Psychiatric History and Examination

The importance of a well-conducted interview technique in the field of psychiatry cannot be

overstated. Effective communication with patients is fundamental to obtaining accurate information,
making a precise diagnosis, establishing a strong patient-physician rapport, and ensuring better
adherence to the management plan. Here are some key points and techniques to consider for a
psychiatric interview:
1. Consistency in Record-Keeping:
 Use a consistent scheme for recording the interview, ensuring that all relevant information is
documented.
 While the interview technique should have flexibility to adapt to clinical circumstances,
maintaining a structured record is crucial for reference and continuity.
2. Patient-Centered Approach:
 Whenever possible, start by interviewing the patient directly. This allows you to establish a
direct connection and build trust.
 In cases where there is a discrepancy between the information provided by the patient and the
informant(s), record both accounts separately. This can help in understanding the different
perspectives.
3. Differentiated from Medical Interviews:
 Recognize that psychiatric interviews differ from routine medical interviews in several key
ways, including:
 Presence of disturbances in thinking, behavior, and emotions that can hinder
communication.
 The importance of obtaining collateral information from significant others.
 The need for detailed information on personal history and pre-morbid personality.
 The requirement for astute observation of the patient's behavior.
 The potential difficulty in establishing rapport, which may need more effort.
 The possibility that patients may lack insight into their illness and have poor
judgment.
 The greater emphasis on eliciting information about stressors and the patient's social
situation.
4. Building Rapport:
 Establishing trust and rapport is crucial in psychiatry. Begin with a warm, non-judgmental,
and empathetic approach.
 Actively listen to the patient, validate their feelings, and make them feel heard and respected.
 Use open-ended questions to encourage the patient to share their thoughts and feelings more
freely.
5. Non-Verbal Cues:
  Pay attention to non-verbal cues, such as body language and facial expressions, as these can
provide valuable insights into the patient's emotional state.
 Maintain appropriate eye contact and body posture to convey attentiveness and empathy.
6. Empathetic Communication:
 Show empathy by acknowledging the patient's emotions and experiences.
 Avoid making judgments or premature conclusions during the interview.
7. Cultural Sensitivity:
 Be aware of and sensitive to cultural differences that may influence a patient's perspective on
their mental health.
8. Encourage Self-Expression:
 Encourage the patient to express their thoughts, feelings, and concerns in their own words.
 Use reflective listening to summarize and confirm your understanding of their statements.
9. Clarify and Summarize:
 Periodically clarify and summarize the information provided to ensure accuracy and to give
the patient an opportunity to correct any misunderstandings.
10. Eliciting Stressors and Social Situation:
 In psychiatric interviews, it is essential to inquire about stressors and the patient's social
situation, as these factors can greatly influence mental health.
11. Patience and Flexibility:
 Recognize that some patients may require more time to open up and share their experiences.
Be patient and flexible in your approach.
Mastering the art of psychiatric interviewing takes time and practice, but it is a critical skill for mental
health professionals. It's essential to approach each patient with empathy, patience, and a commitment
to providing the best care possible.
The process of conducting a psychiatric interview is a critical aspect of the psychiatric assessment.
Here is an overview of the key components and techniques involved in this interview:
1. Establishing Rapport and Empathy:
 Make the patient feel at ease and create an empathetic relationship. Approach the interview
with a warm and non-judgmental attitude.
2. Integrating History and Mental Status Examination:
 In psychiatric assessments, the history-taking interview and the mental status examination
need not be separate processes, although they should be recorded individually.
 Observe abnormalities in verbal and non-verbal communication during the assessment.
3. Recording Verbatim Responses:
 It is helpful to record the patient's responses verbatim, especially when describing their
experiences, thoughts, and feelings. This provides a more accurate representation of their
mental state.
  Use the patient's own spoken language whenever possible.
4. Open-Ended and Non-Directive Questions:
 Use open-ended questions to encourage patients to express themselves freely and in their own
words. Avoid leading or directive questions.
5. Active Listening:
 Actively listen to the patient and demonstrate your interest in their concerns. Listening is an
active, not passive, process.
6. Confidentiality:
 Always observe patient confidentiality. However, in cases of suicidal/homicidal risk or child
abuse, exceptions may be necessary for the patient's safety.
7. Comprehensive Assessment:
 A comprehensive psychiatric interview often requires more than one session, particularly for
complex cases.
Components of a Psychiatric Interview:
 Identification Data:

 Obtain essential identification data, including name, age, sex, marital status,
education, occupation, income, residential and office addresses, religion, and
socioeconomic background. Also, record the source of referral and any
identifying marks in medicolegal cases.
 Informants:
 Recognize that the patient's insight may be limited, so it's important to gather information
from relatives or friends who act as informants.
 Record informants' identification data, their relationship to the patient, whether they live with
the patient, and the duration of their association.
 Assess the reliability of the information based on the informants' relationship with the patient,
their observational ability, familiarity with the patient, and degree of concern.
 Presenting (Chief) Complaints:
 Document the patient's presenting complaints or reasons for consultation, including both the
patient's and informants' versions when relevant.
 Use the patient's own words and note the duration of each complaint.
 Record additional information about the onset, duration, course, predisposing, precipitating,
perpetuating factors, and relief factors.
 History of Present Illness:
 Determine when the patient was last well or asymptomatic.
 Narrate the symptoms of the illness from the earliest time when a change was noticed until
the present in chronological order.
 Enquire about any disturbances in physiological functions (e.g., sleep, appetite, sexual
functioning) and suicidal ideation.
 Past Psychiatric and Medical History:
 Obtain the patient's history of past psychiatric illness, psychotropic medication use, alcohol
and drug abuse or dependence, and psychiatric hospitalization.
 Collect information about any serious medical or neurological conditions, surgeries,
accidents, and hospitalizations.
 Treatment History:
 Inquire about treatment received in the current and previous episodes, including adherence,
treatment response, adverse effects, and drug allergies.
 Family History:
 Record family structure, family history of psychiatric and medical illnesses, alcohol or drug
dependence, and suicide/suicidal attempts.
 Note the current social situation and family dynamics, including communication patterns,
affectivity, cultural and religious values, and social support.
 Perinatal History:

 Inquire about difficulties during pregnancy, including febrile illnesses, medication use,
alcohol or drug exposure.
 Ask about delivery details, complications, and any birth defects.
 Obtain information on prematurity and other factors related to the perinatal period.
 Childhood History:
 Investigate early childhood experiences, including the person who primarily raised the
patient, breast feeding, weaning, and any potential maternal deprivation.
 Record the age of reaching developmental milestones, any neurotic traits or behavioral issues
(e.g., enuresis, temper tantrums), and any relevant fears or phobias.
 Educational History:
 Document the patient's educational journey, including the age when formal education began
and ended.
 Record academic achievements, peer and teacher relationships, and any difficulties with
attendance or truancy.
 Play History:
 Inquire about the types of games played at different developmental stages, with whom, and
where they were played.
 Document peer relationships, especially those of the opposite sex, during childhood.
 Puberty:

 Record the age at which puberty-related changes occurred (e.g., menarche, secondary sexual
characteristics in both genders).
  Ask about nocturnal emissions in males and any issues related to the onset of puberty.
 Menstrual and Obstetric History (in females):
 Obtain information about menstrual regularity, cycle length, any abnormalities, and the
number of children born.
 Document the duration of pregnancy, if applicable.
 Occupational History:
 Gather details about the patient's work history, including the age when work began, job
changes, job satisfaction, and relationships with coworkers, superiors, and subordinates.
 Assess how well the job aligns with the patient's educational and family background.
 Sexual and Marital History:
 Ask about sexual experiences, including masturbation, sexual play, adolescent sexual activity,
and pre-marital/extramarital relationships.
 Inquire about gender identity, contraceptive use, and sexual satisfaction.
 Record information about marriages or relationships, their duration, reasons for termination,
and issues related to interpersonal and sexual relations.
 Premorbid Personality (PMP):
 Describe the individual's personality in detail, focusing on several aspects, including:
 Interpersonal relationships
 Use of leisure time
 Predominant mood
 Attitude toward self and others
 Attitude toward work and responsibility
 Religious beliefs and moral attitudes
 Fantasy life and habits
 Alcohol and Substance History:
 Gather information about alcohol and drug use separately, as these substances can be relevant
to psychiatric symptoms and may co-occur with various psychiatric conditions.
 Physical Examination:
 Perform a thorough general physical examination (GPE) and a systemic examination. This
examination is essential to identify physical conditions that could be related to psychiatric
symptoms, may coexist with mental health diagnoses, or result from psychiatric treatment.
This comprehensive psychiatric assessment allows healthcare providers to understand the patient's
background, development, personality, and the potential impact of physical conditions and substance
use on their mental health. It forms the foundation for an accurate diagnosis and treatment plan in
psychiatry.
Mental Status Examination (MSE) in psychiatric assessment:
1. General Appearance and Behavior:
 General Appearance: Begin by observing the patient's physical appearance, paying attention
to their physique, body habitus (build), approximate height and weight. Consider if they
appear comfortable or uncomfortable, which may reflect their physical health.
 Demeanor and Behavior: Observe the patient's demeanor and behavior. Look for signs of
grooming, hygiene, and self-care. Note their dressing, assessing if it is adequate, appropriate,
or if there are any peculiarities.
 Facies: Examine the non-verbal expression of mood on the patient's face. Note any
expressions that may reveal their emotional state.
 Attitude Towards Examiner: Assess the patient's attitude towards the examiner. Determine
if they are cooperative, guarded, evasive, hostile, combative, attentive, or disinterested.
 Comprehension: Evaluate the patient's comprehension, noting if it appears intact or
impaired. Assess their ability to understand and respond to questions.
 Gait and Posture: Observe the patient's gait and posture, looking for any abnormalities. Pay
attention to the way they sit, stand, walk, and lie down.
 Motor Activity: Evaluate the patient's motor activity. Determine if it is increased or
decreased. Watch for signs of excitement, stupor, or abnormal involuntary movements, such
as tics or tremors.
 Restlessness and Ill at Ease: Note if the patient appears restless or ill at ease.
 Catatonic Signs: Assess for catatonic signs, which can include mannerisms, stereotypies,
posturing, waxy flexibility, negativism, ambivalence, automatic obedience, stupor, echo
phenomena, and forced grasping (commonly seen in catatonia).
2. Speech:
 Rate and Quantity of Speech: Examine the patient's speech in terms of its rate and quantity.
Determine if speech is present or absent, spontaneous or reduced, rapid or slow, and if it
appears appropriate to the context.
 Volume and Tone of Speech: Evaluate the volume of speech, noting if it is increased or
decreased. Pay attention to the pitch or tone, whether it is low, high, or normal.
 Flow and Rhythm of Speech: Assess the flow and rhythm of speech. Look for smooth or
hesitant speech patterns, as well as any abrupt interruptions (blocking).
 Abnormal Speech Patterns: Watch for abnormal speech patterns, such as dysprosody,
stuttering, stammering, cluttering, circumstantiality, tangentiality, verbigeration (repetitive
speech), and stereotypies (repetitive, non-goal-directed movements or sounds).
 Flight of Ideas: Identify any signs of flight of ideas, where thoughts race rapidly.
 Clang Associations: Assess for clang associations, where words are connected based on
sound rather than meaning (e.g., "rhyming" associations).
3. Mood and Affect:
 Mood: Mood refers to the patient's pervasive emotional tone. Determine the quality of their
mood, such as whether it is warm, euphoric, anxious, sad, or shallow. Assess for mood
stability, reactivity, and persistence.
  Affect: Affect is the outward expression of the patient's immediate emotional state. Examine
the range and depth of affect, as well as its appropriateness to the situation.
 Anhedonia: Look for signs of anhedonia, which is the loss of interest or pleasure in activities
that were previously enjoyable.
4. Thought:
 Stream and Form of Thought: Thought is assessed in terms of its stream and form. This
involves examining the spontaneity, productivity, thought blocking (sudden interruption of
thought), and continuity of thought processes. Look for relevance, tangentiality,
circumstantiality, illogical thinking, perseveration (repetition of words, phrases, or ideas), and
verbigeration (the meaningless repetition of words or phrases).
 Content of Thought: Examine the content of the patient's thoughts. This includes inquiring
about any preoccupations, obsessions (recurrent, irrational, intrusive thoughts), phobias
