Human behavior is complex. When it becomes dysfunctional because of environmental stress or brain disease it can mystify the inexperienced clinician. This is especially true of neurobehavioral disorders, which involve neuropsychiatric changes in cognition and emotion that overlap the boundary of psychiatry and neurology. The clinician must appreciate and assess the signs and symptoms of neurobehavioral disorder with the same discernment as in physical syndromes such as myocardial infarction or infectious disease.

This chapter describes the psychiatric history and mental status examination (MSE), in the conduct of an effective psychiatric interview. The steps of the interview process are described along with the techniques the clinician must master in order to elicit information relevant to a diagnostic formulation in an orderly, reliable, and comprehensive manner. The components of the psychiatric history and the MSE are described in accordance with the stages of the interview during which they would usually be obtained.

What can be achieved at the initial psychiatric interview? The outcome depends on the situation in which it is conducted and what the physician and the patient are seeking. For example, a brisk, focused interview in an emergency room contrasts with the more extensive survey appropriate to an outpatient clinic. Both types of interview differ from what is possible at the bedside of a patient who is severely ill in a medical or surgical ward. Despite these observations, fundamental issues can be addressed to varying degree in any clinical situation, as illustrated in Table 4–1. We return to these issues in our discussion of the elements of the psychiatric history.

[Some of this material also appears in Nurcombe B, Gallagher RM: The Clinical Process in Psychiatry: Diagnosis and Management Planning. Cambridge University Press, 1986. Reprinted with the permission of Cambridge University Press.]

Inception

If the interviewer works in a clinic, at the opening of the psychiatric interview he or she goes to the waiting room, introduces himself or herself to the patient, accompanies the patient to the interview room, and shows him or her to a seat. After taking identifying data from the patient, the interviewer can tell the patient what he or she already knows. This approach avoids unnecessary mysteries and clears the way for action. Consider the following example:

Psychiatrist: Your parents came to see me yesterday. They told me they’re worried because your schoolwork has fallen off, although you’ve always been a good student; you’ve dropped most of your friends; and you seem to have become depressed. Last week they found one of your assignments in which you spoke about suicide. They think you may need help for an emotional problem.

Patient (a 16-year-old boy): So?

Psychiatrist: So they asked you to see a psychiatrist. I get the impression you’re not too happy about that.

Patient: No.

Psychiatrist: Maybe we can start by you telling me how you feel about it.

Interviews are not always conducted in an office; they may be transacted beside a patient’s bed, or between pieces of equipment in the examination room of an emergency clinic, or even while driving a car. Wherever they occur they include a pattern to the beginning, a certain formality. The interviewer introduces himself or herself, says why he or she is there, and invites the patient to respond by telling his or her story. If the patient does not want to do so, the interviewer helps the patient to explain why.

Reconnaissance

The interviewer helps the patient tell his or her story as spontaneously as possible. He or she listens and does not interrupt any more than is necessary to keep the story flowing. The interviewer does not rush the reconnaissance nor try to direct it prematurely. If all the interviewer does is ask direct questions, all he or she will get is answers. Open-ended probes should be used as much as possible. The more leading the probe, the less valid the response, unless the issue in question is a simple, unequivocal one. The facilitating techniques we describe later in this chapter are particularly appropriate for the reconnaissance stage.

Detailed Inquiry

After the patient has finished his or her story, the interviewer seeks further information about the present illness, past illness, medical history, early environment, education, and other relevant matters from the psychiatric history. A full detailed inquiry will take several interviews, but a scanning of the features most important for a provisional diagnosis can be accomplished within an hour.

Table 4–2 lists the content of the psychiatric history. The order suggested in the table should not be followed blindly. The interviewer should be prepared to deal with topics in whatever sequence is natural. In accordance with the case, some areas will be emphasized and others pursued in less detail.

Detailed inquiry involves questioning, but the questions are kept as open ended as possible at the outset, moving from general to specific as more detail is required. Compare the following questions:

• How are things in your marriage?
  
• How are things between you and your wife?
  
• How do you and your wife get on?
  
• Is your marriage a happy one?
  
