Observe the gestalt or overall appearance of the patient: whether they appear older or younger than the stated age, the presence of unique physical attributes (prosthetic leg), grooming and neatness, if s/he appears depressed or anxious, and apparent state of health (ill appearing).
Observe the patient's attitudes, both exhibited, and expressed during the interview (particularly for cooperativeness). Other attitudes include angry, guarded, suspicious, attentive, seductive, playful, and obsequious.
Note the patient's motor activity: increased (hyperactivity, agitation), decreased, catatonic, and abnormal movements (tics, tremors). One also asks the patient to draw a simple figure, such as a clock set at a specific time or a square inside a circle, to assess visual–motor integrity.
Determine, primarily by inquiry, the patient's sustained, day-in and day-out, emotional feeling, for example, sad, happy, anxious, angry, depressed, detached, and irritable.
Primarily by observation note how the patient expresses her/his immediate emotional state. Is the patient fully and appropriately responsive to stimuli and circumstances or, are her or his responses flat or blunted (dulled emotional responsiveness), inappropriate (laughing when most would be serious), anhedonic (no enjoyment of anything), or labile? To combine mood and affect, the clinician might say, “The patient's mood was depressed and the affect blunted.”
Observe the following speech characteristics: normal, slowed, reduced, increased, pressured, mute, dysarthria, punning, rhyming.
Observe the patient's use of language for the following characteristics: bizarre, distracting, colorful, word salad (incoherent mix of words and phrases seen in psychotic states), circumstantial, tangential, loosening of associations (connections that are difficult to follow), and neologisms (coining new words).
Determine the presence or absence, via the patient's speech and language, of the following features of the patient's thought content: logical, incoherent, derailment, poverty of content, obsessive, delusional, paranoid. The clinician also notes the content of the thought, describing any delusions in detail.
About abnormal perceptions, typically hallucinations that may be visual, auditory, olfactory, or tactile. Hallucinations are abnormal sensory perceptions in the absence of a stimulus (voices coming from a picture on the wall) while illusions are misinterpretations of stimuli (belief that the doorbell ringing is someone speaking). Depersonalization is the perception that one's body is strange and unreal, as though apart from the patient. Derealization is a similar perception of unreality and estrangement of objects in the environment.
Judgment and insight
Determine if the patient is realistic or unrealistic about her or his problem and other issues. An apparent obliviousness of a serious problem is called “la belle indifference.”
Observe the patient's level of consciousness, for example, comatose, stuporous, drowsy, alert, hyperalert.
Carefully investigate attention and concentration by asking the patient to repeat a series of from three to eight digits (e.g., repeat the following: 8–1-6–3-9); having them subtract from 100 by 7 and continuing doing so with each answer, so-called “serial 7s” (e.g., 100 – 7 = 93; 93 – 7 = 86; and so on); spelling ...