(irrational fears), and delusions (false, unshakable beliefs). Assess for various types of
delusions, such as delusions of persecution, reference, grandeur, love, jealousy, guilt,
nihilism, poverty, somatic (related to the body), hopelessness, helplessness, worthlessness,
and suicidal ideation. Note if the patient experiences Schneiderian first-rank symptoms
(SFRS), which include delusions of control, thought insertion, thought withdrawal, and
thought broadcasting. Also, pay attention to the presence of neologisms (newly coined words
or expressions).
5. Perception:
 Hallucinations: Determine if the patient reports any hallucinations, which are perceptions
experienced in the absence of an external stimulus. Ask about the sensory modality involved
(e.g., auditory, visual, olfactory, gustatory, tactile), whether the hallucinations are elementary
(simple sensory experiences) or complex (e.g., hearing voices), and their characteristics (male
or female voices). Inquire about any command hallucinations that may instruct the patient to
do something.
 Illusions and Misinterpretations: Assess if the patient experiences illusions or
misinterpretations, which involve distorted perceptions or incorrect interpretations of sensory
input.
 Depersonalization/Derealization: Inquire about depersonalization (feeling detached from
oneself) and derealization (feeling that the external world is unreal or strange).
 Somatic Passivity Phenomenon: Evaluate for somatic passivity, where the patient
experiences unusual sensations imposed on their body by an external agency. This is a
Schneiderian first-rank symptom.
6. Cognition (Higher Mental Functions) Assessment:
 Consciousness: Determine the level of consciousness, ranging from conscious to confusion,
somnolence, clouding, delirium, stupor, or coma. You can use tools like the Glasgow Coma
Scale to assess this.
 Orientation: Test the patient's orientation to time, place, and person. Assess if they know the
date, location, and their own identity.
 Attention: Evaluate the patient's ability to sustain attention by asking them to repeat digits
forward and backward (digit span test). Note the longest sequence they can accurately repeat.
 Concentration: Assess the patient's concentration and distractibility by tasks like serial
subtraction (e.g., counting backward by sevens).
 Memory: Examine memory, including immediate retention and recall, recent memory (e.g.,
recalling events from earlier that day), and remote memory (recollection of events from the
past).
 Intelligence: Test general knowledge and intelligence, considering the patient's background
and education level.
 Abstract Thinking: Assess abstract thinking by asking the patient to explain proverbs or
identify similarities and differences between objects.
 Insight: Insight refers to the patient's awareness and understanding of their illness. It involves
several aspects:
 The patient's attitude towards their current state.
 Whether they acknowledge the presence of an illness, whether it's physical, psychiatric, or
both.
 Whether they recognize the need for treatment.
 Their belief in the possibility of recovery.
 Their understanding of the cause of their illness.
Insight is often graded on a six-point scale, as follows:
1. Complete denial of illness: The patient denies having any illness.
2. Slight awareness of being sick: The patient has a vague sense of being unwell but
simultaneously denies it.
3. Awareness of illness attributed to external factors: The patient acknowledges being sick
but attributes it to external or physical causes.
4. Awareness of illness attributed to unknown factors within self: The patient is aware of
being ill but believes it's due to something unknown within themselves.
5. Intellectual Insight: The patient recognizes that they are ill, and their symptoms or social
difficulties are due to their particular irrational thoughts or feelings. However, they do not
apply this knowledge to their current or future experiences.
6. True Emotional Insight: This goes beyond intellectual insight. The patient's awareness of
their illness leads to significant and fundamental changes in their future behavior.
Judgment: Judgment assesses the patient's ability to assess situations correctly and act
appropriately within those situations. It includes social and test judgment.
 Social judgment: This is observed during the patient's hospital stay and interview sessions,
encompassing an evaluation of personal judgment.
 Test judgment: It is assessed by presenting hypothetical test situations to the patient (e.g., a
house on fire, a person lying on the road, a sealed, stamped, addressed envelope on the street).
Their responses are evaluated as either Good/Intact/Normal or Poor/Impaired/Abnormal.
Investigations: After conducting a thorough history and examination, further investigations
are carried out based on diagnostic and etiological possibilities. These investigations may
 include laboratory tests, diagnostic standardized interviews, family interviews, and
psychological tests.
Formulation
A diagnostic formulation is a critical part of the psychiatric assessment process. It involves
summarizing the detailed information obtained from the patient, considering both positive and
important negative aspects, under the focus of care. The formulation helps in organizing the patient's
clinical picture and guides the subsequent steps of the diagnosis, prognosis, and management plan.
Here are the key components of a diagnostic formulation based on the biopsychosocial model:
 Biological Factors: These include any physical or medical factors that may contribute to the
patient's condition. For instance, consider whether there are any underlying medical
conditions, genetics, or neurological factors that could be relevant.
 Psychological Factors: These encompass the patient's emotional and cognitive state. Assess
the patient's thoughts, feelings, and behaviors, and consider any psychological stressors,
trauma, or personality factors that may be contributing to their condition.
 Social Factors: Examine the patient's social environment and relationships. Consider family
dynamics, living conditions, social support, and any external stressors that might influence the
