is assessed both by asking about subjective feelings, and by enquiring about the physical symptoms and cognitions associated with anxiety, as well as by observation. For example, the interviewer should start with a general question such as ‘Have you noticed any changes in your body when you feel upset?’, and then go on to enquire specifically about palpitations, dry mouth, sweating, trembling, and the various other symptoms of autonomic activity and muscle tension. Such features may also be apparent during the interview. To detect anxious thoughts, the interviewer can ask ‘What goes through your mind when you are feeling anxious?’ Possible replies include thoughts of fainting or losing control. Many of these questions overlap with enquiries about the history of the disorder.

Depersonalization and derealization

These are usually symptoms of anxiety disorders, but occasionally they are diagnosed as a separate disorder (see Chapter 15). Their importance in the mental state examination is largely due to the fact that they are easily mistaken for psychotic symptoms and must therefore be distinguished from them. Patients who have experienced depersonalization and derealization find them difficult to describe, and patients who have not experienced them may say that they have done so because they have misunderstood the questions. Try to obtain specific examples of the patient’s experiences. It is useful to begin by asking ‘Do you ever feel that things around you are unreal?’ and ‘Do you ever feel unreal or that part of your body is unreal?’ Patients with derealization often describe things in the environment as seeming artificial and lifeless. Patients with depersonalization may say that they feel detached, unable to feel emotion, or as if they are acting a part.

Thoughts

In this section, any predominant content of the person’s thoughts can first be noted. For example, there may be a preoccupation with persecutory themes, negative or self-deprecating responses to questions, or a repeated return of the conversation to diet and body shape. This information may signify a delusional disorder, depression, and an eating disorder, respectively, and indicate areas for further questioning. However, the main purpose of this section is to determine the nature of the patient’s thoughts, and in particular to identify obsessions and delusions.

Obsessions

Obsessions were described on p. 12. An appropriate question is ‘Do any thoughts keep coming into your mind, even though you try hard to stop them?’ If the patient says ‘Yes’, they should be asked for an example. Patients may be ashamed of obsessional thoughts, especially those about violence or sexual themes, so persistent but sympathetic questioning may be required. Before recording thoughts as obsessional, the interviewer should be certain that the patient accepts them as their own (and not implanted by an outside agency).

Compulsions

Many obsessional thoughts are accompanied by compulsive acts (see p. 13). Some of these can be observed directly (although rarely during the interview), but others are private events (e.g. repeating phrases silently), which are detected only because they interrupt the patient’s conversation. Appropriate questions are ‘Do you have to keep checking activities that you know you have completed?’, ‘Do you have to do things over and over again when most people would have done them only once?’ and ‘Do you have to repeat exactly the same action many times?’ If the patient answers ‘Yes’ to any of these questions, the interviewer should ask for specific examples.

Delusions

A delusion cannot be asked about directly, because the patient does not recognize it as differing from other beliefs. Because of the difficulty that this poses for the interviewer, and the diagnostic significance of delusions, these were described in detail in Chapter 1.

The interviewer may be alerted to the possibility of delusions by information from other people or by events in the history. When searching for delusional ideas, it is useful to begin by asking what might be the reason for other symptoms or unpleasant experiences that the patient has described. For example, a patient who says that life is no longer worth living may be convinced that he is thoroughly evil and that his internal organs are already rotting away. Some patients hide delusions skilfully, and the interviewer needs to be alert to evasions, changes of topic, or other hints that information is being withheld. However, once the delusion has been uncovered, patients often elaborate on it without much prompting.

When ideas are revealed that could be delusional, the interviewer needs to determine whether they meet the criteria for a delusion (see pp. 8–9). First, ascertain how strongly they are held. Achieving this without antagonizing the patient requires patience and tact. The patient should feel that they are having a fair hearing. If the interviewer expresses contrary opinions to test the strength of the patient’s beliefs, their manner should be enquiring rather than argumentative. The next step is to decide whether the beliefs are culturally determined convictions rather than delusions. This judgment may be difficult if the patient comes from a culture or religious group whose attitudes and beliefs are not known to the interviewer. In such cases any doubt can usually be resolved by finding an informant from the same country or religion, and by asking this person whether others from the same background share the patient’s beliefs.

Some types of delusion, which are characteristic of schizophrenia, present particular problems of recognition:

• Delusions of thought broadcasting must be distinguished from the belief that other people can infer a person’s thoughts from his expression or behaviour. When eliciting such delusions an appropriate question is ‘Do you ever feel that other people know what you are thinking, even though you have not spoken your thoughts aloud?’ If the patient says ‘Yes’, the interviewer should ask how other people know this. (Some patients answer ‘Yes’ when they mean that others can infer their thoughts from their facial expression.)

• Delusions of thought insertion. A suitable question is ‘Have you ever felt that some of the thoughts in your mind were not your own but were put there from outside?’ A corresponding question about delusions of thought withdrawal is ‘Do you ever feel that thoughts are being taken out of your head?’ In each case, if the patient answers ‘Yes’, detailed examples should be sought.

• Delusions of control (passivity of thought) present similar difficulties. It is appropriate to ask ‘Do you ever feel that some outside force is trying to take control of you?’ or ‘Do you ever feel that your actions are controlled by some person or thing outside you?’ Some patients misunderstand the question and answer ‘Yes’ when they mean that they have a religious or philosophical conviction that man is controlled by God or some other agency. Others think that the questions refer to the experience of being ‘out of control’ during extreme anxiety, while some say ‘Yes’ when in fact they have experienced auditory hallucinations commanding them to do things. Therefore positive answers should be followed by further questions to eliminate these possibilities.

Finally, the reader is reminded of the various categories of delusion described in Chapter 1 (see pp. 8–12). The interviewer should also distinguish between primary and secondary delusions, and be alert for the experiences of delusional perception and delusional mood. These issues only need to be addressed when there is already clear evidence of a psychosis, when they are useful in distinguishing schizophrenia from other psychotic disorders.

Perceptions

When asking about hallucinations, as with delusions, enquiries should be made tactfully in order to avoid distressing the patient, and to encourage them to elaborate on their experiences without being ridiculed. Questions can be introduced by saying ‘Some people find that, when their nerves are upset, they have unusual experiences.’ This can be followed by enquiries about hearing sounds or voices when no one else is within earshot. Whenever the history makes it relevant, corresponding questions should be asked about visual hallucinations and those in other modalities. Conversely, in assessments where there has been no previous evidence of psychosis at all, it may be appropriate to omit assessment of them altogether.

Auditory hallucinations

If the patient describes auditory hallucinations, certain further questions are required depending on the type of experience, because of their diagnostic significance (see p. 7). Has the patient heard a single voice or several? If there were several voices, did they appear to talk to the patient, or to each other about the patient in the third person? The latter experience must be distinguished from that of hearing actual people talking and believing that they are discussing the patient (an idea or delusion of reference). If the patient says that the voices are speaking to them, the interviewer should find out what the voices say and, if the words are experienced as commands, whether the patient feels that they must be obeyed. Note down examples of the words spoken by hallucinatory voices.

Visual hallucinations

Visual hallucinations must be distinguished from visual illusions. Unless the hallucination is experienced at the time of the interview, this distinction may be difficult because it depends on the presence or absence of a visual stimulus which has been misinterpreted. Ascertaining whether there is an ‘as if’ quality to the image, or asking if it is seen ‘out there, or in your mind’s eye’ may aid the distinction. The interviewer should also distinguish hallucinations from dissociative experiences. The latter are described by the patient as the feeling of being in the presence of another person or a spirit with whom they can converse. Such experiences are reported by people with histrionic personality, although they are not confined to them, and are encouraged by some religious groups. They have little diagnostic significance.

Cognitive function

Early on in the interview, any significant cognitive difficulties will have already become apparent from the patient’s interactions with the interviewer and their responses to questions. If so, the assessment of cognitive function should be brought forward, as the result may lead the interviewer to curtail the rest of the interview or to postpone it until an informant is available. The Mini-Mental State Examination is a widely used cognitive screen.

When evaluating possible dementia and other organic disorders, cognitive testing is a central part of the assessment and is supplemented by more formal testing (see below and Chapter 13). Conversely, if the interview is nearing completion and no evidence or suspicion of such difficulties has arisen, cognition can be assessed very briefly.

Orientation

This is assessed by asking about the patient’s awareness of time, place, and person. Specific questions begin with the day, month, and year. When assessing the replies, remember that many healthy people do not know the exact date and that, understandably, patients in hospital may be uncertain about the day of the week or their precise location. If the patient cannot answer these basic questions correctly, they should be asked about their own identity; this is preserved except in severe dementia, dissociative disorders, or malingering.

Attention and concentration

While taking the history the interviewer should look out for evidence of attention and concentration. In this way an opinion will already have been formed about these abilities before reaching the mental state examination. Formal tests add to this information, and can provide a semi-quantitative indication of changes between occasions. It is usual to begin with the serial sevens test. The patient is asked to subtract 7 from 100 and then to subtract 7 from the remainder repeatedly until the resulting number is less than 7. The time taken to do this is recorded, together with the number of errors. If poor performance seems to be due to lack of skill in arithmetic, the patient should be asked to do a simpler subtraction, or to state the months of the year in reverse order.

Memory

While taking the history the interviewer should compare the patient’s account of past events with those of any other informants, and be alert for gaps or inconsistencies. If memory is impaired, any evidence of confabulation (see p. 320) should be noted. During the mental state examination, tests are given of short-term, recent, and remote memory. Since none of these is wholly satisfactory, the results should be assessed alongside other information about memory and, if there is any doubt, supplemented by standardized psychological tests. Objective evidence of memory impairment and its impact on normal activities (e.g. shopping, dressing) is also essential.