• Do you love your wife?

This approach is similar to the way a surgeon approaches a guarded section of a painful abdomen: from the outside in. Direct questions provoke circumscribed responses and are most appropriate to issues of fact (e.g., What year were you married?).

Some issues are left to a later time after a therapeutic alliance has developed. Unless the patient presents his or her sexual life as a problem at the outset, an exploration of this area is usually postponed.

Transitions

The interviewer never moves abruptly from one topic to another. Change should be signaled. For example, the psychiatrist could say, “Okay. I’d like to go on from there to something else. Could you tell me about the jobs you’ve had? What did you do after you left school?”

Standard versus Discretionary Inquiry

Part of the detailed inquiry is standardized, including questions obligatory for patients of a given age, in a specific clinical situation, or as part of a minimum database. The components of a standard inquiry should be defined for each clinical setting. The rest of the detailed inquiry is largely discretionary and involves the eliciting of evidence supporting or refuting the diagnostic hypotheses generated after reconnaissance.

We now discuss the components of the psychiatric history, which are shown in Table 4–1. Each issue addressed in Table 4–1 must be addressed and the information related to one of the categories shown in Table 4–2.

The Present Illness

An accurate psychiatric history is the guide to diagnosis, intervention, and treatment. To this end, it is useful to define the present episode with its precipitants and then determine whether the present episode constitutes a discrete psychiatric illness or an episode in a chronic psychiatric illness that can be documented chronologically.

Some patients present a variety of subjective concerns. Others have a more focused complaint and can identify particular issues as problematic. Whatever the problem(s) for which the patient or his or her associates seek help, the clinician attempts to delineate them; to understand how the patient experiences them; and to ascertain their duration, onset, development, and persistence.

Precipitation of Illness & Relevant Stressors

If the problems had an onset, the interviewer attempts to determine whether the patient experienced physical or psychosocial stress at that time. The mere coincidence of stress and onset does not substantiate a causal association; indeed, causation remains speculative in some cases. Causation is supported, however, if the patient previously had a breakdown when exposed to a similar stress or if the patient’s account of the stress indicates its personal significance.

Some stressors have universal impact. Others are highly idiosyncratic, and painstaking work may be required before they can be unraveled in psychotherapy. In some cases it is an open question whether an event was a true precipitant, or secondary to a disorder in its early stages, or mere coincidence.

Previous Psychiatric Illness & Behavioral Problems

The interviewer considers the following questions in evaluating the patient for previous psychiatric illness and behavioral problems: Has the patient had any problems of a similar nature in the past? What precipitated them, if anything? Has the patient had any other emotional disorders or physical symptoms related to tension? Has the patient had, or does he or she have, physical or neurologic disease that could contribute to the present problem? Does the patient have, or has he or she had, personal habits (e.g., substance abuse) that could cause, precipitate, or complicate the present problem?

Previous Psychiatric Treatment & Mental Health Intervention

The interviewer should be aware of any therapeutic interventions prior to the current evaluation, including formal psychiatric treatment (or treatment by another mental health professional), emergency evaluations, hospitalizations, or mental health treatment rendered by a primary care physician. The clinician who carried out the treatment and the treating facility should be identified, as should the approximate date(s) and duration of treatment. The patient’s response to each pharmacologic agent and associated side effects should be documented. The type, duration, and results of psychotherapy should be identified. The interviewer will usually verify and amplify this information by requesting records from previous treating professionals and facilities, with appropriate written consent from the patient.

Predisposition & Potentials

The interviewer considers the following questions in evaluating the patient for predisposition to and family history of psychiatric illness: What kind of person was the patient before he or she became ill? What biopsychosocial strengths and weaknesses predisposed the patient to breakdown? These questions require a comprehensive evaluation, and it is unrealistic to expect all of this information to be elaborated in a single interview. However, important pieces of the jigsaw puzzle are usually available, if the interviewer keeps his or her eyes and ears open. The interviewer can seek information about the following additional questions: What personal and environmental strengths, resources, and liabilities are apparent at the present time? What has the patient got going for him or her now? What holds the patient back? What hurdles does he or she face? An inventory is required of the patient’s physical, intellectual, emotional, and social assets and deficiencies. This inventory is crucial to the design of an individualized plan of management.