patient's mental health.
 Differential Diagnosis: List potential diagnoses that could explain the patient's symptoms,
based on the information gathered during the assessment. This helps in narrowing down the
possibilities and arriving at an accurate diagnosis.
 Prognostic Factors: Evaluate the factors that may affect the course and outcome of the
patient's condition. Prognostic factors could include the patient's insight, level of social
support, response to previous treatments, and the chronicity of the condition.
 Management Plan: Based on the diagnostic formulation, develop a comprehensive plan for
managing the patient's condition. This plan should outline the treatment modalities, such as
medication, psychotherapy, or other interventions. It may also include recommendations for
lifestyle changes, support systems, and follow-up assessments.
The formulation should consider all these factors and provide a holistic understanding of the patient's
condition. This comprehensive approach allows for tailored and effective treatment and care.
Psychiatric assessment serves as the foundation for this formulation, guiding the diagnosis and
management of psychiatric disorders.
Organic Mental Disorders
1. Introduction
 Organic mental disorders pertain to psychiatric conditions that result from
demonstrable cerebral diseases or disorders, either primary (direct brain pathology) or
secondary (brain dysfunction due to systemic diseases).
 It's important to distinguish between organic mental disorders and other psychiatric
disorders. The term "organic" implies that these disorders have a clear and
independently diagnosable cerebral disease, unlike other psychiatric disorders, which
may not have a distinct cerebral cause but are still based on biological processes.
2. Types of Psychiatric Disorders
  Broadly, there are three types of psychiatric disorders:
 Those with a known organic cause.
 Those with an unknown or unproven organic factor.
 Those primarily caused by psychosocial factors.
 Organic mental disorders belong to the first category, characterized by established
cerebral pathology.
3. Differentiating Organic from Non-Organic
 It's important to recognize the distinctive features of organic mental disorders when
assessing patients:
 First episode.
 Sudden onset.
 Older age of onset.
 History of drug or alcohol use disorder.
 Concurrent medical or neurological illness.
 Neurological symptoms or signs.
 Presence of confusion, disorientation, memory impairment, or neurological
signs.
 Prominent visual or non-auditory hallucinations.
Delirium
1. Definition and Commonality
 Delirium is a common organic mental disorder encountered in clinical practice.
 It's characterized by:
 A relatively sudden onset.
 Clouding of consciousness, involving a reduced awareness of surroundings and a
decreased ability to respond to environmental stimuli.
 Disorientation, often starting with time, later progressing to place and person.
 Patients may experience perceptual disturbances, including illusions,
misinterpretations, and hallucinations, commonly visual.
 Sleep-wake cycle disruption is prevalent, with nighttime insomnia and daytime
drowsiness.
 Diurnal variation, known as "sundowning," is often observed.
 There's a notable impairment in registering and retaining new memories.
 Psychomotor disturbances like agitation and occasionally retardation can be present.
  Delirium often includes autonomic dysfunction, speech and thought disturbances
(slurred speech, incoherence, delusions), and motor symptoms (asterixis, myoclonus,
etc.).
 Affect may be labile, and verbal and motor perseveration, dysnomia, agraphia, and
comprehension impairment can occur.
2. Diagnosis
 Delirium is primarily diagnosed through clinical assessment. Specific laboratory tests
are not diagnostic.
 According to ICD-10, a definite diagnosis of delirium should encompass symptoms
in five areas, including consciousness and attention impairment, cognitive
disturbances, psychomotor changes, sleep-wake cycle disruption, and emotional
disturbances.
 Delirium typically has a rapid onset, a fluctuating course throughout the day, and a
duration usually less than six months.
3. Predisposing Factors
 Some factors can increase the risk of delirium, such as pre-existing brain damage or
dementia, extremes of age, past delirium episodes, alcohol or drug dependence,
neurological issues, medical illnesses, surgical procedures, psychological stress, and
the use of certain psychotropic medications.
4. Common Causes
 Delirium can be triggered by various factors, including metabolic disturbances,
endocrine disorders, drugs and toxins, nutritional deficiencies, systemic infections,
intracranial causes, and other miscellaneous factors.
5. Management
 Timely recognition and intervention
are crucial because delirium often Predisposing factors in delirium
has an underlying cause that may be  Pre-existing brain damage or dementia
correctable.  Extremes of age (very old or very young)
 Previous history of delirium
 If the cause of delirium is not  Alcohol or drug dependence
immediately apparent, a battery of  Generalised or focal cerebral lesion
investigations should be conducted  Chronic medical illness
to identify underlying factors.  Surgical procedure and postoperative period
 Severe psychological symptoms (such as fear)
 Correction of the underlying cause is  Treatment with psychotropic medicines
paramount, and this may involve  Present or past history of head injury
various medical and supportive  Individual susceptibility to delirium
interventions.
 Symptomatic Measures: Patients who are agitated may require emergency
psychiatric treatment. Small doses of medications can be administered, including:
 Benzodiazepines (e.g., lorazepam or diazepam).
 Antipsychotics (e.g., haloperidol or risperidone).
These medications can be administered orally or parenterally. Maintenance treatment
can continue until recovery occurs, typically within a week's time. It's important to
 note that the prescription of atypical antipsychotics (e.g., olanzapine and risperidone)
to elderly patients with dementia is associated with an increased risk of stroke.