Short-term memory can be assessed by asking the patient to memorize a name and a simple address, to repeat it immediately (to make sure that it has been registered correctly), and to retain it. The interview continues on other topics for 5 minutes before recall is tested. A healthy person of average intelligence should make only minor errors. If recall is imperfect, memory can be prompted (e.g. by saying ‘35, Juniper …’ and the patient may then recall ‘Street’).

Memory for recent events can be assessed by asking about news items from the last few days.

Remote memory can be assessed by asking the patient to recall personal events or well-known items of news from former years. Personal items could be the birth dates of children or the names of grandchildren (provided these are known to the interviewer), and news items could be the names of well-known former political leaders. Awareness of the sequence of events is as important as the recall of individual items.

The reader is again referred to Chapter 13 for detailed assessment of cognitive functioning.

Insight

A note that merely records ‘insight present’ or ‘no insight’ is of little value. Instead the interviewer should enquire about the different aspects of insight discussed on p. 19. This includes the patient’s appraisal of their difficulties and prospects, and whether they ascribe them to illness or to some other cause (e.g. persecution). If the patient recognizes that they are ill, do they think that the illness is physical or mental, and do they think that they need any treatment? If so, what are their views on medication, admission, or psychotherapy, as appropriate? The interviewer should also find out whether the patient thinks that stressful life experiences or their own actions have played a part in causing their illness. The patient’s views on these matters are a guide to their likely collaboration with treatment.

Other components of psychiatric assessment

Although the psychiatric history and mental state examination are the main parts of the psychiatric assessment, several other elements may also be necessary as part of the ‘work-up’ of a patient. This section does not cover more specialized aspects of assessment (e.g. the use of rating scales; see below), or those not directly linked to diagnosis or initial management (e.g. assessment for psychotherapy).

Physical examination

Physical examination provides three kinds of information in the assessment.

• It may reveal diagnostically useful signs (e.g. a goitre or absent reflexes), and it is therefore particularly important in the diagnosis or exclusion of organic disorders (see Chapter 13). Neurological (including cerebrovascular) and endocrine systems most commonly require detailed examination, although other systems should not be neglected. The reader should consult a relevant textbook (e.g. Kaufman, 2002) if instruction is required in these aspects of clinical practice.

• Psychotropic drugs may produce physical side-effects which need to be identified or measured (e.g. hypertension, parkinsonism, or a rash).

• The patient’s general health, nutritional status, and self-care may all be affected by psychiatric disorders.

For these reasons, a physical examination is an integral part of the psychiatric assessment. In practice, however, the extent of the physical examination, and the medical responsibility for it, vary. For example, many outpatients have been referred by, or are also cared for by, another doctor who may have recently carried out an appropriate physical examination. In the case of day- or inpatients, the psychiatrist is generally responsible for their physical as well as their mental health. Certainly every newly admitted patient should have a full physical examination. Whatever the circumstances, the psychiatrist should decide what physical examination is relevant, and either carry it out themselves or ensure that this is done by another doctor. Discussion with a neurologist or other physician is appropriate if the initial examination reveals equivocal or complex findings, or if a second opinion is sought. In some cases, more detailed assessment of higher neurological functions is required, as in the neuropsychiatric examination, which is summarized in Box 3.2. This may be a prelude to formal neuropsychological assessment or neurological investigations.

Laboratory investigations

These vary according to the nature of the differential diagnosis, the treatments that are being given, the patient’s general health, and the resources available. At one extreme, no investigations may be necessary. At the other, extensive brain imaging, genetic testing, and biochemical screening may be needed—for example, if there is a strong suspicion of a treatable organic disorder, a familial dementia, or learning disability. There is no one set of routine investigations that is applicable to every case although, by convention, routine blood tests (full blood count, electrolytes, and liver and thyroid function) are usually carried out on admission to hospital.

Investigations are discussed further in the chapters on individual syndromes and drug treatments.

Psychological assessment

Clinical psychologists and psychological testing can contribute to psychiatric assessment in several ways. However, they are not required in most cases, and their availability is increasingly limited in many settings. We therefore only introduce the topic briefly here, illustrating the main forms and roles of psychological assessment. For further information, see Powell (2009).

Neuropsychological assessment

There are many psychometric tests available which measure different aspects of neuropsychological performance, ranging from overall intelligence to specific domains of memory, speed of processing, or tests that putatively assess functioning of a particular part of the brain (Lezak et al., 2004). Neuropsychological testing in psychiatry is primarily used in the following areas (Grant and Adams, 1996):

• in learning disability, where IQ defines the severity of the condition

• in dementia, where tests measure the severity and domains of cognitive impairment

• if a decline in performance from premorbid abilities is suspected. In this instance, a discrepancy may be seen between verbal and performance IQ

• to monitor the progress of neuropsychological deficits during the course of illness, by repeated administration of tests

• to reveal deficits which may be subtle and neglected clinically, but which may be functionally important. For example, in schizophrenia there are persistent impairments in specific domains of memory and attention, and these predict poor outcome (see Chapter 11)

Box 3.2 The neuropsychiatric examination

Language abilities

Dysarthria is difficulty in the production of speech by the speech organs. Dysphasia is partial failure of language function of cortical origin; it can be receptive or expressive. Testing for dysarthria can be done by giving difficult phrases such as ‘West Register Street’ or a tongue twister.

Receptive dysphasia can be detected by asking the patient to read a passage of appropriate difficulty or, if they fail in this, individual words or letters. If they can read the passage, they are asked to explain it. Comprehension of spoken language is tested by asking the patient to listen to a spoken passage and explain it (first checking that memory is intact), or to respond to simple commands (e.g. to point at named objects).

Expressive dysphasia is detected by asking the patient to name common objects such as a watch, key, and pen, and some of their parts (e.g. the face of a watch), and parts of the body. They are also asked to talk spontaneously (e.g. about hobbies) and to write a brief passage, first to dictation, and then spontaneously, on a familiar topic (e.g. the members of the family). A patient who cannot do these tests should be asked to copy a short passage.

Language disorders point to the left hemisphere in right-handed people. In left-handed patients localization is less certain, but in many it is still the left hemisphere. The type of language disorder gives some further guide to localization. Expressive dysphasia suggests an anterior lesion, receptive dysphasia suggests a posterior lesion, mainly auditory dysphasia suggests a lesion towards the temporal region, and mainly visual dysphasia suggests a more posterior lesion.

Construction abilities

Apraxia is inability to perform a volitional act even though the motor system and sensorium are sufficiently intact for the person to do so. Apraxia can be tested in several ways.

• Constructional apraxia is tested by asking the patient to draw simple figures (e.g. a bicycle, house, or clock face).

• Dressing apraxia is tested by asking the patient to put on some of their clothes.

• Ideomotor apraxia is tested by asking the patient to perform increasingly complicated tasks to command, usually ending with a three-stage sequence such as: (1) touch the right ear with (2) the left middle finger while (3) placing the right thumb on the table.

Apraxia, especially if the patient fails to complete the left side of figures or dressing on the left side, suggests a right-sided lesion in the posterior parietal region. It may be associated with other disorders related to this region, namely sensory inattention and anosognosia.

Agnosia is the inability to understand the significance of sensory stimuli even though the sensory pathways and sensorium are sufficiently intact for the patient to be able to do so. Agnosia cannot be diagnosed until there is good evidence that the sensory pathways are intact and consciousness is not impaired.

• Astereognosia is failure to identify three-dimensional form; it is tested by asking the patient to identify objects placed in their hand while their eyes are closed. Suitable items are keys, coins of different sizes, and paper clips.

• Atopognosia is inability to locate the position of an object on the skin.

• In finger agnosia the patient cannot identify which of their fingers has been touched when their eyes are closed. Right–left confusion is tested by touching one hand or ear and asking the patient which side of the body has been touched.

• Agraphognosia is failure to identify letters or numbers ‘written’ on the skin. It is tested by tracing numbers on the palms with a closed fountain pen or similar object.

• Anosognosia is failure to identify functional deficits caused by disease. It is seen most often as unawareness of left-sided weakness and sensory inattention after a right parietal lesion.

• Agnosias point to lesions of the association areas around the primary sensory receptive areas. Lesions of either parietal lobe can cause contralateral astereognosia, agraphognosia, and atopognosia. Sensory inattention and anosognosia are more common with right parietal lesions. Finger agnosia and right–left disorientation are said to be more common with lesions of the dominant parietal region.

• if an organic cause of psychiatric disorder is suspected, the profile of test results may suggest the location of the lesion. However, this use of neuropsychological testing to localize brain lesions has largely been replaced by neuroimaging.

Cognitive assessment

The term ‘cognitive’ is sometimes used interchangeably with the term ‘neuropsychological.’ In the present context, however, cognitive assessment refers to the assessment of a patient’s cognitions (thoughts), assumptions, and patterns of thinking. It is used to determine the suitability for, and focus of, cognitive therapy (see Chapter 20).

Behavioural assessment

Observations and ratings of behaviour are useful in everyday clinical practice, especially for inpatients. When no ready-made rating scale is available, ad hoc ratings can be devised. For example, a scale could be devised for the nurses to show how much of the time a patient with depression was active and occupied. This could be a five-point scale, in which the criteria for each rating refer to behaviour (e.g. playing cards or talking to other people) relevant to the individual patient. As well as providing baseline information, the scale could also help to monitor progress and response to treatment, complementing the information provided by repeated mental state examinations and qualitative observations.

