TRIPASS XR تري باس

 Appearance 320

Behaviour 320

Speech 321

Mood 321

Thought form 321

Thought content 322

Perceptions 323

Cognition 323

Insight 324

Risk assessment 324

Capacity 324

The physical examination 325

Collateral history 325

Psychiatric rating scales 325

Putting it all together: clinical vignettes 325

OSCE example 1: Assessing suicidal risk 327

OSCE example 2: Assessing delirium 328

Integrated examination sequence for the psychiatric assessment 328

320 • The patient with mental disorder

death) or incriminating (illicit drug misuse, other crime, homicidal

ideas). For interviews undertaken in non-clinical settings such as

police stations or prisons, or for the provision of court reports,

the latter is obviously especially pertinent, and it is important to

be clear with the patients about any limits to confidentiality in

your interview.

Try to develop rapport early in the interview, if possible, and to

consolidate it before raising a sensitive topic, although sometimes

you must cover such material without delay. It is particularly

important to ask about suicidal thoughts.

The uncooperative patient

Adapt your approach to a patient who is mute, agitated, hostile or

otherwise uncooperative during the interview, by relying more on

observation and collateral information. The safety of the patient,

other patients and staff is paramount, so your initial assessment

of an agitated or hostile patient may be only partial.

The mental state examination

The mental state examination (MSE) is a systematic evaluation

of the patient’s mental condition at the time of interview. The

aim is to establish signs of mental disorder that, taken with the

history, enable you to make, suggest or exclude a diagnosis.

While making your specific enquiries, you need to observe,

evaluate and draw inferences in the light of the history. This is

daunting, but with good teaching, practice and experience you

will learn the skills.

The MSE incorporates elements of the history, observation

of the patient, specific questions exploring various mental

phenomena and short tests of cognitive function. Like the history,

its focus is determined by the potential diagnoses. For example,

detailed cognitive assessment in an elderly patient presenting

with confusion is crucial; similarly, you should carefully evaluate

mood and suicidal thoughts when the presenting problem is

depression.

Appearance

Think of this as a written account of a still photograph, prepared

for someone who cannot see it. Observe:

• general elements such as attire and signs of self-neglect

• facial expression

• tattoos and scars (especially any that suggest recent or

previous self-harm)

• evidence of substance misuse (such as injection tracks

from intravenous drug use; spider naevi and jaundice from

alcoholic liver disease)

• possibly relevant physical disease (such as exophthalmos

from thyrotoxicosis).

Behaviour

Think of this as a written account of a video, observing such

features as:

• cooperation, rapport, eye contact

• social behaviour (such as aggression, disinhibition, fearful

withdrawal)

• apparent responses to possible hallucinations or

unobserved stimuli

Mental disorders are very common, frequently coexist with physical

disorders and cause much mortality and morbidity. Psychiatric

assessment is therefore a required skill for all clinicians. It consists

of four elements: the history, mental state examination, selective

physical examination and collateral information. Each element can

be expanded considerably, so the assessment must be adapted

to its purpose. Is it a quick screening of a patient presenting

with other problems, a confirmation of a suspected diagnosis

or a comprehensive review for a second opinion?

The history

General approach

The distinction between symptoms and signs is less clear in

psychiatry than in the rest of medicine. The psychiatric interview,

which covers both, has several purposes: to obtain a history of

symptoms, to assess the present mental state for signs, and to

establish rapport that will facilitate further management.

A comprehensive history covers a range of areas (Box 16.1), but

the nature of the presenting problem and/or the referral question,

and the setting in which the history is being taken, will determine

the degree of detail needed for each. When seeing someone in

the accident and emergency department with a first episode of

psychosis, the focus is on symptoms, recent changes of function,

family history and drug use; when interviewing someone in an

outpatient clinic with a possible personality disorder, assessment

concentrates instead on their personal history, which is essentially

a systematised biography (Box 16.2).

Sensitive topics

Some subjects require particular skill. The common theme is

reluctance to disclose, which can arise because the information

is private, and disclosure is potentially embarrassing (such as

sexual dysfunction, gender identity), distressing (major traumatic

experiences, such as rape, childhood sexual abuse, witnessing a

16.1 Content of a psychiatric history

• Referral source

• Reason for referral

• History of presenting symptom(s)

• Systematic enquiry into other relevant problems and symptoms

• Past medical/psychiatric history

• Prescribed and non-prescribed medication

• Substance use: illegal drugs, alcohol, tobacco, caffeine

• Family history (including psychiatric disorders)

• Personal history

16.2 Personal history

• Childhood development

• Losses and experiences

• Education

• Occupation(s)

• Financial circumstances

• Relationships

• Partner(s) and children

• Housing

• Leisure activities

• Hobbies and interests

• Forensic history

The mental state examination • 321

16

any aspect of life, and at interview appear downcast, withdrawn

and tearful, with little brightening even when talking about their

much-loved children.