Presentation

The interviewer considers the following questions in evaluating the patient’s current presentation for treatment: Why does the patient seek help now? Is the patient being seen at the onset of a disorder or later, either when a relatively defined pattern of symptoms has developed or after the patient has recovered partially but remains troubled by residual difficulties? Did the patient come of his or her own accord, or was he or she persuaded to do so? Did others bring in the patient for treatment? Why?

Insight, Judgment, & Motivation for Treatment

The interviewer considers the following questions in evaluating the patient’s insight, judgment, and motivation for treatment: Does the patient think he or she is unwell? Does the patient think he or she has been referred inappropriately? The patient may be correct. If the patient recognizes his or her own disturbance, does he or she have any idea of its nature or cause? How realistic are these notions?

What kind of help does the patient seek, if any? Is this in line with what is advisable, appropriate, or feasible? Is the patient troubled by doubts concerning his or her problem and the kind of treatment he or she will receive? Fears of craziness or of exotic psychiatric treatments are likely to be inflamed by deep-seated anxieties about helplessness and victimization. These fears are often aggravated by images derived from family or cultural values, including those depicted in the media. It is better that such concerns be expressed as soon as possible and corrected when they are the result of misinformation.

Family History

The family history is an important component of the initial interview. It helps to understand the patient’s family structure and the family influences that were brought to bear on the patient’s growth and development. It documents the patient’s genetic predisposition to psychiatric illness. This initial inquiry is the beginning of a genogram that can be developed in more detail in subsequent interviews. The initial interview should identify each family member for one or two generations and also identify individuals with psychiatric illness for at least two generations. This line of questioning is subtle because of social stigma and the natural reluctance of individuals to disclose family problems. It is desirable to inquire about the presence of psychiatric illness in several ways. The interviewer may begin with an open-ended question such as inquiring whether any family member has had emotional or behavioral problems. Follow-up questions can include whether any family member has been treated by a behavioral health provider and whether anyone in the family has been hospitalized for psychiatric illness.

Social History

The social history should be elicited in the first diagnostic interview, even if time does not permit a full exposition of this subject. This part of the initial interview informs the examiner of the social, cultural, and family structural influences that contribute to the patient’s personality, values, and social integration. Open-ended questions that invite the patient to describe the structure and membership of the nuclear and extended family is a good start. Often the description will be colored by feelings and attitudes toward each person that can be explored in depth in a subsequent interview. Marriages, children, divorces, major illnesses, and deaths within the immediate family should be documented as part of the social history. This part of the interview can be interwoven with the family history of illness, particularly psychiatric illness. The social history is often ignored in initial psychiatric interviews, but the absence of this information limits the diagnostic formulation.

Educational and Occupational History

The initial diagnostic interview should include a brief educational and occupational history. During this part of the interview, the diagnostician is forming a time line to register major events in the patient’s life and evaluating developmental milestones. The educational history helps to give a developmental history extending through the second decade of life, as well as an indirect indication of intellectual capacity and social adjustment. Interruptions in education are often a sign of emerging psychopathology or a discrete behavioral setback or crisis. The occupational history is valuable life history information, but can also indicate periods in a person’s life when an acute psychiatric illness occurred or when the gradual development of psychopathology altered a person’s life, including his ability to work. Choices of educational and occupational paths may provide a window into understanding a patient’s personality, motivation, identification with people who are important to the patient, and family values and influences.

A military history is important when it is relevant to the patient’s life. Major psychiatric illnesses often present for the first time under the stress of military service when the individual is in his late teens and early twenties. Military health care provides substantial documentation of symptoms in an acute psychiatric illness, diagnosis, and response to treatment. If an individual has a medical discharge from the military, the documentation of the illness is very useful data for diagnostic impression, treatment response, and prognosis.

Legal History

A legal history is relevant in an initial psychiatric interview if the interviewer infers that it may be important for the diagnostic impression. To omit this inquiry because it is a difficult subject is an error if it turns out that the diagnostic formulation hinges on this aspect of the history. The content of this history can include lawsuits, divorce and custody disputes, bankruptcy, arrests, convictions, and imprisonment.

Forming Hypotheses

Throughout the initial interview, the diagnostician is working to form hypotheses about the etiology of the current problem under evaluation. This involves an acquired skill set that involves memory, a questioning technique that draws the patient out in a nonintimidating manner, a capacity to convey empathy, and an ability to make each part of the interview productive in terms of information gathering, while also building an alliance with the patient. It is reasonable to take occasional notes, but it is a poor technique to look at a written document constantly instead of the patient. Likewise, it is poor technique to follow a rigid interview outline and not follow leads that the patient offers when they occur. It is precisely this mixture of structure and completeness in acquiring clinical data, combined with spontaneity in following psychodynamic leads and continually forming hypotheses about the patient’s defining life events and diagnosis, that constitutes a skill acquired gradually by the experienced clinician.

The MSE is a set of systematic observations and assessments undertaken by a diagnostician during the clinical interview. Properly conducted, the MSE provides a detailed and systematic description of the patient at that time, information essential to the consolidation of those patterns of clues and inferences that are required for the generation of diagnostic hypotheses. The MSE, guided by the hypothetico-deductive approach to diagnosis, is an essential part of the subsequent inquiry plan. In this section we offer a comprehensive description of the components of the MSE. In regard to a particular patient—and in accordance with the clinical context, background information, and psychiatric history—the interviewer will apply the MSE tactically, pursuing brief, comprehensive, or discretionary lines of inquiry, as warranted.

The Need for Standardization

Because the MSE, like the psychiatric history, should involve routine and discretionary lines of inquiry according to the context of assessment and the diagnostic hypotheses being entertained, it should not be standardized as a whole. Instead the separate observations and assessments that compose the MSE should be standardized. The techniques of eliciting data should be formalized, the phenomena in question clearly defined, and the weight to be placed on each phenomenon clarified.

Reliability

The reliability of a test refers to the likelihood (usually expressed as a correlation) that similar results will be obtained on retesting (test–retest reliability) or that similar results will be obtained by different observers (interrater reliability). Test–retest reliability applies to relatively stable characteristics such as the use of language; it is not to be expected in characteristics (e.g., mood) that are potentially changeable and often linked to a current situation.

When psychiatrists test for the patient’s abstracting ability, for example, by asking the patient to explain proverbs in his or her own words, how certain can the psychiatrist be that the clinical test is a true measure of the ability in question? In other words, what is the validity of the test? Over the years, a set of informal mental state assessments has accumulated but in some instances their validity is questionable. When we describe any clinical test in this chapter, we will consider its validity along with the mental faculties required for adequate performance on the test.

Types of MSEs

Brief Screening MSE

When a patient has been referred to an ambulatory clinic for a situational or personality problem, and none of the indications for a comprehensive screening examination pertain (see next section), a brief, informal screen is sufficient. The brief screening MSE is completed during the inception, reconnaissance, and detailed inquiry stages of the psychiatric interview. In particular, the interviewer notes the patient’s general appearance, motor behavior, quality of speech, relationship to the interviewer, and mood. From the patient’s demeanor, conversation, and history, the interviewer makes inferences about consciousness, orientation, attention, grasp, memory, fund of information, general intellectual level, language competence, and thought process. Abnormal thought content is not investigated unless clinica1 clues indicate the need for such discretionary inquiry (e.g., into hallucinations, obsessions, depersonalization). Physiologic functions (e.g., sleep, appetite, libido, menstrual cycle, energy level) and insight should always be assessed.

Comprehensive Screening MSE

The interviewer should be alerted to the need for a comprehensive screening MSE whenever there is a reasonable possibility that the patient has psychosis or primary or secondary brain dysfunction. Table 4–3 summarizes the settings and clues that mandate a comprehensive MSE. If the clinician has any doubts, the comprehensive screen should be completed.

Components of the MSE

Table 4–4 summarizes the areas to be covered in the MSE. The following sections describe these areas in more detail:

Appearance & Behavior

From the moment the interviewer first greets the patient, he or she will be aware of the patient’s appearance. The interviewer should try to describe it in detail before drawing inferences from it. What is the patient’s physique and habitus? Is there evidence of weight loss or gain? Does the patient have any conspicuous marks or disfigurement? The interviewer should describe the patient’s face and hair. Does the patient look ill? What is the expression of the eyes and mouth? Does the patient appear to be in touch with the surroundings? Is the patient clean and neat, or does he or she exhibit deficiencies in personal hygiene revealed by poor grooming of the skin, hair, or nails? How is the patient dressed? Is the patient’s clothing neat? Is it appropriate or peculiar? After the interviewer describes these characteristics, he or she determines whether an inference may be made about the kind of “statement” the patient is attempting to make with his or her attire.

The interviewer notes general overactivity or underactivity, abnormalities of posture, gross incoordination, or impairment of large muscle function. What is the patient’s gait like and how does he or she sit? The interviewer notes any abnormalities of finer movement and posture, such as tremor, tics, or fidgeting.

Stereotypies are organized, repetitive movements or speech or perseverative postures. They are usually associated with schizophrenia, particularly the catatonic type. A striking variant of postural stereotypy is waxy flexibility, in which the patient will remain indefinitely in a position into which the interviewer places him or her (e.g., standing on one leg). Other disorders of movement associated with catatonia include a stiff expressionless face; facial grimacing or contortions; stiff, awkward, or stilted body movement; and unusual mannerisms of expressive movement or speech. The latter should not be confused with the gracelessness of someone who is socially anxious. The interviewer also notes whether the patient exhibits any rituals such as a need to touch objects repetitively, as in obsessive–compulsive disorder, or any habits such as nail biting, thumb sucking, lip licking, yawning, or scratching.

The interviewer attends to the accent, pitch, tone, and tempo of the patient’s speech, paying particular attention to unusually high or low pitch and abnormal tone, as in the high-pitched “squawking” monotone sometimes encountered in children with early infantile autism.

In mutism, which may occur in advanced brain disorder, severe melancholia, catatonia, or conversion disorder or in the elective mutism of negativistic children, the patient is unable or unwilling to utter anything. In conversion disorder, mutism is less common than is aphonia, in which the patient is able to speak only in a hoarse whisper.

Relationship to the Interviewer

The interviewer should infer the quality of the patient’s relationship by how he or she behaves and by what he or she says. The relationship may be constant, it may vary with the topic being discussed, or it may be influenced by other factors. These factors may remain obscure if they are unexpressed (e.g., when the patient is privately amused by an auditory hallucination). The interviewer should note whether this is the case.

Affective states are difficult to assess, aside from noting whether they are inconstant or are apparently influenced by obscure factors. The interviewer draws on a number of behavioral clues to assess the quality of the patient’s relationship and mood. As a rule, the more inferential the judgment, the more unreliable the conclusion. Interviewers may differ in their inferences concerning a patient’s affect, especially when it is unstable, ambiguous, complex, or shielded by interpersonal caution.

The interviewer’s behavior will inevitably affect the ebb and flow of the patient’s feelings. The patient may be responding appropriately to the interviewer’s friendly approach (or rudeness, for that matter). He or she will also be responding to highly idiosyncratic internal predispositions. For example, a patient may harbor mingled anxiety and deference for somebody he or she perceives as a threatening authority figure who must be placated.

Given the fallibility of inference, the interviewer is well advised to stick closely to observations and be able to cite them. This skill requires training. The beginner may be overly impressed by brilliant intuitive leaps; the expert heeds intuition but realizes how unreliable it is. The beginner grasps for, and holds firmly to, an inference, sometimes in spite of contrary evidence. The expert makes the inference, cites the clues on which it is based, can offer alternative explanations, and discards the inference for a better one if contrary evidence emerges.