Behavioural assessment is also used to evaluate the components of a patient’s disorder—for example, in a phobia, the elements of anticipatory anxiety, avoidance, and coping strategies, and their relationship to stimuli in the environment (e.g. heights), more general circumstances (e.g. crowded places), or internal cues (e.g. awareness of heart action). Behavioural assessment is a necessary preliminary to behaviour therapy (see p. 573).

Personality assessment

In the past, detailed personality testing, including the use of ‘projective’ tests such as the Rorschach test, was often part of psychiatric assessment. These tests are no longer widely used, as they do not measure aspects of personality that are most relevant to psychiatric disorder, and they have not been shown to be valid predictors of diagnosis or outcome. Instead, personality is assessed descriptively as part of the history (described above), supplemented for research purposes with schedules for diagnosing personality disorders (see Chapter 7).

Risk assessment

Risk assessment is an essential part of psychiatric assessment. Risk in this context refers to risk of harm to others (through violence or neglect) and risk to self (through suicide, deliberate self-harm, or neglect). A failure to carry out and clearly document a risk assessment, and the resulting risk management plan, is a common criticism of enquiries that follow homicides and suicides involving psychiatric patients. Risk to self is covered in Chapter 16. Here we consider assessment of the risk of violence to others. Three kinds of information are used to assess such risks—personal factors, factors related to illness, and factors in the mental state. These factors are summarized in Table 3.5, with the most important ones in each category indicated by means of an asterisk.

A history of violence is the best predictor of future violence. Therefore it is important to seek full information on this not only by questioning the patient but, in appropriate cases, from additional sources, including relatives and close acquaintances, previous medical and social services records, and in certain cases the police. Antisocial, impulsive, or irritable features in the personality are a further risk factor. Social circumstances at the time of any previous episodes of violence may reveal provoking factors, and should be compared with the patient’s current situation (see below). Social isolation and a recent life crisis also increase the risk. Among the illness factors, psychotic disorder and drug or alcohol misuse are important, and much more so when they are present together. The combination of psychosis, substance misuse, and personality disorder is associated with the highest risk of violence.

The mental state factors in Table 3.5 require careful consideration. Thoughts of violence to others are very important, especially if they are concerned with a specific person to whom the patient has access. The entry concerning suicidal ideas refers to the occasional killing, usually of family members, by a patient with severe (usually psychotic) depression. Features of morbid jealousy and other delusional disorders may pose specific risks of harm against a perceived aggressor or rival (see p. 305).

Situational factors are extremely important. Actual or perceived confrontational behaviour towards the patient by others may trigger violence, as may a return to situations in which violence has been expressed in the past. Enquiries should always be made about the availability of weapons.

Clinical experience and common sense have to be used to combine the risk factors into an overall assessment. Risk assessment schedules have been developed, but they cannot replace thorough and repeated clinical assessment. The assessment of risk should be shared among the members of the team treating the patient, or if the patient is in individual treatment it may need to be discussed with a colleague. In certain circumstances the assessment may need to be made known to an individual at risk. Risk assessments should be reviewed regularly, combining information from the members of the clinical team. For further information, see Monahan et al. (2005) and Mullen and Ogloff (2009).

Table 3.5 Risk factors for harm to others

Personal factors

Previous violence to others*

Antisocial, impulsive, or irritable personality traits

Male and young

Recent life crisis

Poor social network

Divorced or separated

Unemployed

Social instability

Illness-related factors

Pychotic symptoms*

Substance abuse*

Treatment resistant

Poor compliance with treatment

Stopped medication recently

Factors in the mental state

Irritability, hostility, anger

Suspiciousness

Thoughts of violence towards others

Threats to people to whom patient has access*

Planning of violence*

Persecutory delusions

Delusions of jealousy

Delusions of influence

Hallucinations commanding violence to others

Suicidal ideas with severe depression

Clouding of consciousness

Lack of insight about illness

Situational factors

Confrontation and provocation by others

Situations associated with previous violence

Ready availability of weapons*

Asterisks denote the most important factors in each category.

Although risk assessment is essential, and can be of value in a number of respects (Abderhalden et al., 2008), it is also important to put it in context. First, the vast majority of psychiatric patients pose no risk to others, and are more likely to be the victims than the perpetrators of violence. The assumption that all patients with severe mental illness, especially schizophrenia, are potentially violent is unwarranted and contributes to the stigma that is attached to all psychiatric patients. Secondly, as the physicist Niels Bohr said, ‘Prediction is very difficult, especially about the future.’ Even a complete risk assessment provides only a weak guide to future harm to others. Many such acts are carried out by people with no past history of violence, and many of those who have multiple risk factors will never commit further acts of violence (Szmukler, 2001, 2003).

Assessment of needs

For patients with severe or enduring mental illness, particularly psychosis, there is an increasing focus on their needs in the broadest sense (e.g. physical health, hygiene, social isolation, domestic skills, etc.). The concern arises from findings that such needs are often substantial, and neither well recognized nor met, and from resulting pressure on mental health services to focus more widely than on simply managing the symptoms of disorders. Although the conceptual status of needs is not as straightforward as is often implied, interest in its measurement is well established. The Camberwell Assessment of Need scale is widely used. This rates 22 domains as absent, present, or modified, has versions for different age and patient groups (e.g. those with learning disability; see Chapter 23), and is available in several languages (Phelan et al., 1995).

Special kinds of psychiatric assessment

So far this chapter has been concerned with the complete psychiatric assessment as carried out by psychiatrists on patients who are being seen in a psychiatric setting, and for whom sufficient time is available. However, most assessments do not meet all of these criteria. Many are conducted by non-specialists in non-psychiatric settings, with limited time and imperfect surroundings. Nevertheless, a well-focused interview can often yield a reliable diagnosis and plan of action in a surprisingly short time. This section considers how psychiatric assessment and interviewing are modified in these circumstances.

Interviews in an emergency

In an emergency, the interview has to be brief, focused on the key issues, and effective in leading to a provisional diagnosis and a plan of immediate action. These assessments generally involve acutely distressed or disturbed patients, and often take place in difficult settings, such as a police station or medical ward. The diagnoses that are usually in question are the psychoses (schizophrenia, mania, drug-induced), and delirium and other organic brain disorders. Throughout, the interviewer should consider which questions need to be answered at the time and which can be deferred. The most important issues are those that impact on immediate management decisions. The latter are likely to include whether the patient should be detained, whether laboratory investigations are indicated, whether medication should be given, and whether acute medical treatment is also required.

Because the assessment may be limited by the patient’s ability or willingness to participate fully, seek out all available information before commencing the interview. For example, ask whoever is accompanying the person what they know about the patient and the recent events. The patient’s belongings may reveal evidence of prior illness or medication. If the patient has a past psychiatric history, strenuous efforts should be made to obtain their case notes or to contact a professional involved in their care. The safety of the patient and those around them must also be actively considered when planning the nature and location of the interview.

An emergency assessment should, wherever possible, include the following core information:

• the presenting problem in terms of symptoms or behaviours, together with their onset, course, and present severity

• other relevant symptoms, together with their onset, course, and severity

• history of psychiatric or medical disorder

• current medication

• use of alcohol and drugs

• stressful circumstances around the time of onset and at the present time

• family and personal history, covered by means of a few salient questions

• social circumstances, and the possibilities of support

• personality—this information is valuable, although it may be difficult to obtain in the circumstances of an emergency

• risk assessment, including the immediate risks of harm to self and others.

Interviews in general practice

In general practice, many presentations are with psychiatric disorders, notably depression and anxiety disorders, as well as substance misuse and somatoform disorders. Such cases commonly present with physical complaints (e.g. chronic pain, fatigue), and the doctor needs to be aware of the possibility that the symptoms reflect an underlying psychiatric disorder. The interplay of physical and psychological factors is emphasized by the finding that general practitioners who diagnose psychiatric disorder accurately, as compared with a standard assessment, have a good knowledge of general medicine (Goldberg and Huxley, 1980). Other patients present in primary care with an explicit psychological complaint (e.g. low mood, panic attacks).

Whether the presentation is physical or psychological, it is a challenge to undertake an effective psychiatric assessment, given the very limited time that is usually available. There are two components to achieving this goal. First, the chances of detecting psychiatric disorder can be increased by attending to the way that the interview is conducted—for example, by being alert to cues in the patient’s history, appearance, and behaviour. Secondly, screening questions can be used which detect the common disorders, and which identify areas that may require more detailed assessment (see Table 3.6).

Goldberg and Huxley (1980) reported the first substantive work in this field, and described how the assessment of a patient in general practice whose complaint may have a psychological cause should cover four areas:

• general psychological adjustment: fatigue, irritability, poor concentration, and the feeling of being under stress

• anxiety and worries: physical symptoms of anxiety and tension, phobias, and persistent worrying thoughts

• symptoms of depression: persistent depressive mood, tearfulness, crying, hopelessness, self-blame, thoughts that life is unbearable, ideas about suicide, early-morning waking, diurnal mood variation, weight loss, and loss of libido

• the psychological context (i.e. the patient’s personality and circumstances): although often known to the general practitioner from previous contacts, this should be reviewed and brought up to date.

Subsequently, more formalized sets of screening questions for psychiatric disorders have been developed which are suitable for brief interviews in primary care, and which focus on the disorders that are commonly encountered in this setting. The questions in Table 3.6 are adapted from Spitzer et al. (1994).

