Childhood

This should include details of:

Education

This requires details of:

Occupational history

Summarize the occupational history, giving details of promotion/demotion. Reasons for being sacked repeatedly (e.g. problem drinking) should be explored. Any other difficulties at work should be given.

Psychosexual history

For women, ask about the age of menarche, any menstrual abnormalities, history of pregnancies and the age of menopause, if relevant. The sexual orientation should also be given. Any history of sexual or physical abuse should be detailed, together with sexual and marital history (including any history of infidelity) and any sexual difficulties.

Children

Details of any children should be given, including any disturbances from which they suffer.

Current social situation

Give the patient’s current:

Alcohol

Details should be obtained about the amount of alcohol the patient is currently drinking and the amount drunk in the past, including a history of any withdrawal symptoms (see Chapter 8). Also obtain any history of physical illnesses, injuries (e.g. road traffic accidents), legal problems (e.g. driving offences) or employment difficulties (e.g. being late regularly for work resulting in being sacked), as a result of alcohol intake. The CAGE Questionnaire (Chapter 7) should be routinely administered to patients to screen for alcohol problems; positive answers to two or more of the following four CAGE questions is indicative of problem drinking:

Tobacco

If the patient smokes, the type and number of nicotine-containing products smoked and any previous history of smoking should be obtained.

Illicit drug abuse

Detail the use of illicit drugs currently and in the past, including the types of drugs, the quantities taken, the methods of administration and the consequences.

General appearance

The patient’s general appearance should be described, with particular reference to any features that may be consistent with a psychiatric disorder.

Self-neglect, as evidenced by a lack of personal cleanliness, with hair and clothes that have not been looked after, may be consistent with dementia, psychoactive substance use disorder (of both alcohol and illicit drugs), schizophrenia or a mood disorder. Poorly fitting clothes that appear too loose may be evidence of recent weight loss, as occurs in certain organic disorders such as carcinoma, and in depression. A patient suffering from mania may be dressed in a colourful, flamboyant way.

The presence of calluses on the dorsum of the hands may be consistent with a diagnosis of bulimia nervosa, the patient using the fingers to stimulate the gag reflex in self-induced vomiting. (In such cases the calluses are referred to as Russell’s sign.)

Facial appearance

The facial appearance can also give clues to the diagnosis, particularly with respect to organic disorders, for example the typical facial appearances seen in endocrinopathies such as Cushing’s syndrome, hyperthyroidism and hypothyroidism.

Depressed patients often have downcast eyes, a vertical furrow in the forehead and downturning of the corners of the mouth. Manic patients, on the other hand, may look euphoric and/or irritable. Anxiety in general may be associated with raised eyebrows, widening of the palpebral fissures, mydriasis and the presence of horizontal furrows in the forehead.

Relatively fixed unchanging facies may be caused by the parkinsonian side-effects of antidopaminergic neuroleptic treatment (used in the pharmacotherapy of schizophrenia and mania, for example) or by Parkinson’s disease itself.

The presence of fine, downy ‘lanugo’ hair on the sides of the face (as well as on other parts of the body, which may not be visible until a physical examination is carried out, such as the arms and back) may occur in anorexia nervosa. In bulimia nervosa the face may have a chubby appearance owing to parotid gland enlargement; facial oedema may also occur as a result of purgative abuse.

Underactivity

Stupor in psychiatry refers to a patient who is mute and immobile (akinetic mutism) but who is also fully conscious. It is known that the patient is fully conscious because the eyes, which are often open, may follow objects. Moreover, following the episode of stupor the patient may be able to remember events that took place during it. The condition is sometimes disturbed by periods of excitement and overactivity. It is seen in catatonic, depressive and manic stupor, and may also occur in epilepsy and hysteria. (In neurology stupor has a different meaning. A stuporose patient responds to pain and loud sounds, brief monosyllabic utterances may occur and some spontaneous motor activity takes place.)

Depressive retardation is a lesser form of psychomotor retardation occurring in depression, which, in its extreme form, merges with depressive stupor.

Obsessional slowness may be secondary to repeated doubts and compulsive rituals.

Overactivity

In psychomotor agitation there is overactivity, which is usually unproductive, and restlessness.

Overactivity, distractibility, impulsivity and excitability occur in hyperkinesis, which may be seen in children and adolescents, and is increasingly identified in adults.

In somnambulism (sleep walking) a complex sequence of behaviours is carried out by a person who rises from sleep and is not fully aware of the surroundings.

A compulsion is a repetitive and stereotyped seemingly purposeful behaviour. It is also referred to as a compulsive ritual, and is the motor component of an obsessional thought. Examples of compulsions include:

Psychodynamic aspects

The psychodynamic aspects of movements should not be overlooked. For example, a married or engaged woman may play with her wedding or engagement ring during the interview because she has anxieties about her relationship; if she takes the ring off completely this may be indicative of an unconscious desire to end the relationship.