The quality of the patient’s eye contact is of great importance in gauging affective states. Negativistic patients, especially those with catatonia, may avert their gaze from the interviewer. Children with early infantile autism characteristically demonstrate eccentricities of eye contact, for example, staring “through” the interviewer or averting their gaze from him or her. A delirious patient whose sensorium is impaired may stare into space, as may a melancholic or schizophrenic patient whose thoughts are dominated by gloomy ruminations or delusional preoccupations. Intermittent staring is a feature of different forms of epilepsy. The interviewer notes whether the patient’s attention can be captured, albeit briefly. If not, the interviewer should suspect an organic brain disorder.

Some patients stare at the interviewer intently. He or she should distinguish the wide eyes of awe or fear from the narrowed slits of hypervigilant suspiciousness. Other patients make hesitant eye contact, particularly when they are embarrassed about what they are saying. Not all patients with shifty gaze are liars, and some prevaricators have learned to deliver their lines without batting an eyelash.

The impact of the eyes on interpersonal relations cannot be overestimated. The configuration of supraorbital, circumorbital, and facial musculature; eyelids; palpebral fissure; gaze; depth of ocular focus; pupil size; and conjunctival moisture combine to produce a range of social signals of great significance for interpersonal dominance, competition, attraction, hostility or avoidance, the initiation and punctuation of conversation, and the feedback a person requires to know how the other person has responded to what one has said.

Eyes and face are combined with body posture and movement in a gestalt. The face provides the clues to remoteness, bewilderment, and perplexity, whereas the whole body is involved in tenseness (e.g., clenched fists, sweaty palms, stiff back, leaning forward), restlessness, preoccupation, boredom, and sadness.

The patient may be uncommunicative or, in the extreme, quite mute. In contrast, he or she may be friendly and communicative, even loquacious or garrulous. Patients convey antagonism by hectoring; by being uncooperative, impertinent, or condescending; or even by making direct threats, criticizing, or verbally abusing the interviewer. In contrast, by tone of conversation and demeanor, the patient can convey respect, deference, anxiety to please, or ingratiation. The interviewer notes and describes the following attitudes in the patient: shyness, fear, suspiciousness, cautiousness, assertiveness, indifference, passivity, clowning, interest in the interviewer, clinging, coyness, seductiveness, or invasiveness.

Affect & Mood

Affect refers to a feeling or emotion, experienced typically in response to an external event or a thought. The patient’s relationship to the interviewer is a particular manifestation of affect. Affects are usually associated with feelings about the self or about others who are of personal significance to the individual. Less often, an affect is experienced alone, as though adrift from its reference point. Affect is the conscious component of a monitoring system that signals whether the individual is on track toward a personal goal; whether he or she is obstructed, frustrated, or prevented from achieving the goal; or whether he or she has already attained it. Compare, for example, the anticipatory pleasure at preparing to meet someone beloved; the anxiety and fear at seeing the beloved with a serious rival; the rage and despair of loss; and the exaltation of reunion. Similar, though more complex, affects may attend mountain climbing, solving mathematical puzzles, or giving birth. Whatever the goal, its remoteness, proximity, loss, repudiation, attainment, or inaccessibility are all accompanied by self-monitoring affect.

In contrast to an affect, which may be momentary, mood refers to an inner state that persists for some time, with a disposition to exhibit a particular emotion or affect. For example, a mood of depression may not prevent an individual from deriving momentary diversion from a joke; however, the expression of gloom, sadness, or desolation returns and prevails. Affects and mood are inferred from the patient’s demeanor and spontaneous conversation. A general query such as “How are you feeling, now?” or “How have your spirits been?” can be helpful. The interviewer should try to avoid leading questions such as “Do you feel depressed?”

Demeanor and affect usually coincide, but sometimes they do not. For example, a stiff smile can mask anxiety or depression. If the interviewer suspects this to be the case, he or she can offer an indicating or clarifying interpretation to help the patient recover suppressed emotion, such as “I notice that even though you speak of sad things, you are smiling” or “It’s hard to smile when you feel bad inside.”

The interviewer describes in the mental status report the general qualities of the patient’s emotional expression. Particular morbid affects or moods are noted. For example, is the patient affectively flat,

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