Pervasive disturbance of mood is the most important

feature of depression, mania and anxiety, but mood changes

commonly occur in other mental disorders such as schizophrenia

and dementia. You might ask patients ‘How has your mood

been lately?’, ‘Have you noticed any change in your emotions

recently?’ and ‘Do you still enjoy things that normally give you

pleasure?’ Abnormalities of mood include a problematic pervasive

mood, an abnormal range of affect, abnormal reactivity and

inappropriateness or incongruity. Some terms relating to mood

are defined in Box 16.5.

Some patients prompt affective responses in the interviewer,

via the process of countertransference. The elated gaiety of some

hypomanic patients can be infectious, as can the hopeless gloom

of some people with depression. Recognising these responses in

yourself can be helpful in understanding how the patient relates

to others and vice versa.

Thought form

As with speech, this is a not an assessment of what the patient

is thinking about, but how they think about it. Assess it by

observing how thoughts appear to be linked together, and the

speed and directness with which the train of thought moves,

considering rate, flow, sequencing and abstraction. Some terms

relating to thought form are defined in Box 16.6.

Thinking may appear speeded up, as in hypomania, or

slowed down, as in profound depression. The flow of subjects

• over-activity (agitation, pacing, compulsive hand washing)

• under-activity (stupor, motor retardation)

• abnormal activity (posturing, involuntary movements,

Box 16.3).

Speech

This is not a description of what the patient says (that is, content),

but of how they say it (form). Assess:

• articulation (such as stammering, dysarthria)

• quantity (mutism, garrulousness)

• rate (pressured, slowed)

• volume (whispering, shouting)

• tone and quality (accent, emotionality)

• fluency (staccato, monotonous)

• abnormal language (neologisms, dysphasia, clanging,

Box 16.4).

Mood

Mood is the patient’s pervasive emotional state, while affect is the

observable expression of their emotions, which is more variable

over time. Think of mood as the emotional climate and affect

as the weather. Both have elements of subjective experience

(that is, how the patient feels, according to their own report and

your specific questions) and how the patient appears to feel,

according to your own objective observation. So a depressed

patient might describe feeling sad, hopeless and unable to enjoy

16.3 Behaviour: definitions

Term Definition

Agitation A combination of psychic anxiety and excessive,

purposeless motor activity

Compulsion A stereotyped action that the patient cannot

resist performing repeatedly

Disinhibition Loss of control over normal social behaviour

Motor retardation Decreased motor activity, usually a combination

of fewer and slower movements

Posturing The maintenance of bizarre gait or limb positions

for no valid reason

16.4 Speech: definitions

Term Definition

Clang associations Thoughts connected by their similar sound

rather than by meaning

Echolalia Senseless repetition of the interviewer’s words

Mutism Absence of speech without impaired

consciousness

Neologism An invented word, or a new meaning for an

established word

Pressure of speech Rapid, excessive, continuous speech (due to

pressure of thought)

Word salad A meaningless string of words, often with loss

of grammatical construction

16.5 Mood: definitions

Term Definition

Blunting Loss of normal emotional sensitivity to experiences

Catastrophic

reaction

An extreme emotional and behavioural over-reaction

to a trivial stimulus

Flattening Loss of the range of normal emotional responses

Incongruity A mismatch between the emotional expression and

the associated thought

Lability Superficial, rapidly changing and poorly controlled

emotions

16.6 Thought form: definitions

Term Definition

Circumstantiality Trivia and digressions impairing the flow but

not direction of thought

Concrete thinking Inability to think abstractly

Flights of ideas Rapid shifts from one idea to another,

retaining sequencing

Loosening of

associations

Logical sequence of ideas impaired. Subtypes

include knight’s-move thinking, derailment,

thought blocking and, in its extreme form,

word salad

Perseveration Inability to shift from one idea to the next

Pressure of thought Increased rate and quantity of thoughts

322 • The patient with mental disorder