If the interview is conducted with psychological issues in mind, and screening questions are used appropriately, then it should be possible to identify many psychiatric disorders in the 10 to 15 minutes that are available in primary care. A preliminary plan can be made, and a further appointment arranged in order to evaluate the diagnosis and discuss management in more detail.

Interviews in a general hospital

Similar considerations apply to interviews that are conducted in a general medical setting, such as an Accident and Emergency department or a medical ward. In these situations, particular attention may again need to be given to physical symptoms and the possibility of somatoform disorder, and to the assessment of suicidal risk. Delirium and the possibility of other organic disorders is also a common reason for a psychiatric consultation involving a medical or surgical inpatient. Therefore a focused assessment of cognitive function is often required (see p. 316).

Interviews in the patient’s home

It is often appropriate to add to the information about a patient’s circumstances by visiting their home, or arranging for another member of the team to do so. Many services now try to assess a significant proportion of patients at home, particularly in the case of severely ill and disorganized patients who would otherwise fail to attend for assessment. Such a visit often throws new light on the patient’s home life and gives a more realistic evaluation of the relationship between family members. Home visits are especially important in the assessment of elderly patients. Before arranging a visit the psychiatrist should, if possible, talk to the general practitioner, who often has first-hand knowledge of the family, gained over a period of many years. The safety of the interviewer should always be considered before embarking on a domiciliary visit. The interviewer should ensure that another member of the team is aware of the location and time of the visit. If there is any concern about potential risk, a joint assessment should be made.

Table 3.6 Brief screening questions for psychiatric disorders

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Interviews with the family

In child and adolescent psychiatry in particular, an interview is usually conducted with several family members together to find out their attitudes to the patient and the illness, and the nature of any conflicts within the family. The interviewer should remember that the family has usually tried to help the patient but failed, and may be feeling demoralized, frustrated, or guilty, so they should be careful not to add to these feelings.

The interviewer should ask the following questions:

• How has the illness affected family life, and how have the family tried to cope?

• What are the relationships and alliances within the family? Are there important differences of opinion between the members of the family?

• Are the family members willing to try new ways of helping the patient?

For further information about family interviews, see Goldberg (1997). Family interviewing in the context of family therapy is covered in Chapter 20.

Patient characteristics that may affect the interview

Interviews can prove difficult for a variety of reasons. Many of these reflect the situation (e.g. noisy surroundings, lack of time) or interviewer characteristics (e.g. inexperience, tiredness). However, other problems arise from the characteristics of the patient, and these are outlined here. Remember that such problems can be diagnostically useful—for example, a patient may be monosyllabic because of depression, and a disturbed patient may have delirium.

Anxious patients

Although anxiety may be part of the patient’s disorder, it may also relate to the interview. If the person seems unduly anxious, the interviewer can say that many people feel anxious when they first take part in a psychiatric interview, and then go on to explore the patient’s concerns.

Taciturn patients

Taciturn patients can be encouraged to speak more freely if the interviewer shows non-verbal expressions of concern (e.g. leaning forward a little in the chair with an expression of interest), in addition to verbal expressions that are part of any good interview.

Garrulous patients

It is not easy to curb an over-talkative patient. If efforts to focus the interview are unsuccessful, the interviewer should wait for a natural break in the flow of speech and then explain that, because time is limited, they propose to interrupt from time to time to help the patient to keep focused on the issues that are important for planning treatment. If this proposal is made tactfully, most garrulous patients will accept it.

Overactive patients

Some patients are so active and restless that systematic questioning about their mental state is difficult. The interviewer then has to limit their questions to a few that seem particularly important, and concentrate on observing the patient’s behaviour. However, if the patient is being seen in an emergency, some of their overactivity may be a reaction to other people’s attempts to restrain them. In such cases a quiet but confident approach by the interviewer may calm the patient enough to allow more adequate examination.

Confused patients

When the patient gives a history in a muddled way, or appears perplexed, the interviewer should test cognitive functions early in the interview. If there is evidence of impaired cognition or consciousness, the interviewer should try to orientate and reassure the patient, before starting the interview again in a simplified form. In such cases every effort should be made to interview another informant.

Uncooperative or ‘difficult’ patients

Some patients are reluctant to be interviewed and have come at the insistence of a third party (e.g. their partner). If the patient seems unwilling to collaborate, the interviewer should talk over the circumstances of the referral, and try to persuade them that the interview will be in their own interests. Remember that lack of cooperation may occur because the patient does not realize that they are ill (e.g. some patients with depression, delirium, or psychosis). In such cases it may be necessary to interview an informant before returning to the patient.

Some patients try to dominate the interview, especially when the interviewer is younger than them. Others adopt an unduly friendly approach that threatens to convert the interview into a social conversation. In either case, the interviewer should explain why he needs to guide the patient towards relevant issues. In the longer term, developing a manner which is confident and assertive, but not domineering, helps to avoid such problems.

Unresponsive patients

If the patient is mute or stuporous, it is essential to interview an informant who can describe the onset and course of the condition. With regard to the mental state, the interviewer can only observe behaviour, but this can be informative. Because some stuporous patients change rapidly from inactivity to violent overactivity, it is wise to have help available when seeing such a patient.

Before deciding that a patient is mute, the interviewer should allow adequate time for reply, and try several topics. If the patient still fails to respond, attempt to persuade them to communicate in writing. Apart from observations of behaviour, the interviewer should note whether the patient’s eyes are open or closed. If they are open, note whether they follow objects, move apparently without purpose, or are fixed. If the eyes are closed, find out whether the patient opens them on request, and if not, whether attempts at opening them are resisted. A physical examination, including neurological assessment, is essential in all such cases. In addition, certain signs that are found in catatonia should be sought (see p. 16).

Patients with limited intelligence

The procedures for interviewing people with low IQ (learning disability) are similar to those for people with normal intelligence, but certain points should receive particular attention. Questions should be brief and worded in a simple way. It may be difficult to avoid closed questions, but if they are used the answers should be checked. For example, if the question ‘Are you sad?’ is answered ‘Yes’, the question ‘Are you happy?’ should not be answered in the same way. People with learning disability may have difficulty in timing the onset of symptoms or describing their sequence, and to obtain this and other information it is important to interview an informant.

For further discussion of the assessment of patients with learning disability, see Chapter 23.

Patients from another culture

If the patient and interviewer do not speak the same language, an interpreter will obviously be needed. However, accurate translation is not the only requirement. The interviewer may be unfamiliar with the patient’s culture as well as not knowing the language, and may find it more difficult to ascertain the significance of the patient’s manner and appearance. Female patients, particularly those from more paternalistic cultures, may be reluctant to describe personal matters to a male interviewer. Even when these problems are absent, the presence of a third person, and the process of translation, affect the interview and lengthen it considerably. If possible the interpreter should be a health professional, as they can then assist in the assessment itself.

Certain factors may have different implications for a patient from another culture to those that they would have in the interviewer’s culture. The stigma of mental illness may be greater. Priorities within the family may be different, with the well-being of the family outweighing that of its individual members. Emotional disorder may be experienced more in terms of physical symptoms than of mental ones. Expectations and fears about treatment may be based on knowledge of less developed services in the country of origin. Behaviours that suggest illness in one culture may be socially sanctioned ways of expressing distress in others (e.g. displays of extreme emotion). Ideas about causation may differ, an extreme example being that distress may be ascribed to the actions of evil spirits. It may be particularly difficult to decide whether strongly held ideas are delusional or normal within the culture or subculture. The influence of cultural differences on diagnosis and classification was discussed on p. 33.

Children and the elderly

Assessment of children and adolescents is described in Chapter 22 and has been discussed by Bostic and Martin (2009). Assessment in elderly patients is described in Chapter 18 and has been discussed by Jacoby (2009).

Integrating and evaluating the information

So far this account of assessment has been largely about sequential data gathering. The following section explains how the facts that emerge are evaluated and integrated with knowledge of psychiatry, in order to arrive at a diagnosis, provide prognostic information, and determine treatment decisions. We emphasize again that, in practice, information is evaluated as it is collected, with hypotheses being tested as they arise during the assessment. Clearly, this skill takes time to learn and also requires a solid foundation of psychiatric knowledge.

Drawing conclusions and making decisions

The areas in which an opinion must be formed, or a decision made, are listed in Table 3.7. It may also be useful to think in terms of a set of rhetorical questions that need to be answered:

• What is the diagnosis?

• What are the effects on the patient’s life?

• Are there immediate risks that need to be managed?

• What are the patient’s current circumstances?

• Why has the disorder occurred?

• What treatment is indicated?

• What is the prognosis?

• What other information is needed to answer these questions?

• What does the patient need and want to know?

What is the diagnosis?

The first step is to make a diagnosis using information about the symptoms and signs that has been obtained from the history and mental state examination and, in relevant cases, from the physical examination and any investigations that have been performed. This information is then used to make a diagnosis based upon knowledge of psychiatric classification and the criteria for each diagnostic category. Sometimes a diagnosis has to be provisional until further information becomes available. The diagnosis of particular psychiatric disorders is discussed in subsequent chapters; here we are concerned with the general approach to assessment. Diagnosis is accompanied by an assessment of the severity of the disorder in order to determine whether it is mild, moderate, or severe. Remember that the outcome of some assessments is that the patient does not have a psychiatric disorder of any kind.

Table 3.7 Topics to be evaluated in a psychiatric assessment

The patient’s problem and its consequences

• Diagnosis

• Impact on self and others (dysfunction)

• Risk to self and others

• Effects on others

The patient and their circumstances

• Personal history

• Current circumstances

• Personality

Aetiology

The response to the patient’s problem

• Treatment

• Prognosis

The patient’s understanding of the above

What are the effects on the patient’s life?