 Supportive medical or nursing care

Dementia
Dementia is a chronic organic mental disorder characterized by the following main clinical features:
 Impairment of intellectual functions.
 Impairment of memory, predominantly affecting recent memory (especially in the early
stages).
 Deterioration of personality with a lack of personal care.
Additional Features: In addition to the main clinical features, dementia may also present with:
 Emotional lability, marked by significant variations in emotional expression.
 Catastrophic reaction, where the patient may react with sudden rage when faced with tasks
beyond their residual intellectual capacity.
 Thought abnormalities, such as perseveration and delusions.
 Development of urinary and fecal incontinence in later stages.
 Disorientation in time; disorientation in place and person may also develop in later stages.
 The presence of neurological signs may vary depending on the underlying cause.
Dementia typically has a progressive course, although some forms of dementia can be reversible. This
structured format provides a clear understanding of the clinical features and additional aspects
associated with dementia.
Delirium VS Dementia

Features Delirium Dementia

Onset Usually acute Usually insidious

Usually recover in 1 week; may take up to 1 Usually protracted, although it may

Course month in some cases be reversible

Clinical Features

a. Consciousness Clouded Usually normal

 Features Delirium Dementia

Usually normal; disturbed only in late

b. Orientation Grossly disturbed stages

c. Memory - -

- Immediate retention and

recall Disturbed Normal

- Recent memory Disturbed Disturbed

- Remote memory Disturbed only in late stages Disturbed only in late stages

d. Comprehension Impaired Impaired only in late stages

e. Sleep-wake cycle Grossly disturbed Usually normal

f. Attention and
concentration Grossly disturbed Usually normal

g. Diurnal variation Marked; sundowning may be present Usually absent

h. Perception Visual illusions and hallucinations very common Hallucinations may occur

i. Other features Asterixis; multifocal myoclonus Catastrophic reaction; perseveration