APPROACH TO CLINICAL INTERVIEWING AND DIAGNOSIS; CASE HISTORY; MENTAL STATUS EXAMINATION;

ORGANIZATION AND PRESENTATION OF PSYCHIATRIC INFORMATION

An atmosphere and relation of trust and opennnes to enable

the patient to feel comfortable in sharing private experiences
is needed.
This relationship manifests in rapport (spontaneous
emotional resonance between the client and interviewer)
and lays the foundation for the subsequent interviewing
tasks (collection of information, givin feedback, etc.)
Characteristicsin the interviewer’s approach to the patient
contribute to the building of the relationship: respect for
others, calm manner, genuine caring, nonjudgmental
attitude, dependability, openness, warmth, honesty and
consistency.
Quiet room, free from distractions, chair at same level with that of interviewer to help them be at ease.
Attentive listening: facing the ptient, making eye contact, nodding, making sure the patient knows they are being listened
to.
Asking questions: They must be asked in a calm and slow manner, thoughtful questions must be asked. The patient must
be allowed to answer in their own pace. The types of questions are given below. Open ended questions are helpful in
eliciting information while closed ended questions to guide conversations and get specific answers.
Safe environemt : must be present to fascilitate talking about feelings freely as most cultures do not permit open
expression. The examiner must be caring and listen closely, respond appropriately with non vebral cues such as lean
forward nod, or smile. Patient may be asked about their non vebral cues gently. “ You seem tearful and your hands are
shaking when speaking about this” or “please continue” “tell me more”
Empathize: trying to imagine self in the patient;s position and understand how they see the world.
Different situations : Reassurance with anxious patients Calm manner and reassurance are particularly needed for an
over anxious patient, whereas techniques of verbal and nonverbal facilitation should be used more with a taciturn
patient. An over talkative patient may be initially told about the time limit, may need to be interrupted at the natural
breaks and
asked more direct questions.
Assertiveness and pursusion with hostile and dominating pateints When the patient is hostile and resentful, the
interviewer should talk about the circumstances of referral and try to persuade the patient that the interview is intended
to be in his own interest.
Some people may like to dominate the interview when the interviewer should interrupt gently and firmly, and ensure
what is being said is relevant to the present problem

SOCIODEMOGRAOHIC 1. NAME  Helps in determining the social class and

DATA 2. AGE environment of the client and assessing risk
3. SEX factors, associated.
 4. MARITAL STATUS  Elimination can lead to lack of thoroughness
5. OCCUPATION and counter transference
6. INCOME
7. LANGUAGE
8. RELGION
9. NATIONALITY
10. PLACE OF RESIDENCE
11. FAMILY TYPE

SOURCE AND 1. REFERRED BY AND FOR  To get a context of the patient’s referral along
REASONS OF WHAT with understanding goals of assessment and
REFERRAL psychiatric history
 TREATMENT HISTORY to establish duration
and type of treatment response to treatment
HISTORY OF 1. PATIENT’S VERSION  Assessing consistency and coherence of history
PRESENT ILLNESS 2. INFORMANTS VERSION and corroboration of information between
3. ONET patient’s and informant’s version
4. PRECIPITATING FACTORS  Understand nature of problem
5. PERPETUATING FACTORS  ONSET When did it start , abrupt, acute,
6. BIOLOGICAL insidious
FUNCTIONING  PRECIPITATING Events that occur shortly
7. SOCIAL FUNCTIONING before
8. INTERPERSONAL  To get a comprehensive timeline and avoid
FUNCTIONING memory lapses use Presumptive Stressful Life
9. TREATMENT HISTORY Events Scale (PSLES)
 Understand Developmental trajectory of
symptoms, deteriorating or
 PERPETUATING factor of the illness which may
be an illness or psychosocial consequences
 NEGATIVE HISTORY for ruling out physical and
mental symptoms


PAST HISTORY 1. PHYSICAL ILLNESS  Medical and physical functioning

2. PSYCHIATRIC ILLNESS  Mental illness symptoms, date, duration,
treatment, hospitalization, response to
treatment, adherence
 Longitudinal and cross sectional profile of
illness
 History of delinquency, discipline, drug use,
illegal activity
FAMILY HISTORY 1. FAMILY TREE  PARENTS – age, illness, education, occupation,
2. PARENTS personality traits, marital discord
3. FAMILY ENVIRONMENT  Family history of medical and psychiatric illness,
alcoholism, drugs, epilepsy
 SUPPORT SYSTEM instrumental, emotional,
behaviour and attitude of important people
towards client, perceived support, dependency
PERSONAL HISTORY 1. PRENATAL  PLANNED, WANTED UNWANTED pregnancy,
2. EARLY CHILDHOOD 0-5 Y problems during pregnancy, type of birth,
3. MIDDLE CHILDHOOD 5- complications during birth
11Y  0-5 Y milestones, tilet training, weaning,
4. LATE CHILDHOOD EARLY illnesses, temperament
TEENS  5-11 Y relationship with parents , siblings,
5. PSYCHOSEXUAL HISTORY sibling rivalry, adaptation to school demands,
6. MENSTRUAL HISTORY friends, education, frustration tolerance,
7. MARITAL HISTORY childhood disorders like thumb sucking nail
biting encopresis enureisis , temper tantrums ,
focus concentration
 11-17 Y personality peer relations, values,
morals anxiety inferiority, functionality
 Sexual history , intimate relations, attitude
towards sex
 MENSTRUAL
 MARITAL type of marriage , adequacy,
 connection, discord, separation, adjustment
PREMORBID 1. ATTITUDE  Attitude towards self, strengths, shortcomings
PERSONALOTY 2. COGNITION  Relations with others, socialisation, support
3. AFFECT  Attitude towards work, colleagues, superiors
4. SOCIALIZATION  Mood changeable , how long they last,
5. HABITS expression of feelings
 Character self- conscious sensitive suspicious
irritable selfish resentful timid
 Habits of work, drugs, food

MENTAL STATUS EXAMINATION

1. CONSCIOUSNESS
 ALERTNESS – Responsiveness to environmental stimuli. Readiness to respond, state of arousal (reticular
activating system); the intensity of stimulus needed to arouse patient (Glasgow coma scale). States of
arousal include alertness, wakefulness, lethargy, clouding of consciousness, sleep, obtundation, stupor,
and coma.
i. Normal alertness
ii. Somnolence
iii. Obtundation – moderate reduction, stimuli of mild to moderate intensity fail to arouse, if arousal
occurs it is slowed
iv. Stupor - unresponsiveness to all but the most vigorous stimuli, drifts back to sleep like state
v. Coma – unarousable unresponsiveness, most noxious stimuli is unable to elicit reflexes
 AWARENESS – content of consciousness on a higher cognitive functioning level (cortical activation and
ascending reticular activation)
i. Delirium
ii. Clouding of consciousness – reduced awareness mainly inattention, stimuli perceived consciously
but ignored or misinterpreted
iii. Twilight state
iv. Stupor

 PSYCHOMOTOR SPEED :Psychomotor” speed combines or conflates, two general neurological processes,
basic cognitive speed and basic motor speed. The former is a mental decision-making process, and the
latter is basic motor reaction time or speed of movement.
 Psychomotor speed is particularly a function of the basal ganglia (striatum, globus pallidus, subthalamic
nucleus, substantia nigra) and their white matter connections from frontal lobe regions (dorsolateral,
orbitofrontal, anterior cingulate, supplementary motor area)
i. Decreased speed, activity, and movements can reflect psychomotor speed or a neurological or
psychiatric disorder, for example, bradykinesia, decreased facial expressiveness, or overall
paucity of movement. Causes of decreased psychomotor speed and activity include delirium,
dementia, depression, parkinsonism, frontal lobe disease, or catatonia
 ii. Conversely, there may be signs of increased speed or activity, such as fidgetiness and inability to
sit still, hand wringing. Causes of increased psychomotor speed and activity include delirium,
agitation, anxiety, mania, psychosis, delirium, or akathisia
2. GENERAL APPEARANCE AND BEHAVIOUR
 GROOMING- personal cleanliness; dress appropriateness; hair well kempt
i. signs of self-neglect (dementia, schizophrenia, depression, substance abuse);
ii. Immaculate perfection, red dry hands – OCD
iii. Overdressing, loud dressing, elaborate- in mania;
iv. Inappropriate clothing, weather inappropriate or hiding from someone – Psychosis, delusion of
persecution
v. Chewed nails – anxiety
vi. asymmetry in cleanliness in parietal lobe lesion
 FACIAL EXPRESSION AND POSTURE- nonverbal cues ;
i. Depression- downcast eyes, down turning of corners of mouth;
ii. Avoiding eye contact0- depressive or shame (OCD )
iii. Avoids eye contact on purpose- defiance
iv. Shifting eye contact- easily distracted
v. Hypervigilant gaze, fleeting eye contact -
vi. still expressionless face may be seen in Parkinsons, drug-induced or schizophrenia;
vii. anxiety with raised eyebrows
 SOCIAL BEHAVIOUR AND ATTITUDE- attitude towards examiner
i. Depression and anxiety- tense, withdrawn,
ii. Mania, histrionic - disinhibition or overfamiliarity,
iii. ID, dementia or delirium - guarded or aggressive, inappropriate odd response
iv. cooperativeness, friendliness, trustfulness, seductiveness, ingratiating, hostility, guardedness and
evasiveness
 RAPPORT - An instantaneous emotional resonance between the patient and the interviewer usually
develops early in the interview (vide supra). Difficult in schizophrenia, odd,
i. May try to establish dominance, you don’t know enough- narcissistic
ii. Evasive, suspicious, hostile
iii. Defensive – not answering all questions, answering vaguely
iv. Ingratiating overcompliant – dependent
v. Seductive- histrionic
vi. Exhibitionistic attitude, inappropriately dressed sexual nature- paraphilia
vii.
 MOTOR BEHAVIOUR
i. Parkinsonism- Slow rigid gait with short shuffling steps, with loss of automatic associated
movements
ii. Adhd- restless, fidgeting, not sitting in one place
iii. Motor Restlessness may also be an extrapyramidal symptom
iv. Manic- rapid walking,
v. Schizoprhhenia- lip movement, silly smiling, abnormal, mannerisms, ambitendency ( alternating
between resistance and cooperation to instructions, getting stuck in movements)
vi. Slowness and lack of spontaneity- subcortical dementia or depressive
vii. Tics
viii. Anxiety- exaggeration of movements such as fidgeting and frequent change in posture
3. COGNITIVE FUNCTIONS
 ORIENTATION: day date month year season and time
 ATTENTION: Elements of attention include selectivity and the ability to sustain, divide, and shift attention.
In addition to difficulty concentrating, patients with abnormal attention may have impersistence,
distractibility, and increased vulnerability to interference.
i. Attention requires the ascending reticular activating system in the upper brain stem,
ii. the reticular nucleus of the thalamus for modulating sensory input,
iii. prefrontal cortex for complex attention, and
iv. parietal cortex for shifting attention
 MEMORY
i. Short term – immediate recall
ii. Working memory – manipulation
iii. Recent memory- new learning
iv. Remote memory – retrieval of old information
 ABSTRACTION
 INTELLIGENCE
 JUDGEMENT
4. SPEECH – verbal fluency, comprehension, repetition, naming
 Normal productivity, adequate
  Prosody or inflection and melodic quality of speech
 Unspontaneous
 Talkative , rapid , pressured
 Slow , hesitant
 Dramatic or monotonous
 Overabundant speech
 Lack of productivity or decreased reaction time – depressive
 Blurting out answer before question, rapid and pressured speech- mania,

5. MOOD AND AFFECT – broad, restricted, labile, flat; dysphoric, euthymic, euphoric,
 Mood is pervasive and sustained emotion that colours our perception of the world
i. QUALITY
ii. STABILITY- to what extent is mood consistent across the day
iii. REACTIVITY- change of mood based on external events
iv. PERSISTENCE – how long does the mood last

 Affect is the pattern of observable behaviour that is the expression of the emotion it may be variable in
response to changing emotional states. Aspects
i. Quality
ii. Range – Range of variation in facial expression, tone, use of hands, body movements. spectrum
displayed over period of time in reference to various themes and topics in the interview . full and
increased in mania and constricted in depression and schizophrenia. CONSTRICTED, BLUNTED
OR FLAT
iii. APPROPRIATENESS- Congruity of emotion to the prevailing thought or speech
iv. Mobility- ease with which affect changes form one mode to another. Decreased in depression and
increased in mania. Rapid change of affect from one mode to another is called lability [dementia,
pseudobulbar palsy), drug intoxications, early in schizophrenia, and some types of neurotic or
personality disorders.]
v. Relatedness (communicability): Capacity to connect with the interviewer, usually present in
mania with infectious jocularity but absent in schizophrenia
vi. Assess whether the patient’s perceived affect corresponds to his or her underlying mood. Assess
for dysphoria or euphoria and whether it is congruent with the context or situation.
vii. Intensity of expression (depth of affect): Increased in mania, and certain personality disorders,
and decreased (blunted) or absent (flat) in schizophrenia.
viii. Lability - Assess whether the patient has periods of provoked or unprovoked emotional
outbursts and how quickly they resolve. Specifically consider pseudobulbar affect with
incontinent crying or laughing from bilateral pyramidal tract disease, Witzelsucht with facetious
humor from orbitofrontal disease, or moria with childlike excitement from frontal disease.
ix. RELATEDNESS AND COMMUNICABILITY
6. THOUGHT
 STREAM
i. Rate- no of words per minute
ii. Reaction time – interval between questions and responses
iii. Quantity- Increased in mania, reduced in depression, shy and ID
iv. Volume – Low in depression, sighing and drop in volume as though mourning, manics speak in a
loud volume
v. Tone – monotonous or normal prosody
 FORM
i. Normal form indicates logical coherent and sequential speech which makes use of goal direction
to guide
ii. Abnormalities in FTD may happen when speech is poor in understandability, illogical, lack of
meaningful connections. May have shifts in between two sentences or in the middle of a sentence
iii. Check whether these shifts are based on some understandable and superficial (e.g. phonetic)
connections like clang association (words rhyming),
iv. punning (words with more than one meaning),
v. assonance (words sounding similar),
vi. word association or any external cues.
vii. If so, that will indicate flight of ideas which, when associated with pressured speech, is often seen
in mania.
viii. When no such connections (semantic or phonetic) are found but the grammatical structure
(syntax) is preserved, the shifts between the ideas make the speech difficult to understand and
indicate loosening of association (derailment), which is seen in some cases of chronic
schizophrenia. When the grammatical structure is also lost, the speech is reduced to a string of
unrelated words called verbigeration (word salad, incoherence)
 POSSESSION
  CONTENT
7. PERCEPTION
 Hallucinations –
i. Auditory – most common, first person or thought echo, second person, third person, command
hallucinations, gender of voices, how many, how much do they compel you, is the conversational
back and forth
ii. Gustatory – taste, rotten, poisoned etc
iii. Tactile – alcohol withdrawal, cocaine use, bugs crawling, burning, skin tearing, temporal lobe
dysfunction
iv. Olfactory – particular smell that no one else can smell
 Delusions
 Depersonalization
 Derealisation
8. COGNITIVE FUNCTIONS
 ATTENTION CONCENTRATION
 LANGUAGE
 ORIENTATION
 MEMORY
 INTELLIGENCE
 GK
 ABSTRACT THINKING
 JUDGEMENT
9. INSIGHT – awareness of condition, what brought you here, change in behaviour, reasons for change, other noticed
change, do you think you need treatment
 LEVEL 1 – complete denial
 LEVEL 2- Accepted and denied fluctuating
 LEVEL 3 – reasons on external factors
 LEVEL 4 – unknown factors
 LEVEL 5 - intellectual insight
 LEVEL 6 – emotional insight

AROUSAL  Loud calling of name

 Tapping table with varied intensity
 Pinching achilles heel
 Rubbing sternum
ORIENTATION  Day
 Date
 Month
 Year
 Season
 Place
ATTENTION  Digit span forwards backwards
 Serial subtraction, 7s, 3 s,
 Backward spelling
 Reverse days of week or months
PSYCHOMOTOR SPEED  Reciting ABC as fast
 Speed of counting
SPEECH  Word list generation – 18 words without
cueing
 Comprehension questions
 Vocabulary
 Repetition , no ifs and buts

ABSTRACTION  Similarities
 Proverbs
 Concrete, functional, conceptual,
overabstraction
MEMORY  Word list learning , recall as many as
possible, normals can completele
learning by 3-4 repetitions
 Digit span
 Remote – 3-4 public events
 Vocabulary for semantic
EXECUTIVE FUNCTION  Go no go- examiner taps once – subject
taps ; examiner taps twice – no response
 
JUDGEMENT  Testable executive attributes include
insight and the ability to abstract. Insight
relates to the awareness and
understanding of their illness and its
consequences.
 Personal and social appropriate goals
 Unfamiliar proverbs
 What would you do if you saw a fire in a
theatre

INSIGHT  After completion of a full examination, a

simple question to the patient—“And how
concerned are you about your
trouble?”—may demonstrate a lack of
realization or a serious misinterpretation
of the problem. The examiner compares
the patient’s responses with those of the
caregiver, family, or other objective
sources