When patients describe their problems, they will include both symptoms and other matters. A key purpose of the assessment is to identify and characterize the psychopathology, as it is these that determine which disorder will be diagnosed. However, it is also necessary to enquire about the effects that the patient’s symptoms are having on their life, in part since evidence of impaired functioning is relevant to, or an essential part of, most diagnoses. It is therefore helpful to ascertain the patient’s usual level of functioning and how far the current state differs from it.

Are there immediate risks that need to be managed?

As we have discussed, risk assessment is a core part of the psychiatric assessment. Once any risks have been identified, they need to be managed. For example, if the patient is at risk of self-neglect or self-harm, this will influence whether compulsory admission is necessary. If a risk of harm to another party has been identified, that individual may need to be warned. Risk management is covered on p. 437.

What are the patient’s current circumstances?

A knowledge of the patient’s accommodation, finances, interests, values, and relationships may influence both management and prognosis. For example, a homeless person will require a different care package from a patient with the same disorder who has a stable home and a carer. The current circumstances may also act as maintaining factors for the disorder, and therefore be a target for intervention.

Why has the disorder occurred?

Aetiology is discussed in Chapter 5. Here we are concerned with how aetiological factors are applied to the individual patient. A useful approach is a chronological one, with causes being divided into those that are predisposing, precipitating, and perpetuating. Predisposing factors may be genetic or related to temperament, or to damage to the brain in early life. Precipitating factors are often stressful life events. Perpetuating (maintaining) factors may be continuing stressors, or related to the way that the patient attempts to cope with stressors (e.g. avoiding anxiety-provoking situations, misusing alcohol). Perpetuating factors are highly relevant to treatment.

life chart is a tool for evaluating the role of life events in aetiology (Sharpe, 1990). It helps to reveal the time relationships between episodes of physical and mental disorder and potentially stressful events in the patient’s life. It is often useful when the history is long and complicated. The chart has three columns—one for life events, one for physical disorder, and one for mental disorder. Its rows represent the years in the patient’s life. Completion of a life chart requires detailed enquiry into the timing of events, but is worthwhile as it may clarify the relationships between stressors and the onset of illness, and also between physical and mental disorders.

A comment about personality is appropriate here. Clear appreciation of a patient’s personality is part of the full understanding of their life history and their psychiatric disorder. For this reason we emphasize the collection of sufficient and reliable information about personality during the assessment. As well as aiding the aetiological formulation, this knowledge is useful when planning management and predicting outcome. For example, comorbid personality disorder worsens the prognosis of many conditions, and may also influence decisions about psychological treatment.

What treatment is indicated?

A key decision to be made is what, if any, treatment the patient requires. If treatment is indicated, the options should be discussed with the patient, and the evidence for each possible treatment presented in terms of efficacy, side-effects, etc. These issues are discussed in later chapters, especially Chapters 19 and 20.

What is the prognosis?

The prognosis depends primarily on the disorder concerned. It also depends on the individual characteristics of the patient (e.g. their age, severity of symptoms, comorbid conditions, etc.). Not all of this information may be available after an initial assessment. However, it is usually possible to make a cautious prediction about the short-term outcome at this stage, and most patients will expect and appreciate this. The patient can be told that more accurate and longer-term prognostic judgements will be possible as further information is obtained, and the course of the disorder is followed over subsequent weeks and months.

What other information is needed to answer these questions?

For many patients, assessment is not complete after one interview, often because not all of the questions posed here can be answered with any certainty. Assessment should be viewed as an iterative process in which opinions and conclusions undergo continuing review (both within the initial interview and thereafter), as further information about the patient and their illness is obtained. For descriptive purposes, this chapter focuses on the diagnostic purpose of assessment, but in practice there is no firm distinction between this and the other goals of assessment (e.g. to assess risk, or response to treatment). Each interaction between the psychiatrist and the patient contains a mixture of assessment, evaluation, review, and decision making. Assessment, and its revision, is a process that continues throughout treatment and follow-up.

What does the patient need and want to know?

The guiding principle is that, as a rule, a patient (and their carer) should be given as much information as possible about the diagnosis, and the likely prognosis and presumed causation, and should be fully involved in, and aware of, all decisions that affect them. The practical implications are introduced below, and are discussed in later chapters with regard to specific disorders and treatments.

Other issues that affect how the information is evaluated

Disease and illness

These concepts were introduced in Chapter 2, but a brief mention is required here. Illness refers to a patient’s experience, and disease refers to the pathological cause of this experience. Patients can be diseased without feeling ill, or feel ill without having an identifiable disease. In general medicine, patients tell doctors about their experience of illness, and doctors seek to discover the disease that is causing the illness, as this will guide treatment. Patients and their relatives also want to find a cause and a treatment for their illness, but they do not always understand how a medical diagnosis helps in finding these. Psychiatrists also search for disease as a cause of illness, but should always look for other causes, too. The patient’s experience can be understood sometimes as an extreme variation from the norm, sometimes as a reaction to circumstances, and sometimes as a combination of both. Other mental health professionals may emphasize one or other of these factors to a greater extent, depending on their background. For example, psychologists focus on variation from the norm, whereas social workers focus on the role of reaction to circumstances. These differences in emphasis can lead to apparent disagreements during multidisciplinary assessment. It is important that psychiatrists are aware of this possibility, so that they can help to resolve such disputes.

Evaluations by experienced psychiatrists

Throughout this chapter, a systematic and logical approach to assessment has been advocated, in which information is collected carefully, and eliciting of symptoms and signs forms the basis of diagnosis. Anyone new to psychiatry should always follow this approach closely. However, studies show that experienced psychiatrists actually carry out assessments rather differently. They make rapid diagnoses, often within the first few minutes of the interview, that presumably reflect the predictive power of the patient’s initial appearance, behaviour, and utterances (Gauron and Dickinson, 1966; Kendell, 1975). The psychiatrist may not realize the cues and clues that they are using to form these diagnostic judgements. Schwartz and Wiggins (1987) called this process typification. The rest of the interview then functions primarily to confirm and refine this diagnostic opinion.

As experience is gained, a clinician is likely to use this kind of strategy increasingly often in assessment. If they have a firm grasp of psychopathology and diagnostic classification, typification can be used effectively. However, we emphasize that this approach should not be attempted until the ‘textbook’ approach to psychiatric assessment has been mastered and further experience accumulated. The interviewer should always ensure that they have not come to premature conclusions about a case, causing them to fail to gather necessary information, or to disregard contrary evidence that emerges.

Recording and communicating information

Having completed the assessment, it is necessary to record and communicate your understanding of the patient, their disorder, and its management. These records and communications take a variety of forms, according to their source, intended purpose, and recipients. As with assessment itself, it is helpful to learn the ‘traditional’ and relatively detailed formats for communicating information (e.g. case summaries and formulations), while also appreciating that in practice many other—and briefer—modes of communication are appropriate. Regardless of format, all communications should follow certain basic principles.

• Information should be presented clearly and concisely. Include important negatives (e.g. ‘He is not suicidal’). Avoid repetition of information that is already known to the recipient. Use subheadings to highlight key points (e.g. ‘Diagnosis: …’, ‘Current medication …’, ‘Acute risks: …’).

• In many countries, patients are entitled to read what is written about them. This information may also be used for legal purposes. In some countries, including the UK, it is now expected that patients will be copied into all correspondence between doctors which concerns them, unless there is a compelling reason not to do so or unless they decline the offer. Ensure that all information is accurate, and that any opinions or inferences you make are reasonable, and avoid unwarranted or unnecessarily personal comments. It is sometimes better to communicate verbally with the doctor or other health professional in order to expand on some details of the case. The patient should be told that they will receive a copy of the letter, and invited to contact you if it is unclear or contains errors of fact.

• All communications should be kept confidential.

A switch from paper to electronic health records is occurring in many settings and poses significant challenges for psychiatry, even though the same principles apply with regard to the records’ content and nature, whether they are electronic or not. For example, it may raise extra concerns about confidentiality, and about responsibility for backdating, updating, and maintaining the electronic records. Equally, it provides opportunities—for example, the ability to keep in contact with patients remotely via mobile phone or Internet connections (e.g. for monitoring of symptoms or reminders about medication), and to have access to patient records from any location and at all times (e.g. out of hours). Psychiatrists need to be aware of the policies and procedures regarding electronic records in their own clinical setting, as these are likely to develop significantly in the next few years.

Here we consider a range of ways in which information is recorded and shared—within the psychiatric team, and between the psychiatrist and other doctors, but first, between the psychiatrist and the patient.

Explaining the diagnosis and management plan to the patient

When discussing the conclusions from your assessment with the patient, and with their relatives, it may be useful to begin by briefly summarizing the key points for them. This helps to ensure that you have understood the history correctly and have not omitted anything which in their opinion is significant. This process is also helpful in that it demonstrates your engagement and empathy with the patient, and sets the scene for discussion about the diagnosis and how you propose to proceed.

When introducing the diagnosis, do not use medical terms without explaining them. The patient may misunderstand their meaning or make incorrect assumptions about their implications. Explain the significance of the diagnosis in terms of cause, prognosis, and treatment options—and any diagnostic uncertainty that remains.

When discussing the proposed plan of management, it is useful to begin by asking what treatment the patient has been expecting, and whether they have strong feelings about this—for example, with regard to the use of medication. The plan should be explained in an unhurried way, checking from time to time that the patient has understood. Whether drug treatment or psychological treatment is planned, there are several relevant issues to raise and discuss (see Chapters 19 and 20). It is important to set aside enough time for this explanation during the interview, as it is likely to improve concordance with the treatment plan. If, after they have been given a full explanation, the patient refuses to accept part of the plan, the interviewer should try to negotiate an acceptable alternative.