Rapport

It is useful to record the nature of the rapport established with the patient. A positive rapport aids the formation of a constructive therapeutic relationship (see Chapter 4). A negative rapport may occur, for example, in the case of patients admitted to hospital against their will, and in some personality disorders (see Chapter 15). The rapport can be indicative of both the transference and the countertransference (see Chapter 4), and should be borne in mind when considering the underlying psychodynamics of the doctor’s relationship with the patient and the latter’s response to various types of treatment (such as individual psychotherapy). It is important that the doctor tries to establish a positive rapport.

Rate, quantity and articulation

The rate at which the patient speaks should be noted first. It may be increased in mania and reduced in dementia and depression. The quantity of speech may be increased in mania and anxiety but reduced in dementia, schizophrenia and depression.

There is an increase in both the quantity and rate of speech in pressure of speech, seen for example in mania; it is difficult to interrupt such speech. In logorrhoea, also called volubility, the speech is fluent and rambling, with the use of many words.

In poverty of speech there is a restricted amount of speech and any replies to questions may be monosyllabic. Mutism is the complete loss of speech.

The patient’s accent may cause words to be pronounced in such a way as to be mistaken for neologisms by the interviewer. It should also be borne in mind that some people may normally speak in a way that could cause an incorrect psychiatric diagnosis to be made. For example, it is perfectly normal for some people from New York to speak in a rapid, pressured and loud manner; this should be taken into consideration before it is suggested that such a person is hypomanic.

Dysarthria is difficulty in the articulation of speech, dysprosody is the loss of its normal melody. In stammering, the flow of speech is broken by pauses and the repetition of parts of words.

Form of speech

The form of the patient’s speech (i.e. the way in which he or she speaks) is noted (the content of the speech is considered later). If a disorder in the form of speech is suspected or found, it is useful to record a sample of the patient’s speech that shows this.

In flight of ideas, the speech consists of a stream of accelerated thoughts, with abrupt changes from topic to topic and no central direction (Figure 5.3). The connections between the thoughts may be based on:

Figure 5.3 • Diagrammatic representation of flight of ideas.

In circumstantiality, thinking appears slow, with the incorporation of unnecessary trivial details, but the goal of thought is finally reached (Figure 5.4).

Figure 5.4 • Diagrammatic representation of circumstantiality, showing how the goal of thought is finally reached.

In passing by the point (also called vorbeigehen) the answers to questions, although clearly incorrect, demonstrate that the patient understands the question. For example, when asked ‘How many legs does a cow have?’ the patient may answer ‘Five’. It is seen in the Ganser syndrome (first described in criminals awaiting trial).

A neologism is a new word constructed by the patient or an everyday word used in a special way. For instance, a woman suffering from schizophrenia who believed that electricity workers were interfering with her home said that they were doing this by means of instruments she termed ‘electroenergators’, which affected her electrical sockets.

In perseveration (of both speech and movement), mental operations are continued beyond the point at which they are relevant. In palilalia, the patient repeats a word with increasing frequency; for example, a 79-year-old woman with Alzheimer’s disease said ‘Knife..knife..knife, knife, knife, …’, faster and faster. In logoclonia, the patient repeats the last syllable of the last word. For example, a woman with Alzheimer’s disease enquired ‘What’s the matter-er-er-er-er-er?’.

Echolalia is the automatic imitation by the patient of another person’s speech, even when they do not understand it (e.g. another language).

In thought blocking, there is a sudden interruption in the train of thought, before it is completed, leaving a ‘blank’. After a period of silence, the patient cannot recall what he or she had been saying or had been thinking of saying.

Disorders (loosening) of association occur particularly in schizophrenia and may be considered to be a schizophrenic language disorder. They are also sometimes called formal thought disorder. An example is knight’s move thinking, in which there are odd tangential associations between ideas, leading to disruptions in the smooth continuity of speech. (This is like the knight’s moves in a game of chess, which appear to jump abruptly from one square to another with which it is not directly connected.) In schizophasia – also called word salad or speech confusion – the speech is an incoherent and incomprehensible mixture of words and phrases.

The following five features of formal thought disorder were described by the psychiatrist Schneider:

Schneider considered normal thinking to contain the features of constancy, in which a completed thought persists, organization, in which the contents of thought are separated from each other in an organized manner, and continuity, in which there is a continuity of the sense of the whole. In schizophrenia, the following three disorders of the form of thought were described by Schneider as corresponding to these three features of normal thinking:

Anxiety

When assessing mood it is important to remember that, in addition to depression and hypomania (or mania), anxiety can also be considered to be a mood disorder. Anxiety is a feeling of apprehension, tension or uneasiness owing to the anticipation of an external or internal danger. Types of anxiety include: