Appearance and behaviour

Self neglect, often characterised by a dirty, unkempt appearance, may be associated with a number of psychiatric disorders, including depression, schizophrenia and alcohol dependence. Odd or inappropriate dress can be a useful clue to the presence of mania, when bright colours or excessive make-up may reflect the patient’s elated mood, or schizophrenia, when it may be associated with psychotic symptoms (e.g. wearing a motorcycle helmet indoors in the belief that it will protect against ‘voices’).

Facial expression and posture can give an indication of mood. Does the patient look sad, worried, frightened, angry, happy, or does the face betray no emotion? Movement and behaviour during the interview should also be described. Is there restlessness or agitation? Agitation often indicates distress, and can occur with most psychiatric disorders. Reduced movement or motor retardation is commonly associated with depression, but also occurs in schizophrenia and can be induced by sedative and antipsychotic drugs.

The patient’s co-operation with the assessment and interaction with the interviewer should be described. Is their behaviour disinhibited or aggressive? Do they seem to be responding to psychotic phenomena such as hallucinations?

Speech

The way in which speech is delivered is described in this section of the examination. For example, the rate of speech may be reduced in depression or increased in mania. A particularly marked increase in rate, where the words seem to fall on top of each other, is described as ‘pressure of speech’. Abnormalities in the volume of speech, such as whispering or shouting, should also be recorded. The content of the speech is considered under the heading ‘Thoughts’.

Affect

The term ‘affect’ refers to the emotional state in the short term, such as during the course of an interview. ‘Mood’ is the prevailing emotional state over a longer period. Abnormalities of affect include depression, elation, anxiety or anger, all of which are normal emotions in the right circumstances. Affect should be considered both objectively (based on appearance, behaviour and content of speech during the interview) and subjectively by asking the patient ‘how are you feeling in yourself?’.

You should consider the predominant affect during the interview, and the degree of variation. Normally, the affect is appropriate to the circumstances of the individual and is reactive to events, so it is likely to vary during the course of an interview depending on the topic discussed. Reduced reactivity (variation) of affect is typical of depression and increased reactivity, known also as emotional lability, occurs in mania and some organic disorders. In schizophrenia, the person can seem emotionally empty (blunting of affect) or their affect can be out of keeping with the circumstances (incongruity of affect).

It is appropriate to ask about suicidal thoughts alongside affect (see p. 13).

Thoughts

We gain access to the patient’s thoughts via their speech, and it is important to listen carefully to the way our patients speak to us (form), as well as what they tell us (content). Abnormalities of the rhythm and flow of thought are known as ‘formal thought disorder’ and are most commonly associated with schizophrenia, but can occur in mania and organic brain disorders (Fig. 2). Changes can be subtle, and you should be alerted to the possibility of formal thought disorder if you find yourself losing the thread of the conversation.

Fig. 2 Abnormalities of thought form.