Box 3.3 summarizes the points that should be considered when communicating with patients and their relatives. In the NHS in the UK, this information will usually be recorded on a pro forma as part of the Care Programme Approach (CPA) for any patients who require either prolonged or complex secondary care (see Chapter 21).

The importance of case notes

Good case records, whatever their format, are important in every branch of medicine. In psychiatry they are vital because a large amount of information has to be collected from a variety of sources. It is important to summarize the information in a way that allows essential points to be grasped readily by someone new to the case, especially a colleague who has been called to deal with an emergency. Case notes are not just an aide-mémoire for the writer—they are important for others concerned with the patient. They are also of medico-legal importance. If a psychiatrist is called upon to justify his actions after a serious untoward incident, after a complaint has been made, or in court, he will be greatly assisted by notes which are comprehensive but concise, well organized, and legible. Indeed, imagining being in a situation of this kind may help the psychiatrist to judge what constitutes appropriate record keeping, not just for case notes but for other forms of communication.

Box 3.3 Communicating with patients and relatives

Relevant questions from the following list can be helpful when deciding what information should be given to patients and their relatives.

The diagnosis

• What is the psychiatric diagnosis? If it is uncertain, what are the main possibilities?

• Is there a general medical diagnosis?

• What further information or investigations are required?

• What are the implications of the diagnosis for this patient?

• What may have caused the condition?

The care plan

• What is the plan, and how will it help the patient and their family?

• Are there any legal powers to be used? If so, why, and what is their effect?

• What needs to be communicated about medication or psychological treatments?

Who does what?

• Who is the key worker and what will they do?

• What is the role of the psychiatrist, and how often will they see the patient?

• What is the role of the other members of the psychiatric team?

• What is the role of the general practitioner?

• What can the family (or other carers) do to help the patient?

Emergencies

• What are the likely acute risks, and how might they be avoided?

• Are there possible early warning signs of a crisis?

• Who should be approached in an emergency, and how can they be found quickly?

Inpatient admission notes

When a patient is admitted to hospital urgently, the doctor often has only limited time available, so it is then particularly important to record the right topics. The admission note should contain at least the following:

• the reasons for admission

• any information that is required for a decision about provisional diagnosis and immediate treatment. This may include a physical examination and laboratory investigations

• any other relevant information that will not be available later, such as details of the mental state on admission (and prior to medication), and information from any informant who may not be available again.

If there is time, a systematic history can be added. However, inexperienced interviewers sometimes spend too much time on details that are not essential to the immediate decisions, while failing to record details of the mental state that may be transitory and yet of great importance in diagnosis. The rest of the assessment can always be completed over the next few days. The admission note should end with a brief plan of immediate management, which has been agreed with the senior nurses caring for the patient at the time.

Continuation (progress) notes

Continuation notes for both inpatients and patients in the community need to be succinct, clear, and regularly updated, and to contain specific information if they are to be of value. Instead of recording merely that the patient feels better or is behaving more normally, record in what ways they feel better (e.g. less preoccupied with thoughts of suicide). The notes should also record treatments, including both medication and other interventions, accompanied by a brief explanation of the rationale for the treatment, and the temporal relationship between a change in treatment and change in clinical state. Major life events and stressors should be recorded.

A careful note should be made of any information or advice given by the doctor to the patient or their relatives. This should be sufficient to make it clear whether the patient was appropriately informed when consenting to any new treatment. In addition it should enable anyone giving advice later to know whether or not it differs from what was said before, so that any necessary explanation can be given.

Observations of progress are made not only by psychiatrists but also by nurses, occupational therapists, clinical psychologists, and social workers. Often these other professionals keep separate notes, but it is desirable that important items of information are written in the medical record. A note should also be kept of formal discussions between members of the team.

Discharge notes

It is particularly important to set out clearly the plans made for the patient’s further care on discharge from hospital, including the identity of the key worker, and how the patient or their carer can contact the team in an emergency. These arrangements are formalized in the UK in the CPA (see above and Chapter 21), in part because it is recognized that the days after discharge are a particularly high-risk period for suicide. A phone call to the patient’s general practitioner is desirable if there are any acute concerns about the patient’s welfare, or if there is any delay in production of the discharge letter or case summary.

Case summaries

Case summaries are generally used for inpatients, but they are valuable for all patients with complex, longstanding, or recurrent disorders. In the inpatient setting they are ideally written in two parts, the first part being written soon after admission, to record the initial presentation, and the second part being written at discharge, filling in the subsequent progress. In practice, however, a single summary covering all of the salient aspects of the case is often produced.

Summaries should be brief but comprehensive, written in telegraphic style using a standard format, to help other people to find particular items of information. A completed summary should seldom need to be any longer than one to one and a half typewritten pages. An example is given in Box 3.4. The completed summary will provide a valuable record should the patient become ill again, especially if they are under the care of a different team.

Some of the items in the summary call for comment. The reason for referral should state the problem rather than anticipate the diagnosis—for example, ‘found wandering at night in an agitated state, shouting about God and the devil’, rather than ‘for treatment of schizophrenia.’ The description of personality is important, and the writer should strive to find words and phrases that characterize the person. Unless an abnormality has been found, the results of the physical examination can be summarized briefly. However, when the mental state is recorded, a comment should be made under each heading as to whether or not any abnormality has been found. Diagnosis should be recorded using terms from ICD-10 or DSM-IV. If the diagnosis is uncertain, alternatives can be listed, with an indication of which is judged to be more likely. More than one diagnosis may be required in some cases.

Box 3.4 Example of a case summary

Patient: Mrs AB. Date of birth: 7.2.76

Consultant: Dr C. Summary compiled by Dr D.

Admitted: 27.6.10 Discharged: 22.7.10

Reason for referral: Severe depression with suicidal ideation and intent.

Family history: Father, 66, retired gardener, well, mood swings, poor relationship with patient. Mother, 57, housewife, well, spiritualist, distant relationship with patient. Sister, Joan, 35, divorced, well. Home materially adequate, little affection. Mental illness: father’s brother—‘manic depression’; father’s sister—?depression.

Personal history and current circumstances: Birth and early development normal. Childhood health good. School 6–16, uneventful, left with few GCSEs. Few friends, felt lonely much of time. Worked 16–22, shop assistant. Several boyfriends; married at 22, husband 2 years older, lorry driver. Unhappy in last year following his infidelity. Children: Jane, 7, well; Paul, 4, epileptic. Current financial worries.

Previous illness: Aged 24, (postnatal) depressive illness lasting a few weeks, saw counsellor. Hypothyroidism (idiopathic), on thyroxine.

Previous personality: Few friends, worries easily, lacks self-confidence. No obsessional or cyclothymic traits. Shares mother’s interest in the supernatural. Drinks occasionally, non-smoker, denies drugs.

History of present illness: For 6 weeks, since learning of husband’s infidelity, increasingly low-spirited and tearful, waking early, worse in morning, neglecting children. Anhedonic, loss of appetite and libido. Worrying about marriage. Hears her (dead) grandmother’s voice in the night. Strong suicidal ideation, culminating in abortive attempt to hang herself on night of admission. Getting worse despite fluoxetine for 2 months (40 mg daily for past 3 weeks), taken regularly. On waiting list for CBT.

On examination: Physical: n.a.d., no evidence of myxoedema. Mental state: dishevelled, agitated, psychomotor retardation. Speech: slow, quiet, normal form. Thoughts: preoccupied with worries about her husband’s infidelity, and whether there is a conspiracy with the mistress. Not delusional in nature. Prominent ideas of suicide, finding them hard to resist, wishing she were dead. Mood: subjectively and objectively very depressed, with self-blame, hopelessness. Perceptions: imagines she hears her dead grandmother talking to her in derogatory tones; however, this is not a hallucination. Cognition: attention and concentration poor. Memory not formally tested. Insight: thinks she is ill, consents to admission; her views on treatment are unclear.

Special investigations: Haemoglobin, electrolytes, TSH n.a.d.

Treatment and progress: Initially on close observations. Medication changed to venlafaxine, progressively increased to 225 mg per day, augmented by mirtazapine, 30 mg nocte, graded activities, joint interviews with husband to improve marital relationship. Discussed problem-solving strategies, applied to financial worries and marital relationship (including joint session with husband). Gradual improvement in mood and loss of suicidal ideation. Successful weekend at home before final discharge.

Condition on discharge: Mild residual depressive symptoms. Hopeful but worried about future of marriage. Childcare—no concerns, husband and patient’s sister (lives nearby) are supportive.

Diagnosis: (ICD-10) F33.2 Recurrent depressive disorder, current episode severe without psychotic symptoms. Now resolving.

Prognosis: Depends on outcome of marital problems. If these improve, the short-term prognosis is good, but will be at risk of further depressive episodes.

Further management

• Under CPA. Key worker is Jo Smith, community psychiatric nurse, who will visit on 27.7.10.

• Continue venlafaxine 225 mg daily and mirtazapine 30 mg nocte for at least 9 months. GP to prescribe.

• CBT with psychologist starts on 3.8.10.

• Patient and husband will contact Relate for help with their relationship.

• Patient has a copy of her care plan, and she and her husband know who to contact in an emergency.

• First review with psychiatrist in 2 weeks.

The summary of treatment should include the dosage and duration of any medication. The prognosis should be stated briefly but as definitely as possible. Statements such as ‘prognosis guarded’ are of little help to anyone. The writer should note how certain the prognosis is and the reasons for any uncertainty, such as doubt about the patient’s future compliance with treatment. The summary of future treatment should specify not only what is to be done, but also who is to do it. The roles of the mental health team and of the general practitioner and any other agencies should be made clear.

Formulations

A formulation is an exercise in clinical reasoning that helps the writer to think clearly about the diagnosis, aetiology, treatment, and prognosis (see Table 3.8). A formulation should not contain speculation, but it may contain hypotheses that can be tested by obtaining further information. Although now uncommon in clinical practice, formulations are extremely useful for developing skills in diagnostic reasoning, for understanding how psychiatric knowledge can be applied to the individual patient, and for learning how to prioritize and focus on the problems that require attention. Even for an experienced psychiatrist, a formulation remains a valuable exercise and aid.

A formulation is divided into several sections, as in the example shown in Box 3.5. A short opening statement is followed by the differential diagnosis. This consists of a list of reasonable possibilities in decreasing order of probability, together with a note of the evidence for and against each alternative, followed by a conclusion about the most probable diagnosis. To produce a good differential diagnosis, it is necessary to have elicited and interpreted the key symptoms and signs (see Chapter 1) and to know the cardinal features of the major psychiatric disorders and how they are classified (see Chapter 2). Under aetiology, predisposing, precipitating, and perpetuating causes should be identified. This requires a grounding in the causation of psychiatric disorders (see Chapter 5). There follows a list of outstanding problems and any further information that is needed. Next a concise plan of management is outlined, and finally there is a statement about the prognosis.

Table 3.8 The formulation

Statement of the problem

Differential diagnosis

Aetiology

Plan of treatment

Prognosis

Problem lists

A problem list is useful in cases where there are multiple issues to be addressed, especially complex social problems. The list identifies the range of problems (or needs), summarizes the solution(s) proposed, states who is responsible for each action, and gives a review date. It is best to draw up the list with the patient, to ensure that they are fully involved in the identification of problems and in how these will be addressed. This is formalized in problem-solving counselling (see p. 576).

Table 3.9 shows a problem list that might be drawn up following the initial assessment of a man who had taken an overdose and was found to have anxiety symptoms and many social problems. As progress is made in dealing with problems in this list, new ones may be added or existing ones modified or removed. For example, it might transpire that this patient’s sexual difficulties are a cause of the marital problem rather than a result of it, and that counselling should be offered. Item 4 would then be amended.

Letters to the general practitioner

When a letter is written to a general practitioner after an initial assessment, the first step is to consider what they already know about the patient, and what questions were asked when they referred them. If the referral letter outlined the salient features of the case, there is no need to repeat these in the reply. If the patient is less well known to the general practitioner, or if the referral has come from another source, more detailed information should be given. The letter should state clearly the diagnosis (if one has been made), or the range of differential diagnoses that are still being considered.

Treatment and prognosis are dealt with next. When discussing treatment, the dosage, timing, and duration of any drug treatment should be stated. Responsibility for future prescribing should be stated. Name any key worker, therapists, and other agencies involved, and the nature of their involvement. State the date of the patient’s next appointment, and whether you have advised the patient to see the general practitioner in the interim (e.g. for blood tests). These details should, if possible, be agreed with the general practitioner by phone before the letter is written to confirm them. The letter should emphasize a collaborative approach, and encourage the general practitioner to get in touch if they are unclear about the arrangements, or concerned about the patient.

Box 3.5 Example of a formulation

(Note: This formulation refers to the case summarized in Box 3.4, at the time of admission. By comparing the two ways of condensing information, the reader can appreciate the difference between the two approaches.)

Opening statement

Mrs AB is a 34-year-old married woman who for 6 weeks has been feeling increasingly depressed and suicidal, despite antidepressant treatment.

Differential diagnosis

Recurrent depressive disorder. For: subjective and objective low mood, anhedonia, lack of motivation, anergia, poor concentration, early-morning waking, loss of appetite and libido. Lack of energy and motivation. Suicidal. Past history of depressive episode. Against: none, unless current depressive episode is better explained by one of the diagnoses listed below.

Bipolar disorder. For: long-standing mood variability, family history of bipolar disorder. Against: no evidence of past clinically significant mood elevation, or current hypomanic or mixed affective symptoms.

Organic mood disorder. For: history of hypothyroidism. Against: no somatic symptoms or abnormalities on physical exam; TSH normal.

Schizophrenia. For: she believes that her husband is conspiring against her, and that her dead grandmother talks to her. Against: the belief is not a delusion, and the voice is not a hallucination. Both symptoms are mood congruent, and consistent with a severe depression. She has no first-rank symptom of schizophrenia, and retains insight.

Personality disorder. For: mood variation and predominant mild low mood for many years. Against: these do not meet the criteria for a cyclothymic personality disorder; clear recent exacerbation with somatic symptoms.

Conclusions: Severe depression. In ICD-10, diagnosis is F33.2: recurrent depressive disorder, current episode severe without psychotic symptoms.

Aetiology

Predisposing: Genetic—family history of mood disorder. Sad childhood—lack of close relationship with parents or others. Personality trait—neuroticism. Previous depressive episode.

Precipitating: discovery of husband’s infidelity. Mrs AB was predisposed to react severely to this news, given her predisposing factors.

Perpetutating: ongoing marital arguments, worry about debts. Her sister’s divorce and subsequent unhappiness (and financial worries) add to her own concerns.

Treatment

Given her diagnosis, and non-response to an adequate trial of fluoxetine, switching or augmentation of her antidepressant is indicated, together with referral for CBT. Joint interviews with the patient and her husband may help to reduce the marital problems. Suggest sources of financial advice to reduce this stressor.

Prognosis

Mrs AB has a good chance of a full therapeutic response to the planned treatment plan, especially if the marital problems can be improved. However, given her history and the predisposing factors noted above, she is at increased risk of further depressive episodes, particularly at times of stress.

Table 3.9 A problem list

Images

The same principles apply to subsequent correspondence during psychiatric care. That is, keep letters concise, focusing only on those issues which have changed since the last letter (e.g. symptoms, circumstances, treatments, and what is expected of the general practitioner). It is also helpful to highlight at the top of the letter the diagnosis, current state, current treatments (especially drugs and doses), and date of the next appointment.

As noted earlier, it is now standard practice for patients (and their carers, if requested) to be sent copies of all correspondence about them. All letters and other documents should be prepared with this in mind.

Standardized assessment methods

In research, and sometimes in clinical practice, it is helpful to use standardized methods to assess symptoms and syndromes, as well as disabilities and other consequences of psychiatric disorders. Such methods improve reliability and facilitate comparison of findings across time and between psychiatrists.

Standardized methods of assessment are of four main types. Three are considered in turn below:

• those that rate symptoms in order to make a diagnosis; these have been important in the development of contemporary psychiatric classifications, and were introduced in Chapter 2. The Mini-Mental State Examination is another example of this type

• those that rate the severity of a symptom or group of symptoms

• those that assess the overall evidence for and effects of psychiatric disorder; these are called global rating scales, and they include quality-of-life measures.

In addition there are schedules for the assessment of need.

For a review of rating scales in psychiatry, see Tyrer and Methuen (2007).

Standardized diagnostic assessments

A range of diagnostic assessment schedules have been developed. The leading ones in current use are mentioned here. Additional examples that relate to specific diagnoses are considered in the relevant chapters (and see also the Further Reading section at the end of this chapter). An important distinction is between those schedules designed for use by interviewers with training in psychiatry, and those for use by interviewers without such training. Schedules in the latter category (generally used in large-scale epidemiological research) require more precise rules for detecting symptoms, and for diagnosing syndromes.

Present State Examination (PSE) and Schedules for Clinical Assessment in Neuropsychiatry (SCAN)

The Present State Examination (PSE) is the archetypal interview schedule for use by trained psychiatrists. Its development began in the late 1950s, and the ninth edition was the first to be published for use by others (Wing et al., 1974). It became widely used, notably in seminal international studies on the diagnosis of schizophrenia (see Chapter 11). The interviewer identifies abnormal phenomena that have been present during a specified period of time and rates their severity. Each of the 140 items is defined in detail in a glossary. Computer programs generate a symptom score, a diagnosis (CATEGO), and a measure of the severity of non-psychotic symptoms (the Index of Definition).

The tenth edition of the PSE was incorporated into the Schedules for Clinical Assessment in Neuropsychiatry (SCAN), a more extensive schedule which can be used to diagnose a broader range of disorders, including eating, somatoform, substance abuse, and cognitive disorders, using ICD-10 or DSM-IV criteria (World Health Organization, 1992a; Janca et al., 1994). A computer-assisted version is available.

Structured Clinical Interview for Diagnosis (SCID)

The Structured Clinical Interview for Diagnosis (SCID) is a diagnostic assessment procedure designed to make DSM diagnoses (Spitzer et al., 1987). It can be used by the clinician as part of a normal assessment procedure, or in research or screening as a systematic evaluation of a whole range of medical states. Box 3.6 illustrates how the SCID assesses, in a standardized fashion, the presence of delusions. The SCID-II is available for making Axis II (i.e. personality disorder) diagnoses.

Diagnostic Interview Schedule (DIS)

This schedule was developed in the USA as part of the Epidemiological Catchment Area (ECA) project (Robins et al., 1981). The fully structured interview schedule was developed for use by non-clinicians, but employs diagnostic criteria used by clinicians. The DIS covers the most common adult diagnoses that can be evaluated by assessing the content of the interview alone (for example, it omits bulimia nervosa). Diagnoses are first made on a lifetime basis. Then the interviewer asks how recently the last symptom was experienced. On the basis of the answer, the disorder is recorded as occurring within the last 2 weeks, or within the last 1, 2, 6, or 12 months. The reliability and validity, as determined by a second DIS given by a psychiatrist and by a clinical interview by a psychiatrist, are reasonable.

Box 3.6 SCID questions about delusions

Psychotic and associated symptoms

This module is for coding psychotic and associated symptoms that have been present at any point in the patient’s lifetime.

For all psychotic and associated symptoms coded ‘3’, determine whether the symptom is ‘not organic’, or whether there is a possible or definite organic cause. The following questions may be useful if the overview has not already provided the information: ‘When you were experiencing the psychotic symptoms were you taking any drugs or medicine? Drinking a lot? Physically ill?’ If the patient has not acknowledged psychotic symptoms, proceed by saying ‘Now I am going to ask you about unusual experiences that people sometimes have.’

If the patient has acknowledged psychotic symptoms, proceed by saying ‘You have told me about (psychotic experiences). Now I am going to ask you more about those kinds of things.’

Delusions

These are any false personal belief(s) based on incorrect inference about external reality and firmly sustained despite what almost everyone else believes, and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. Code overvalued ideas (any unreasonable and sustained belief(s) maintained with less than delusional intensity) as ‘2.’ Note that a single delusion may be coded ‘3’ on more than one of the following items: ‘Did it ever seem that people were talking about you or taking special notice of you?

Delusions of reference (i.e. false attribution of personal significance to objects or events in the environment): ‘What about receiving special messages from the TV, radio, or newspaper, or from the way things were arranged around you?’

(Describe as 1, 2, or 3, where 1 = possible/definite organic, and 3 = not organic.)

Persecutory delusions (i.e. belief that the individual (or their group) is being attacked, harassed, cheated, persecuted, or conspired against):‘What about anyone going out of their way to give you a hard time, or trying to hurt you?’

(Describe as 1, 2, or 3, where 1 = possible/definite organic, and 3 = not organic.)

Grandiose delusions (i.e. content involves exaggerated power, knowledge, or importance): ‘Did you ever feel that you were especially important in some way, or that you had powers to do things that other people could not do?’

(Describe as 1, 2, or 3, where 1 = possible/definite organic, and 3 = not organic.)

The section on delusions in SCID continues with questions about other kinds of delusions (somatic, nihilistic, etc.).

Composite International Diagnostic Interview (CIDI)

This interview was produced for the World Health Organization and the US Alcohol Drug Abuse and Mental Health Administration. It is a comprehensive and standardized interview derived from the DIS. It is used for the assessment of mental disorders and to provide diagnoses according to ICD and DSM-IV criteria. It is available in 16 languages and is designed to be used by clinicians and non-clinicians in different cultures. The interview includes questions about symptoms and problems experienced at any time in life, as well as questions about current state (World Health Organization, 1989; Janca et al., 1994).

Instruments for measuring symptoms

In addition to instruments designed to record the presence of symptoms and make diagnoses, other scales measure the severity of symptoms or their fluctuation with time. Some instruments rate one or a few symptoms, while others rate a broad group of symptoms as an overall measure of the severity of a disorder.

Ratings of depressive symptoms

Hamilton Rating Scale for Depression (HRSD or HAM-D; Hamilton, 1967)

This scale (available in 17- and 21-item versions) is filled in by an interviewer who uses an unstructured interview. It measures the severity of the depressive syndrome rather than the symptom of depression.

Beck Depression Inventory (BDI; Beck et al., 1961)

This 21-item inventory is usually completed by the patient. Each item has four statements, and the patient chooses the one that applies best to their feelings during the previous week.

Montgomery-Asberg Depression Rating Scale (MADRS; Montgomery and Asberg, 1979)

This inventory has 10 items rated on a four-point scale by an interviewer using definitions for each point. Only psychological symptoms of depression are rated. Along with the HAM-D, it is widely used in antidepressant drug trials.

Patient Health Questionnaire 9 (PHQ-9; Kroenke et al., 2001)

This questionnaire rates each of the nine DSM-IV criteria for depression on a scale of 0 to 3. It is adapted from an American questionnaire called Prime-MD. A score of > 10 has a sensitivity and specificity of 88% for major depression. The PHQ-9 has been adopted in the NHS in the UK as the screening tool for depression in primary care, and is also used in decisions about referral for psychological therapy, and monitoring of outcome.

Ratings of anxiety symptoms

Hamilton Anxiety Scale (HAS; Hamilton, 1959)

In this widely used scale, 13 items are rated by an interviewer on five-point scales, each on the basis of a brief description. The interviewing method is for the rater to decide. Some depressive symptoms are included so that the scale is in fact a measure of the severity of the anxiety syndrome and not of the symptom of anxiety.

Clinical Anxiety Scale (CAS; Snaith et al., 1982)

This scale was developed from the HAS, to focus more clearly on the symptom of anxiety, and its use is not restricted to patients with a diagnosis of anxiety disorder.

The State–Trait Anxiety Inventory (STAI; Spielberger et al., 1983)

This is a self-rating scale with 20 statements, which is completed in two ways—as the person feels when they are completing the scale (trait), and how they feel generally (state).

Ratings of other symptoms

Yale–Brown Obsessive Compulsive Scale (YBOCS) (Goodman et al., 1989a)

This clinician-rated scale assesses 10 symptoms on a four-point scale in patients diagnosed as having obsessive–compulsive disorder. Depressive and anxiety symptoms and obsessional personality traits are not rated.

Young Mania Rating Scale (Young et al., 1978)

Symptoms of mania are rated, both by the patient and by the clinician, on an 11-item scale, with each item rated from 0 to 5.

Ratings of motor symptoms

A range of scales are available, especially related to side-effects of antipsychotic medication. They include the Extrapyramidal Symptoms Rating Scale (ESRS; Chouinard et al., 1980) and the Barnes Akathisia Rating Scale (BARS; Barnes, 1989).

Ratings used in the assessment of cognitive impairment and dementia

The Mini-Mental State Examination (MMSE; Folstein et al., 1975) has already been introduced. Other scales that are used to assess cognitive impairment, and the behavioural symptoms of dementia, are discussed in Chapter 13.

Ratings of symptoms of schizophrenia

These are discussed in Chapter 11. The Positive and Negative Syndrome Scale (PANSS) is widely used in research (Kay et al., 1987).

Ratings of personality and its disorders

These are discussed in Chapter 7.

Ratings of broad groups of symptoms

General Health Questionnaire (GHQ; Goldberg, 1972)

The General Health Questionnaire (GHQ) is designed for use as a screening instrument in primary care, general medical practice, or community surveys. The original instrument contained 60 items, but shorter versions (e.g. GHQ-30) have also been developed. Even the full version can be completed within 10 minutes. The symptom ratings are added to a score that indicates overall severity, which is expressed by whether a psychiatrist would judge the patient to be a ‘case’ or a ‘non-case’ (Goldberg and Hillier, 1979).

Brief Psychiatric Rating Scale (BPRS; Overall and Gorham, 1962)

This instrument has 16 items, each scored on a seven-point scale. There are criteria to define the symptom items, but not for the severity ratings. The time period is not defined and must be decided by the rater. The BPRS is used mainly for rating psychotic disorders.

Global rating scales

Global Assessment of Functioning (GAF)

This instrument was introduced in DSM-IV, and is a revised version of the Global Assessment Scale (GAS; Endicott et al., 1976). The GAF is a 100-point scale on which the clinician rates the overall functioning of the patient. Each decile has a brief description of psychological, social, and occupational performance.

Clinical Global Impression (CGI; Guy, 1976)

This rating scale has two items. The main one, global severity, requires the clinician to rate the overall severity of the patient’s illness at the time of interview, relative to other patients with the same diagnosis. The global change item rates change relative to a baseline assessment. The CGI is often used as a measure of efficacy in drug trials.

Quality-of-life scales

There is increasing interest in quality of life as a key measure of outcomes throughout medicine. Over 100 scales are now available, many of which are over-complex and unconvincing. Quality-of-life scales that are commonly used in psychiatry include the relatively simple EuroQoL, the SF-36, and the Lancashire Quality of Life scale. Although detailed scales can be helpful in structuring an assessment, they rarely add more to a global assessment of satisfaction with life completed by the patient.

Health of the Nation Outcome Scale (HoNOS; Wing et al., 1998)

The HoNOS is an 18-item scale that rates clinical problems and social functioning. It was developed as an instrument to measure progress towards a UK NHS target to improve the health and social functioning of mentally ill people, and is now being used routinely for this purpose. It was designed to be applicable to all psychiatric disorders, so what it gains in applicability it loses in specificity. The equal weighting of the different variables has attracted criticism but has not limited its use. The HoNOS has been adapted for use in different countries, and for the elderly, those with learning disability, and other clinical groups.

Further reading

Cooper JE and Oates M (2009). The principles of clinical assessment in general psychiatry. In: Gelder MG, Andreasen NC, López-Ibor JJ Jr and Geddes JR (eds) The New Oxford Textbook of Psychiatry, 2nd edn. Oxford University Press, Oxford. pp. 62–78.

Maguire P and Pitceathly C (2002). Key communication skills and how to acquire them. British Medical Journal325, 697–700.

Poole R and Higgo R (2006). Psychiatric Interviewing and Assessment. Cambridge University Press, Cambridge.